The recently published guidelines from the EASL/AASLD provide a framework for the diagnosis and management of patients with HE 1. Our opinion statements aim to define the role and responsibilities of all those healthcare providers who at times care for patients with cirrhosis and HE (Fig. 1). Although developed before the EASL/AASLD guidelines were published, the expert consensus opinion statements discussed here do not differ significantly from these guidelines.
In developing these statements we have acknowledged that making a definitive diagnosis of HE can be difficult. However, it is possible for all those healthcare providers who encounter patients with cirrhosis to identify cognitive impairment and be aware of HE in terms of the impact on patients. For those healthcare providers who do not have primary responsibility for management of patients with cirrhosis we believe that it is reasonable that patients with suspected HE are referred to their gastroenterologist or liver specialist. It is then the responsibility of the primary provider (gastroenterologist or liver specialist) to ensure that appropriate clinical assessments are undertaken to make a diagnosis of overt HE. The use of psychometric and neurophysiological tests is essential to identify minimal HE, but the authors also felt they can be useful in the assessment of lower grades of overt HE. Gastroenterologists who have appropriate training and facilities/equipment should be prepared to supplement clinical assessment with such tests. If appropriate facilities or trained staff are not available, discussion with a liver specialist or liver unit should be considered. As HE is a decompensation event, such a discussion can be helpful to allow prompt consideration of whether the patient should be evaluated for liver transplantation.
Specific therapy for overt HE episodes includes supportive care, treatment of underlying precipitants, and initiation of specific therapy; first-line choices are nonabsorbable disaccharides or short-course antibiotics 1. All patients recovering from an acute episode of overt HE should also receive secondary prophylaxis to reduce the risk of recurrence; the evidence-based choices include nonabsorbable disaccharides and/or rifaximin 1. Appropriate therapy can reduce the duration of admission and reduce the risk of subsequent readmission. However, to maximize the benefits from therapy, early diagnosis is essential to allow prompt initiation of recommended treatment.
We recommend that our conclusions and recommendations be considered further by our colleagues in gastroenterology and hepatology and those in other disciplines and hope that these recommendations assist in the development of regional/national cross-speciality guidelines to improve the identification and triage of patients who may have HE and facilitate appropriate management. We also hope that future guidelines consider the management of patients with HE from initial ‘suspicion’ of cognitive impairment, which may be by a clinician or healthcare provider not routinely responsible for management of an individual’s liver disease.
D.L.S., A.A.D., R.J., G.K., R.J.de.K., W.L., J.K.R. and H.W. contributed to the Delphi process (voting and commentary), developed the consensus statements and revised the manuscript. I.E.J.M. coordinated the Delphi process and developed the first draft of the manuscript
The Delphi process was supported by an independent grant from Norgine. Norgine had no input into the development of these consensus statements, nor in this publication.
Debbie L. Shawcross has served as a speaker, consultant and an advisory board member for Norgine and has received research funding from Higher Education Funding Council for England (HEFCE), The Wellcome Trust, The European Foundation for Alcohol Research (ERAB), The Royal Society, The Foundation for Liver Research, and Norgine. Arthur A. Dunk has received an honorarium from Norgine. Rajiv Jalan has received an honorarium for speaking from 4C Consultants/Norgine, has served as a consultant for Grifols Inc., Ocera Therapeutics and Conatus, and has received research funding from Grifols Inc., Ocera Therapeutics Inc., Sequana Medical AG and Norgine BV. Gerald Kircheis serves on the Speaker’s Bureau for Merz Pharmaceuticals and Norgine and is a joint patent holder for a bedside Critical Flicker Frequency Analyser. Robert J. de Knegt has received an honorarium for speaking or consulting from AbbVie, BMS, Gilead, Janssen-Cilag, Medtronic, Merck/Schering-Plough, Norgine and Roche, and has received research grants from BMS, Janssen-Cilag, Medtronic and Roche. Wim Laleman has served as a consultant to Norgine, Gilead, MSD, Roche, Gore and BMS. John K. Ramage has received an honorarium from Norgine. Heiner Wedemeyer has received honoraria for speaking or consulting from Abbott, Achillon, Abbvie, BMS, Gilead, Eiger, Janssen, Merck, Novartis, Roche and Transgene, has received honoraria from Falk and 4C Consultants/Norgine, and received research support from Roche, BMS, Novartis, Roche Diagnostics and Abbott. Ian E.J. Morgan is a director of 4C Consultants International, which has received funding from Norgine.
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