Minimal hepatic encephalopathy in patients with liver cirrhosis: magnetic resonance spectroscopic brain findings versus neuropsychological changes

Minimal hepatic encephalopathy [MHE] is a subtle complication of cirrhosis that may have a detrimental effect on daily functioning and may progress to overt hepatic encephalopathy [HE]. The aims of this study were to identify MHE and assess neuropsychological changes in those patients. A case-control study was conducted in 35 cirrhotic patients. MHE was identified by brain [hydrogen-1] magnetic resonance spectroscopy [1H-MRS]. Neuropsychological changes were evaluated using cognitive abilities screening instrument [CASI] test, Hamilton depression scale, and soft neurological sign assessment. Of the patients, 16 [45.7%] had significant brain 1H-MRS findings suggesting MHE in the form of decreased myo-Inositol/creatine [mI/Cr] and choline/creatine [Cho/Cr] ratios and increased glutamine-glutamate/creatine [Glx/Cr] ratios in white and grey matters compared to patients without MHE and healthy controls. Patients with MHE had significantly lower abstract thinking subset and total CASI score in comparison to patients without MHE [p = 0.03 and p = 0.05, respectively] and controls [p = 0.003 andp = 0.02, respectively]. No statistically significant differences were observed amongst different groups regarding other CASI subsets, depression, and soft neurological assessment in spite of a tendency towards increased values in patients with MHE. MHE associated with neurophysiological changes demonstrated by 1H-MRS preceded neuropsychological changes. Thus, 1H-MRS may be considered as a potential tool for diagnosis of cirrhosis-associated cerebral dysfunction and a promising method for prioritisation of subjects awaiting liver transplantation

N-terminal pro-brain natriuretic peptide: prognostic potential in end stage liver cirrhosis in a cohort free of heart failure; an Egyptian insight

Background and Aim: Natriuretic peptide [NP] system has emerged as one of the most important hormonal systems in control of cardiovascular homeostasis. Liver cirrhosis may affect NP levels that ere well described in heart failure. NP prognostic evaluation was well established in many diseases. Our aims were to measure serum and ascitic NT-proBNP levels in cirrhotic and cardiac Egyptian patients to diagnose a cut-off value for exclusion of heart failure, to assess if cirrhosis per se may contribute in NT-proBNP elevation and to assess the contribution of these levels as predictors of mortality in liver cirrhosis

Patients and Methods: A prospective cohort study was conducted in 80 patients [50 cirrhotics and 30 had heart failure]. Serum and ascitic [if available] NT-proBNP were measured. Cirrhotic patients were followed for 1-year. Kaplan-Meier survival analysis was used to evaluate 1-year survival rates. Logistic regression analyses were performed with 1-year mortality as the dependent variable

Results: Median serum and ascitic NT-proBNP levels in cirrhotics were 239.4 and 267 pg/ml versus 10596.6 and 9771 pg/ml in heart failure patients [P<0.001]. Serum and ascitic NT-proBNP cut-off values >1000 pg/ml resulted in sensitivity of 100% and 93.3% and specificity of 97.8% and 92.5% for exclusion of cardiac disease in cirrhotics. NT-proBNP was elevated in cirrhotics compared with age matched controls [P<0.001] and significantly correlated with severity of liver cirrhosis based on Child-Pugh and MELD [P=0.05, P<0.001 respectively]. Higher NT-proBNP associated with increased 1-year mortality. NT-proBNP was an independent predictor for mortality in cirrhotics in addition to other conventional factors

Conclusion: NT-pro BNP could be a powerful initial non-invasive diagnostic tool for exclusion of heart disease in cirrhotic patients. End stage cirrhosis per se may contribute to NT-proBNP elevation. NT-proBNP provided incremental information in 1-year mortality prediction in decompensated cirrhotics

Assessment of vitreoretinal interface and clinically significant macular edema by OCT and fluorescein angiography

To assess the changes occurring at the vireoretinal interface with clinically significant macular edema using optical coherent tomography [OCT] and fundus fluorescein angiography [FFA]. Ninety nine eyes of 84 patients suffering from macular edema of different etiologies were included in this study. They were divided according to the cause of macular edema into 6 groups. Treatment modalities were done to be evaluated in the follow up. All cases were followed up at regular visits one week, one month, and six months with routine ocular examinations. FFA and OCT changes were determined and evaluated at one month and 6 months after treatment. In diabetic group [40 eyes], there were 22 eyes with different stages of PVD seen by OCT in comparison to 5 eyes only demonstrated by FFA, ERM seen by OCT of different stages in 14 eyes while in FFA 10 eyes only, In the RVO group [15 eyes], there were 6 eyes with different stages of PVD seen by OCT in comparison to no eyes demonstrated by FFA, In the IGS group [10 eyes], there were 3 eyes with different stages of PVD seen by OCT in comparison to no eyes demonstrated by FFA, In the CNV group [17 eyes], there were 4 eyes with different stages of PVD seen by OCT in comparison to no eyes demonstrated by FFA, ERM seen by OCT of different stages in 3 eyes while in FFA one eye only, In the RP group [10 eyes], there were 2 eyes with different stages of PVD seen by OCT in comparison to no eyes demonstrated by FFA. In the TME group [7 eyes], there were 3 eyes with different stages of PVD seen by OCT in comparison to no eyes demonstrated by FFA, ERM seen by OCT and FFA of different stages in 4 eyes. OCT provided us with valuable information on the retinal morphologic changes associated with ME of different etiologies and analyzing vitreomacular relationship and detecting macular SRD undetectable on biomicroscopy and FFA

Psychiatric profiles in patients with liver cirrhosis

Psychiatric disorders are common comorbidities in patients with liver cirrhosis that may impair patients' quality of life. The purpose of this study was to evaluate the common psychiatric disorders in cirrhotic patients in our locality. Subjects and Psychiatric disorders were prospectively assessed by administration of Symptom Checklist-90 revised [SCL-90-R], Hamilton anxiety rating scale, and Hamilton Checklist of Symptoms of depressive illness to 200 patients with liver cirrhosis and 200 control volunteers of matched age. In addition, clinical data, abdominal ultrasonography and laboratory data [liver function tests for patients] were collected. Results. Compared with controls, cirrhotic patients were significantly more likely to have depression [43.5% versus 14%, P< 0.001], anxiety [16.5% versus 5.5% P< 0.001] and increased mean scores of SCL-90-R subscales ['e.g. somatizalion, depression and hostility,]. Increasing severity of liver cirrhosis [based on the Child-Pugh score] was associated with increased frequency of Psychiatric disorders. Compared with the control group, patients with liver cirrhosis showed significantly higher frequency of comorbid psychiatric disorders which is increased by worsening disease severity