Grading of HE Based on Presentation

Arun Jesudian, MD: It reminds me of the general approach to taking care of these patients that comes from our guidelines, the AASLD, or the American Association for the Study of Liver Diseases, issues guidelines on treatment of complications of cirrhosis, like HE [hepatic encephalopathy], and if you are not familiar with this, they refer to the general inpatient care of HE patients as adhering to a 4-pronged approach. A lot of it is what you just described for us, but it starts with general support of care of a patient with altered mental status, and then excluding other causes of altered mental status so that you are comfortable in the diagnosis of HE. The third part is grading the severity of HE, and then finally treating empirically for HE. We covered a lot of the first couple, which is assessing them or supporting them through this altered mental status episode, assessing them for alternate causes. In terms of grading HE, I’m curious if that’s something that goes through your mind as an emergency department physician, or whether you’re really just treating that patient clinically? Do you think about the grading of HE at all?

James Williams, MS, DO, FACEP: It’s a biased question because this is one of my interests about renal failure and hepatic encephalopathy. I’m happy if I can get emergency physicians to think about hepatic encephalopathy. If we get into the grading system, then I’m really happy about that; that’s taking it to the next level. In the emergency department we have such a demand, supply mismatch that we must try to keep people moving, and sometimes to get the nuances of grading hepatic encephalopathy is not appreciated. The importance of why we need to move to that is because currently I would pause that it’s typically underdiagnosed. When you’re consulted by hospitalists or the admitting physicians, it’s going to be a dinger after I see them. Would that be a fair statement?

Arun Jesudian, MD: Absolutely. It usually is, say, 24-hours after you’ve seen them and sometimes longer than that.

James Williams, MS, DO, FACEP: Right. So if I can get my colleagues to think, number one, hepatic encephalopathy and then knowing the grading and classification, whether you’re talking about the etiology of it or what the grading is in its spectrum of presentation. I think the latter is arguably more important because that will lower their threshold to say maybe this really is HE or something else that I’m considering, and therefore I should start treatment. As an example, there would be no reason for me to say, I have a chest x-ray. There’s pneumonia. I have a lactate of 2.5 and a white count of 14, but I’ll let the hospitalist or the pulmonologist start antibiotics upstairs, right?

Arun Jesudian, MD: Right.

James Williams, MS, DO, FACEP: We must push it to our colleagues to say this is HE, and I can say that it’s a lower grade of progression or more severe, but I got to start my treatment right here. There’s no reason for me to wait until the patient gets upstairs, and even then it might be a day or more later, and we know that that’s going to portend worse outcomes.

Arun Jesudian, MD: Yes, definitely. I couldn’t agree more with that sentiment and I’m happy that it is an interest of yours. In terms of grading, just so everyone is aware, generally speaking, hepatic encephalopathy can be graded as covert, the subtle encephalopathy where the patient is not obviously impaired when you as a clinician assess them, but if you look at their cognitive function it is abnormal. Then overt, and these are the patients we see in the emergency department, the patients that we’re admitting to the hospital. The grades of overt hepatic encephalopathy when you look at the most utilized criteria are grades 2, 3, and 4, where 4 is coma. Those are your ICU patients who need to be intubated for airway protection. Three is somnolence, the patients who are falling asleep in front of you who can progress to 4. And 2 is the patient who is altered and may have asterisks but is not quite as lethargic as the others, and these are the patients that we’ve been speaking about in this discussion today. Grading by number maybe isn’t as important as appreciating how impaired the patient is and appreciating what the diagnosis is, and just as you said, treating them early when that is your assessment that they have overt hepatic encephalopathy.

Transcript Edited for Clarity