Arun Jesudian, MD: You mentioned treatment. But if you could revisit that for me. Once you’ve made the diagnosis, what medications are you starting? And, just as you mentioned, what are some barriers to starting them before they’re actually in a hospital bed upstairs?

James Williams, MS, DO, FACEP: Sure. It’s important to go over that classification—thanks for going through that specifically—because the grade 1 is the one, typically, that we might miss in the emergency department because it’s subtle. That’s the person who’s brought in by the caregiver who says, “They’re just not right,” and they may know that they have liver disease and recognize this subtle change. In the emergency department, we might blow that off to say, “Well, their ammonia’s normal. I’m not really seeing a difference because they’re answering questions and are verbal.” But it is a subtle thing. So that would be a missed opportunity for initiating treatment early. The others are more a low-hanging fruit so, hopefully, we would pick that up. Once we get the diagnosis then treatment, by and large, it’s important to treat all the underlying issues. Supportive care is key, whether it’s a fluid balance, electrolyte derangement, or treating any infections that are there. That’s going to be important because they may have been the precipitants for hepatic encephalopathy. I would also typically start with rifaximin [Xifaxan] and lactulose. Several studies have shown that we can have a decreased length of stay in the hospital if I have dual therapy rather than monotherapy. The only limiting factor that I’ve found with the rifaximin is that they must be awake and alert enough to pass a swallow test. If they can do that, which in my practice would be most patients, that’s when I would start right in the emergency department. That’s important because it’s helpful also to the hospitalist or admitting service to let them know it’s a mental cue that, “Yeah, we do need to continue this therapy,” that they do have this. It’s not just a one and done treatment.

Arun Jesudian, MD: Yes. Thank you for talking about length of stay because it’s such an important point that if we treat these patients with the optimal treatment regimen, which is a combination of lactulose and rifaximin, we can impact their length of stay and, certainly, their risk of readmission.

Transcript Edited for Clarity