A patient is suspected of having hepatic encephalopathy (HE) attributable to liver failure from alcoholism. He has asterixis but no mental confusion or mental status changes. Does this patient really have encephalopathy if asterixis is the only manifestation? — Miriam Anderson, NP-C, Fargo, N.D.

HE is a common complication of cirrhosis, characterized by a number of neuropsychiatric manifestations ( J Hepatol. 2011;54:1030-1040). Neuropsychologic impairment, which is common among outpatients with cirrhosis, is frequently asymptomatic and is often not perceived by the clinician. Minimal hepatic encephalopathy (MHE) has recently been described in an effort to capture the subtle and early phases of the spectrum of encephalopathy (Curr Gastroenterol Rep. 2011;13:26-33). MHE has been associated with a poorer quality of life and driving impairment and vehicle accidents. The West Haven scale establishes four stages of HE based on alterations in the state of consciousness, intellectual function, behavior, and neuromuscular signs.

Depending on how your patient is assessed, he may have minimal encephalopathy or grade 1 HE under the West Haven criteria. With grade 1 HE, the patient may exhibit any of the following: trivial lack of awareness, euphoria or anxiety, shortened attention span and impairment of ability to add or subtract. The associated asterixis may consist of a few flapping motions. — Sharon Dudley-Brown, PhD, FNP-BC, co-director, gastroenterology & hepatology, nurse practitioner fellowship program, Johns Hopkins University Schools of Medicine & Nursing, Baltimore (155-5)