Arun Jesudian, MD: We also look with simple imaging like an ultrasound with doppler for other potentially precipitating factors like a portal vein thrombosis or hepatocellular carcinoma/liver cancer, which might have caused them to decompensate with this episode of encephalopathy. Then in the blood work, it sounds like you’re also interested in hepatorenal syndrome, so even on the basic blood work we can sometimes find other major problems like acute kidney injury or electrolyte derangements. Hyponatremia’s a big one, hypokalemia. Anything else in terms of precipitating factors that you look for? I imagine you look through medications closely.

James Williams, MS, DO, FACEP: Well, I’m not sure about your patients, but not all my patients do exactly what we recommend. Medication noncompliance is a challenge. Just last night I saw a patient and she admitted, she said, “I’m a terrible patient. I don’t take any of my antihypertensive or my antidiabetic medications.” So that’s a big problem. To draw another analogy, sometimes it’s like a psychiatric patient; again, I’m talking to my emergency medicine colleagues and the patients feel great, so they stop taking their medication. Well, of course, that’s going to lead unfortunately to a bad outcome. The patients, particularly if they’re only on lactulose, know it’s a terrible medication. They don’t like it. I say that it’s a terrible medication only in so far as that it causes some diarrhea, and the patients don’t like that, so they oftentimes will stop and that’s going to precipitate then another episode of HE [hepatic encephalopathy], and it’s a rapid cycle. That’s what I find so fascinating about these patients, they are complex. It’s not just one simple thing like appendicitis, take it out, and we’re done. One thing leads to another and there are multiple diagnoses at the same time. I’d underscore that one of the benefits I’ve found is that if I can optimize what the therapeutic benefit of these medicines is and then decrease the side effects, then that’s going to lead to patient compliance, and hopefully, that’s going to decrease my re-hospitalization and optimize outcome and minimize mortality and morbidities. That’s a big thing. Just give the patients something that they’re not going hate taking, that will increase their compliance.

Arun Jesudian, MD: Hepatic encephalopathy is unique in some ways because as it gets worse, it’s more likely patients are not going to take their medications, which is too bad. They’re oftentimes patients who have the best of intentions. They can be very compliant and always take their medications, but once they’re altered, that’s one of the first things to go is remembering to take lactulose 3 times a day or taking their rifaximin [Xifaxan] twice a day, and then they all of a sudden can get worse. We see both patients who baseline have trouble adhering to medication requirements or the patients who are very compliant, but because of the condition then run into problems where they're not taking their medications as prescribed or at all. When it comes to medications, another thing that I look for is have they been taking any sedating medications? Sometimes those can be the patient just taking them on their own. They might be taking opioids, benzos [benzodiazepines], or sleep aids, and those may or may not be prescribed for them. Sometimes another physician who’s taking care of them is prescribing that medication for a condition, not necessarily thinking how it might adversely affect their mental status because of their HE.

James Williams, MS, DO, FACEP: Yeah. I would agree completely.

Transcript Edited for Clarity