Management of hepatic encephalopathy in Germany: a survey among physicians

Abstract

Background Hepatic encephalopathy (HE) is a severe complication of liver cirrhosis with impairment of quality of life and prognosis. Management patterns among physicians have not been investigated yet.

Methods A questionnaire containing 17 questions was sent out to 1468 gastroenterologists and 120 general practitioners (GPs). It included questions regarding diagnostic, therapeutic, and management strategies used in patients with overt HE (OHE) and covert HE (CHE).

Results The response rate was 12 % (n = 172) for gastroenterologists and 45 % (n = 54) for GPs. Of gastroenterologists, 26.7 % examine patients with an initial diagnosis of liver cirrhosis regarding HE. Gastroenterologists favored a combination of different testing strategies (27.9 %) and clinical examination (23.0 %), while the biggest part of the GPs use clinical examination (55.3 %); 63.7 % of gastroenterologists and 28.3 % of GPs give correct nutritional advices to patients with HE. Treatment strategies for acute bouts of OHE and secondary prophylaxis varied widely in both groups. Preferred medication was lactulose followed by rifaximin or a combination therapy. More than half of the GPs (53.7 %) were not familiar with minimal HE (MHE). About one-third of both groups never tried to diagnose MHE.

Conclusion Our data strongly indicate that management of HE is very heterogeneous among gastroenterologists as well as selected GPs working in Germany and not driven by evidence-based international guidelines. Thus, the national guideline is more than welcome.

Zusammenfasung

Einleitung Die hepatische Enzephalopathie (HE) ist eine schwerwiegende Komplikation der Leberzirrhose. Das Management der HE durch deutsche Ärzte wurde bisher nicht untersucht.

Methoden Ein elektronischer Fragebogen mit 17 Fragen wurde an 1468 Gastroenterologen und an 120 Hausärzte versendet. Der Fragebogen beinhaltete Fragen zum Management bei Patienten mit overter HE (OHE) und covert HE (CHE).

Ergebnisse Die Rücksenderate war 12 % (n = 172) für Gastroenterologen und 45 % (n = 54) für Allgemeinmediziner. 26,7 % aller Gastroenterologen gaben an, ihre Patienten bei Erstdiagnose einer Leberzirrhose immer auf das Vorliegen einer HE zu untersuchen. Während Gastroenterologen eine Kombination verschiedener Testverfahren (27,9 %) bzw. eine alleinige klinische Untersuchung (23,0 %) einsetzen, diagnostizieren Hausärzte die HE vorrangig klinisch (55,3 %). 63,7 % der Gastroenterologen und 28,3 % der Hausärzte geben Patienten mit einer HE korrekte Ernährungsempfehlungen. Die Strategien zur Behandlung und zur Sekundärprophylaxe waren in beiden Gruppen sehr heterogen. Die bevorzugte Medikation war Lactulose, gefolgt von Rifaximin und einer Kombinationsbehandlung. 53,7 % der Hausärzte waren mit der minimalen HE (MHE) nicht vertraut.

Schlussfolgerung Die Ergebnisse dieser Umfrage zeigen, dass das diagnostische und therapeutische Management der HE sowohl unter in Deutschland tätigen Gastroenterologen als auch Hausärzten ausgesprochen uneinheitlich ist und die 2014 publizierte internationale Leitlinie nicht umgesetzt wird.

Key words

liver cirrhosis - brain dysfunction - end-stage liver disease - medical treatment

Schlüsselwörter

Leberzirrhose - Hirndysfunktion - terminale Lebererkrankung - medikamentöse Behandlung

• References

• 1 Mokdad AA, Lopez AD, Shahraz S. et al. Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis. BMC Med 2014; 12: 145
• 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; 60: 715-735
• 3 Ferenci P. Therapy of acute and chronic hepatic encephalopathy in patients with liver cirrhosis. Z Gastroenterol 1998; 36: 909-916
• 4 Bajaj JS, Schubert CM, Heuman DM. et al. Persistence of cognitive impairment after resolution of overt hepatic encephalopathy. Gastroenterology 2010; 138: 2332-2340
• 5 Labenz C, Baron JS, Toenges G. et al. Prospective evaluation of the impact of covert hepatic encephalopathy on quality of life and sleep in cirrhotic patients. Aliment Pharmacol Ther 2018; 48: 313-321
• 6 Jepsen P, Ott P, Andersen PK. et al. Clinical course of alcoholic liver cirrhosis: a Danish population-based cohort study. Hepatology 2010; 51: 1675-1682
• 7 Labenz C, Worns MA, Schattenberg JM. et al. Epidemiology of hepatic encephalopathy in german hospitals – the EpHE study. Z Gastroenterol 2017; 55: 741-747
• 8 Gerbes AL, Labenz J, Appenrodt B. et al. Updated S2k-Guideline “Complications of liver cirrhosis”. German Society of Gastroenterology (DGVS). Z Gastroenterol 2019; 57: 611-680
• 9 Vergara-Gomez M, Flavia-Olivella M, Gil-Prades M. et al. Diagnosis and treatment of hepatic encephalopathy in Spain: results of a survey of hepatologists. Gastroenterol Hepatol 2006; 29: 1-6
• 10 Sharma BC, Sharma P, Agrawal A. et al. Secondary prophylaxis of hepatic encephalopathy: an open-label randomized controlled trial of lactulose versus placebo. Gastroenterology 2009; 137: 885-891
• 11 Sharma P, Sharma BC, Agrawal A. et al. Primary prophylaxis of overt hepatic encephalopathy in patients with cirrhosis: an open labeled randomized controlled trial of lactulose versus no lactulose. J Gastroenterol Hepatol 2012; 27: 1329-1335
• 12 Bass NM, Mullen KD, Sanyal A. et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med 2010; 362: 1071-1081
• 13 Sidhu SS, Sharma BC, Goyal O. et al. L-ornithine L-aspartate in bouts of overt hepatic encephalopathy. Hepatology 2018; 67: 700-710
• 14 Varakanahalli S, Sharma BC, Srivastava S. et al. Secondary prophylaxis of hepatic encephalopathy in cirrhosis of liver: a double-blind randomized controlled trial of L-ornithine L-aspartate versus placebo. Eur J Gastroenterol Hepatol 2018; 30: 951-958
• 15 Butterworth RF. Beneficial effects of L-ornithine L-aspartate for prevention of overt hepatic encephalopathy in patients with cirrhosis: a systematic review with meta-analysis. Metab Brain Dis 2019 Jul 23 [Epub ahead of print]
• 16 Goh ET, Stokes CS, Sidhu SS. et al. L-ornithine L-aspartate for prevention and treatment of hepatic encephalopathy in people with cirrhosis. Cochrane Database Syst Rev 2018; 5: CD012410
• 17 Bajaj JS, Hafeezullah M, Hoffmann RG. et al. Minimal hepatic encephalopathy: a vehicle for accidents and traffic violations. Am J Gastroenterol 2007; 102: 1903-1909
• 18 Kircheis G, Knoche A, Hilger N. et al. Hepatic encephalopathy and fitness to drive. Gastroenterology 2009; 137: 1706-1715
• 19 Formentin C, De Rui M, Zoncape M. et al. The psychomotor vigilance task: role in the diagnosis of hepatic encephalopathy and relationship with driving ability. J Hepatol 2019; 70: 648-657
• 20 Bajaj JS, Etemadian A, Hafeezullah M. et al. Testing for minimal hepatic encephalopathy in the United States: an AASLD survey. Hepatology 2007; 45: 833-834
• 21 Sharma P, Sharma BC. Management patterns of hepatic encephalopathy: a nationwide survey in India. J Clin Exp Hepatol 2015; 5: 199-203
• 22 Roman E, Cordoba J, Torrens M. et al. Minimal hepatic encephalopathy is associated with falls. Am J Gastroentero 2011; 106: 476-482
• 23 Labenz C, Toenges G, Schattenberg JM. et al. Clinical predictors for poor quality of life in patients with covert hepatic encephalopathy. J Clin Gastroenterol 2019; 53: e303-e307
• 24 Campagna F, Montagnese S, Ridola L. et al. The animal naming test: an easy tool for the assessment of hepatic encephalopathy. Hepatology 2017; 66: 198-208
• 25 Labenz C, Beul L, Toenges G. et al. Validation of the simplified animal naming test as primary screening tool for the diagnosis of covert hepatic encephalopathy. Eur J Intern Med 2019; 60: 96-100
• 26 Labenz C, Toenges G, Huber Y. et al. Development and validation of a prognostic score to predict covert hepatic encephalopathy in patients with cirrhosis. Am J Gastroenterol 2019; 114: 764-770
• 27 Ditisheim S, Giostra E, Burkhard PR. et al. A capillary blood ammonia bedside test following glutamine load to improve the diagnosis of hepatic encephalopathy in cirrhosis. BMC Gastroenterol 2011; 11: 134
• 28 Brannelly NT, Killard AJ. An electrochemical sensor device for measuring blood ammonia at the point of care. Talanta 2017; 167: 296-301