Status epilepticus in patients with cirrhosis: How to avoid misdiagnosis in patients with hepatic encephalopathy

PURPOSE Status epilepticus (SE) in patients with cirrhosis is a rare but serious situation. Diagnosis may be difficult in emergency presentation, especially when patients present with hepatic encephalopathy (HE). Misdiagnosis must be avoided since some anti-epileptic drugs aggravate HE. In this retrospective study, we therefore assessed the frequency of SE in patients with cirrhosis, evaluated the accuracy of diagnosis and determined rates of mortality. METHOD We reviewed data from all patients hospitalized from 2005 to 2013 in the Hepatology ICU for complications of cirrhosis with an initial diagnosis of SE. We attempted to reach a consensus decision on a possible diagnosis of SE in reviews of EEG traces and medical records by an expert electrophysiologist, a hepatologist and a neurologist. RESULTS An initial diagnosis of SE was made for 20 patients with cirrhosis. Critical review suggested that 15 of these patients were correctly diagnosed with true SE. However, initial diagnoses may have been mistaken for at least 3 patients, who presented clinical and electrical signs of HE without evidence for SE. Overall, we estimated a prevalence of 0.7% for SE in patients with cirrhosis (15 of 2010 patients admitted to our ICU) in our series. In-hospital mortality was of 73%. In the 12 months after the SE episode, mortality was 87%. CONCLUSION As SE may be misdiagnosed in patients with cirrhosis, a joint review of the patients by neurologists and hepatologists could reduce errors in diagnosis.