Differential Diagnosis of HE

Arun B. Jesudian, MD: That actually brings up another point that I’d like to discuss. What are some of the alternative explanations for impaired cognition or altered mental status, even in a cirrhosis patient, that we should not miss?

Kimberly A. Brown, MD: Great question. I think it is incredibly difficult sometimes to tease these things out. Certainly, the most obvious one is our patients are at risk for falls. They all have coagulopathy and low platelets and are at risk of subdural hematoma. So in patients who have come into the hospital, I think it’s a reasonable thing to do imaging of the head to rule out those types of causes. With drugs and medications, they’re going to be more sensitive. But is it the drug and medication that in you would be fine, but in them would be worsening the encephalopathy? I don’t know. But certainly, drugs and medications just by themselves as they could in any person.

I find that patients who have had prior head injury, closed head injuries are particularly susceptible and have a very difficult time. I think their brains are just more sensitive to whatever is going on. And then the biggest thing that I have trouble with is teasing out dementia. I have some patients, any of us I guess are at risk of dementia, but as they get older, the changes don’t seem encephalopathy to me, but I can’t tell. Unfortunately, when a patient goes to see another provider, if they see liver disease on their record, then all of a sudden everything is attributed to their liver disease. Their broken arm, their eye itching, their confusion, I mean everything. It’s very difficult to find a neurologist, and I don’t even know if can they tease that out. What is dementia? What is encephalopathy? It’s really important for us because if we’re moving a patient to transplant, what’s going to get better? So I think those are the things that I struggle with.

Arun B. Jesudian, MD: Yes. Definitely. Our patients are at risk for other neurologic problems. Our patients with fatty liver disease, NAFLD [nonalcoholic fatty liver disease], and NASH [nonalcoholic steatohepatitis], have risk factors for multi-infarct dementia or strokes or other problems. Many of our patients have alcohol use disorder and that can affect their brain sort of independently of their cirrhosis. We also find ourselves in a situation where you’re trying to figure out what is hepatic encephalopathy that will resolve by and large after a transplant, and what might be more longstanding cognitive impairment. Sometimes it’s very difficult to distinguish between the 2. I’d say, as outpatients, we don’t routinely image their brains unless we are really concerned that we’re missing something.

Kimberly A. Brown, MD: I think it’s more the inpatient when they come in. Oftentimes, they have a history of a recent fall or something like that. I have actually picked up 2 brain tumors. Not that you should routinely scan somebody’s brain to look for that, but to your point, there are sometimes other causes of confusion.

Arun B. Jesudian, MD: In changing gears just a bit, there’s recently been developed a new ICD-10 [International Classification of Diseases, 10th revision] code specifically for hepatic encephalopathy. It had been sort of captured under generic cirrhosis or liver disease ICD-10 classification up until that point. Has that changed your practice in any way? Have you noticed anything different in terms of your workflow or whether that’s been helpful to have a specific diagnosis code?

Kimberly A. Brown, MD: I haven’t noticed a change in my practice. I think moving forward it will help us to better identify the patients within our care that specifically have that diagnosis. We’re working on a project right now within our system to try to better connect patients to care after they leave the hospital. So having a specific diagnosis where we can pull those patients from is going to be very helpful. It may also be helpful in terms of ensuring that insurance can pay for medications that they might need.

Arun B. Jesudian, MD: Yes.

Kimberly A. Brown, MD: Because it has a specific diagnosis that’s related to that therapy.

Arun B. Jesudian, MD: I was just thinking the same thing. Certainly, when there are medications involved that require prior authorization and it’s very helpful to have the diagnosis associated with your prescription that is the specific FDA-approved indication. For example, hepatic encephalopathy.

Transcript edited for clarity