Outpatient vs Inpatient Care of HE

Arun B. Jesudian, MD: Can you give us a sense of which degree of encephalopathy or which episodes you feel comfortable managing in the outpatient setting and which ones require hospital admission?

Kimberly A. Brown, MD: That’s a really good question. Most patients will come to the emergency room. Their families recognize that they’re confused, so they come to the emergency room. I don’t think those patients can go home and be managed safely. The ones that I think maybe I would start an outpatient medication on are the patients that really are very early. They might be sort of right between covert and overt. They’re having sleep disturbance. They’re having trouble with memory. And they’re having trouble with calculations or focus and concentration. That patient’s encephalopathic. I don’t think they require admission, but I think that I would start medication in that patient.

There are patients I have that are very reliable and are on medications at baseline. Those patients may have a little bit of a worsening, certainly a little bit, not a lot. I think families have even gotten to the point where they hold their water pills, give them extra doses of lactulose, make them drink fluids, and if it doesn’t get better within 24 hours, then they come into the hospital. I think those are not the common patient, but I think those are some of the things that I see happening in my patients.

Arun B. Jesudian, MD: I agree with you. I think there are patients you’ve known for a long time, who you have on treatment, say lactulose and rifaximin, who’s a bit more confused and they reliably call you. We oftentimes try some additional lactulose and hold the diuretics, as you mentioned, to see if this is an episode that could be managed at home. And if and when it doesn’t get better, then we’re often sending them to the emergency department.

There are patients in the outpatient setting who seem to have covert or early overt HE [hepatic encephalopathy] where your clinical sense is that there may not be something scary going on. For example, you don’t think they probably have a bacterial infection or that they’re actively having a GI [gastrointestinal] bleed, so you can start or titrate their medications and see how they do. In the office, how do you assess your patients for both overt and covert hepatic encephalopathy? What sort of bedside assessment do you do?

Kimberly A. Brown, MD: I think the standard is to look for asterixis. That is what we all learned in medical school, but in the absence of that, it doesn’t mean that the patient doesn’t have encephalopathy. I’m often asking, not only the patient, how is their memory? Are they able to balance a checkbook? What is their sleep-wake cycle? Oftentimes, that reversal that we commonly see in patients with cirrhosis, I think is a manifestation of encephalopathy. What about tremor? So I’m asking those questions. With respect to the caregiver, I’m also asking them, because to your point, sometimes they notice personality changes. One patient’s wife after transplant said to me, “I don’t like him anymore.” He apparently now had his baseline personality, which had been altered for so long, and they liked that one better. But it is amazing how you see that reversal and people coming back to themselves. I think caregivers have a big role to play here in terms of noticing those early, subtle signs.

Arun B. Jesudian, MD: Definitely. I’ve also heard the complaint that the patient is complaining again, so they must be feeling better after the transplant or after a hospitalization.

Transcript edited for clarity