Session Title: Category 2b. CIRRHOSIS AND ITS COMPLICATIONS: b. CLINICAL ASPECTS
Presentation Date: Apr 15, 2010
MINIMAL HEPATIC ENCEPHALOPATHY (MHE): SIMPLIFIED DIAGNOSIS AND RELATIONSHIP WITH THE DEVELOPMENT OF OVERT HEPATIC ENCEPHALOPATHY (OHE)
C. Pasquale1*, L. Ridola1, I. Pentassuglio1, S. Nardelli1, M. Trezza1, C. Marzano1, C. Merkel2, O. Riggio1
1Clinical Medicine, Sapienza University of Rome, Rome, 2Clinical and Experimental Medicine, University of Padua, Padua, Italy. *firstname.lastname@example.org
Introduction: Cognitive deficits in cirrhotics, also known as MHE, may have important implications being associated to reduced quality of life and driving capacity. Moreover, patients with MHE are at risk of developing OHE. However, in practice the presence of MHE is seldom searched due to lack of standardized technique. The Psychometric Hepatic Encephalopathy Score (PHES), which includes Digit-Symbol-Test (DST), Trail-Making-TestA, Trail-Making-TestB, Serial-Dotting-Test (SDT) and Line-Tracing-Test (LTT) is considered the gold standard.
Aims of the study:
1) simplify the PHES
2) establish if any correlation exists between PHES or simplified PHES (SPHES) and development of HE.
Patients/methods: 79 consecutive cirrhotic patients, (M/F49/30, 60±13yrs, ChildClass A/B/C 33/31/15, MELD-score 14±6) were studied. 20 patients showed large varices at endoscopy and 6 were TIPS carriers. All patients were examined according to PHES: in 45 MHE was diagnosed. The results of each psychometric test ware expressed as z-scores of an Italian population standardized for age and education. In order to simplify the evaluation of MHE, a backward logistic regression analysis was performed incorporating at the first step the z-scores of the 5 tests included in PHES, and stepwise eliminating variables whose removal did not impair the regression.
Results: Logistic analysis showed that a model containing DST, SDT, and LLT was not significantly different from that containing the whole set of 5 variables (Table). Rate of patients correctly classified did not change significantly (94%).
20/79 patients developed an episode of OHE during FU. The probability of developing OHE was significantly higher in MHE+ than in MHE- patients identified either according to PHES (p=0.012) or SPHES (p=0.019). At a Cox's analysis including Child-Pugh class, MELD-score and the presence of large porto-systemic shunt, either PHES (RR3.75, p=0.03) or SPHES (RR3.17, p=0.04) were associated to OHE during follow-up.
Conclusions: A simplified battery of psychometric tests including DS, SDT and LTT (SPHES) does not impair the diagnostic ability of the whole PHES, and correlates with the development of OHE as well as PHES. Both SPHES and PHES are independent factors for the occurrence of OHE. SPHES deserves further validation in an independent group of patients.
[Backward stepwise logistic regression analysis]