Screening for minimal hepatic encephalopathy in asymptomatic drivers with liver cirrhosis

Minimal hepatic encephalopathy [MHE] represents a part of the spectrum of hepatic encephalopathy [HE]. It can have a far-reaching impact on quality and ability to function in daily life and may progress to overt HE. This study was designed to screen for MHE in drivers with liver cirrhosis in Mansoura, a city in the Nile delta in Egypt. A total of 174 consecutive drivers with positive serology for viral markers and cirrhosis were screened for MHE. Questionnaires and standard psychometric tests and well-informed consent were performed at the same setting. The diagnosis of MHE was made when one or both symbol digit test [SDT] and number connection test [NCT] appeared abnormal. Beck's inventory and Mini Mental State Examination questionnaires were performed for those diagnosed as MHE. After overnight fasting, venous blood samples were taken for haematologic tests and routine liver function tests by conventional methods. Arterial ammonia was also measured. A total of 66 patients showed evidence for MHE out of 139 patients who fulfilled the inclusion criteria. No significant differences were present, apart from a significantly elevated arterial ammonia level [p-value <0.001] and a bad self-reported driving history [p < 0.05] in the MHE-positive group when compared with the MHE-negative group. Multivariate logistic regression revealed that advanced Child-Pugh grade [p < 0.001], hepatitis B virus [HBV]-related a etiology [p < 0.001] and smoking are significant risk factors for MHE. MHE is significantly commoner among Child-Pugh C patients [p < 0.05] when compared with the other Child-Pugh grades. Our data revealed a high prevalence of MHE [47%] among Egyptian drivers with liver cirrhosis. It is hence recommended to include the driving history as well as regular pencil-paper standard psychometric testing in evaluating those at risk, especially in the outpatient setting, for early detection and proper management

A randomized trial of endoscopic variceal ligation versus cyanoacrylate injection for treatment of bleeding junctional varices.

Background : There is scarcity of data concerning the management of bleeding junctional gastroesophageal varices. Aim: Our aim was to compare the efficacy and safety of endoscopic variceal ligation (EVL) with cyanoacrylate injection for the treatment of bleeding junctional varices. Methods: One hundred fifty patients with bleeding junctional varices were included in the study. Patients were subjected after randomization to either EVL of junctional varices (group l: 75 patients) or cyanoacrylate injection (group ll: 75 patients). Endoscopic sessions were continued till obliteration of the varices. Clinical as well as biochemical parameters and severity of liver disease were assessed in all patients. Results: Control of active variceal bleeding was achieved in 61 patients (81%) in group I and in 68 patients (91%) in group II with no significant difference (p =0.07). Re-bleeding was seen in 12 patients (16%) in group I and 5 patients in group II (6%). Junctional varix obliteration was achieved after one session in 33% of patients in group I and 52% of patients in group II, however after 2 sessions it was achieved in 67% in group I and 93 % in group II. After 3 sessions variceal obliteration was achieved in 99% in group l. Fever, chest pain and dysphagia were observed more frequently in group II than in group I. Long term complications including spontaneous bacterial peritonitis, hepatic encephalopathy and hepatorenal syndrome were also observed more frequently group II than in group I. Conclusion: EVL may be a good alternative to cyanoacrylate injection in treatment of bleeding junctional varices.