Profile of hepatic encephalopathy in children with cirrhosis and response to lactulose

Hepatic encephalopathy [HE] is associated with a poor prognosis. There is paucity of data on the treatment of HE with lactulose in children with cirrhosis. Patients and Retrospective analysis of consecutive cirrhotic patients [<18 years] with HE was done. HE was defined according to West-Haven criteria. Response was defined as complete if patients recovered completely from HE, partial response was defined as improvement of encephalopathy by one or more grades from admission but not complete recovery, and defined as non response if patient did not show any improvement or deteriorated further even after 10 days of lactulose therapy. A total of 300 patients were admitted with cirrhosis and HE [278 adults and 22 children]. Of 22 patients, 16 [73%] patients had complete response to lactulose and six [27%] patients did not [three [13.5%] patients worsened [non response] and three [13.5%] did not recover fully even after 10 days of treatment [partial response]. Comparing baseline characteristics of patients who had complete response [n=16] versus partial [n=3] and non response [w=3], there was significant difference in mean arterial pressure [78.1 +/- 10.7 vs 62.6 +/- 5.0 mmHg, P=0.003], serum sodium [131.3 +/- 3.2 vs 126.515.2, P=0.01] and serum creatinine [0.78 +/- 0.3 vs 1.1 +/- 0.3 mg/dl, P=0.02]. We did not find any difference in baseline characteristics of these patients regarding CTP score [9.6 +/- 1.2 vs 10.6 +/- 1.2], MELD score [17.612.9 vs 17.1 +/- 3.4] severity of HE [2.5 +/- 0.6 vs 2.6 +/- 0.5] and etiology of precipitating factors [P=0.78]. Lactulose therapy causes complete recovery from hepatic encephalopathy in 73% of pediatrics patients with cirrhosis

Predictors of minimal hepatic encephalopathy in patients with cirrhosis

Minimal hepatic encephalopathy [MHE] impairs patient's daily functioning of life. Predictors of MHE in cirrhotic patients have not been evaluated. A total of 200 cirrhotic patients [Child A, 74[37%]; Child B, 72[36%]; Child C, 54[27%]] were evaluated by psychometry, P300 auditory event-related potential [P300ERP] and critical flicker frequency [CFF]. MHE was diagnosed by abnormal psychometry [>2S.D.] and P300ERP [>2.5 S.D.]. Univariate and multivariate logistic regression analyses were performed to determine the predictors of MHE. Eighty-two [41%] patients were diagnosed to have MHE - 26/74 [35%] in Child a, 26/72 [36%] in Child B and 30/54 [56%] in Child C. Ninety-seven [48.5%] patients had abnormal psychometric tests, and 96 [48%] had prolonged P300ERP [>385 ms]. Sixteen [16.5%] patients with abnormal psychometry had P300ERP > 358 ms. One hundred and three patients had CFF value <39 Hz with specificity of 86.6% and sensitivity of 72.9% for MHE. Model for end-stage liver disease [MELD] [17.9 +/- 5.7 vs. 13.4 +/- 4.2, P=0.005], Child-Turcotte-Pugh [CTP] score [8.4 +/- 2.5 vs. 7.7 +/- 2.2, P=0.02], ammonia [104.8 +/- 37.9 vs. 72.5 +/- 45.2 micro mol/L, P=0.001] and CFF [37.0 +/- 2.8 vs. 41.0 +/- 3.4 Hz, P=0.001] were significantly higher in MHE as compared to non-MHE patients. Ninety-one [45.5%] patients had MELD>15.5, 115 [57.5%] had CTP score> 7.5, while 93 [46.5%] had venous ammonia >84.5 micro mol/L. On univariate analysis, MELD [8.52[95% CI, 4.11-16.26; P=0.001]], CFF [17.34[95% CI, 8.16-36.85; P=0.001]] and venous ammonia [7.80 [95% CI, 4.11-14.81; P= 0.003]] were associated with MHE; while CTP score [1.51[95% CI, 0.85-2.69; P=0.30]] was not significant. On multivariate analysis, MELD, CFF and venous ammonia were predictive of MHE. Prevalence of MHE in this study was 41%; and MELD>15.5, CFF< 39 Hz and venous ammonia >84.5 micro mol/L were predictive of MHE