The Misdiagnosis and Underdiagnosis of Hepatic Encephalopathy

Abstract

Patients with cirrhosis are at risk of developing hepatic encephalopathy (HE), which can present with a wide range of symptoms, including confusion, lethargy, inappropriate behavior, and altered sleep patterns. In addition to HE, patients with cirrhosis are at risk of developing mild cognitive impairment, dementia, and delirium, which have features closely resembling HE. Given the similar presentation of these conditions, misdiagnosis can and does occur. Mild cognitive impairment is common in individuals aged 50 years and older and can progress to dementia in those affected. Dementia and HE are both characterized by sleep disturbance and cognitive dysfunction, thus differentiating these conditions can be difficult. Furthermore, delirium can disrupt sleep patterns, and liver disease is recognized as a risk factor for its development. As HE is a cirrhosis-related complication, determining if a patient has undiagnosed cirrhosis is critical, particularly given the large number of patients with asymptomatic, compensated cirrhosis. Separately, underdiagnosis of minimal HE can occur even in patients with diagnosed liver disease, related, in part, to lack of testing. Given the availability of effective therapies for managing symptoms and preventing future episodes, accurate diagnosis of HE is essential.

Figure 1.

Regions of the brain affected by AD, HE, MCI, dementia, and delirium (7,10,11,13). AD, Alzheimer disease; HE, hepatic encephalopathy; MCI, mild cognitive impairment.

Figure 2.

Main sources of underdiagnosis of hepatic encephalopathy: (a) undiagnosed liver disease and (b) challenges with diagnosing minimal hepatic encephalopathy.