Session Title: Category 2b. CIRRHOSIS AND ITS COMPLICATIONS: b. CLINICAL ASPECTS
Presentation Date: Apr 15, 2010
SEVERITY OF CHRONIC COGNITIVE IMPAIRMENT IN CIRRHOSIS INCREASES WITH NUMBER OF EPISODES OF OVERT HEPATIC ENCEPHALOPATHY
J. Bajaj1*, C. Schubert2, A.J. Sanyal1, D. Bell1, L. Pisney1, D.M. Heuman1
1Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 2Biostatistics, Virginia Commonwealth University, Richmond, VA, USA. *firstname.lastname@example.org
Introduction: Hepatic encephalopathy (HE) in cirrhosis is associated with morphological evidence of neuronal and astrocyte injury. Mental status changes of HE usually can be reversed with treatment, but cognitive impairment could persist.
Aim: To determine whether recurrent acute episodes of HE may lead to progressive chronic cognitive impairment.
Methods: Patients with cirrhosis and ≥1 prior HE episodes, in clinical remission on lactulose/rifaximin with mini-mental status exam (MMSE)>25, were enrolled. All patients underwent a test battery including number connection A+B (NCT-A/B), digit symbol (DST) & block design (BDT), and the inhibitory control tests(ICT; lures and targets are outcomes). A high ICT lure, NCT-A/B score and a low DST, BDT and ICT target score indicate poor performance. Number of HE episodes and hospitalizations and duration between the 1st hospitalization and current testing were correlated with individual psychometric tests.
Results: 50 patients (Age 56 yrs,39 men,78% HCV, mean MMSE 27, 40 on lactulose, 5 with rifaximin & 5 both) were included. Mean followup was 13±12 months with a median of 2 HE episodes (range 1-13) and 1 HE hospitalization (range, 1-7). The precipitating factors for the first hospitalization were infections in 18, TIPS in 10, medications in 7 and spontaneous in the rest. 33 patients had >1 HE hospitalization. Scores on tests were highly abnormal in all patients [mean scores: NCT-A 48±22 seconds, NCT-B 149±87 seconds, DST 41±13, BDT 26±15, ICT lures 15±9 and ICT targets (% correct) 89±12%]. Scores on ICT lures (r=-0.50, p=0.002), ICT targets (r=-0.43, p=0.009),NCT-B (r=0.35, p=0.047) and DST (r=-0.46, p=0.009) were highly correlated with the number of HE episodes . Psychometric performance and number of HE hospitalizations were also correlated; ICT lures (r=-0.59, p=0.0001), ICT targets (r=-0.44, p=0.015), DST (r=0.46, p=0.009) and NCT-B (r=0.35, p=0.05). ICT lures (r=0.48, p=0.007) and DST (r=-0.36 p=0.04) scores were also significantly correlated with time from first HE episode to testing.
Conclusion: In cirrhosis, deficits in working memory, psychomotor speed, attention and response inhibition increase with number and severity of episodes of overt HE. The metabolic derangements that produce overt HE also may cause chronic neurological injury that is not readily reversible.