‘Do your due diligence’ in cases of suspected, recurrent hepatic encephalopathy
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PHILADELPHIA — Hepatologists and gastroenterologists must be internal medicine physicians, not just specialists, to determine the root cause of complaints in patients with suspected hepatic encephalopathy, according to an expert.
“People have to remember that not everything a patient complains about in cirrhosis is hepatic encephalopathy. Please do your due diligence,” Jasmohan S. Bajaj, MD, FACG, professor of medicine in the division of gastroenterology, hepatology and nutrition at Virginia Commonwealth University, said in an interview with Healio. “We are internal medicine doctors after all, not just specialists. So, if someone is complaining of sleep problems, please do check them out for sleep apnea before condemning them to a life of lactulose.”
Bajaj said less than half of patients with cognitive complaints seen in a specialized clinic had covert or minimal hepatic encephalopathy (HE). Rather, they are really dealing with dementia, sleep apnea or alcohol-related side effects.
“Diagnose the sleep apnea. Be a hero for everyone,” Bajaj said in his presentation.
Additionally, specialists must ensure when HE is seen repeatedly, they are looking for the precipitating factor.
“For example, someone has multiple UTIs that every time land them up with hepatic encephalopathy, check to see if they have a kidney stone because until that kidney stone goes away, the people will keep on coming back with UTIs and coming back with HE,” Bajaj said. “This gets worse with fragmentation of care. The patient you may be seeing right now may have had two or three admissions in different hospitals and you may have the medical records of only one and sometimes people, because they’ve had so many hospitalizations ... [they] blend with each other and that’s important for us to realize.”
These precipitating factors range from infections to gastrointestinal bleeding to electrolyte disorder to diuretic overdose.
Of course, Bajaj said, if a patient’s root condition is HE, they need treatment, but they also require proper testing and monitoring.
“People can have HE in subclinical forms, but that requires specific testing,” he said. “If you do happen to start people on lactulose ... make sure that you check in with them very frequently to see if it’s working.”
When starting lactulose and a patient has an overt HE episode, Bajaj said the care needs to be brought back to the Bristol Stool Scale. If a patient has a score of five or higher, they should not receive more lactulose. Rather, he said, you can use rifaximin in your treatment protocol.
“Even one bowel movement at five or higher, that is enough. You don’t need to have them have two to three bowel movements,” Bajaj said. “Every patient is their own person, and this is a nice way of personalizing this without causing them to either stop the lactulose or get dehydrated and come back with hepatic encephalopathy.”
Bajaj recommended the Dieta App to help manage HE in cirrhosis, as it helps calculate the Bristol Stool Scale and allows for self-titration of lactulose.
Reference:
- Fagan A, et al. Am J Gastroenterol. 2024;doi:10.14309/ajg.0000000000002646.
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Bajaj J. Managing complications of cirrhosis. Presented at: ACG Annual Scientific Meeting; Oct. 25-30, 2024; Philadelphia (hybrid meeting).
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