West Haven Criteria Research Articles

S1161 Relationship of Ammonia Level With Mortality in Patients With Cirrhosis

INTRODUCTION: Elevated ammonia level is a frequent lab finding in patients with liver cirrhosis. The clinical utility of measuring ammonia levels is controversial. Recent studies have shown the prognostic role of ammonia level in cirrhotic patients, suggesting an association with multi-organ failure, and increased mortality. This study aimed to evaluate the predictive value of ammonia level in overall all-cause mortality. METHODS: This is a retrospective single-center cohort study at our tertiary care hospital, which included patients with end-stage liver disease (ESLD) admitted between January 2016 and December 2019. The study included patients between the ages of 20–90 years who were admitted with cirrhosis complications. A venous ammonia level recorded at the time of admission. Patients with acute liver failure, advanced hepatocellular carcinoma, ischemic hepatitis, or other malignancies were excluded. We identified 281 patients who met the inclusion criteria. Data collection included etiology of cirrhosis, Intensive Care Unit (ICU) admission status, laboratory studies, a model for end-stage liver disease (MELD) score, length of hospital stay, and date of death. Grade of Hepatic Encephalopathy (HE) was defined by West Haven Criteria. Logistic regression with odds ratio (ORs) and 95% confidence intervals (CIs) were used to investigate the association between admission ammonia level to the 28-day all-cause mortality. RESULTS: There were 118 (42%) females and 163 (58%) male patients with a mean age of 58.2 ± 11.6. In this cohort, the most common etiology of ESLD was secondary to alcohol (33%), followed by non-alcoholic fatty liver disease (21%). The mean ammonia level on admission was 95.6 µ/dL ± 99.8 µ/dL. At the time of hospital admission, 57 patients (20%) got admitted to the ICU. At the initial evaluation, 141(50%) patients had Grade 1 HE, 93(33%) patients had Grade 2 HE, and 47(17%) patients had Grade 3 or 4 HE. The mean MELD-Na at the time of admission was 21.5 ± 7.0. Logistic regression analysis showed that plasma ammonia did not correlate with the overall all-cause mortality at 28-days (Odds Ratio 1.00[0.999–1.005], P = 0.07) [Tables 1 and 2]. CONCLUSION: Despite recent literature about ammonia association with increased mortality, our single-center retrospective study did not find any clear association between high serum ammonia levels and mortality. Further large-scale multicenter prospective studies are needed to confirm the validity.Table 1.: Demographics and laboratory findings of our patient population

Influence of valproate-induced hyperammonemia on treatment decision in an adult status epilepticus cohort

IntroductionStatus epilepticus (SE) is a neurological emergency in which immediate intervention is required to prevent permanent brain damage and death. Intravenous (IV) valproic acid (VPA) is often used for the treatment of SE. However, IV VPA frequently increases the blood ammonia level. In this study, we explore the impact of IV VPA-induced hyperammonemia (HA) on treatment management of SE and discuss the challenges related to this particular condition. MethodsWe used data from medical records of 31 adult patients (≥18 years) treated with IV VPA for SE at Oslo University Hospital between January 2006 and October 2019. Clinical and blood sample data and information about the influence of HA on treatment were collected. Correlations between ammonia levels and other continuous or categorical variables were tested using the Pearson's correlation coefficient. The Kruskal–Wallis H-test was used to analyze associations between different variables and treatment decisions. ResultsThirty of 31 patients had increased ammonia level during IV VPA treatment. In 16/30 patients, VPA was discontinued, and in 6/30 patients, the dose was reduced. We found a difference in the median peak ammonia level among the groups where VPA was discontinued (99 μmol/l), reduced (71 μmol/l), and continued (55.5 μmol/l) (P = 0.008). Also clinical status, measured by West Haven Criteria, varied among the groups where VPA was discontinued (3.5), reduced (2.5), and continued (2.0) (P = 0.01). Treatment decisions at peak ammonia were not associated with the level of liver enzymes and bilirubin. ConclusionHyperammonemia had a substantial impact on further management. To date, no recommendations exist on how to manage VPA-induced HA in SE. We call for systematic prospective studies and evidence-based guidelines.

Overview of Serum Interleukin-18 (IL-18) Levels in Liver Cirrhosis Patients and Their Correlation to Hepatic Encephalopathy

Background: The inflammatory process has an important role in the pathophysiology of hepatic encephalopathy (HE) in liver cirrhosis. IL-18 is a key mediator who plays a role in neuroinflamation processes that can lead to symptoms of HE. This study aimed to determine serum IL-18 levels in liver cirrhosis patients and to assess the association of serum IL-18 levels with HE.Method: A total of 52 subjects (32 patients with liver cirrhosis and 20 healthy controls) were enrolled in this study. Thirty two (32) patients with liver cirrhosis will be assessed for HE based on West-Haven criteria. All subjects were examined for serum IL-18 levels which is measured by ELISA method. We performed a comparative analysis between serum IL-18 levels of liver cirrhosis patients and healthy controls, a correlation analysis between serum IL-18 levels and HE, and a comparative analysis of serum IL-18 levels among degrees of HE.Results: Mean serum IL-18 levels in the liver cirrhosis group were 688.5 ± 674.3 pg/mL, and in the healthy controls group were 163.9 ± 100 pg/mL with p value = 0.01 (p 0.05). There was a significant correlation between IL-18 and HE (r = 0.85; p = 0.00). Serum IL-18 levels in covert and overt HE groups were significantly higher than those without HE (p 0.05).Conclusion: Serum IL-18 levels were significantly higher in liver cirrhosis patients than in healthy controls. There was a positive correlation between IL-18 and HE. Serum IL-18 levels in liver cirrhosis patients with HE were significantly higher than those without HE.

Application of the Molecular Adsorbent Recirculating System in Type 1 Hepatorenal Syndrome in the Course of Alcohol-Related Acute on Chronic Liver Failure.

BackgroundThis study aimed to evaluate the Molecular Adsorbent Recirculating System (MARS) effectiveness in patients with alcohol-related acute-on-chronic liver failure (AoCLF) complicated with type 1 hepatorenal syndrome (HRS). So far, MARS efficacy and safety has been demonstrated in various acute liver failure scenarios.Material/MethodsData from 41 MARS procedures (10 patients with type 1 HRS, in the course of alcohol-related AoCLF were considered for this study. Biochemical tests of blood serum were performed before and after each procedure. The condition of patients was determined before and after the treatment with the use of the model for end-stage liver disease – sodium (MELD-Na) and the stage of encephalopathy severity based on the West Haven criteria.ResultsDuring the observation period (20.5±13.9 days), 5 patients died, and the remaining 5 surviving patients were discharged from the hospital. In the group of 10, the 14-day survival, starting from the first MARS treatment, was 90%. The MARS procedure was associated with a 19% reduction in bilirubin (27.5±6.1 versus 22.3±4.0 mg/dL, P<0.001), 37% reduction in ammonia (44.1±22.5 versus 27.6±20.9 P<0.001), 27% reduction in creatinine (1.5±1.0 versus 1.1±0.6 mg/dL, P<0.001) and 14% reduction urea (83.8±36.1 versus 72.1±33.3, P<0.001) in blood serum samples, with stable hemodynamic parameters. In the group of patients discharged from the clinic (n=5), the MARS treatments resulted in an improvement in hepatic encephalopathy (West Haven; P=0.043), as well as a reduction in the MELD-Na score (P=0.015).ConclusionsMARS is a hemodynamically safe method for supporting the function of the liver and the kidneys. Application of the MARS reduces the symptoms of encephalopathy in patients with alcohol-related type 1 HRS.

Role of Brain Biomarkers S-100-Beta and Neuron-Specific Enolase for Detection and Follow-Up of Hepatic Encephalopathy in Cirrhosis before, during and after Treatment with L-Ornithine-L-Aspartate

Introduction: Hepatic encephalopathy (HE), in the context of liver cirrhosis, seems to result from low-grade cerebral edema of the astrocytes. Serum brain biomarkers S-100-beta und neuron-specific enolase (NSE) are often elevated in brain injury. We hypothesized that neuromarkers S-100-beta and NSE can be used in the diagnosis of HE, compared with standardized diagnostic tools. Material and Methods: A prospective non-randomized intervention study was performed using L-ornithine-L-aspartate (LOLA) for HE treatment. Primary endpoint was the evaluation of neuromarkers S-100-beta and NSE for detection and diagnosis of follow-up of HE. As secondary endpoints, the efficacy of LOLA on the course of HE and the diagnostic role of Portosystemic-Encephalopathy-Syndrome score (PHES) and critical flicker frequency (CFF) were analyzed. For diagnosis of covert (CHE) and overt (OHE) HE, West-Haven criteria (WHC), PHES and CFF were assessed at study entry. LOLA was applied (20 g i.v.) for 6 days. At the end of the study, HE evaluation was repeated. S-100-beta, NSE and ammonia were assessed in each patient before, during and after therapy with LOLA. Results: 30 patients were included. At study entry, CHE was diagnosed in 50% and OHE in 50% of all subjects. A total of 25 participants completed the study. After LOLA therapy, deterioration of HE occurred in <11%, while most patients showed improvement (e.g. improved CFF in 79%). No significant correlation with HE severity (as diagnosed by WHC, PHES and CFF) could be demonstrated for any biochemical parameter. In addition, there were no significant changes in brain biomarkers during the treatment period. Discussion: While CFF as well as PHES showed good correlation with treatment response, S-100-beta and NSE did not significantly correlate with HE severity compared to proven diagnostic methods, and do not seem reliable biochemical markers for the follow-up under therapy.

Raised serum Interleukin-6 identifies patients with liver cirrhosis at high risk for overt hepatic encephalopathy.

Systemic inflammation is a driving force for the development of hepatic encephalopathy and recent studies demonstrated that elevated Interleukin-6 (IL-6) serum levels are associated with the presence of minimal hepatic encephalopathy in patients with liver cirrhosis. To test the hypothesis that IL-6 is a suitable marker to identify patients with liver cirrhosis at high risk for the development of overt hepatic encephalopathy. 201 patients were included into this prospective cohort study and were followed for a mean time of 322days. Covert hepatic encephalopathy was diagnosed according to the West-Haven criteria (hepatic encephalopathy grade 1) and with the portosystemic encephalopathy (PSE) test. The cumulative incidence of overt hepatic encephalopathy was higher in patients with IL-6 levels above the median of 9pg/mL than in patients with IL-6 levels at or below the median (35.6% vs 1.9%, P<.001). After adjustment for covert hepatic encephalopathy, history of overt hepatic encephalopathy, C-reactive protein (CRP) and model for end-stage liver disease (MELD), IL-6 levels above the median remained independently associated with the development of overt hepatic encephalopathy. The predictive performance of IL-6 regarding the development of overt hepatic encephalopathy during the next 180days (AUROC, 0.931) was numerically higher than that of MELD (AUROC, 0.841) or CRP (AUROC, 0.835). In patients without prior overt hepatic encephalopathy, the predictive performance of IL-6 (AUROC, 0.966) was even significantly higher than that of MELD (AUROC 0.843) or CRP (AUROC 0.850). The ideal cut-off for IL-6 in this setting was 23.5pg/mL with a sensitivity and specificity of 89.3% and 89.5% respectively. IL-6 serum levels are closely linked to the development of overt hepatic encephalopathy in patients with liver cirrhosis.

P: 81 Previously Identified Candidate Gene Associations in Hepatic Encephalopathy Do Not Replicate in the STOPAH Cohort

BACKGROUND: Hepatic encephalopathy (HE) is a common complication of cirrhosis and negatively affects quality of life and prognosis. However, the development of HE is not inevitable, even in patients severe hepatic decompensation. Recently, there has been interesting the possibility that the susceptibility to develop HE is, at least in part, genetically determined. In 2017, Gil-Gómez et al (J Hepatol 2017;66(Suppl 1):S144) reported significant associations between variants in nine candidate genes and the presence of overt HE in 400 patients included in the CLIF consortium cross-sectional study. In this study overt HE was diagnosed using the West Haven criteria, while acute on chronic liver failure (ACLF) was diagnosed using the CLIF-OF score. The aim of the present study was to replicate these findings in participants in the STOPAH alcoholic hepatitis treatment trial. METHODS: Genomic DNA was available in 731 participants in the STOPAH trial. Overt HE was diagnosed using the West Haven criteria; ACLF was diagnosed using the CLIF-OF score. Data on six of the nine SNP associated with overt HE and/or ACLF in the Spanish study were identified in the STOPAH GWAS database. Genotypic association analyses were undertaken for each of the genetic variants in the entire population and in subgroups defined by the presence of overt HE and/or ACLF. RESULTS: A total of 199 (27.2%) of the 731 STOPAH participants had overt HE on admission, while 193 (26.4%) had ACLF; patients were classified as follows: HE and ACLF (n = 61), HE but no ACLF (138); ACLF but no HE (n = 132); no ACLF and no HE (n = 400). Only one significant association was identified viz. rs752949 in SLC1A2 in participants with overt HE but without ACLF (Table 1); however, the significance of this association was lost when the data were corrected for multiple testing. CONCLUSIONS: The previously reported genetic associations with overt HE were not replicated in the present study. The number of participants was almost double that in the Spanish study but the proportions of patients with HE and ACLF were similar. Not all of the reported SNPs were available but at least two SNPs were tested for association in each patient subgroup. Further large case-control studies and meta-analyses of existing data are needed.

P: 35 Hepatic Encephalopathy Is an Independent Risk Factor for the Occurrence of Infection in Cirrhotic Patients With Acute Decompensation

BACKGROUND: Hepatic encephalopathy (HE) in cirrhotic patients increases mortality with worsening of HE grade 1. Infection is important in the pathogenesis and a common reason for progression to HE and death in these patients 2. However, HE role as a predisposing factor to infection in patients with acute decompensation (AD) is not known. It's recently shown that CNS injury leads to secondary immunodeficiency, and significantly increases susceptibility to infection (Pneumonia is the commonest serious complication with stroke 3), with development of the so known CNS injury-induced immunodepression (CIDS). But those studies focused only on organic brain injuries, like stroke, TBI and SCI4. Our study aims to determine whether HE is associated with the development of new infections in cirrhotic patients with AD. METHODS: Patients were identified at two institutions (AIIMS &amp; UCL) as part of ongoing prospective studies of AD. Culture positive Infections and severity of HE (classified by West Haven Criteria) were measured on the day of admission, and new culture positive infections were assessed for up to 28 days after admission. Organ failures were defined as CLIF-organ failure score. Cox-proportional hazard analysis was used to assess predictors of infection. RESULTS: 759 cirrhotic patients with AD were included with a median age of 45 years, and varying degrees of HE; grade 0/1 (n = 452), grade 2–4 (n = 307). On day 0, Patients classified into 4 groups; no HE no infection (n = 359), overt HE no infection (n = 222), no HE with infection (n = 93), overt HE with infection (n = 85). OFs (Liver, Renal, Brain, Coagulation, Respiratory, and Circulatory) and ACLF grades were measured on Day 0, with ACLF grade 0, 1, 2, and 3 (n = 242, 99, 206, and 212 respectively). On univariate and multivariate analyses, Overt HE (with no baseline infection) was independently predictive of new infections (1.639 and 1.608; P = 0.006, and 0.016 respectively). Furthermore, age and circulatory failure were also independent risk factors for infection (P = 0.001, and 0.017 respectively). Overall, HE was higher in non-survivors (n = 191) compared to survivors (n = 116). CONCLUSIONS: The results of this study show for the first time that, in AD patients, overt HE not only associated with higher mortality but is also an independent risk factor for infection. We also showed that Age and Circulatory failure are independent risk factors for infections. That would make them, after further studies, an indication for prophylactic antibiotics.

P: 47 Risk of Recurrent Hepatic Encephalopathy (HE) in Patients With Liver Cirrhosis: A German Registry Study

BACKGROUND: Patients with Hepatic Encephalopathy (HE) show a low quality of life, recurrent hospitalizations and an increased mortality. We aimed to assess the natural course of patients after a recent HE-episode under the conditions of the German health system, as respective data were not available. METHODS: Fifteen sites from Germany - 8 of them liver transplant (LT) centers - took part in an observational prospective study including cirrhotic patients who had been hospitalized due to an acute episode of HE within 3 months before recruitment. Age &lt; 18 years, no liver cirrhosis, malignancies and current hospitalization were exclusion criteria. Demographic and clinical data, health related quality of life (HRQoL) score SF-36, psychometric hepatic encephalopathy score (PHES) and critical flicker frequency (CFF) were assessed and monitored quarterly for one year. Primary endpoint was a novel clinical manifestation of HE necessitating hospital admission. Secondary endpoints were the combined endpoint of hospital admission for a novel HE episode and/or death, the dynamics of the West Haven Criteria (WHC) as well as changes in CFF, PHES and SF-36. RESULTS: A total of 115 patients were recruited. Fourteen patients (12.4 %) died during the study period due to complications of liver cirrhosis other than HE. For 67 subjects follow-up data were available in accordance with the protocol. After a median of 113 days half of the per protocol cohort (N = 34) was re-admitted due to a recurrent manifestation of HE. The patient groups with and without re-hospitalization differed significantly regarding recruitment sites (LT centers vs no LT centers) (P = 0.005), interval from discharge to recruitment (P = 0.007), history of more than 4 HE relapses prior to recruitment (P = 0.029), SF-36 mental score (P = 0.046) and PHES ≤ −3 (P = 0.004), whereas CFF, clinical (e.g. MELD score, WHC grade) and laboratory data did not differ. Of note, CFF performance was correct only in about half of both, the total and the per protocol group. Patients with incorrect CFF performance had worse PHES results than those with valid CFF measurement. Multiple logistic regression analysis revealed a PHES test result of ≤−3 as an independent risk factor for re-hospitalization (P = 0.046). CONCLUSIONS: Mortality in our cohort is comparatively low. Despite advanced treatment strategies, patients with a history of HE are still sincerely jeopardized to develop recurrent clinical HE. The PHES test appears useful for detection, monitoring and stratification of recurrent HE. Patients with PHES ≤−3 at baseline had an increased risk of deterioration.

P: 41 Precipitants of Hepatic Encephalopathy, In-hospital Mortality and Its Predictors

BACKGROUND: Hepatic encephalopathy (HE) is a common complication of liver dysfunction, including acute liver failure and liver cirrhosis. HE presents as a spectrum of neuropsychiatric symptoms ranging from subtle fluctuating cognitive impairment to coma. It is a significant contributor of morbidity in patients with liver disease. Common culprits include gastrointestinal bleeding, infection, constipation, hypokalemia, hyponatremia, and medications such as opiates and benzodiazepines. This study aim to evaluate the change in common precipitants of HE, in-hospital mortality and its predictors. METHODS: This descriptive study was conducted in Hepatology division of Asian Institute of Medical Sciences, Hyderabad, Pakistan from October 2018 to April 2019. A total of 82 cirrhotic patients with HE were included in the study. Frequency of precipitating factors were determined and in-hospital mortality was evaluated. RESULTS: A total of 82 cirrhotic patients with mean age 52.31 years, with males 62.2%. Common etiology for cirrhosis was HCV 64.63%, 56.09% were CTP B, 36.58% patients had MELD in between 11-15. According to West Haven criteria most common grades were Grade II 52.43%, Grade III 17% and Grade IV 16%. Most common precipitants were hyponatremia 18%, constipation 12%, hypokalemia 5%, infections 10%, variceal upper GI bleeding 4%, 24% had mixed precipitants and in 27% patients no precipitant found. 42.7% had Acute Kidney Injury (AKI) mostly associated with electrolyte imbalance. 70.7% were improved and discharged, 11% were expired, 18.3% discharged on request. AKI, SBP and Shock were associated with high mortality. CONCLUSIONS: Electrolyte imbalance, constipation and infections were leading causes of HE. AKI was independent predictor of HE and in-hospital mortality along with SBP and shock.

Clinical Predictors for Poor Quality of Life in Patients With Covert Hepatic Encephalopathy.

Current EASL/AASLD guidelines recommend treatment of covert hepatic encephalopathy (HE) only in symptomatic patients, for example, in those with impaired quality of life or with affected driving abilities. Because testing for impaired quality of life is time consuming, the aim of the present study was to identify simple clinical predictors for poor quality of life in patients with covert HE (CHE). In total, 139 cirrhotic in- and outpatients without a history of overt hepatic encephalopathy were enrolled. Diagnosis of HE grade 1 (HE1) was diagnosed clinically according to the West-Haven Criteria. Critical flicker frequency and the Psychometric Hepatic Encephalopathy Score were used to detect minimal HE (MHE). Chronic Liver Disease Questionnaire was used to assess health-related quality of life (HrQoL). CHE was detected in 51 (36.7%) patients. Multivariate analysis identified a history of falls in the previous year (P=0.003) and female gender (P=0.030) as independent predictors of reduced HRQoL in patients with CHE. Comparison of patients with and without a history of falls revealed relevant differences in the subdomains-abdominal symptoms, fatigue, systemic symptoms, emotional functions and worries. A history of falls and female gender are associated with impaired HRQoL in patients with CHE. These data indicate that a history of falls should be considered as a treatment indication in patients with CHE to improve HRQoL and ultimately prognosis.

Effect of patient's compliance with nursing instructions on minimizing hepatic encephalopathy

Background: Hepatic encephalopathy is a common complication occurs in 30-70% of cirrhotic patients. Aim: To evaluate effect of patient's compliance with nursing instructions on minimizing hepatic encephalopathy. Research design: Quasi- experimental design. Setting: Tropical Medicine and Gastroenterology department at El - Rajhi liver Hospital in Assuit University Hospital. Patients and Methods: Sixty adult patients child B or C liver cirrhosis. Tools: I: Structured interview patient questionnaire. II: Compliance assessment questionnaire. III: West-Haven criteria. Results: There was a statistically significant difference between study and control group patients regarding severity of hepatic encephalopathy through three months (p<0.005) and a highly significant relation was documented between compliance of patients with nursing instructions and severity of hepatic encephalopathy (p<0.001). Conclusion and recommendations: Hepatic encephalopathy was minimized among patients who complied with nursing instructions. Simplified illustrated and comprehensive Arabic language instructions hand book should be available for patients about preventive measures of hepatic encephalopathy.

Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients.

BACKGROUNDLiver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE.AIMTo investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis.METHODSThis is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission.RESULTSThe HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220).CONCLUSIONChronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.

Інтенсивна терапія та малоінвазивні втручання в комплексному лікуванні крово-теч із варикозно розширених вен стравоходу у пацієнтів із декомпенсованим цирозом печінки

From January 2004 to December 2010 in the clinic of Transcarpathian Regional Clinical Hospital 64 patients with bleed-ing from esophageal varices with C-class liver cirrhosis by Child-Turcotte-Pugh criteria were examined and treated. The initial bleeding arrestin 39 (61%) patients was achieved with complex medical therapy and endoscopic sclerotherapy (ES). In 25 (39%) patients due to the inefficiency of the ES, authors used a Blakemore-Sengstaken tube. The III class of encephalopa-thy by West-Haven criteria was diagnosed in the in 37 (57.8%), in 27 it was of IV degree. In 3 (4.7%) patients ascites was transient and in 61 (95.3%) – refractory. In order to treat liver failure, as a major complication that caused bleeding adverse outcome in 27 patients with IV degree of encephalopathy authors used albuminperitoneal dialysis. Inorder to treat in-traabdominal hypertension at ascites in20 patients with III degree of hepatic encephalopathy authors applied laparocentesis with fluid evacuation. In17 patients they used extracorporeal ultrafiltration of asciticfluid with it’s subsequent intravenous reinfusion. In the subgroup of 39 patients with effective sclerotherapy the mortality rate was 23.1%. In the subgroup of 25 patients where the ES was ineffective and the Blackmore tube was applied, the mortality rate was 32%. Amongthe 20 pa-tients after laparocentesis with ascitic fluid evacuation 8 (40%) died. In the 17 patients after extracorporeal ultrafiltration of ascitic fluid with its subsequent intravenous reinfusion 2 (11.8%). In the subgroup where albumin peritoneal dialysis was applied 7 patients died (25.9%).A total of 17 (26.6%) patients died within the observation period of up to 5 days.

Serial assessment of hepatic encephalopathy in patients hospitalised for acute decompensation of cirrhosis

Introduction and aimHepatic encephalopathy (HE) is a frequent complication of cirrhosis, but the clinical and prognostic significance of the progression of mental status in hospitalised cirrhotics is unknown. We aimed to investigate the prognostic significance of serial evaluation of HE in patients hospitalised for acute decompensation (AD) of cirrhosis. Materials and methodsPatients (n=293) were evaluated for HE (West-Haven criteria) at admission and at day-3 and classified in two groups: (1) Absent or improved HE: HE absent at admission and at day-3, or any improvement at day-3; (2) Unfavourable progression: Development of HE or HE present at admission and stable/worse at day-3. ResultsUnfavourable progression of HE was observed in 31% of patients and it was independently associated with previous HE, Child–Pugh C and acute-on-chronic liver failure (ACLF). MELD score and unfavourable progression of HE were independently associated with 90-day mortality. The 90-day Kaplan–Meier survival probability was 91% in patients with MELD<18 and absent or improved HE and only 31% in subjects with both MELD≥18 and unfavourable progression of HE. Unfavourable progression of HE was also related to lower survival in patients with or without ACLF. Worsening of GCS at day-3 was observed in 11% of the sample and was related with significantly high mortality (69% vs. 27%, P<0.001). ConclusionAmong cirrhotics hospitalised for AD, unfavourable progression of HE was associated with high short-term mortality and therefore can be used for prognostication and to individualise clinical care.

Hepatic Encephalopathy: Definition, Clinical Grading and Diagnostic Principles.

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.

L-Ornithine L-Aspartate (LOLA) for Hepatic Encephalopathy in Cirrhosis: Results of Randomized Controlled Trials and Meta-Analyses.

This manuscript represents an appraisal of the evidence in support of l-ornithine-l-aspartate (LOLA) for the management and treatment of hepatic encephalopathy (HE) in cirrhosis. Meta-analyses of randomized controlled trials (RCTs) conducted over the last two decades generally reveal evidence of benefit of LOLA in a range of clinical presentations. This included improvement of mental state grade in overt HE (OHE) assessed by West Haven criteria as well as in minimal HE (MHE) assessed by psychometric testing where the oral formulation of LOLA was determined to be particularly effective. However, concerns over study quality were noted in one meta-analysis. Nevertheless, the concomitant lowering of fasting blood ammonia was reported in all RCTs using this endpoint. Network meta-analyses showed that LOLA appears to be comparable (or superior) in efficacy to non-absorbable disaccharides or probiotics. Emerging evidence from single RCTs show efficacy of LOLA for the treatment of post-transjugular intrahepatic portosystemic shunt (TIPSS) HE as well as for secondary HE prophylaxis. These findings provide support for the use of LOLA in the treatment of HE and future trials should focus on the use of LOLA for prophylaxis.

Relationship Between Intraoperative Bispectral Index and Consciousness Recovery in Patients With Hepatic Encephalopathy Undergoing Liver Transplant: A Retrospective Analysis

BackgroundAlthough liver transplant (LT) improves liver function and restores symptoms of hepatic encephalopathy (HE), there is no index to predict the recovery of consciousness in patients with HE during LT. In this study, we evaluated the relationship between intraoperative bispectral index (BIS) values and the recovery of consciousness in patients with HE who were undergoing LT. MethodsPatients with HE who underwent LT from June 2011 to December 2017 at our institution were enrolled. A total of 64 patients were enrolled, and, using the West Haven Criteria, they were divided into 2 groups: nonsevere HE group (n = 26), grades 1 to 2 HE; and severe HE group (n = 38), grades 3 to 4 HE. Grade of HE, intraoperative BIS, minimum alveolar concentration values, postoperative Glasgow Coma Scale (GCS) score, and the time to recover consciousness were compared. ResultsThe severe HE group showed lower BIS after anesthetic induction compared with the nonsevere HE group (P = .005). In the severe HE group, intraoperative BIS gradient (the difference between values measured 4 hours after reperfusion and immediately after anesthesia induction) was significantly larger than in the nonsevere HE group (P = .001). Time to recovery of consciousness was prolonged in the severe HE group (P = .002). Model for End-Stage Liver Disease (MELD) score and the GCS score at 24 hours after LT were associated with delayed recovery of consciousness (MELD score: hazard ratio, 1.103; 95% CI, 1.002–1.214; P = .046; GCS score at 24 hours after LT: hazard ratio, 0.688; 95% CI, 0.566–0.835; P < .001). ConclusionsOur study indicated that BIS values immediately after anesthesia induction were significantly lower in patients with severe HE. However, it did not show a significant relationship with the time to recovery of consciousness after LT. Multivariate analysis demonstrated that MELD score and GCS score at 24 hours after LT were associated with the time to recovery of consciousness.

Clinical Aspects and Precipitating Factors of Hepatic Encephalopathy Associated with Cirrhosis in a Cameroonian Population

Background: Hepatic Encephalopathy (HE), a common complication of cirrhosis, is associated with a pejorative prognosis. This study aims to describe the clinical presentation, precipitating factors and outcome of HE. Methods: This was a cross-sectional multicenter inpatient study in cirrhotic patients admitted for HE in four tertiary hospitals in Yaounde (Cameroon) from December 2016 to May 2017. The diagnosis of HE was based on West Haven clinical criteria. The diagnosis of cirrhosis was made using clinical and/or biological, endoscopic and/or ultrasonography signs. Results: A total of 53 patients with HE (mean age: 49.9 ± 18.9 years, 35 Males) were included. The frequency of hospital admission for HE was 4.9%. HE grade III was the most common (37.7%), followed by grades I and II (26.4% and 26.4%, respectively). Grade IV was present in 9.4% of cases. According to the Child-Pugh score, 72.1% of the patients were at stage C and 27.9% at stage B. The main precipitating factors found were: constipation (38.5%), hyponatremia (35.9%), hepatocellular carcinoma (HCC) (31.7%), herbal medicine (28.3%), hypokalemia (25.6%), gastrointestinal bleeding (22.6%) and ascitic fluid infection (spontaneous bacterial peritonitis) (13.8%). In 5.7% of cases, no factor was identified. Mortality rate during hospitalization was 45.3% and was significantly associated with stage III (RR = 11.1; 95% CI: 1.9 - 64.5; p = 0.003) and IV (RR = 24; 95% CI: 1.6 - 40.9; p = 0.01) of HE; Child-Pugh C score (RR = 15.2; 95% CI: 1.7 - 30.1; p = 0.003) and hypokalemia (RR = 12.2; 95% CI: 1.3 - 19; p = 0.01). Conclusion: HE is a common complication during cirrhosis with a poor prognosis. In the majority of cases, a precipitating factor could be determined.

Clinical Profile of Patients with Hepatic Encephalopathy in Cirrhosis of Liver

Backgroud: Hepatic encephalopathy (HE) is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of other known causes of brain disease. In India hepatic encephalopathy is considered as indicator of poor prognosis in patients of cirrhosis of liver with 1 year survival in just 42% patients and 3 year survival in 23% of patients. Aim and Objective: Study clinical profile for adverse outcome in patients of hepatic encephalopathy due to cirrhosis of liver. Methods and Methodology: This was a cohort type of study done for a period of 2 years from September 2016 to September 2018 on a study population of 130 patients. Cirrhosis of liver was confirmed by ultrasound of liver. Results: Study included 130 patients of HE secondary to cirrhosis of liver, 82% were males, 44% and 45 % of patients were in grade 2 and grade 3 of West Haven criteria respectively. Icterus, ascites and asterexis were present in almost 65% patients. Cirrhosis was associated with alcohol dependence among 75% of patients followed by NAFLD in 6.15% of patients. Other unknown causes were among 19(14.62%) patients. In our study lactulose was found as the leading treatment modality in 73.84% of patients. Conclusion: Most of the patients were in grade III of HE, alcohol was the most common etiology of cirrhosis, icterus was the most common sign of liver cell failure, most common drug used was lactulose.