Luminary Learning Gastrointestinal Disorder- Issue 1

Latest Concepts in Inpatient Hepatic Encephalopathy Management •  3 Discussion The patient should be considered for splenorenal shunt embolization for persistent HE not responding to medical treatment and relatively low MELD score (MELD <15). Previous studies showed that approximately 45–70% of patients with refractory HE had large portosystemic shunts discovered on evaluation and that the embolization of the portosystemic shunt was a safe and effective treatment. The patient received the embolization of the splenorenal shunt and his hepatic encephalopathy significantly improved. Introduction Hepatic encephalopathy (HE) is a major neuropsychiatric abnormality seen in patients with decompensated cirrhosis or portosystemic shunting. The clinical presentation ranges from subtle brain function changes that require neuropsychometric testing for diagnosis to a hepatic coma state. The severity of HE can be graded into covert HE (West Haven Criteria Grade 0–1) and overt HE (West Haven Criteria Grade 2–4). Most patients with overt HE will require inpatient manage- ment and this will be the focus for this chapter. Overt HE occurs in approximately 30–45% of patients with cirrhosis and 10–60% of patients with transjugular portosystemic shunt (TIPS) [1–3]. In the U.S. Nationwide Inpatient Sample, the National estimate of annual incidence of overt HE admission is 110,000–115,000. The average length of inpatient stay was 8.5 days and the average total inpatient charges were $63,108 per case [4]. Moreover, overt HE is associated with increased risk of mortality in hospitalized patients with cirrhosis independently of the severity of cirrhosis (adjusting for the MELD score) [5] or extrahe- patic organ failures [6]. Management of the hospitalized patient with overt HE focuses on correcting the underlying precipitating factors and providing pharmacologic treatment that reduces ammoniagenesis. Most patients will require maintenance medication to prevent recurrence of HE and to prevent hospital readmission. Hepatic Encephalopathy in Acute-on-Chronic Liver Failure For the past two decades, the concept of acute-on-chronic liver failure (ACLF) has been proposed on the basis that patients with chronic liver disease or cirrhosis who developed acute unexpected hepatic decompensation and extrahepatic organ failure have significant increased risk of short- term mortality [7]. Three different definitions have been proposed from three different regions of the world [8–10]. The most current definition by a working group on behalf of the Working Party of the World Gastroenterology Organization is as follows: “ACLF is a syndrome in patients with chronic liver disease with or without previously diagnosed cirrhosis which is characterized by acute hepatic decompensation resulting in liver failure (jaundice and prolongation of the inter- national normalized ratio) and one or more extrahepatic organ failures that is associated with increased mortality within a period of 28 days and up to 3 months from onset” [11].