The Misdiagnosis and Underdiagnosis of Hepatic Encephalopathy

Patients with cirrhosis are at risk of developing hepatic encephalopathy, which can present with a wide range of symptoms, including confusion, lethargy, inappropriate behavior, and altered sleep patterns. In addition to hepatic encephalopathy, patients with cirrhosis are at risk of developing mild cognitive impairment, dementia, and delirium, which have features closely resembling hepatic encephalopathy. Given the similar presentation of these conditions, misdiagnosis can and does occur. Mild cognitive impairment is common in individuals aged ≥50 years and can progress to dementia in those affected. Dementia and hepatic encephalopathy are both characterized by sleep disturbance and cognitive dysfunction, thus differentiating these conditions can be difficult. Furthermore, delirium can disrupt sleep patterns, and liver disease is recognized as a risk factor for its development. As hepatic encephalopathy is a cirrhosis-related complication, determining if a patient has undiagnosed cirrhosis is critical, particularly given the large number of patients with asymptomatic, compensated cirrhosis. Separately, underdiagnosis of minimal hepatic encephalopathy can occur even in patients with diagnosed liver disease, related, in part, to lack of testing. Given the availability of effective therapies available for managing symptoms and preventing future episodes, accurate diagnosis of hepatic encephalopathy is essential.