Hepatic Encephalopathy Can Present as Acute Fluctuating Delirium
Yes, patients with liver disease can absolutely experience acute fluctuating delirium as a manifestation of hepatic encephalopathy (HE), and this fluctuating course is a hallmark feature of the condition. 1
Understanding the Fluctuating Nature of HE
The 2022 EASL guidelines explicitly recognize that overt HE is classified by its time course as episodic, recurrent (>2 bouts within 6 months), or persistent (no return to baseline between episodes), confirming that fluctuation is an inherent characteristic of this condition. 1 The terminology itself has evolved to align with standard neurological practice—the EASL now recommends replacing "brain failure" with "acute encephalopathy" in accordance with international guidelines on delirium. 1
Critical Diagnostic Considerations
In patients with suspected HE presenting with delirium, you must actively identify alternative or additional causes of neuropsychiatric impairment, as this improves both prognostic accuracy and treatment outcomes—this recommendation achieved 100% consensus among experts. 1 This is particularly important because:
- 22% of patients with liver disease suspected of having HE actually have extrahepatic causes for their acute encephalopathy, including infections (particularly urinary infections). 1
- HE can occur on top of pre-existing conditions like dementia, making the clinical picture more complex. 1
Diagnostic Workup for Fluctuating Delirium in Liver Disease
When evaluating a patient with liver disease and acute fluctuating mental status:
- Measure plasma ammonia levels—a normal value brings the diagnosis of HE into question (95% consensus). 1
- Perform brain imaging (CT or MRI) if diagnostic doubts exist or if the patient fails to respond to treatment (96% consensus), though no imaging definitively proves HE. 1
- Use West Haven criteria for grading when at least temporal disorientation is present (grades ≥2), and add the Glasgow coma scale for grades III-IV. 1
Management Approach
Identify and manage precipitating factors immediately (100% consensus)—common triggers include constipation, gastrointestinal bleeding, infections, hyponatremia, and dehydration/diuretic overdose. 1, 2 These precipitants are critical because they can trigger the acute fluctuating presentation you're observing. 1
For treatment of the acute episode:
- Lactulose is first-line therapy, reducing blood ammonia by 25-50% with clinical response in approximately 75% of patients. 2
- Rifaximin is added as adjunct therapy for recurrent episodes (>1 additional episode within 6 months of the first). 1, 2
- Patients with grades 3-4 HE require ICU monitoring due to aspiration risk. 1
Common Pitfall to Avoid
The most critical error is assuming all altered mental status in liver disease patients is HE. You must perform the same standardized diagnostic evaluation as for any patient with altered consciousness, as alternative diagnoses are present in nearly one-quarter of cases. 1 The fluctuating nature of symptoms does not exclude other causes—infections, metabolic derangements, and structural brain lesions can all coexist with or mimic HE. 1, 3