Possible acceleration of alcoholic cirrhosis in a patient with bulimia

We report the case of a 27-year-old Caucasian woman with a history of bulimia and alcohol abuse who developed cirrhosis at a rapid rate. We hypothesize that the patient's bulimia, in combination with other possible predisposing factors, potentially accelerated the development of her alcoholic cirrhosis and subsequent medical complications. The association between eating disorders and liver disease is discussed, and the importance of aggressive treatment of eating disorders in combination with alcohol abuse is highlighted.

Predictors of mortality in alcoholic men: a 20-year follow-up study

This study investigates the predictors of mortality in 156 male alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that an older age, liver cirrhosis, and separation or divorce at intake were all associated with a shorter time to death. These results corroborate those of other follow-up studies that have identified age, health, and social support as independent correlates of mortality in alcoholics. From a therapeutic standpoint, the most alterable predictor is social support. Thus, the establishment of a salutary social network and social support system should be an integral part of the alcoholic's treatment plan.

Abstracting capacity in cirrhotic alcoholics: negative findings

OBJECTIVE

Alcoholic and nonalcoholic cirrhotics and normal controls were compared to determine the extent to which the cognitive deficits frequently observed in alcoholics are attributable to hepatic encephalopathy.

METHOD

A battery of neuropsychological tests was administered measuring verbal and nonverbal abstracting capacity.

RESULTS

No significant differences between the three groups were observed. Both the alcoholic (n = 43) and nonalcoholic (n = 63) subjects performed comparably to normal controls (n = 21) and the former two groups performed comparably to each other on seven indicators of abstracting capacity.

CONCLUSIONS

Deficits in reasoning ability are not invariably associated with chronic alcoholism. In addition, low grade hepatic encephalopathy concomitant to cirrhosis in both alcoholics and nonalcoholics does not impact adversely on abstracting capacity.

Rapidly cycling bipolar II disorder following liver transplantation

During the last decade the psychiatric aspects of liver transplantation have been widely described. Although affective complications are some of the most prevalent, a complete and persistent bipolar II syndrome following transplantation has never been reported before. In this paper we describe a patient who developed a rapidly cycling bipolar II disorder after liver transplantation. He presented a major depressive episode within the first 48 hours following transplantation, and subsequently started cycling from depression to hypomania with only brief periods of euthymia. One year after transplantation, only lithium carbonate has proved to be useful to ameliorate his persistent disorder. There was no premorbid or family history of affective illness. Although the course of the disorder seemed to be independent from any pharmacologic or psychosocial factor, it is suggested that transplantation, corticosteroids, and cyclosporine may have played some role in the pathogenesis of the syndrome.

[Liver transplantation in alcoholic liver cirrhosis: social psychological aspects and occupational rehabilitation]

Social-psychological aspects and rehabilitation after liver transplantation were examined in 21 patients. One-year survival was not different in patients with alcoholic liver disease compared with patients with other end-stage liver disease (65% vs 71%). After liver transplantation a temporary return to alcohol drinking was observed in 3 patients (14%). 52% of patients transplanted for alcoholic liver disease are occupationally rehabilitated. Social-psychological conflicts were reported by 46%. Patients with alcoholic liver disease are potential candidates for hepatic transplantation.

The short-term psychological health of alcoholic and non-alcoholic liver transplant recipients

In response to limited resources and overwhelming clinical need, we previously developed an approach to alcoholic patient selection for liver transplant based on factors reported to predict short- and long-term sobriety in prospective studies of alcoholics. The present study reports follow-up data comparing alcohol dependent (n = 22, DSM-3-R criteria) and non-dependent (n = 39) subjects followed from 6 months to 3 years post-transplant. Nine percent of the alcoholics had returned to symptomatic drinking with 14% reporting some exposure to ethyl alcohol. Nearly half (46%) of the non-alcoholic group reported occasional social alcohol use. The alcoholic patients were less likely to be in their first marriage and more likely to be asked about alcohol use at follow-up clinic visits. In most other respects the two groups resembled each other more often than they differed. The alcoholic group reported continued high rates of prognostic factors associated with long-term abstinence although the content of these shifted noticeably between pre- and postoperative assessment. Members of both groups reported high frequencies of medication side effects, of missed doses of medications, and of depressive symptoms. Most felt the transplant had improved their lives but had brought on significant financial burden. There were no differences in subjective appraisals of either psychological or physical health between the two groups. These follow-up data suggest that carefully selected alcohol dependent patients will do as well as non-dependent patients after liver transplant.

Liver transplantation for alcoholic liver disease

BACKGROUND

Alcoholism is the leading cause of end-stage liver failure in the United States, but the application of liver transplantation to the treatment of alcoholic liver disease remains controversial because of medical and ethical concerns. Information about the outcome of patients who undergo transplantation for alcoholic cirrhosis would help to resolve these concerns.

METHODS

The results of 41 patients (Group 1) with alcoholic liver disease were compared with those of patients who underwent liver transplantation for other medical problems (group 2) at this center. Thirty of the 32 survivors from group 1 and 30 matched subjects from group 2 were interviewed to assess substance dependence, recidivism, and activity level.

RESULTS

Compared with control subjects, patients with alcoholic liver disease had equivalent patient and graft survival rates and achieved an equal level of postoperative health. These results were achieved even though patients with alcoholic liver disease had significantly worse liver failure and more morbidity before surgery, and one third of the patients in this group were not abstinent before transplantation.

CONCLUSIONS

We conclude that patients with alcoholic liver disease merit equal consideration for liver transplantation compared with other causes of liver failure. Treatment of the addictive disorder should be included before and after surgery.

Improvement in cognitive functioning of alcoholics following orthotopic liver transplantation

Cognitive functioning in alcoholic cirrhotics before and 1 year following orthotopic liver transplantation was compared with age- and sex-matched normal subjects. The alcoholic group improved significantly following transplantation on tests measuring psychomotor, visuopractic and abstracting abilities whereas the performance of normal controls remained virtually unchanged. In contrast, memory capacity in alcoholics with cirrhosis did not statistically improve following successful transplantation. Further investigation, using more sophisticated measures of memory function, are required to determine whether memory deficits are either associated with alcohol neurotoxicity or an irreversible component of hepatic encephalopathy. These findings suggest that a reversible hepatic encephalopathy underlies many of the neuropsychologic deficits observed in cirrhotic alcoholics and can be ameliorated following successful liver transplantation.

The role of cirrhosis in memory functioning of alcoholics

The effects of alcoholism and liver disease on memory functioning in alcoholics were studied by comparing four groups: normal healthy controls, alcoholics without liver disease, alcoholics with biopsy-confirmed cirrhosis, and nonalcoholics with postnecrotic cirrhosis. Memory capacity was evaluated employing the Benton Visual Retention Test (BVRT), the Rey-Osterreith Complex Figure Test, Digit Span, and the Brown Peterson four-word short-term memory test. A 2 x 2 ANOVA revealed significant main effects for both alcohol and cirrhosis on Digits Forward and the total score on the Brown Peterson test. Additionally, there were significant main effects for cirrhosis on the BVRT. The Brown Peterson test was analyzed using a repeated measures 2 x 2 ANOVA. Significant effects for cirrhosis were observed at all three interpolation periods. The effects for alcohol approached significance at the 30-sec (most difficult) interpolation period. Analysis of error patterns on the Brown Peterson test indicated that overall omission errors were most commonly made among all groups. Significant effects were found for alcohol on omissions and intrusion, while the cirrhosis factor yielded significant effects for phonemic, perseverative, and omission errors. This study demonstrates the importance of liver disease underlying the etiology of memory impairments in alcoholics. The results confirm our earlier findings that neuropsychologic deficits seen in alcoholics may be the result of the combination of alcohol abuse and liver disease.

Psychiatric comorbidity in alcoholism: importance of ascertainment source

Although psychiatric comorbidity is often observed among individuals in treatment facilities for alcoholism, the prevalence and pattern of psychiatric comorbidity among alcoholic cirrhotics has not been well characterized. The present study aimed first to compare the prevalence of psychiatric comorbidity in cirrhotic individuals with alcoholism ascertained from a gastroenterology service with alcoholics ascertained from a treatment facility for alcoholism. Consistent with the findings of other investigators, the data suggest that there is a great degree of variability regarding the severity of alcoholism in alcoholic cirrhotic individuals. Furthermore, cirrhotics with alcoholism exhibited a less severe clinical picture of alcoholism as measured by less alcohol dependence and lower prevalence of psychiatric comorbidity than individuals in treatment for alcoholism. The main conclusion of this study is that ascertainment source is an important determinant of psychiatric comorbidity observed in alcoholic samples.

[Oral bacteriotherapy with Bifidobacterium bifidum and Lactobacillus acidophilus in cirrhotic patients]

Thirty-five patients with alcohol cirrhosis were treated for several months (average 4 months) with Infloran (6 capsules daily). Thirty cirrhotics were treated for the same length of time with lactulose and diuretics. Infloran-treated patients showed reduced ammonium levels, improvement of mental status and psychological performance. In addition, patients who required hospitalization had shorter in-patient periods thanks to a more rapid psychological and physical improvement. Infloran may be considered a valid alternative to conventional therapy for the out-patient management of subjects with alcoholic cirrhosis.

Psychomotor dysfunctions in alcoholic and post-necrotic cirrhotic patients without overt encephalopathy

Psychometric tests, visual reaction time tests and electroencephalograms were performed in 26 cirrhotic patients without overt portal-systemic encephalopathy and in 26 healthy individuals. Cirrhotics performed poorly, compared with controls, on intelligence, learning and memory, perceptual motor and spatial tests. Non-alcoholic scored lower than alcoholic cirrhotics compared with controls in most tests. Visual reaction time ability was lower in cirrhotics than controls, but the etiology of the cirrhosis did not influence the test results. EEG was normal in all subjects. We conclude that psychomotor tests are the most useful tool for the detection of latent encephalopathy and in the discrimination of different cirrhosis.

Impact of cirrhosis on the neuropsychological test performance of alcoholics

Alcoholics and nonalcoholics with biopsy-proven cirrhosis were compared to each other and to a normal control group on a comprehensive battery of neuropsychological tests. No systematic differences were found between the two liver disease groups. These results indicate that a history of alcoholism does not substantially contribute to the manifest neuropsychological deficits beyond that due to a coexistent hepatic encephalopathy.

The diagnosis and prevalence of subclinical hepatic encephalopathy in apparently healthy, ambulant, non-shunted patients with cirrhosis

Thirty-seven patients, all with histologic evidence of cirrhosis and with a normal neurological examination and normal mental status were evaluated by psychometric testing for subclinical hepatic encephalopathy. They were all regarded as having well compensated cirrhosis, not requiring any treatment or dietary restrictions and they were working, and many of them driving. A group of 19 patients with a history of alcoholism, or medical disorders, but without clinical or biochemical evidence of cirrhosis, served as controls. They were matched by age, sex, education, and alcohol consumption. Investigations performed were an EEG, fasting arterial ammonia, liver biochemical tests and a series of verbal and performance psychometric tests. The EEG was abnormal in 3 (8.3%) of patients, the ammonia elevated in 17 (45.9%) of patients and 26 patients (70.3%) failed 2 or more psychometric tests, as compared to 2 (10.5%) of the control group. It is concluded that 2 out of 3 patients with stable, well compensated cirrhosis were suffering from subclinical hepatic encephalopathy and that impairment of performance rather than verbal skills occurred. The digital symbol test, trail test (number connection test) and block design tests readily identified the patients with subclinical hepatic encephalopathy. The implication of these observations in patients with cirrhosis, especially those working in mechanical or skilled occupations, needs consideration.

Hepatic dysfunction and neuropsychological test performance in alcoholics with cirrhosis

Fifteen alcoholic inpatients who had had a liver biopsy for medical reasons were given a series of laboratory tests and a neuropsychological test battery. Results indicated significant correlations between the biochemical measures of hepatic dysfunction and different aspects of cognitive test performance.

Assessing the influence of confounding subject variables in neuropsychological research in alcoholism and related disorders

With the recent emphasis on clinical research there has developed a greater sophistication in identifying and uncovering possible confounding subject variables. The investigator searching for etiologies and underlying relationships is accordingly increasingly faced with the question of how to deal with, or control numerous subject variables which may covary with the condition or disorder under study. The present paper describes some of these variables and the problems their presence raises for the conduct of clinical research. Although most of the examples described such as childhood hyperactivity, head injury, psychopathology, and physical disorders of the subjects are specifically relevant to neuropsychological research in alcoholism, many of them should be pertinent also for related areas of inquiry. The difficulties and problems in controlling, ruling out and taking such variables into account, as well as guidelines and strategies for their treatment and management, are considered. The question of the generality of findings which arises when so many subject variables are controlled is discussed. It is concluded that we are just on the threshold of identifying and clarifying the behavioral effects of numerous subject variables, conditions and disorders. The implications of this situation for the validity of our current research findings are discussed.

The effect of lactulose on psychomotor performance tests in alcoholic cirrhotics without overt hepatic encephalopathy

Thirty-two alcoholic cirrhotics without clinical evidence of encephalopathy were randomized to lactulose or sucrose treatment in order to evaluate the effects of chronic lactulose therapy on five psychomotor performance tests. Statistically significant improvement was seen in three of the five tests in the lactulose-treated group, while no significant improvement in any test was noted in the sucrose group. However, because of the limited extent of improvement in the lactulose treated group, problems with medication intolerance, and lack of improvement in complex psychosocial behavior, the impact of chronic lactulose therapy on mental function in cirrhotics without overt encephalopathy appears to be limited.

Quantitative psychometric testing and subclinical hepatic encephalopathy--comparative study between encephalopathic and non-encephalopathic patients with liver cirrhosis

Six quantitative psychometric tests were performed on 51 healthy subjects, 19 cirrhotic patients with subclinical hepatic encephalopathy (SHE), 32 cirrhotic patients without SHE, and 26 patients with other diseases. Strong correlations between age and the results of all the psychometric tests were observed in the healthy subjects (p less than 0.005). Sex and etiology of liver cirrhosis did not affect the test results. SHE patients, compared with non-SHE and health subjects, presented impairment in the ability to perform the tests, even in the absence of obvious clinical and electroencephalogram findings. In SHE patients, trailmaking test A (TMT A) yielded the highest frequency of abnormal values, 63%. TMT A results were abnormal in 80% of SHE patients with abnormal scores in other tests, and thus it seemed to be the most sensitive test. Liver function tests did not correlate with psychometric testing in any of the groups. Blood ammonia levels in SHE patients with abnormal TMT A scores correlated with TMT A scores (r = 0.752, p less than 0.01); this was not the case in SHE nor non-SHE patients with normal TMT A results. These data demonstrate the usefulness of psychometric tests in detecting SHE.