Practical Issues in the Management of Overt Hepatic Encephalopathy.

Hepatic encephalopathy (HE) is a condition that encompasses a range of neuropsychiatric abnormalities in patients with significant liver disease. Overt HE occurs in approximately 30% to 45% of patients with cirrhosis. This article discusses practical issues in the management of patients with overt HE and cirrhosis, including a recently developed 4-pronged approach that consists of identifying and correcting precipitating factors, recognizing and treating concomitant medical conditions, commencing empiric treatment, and caring for the unconscious patient. Following recovery from overt HE, a plan of action should be developed to prevent readmissions.

A New Look at Precipitants of Overt Hepatic Encephalopathy in Cirrhosis.

BACKGROUND AND AIMS: Overt hepatic encephalopathy (HE) is a major cause of significant morbidity and mortality in patients with liver cirrhosis. We examined the frequency and profile of the precipitating factors resulting in hospitalizations for overt HE. METHODS: We conducted both retrospective and prospective studies to identify clinical precipitants of overt HE in patients with cirrhosis. The retrospective study patients were hospitalized at a large urban safety-net hospital, and the prospective study included the patients admitted at a liver transplant center. RESULTS: There were a total of 149 patients with cirrhosis and overt HE (91 males, mean age 55.3 ± 8.6 years) in the retrospective group and 45 patients (27 males, mean age 58.3 ± 8.2 years) in the prospective group of the study. The average MELD score was 16 ± 6.8 in the retrospective group and 22.7 ± 7.2 in the prospective group. Dehydration (46-76%), acute kidney injury (32-76%), lactulose nonadherence (about 50%), constipation (about 40%), and infections (20-42%) were the most frequently identified precipitants for hospitalization in retrospective and prospective groups. Multiple precipitants were identified in 60 (40.3%) patients in the retrospective group and 34 (76%) patients in the prospective group. CONCLUSIONS: Multiple concurrent precipitating factors were identified in the majority of patients with overt HE requiring hospitalization. Dehydration due to various causes was the most common precipitant of overt HE, followed by acute kidney injury (AKI), constipation, and infections. Prevention of dehydration, AKI, and constipation by close outpatient monitoring may be an effective measure to prevent hospitalization for overt HE in patients with cirrhosis.

Assessment of the incidence of squamous cell papilloma of the esophagus and the presence of high-risk human papilloma virus.

BACKGROUND AND AIMS: There has been a recent increase in the incidence of oropharyngeal cancer (OPC) associated with high-risk human papilloma virus (HPV) infection. We investigated the incidence of esophageal papilloma and the presence of high-risk HPV infection. METHODS: This is a cross-sectional study conducted at a County teaching hospital. Patients with esophageal papilloma between January 2000 and December 2013 were identified. Patients with sufficient specimens were tested for the HPV virus. RESULTS: Sixty patients with esophageal papilloma lesions were identified from 2000 to 2013. (31 males, age 51 ± 13 years). The incidence was 0.13% in 2000 and increased to 0.57% in 2013 (P < 0.0001). Twenty-nine patients (48.3%) had a papilloma that was more than 5 mm in size, and 20% had multiple lesions. The papilloma was located in the distal esophagus in 35 (58.3%) patients, mid esophagus in 17 (28.3%) patients, and proximal in 8 (13.3%) patients. Three (5%) patients had associated OPC, and 9 (47.4%) of the 19 patients tested were positive for high-risk HPV serotype 16. CONCLUSIONS: The incidence of esophageal papilloma has increased by fourfolds over the past 14 years. About half of the tested patients demonstrated high risk HPV. This may suggest a potential growing risk for esophageal squamous cell cancer in the future.

Recognizing cardiac syncope in patients presenting to the emergency department with trauma.

BACKGROUND: Cardiac syncope is associated with poor outcomes and may result in traumatic injuries. In patients presenting to the emergency department (ED) with trauma, recognizing the cause of syncope is particularly challenging. Also, clinical markers to identify cardiac syncope are not well established. STUDY OBJECTIVES: We sought to evaluate clinical markers that could identify cardiac syncope in patients with traumatic falls derived from a large urban trauma database. METHODS: All patients presenting to the ED during a 10-year study period with a traumatic fall were identified retrospectively. The subset of patients with syncope was ascertained by chart review and defined as cardiac syncope (e.g., presence of dysrhythmia, valvular abnormality), non-cardiac syncope (e.g., vasovagal, neurological), or syncope of unknown cause. RESULTS: Of the 5420 patients with traumatic falls, 180 (3.3%) patients with syncope were identified. Among the 180 patients with syncope, the cause was identified as cardiac in 24 (13%), noncardiac in 58 (32%), and unknown in 98 (54%). Three independent predictors (i.e., risk factors) of cardiac syncope were identified: age >65 years, presence of coronary artery disease, and pathological Q waves. Presence of at least one risk factor accurately predicted cardiac syncope in this population, with a sensitivity of 100%, a specificity of 43%, and a negative predictive value of 100% (area under the receiver operating characteristic curve: 0.80 ± 0.04). CONCLUSION: In patients with traumatic falls and syncope, simple clinical and electrocardiographical variables may identify patients with cardiac causes of syncope. Proper identification of cardiac syncope in this population can potentially prevent recurrence of life-threatening traumatic injury.

Bleeding risk in patients with esophageal varices undergoing transesophageal echocardiography.

BACKGROUND: Bleeding from esophageal varices is a major potential concern during transesophageal echocardiography (TEE) in patients with cirrhosis of the liver. As there are limited data on its risk in these patients, this was retrospectively assessed at our institution. METHODS: The hospital electronic medical record database at our university affiliated teaching hospital was searched for all patients with esophageal varices undergoing TEE from 2000 to 2012 and patient charts were reviewed for procedure-related bleeding complications. RESULTS: Twenty-four patients with esophageal varices were found (18 men, 57 ± 14 years). Nine patients had grade 2 esophageal varices, 15 patients had grade 1 varices, and 12 patients had portal hypertensive gastropathy. Alcoholic liver disease (9) and hepatitis C (8) were the most common etiologies of the cirrhosis with an average MELD score of 15. The most common indication for TEE was for possible endocarditis (15). Medications potentially increasing bleeding risk included warfarin in 2 and aspirin in 7 patients. Twelve patients were taking ß-blockers for portal hypertension. There were no immediate bleeding complications and none of these patients were readmitted with bleeding. CONCLUSIONS: TEE can be performed without serious bleeding risk in patients with grade 1 or 2 esophageal varices.