Vitamin B-12 and folate function in chronic alcoholic men with peripheral neuropathy and encephalopathy

Forty-six male alcoholics hospitalized with polyneuropathy or intellectual impairment were studied after at least 2 wk of alcohol abstention. Neurological evaluation included neurophysiological examination of the sural nerve and tibial nerve, neurophysiological examinations, and CT-scanning of the brain. Alcohol and vitamin intakes were quantified by the interview method. Vitamin B-12 and folate status included examinations of peripheral blood and bone marrow aspirate, plasma vitamin B-12, plasma and erythrocyte folate, formiminoglutamic acid excretion test (FiGlu), methylmalonic acid excretion, and deoxyuridine suppression test (dU) on phytohemagglutinin-stimulated peripheral lymphocytes. The liver function was assessed by galactose elimination capacity and plasma clearance of antipyrine. There was no hematological sign of folate or vitamin B-12 deficiency. About 8% had low plasma folate, while neither erythrocyte folate nor plasma vitamin B-12 were decreased. However, half of the patients had functional folate deficiency as determined by abnormal FiGlu or dU. Compared to the remaining patients, those with abnormal FiGlu or dU had significantly more abnormal neurophysiological tests, and lower folate intake. There was no correlation between FiGlu or dU and the quantitative liver function tests. It is concluded that 1) folate deficiency may contribute to the development of alcoholic polyneuropathy, 2) the classical parameters for folate deficiency (blood concentrations, peripheral blood, and bone marrow examinations) are not reliable in diagnosing folate deficiency and 3) functional tests like FiGlu and dU are necessary to diagnose folate deficiency in alcoholics.

Brainstem auditory evoked potentials in toxic, metabolic and anoxic coma

The aim of this study was to evaluate the efficacy of brainstem auditory evoked responses as a prognostic tool in conditions of coma which interfere with cerebral metabolism. Thirteen patients in coma resulting from different systemic disorders (barbiturate intoxication, cardiac arrest, chronic hepatic insufficiency) were included in the study. Brainstem auditory evoked potentials were recorded and patients were graded according to the results. When used in conjunction with other clinical parameters (Glasgow Coma Scale), brainstem auditory evoked potentials provided a more reliable prognostic tool than the traditional EEG exam alone. A good correlation was found between electrophysiological data and clinical outcome not only in barbiturate (toxic) coma, but also in hepatic (metabolic) coma. Of particular significance was the disappearance of the components which follow wave III (grade 2), leading to a fatal outcome in all three patients in hepatic coma.

Hepatic encephalopathy and reversible cortical blindness

We report a case of recurrent hepatic encephalopathy accompanied by transient cortical blindness. The patient with cryptogenic liver cirrhosis had six attacks of hepatic encephalopathy of grades II to III during 1 yr after admission. In the beginning of each episode of encephalopathy, when the patient was conscious, a complete loss of vision occurred, but with a normal pupillary reflex to light. At the same time, the visual evoked potential recorded the second negative wave with a prolonged latency and a diminished amplitude. His sight completely returned, and the electroencephalogram tracing and the visual evoked potential response normalized after treatment for the encephalopathy. The loss of vision was thought to be cortical blindness accompanied by hepatic encephalopathy. Thus, in rare cases of hepatic encephalopathy, the visual cortex may be affected, and cortical blindness may occur before the loss of consciousness.

The effect of fulminant hepatic failure on protein C antigen and activity

In eighteen patients with fulminant hepatic failure (FHF), in grade III or IV coma, both protein C antigen and activity were significantly decreased (0.35 +/- 0.03 u/ml and 0.35 +/- 0.03 u/ml respectively). There was a significant correlation between protein C antigen and activity (r = 0.61, p less than 0.01). Protein C antigen levels were inversely correlated with prothrombin time (r = -0.57, p less than 0.05) as were protein C activity levels (r = -0.57, p less than 0.05). There was also significant correlations between fibrinogen and protein C antigen (r = 0.69, p less than 0.01) and protein C activity (r = 0.61, p less than 0.01). These results demonstrate that the naturally occurring inhibitor of coagulation, protein C, is present at low levels in FHF and this is probably due to the lack of synthesis of the protein in the damaged liver. The low levels of protein C may make these patients more susceptible to the disseminated intravascular coagulation which is known to occur in FHF and this in turn will lead to a further reduction in protein C levels.

Amino acid changes in autopsied brain tissue from cirrhotic patients with hepatic encephalopathy

Brain tissue was obtained at autopsy from nine cirrhotic patients dying in hepatic coma and from an equal number of controls, free from neurological, psychiatric, or hepatic diseases, matched for age and time interval from death to freezing of dissected brain samples. Glutamine, glutamate, aspartate, and gamma-aminobutyric acid (GABA) levels were measured in homogenates of cerebral cortex (prefrontal and frontal), caudate nuclei, hypothalamus, cerebellum (cortex and vermis), and medulla oblongata as their o-phthalaldehyde derivatives by HPLC using fluorescence detection. Glutamine concentrations were found to be elevated two- to fourfold in all brain structures, the largest increases being observed in prefrontal cortex and medulla oblongata. Glutamate levels were selectively decreased in prefrontal cortex (by 20%), caudate nuclei (by 27%), and cerebellar vermis (by 17%) from cirrhotic patients. On the other hand, GABA content of autopsied brain tissue from these patients was found to be within normal limits in all brain structures. It is suggested that such region-selective reductions of glutamate may reflect loss of the amino acid from the releasable (neurotransmitter) pool. These findings may be of significance in the pathogenesis of hepatic encephalopathy resulting from chronic liver disease.

The surgical risk of colectomy in patients with cirrhosis

The records of 54 patients with documented cirrhosis who underwent colectomy between January 1970 and January 1984 were studied to assess the operative risk and to determine the preoperative predictive risk factors. In-hospital mortality was 24 percent (13 patients), and postoperative complications occurred in 48 percent (26 patients). The risk of surgical intervention was significantly increased if encephalopathy, ascites, anemia, or hypoalbuminemia was present before operation. A simple operative risk index involving the presence of encephalopathy and ascites and the levels of hemoglobin and albumin is proposed to help distinguish a low-risk subgroup in whom postoperative mortality was 12.8 percent from a high-risk subgroup in whom postoperative mortality was 53.3 percent.

Recurrent reversible acute renal failure from amphotericin

A patient with cryptogenic cirrhosis and disseminated sporotrichosis developed acute renal failure immediately following the administration of amphotericin B on four separate occasions. The abruptness of the renal failure and its reversibility within days suggests that there was a functional component to the renal dysfunction. We propose that amphotericin, in the setting of reduced effective arterial volume, may activate tubuloglomerular feedback, thereby contributing to acute renal failure.

Neurological sequelae in patients recovered from fulminant hepatic failure

Two teenage patients with fulminant hepatic failure progressing to grade 4 encephalopathy with clinical signs of cerebral oedema are described, in whom permanent neurological injury (involving the brain stem in one and the cerebral cortex in the other) was the sequel to an otherwise full recovery. The present day management of cerebral oedema may, as in these two cases, ensure the survival of patients with fulminant hepatic failure who would previously have been likely to die from the effects of raised intracranial pressure. As a result it is now possible more recovered cases will be seen with residual neurological deficits, a previously very rarely recorded event.

Acute liver failure. Experience with 145 patients

Acute liver failure (ALF) is an uncommon but serious disease still carrying a high mortality. This report describes one of the largest series of cases of acute failure, managed on a simple intensive supportive therapeutic regimen. One hundred fifty-eight patients with ALF were admitted to the Rajgarhia Liver Unit of the All-India Institute of Medical Sciences (AIIMS) during the period July 1976 to December 1981. Data from 145 were completed and analyzed for this report. Of the patients, 85.4% were below the age of 40 years. The female-to-male ratio was 1.3:1. Of the 77 women in the reproductive age group, 59.7% were pregnant. All cases of ALF were secondary to viral hepatitis. Cerebral edema, bleeding, infection, and renal failure were seen in 57.2, 57.2, 39.3, and 16.5% of patients, respectively. Overall survival was 28.9% of patients. It was 33% below the age of 40 years and only 4.8% above this age. Pregnancy did not adversely affect the prognosis. Survival was related to grade of coma, being 22.8% for patients in Grade IV coma and 62% for patients in Grade I coma. In fatal cases the immediate complications resulting in death were cerebral edema (63%), bleeding (30%), renal failure (10.6%), and infection (8.7%). Presence of HBsAg, a serum bilirubin of over 20 mg%, and serum sodium less that 119 mEq/liter were indicators of poor prognosis. A simple, intensive, support therapy yielded results comparable to those reported by centers using a variety of complex therapeutic regimens.

Clinical and portal hemodynamic features in cirrhotic patients having a large spontaneous splenorenal and/or gastrorenal shunt

Clinical and portal hemodynamic features in 28 cirrhotic subjects with a large spontaneous spleno- and/or gastrorenal shunt were studied in comparison with 30 control cirrhotic cases without such collaterals. Forty-six percent of the former had chronic hepatic encephalopathy, but none of the latter was encephalopathic. These patients with large renal shunts were divided into those with and those without encephalopathy. Large esophageal varices were significantly less common in patients with a large shunt and encephalopathy compared with those who had a large shunt but no encephalopathy, and the control. But there was no significant difference of past variceal bleeding among these three groups. In all those with encephalopathy, part of superior mesenteric venous blood was shunting through these collaterals into the left renal vein or inferior vena cava, but the same was not demonstrable in patients with a large shunt and no encephalopathy and control cirrhotics. In the chronic encephalopathic, portal venous flow was estimated to be less than one-half of that in control cirrhotics, and the portion of superior mesenteric venous blood that was flowing hepatofugally through a large shunt into the left renal vein seemed about the same or greater than the portal venous flow. Thus, a large spontaneous spleno- and/or gastrorenal shunt might prevent development of large esophageal varices but not variceal hemorrhage and it increased a risk of chronic hepatic encephalopathy.

Management of acute liver failure

We describe our experience in the treatment of acute liver failure in 620 patients who developed grade 3 or 4 encephalopathy between 1973 and June 1985. The principal aetiologies were paracetamol-induced hepatic necrosis, viral hepatitis, halothane hepatitis and idiosyncratic drug reactions. Cerebral oedema is a major cause of death in these patients and is most effectively treated with mannitol (20%). Renal failure occurs in between 30% and 75% of cases, depending on aetiology, and is most effectively managed by haemodialysis. Electrolyte and acid-base abnormalities are common. Haemodynamic abnormalities encountered include a high cardiac output, low peripheral vascular resistance, hypotension and venodilatation. Assisted mechanical ventilation is frequently required to treat hypoxia caused by pneumonia, atelectasis, haemorrhage and oedema. A coagulopathy is always present but coagulation factors and platelets are given only when the patient is clinically bleeding. These patients are prone to sepsis and this is a significant cause of death. Hypoglycaemia is common and must be actively and frequently sought. The use of charcoal haemoperfusion has been associated with improved survival, especially when it is started during the grade 3 phase of encephalopathy. Recently survival figures of between 47% and 60% have been achieved for patients with paracetamol-induced liver failure and hepatitis A and B. However the figure for non A non B hepatitis and halothane- and drug-induced liver failure are disappointing at around 15% and liver transplantation is being explored as a treatment option in these patients.