RESUMO
Objective:To investigate the diagnostic value of independent and combined subtests of the psychometric hepatic encephalopathy score (PHES) in mild hepatic encephalopathy(MHE) of patients with liver cirrhosis, so as to optimize the PHES.Methods:This was a prospective, multicenter and real-world study which was sponsored by the National Clinical Research Center of Infectious Diseases and the Portal Hypertension Consortium. Twenty-six hospitals from 13 provinces, autonomous regions and municipalities countrywide participated in this study, induding Tianjin Third Central Hospital, the Fourth People′s Hospital of Qinghai Province, the Second Affiliated Hospital of Baotou Medical College, the Third People′s Hospital of Taiyuan, the Fifth Medical Center of PLA General Hospital and so on. From October 2021 to February 2022, outpatients and hospitalized patients with liver cirrhosis and no obvious hepatic encephalopathy were consecutively enrolled. All patients received 5 PHES subjects in the same order: number connection test(NCT)-A, NCT-B, digit symbol test(DST), line tracing test(LTT) and serial dotting test(SDT), and the scores were calculated. The total score of PHES <-4 was taken as the cut-off value for diagnosing MHE. Compare the differences in each subtest between MHE group and non-MHE group. Receiver operating characteristic curve(ROC) and area under the curve(AUC) was performed to assess the diagnostic value of independent and combined subtests in MHE. Mann-Whitney U test and DeLong test were used for statistical analysis. Results:A total of 581 patients with liver cirrhosis were enrolled, 457 were diagnosed as MHE, and the incidence of MHE was 78.7%. The results of NCT-A, NCT-B, SDT, LTT, DST of MHE group were 60.00 s(47.01 s, 88.00 s), 90.45 s(69.32 s, 125.35 s), 74.00 s(57.65 s, 96.60 s), 74.72(60.00, 98.61) and 27.00(20.00, 36.00), respectively. Compared those of non-MHE group(34.00 s(29.15 s, 44.48 s), 50.00 s(40.98 s, 60.77 s), 50.00 s(41.07 s, 63.03 s), 46.23(38.55, 59.42) and 42.00(34.00, 50.75)), the differences were statistically significant( Z=12.37, 12.98, 9.83, 11.56, 10.66; all P<0.001). The AUC(95% confidence interval(95% CI)) of subtests of PHES NCT-B, NCT-A, LTT, DST and SDT alone in MHE diagnosis were 0.880(0.849 to 0.910), 0.862(0.828 to 0.896), 0.838(0.799 to 0.877), 0.812(0.772 to 0.851) and 0.788(0.743 to 0.832), respectively. The combination of 2 PHES subtests significantly increased the diagnostic efficacy. Among them the diagnostic efficacy of the combination of NCT-B and LTT was the best, the AUC(95% CI) was 0.924(0.902 to 0.947), the specificity was 91.9% and the sensitivity was 79.2%, which was better than a single PHES subtest (NCT-A, NCT-B, SDT, LTT and DST) and the combination of NCT-A and DST(AUC was 0.879, 95% CI0.847 to 0.910) which was recommended by guidelines on the management of hepatic encephalopathy in cirrhosis, the differences were statistically significant ( Z=3.78, 3.83, 5.57, 5.51, 5.38, 2.93; all P<0.01). Furthermore, compared between the combination of NCT-B and LTT and the combination of 3 subests of PHES, only the diagnostic efficacy of combination of NCT-B, LTT and SDT (AUC was 0.936, 95% CI 0.916 to 0.956) was better than that of the combination of NCT-B and LTT, the difference was statistically significant( Z=2.32, P=0.020). Conclusion:Based on the diagnostic efficacy and clinical feasibility of PHES subtests and their combinations, the combination of NCT-B and LTT is recommended for the diagnosis of MHE.
RESUMO
Hepatic encephalopathy (HE) is a common serious complication of liver cirrhosis, with sudden onset, indicating a poor prognosis in patients with chronic liver disease. Minimal hepatic encephalopathy (MHE) is an early stage of HE with no apparent symptoms, but it shows abnormal results in neuropsychological and/or neurophysiological tests. MHE affects patients' quality of life, employability, driving ability, and has a high risk of developing overt hepatic encephalopathy (OHE). This article aims to explore various diagnostic methods, strengthen the routine work of clinicians in diagnosis and treatment, and develop an effective MHE screening protocol.
Assuntos
Humanos , Encefalopatia Hepática/diagnóstico , Cirrose Hepática/diagnóstico , Hepatopatias , Programas de Rastreamento , Testes Neuropsicológicos , Psicometria , Qualidade de VidaRESUMO
Objective:To explore the correlation of cognitive impairment with abnormal brain regions having low-frequency fluctuation (ALFF) by resting-state blood oxygen level-dependent functional magnetic resonance imaging (BOLD-fMRI) in patients with mild hepatic encephalopathy (MHE).Methods:Fifty-nine patients (28 patients with chronic cirrhosis and 31 patients with MHE, according to results of digital symbol test [DST] scores/digital connection test A [NCT-A] scores) admitted to our hospital from March 2018 to January 2020 were enrolled; 33 healthy control subjects matched in gender, age and years of education were chosen as controls. Resting-state BOLD-fMRI was performed in all subjects, and the original images were processed to obtain ALFF brain map. Statistical methods were used to obtain the brain regions with different ALFF values in the three groups, and the brain regions enjoying correlations between ALFF values and venous blood ammonia content/DST scores/NCFA scores in patients from the MHE group.Results:As compared with the control group, patients in the MHE group exhibited significantly lower ALFF values in the right central posterior gyrus, bilateral cuneiform lobe, left lateral occipital gyrus, left occipital gyrus, and left pars opercularis, and significantly increased ALFF values in the right thalamus, left parahippocampal gyrus and surrounding ventricle (bilateral caudate nucleus head)( P<0.05). Bivariate correlation analysis suggested that ALFF values were negatively correlated with blood ammonia in the left pars opercularis, left margin superior gyrus, bilateral precuneus, left superior temporal gyrus, right middle frontal gyrus and surrounding area, and right insula ( P<0.05); ALFF values were positively correlated with DST scores in left medial cingulate gyrus and right cerebellar hemisphere; ALFF values in the left frontal lobe and left posterior cerebellar lobe were positively correlated with NCT-A scores, and ALFF values in the left parahippocampal gyrus were negatively correlated with NCT-A scores ( P<0.05). Conclusion:The ALFF differences in multiple brain regions of patients with MHE may be related to cognitive impairment.
RESUMO
La encefalopatía hepática mínima (EHm) afecta del 30% al 50% de los pacientes cirróticos. Su detección es esencial por su relación con la encefalopatía hepática clínica, la alteración de la habilidad para conducir, el mayor riesgo de caídas, la alteración de la calidad de vida, la progresión más acelerada de la cirrosis y la supervivencia. A pesar de la información fidedigna de su relevancia clínica, pronóstica y social, la detección de EHm no está generalizada en la práctica clínica. El espectro de la encefalopatía hepática engloba diversas alteraciones de las funciones cerebrales, por lo que se requiere realizar más de un test para su diagnóstico. Además, las alteraciones iniciales difieren de un paciente a otro. Esto ha dificultado el desarrollo de una estrategia diagnóstica universal. Como resultado, no disponemos de datos suficientes para generar recomendaciones basadas en la evidencia del impacto del tratamiento de la EHm en la calidad de vida y la supervivencia, así como de su rentabilidad. Por lo tanto, las guías clínicas actuales sugieren que se evalúe la EHm cuando se afecta la calidad de vida de los pacientes, ya que no se conocen las consecuencias del tamizaje. Las terapias reductoras de amonio se consideran la piedra angular del tratamiento de la EHm. Los disacáridos no absorbibles, la rifaximina y, más recientemente, los probióticos, han mostrado efectos beneficiosos. Se necesitan más ensayos controlados con placebo para evaluar la eficacia, seguridad y rentabilidad de los regímenes de tratamiento disponibles para evaluar el impacto del tratamiento de la EHm en el pronóstico a largo plazo de estos pacientes.
Minimal hepatic encephalopathy (MHE) affects up to 30-50% of cirrhotic patients. The detection of MHE is essential because of its relationship with overt hepatic encephalopathy, impairment of motor vehicle driving abilities, higher risk of falls, quality of life impairment, faster cirrhosis progression and survival. Despite the robust evidence regarding its clinical, prognostic and social relevance, MHE testing is not widespread in routine clinical care. Hepatic encephalopathy spectrum covers various alterations in complex brain functions, requiring more than one test to be quantified. In addition, initial disturbances differ from one patient to another. All this has made it difficult to develop a universal diagnostic strategy. As a consequence, there is a lack of available robust data in the literature to generate evidence-based recommendations related to the impact of MHE treatment on quality of life and survival of these patients, as well as on cost-effectiveness. Therefore, current clinical guidelines suggest MHE testing only when patients have problems with their quality of life, since consequences of the screening procedure are still unclear. Ammonia lowering therapies have been considered the cornerstone of MHE treatment. Beneficial effects of non-absorbable disaccharides (lactulose or lactitol), rifaximin and more recently, probiotics have been reported. Further placebo-controlled trials are needed to assess the efficacy, safety, and cost-effectiveness of available treatment regimes to evaluate the impact of MHE treatment on the long-term prognosis of these patients.
Assuntos
Humanos , Encefalopatia Hepática , Probióticos , Lactulose , Cirrose Hepática , RifaximinaRESUMO
Objective To assess the value of Stroop smartphone application (EncephalApp-Stroop) in screening minimal hepatic encephalopathy (MHE).Methods Ninety hepatitis B cirrhotic patients without overt hepatic encephalopathy (OHE),admitted to our hospital from January 2015 to February 2016,and other 90 healthy volunteers were chosen in our study.Psychometric hepatic encephalopathy scale (PHES) and EncephalApp-Stroop were performed.Normal reference value formulas were established based on the 5 psychometric tests at PHES in healthy controls.EncephalApp-Stroop contained "off'state (neutral stimuli) and "on" state (incongruent stimuli).The time of completing five correct runs and the number of rtms in "on" and "off'states were calculated.PHES was used to diagnose MHE as gold standard to compare the results of OHE patients and healthy subjects and the results of patients with/without MHE.EncephalApp-Stroop results were compared with PHES results by receiver operator characteristic analysis.Results OHE patients had significantly longer time than healthy subjects in Stroop "on" and "off'states (P<0.05).Traditionally,the total scores of PHES below-4 were diagnosed as MHE,and all the 90 patients taking PHES as gold standard,52 patients were diagnosed as MHE.The time at Stroop "on" and "off'states and the number of trials completing 5 correct runs were longer/larger in patients with MHE as compared with those in patients without MHE,with significant differences (P<0.05).The validation cohort of EncephalApp-Stroop showed 87% sensitivity and 79% specificity.Conclusion The EncephalApp-Stroop is a valid,short and reliable tool for screening MHE.
RESUMO
Covert hepatic encephalopathy (CHE) is defined as presence of neuropsychological and/or neurophysiological abnormalities in cirrhotic patients without disorientation or asterixis. The West-Haven criteria are most often used to grade hepatic encephalopathy (HE), with scores ranging from 0 to 4. In 2011, the minimal (grade 0) and grade 1 hepatic encephalopathy were collectively referred to as CHE by SONIC classification. It is difficult for clinicians to diagnose CHE because its clinical manifestation is not obvious. So far, there is no consensus on CHE treatment. Here we have reviewed the articles regarding the diagnoses and treatment of CHE, hoping to provide guidance for the clinicians in clinical practice.
RESUMO
Objective To study the regional homogeneity (ReHo) of default-mode network (DMN) in patients with minimal hepatic encephalopathy (MHE) with resting state fMRI.Methods Eighteen MHE patients and eighteen healthy controls (HC) underwent standard resting state fMRI scan.The resting state fMRI data were analyzed with the ReHo method to observe the changes of DMN in the patients in contrast to the controls.Results Compared to healthy controls,MHE patients showed lower ReHo in bilateral MPFC/anterior cingulate cortex(V=13.257 cm3;MNI coordinates=3,24,66;t=-3.493 7),bilateral precuneus/posterior cingulate cortex(V=4.752 cm3;MNI coordinates=9,-54,45;t=-2.634 1),while higher ReHe in right medial prefrontal cortex(V=5.049 cm3;MNI coordinates=21,63,6;t=4.017 5).Conclusion In MHE patients,there is abnormal neuron activation in the widespread DMN regions under resting state, which indicated abnormal spontaneous activity consistency within DMN and endogenous brain function injury in MHE patients.ReHo can be used to observe DMN changes in MHE patients.
RESUMO
Objective To investigate the metabolites of serum samples from liver cirrhotic patients with or without minimal hepatic encephalopathy,and even overt hepatic encephalopathy,then to find out diagnostic markers for minimal hepatic encephalopathy.Methods High performance liquid chromatography-orbit trap mass spectrometry (UPLC/LTQ-Orbit trap MS) technology was applied to analyze the serum metabolites from 38 patients of liver cirrhosiswith hepatitis B and 33 healthy volunteers.Results The serum metabolites of patients with simple liver cirrhosis were different from those of patients with minimal or overt hepatic encephalopathy.The serum metabolites of patients with minimal hepatic encephalopathy was mostly similar with those of overt hepatic encephalopathy patients.Arginase,L-tyrosine,glutamic acid,two L-phenylalanine peptide,homovanillic acid,omithine,L-serine were increased in patients with minimal or overt hepatic encephalopathy,and hypoxanthine decreased in patients with minimal or overt hepatic encephalopathy patients.Conclusions The serum metabolites of patients with minimal hepatic encephalopathy are mostly similar to those of patients with overt hepatic encephalopathy.Arginase,L-tyrosine,glutamic acid,two L-phenylalanine peptide,homovanillic acid,ornithine,L-serine maybe the early metabolites biomarkers to diagnose minimal hepatic encephalopathy.Hypoxanthine is likely to be an effective complement to treat patients with hepatic encephalopathy.
RESUMO
The aim of this study was to validate a new paper and pencil test battery to diagnose minimal hepatic encephalopathy (MHE) in Korea. A new paper and pencil test battery was composed of number connection test-A (NCT-A), number connection test-B (NCT-B), digit span test (DST), and symbol digit modality test (SDMT). The norm of the new test was based on 315 healthy individuals between the ages of 20 and 70 years old. Another 63 healthy subjects (n = 31) and cirrhosis patients (n = 32) were included as a validation cohort. All participants completed the new paper and pencil test, a critical flicker frequency (CFF) test and computerized cognitive function test (visual continuous performance test [CPT]). The scores on the NCT-A and NCT-B increased but those of DST and SDMT decreased according to age. Twelve of the cirrhotic patients (37.5%) were diagnosed with MHE based on the new paper and pencil test battery. The total score of the paper and pencil test battery showed good positive correlation with the CFF (r = 0.551, P < 0.001) and computerized cognitive function test. Also, this score was lower in patients with MHE compared to those without MHE (P < 0.001). Scores on the CFF (32.0 vs. 28.7 Hz, P = 0.028) and the computer base cognitive test decreased significantly in patients with MHE compared to those without MHE. Test-retest reliability was comparable. In conclusion, the new paper and pencil test battery including NCT-A, NCT-B, DST, and SDMT showed good correlation with neuropsychological tests. This new paper and pencil test battery could help to discriminate patients with impaired cognitive function in cirrhosis (registered at Clinical Research Information Service [CRIS], https://cris.nih.go.kr/cris, KCT0000955).
Assuntos
Humanos , Cognição , Estudos de Coortes , Diagnóstico , Fibrose , Voluntários Saudáveis , Encefalopatia Hepática , Serviços de Informação , Coreia (Geográfico) , Cirrose Hepática , Testes Neuropsicológicos , Reprodutibilidade dos TestesRESUMO
Objetivos: la encefalopatía hepática mínima constituye el estadio subclínico previo al desarrollo de encefalopatía hepática clínica en el paciente cirrótico, además de asociarse con un deterioro de la calidad de vida de estos pacientes y con un riesgo incrementado de accidentes laborales e incapacidad de conducción de vehículos. El Psychometric Hepatic Encephalopathy Score es considerado actualmente el método diagnóstico de elección en el diagnóstico de la EHM. El objetivo de este trabajo fue diseñar las tablas de normalidad del PHES para la población cubana. Población y métodos: se estudió una muestra conformada por 520 personas sanas de las provincias de Villa Clara, Sancti Spíritus y Cienfuegos. Las mismas realizaron las 5 pruebas incluidas en el PHES. Se analizaron las variables edad, sexo, años de escolarización, procedencia y consumo diario de alcohol. Mediante la prueba de la t de Student, ANOVA y el coeficiente de correlación de Pearson, se realizó el análisis univariante. Se efectuó un análisis de regresión lineal múltiple para cada prueba, y se construyeron las tablas de normalidad. Resultados: en el análisis multivariante (regresión lineal múltiple) la edad y los años de escolarización fueron las 2 variables independientes relacionadas con el rendimiento en cada una de las cinco pruebas. Conclusión: la disponibilidad de las tablas de normalidad del PHES permitirá contar con un método diagnóstico de referencia aplicable a los pacientes cubanos con cirrosis hepática, sin la necesidad de configurar grupos controlados por la edad y el nivel de escolaridad regionalmente
Objectives: Minimal hepatic encephalopathy (MHE) is the subclinical stage prior to the development of clinical hepatic encephalopathy in cirrhotic patients. For these patients, it is associated with impaired quality of life, increased risk of accidents, and incapacity for driving vehicles. The Psychometric Hepatic Encephalopathy Score (PHES) is currently considered to be the diagnostic method of choice for diagnosis of MHE. The aim of this work was to design PHES normality tables for the Cuban population. Population and Methods: The study sample consisted of 520 healthy people from the provinces of Villa Clara, Sancti Spiritus and Cienfuegos who all took the 5 tests included in the PHES. Variables of age, sex, years of schooling, place of origin, and daily alcohol consumption were analyzed. Univariate analysis with the Students t test, ANOVA and Pearson correlation coefficient was performed. Multivariable linear regression for each test was performed and normality tables were constructed. Results: Multivariate analysis used multiple linear regression with age and years of schooling as the independent variables related to performance for each of the 5 tests. Conclusions: The availability of normality tables provides a diagnostic reference method for PHES which is applicable to Cuban patients with liver cirrhosis without requiring control groups for age and regional education level
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Fibrose , Encefalopatia Hepática , Testes NeuropsicológicosRESUMO
La encefalopatía hepática mínima (EHM) es un síndrome neurocognitivo, potencialmente reversible, constituido por una serie de alteraciones neuropsicológicas en pacientes con hepatopatía aguda o crónica, sin evidencia de anormalidades neurológicas durante la exploración física. La EHM es responsable del déficit cognitivo y tiene un impacto negativo sobre la calidad de vida de los pacientes, esencialmente con diagnóstico de cirrosis. La imposibilidad para detectar de manera clínica las alteraciones neuropsicológicas, alienta al clínico para la utilización de pruebas psicométricas, las cuales constituyen la base del cribado y el diagnóstico. La EHM modifica el pronóstico de la enfermedad. La detección oportuna permite intervenir el riesgo de desarrollar encefalopatía hepática clínica (EH) en los pacientes con cirrosis, lo cual se ha relacionado con una menor supervivencia.
Minimal hepatic encephalopathy (MHE) is a potentially reversible neurocognitive syndrome that consists of a series of neuropsychological disorders in patients with acute and chronic liver disease. A physical examination may or may not show evidence of neurological abnormalities. MHE is responsible for cognitive impairment, has a negative impact on quality of life of patients, essentially cirrhosis. The impossibility of detecting this neuropsychological disorder clinically has led to the use of psychometric tests for screening and diagnosis. MHE modifies the prognosis of disease, and early detection allows intervention against the risk of developing clinical hepatic encephalopathy (HE) in patients with cirrhosis which has been associated with decreased survival.
Assuntos
Humanos , Masculino , Feminino , Encefalopatias , Encefalopatia Hepática , Cirrose HepáticaRESUMO
Objetivo: la encefalopatía hepática mínima constituye el estadio subclínico previo al desarrollo de encefalopatía hepática clínica en el paciente cirrótico, además de asociarse a un deterioro de la calidad de vida de estos pacientes y a un riesgo incrementado de accidentes laborales e incapacidad de conducción de vehículos. El Psychometric Hepatic Encephalopathy Score es considerado actualmente el método diagnóstico de elección en el diagnóstico de la EHM. El objetivo de este trabajo fue diseñar las tablas de normalidad del PHES para la población cubana. Métodos: se estudió una muestra conformada por 520 personas sanas de las provincias de Villa Clara, Sancti Spíritus y Cienfuegos. Las mismas realizaron los cinco tests incluidos en el PHES. Se analizaron las variables edad, sexo, años de escolarización, procedencia, y consumo diario de alcohol. Mediante la prueba de la t de Student, ANOVA y el coeficiente de correlación de Pearson se realizó el análisis univariante. Se efectuó un análisis de regresión lineal múltiple para cada test y se construyeron las tablas de normalidad. Resultados: en el análisis multivariante (regresión lineal múltiple) la edad y los años de escolarización fueron las dos variables independientes relacionadas con el rendimiento en cada uno de los cinco test. Conclusiones: la disponibilidad de las tablas de normalidad del PHES permitirá contar con un método diagnóstico de referencia aplicable a los pacientes con cirrosis hepática cubanos, sin la necesidad de configurar grupos controlados por edad y nivel de escolaridad regionalmente.
Objective: minimal hepatic encephalopathy (MHE) is the subclinical stage pre-clinical development of hepatic encephalopathy in cirrhotic patients, in addition to associated with impaired quality of life of these patients and an increased risk of accidents and disability of driving. The Psychometric Hepatic Encephalopathy Score (PHES) is currently considered the diagnostic method of choice in the diagnosis of MHE. The objective of this work was to design tables PHES normality for the Cuban population. Method: a sample composed of 520 healthy people in the provinces of Villa Clara, Sancti Spiritus and Cienfuegos were studied. They made the five tests included in the PHES. The variables age, sex, years of education, origin, and daily alcohol consumption were analyzed. By t test of Student, ANOVA and Pearson correlation coefficient univariate analysis. an analysis of multiple linear regression for each test was performed and normal tables were constructed. Results: in the multivariate analysis (multiple linear regression) age and years of schooling were the two independent variables related to performance in each of the five tests. Conclusions: the availability of tables PHES normality will provide a diagnostic method applicable reference to patients with liver cirrhosis Cubans, without the need to configure controlled for age and education level regional groups.
Assuntos
Humanos , Encefalopatia Hepática , Consumo de Bebidas Alcoólicas , Cuba , Cirrose HepáticaRESUMO
Hepatic encephalopathy is a spectrum of neurocognitive manifestations often seen in patients with liver injury or rarely in patients with portosystemic shunting without liver injury. It can be divided into minimal (covert) hepatic encephalopathy and overt hepatic encephalopathy, depending on the severity. Patients with hepatic encephalopathy have compromised clinical outcomes, decreased quality of life, and increased healthcare utilization, often resulting in a heavy financial and personal burden on caregivers. The diagnosis remains largely clinical, with the exclusion of possible other causes for the altered mental status. Current treatment strategies include nonabsorbable disaccharides and antibiotics. This review will focus on the diagnosis, management and clinical impact of hepatic encephalopathy.
Assuntos
Humanos , Antibacterianos , Cuidadores , Atenção à Saúde , Diagnóstico , Dissacarídeos , Encefalopatia Hepática , Fígado , Cirrose Hepática , Hepatopatias , Derivação Portossistêmica Cirúrgica , Qualidade de VidaRESUMO
INTRODUCCIÓN: en la hipertensión portal prehepática secundaria a obstrucción trombótica, pueden aparecer trastornos neurocognoscitivos, similares a la encefalopatía sistémica vista en afecciones hepáticas crónicas, la que puede estar bien definida clínicamente o en una forma subaguda, actualmente llamada encefalopatía hepática mínima. Esta consiste en la detección de déficits neuropsicológicos en pacientes sin alteraciones en la exploración neurológica rutinaria. En los niños, es difícil su estudio debido a la falta de pruebas neuropsicológicas estandarizadas para todas las edades. OBJETIVO: identificar la presencia de alteraciones neuropsicológicas en los pacientes pediátricos con hipertensión portal prehepática. MÉTODOS: se estudiaron 12 pacientes con hipertensión portal prehepática secundaria a cateterismo umbilical, mediante diferentes técnicas psicológicas. Las variables fueron: edad, tiempo de evolución de la enfermedad, forma clínica de inicio, alteraciones neuropsicológicas y procedimiento quirúrgico empleado. RESULTADOS: predominaron los pacientes entre 10 y 14 años de edad, y con un tiempo de evolución de la enfermedad entre 6 y 10 años. El sangrado digestivo alto fue la forma clínica de inicio más frecuente. En 11 casos se detectaron déficits en la atención involuntaria, concentración de la atención, memoria inmediata y dinámica de la actividad de la memoria. En 8 pacientes se afectó el pensamiento en su aspecto operacional, y en 6 la dinámica de la actividad del pensamiento. La mayoría de los niños con alteraciones neuropsicológicas no estaban intervenidos quirúrgicamente. CONCLUSIONES: existen trastornos predictivos de encefalopatía hepática mínima en pacientes con hipertensión portal prehepática. No utilizar el tratamiento quirúrgico puede estar relacionado con la aparición de las alteraciones neuropsicológicas. Teóricamente la solución sería derivaciones portoportales realizadas precozmente, o procedimientos que eliminen la obstrucción portal. Se requiere profundizar y generalizar esta investigación al resto de los pacientes con el diagnóstico de esta enfermedad
INTRODUCTION: in the prehepatic portal hypertension secondary to thrombotic obstruction, there may appear neurocognitive disorders similar to systemic encephalopathy seen in chronic hepatic illnesses. This portal hypertension may be clinically well-defined or occurs in a subacute form currently known as minimal hepatic encephalopathy. This consists of neurophyshcological deficits in patients without alterations in the routine neurological exploration. It is difficult to study it in children due to lack of standardized neuropsychological tests for all ages. OBJECTIVES: to identify the presence of neupsychological alterations in pediatric patients with prehepatic portal hypertension. METHODS: twelve patients with prehepatic portal hypertension secondary to umbilical catheterism were studied through different psychological techniques. The study variables were age, time of progression of disease, initial clinical form, neuropsychological alterations and surgical procedure used. RESULTS: predominance of patients aged 10 to 14 years and time of progression ranging 6 to 10 years. The upper digestive bleeding was the most common initial clinical form. Eleven patients showed deficit in involuntary attention, focused attention, immediate memory and dynamics of the memorizing activity. Eight patients suffered problems in the operational aspect of their thinking and 6 had the dynamics of their thinking affected. Most of children with neuropsychological alterations were not operated on. CONCLUSIONS: there are predictive disorders of minimal hepatic encephalopathy in patients suffering prehepatic portal hypertension. The failure to use the surgical treatment may be related to occurrence of neuropsychological alterations. Theoretically speaking, the solution would lie in performing early portoportal shunts or procedures eliminating the portal obstruction. It is necessary to delve into this research and generalize the results to the rest of patients diagnosed with this disease.
Assuntos
Humanos , Encefalopatia Hepática/diagnóstico , Testes Neuropsicológicos , Relatos de Casos , Estudos ProspectivosRESUMO
Objective The psychometric hepatic encephalopathy scale (PHES),including five psychometric tests,is a standard for the diagnosis of minimal hepatic encephalopathy (MHE) and enjoys predictive value of overt hepatic encephalopathy (OHE).We investigate whether a simplified PHES is as useful as the whole PHES.Methods Seventy consecutive hepatitis B cirrhotic patients without OHE,admitted to our hospital from October 2012 to June 2013,and other 72 healthy volunteers were chosen in our study.PHES was performed in both groups.Expected normal reference value formula were established based on the 5 psychometric tests in healthy controls,and backward logistic regression was performed by eliminating stepwise variables of PHES to get a simplified PHES (SPHES).Then,SPHES was performed on the 70 patients and followed up for a year to detect the prevalence rate of MHE and OHE.Results PHES was easily influenced by age and educational level.In patients with liver cirrhosis,44.29% patients (31/70) had MHE based on PHES and 41.43% (9/70) had MHE based on SPHES,without significant differences (P>0.05).According to the follow-up study,21 patients developed OHE; the number of developing OHE showed no significant difference between MHE patients dignosed by PHES and SPHES (P>0.05).Conclusion SPHES is as good as PHES in diagnosing MHE and predicting the occurrence of OHE,which consumes less time and is more suitable for clinical screening.
RESUMO
RESUMO INTRODUÇÃO: A encefalopatia hepática mínima (EHM) tem sido associada a alterações na capacidade de condução de veículos, ao aparecimento da forma explícita de encefalopatia hepática e a um pior prognóstico. Contudo, o seu real impacto na qualidade de vida (QV) permanece controverso. Com o desenvolvimento das normas de aplicação e cotação da Pontuação Psicométrica da Encefalopatia Hepática (PPEH) para diagnóstico da EHM para a população portuguesa, este estudo tem como objetivo determinar o efeito desta perturbação neurocognitiva na QV dos pacientes. MÉTODOS: A amostra é composta por dois grupos: Grupo Controle (GC; n = 8) e Grupo Cirrose Hepática (GCH; n = 8). Dos oito pacientes pertencentes ao GCH, quatro revelaram presença de EHM, diagnosticada de acordo com os critérios da PPEH. A QV foi avaliada através do Medical Outcomes Study, Short Form-36 (SF-36). RESULTADOS: Em comparação com o GC, o GCH apresentou pontuações significativamente mais baixas em todos os domínios do SF-36, com exceção da sub-dimensão dor física. Quando se compara os pacientes com e sem EH não se observam diferenças significativas em nenhum dos domínios do SF-36. CONCLUSÕES: Os pacientes com cirrose hepática apresentam uma pior QV em relação aos indivíduos saudáveis; a EHM não afeta a QV. Estudos com maior número de pacientes são necessários para confirmação destes achados
INTRODUCTION: Minimal hepatic encephalopathy (MHE) has been associated with changes in the ability to drive, with the onset of the explicit form of hepatic encephalopathy and with a worse prognosis. However, the impact of MHE on quality of life (QoL) remains controversial. With the standardization of the Psychometric Hepatic Encephalopathy Score (PHES) for the diagnosis of MHE in the Portuguese population, this study aimed to determine the effect of this neurocognitive disorder on the patients' QoL. METHODS: The sample consisted of two groups: the control group (CG, n = 8) and the liver cirrhosis group (LCG, n = 8). Of the eight patients in the LCG, four presented with MHE, diagnosed according to PHES criteria. QoL was assessed using the Medical Outcomes Study, Short Form 36 (SF-36). RESULTS: Compared with the CG, the LCG had significantly lower scores in all domains of the SF-36, except for the physical pain subdomain. When patients with and without HE were compared, no significant differences were found in any of the SF-36 domains. CONCLUSIONS: Patients with liver cirrhosis have a worse QoL when compared with healthy controls; EHM does not affect QoL. Further studies with a higher number of patients are required to confirm these findings
Assuntos
Humanos , Masculino , Adulto , Qualidade de Vida/psicologia , Encefalopatia Hepática/psicologia , Cirrose Hepática/complicações , Desempenho Psicomotor , Atividades Cotidianas/psicologia , Encefalopatia Hepática/etiologia , Testes NeuropsicológicosRESUMO
Objective To evaluate the prognosis and safety of long-term oral Branched-Chain Amino Acids (BCAAs) for patients with cirrhosis.Methods Randomized controlled trials (RCTs) were identified from CBM (between January 1978 and September 2013),CNKI (between January 1979 and September 2013),PubMed (between January 1970 and September 2013),EMBASE (between January 1970 and September 2013),and Cochrane Library (issue 4,2013).Publications of the RCTs on the treatment of cirrhosis with oral BCAAS were included and analyzed according to the criteria of Cocbrane handbook.Results Six RCTs involving 1 047 patients were included.The results showed that oral BCAAs improved the event-free survival when compared with the control group [RR =1.13,95% CI =(1.05,1.23),P =0.001].BCAAs supplements had no effect on mortality or had no definite effect on the deteriorative rate of minimal hepatic encephalopathy (MHE) or quality of life (QOL).As reported in some trials,the main side effects of BCAAs were gastrointestinal symptoms.Conclusions Long-term oral BCAAs may improve event-free survival in cirrhotic patients.However,no definite conclusion can be made without evidences from larger,randomized,double-blind,placebo-controlled,and multicenter trials.
RESUMO
Background and Aim Helicobacter pylori (H. pylori) bacteria convert urea to ammonia, which has been implicated in causation of hepatic encephalopathy in patients with liver cirrhosis. The role of H. pylori infection in causation of minimal hepatic encephalopathy (MHE) has not been well studied. We looked at the relationship of H. pylori infection with MHE and hyperammonemia in patients with liver cirrhosis and the effects of anti-H. pylori treatment in patients with MHE and H. pylori infection. Methods Patients with liver cirrhosis underwent psychometric tests for detection ofMHE, rapid urease test to look for evidence of H. pylori infection and measurement of fasting blood ammonia levels. Patients with MHE were treated with triple-drug anti-H. pylori treatment for one week. Rapid urease test, blood ammonia levels, and psychometric tests were repeated four weeks after treatment. Results H. pylori infection was found more often in patients with MHE (63%) than in those without MHE (37%). Blood ammonia levels were significantly higher in patients with MHE than those without. After H. pylori treatment in patients with MHE, blood ammonia levels showed a significant decline and psychometric test results returned towards normal. Conclusion In patients with liver cirrhosis, there is a significant association between H. pylori infection and MHE. Anti-H. pylori therapy results in reduction in blood ammonia levels and improvement in MHE.
RESUMO
@#ObjectiveTo assess the effects of rehmannia and storesin on minimal hepatic encephalopathy(MHE) in rat model.MethodsMHE rat model was induced by carbon tetrachloride (CCl4) intragastric administration. The effects of rehmannia and storesin on spontaneous movement and learning and memory function of model animals were evaluated with open field test and Morris water maze in 3 dose groups. Lactulose was used in the positive group.ResultsThe spontaneous movement and the spatial learning and memory ability of the model rats both improved significantly in the high dose group. Meanwhile, the serum level of alanine transarninase(ALT) and ammonia(Amm) also decreased in the high dose group.ConclusionRehmannia and storesin has therapeutical effect on MHE rat model.
RESUMO
Minimal hepatic encephalopathy (MHE) is the mildest form of spectrum of hepatic encephalopathy (HE). Patients with MHE have no recognizable clinical symptoms of HE but have mild cognitive and psychomotor defi cits. The prevalence of MHE is high in patients with cirrhosis of liver and varies between 30% and 84%; it is higher in patients with poor liver function. The diagnostic criteria for MHE have not been standardized but rest on careful patient history and physical examination, normal mental status examination, demonstration of abnormalities in cognition and/or neurophysiological function, and exclusion of concomitant neurological disorders. MHE is associated with impaired health-related quality of life, predicts the development of overt HE and is associated with poor survival. Hence, screening all patients with cirrhosis for MHE using psychometric tests, and treatment of those patients diagnosed to have MHE has been recommended. Ammonia plays a key role in the pathogenesis of MHE, which is thought to be similar to that of overt HE. Thus, ammonia-lowering agents such as lactulose and probiotics have been tried. These agents have been shown to improve cognitive and psychometric defi cits, and have good safety profile. Future studies will better defi ne the role of other drugs, such as rifaximin, acetyl L-carnitine and L-ornithine L-aspartate.