![]() ![]() Case ReportĪ 61-year-old woman with cirrhosis secondary to nonalcoholic steatohepatitis presented to the emergency room (ER) with increased frequency of intermittent confusion and emotional lability for one month. We present a case of a patient with cirrhosis presenting with altered mental status, where a brain CT scan provided the diagnosis and led to changes in management to successfully treat the patient. Therefore, the literature does not support routine use of neurologic imaging as part of the evaluation for altered mental status in the patient with cirrhosis. Another investigation reported that, among 178 brain CT scans performed for 152 HE hospitalizations, only 1% of the CT scans led to a change in diagnosis or management. One study reported no findings of acute intracranial abnormalities on the computed tomography (CT) scan in a cohort of patients with cirrhosis and AMS, but without focal neurologic deficits on physical exam. The current literature suggests imaging of the brain should not be performed in a patient presenting to the hospital with suspected HE, as the diagnostic yield has been shown to be low. Though a patient with cirrhosis presenting with altered mental status (AMS) is often presumed to have HE, the differential diagnosis includes etiologies such as cerebrovascular accident, intracerebral hemorrhage (ICH), or a structural brain lesion, all of which can present with similar symptoms to HE and may lead providers to order brain imaging. The presentation of HE varies from covert HE, which can include sleep-wake disturbances and shortened attention span, to overt HE, which may lead to confusion, disorientation, and behavioral and personality changes. Hepatic encephalopathy (HE) affects 30–45% of patients with cirrhosis and is a leading cause of morbidity and mortality in this population, as well as healthcare costs and resource utilization. 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. ![]() 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. When a patient with cirrhosis presents with altered mental status (AMS), routine neurologic imaging is not typically recommended, due to low diagnostic yield. Hepatic encephalopathy represents a continuum of neuropsychiatric symptoms among patients with end-stage liver disease. ![]()
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