Overuse of Head Computed Tomography in Cirrhosis With Altered Mental Status

Rahimi, Robert S.; Rockey, Don C.

doi:10.1016/j.amjms.2016.02.022

Cited by 20 publications

(27 citation statements)

References 50 publications

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“…This highlights nutrition as an area of concern. Another response element group that was concerning was the relatively high proportion of respondents who would perform brain scanning with computed tomography or magnetic resonance imaging in patients with advanced HE grades, which although useful to detect intracerebral hemorrhage, has been shown to be of doubtful value in patients without focal neurological deficits …”

Section: Discussionmentioning

confidence: 99%

“…Another response element group that was concerning was the relatively high proportion of respondents who would perform brain scanning with computed tomography or magnetic resonance imaging in patients with advanced HE grades, which although useful to detect intracerebral hemorrhage, has been shown to be of doubtful value in patients without focal neurological deficits. (17,18) Currently only OHE is routinely treated. Although most practitioners ordered lactulose correctly for OHE patients, they also treated patients with grades <2 over half the time leading to concerns for overtreatment in this patient population.…”

Section: Discussionmentioning

confidence: 99%

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Assessment of the spectrum of hepatic encephalopathy: A multicenter study

et al. 2018

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Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However, its severity assessment is often subjective, which needs to be studied systematically. The aim was to determine how accurately trainee and nontrainee practitioners grade and manage HE patients throughout its severity. We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and nontrainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades <2 or ≥2 HE and trainees/nontrainees. In total, 108 respondents (62 trainees, 46 nontrainees) were included. For patients with grades <2 versus ≥2 HE, a higher percentage of respondents were better at correctly diagnosing grades ≥2 compared with grades <2 (91% versus 64%; P < 0.001). Specialized cognitive testing was checked significantly more often in grades <2, whereas more aggressive investigation for precipitating factors was ordered in HE grades >2. Serum ammonia levels were ordered in almost a third of grade ≥2 patients. For trainees and nontrainees, HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and more likely to perform a more thorough workup for precipitating factors compared with nontrainee respondents. There was excellent concordance in the classification of grade ≥2 HE between nontrainees versus trainees, but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing, and nutritional management between trainees and nontrainees. These results have important implications at the patient level, interpreting multicenter clinical trials, and in the education of practitioners. Liver Transplantation 24 587-594 2018 AASLD.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Assessment of the spectrum of hepatic encephalopathy: A multicenter study

et al. 2018

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“…One study showed that more than two-thirds of patients admitted with AMS in the setting of cirrhosis underwent brain imaging, but structural brain abnormalities were only found in patients who had focal neurological findings on physical examination 35. Another study by Donovan and colleagues36 evaluated the diagnostic yield of computed tomography (CT) scan in detecting intracranial hemorrhage in patients with cirrhosis and AMS; only 3% of the scans showed evidence of intracranial hemorrhage.…”

Section: Diagnosismentioning

confidence: 99%

Hepatic Encephalopathy: An Update on the Pathophysiology and Therapeutic Options

Elwir¹,

Rahimi²

2017

Journal of Clinical and Translational Hepatology

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Hepatic encephalopathy is a spectrum of reversible neuropsychiatric abnormalities, seen in patients with liver dysfunction and/or portosystemic shunting. One of the most debilitating complications of cirrhosis, encephalopathy affects 30–45% of cirrhotics. In addition to significantly affecting the lives of patients and their caregivers, it is also associated with increased morbidity and mortality as well as significant utilization of health care resources. In this paper, we provide an overview on the pathophysiology, diagnosis, management and newer therapies of hepatic encephalopathy.

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“…However, ICH is typically accompanied by focal neurological deficit(s) (FND) on physical examination. Despite low diagnostic yield in the absence of FND demonstrated by several studies, [5][6][7] noncontrast head CT (HCT) is still frequently used in evaluation of cirrhotic patients presenting with altered consciousness, contributing to higher healthcare costs. 5 The American Association for the Study of Liver Diseases (AASLD) and European…”

Section: Introductionmentioning

confidence: 99%

Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy

Hanna

Gill

Imam

et al. 2021

BMJ Open Gastroenterol

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Goals and backgroundThe utility of routine head CT (HCT) in hepatic encephalopathy (HE) evaluation is unclear. We investigated HCT yield in detecting acute intracranial abnormalities in cirrhotic patients presenting with HE.StudyRetrospective review of cirrhotic patient encounters with HE between 2016 and 2018 at Beaumont Health, in Michigan was performed. A low-risk (LR) indication for HCT was defined as altered mental status (AMS), which included dizziness and generalised weakness. A high-risk (HR) indication was defined as trauma/fall, syncope, focal neurological deficits (FNDs) or headache. Descriptive statistics and univariate/multivariate analyses by logistic regression were performed using SPSS to identify HCT abnormality correlates.ResultsFive hundred twenty unique encounters were reviewed. Mean age was 63.4 (12.1) years, 162 (37.5%) had alcoholic cirrhosis and median Model for End-Stage Liver Disease (MELD)-score was 17 (13–23). LR indication was reported in 408 (78.5%) patients and FNDs reported in 24 (4.6%) patients. Only 13 (2.5%) patients were found to have an acute intracranial pathology (seven haemorrhagic stroke, two ischaemic stroke, four subdural haematoma). Aspirin use prior to presentation (aOR 4.6, 95% CI 1.1 to 19.2), and HR indication (aOR 7.3, 95% CI 2.3 to 23.8) were independent correlates of acute intracranial pathology on HCT. Age, sex, MELD-score, haemoglobin, platelet count, race and cirrhosis aetiology did not correlate with HCT abnormalities. Number needed to screen to identify one acute pathology was 14 in HR indications versus 82 for LR indications.ConclusionRoutine HCTs in cirrhotic patients presenting with HE with AMS in the absence of history of trauma, headache, syncope, FNDs or aspirin use is of low diagnostic yield.

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Overuse of Head Computed Tomography in Cirrhosis With Altered Mental Status

Cited by 20 publications

References 50 publications

Assessment of the spectrum of hepatic encephalopathy: A multicenter study

Assessment of the spectrum of hepatic encephalopathy: A multicenter study

Hepatic Encephalopathy: An Update on the Pathophysiology and Therapeutic Options

Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy

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