Evaluation of Critical Flicker Frequency in Quantification of Minimal Hepatic Encephalopathy in Patients of Chronic Liver Disease with Gastrointestinal Bleed

Abstract

Background: Gastrointestinal bleeding is a risk factor for development of hepatic encephalopathy (HE), but not all patients of cirrhosis will develop overt encephalopathy. Minimal HE may seriously impair patient's daily functioning, quality of life and predict future bouts of overt HE. Prevalence of minimal HE in cirrhotic patients after GI bleed has not been studied.Materials and Methods: Consecutive 26 patients (age, 48 ± 10.47 years; M:F 23:3) of cirrhosis with gastrointestinal bleed who met inclusion criteria were included after clinical stabilization and appropriate endotherapy. All patients underwent mini-mental scale examination and if the score was >24, patients underwent number connection tests-A and B (NCT-A and B), digit symbol test (DST), serial dot test (SDT), line tracing test (LTT), critical flicker frequency (CFF) and arterial ammonia. Minimal HE was diagnosed with ≥2 abnormal psychometric tests.Results: Prevalence of minimal hepatic encephalopathy was seen in 22 (84.61%) patients. CFF was <39 Hz in 18 patients (69.2%). Arterial ammonia was significantly higher in patients with MHE as compared to patients without MHE (66.5 ± 29.81 vs 42.5 ± 5 μmol/L, P = 0.002). Patients with MHE had significantly lower CFF than those without MHE (37.5 ± 2.2 vs 40.8 ± 1.47 Hz, IQR: 36.2–38.9 and 39.3–41.9). CFF sensitivity, specificity, positive predictive value and negative predictive value in diagnosing MHE was 77.2%, 75%, 94.40% and 37.50%, respectively (95% CI: 54.6–92.1%, 19.4–99.4%, 72.7–98.9% and 8.5–75.5%, respectively). CFF significantly correlated with psychometric tests [NCT-A (−0.652, P = 0.001), DST (−0.496, P = 0.01), SDT (0.401, P = 0.042), LTT (−0.727, P = 0.001) and arterial ammonia (−0.479, P = 0.014)].Conclusion: About 84% of patients of cirrhosis with upper GI bleed had minimal hepatic encephalopathy. CFF has high sensitivity and specificity in diagnosing minimal HE. Background: Gastrointestinal bleeding is a risk factor for development of hepatic encephalopathy (HE), but not all patients of cirrhosis will develop overt encephalopathy. Minimal HE may seriously impair patient's daily functioning, quality of life and predict future bouts of overt HE. Prevalence of minimal HE in cirrhotic patients after GI bleed has not been studied. Materials and Methods: Consecutive 26 patients (age, 48 ± 10.47 years; M:F 23:3) of cirrhosis with gastrointestinal bleed who met inclusion criteria were included after clinical stabilization and appropriate endotherapy. All patients underwent mini-mental scale examination and if the score was >24, patients underwent number connection tests-A and B (NCT-A and B), digit symbol test (DST), serial dot test (SDT), line tracing test (LTT), critical flicker frequency (CFF) and arterial ammonia. Minimal HE was diagnosed with ≥2 abnormal psychometric tests. Results: Prevalence of minimal hepatic encephalopathy was seen in 22 (84.61%) patients. CFF was <39 Hz in 18 patients (69.2%). Arterial ammonia was significantly higher in patients with MHE as compared to patients without MHE (66.5 ± 29.81 vs 42.5 ± 5 μmol/L, P = 0.002). Patients with MHE had significantly lower CFF than those without MHE (37.5 ± 2.2 vs 40.8 ± 1.47 Hz, IQR: 36.2–38.9 and 39.3–41.9). CFF sensitivity, specificity, positive predictive value and negative predictive value in diagnosing MHE was 77.2%, 75%, 94.40% and 37.50%, respectively (95% CI: 54.6–92.1%, 19.4–99.4%, 72.7–98.9% and 8.5–75.5%, respectively). CFF significantly correlated with psychometric tests [NCT-A (−0.652, P = 0.001), DST (−0.496, P = 0.01), SDT (0.401, P = 0.042), LTT (−0.727, P = 0.001) and arterial ammonia (−0.479, P = 0.014)]. Conclusion: About 84% of patients of cirrhosis with upper GI bleed had minimal hepatic encephalopathy. CFF has high sensitivity and specificity in diagnosing minimal HE.