Psych · Consultation-liaison — hepatic encephalopathy and advanced transplant psychiatry
Hepatic encephalopathy and advanced transplant psychiatry
Also known as Hepatic encephalopathy psychiatry · Covert hepatic encephalopathy · West Haven criteria · Liver transplant psychiatry · Alcohol-associated liver disease transplant · SIPAT liver · Psychotropics in cirrhosis · Valproate hyperammonaemic encephalopathy
Exam-exhaustive fellowship reference on hepatic encephalopathy for the C-L psychiatrist (West Haven and covert–overt classification, gut–liver–brain mechanisms, precipitants, discrimination from primary psychiatric illness, capacity and driving, lactulose/rifaximin, benzodiazepine risk) and advanced liver transplant psychiatry (psychosocial evaluation, alcohol-associated pathways including early LT after Mathurin, adherence and relapse risk, depression outcomes, CNI/steroid neurotoxicity, psychotropics in cirrhosis). FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Missing hepatic encephalopathy and labelling fluctuating confusion, personality change, or 'depression' as primary psychiatric illness
- Using ammonia level alone to confirm or exclude HE
- Benzodiazepines for agitation in cirrhosis precipitating or deepening HE
- Valproate continued or started when hyperammonaemic encephalopathy is possible
- Psychiatry used only as a permanent listing veto without optimising modifiable depression, substance engagement, or support
- Inventing a universal statutory six-month alcohol abstinence rule for all programmes
- Labelling tacrolimus or steroid neurotoxicity as new primary schizophrenia after transplant
- Ignoring post-transplant depression and nonadherence as graft-outcome risks
Meet the patient
A 58-year-old with known alcohol-related cirrhosis is admitted with a week of "behaving oddly". The registrar calls you because he is "low, won't engage, and might be psychotic". At the bedside he is disoriented to the day, irritable, and his sleep is inverted — awake and confused at 3am, dozing through the ward round. Hold his wrists cocked back and a coarse flap appears.[2][5]
The trap on this ward round is obvious to the examiner and invisible to the tired registrar: this is not a primary psychiatric illness. It is hepatic encephalopathy until proven otherwise. The asterixis, the sleep–wake inversion, and the cirrhosis are the giveaway. Everything below is how you stop the team attaching a new bipolar label and a benzodiazepine to a patient whose brain is failing because his liver is.[2][5][16]
References18ShowHide
- [1]Ferenci P, Lockwood A, Mullen K, et al. Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998 Hepatology, 2002.PMID 11870389
- [2]Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver Hepatology, 2014.PMID 25042402
- [3]American Association for the Study of Liver Diseases; European Association for the Study of the Liver Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Hepatol, 2014.PMID 25015420
- [4]Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy N Engl J Med, 2010.PMID 20335583
- [5]Patidar KR, Bajaj JS Covert and Overt Hepatic Encephalopathy: Diagnosis and Management Clin Gastroenterol Hepatol, 2015.PMID 26164219
- [6]Shaw J, Bajaj JS Covert Hepatic Encephalopathy: Can My Patient Drive? J Clin Gastroenterol, 2017.PMID 28027071
- [7]Bajaj JS, Lauridsen M, Tapper EB, et al. Important Unresolved Questions in the Management of Hepatic Encephalopathy: An ISHEN Consensus Am J Gastroenterol, 2020.PMID 32618647
- [8]Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis N Engl J Med, 2011.PMID 22070476
- [9]DiMartini A, Crone C, Dew MA Alcohol and substance use in liver transplant patients Clin Liver Dis, 2011.PMID 22032526
- [10]Dew MA, DiMartini AF, Steel J, et al. Meta-analysis of risk for relapse to substance use after transplantation of the liver or other solid organs Liver Transpl, 2008.PMID 18236389
- [11]Dew MA, DiMartini AF, De Vito Dabbs A, et al. Rates and risk factors for nonadherence to the medical regimen after adult solid organ transplantation Transplantation, 2007.PMID 17460556
- [12]Dew MA, Rosenberger EM, Myaskovsky L, et al. Depression and Anxiety as Risk Factors for Morbidity and Mortality After Organ Transplantation: A Systematic Review and Meta-Analysis Transplantation, 2015.PMID 26492128
- [13]Maldonado JR, Dubois HC, David EE, et al. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): a new tool for the psychosocial evaluation of pre-transplant candidates Psychosomatics, 2012.PMID 22424160
- [14]Dew MA, DiMartini AF, Dobbels F, et al. The 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for the Psychosocial Evaluation of Adult Cardiothoracic Transplant Candidates and Candidates for Long-term Mechanical Circulatory Support Psychosomatics, 2018.PMID 30197247
- [15]Telles-Correia D, Barbosa A, Cortez-Pinto H, et al. Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicity World J Gastrointest Pharmacol Ther, 2017.PMID 28217372
- [16]Grønbæk L, Watson H, Vilstrup H, et al. Benzodiazepines and risk for hepatic encephalopathy in patients with cirrhosis and ascites United European Gastroenterol J, 2018.PMID 29774154
- [17]Segura-Bruna N, Rodriguez-Campello A, Puente V, et al. Valproate-induced hyperammonemic encephalopathy Acta Neurol Scand, 2006.PMID 16774619
- [18]Appelbaum PS Clinical practice. Assessment of patients' competence to consent to treatment N Engl J Med, 2007.PMID 17978292