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Extrahepatic conditions and hepatic encephalopathy in elderly patients
Abbasi J Akhtar1, Moustafa E Alamy, Thomas T Yoshikawa
1Department of Internal Medicine, Charles R. Drew University of Medicine & Science, Martin Luther King Jr-Charles R. Drew Medical Center, Los Angeles, California 90059, USA. abakhtar@cdrewu.edu
Purpose:
Extrahepatic conditions can cause, exacerbate, or mimic hepatic encephalopathy in any patient with advanced liver disease, particularly in older persons. The aim of this study was to characterize the clinical features and frequency of extrahepatic conditions and the effect of therapeutic interventions upon the encephalopathy.
Design:
Survey.
Setting:
Inner city community hospital.
Methods:
Retrospective chart review of 294 elderly patients (age 65-97) with liver disease and suspected hepatic encephalopathy, during a 15-year period, that included 188 men and 106 women.
Results:
Extrahepatic conditions were found in 64 patients (22%); 29 (10%) patients had > 1 extrahepatic condition. Category and frequency of the extrahepatic conditions found in these 64 patients were as follows: urinary tract infection, 21 (33%); cellulitis/infected pressure ulcers, 16 (25%); pneumonia, 16 (25%); septicemia (with positive blood cultures), 10 (16%); silent myocardial infarction, 10 (16%); drug toxicity (nonsteroidal anti-inflammatory drugs, sedatives, hypnotics, antidiabetics), 6 (9%); meningitis, 6 (9%); head injury, 5 (8%); stroke, 5 (8%); and subdural hematoma, 5 (8%).
Conclusion:
A significant proportion of elderly patients with liver disease and presumptive diagnosis of hepatic encephalopathy may have extrahepatic condition(s), and the treatment of the latter may improve clinical outcome of such patients. A high index of suspicion, low threshold of diagnostic measures, and prompt treatment of any associated extrahepatic condition are essential to prevent significant morbidity and mortality of these patients.