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Singh J, Ebaid M, Saab S. Advances in the management of complications from cirrhosis. Gastroenterol Rep (Oxf) 2024; 12:goae072. [PMID: 39104730 PMCID: PMC11299547 DOI: 10.1093/gastro/goae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 08/07/2024] Open
Abstract
Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.
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Affiliation(s)
- Jasleen Singh
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark Ebaid
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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2
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Li X, Liu S, Guo Y, Zu H, Xiang H, Yang S, Zhang X, Meng F, Bianba Y, Li J, Liu F, Lei C, Lv J, Yang Q, Fu W, Ye W, Chen J, Gao Y, Wu C, Wang N, Zheng Q, Wang F, Yu J, Wang J, Yang X, Wang X, Liu Y, Zhao X, Wu C, Gou W, Bajaj JS, Wang F, Fu J, Qi X. Detection of minimal hepatic encephalopathy in patients with cirrhosis based on the Stroop-CN model (NCRCID-CHESS 2106): a prospective multicenter study. MedComm (Beijing) 2024; 5:e627. [PMID: 39015557 PMCID: PMC11247336 DOI: 10.1002/mco2.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 07/18/2024] Open
Abstract
Minimal hepatic encephalopathy (MHE) has a substantial impact on the clinical outcomes and quality of life (QOL) of patients with cirrhosis. However, timely diagnosis and intervention are challenging due to sophisticated diagnostic methods. In this study, 673 healthy controls and 905 patients with cirrhosis were screened, and 660 healthy controls and 757 patients with cirrhosis, divided into the test (292 patients) and validation (465 patients) cohort, were analyzed after screening. A diagnostic model of the Stroop test (Stroop-CN) was constructed by multivariate linear regression based on the results of healthy controls. The prevalence of MHE and the comparison results with psychometric hepatic encephalopathy score through the Stroop-CN model were stable in the test and validation cohorts. Moreover, the prevalence of MHE remained significantly higher in patients with worse disease conditions marked as high Child-Pugh grades and the Model for End-stage Liver Disease and Sodium (MELD-Na) scores in the test and validation cohort. The EuroQol 5-D questionnaire revealed that patients with MHE had a worse QOL than those without MHE both in the test and validation cohort. In conclusion, an easy and practical Stroop-CN model for MHE diagnosis based on the EncephalApp is established. It is found that a considerable number of Chinese patients with cirrhosis experience MHE, which significantly impacts their QOL.
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Affiliation(s)
- Xiaoyan Li
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Shanghao Liu
- Center of Portal HypertensionDepartment of RadiologyZhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University)NanjingChina
- Basic Medicine Research and Innovation Center of Ministry of EducationZhongda HospitalSoutheast UniversityNanjingChina
- State Key Laboratory of Digital Medical EngineeringNanjingChina
| | - Ying Guo
- Department of HepatologyThe Third People's Hospital of TaiyuanTaiyuanChina
| | - Hongmei Zu
- Department of GastroenterologyThe Fourth People's Hospital of Qinghai ProvinceXiningChina
| | - Huiling Xiang
- Department of Gastroenterology and HepatologyTianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Institute of Hepatobiliary DiseaseTianjinChina
| | - Shaoqi Yang
- Department of GastroenterologyThe General Hospital of Ningxia Medical UniversityYinchuanChina
| | - Xiaoning Zhang
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Fanping Meng
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Yangzhen Bianba
- Department of HepatologyThe Third People's Hospital of Tibet Autonomous RegionLhasaChina
| | - Jie Li
- Department of Infectious DiseasesNanjing Drum Tower Hospital, The Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Fei Liu
- Department of Infectious DiseasesHunan Key Laboratory of Viral HepatitisXiangya HospitalCentral South UniversityChangshaChina
| | - Chuang Lei
- Department of Infectious DiseasesThe First People's Hospital of Changde CityChangdeChina
| | - Jiaojian Lv
- Department of Infectious DiseaseLishui City People's HospitalLishuiChina
| | - Qiao‐hua Yang
- Hepatology Department of Infectious Diseases CenterThe First People's Hospital of HuaihuaHuaihuaChina
| | - Wei Fu
- Department of HepatologyShenyang 739 HospitalShenyangChina
| | - Wei Ye
- Liver Cirrhosis Treatment CenterNanjing Hospital Affiliated to Nanjing University of Traditional Chinese MedicineNanjingChina
| | - Jiafang Chen
- Department of GastroenterologyDatong City Fourth People's HospitalDatongChina
| | - Yanjing Gao
- Department of GastroenterologyQilu Hospital of Shandong UniversityJinanChina
| | - Caiyun Wu
- Department of HepatologyThird People′s Hospital of Linfen CityLinfenChina
| | - Ningning Wang
- Department of GastroenterologyThe First Hospital of China Medical UniversityShenyangChina
| | - Qi Zheng
- Department of HepatologyHepatology Research InstituteThe First Affiliated HospitalFujian Medical UniversityFuzhouChina
| | - Fang Wang
- Department of HepatologyShenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease, The Second Affiliated Hospital, School of Medicine, Southern University of Science and TechnologyShenzhenChina
| | - Jiali Yu
- Department of GastroenterologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Jing Wang
- Department of GastroenterologyThe Second Affiliated Hospital of Baotou Medical CollegeBaotouChina
| | - Xiaoting Yang
- Department of GastroenterologyWuzhong People's HospitalWuzhongChina
| | - Xiangmei Wang
- Department of Severe HepatologyMengchao Hepatobiliary Hospital of Fujian Medical UniversityFuzhouChina
| | - Yayuan Liu
- Department of GastroenterologyCentral hospital of DandongDandongChina
| | - Xuelan Zhao
- Department of Gastroenterology Liver DiseasesChongqing Public Health Medical CenterChongqingChina
| | - Chenxi Wu
- Liver Disease Diagnosis and Treatment CenterYiyang Fourth People's HospitalYiyangChina
| | - Wei Gou
- Qingdao Sixth People's HospitalQingdaoChina
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and Central Virginia Veterans Healthcare SystemRichmondVirginiaUSA
| | - Fu‐Sheng Wang
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Junliang Fu
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Xiaolong Qi
- Center of Portal HypertensionDepartment of RadiologyZhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University)NanjingChina
- Basic Medicine Research and Innovation Center of Ministry of EducationZhongda HospitalSoutheast UniversityNanjingChina
- State Key Laboratory of Digital Medical EngineeringNanjingChina
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Smith ML, Wade JB, Wolstenholme J, Bajaj JS. Gut microbiome-brain-cirrhosis axis. Hepatology 2024; 80:465-485. [PMID: 36866864 PMCID: PMC10480351 DOI: 10.1097/hep.0000000000000344] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/10/2023] [Indexed: 03/04/2023]
Abstract
Cirrhosis is characterized by inflammation, degeneration, and fibrosis of liver tissue. Along with being the most common cause of liver failure and liver transplant, cirrhosis is a significant risk factor for several neuropsychiatric conditions. The most common of these is HE, which is characterized by cognitive and ataxic symptoms, resulting from the buildup of metabolic toxins with liver failure. However, cirrhosis patients also show a significantly increased risk for neurodegenerative diseases such as Alzheimer and Parkinson diseases, and for mood disorders such as anxiety and depression. In recent years, more attention has been played to communication between the ways the gut and liver communicate with each other and with the central nervous system, and the way these organs influence each other's function. This bidirectional communication has come to be known as the gut-liver-brain axis. The gut microbiome has emerged as a key mechanism affecting gut-liver, gut-brain, and brain-liver communication. Clinical studies and animal models have demonstrated the significant patterns of gut dysbiosis when cirrhosis is present, both with or without concomitant alcohol use disorder, and have provided compelling evidence that this dysbiosis also influences the cognitive and mood-related behaviors. In this review, we have summarized the pathophysiological and cognitive effects associated with cirrhosis, links to cirrhosis-associated disruption of the gut microbiome, and the current evidence from clinical and preclinical studies for the modulation of the gut microbiome as a treatment for cirrhosis and associated neuropsychiatric conditions.
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Affiliation(s)
- Maren L Smith
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - James B Wade
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer Wolstenholme
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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Ortiz-Treviño JF, Kuljacha-Gastélum AL, Tovar-Durán A, Wade-Isidro ME. Stroop test, Quickstroop, and the 1-min animal naming test for minimal hepatic encephalopathy diagnosis: A multicenter study in Mexico. Ann Hepatol 2024; 29:101531. [PMID: 39033930 DOI: 10.1016/j.aohep.2024.101531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 07/04/2024] [Accepted: 07/09/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION AND OBJECTIVES Although the Psychometric Hepatic Encephalopathy Score (PHES) remains the gold standard in diagnosing minimal hepatic encephalopathy (MHE), its complexity limits its application in clinical practice. While more convenient tests, such as the Stroop test, Quickstroop, and the 1-min animal naming test (ANT-1), have emerged, they haven't been validated in our setting. Our objective was to validate these tests in our population. PATIENTS AND METHODS This multicenter, observational, descriptive, and cross-sectional study was conducted in three hospitals in northeastern Mexico. MHE was defined as a PHES <-4. We included patients with cirrhosis aged >15 years without a history of overt hepatic encephalopathy. Data regarding sex, age, education, Child-Pugh/MELD-Na scores, etiology of cirrhosis, diabetes, hypertension, obesity, ascites, and clinically significant portal hypertension was collected. Fisher's exact test, Mann-Whitney U test, and receiver operating characteristic (ROC) curves were used for statistical analysis. RESULTS Of the 121 patients included, 35.5 % were diagnosed with MHE. The presence of MHE was significantly associated with education level, years of study, and scores in the Stroop test, Quickstroop, and ANT-1. The AUROC curves were 77.9 %, 74.6 %, and 72.7 % for the Stroop test, Quickstroop, and ANT-1, respectively. The resulting cut-off points were 218.398 (sensitivity: 74 %; specificity: 74 %), 40.535 (sensitivity: 77 %; specificity: 68 %), and <16 animals (sensitivity: 58 %; specificity: 79 %), respectively. CONCLUSIONS These tests are valid diagnostic tools for detecting MHE in our population. Their simpler use and applicability could increase the early diagnosis of MHE and prompt primary prophylaxis initiation for overt hepatic encephalopathy.
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Affiliation(s)
- Juan F Ortiz-Treviño
- Gastroenterology department, high specialty medical unit (UMAE) No. 25, Northeast National Medical Center, IMSS, Monterrey, Nuevo León, P.C. 64320, Mexic
| | - Alma L Kuljacha-Gastélum
- Gastroenterology department, high specialty medical unit (UMAE) No. 25, Northeast National Medical Center, IMSS, Monterrey, Nuevo León, P.C. 64320, Mexic.
| | - Alejandro Tovar-Durán
- Gastroenterology Department, Zone General Hospital No. 33, IMSS, Monterrey, Nuevo León, P.C. 64010, Mexic
| | - Martha E Wade-Isidro
- Gastroenterology Department, Zone General Hospital No. 17, IMSS, Monterrey, Nuevo León, P.C. 64420, Mexic
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Singh J, Ibrahim B, Han SH. Nontraditional Treatment of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:297-315. [PMID: 38548441 DOI: 10.1016/j.cld.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The pathophysiology of hepatic encephalopathy (HE) is complex, with hyperammonemia playing a central role in its development. Traditional therapies for HE have targeted ammonia and include medications such as lactulose and rifaximin. Although these agents are considered standard of care, nontraditional treatments seek to affect other factors in the pathogenesis of HE. Finally, procedural therapies include albumin dialysis, shunt closure, and the ultimate cure for HE, which is liver transplant. The treatments discussed provide alternative options for patients who have failed standard of care. However, more high-quality studies are needed to routinely recommend many of these agents.
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Affiliation(s)
- Jasleen Singh
- Department of Medicine, University of California at Los Angeles; Los Angeles, CA, USA.
| | - Brittney Ibrahim
- Department of Surgery, University of California at Los Angeles; Los Angeles, CA, USA
| | - Steven-Huy Han
- Department of Medicine, University of California at Los Angeles; Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles; Los Angeles, CA, USA
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Lv XH, Lu Q, Deng K, Yang JL, Yang L. Prevalence and Characteristics of Covert/Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2024; 119:690-699. [PMID: 37856206 DOI: 10.14309/ajg.0000000000002563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Covert/minimal hepatic encephalopathy (C/MHE) is the mildest form of hepatic encephalopathy (HE), but it is closely related to the quality of life and prognosis of patients with cirrhosis. Currently, the epidemiological data of C/MHE have not been well described. METHODS We searched the PubMed, Embase, and Cochrane Library databases for relevant articles. We performed a random-effects meta-analysis of proportions to estimate the pooled prevalence of C/MHE in patients with cirrhosis. We also examined potential risk factors for C/MHE by comparing characteristics of patients with and without C/MHE. RESULTS Finally, a total of 101 studies were included. The prevalence of C/MHE was 40.9% (95% confidence interval, 38.3%-43.5%) among patients with cirrhosis worldwide. The pooled C/MHE prevalence was 39.9% (95% confidence interval 36.7%-43.1%) based on studies using the psychometric HE score as a diagnostic tool. Meta-regression models showed that geographic region, sample size, mean age, sex ratio, and Child-Pugh classification were influencing factors for the heterogeneity of C/MHE prevalence. The presence of C/MHE was found to be associated with various factors including age, level of education, alcoholic etiology, Child-Pugh classification, MELD score, history of overt HE, presence of other complications, and laboratory tests related to impaired liver function. DISCUSSION This study reports detailed data on the prevalence of C/MHE as well as clinical features associated with C/MHE, suggesting that C/MHE is one of the most common complications of liver cirrhosis.
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Affiliation(s)
- Xiu-He Lv
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Qing Lu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Kai Deng
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jin-Lin Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Nadeem M, Tafader A, Park D, Fagan A, Wade JB, Bajaj JS. A specialized HE testing clinic improves rational decision-making for therapy in cirrhosis. Hepatol Commun 2023; 7:e0301. [PMID: 38016049 PMCID: PMC10578715 DOI: 10.1097/hc9.0000000000000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 08/31/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Cognitive complaints in cirrhosis are often attributed to HE with reflexive therapy if specialized tests are not performed. The aim was to determine the utility of a specialized HE clinic for management decisions. METHODS Cirrhosis patients with cognitive complaints were referred through a dedicated consult pathway to a specialized clinic and followed for 6 months. This clinic included detailed history, medication review, standardized tests [Mini-Mental Status Exam (MMSE), Psychometric HE Score, and others], and obstructive sleep apnea screening. Results were communicated with patients and referring providers. A subset was offered repeat testing. RESULTS A total of 286 patients were tested between 2012 and 2022. Of the 286 patients, 4 patients who showed a Mini-Mental State Exam <25 were referred to neurology. Thirty-nine percent had normal Psychometric HE Score (higher in younger patients, without prior HE, depression, and lower Model for End-Stage Liver Disease-Sodium), while 172 (61%) patients had cognitive impairment. Of the 172 patients, 51 did not want management change, 84 were started on HE therapy, and 37 were considered impaired due to other causes. In 51 without management change, 32 refused lactulose, while the remaining were counseled regarding lactulose titration. Of the 84 patients with HE-therapy initiation, lactulose was initiated in 56 and rifaximin in 28; most therapies continued over 6 months. The ones who were retested improved their Psychometric HE Score. The 37 with other causes (obstructive sleep apnea, mood disorders, substance use, and mild cognitive impairment) led to specialized referrals. No overt HE was found over 6 months in those without HE-related impairment. The clinic was billed for. CONCLUSIONS A specialized HE clinic for patients with cirrhosis and cognitive complaints established through a dedicated consult pathway showed that 39% of referred patients had normal cognitive performance, while the results guided management changes, including for HE and other causes in the remaining patients.
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Affiliation(s)
- Mahum Nadeem
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Asiya Tafader
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Dan Park
- Department of Medicine, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Andrew Fagan
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - James B. Wade
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
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Ballester MP, Tranah TH, Balcar L, Fiorillo A, Ampuero J, Kerbert AJC, Thomsen KL, Escudero MD, Mandorfer M, Reiberger T, Shawcross DL, Romero-Gómez M, Montoliu C, Carbonell-Asins JA, Jalan R. Development and validation of the AMMON-OHE model to predict risk of overt hepatic encephalopathy occurrence in outpatients with cirrhosis. J Hepatol 2023; 79:967-976. [PMID: 37277075 DOI: 10.1016/j.jhep.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND & AIMS Neuropsychological and psychophysical tests are recommended to assess the risk of overt hepatic encephalopathy (OHE), but their accuracy is limited. Hyperammonaemia is central in the pathogenesis of OHE, but its predictive utility is unknown. In this study, we aimed to determine the role of neuropsychological or psychophysical tests and ammonia, and to develop a model (AMMON-OHE) to stratify the risk of subsequent OHE development in outpatients with cirrhosis. METHODS This observational, prospective study included 426 outpatients without previous OHE from three liver units followed for a median of 2.5 years. Psychometric hepatic encephalopathy score (PHES) <-4 or critical flicker frequency (CFF) <39 was considered abnormal. Ammonia was normalized to upper limit of normal (AMM-ULN) at the respective reference laboratory. Multivariable frailty competing risk and random survival forest analyses were performed to predict future OHE and to develop the AMMON-OHE model. External validation was carried out using 267 and 381 patients from two independent units. RESULTS Significant differences were found in time-to-OHE (log-rank p <0.001) according to PHES or CFF and ammonia, with the highest risk in patients with abnormal PHES plus high AMM-ULN (hazard ratio 4.4; 95% CI 2.4-8.1; p <0.001 compared with normal PHES and AMM-ULN). On multivariable analysis, AMM-ULN but not PHES or CFF was an independent predictor of the development of OHE (hazard ratio 1.4; 95% CI 1.1-1.9; p = 0.015). The AMMON-OHE model (sex, diabetes, albumin, creatinine and AMM-ULN) showed a C-index of 0.844 and 0.728 for the prediction of a first episode of OHE in two external validation cohorts. CONCLUSIONS In this study, we developed and validated the AMMON-OHE model, comprising readily available clinical and biochemical variables that can be used to identify outpatients at the highest risk of developing a first episode of OHE. IMPACT AND IMPLICATIONS In this study, we aimed to develop a model to predict which patients with cirrhosis are at risk of developing overt hepatic encephalopathy (OHE). Using data from three units and including 426 outpatients with cirrhosis, we developed the AMMON-OHE model - comprising sex, diabetes, albumin, creatinine and ammonia levels - which demonstrated good predictive ability. The AMMON-OHE model performs better than PHES and CFF to predict the first episode of OHE in outpatients with cirrhosis. This model was validated in 267 and 381 patients from two independent liver units. The AMMON-OHE model is available online for clinical use.
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Affiliation(s)
- Maria Pilar Ballester
- Digestive Disease Department, Hospital Clínico Universitario de Valencia, Spain; INCLIVA Biomedical Research Institute, Valencia, Spain.
| | - Thomas H Tranah
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King´s College London, London, United Kingdom
| | - Lorenz Balcar
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | | | - Javier Ampuero
- Digestive Diseases Department, Ciberehd, Virgen del Rocío University Hospital, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), University of Seville, Sevilla, Spain
| | - Annarein J C Kerbert
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Karen L Thomsen
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - María Desamparados Escudero
- Digestive Disease Department, Hospital Clínico Universitario de Valencia, Spain; Department of Medicine, Faculty of Medicine, University of Valencia, Spain
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Debbie L Shawcross
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King´s College London, London, United Kingdom
| | - Manuel Romero-Gómez
- Digestive Diseases Department, Ciberehd, Virgen del Rocío University Hospital, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), University of Seville, Sevilla, Spain
| | - Carmina Montoliu
- INCLIVA Biomedical Research Institute, Valencia, Spain; Department of Pathology, Faculty of Medicine, University of Valencia, Spain
| | | | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; European Foundation for the Study of Chronic Liver Failure (EF Clif), Spain.
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Ehrenbauer AF, Schneider H, Stockhoff L, Tiede A, Lorenz C, Dirks M, Witt J, Gabriel MM, Wedemeyer H, Hinrichs JB, Weissenborn K, Maasoumy B. Predicting overt hepatic encephalopathy after TIPS: Value of three minimal hepatic encephalopathy tests. JHEP Rep 2023; 5:100829. [PMID: 37600959 PMCID: PMC10432804 DOI: 10.1016/j.jhepr.2023.100829] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background & Aims Hepatic encephalopathy (HE) is a frequent and severe complication in patients after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for post-TIPS HE remain poorly defined. Minimal HE (mHE) is a well-known risk factor for overt HE in patients with cirrhosis without TIPS. We aimed to evaluate three tools frequently used for diagnosing mHE for their dynamic changes and their predictive value for overt HE after TIPS. Methods We prospectively recruited 84 consecutive patients before TIPS insertion and monitored them for 180 days for post-TIPS HE. Before TIPS insertion, the patients underwent the portosystemic encephalopathy (PSE) syndrome test, the animal naming test (ANT), and the critical flicker frequency (CFF). Patients were retested after TIPS insertion. Results The majority of patients were male (67.9%), and the predominant indication for TIPS was refractory ascites (75%). Median age was 59 years, model for end-stage liver disease score was 12, and 66.3%, 64.6%, and 28.4% patients had evidence for mHE according to the PSE syndrome test, ANT, and CFF, respectively. Overall, 25 patients developed post-TIPS HE within 180 days after TIPS insertion. Post-TIPS incidence of overt HE was 22.2, 28.6, 45.5, and 55.6% in those with no, one, two, and three pathological tests at baseline, respectively. However, none of the three tests was significantly associated with post-TIPS HE. Of note, mean performance in all tests remained stable over time after TIPS insertion. Conclusions PSE syndrome test, ANT and CFF, which are frequently used for diagnosing mHE have limited value for predicting HE after TIPS insertion. We could not find evidence that TIPS insertion leads to a psychometric decline in the long term. Impact and implications This prospective observational study compared three diagnostic tests for mHE and showed the limited value of these tests for predicting overt HE in patients with cirrhosis undergoing TIPS insertion. In addition, the results suggest that cognitive performance generally remains stable after TIPS insertion. These results are important for physicians and researchers involved in the management of patients with cirrhosis undergoing TIPS procedures. The study's findings serve as a starting point for further investigations on the development of more effective strategies for predicting and managing post-TIPS HE. Clinical trial number ClinicalTrials.gov NCT04801290.
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Affiliation(s)
- Alena F. Ehrenbauer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Hannah Schneider
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Lena Stockhoff
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Anja Tiede
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Charlotte Lorenz
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Meike Dirks
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Jennifer Witt
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
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10
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Rogalski P, Bogdanowska-Charkiewicz D, Rogalska-Plonska M, Lukaszewicz-Zajac M, Kostecka-Roslen I, Mroczko B, Dabrowska M, Wasielica-Berger J, Aleksiejuk E, Antonowicz S, Dabrowski A, Daniluk J, Janica J. Elevated levels of soluble glycoprotein V - The plasma marker of platelet activation by thrombin in patients with early stage primary biliary cholangitis (PBC). Adv Med Sci 2023; 68:71-78. [PMID: 36758500 DOI: 10.1016/j.advms.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/30/2022] [Accepted: 01/19/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE There is a growing body of evidence for a prothrombotic tendency in patients with primary biliary cholangitis (PBC). The aim of the study was to evaluate coagulation disorders in patients with early stage PBC compared to healthy controls and evaluation of their relationship with clinical data, with particular emphasis on minimal hepatic encephalopathy (MHE). PATIENTS AND METHODS Fifty-one participants (PBC group - 38 patients, all patients but one Child-Pugh A; control group - 13 healthy controls) were included in our prospective, single center study. We assessed the plasma levels of sGPV, plasma procoagulant phospholipids (PPL) and rotational thromboelastometry (ROTEM) profiles in all study participants. Porto-systemic encephalopathy syndrome test was used to assess MHE. RESULTS The sGPV levels were higher in the PBC group compared to the controls: 36.07 ± 11.32 ng/mL vs 27.04 ± 11.72 ng/mL, p = 0.031. The PPL level was lower in the PBC group compared to controls resulting in increased clotting time in a factor Xa-based coagulation assay: 54.65 (47.83-58.83) sec. vs 45.90 (43.3-50.5) sec., p = 0.0065. PPL levels were correlated with platelet count (rho = -0.46, p = 0.001). ROTEM parameters did not differ significantly between groups. Coagulation parameters did not differ significantly between patients with and without MHE. CONCLUSIONS We have showed increased levels of sGPV - a plasma marker of platelet activation by thrombin in patients with early stage PBC compared to healthy controls. We found no relationship between the coagulation disorders and the occurrence of MHE. The PPL level was lower in the PBC group.
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Affiliation(s)
- Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland.
| | | | | | | | - Ines Kostecka-Roslen
- Department of Haematological Diagnostics, Medical University of Bialystok, Bialystok, Poland
| | - Barbara Mroczko
- Department of Biochemical Diagnostics, Medical University of Bialystok, Bialystok, Poland
| | - Milena Dabrowska
- Department of Haematological Diagnostics, Medical University of Bialystok, Bialystok, Poland
| | - Justyna Wasielica-Berger
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Elzbieta Aleksiejuk
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Stefania Antonowicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Jaroslaw Daniluk
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Jacek Janica
- Department of Radiology, Medical University of Bialystok, Bialystok, Poland; Department of Paediatric Radiology, Medical University of Bialystok, Bialystok, Poland
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11
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Kim MJ, Kim JH, Jung JH, Kim SE, Kim HS, Jang MK, Park SH, Lee MS, Suk KT, Kim DJ, Choi EK, Park JW. Serum S100B Levels in Patients with Liver Cirrhosis and Hepatic Encephalopathy. Diagnostics (Basel) 2023; 13:diagnostics13030333. [PMID: 36766438 PMCID: PMC9914222 DOI: 10.3390/diagnostics13030333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the main complications of liver cirrhosis (LC) and is classified into minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy (overt HE). S100B is expressed mainly in astrocytes and other glial cells, and S100B has been reported to be associated with various neurological disorders. The present study aimed to investigate the diagnostic ability of serum S100B to discriminate the grade of HE and the parameters correlated with serum S100B levels. Additionally, we investigated whether serum S100B levels can be used to predict 1-year mortality in cirrhotic patients. In total, 95 cirrhotic patients were consecutively enrolled and divided into the following three groups: (i) without any types of HEs; (ii) with MHE; and (iii) with overt HE. The diagnosis of MHE was made by the Mini-Mental State Examination (MMSE) and Psychometric Hepatic Encephalopathy Score (PHES). Among the three groups, there were no significant differences in serum S100B levels regardless of HE severity. The clinical parameters correlated with serum S100B levels were age, serum bilirubin, and creatinine levels. The Model for End-Stage Liver Disease (MELD) score showed a significant positive correlation with serum S100B levels. The relationship between serum S100B levels and MELD score was maintained in 48 patients without any type of HE. Additionally, hyperammonemia, low cholesterol levels, and the combination of serum S100B levels ≥ 35 pg/mL with MELD score ≥ 13 were factors for predicting 1- year mortality. In conclusion, serum S100B level was not useful for differentiating the severity of HE. However, we found that serum S100B levels can be affected by age, serum bilirubin, and creatinine in cirrhotic patients and are associated with MELD scores. Additionally, serum S100B levels showed the possibility of predicting 1-year mortality in cirrhotic patients. These findings suggest that serum S100B levels may reflect liver dysfunction and prognosis in liver disease.
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Affiliation(s)
- Mo-Jong Kim
- Ilsong Institute of Life Science, Hallym University, Seoul 07247, Republic of Korea
- Department of Biomedical Gerontology, Graduate School of Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Jung-Hee Kim
- Department of Internal Medicine, Dongtan Sacred Heart Hospital of Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Jang-Han Jung
- Department of Internal Medicine, Dongtan Sacred Heart Hospital of Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Sung-Eun Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Hallym University Sacred Heart Hospital of Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si 14068, Republic of Korea
| | - Hyoung-Su Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Republic of Korea
| | - Myoung-Kuk Jang
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Republic of Korea
| | - Sang-Hoon Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital of Hallym University Medical Center, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Myung-Seok Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital of Hallym University Medical Center, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Ki Tae Suk
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea
| | - Dong Joon Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea
| | - Eun-Kyoung Choi
- Ilsong Institute of Life Science, Hallym University, Seoul 07247, Republic of Korea
- Department of Biomedical Gerontology, Graduate School of Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Ji-Won Park
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Hallym University Sacred Heart Hospital of Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si 14068, Republic of Korea
- Correspondence: ; Tel.: +82-31-380-3705
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12
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Margaryan SR, Mitupov ZB, Razumovsky AY. [Hepatic encephalopathy after portosystemic bypass surgery]. Khirurgiia (Mosk) 2023:57-65. [PMID: 37379406 DOI: 10.17116/hirurgia202307157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The most effective modern treatment for gastrointestinal bleeding following portal hypertension is portosystemic bypass surgery. Hepatic encephalopathy after these procedures is still an urgent problem in modern pediatric surgery, and radical treatment is unknown. To optimize treatment outcomes in children with hepatic encephalopathy, we should choose adequate treatment considering the risk of hepatic encephalopathy in the future. In this review, the authors discuss modern data on hepatic encephalopathy regarding symptoms, advantages and disadvantages of various treatment methods. Risk of hepatic encephalopathy with and without surgical treatment, as well as methods of diagnosis and treatment are particularly analyzed. Total portosystemic bypass surgery, especially portocaval shunt, is followed by higher risk of hepatic encephalopathy compared to selective shunts and physiological mesoportal bypass. The last two approaches are advisable to improve treatment outcomes in children with hepatic encephalopathy.
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Affiliation(s)
- S R Margaryan
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
| | - Z B Mitupov
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
| | - A Yu Razumovsky
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
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13
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Ngu NLY, Saxby E, Farmer CC, Lyon S, Le S. Functional recovery from refractory hepatic encephalopathy following angiographic obliteration of a large, spontaneous portal-umbilical portosystemic shunt: a case report. CVIR Endovasc 2022; 5:45. [PMID: 36002541 PMCID: PMC9402870 DOI: 10.1186/s42155-022-00320-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/08/2022] [Indexed: 11/11/2022] Open
Abstract
Background Hepatic encephalopathy (HE) as a consequence of cirrhosis with portal hypertension has a profound impact on quality of life for both patients and caregivers, has no gold-standard diagnostic test, and is a risk factor for mortality. Spontaneous portosystemic shunts (SPSS) are common in patients with cirrhosis, can be challenging to identify, and in some cases, can drive refractory HE. Cross-sectional shunt size greater than 83mm2 is associated with liver disease severity, overt HE, and mortality. Case presentation We report a patient with refractory HE and frequent hospitalization in the context of an occult spontaneous portal-umbilical portosystemic shunt with an estimated cross-sectional area of 809mm2. Following identification and angiographic retrograde transvenous obliteration of the SPSS using plugs, coils and sclerosant, there was improvement in neurocognitive testing and no further hospitalization for HE. Conclusion SPSS in the context of cirrhosis with portal hypertension can contribute to the debilitating effects of refractory HE. This case highlights the opportunity to search for SPSS in patients with HE unresponsive to therapy as angiographic obliteration is usually safe, well-tolerated, and clinically effective.
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14
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Ballester MP, Gallego JJ, Fiorillo A, Casanova-Ferrer F, Giménez-Garzó C, Escudero-García D, Tosca J, Ríos MP, Montón C, Durbán L, Ballester J, Benlloch S, Urios A, San-Miguel T, Kosenko E, Serra MÁ, Felipo V, Montoliu C. Metabolic syndrome is associated with poor response to rifaximin in minimal hepatic encephalopathy. Sci Rep 2022; 12:2463. [PMID: 35165326 PMCID: PMC8844048 DOI: 10.1038/s41598-022-06416-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/18/2022] [Indexed: 12/13/2022] Open
Abstract
AbstractPatients with cirrhosis may show minimal hepatic encephalopathy (MHE), for which rifaximin is effective. Metabolic syndrome may be associated with cognitive impairment. Our aims were to evaluate the influence of metabolic syndrome features on response to rifaximin for neurological and inflammatory alterations in MHE. A prospective cohort study was conducted in 63 cirrhotic patients and 30 controls from two tertiary centres recruited between 2015 and 2019. Metabolic syndrome was defined according to the Adult Treatment Panel-III. Patients were classified into 31 without and 32 with MHE according to the Psychometric Hepatic Encephalopathy Score (PHES). All participants performed specific psychometric tests, and inflammatory parameters were studied. Patients with MHE received rifaximin (400 mg/8 h). Response was evaluated by PHES at 3 and 6 months. Response according to metabolic syndrome manifestations was compared. The response rate was 66%. Older age (p = 0.012) and all metabolic syndrome diseases (p < 0.05) were associated with non-response, plus an increase in risk as the number of manifestations rose (p < 0.001). Patients with metabolic manifestations exhibited worse processing speed (p = 0.011), working memory (p = 0.005), visual coordination (p = 0.013) and lower proportion of activated CD4+ lymphocytes (p = 0.039) at baseline, as well as worse concentration (p = 0.030), bimanual coordination (p = 0.004) and higher levels of intermediate monocytes (p = 0.026), CX3CL1 (p < 0.05), IL-17 (p = 0.022), AHR (p = 0.010) and IgG (p < 0.05) at 3 and/or 6 months of rifaximin. Patients with clinical signs of metabolic syndrome have poor response to rifaximin for MHE, with a higher proportion of neurological alterations associated with a pro-inflammatory environment.
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15
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Attia MS, Youssef AO, Abdel-Sattar NA, Amin MA, Alharthi S, Mohamed EH, Mahmoud SA, Abou-Omar MN. A highly selective and sensitive spectrofluorimetric method for the assessment of 3-nitrotyrosine in serum using (Eu(TTA) 3Phen) photo probe. RSC Adv 2022; 12:4536-4542. [PMID: 35425515 PMCID: PMC8981050 DOI: 10.1039/d1ra07351f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 01/22/2022] [Indexed: 11/21/2022] Open
Abstract
A simple, accurate and fast method was developed for the assessment of 3-nitrotyrosine as a biomarker for the early diagnosis of liver cirrhosis with minimal hepatic encephalopathy (MHE) using a (Eu(TTA)3Phen) photo probe. 3-Nitrotyrosine can remarkably quench the luminescence intensity of the (Eu(TTA)3Phen) complex in DMSO at pH = 9 and λem = 617 nm. The quenching of the luminescence intensity of (Eu(TTA)3Phen) complex particularly the electrical emission band at λem = 617 nm is used for the assessment of 3-nitrotyrosine in different serum samples of patients with liver cirrhosis. A simple, accurate and fast method was developed for the assessment of 3-nitrotyrosine as a biomarker for the early diagnosis of liver cirrhosis with minimal hepatic encephalopathy (MHE) using a (Eu(TTA)3Phen) photo probe.![]()
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Affiliation(s)
- Mohmed S Attia
- Chemistry Department, Faculty of Science, Ain Shams University Cairo 11566 Egypt
| | - Ahmed O Youssef
- Chemistry Department, Faculty of Science, Ain Shams University Cairo 11566 Egypt
| | - Nour A Abdel-Sattar
- Chemistry Department, Faculty of Science, Ain Shams University Cairo 11566 Egypt
| | - Mohammed A Amin
- Department of Chemistry, College of Science, Taif University P.O. Box 11099 Taif 21944 Saudi Arabia
| | - Sarah Alharthi
- Department of Chemistry, College of Science, Taif University P.O. Box 11099 Taif 21944 Saudi Arabia
| | - Ekram H Mohamed
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, The British University in Egypt El Sherouk City Cairo Egypt
| | - Safwat A Mahmoud
- Physics Department, Faculty of Science, Northern Border University Arar Saudi Arabia
| | - Mona N Abou-Omar
- Department of Chemistry, Faculty of Women for Arts, Science and Education, Ain Shams University Cairo Egypt
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16
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Abstract
BACKGROUND Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival. METHODS This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications. RESULTS There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis. CONCLUSION Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- AVB, acute variceal bleeding
- BMI, body mass index
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- CTP, Child Turcotte Pugh Score
- DAAs, direct-acting antiviral agents
- GGT, gamma glutamyl transpeptidase
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HE, hepatic encephalopathy
- HR, hazard ratio
- HRQoL, health-related quality of life
- HVPG, hepatic vein pressure gradient
- MELD, Model for End Stage Liver disease
- MetS, metabolic syndrome
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NSBB, Non-selective beta blockers
- NVHCP, National Viral Hepatitis Control programme
- SAAG, Serum-ascites albumin gradient
- SBP, spontaneous bacterial peritonitis
- WHO, World Health Organization
- cirrhosis, ascites
- hepatic encephalopathy
- hepatocellular carcinoma
- portal hypertension
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17
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Sahney A, Wadhawan M. Encephalopathy in Cirrhosis: Prevention and Management. J Clin Exp Hepatol 2022; 12:927-936. [PMID: 35677508 PMCID: PMC9168742 DOI: 10.1016/j.jceh.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a major neuropsychiatric complication of cirrhosis. The clinical manifestations of HE ranges from mild confusion, disorientation to altered behaviour and coma in advanced stages. HE is an important cause of recurrent admissions in liver cirrhosis patients. HE is the most common cause of altered mentation in a patient of liver cirrhosis. Lactulose and rifaximin are approved treatment options for the treatment of HE. In patients who have localised neurological signs or are not improving with lactulose and rifaximin should be investigated for other causes of altered sensorium.
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Affiliation(s)
| | - Manav Wadhawan
- Address for correspondence: Manav Wadhawan, Institute of Digestive & Liver Diseases, BLK Superspeciality Hospital, Delhi, India.
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18
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Ibáñez-Samaniego L, Rapado-Castro M, Cabrero L, Navarrete C, García-Mulas S, Ahumada A, Marquez L, Pérez MD, Rincon D, Bañares R, Garcia-Martinez R. Hepatitis C eradication improves cognitive function in patients with or without cirrhosis: A prospective real-life study. Eur J Neurol 2021; 29:400-412. [PMID: 34634159 DOI: 10.1111/ene.15138] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND PURPOSE Hepatitis C virus (HCV) infection is associated with neuropsychiatric disturbances that impact on functioning and health-related quality of life (HRQoL). Reversibility at different liver disease stages is unknown, particularly in cirrhosis. We aimed to evaluate cognition, functioning, and HRQoL following HCV eradication at different liver disease stages. METHODS A random sample (n = 152) of consecutive patients treated with direct-acting antiviral agents (DAAs) between April 2015 and March 2017 were included. A comprehensive neuropsychological assessment, functioning and HRQoL questionnaires were applied at baseline, and 12 and 48 weeks after the end of antivirals. RESULTS One-hundred thirty-five patients who achieved virological response completed the follow-up, of whom 44 had cirrhosis (27% decompensated). Twenty-one percent had cognitive impairment before starting DAAs (34.1% cirrhotic vs. 14.4% noncirrhotic, p < 0.011). Viral eradication was associated with a decrease in cognitive impairment to 23% of cirrhotic and 6% of noncirrhotic patients (p < 0.05). Interestingly, older patients (B = 0.11, 95% confidence interval [CI] = 0.03-0.19) with baseline cognitive impairment (B = 3.58, 95% CI = 1.54-5.62) were those with higher cognitive benefit, regardless of liver disease. Persistent cognitive impairment was associated with having higher cardiovascular risk, cirrhosis, lower education, and higher anxiety and depression scores. Functioning and HRQoL also improved after eradication but remained worse in the cirrhotic group. CONCLUSIONS Viral eradication decreases the prevalence of cognitive impairment and improves functioning and HRQoL. Patients with lower brain reserve (older patients) and baseline cognitive impairment may benefit the most. Identification and treatment of HCV patients through screening programs may reduce the burden of cognitive disturbances beyond the prevention of liver disease progression.
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Affiliation(s)
- Luis Ibáñez-Samaniego
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain.,Gregorio Marañón Institute of Health Research, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Rapado-Castro
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Gregorio Marañón University General Hospital, Madrid, Spain.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne & Melbourne Health, Carlton, Victoria, Australia.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Lucia Cabrero
- Gregorio Marañón Institute of Health Research, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Navarrete
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Seila García-Mulas
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Adriana Ahumada
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Laura Marquez
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Maria Dolores Pérez
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Diego Rincon
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain.,Gregorio Marañón Institute of Health Research, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Rafael Bañares
- Hepatology Unit, Department of Digestive Diseases, Gregorio Marañón University General Hospital, Madrid, Spain.,Gregorio Marañón Institute of Health Research, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Rita Garcia-Martinez
- Gregorio Marañón Institute of Health Research, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain.,Department of Internal Medicine, Gregorio Marañon University General Hospital, Madrid, Spain
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Hepatic Encephalopathy is Associated With Slow Speech on Objective Assessment. Am J Gastroenterol 2021; 116:1950-1953. [PMID: 34465696 DOI: 10.14309/ajg.0000000000001351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION There are no available low-burden, point-of-care tests to diagnose, grade, and predict hepatic encephalopathy (HE). METHODS We evaluated speech as a biomarker of HE in 76 English-speaking adults with cirrhosis. RESULTS Three speech features significantly correlated with the following neuropsychiatric scores: speech rate, word duration, and use of particles. Patients with low neuropsychiatric scores had slower speech (22 words/min, P = 0.01), longer word duration (0.09 seconds/word, P = 0.01), and used fewer particles (0.85% fewer, P = 0.01). Patients with a history of overt HE had slower speech (23 words/min, P = 0.005) and longer word duration (0.09 seconds/word, P = 0.005). DISCUSSION HE is associated with slower speech.
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20
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Minimal hepatic encephalopathy may be present despite the absence of non-invasive and elastography evidence of cirrhosis in patients with primary biliary cholangitis. Adv Med Sci 2021; 66:293-301. [PMID: 34192643 DOI: 10.1016/j.advms.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/25/2021] [Accepted: 06/20/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE Minimal hepatic encephalopathy (MHE) is an important complication of chronic liver disease (CLD); however, MHE burden in patients with primary biliary cholangitis (PBC) has not been determined yet. Therefore, our study aimed to assess the prevalence of MHE in a typical cohort of middle-aged, patients with PBC suspicion of liver fibrosis and to investigate the relationship between MHE, basic laboratory tests and the stage of liver fibrosis. PATIENTS AND METHODS Fifty-one patients (38 with PBC and 13 controls), were prospectively enrolled. Portosystemic Encephalopathy-Syndrome test was used to diagnose MHE. Elastography point qualification (ElastPQ) and non-invasive markers (APRI and FIB-4) were used to assess liver fibrosis. The severity of CLD was assessed using the Model of End-Stage Liver Disease (MELD) and Child-Pugh score. RESULTS MHE was diagnosed in 9 patients (24.3%) with PBC and none in the control group. As many as 44.4% of the patients with MHE had neither advanced fibrosis nor cirrhosis, as demonstrated using non-invasive markers of liver fibrosis or ElastPQ. The MELD score was the only predictor of MHE with cut-off value 8.5 [AUC = 0.753, CI95% = 0.569 to 0.938)] with sensitivity of 56%, specificity of 85% and accuracy of the test of 78%. Non-invasive markers of liver fibrosis and ElastPQ did not predict MHE. CONCLUSIONS MHE may occur in PBC despite no evidence of advanced liver fibrosis or cirrhosis. The slightly elevated MELD score may indicate a substantially increased risk of MHE in patients with PBC.
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21
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Pessidjo Djomatcho L, Kowo MP, Ndam AN, Njonnou SRS, Kenfack GU, Andoulo FA, Bagnaka SFE, Bekolo WT, Malongue A, Babagna ID, Sida MB, Luma H, Njoya O. Normalisation of the psychometric encephalopathy score within the Cameroonian population. BMC Gastroenterol 2021; 21:287. [PMID: 34247589 PMCID: PMC8273953 DOI: 10.1186/s12876-021-01858-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 06/28/2021] [Indexed: 12/15/2022] Open
Abstract
Background Minimal hepatic encephalopathy (MHE) is the presence of neuropsychological abnormalities detectable by psychometric tests. Psychometric Hepatic Encephalopathy Score (PHES) is a gold standard test for the early diagnosis of MHE in cirrhotic patients. The aim of this study was to standardize the PHES in a healthy Cameroonian population and to evaluate the prevalence of MHE among cirrhotic patients.
Methods This was a prospective, multicentric study from 1 December 2018 to 31 July 2019 in two groups: healthy volunteers and cirrhotic patients without clinical signs of hepatic encephalopathy. The results of the number connection test-A, number connection test-B, serial dotting test, line tracing test were expressed in seconds and those of the digit symbol test in points. Results A total of 102 healthy volunteers (54 men, 48 women) and 50 cirrhotic patients (29 men, 31 women) were included. The mean age was 38.1 ± 12.55 years in healthy volunteers and 49.3 ± 15.6 years in cirrhotic patients. The mean years of education level was 11.63 ± 4.20 years in healthy volunteers and 9.62 ± 3.9 years in cirrhotic patients. The PHES of the healthy volunteer group was − 0.08 ± 1.28 and the cut-off between normal and pathological values was set at − 3 points. PHES of the cirrhotic patients was − 7.66 ± 5.62 points and significantly lower than that of volunteers (p < 0.001). Prevalence of MHE was 74% among cirrhotic patients. Age and education level were associated with MHE.
Conclusion PHES cut-off value in Cameroonians is − 3, with MHE prevalence of 74% among cirrhotic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-01858-7.
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Affiliation(s)
| | - Mathurin Pierre Kowo
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon. .,University Teaching Hospital Yaounde, Yaoundé, Cameroon.
| | - Antonin Ndjitoyap Ndam
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Yaounde General Hospital, Yaoundé, Cameroon
| | | | - Gabin Ulrich Kenfack
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Firmin Ankouane Andoulo
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Yaounde Central Hospital, Yaoundé, Cameroon
| | - Servais Fiacre Eloumou Bagnaka
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon.,Gynaeco-Obstetric and Paediatric Hospital Douala, Douala, Cameroon
| | - Winnie Tatiana Bekolo
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon.,Gynaeco-Obstetric and Paediatric Hospital Douala, Douala, Cameroon
| | | | | | - Magloire Biwolé Sida
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Henry Luma
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Douala General Hospital, Douala, Cameroon
| | - Oudou Njoya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,University Teaching Hospital Yaounde, Yaoundé, Cameroon
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Santana Vargas ÁD, Higuera-De la Tijera F, Perez Hernandez JL. Auditory and visual P300 event-related potentials to detect minimal hepatic encephalopathy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 114:83-88. [PMID: 33562990 DOI: 10.17235/reed.2021.7709/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Diagnosis of Minimal hepatic encephalopathy (MHE) requires psychometric tests, although new methods are needed since sensitivity, specificity, and accuracy are low. The P300 event-related potential (ERP) is obtained by auditory and visual stimuli, although only the auditory P300 has been used to detect MHE. We aimed to compare the diagnostic features of auditory and visual P300 to detect MHE. MATERIALS AND METHODS Sixty patients with liver cirrhosis and thirty-five healthy controls completed the Psychometric Hepatic Encephalopathy Score (PHES), the critical flicker frequency (CFF), auditory, and visual P300. MHE was diagnosed if PHES and CFF scores were abnormal. RESULTS Fifty-three cirrhotic patients (age 54.5±8.6 years) completed all tests. Abnormal scores were: PHES (49.1%), CFF (67.9%). The proportion of MHE was 21.4%. The area under the receiver operating ROC curves (AUROC) for auditory P300 was better than visual P300 for distinguishing MHE from controls (AUROC 0.792 vs 0.725; p<0.005 for both; accuracy 73.8%vs 70.2%; sensitivity 72.2% both; specificity 74.2 vs 69.7, respectively. Among cirrhotic patients, only auditory P300 was useful to detect MHE, AUROC 0.723 p<0.05; 77.4% accuracy; 61.1% sensitivity; and 81.8% specificity. CONCLUSIONS The auditory P300 sensitivity, specificity, and accuracy were similar to those of CFF. Our results showed that only auditory P300 is useful to differentiate patients with MHE. Although both modalities, auditory and visual, differentiated patients with cirrhosis from controls, we consider the visual P300 is not suitable for detecting MHE.
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23
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Alsebaey A. Prediction of minimal encephalopathy in patients with HCV-related cirrhosis using albumin-bilirubin, platelets-albumin-bilirubin score, albumin-bilirubin-platelets grade and ammonia level. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-0023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
Minimal hepatic encephalopathy (MHE) is a complication of liver cirrhosis causing low quality of life, driving skills and higher traffic violation. The neuro-psychometric tests are the gold standard but difficult clinically and time-consuming. The aim was to assess albumin-bilirubin (ALBI), platelets-albumin-bilirubin (PALBI) score, albumin-bilirubin-platelets (ALBI-PLT) grade and ammonia level as MHE predictors. All the patients (n = 257) underwent critical flicker frequency number connection, serial dotting and digit symbol test for MHE diagnosis (n = 166, 64.6%). Liver function, INR, CBC and arterial ammonia were measured.
Results
There was statistically significant difference (p < 0.05) between MHE patients and those without as regards ammonia (86.59 ± 23.25 vs. 63.56 ± 24.2 μmol/L), ALBI score (−2.13 ± 0.53 vs. −2.49 ± 0.38), PALBI score (−2.33 ± 0.39 vs. −2.55 ± 0.26) and ALBI-PLT (3.98 ± 0.49 vs. 3.70 ± 0.56). Patients with MHE were mainly Child-Pugh B and C and also ALBI grade 2 and 3. For MHE discrimination, ALBI, PALBI, ALBI-PLT and ammonia had the following cutoffs >−2.36 (57.23% sensitivity, 77.78% specificity), >−2.5 (60.84% sensitivity, 67.9% specificity), > 3 (87.35% sensitivity, 27.16% specificity) and > 76.5 (69% sensitivity, 72.5% specificity) respectively (p = 0.001). On comparison of the area under the curve, ALBI is comparable to PALBI (p = 0.245) and ammonia (p = 0.603). The ALBI-PLT is inferior to ALBI (p = 0.018) and ammonia (p = 0.021) but comparable to PALBI (p = 0.281). ALBI (odds = 5.64), PALBI (odds = 7.86), ALBI-PLT (odds = 2.86), ammonia (odds = 1.05), Child-Pugh score (odds = 2.13), MELD (odds = 1.26) are independent predictors of MHE.
Conclusion
ALBI, PALBI and ammonia are clinical useful model for MHE prediction.
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Machado JÚnior PAB, Ziliotto RD, Ferreira APVN, Buson TM, Couto CMD, Pissaia Junior A. USE OF THE STROOP ENCEPHALAPP FOR COVERT HEPATIC ENCEPHALOPATHY SCREENING IN CIRRHOTIC PATIENTS IN SOUTHERN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:399-403. [PMID: 33237215 DOI: 10.1590/s0004-2803.202000000-73] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Covert hepatic encephalopathy (CHE) is difficult to detect due to the lack of easily applicable screening tools. The Stroop EncephalApp is a smartphone application already validated for CHE screening. However, its applicability to the Brazilian population is not known. OBJECTIVE To estimate the prevalence of CHE and evaluate the use of Stroop EncephalApp in a cirrhotic population in Brazil. METHODS In this cross-sectional study, we evaluated 99 patients previously diagnosed with liver cirrhosis in a Private Hospital in Curitiba/PR. Patients were initially submitted to the mini mental state examination (MMSE) to exclude individuals with dementia. After, the Psychometric Hepatic Encephalopathy Score (PHES) test was performed and lastly, the Stroop EncephalApp test. Results were adjusted for age, sex and education levels to evaluate the accuracy of the app on detecting the disease, comparing its results with the gold standard method (PHES). Patients with one or more of the following were excluded: dementia, inadequate MMSE score, illiteracy, color blindness, history of drugs/alcohol abuse within the past 3 months and previous or actual episodes of encephalopathy. The statistical analysis was performed by SPSS 2.0 and the significance adopted by 5%. RESULTS We included 82 individuals in the final analysis. Among these patients, 29 were diagnosed with CHE by the PHES test (35.36% prevalence) and 28 of those obtained equal diagnosis by the Stroop EncephalApp (96.6% sensitivity). A total of 53 patients obtained negative results for CHE by PHES, while the Stroop test classified 27 of them as having the disease. In the multivariate analysis, high levels of education were associated with better performance during the tests. No significant relationship was observed between age and sex with the probability of diagnosing CHE through the PHES test.
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Affiliation(s)
| | - Rafaela Deneka Ziliotto
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil
| | | | - Thiago Mesquita Buson
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil
| | | | - Alcindo Pissaia Junior
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil.,Hospital Nossa Senhora das Graças (HNSG), Serviço de Hepatologia, Curitiba, PR, Brasil
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Tateyama M, Naoe H, Tanaka M, Tanaka K, Narahara S, Tokunaga T, Kawasaki T, Yoshimaru Y, Nagaoka K, Watanabe T, Setoyama H, Sasaki Y, Tanaka Y. Loss of skeletal muscle mass affects the incidence of minimal hepatic encephalopathy: a case control study. BMC Gastroenterol 2020; 20:371. [PMID: 33167879 PMCID: PMC7654593 DOI: 10.1186/s12876-020-01501-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023] Open
Abstract
Background Sarcopenia is a syndrome characterized by progressive and systemic decreases in skeletal muscle mass and muscle strength. The influence or prognosis of various liver diseases in this condition have been widely investigated, but little is known about whether sarcopenia and/or muscle mass loss are related to minimal hepatic encephalopathy (MHE). Methods To clarify the relationship between MHE and sarcopenia and/or muscle mass loss in patients with liver cirrhosis. Methods Ninety-nine patients with liver cirrhosis were enrolled. MHE was diagnosed by a neuropsychiatric test. Skeletal mass index (SMI) and Psoas muscle index (PMI) were calculated by dividing skeletal muscle area and psoas muscle area at the third lumbar vertebra by the square of height in meters, respectively, to evaluate muscle volume. Results This study enrolled 99 patients (61 males, 38 females). MHE was detected in 48 cases (48.5%) and sarcopenia in 6 cases (6.1%). Patients were divided into two groups, with or without MHE. Comparing groups, no significant differences were seen in serum ammonia concentration or rate of sarcopenia. SMI was smaller in patients with MHE (46.4 cm2/m2) than in those without (51.2 cm2/m2, P = 0.027). Similarly, PMI was smaller in patients with MHE (4.24 cm2/m2) than in those without (5.53 cm2/m2, P = 0.003). Skeletal muscle volume, which is represented by SMI or PMI was a predictive factor related to MHE (SMI ≥ 50 cm2/m2; odds ratio 0.300, P = 0.002, PMI ≥ 4.3 cm2/m2; odds ratio 0.192, P = 0.001). Conclusions Muscle mass loss was related to minimal hepatic encephalopathy, although sarcopenia was not. Measurement of muscle mass loss might be useful to predict MHE.
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Affiliation(s)
- Masakuni Tateyama
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hideaki Naoe
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Motohiko Tanaka
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan.
| | - Kentaro Tanaka
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Satoshi Narahara
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Takayuki Tokunaga
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Takeshi Kawasaki
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Yoko Yoshimaru
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Katsuya Nagaoka
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Takehisa Watanabe
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hiroko Setoyama
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan.,Kumamoto Rosai Hospital, 1670 Takeharatyo, Yatsushiro City, Kumamoto, Japan
| | - Yutaka Sasaki
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan.,Department of Health and Nutrition, Nagasaki International University, 2825-7 Huis Ten Bosch Machi, Sasebo City, Nagasaki, 859-3298, Japan
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Chuo-ku, Kumamoto, 860-8556, Japan
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Direct antivirals and cognitive impairment in hepatitis C: a clinical-neurophysiologic study. J Neurovirol 2020; 26:870-879. [PMID: 32910431 PMCID: PMC7716927 DOI: 10.1007/s13365-020-00904-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/05/2020] [Accepted: 08/26/2020] [Indexed: 12/26/2022]
Abstract
Cognition was assessed in hepatitis C virus (HCV) patients, who did not meet the criteria for a minimal hepatic encephalopathy. Their liver function was compensated. We then disentangled potential cognitive changes associated with a sustained virologic response at 12 weeks (SVR-12), following treatment with direct antiviral agents (DAAs). We studied 23 selected HCV patients with a battery of standard neuropsychological tests, and with recordings of the P300 wave, a cerebral potential of “cognitive” significance. There was a baseline evaluation (T0) and a second one 6 months later (T1). We had 2 control groups of comparable age and sex, i.e., 15 patients suffering from non-alcoholic fatty liver disease (NAFLD) and 15 healthy subjects. At T0, we detected a significant (p < 0.05) cognitive impairment in the HCV group, which involved episodic and working memory, attention, visuospatial and verbal abilities, executive functions, and logic reasoning. The P300 latency was significantly (p < 0.05) delayed in the group. At T1, we observed some significant (p < 0.05) HCV recovery in given test domains, e.g., memory, executive functions, and reasoning. Accordingly, the P300 latency shortened significantly (p < 0.05). HCV patients exhibited subtle cognitive defects, somehow independent of their liver condition, possibly linked to direct or indirect brain involvement by the virus. These defects partly recovered following the SVR-12, as achieved through DAAs. The P300 wave was a valid neurophysiologic counterpart of these changes. DAAs can have a role in the early preservation of cognition in HCVs.
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Abstract
Minimal hepatic encephalopathy, previously called subclinical hepatic encephalopathy, represents the earliest and mildest form of hepatic encephalopathy. It is the most under-recognized and underdiagnosed form of hepatic encephalopathy. Although there is no diagnostic gold standard, validated testing modalities have been devised to detect this neurocognitive complication. The newest developments include medically related apps for smartphones or tablets that can be easily used to diagnose and monitor minimal hepatic encephalopathy. Although recognition of this neurocognitive impairment can be challenging, early detection is paramount with the discovery of an association with worse clinical outcomes in patients diagnosed with minimal hepatic encephalopathy.
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Affiliation(s)
- Briette Verken Karanfilian
- Department of Internal Medicine, Rutgers- Robert Wood Johnson Medical School, 125 Paterson Street, CAB 7302, New Brunswick, NJ 08901, USA
| | - Taeyang Park
- Department of Internal Medicine, Rutgers- Robert Wood Johnson Medical School, 125 Paterson Street, CAB 7302, New Brunswick, NJ 08901, USA.
| | - Frank Senatore
- Department of Gastroenterology and Hepatology, Rutgers- Robert Wood Johnson Medical School, 125 Paterson Street, CAB 7302, New Brunswick, NJ 08901, USA
| | - Vinod K Rustgi
- Center for Liver Diseases and Masses, Robert Wood Johnson Medical School, Clinical Academic Building (CAB), 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA
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Wernberg CW, Schaffalitzky de Muckadell OB, Vilstrup H, M. Lauridsen M. Prediction of overt hepatic encephalopathy by the continuous reaction time method and the portosystemic encephalopathy syndrome test in clinically mentally unimpaired patients with cirrhosis. PLoS One 2019; 14:e0226283. [PMID: 31830113 PMCID: PMC6907801 DOI: 10.1371/journal.pone.0226283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background and aim Predicting overt hepatic encephalopathy (OHE) is important because the condition is frequent, often requires hospitalization and is potentially preventable. The risk of OHE is related to pre-existing discrete cognitive defects, and for clinical practice it is recommended to apply two different psychometric tests to detect such deficits. We used the continuous reaction time test (CRT) and the portosystemic encephalopathy (PSE) syndrome test and examined their single and combined value for OHE prediction in cirrhosis patients. Patients and methods We studied 130 clinically mentally unimpaired cirrhosis patients by the two tests and followed them for an average of 38.5 months. The CRT measures velocity and stability of motor reaction times to 150 repeated auditory signals. The PSE is a five sub-set paper-and-pencil test battery evaluating cognitive and psychomotor processing, speed and vision-motor coordination. We collected data on episodes of OHE during follow-up. The clinical course was analysed in patient groups according to the outcome of each test and of both tests together. No anti-HE treatment was initiated except for cases with OHE. Results At baseline, the CRT test was abnormal in 74 patients and the PSE in 47. During follow-up 35 patients (27%) experienced 74 OHE events. 23 patients with abnormal CRT experienced OHE (prediction sensitivity 65%). The PSE predicted OHE in 14 patients (prediction sensitivity 40%). One or both tests were abnormal in 87/130 (67%) and this predicted OHE in 27 patients (21%) (prediction sensitivity 77%). Conclusion The CRT test was clinically useful in identifying two-thirds of clinically mentally unimpaired cirrhosis patients who later experienced OHE, and the use of both the CRT and PSE showed satisfactory prediction by identifying three-fourths of later OHE cases.
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Affiliation(s)
- Charlotte W. Wernberg
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Region of Southwest of Denmark, Denmark
- * E-mail:
| | | | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Central Denmark Region, Denmark
| | - Mette M. Lauridsen
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Region of Southwest of Denmark, Denmark
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Safety profile of sedative endoscopy including cognitive performance in liver cirrhosis: A double-blind randomized controlled trial. Sci Rep 2019; 9:16798. [PMID: 31727915 PMCID: PMC6856546 DOI: 10.1038/s41598-019-52897-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022] Open
Abstract
The indiscriminate use of sedative drugs during endoscopy can pose multiple risks including cognitive impairment in advanced liver cirrhosis. However, the data are scarce regarding which sedative drugs are safest in these populations. The aim of this study was to evaluate the safety profiles including cognitive performance among midazolam, propofol, and combination therapy in advanced cirrhotic patients. This double-blind randomized controlled study included 60 consecutive advanced cirrhotic patients who underwent upper gastrointestinal endoscopy. The Stroop application was used to screen for cognitive impairment. Patients were randomly assigned to one of 3 groups, midazolam, propofol, or the combination group, and underwent Stroop test before and two hours after the completion of endoscopy. Hemodynamic safety and the subjective satisfaction score were also evaluated. Patients did not show significant changes in on-time or off-time on the Stroop test before and two hours after sedatives, and there was no significant difference among the 3 treatment groups. Also, there were no significant vital sign changes after sedatives. Time-to-recovery was longest in midazolam group, and patient awakening and patient memory were highest in propofol group. However, all 3 groups showed no difference in patient satisfaction, but the combination group was more preferred in terms of subjective satisfaction by physicians. Factors affecting worsened Stroop speed after sedatives were older age, low education level and high MELD score. All sedative methods using midazolam, propofol, or combination therapy showed similar safety profile in advanced cirrhosis, and were not associated with increased risk of cognitive impairment.
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Yanny B, Winters A, Boutros S, Saab S. Hepatic Encephalopathy Challenges, Burden, and Diagnostic and Therapeutic Approach. Clin Liver Dis 2019; 23:607-623. [PMID: 31563214 DOI: 10.1016/j.cld.2019.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is an important cause of morbidity and mortality in patients with cirrhosis. The impact of HE on the health care system is similarly profound. The number of hospital admissions for HE has increased in the last 10-year period. HE is a huge burden to the patients, care givers, and the health care system. HE represents a "revolving door" with readmission, severely affects care givers, and has effects on cognition that can persists after liver transplant. This article reviews the current literature to discuss the challenges and diagnostic and therapeutic approaches to HE.
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Affiliation(s)
- Beshoy Yanny
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA.
| | - Adam Winters
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA
| | - Sandra Boutros
- Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA; Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA; Department of Nursing, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
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Abstract
In general, hepatic encephalopathy (HE) is defined as a brain dysfunction caused by liver insufficiency and/or portal-systemic blood shunting. This article relates to the so-called type C HE: that is, HE in patients with liver cirrhosis. It manifests as a wide spectrum of neurological or psychiatric abnormalities, ranging from subclinical alterations, detectable only by neuropsychological or neurophysiological assessment, to coma. Several scales have been developed for grading the extent of HE. The most often used is the West Haven criteria (WHC), which differentiate between four grades of clinically overt HE. Patients with liver cirrhosis without clinically overt symptoms of HE but neuropsychological or neurophysiological findings indicating brain dysfunction are considered to have minimal hepatic encephalopathy (MHE). For simplification, some experts suggest differentiating between covert HE (MHE plus grade I HE according to WHC) and overt HE (WHC grades II-IV). Diagnosis of both MHE and overt HE is hampered by the fact that none of the symptoms of HE or the findings in the various diagnostic measures applied are specific. Thus, a diagnosis of HE or MHE can only be made after exclusion of other possible causes of brain dysfunction.
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Affiliation(s)
- Karin Weissenborn
- Clinic for Neurology, Hannover Medical School, 30623, Hannover, Germany.
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Nguyen HH, Swain MG, Wong P, Congly SE. Canadian regulations and legal ramifications for hepatic encephalopathy: a descriptive analysis. CMAJ Open 2018; 6:E575-E579. [PMID: 30510040 PMCID: PMC6277253 DOI: 10.9778/cmajo.20180024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy, a form of brain dysfunction seen in the setting of liver insufficiency, negatively affects driving performance and so is both a patient and public safety issue. We aimed to review the motor vehicle codes in each Canadian province and territory relating to the reporting of patients with hepatic encephalopathy and to search a Canadian legal database for cases of motor vehicle collisions involving patients with hepatic encephalopathy. METHODS In this descriptive analysis, the transportation agencies of each Canadian province and territory were contacted via telephone and/or email between April and August 2017. Requirements of physicians to report medical conditions (including liver disease and hepatic encephalopathy) affecting a patient's fitness to drive were assessed. WestlawNext Canada was searched for any Canadian cases on hepatic encephalopathy and driving-related lawsuits from inception to Dec. 31, 2017. RESULTS Reporting of medically unfit drivers is a requirement in all Canadian provinces and territories except Alberta, Quebec and Nova Scotia. Hepatic encephalopathy, cirrhosis and advanced liver disease were not specifically identified as reportable medical conditions in any province or territory. Our search did not identify any lawsuits involving a motor vehicle collision in Canada that were made either against physicians caring for patients with hepatic encephalopathy or against such patients themselves. INTERPRETATION Although hepatic encephalopathy has a substantial impact on driving performance, it is not specifically identified as a reportable medical condition in Canada. Increasing awareness of the potential impact of hepatic encephalopathy on safe driving for health care providers and the public is critical.
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Affiliation(s)
- Henry H Nguyen
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Mark G Swain
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Philip Wong
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Stephen E Congly
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que.
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Xiao G, Ye Q, Han T, Yan J, Sun L, Wang F. Study of the sleep quality and psychological state of patients with hepatitis B liver cirrhosis. Hepatol Res 2018; 48:E275-E282. [PMID: 28888081 DOI: 10.1111/hepr.12981] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/19/2017] [Accepted: 09/05/2017] [Indexed: 12/14/2022]
Abstract
AIM We aimed to investigate sleep quality, mild hepatic encephalopathy, anxiety, and depression in patients with hepatitis B cirrhosis by using a variety of scales and questionnaires. METHOD A cohort of 341 patients with hepatitis B liver cirrhosis were categorized by Child-Pugh grading (A, B, and C) in this cross-sectional study. Pittsburgh Sleep Quality Index (PSQI), Number Connection Test-A (NCT-A), and Hospital Anxiety and Depression (HAD) evaluated the questionnaires and statistically analyzed the intrinsic correlation. The control group included 50 healthy individuals. Of 341 patients, 213 had a PSQI index >5 points. RESULTS The PSQI, NCT-A, anxiety scale (HAD [a]), and depression scale (HAD [d]) of the patients were significantly different. The NCT-A-positive patients revealed 214 cases of possible minimal hepatic encephalopathy (MHE) during a preliminary screening of patients. The PSQI score of NCT-A-positive patients was significantly elevated compared to NCT-A-negative patients (P < 0.001). HAD (a) and HAD (d) were significantly different between the NCT-A-positive and NCT-A-negative groups (P = 0.002 and P = 0.006, respectively). Univariate Pearson's correlation analysis found that NCT-A and HAD (a) were positively correlated with PSQI (P < 0.001 and P = 0.045, respectively); however, Child-Pugh score and HAD (d) were not correlated with PSQI (P = 0.061 and P = 0.059, respectively). CONCLUSION These results indicated that patients with hepatitis B liver cirrhosis have a disturbed sleep, which might be an MHE symptom, further causing considerable anxiety. Thus, the evaluation of sleep quality and psychological state of patients with hepatitis B liver cirrhosis necessitates further investigation to guide positive intervention.
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Affiliation(s)
- Guoqing Xiao
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Qing Ye
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Tao Han
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Junqing Yan
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Lixia Sun
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Fengmei Wang
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
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Jeong JY, Jun DW, Bai D, Kim JY, Sohn JH, Ahn SB, Kim SG, Kim TY, Kim HS, Jeong SW, Cho YK, Song DS, Kim HY, Jung YK, Yoon EL. Validation of a Paper and Pencil Test Battery for the Diagnosis of Minimal Hepatic Encephalopathy in Korea. J Korean Med Sci 2017; 32:1484-1490. [PMID: 28776344 PMCID: PMC5546968 DOI: 10.3346/jkms.2017.32.9.1484] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 06/03/2017] [Indexed: 12/20/2022] Open
Abstract
The aim of this study was to validate a new paper and pencil test battery to diagnose minimal hepatic encephalopathy (MHE) in Korea. A new paper and pencil test battery was composed of number connection test-A (NCT-A), number connection test-B (NCT-B), digit span test (DST), and symbol digit modality test (SDMT). The norm of the new test was based on 315 healthy individuals between the ages of 20 and 70 years old. Another 63 healthy subjects (n = 31) and cirrhosis patients (n = 32) were included as a validation cohort. All participants completed the new paper and pencil test, a critical flicker frequency (CFF) test and computerized cognitive function test (visual continuous performance test [CPT]). The scores on the NCT-A and NCT-B increased but those of DST and SDMT decreased according to age. Twelve of the cirrhotic patients (37.5%) were diagnosed with MHE based on the new paper and pencil test battery. The total score of the paper and pencil test battery showed good positive correlation with the CFF (r = 0.551, P < 0.001) and computerized cognitive function test. Also, this score was lower in patients with MHE compared to those without MHE (P < 0.001). Scores on the CFF (32.0 vs. 28.7 Hz, P = 0.028) and the computer base cognitive test decreased significantly in patients with MHE compared to those without MHE. Test-retest reliability was comparable. In conclusion, the new paper and pencil test battery including NCT-A, NCT-B, DST, and SDMT showed good correlation with neuropsychological tests. This new paper and pencil test battery could help to discriminate patients with impaired cognitive function in cirrhosis (registered at Clinical Research Information Service [CRIS], https://cris.nih.go.kr/cris, KCT0000955).
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Affiliation(s)
- Jae Yoon Jeong
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
| | - Daiseg Bai
- Division of Clinical Psychology, Department of Psychiatry, Yeungnam University Hospital, Daegu, Korea
| | - Ji Yean Kim
- Division of Clinical Psychology, Department of Psychiatry, Yeungnam University Hospital, Daegu, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sang Bong Ahn
- Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Tae Yeob Kim
- Institute of Medical Science, Hanyang University, Seoul, Korea
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Yong Kyun Cho
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Eileen L Yoon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
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Serra MM, Besada CH, Cabana Cal A, Saenz A, Stefani CV, Bauso D, Golimstok AB, Bandi JC, Giunta DH, Elizondo CM. Central nervous system manganese induced lesions and clinical consequences in patients with hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2017; 12:92. [PMID: 28521822 PMCID: PMC5437640 DOI: 10.1186/s13023-017-0632-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/13/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Around 47-74% of patients with hereditary hemorrhagic telangiectasia (HHT) have hepatic vascular malformations (HVMs); magnetic resonance images (MRI) of the central nervous system (CNS) might show in T1 sequences a hyper-intensity signal in different areas, mainly in the basal ganglia (BG) as consequence of manganese (Mn) deposits as observed in cirrhotic patients. These patients might suffer from different neuropsychiatric disorders (hepatic encephalopathy). In HHT patients, even in the presence of hepatic shunts, hepatocellular function is usually preserved. Additionally, Mn shares iron absorption mechanisms, transferrin and CNS transferrin receptors. In iron deficiency conditions, the Mn may harbor transferrin and access BG. The objectives were to describe frequency of BG Mn deposit-induced lesions (BGMnIL) in HHT patients, its relationship with iron deficiency anemia (IDA) and HVMs. Finally, explore the association between neuropsychological and motor consequences. We performed a cross-sectional study. We determined HHT patients with or without BG-MnIL by the MRI screening of the CNS. We included all patients with lesions and a random sample of those without lesions. All patients underwent standardized and validated neuropsychological assessment to evaluate BG actions. Results were analyzed with multiple logistic regression, adjusting for potential confounders. RESULTS Among 307 participants from a cohort included in the Institutional HHT Registry, 179 patients had MRI performed and Curaçao Criteria ≥3. The prevalence of BG-MnIL was 34.6% (95%CI 27.69-42.09). While neuropsychological symptoms were present in all patients, BG-MnIL patients performed poorly in three of the neuropsychological tests (serial dotting, line tracing time, number connection test A). HVMs frequency in BG-MnIL was 95.1%, versus 71.4% in those without lesions (p < 0.001). IDA frequency was 90.3% versus 54% (p < 0.001). When IDA is present, estimated risk for BG-MnIL is remarkably high (OR 7.73, 95%CI 2.23-26.73). After adjustment for possible confounders (gender, age, presence of HVMs), IDA was still associated with increased risk of BG-MnIL (adjusted OR 6.32, 95% CI 2.32-17.20; p < 0.001). CONCLUSIONS Physicians should assess BG-MnIL in HHT patients in CNS-MRI. IDA and HVMs present increased risk of lesions. Patients with BG-MnIL have neuropsychological impairment, and they might benefit from sparing IDA, or undergoing future therapeutic options. TRIAL REGISTRATION NCT01761981 . Registered January 3rd 2013.
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Affiliation(s)
- M M Serra
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina. .,HHT Unit. Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina. .,ARG (Argentine Rendu Study Group), Ciudad Autonoma de Buenos Aires, Argentina.
| | - C H Besada
- Radiology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - A Cabana Cal
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - A Saenz
- ARG (Argentine Rendu Study Group), Ciudad Autonoma de Buenos Aires, Argentina
| | - C V Stefani
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - D Bauso
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - A B Golimstok
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - J C Bandi
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina.,HHT Unit. Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina.,Hepatology area, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - D H Giunta
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina.,Internal Medicine Research Unit, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - C M Elizondo
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina.,ARG (Argentine Rendu Study Group), Ciudad Autonoma de Buenos Aires, Argentina.,Internal Medicine Research Unit, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
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Kyrana E, Dhawan A. Minimal hepatic encephalopathy in children, uncommon or unrecognised? Time to act. J Hepatol 2017; 66:478-479. [PMID: 27908802 DOI: 10.1016/j.jhep.2016.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 11/21/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Eirini Kyrana
- Paediatric Liver, GI and Nutrition Centre and MOWATLabs, King's College Hospital, London, United Kingdom
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and MOWATLabs, King's College Hospital, London, United Kingdom.
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Gupta T, Rathi S, K Dhiman R. Managing Encephalopathy in the Outpatient Setting. Euroasian J Hepatogastroenterol 2017; 7:48-54. [PMID: 29201772 PMCID: PMC5663774 DOI: 10.5005/jp-journals-10018-1211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 10/14/2016] [Indexed: 12/18/2022] Open
Abstract
In cirrhosis of liver, hepatic encephalopathy (HE) has an important impact on health-related quality of life. It is important to define whether HE is episodic, recurrent, or persistent; types A, B, or C; overt HE or covert HE; and spontaneous or precipitated. The overt HE is clinically evident and needs hospitalization. Nonabsorbable disaccharides, rifaximin, and probiotics are proven to be useful in the treatment of overt HE. Covert HE includes both minimal HE and grade I HE. It is not apparent on routine clinical examination. Presence of poor work productivity, increased accidental injuries on complex machinery and driving, etc., raise the suspicion of cognitive dysfunction. Specialized neurocognitive testing like psychometric HE, computerized tests like critical flicker frequency tests, inhibitory control tests, Stroop encephalopathy tests, and electroencephalography are needed to diagnose overt HE. Various studies have shown lactulose and rifaximin to be useful in overt HE. However, presence of persistent and recurrent HE in cirrhosis is an indication for liver transplant. Lactulose is effective both in improving reversal of minimal HE and in reducing the risk of development of overt HE. How to cite this article: Gupta T, Rathi S, Dhiman RK. Managing Encephalopathy in the Outpatient Setting. Euroasian J Hepato-Gastroenterol 2017;7(1):48-54.
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Affiliation(s)
- Tarana Gupta
- Department of Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Sahaj Rathi
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Radha K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Badea MA, Drug VL, Dranga M, Gavrilescu O, Stefanescu G, Popa I, Mihai C, Cijevschi-Prelipcean C. Diagnosis of minimal hepatic encephalopathy in a tertiary care center from eastern Romania: validation of the psychometric hepatic encephalopathy score (PHES). Metab Brain Dis 2016; 31:1463-1471. [PMID: 27461111 DOI: 10.1007/s11011-016-9878-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
The psychometric hepatic encephalopathy score (PHES) is frequently used as a "gold standard" for the diagnosis of minimal hepatic encephalopathy (MHE). In Romania, there are currently no widely available tests for the detection of MHE. In this study we aimed to standardize the PHES in a healthy Romanian population and to estimate the prevalence of MHE in a group of Romanian patients with liver cirrhosis. A total of 260 healthy volunteers and 106 patients with liver cirrhosis were included in the study. The five neuropsychological tests comprising the PHES were administered to all enroled subjects. Blood samples for routine tests and serum ammonia were collected. In the healthy volunteer group age and education years were found to be predictors of all tests and gender only in two tests: digit symbol test and serial dotting test. The PHES of the healthy volunteer group was 0,43 ± 1,37 and the cut-off between normal and pathological values was set at -3 points. In the liver cirrhosis group the mean PHES was -2,44 ± 3,41, significantly lower than in the control group (p = 0,001). The estimated prevalence of MHE was 34,7 % (37 patients). In patients with cirrhosis there was a significant correlation between PHES and the severity of the liver disease according to Child-Pugh classification (r = 0,529, p = 0,001) and MELD score (r = -0,525, p = 0,001). According to our results, accurate Romanian PHES norms for the diagnosis of MHE have been developed. MHE was diagnosed in a significant proportion of Romanian patients with liver cirrhosis.
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Affiliation(s)
- Mircea Alexandru Badea
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania.
- Institute of Gastroenterology and Hepatology, Iasi, Romania.
| | - Vasile Liviu Drug
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Mihaela Dranga
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Otilia Gavrilescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Gabriela Stefanescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Iolanda Popa
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Catalina Mihai
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Cristina Cijevschi-Prelipcean
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
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Morgan MY, Amodio P, Cook NA, Jackson CD, Kircheis G, Lauridsen MM, Montagnese S, Schiff S, Weissenborn K. Qualifying and quantifying minimal hepatic encephalopathy. Metab Brain Dis 2016; 31:1217-1229. [PMID: 26412229 DOI: 10.1007/s11011-015-9726-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 09/01/2015] [Indexed: 12/11/2022]
Abstract
Minimal hepatic encephalopathy is the term applied to the neuropsychiatric status of patients with cirrhosis who are unimpaired on clinical examination but show alterations in neuropsychological tests exploring psychomotor speed/executive function and/or in neurophysiological variables. There is no gold standard for the diagnosis of this syndrome. As these patients have, by definition, no recognizable clinical features of brain dysfunction, the primary prerequisite for the diagnosis is careful exclusion of clinical symptoms and signs. A large number of psychometric tests/test systems have been evaluated in this patient group. Of these the best known and validated is the Portal Systemic Hepatic Encephalopathy Score (PHES) derived from a test battery of five paper and pencil tests; normative reference data are available in several countries. The electroencephalogram (EEG) has been used to diagnose hepatic encephalopathy since the 1950s but, once popular, the technology is not as accessible now as it once was. The performance characteristics of the EEG are critically dependent on the type of analysis undertaken; spectral analysis has better performance characteristics than visual analysis; evolving analytical techniques may provide better diagnostic information while the advent of portable wireless headsets may facilitate more widespread use. A large number of other diagnostic tools have been validated for the diagnosis of minimal hepatic encephalopathy including Critical Flicker Frequency, the Inhibitory Control Test, the Stroop test, the Scan package and the Continuous Reaction Time; each has its pros and cons; strengths and weaknesses; protagonists and detractors. Recent AASLD/EASL Practice Guidelines suggest that the diagnosis of minimal hepatic encephalopathy should be based on the PHES test together with one of the validated alternative techniques or the EEG. Minimal hepatic encephalopathy has a detrimental effect on the well-being of patients and their care-givers. It responds well to treatment with resolution of test abnormalities and the associated detrimental effects on quality of life, liver-related mortality and morbidity. Patients will only benefit in this way if they can be effectively diagnosed. Corporate efforts and consensus agreements are needed to develop effective diagnostic algorithms.
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Affiliation(s)
- Marsha Y Morgan
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London, NW32PF, UK.
| | - Piero Amodio
- Department of Medicine, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Nicola A Cook
- Department of Medicine, St Mary's Hospital Campus, Imperial College, London, W2 1NY, UK
| | - Clive D Jackson
- Department of Neurophysiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, Pond Street, London, Hampstead, NW3 2QG, UK
| | - Gerald Kircheis
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Mette M Lauridsen
- Department of Gastroenterology, Hospital of South West Jutland, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Sara Montagnese
- Department of Medicine, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Sami Schiff
- Department of Medicine, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, 30623, Hannover, Germany
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Lee Y, Kim C, Suk KT, Choi HC, Bang CS, Yoon JH, Baik GH, Kim DJ, Jang MU, Sohn JH. Differences in cognitive function between patients with viral and alcoholic compensated liver cirrhosis. Metab Brain Dis 2016; 31:369-76. [PMID: 26563125 DOI: 10.1007/s11011-015-9761-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
As alcohol induces change in frontal cortex primarily involved in cognition, cognitive function may be different between viral and alcoholic liver cirrhosis (LC). This study aimed to determine the differences of cognitive function between viral and alcoholic compensated LC. From October 2011 to March 2013, 80 patients (viral: 37; alcohol: 43) with compensated LC were prospectively enrolled. Neuropsychological functions including attention, language, visuospatial, verbal memory, visual memory, and frontal/executive function were evaluated between two groups and compared with age-matched normal group (n = 1000). Cumulative incidence rate of overt hepatic encephalopathy (HE) was calculated. In the comparison with normal group, both two groups showed decreased memory function, frontal/executive function, and Korea-Mini Mental Status Examination. In the analysis of two groups, memory function by Verbal Learning Test (recognition: 20.1 ± 3.6 and 17.8 ± 4.8, p = 0.022), visuospatial function by Ray-Complex Figure Copy Test (recognition: 19.0 ± 2.6 and 17.3 ± 4.0, p = 0.043), frontal/executive function by Controlled Oral Ward Association (semantic: 17.1 ± 6.9 and 12.7 ± 6.9, p = 0.004), and the Korea-Mini Mental Status Examination (27.5 ± 1.9 and 26.2 ± 3.1, p = 0.03) showed low scores in alcoholic compensated LC patients. The 1-, 2-, and 3-year cumulative incidence rates of overt HE were 23%, 26%, and 26% and 33%, 43%, and 49% in the viral and alcoholic compensated LC group, respectively (p = 0.033). Impaired memory and frontal lobe executive functions and early development of overt HE were more common in patients with alcoholic LC. For patients with alcoholic LC, more integrated tests for early detection of minimal HE and intensive treatment should be considered to prevent overt HE.
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Affiliation(s)
- Yunhyeong Lee
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Chulho Kim
- Department of Neurology, Hallym University College of Medicine, Chuncheon, South Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
- Department of Medicine, Columbia University, New York, NY, USA
- Department in Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon,, Gyo-dong, 200-704, South Korea
| | - Hui Chul Choi
- Department of Neurology, Hallym University College of Medicine, Chuncheon, South Korea.
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gyo-dong, 200-704, South Korea.
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jai Hoon Yoon
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Min Uk Jang
- Department of Neurology, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jong Hee Sohn
- Department of Neurology, Hallym University College of Medicine, Chuncheon, South Korea
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