A Head CT is Unnecessary in the Initial Evaluation of A Cirrhotic Patient with Recurrent Hepatic Encephalopathy

The independent risk factors for abnormal head computed tomography in patients with hepatic encephalopathy

It's known that head computed tomography (CT) is used excessively to exclude intracranial hemorrhage in patients with hepatic encephalopathy (HE) in the emergency department. However, the independent risk factors for abnormal head CT in patients with HE have not been studied extensively to date. In this retrospective study, patients with an ammonia level of >90 U/L who were clinically considered HE and had head CT were included. The characteristics of patients with abnormal head CT and independent risk factors for abnormal CT were investigated. Three hundred seventy-eight patients were included in the study. CT findings of 18 (4.8%) of the patients were abnormal: 12 had intracranial hemorrhage, 1 had an ischemic stroke, and 5 had an intracranial mass. Intracranial hemorrhage (odds ratio [OR] 12.5), history of recent trauma (OR 23.4), history of active malignancy (OR 10.3), thrombocyte count <100.000/μL (OR 4.3), and international normalized ratio ≥1.5 (OR 3.2) were found to be independent risk factors for abnormal head CT. Head CT scan may be considered in patients with HE if any of the following are present: intracranial bleeding history, recent trauma history, active malignancy, platelet count <100,000/μL, and international normalized ratio >1.5.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Neurologic Imaging in a Patient with Cirrhosis and Altered Mental Status: To CT or Not to CT

Hepatic encephalopathy represents a continuum of neuropsychiatric symptoms among patients with end-stage liver disease. When a patient with cirrhosis presents with altered mental status (AMS), routine neurologic imaging is not typically recommended, due to low diagnostic yield. Guidance from the American Association for the Study of Liver Disease states that, on initial presentation, brain imaging is not required unless there are other signs of intracranial pathology, including focal neurologic deficits. We present a case of a 61-year-old female with cirrhosis presenting with AMS without focal deficits, in whom neurological imaging revealed a meningioma and subsequent resection led to symptom improvement.

Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy

Goals and background

The utility of routine head CT (HCT) in hepatic encephalopathy (HE) evaluation is unclear. We investigated HCT yield in detecting acute intracranial abnormalities in cirrhotic patients presenting with HE.

Study

Retrospective review of cirrhotic patient encounters with HE between 2016 and 2018 at Beaumont Health, in Michigan was performed. A low-risk (LR) indication for HCT was defined as altered mental status (AMS), which included dizziness and generalised weakness. A high-risk (HR) indication was defined as trauma/fall, syncope, focal neurological deficits (FNDs) or headache. Descriptive statistics and univariate/multivariate analyses by logistic regression were performed using SPSS to identify HCT abnormality correlates.

Results

Five hundred twenty unique encounters were reviewed. Mean age was 63.4 (12.1) years, 162 (37.5%) had alcoholic cirrhosis and median Model for End-Stage Liver Disease (MELD)-score was 17 (13–23). LR indication was reported in 408 (78.5%) patients and FNDs reported in 24 (4.6%) patients. Only 13 (2.5%) patients were found to have an acute intracranial pathology (seven haemorrhagic stroke, two ischaemic stroke, four subdural haematoma). Aspirin use prior to presentation (aOR 4.6, 95% CI 1.1 to 19.2), and HR indication (aOR 7.3, 95% CI 2.3 to 23.8) were independent correlates of acute intracranial pathology on HCT. Age, sex, MELD-score, haemoglobin, platelet count, race and cirrhosis aetiology did not correlate with HCT abnormalities. Number needed to screen to identify one acute pathology was 14 in HR indications versus 82 for LR indications.

Conclusion

Routine HCTs in cirrhotic patients presenting with HE with AMS in the absence of history of trauma, headache, syncope, FNDs or aspirin use is of low diagnostic yield.

Laboratory Abnormalities of Hepatic Encephalopathy

Currently, there is no gold standard serologic or imaging modality to detect hepatic encephalopathy (HE). It is a clinical diagnosis gathered from the history and physical. Imaging is nonspecific; however, PET and MRI have shown areas of utility, but are not widely available, cost-efficient, or necessary for diagnosis. Electroencephalogram has shown promise as it can be used in conjunction with the Portal Systemic Hepatic Encephalopathy Score test to diagnose minimal HE. Further research on these techniques would need to be performed to identify strict criteria and cutoffs for diagnosing HE as well as associated sensitivities and specificities.