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Song J, Westover MB, Zhang R. A neural mass model for disturbance of alpha rhythm in the minimal hepatic encephalopathy. Mol Cell Neurosci 2024; 128:103918. [PMID: 38296121 DOI: 10.1016/j.mcn.2024.103918] [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] [Received: 11/27/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/13/2024] Open
Abstract
One of the early markers of minimal hepatic encephalopathy (MHE) is the disruption of alpha rhythm observed in electroencephalogram (EEG) signals. However, the underlying mechanisms responsible for this occurrence remain poorly understood. To address this gap, we develop a novel biophysical model MHE-AWD-NCM, encompassing the communication dynamics between a cortical neuron population (CNP) and an astrocyte population (AP), aimed at investigating the relationship between alpha wave disturbance (AWD) and mechanistical principles, specifically concerning astrocyte-neuronal communication in the context of MHE. In addition, we introduce the concepts of peak power density and peak frequency within the alpha band as quantitative measures of AWD. Our model faithfully reproduces the characteristic EEG phenomenology during MHE and shows how impairments of communication between CNP and AP could promote AWD. The results suggest that the disruptions in feedback neurotransmission from AP to CNP, along with the inhibition of GABA uptake by AP from the extracellular space, contribute to the observed AWD. Moreover, we found that the variation of external excitatory stimuli on CNP may play a key role in AWD in MHE. Finally, the sensitivity analysis is also performed to assess the relative significance of above factors in influencing AWD. Our findings align with the physiological observations and provide a more comprehensive understanding of the complex interplay of astrocyte-neuronal communication that underlies the AWD observed in MHE, which potentially may help to explore the targeted therapeutic interventions for the early stage of hepatic encephalopathy.
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Affiliation(s)
- Jiangling Song
- The Medical Big Data Research Center, Northwest University, Xi'an, China
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Rui Zhang
- The Medical Big Data Research Center, Northwest University, Xi'an, China.
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Chaganti J, Zeng G, Tun N, Lockart I, Abdelshaheed C, Cysique L, Montagnese S, Brew BJ, Danta M. Novel magnetic resonance KTRANS measurement of blood-brain barrier permeability correlated with covert HE. Hepatol Commun 2023; 7:02009842-202304010-00018. [PMID: 36972380 PMCID: PMC10043555 DOI: 10.1097/hc9.0000000000000079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/22/2022] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Using dynamic contrast-enhanced (DCE) MR perfusion and MR spectroscopy this study aimed to characterize the blood-brain barrier permeability and metabolite changes in patients with cirrhosis and without covert HE. METHODS Covert HE was defined using psychometric HE score (PHES). The participants were stratified into 3 groups: cirrhosis with covert HE (CHE) (PHES<-4); cirrhosis without HE (NHE) (PHES≥-4); and healthy controls (HC). Dynamic contrast-enhanced MRI and MRS were performed to assess KTRANS, a metric derivative of blood-brain barrier disruption, and metabolite parameters. Statistical analysis was performed using IBM SPSS (v25). RESULTS A total of 40 participants (mean age 63 y; male 71%) were recruited as follows: CHE (n=17); NHE (n=13); and HC (n=10). The KTRANS measurement in the frontoparietal cortex demonstrated increased blood-brain barrier permeability, where KTRANS was 0.01±0.02 versus 0.005±0.005 versus 0.004±0.002 in CHE, NHE, and HC patients, respectively (p = 0.032 comparing all 3 groups). Relative to HC with a value of 0.28, the parietal glutamine/creatine (Gln/Cr) ratio was significantly higher in both CHE 1.12 mmoL (p < 0.001); and NHE 0.49 (p = 0.04). Lower PHES scores correlated with higher glutamine/Cr (Gln/Cr) (r=-0.6; p < 0.001) and lower myo-inositol/Cr (mI/Cr) (r=0.6; p < 0.001) and lower choline/Cr (Cho/Cr) (r=0.47; p = 0.004). CONCLUSION The dynamic contrast-enhanced MRI KTRANS measurement revealed increased blood-brain barrier permeability in the frontoparietal cortex. The MRS identified a specific metabolite signature with increased glutamine, reduced myo-inositol, and choline, which correlated with CHE in this region. The MRS changes were identifiable in the NHE cohort.
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Affiliation(s)
- Joga Chaganti
- Department of Medical Imaging, St Vincent's Hospital, Sydney, Australia
- School of Clinical Medicine, St Vincent's Healthcare Campus, Faculty of Medicine, UNSW, Sydney, Australia
| | - Georgia Zeng
- School of Clinical Medicine, St Vincent's Healthcare Campus, Faculty of Medicine, UNSW, Sydney, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, Australia
| | - Nway Tun
- School of Clinical Medicine, St Vincent's Healthcare Campus, Faculty of Medicine, UNSW, Sydney, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, Australia
| | - Ian Lockart
- School of Clinical Medicine, St Vincent's Healthcare Campus, Faculty of Medicine, UNSW, Sydney, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, Australia
| | | | - Lucette Cysique
- Faculty of Science, School of Psychology, UNSW, Sydney, Australia
| | | | - Bruce J Brew
- School of Clinical Medicine, St Vincent's Healthcare Campus, Faculty of Medicine, UNSW, Sydney, Australia
- Departments of Neurology and Immunology, St Vincent's Hospital, Sydney, Australia
- Peter Duncan Neurosciences Unit Applied Medical Research Centre, St Vincent's Hospital, Sydney, Australia
| | - Mark Danta
- School of Clinical Medicine, St Vincent's Healthcare Campus, Faculty of Medicine, UNSW, Sydney, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, Australia
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Won SM, Oh KK, Gupta H, Ganesan R, Sharma SP, Jeong JJ, Yoon SJ, Jeong MK, Min BH, Hyun JY, Park HJ, Eom JA, Lee SB, Cha MG, Kwon GH, Choi MR, Kim DJ, Suk KT. The Link between Gut Microbiota and Hepatic Encephalopathy. Int J Mol Sci 2022; 23:ijms23168999. [PMID: 36012266 PMCID: PMC9408988 DOI: 10.3390/ijms23168999] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Hepatic encephalopathy (HE) is a serious complication of cirrhosis that causes neuropsychiatric problems, such as cognitive dysfunction and movement disorders. The link between the microbiota and the host plays a key role in the pathogenesis of HE. The link between the gut microbiome and disease can be positively utilized not only in the diagnosis area of HE but also in the treatment area. Probiotics and prebiotics aim to resolve gut dysbiosis and increase beneficial microbial taxa, while fecal microbiota transplantation aims to address gut dysbiosis through transplantation (FMT) of the gut microbiome from healthy donors. Antibiotics, such as rifaximin, aim to improve cognitive function and hyperammonemia by targeting harmful taxa. Current treatment regimens for HE have achieved some success in treatment by targeting the gut microbiota, however, are still accompanied by limitations and problems. A focused approach should be placed on the establishment of personalized trial designs and therapies for the improvement of future care. This narrative review identifies factors negatively influencing the gut–hepatic–brain axis leading to HE in cirrhosis and explores their relationship with the gut microbiome. We also focused on the evaluation of reported clinical studies on the management and improvement of HE patients with a particular focus on microbiome-targeted therapy.
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Gupta P, Vyas S, Salan T, Jain C, Taneja S, Dhiman RK, Singh P, Ahuja CK, Ray N, Govind V. Whole brain atlas-based diffusion kurtosis imaging parameters for evaluation of minimal hepatic encephalopathy. Neuroradiol J 2022; 35:67-76. [PMID: 34187242 PMCID: PMC8826285 DOI: 10.1177/19714009211026924] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSES Minimal hepatic encephalopathy (MHE) has no recognizable clinical symptoms, but patients have cognitive and psychomotor deficits. Hyperammonemia along with neuroinflammation lead to microstructural changes in cerebral parenchyma. Changes at conventional imaging are detected usually at the overt clinical stage, but microstructural alterations by advanced magnetic resonance imaging techniques can be detected at an early stage. MATERIALS AND METHODS Whole brain diffusion kurtosis imaging (DKI) data acquired at 3T was analyzed to investigate microstructural parenchymal changes in 15 patients with MHE and compared with 15 age- and sex-matched controls. DKI parametric maps, namely kurtosis fractional anisotropy (kFA), mean kurtosis (MK), axial kurtosis (AK) and radial kurtosis (RK), were evaluated at 64 white matter (WM) and gray matter (GM) regions of interest (ROIs) in the whole brain and correlated with the psychometric hepatic encephalopathy score (PHES). RESULTS The MHE group showed a decrease in kFA and AK across the whole brain, whereas MK and RK decreased in WM ROIs but increased in several cortical and deep GM ROIs. These alterations were consistent with brain regions involved in cognitive function. Significant moderate to strong correlations (-0.52 to -0.66; 0.56) between RK, MK and kFA kurtosis metrics and PHES were observed. CONCLUSION DKI parameters show extensive microstructural brain abnormalities in MHE with minor correlation between the severity of tissue damage and psychometric scores.
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Affiliation(s)
- Prateek Gupta
- Department of Radiodiagnosis and
Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh,
India
| | - Sameer Vyas
- Department of Radiodiagnosis and
Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh,
India,Sameer Vyas, Department of Radiodiagnosis
and Imaging, Postgraduate Institute of Medical Education and Research,
Chandigarh, India.
| | - Teddy Salan
- Department of Radiology, University
of Miami, USA
| | - Chirag Jain
- Department of Radiodiagnosis and
Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh,
India
| | - Sunil Taneja
- Department of Hepatology,
Postgraduate Institute of Medical Education and Research, Chandigarh,
India
| | - RK Dhiman
- Department of Hepatology,
Postgraduate Institute of Medical Education and Research, Chandigarh,
India
| | - Paramjeet Singh
- Department of Radiodiagnosis and
Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh,
India
| | - Chirag K Ahuja
- Department of Radiodiagnosis and
Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh,
India
| | - Nirmalya Ray
- Department of Radiodiagnosis and
Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh,
India
| | - Varan Govind
- Department of Radiology, University
of Miami, USA
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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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Yazici A, Emre Yildirim A, Konduk B, Aytaç İ, Barutçu S. A novel method: can stapedial acoustic reflex have a role in the diagnosis of minimal hepatic encephalopathy? Eur J Gastroenterol Hepatol 2021; 33:717-721. [PMID: 32568804 DOI: 10.1097/meg.0000000000001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Stapedial acoustic reflex is an easily accessible and applicable test which is also valuable for the clinical conditions which affect the various locations of the central nervous system. Searching the diagnostic value of stapedial acoustic reflex at minimal hepatic encephalopathy is the aim of this research. METHODS Diagnosis of minimal hepatic encephalopathy was conducted by mini-mental state and critical flickered frequency tests. Minimal hepatic encephalopathy diagnosed patients were established in the first group. Cirrhosis (without minimal hepatic encephalopathy or overt hepatic encephalopathy) diagnosed patients were created the control group. The stapedial acoustic reflex test was applied for minimal hepatic encephalopathy and the control group by audiologists in a soundproof room. RESULTS In total, 221 patients were screened and 97 patients meet the inclusion criterions. Out of 97 patients, 52 were the minimal hepatic encephalopathy patients and the remaining patients were the control group. Acoustic reflex tests battery includes the evaluation of two pathways called ipsilateral and contralateral. Ipsilateral way test results were found positive in all minimal hepatic encephalopathy patients and 95% positive in the control group. Contralateral acoustic reflex test results were found 36% positive in minimal hepatic encephalopathy patients and 95% positive in the control group, respectively. A comparison of ipsilateral and contralateral acoustic reflex test results was displayed a statistical significance. CONCLUSION Stapedial acoustic reflex test results of cirrhosis patients may cover additional parameters for the diagnosis of minimal hepatic encephalopathy.
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Affiliation(s)
| | - Abdullah Emre Yildirim
- Gastroenterology, University of Gaziantep Medical Faculty, Department, Gaziantep, Turkey
| | - BuğraTolga Konduk
- Gastroenterology, University of Gaziantep Medical Faculty, Department, Gaziantep, Turkey
| | | | - Sezgin Barutçu
- Gastroenterology, University of Gaziantep Medical Faculty, Department, Gaziantep, Turkey
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Gou LB, Zhang W, Guo DJ, Zhong WJ, Wu XJ, Zhou ZM. Aberrant brain structural network and altered topological organization in minimal hepatic encephalopathy. ACTA ACUST UNITED AC 2021; 26:255-261. [PMID: 32209507 DOI: 10.5152/dir.2019.19216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE We aimed to investigate the multilevel impairments of brain structural network in patients with minimal hepatic encephalopathy (MHE). METHODS Twenty-two patients with MHE and 22 well-matched healthy controls (HC) underwent structural magnetic resonance imaging (MRI) brain scans and neuropsychological evaluations. Individual brain structural networks were constructed using diffusion tensor imaging. Comparing with HC, we investigated the possible impairments of brain structural network in MHE, by applying graph-theory approaches to analyze the topological organization at global, modular, and local levels. The correlations between altered brain structural network and neuropsychological tests scores and venous ammonia levels were also examined in MHE patients. RESULTS In the MHE group, small-worldness showed significant decrease and normalized characteristic path length showed increase at the global level. In the modular section, six modules were identified. The inter-modular connective strengths showed significant increase between modules 2 and 4 and between modules 4 and 5. The results of node analysis showed similar hub distributions in the MHE and HC groups except for the right postcentral gyrus, which was only found in the MHE group. No significant differences were found in connective strength of edges between MHE and HC groups using network-based statistics. CONCLUSION The altered brain structural networks with reduced network integration and module segregation were demonstrated in patients with MHE. The dysconnectivity of brain structural network could provide an explanation for the brain dysfunctions of MHE.
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Affiliation(s)
- Lu-Bin Gou
- Department of Radiology, First Hospital of Lan Zhou University, Gansu, China
| | - Wei Zhang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Da-Jing Guo
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei-Jia Zhong
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Jia Wu
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhi-Ming Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Lu B, Wu C, Azami NLB, Xie D, Zhao C, Xu W, Hui D, Chen X, Sun R, Song J, An Y, Li K, Wang H, Ye G, Sun M. Babao Dan improves neurocognitive function by inhibiting inflammation in clinical minimal hepatic encephalopathy. Biomed Pharmacother 2021; 135:111084. [PMID: 33383371 DOI: 10.1016/j.biopha.2020.111084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/22/2020] [Accepted: 11/28/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Inflammation has been considered a precipitating event that contributes to neurocognitive dysfunction in minimal hepatic encephalopathy (MHE). Inhibition TLR-4 related inflammation can effectively improve neurocognitive dysfunction of MHE. Our previous study showed that Babao Dan (BBD) effectively inhibited inflammation and ameliorated neurocognitive function in rats with acute hepatic encephalopathy (HE) and chronic HE. The mechanism may lie in the regulation of TLR4 signaling pathway. Therefore, this study aimed to evaluate the role of BBD in the treatment of MHE patients with cirrhosis and to elucidate the underlying mechanism by which BBD regulated TLR4 pathway to alleviate inflammation. METHODS A randomized controlled trial (n = 62) was conducted to evaluate the clinical efficacy between BBD plus lactulose (n = 31) and lactulose alone (n = 31) in MHE patients by testing neurocognitive function (NCT-A and DST), blood ammonia, liver function (ALT, AST and TBIL) and blood inflammation (IL-1β, IL-6 and TNF-α). Afterward, we detected NO, inflammatory cytokines (IL-1β, IL-6 and TNF-α) and the phosphorylation of P65, JNK, ERK as well as P38 in LPS-activated rat primary bone marrow-derived macrophages (BMDMs), peritoneal macrophages (PMs), and mouse primary BMDMs/PMs/microglia/astrocytes, to investigate the underlying mechanism of BBD inhibiting inflammation through TLR4 pathway. Also, the survival rate of mice, liver function (ALT, AST), blood inflammation (IL-1β, IL-6 and TNF-α), inflammatory cytokines (IL-1β, IL-6 and TNF-α) and histopathological changes in the liver, brain and lung were measured to assess the anti-inflammatory effect of BBD on neurocognitive function in endotoxin shock/endotoxemia mice. RESULTS BBD combined with lactulose significantly ameliorated neurocognitive function by decreasing NCT-A (p<0.001) and increasing DST (p<0.001); inhibited systemic inflammation by decreasing IL-1β (p<0.001), IL-6(p<0.001) and TNF-α (p<0.001); reduced ammonia level (p = 0.005), and improved liver function by decreasing ALT(p = 0.043), AST(p = 0.003) and TBIL (p = 0.026) in MHE patients. Furthermore, BBD inhibited gene and protein expression of IL-1β, IL-6 and TNF-α as well as NO in rat primary BMDMs/PMs, and mouse primary BMDMs/PMs/microglia/astrocytes in a dose-dependent manner. BBD inhibited the activation of mouse primary BMDMs/PMs/microglia/astrocytes by regulating TLR4 pathway involving the phosphorylation of P65, JNK, ERK and P38. Also, BBD reduced the mortality of mice with endotoxin shock/endotoxemia; serum levels of ALT, AST, IL-1β, IL-6 and TNF-α; gene expression of IL-1β, IL-6 and TNF-α in the liver, brain and lung, and tissue damage in the liver and lung. CONCLUSION Our study provided for the first time clinical and experimental evidence supporting the use of BBD in MHE, and revealed that BBD could play a crucial role in targeting and regulating TLR4 inflammatory pathway to improve neurocognitive function in MHE patients.
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Affiliation(s)
- Bingjie Lu
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Chao Wu
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Nisma Lena Bahaji Azami
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Dong Xie
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Changqing Zhao
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Wan Xu
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Dengcheng Hui
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Xi Chen
- Shanghai Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, 200082, China.
| | - Runfei Sun
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Jingru Song
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Yongtong An
- Central Research Institute, Shanghai Pharmaceuticals Holding Co., Ltd., Shanghai, 201203, China.
| | - Kun Li
- The MOE Key Laboratory for Standardization of Chinese Medicines and the SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Huijun Wang
- The MOE Key Laboratory for Standardization of Chinese Medicines and the SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Guan Ye
- Central Research Institute, Shanghai Pharmaceuticals Holding Co., Ltd., Shanghai, 201203, China.
| | - Mingyu Sun
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
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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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Kumar M, Kainth S, Kumar S, Bhardwaj A, KumarAggarwal H, Maiwall R, Jamwal KD, Shasthry SM, Jindal A, Choudhary A, Anand L, Dhamija RM, Chibbar G, Chander Sharma B, Sarin SK. Prevalence of and Factors Associated with Sleep-Wake Abnormalities in Patients with Cirrhosis. J Clin Exp Hepatol 2021; 11:453-465. [PMID: 34276152 PMCID: PMC8267360 DOI: 10.1016/j.jceh.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Sleep-wake abnormalities [poor nighttime sleep and excessive daytime sleepiness (EDS)] are common in patients with cirrhosis. The aim of this study was to assess the prevalence of sleep-wake abnormalities and clinical factors associated with these abnormalities in a group of patients with cirrhosis. METHODS 1098 patients with cirrhosis [Child Turcotte Pugh (CTP) class A, 22.2%; CTP class B, 29.2% and CTP class C, 48.6%], with either no ascites or mild ascites controlled on diuretics, and no history of or current overt hepatic encephalopathy were included in the study. RESULTS Poor nighttime sleep and EDS were found in 569 (51.8%) and 489 (44.5%) patients respectively. On multivariate analysis, factors associated with poor nighttime sleep were CTP class C (vs. class A), presence of minimal hepatic encephalopathy (MHE), intermediate or evening type of diurnal preference category (vs. morning type), high risk for obstructive sleep apnea (OSA), diuretic use, presence of major depression, and presence of generalized anxiety disorder (GAD). Factors associated with EDS on multivariate analysis were CTP class B and C (vs. class A), intermediate or evening type of diurnal preference category (vs. morning type), high risk for OSA, presence of major depression, and presence of GAD. CONCLUSIONS Sleep-wake abnormalities are common in patients with cirrhosis. CTP status, diurnal preference chronotype, risk of OSA, major depression and GAD are associated with both poor nighttime sleep and EDS. MHE and diuretic use are associated with poor nighttime sleep, but not with EDS.
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Key Words
- ACLF, Acute on chronic liver failure
- BQ, Berlin questionnaire
- CFF, Critical flicker frequency
- CLDQ, Chronic liver disease questionnaire
- CSM, Composite scale of morningness
- CTP, Child Turcotte Pugh
- EDS, Excessive daytime sleepiness
- ESS, Epworth sleepiness scale
- GAD, generalized anxiety disorder
- HE, Hepatic encephalopathy
- HRQOL, Health related quality of life
- MHE, Minimal hepatic encephalopathy
- NASH, Non-alcoholic steatohepatitis
- OSA, Obstructive sleep apnea
- PHQ, Patient health questionnaire
- PSQI, Pittsburgh sleep quality index
- cirrhosis
- insomnia
- sleep disturbances
- sleep-wake abnormalities
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Affiliation(s)
- Manoj Kumar
- Department of Hepatology and Liver Transplantation, New Delhi, India,Address for correspondence: Manoj Kumar, MD, DM, Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070 India.
| | - Sumeet Kainth
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Sachin Kumar
- Department of Pulmonary Medicine, New Delhi, India
| | | | - Hemant KumarAggarwal
- Department of Pulmonary Medicine, New Delhi, India,Department of Respiratory Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Rakhi Maiwall
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Kapil D. Jamwal
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | | | - Ankur Jindal
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Ashok Choudhary
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Lovkesh Anand
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | | | - Guresh Chibbar
- Department of Biostatistics, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Barjesh Chander Sharma
- Department of Hepatology and Liver Transplantation, New Delhi, India,Corresponding author.
| | - Shiv K. Sarin
- Department of Hepatology and Liver Transplantation, New Delhi, India
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11
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Chen LH, Shi JY, Zou TX, Zhang L, Gou Y, Lin Y, Chen HJ. Disturbance of thalamic metabolism and its association with regional neural dysfunction and cognitive impairment in minimal hepatic encephalopathy. Eur J Radiol 2020; 131:109252. [PMID: 32949859 DOI: 10.1016/j.ejrad.2020.109252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/12/2020] [Accepted: 08/10/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To conduct the first investigation on thalamic metabolic alterations in minimal hepatic encephalopathy (MHE) and elucidate their association with intrinsic neural activity change and cognitive dysfunction. METHODS Thirty-eight cirrhotic patients [18 with MHE, 20 without MHE (NHE)] and 21 healthy controls (HC) were included, all of whom underwent 1H-magnetic resonance spectroscopy, resting-state functional magnetic resonance imaging (fMRI), as well as cognitive assessment based on the Psychometric Hepatic Encephalopathy Score (PHES). Metabolite ratios in the thalamus were measured, including N-acetyl aspartate (NAA)/creatine (Cr), glutamate plus glutamine (Glx)/Cr, choline (Cho)/Cr, and myo-inositol (mI)/Cr. Intrinsic neural activity was evaluated based on frequency-specific amplitude of low-frequency fluctuations (ALFF) using fMRI signals. RESULTS MHE patients showed an increase in Glx/Cr and a decrease in Cho/Cr and mI/Cr, compared with HC. These changes were aggravated from NHE to MHE. Cho/Cr and mI/Cr were positively correlated with regional ALFF derived from the frequency-specific band (0.01-0.027 Hz) and PHES. Receiver operating characteristic curve analysis showed that Cho/Cr and mI/Cr measurements exhibited moderate discrimination ability between NHE and MHE. CONCLUSION Our findings provide evidence that MHE is associated with disturbed metabolism in the thalamus, which may contribute to the altered neural activity and underlie the mechanisms of cognitive impairments. MRS measurements in the thalamus could serve as the potential biomarker for diagnosing MHE among cirrhotic patients.
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Affiliation(s)
- Li-Hong Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Jia-Yan Shi
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Tian-Xiu Zou
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Ling Zhang
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China; Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Yaoping Gou
- Fujian Provincial Key Laboratory of Plasma and Magnetic Resonance, Department of Electronic Science, Xiamen University, Xiamen, 361005, China
| | - Yanqin Lin
- Fujian Provincial Key Laboratory of Plasma and Magnetic Resonance, Department of Electronic Science, Xiamen University, Xiamen, 361005, China.
| | - Hua-Jun Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
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Animal Naming Test - a simple and accurate test for diagnosis of minimal hepatic encephalopathy and prediction of overt hepatic encephalopathy. Clin Exp Hepatol 2020; 6:116-124. [PMID: 32728628 PMCID: PMC7380476 DOI: 10.5114/ceh.2019.95105] [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: 11/24/2019] [Accepted: 03/05/2020] [Indexed: 01/02/2023] Open
Abstract
Aim of the study Minimal hepatic encephalopathy (MHE) is the mildest form in the spectrum of hepatic encepha-lopathy (HE). We compared the usefulness of the Psychometric Hepatic Encephalopathy Score (PHES) and Animal Naming Test (ANT) for the diagnosis of MHE and the prediction of the development of overt episodes of HE. Material and methods 103 consecutive patients with liver cirrhosis without overt HE were subjected to PHES and ANT evaluation. The receiver-operating characteristic curve was used to determine the optimum cut-off of the ANT value for the diagnosis of MHE. Results Thirty-seven (35.9%) patients had MHE as assessed by altered PHES. ANT (< 14) was positive in 36 (34.95%) patients with MHE with a sensitivity of 89.19% and specificity of 95.7%, positive predictive value (PPV) of 91.67%, negative predictive value (NPV) of 94.03% and diagnostic accuracy of 93.20%. The area under the curve for diagnosis of MHE was 0.978 (95% CI: 0.954-1.0). MHE patients had significantly lower ANT as compared to non-MHE patients and controls (10.81 ±0.324 vs. 15.27 ±0.147 vs. 15.78 ±0.192, respectively, p = 0.01). ANT correlated with PHES (r = 0.752, p = 0.001) and also with Child-Pugh (r = –0.408, p = 0.001) and MELD (r = –0.318, p = 0.001) scores. During follow-up, 14 patients in the MHE group and 4 in the non-MHE group developed overt episodes of HE (p = 0.001). Conclusions ANT is simple and accurate for the diagnosis of MHE and prediction of overt episodes of HE in patients with cirrhosis and correlates well with the Child-Pugh and MELD scores.
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Mizuno Y, Ishikawa T, Ishida J, Kobayashi A, Konakahara Y, Kinoshita A, Hama H, Hokari A, Saruta M. The Molar Ratio of Total Branched-chain Amino Acids to Tyrosine Predicts a Digit Symbol Test Abnormality in Cirrhotic Patients. Intern Med 2020; 59:1695-1704. [PMID: 32296001 PMCID: PMC7434536 DOI: 10.2169/internalmedicine.4298-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective We aimed to investigate the association between the digit symbol test (DST) and clinical characteristics, including the nutritional status of liver cirrhosis patients. Methods Fifty-nine cirrhotic patients without a history of overt hepatic encephalopathy were retrospectively evaluated. We examined neuropsychological abnormalities (NPAs) using the DST. We also estimated the detailed nutritional status using the Food Frequency Questionnaire (FFQ). The patients were divided into two groups according to their DST status: patients with normal DST scores (DST-Nor group, n=45) and those with abnormal DST scores (DST-Abn group, n=14). The clinical and nutritional findings of the two groups were compared. Results Overall, 14 (23.7%) patients had a DST abnormality. There were significant differences between the two groups in serum albumin (Alb; p=0.0043), valine (Val; p=0.0016), leucine (Leu; p=0.0078), isoleucine (Ile; p=0.0022), the molar ratio of total branched-chain amino acids to tyrosine (BTR; p=0.00025), total-bilirubin (T-Bil; p=0.0071), prothrombin time (%) (PT; p=0.028), and serum sodium (Na; p=0.035). A multivariate analysis found the BTR to be the only independent predictor of a DST abnormality (hazard ratio, 9.24; p<0.031). An FFQ analysis, revealed that the nutritional findings of patients with and without a DST abnormality, were similar. Conclusion The BTR was useful for predicting the risk of NPAs, as defined by a DST abnormality. The risk of NPAs may be estimated by monitoring the BTR.
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Affiliation(s)
- Yusuke Mizuno
- Department of Gastroenterology and Hepatology, The Jikei University Daisan Hospital, Japan
| | - Tomohisa Ishikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Jinya Ishida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Akemi Kobayashi
- Clinical Nutritional Supports, Jikei University Hospital, Japan
| | | | - Akiyoshi Kinoshita
- Department of Gastroenterology and Hepatology, The Jikei University Daisan Hospital, Japan
| | - Hironobu Hama
- Clinical Nutritional Supports, Jikei University Hospital, Japan
| | - Atsushi Hokari
- Department of Gastroenterology and Hepatology, The Jikei University Katsushika Medical Center, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
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Stawicka A, Jaroszewicz J, Zbrzeźniak J, Sołowianowicz N, Woszczenko A, Świderska M, Flisiak R. Clinical Usefulness of the Inhibitory Control Test (ICT) in the Diagnosis of Minimal Hepatic Encephalopathy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E3645. [PMID: 32455895 PMCID: PMC7277853 DOI: 10.3390/ijerph17103645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/21/2022]
Abstract
Background: Minimal hepatic encephalopathy (MHE) refers to a number of neuropsychiatric and neurophysiological disorders in patients with cirrhosis who do not show abnormalities on physical examination or in clinical tests. The aim of this study was to determine the prevalence, risk factors, and predictive value of minimal hepatic encephalopathy and the usefulness of the inhibitory control test (ICT) in the diagnosis. Methods: Seventy patients (mean age 53 years, range 24-77) with liver cirrhosis were enrolled in the study. MHE was diagnosed based on PHES (psychometric hepatic encephalopathy score) and ICT. PHES and ICT were validated in a group of 56 control subjects. Results: Minimal hepatic encephalopathy was diagnosed using PHES in 21 patients (30%). ICT diagnosed MHE in 30 patients (42%), and the test had a sensitivity of 65% and a specificity of 57% compared to PHES. The ICT score (lures/target accuracy rate) correlated with the age of subjects (R = 0.35, p = 0.002) and only slightly with education (education in years R = -0.22, p = 0.06). MHE diagnosed with PHES or ICT was associated with a significantly higher model of end-stage liver disease (MELD) score in the follow-up. MHE diagnosed with ICT was correlated with a significantly higher incidence of symptoms of decompensated cirrhosis (p = 0.02) in the follow-up. Conclusions: ICT had moderate sensitivity and specificity in diagnosing MHE compared to PHES. Importantly, MHE detected with PHES or ICT was associated with poorer survival and a more severe progression of the disease.
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Affiliation(s)
- Agnieszka Stawicka
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Bialystok, Poland; (J.J.); (J.Z.); (N.S.); (A.W.); (M.Ś.); (R.F.)
| | - Jerzy Jaroszewicz
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Bialystok, Poland; (J.J.); (J.Z.); (N.S.); (A.W.); (M.Ś.); (R.F.)
- Department of Infectious Diseases and Hepatology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Justyna Zbrzeźniak
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Bialystok, Poland; (J.J.); (J.Z.); (N.S.); (A.W.); (M.Ś.); (R.F.)
| | - Natalia Sołowianowicz
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Bialystok, Poland; (J.J.); (J.Z.); (N.S.); (A.W.); (M.Ś.); (R.F.)
| | - Aleksandra Woszczenko
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Bialystok, Poland; (J.J.); (J.Z.); (N.S.); (A.W.); (M.Ś.); (R.F.)
| | - Magdalena Świderska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Bialystok, Poland; (J.J.); (J.Z.); (N.S.); (A.W.); (M.Ś.); (R.F.)
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Bialystok, Poland; (J.J.); (J.Z.); (N.S.); (A.W.); (M.Ś.); (R.F.)
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Reja M, Phelan LP, Senatore F, Rustgi VK. Social Impact of Hepatic Encephalopathy. Clin Liver Dis 2020; 24:291-301. [PMID: 32245534 DOI: 10.1016/j.cld.2020.01.008] [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: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is a multifaceted disorder, with effects stretching far beyond office visits and hospitalizations. Patients with HE suffer from varying degrees of altered consciousness, intellectual disability, and personality changes. A large social impact exists for patients with HE. Quality of life and activities of daily living, such as work capacity, driving ability, and sleep quality, have been shown to be affected. Additionally, caregiver and financial burdens are highly prevalent. Multiple tools exist to assess quality of life, including the CLD-Q questionnaire. Common treatments for HE, including rifaximin and lactulose, have been shown to improve overall quality of life.
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Affiliation(s)
- Mishal Reja
- Department of Medicine, Rutgers Robert Wood Johnson University Hospital, Clinical Academic Building (CAB), 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA.
| | - Lauren Pioppo Phelan
- Department of Medicine, Rutgers Robert Wood Johnson University Hospital, Clinical Academic Building (CAB), 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA
| | - Frank Senatore
- Department of Gastroenterology, Rutgers Robert Wood Johnson University Hospital, Clinical Academic Building, 125 Paterson Street, Suite 5100B, 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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Dhiman RK, Thumburu KK, Verma N, Chopra M, Rathi S, Dutta U, Singal AK, Taneja S, Duseja A, Singh M. Comparative Efficacy of Treatment Options for Minimal Hepatic Encephalopathy: A Systematic Review and Network Meta-Analysis. Clin Gastroenterol Hepatol 2020; 18:800-812.e25. [PMID: 31476436 DOI: 10.1016/j.cgh.2019.08.047] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We aimed to synthesize evidence for most effective treatments for minimal hepatic encephalopathy (HE) and prevention of overt HE in patients with cirrhosis. METHODS We performed a systematic search of the PubMed, EMBASE, OvidSP, and Cochrane Central Register of Controlled Trials databases through July 26, 2018, for randomized controlled trials evaluating treatments for minimal HE in patients with cirrhosis, with primary outcomes of reversal of minimal HE or prevention of overt HE. We conducted a meta-analysis and then used network meta-analysis and surface under cumulated ranking (SUCRA) to pool the direct and indirect estimates and rank the different treatments. We appraised study quality using the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS Our meta-analysis and network meta-analysis included 25 trials, comprising 1563 participants. Agents found to be effective in reversing minimal HE compared with placebo or no treatment included rifaximin (odds ratio [OR], 7.53; 95% predictive interval [PrI], 4.45-12.73; SUCRA, 89.2%; moderate quality), lactulose (OR, 5.39; 95% PrI, 3.60-8.0; SUCRA, 67.2%; moderate quality), the combination of probiotics and lactulose (OR, 4.66; 95% PrI, 1.90-11.39; SUCRA, 52.4%; low quality), L-ornithine L-aspartate (OR, 4.45; 95% PrI, 2.67-7.42; SUCRA, 47.2%; low moderate quality), and probiotics (OR, 3.89; 95% PrI, 2.52-6.02; SUCRA, 34.1%; low quality). Agents found to be effective in preventing episodes of overt HE compared with placebo or no treatment included L-ornithine L-aspartate (OR, 0.19; 95% PrI, 0.04-0.91; SUCRA, 75.1%; high moderate quality), lactulose (OR, 0.22; 95% PrI, 0.09-0.52; SUCRA, 73.9%; moderate quality), and probiotics (OR, 0.27; 95% PrI, 0.11-0.62; SUCRA, 59.6%; low quality). CONCLUSIONS In a meta-analysis of data from 25 trials, we found rifaximin and lactulose to be most effective for reversal of minimal HE in patients with cirrhosis. L-ornithine L-aspartate and lactulose are most effective in the prevention of overt HE. Lactulose was the only agent that was effective in reversing minimal HE, preventing overt HE, reducing ammonia, and improving quality of life, with tolerable adverse effects. International prospective register of systematic reviews ID: 107003.
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Affiliation(s)
| | | | | | | | | | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | | | | | - Meenu Singh
- Department of Paediatrics, Chandigarh, India
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Luo M, Ma P, Li L, Cao WK. Advances in psychometric tests for screening minimal hepatic encephalopathy: From paper-and-pencil to computer-aided assessment. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:398-407. [PMID: 31060994 DOI: 10.5152/tjg.2019.18226] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Minimal hepatic encephalopathy (MHE) is a major neuropsychiatric complication of liver cirrhosis and portosystemic shunting. Although MHE produces a spectrum of cognitive impairments in the domains of short-term attention, working memory, and executive function, it generally does not present with obvious clinical manifestation on conventional assessments. Paper-and-pencil psychometric tests, such as the psychometric hepatic encephalopathy score and the repeatable battery for the assessment of neuropsychological status, are recommended to diagnose MHE. However, these tests are neither rapid nor convenient to use in practice. To facilitate repeated testing in clinic and follow-up, computer-aided psychometric tests, such as the scan test, Cognitive Drug Research assessment battery, inhibitory control test, EncephalApp Stroop App, and critical flicker frequency, have been used to screen for MHE among patients with liver cirrhosis. The aim of this review was to describe the progression from the utility of paper-and-pencil to computer-aided psychometric tests for MHE screening in clinical practice.
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Affiliation(s)
- Ming Luo
- Department of Gastroenterology, Ningxia People's Hospital, Ningxia, China
| | - Ping Ma
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Lei Li
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Wu-Kui Cao
- Tianjin Liver Disease Institute, Tianjin Second People's Hospital, Tianjin, China
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18
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Zeng G, Penninkilampi R, Chaganti J, Montagnese S, Brew BJ, Danta M. Meta-analysis of magnetic resonance spectroscopy in the diagnosis of hepatic encephalopathy. Neurology 2020; 94:e1147-e1156. [DOI: 10.1212/wnl.0000000000008899] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/20/2019] [Indexed: 12/18/2022] Open
Abstract
ObjectiveVarious imaging modalities have been used to explore pathogenic mechanisms and stratify the severity of hepatic encephalopathy (HE). The hypothesis of this meta-analysis was that there is a progressive identifiable derangement of imaging measures using magnetic resonance spectroscopy (MRS) related to the severity of the HE.MethodsStudies with more than 10 cases and HE diagnosis were identified from the electronic databases PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Literatura Latino Americana em Ciências da Saúde (LILACS), and Cochrane Central Register of Controlled Trials (CENTRAL) through July 25, 2018. Participants were stratified into healthy controls and patients with non-HE (NHE) (cirrhosis without HE), minimal HE (MHE), and overt HE (OHE). Analyses were organized by metabolite studied and brain region examined. Statistical meta-analysis was performed using the metafor package in R (v3.4.1). Pooled standardized mean differences between patient groups were calculated using a random effects model.ResultsWe identified 31 studies (1,481 patients) that included data for cirrhosis-related HE. We found the parietal region to be the most reliable in differentiating between patients with and without MHE, with standard mean differences of +0.82 (95% confidence interval [CI] +0.49 to +1.15, p < 0.0001, I2 = 37.45%) for glutamine/glutamate, −0.36 (95% CI −0.61 to −0.10, p = 0.007, I2 = 20.00%) for choline, and−0.77 (95% CI −1.19 to −0.34, p = 0.0004, I2 = 67.48%) for myo-inositol. We also found that glutamine/glutamate was the metabolite that reliably correlated with HE grade in all brain regions.ConclusionsThe meta-analysis reveals that MRS changes in glutamine/glutamate, choline, and myo-inositol, particularly in the parietal lobe, correlate with the severity of HE. MRS may be of value in the assessment of HE.
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Awad MMED, El-Deib AERM, Attia FM, Negm M, Soliman MHM, Omar WH. Role of minimal hepatic encephalopathy in road traffic accidents. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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20
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Xu XY, Ding HG, Li WG, Jia JD, Wei L, Duan ZP, Liu YL, Ling-Hu EQ, Zhuang H, Hepatology CSO, Association CM. Chinese guidelines on management of hepatic encephalopathy in cirrhosis. World J Gastroenterol 2019; 25:5403-5422. [PMID: 31576089 PMCID: PMC6767982 DOI: 10.3748/wjg.v25.i36.5403] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/07/2019] [Accepted: 08/24/2019] [Indexed: 02/06/2023] Open
Abstract
The Chinese Society of Hepatology developed the current guidelines on the management of hepatic encephalopathy in cirrhosis based on the published evidence and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of hepatic encephalopathy (HE) including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy, emphasizing the importance on screening MHE in patients with end-stage liver diseases. The guidelines emphasized that early identification and timely treatment are the key to improve the prognosis of HE. The principles of treatment include prompt removal of the cause, recovery of acute neuropsychiatric abnormalities to baseline status, primary prevention, and secondary prevention as soon as possible.
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Affiliation(s)
- Xiao-Yuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing 100034, China
| | - Hui-Guo Ding
- Hepatology and Digestion Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Wen-Gang Li
- Department of Liver Oncology, Cancer Radiation Therapy Center, Fifth Medical Center, PLA General Hospital, Beijing 100039, China
| | - Ji-Dong Jia
- Hepatology Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lai Wei
- Hepatobiliary and Pancreatic Department, Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Zhong-Ping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Yu-Lan Liu
- Department of Gastroenterology, Peking University People's Hospital, Beijing 100044, China
| | - En-Qiang Ling-Hu
- Department of Gastroenterology, First Medical Center, PLA General Hospital, Beijing 100853, China
| | - Hui Zhuang
- Department of Pathogenic Biology, Peking University Health Science Center, Beijing 100191, China
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21
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Management of Hepatic Encephalopathy in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Malik A, Kardashian AA, Zakharia K, Bowlus CL, Tabibian JH. Preventative care in cholestatic liver disease: Pearls for the specialist and subspecialist. LIVER RESEARCH 2019; 3:118-127. [PMID: 32042471 PMCID: PMC7008979 DOI: 10.1016/j.livres.2019.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cholestatic liver diseases (CLDs) encompass a variety of disorders of abnormal bile formation and/or flow. CLDs often lead to progressive hepatic insult and injury and following the development of cirrhosis and associated complications. Many such complications are clinically silent until they manifest with severe sequelae, including but not limited to life-altering symptoms, metabolic disturbances, cirrhosis, and hepatobiliary diseases as well as other malignancies. Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most common CLDs, and both relate to mutual as well as unique complications. This review provides an overview of PSC and PBC, with a focus on preventive measures aimed to reduce the incidence and severity of disease-related complications.
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Affiliation(s)
- Adnan Malik
- Department of Public Health and Business Administration, The University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Internal Medicine, Beaumont Hospital, Dearborn, MI, USA
| | - Ani A. Kardashian
- University of California Los Angeles Gastroenterology Fellowship Training Program, Vatche and Tamar Manoukian Division of Digestive Diseases, Los Angeles, CA, USA
| | - Kais Zakharia
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa, IA, USA
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, CA, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-University of California Los Angeles Medical Center, Sylmar, CA, USA
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Ammonia-induced mitochondrial impairment is intensified by manganese co-exposure: relevance to the management of subclinical hepatic encephalopathy and cirrhosis-associated brain injury. Clin Exp Hepatol 2019; 5:109-117. [PMID: 31501786 PMCID: PMC6728860 DOI: 10.5114/ceh.2019.85071] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 12/30/2022] Open
Abstract
Aim of the study Hepatic encephalopathy (HE) is a neuropsychiatric syndrome ensuing from liver failure. The liver is the major site of ammonia detoxification in the human body. Hence, acute and chronic liver dysfunction can lead to hyperammonemia. Manganese (Mn) is a trace element incorporated in several physiological processes in the human body. Mn is excreted through bile. It has been found that cirrhosis is associated with hyperammonemia as well as body Mn accumulation. The brain is the primary target organ for both ammonia and Mn toxicity. On the other hand, brain mitochondria impairment is involved in the mechanism of Mn and ammonia neurotoxicity. Material and methods The current study was designed to evaluate the effect of Mn and ammonia and their combination on mitochondrial indices of functionality in isolated brain mitochondria. Isolated brain mitochondria were exposed to increasing concentrations of ammonia and Mn alone and/or in combination and several mitochondrial indices were assessed. Results The collapse of mitochondrial membrane potential, increased mitochondrial permeabilization, reactive oxygen species formation, and a significant decrease in mitochondrial dehydrogenase activity and ATP content were evident in Mn-exposed (0.005-1 mM) brain mitochondria. On the other hand, ammonia (0.005-0.5 mM) caused no significant changes in brain mitochondrial function. It was found that co-exposure of the brain mitochondria to Mn and ammonia causes more evident mitochondrial impairment in comparison with Mn and/or ammonia alone. Conclusions These data indicate additive toxicity of ammonia and Mn in isolated brain mitochondria exposed to these neurotoxins.
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González-Regueiro J, la Tijera MHD, Moreno-Alcántar R, Torre A. Pathophysiology of hepatic encephalopathy and future treatment options. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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González-Regueiro JA, Higuera-de la Tijera MF, Moreno-Alcántar R, Torre A. Pathophysiology of hepatic encephalopathy and future treatment options. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:195-203. [PMID: 31014748 DOI: 10.1016/j.rgmx.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/28/2019] [Accepted: 02/18/2019] [Indexed: 06/09/2023]
Abstract
Understanding of the pathophysiology of hepatic encephalopathy has conditioned new treatment options. Ammonia detoxification in hepatic encephalopathy is regulated by two enzymes: glutaminase or glutamine synthetase. The first produces ammonia and the second detoxifies the ammonia, which is why treatments are aimed at glutaminase inhibition or glutamine synthetase activation. At present, we know that both enzymes are found not only in the liver, but also in the muscle, intestine, kidney, and brain. Therefore, current treatments can be directed at each enzyme at different sites. Awareness of those potential treatment sites makes different options of approach possible in the patient with hepatic encephalopathy, and each approach should be personalized.
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Affiliation(s)
- J A González-Regueiro
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | - R Moreno-Alcántar
- Departamento de Gastroenterología, Centro Médico Nacional Siglo XXI, Ciudad de México, México
| | - A Torre
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México; Unidad de Hepatología y Trasplante Hepático, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México.
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Heiser C, Haller B, Sohn M, Hofauer B, Knopf A, Mühling T, Freiherr J, Bender M, Tiller M, Schmidt A, Schepp W, Gundling F. Olfactory Function is Affected in Patients with Cirrhosis Depending on the Severity of Hepatic Encephalopathy. Ann Hepatol 2018; 17:822-829. [PMID: 30145560 DOI: 10.5604/01.3001.0012.3143] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Olfactory functions are altered to a variable degree by chronic liver disease. Few studies including only small populations of patients emphasized the possibility of hepatic encephalopathy (HE) influencing olfactory nervous tasks. So far, no study has explicitly focused on olfactory function depending on the severity of HE as assessed by objective diagnostic procedures. Thus we performed a study using the "Sniffin' Sticks" test system, critical flicker-fusion frequency (CFF) and clinical West Haven criteria. MATERIAL AND METHODS 54 cirrhotic patients with liver cirrhosis were included. Furthermore, 43 adult volunteers participating as a non-cirrhotic control group. Olfactory testing was performed using the "Sniffin' Stick" test battery (Burghart Medizintechnik, Wedel, Germany) which renders a widely-used tool both in clinical and research settings for the assessment of olfactory threshold, odor identification and discrimination. Several complications of cirrhosis were diagnosed by reference methods. Statistical analysis of cirrhosis-associated complications and their relation to olfactory function was performed. Assessment of HE and classification of different stages were performed according to clinical criteria (West- Haven criteria) and according to CFF, which was determined using a portable analyzer. RESULTS Olfactory function was significantly reduced in cirrhotic patients (in 61.1%) compared to controls (p < 0.001). Among cirrhotics patients, the prevalence of olfactory deficits (hyposmia, anosmia) increased with the severity of HE as assessed by CFF and clinical criteria (p = 0.008 and p = 0.097, respectively). No correlation was observed between olfactory deficits and severity of liver disease as assessed by Child-Pugh-Score, etiology of cirrhosis and complications of cirrhosis such as ascites and portal venous hypertension. CONCLUSIONS Olfactory testing serves as a screening tool for HE and may facilitate grading of HE-severity.
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Affiliation(s)
- Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Statistics and Epidemiology Technical University of Munich, Munich, Germany
| | - Maximilian Sohn
- Department of Visceral Surgery, Bogenhausen Academic Teaching Hospital, University of Munich, Germany
| | - Benedikt Hofauer
- Department of Otorhinolaryngology, Head and Neck Surgery, Technical University of Munich, Munich, Germany
| | - Andreas Knopf
- Institute of Medical Statistics and Epidemiology Technical University of Munich, Munich, Germany
| | - Tobias Mühling
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Jessica Freiherr
- Institute of diagnostic and interventional neuroradiologiy, RWTH Aachen, Aachen
| | - Martin Bender
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Maximilian Tiller
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Anna Schmidt
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Wolfgang Schepp
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
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Cai X, Wang L, Hu C. Retracted
: Efficacy of different drugs in the treatment of minimal hepatic encephalopathy: A network meta‐analysis involving 826 patients based on 10 randomized controlled trials. J Cell Biochem 2018; 119:8336-8345. [PMID: 29932239 DOI: 10.1002/jcb.26886] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/21/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Xiao‐Jun Cai
- Heilongjiang Academy of Traditional Chinese MedicineHarbinP.R. China
| | - Lei Wang
- Heilongjiang Academy of Traditional Chinese MedicineHarbinP.R. China
| | - Chun‐Mei Hu
- The Third Hospital of Heilongjiang ProvinceBeianP.R. China
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Stroop Test Validation to Screen for Minimal Hepatic Encephalopathy in Pediatric Extrahepatic Portal Venous Obstruction. J Pediatr Gastroenterol Nutr 2018; 66:802-807. [PMID: 29373442 DOI: 10.1097/mpg.0000000000001895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Minimal hepatic encephalopathy (MHE) has been reported in children with extrahepatic portal vein obstruction (EHPVO). MHE assessment is restricted to research situations as neuropsychiatric tests are time-intensive. Computerized Stroop Test (CST) has been used in cirrhotic adults for MHE screening. The study aims to assess MHE frequency in young Indian children with EHPVO and validate CST for MHE screening in pediatric EHPVO. METHODS Thirty-seven children with EHPVO between 7 and 12 years of age and 37 age- and sex-matched controls were enrolled. Fasting plasma ammonia was measured. MHE was diagnosed by Revised Amsterdamse Kinder Intelligentie Test. The performance of a Tamil language version of CST in MHE screening was assessed. RESULTS MHE was diagnosed in 18.9% (7/37) of EHPVO (EHPVO-MHE). Plasma ammonia levels were higher in EHPVO-MHE compared to EHPVO without MHE (EHPVO-No-MHE) but abnormal plasma ammonia levels are unsuitable for MHE screening. CST was administered in 35 EHPVO and 37 controls. EHPVO-MHE, compared to EHPVO-No-MHE, had longer "on time," "off time," "(on+off) time," and "(on-off) time." For MHE diagnosis, specificity and sensitivity of "(on+off) time" were 100% and 89.6% for a cutoff of >180.4 seconds (area under receiver operating characteristic = 0.97). CONCLUSIONS In the absence of other risk factors for neurological insult or patent surgical shunts, MHE frequency in young Indian children with EHPVO, determined by Revised Amsterdamse Kinder Intelligentie Test, was lesser than in earlier studies. CST is suitable for MHE screening in clinical practice to select patients for neuropsychiatric evaluation.
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Zakharia K, Tabibian A, Lindor KD, Tabibian JH. Complications, symptoms, quality of life and pregnancy in cholestatic liver disease. Liver Int 2018; 38:399-411. [PMID: 28921801 DOI: 10.1111/liv.13591] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 09/12/2017] [Indexed: 12/11/2022]
Abstract
Cholestatic liver diseases (CLDs) encompass a variety of disorders of bile formation and/or flow which generally result in progressive hepatobiliary injury and ultimately end-stage liver disease. Many patients with CLD are diagnosed between the ages of 20-50 years, a particularly productive period of life professionally, biologically and in other respects; it is not surprising, thus, that CLD is often associated with impaired health-related quality of life (HRQOL) and uncertainty regarding implications for and outcomes of pregnancy. Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most prominent CLDs, both having considerable morbidity and mortality and representing major indications for liver transplantation. These disorders, as a consequence of their complications (eg ascites, hepatic osteodystrophy), associated conditions (eg inflammatory bowel disease) and symptoms (eg pruritus and fatigue), can significantly impair an array of domains of HRQOL. Here we review these impactful clinical aspects of PSC and PBC as well as the topics of fertility and pregnancy.
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Affiliation(s)
- Kais Zakharia
- Internal Medicine Residency Program, Beaumont Health - Dearborn, Dearborn, MI, USA
| | - Anilga Tabibian
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Keith D Lindor
- Arizona State University, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
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Greinert R, Ripoll C, Zipprich A. Covert hepatic encephalopathy leads to distinct alterations in the emotional state, independently of MELD-Score. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2018; 56:461-468. [PMID: 29341039 DOI: 10.1055/s-0043-123766] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Covert hepatic encephalopathy impairs many aspects of quality of life, although its impact on the emotional state has not been evaluated. This study aims to evaluate the impact of covert hepatic encephalopathy on the emotional state and which factors are associated with changes in the emotional state in patients with cirrhosis. METHODS This single-center study included all patients with cirrhosis who underwent the portosystemic encephalopathy syndrome (PSE) test, critical flicker frequency, and emotional state assessment with the Eigenschaftswörterliste 60-S in 2011. Covert hepatic encephalopathy was defined by abnormal PSE. Parametric and non-parametric tests were used according to variable distribution. RESULTS One hundred seventeen patients with cirrhosis were included (median age: 59 [interquartile range: 48 - 67], 32 % female, 74 % alcohol-associated). Seventy patients had covert hepatic encephalopathy (60 %) with a higher MELD (16 [interquartile range: 13 - 21], p = 0.001) and a higher Child-Pugh score (p = 0.003) compared to patients without encephalopathy. Patients with covert encephalopathy felt reduced mental activity (p = 0.004), lower general well-being (p = 0.001), and reduced extraversion (p = 0.021). The scores in the negative domains such as general lethargy (p = 0.031) and anxiousness/depressiveness (p = 0.033) were higher in patients with covert hepatic encephalopathy. There was no correlation between MELD and the emotional state. Patients with 2 pathological tests (critical flicker frequency and PSE) showed the most distinct alterations in the emotional state in the group of patients with covert hepatic encephalopathy. CONCLUSIONS Patients with covert hepatic encephalopathy have an alteration of the emotional state, which is more marked in patients with 2 pathological tests. Interestingly, MELD had no impact on the emotional state.
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Association of Helicobacter pylori with the Risk of Hepatic Encephalopathy. Dig Dis Sci 2017; 62:3614-3621. [PMID: 29119412 DOI: 10.1007/s10620-017-4834-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 11/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Hepatic encephalopathy is the common manifestation of decompensated cirrhosis. The association between Helicobacter pylori (H. pylori) infection and hepatic encephalopathy has been shown in many epidemiologic studies. This meta-analysis was conducted to summarize all available studies to estimate the association between H. pylori infection and hepatic encephalopathy. METHODS A comprehensive literature review was conducted using MEDLINE and EMBASE database through March 2017 to identify studies that reported the association between H. pylori infection and hepatic encephalopathy. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. RESULTS Of 15,233 studies, eleven studies (four cross-sectional, four case-control, and three cohort studies) met the eligibility criteria and were included in the meta-analysis. The pooled OR of hepatic encephalopathy in patients with H. pylori infection was 1.73 (95% CI 1.09-2.73) when compared with the patients without H. pylori infection. The association between H. pylori and hepatic encephalopathy was not statistically significant after the sensitivity analysis, excluding those using ELISA alone, with a pooled OR of 1.92 (95% CI 0.91-4.05, I 2 = 62%). There was no publication bias of overall included studies assessed by the funnel plots and Egger's regression asymmetry test. CONCLUSIONS This study demonstrated a potential association between H. pylori infection and risk of hepatic encephalopathy. Future studies are required to assess the effect of chronicity of infection on the development of hepatic encephalopathy.
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Jeyaraj R, Morgan MY, Gluud LL. Aminoglycosides and metronidazole for people with cirrhosis and hepatic encephalopathy. Hippokratia 2017. [DOI: 10.1002/14651858.cd012734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Rebecca Jeyaraj
- Division of Medicine, Royal Free Campus, University College London; UCL Institute for Liver & Digestive Health; Rowland Hill Street Hampstead London UK NW3 2PF
| | - Marsha Y Morgan
- Division of Medicine, Royal Free Campus, University College London; UCL Institute for Liver & Digestive Health; Rowland Hill Street Hampstead London UK NW3 2PF
| | - Lise Lotte Gluud
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Kettegaards Alle Hvidovre Denmark 2650
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Srivastava A, Chaturvedi S, Gupta RK, Malik R, Mathias A, Jagannathan NR, Jain S, Pandey CM, Yachha SK, Rathore RKS. Minimal hepatic encephalopathy in children with chronic liver disease: Prevalence, pathogenesis and magnetic resonance-based diagnosis. J Hepatol 2017; 66:528-536. [PMID: 27815224 DOI: 10.1016/j.jhep.2016.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/17/2016] [Accepted: 10/18/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed to study MHE in children with chronic liver disease (CLD) and to validate non-invasive objective tests which can assist in its diagnosis. METHODS We evaluated 67 children with CLD (38 boys; age 13 [7-18] years) and 37 healthy children to determine the prevalence of MHE. We also assessed the correlation of MHE with changes in brain metabolites by magnetic resonance spectroscopy (1HMRS), diffusion tensor imaging (DTI) derived metrics, blood ammonia and inflammatory cytokines (interleukin-6 [IL6], tumor necrosis factor alpha [TNF-α]). In addition, the accuracy of MR-based investigations for diagnosis of MHE in comparison to neuropsychological tests was analysed. RESULTS Thirty-four (50.7%) children with CLD had MHE on neuropsychological tests. MHE patients had higher BA (30.5 [6-74] vs. 14 [6-66]μmol/L; p=0.02), IL-6 (8.3 [4.7-28.7] vs. 7.6 [4.7-20.7]pg/ml; p=0.4) and TNF-α (17.8 [7.8-65.5] vs. 12.8 [7.5-35]pg/ml; p=0.06) than No-MHE. 1HMRS showed higher glutamine (2.6 [2.1-3.3] vs. 2.4 [2.0-3.1]; p=0.02), and lower choline (0.20 [0.14-0.25] vs. 0.22 [0.17-0.28]; p=0.1) and myo-inositol (0.25 [0.14-0.41] vs. 0.29 [0.21-0.66]; p=0.2) in MHE patients than those without MHE. Mean diffusivity (MD) on DTI was significantly higher in 6/11 brain areas in patients with MHE vs. no MHE. Brain glutamine had a significant positive correlation with blood ammonia, IL-6, TNF-α and MD of various brain regions. Neuropsychological tests showed a negative correlation with blood ammonia, IL6, TNF-α, glutamine and MD. Frontal white matter MD had a sensitivity and specificity of 73.5% and 100% for diagnosing MHE. CONCLUSIONS In children with CLD, 50% have MHE. There is a significant positive correlation between markers of hyperammonemia, inflammation and brain edema and these correlate negatively with neuropsychological tests. MD on DTI is a reliable tool for diagnosing MHE. LAY SUMMARY Fifty percent of children with chronic liver disease develop minimal hepatic encephalopathy (MHE) and perform poorly on neuropsychological testing. These children have raised blood ammonia, inflammatory cytokines and mild cerebral edema on diffusion tensor imaging as compared to children without MHE. The higher the ammonia, inflammatory cytokines and cerebral edema levels the poorer the performance on neuropsychological assessment. The estimation of mean diffusivity on diffusion tensor imaging is an objective and reliable method for diagnosing MHE.
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Affiliation(s)
- Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
| | - Saurabh Chaturvedi
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | | | - Rohan Malik
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | | | - Sunil Jain
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Chandra Mani Pandey
- Department of Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Abstract
BACKGROUND Hepatic encephalopathy is a disorder of brain function as a result of liver failure or portosystemic shunt or both. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning, and represent a significant burden on healthcare resources. Probiotics are live micro-organisms, which when administered in adequate amounts, may confer a health benefit on the host. OBJECTIVES To determine the beneficial and harmful effects of probiotics in any dosage, compared with placebo or no intervention, or with any other treatment for people with any grade of acute or chronic hepatic encephalopathy. This review did not consider the primary prophylaxis of hepatic encephalopathy. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, conference proceedings, reference lists of included trials, and the World Health Organization International Clinical Trials Registry Platform until June 2016. SELECTION CRITERIA We included randomised clinical trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in people with hepatic encephalopathy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. We conducted random-effects model meta-analysis due to obvious heterogeneity of participants and interventions. We defined a P value of 0.05 or less as significant. We expressed dichotomous outcomes as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 21 trials with 1420 participants, of these, 14 were new trials. Fourteen trials compared a probiotic with placebo or no treatment, and seven trials compared a probiotic with lactulose. The trials used a variety of probiotics; the most commonly used group of probiotic was VSL#3, a proprietary name for a group of eight probiotics. Duration of administration ranged from 10 days to 180 days. Eight trials declared their funding source, of which six were independently funded and two were industry funded. The remaining 13 trials did not disclose their funding source. We classified 19 of the 21 trials at high risk of bias.We found no effect on all-cause mortality when probiotics were compared with placebo or no treatment (7 trials; 404 participants; RR 0.58, 95% CI 0.23 to 1.44; low-quality evidence). No-recovery (as measured by incomplete resolution of symptoms) was lower for participants treated with probiotic (10 trials; 574 participants; RR 0.67, 95% CI 0.56 to 0.79; moderate-quality evidence). Adverse events were lower for participants treated with probiotic than with no intervention when considering the development of overt hepatic encephalopathy (10 trials; 585 participants; RR 0.29, 95% CI 0.16 to 0.51; low-quality evidence), but effects on hospitalisation and change of/or withdrawal from treatment were uncertain (hospitalisation: 3 trials, 163 participants; RR 0.67, 95% CI 0.11 to 4.00; very low-quality evidence; change of/or withdrawal from treatment: 9 trials, 551 participants; RR 0.70, 95% CI 0.46 to 1.07; very low-quality evidence). Probiotics may slightly improve quality of life compared with no intervention (3 trials; 115 participants; results not meta-analysed; low-quality evidence). Plasma ammonia concentration was lower for participants treated with probiotic (10 trials; 705 participants; MD -8.29 μmol/L, 95% CI -13.17 to -3.41; low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial.When probiotics were compared with lactulose, the effects on all-cause mortality were uncertain (2 trials; 200 participants; RR 5.00, 95% CI 0.25 to 102.00; very low-quality evidence); lack of recovery (7 trials; 430 participants; RR 1.01, 95% CI 0.85 to 1.21; very low-quality evidence); adverse events considering the development of overt hepatic encephalopathy (6 trials; 420 participants; RR 1.17, 95% CI 0.63 to 2.17; very low-quality evidence); hospitalisation (1 trial; 80 participants; RR 0.33, 95% CI 0.04 to 3.07; very low-quality evidence); intolerance leading to discontinuation (3 trials; 220 participants; RR 0.35, 95% CI 0.08 to 1.43; very low-quality evidence); change of/or withdrawal from treatment (7 trials; 490 participants; RR 1.27, 95% CI 0.88 to 1.82; very low-quality evidence); quality of life (results not meta-analysed; 1 trial; 69 participants); and plasma ammonia concentration overall (6 trials; 325 participants; MD -2.93 μmol/L, 95% CI -9.36 to 3.50; very low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial. AUTHORS' CONCLUSIONS The majority of included trials suffered from a high risk of systematic error ('bias') and a high risk of random error ('play of chance'). Accordingly, we consider the evidence to be of low quality. Compared with placebo or no intervention, probiotics probably improve recovery and may lead to improvements in the development of overt hepatic encephalopathy, quality of life, and plasma ammonia concentrations, but probiotics may lead to little or no difference in mortality. Whether probiotics are better than lactulose for hepatic encephalopathy is uncertain because the quality of the available evidence is very low. High-quality randomised clinical trials with standardised outcome collection and data reporting are needed to further clarify the true efficacy of probiotics.
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Affiliation(s)
- Rohan Dalal
- Sydney Medical School, Westmead Hospital, Sydney, Australia
| | - Richard G McGee
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145
| | - Stephen M Riordan
- Gastrointestinal and Liver Unit, The Prince of Wales, Barker St, Randwick, Australia, NSW 2031
| | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Edward Ford Building A27, Sydney, NSW, Australia, 2006
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Abstract
INTRODUCTION Minimal hepatic encephalopathy (MHE) can reverse after short-term treatment. However, relapse rate of MHE after stopping treatment has not been studied so far. We aimed to evaluate long-term (9 months) efficacy of a short-term (3 months) treatment of MHE with lactulose/rifaximin, for maintenance of remission from MHE. MATERIAL AND METHODS In this prospective study, consecutive patients with cirrhosis and MHE were treated with lactulose/rifaximin for 3 months. After treatment, they were followed up for 6 months. Psychometric testing for diagnosis of MHE was performed at baseline, 3 months and 9 months. RESULTS Of the 527 patients screened, 351 were found eligible and tested for MHE. Out of these, 112 (31.9%) patients had MHE (mean age 55.3 years; 75% males). They were randomized to receive Rifaximin (n = 57; 1,200 mg/day) or Lactulose (n = 55; 30-120 mL/day) for three months. At 3 months, 73.7% (42/57) patients in Rifaximin group experienced MHE reversal compared to 69.1% (38/55) in Lactulose group (p = 0.677). Six months after stopping treatment, 47.6% (20/42) in rifaximin group and 42.1% (16/38) patients in lactulose group experienced MHE relapse (p = 0.274). The overt hepatic encephalopathy development rate (7.1% vs. 7.9%) and mortality rate (0.23% vs. 0%) were similar in both groups. The Child-Turcotte-Pugh score and model for end stage liver disease (MELD) scores of patients who had MHE relapse were higher compared to those who didn't. On multivariate regression analysis, MELD score was an independent predictor of MHE relapse. CONCLUSION Of the patients who became MHE negative after short-term (3 months) treatment with rifaximin/lactulose, almost 50% had a relapse of MHE at 6 months follow-up.
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Affiliation(s)
- Omesh Goyal
- Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sandeep S Sidhu
- Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Harsh Kishore
- Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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de Souza KZ, Zago-Gomes MP. Frontal assessment battery: A tool for screening minimal hepatic encephalopathy? World J Hepatol 2016; 8:1262-1268. [PMID: 27843536 PMCID: PMC5084055 DOI: 10.4254/wjh.v8.i30.1262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 07/10/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To apply the Frontal Assessment Battery to cirrhotic patients with or without overt hepatic encephalopathy (OHE) and controls.
METHODS The frontal assessment battery (FAB) was applied to 87 patients with liver cirrhosis (16 with and 71 without OHE) and 40 control subjects without cirrhosis treated at the alcohol and liver outpatient clinics and the gastroenterology ward of the Cassiano Antônio de Moraes University Hospital (Hospital Universitário Cassiano Antônio de Moraes - HUCAM), Espírito Santo, Brazil.
RESULTS The average FAB score was lower for the cirrhotic than for the non-cirrhotic patients (10.6 ± 3.67 vs 12.25 ± 2.72, P = 0.015). The FAB score was lower for the cirrhotic patients with OHE than for the patients without OHE (8.25 ± 4.55 vs 11.14 ± 3.25, P = 0.027). The total FAB score was lower for the cirrhotic patients without OHE than for the non-cirrhotic patients, although this difference was not significant (11.14 ± 3.25 vs 12.25 ± 2.72, P = 0.067). Nevertheless, the difference in the scores on the subtest that assessed the ability to inhibit a response previously conditioned to a stimulus was significant (1.72 ± 0.93 vs 2.2 ± 0.85, P = 0.011).
CONCLUSION The present study indicates that the FAB is a promising tool for outpatient minimal HE screening and the assessment of HE severity.
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Tsai CF, Chu CJ, Wang YP, Liu PY, Huang YH, Lin HC, Lee FY, Lu CL. Increased serum interleukin-6, not minimal hepatic encephalopathy, predicts poor sleep quality in nonalcoholic cirrhotic patients. Aliment Pharmacol Ther 2016; 44:836-45. [PMID: 27518472 DOI: 10.1111/apt.13765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 03/07/2016] [Accepted: 07/24/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sleep-wake disturbances are common in patients with cirrhosis and have a considerable effect on health-related quality of life; however, the underlying mechanism behind the phenomenon is unclear. Cytokines are involved in the mediation of signalling pathways regulating fibrogenesis, leading to cirrhosis. In addition, increased cytokines could contribute to sleep disturbances. AIM To determine the relationship between pro-inflammatory cytokines and sleep disturbance in cirrhotic patients. METHODS Ninety-eight nonalcoholic cirrhotic patients without overt hepatic encephalopathy were enrolled in this cross-sectional study. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality. The Psychometric Hepatic Encephalopathy Score (PHES) was used to examine cognitive performance and define minimal hepatic encephalopathy (MHE). The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the mood status of the patients. Pro-inflammatory cytokines that include interleukin 6 (IL-6) and tumour necrosis factor-α, as well as HBV-DNA or HCV-RNA levels were determined in patients. RESULTS A total of 56 (57%) cirrhotic patients were identified as 'poor' sleepers (PSQI > 5). After multivariate analysis, IL-6 (P = 0.001) and HADS scores (P = 0.002) were found to be independent predictive factors of poor sleep quality. No significant relationships were observed between the sleep indices and the presence of MHE. HCV-RNA, but not HBV-DNA, viraemia was associated with sleep disturbance in cirrhotic patients. CONCLUSIONS Sleep disturbance is found commonly in cirrhotic patients and a high serum IL-6 level is predictive of poor sleep quality. Minimal hepatic encephalopathy by itself may not contribute to sleep dysfunction in cirrhotic patients.
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Affiliation(s)
- C-F Tsai
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - C-J Chu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Y-P Wang
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - P-Y Liu
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Y-H Huang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - H-C Lin
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - F-Y Lee
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - C-L Lu
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan. , .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. , .,Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan. , .,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. ,
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Greinert R, Ripoll C, Hollenbach M, Zipprich A. Stepwise diagnosis in covert hepatic encephalopathy: critical flicker frequency and MELD-score as a first-step approach. Aliment Pharmacol Ther 2016; 44:514-21. [PMID: 27385440 DOI: 10.1111/apt.13721] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/29/2016] [Accepted: 06/16/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnosis of covert hepatic encephalopathy (CHE) by means of portosystemic encephalopathy syndrome (PSE) test is costly and therefore infrequently performed. AIM To determine the ability of critical flicker frequency (CFF) alone or in combination with laboratory findings, as an initial test to pre-select which patients should undergo further testing for the diagnosis of covert hepatic encephalopathy. METHODS This single-centre study included all patients with cirrhosis who underwent PSE and CFF in 2011. CHE was defined by abnormal PSE test. Logistic regression analysis was performed to identify predictors of CHE. ROC curves were used to identify cut-offs of these independent predictors. RESULTS One hundred and seventeen patients were included. Seventy (60%) had CHE with a higher MELD [16 (IQR 13-21); P = 0.001] and lower CFF [38 Hz (IQR 36-41) P = 0.0011]. On multivariate analyses, CFF [OR 0.83 (95% CI 0.74-0.94)] and MELD [OR 1.13 (95% CI 1.04-1.22)] were identified as independent predictors of CHE. Sensitivity and specificity of a CFF cut-off of 43 Hz was 93.5% and 42.9%, and for a MELD cut-off of 24, it was 97.5% and 32.8% respectively. Most patients with a MELD-Score <24 and a CFF >43 Hz did not have CHE (78%) and with a MELD-Score >24 and CFF <43 Hz most patients had CHE (85%). Therefore, 27% of patients could avoid further testing with a diagnostic accuracy of 81%. CONCLUSION The combination of MELD-score and critical flicker frequency may be used as a first diagnostic step to filter patients, in whom further covert hepatic encephalopathy testing could be avoided.
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Affiliation(s)
- R Greinert
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - C Ripoll
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - M Hollenbach
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - A Zipprich
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Low-light-level therapy as a treatment for minimal hepatic encephalopathy: behavioural and brain assessment. Lasers Med Sci 2016; 31:1717-1726. [DOI: 10.1007/s10103-016-2042-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 07/27/2016] [Indexed: 12/15/2022]
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40
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Nardone R, Taylor AC, Höller Y, Brigo F, Lochner P, Trinka E. Minimal hepatic encephalopathy: A review. Neurosci Res 2016; 111:1-12. [PMID: 27153746 DOI: 10.1016/j.neures.2016.04.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/02/2016] [Accepted: 04/23/2016] [Indexed: 02/07/2023]
Abstract
Minimal hepatic encephalopathy (MHE) is the earliest form of hepatic encephalopathy and can affect up to 80% of patients with liver cirrhosis. By definition, MHE is characterized by cognitive function impairment in the domains of attention, vigilance and integrative function, but obvious clinical manifestation are lacking. MHE has been shown to affect daily functioning, quality of life, driving and overall mortality. The diagnosis can be achieved through neuropsychological testing, recently developed computerized psychometric tests, such as the critical flicker frequency and the inhibitory control tests, as well as neurophysiological procedures. Event related potentials can reveal subtle changes in patients with normal neuropsychological performances. Spectral analysis of electroencephalography (EEG) and quantitative analysis of sleep EEG provide early markers of cerebral dysfunction in cirrhotic patients with MHE. Neuroimaging, in particular MRI, also increasingly reveals diffuse abnormalities in intrinsic brain activity and altered organization of functional connectivity networks. Medical treatment for MHE to date has been focused on reducing serum ammonia levels and includes non-absorbable disaccharides, probiotics or rifaximin. Liver transplantation may not reverse the cognitive deficits associated with MHE. We performed here an updated review on epidemiology, burden and quality of life, neuropsychological testing, neuroimaging, neurophysiology and therapy in subjects with MHE.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Christian Doppler Klinik and Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Franz Tappeiner Hospital, Italy.
| | - Alexandra C Taylor
- Department of Neurology, Christian Doppler Klinik and Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Yvonne Höller
- Department of Neurology, Christian Doppler Klinik and Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Italy; Department of Neurological and Movement Sciences, Section of Clinical Neurology, University of Verona, Italy
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik and Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
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Jackson CD, Gram M, Halliday E, Olesen SS, Sandberg TH, Drewes AM, Morgan MY. New spectral thresholds improve the utility of the electroencephalogram for the diagnosis of hepatic encephalopathy. Clin Neurophysiol 2016; 127:2933-2941. [PMID: 27236607 DOI: 10.1016/j.clinph.2016.03.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/19/2016] [Accepted: 03/14/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The utility of the electroencephalogram (EEG) for the diagnosis of hepatic encephalopathy, using conventional spectral thresholds, is open to question. The aim of this study was to optimise its diagnostic performance by defining new spectral thresholds. METHODS EEGs were recorded in 69 healthy controls and 113 patients with cirrhosis whose neuropsychiatric status was classified using clinical and psychometric criteria. New EEG spectral thresholds were calculated, on the parietal P3-P4 lead derivation, using an extended multivariable receiver operating characteristic curve analysis. Thresholds were validated in a separate cohort of 68 healthy controls and 113 patients with cirrhosis. The diagnostic performance of the newly derived spectral thresholds was further validated using a machine learning technique. RESULTS The diagnostic performance of the new thresholds (sensitivity 75.0%; specificity 77.4%) was better balanced than that of the conventional thresholds (58.3%; 93.2%) and comparable to the performance of a machine learning technique (72.9%; 76.8%). The diagnostic utility of the new thresholds was confirmed in the validation cohort. CONCLUSIONS Adoption of the new spectral thresholds would significantly improve the utility of the EEG for the diagnosis of hepatic encephalopathy. SIGNIFICANCE These new spectral EEG thresholds optimise the performance of the EEG for the diagnosis of hepatic encephalopathy and can be adopted without the need to alter data recording or the initial processing of traces.
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Affiliation(s)
- Clive D Jackson
- Department of Neurophysiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK.
| | - Mikkel Gram
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark.
| | - Edwin Halliday
- Department of Neurophysiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK.
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark.
| | - Thomas Holm Sandberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Marsha Y Morgan
- UCL Institute for Liver and Digestive Health, Department of Medicine, Royal Free Campus, University College London, Hampstead, London NW3 2PF, UK.
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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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Reversal of Low-Grade Cerebral Edema After Lactulose/Rifaximin Therapy in Patients with Cirrhosis and Minimal Hepatic Encephalopathy. Clin Transl Gastroenterol 2015; 6:e111. [PMID: 26378384 PMCID: PMC4816249 DOI: 10.1038/ctg.2015.38] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 07/14/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES: Decreased magnetization transfer ratio (MTR) in the brain characterizes cerebral edema (CE) in patients with liver cirrhosis, but the role of treatment on its reversibility has not been studied in patients who have minimal hepatic encephalopathy (MHE). This study was carried to evaluate the reversibility of CE with lactulose and rifaximin treatment in patients with MHE and role of ammonia, pro-inflammatory interleukins (IL-1, IL-6) and tumor necrosis factor (TNF)-α in its pathogenesis. METHODS: Twenty-three patients with cirrhosis (14 with MHE, 9 without MHE (NMHE)) and 6 healthy controls underwent ammonia, IL-1, IL-6, TNF-α estimation, and MTR in frontal white matter (FWM), parietal white matter (PWM), internal capsule (IC), and basal ganglia (BG). RESULTS: Ammonia was significantly higher in the cirrhosis group compared with controls and in MHE compared with the NMHE group. Ammonia correlated positively with IL-1 and IL-6. MTRs in FWM, PWM, IC, and BG were significantly lower in the MHE group compared with controls and in PWM, IC, and BG compared with the NMHE group. MHE patients showed significant MTR increase in FWM, PWM, and IC with treatment. IL-6 and ammonia had significant negative and significant positive psychometric hepatic encephalopathy score (PHES) correlation with MTR in various regions. CONCLUSIONS: This study, for the first time, demonstrated the reversibility of low-grade CE with treatment in patients with MHE. Negative correlation between ammonia, IL-6 levels, and MTR and positive correlation between PHES and MTR in MHE patients suggests the role of inflammation and ammonia in the genesis of low-grade CE.
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Gupta D, Ingle M, Shah K, Phadke A, Sawant P. Prospective comparative study of inhibitory control test and psychometric hepatic encephalopathy score for diagnosis and prognosis of minimal hepatic encephalopathy in cirrhotic patients in the Indian subcontinent. J Dig Dis 2015; 16:400-7. [PMID: 25858627 DOI: 10.1111/1751-2980.12248] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to determine the usefulness of inhibitory control test (ICT) for diagnosing minimal hepatic encephalopathy (MHE) in the Indian subcontinent and its correlation with the severity of liver disease and to determine its prognostic significance. METHODS Two hundred patients with cirrhosis and 200 healthy controls were enrolled. Only patients were administered with psychometric hepatic encephalopathy score (PHES), while both patients and controls were subjected to ICT. MHE was diagnosed when PHES ≤ -5. ICT was considered abnormal when the numbers of ICT lures were ≥ 14. RESULTS Overall, 135 (67.5%) patients had MHE. Mean ICT lures were higher in cirrhotic patients with MHE than those without MHE (17.27, 95% confidence interval [CI] 13.9-22.3 vs 8.79, 95% CI 6.8-12.60, P < 0.001). Target accuracy was lower in patients with MHE than in those without (84.35, 95% CI 78.5-89.8 vs 95.36, 95% CI 90.1-99.2, P < 0.001). ICT had a sensitivity of 92.6% and specificity of 78.5% with the area under the receiver operating characteristic curve of 0.855 (95% CI 0.791-0.920) for MHE. ICT was correlated with Child-Turcotte-Pugh class (P < 0.001) and the model for end-stage liver disease score (P < 0.001) and predicted the development of overt hepatic encephalopathy (OHE) and probable survival with excellent test-retest reliability. CONCLUSIONS ICT is useful for diagnosing MHE in patients with cirrhosis. It is correlated with disease severity and predicts the development of OHE and probable survival with excellent test-retest reliability.
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Affiliation(s)
- Dhaval Gupta
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & Hospital, Mumbai, India
| | - Meghraj Ingle
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & Hospital, Mumbai, India
| | - Kaivan Shah
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & Hospital, Mumbai, India
| | - Aniruddha Phadke
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & Hospital, Mumbai, India
| | - Prabha Sawant
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & Hospital, Mumbai, India
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Main target of minimal hepatic encephalopathy: Morphophysiological, inflammatory and metabolic view. Physiol Behav 2015; 149:247-54. [PMID: 26079568 DOI: 10.1016/j.physbeh.2015.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/25/2015] [Accepted: 06/10/2015] [Indexed: 12/12/2022]
Abstract
Although often not considered clinically relevant and, therefore, not diagnosed or treated, minimal hepatic encephalopathy (MHE) has been shown to affect daily functioning, quality of life, driving and overall mortality. To discover early impairments involved in MHE, we studied one of its precipitating factors, portal hypertension. Rats were trained on a stimulus-response task using the Morris water maze. Two groups of animals were used: a SHAM (sham-operated) group (n= 13) and a portal hypertension (PH) group (n= 13). The triple portal vein ligation method was used to create an animal model of an early developmental phase of HE. Brain metabolic activity was studied with cytochrome c-oxidase histochemistry (C.O.). Neuronal nuclear volume was assessed by nucleator probe; the number of glial fibrillary acidic protein-immunoreactive astrocytes (GFAP-IR) and proinflammatory mediators was measured. The results revealed that the PH group was not able to reach the behavioural criterion, in contrast to the SHAM group. The metabolic brain consumption revealed decreased C.O. activity in the ventral striatum. The PH group showed lower density of GFAP-IR and an increase in the tumour necrotic factor-α (TNF-α). The PH group showed decreased neuronal nuclear volume in the dorsal striatum. On the contrary, increased neuronal nuclear volume was found in the ventral striatum. For the first time, a relationship has been established between inflammation, astrocytic and neural damage, and brain metabolic impairment in a model of MHE. Disruption of the striatum and related structures was highlighted as the main target in early stages of HE. Finally, a simple task was presented to assess the subtle impairments found in the clinic, which could provide fresh insights into the development of new tools for the assessment of MHE.
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Tsai CF, Chu CJ, Huang YH, Wang YP, Liu PY, Lin HC, Lee FY, Lu CL. Detecting minimal hepatic encephalopathy in an endemic country for hepatitis B: the role of psychometrics and serum IL-6. PLoS One 2015; 10:e0128437. [PMID: 26039496 PMCID: PMC4454579 DOI: 10.1371/journal.pone.0128437] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 04/27/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND & AIMS It remains unknown what the prevalence of minimal hepatic encephalopathy is in Taiwan, a highly endemic country for chronic viral hepatitis infection. It is also unclear whether abnormal serum cytokine levels can be indicative of the presence of minimal hepatic encephalopathy. We aimed to standardize the tests of psychometric hepatic encephalopathy score and predictive value of proinflammatory cytokines in minimal hepatic encephalopathy in Taiwan. METHODS 180 healthy subjects and 94 cirrhotic patients without a history of overt hepatic encephalopathy from a tertiary center were invited to participate in this cross-sectional study. Blood sampling for determination of serum levels of interleukin 6 and 18 and tumor necrosis factor-α was performed. Based on the normogram of psychometric hepatic encephalopathy score from healthy volunteers, patients with minimal hepatic encephalopathy were identified from the cirrhotic patients using the criterion of a psychometric hepatic encephalopathy score less than -4. RESULTS In the healthy subjects, age and education were predictors of subtests of psychometric hepatic encephalopathy score. Minimal hepatic encephalopathy was identified in 27 (29%) cirrhotic patients. Serum interleukin 6 level (OR = 6.50, 95% CI = 1.64-25.76, P = 0.008) was predictive of the presence of minimal hepatic encephalopathy after multivariate analysis. CONCLUSIONS The psychometric hepatic encephalopathy score can be a useful tool for detecting patients with minimal hepatic encephalopathy in Taiwan and around one third of cirrhotic outpatients fulfill this diagnosis. A high serum interleukin 6 level is predictive of the presence of minimal hepatic encephalopathy.
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Affiliation(s)
- Chia-Fen Tsai
- Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chi-Jen Chu
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Po Wang
- Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Yi Liu
- Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Han-Chieh Lin
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Yauh Lee
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ching-Liang Lu
- Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan
- * E-mail:
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Rathi S, Dhiman RK. Hepatobiliary Quiz (Answers)-14 (2015). J Clin Exp Hepatol 2015; 5:175-8. [PMID: 26155047 PMCID: PMC4491639 DOI: 10.1016/j.jceh.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 05/21/2015] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Dhiman RK. Impact of minimal/covert hepatic encephalopathy on patients with cirrhosis. Clin Liver Dis (Hoboken) 2015; 5:75-78. [PMID: 31040955 PMCID: PMC6490468 DOI: 10.1002/cld.452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/18/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Radha K. Dhiman
- Department of HepatologyPostgraduate Institute of Medical Education & ResearchChandigarhIndia
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Agrawal S, Umapathy S, Dhiman RK. Minimal hepatic encephalopathy impairs quality of life. J Clin Exp Hepatol 2015; 5:S42-8. [PMID: 26041957 PMCID: PMC4442849 DOI: 10.1016/j.jceh.2014.11.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 11/26/2014] [Indexed: 01/18/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) is the mildest form of the spectrum of neurocognitive impairment in cirrhosis. It is a frequent occurrence in patients of cirrhosis and is detectable only by specialized neurocognitive testing. MHE is a clinically significant disorder which impairs daily functioning, driving performance, work capability and learning ability. It also predisposes to the development of overt hepatic encephalopathy, increased falls and increased mortality. This results in impaired quality of life for the patient as well as significant social and economic burden for health providers and care givers. Early detection and treatment of MHE with ammonia lowering therapy can reverse MHE and improve quality of life.
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Affiliation(s)
| | | | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India
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Weissenborn K. Diagnosis of minimal hepatic encephalopathy. J Clin Exp Hepatol 2015; 5:S54-9. [PMID: 26041959 PMCID: PMC4442856 DOI: 10.1016/j.jceh.2014.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 06/05/2014] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (mHE) has significant impact upon a liver patient's daily living and health related quality of life. Therefore a majority of clinicians agree that mHE should be diagnosed and treated. The optimal means for diagnosing mHE, however, is controversial. This paper describes the currently most frequently used methods-EEG, critical flicker frequency, Continuous Reaction time Test, Inhibitory Control Test, computerized test batteries such as the Cognitive Drug Research test battery, the psychometric hepatic encephalopathy score (PHES) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)-and their pros and cons.
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Key Words
- CDR, cognitive drug research
- CFF, critical flicker frequency
- CRT, continuous reaction time test
- EEG, electroencephalography
- ICT, inhibitory control test
- PHES, psychometric hepatic encephalopathy score
- PSE, portosystemic encephalopathy
- RBANS, repeatable battery for the assessment of neuropsychological status
- TA, target accuracy
- WL, weighted lures
- diagnostic means
- diagnostic use
- mHE, minimal hepatic encephalopathy
- minimal hepatic encephalopathy
- sensitivity
- specificity
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Affiliation(s)
- Karin Weissenborn
- Address for correspondence: Karin Weissenborn, Department of Neurology, Hannover Medical School, 30623 Hannover, Germany. Tel.: +49 511 532 2339; fax: +49 511 532 3115.
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