- Email: [email protected]
Reversal of Low-Grade Cerebral Edema in Patients with Cirrhosis and Minimal Hepatic Encephalopathy After Lactulose and Rifaximin Therapy
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Corresponding author: Sudhir Maharshi. Email: [email protected]
ANEMIA PROFILE IN PATIENTS OF CHRONIC LIVER DISEASE FROM NORTH INDIAN TERTIARY HOSPITAL Abdul Rauf, Pankaj Tyagi, Vikas Singla, Praveen Sharma, Ashish Kumar, Anil Arora Gastroenterology Sir Ganga Ram Hospital, New Delhi, India Background: Patients with Chronic liver disease are known to have malnutrition. However the data on prevalence of the type of anemia and etiology of anemia is sparse. Aim: To know the prevalence of anemia and etiology of anemia in patients with CLD Methods: Consecutive patients of CLD in whom complete anemia profile were done were included in the study. The study was done in patients which were admitted in Sir Ganga Ram Hospital in the period of 18 months from Dec 2010 up to Jun 2012.Patients on hematenics or who were given packed cells infusion were excluded from the study. All patients had detailed history, examination, relevant blood investigation and complete anemia profile. Patients were divided into two group; Alcohol related CLD (ALD) and Other etiology of CLD (Non-ALD )
Results: one hundred ten patients were included, male: female: 69%: 31%. Fifty patients were in alcoholic group. Child A:B:C: 15%:45%:40%.Anemia was present in 90% and 80% in ALD and Non-ALD respectively. Leucopenia was present in 25% in ALD and 33% in Non-ALD. Iron deficiency was seen in 58% in Non ALD were as it was 35% in ALD group. Vitamin B12 deficiency was seen in 15% in Non-ALD group and 5% in ALD group. Folic acid deficiency was seen in 5% in Non-ALD group and 15% in ALD group. Conclusion: Anemia is very common in CLD patients with Iron deficiency being the most common cause of the anemia. Corresponding author: Abdul Rauf. Email: [email protected]
REVERSAL OF LOW-GRADE CEREBRAL EDEMA IN PATIENTS WITH CIRRHOSIS AND MINIMAL HEPATIC ENCEPHALOPATHY AFTER LACTULOSE AND RIFAXIMIN THERAPY Rahul Rai*, Radha K. Dhiman*, Chirag K. Ahujay, Naveen Kalra*, Ajay Duseja*, Niranjan Khandelwaly, Yogesh Chawla* Department of Hepatology, and yDepartment of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
*
PLENARY SESSION Background: Minimal hepatic encephalopathy (MHE) is the mildest form of spectrum of HE. Evidence suggests that inflammation modulates cerebral effects of ammonia resulting in low grade cerebral edema causing MHE. Decreased magnetization transfer ratio (MTR) in brain has been described to characterize brain edema in cirrhotics, but the data limited in MHE. Objectives: To study arterial ammonia, pro-inflammatory interleukins (IL-1, IL-6), tumor necrosis factor-alpha (TNF-a) and MTR, in MHE before and after treatment. Methods: Twenty-three cirrhotics (non-MHE, n = 9; MHE, n = 14) and 6 healthy controls underwent ammonia, IL-1, IL-6, TNF-a estimation; and MTR in frontal white matter (FWM), parietal white matter (PWM), internal capsule (IC) and basal ganglia (BG). Seven patients in MHE and nonMHE group had similar investigations repeated after 8 weeks; MHE group received rifaximin. Results: Ammonia was significantly higher in cirrhotics compared to controls; and in MHE compared to nonMHE group. IL-1 and IL-6 were significantly elevated in MHE patients when compared with controls. Arterial
Journal of Clinical and Experimental Hepatology | March 2014 | Vol. 4 | No. S2 | S39–S54
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Cirrhosis and Complications
of HE after AVB, however, there is no data on role of rifaximin for prophylaxis of HE after AVB. We compared efficacy of lactulose versus rifaximin for prophylaxis of HE after AVB in patients with cirrhosis. Methods: Consecutive patients of cirrhosis with AVB and no HE at time of presentation were randomized to lactulose [group-L (30 ml 6 hourly)] or rifaximin [group-R (400 mg; 8 hourly)] for 5 days along with standard treatment of AVB as per Baveno V guidelines. Primary endpoint was development of overt HE as per West Haven criteria within 5 days of randomization. Results: 80 patients were randomized into two groups; group-L (n = 40, age 41.6 9.6 years, 33 men) and group-R (n = 40, age 38.6 10.4 years, 34 men). There was no significant difference in baseline characteristics between the two groups. Characteristics of variceal bleed were also similar in group-L vsgroup-R (mean arterial pressure 79.8 6.4 vs82.2 8.1 mmHg), Hb (7.7 1.4 vs7.8 1.3 g/dL), time to endoscopy (6.2 1.6vs 6.1 1.7 hours) and esophageal source of bleed (90% vs93%). There was no difference in development of hepatic encephalopathy (group-L vsgroup-R 7/40 vs 6/40; P = 1.0) and mortality (group-L vsgroup-R 5/40 vs 6/40; P = 1.0) in two groups. Conclusions: Lactulose and rifaximin are equally effective for prophylaxis of hepatic encephalopathy in patients of cirrhosis with acute variceal bleed.
ABSTRACTS
ammonia correlated positively with IL-1 and IL-6 in cirrhotics. MTRs in FWM, PWM, IC and BG were significantly decreased in MHE group when compared to controls (P = 0.002, 0.002, 0.003 and 0.019 respectively); and in PWM, IC and BG when MHE group was compared to non-MHE group (P = 0.001, 0.013 and 0.031 respectively). In MHE patients after treatment, significant MTR increase was seen in FWM (P = 0.028), PWM (P = 0.043) and IC (P = 0.028).in cirrhotics, IL-6 and ammonia had significantly negative; and psychometric hepatic encephalopathy scores had significantly positive correlations with MTR in various regions. Conclusion: Decreased MTR and improvement after treatment suggests reversible low-grade cerebral edema in MHE patients and is likely to be related to inflammation and metabolism of ammonia. Corresponding author: Radha K. Dhiman. Email: [email protected]
PERSISTENCE OF COGNITIVE IMPAIRMENT AFTER RESOLUTION OF OVERT HEPATIC ENCEPHALOPATHY Cirrhosis and Complications
Shridharan Umapathyy, Radha K. Dhiman*, Sandeep Groverz, Ajay Dusejay, Yogesh K. Chawla* Department of Hepatology, yDepartment of Internal Medicine, and zDepartment of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India *
PLENARY SESSION Background and Objectives: Hepatic encephalopathy (HE) represents a spectrum of neurocognitive impair-
S54
22ND ANNUAL CONFERENCE – 2014
ment seen in cirrhotic patients and is considered to be fully reversible with treatment, however recent evidence suggests otherwise. This longitudinal study was carried out to evaluate the persistence of cognitive impairment in cirrhotics with prior overt HE (OHE) episode despite treatment. Methods: Of 213 patients screened, 107 patients who met the eligibility criteria were enrolled and 102 patients completed the study (52 patients without prior OHE episode and 50 patients with prior OHE). All patients underwent psychometric hepatic encephalopathy score (PHES) evaluation at 3 separate visits (Day 1, Day 3 and between 30 and 60 days). One point improvement in PHES between first and second evaluation was considered as a measure of learning. Results: Patients with previous OHE episode showed learning impairment in PHES on repetition on 3rd day (P = 0.084), while patients without prior OHE episode demonstrated learning effect (P < 0.0001) irrespective of having Minimal HE (MHE) or not. Univariate analysis demonstrated that Child-Turcotte-Pugh score, lactulose and/or rifaximin therapy, presence of MHE and previous OHE episode were associated with learning impairment. Multivariate analysis demonstrated that only presence of previous episode of OHE (adjusted odds ratio [95%, confidence interval; 38.398, 9.192–160.4]; P < 0.0001) significantly affected learning. Conclusions: This study conclusively demonstrated learning impairment in cirrhotic patients with previous episode of OHE despite normal mental status. Improvement in PHES on repetition can be used as a measure of learning in future studies. Corresponding author: Radha K. Dhiman. Email: [email protected]
© 2014, INASL
Corresponding author: Sudhir Maharshi. Email: [email protected]
ANEMIA PROFILE IN PATIENTS OF CHRONIC LIVER DISEASE FROM NORTH INDIAN TERTIARY HOSPITAL Abdul Rauf, Pankaj Tyagi, Vikas Singla, Praveen Sharma, Ashish Kumar, Anil Arora Gastroenterology Sir Ganga Ram Hospital, New Delhi, India Background: Patients with Chronic liver disease are known to have malnutrition. However the data on prevalence of the type of anemia and etiology of anemia is sparse. Aim: To know the prevalence of anemia and etiology of anemia in patients with CLD Methods: Consecutive patients of CLD in whom complete anemia profile were done were included in the study. The study was done in patients which were admitted in Sir Ganga Ram Hospital in the period of 18 months from Dec 2010 up to Jun 2012.Patients on hematenics or who were given packed cells infusion were excluded from the study. All patients had detailed history, examination, relevant blood investigation and complete anemia profile. Patients were divided into two group; Alcohol related CLD (ALD) and Other etiology of CLD (Non-ALD )
Results: one hundred ten patients were included, male: female: 69%: 31%. Fifty patients were in alcoholic group. Child A:B:C: 15%:45%:40%.Anemia was present in 90% and 80% in ALD and Non-ALD respectively. Leucopenia was present in 25% in ALD and 33% in Non-ALD. Iron deficiency was seen in 58% in Non ALD were as it was 35% in ALD group. Vitamin B12 deficiency was seen in 15% in Non-ALD group and 5% in ALD group. Folic acid deficiency was seen in 5% in Non-ALD group and 15% in ALD group. Conclusion: Anemia is very common in CLD patients with Iron deficiency being the most common cause of the anemia. Corresponding author: Abdul Rauf. Email: [email protected]
REVERSAL OF LOW-GRADE CEREBRAL EDEMA IN PATIENTS WITH CIRRHOSIS AND MINIMAL HEPATIC ENCEPHALOPATHY AFTER LACTULOSE AND RIFAXIMIN THERAPY Rahul Rai*, Radha K. Dhiman*, Chirag K. Ahujay, Naveen Kalra*, Ajay Duseja*, Niranjan Khandelwaly, Yogesh Chawla* Department of Hepatology, and yDepartment of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
*
PLENARY SESSION Background: Minimal hepatic encephalopathy (MHE) is the mildest form of spectrum of HE. Evidence suggests that inflammation modulates cerebral effects of ammonia resulting in low grade cerebral edema causing MHE. Decreased magnetization transfer ratio (MTR) in brain has been described to characterize brain edema in cirrhotics, but the data limited in MHE. Objectives: To study arterial ammonia, pro-inflammatory interleukins (IL-1, IL-6), tumor necrosis factor-alpha (TNF-a) and MTR, in MHE before and after treatment. Methods: Twenty-three cirrhotics (non-MHE, n = 9; MHE, n = 14) and 6 healthy controls underwent ammonia, IL-1, IL-6, TNF-a estimation; and MTR in frontal white matter (FWM), parietal white matter (PWM), internal capsule (IC) and basal ganglia (BG). Seven patients in MHE and nonMHE group had similar investigations repeated after 8 weeks; MHE group received rifaximin. Results: Ammonia was significantly higher in cirrhotics compared to controls; and in MHE compared to nonMHE group. IL-1 and IL-6 were significantly elevated in MHE patients when compared with controls. Arterial
Journal of Clinical and Experimental Hepatology | March 2014 | Vol. 4 | No. S2 | S39–S54
S53
Cirrhosis and Complications
of HE after AVB, however, there is no data on role of rifaximin for prophylaxis of HE after AVB. We compared efficacy of lactulose versus rifaximin for prophylaxis of HE after AVB in patients with cirrhosis. Methods: Consecutive patients of cirrhosis with AVB and no HE at time of presentation were randomized to lactulose [group-L (30 ml 6 hourly)] or rifaximin [group-R (400 mg; 8 hourly)] for 5 days along with standard treatment of AVB as per Baveno V guidelines. Primary endpoint was development of overt HE as per West Haven criteria within 5 days of randomization. Results: 80 patients were randomized into two groups; group-L (n = 40, age 41.6 9.6 years, 33 men) and group-R (n = 40, age 38.6 10.4 years, 34 men). There was no significant difference in baseline characteristics between the two groups. Characteristics of variceal bleed were also similar in group-L vsgroup-R (mean arterial pressure 79.8 6.4 vs82.2 8.1 mmHg), Hb (7.7 1.4 vs7.8 1.3 g/dL), time to endoscopy (6.2 1.6vs 6.1 1.7 hours) and esophageal source of bleed (90% vs93%). There was no difference in development of hepatic encephalopathy (group-L vsgroup-R 7/40 vs 6/40; P = 1.0) and mortality (group-L vsgroup-R 5/40 vs 6/40; P = 1.0) in two groups. Conclusions: Lactulose and rifaximin are equally effective for prophylaxis of hepatic encephalopathy in patients of cirrhosis with acute variceal bleed.
ABSTRACTS
ammonia correlated positively with IL-1 and IL-6 in cirrhotics. MTRs in FWM, PWM, IC and BG were significantly decreased in MHE group when compared to controls (P = 0.002, 0.002, 0.003 and 0.019 respectively); and in PWM, IC and BG when MHE group was compared to non-MHE group (P = 0.001, 0.013 and 0.031 respectively). In MHE patients after treatment, significant MTR increase was seen in FWM (P = 0.028), PWM (P = 0.043) and IC (P = 0.028).in cirrhotics, IL-6 and ammonia had significantly negative; and psychometric hepatic encephalopathy scores had significantly positive correlations with MTR in various regions. Conclusion: Decreased MTR and improvement after treatment suggests reversible low-grade cerebral edema in MHE patients and is likely to be related to inflammation and metabolism of ammonia. Corresponding author: Radha K. Dhiman. Email: [email protected]
PERSISTENCE OF COGNITIVE IMPAIRMENT AFTER RESOLUTION OF OVERT HEPATIC ENCEPHALOPATHY Cirrhosis and Complications
Shridharan Umapathyy, Radha K. Dhiman*, Sandeep Groverz, Ajay Dusejay, Yogesh K. Chawla* Department of Hepatology, yDepartment of Internal Medicine, and zDepartment of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India *
PLENARY SESSION Background and Objectives: Hepatic encephalopathy (HE) represents a spectrum of neurocognitive impair-
S54
22ND ANNUAL CONFERENCE – 2014
ment seen in cirrhotic patients and is considered to be fully reversible with treatment, however recent evidence suggests otherwise. This longitudinal study was carried out to evaluate the persistence of cognitive impairment in cirrhotics with prior overt HE (OHE) episode despite treatment. Methods: Of 213 patients screened, 107 patients who met the eligibility criteria were enrolled and 102 patients completed the study (52 patients without prior OHE episode and 50 patients with prior OHE). All patients underwent psychometric hepatic encephalopathy score (PHES) evaluation at 3 separate visits (Day 1, Day 3 and between 30 and 60 days). One point improvement in PHES between first and second evaluation was considered as a measure of learning. Results: Patients with previous OHE episode showed learning impairment in PHES on repetition on 3rd day (P = 0.084), while patients without prior OHE episode demonstrated learning effect (P < 0.0001) irrespective of having Minimal HE (MHE) or not. Univariate analysis demonstrated that Child-Turcotte-Pugh score, lactulose and/or rifaximin therapy, presence of MHE and previous OHE episode were associated with learning impairment. Multivariate analysis demonstrated that only presence of previous episode of OHE (adjusted odds ratio [95%, confidence interval; 38.398, 9.192–160.4]; P < 0.0001) significantly affected learning. Conclusions: This study conclusively demonstrated learning impairment in cirrhotic patients with previous episode of OHE despite normal mental status. Improvement in PHES on repetition can be used as a measure of learning in future studies. Corresponding author: Radha K. Dhiman. Email: [email protected]
© 2014, INASL