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El-Shazly H, Abdel-Samiee M, Tharwa ES, Zaghla H, Abass S, El-Warraky M, Ibrahim ES. The association between character of portal blood flow and post-TIPS incidence of hepatic encephalopathy. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-00038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hepatic encephalopathy (HE) is one of the serious complications observed post-TIPS operations in patients with different complications of portal hypertension such as refractory ascites, refractory hydrothorax, bleeding varices, and hepato-renal syndrome. Herein, we aimed to clarify predisposing factors for post-TIPS incidence of HE according to pre-TIPS hemodynamics.
Results
Fifty patients were enrolled in this study with different complications of portal hypertension; most of them have Child A and B scores. Patients were evaluated by ultrasound Doppler for the flow inside the portal vein and clinically recorded into two groups: group 1, 31 patients with hepatopetal flow; and group 2, 19 patients with hepatofugal flow. Then, TIPS was performed and patients were reassessed 1 month later to detect HE. Multiple variables such as age, gender, etiology of liver disease, and indication for TIPS had no significant differences. The incidence of HE post-TIPS was observed more at group 1 more than at group 2 (P = 0.02).
Conclusions
Post-TIPS incidence of HE was interestingly related to pre-TIPS flow in the portal vein (hepatopetal group more than hepatofugal group). Patients with hepatofugal flow in the portal vein are perfect candidate for TIPS than patients with hepatopetal flow in the portal vein. Patients with previous history of HE are contraindicated for TIPS except as a bridge for liver transplantation.
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Cognitive and neurophysiological assessment of patients with minimal hepatic encephalopathy in Brazil. Sci Rep 2020; 10:8610. [PMID: 32451417 PMCID: PMC7248115 DOI: 10.1038/s41598-020-65307-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/29/2020] [Indexed: 11/17/2022] Open
Abstract
Minimal hepatic encephalopathy is a syndrome caused by cirrhosis, with a broad spectrum of clinical manifestations. Its diagnosis is based on abnormal results of cognitive and neurophysiological tests, but there are no universally available criteria, especially in Brazil, where local testing standards are required. The objective of the present study was to compare the performance of the mini-mental state examination (MMSE), Rey’s auditory-verbal learning test (RAVLT), psychometric score of hepatic encephalopathy (PHES), topographic mapping of brain electrical activity (TMBEA) and long-latency auditory evoked potential (P300) in the detection of minimal hepatic encephalopathy in Brazil. From 224 patients with cirrhosis included in the global sample, 82.5% were excluded due to secondary causes responsible for cognitive or neurophysiological dysfunction. The final sample consisted of 29 cirrhotics, with predominance of A5 Child-Pugh classification, and 29 controls paired in critical variables such as age, educational level, gender, professional category, scores suggestive of mild depression, association with compensated type 2 diabetes mellitus and sociodemographic characteristics. Overall, performance on cognitive tests and TMBEA did not show a statistically significant difference. There was a marked difference in P300 latency adjusted for age, with patients with cirrhosis showing a mean of 385 ± 78 ms (median of 366.6 ms) and healthy volunteers exhibiting a mean of 346.2 ± 42.8 ms (median of 348.2 ms) (p < 0.01). These findings suggest that, in the earliest stages of cirrhosis, age-adjusted P300 latency was superior to cognitive assessment and TMBEA for detection of minimal hepatic encephalopathy.
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Amodio P, Montagnese S. Clinical neurophysiology of hepatic encephalopathy. J Clin Exp Hepatol 2015; 5:S60-8. [PMID: 26041960 PMCID: PMC4442865 DOI: 10.1016/j.jceh.2014.06.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 06/05/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVES Hepatic encephalopathy (HE) has relevant impact on the quality of life of patients and their caregivers and causes relevant costs because of hospitalizations and work days lost. Its quantification is important to perform adequate clinical trials on this relevant complication of cirrhosis and portal-systemic shunting. Clinical neurophysiology, which detects functional alterations of the nervous system, has been applied to the study of HE for over 60 years. This review aims at summarizing and clarifying the role of neurophysiologic techniques in the study of HE. METHODS A narrative review was performed aiming at interpreting the cited papers and the techniques on the basis of their physiological and pathophysiological meaning. RESULTS The potential role of EEG, quantified EEG, evoked potentials-both exogenous, endogenous and motor-have been clarified to the reader that may be unfamiliar with neurophysiology. CONCLUSIONS The EEG, reflecting the oscillatory changes of neural network is the preferable tool to detect and monitor HE, with the exception of its most severe stage, when EEG flattens. SSEP and MEP have indication to detect and monitor transmission alterations that are likely related to myelin changes and microedema.
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Key Words
- BAEPs, brainstem acoustic evoked potentials
- EEG
- EEG, electroencephalogram
- EPs, evoked potentials
- ERPs, event related potentials
- HE, hepatic encephalopathy
- MEG, magnetoencephalogram
- MEPs, motor evoked potentials
- SSEPs, somatosensory evoked potential
- VEPs, visual evoked potentials
- cirrhosis
- evoked potentials
- fVPS, flash visual evoked potentials
- hepatic encephalopathy
- neurophysiology
- pVEPs, pattern reversal visual evoked potentials
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Affiliation(s)
- Piero Amodio
- Address for correspondence: Piero Amodio, Department of Medicine, DIMED, University of Padua, via Giustiniani, 2; 35128 Padova, Italy. Fax: +39 049 7960903.
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Moon JH, Jun DW, Yum MK, Lee KN, Lee HL, Lee OY, Yoon BC, Choi HS, Hahm JS, Seol IJ, Oh JW, Kim CR. Prolonged N200 is the early neurophysiologic change in the patient with minimal hepatic encephalopathy. Scand J Gastroenterol 2014; 49:604-10. [PMID: 24646220 DOI: 10.3109/00365521.2013.878382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In neurophysiological studies, P300, is well known for reflecting early cognitive impairment in minimal hepatic encephalopathy (MHE). Although P300 is investigated extensively, other early event-related potential (ERP) parameters have not been studied in MHE. METHODS The subjects were 21 adult cirrhotic patients without clinical encephalopathy and 29 normal controls. For neuropsychological testing, number connection tests, A and B (NCT-A, NCT-B), the line tracing test, the serial dotting test (SDT), and the digit symbol test (DST) were performed. For ERP testing, auditory oddball paradigms were used. The N100, P200, N200, and P300 parameters were measured. RESULTS Cirrhosis had longer neuropsychological performance scores on NCT-A, SDT, and DST than the control group. In neurophysiological test, cirrhotic patients showed longer latencies for N100, P200, N200, and P300 than the control group. Although P300 alteration was not seen in patients without MHE compared to the control group (325.4±43.3 vs. 345.21±35.1, p=0.25), N200 latency was significantly prolonged in cirrhotic patients without MHE compared to the healthy group (242.1±30.3 vs. 259.58±33.3, p=0.006). N200 also showed good correlation with psychometric hepatic encephalopathy score and critical flicker frequency. CONCLUSIONS N200 is a useful tool for assessing early changes of cognitive dysfunction in cirrhosis. It suggests that slower auditory cortical processing is the first sign of cerebral deterioration in patients with hepatic encephalopathy.
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Affiliation(s)
- Jin-Hwa Moon
- Department of Pediatrics, Hanyang University School of Medicine , Seoul , Korea
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Ni L, Qi R, Zhang LJ, Zhong J, Zheng G, Wu X, Fan X, Lu GM. Brain regional homogeneity changes following transjugular intrahepatic portosystemic shunt in cirrhotic patients support cerebral adaptability theory—A resting-state functional MRI study. Eur J Radiol 2014; 83:578-83. [DOI: 10.1016/j.ejrad.2013.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/21/2013] [Accepted: 10/21/2013] [Indexed: 11/25/2022]
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Torres DS, Abrantes J, Brandão‐Mello CE. Cognitive assessment of patients with minimal hepatic encephalopathy in Brazil. Metab Brain Dis 2013; 28:473-83. [PMID: 23625323 PMCID: PMC3734603 DOI: 10.1007/s11011-013-9405-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 04/04/2013] [Indexed: 01/16/2023]
Abstract
Minimal hepatic encephalopathy is a syndrome caused by liver cirrhosis and accompanied by a broad spectrum of cognitive symptoms. The objective of the present study was to describe the prevalence of minimal hepatic encephalopathy in cirrhotic patients and to compare their cognitive performance with controls using standardized tests. Patients receiving medication or experiencing comorbidities associated with cognitive disorders were excluded. The final cohort was compared with a control-matched group using the Mini-Mental State Examination (MMSE), as well as Simple Drawing, Clock Drawing, Rey Auditory-Verbal Learning Test (RAVLT), Random Letter, Stroop, Trail-Making Test (TMT) A and B, Boston Naming, Category Verbal Fluency, Digit Span, Constructional Praxis, Processing Speed, and Similarities Tests. The results indicated no differences in the prevalence of cognitive complaints spontaneously reported by 29 patients with cirrhosis versus 22 healthy controls. The most affected tests included: MMSE (26.3 ± 2 vs. 28.1 ± 1.8 points; p = 0.004), learning (35.4 ± 9 vs. 41 ± 9.1 points; p = 0.041), retroactive interference (0.67 ± 0.22 vs. 0.84 ± 0.16 points; p = 0.004), and recognition (8.7 ± 2.6 vs. 11.2 ± 4.1 points; p = 0.024) in RAVLT, TMT-A (63.2 ± 29.3 vs. 47.6 ± 16.5 s; p = 0.029) and TMT-B (197.9 ± 88.1 vs. 146.8 ± 76.5 s; p = 0.03). No differences were observed with respect to age, gender, and education. In conclusion, MMSE proved to be a useful tool for detecting global cognitive impairment experienced by cirrhosis patients. Moreover, the most impaired cognitive functions were verbal episodic memory and information processing speed. These findings suggest that minimal hepatic encephalopathy represents a disorder that affects the medial temporal system and, possibly, the prefrontal cortex, and this requires further study.
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Affiliation(s)
- D. S. Torres
- Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ Brazil
- Serviço de Gastroenterologia e Hepatologia do Hospital Universitário Gaffrée e Guinle (Hepatology Outpatient Clinic of the Gaffrée and Guinle University Hospital), Rua Mariz e Barros, 775, Tijuca, Rio de Janeiro, RJ Brazil 20270‐004
| | - J. Abrantes
- Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ Brazil
- Serviço de Gastroenterologia e Hepatologia do Hospital Universitário Gaffrée e Guinle (Hepatology Outpatient Clinic of the Gaffrée and Guinle University Hospital), Rua Mariz e Barros, 775, Tijuca, Rio de Janeiro, RJ Brazil 20270‐004
| | - C. E. Brandão‐Mello
- Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ Brazil
- Serviço de Gastroenterologia e Hepatologia do Hospital Universitário Gaffrée e Guinle (Hepatology Outpatient Clinic of the Gaffrée and Guinle University Hospital), Rua Mariz e Barros, 775, Tijuca, Rio de Janeiro, RJ Brazil 20270‐004
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Koziarska D, Wunsch E, Milkiewicz M, Wójcicki M, Nowacki P, Milkiewicz P. Mini-Mental State Examination in patients with hepatic encephalopathy and liver cirrhosis: a prospective, quantified electroencephalography study. BMC Gastroenterol 2013; 13:107. [PMID: 23815160 PMCID: PMC3716589 DOI: 10.1186/1471-230x-13-107] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 06/28/2013] [Indexed: 12/23/2022] Open
Abstract
Background Mini-Mental State Examination (MMSE) is one of the most commonly used methods in the assessment of cognitive mental status. MMSE has been used in hepatology but its usefulness in the evaluation of hepatic encephalopathy (HE) has never been properly assessed. The aim of the study was to investigate the value of MMSE in detection of HE in patients with cirrhosis. Methods One hundred and one consecutive patients with liver cirrhosis underwent neurological examination, MMSE and electroencephalography (EEG). Spectral analysis of EEG was done with calculation of mean dominant frequency (MDF) and relative power of delta, theta, alpha and beta rhythms. Minimal HE was diagnosed in patients with normal neurological status and alterations in spectral EEG. Statistical analysis included Fisher’s exact and Anova analysis. Categorical data were compared using Levene’s test for equality of variances. Correlation-coefficient analysis was performed by the Pearson’s r or Z-test, as needed. Tests performance was assessed by the calculating the area under the ROC curve (AUC) and evaluating its difference from reference area (AUC=0.5). A p value <0.05 was considered statistically significant. Results Overt HE was identified in 49 (48.5%) and minimal HE in 22 (21.8%) patients. Although there were significant correlations between both severity of liver disease (Child-Pugh classification), overt HE (West-Haven criteria) and various MMSE items, MDF showed no correlation with any of MMSE items as well as MMSE summary score. MMSE (score and items) did not discriminate patients without HE and minimal HE. The only significant differences between patients without HE and with overt HE were seen in respect of MMSE score (p<0.02), orientation to place (p<0.003), repetition (p<0.01) and complex commands-understanding (p<0.02). Test performance analysis has shown that MMSE has no value as a prediction method in determining minimal HE and in respect of overt HE has a sensitivity of 63% and specificity of 52% by a cut-off level at 27.5 points to diagnose overt HE. Conclusions In conclusion, although MMSE score and single items are altered in patients with overt HE, MMSE has no value in the assessment of minimal HE. Because MMSE could be impaired in several cognitive dysfunctions, more specific test should be used for measuring HE.
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Affiliation(s)
- Dorota Koziarska
- Department of Neurology, Pomeranian Medical University, ul. Unii Lubelskiej 1, 71-252, Szczecin, Poland
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Dynamic changes of intrinsic brain activity in cirrhotic patients after transjugular intrahepatic portosystemic shunt: a resting-state FMRI study. PLoS One 2012; 7:e46681. [PMID: 23056400 PMCID: PMC3462766 DOI: 10.1371/journal.pone.0046681] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 09/02/2012] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The majority of cirrhotic patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) experienced the first post-TIPS hepatic encephalopathy (HE) episode within the first three months after TIPS insertion. However, so far, little is known about the exact neuro-pathophysiological mechanism of TIPS's effects on brain function. We aimed to investigate the dynamics of brain function alteration of post-TIPS patients using resting-state functional MRI (rs-fMRI). MATERIALS AND METHODS Sixteen cirrhotic patients who were scheduled for TIPS and 16 healthy controls were included in the rs-fMRI scans. Ten patients repeated the MRI study in a median 8-day follow-up interval following TIPS and seven in a median 3-month follow-up. The amplitude of low frequency fluctuation (ALFF), an index reflecting the spontaneous brain activity, was compared between patients before TIPS and healthy controls as well as patients pre- and post-TIPS. RESULTS Compared with healthy controls, patients showed decreased ALFF in frontal and parietal regions and increased ALFF in insula. Patients who underwent the median 8-day follow-up fMRI examinations showed decreased ALFF in posterior cingulate cortex (PCC)/precuneus and increased ALFF in anterior cingulate cortex (ACC). Of 10 patients in this group, 9 had moderate to large increase rate of ALFF value (>20%, mean 49.19%) in ACC, while only one patient with the smallest increase rate of ALFF value (<10%) in ACC, who experienced three episodes of overt HE during the 3-month follow-up. In the median 3-month follow up observation, patients displayed persistently decreased ALFF in PCC, ACC and medial prefrontal cortex (MPFC), while no increased regional ALFF was observed. CONCLUSION TIPS insertion alters cirrhotic patients' ALFF patterns in the resting state, which may imply different short-term and moderate-term effects on cirrhotic patients, i.e., both impairment and compensatory mechanism of brain functions in peri-TIPS and continuous impairment of brain function 3 months following TIPS.
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Abstract
Hepatic encephalopathy is a complex and potentially reversible neuropsychiatric syndrome complicating acute or chronic liver disease. Clinical manifestations are multiple and varied, ranging from minimal neurological changes to coma. Ammonia is the main toxic substance involved in the pathogenesis of hepatic encephalopathy, although other mechanisms, such as modifications of the blood-brain barrier, disruptions in neurotransmission and abnormalities in GABAergic and benzodiazepine pathways may also play a role. The identification and treatment of precipitating factors is crucial in the management of patients with hepatic encephalopathy. Current treatments are based on reducing intestinal ammonia load by agents such as antibiotics or disaccharides, although their efficacy is yet to be clearly established.
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Bajaj JS. Current and future diagnosis of hepatic encephalopathy. Metab Brain Dis 2010; 25:107-10. [PMID: 20213105 DOI: 10.1007/s11011-010-9176-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 01/28/2010] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA.
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Diagnostic and prognostic values of critical flicker frequency determination as new diagnostic tool for objective HE evaluation in patients undergoing TIPS implantation. Eur J Gastroenterol Hepatol 2009; 21:1383-94. [PMID: 19738480 DOI: 10.1097/meg.0b013e328310e0c3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The diagnostic and prognostic value of critical flicker frequency (CFF) analysis for assessment of severity and dynamics of hepatic encephalopathy (HE) was studied before and after implantation of a transjugular intrahepatic portosystemic shunt (TIPS). BASIC METHODS Sixty-three cirrhotic patients were retrospectively analyzed for the consequences of TIPS implantation. Thirty-one cirrhotic patients without TIPS implantation served as age-matched, sex-matched, Child-Pugh-matched controls. CFF and computer psychometric tests as objective test parameters of HE-severity were evaluated for analysis of visual discrimination ability, general arousal and cognitive function. Kaplan-Meier method and Cox proportional hazards regression model were used for analysis of prognostic significances. MAIN RESULTS In the control group, HE-severity was stable during the observation period (442+/-428 days) with minimal changes in CFF (-0.1+/-1.9 Hz). In the intervention group, TIPS implantation had no effect on HE-severity in 44% of the patients and CFF shifted by only 0.01+/-1.5 Hz. Thirty-five and 21% of the patients experienced an aggravation or improvement of HE after TIPS implantation, respectively. In HE improvers CFF increased by 3.3+/-2.3 Hz and decreased by 3.5+/-1.5 Hz in those experiencing an aggravation of HE-severity. Univariate analysis showed that overall survival in the study population inversely correlated with HE-severity and serum alkaline phosphatase activity and positively correlated with serum sodium, albumin and CFF. Serum albumin, alkaline phosphatase levels and CFF were independent predictors of survival in a multivariate Cox regression analysis. CONCLUSION The data show that pre-TIPS HE does not predict post-TIPS encephalopathy. Otherwise, CFF can reliably pick up the evolution of HE-severity after TIPS implantation. Low pre-TIPS CFF is indicative for a poor prognosis and may help to identify transplant candidates without delay.
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Guerit JM, Amantini A, Fischer C, Kaplan PW, Mecarelli O, Schnitzler A, Ubiali E, Amodio P. Neurophysiological investigations of hepatic encephalopathy: ISHEN practice guidelines. Liver Int 2009; 29:789-96. [PMID: 19638107 DOI: 10.1111/j.1478-3231.2009.02030.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
By studying neuronal activity through neuronal electrogenesis, neurophysiological investigations provide a functional assessment of the nervous system and, therefore, has been used for quantitative assessment and follow-up of hepatic encephalopathy (HE). The different clinical neurophysiological approaches can be classified depending on the function to explore and their sensitivity to HE. The reliable techniques are those that reflect cortical function, i.e., cognitive-evoked potentials (EPs) (P300 paradigm), electroencephalogram (EEG), visual EPs (latency>100 ms) and somatosensory EPs (SEPs) (latency between 25 and 100 ms). Short-latency EPs (brainstem acoustic EPs, SEPs of a latency<25 ms) are in principle insensitive to HE, but can disclose brainstem conduction deficits due to oedema. SEPs and motor EPs can disclose myelopathies. Because of its parallelism to the clinical examination, clinical neurophysiology can complement the neurological examination: (i) to provide evidence of HE in patients who have normal consciousness; (ii) to rule out, at least under some conditions, disturbances of consciousness due to other causes (e.g. drug-induced disturbances, non-convulsive status epilepticus) with the reservation that the mildest degrees of encephalopathy might be associated with an EEG pattern similar to that induced by drugs; and (iii) to demonstrate the worsening or, conversely improvement, of HE in the follow-up period.
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Liu F, Zhang CQ. Pathogenesis of hepatic encephalopathy and its prevention after transjugular intrahepatic portosystemic shunt. Shijie Huaren Xiaohua Zazhi 2009; 17:798-804. [DOI: 10.11569/wcjd.v17.i8.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the increasing use of transjugular intrahepatic portosystemic shunt (TIPS), we have obtained a breakout progress in the therapy of acute esophageal and gastric-fundus variceal bleeding and refractory ascites. whereas the patency of stent and hepatic encephalopathy (or namely portal-systemic encephalopathy, PSE) after TIPS become two great problems for TIPS. The patency of stent has been improved greatly after the use of covered stent such as Viator stents or covered vascular stents. But the problem of hepatic encephalopathy has not been well solved. In this review, we try to explore the pathogenesis of hepatic encephalopathy and its prevention after TIPS.
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Crone CC, Gabriel GM, DiMartini A. An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist. PSYCHOSOMATICS 2006; 47:188-205. [PMID: 16684936 DOI: 10.1176/appi.psy.47.3.188] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Liver disease is a common cause of morbidity and mortality in the United States and elsewhere. Arising from infectious, hereditary, or toxin-induced sources, the detection of liver disease often requires a high index of suspicion. Clinical presentations are highly variable and are often accompanied by neuropsychiatric symptoms. This fact, along with an increased incidence of liver disease among patients with primary psychiatric disorders and the presence of varied drug use, complicates the tasks of providing care to patients with liver disease. To assist the consultation-liaison psychiatrist, the authors present the first of a two-part series focused on psychiatric issues in liver disease.
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Affiliation(s)
- Catherine C Crone
- Inova Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA.
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Mack CL, Zelko FA, Lokar J, Superina R, Alonso EM, Blei AT, Whitington PF. Surgically restoring portal blood flow to the liver in children with primary extrahepatic portal vein thrombosis improves fluid neurocognitive ability. Pediatrics 2006; 117:e405-12. [PMID: 16481447 DOI: 10.1542/peds.2005-1177] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Children with primary extrahepatic portal vein thrombosis (EHPVT) have portal-systemic shunting, which may lead to disturbed neurocognitive function similar to portal-systemic encephalopathy (PSE) seen with chronic liver disease and cirrhosis. The functions most affected are those involving fluid cognitive ability, which comprise neurocognitive domains such as attention, processing speed, and short-term memory, that are particularly vulnerable to systemic illness or diffuse neurologic insult. We determined the fluid cognitive ability of children with EHPVT and whether surgically restoring portal blood flow by mesenteric left portal vein bypass (MLPVB) improved it. DESIGN Twelve children with EHPVT and no overt PSE underwent comprehensive neurocognitive testing before and 1 year after undergoing surgery with intent to perform MLPVB. The evaluations sampled 4 functional domains at both time points: (1) neurobehavioral (behavior, emotional, executive functioning); (2) broad cognitive (intelligence, achievement); (3) fluid ability (attention, mental speed, working memory, memory encoding); and (4) visual motor (drawing, fine motor). Tasks in the fluid-ability and visual-motor domains were expected to be especially sensitive to adverse effects of EHPVT and to be most likely to show improvement with MLPVB. The test group consisted of 8 subjects who underwent successful MLPVB, and the comparison group was composed of 3 patients who received distal splenorenal shunts and one whose MLPVB failed. RESULTS Both groups demonstrated similar fluid cognitive ability at initial evaluation. Successful MLPVB resulted in significantly improved fluid cognitive function: in the fluid cognitive domain, significant improvements were seen for the hit reaction time variability in the Conner's Continuous Performance Test, the attention scale of the Cognitive Assessment System, and immediate verbal memory in the Children's Memory Scale. In the visual-motor domain, z scores on the Grooved Pegboard Test improved. No improvement was observed in the comparison group. DISCUSSION The results show that surgically restoring portal flow to the liver in children with primary EHPVT results in improved fluid cognitive ability. Subjects showed some neurocognitive abnormalities involving mainly fluid cognitive ability consistent with minimal PSE seen in adults with chronic liver disease. Cognitive defects in patients with minimal PSE seem to relate primarily to attention and fine motor skill, and although affected patients can function in everyday life, they are at risk for performance deficits in educational and vocational situations requiring the ability to pay close attention and react quickly (eg, driving, employment in manufacturing). The tests we administered in these domains are pediatric equivalents to measures used to detect minimal PSE in adults and should detect abnormalities in the same functional domains. Our results suggest that a narrow battery of tests could be used to detect minimal PSE in children in a manner similar to the 5-test battery used in adults, eliminating the need for the comprehensive and broad testing we performed. Our findings suggest that shunting of portal blood from the liver in primary EHPVT can result in PSE and question whether it is as benign a disease as previously thought. The importance of our findings is twofold. For understanding the pathophysiology of PSE, we have shown that restoring blood flow to the liver improves cognitive function in children with EHPVT. For therapy for EHPVT, it becomes clear that MLPVB is an excellent treatment option. It is effective for treating the complications of portal hypertension and provides effective portal blood flow that other medical and surgical therapies do not. The findings provide additional evidence that primary EHPVT should be considered curable by MLPVB. However, comparison of overall risks and benefits of MLPVB with those of other therapeutic options and longer-term outcome studies must be completed before MLPVB can be fully endorsed as the best treatment for EHPVT in children. CONCLUSIONS Surgical restoration of portal venous flow to the liver in children with primary EHPVT by MLPVB improves fluid cognitive ability. MLPVB should be considered in treating primary EHPVT, because it corrects portal blood flow and could optimize learning potential.
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Affiliation(s)
- Cara L Mack
- Pediatrics, Northwestern University Feinberg School of Medicine, Children's Memorial Hospital, Chicago, Illinois, USA
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Abstract
The neurophysiological tools used to study hepatic encephalopathy (HE) are the electroencephalogram (EEG) and the evoked potentials (EPs), both exogenous and endogenous. These tools are used (1) to diagnose HE in patients with severe liver disease and mental alteration, (2) to grade overt HE and monitor the effect of treatment for HE, (3) to diagnose minimal HE (4) to predict the occurrence of episodes of overt HE or liver-related death. The rationale for the use of each of these tools together with their theoretical and practical role is reviewed.
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Affiliation(s)
- Piero Amodio
- Clinical Medicine 5-Department of Clinical and Experimental Medicine and CIRMANMEC, University of Padova, Padova, Italy.
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Montagnese S, Amodio P, Morgan MY. Methods for diagnosing hepatic encephalopathy in patients with cirrhosis: a multidimensional approach. Metab Brain Dis 2004; 19:281-312. [PMID: 15554423 DOI: 10.1023/b:mebr.0000043977.11113.2a] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
There is no "gold standard" for diagnosing hepatic encephalopathy in patients with cirrhosis. In consequence, the presence of this condition, unless floridly overt, is often missed. As a result, the majority of patients are denied the benefits of treatment. There are a number of individual techniques, which access different aspects of cerebral function that can be used, singly or in combination, to provide diagnostic information in this condition, including mental state assessment, psychometric testing, electroencephalography, sensory and cognitive evoked potentials, and neuroimaging. These have been variously applied to the study of hepatic encephalopathy but fundamental differences in the essential aims of the studies, as well as differences in the patient populations and the acquisition and analysis of the data, have made comparisons difficult. Thus, there is no clear consensus as to the sensitivity, specificity, or validity of these tests when used alone or in combination. There are, however, a number of additional methods that could be used to analyze the electrophysiological data, and a number of alternative evoked potentials that could be measured to provide better diagnostic information. In addition, there are a number of techniques, such as critical flicker frequency and smooth pursuit eye movements, which have not yet been applied systematically in this condition and which may provide useful diagnostic information. Clearly the methods for assessing hepatic encephalopathy need to be reviewed, newer methods for analyzing the electrophysiological data and newer techniques for assessing alternative aspects of cerebral function need to be explored for their diagnostic utility. This process should aim at developing a multidimensional diagnostic tool.
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Affiliation(s)
- Sara Montagnese
- Centre of Hepatology, Royal Free Campus, Royal Free and University College Medical School, Rowland Hill Street, Hampstead, London, United Kingdom
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Abstract
The term minimal hepatic encephalopathy refers to the subtle changes in cognitive function, electrophysiological parameters, cerebral neurochemical/neurotransmitter homeostasis, cerebral blood flow, metabolism, and fluid homeostasis that can be observed in patients with cirrhosis who have no clinical evidence of hepatic encephalopathy. Use of this term emphasizes the fact that the entity of hepatic encephalopathy is a single syndrome with quantitatively distinct features relating to severity. The absence of clinical evidence of hepatic encephalopathy is key to the diagnosis and can only be determined by a detailed assessment of the patients' history and a comprehensive neurological assessment of consciousness, cognitive, and motor function. The neuropsychological features of minimal hepatic encephalopathy point to a disorder of executive functioning, particularly selective attention and psychomotor speed, but other abnormalities may be observed. Alterations in electrophysiological variables have been described; endogenous evoked potentials are, in principle, more likely to reflect the presence of minimal hepatic encephalopathy, since they reflect cognitive phenomena rather than mere stimulus conduction but the specificity of the changes observed is unclear at present. Changes have also been described in the execution of diadochokinetic movements and in the capacity to discriminate flickering light, both of which may have diagnostic potential. The changes observed in cerebral blood flow and metabolism in SPET, PET, and 1H and 31P MRS studies reflect the pathogenic process that underlies the condition rather than providing diagnostic information. Similarly, the morphological brain abnormalities identified in this population, including mild brain oedema, hyperintensity of the globus pallidus and other subcortical nuclei observed in cerebral MR studies, and the central and cortical atrophy observed in neural imaging studies, are unlikely to have diagnostic utility. The presence of minimal hepatic encephalopathy is not without clinical consequence; it has a detrimental effect on health-related quality of life, the ability to perform complex tasks such as driving, and on outcome.
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Affiliation(s)
- Piero Amodio
- Clinica Medica 5, CIRMANMEC, University of Padova, Italy.
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Li YY, Nie YQ, Sha WH, Zeng Z, Yang FY, Ping L, Jia L. Prevalence of subclinical hepatic encephalopathy in cirrhotic patients in China. World J Gastroenterol 2004; 10:2397-401. [PMID: 15285027 PMCID: PMC4576296 DOI: 10.3748/wjg.v10.i16.2397] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2003] [Revised: 11/21/2003] [Accepted: 12/08/2003] [Indexed: 12/15/2022] Open
Abstract
AIM Subclinical hepatic encephalopathy (SHE) is a common complication of liver diseases. The aim of this study was to find out the normal value of psychometric test and to investigate the prevalence of SHE in Chinese patients with stabilized hepatic cirrhosis. METHODS Four hundred and nine consecutive cirrhotic patients without overt clinical encephalopathy were screened for SHE by using number connection test part A (NCT-A) and symbol digit test (SDT). SHE was defined as presence of at least one abnormal psychometric test. The age-corrected normal values were defined as the mean+/-2 times standard deviation (2SD), and developed in 356 healthy persons as normal controls. Four hundred and sixteen patients with chronic viral hepatitis were tested as negative controls to assess the diagnostic validity of this test battery. RESULTS There was no significant difference in NCT scores and SDT quotients between healthy controls and chronic hepatitis group (P>0.05). In all age subgroups, the NCT and SDT measurements of cirrhotic patients differed significantly from those of the controls (P<0.05). When mean+/-2SD of SDT and NCT measurements from healthy control group was set as the normal range, 119 cirrhotic patients (29.1%) were found to have abnormal NCT-A and SDT tests, 53 (13.0%) were abnormal only in SDT and 36 (8.8%) only in NCT-A. Taken together, SHE was diagnosed in 208 (50.9%) cirrhotic patients by this test battery. The prevalence of SHE increased from 39.9% and 55.2% in Child-Pugh's grade A and B groups to 71.8% in Child-Pugh's grade C group (P<0.05). After the adjustment of age and residential areas required from the tests, no correlation was found in the rate of SHE and causes of cirrhosis, education level and smoking habit. CONCLUSION Psychometric tests are simple and reliable indicators for screening SHE among Chinese cirrhotic patients. By using a NCT and SDT battery, SHE could be found in 50.9% of cirrhotic patients without overt clinical encephalopathy. The prevalence of SHE is significantly correlated with the severity of liver functions.
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Affiliation(s)
- Yu-Yuan Li
- Department of Gastroenterology, First Municipal People's Hospital of Guangzhou, Guangzhou 510180, Guangdong Province, China.
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Abstract
During the last 15 years the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become a safe and effective treatment of portal hypertension. Its major obstacle, the high rate of shunt insufficiency, is going to be solved by the availability of covered stents showing a patency rate of up to 90%. The treatment of acute oesophageal and gastric variceal bleeding is an unsolved problem because variceal bleeding remains the major cause of death in patients with cirrhosis. TIPS has become the rescue treatment of choice because it combines high efficacy with low invasiveness. In this context, the timing of the rescue TIPS is of major importance for achieving definitive haemostasis before multi-organ failure develops. In the prevention of re-bleeding, TIPS is accepted as a second-line treatment, required in about 10-20% of patients. TIPS may be indicated when more than two significant re-bleedings occurred within a time frame of 12 months in spite of adequate first-line measures i.e. drugs or ligation. Refractory ascites is the third main indication for TIPS. Five randomized studies comparing TIPS with paracentesis show good response and comparable survival. Interpretations of authors and comments of reviewers are, however, controversial and do not permit a definitive recommendation.
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Affiliation(s)
- Martin Rössle
- Praxiszentrum für Gastroenterologie, University Hospital, Bertoldstrasse 48, 79098 Freiburg, Germany.
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Li Destri G, La Greca G, Greco L, Greco R, Licitra E, Lanteri R, Di Cataldo A. Arterialization of the portal stump by right renal artery after portocaval shunt in the rat. Microsurgery 2004; 24:77-80. [PMID: 14748031 DOI: 10.1002/micr.10197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Portosystemic shunts cause severe secondary effects, so that arterializations of the portal stump are planned to increase the blood supply to the liver. The aim of this study was to verify the technical feasibility of arterialization of the portal stump with the right renal artery in order to obtain a valid experimental model to study the pathophysiology of arterial revascularization of the liver. Twenty rats underwent end-to-side portocaval shunt + end-to-end anastomosis between the right renal artery and portal stump; another 20 rats were subjected to the same surgical procedure, but the portal stump underwent a reduction in size. In our study, both techniques gave good results, but the use of an operating microscope and good microsurgical training were essential in achieving a good patency rate (78.3%).
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Affiliation(s)
- Giovanni Li Destri
- Department of Surgical Sciences, Organ Transplantations, and Advanced Technologies, University of Catania, Catania, Italy
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Affiliation(s)
- M Lewis
- Academic Unit of Medicine, St James's University Hospital, Leeds, UK.
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