Strategies for Improving Diagnosis of HE

James Williams, DO, MS, FACEP: I want to ask you to grade emergency medicine. What are some things that are missed sometimes? What would you tell all the emergency physicians to consider in these patients?

Arun Jesudian, MD: First and foremost, the approach that you suggested is an ideal 1 for emergency medicine physicians. I completely understand that there’s so much going on in your typical emergency department, with many types of patients coming through the door. By no means do I want someone to think exactly the way I do in terms of liver disease. Keeping hepatic encephalopathy [HE] on the differential diagnosis for any patient is important because this might be their first episode, and they might have undiagnosed cirrhosis. That’s important to be aware of as you’re assessing patients with altered mental status. Look for signs of chronic liver disease that might tip you off to that diagnosis.

Everything we’ve discussed are the important elements of an initial evaluation: ruling out other causes, not necessarily relying on a serum pneumonia level, and going through that checklist of potentially precipitating events. This is probably the most important part of this evaluation because you’ll find a lot of life-threatening diseases that way: serious infections, variceal or other gastrointestinal bleeding, hepatorenal syndrome, significant electrolyte disturbances, even liver cancer, hepatocellular carcinoma. Those can be picked up relatively quickly.

It’s important to initiate treatment early. If those things happened in patients with HE in the emergency department, we’d be in a much better situation nationwide in terms of outcomes, length of stay, and probably readmissions. It seems straightforward when you and I are talking, but it’s tougher in the real world. I can’t imagine how many patients you see during a shift and how many different diseases you encounter. Hopefully, we’re raising some awareness about hepatic encephalopathy, which is an increasingly encountered diagnosis in the hospital.

James Williams, DO, MS, FACEP: You’re right. When you talk about the increasing incidences, it’s going to be dramatic, particularly with nonalcoholic steatohepatitis. And obesity is such a challenge in our country; one-third of Americans are not just overweight but obese. This could potentially be a dramatically increasing concern.

Arun Jesudian, MD: It is. I’m sure you’ve encountered what we have, which is that over the past few years with the COVID-19 pandemic, we’ve also seen an increasing number of patients with alcohol-associated cirrhosis and alcoholic hepatitis, both of which can cause hepatic encephalopathy. We’re seeing more sick patients with end-stage-type liver disease. The 2 major drivers of that are fatty liver disease, and there’s quite a bit of alcohol-associated liver disease.

Transcript Edited for Clarity