title: Altered mental status in cirrhosis: etiologies and outcomes.
abstract: BACKGROUND
  Cirrhotic patients admitted with altered mental status (AMS) represent a clinical challenge, as many potentially life-threatening diseases must be considered. Although many patients with AMS have hepatic encephalopathy (HE), other causes of AMS occur, and we hypothesized that these may have different outcomes.
  
  
  OBJECTIVE
  We aimed to understand the causes of AMS in cirrhotic patients admitted to the hospital and investigate their associated outcomes.
  
  
  METHODS
  We performed a retrospective cohort study in 1218 inpatients with cirrhosis. Altered mental status was defined a priori (HE, sepsis/infectious, metabolic, exogenous drugs/toxins, structural lesions, or psychiatric abnormalities).
  
  
  RESULTS
  Patients with AMS had higher levels of serum bilirubin, international normalized ratio, blood urea nitrogen, creatinine, and lower levels of albumin and platelets than those with normal mental status (NMS) (P = < 0.001). The most common cause of AMS was HE, accounting for nearly half of all patients. Other causes of AMS included the following: sepsis/infection (23%), metabolic disorders (8%), drugs/toxins (7%), structural lesions (5%), psychiatric disorders (1%), or multiple causes (8%). Mortality in patients with AMS was 35% compared to 16% in those with NMS (P < 0.0001). Patients with sepsis/infection, structural lesions, or multiple disorders causing AMS had the highest mortality (61%, 68%, and 79%, respectively).
  
  
  CONCLUSIONS
  Nearly one third of admissions in cirrhotic patients were due to AMS, most commonly caused by HE. The overall mortality of patients admitted with AMS was greater than with NMS, particularly for those with infection or structural lesions, emphasizing the importance of a search for these causes of AMS in all patients with cirrhosis.
authors.affiliation: Divisions of Digestive and Liver Diseases, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX, USA.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Rahimi
authors.forename: Alan C
authors.initials: AC
authors.lastname: Elliott
authors.forename: Don C
authors.initials: DC
authors.lastname: Rockey
mesh_terms: D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D006501:Hepatic Encephalopathy / Q000401:mortality / Q000523:psychology*; D006801:Humans; D008103:Liver Cirrhosis / Q000401:mortality / Q000523:psychology*; D008297:Male; D001523:Mental Disorders / Q000401:mortality / Q000523:psychology*; D008875:Middle Aged; D012189:Retrospective Studies; D018805:Sepsis / Q000401:mortality / Q000523:psychology*; D015996:Survival Rate; D013781:Texas / Q000453:epidemiology