Hepatic encephalopathy in chronic liver disease; predisposing factors in a developing country

Abstract

Objective: To find out the risk factors for developing Hepatic Encephalopathy in patients suffering from Chronic liver disease.Background: Hepatic encephalopathy (HE) is a neuropsychiatric disorder that is caused by liver damage. In its pathology, alterations in normal brain function are associated with an increase in blood ammonia, benzodiazepine like substances, products of neurotoxic fatty acids, and other gut derived toxins, which gain access to the brain as a result of liver dysfunction. Study Design: Hospital based descriptive, cross sectional study. Setting: Medical Unit 1, Ward- 5, Jinnah Post Graduate Medical Centre, Karachi.Duration: July 2013 to December 2013Patients and Methods: About 150 patients admitted in medical unit 1 with a diagnosis of chronic liver disease in a state of hepatic encephalopathy were included in this study. Patients suffering from viral or bacterial encephalitis, stroke, brain tumor, Wernicke’s encephalopathy were excluded from the study.Results and Observations: There were 96 (64%) female and 54 (36%) were male patients. Mean age of the patients was 52.45 (±12.271) years. 80 (53.33%) patients were having constipation. Infection was found in 55 (36.66%) cases. Upper GI Bleed was present in 51 (34%) patients. 44 (29.33%) patients had moderate to severe electrolyte imbalance as the cause. Constipation alone was the cause in 11.33% of cases. More than one factor was found to be responsible in around 56% of patients while in 6.6% of cases none of these precipitating factors was isolated.Conclusion: Constipation is the commonest cause of hepatic encephalopathy followed by infection, upper GI bleed and electrolyte imbalance.DOI: http://dx.doi.org/10.3126/ajms.v6i2.11099Asian Journal of Medical Sciences Vol.6(2) 2015 36-43

Clinical Profile, Precipitating Factors and Outcome of Hepatic Encephalopathy in Patients with Liver Cirrhosis

“…Similar were the findings in many studies by Raphael et al 8 , Sethuraman et al 9 , Mumtaz et al 12 , Singh et al 13 and Nayak et al 14 where majority of cirrhotic patients with encephalopathy were observed in Child class C.…”

“…The proportion of grade I, II, III, IV HE were 22.1 %, 36.5%, 25% and 16.4% respectively. The majority of cases were in grade III and II in the study by Sethuraman et al 9 Similar were the findings in the studies by Kumar et al 10 Mumtaz et al 12 ,Singh et al 13 and Poudyal et al 15 Contrary to above studies, majority (36%) of the patients were in grade IV HE followed by 30% in grade III ,10% in grade II and 24% had grade I HE in the study by Nayak et al 14 In the current study, majority of 65% patients were of Child class C. This was followed by 30 % patients in Child class B and 5% patients in Child class A.…”

“…In the study by Mumtaz et al 12 , 53% had one identifiable precipitant, while 30% had two and only 5% had more than two precipitating factors while no precipitant was noted in 12% patients. Similarly, more than one factor was found to be responsible in around 56% of patients while in 6.6% of cases none of these precipitating factors was identified according to Arisar et al 17 The average hospital stay was 10 days in the current study. It was 11 days and almost similar to the study by Iqbal et al 11 Mean hospital stay were only 4 and 5 days according to Mumtaz et al 12 and Raphel et al 8 respectively.…”

“…[11][12][13] Chronic alcohol consumption leading to alcoholic liver disease in 92.9% followed by chronic viral hepatitis B in 2.9% and hepatitis C seen in 1.4 % patients were the most common aetiology of cirrhosis in the current study. Chronic alcohol ingestion in 88.35% followed by chronic Hepatitis B in 4.85% and chronic hepatitis C infection in 0.97% patients were the causes of cirrhosis in the study by Sathuraman et al 9 Similar were the findings in the studies by Singh et al 13 and Nayak et al 14 where alcohol was the predominant cause seen in 66% and 76% respectively. All these studies were in contrary to the findings by Mumtaz et al 12 in the Islamic country of Pakistan where Hepatitis C virus was the cause of cirrhosis observed in 70% .…”

“…Among the precipitating factors, the most common was upper GI bleed in 40%, spontaneous bacterial peritonitis in 33.6% in the current study. Upper GI bleed was similarly, the most common precipitating factor for HE in their published studies by Kumar et al 10 , Iqbal et al 11 and Nayak et al 14 Constipation followed by upper GI bleed and infection were the most important precipitating factor in the studies by Sethuraman et al 9 , Tariq et al 16 and Arisar et al 17 Infection (44%) was the common precipitating factor followed by gastrointestinal bleeding (38%) and constipation (38%) in the study by Masood et al 18 Similarly, infection (49.2%) was the most common precipitating factor but followed by electrolyte imbalance (41%), constipation (33.33%), and gastrointestinal bleeding (16%) in a previous Nepalese study, by Poudyal et al 15 Spontaneous bacterial peritonitis (20.5%) followed by constipation(18.3%),urinary tract infection (15.3%), upper gastrointestinal bleeding (13.6%), dyselectrolytemia (9.4%) were the precipitating factors in the study by Mumtaz et al 12 Excessive use of diuretics in massive ascites (27.2% ) was the most common precipitating factor followed by infections (21.6%) and GI bleeding (17.3%) according to Raphel et al 8 All these studies suggest upper GI bleed, infections, constipation, dyselectrolyemia are the common precipitants for HE.…”