Regional reduction in gray and white matter volume in brains of cirrhotic patients: voxel-based analysis of MRI

Chronic hepatic encephalopathy is a characteristically reversible neuropsychiatric disorder that occurs mainly in patients with liver cirrhosis. The brain regions critically involved in the pathophysiology of cirrhosis are not clear. Magnetic resonance imaging (MRI) with voxel-based morphometry (VBM) is a valuable tool for evaluating structural brain changes in many neurodegenerative diseases. We performed an MRI scan on 18 patients with liver cirrhosis and 16 age-matched healthy controls. We evaluated brain regional structural changes, regional differences and the relationship of these changes with the blood levels of ammonia and the results of neuropsychological tests in patients with cirrhosis. The VBM showed reduction in the volume of gray matter in the cerebellum and occipital lobe and in the volume of white matter in the cingulate, parietal, temporal, occipital lobe and precentral area in cirrhotic patients compared with controls. There were significant correlations between the volume of these regions with the plasma levels of ammonia and the results of neuropsychological tests. Voxel-based analysis of MRI revealed evidence for structural abnormalities of brain in patients with cirrhosis. Abnormal function in the above regions may account for the ammonia-mediated changes and neuropsychological deficits in hepatic encephalopathy.

Coping strategies and quality of life among liver transplantation candidates

The maintenance of self-reported quality of life (QL) among people on the liver transplantation waiting list is one of the priority objectives of transplantation teams. Although there are different determinant factors of QL, results are not conclusive. In our study, the goal was to evaluate both the influence of cirrhosis etiology (ethylic and non-ethylic) and the coping strategies used concerning QL. A sample of 93 patients was selected, divided into two groups: ethylic cirrhosis (EC) and non-ethylic cirrhosis (NEC). QL was evaluated through the SF-36 Health Survey, and coping strategies through the Medical Coping Modes Questionnaire (MCMQ). Our results indicated that subjects with EC obtained similar QL levels to subjects with NEC, on all the SF-36 and MCMQ subscales. Furthermore, negative correlations were found between avoidance and acceptance-resignation coping strategies with the SF-36 components. Consequently, the acceptance-resignation strategy was associated with a worse perception of physical functioning, general and mental health, and vitality and role-emotional. Overall, these results suggest that cirrhosis etiology is not a determinant factor of QL, whereas the acceptance-resignation coping strategy might lead to lower self-perception of QL.

Quality of life and nutritional status in alcohol addicts and patients with chronic liver disease

OBJECTIVE

The aim of the study was to assess and compare the nutritional status and quality of life in chronic liver disease (alcoholic and non-alcoholic) patients and alcohol addicts.

METHODS

Patients with alcoholic liver disease (n=41), nonalcoholic liver disease (n=40), alcohol addicts (n=25) without liver disease and healthy controls (n=25) were randomly selected. Nutritional status was assessed using anthropometric measurements viz. skin fold thickness, arm muscle circumference and area. Biochemical estimations included liver function tests. Food intake was assessed using 48 hour recall and macro-nutrient intake was calculated. Quality of life was assessed using the SF-36 questionnaire.

RESULTS

The mean value of mid-arm muscle area was significantly lower in patients from the non-alcoholic liver disease group when compared with the other 2 groups (p= 0.0). Body fat store depletion was significantly lower in the alcohol addict group when set against the alcoholic liver disease and non-alcoholic liver disease groups (p= 0.0). The mean percentages of ideal calories (p= 0.0) and proteins (p= 0.0) were significantly higher in alcohol addicts but no significant differences in the mean percentage of fat intake (p= 0.1) was observed. The frequency of macro-nutrient deficiency was highest in the non-alcoholic liver disease group (p= 0.0). Ethanol consumption was not significantly different between alcohol addicts and patients suffering from alcoholic liver disease (p=0.06). Patients with liver disease (irrespective of aetiology) scored significantly lower on the quality of life scale when compared to alcohol addicts.

CONCLUSIONS

Malnutrition is more frequent and severe in patients suffering from chronic liver disease in comparison to alcohol addicts. The health status is significantly poorer in patients suffering from alcoholic liver disease. Alcohol does not seem to play a primary role in the pathogenesis of liver disease and malnutrition.

[Stabilisation of abstinence by means of psychoeducation for patients with alcoholic liver disease awaiting liver transplantation]

BACKGROUND

A manualised six-month psychoeducational intervention was conducted in patients with alcoholic liver disease and abstinence problems who were waiting for a transplantation.

OBJECTIVES

In a naturalistic design it was investigated whether the intervention could improve patients' alcohol abstinence.

METHODS

Between January 2002 and November 2003, 72 patients were enrolled in the therapeutic intervention, 48 of whom participated in group therapy. Health-related quality of life (SF-12), anxiety and depression (HADS-D), symptom strain (BSI) and social support (F-SOZU) were measured. Alcohol abstinence was examined in each group session by measuring the alcohol concentration in breath.

RESULTS

At the beginning and end of the group therapy patients showed subsyndromal measures of anxiety and depression and minor symptoms of psychopathology. Physical quality of life was reduced (t = -8.694; df = 44; p < .001). Mental quality of life was in the range of the normative sample and was correlated with depression (r = -0.400; p = .009). Patients perceived high social support (t = 8.213; df = 45; p < .001). During the course of therapy four patients had relapses but the remaining patients stayed abstinent. Physical quality of life improved (t = -2.275; df = 27; p = .031), mental quality of life and symptom strain remained stable.

CONCLUSIONS

The therapy presented here facilitated a stabilisation of mental well-being in patients with alcoholic liver disease who were waiting for organ transplantation. The relapse rate measured by alcohol concentration in breath remained low.

Utility of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in patients with end-stage liver disease awaiting liver transplant

Cognitive impairment is common among patients with end-stage liver disease (ESLD). This study examined cognitive dysfunction in patients with ESLD using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

METHOD

66 patients with ESLD awaiting liver transplant were recruited. Patients were evaluated with the RBANS, Peabody Picture Vocabulary Test-Revised, and Beck Depression Inventory-II.

RESULTS

Patients with ESLD uniformly performed below expectations on all RBANS index scores compared to the healthy normative sample (all p's<.0001) and they also displayed a "subcortical" pattern of cognitive performance (p<.0001). Performances on RBANS attention, language, immediate memory, and total index scores were correlated with education and ethnicity (r's range=|.32-.57|; p's<.01). There was no association between performance on any of the RBANS index scores or subtests and ESLD patient characteristics. In summary, the RBANS appears to adequately characterize known patterns of cognitive dysfunction in ESLD patients.

Ein manualisiertes Gruppentherapiekonzept für alkoholabhängige Patienten vor der Lebertransplantation/ Manualised group therapy concept for patients with alcoholic cirrhosis awaiting liver transplantation

OBJECTIVES

Patient compliance after transplantation is of key importance since even moderate deviations from the prescribed therapy regime may cause organ rejection. Patients with alcoholic liver cirrhosis require special therapeutic preparation before the liver transplantation.

METHODS

A manualised group therapy with the aim of maintaining alcohol abstinence, increasing coping skills and therapy adherence is presented and illustrated with a case history. The manual is based on the elements of psychoeducation and problem-solving training. In a second article the results of the clinical evaluation are described.

When alcohol abstinence criteria create ethical dilemmas for the liver transplant team

In the setting of transplant medicine, decision making needs to take into account the multiple clinical and psychosocial case variables, rather than turn to arbitrary rules that cannot be scientifically supported

Patient's experience

A Bond with the support of Colin Rees

Wasting your organ with your lifestyle and receiving a new one?

Alcoholic liver disease is the leading cause of end-stage liver disease and the second most common indication for liver transplantation (OLT) in the United States and Europe, with the number of patients receiving transplants each year representing about 5% of the estimated deaths from alcoholic cirrhosis. Long-term patient survival rates compare favorable with those for other chronic liver diseases. Nevertheless, there remains a certain ambivalence about the role of OLT in patients suffering from alcoholic cirrhosis, based partly on concerns regarding alcohol relapse and functional outcome post-transplant in an era of donor organ shortage and priority setting. This review article focuses especially on compliance and social rehabilitation of patients who have undergone OLT for alcoholic cirrhosis. Furthermore, pre-transplant evaluation and selection of potential candidates are discussed and guidelines are given to clarify the role of OLT in the management of patients suffering from alcoholic cirrhosis. It appears very important to mention that alcoholism is not a fault but represents a disease, and provided that the underlying disease can be treated, consequent disease (end-stage liver disease) should be treated, too.

[Gender difference of clinical features in Japanese patients with alcoholic liver cirrhosis]

Gender difference of alcohol intake and laboratory data was investigated in 165 Japanese patients with alcoholic liver cirrhosis. Mean age of first drinking and habitual drinking were higher in female. Duration of drinking was shorter in female. Although cumulative alcohol intake was larger in male, mean daily alcohol intake did not differ in both gender. Moreover, daily alcohol intake adjusted to body weight was significantly larger in female. Body mass index, serum levels of total protein, albumin and cholinesterase were significantly decreased in female. Platelet counts on admission did not differ in both gender. However, it was significantly increased in female after one month abstinence. C reactive protein, ammonia and serum levels of total bilirubin were significantly higher in female as compared to male. In conclusion, female alcoholics seems to progress to liver cirrhosis earlier because of high daily alcohol intake adjusted to body weight, poor nutritional condition and inflammation caused by endotoxin.

Correlation between a psychometric test and biochemical indices of hepatic encephalopathy in alcoholics

BACKGROUND/AIMS

In alcohol abusers an alteration of responses to psychometric tests has been reported, even when clinical symptoms of hepatic encephalopathy (HE) are absent. Our research was intended to individualize a simple psychometric test, easy enough to be performed also at the patient's home, able to reveal an impending encephalopathy and, consequently, to facilitate earlier treatment.

METHODOLOGY

Twenty-six consecutive male alcoholics were engaged and, after informed consent, the following schedule was applied: administration of a psychometric test, followed by a drawing of blood for the determination of many blood parameters. After 15 days of treatment to detoxicate patients, psychometric tests and blood examinations were repeated.

RESULTS

The results confirmed that common blood examinations are not useful to monitor brain damage in chronic alcoholism, that a psychometric test is able to demonstrate a therapeutic improvement and that a positive and significant correlation has been observed between BBCA/AAA ratio and WAIS Score.

CONCLUSIONS

These preliminary results suggest that it is possible to suspect dangerous biochemical changes by means of a simple psychometric test.

Cognitive impairment in alcoholic and nonalcoholic cirrhotic patients

Cognitive impairment is common in patients with advanced liver disease. It has been suggested that patients with alcoholic liver disease (ALD) have more impaired cognition than nonalcoholics. The objective of this study was to characterize any differences in cognitive functions between alcoholic cirrhotic patients and non-alcoholic cirrhotic patients of similar age, education, and severity of liver disease. We assessed cognitive functions in 117 patients with alcoholic cirrhosis and 163 patients with nonalcoholic cirrhosis using a brief battery of neuropsychological tests. In addition, all patients had standard psychiatric examinations to assess the effect of the disease severity, alcoholism, anxiety, and depression on the test scores. The study showed a higher proportion of patients with cognitive impairment in the alcoholic group. Alcoholics performed poorly in tests of memory and motor speed compared with nonalcoholics, despite similar premorbid IQ and education. Because patients with alcoholic cirrhosis had more severe liver disease (Child-Pugh score 8.5 +/- 2.2 vs. 7.6 +/- 2.2, P =.03) than nonalcoholics, the results were reanalyzed after adjusting for the linear effects of Child-Pugh score on cognitive test scores. We also used two-way analysis of variance to examine the interaction between Child class and alcoholism. Finally, the test scores were compared within each Child class. These analyses revealed no primary or interaction effect of alcoholism and confirmed that the differences in the test scores observed in alcoholics reflect the greater severity of their liver disease. The severity of cognitive impairment is similar in both alcoholic and non-alcoholic cirrhotic patients when adjusted for the severity of liver disease.

Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests

The prevalence and the clinical implications of subclinical cognitive alterations in cirrhotic patients have not been well defined as yet. Therefore, we performed a study to assess the clinical features and the survival of cirrhotic patients with cognitive alterations detected by the number connection test (NCT) and a set of computerized psychometric tests (Scan, Choice1, and Choice2) measuring the reaction times and the percentage of errors in performing specific tasks. Ninety-four cirrhotic patients (aged 58 +/- 9 years) without overt hepatic encephalopathy and 80 controls (aged 53 +/- 15 years) were consecutively enrolled. The median follow-up in cirrhotic patients was 426 days (lower quartile = 213 days; upper quartile = 718 days). Results of the NCT, Scan test, and Choice2 test were significantly worse in cirrhotic patients, whereas Choice1 did not differ significantly from the controls. In cirrhotic patients, the prevalence of altered psychometric tests was 21% (CI95% = 14%-31%) by NCT, 23% (CI95% =15%-33%) by Scan test, and 20% (CI95% =16%-30%) by Choice2 test. The alterations of NCT, Scan, and Choice2 were found to be related to the severity of liver disease, independently of its etiology. Increased risk of death was found to be associated with altered Scan test (hazard ratio = 2.4; CI95% =1. 1-5.3), or altered Choice2 test (hazard ratio = 2.8; CI95% = 1.2-6. 3). Multivariate regression showed that Scan and Choice2 tests had prognostic value on survival, in addition to Child-Pugh classes in the first year of follow-up.

Psychiatric and social outcome following liver transplantation for alcoholic liver disease: a controlled study

Psychiatric outcome, quality of life, and alcohol consumption were compared between patients transplanted for alcoholic liver disease and those transplanted for other chronic liver diseases. Instruments used included the Clinical Interview Schedule, the 28-item General Health Questionnaire, the Hospital Anxiety and Depression Scale, and the Nottingham Health Profile. There was no difference between the two groups with regard to median scores or "caseness" on these instruments, except for physical mobility on the Nottingham Health Profile, where the alcoholic group was more likely to experience difficulties (p = 0.03). The majority of those transplanted for alcoholic liver disease remained abstinent, although 7 of the 31 in the alcoholic group (23%) were drinking above recommended safe limits. Psychosocial outcome is similar for individuals transplanted for alcoholic liver disease and those transplanted for other chronic liver diseases. Patients should not be excluded from transplantation on grounds of their drinking history.

Personality disorder as a contraindication for liver transplantation in alcoholic cirrhosis

Severe personality disorder has been proposed as a contraindication for liver transplantation. Seventy-three subjects with alcoholic-related liver disease were evaluated for personality disorder and followed for 6 months. The subjects with severe personality disorder had higher rates of divorce, higher rates of comorbid drug abuse or dependence, lower Weschler Adult Inventory Scale IQ estimates, and higher scores on indicators of emotional impairment. Personality disorder was not associated with a higher rate of return to alcohol use during the follow-up period. Three subjects with personality disorder underwent liver transplantation without behavioral or substance abuse complications. This study does not support routine exclusion of subjects based solely on a diagnosis of a severe personality disorder.

[Treatment of alcoholic liver diseases and psychiatric and psychosocial problems]

Only about 15% of the subjects abusing ethanol will eventually develop cirrhosis of the liver, suggesting that other factors in addition to the consumption of large quantities of ethanol play a role in the pathogenesis of alcoholic cirrhosis. Important contributors may be infection with hepatitis viruses, in particular HCV, protein-calorie malnutrition and immunologic factors. Abstinence improves the prognosis of patients with alcoholic cirrhosis, provided that the liver disease is not too far advanced. No pharmacotherapeutic intervention has shown a convincing improvement of the prognosis of alcoholic liver disease, so that the therapeutic efforts should be mainly directed towards abstinence. The patient with alcoholic liver disease needs support and guidance by the treating physicians. Supportive treatment with Disulfiram, Acamprosate or Naltrexon can help with achieving durable abstinence.

Liver transplantation for alcoholic liver disease: selection and outcome

There is clear consensus that patients with alcoholic cirrhosis should be considerated for liver transplantation, barring complicating medical or psychosocial problems. Short-term and long-term survival rates are comparable to patients receiving transplants for other conditions, and the relapse rate to alcohol use averages 15%, with troublesome drinking seen uncommonly. To date, no nationally accepted selection criteria have been established and proved effective in predicting long-term sobriety and compliance. To maximize the outcome of liver transplantation in patients with alcoholic liver disease, an approach to the selection of candidates is outlined herewith. 1. Minimum pretransplant sobriety period of 6 months. 2. Assessment of overall psychosocial support and stress. 3. Assessment of comorbid psychiatric conditions that may impair ability to comply with the transplant protocol during and after transplantation. 4. Assessment of past and present compliance with medical treatment. 5. Acceptance of problem with alcohol and willingness to sign an alcohol contract. 6. Willingness to participate in alcohol rehabilitation treatment program. 7. Willingness to participate in liver support groups to improve understanding of the condition and obtain social support. 8. Willingness to undergo random toxicology screening to assess compliance with sobriety.

Possible acceleration of alcoholic cirrhosis in a patient with bulimia

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

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

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

Abstracting capacity in cirrhotic alcoholics: negative findings

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Rapidly cycling bipolar II disorder following liver transplantation

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

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

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

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

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

Liver transplantation for alcoholic liver disease

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improvement in cognitive functioning of alcoholics following orthotopic liver transplantation

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

The role of cirrhosis in memory functioning of alcoholics

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

Psychiatric comorbidity in alcoholism: importance of ascertainment source

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

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

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

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

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

Impact of cirrhosis on the neuropsychological test performance of alcoholics

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

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

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

Hepatic dysfunction and neuropsychological test performance in alcoholics with cirrhosis

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

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

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

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

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

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

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