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Altered Mental Status in Cirrhosis
  1. Robert S. Rahimi, MD*,
  2. Alan C. Elliott, MAS,
  3. Don C. Rockey, MD*
  1. From the Divisions of *Digestive and Liver Diseases, and†Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX.
  1. Received November 5, 2012, and in revised form January 25, 2013.
  2. Accepted for publication December 30, 2012.
  3. Reprints: Don C. Rockey, MD, Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 803, Charleston, SC. E-mail: rockey{at}musc.edu.
  4. Supported in part by National Institutes of Health Grant 5-T32-DK007745-15.
  5. The authors declare no funding or conflicts of interest.
  6. Robert S. Rahimi was responsible for the study concept and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and statistical analysis; Alan C. Elliott, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, and statistical analysis; and Don C. Rockey, study concept and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content.
  7. Dr Rockey shall act as the guarantor for the manuscript, and all authors approved of the final version of the manuscript.

Etiologies and Outcomes

Abstract

Background Cirrhotic patients admitted with altered mental status (AMS) represent a clinical challenge, as many potentially life-threatening diseases must be considered. Although many patients with AMS have hepatic encephalopathy (HE), other causes of AMS occur, and we hypothesized that these may have different outcomes.

Aim We aimed to understand the causes of AMS in cirrhotic patients admitted to the hospital and investigate their associated outcomes.

Methods We performed a retrospective cohort study in 1218 inpatients with cirrhosis. Altered mental status was defined a priori (HE, sepsis/infectious, metabolic, exogenous drugs/toxins, structural lesions, or psychiatric abnormalities).

Results Patients with AMS had higher levels of serum bilirubin, international normalized ratio, blood urea nitrogen, creatinine, and lower levels of albumin and platelets than those with normal mental status (NMS) (P = < 0.001). The most common cause of AMS was HE, accounting for nearly half of all patients. Other causes of AMS included the following: sepsis/infection (23%), metabolic disorders (8%), drugs/toxins (7%), structural lesions (5%), psychiatric disorders (1%), or multiple causes (8%). Mortality in patients with AMS was 35% compared to 16% in those with NMS (P < 0.0001). Patients with sepsis/infection, structural lesions, or multiple disorders causing AMS had the highest mortality (61%, 68%, and 79%, respectively).

Conclusions Nearly one third of admissions in cirrhotic patients were due to AMS, most commonly caused by HE. The overall mortality of patients admitted with AMS was greater than with NMS, particularly for those with infection or structural lesions, emphasizing the importance of a search for these causes of AMS in all patients with cirrhosis.

Key Words
  • liver
  • hepatic encephalopathy
  • sepsis
  • portal hypertension
  • infection

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