The patient PATHWAY

BLIPS

Hepatic encephalopathy is a complication of chronic liver disease that includes a range of symptoms from sleep disturbances to coma. When symptoms are visible, it is called clinical encephalopathy, which can affect 15 to 50% of patients with cirrhosis over the course of its progression. It progresses in flare-ups but can become chronic and persist in daily life. It is a risk factor for excess mortality during cirrhosis. When symptoms are frustrating, affecting one or more neurocognitive axes, it is called non-clinical hepatic encephalopathy. A battery of psychometric tests must then be performed to detect these neurocognitive disorders, particularly those affecting attention, memory, and language. When encephalopathy becomes chronic, it can hamper the daily lives of patients, also impacting their caregivers, with impaired vigilance, road accidents, and even comas requiring hospitalization. Symptoms are mainly due to an abnormal increase in the level of ammonia in the body, normally eliminated by the liver, muscles or kidneys; but in cases of chronic liver disease, the liver no longer plays its role, patients can also be sarcopenic with a decrease in their muscle mass and can also suffer from renal failure. The accumulation of ammonia leads to cerebral toxicity which causes the symptoms. Oral drug treatments are available, and in the event of complete resolution of symptoms under these treatments, chronic hepatic encephalopathy can then be a cause in itself for an indication for a liver transplant, the transplant allowing the resolution of symptoms. This is why it is important to carefully search for and characterize it, so as not to overlook another underlying neurological pathology whose evolution would be uncertain after liver transplantation.

The BLIPS patient pathway

The BLIPS (Brain LIver Pitié-Salpêtrière) care pathway, dedicated to patients with chronic liver disease and neurocognitive disorders, was designed to meet the following needs:

Characterization of neurocognitive disorders experienced by the patient or perceived by those around them and/or by their referring physician. These disorders may include attention and memory disorders, psychomotor retardation, difficulty managing both routine and administrative tasks, and/or sleep disorders.

We carry out a multimodal exploration of these complaints to better specify their origin: pure hepatic encephalopathy or associated with another cause, or even absence of hepatic encephalopathy but presence of another cause.

Each patient is seen by several specialists:

• Consultation with a hepatologist, a neurologist, and a neuropsychologist. A biological assessment, as well as an electroencephalogram and a cerebral MRI coupled with spectroscopy, are also performed on the day of hospitalization.
• Consultation by a senior hepatologist: understand the overall history of the patient's liver disease, assess its severity, and above all, retrace the neurocognitive history to better interpret the current context.
• Consultation by a senior neurologist: assess neurological disorders to look for a potential cause other than hepatic encephalopathy.
• Consultation by a neuropsychologist: interview with the patient then carrying out numerous psychometric tests to objectively characterize the existence or not of neurocognitive disorders (affecting memory, attention, executive function, verbal fluency in particular), as well as potential anxiety-depressive disorders.