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How to diagnose and manage hepatic encephalopathy: a consensus statement on roles and responsibilities beyond the
Debbie L Shawcross1, Arthur A Dunk, Rajiv Jalan
1aInstitute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital bInstitute of Liver and Digestive Health, Royal Free Hospital, London cDepartment of Gastroenterology, Eastbourne District General Hospital, Eastbourne d4C Consultants International, Hemel Hempstead eDepartment of Gastroenterology, Hampshire Hospitals Foundation Trust, Basingstoke, UK fClinic for Gastroenterology Hepatology and Infectious Disease, University Hospital, Dusseldorf gDepartment of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany hDepartment of Gastroenterology and Hepatology, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands iDepartment of Liver and Biliopancreatic Disorders, University Hospitals Leuven - KU LEUVEN, Leuven, Belgium.
Introduction:
Hepatic encephalopathy is defined as brain dysfunction caused by liver insufficiency and/or portosystemic shunting. Symptoms include nonspecific cognitive impairment, personality changes and changes in consciousness. Overt (symptomatic) hepatic encephalopathy is a common complication of cirrhosis that is associated with a poor prognosis. Patients with hepatic encephalopathy may present to healthcare providers who do not have primary responsibility for management of patients with cirrhosis. Therefore, we developed a series of 'consensus points' to provide some guidance on management.
Methods:
Using a modified 'Delphi' process, consensus statements were developed that summarize our recommendations for the diagnosis and management of patients with hepatic encephalopathy. Points on which full consensus could not be reached are also discussed.
Results:
Our recommendations emphasize the role of all healthcare providers in the identification of cognitive impairment in patients with cirrhosis and provide guidance on steps that might be considered to make a diagnosis of overt hepatic encephalopathy. In addition, treatment recommendations are summarized. Minimal hepatic encephalopathy can have a significant impact on patients; however, in most circumstances identification and management of minimal hepatic encephalopathy remains the responsibility of specialists in liver diseases.
Conclusion:
Our opinion statements aim to define the roles and responsibilities of all healthcare providers who at times care for patients with cirrhosis and hepatic encephalopathy. We suggest that these recommendations be considered further by colleagues in other disciplines and hope that future guidelines consider the management of patients with cirrhosis and with a 'suspicion' of cognitive impairment through to a formal diagnosis of hepatic encephalopathy.
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