Modified-orientation log to assess hepatic encephalopathy

Abstract

Background: The subjectivity of the West-Haven criteria (WHC) hinders hepatic encephalopathy (HE) evaluation. The new HE classification has emphasised assessment of orientation. The modified-orientation log (MO-log, eight questions, scores 0-24; 24 normal) is adapted from a validated brain injury measure.

Aim: To validate MO-log for HE assessment in cirrhosis.

Methods: Cirrhotics admitted with/without HE were administered MO-log. We collected cirrhosis/HE details, admission/daily MO-logs and WHC (performed by different examiners), time to reach normal mentation (MO-log ≥23) and MO-log/WHC change (Δ) over day 1. Outcomes were in-hospital mortality, duration to normal mentation and length-of-stay (LOS). Regressions were performed for each outcome. MO-log inter-rater reliability was measured.

Results: Ninety-six HE (55 ± 8 years, MELD 21) and 20 non-HE (54 ± 5 years, MELD 19) in-patients were included. In HE patients, median admission WHC was 3 (range 1-4). Mean MO-log was 12 ± 8 (range 0-22). Their LOS was 6 ± 5 days and 13% died. Time to reach normal mentation was 2.4 ± 1.7 days. Concurrent validity: there was a significant negative correlation between admission MO-log and WHC (r = -0.79, P < 0.0001). Discriminant validity: admission MO-logs were significantly lower in those who died (7 vs. 12, P = 0.03) and higher in those admitted without HE (23.6 vs. 12, P < 0.0001). MO-log improved in 69% on day 1 (ΔMO-log 4 ± 8) which was associated with lower duration to normal mentation (2 vs. 3.5 days, P = 0.03) and mortality (3% vs.43%, P < 0.0001), not ΔWHC. Regression models for all outcomes included admission/ΔMO-log but not WHC as a predictor. Inter-rater reliability: ICC for MO-log inter-rater observations was 0.991.

Conclusions: Modified-orientation log is a valid tool for assessing severity and is better than West-Haven criteria in predicting outcomes in hospitalised hepatic encephalopathy patients.

Figure 1

Comparison of the admission West-Haven grade with the modified-orientation (MO)-log scores. There was a significant negative correlation between the admission MO-log and West-Haven grade of HE; 0 is the worst and 24 is the best performance on MO-log (r = −0.79, P < 0.0001). The West-Haven grades and MO-logs were assigned by different examiners.

Figure 2

Differences in mortality between those who improve their modified-orientation (MO)-log score within the first day of admission compared to those who do not. Mortality was significantly higher in those who did not improve compared to those who improved MO-log within the first day of admission.