Jamak Modaresi Esfeh, MD: Finding Hepatic Encephalopathy

February 26, 2020

What is the primary care physician's role in detecting the rare hepatologic condition?

Jamak Modaresi Esfeh, MD

Hepatic encephalopathy is a rare, critical condition that could cost a patient brain function if not handled expediently and with the right measure.

But, it’s also a condition that’s become well-defined, and certainly treatable.

In an interview with HCPLive® on the intricacies of the rare liver-based condition, Jamak Modaresi Esfeh, MD, hepatologist and medical director of the Living Donor Liver Transplant program at the Cleveland Clinic, explained the role of primary care physicians in monitoring symptoms and screening for hepatic encephalopathy in potential patients.

HCPLive: How can hepatic encephalopathy present in patients?

Esfeh: Encephalopathy can be overt or covert. In overt hepatic encephalopathy, patient is presents with symptoms that can be identified by routine physical exam (in many cases even the care giver can detect the difference). These patients develop changes in the behavior, distraction, reversal of sleep cycle and disorientation to time, persons, locations, and a change in mental status. This can be seen in 30% to 40% of cirrhotic patients.

The covert hepatic encephalopathy causes minimal changes which can be difficult to detect and identify.

HCPLive: How may it affect patients?

Esfeh: We have 3 different types of hepatic encephalopathy: type A, type B, and type C. Type A is usually in patients with acute liver failure. Type B is when there is a portal-systemic bypass in the absence of intrinsic hepatocellular disease. And finally type C, which can be seen in cirrhotic patients. A Bulk of patients with hepatic encephalopathy have cirrhosis.

Some patients have minimal functional cognitive deficit, and they might appear to be asymptomatic. It is only with the help of specific psychological or electrophysiologic testing, that one can come up with the correct diagnosis. On the other side, we have patients with overt hepatic encephalopathy, with usual signs and symptoms detected clinically without any specific testing. The severity of hepatic encephalopathy is graded based on the clinical manifestations from minimal to grades I, II,III and IV.

HCPLive: What role can primary care physicians play in properly detecting affected or at-risk patients?

Esfeh: There is an important role for primary care physicians, because one of the most common triggers and precipitating factors for hepatic encephalopathy is actually the usage of medications like benzodiazepines or narcotics. Constipation is another very well-known risk factor for hepatic encephalopathy

HCPLive: What are some of the commonly misconceived encephalopathy biomarkers?

Esfeh: Ammonia is one of the well-studied toxins that precipitates encephalopathy. However, the common mistake is building up the diagnosis based on an elevated ammonia level only or monitoring the level after diagnosis is made.

An elevated ammonia concentration is not necessarily required to make the diagnosis. Also, it is not specific for hepatic encephalopathy only. Elevated ammonia level can be seen in a number of condition including but not limited to: shock, smoking, some medications, etc., unless, in some unusual cases, it is not needed to monitor the level.

As a side note, ammonia level is influenced by many factors including fist clenching, use of a tourniquet, and whether the sample was placed on ice.

HCPLive: What is the most common method for diagnosing hepatic encephalopathy?

Esfeh: Even in this era, we go by a combination of clinical manifestations and physical examination, trying to pertain the cognitive and neurological impairment of the patient. Of course, one needs to exclude other mental conditions, like seizure, trauma, medication side effects among others.

We don't necessarily needed to get a CT scan in every single patient with hepatic encephalopathy.