Assessment of the spectrum of hepatic encephalopathy: A multicenter study

Liver Transpl. 2018 May;24(5):587-594. doi: 10.1002/lt.25032.


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.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Ammonia / blood
  • Biomarkers / blood
  • Canada
  • Clinical Competence
  • Cognition
  • Diet, Protein-Restricted
  • Education, Medical, Graduate
  • Gastroenterologists* / education
  • Gastroenterologists* / trends
  • Gastroenterology / education
  • Health Care Surveys
  • Hepatic Encephalopathy / blood
  • Hepatic Encephalopathy / diagnosis*
  • Hepatic Encephalopathy / psychology
  • Hepatic Encephalopathy / therapy
  • Humans
  • Liver Function Tests* / trends
  • Neuropsychological Tests*
  • Nurse Practitioners* / trends
  • Patient Simulation
  • Physician Assistants* / trends
  • Practice Patterns, Nurses'
  • Practice Patterns, Physicians'
  • Predictive Value of Tests
  • Rifamycins / therapeutic use
  • Rifaximin
  • Risk Factors
  • Severity of Illness Index
  • United States
  • Video Recording


  • Biomarkers
  • Rifamycins
  • Ammonia
  • Rifaximin