Epidemiology of hepatic encephalopathy in german hospitals – the EpHE study

 

 Buy Article Permissions and Reprints

Abstract

Background Hepatic encephalopathy (HE) is a serious complication of liver cirrhosis. The proportion of patients with liver cirrhosis attending German hospitals suffering from HE is unknown.

Methods In the first part of the study, data of 14 community hospitals and 5 university hospitals covering the years 2010 and 2011 were analyzed retrospectively for the DRG codes of liver cirrhosis and hepatic encephalopathy. In the second prospective part of the multicenter observational study, all patients with liver cirrhosis attending the departments of gastroenterology of 16 participating community hospitals within a study period of 3 months were included and screened for HE clinically according to the West Haven criteria (grades 1 – 4).

Results A diagnosis of liver cirrhosis has been coded in 6366 cases in 2010 and in 7279 cases in 2011. In the vast majority of hospitals, less than 20 % of these cases had an additional DRG code for HE. Two hundred seventy-eight patients with liver cirrhosis were included into the prospective study. A clinically detectable HE was present in 36 % of the patients (n = 99). The majority was classified as West Haven 1 (n = 59, 59.6 %). Of the patients without clinical sings of HE, 48 % (n = 134) showed a pathological NCT.

Conclusion Our data suggest that HE is underdiagnosed in German hospitals. Since treatment of HE may improve the prognosis of the patients as well as their quality of life, hospitalized patients with liver cirrhosis should be routinely screened for HE.

Zusammenfassung

Hintergrund Die hepatische Enzephalopathie (HE) ist eine ernste Komplikation der Leberzirrhose. Es ist unbekannt, wie hoch der Anteil von stationären Patienten mit Leberzirrhose in Deutschland ist, die an einer HE leiden.

Methoden Im ersten Teil der Studie analysierten wir retrospektiv die Anzahl der DRG Codes für Leberzirrhose und HE, die in den Jahren 2010 und 2011 in 14 allgemeinen und 5 universitären Kliniken kodiert wurden. Im prospektiven Teil der multizentrischen Studie wurden alle Patienten mit Leberzirrhose, welche über einen Zeitraum von 3 Monaten stationär in den teilnehmenden Kliniken behandelt wurden, auf das Vorliegen einer HE gemäß der West Haven Kriterien (Grad 1 – 4) untersucht.

Ergebnisse Die Diagnose Leberzirrhose wurde 2010 bei 6.366 und 2011 bei 7.279 Fällen kodiert. Der Anteil mit zusätzlicher Kodierung einer HE lag in dem weit überwiegenden Teil der Kliniken unter 20 %. 278 Patienten mit Leberzirrhose wurden in die prospektive Studie eingeschlossen. Klinische Zeichen der HE lagen bei 36 % der Patienten vor (n = 99). Der Großteil dieser wurde als Grad I nach den West Haven Kriterien klassifiziert (n = 59, 59.6 %). 48 % (n = 134) der Patienten ohne klinische Zeichen einer HE boten einen pathologischen ZVT.

Schlussfolgerung Unsere Daten lassen vermuten, dass die HE in deutschen Kliniken zu selten diagnostiziert wird. Da die Behandlung einer HE nicht nur die Lebensqualität der Patienten, sondern auch die Prognose verbessert, sollte ein Screening auf eine HE in die klinische Routine implementiert werden.

• 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
  CrossrefPubMedGoogle Scholar
• 2 Giarelli L, Melato M, Laurino L. et al. Occurrence of liver cirrhosis among autopsies in Trieste. IARC Sci Publ 1991; 112: 37-43
  PubMedGoogle Scholar
• 3 Graudal N, Leth P, Marbjerg L. et al. Characteristics of cirrhosis undiagnosed during life: a comparative analysis of 73 undiagnosed cases and 149 diagnosed cases of cirrhosis, detected in 4929 consecutive autopsies. J Intern Med 1991; 230: 165-171
  CrossrefPubMedGoogle Scholar
• 4 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
  Google Scholar
• 5 Ferenci P. [Therapy of acute and chronic hepatic encephalopathy in patients with liver cirrhosis]. Z Gastroenterol 1998; 36: 909-916
  PubMedGoogle Scholar
• 6 Cordoba J. New assessment of hepatic encephalopathy. J Hepatol 2011; 54: 1030-1040
  CrossrefPubMedGoogle Scholar
• 7 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; 35: 716-721
  CrossrefPubMedGoogle Scholar
• 8 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
  CrossrefPubMedGoogle Scholar
• 9 Das A, Dhiman RK, Saraswat VA. et al. Prevalence and natural history of subclinical hepatic encephalopathy in cirrhosis. J Gastroenterol Hepatol 2001; 16: 531-535
  CrossrefPubMedGoogle Scholar
• 10 Ortiz M, Jacas C, Cordoba J. Minimal hepatic encephalopathy: diagnosis, clinical significance and recommendations. J Hepatol 2005; 42: S45-S53
  CrossrefPubMedGoogle Scholar
• 11 Groeneweg M, Moerland W, Quero JC. et al. Screening of subclinical hepatic encephalopathy. J Hepatol 2000; 32: 748-753
  CrossrefPubMedGoogle Scholar
• 12 Bajaj JS. Review article: the modern management of hepatic encephalopathy. Aliment Pharmacol Ther 2010; 31: 537-547
  CrossrefPubMedGoogle Scholar
• 13 Amodio P, Del Piccolo F, Petteno E. et al. Prevalence and prognostic value of quantified electroencephalogram (EEG) alterations in cirrhotic patients. J Hepatol 2001; 35: 37-45
  CrossrefPubMedGoogle Scholar
• 14 Kircheis G, Fleig WE, Gortelmeyer R. et al. Assessment of low-grade hepatic encephalopathy: a critical analysis. J Hepatol 2007; 47: 642-650
  CrossrefPubMedGoogle Scholar
• 15 Kircheis G, Wettstein M, Timmermann L. et al. Critical flicker frequency for quantification of low-grade hepatic encephalopathy. Hepatology 2002; 35: 357-366
  CrossrefPubMedGoogle Scholar
• 16 Weissenborn K, Ennen JC, Schomerus H. et al. Neuropsychological characterization of hepatic encephalopathy. J Hepatol 2001; 34: 768-773
  Google Scholar
• 17 Amodio P, Campagna F, Olianas S. et al. Detection of minimal hepatic encephalopathy: normalization and optimization of the Psychometric Hepatic Encephalopathy Score. A neuropsychological and quantified EEG study. J Hepatol 2008; 49: 346-353
  CrossrefPubMedGoogle Scholar
• 18 Cooper AJ, Plum F. Biochemistry and physiology of brain ammonia. Physiol Rev 1987; 67: 440-519
  CrossrefPubMedGoogle Scholar
• 19 Aldridge DR, Tranah EJ, Shawcross DL. Pathogenesis of hepatic encephalopathy: role of ammonia and systemic inflammation. J Clin Exp Hepatol 2015; 5: S7-S20
  Google Scholar
• 20 Shawcross DL, Wright G, Olde Damink SW. et al. Role of ammonia and inflammation in minimal hepatic encephalopathy. Metab Brain Dis 2007; 22: 125-138
  CrossrefPubMedGoogle Scholar

• Supplementary Material