Assessment of the spectrum of hepatic encephalopathy: A multicenter study.

Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However, its severity assessment is often subjective, which needs to be studied systematically. The aim was to determine how accurately trainee and nontrainee practitioners grade and manage HE patients throughout its severity. We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and nontrainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades <2 or ≥2 HE and trainees/nontrainees. In total, 108 respondents (62 trainees, 46 nontrainees) were included. For patients with grades <2 versus ≥2 HE, a higher percentage of respondents were better at correctly diagnosing grades ≥2 compared with grades <2 (91% versus 64%; P < 0.001). Specialized cognitive testing was checked significantly more often in grades <2, whereas more aggressive investigation for precipitating factors was ordered in HE grades >2. Serum ammonia levels were ordered in almost a third of grade ≥2 patients. For trainees and nontrainees, HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and more likely to perform a more thorough workup for precipitating factors compared with nontrainee respondents. There was excellent concordance in the classification of grade ≥2 HE between nontrainees versus trainees, but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing, and nutritional management between trainees and nontrainees. These results have important implications at the patient level, interpreting multicenter clinical trials, and in the education of practitioners. Liver Transplantation 24 587-594 2018 AASLD.

Noninvasive assessment of liver fibrosis: serum markers, imaging, and other modalities.

Liver fibrosis is a common pathway of injury after chronic insult to the liver. The evolution of liver fibrosis to cirrhosis has many clinical implications, including bleeding, infection, hepatocellular carcinoma, and death. The reference standard for diagnosing liver fibrosis is currently histologic assessment of tissue obtained through liver biopsy. Although this provides valuable information, it has limitations, including its invasiveness, sampling error, observer variability, and the use of categorical scoring systems. This article outlines the various noninvasive markers, including blood tests, imaging, and novel technologies. It examines the principles behind their development, their diagnostic accuracy, and their evolution.

Review article: the assessment of liver function using breath tests.

BACKGROUND: Hepatologists have long sought to develop a test for assessing liver function, but this aim has been stalled by the complexity of the liver and its diverse functions. Results of metabolic tests, including breath tests, correlate with clinical and histological parameters of patients with liver disorders; however, these tests tend to be cumbersome and impractical for everyday use. The recent development of a real-time, point-of-care liver function breath test has made it straightforward to assess the metabolic function of the liver. AIM: To review the available data on the use of breath tests for assessing liver reserve in various conditions and their application in various clinical hepatology settings. RESULTS: The (13)C-methacetin breath test enables accurate follow-up of patients with acute or chronic liver damage, where overall hepatic function is significantly suppressed by known causes of liver disorders, including acute, sub-acute or chronic conditions. The metabolic breath test can detect both gradual and spontaneous improvements in liver function and the effects of treatment. CONCLUSIONS: Breath testing that provides continuous quantification of methacetin metabolism may be a sensitive tool for the diagnosis and follow-up of patients with liver disorders.