GHAPPcast: Recognizing and Managing Overt Hepatic Encephalopathy

So when we think about our patients with cirrhosis, but in particular, decompensated cirrhosis, Any patient that comes to our practice, though, with cirrhosis who want to be mindful of risk factors that these patients may have or something that could predispose them for the development of OHE and talking about these factors or these precipitants with patients and their caregivers.

These involve factors that can lead to a greater buildup of ammonia, such as infections, GI bleed, prolonged fasting, constipation.

that causes electrolyte imbalances, including diarrhea, even a viral diarrhea or diarrhea, which we can sometimes see associated with use of first-line therapy, use of lactulose, which we use to obviously clear ammonia, but if too effective, you know, when our patients are having diarrhea, can actually precipitate an episode of OHE.

So again, having these in the back of our mind when we're seeing patients, even those that have been well-compensated, maybe a UTI, a recurrent UTI, Other factors that can predispose include sedating medication.

So remembering to talk to our patients about avoiding the use of opioids, other sedatives, benzodiazepines, issues with shunting that can happen, such as what we see with tips, which can actually increase access of toxins to the brain, suddenly opening up that pathway.

Sarcopenia is another one.

It's often seen with advanced cirrhosis and it's also implicated in patients with reduced muscle mass and they're less able to use skeletal muscle ammonia metabolism pathways.

So something that we really need to be thinking about from subtle risk factors to very overt

ones.

I am so glad that you brought up ammonia.

If there's one thing that people remember from our conversation today, it's that with increased production and impaired clearance of ammonia is a strong driving factor for overt hepatic encephalopathy, laboratory testing is of little or any use.

OHE is a clinical diagnosis.

And so blood testing of ammonia has no diagnostic or prognostic benefit for cirrhotics.

We still see it happen.

We still see it happen.

Absolutely.

And I'm not saying that it never has any use ever, but so many things can cause an elevated ammonia level.

Even even just using a tourniquet can cause those ammonia levels to go up.

And just because you have an elevated ammonia level does not mean that you have an altered mental status and an elevated ammonia level does not mean that encephalopathy is present.

But a normal ammonia level in somebody who has altered mental status should make you question where you're going, what your diagnosis is.

Really with this disease state, it is so much more valuable to get a good history and infection workup because sometimes, just as you said, new onset overt encephalopathy can be your first sign of infection, which cirrhotics are more at an increased risk of getting.

So it's one of these things that, again, just good history.

This is a clinical diagnosis.

It is not a laboratory diagnosis.

And to remember, really remember that, that serum ammonia levels just don't have any use in somebody with chronic liver disease.