Evaluating for Infections in Overt HE

Arun Jesudian, MD: Another concept that I wanted to bring up is that in these patients, certainly treatment is important, but the step before that in that 4-pronged approach is ruling out precipitating factors. What else could be going on in them that caused this hepatic encephalopathy [HE] to either start new or be exacerbated? We’ve discussed some of these, but just to highlight the importance of the step and the evaluation, can we talk through some of these precipitating factors, common conditions, that we see in these patients? You talked a bit about infections, but infections are a big one in this population. What type of infections are you evaluating these patients for?

James Williams, MS, DO, FACEP: The most common complication that we consider is spontaneous bacterial peritonitis because of the translocation of gut bacteria. That can be a life-threatening peritonitis, but often it’s a much more subtle presentation, and it’s complicated by the fact that they also have hepatic encephalopathy. If you have, in distinction, somebody who is cogent and rational, and they can articulate their abdominal pain pretty clearly, when you have somebody, certainly if it’s overt HE, but if it’s less significant, they’re not going to be as articulate in telling you how severe their abdominal pain is. So somebody may not think about SBP [spontaneous bacterial peritonitis] in their diagnosis. That’s one important consideration of one of the infections. Another thing that’s important, certainly if somebody has overt HE, if they are obtunded, as an example, and this may not have been the precipitating theme but at least a coincident problem would be aspiration pneumonia. Even if it’s chronic microaspiration because they have these periods of waxing and waning alertness and subtle lethargy or obtundation, that’s another big one. Certainly, if they’re diabetic you must think about any kind of skin and soft tissue infections. It’s important to look at these patients from head to toe; truly look at their toes and their feet because that’s often the source of the infections as well. Those would be the big 3—SBP, pneumonia, and skin and soft tissue infections.

Arun Jesudian, MD: I’m glad you brought up SBP because many of these patients have ascites, and just as you mentioned, the best way to diagnose SBP is with a diagnostic paracentesis and not necessarily relying on clinical signs. Unlike other infections, they’re not quite reliable, and this population may not have fever, have pain, or even have leukocytosis. But a patient with ascites, who has altered mental status, definitely, a diagnostic paracentesis is important as is a chest x-ray, what you eluded to with pneumonia. We’ll always send urine, UA [urinalysis] and urine culture because UTIs can be present without symptoms, and a full exam in those diabetic patients, looking at the feet. That’s not something I had thought about, but it’s so important in this day and age. There’s so much coexisting diabetes and chronic liver disease because of fatty liver disease NAFLD [Nonalcoholic fatty liver disease]/NASH [nonalcoholic steatohepatitis]. Also, blood cultures. This population can have serious blood stream infections and it not be quite evident to you because they don’t tend to mount fevers or rigors, so that full infectious work up is so important.

Transcript Edited for Clarity