FOUR score, a reliable score for assessing overt hepatic encephalopathy in cirrhotic patients

Hepatic encephalopathy (HE) is a frequent complication of cirrhosis and a major public health problem. The incidence is increasing because of improved cirrhosis prognosis. The most widely used scale used to evaluate HE is the West-Haven (WH) scale, with scores ranging from 0 to 4. This scale is easy to use but not suitable for patients with altered consciousness and is not well known by physicians other than hepatologists who manage these conditions. For deep coma, the validated Glasgow Coma Scale (GCS) has been proposed. A new scale for comatose patients, the Full Outline of UnResponsiveness (FOUR) score, has recently been proposed and widely validated. The scale covers eye and motor responses, brainstem reflexes and breathing patterns and is the most validated coma scale.

To assess the diagnostic value of the FOUR score for detecting overt HE (OHE) in cirrhotic patients.

We prospectively included all patients admitted for cirrhosis at La Pitié-Salpêtrière Hospital from June 2012 to March 2014. Neurological status was assessed by a senior neurologic intensive care physician in the 24 first hours of ICU admission. The recently described and validated French version of the FOUR score was used.

We screened 100 cirrhotic patients and included 94 (70 males [75 %], mean age 57 ± 11 years): 29 (31 %) with OHE (WH grades 2-4) and 65 (69 %) with No-OHE (WH grades 0-1). Mean FOUR and GCS scores were lower for OHE than No-OHE patients (p < 0.0001). The FOUR score could distinguish between WH grades 0-1, 2-3 and 4 (p < 0.0001). Furthermore, it could accurately detect and quantify OHE with an area under the c-index of 0.88 ± 0.10. The FOUR score was associated with outcome.

The FOUR score can be used to detect and quantify HE in cirrhotic patients, especially by non-hepatologists who are not familiar with the WH scale.