Natural Progression of HE

Arun B. Jesudian, MD: In patients with overt hepatic encephalopathy, I know there are a variety of clinical courses and outcomes, but can you give us an idea about what the natural history is, generally speaking, for a patient who’s at that point where they have OHE, overt hepatic encephalopathy?

Kimberly A. Brown, MD: It’s a great teaching point because I will often pose the question to my fellows. You have 3 patients, 1 who has ascites, 1 who has a variceal bleed, and 1 who has recurrent encephalopathy. Who dies first? They always pick the person who has the variceal bleed, and it’s not that person. It’s the person with recurrent encephalopathy. So of the things we see in patients with advanced liver disease, having encephalopathy, that’s the one that is the biggest red flag, isn’t it? The one that says, I’m the person who’s going to die first. It’s critically important that we change how we approach this and recognize that this is a very serious phenomenon for patients and is telling us that the patient is at significant risk.

Arun B. Jesudian, MD: Absolutely. As you mentioned, all decompensations are not created equally, and certainly among them overt HE is probably, if not the worst, one of the worst manifestations of end-stage liver disease. In this population, sometimes for nonspecialists, it’s difficult to appreciate how sick they are, but their life expectancy is less than 2 years if they’re at this point where they’ve decompensated in terms of their cirrhosis. Are there patients for whom the first time you recognized their decompensation, it’s with encephalopathy? Has that been your experience?

Kimberly A. Brown, MD: It is. One of the things, even I as a liver physician, fall short on is, I fail to tell patients to anticipate something like this. The first time this happens in a patient, it is very scary for the patient and their caregivers. Now, you don’t want to alarm them and say, something like this is going to happen in your future, watch out for it. But I think we are remiss if we don’t tell them all of the things they might be looking out for. We tell them about ascites, we tell them bleeding and lower extremity edema, but sometimes we forget to tell them that this might be the first thing that happens. It is very scary for families and patients.

Arun B. Jesudian, MD: Definitely.

Transcript edited for clarity