Uso do Stroop EncephalApp para o screening de encefalopatia hepática mínima em pacientes cirróticos no sul do Brasil / Use of the stroop encephalapp for covert hepatic encephalopathy screening in cirrhotic patients in southern brazil

ABSTRACT BACKGROUND: Covert hepatic encephalopathy (CHE) is difficult to detect due to the lack of easily applicable screening tools. The Stroop EncephalApp is a smartphone application already validated for CHE screening. However, its applicability to the Brazilian population is not known. OBJECTIVE: To estimate the prevalence of CHE and evaluate the use of Stroop EncephalApp in a cirrhotic population in Brazil. METHODS: In this cross-sectional study, we evaluated 99 patients previously diagnosed with liver cirrhosis in a Private Hospital in Curitiba/PR. Patients were initially submitted to the mini mental state examination (MMSE) to exclude individuals with dementia. After, the Psychometric Hepatic Encephalopathy Score (PHES) test was performed and lastly, the Stroop EncephalApp test. Results were adjusted for age, sex and education levels to evaluate the accuracy of the app on detecting the disease, comparing its results with the gold standard method (PHES). Patients with one or more of the following were excluded: dementia, inadequate MMSE score, illiteracy, color blindness, history of drugs/alcohol abuse within the past 3 months and previous or actual episodes of encephalopathy. The statistical analysis was performed by SPSS 2.0 and the significance adopted by 5%. RESULTS: We included 82 individuals in the final analysis. Among these patients, 29 were diagnosed with CHE by the PHES test (35.36% prevalence) and 28 of those obtained equal diagnosis by the Stroop EncephalApp (96.6% sensitivity). A total of 53 patients obtained negative results for CHE by PHES, while the Stroop test classified 27 of them as having the disease. In the multivariate analysis, high levels of education were associated with better performance during the tests. No significant relationship was observed between age and sex with the probability of diagnosing CHE through the PHES test.

RESUMO CONTEXTO: A encefalopatia hepática mínima (EHM) é uma complicação neuro-psiquiátrica da cirrose cuja detecção é dificultada pela falta de ferramentas práticas. O Stroop EncephalApp é um aplicativo de smartphones capaz de detectar a doença, entretanto sua aplicabilidade na população brasileira ainda não é conhecida. OBJETIVO: Avaliar o uso do Stroop EncephalApp para diagnóstico e avaliação de EHM em uma população de pacientes cirróticos no Brasil. MÉTODOS: Através de um estudo observacional transversal, 99 indivíduos sabidamente cirróticos foram recrutados do ambulatório de hepatologia de um hospital privado em Curitiba/PR. Primeiramente, foram aplicados o mini exame do estado mental (MEEM) para excluir indivíduos com demência; após, foram aplicados o Escore Psicométrico da Encefalopatia Hepática (PHES), atual padrão-ouro para diagnóstico de EHM, e posteriormente o Stroop EncephalApp, ajustando para idade, sexo e anos de formação acadêmica, buscando avaliar a eficiência do aplicativo em detectar a doença e comparar seus resultados com o atual padrão-ouro. Foram excluídos do estudo indivíduos com demência, pontuação insuficiente no MEEM, analfabetos, daltônicos, e com histórico de abuso de álcool/drogas ilícitas nos últimos 3 meses e paciente com episódios prévios ou atuais de encefalopatia hepática. A análise estatística foi realizada pelo SPSS 2.0 e a significância adotada em 5%. RESULTADOS: Um total de 82 indivíduos foram incluídos na análise final. Destes, 29 foram diagnosticados com EHM (35,36% de prevalência) através do PHES e 28 obtiveram o mesmo resultado após a aplicação do Stroop (96,6% de sensibilidade). Cinquenta e três pacientes obtiveram um resultado negativo para EHM através do PHES, sendo que 27 desses obtiveram um resultado positivo para EHM através do Stroop. Na análise multivariada, níveis elevados de escolaridade estiveram associados com melhor desempenho durante a execução dos testes. Não houve associação significativa entre idade e sexo com a probabilidade de apresentar encefalopatia através do PHES. CONCLUSÃO: O Stroop EncephalApp é uma ferramenta viável e com boa sensibilidade para o screening de EHM, mas possui baixa especificidade na população estudada.

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

Shunts portosistémicos espontáneos en pacientes con encefalopatía hepática / Spontaneous portal-systemic shunts in hepatic encephalopathy patients: preliminary experience

Hepatic encephalopathy (HE) is a neuropsychiatric syndrome caused by hepatic dysfunction and portosystemic shunting of the intestinal blood. For HE patients nonresponsive to standard therapy, the presence of large spontaneous portal-systemic shunts can occasionally be the cause of the problem. Objective: To assess the prevalence of portal-systemic shunts in patients with cirrhosis and recurrent or persistent HE. Patients and Methods: Ten patients with liver cirrhosis were analyzed who repeatedly developed HE despite pharmacotherapy. Also, we studied seven control patients with cirrhosis and no HE, who were considered the control group. Results: Large spontaneous portal-systemic shunts were detected in all patients with HE and none in the control group (X2 13.1; P: 0.0003). If only splenorenal shunts are considered, the difference is also significant (X2 5.69; p: 0.017). Conclusion: Our study confirmed that the presence of large spontaneous portal-systemic shunts is frequent in patients with cirrhosis and recurrent or persistent HE.

La encefalopatía hepática (EH) es un síndrome neuropsiquiátrico causado por insuficiencia hepática o presencia de shunts portosistémicos (SPS) intra o extrahepáticos. En pacientes con EH refractaria a tratamiento médico habitual se ha planteado que la presencia de SPS podría ser la causa del problema. Objetivo: Evaluar la prevalencia de SPS espontáneos extrahepáticos en pacientes con cirrosis y EH recurrente o persistente. Pacientes y Métodos: Se evaluaron 10 pacientes con EH recurrentes o persistente. También, se estudiaron 7 pacientes con cirrosis y sin EH que se consideraron como grupo control. Resultados: Todos los pacientes con EH recurrente o persistente presentaron SPS; 7 presentaron shunts esplenorrenales espontáneos y 3 presentaron presencia de la vena umbilical recanalizada. Ningún paciente en el grupo control presentó SPS (X2 13,1; p: 0,0003). Si se considera sólo los shunts esplenorrenales, la diferencia también es significativa (X2 5,69; p: 0,017). Conclusión: En nuestros pacientes con cirrosis y EH recurrente o persistente fue frecuente la presencia de SPS espontáneos.

Supervivencia de pacientes con cirrosis hepática en el Hospital General Regional del IMSS, Durango / Survival in patients with liver cirrhosis at the Durango, IMSS Regional General Hospital

INTRODUCTION: In Mexico, hepatic cirrhosis mortality exhibits important regional differences. AIM: To analyze global survival of cirrhotic patients, according to etiology and functional status. MATERIAL AND METHODS: Between March 1990 to August 1998, newly diagnosed patients with hepatic cirrhosis were included in a follow-up study. Subjects were analyzed monthly. Information on clinical evolution, complications, and dates of events (death) and complications were registered. Survival was estimated using Kaplan-Meier method. RESULTS: Ninety nine subjects were included in the survival analysis, 66 with alcoholic and 33 with viral cirrhosis (HCV and HBV in 24 and nine patients, respectively). Ninety seven percent of patients were decompensated at diagnosis, and 81 had ascites. Probabilities for survival in the entire series were 69.7, 37.6 and 23.6 at 24, 48, and 60 months, respectively. There were no significant differences in the survival of patients grouped according to etiology. When survival was analyzed by Child-Pugh score, it was slightly higher in the alcoholic cirrhosis group. CONCLUSIONS: In this study survival probability of patients with viral cirrhosis was lower than in patients with alcohol cirrhosis.

Etiology of sporadic acute and fulminant non-A, non-B viral hepatitis in north India.

BACKGROUND: Viral hepatitis is a major public health problem in India. AIM: To investigate the association of various hepatitis viruses in patients with acute liver diseases in north India. METHODS: One hundred and thirteen patients with acute viral hepatitis (AVH; n = 70) or fulminant hepatic failure (FHF; N = 43) were evaluated for the presence of hepatitis A, B, C and E virus infection. Hepatitis C virus (HCV) testing was done using second-generation anti-HCV ELISA test and reverse transcriptase polymerase chain reaction (PCR) for the detection of HCV RNA in the serum of patients with non-A, non-B (NANB) hepatitis. Detection of IgM anti-HEV antibody was done in patients found negative for the above viruses (n = 53). RESULTS: Hepatitis A and B viruses accounted for 3.5% and 42.5% of the 113 cases, respectively. HCV infection accounted for 12% of the NANB cases with AVH and 15.5% with FHF. PCR was more useful than serological tests for the detection of HCV infection. HEV infection accounted for 49% of the NANB, non-C cases with AVH and 25% with FHF; pregnant women with HEV infection had a fulminant course. No etiological agent could be established in 28.3% of cases. CONCLUSION: HEV is the most important cause of NANB hepatitis; hepatitis B virus is still a major concern, while HCV is not an important cause of acute viral liver disease in India.

Encefalopatía hepática

Mental deterioration in patients with fulminant hepatitis is a poor prognosis sign. Patients in stages III or IV with stupor or coma have cerebral edema. The increase in cerebral fluid eventually leads to endocraneal hypertension. Brain edema is not the cause of encephalopathy, only when the structures are displaced or intracraneal pressure increases, pupilary abnormalities, abnormal caloric reflexes and myoclonic seizures appears. Significant elevation of intracraneal pressure can be asymptomatic leading to temporal lobe herniation and death. Liver transplantation has changed the prognosis, and subdural and epidural monitoring has been developed in order to evaluate this problem optimally. Monitoring of cerebral perfusion pressure (mean arterial pressure - endocraneal pressure) to assess brain flow is essential. Values of less than 40mmHg imply cerebral ischemia. In patients with cirrhosis encephalopathy has several stages, and sleep disturbances can present very early. Asterixis is a sensible but not specific sign and the classic "faetor hepaticus" is not frequent. Most of the time a precipitating factor can be identified: gastrointestinal bleeding, sedatives, iuremia, infections, constipation, high protein intake and hypokalemia, chronic porto-systemic encephalopathy is mainly related to spontaneous porto-systemic collaterals or surgically created shunts. The most important pathogenetic factors are: ammonia, glutamate, increase cerebral serotonine, increase GABA tone and recently the presence of endogenous benzodiazepines. New therapeutic modalities included the administration of flumazenil, vegetable protein, lactulose and sodium benzoate...

Hepatic encephalopathy in Saudi Arabia: retrospective analysis of 51 patients.

The clinical features, prognostic factors, and outcome of 51 patients with hepatic encephalopathy (HE), were retrospectively reviewed. The mean (+/- SD) age of patients was 47.2 (+/- 14.8) years. Seventy-five percent of patients were males and 73% were Saudi. All identified episodes of hepatic encephalopathy were associated with chronic underlying liver disease and no episode occurred as a result of acute fulminant hepatic failure. Most patients presented in advanced stage of hepatic dysfunction and had one or more precipitating factors. In-hospital mortality rate was 41% (21 out of 51 patients). Gastrointestinal tract bleeding, electrolytes imbalance and alkalosis were associated with significantly higher mortality rate. However, unadjusted analysis failed to identify certain base-line independent prognostic factors.

Trasplante hepatico: experiencia en Medellin / Hepatic transplantation: experience in Medellin

Presentamos los primeros trasplantes hepaticos, variedad ortotopica, hechos en Medellin. La indicacion mas comun entre nosotros fue la cirrosis biliar primaria. Sin embargo, no hemos practicado trasplantes en menores de 1 ano, en los cuales la indicacion mas frecuente es la atresia de las vias biliares. Los factores que motivaron la decision del trasplante fueron en su orden: varices esofagicas con episodios de sangrado recurrente, en 8 casos: encefalopatias, en 5; y prurito intratable, en 3. Hubo dos casos en los cuales se usaron higados con grupo sanguineo diferente, uno de ellos sobrevivio 2 meses y el otro, mas de 4 anos. Las complicaciones biliares posoperatorias se presentaron en el 30% de los pacientes y fueron: necrosis del coledoco, necrosis vesicular y moldes biliares. Las vasculares se presentaron en el 40% e incluyeron: dos trombosis de la arteria hepatica, una ruptura de falso aneurisma con hemobilia y un embolismo aereo cerebral. Esto nos obliga a depurar mas la tecnica quirurgica. En el 70% de los casos empleamos tratamiento inmunosupresor triconjugado con ciclosporina, azatioprina y corticoides. Todos los episodios de rechazo se controlaron bien con bolos de metilprednisolona; no hubo casos de rechazo hiperagudo o acelerado en los pacientes que sobrevivieron un lapso prolongado. El empleo de la derivacion venosa solo se necesito en un 20% de los casos. La sobrevida a 1 y 2 anos es del 29%, aunque tenemos un caso que sobrevivio 4 anos y 3 meses