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Özgör B, Gungor S, Aladağ M, Varol FI, Aslan M, Yilmaz S, Gungor S. The Value of Electroencephalogram (EEG) Findings in the Evaluation and Treatment Management of Pediatric Acute Liver Failure. Cureus 2024; 16:e54300. [PMID: 38496192 PMCID: PMC10944321 DOI: 10.7759/cureus.54300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
Background Pediatric acute liver failure (PALF) is still life-threatening and requires urgent care. The presence of encephalopathy is a clinical diagnosis, but it is more difficult to diagnose in children than in adults, and an electroencephalogram (EEG) can be invaluable. The role of EEG in managing the treatment of patients with PALF, other than the identification of encephalopathy, is unknown. This study aimed to investigate patients' EEGs, which may guide in choosing the most appropriate treatment in encephalopathy children. A further aim was to investigate a new score method, based on the laboratory results, which might indicate the presence of encephalopathy in cases with PALF. Methods Medical data of 33 PALF patients followed in our clinic were reviewed retrospectively. This study included 33 patients, whose EEG recording was taken on the first day of supportive treatment due to liver failure in the pediatric intensive care unit (PICU). The EEG findings were categorized into three classes: normal, epileptic and non-epileptic paroxysmal, and background encephalopathic patterns including widespread slowing and voltage suppression. Result This retrospective study included 13 male and 20 female patients with a mean age at presentation of 4.82±4.81 months whose EEG was performed on the first day of supportive therapy for liver failure in the PICU. The EEG findings were categorized into three groups: normal, epileptic and non-epileptic paroxysms, and encephalopathic patterns including diffuse background slowing and voltage suppression. Comparing EEG findings and treatments, we found that the normal EEG group responded well to liver-supporting therapy and the rate of plasmapheresis treatment was significantly higher in the diffuse slowing group. Patients with diffuse slowing of the EEG were 9.6 times more likely to receive plasmapheresis. We found that above a cut-off of ≥7.5 for the TAI (total bilirubin, albumin, and international normalized ratio (INR)) score used in our study, the risk of developing encephalopathy increased 14.4-fold. Conclusions In PALF, EEG findings can provide findings that will help clinicians in determining treatment selection and prognosis, as well as detecting epileptic focus and encephalopathy. The TAI score can be used to assess the risk of encephalopathy in cases of PALF, when it is challenging to identify encephalopathy or when an EEG is not possible.
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Affiliation(s)
- Bilge Özgör
- Pediatric Neurology, İnönü University, Malatya, TUR
| | - Sukru Gungor
- Pediatric Gastroenterology, İnönü University, Malatya, TUR
| | - Merve Aladağ
- Pediatric Medicine, Nurdağı State Hospital, Gaziantep, TUR
| | - Fatma I Varol
- Pediatric Gastroenterology, İnönü University, Malatya, TUR
| | - Mahmut Aslan
- Pediatric Neurology, Mersin City Hospital, Mersin, TUR
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Angerville B, Jurdana MA, Martinetti MP, Sarba R, Nguyen-Khac É, Naassila M, Dervaux A. Alcohol-related cognitive impairments in patients with and without cirrhosis. Alcohol Alcohol 2024; 59:agae008. [PMID: 38366913 DOI: 10.1093/alcalc/agae008] [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: 09/11/2023] [Revised: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 02/19/2024] Open
Abstract
AIMS up to 80% of patients with alcohol use disorder display cognitive impairments. Some studies have suggested that alcohol-related cognitive impairments could be worsened by hepatic damage. The primary objective of this study was to compare mean scores on the Brief Evaluation of Alcohol-Related Neurocognitive Impairments measure between alcohol use disorder patients with (CIR+) or without cirrhosis (CIR-). METHODS we conducted a prospective case-control study in a hepatology department of a university hospital. All patients were assessed using the Evaluation of Alcohol-Related Neuropsychological Impairments test. RESULTS a total of 82 patients (50 CIR+, 32 CIR-) were included in this study. CIR- patients were significantly younger than CIR+ patients (respectively, 45.5 ± 6.8 vs 60.1 ± 9.0; P < .0001). After adjusting for age and educational level, the mean Evaluation of Alcohol-Related Neuropsychological Impairments total scores in the CIR+ group were significantly lower than in the group of CIR- patients (14.1 ± 0.7 vs 7.8 ± 0.4, respectively, P < .0001). The mean subscores on delayed verbal memory, alphabetical ordination, alternating verbal fluency, visuospatial abilities, and ataxia subtests were also significantly lower in the CIR+ than in the CIR- group (respectively, 1.9 ± 0.2 vs 2.8 ± 0.2; 1.8 ± 0.2 vs 2.7 ± 0.2; 2.2 ± 0.2 vs 3.6 ± 0.2; 0.7 ± 0.2 vs 1.6 ± 0.2; 0.7 ± 0.2 vs 3.1 ± 0.2; P < .0001 for all comparisons). CONCLUSIONS in the present study, alcohol use disorder patients with cirrhosis presented more severe cognitive impairments than those without cirrhosis. Longitudinal studies are needed to investigate how cirrhosis can influence cognitive impairments.
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Affiliation(s)
- Bernard Angerville
- Filière universitaire d'addictologie, EPS Barthélémy Durand, Étampes, 91150, France
- Université de Picardie Jules Verne, Centre Universitaire de Recherche en Santé, INSERM UMR 1247, Groupe de Recherche sur l'Alcool & les Pharmacodépendances, Amiens, 80000, France
| | - Marie-Alix Jurdana
- Université de Picardie Jules Verne, Centre Universitaire de Recherche en Santé, INSERM UMR 1247, Groupe de Recherche sur l'Alcool & les Pharmacodépendances, Amiens, 80000, France
| | | | - Ruxandra Sarba
- Département d'Hépato-Gastroenterologie, CHU d'Amiens, Amiens, 80000, France
| | - Éric Nguyen-Khac
- Université de Picardie Jules Verne, Centre Universitaire de Recherche en Santé, INSERM UMR 1247, Groupe de Recherche sur l'Alcool & les Pharmacodépendances, Amiens, 80000, France
- Département d'Hépato-Gastroenterologie, CHU d'Amiens, Amiens, 80000, France
| | - Mickael Naassila
- Université de Picardie Jules Verne, Centre Universitaire de Recherche en Santé, INSERM UMR 1247, Groupe de Recherche sur l'Alcool & les Pharmacodépendances, Amiens, 80000, France
| | - Alain Dervaux
- Filière universitaire d'addictologie, EPS Barthélémy Durand, Étampes, 91150, France
- Université de Picardie Jules Verne, Centre Universitaire de Recherche en Santé, INSERM UMR 1247, Groupe de Recherche sur l'Alcool & les Pharmacodépendances, Amiens, 80000, France
- Laboratoire de recherche PSYCHOMADD, Université paris Saclay, Villejuif, 94800, France
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Miwa T, Richardson JK, Murphy SL, Ellmers TJ, Miwa Y, Maeda T, Hanai T, Shimizu M. Short-latency reaction time and accuracy are impaired in patients with cirrhosis: An international multicenter retrospective study. Geriatr Gerontol Int 2024; 24:25-31. [PMID: 37973613 DOI: 10.1111/ggi.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
AIM The inability to quickly react to an external event can lead to an increased risk for accidents (e.g., falls, car crashes) in patients with cirrhosis. The aim of this study was to determine whether a novel clinically feasible measure of simple reaction time (SRT) and reaction accuracy (RA)-a go/no-go task occurring within 400 ms-could differentiate patients with cirrhosis from controls. METHODS This retrospective study included 160 patients with cirrhosis and 160 controls assessed between January 2010 and October 2022. SRT and RA were evaluated using a ruler drop paradigm and compared using propensity score matching. Factors distinguishing patients with cirrhosis from controls were assessed using logistic regression and receiver operating characteristics curve (ROC) analyses. RESULTS Propensity score matching identified 112 participants in each group with comparable baseline characteristics. As compared with controls, patients with cirrhosis exhibited significantly prolonged SRT (200 vs. 174 ms; P < 0.001) and diminished total RA (63% vs. 73%; P < 0.001). After adjustment for confounding factors, SRT and RA independently identified patients with cirrhosis. ROC analyses showed that SRT more effectively identified patients with cirrhosis than did the number-connection test/trail-making test-B (area under the curve, 0.87 vs. 0.60; P < 0.001). CONCLUSIONS Patients with cirrhosis demonstrated impairments in short-latency cognitive function. Given that SRT and RA are associated with balance, falls, and response to perturbation, these parameters may present a task-specific method to identify patients with cirrhosis at high risk of falls and motor vehicle crashes. Geriatr Gerontol Int 2024; 24: 25-31.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
- Health Administration Center, Gifu University, Gifu, Japan
| | - James K Richardson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Susan L Murphy
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Toby J Ellmers
- Department of Brain Sciences, Centre for Vestibular Neurology, Imperial College London, London, UK
| | - Yoshiyuki Miwa
- Miwa Clinic, Gastroenterology and Hepatology, Gifu, Japan
| | - Teruo Maeda
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu, Japan
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
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Bellafante D, Gioia S, Faccioli J, Riggio O, Ridola L, Nardelli S. The Management of Hepatic Encephalopathy from Ward to Domiciliary Care: Current Evidence and Gray Areas. J Clin Med 2023; 13:166. [PMID: 38202173 PMCID: PMC10780160 DOI: 10.3390/jcm13010166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/24/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Hepatic encephalopathy (HE) is a common complication of advanced liver disease and acute liver failure. It is a condition that features several neuropsychiatric symptoms that affect mortality, morbidity and the quality of patients' and caregivers' lives. An HE diagnosis is generally an exclusion diagnosis. Once the patient is admitted to the hospital, clinical examination, blood tests and eventually neuroimaging should be performed with the aim of ruling out other causes of acute brain dysfunction. Moreover, HE is recognized using various precipitants that can potentially promote its onset, alone or in combination, and must be identified. Once the diagnostic process is complete, a correct treatment should be started. The anti-HE treatment is based on a combination of the correction of precipitants; non-absorbable antibiotics, such as rifaximin; and non-absorbable disaccharides. Once the patient is discharged from the hospital, specific anti-HE therapy should be maintained in order to prevent other HE episodes.
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Affiliation(s)
| | | | | | | | | | - Silvia Nardelli
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, 00185 Rome, Italy; (D.B.)
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Zacharias HD, Kamel F, Tan J, Kimer N, Gluud LL, Morgan MY. Rifaximin for prevention and treatment of hepatic encephalopathy in people with cirrhosis. Cochrane Database Syst Rev 2023; 7:CD011585. [PMID: 37467180 PMCID: PMC10360160 DOI: 10.1002/14651858.cd011585.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Hepatic encephalopathy describes the spectrum of neuropsychiatric changes that may complicate the course of cirrhosis and detrimentally affect outcomes. Ammonia plays a key role in its development. Rifaximin is a non-absorbable antibiotic that inhibits urease-producing bacteria and reduces absorption of dietary and bacterial ammonia. OBJECTIVES To evaluate the beneficial and harmful effects of rifaximin versus placebo, no intervention, or non-absorbable disaccharides for: (i) the prevention of hepatic encephalopathy, and (ii) the treatment of minimal and overt hepatic encephalopathy, in people with cirrhosis, both when used alone and when combined with a non-absorbable disaccharide. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Clinical Trials Register, CENTRAL, MEDLINE, Embase, three other databases, the reference lists of identified papers, and relevant conference proceedings. We wrote to authors and pharmaceutical companies for information on other published, unpublished, or ongoing trials. Searches were performed to January 2023. SELECTION CRITERIA We included randomised clinical trials assessing prevention or treatment of hepatic encephalopathy with rifaximin alone, or with a non-absorbable disaccharide, versus placebo/no intervention, or a non-absorbable disaccharide alone. DATA COLLECTION AND ANALYSIS Six authors independently searched for studies, extracted data, and validated findings. We assessed the design, bias risk, and participant/intervention characteristics of the included studies. We assessed mortality, serious adverse events, health-related quality of life, hepatic encephalopathy, non-serious adverse events, blood ammonia, Number Connection Test-A, and length of hospital stay. MAIN RESULTS We included 41 trials involving 4545 people with, or at risk for, developing hepatic encephalopathy. We excluded 89 trials and identified 13 ongoing studies. Some trials involved participants with more than one type of hepatic encephalopathy or more than one treatment comparison. Hepatic encephalopathy was classed as acute (13 trials), chronic (7 trials), or minimal (8 trials), or else participants were considered at risk for its development (13 trials). The control groups received placebo (12 trials), no/standard treatment (1 trial), or a non-absorbable disaccharide (14 trials). Eighteen trials assessed rifaximin plus a non-absorbable disaccharide versus a non-absorbable disaccharide alone. We classified 11 trials as at high risk of overall bias for mortality and 28 for non-mortality outcomes, mainly due to lack of blinding, incomplete outcome data, and selective reporting. Compared to placebo/no intervention, rifaximin likely has no overall effect on mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.50 to 1.38; P = 48, I2 = 0%; 13 trials, 1007 participants; moderate-certainty evidence), and there may be no overall effect when compared to non-absorbable disaccharides (RR 0.99, 95% CI 0.49 to 1.97; P = 0.97, I2 = 0%; 10 trials, 786 participants; low-certainty evidence). However, there is likely a reduction in the overall risk of mortality when comparing rifaximin plus a non-absorbable disaccharide to a non-absorbable disaccharide alone (RR 0.69, 95% CI 0.55 to 0.86; number needed to treat for an additional beneficial outcome (NNTB) = 22; P = 0.001, I2 = 0%; 14 trials, 1946 participants; moderate-certainty evidence). There is likely no effect on the overall risk of serious adverse events when comparing rifaximin to placebo/no intervention (RR 1.05, 95% CI 0.83 to 1.32; P = 68, I2 = 0%; 9 trials, 801 participants; moderate-certainty evidence) and there may be no overall effect when compared to non-absorbable disaccharides (RR 0.97, 95% CI 0.66 to 1.40; P = 85, I2 = 0%; 8 trials, 681 participants; low-certainty evidence). However, there was very low-certainty evidence that use of rifaximin plus a non-absorbable disaccharide may be associated with a lower risk of serious adverse events than use of a non-absorbable disaccharide alone (RR 0.66, 95% CI 0.45 to 0.98; P = 0.04, I2 = 60%; 7 trials, 1076 participants). Rifaximin likely results in an overall effect on health-related quality of life when compared to placebo/no intervention (mean difference (MD) -1.43, 95% CI -2.87 to 0.02; P = 0.05, I2 = 81%; 4 trials, 214 participants; moderate-certainty evidence), and may benefit health-related quality of life in people with minimal hepatic encephalopathy (MD -2.07, 95% CI -2.79 to -1.35; P < 0.001, I2 = 0%; 3 trials, 176 participants). The overall effect on health-related quality of life when comparing rifaximin to non-absorbable disaccharides is very uncertain (MD -0.33, 95% CI -1.65 to 0.98; P = 0.62, I2 = 0%; 2 trials, 249 participants; very low-certainty evidence). None of the combined rifaximin/non-absorbable disaccharide trials reported on this outcome. There is likely an overall beneficial effect on hepatic encephalopathy when comparing rifaximin to placebo/no intervention (RR 0.56, 95% CI 0.42 to 0.77; NNTB = 5; P < 0.001, I2 = 68%; 13 trials, 1009 participants; moderate-certainty evidence). This effect may be more marked in people with minimal hepatic encephalopathy (RR 0.40, 95% CI 0.31 to 0.52; NNTB = 3; P < 0.001, I2 = 10%; 6 trials, 364 participants) and in prevention trials (RR 0.71, 95% CI 0.56 to 0.91; NNTB = 10; P = 0.007, I2 = 36%; 4 trials, 474 participants). There may be little overall effect on hepatic encephalopathy when comparing rifaximin to non-absorbable disaccharides (RR 0.85, 95% CI 0.69 to 1.05; P = 0.13, I2 = 0%; 13 trials, 921 participants; low-certainty evidence). However, there may be an overall beneficial effect on hepatic encephalopathy when comparing rifaximin plus a non-absorbable disaccharide to a non-absorbable disaccharide alone (RR 0.58, 95% CI 0.48 to 0.71; NNTB = 5; P < 0.001, I2 = 62%; 17 trials, 2332 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Compared to placebo/no intervention, rifaximin likely improves health-related quality of life in people with minimal hepatic encephalopathy, and may improve hepatic encephalopathy, particularly in populations with minimal hepatic encephalopathy and when it is used for prevention. Rifaximin likely has no overall effect on mortality, serious adverse events, health-related quality of life, or hepatic encephalopathy compared to non-absorbable disaccharides. However, when used in combination with a non-absorbable disaccharide, it likely reduces overall mortality risk, the risk of serious adverse events, improves hepatic encephalopathy, reduces the length of hospital stay, and prevents the occurrence/recurrence of hepatic encephalopathy. The certainty of evidence for these outcomes is very low to moderate; further high-quality trials are needed.
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Affiliation(s)
- Harry D Zacharias
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Fady Kamel
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Jaclyn Tan
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Nina Kimer
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lise Lotte Gluud
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Marsha Y Morgan
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
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Hansen MKG, Kjærgaard K, Eriksen LL, Grønkjær LL, Mikkelsen ACD, Sandahl TD, Vilstrup H, Thomsen KL, Lauridsen MME. Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use. Metab Brain Dis 2022; 37:589-605. [PMID: 35102491 DOI: 10.1007/s11011-022-00913-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?
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Affiliation(s)
- Mads Kingo Guldberg Hansen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Kristoffer Kjærgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lotte Lindgreen Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lea Ladegaard Grønkjær
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Anne Catrine Daugaard Mikkelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Mette Munk Enok Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
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Özbaş B, Keskin O, Hecker H, Karahan I, Özbaş C, Kalkan Ç, Kartal A, Önder FO, Öncü BK, Gençdal G, Akyildiz M, Günşar F, Idilman R, Weissenborn K, Özütemiz Ö, Yurdaydin C. Determination of Turkish norms of psychometric tests for diagnosing minimal hepatic encephalopathy and proposal of a high sensitive screening test battery. Hepatol Int 2021; 15:1442-1455. [PMID: 34085147 DOI: 10.1007/s12072-021-10207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Psychometric hepatic encephalopathy score (PHES) needs local standardization. AIMS This study aimed at standardizing PHES for Turkish patients and compare them with German norms; to determine minimal hepatic encephalopathy (mHE) prevalence with two different methods [PHES battery and Critical Flicker Frequency (CFF)] and to assess whether sub-tests of the battery can be used for screening for mHE. METHODS Healthy volunteers (n = 816; 400 male) and cirrhotics (n = 124; 58 male) were included. For mHE diagnosis PHES score threshold was set at ≤ - 5 points and that of CFF at < 39 Hz. For comparing German and Turkish norms, datasets were combined. Multiple backward procedure was applied to assess effects of age, sex and education on single tests of the battery. Receiver operating characteristic (ROC) curves were created for assessing diagnostic capabilities of subtests of the battery. RESULTS PHES norms for Turks were developed. MHE prevalence in compensated cirrhotics was 29.8% and 27.4% with PHES and CFF tests, respectively, with low compatibility (kappa coefficient 0.389); mHE prevalence decreased to 16% when both tests were combined. Turks performed worse vs Germans in the digit symbol (DS) and serial dotting (SD) subtests but performed better in other subtests. In ROC analyzes of subtests, the combination of DS + SD tests achieved an AUROC of 0.974 versus PHES. CONCLUSIONS Use of two methods for diagnosing mHE is important for research purposes. From a clinical perspective, sensitivity with acceptable specificity may suffice for screening instruments for mHE. Combined use of DS and SD subtests of the PHES battery appears suitable for this purpose.
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Affiliation(s)
- Burak Özbaş
- Department of Internal Medicine, Ankara University Medical School, Ankara, Turkey
| | - Onur Keskin
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | - Hartmut Hecker
- Department of Biometrics, Hannover Medical School, Hannover, Germany
| | - Irfan Karahan
- Department of Internal Medicine, Ankara University Medical School, Ankara, Turkey
| | - Cansu Özbaş
- Department of Public Health, Gazi University Medical School, Ankara, Turkey
| | - Çağdaş Kalkan
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | - Aysun Kartal
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | - Fatih Oğuz Önder
- Department of Internal Medicine, Ankara University Medical School, Ankara, Turkey
| | - Burcu Kahveci Öncü
- Department of Psychiatry, Ankara University Medical School, Ankara, Turkey
| | - Genco Gençdal
- Department of Gastroenterology and Hepatology, Koç University Medical School, Istanbul, Turkey
| | - Murat Akyildiz
- Department of Gastroenterology and Hepatology, Koç University Medical School, Istanbul, Turkey
| | - Fulya Günşar
- Department of Gastroenterology, Ege University Medical School, Izmir, Turkey
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | | | - Ömer Özütemiz
- Department of Gastroenterology, Ege University Medical School, Izmir, Turkey
| | - Cihan Yurdaydin
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey.
- Department of Gastroenterology and Hepatology, Koç University Medical School, Istanbul, Turkey.
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Artificial Intelligence and Its Application to Minimal Hepatic Encephalopathy Diagnosis. J Pers Med 2021; 11:jpm11111090. [PMID: 34834442 PMCID: PMC8626051 DOI: 10.3390/jpm11111090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a brain dysfunction caused by liver insufficiency and/or portosystemic shunting. HE manifests as a spectrum of neurological or psychiatric abnormalities. Diagnosis of overt HE (OHE) is based on the typical clinical manifestation, but covert HE (CHE) has only very subtle clinical signs and minimal HE (MHE) is detected only by specialized time-consuming psychometric tests, for which there is still no universally accepted gold standard. Significant progress has been made in artificial intelligence and its application to medicine. In this review, we introduce how artificial intelligence has been used to diagnose minimal hepatic encephalopathy thus far, and we discuss its further potential in analyzing speech and handwriting data, which are probably the most accessible data for evaluating the cognitive state of the patient.
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Kimer N, Gluud LL, Pedersen JS, Tavenier J, Møller S, Bendtsen F. The Psychometric Hepatic Encephalopathy Syndrome score does not correlate with blood ammonia, endotoxins or markers of inflammation in patients with cirrhosis. Transl Gastroenterol Hepatol 2021; 6:8. [PMID: 33409402 DOI: 10.21037/tgh.2020.02.14] [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: 10/11/2019] [Accepted: 02/10/2020] [Indexed: 12/18/2022] Open
Abstract
Background The pathogenesis of hepatic encephalopathy (HE) remains unclear but impaired clearance of gut-derived neurotoxins and increased systemic inflammation are thought to play key roles. The diagnosis is based on detection of neurophysiological and neuropsychometric abnormalities. The Psychometric Hepatic Encephalopathy Score (PHES) have been found to correlate with markers of systematic inflammation including interleukin 6, C-reactive protein (CRP) and tumor necrosis factor-α (TNF-α). This study explores the associations between the PHES score and systemic inflammation, endotoxins and disease severity using baseline data from a trial involving patients with cirrhosis and minimal or no HE (NCT01769040). Methods Arterial blood was obtained during hepatic vein catheterization, from 54 patients [median age 55 (range, 33-70) years; 83% men] with decompensated but stable cirrhosis. None had clinical evidence of HE but 34 (55.6%) had an abnormal PHES score indicating the presence of minimal HE. Relationships were sought between the PHES score and markers of systemic inflammation, high sensitivity-CRP, cytokines (SDF-1α, TGF-b1, IP-10, IL-6, 10 and 18, and TNF-α; lipopolysaccharide (LPS), the lipopolysaccharide binding protein (LBP) and soluble CD14 (sCD14); and the blood ammonia. Results No significant relationships were found between the PHES score and any of the variables tested with the single exception of the correlation with serum IL-6 (r=-0.29, 95% confidence interval, -0.53 to -0.02, P=0.031). No independent predictors of the PHES score were identified in regression analyses. Conclusions No predictive associations were identified between the PHES scores and circulating blood ammonia, endotoxins, or markers of systemic inflammation in this patient population.
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Affiliation(s)
- Nina Kimer
- Gastrounit, Medical Division, University Hospital Hvidovre, Hvidovre, Denmark.,Centre of Diagnostic Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University Hospital Hvidovre, Hvidovre, Denmark
| | - Lise Lotte Gluud
- Gastrounit, Medical Division, University Hospital Hvidovre, Hvidovre, Denmark
| | | | - Juliette Tavenier
- Clinical Research Centre, University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Møller
- Centre of Diagnostic Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University Hospital Hvidovre, Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastrounit, Medical Division, University Hospital Hvidovre, Hvidovre, Denmark
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10
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Menozzi M, Gosse J, Talamonti M, Di Bernardini E, Quispe Cornejo A, Gustot T, Creteur J, Peluso L, Taccone FS. The use of automated pupillometry in critically ill cirrhotic patients with hepatic encephalopathy. J Crit Care 2020; 62:176-182. [PMID: 33388562 DOI: 10.1016/j.jcrc.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE To evaluate whether pupillary abnormalities would correlate with the severity of encephalopathy in critically ill cirrhotic patients. METHODS In this retrospective study, we enrolled adult cirrhotic patients admitted to the Intensive Care Unit undergoing automated pupillometry assessment within the first 72 h since ICU admission. Encephalopathy was assessed with West-Haven classification and Glasgow Coma Scale. Pupillometry-derived variables were also correlated with biological variables, including ammonium, renal function or inflammatory parameters, measured on the day of pupillary assessment. RESULTS A total of 62 critically ill cirrhotic patients (Age 61 [52-68] years; 69% male) were included. Median GCS and West-Haven classification were 14 [11-15] and 1 [0-3], respectively. There was a significant although weak correlation between GCS and constriction velocity (CV; R2 = 0.1; p = 0.017). We observed significant differences in CV and DV values among different levels of West-Haven classification. When only patients with encephalopathy (n = 42) or severe HE (n = 18) were considered, a weak correlation between GCS and worst CV was observed. When patients receiving sedatives or opioids were excluded, no significant correlation between pupillometry and clinical variables was observed. CONCLUSIONS Pupillary function assessed by the automated pupillometry was poorly associated with encephalopathy scales in cirrhotic patients.
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Affiliation(s)
- Marco Menozzi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Juliette Gosse
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marta Talamonti
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Eugenio Di Bernardini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Armin Quispe Cornejo
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Thierry Gustot
- Liver Transplant Unit, Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
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11
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Minimal Hepatic Encephalopathy and Mild Cognitive Impairment Worsen Quality of Life in Elderly Patients With Cirrhosis. Clin Gastroenterol Hepatol 2020; 18:3008-3016.e2. [PMID: 32205222 PMCID: PMC7502426 DOI: 10.1016/j.cgh.2020.03.033] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/03/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis are growing older. The overlap between minimal hepatic encephalopathy (MHE) and predementia mild cognitive impairment (MCI) could affect quality of life (QOL). We investigated the performance of elderly patients with cirrhosis on tests for MHE and MCI and their effects on QOL. METHODS We recruited outpatients with cirrhosis (n = 109) and without cirrhosis (controls, n = 100), 65 years or older, at 4 centers (derivation cohort). All study participants were assessed for psychometric hepatic encephalopathy score (PHES), EncephalApp score, and QOL. MCI was tested in patients with cirrhosis using the repeatable battery for assessment of neuropsychological status and assigned to the following groups: unimpaired, MCI only, MHE only, and MCI+MHE. We created adjusted norms to detect MHE using PHES and EncephalApp scores from the controls. Findings were validated using data from a separate cohort of 77 patients with cirrhosis (mean age, 69.49 ± 4.36 y; 72% men) at the same study sites. RESULTS Controls were older but were more educated, performed better cognitively, and had better QOL. Among patients with cirrhosis, age, education, model for end-stage liver disease score, EncephalApp score, and QOL were similar, but PHES and repeatable battery for assessment of neuropsychological status differed among sites. In the derivation cohort, the presence of MHE, with or without MCI, was associated with poor QOL, which was lowest in the MCI+MHE group. When we adjusted for age, sex, and education, 49% of patients with cirrhosis had MHE based on the EncephalApp and 8% had MHE based on the PHES. A similar pattern (49% MHE based on EncephalApp and 6% MHE based on PHES) was found in a validation cohort. CONCLUSIONS In a multicenter study of patients with cirrhosis (>65 y) and controls, the presence of MHE, regardless of MCI, was associated with poor cognition and QOL. We created adjusted norms that defined the high sensitivity of EncephalApp for the detection of MHE in older individuals and validated it in a separate cohort.
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12
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Han W, Zhang H, Han Y, Duan Z. Cognition-tracking-based strategies for diagnosis and treatment of minimal hepatic encephalopathy. Metab Brain Dis 2020; 35:869-881. [PMID: 32495311 PMCID: PMC7354280 DOI: 10.1007/s11011-020-00539-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/23/2020] [Indexed: 12/11/2022]
Abstract
Minimal hepatic encephalopathy (MHE), which shows mild cognitive impairment, is a subtle complication of cirrhosis that has been shown to affect daily functioning and quality of life. However, until 2014, relevant guidelines do not give much attention to the diagnosis and treatment of MHE, resulting in patients being ignored and denied the benefits of treatment. In this review, we summarize recent cognition-based research about (1) alteration of nerve cells, including astrocytes, microglial cells and neurons, in mild cognitive impairment in MHE; (2) comparison of methods in detecting cognitive impairment in MHE; and (3) comparison of methods for therapy of cognitive impairment in MHE. We hope to provide information about diagnosis and treatment of cognitive impairment in patients with MHE.
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Affiliation(s)
- Weijia Han
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Huanqian Zhang
- Yidu Central Hospital of Weifang Medical College, Shandong, China
| | - Ying Han
- Department of Immunologic Liver Disease, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Zhongping Duan
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China.
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13
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Propofol alone prevents worsening hepatic encephalopathy rather than midazolam alone or combined sedation after esophagogastroduodenoscopy in compensated or decompensated cirrhotic patients. Eur J Gastroenterol Hepatol 2020; 32:1054-1061. [PMID: 32433420 PMCID: PMC7337114 DOI: 10.1097/meg.0000000000001755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND This study was conducted to determine which type and dose of sedative drugs should be given to cirrhotic patients with compensation or decompensation during esophagogastroduodenoscopy (EGD) to prevent hepatic encephalopathy (HE) after sedation. METHODS We reviewed the medical records of cirrhotic patients consecutively admitted to the hospital and conducted a number connection test (NCT) before and 2 h after EGD with moderate sedation. Sedation was performed using either propofol alone, midazolam alone, or combined propofol + midazolam. RESULTS Sixty-seven patients were admitted for a screening EGD. The NCT before and after sedation were not significantly different in the propofol alone (pre-NCT = 47.3 ± 19.71 seconds vs. post-NCT = 49.4 ± 21.79 seconds, P = 0.6389). In the midazolam alone (pre-NCT = 50.3 ± 20.56 vs. post-NCT = 63.7 ± 33.17, P = 0.0021) and in the combined propofol + midazolam (pre-NCT = 47.4 ± 20.99 vs. post-NCT = 60.0 ± 30.79, P = 0.0002), NCT were significantly delayed. The propofol alone group received 52.3 ± 16.31 mg (0.82 ± 0.29 mg/kg). In 45 (67.2%) decompensated patients, only the propofol alone was not significantly different between pre-NCT (49.2 ± 22.92) and post-NCT (52.3 ± 24.90) (P = 0.4548). Serum sodium level was significantly correlated with delta-NCT (r = 0.3594, P = 0.0028). CONCLUSION Propofol alone could be the best sedation strategy for cirrhotic patients with compensation or decompensation without aggravation of covert or overt HE. Hyponatremia could be a risk factor for developing or worsening HE after EGD with sedation.
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14
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Bajaj JS, Lauridsen M, Tapper EB, Duarte-Rojo A, Rahimi RS, Tandon P, Shawcross DL, Thabut D, Dhiman RK, Romero-Gomez M, Sharma BC, Montagnese S. Important Unresolved Questions in the Management of Hepatic Encephalopathy: An ISHEN Consensus. Am J Gastroenterol 2020; 115:989-1002. [PMID: 32618647 DOI: 10.14309/ajg.0000000000000603] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Management of hepatic encephalopathy (HE) remains challenging from a medical and psychosocial perspective. Members of the International Society for Hepatic Encephalopathy and Nitrogen Metabolism recognized 5 key unresolved questions in HE management focused on (i) driving, (ii) ammonia levels in clinical practice, (iii) testing strategies for covert or minimal HE, (iv) therapeutic options, and (v) nutrition and patient-reported outcomes. The consensus document addresses these topical issues with a succinct review of the literature and statements that critically evaluate the current science and practice, laying the groundwork for future investigations.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University, McGuire VA Medical Center, Richmond, Virginia, USA
| | | | | | | | | | | | | | - Dominique Thabut
- Paris Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Radha K Dhiman
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
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15
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Karanfilian BV, Cheung M, Dellatore P, Park T, Rustgi VK. Laboratory Abnormalities of Hepatic Encephalopathy. Clin Liver Dis 2020; 24:197-208. [PMID: 32245527 DOI: 10.1016/j.cld.2020.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Currently, there is no gold standard serologic or imaging modality to detect hepatic encephalopathy (HE). It is a clinical diagnosis gathered from the history and physical. Imaging is nonspecific; however, PET and MRI have shown areas of utility, but are not widely available, cost-efficient, or necessary for diagnosis. Electroencephalogram has shown promise as it can be used in conjunction with the Portal Systemic Hepatic Encephalopathy Score test to diagnose minimal HE. Further research on these techniques would need to be performed to identify strict criteria and cutoffs for diagnosing HE as well as associated sensitivities and specificities.
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Affiliation(s)
- Briette Verken Karanfilian
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Maggie Cheung
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Peter Dellatore
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Taeyang Park
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Vinod K Rustgi
- Department Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA.
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16
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Shrestha D, Rathi S, Grover S, Taneja S, Duseja A, Chawla YK, Dhiman RK. Factors Affecting Psychological Burden on the Informal Caregiver of Patients With Cirrhosis: Looking Beyond the Patient. J Clin Exp Hepatol 2020; 10:9-16. [PMID: 32025162 PMCID: PMC6995890 DOI: 10.1016/j.jceh.2019.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Cirrhosis leads to considerable morbidity and mortality, compromises quality of life, and often necessitates assistance in activities of daily living. An informal caregiver bears the psychological burden of coping with the needs of the patient and the knowledge of morbid prognosis of a loved one. This aspect is rarely recognized and almost never addressed in a clinical practice. METHODS This cross-sectional study assessed the factors influencing psychological burden of cirrhosis on the caregivers in a predominantly lower-middle socioeconomic class Indian population. Patients underwent psychometric tests [Psychometric Hepatic Encephalopathy Score (PHES)], and questionnaires for quantifying caregiver burden [Perceived Caregiver Burden (PCB) and Zarit Burden Interview (ZBI)] and assessing depression [Beck Depression Inventory (BDI)] and anxiety [Beck Anxiety Inventory (BAI)] were administered. RESULTS One hundred patients with cirrhosis [70% male, 27% with past hepatic encephalopathy (HE), and 53% with minimal HE] and their caregivers (66% women, 81% spouse, 26.51 years of mean relationship) were evaluated. Caregiver burden scores were higher in patients with previous overt HE than in those without previous overt HE [PCB (74.63 vs. 66.15, P = 0.001), ZBI (27.93 vs. 21.11, P = 0.023), BDI (11.63 vs. 8.96, P = 0.082), and BAI (11.37 vs. 8.12, P = 0.027)]. Similarly, caregivers of patients with minimal HE had higher caregiver burden that those of patients who did not have minimal HE [PCB (70.74 vs. 65.85, P = 0.027), ZBI (26 vs. 19.51, P = 0.015)]. Burden scores correlated well with each other and with liver disease severity scores and negatively correlated with socioeconomic status. Repeated hospital admissions, alcohol as etiology, and lower socioeconomic status were the independent predictors of caregiver burden. CONCLUSION Higher perceived burden is common in caregivers of patients with cirrhosis. Repeated hospital admissions, alcoholism, and lower socioeconomic status influence caregiver burden.
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Affiliation(s)
- Deepa Shrestha
- Department of Internal Medicine, Postgraduate Institution of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Postgraduate Institution of Medical Education and Research, Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institution of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institution of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institution of Medical Education and Research, Chandigarh, India
| | - Yogesh K. Chawla
- Department of Hepatology, Postgraduate Institution of Medical Education and Research, Chandigarh, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institution of Medical Education and Research, Chandigarh, India,Address for correspondence: Radha K Dhiman, MD, DM, FAMS, FACG, FRCP Edin, FRCP London, FAASLD Professor and Head, Department of Hepatology Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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17
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Pawar VB, Surude RG, Sonthalia N, Zanwar V, Jain S, Contractor Q, Rathi PM. Minimal Hepatic Encephalopathy in Indians: Psychometric Hepatic Encephalopathy Score and Inhibitory Control Test for Diagnosis and Rifaximin or Lactulose for Its Reversal. J Clin Transl Hepatol 2019; 7:304-312. [PMID: 31915599 PMCID: PMC6943207 DOI: 10.14218/jcth.2017.00037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 05/28/2018] [Accepted: 02/14/2019] [Indexed: 12/15/2022] Open
Abstract
Background and Aims: Psychometric hepatic encephalopathy score (PHES) is used widely for diagnosis of minimal hepatic encephalopathy (MHE). This prospective study aimed to determine the utility of the inhibitory control test (ICT) for the diagnosis of MHE. Additionally, the efficacy of rifaximin and lactulose for reversal of MHE was evaluated. Methods: A total of 180 eligible cirrhotic patients underwent testing for MHE. When PHES was ≤ -5 and ICT lures were ≥ 14, MHE was diagnosed. The 108 patients with MHE were randomized to three groups for treatment with either lactulose, rifaximin, or placebo. Treatment outcomes were measured at the end of 3 months. Results: The 108 patients with MHE diagnosed by PHES and/or ICT accounted for 60%. The diagnosis of MHE was made by both ICT and PHES positivity in 56 patients, by abnormal ICT and normal PHES in 37 patients, and by abnormal PHES and normal ICT in 15 patients. For diagnosis of MHE, ICT had sensitivity of 78.87%, specificity of 66.06% with 60.22% positive predictive value and 82.76% negative predictive value. An area under the curve value of 0.724 (95% CI: 0.653-0.788) was obtained for diagnosis of MHE. Reversal of MHE was seen in 71.42%, 70.27% and 11.11% of patients in the rifaximin, lactulose and placebo arms (p < 0.001). Rifaximin showed better tolerability compared to lactulose. Conclusions: For the diagnosis of MHE, ICT is a simple tool but has lower sensitivity and better specificity than PHES. Rifaximin is as efficacious as lactulose in the treatment of MHE and better tolerated.
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Affiliation(s)
- Vinay B. Pawar
- Correspondence to: Vinay B. Pawar, Department of Gastroenterology, Topiwala National Medical College and BYL Ch Hospital, Dr. A.L Nair Road, Mumbai, Maharashtra 400008, India. Tel: +22-23021639, E-mail:
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18
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Kim M, Liotta EM, Zee PC, Ganger DR, Ladner DP, Karmarkar A, Peipert JD, Sorond FA, Prabhakaran S, Reid KJ, Naidech AM, Maas MB. Impaired cognition predicts the risk of hospitalization and death in cirrhosis. Ann Clin Transl Neurol 2019; 6:2282-2290. [PMID: 31631586 PMCID: PMC6856598 DOI: 10.1002/acn3.50924] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/14/2019] [Accepted: 09/23/2019] [Indexed: 12/15/2022] Open
Abstract
Objective Cognitive impairment, detected in up to 80% of patients with liver cirrhosis, is associated with negative health outcomes but is underdiagnosed in the clinical setting due to the lack of practical testing method. This single‐center prospective observational study aimed to test the feasibility and prognostic utility of in‐clinic cognitive assessment of patients with liver cirrhosis using the NIH Toolbox cognition battery (NIHTB). Methods Patients recruited from a hepatology/transplant clinic underwent cognitive assessments using West‐Haven Grade (WHG) and NIHTB between November 2016 and August 2018 and were prospectively followed until December 2018. The primary outcome was a composite end point of hospitalization related to overt hepatic encephalopathy (OHE) and all‐cause mortality during follow‐up, evaluated by a Cox proportional hazards regression model that adjusted for a priori covariates (age and MELD‐Na). Results Among 127 patients (median age 60 years, 48 [38%] women) assessed, cognitive performance was significantly impaired in 82 [78%] patients with WHG 0 and 22 [100%] patients with WHG 1 and 2. Over a median of 347 days follow‐up, 18 OHE and 8 deaths were observed. Lower cognitive performance was associated with an increased risk of OHE/death adjusting for age and MELD‐Na. Subclinical cognitive impairment detected by NIH Toolbox in WHG 0 patients was significantly associated with greater mortality. Median time to complete the two prognostically informative NIH Toolbox tests was 9.4 min. Interpretation NIH Toolbox may enable a rapid cognitive screening in the outpatient setting and identify patients at high risk for death and hospitalization for severe encephalopathy.
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Affiliation(s)
- Minjee Kim
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois.,Center for Circadian and Sleep Medicine, Department of Neurology, Northwestern University, Chicago, Illinois.,Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois
| | - Eric M Liotta
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois.,Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois.,Division of Organ Transplantation, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Phyllis C Zee
- Center for Circadian and Sleep Medicine, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Daniel R Ganger
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois.,Division of Organ Transplantation, Department of Surgery, Northwestern University, Chicago, Illinois.,Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois.,Division of Organ Transplantation, Department of Surgery, Northwestern University, Chicago, Illinois.,Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Ameeta Karmarkar
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - John D Peipert
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois.,Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Farzaneh A Sorond
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | | | - Kathryn J Reid
- Center for Circadian and Sleep Medicine, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Andrew M Naidech
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois.,Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois.,Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Matthew B Maas
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois.,Center for Circadian and Sleep Medicine, Department of Neurology, Northwestern University, Chicago, Illinois
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19
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Gluud LL, Jeyaraj R, Morgan MY. Outcomes in Clinical Trials Evaluating Interventions for the Prevention and Treatment of Hepatic Encephalopathy. J Clin Exp Hepatol 2019; 9:354-361. [PMID: 31360028 PMCID: PMC6637116 DOI: 10.1016/j.jceh.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 02/06/2019] [Indexed: 12/12/2022] Open
Abstract
Randomised clinical trials and systematic reviews of research findings can provide high-quality evidence for decision-making in the management of patients with hepatic encephalopathy. A large number of clinical trials have been undertaken, over the last 50 years, relative to the prevention and treatment of this condition. However, changes have been made, during this time, in the classification of hepatic encephalopathy, diagnostic criteria and assessment measures. These temporally based changes and the consequent lack of standardisation make it difficult to compare interventions and to evaluate their comparative efficacy and safety. While some consensus has been reached in relation to the diagnostic evaluation, classification and monitoring of patients in clinical trials, there is less surety about the choice of clinical endpoints. These outcome measures should be universally applicable, easily measured and clinically relevant. This article reviews the current recommendations regarding outcome selection and outlines some of the potential problems and pitfalls inherent in clinical trial evaluating interventions for the management of hepatic encephalopathy.
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Affiliation(s)
- Lise L. Gluud
- Gastrounit, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre Denmark
| | - Rebecca Jeyaraj
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, Hampstead, London, NW3 2PF, UK
| | - Marsha Y. Morgan
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, Hampstead, London, NW3 2PF, UK
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20
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Hepatic encephalopathy 2018: A clinical practice guideline by the Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2019; 51:190-205. [PMID: 30606696 DOI: 10.1016/j.dld.2018.11.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 12/11/2022]
Abstract
Hepatic encephalopathy (HE) is a common, worrisome and sometimes difficult to manage complication of end-stage liver disease. HE is often recurrent, requiring multiple hospital admissions. It can have serious implications in terms of a patient's ability to perform complex tasks (for example driving), their earning capacity, their social and family roles. This guideline reviews current knowledge on HE definition, pathophysiology, diagnosis and treatment, both by general principles and by way of a summary of available drugs and treatment strategies. The quality of the published, pertinent evidence is graded, and practical recommendations are made. Where possible, these are placed within the Italian health service context, with reference to local diagnosis and management experience.
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Abstract
In general, hepatic encephalopathy (HE) is defined as a brain dysfunction caused by liver insufficiency and/or portal-systemic blood shunting. This article relates to the so-called type C HE: that is, HE in patients with liver cirrhosis. It manifests as a wide spectrum of neurological or psychiatric abnormalities, ranging from subclinical alterations, detectable only by neuropsychological or neurophysiological assessment, to coma. Several scales have been developed for grading the extent of HE. The most often used is the West Haven criteria (WHC), which differentiate between four grades of clinically overt HE. Patients with liver cirrhosis without clinically overt symptoms of HE but neuropsychological or neurophysiological findings indicating brain dysfunction are considered to have minimal hepatic encephalopathy (MHE). For simplification, some experts suggest differentiating between covert HE (MHE plus grade I HE according to WHC) and overt HE (WHC grades II-IV). Diagnosis of both MHE and overt HE is hampered by the fact that none of the symptoms of HE or the findings in the various diagnostic measures applied are specific. Thus, a diagnosis of HE or MHE can only be made after exclusion of other possible causes of brain dysfunction.
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Affiliation(s)
- Karin Weissenborn
- Clinic for Neurology, Hannover Medical School, 30623, Hannover, Germany.
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22
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Amodio P. Current Diagnosis and Classification of Hepatic Encephalopathy. J Clin Exp Hepatol 2018; 8:432-437. [PMID: 30564001 PMCID: PMC6286442 DOI: 10.1016/j.jceh.2018.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy is a brain dysfunction caused by liver insufficiency and/or portal-systemic shunt; it manifests as a wide spectrum of neurological or psychiatric abnormalities ranging from subclinical alterations to coma. It should be differentiated from other neurological/psychiatric disorders that can occur in patients with liver disease. Its classification needs to take into account the underlying condition, severity, course, precipitating factors, and-possibly-sensitivity to ammonia-lowering agents.
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Affiliation(s)
- Piero Amodio
- Address for correspondence: Piero Amodio, MD, FRCP, Department of Medicine –DIMED- University of Padova, via Giustiniani, 2, 35128 Padova, Italy. Fax: +39 049 7960903.
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Amodio P. Hepatic encephalopathy: Diagnosis and management. Liver Int 2018; 38:966-975. [PMID: 29624860 DOI: 10.1111/liv.13752] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is a peculiar kind of brain dysfunction caused by liver insufficiency and/or portal-systemic shunting. It is related to gut-derived substances. It is a relevant cause of morbidity and hospitalisation for patients with cirrhosis. The prognosis of HE is important in terms of survival and re-hospitalisation. It is related to impaired quality of life, falls and poor driving; presents a relevant burden for caregivers and health services; and may negatively impact on patient's job and income. Proper diagnosis and classification are expected to improve HE management. Once diagnosed, the management and therapeutic options for HE are generally clear. The improvement of knowledge in recent years has also clarified which are the further aims of research in this field of medicine. Prophylaxis of overt HE should always be performed, and this is generally secondary prophylaxis. Primary prophylaxis should be done immediately after upper gastrointestinal bleeding. Great advances in the detection and treatment of mild forms of HE are expected to lead to further improvement in patient management.
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Affiliation(s)
- Piero Amodio
- Department of Medicine -DIMED- and CIRMANMEC, University of Padova, Padova, Italy
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24
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Cook NA, Kim JU, Pasha Y, Crossey MM, Schembri AJ, Harel BT, Kimhofer T, Taylor-Robinson SD. A pilot evaluation of a computer-based psychometric test battery designed to detect impairment in patients with cirrhosis. Int J Gen Med 2017; 10:281-289. [PMID: 28919805 PMCID: PMC5593417 DOI: 10.2147/ijgm.s140197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Psychometric testing is used to identify patients with cirrhosis who have developed hepatic encephalopathy (HE). Most batteries consist of a series of paper-and-pencil tests, which are cumbersome for most clinicians. A modern, easy-to-use, computer-based battery would be a helpful clinical tool, given that in its minimal form, HE has an impact on both patients' quality of life and the ability to drive and operate machinery (with societal consequences). AIM We compared the Cogstate™ computer battery testing with the Psychometric Hepatic Encephalopathy Score (PHES) tests, with a view to simplify the diagnosis. METHODS This was a prospective study of 27 patients with histologically proven cirrhosis. An analysis of psychometric testing was performed using accuracy of task performance and speed of completion as primary variables to create a correlation matrix. A stepwise linear regression analysis was performed with backward elimination, using analysis of variance. RESULTS Strong correlations were found between the international shopping list, international shopping list delayed recall of Cogstate and the PHES digit symbol test. The Shopping List Tasks were the only tasks that consistently had P values of <0.05 in the linear regression analysis. CONCLUSION Subtests of the Cogstate battery correlated very strongly with the digit symbol component of PHES in discriminating severity of HE. These findings would indicate that components of the current PHES battery with the international shopping list tasks of Cogstate would be discriminant and have the potential to be used easily in clinical practice.
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Affiliation(s)
- Nicola A Cook
- Liver Unit, Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jin Un Kim
- Liver Unit, Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Yasmin Pasha
- Liver Unit, Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mary Me Crossey
- Liver Unit, Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Adrian J Schembri
- Cogstate, Inc., New Haven, CT, USA.,Department of Psychology, Royal Melbourne Institute of Technology University, Melbourne, VIC, Australia
| | - Brian T Harel
- Cogstate, Inc., New Haven, CT, USA.,Child Study Center, Yale University, New Haven, CT, USA
| | - Torben Kimhofer
- Section of Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Simon D Taylor-Robinson
- Liver Unit, Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK
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25
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Critical flicker fusion frequency in demyelinating and ischemic optic neuropathies. Int Ophthalmol 2017; 38:1069-1077. [DOI: 10.1007/s10792-017-0561-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
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26
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Hanquinet S, Morice C, Courvoisier DS, Cousin V, Anooshiravani M, Merlini L, McLin VA. Globus pallidus MR signal abnormalities in children with chronic liver disease and/or porto-systemic shunting. Eur Radiol 2017; 27:4064-4071. [DOI: 10.1007/s00330-017-4808-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/01/2017] [Accepted: 03/13/2017] [Indexed: 01/07/2023]
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27
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Montagnese S, De Rui M, Angeli P, Amodio P. Neuropsychiatric performance in patients with cirrhosis: Who is "normal"? J Hepatol 2017; 66:825-835. [PMID: 27923694 DOI: 10.1016/j.jhep.2016.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/24/2016] [Accepted: 11/24/2016] [Indexed: 02/08/2023]
Abstract
In patients with cirrhosis a normal neuropsychiatric performance has been traditionally defined by the absence of any degree of hepatic encephalopathy and/or the absence of psychometric or neurophysiological abnormalities, compared with data from the healthy population. As the understanding and management of end-stage liver disease continues to change, it is our impression that the concept of normal neuropsychiatric performance also needs updating. This review explores novel and more pragmatic interpretations of neuropsychiatric "normality" compared with top personal performance, in terms of risk of overt hepatic encephalopathy or brain failure and in relation with events such as liver transplantation, decompensation, acute-on-chronic liver failure and transjugular intrahepatic portosystemic shunt placement.
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Affiliation(s)
| | - Michele De Rui
- Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Angeli
- Department of Medicine, University of Padua, Padua, Italy
| | - Piero Amodio
- Department of Medicine, University of Padua, Padua, Italy
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28
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De Rui M, Montagnese S, Amodio P. Recent developments in the diagnosis and treatment of covert/minimal hepatic encephalopathy. Expert Rev Gastroenterol Hepatol 2016; 10:443-50. [PMID: 26758861 DOI: 10.1586/17474124.2016.1141675] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The terms minimal hepatic encephalopathy and covert hepatic encephalopathy are defined. Clinical assessment is unreliable and both require the use of diagnostic tools. Of these, psychometric tests are the most widely used. They require proper standardization and may be biased by patient cooperation or lack thereof. The measure of the critical flicker frequency and of the electroencephalogram, possibly quantified, are also useful. The alteration of any of them is not strictly parallel in size and may vary from patient to patient. When possible, the use of multiple measures might increase diagnostic reliability. These functional measures should be interpreted within the clinical/biochemical profile of the patient to exclude other disorders. A flow chart for treatment is proposed on the basis of current knowledge.
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Affiliation(s)
- M De Rui
- a Department of Medicine , University of Padua , Padua , Italy
| | - S Montagnese
- a Department of Medicine , University of Padua , Padua , Italy
| | - P Amodio
- a Department of Medicine , University of Padua , Padua , Italy
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29
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Badea MA, Drug VL, Dranga M, Gavrilescu O, Stefanescu G, Popa I, Mihai C, Cijevschi-Prelipcean C. Diagnosis of minimal hepatic encephalopathy in a tertiary care center from eastern Romania: validation of the psychometric hepatic encephalopathy score (PHES). Metab Brain Dis 2016; 31:1463-1471. [PMID: 27461111 DOI: 10.1007/s11011-016-9878-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
The psychometric hepatic encephalopathy score (PHES) is frequently used as a "gold standard" for the diagnosis of minimal hepatic encephalopathy (MHE). In Romania, there are currently no widely available tests for the detection of MHE. In this study we aimed to standardize the PHES in a healthy Romanian population and to estimate the prevalence of MHE in a group of Romanian patients with liver cirrhosis. A total of 260 healthy volunteers and 106 patients with liver cirrhosis were included in the study. The five neuropsychological tests comprising the PHES were administered to all enroled subjects. Blood samples for routine tests and serum ammonia were collected. In the healthy volunteer group age and education years were found to be predictors of all tests and gender only in two tests: digit symbol test and serial dotting test. The PHES of the healthy volunteer group was 0,43 ± 1,37 and the cut-off between normal and pathological values was set at -3 points. In the liver cirrhosis group the mean PHES was -2,44 ± 3,41, significantly lower than in the control group (p = 0,001). The estimated prevalence of MHE was 34,7 % (37 patients). In patients with cirrhosis there was a significant correlation between PHES and the severity of the liver disease according to Child-Pugh classification (r = 0,529, p = 0,001) and MELD score (r = -0,525, p = 0,001). According to our results, accurate Romanian PHES norms for the diagnosis of MHE have been developed. MHE was diagnosed in a significant proportion of Romanian patients with liver cirrhosis.
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Affiliation(s)
- Mircea Alexandru Badea
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania.
- Institute of Gastroenterology and Hepatology, Iasi, Romania.
| | - Vasile Liviu Drug
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Mihaela Dranga
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Otilia Gavrilescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Gabriela Stefanescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Iolanda Popa
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Catalina Mihai
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Cristina Cijevschi-Prelipcean
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
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30
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Nardone R, De Blasi P, Höller Y, Brigo F, Golaszewski S, Frey VN, Orioli A, Trinka E. Intracortical inhibitory and excitatory circuits in subjects with minimal hepatic encephalopathy: a TMS study. Metab Brain Dis 2016; 31:1065-70. [PMID: 27255390 DOI: 10.1007/s11011-016-9848-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 05/25/2016] [Indexed: 01/31/2023]
Abstract
Minimal hepatic encephalopathy (MHE) is the earliest form of hepatic encephalopathy (HE) and affects up to 80 % of patients with liver cirrhosis. By definition, MHE is characterized by psychomotor slowing and subtle cognitive deficits, but obvious clinical manifestations are lacking. Given its covert nature, MHE is often underdiagnosed. This study was aimed at detecting neurophysiological changes, as assessed by means of transcranial magnetic stimulation (TMS), involved in the early pathogenesis of the HE. We investigated motor cortex excitability in 15 patients with MHE and in 15 age-matched age-matched cirrhotic patients without MHE; the resting motor threshold, the short-interval intracortical inhibition (SICI) and the intracortical facilitation (ICF) were examined. Paired-pulse TMS revealed significant increased SICI and reduced ICF in the patients with MHE. These findings may reflect abnormalities in intrinsic brain activity and altered organization of functional connectivity networks. In particular, the results suggest a shift in the balance between intracortical inhibitory and excitatory mechanisms towards a net increase of inhibitory neurotransmission. Together with other neurophysiological (in particular EEG) and neuroimaging techniques, TMS may thus provide early markers of cerebral dysfunction in cirrhotic patients with MHE.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini, 5, 39012, Merano, BZ, Italy.
| | | | - Yvonne Höller
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini, 5, 39012, Merano, BZ, Italy
- Department of Neurological and Movement Sciences, Section of Clinical Neurology, University of Verona, Verona, Italy
| | - Stefan Golaszewski
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Vanessa N Frey
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Andrea Orioli
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini, 5, 39012, Merano, BZ, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
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31
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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: 45] [Impact Index Per Article: 5.6] [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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