Prevalence of Helicobacter pylori Infection in Patients with Minimal Hepatic Encephalopathy

Abstract

Background: Ammonia is a critical factor in the pathogenesis of minimal hepatic encephalopathy (MHE). Most of the ammonia is from bacterial production in the intestinal tract. Non-absorbable antibiotics and non-absorbable disaccharides are therefore the therapy of choice. A few studies have addressed the effect of ammonia produced by H. pylori in the pathogenesis of MHE.
 Methods: In this prospective clinical trial, 84 consecutive patients with liver cirrhosis (LC) underwent laboratory, psychometric und neurophysiological testing to determine serological H. pylori status, MHE and blood ammonia levels. Relevant clinical and demographic characteristics were documented.
 Results: Out of 84 LC patients (83% male), 29% presented with MHE as assessed by critical flicker frequency analysis (CFF). The prevalence of H. pylori infection in the cohort was 21%; 22% of H. pylori-infected patients presented with MHE according to the criterion of a positive CFF result. If the criterion for MHE was a positive CFF and a positive NCT-A result, then 17% of H. pylori positive patients suffered from MHE. The prevalence of MHE in H. pylori-negative patients, based on CFF alone and on the combination, was 30%. A proportion of 19% of the patients with MHE had increased blood ammonia levels.
 Conclusion: The amount of ammonia produced by H. pylori does not affect venous ammonia levels. Therefore, an additional benefit of H. pylori eradication in the treatment of hepatic encephalopathy in patients with LC is unlikely to occur.
 Key words: – – – – – .
 Abbreviations: CFF: critical flicker frequency analysis; GCP: good clinical practice; GI : gastrointestinal; HE: hepatic encephalopathy; H. pylori: Helicobacter pylori; LC: liver cirrhosis; MHE: minimal hepatic encephalopathy; NASH: non-alcoholic steatohepatitis; NCT-A: number connection test-A; NCT-B: number connection test-B; PHES: Psychometric hepatic encephalopathy score.

Chinese guidelines on management of hepatic encephalopathy in cirrhosis

“…There may be a relationship between Hp infection and HE in cirrhosis. Eradicating Hp may be beneficial for the clinical prevention and treatment of HE in liver cirrhosis[72-74].…”

Minimal Hepatic Encephalopathy: Effect of H. pylori infection and small intestinal bacterial overgrowth treatment on clinical outcomes

“…However, scanty data is available with regards to the same in MHE 8 . Work done by Schulz and his colleagues in a prospective clinical trial (though without healthy control group for comparison) failed to show an increased prevalence of Hp infection in patients presenting with MHE as opposed to those without MHE 9 . In addition to this, much interest has recently developed to define the role of small intestinal bacterial overgrowth (SIBO) among patients with MHE 10,11 .…”

Current approach to treatment of minimal hepatic encephalopathy in patients with liver cirrhosis

“…The increase in arterial ammonia has been found in patients manifesting some signs of cerebral dysfunction such as mild lethargy, brisk deep tendon reflexes, or increased resistance to passive arm movement[ 18 ], and in patients with the specific diagnosis of MHE[ 19 - 23 ] including those with concomitant MHE and sarcopenia[ 7 , 23 ]. An increase in the production of ammonia may be related to dysbiosis, small intestinal bacterial overgrowth (SIBO), or Helicobacter pylori infection as a result of increased activity of bacterial urease, intestinal urea hydrolysis, and absorption of nitrogenous products[ 20 , 24 ]. This, together with decreased intestinal motility and altered integrity of the intestinal barrier, facilitate the increase in bacterial translocation and endotoxin release to the circulation[ 25 , 26 ].…”

“…An increase in Enterobacteriaceae ( Escherichia coli) and Staphylococcus spp. has been related to MHE, and nearly 22% of patients with cirrhosis and MHE have H. pylori infection[ 20 , 29 ].…”