STUDY OF CLINICAL SPECTRUM AND ITS PRECIPITATING FACTORS OF HEPATIC ENCEPHALOPATHY IN CIRRHOSIS OF LIVER
Main Article Content
Keywords
Hepatic encephalopathy, cirrhosis, precipitating factors, West Haven classification, Child-Pugh score, hyperammonaemia, mortality, infections, gastrointestinal bleeding, electrolyte imbalance.
Abstract
Hepatic encephalopathy (HE) is a serious neuropsychiatric complication of liver cirrhosis characterized by a spectrum of cognitive and motor disturbances. It primarily results from the accumulation of neurotoxins, especially ammonia, due to impaired hepatic clearance. This observational study aimed to assess the clinical presentation, common precipitating factors, and their relationship with outcomes in patients with cirrhosis-related HE. Conducted at Meenakshi Medical College and Research Institute between December 2023 and May 2024, the study enrolled 50 patients diagnosed with HE. Clinical history, examination findings, laboratory results, and imaging were recorded. HE was graded using the West Haven classification, and liver function was assessed with the Child-Pugh score. Among the 50 participants, 68% were male, with most aged between 41 and 60 years. Constipation (42%), gastrointestinal bleeding (28%), infections (24%), and hyponatremia (26%) were the most common precipitating factors. A majority of patients presented with advanced HE, with grade III in 30% and grade IV in 28%. Mortality was highest in patients with grade IV HE (79%), with infections and gastrointestinal bleeding being the leading contributors. The findings underscore that HE frequently affects middle-aged males with advanced liver disease and that early identification and management of reversible triggers—particularly infections, gastrointestinal bleeding, and electrolyte disturbances—are crucial in improving patient outcomes. Timely interventions may significantly reduce both morbidity and mortality associated with HE in cirrhotic patients.
References
2. Qureshi, M. O., Khokhar, N., Shafqat, F., 2014, Ammonia levels and the severity of hepatic encephalopathy. Journal of the College of Physicians and Surgeons Pakistan, 24(3), 160–163. https://www.jcpsp.pk/archive/2014/Mar2014/07.pdf
3. Tariq, M., Iqbal, S., Khan, N. U., Basri, R., 2009, Precipitating factors of hepatic encephalopathy. Rawal Medical Journal, 34(1), 95–101. https://rmj.org.pk/fulltext/27-1249409570.pdf
4. Bernal, W., Hall, C., Karvellas, C. J., Auzinger, G., Sizer, E., Wendon, J., 2007, Arterial ammonia and clinical risk factors for encephalopathy and intracranial hypertension in acute liver failure. Hepatology, 46(6), 1844–1852. https://doi.org/10.1002/hep.21847
5. Hameed, A., Rehman, M., Saeedi, I., Shah, D., 2001, Factors precipitating hepatic encephalopathy in cirrhotic liver. Postgraduate Medical Institute, 15, 91–95. https://www.pgmipeshawar.edu.pk
6. Abu-Assi, S., Vlaeevie, Z. R., 2001, Hepatic encephalopathy: metabolic consequences of cirrhosis are often reversible. Postgraduate Medicine, 109, 123–129. https://doi.org/10.3810/pgm.2001.05.897
7. Vilstrup, H., Amodio, P., Bajaj, J. S., et al., 2014, Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by AASLD and EASL. Hepatology, 60(2), 715–735. https://doi.org/10.1002/hep.27210
8. Sheikh, S., 1998, Portal systemic encephalopathy in chronic liver disease: experience at People Medical College, Nawabshah. Journal of the College of Physicians and Surgeons Pakistan, 8, 53–55. https://www.jcpsp.pk/archive/1998/Jan1998/10.pdf
9. Sargent, S., Fullwood, D., 2006, The management of hepatic encephalopathy and cerebral edema in acute liver failure. British Journal of Neuroscience Nursing, 2, 448–453. https://doi.org/10.12968/bjnn.2006.2.9.21840
10. World Health Organization, 2017, Liver disease in India: WHO 2017 data. WHO Geneva. https://www.worldlifeexpectancy.com/india-liver-disease
11. Poordad, F. F., 2007, The burden of hepatic encephalopathy. Alimentary Pharmacology & Therapeutics, 25(Suppl 1), 3–9. https://doi.org/10.1111/j.1365-2036.2006.03184.x
12. Bianchi, G., Giovagnoli, M., Sasdelli, A. S., Marchesini, G., 2012, Hepatic encephalopathy and health-related quality of life. Clinics in Liver Disease, 16(1), 159–170. https://doi.org/10.1016/j.cld.2011.09.010
13. Bajaj, J. S., 2020, The role of microbiota in hepatic encephalopathy. Gut Microbes, 11(6), 1386–1399. https://doi.org/10.1080/19490976.2020.1805287
14. Hadjihambi, A., Arias, N., Sheikh, M., Jalan, R., 2017, Hepatic encephalopathy: a critical current review. Hepatology International, 12(Suppl 1), 135–147. https://doi.org/10.1007/s12072-017-9803-7
15. Devrajani, B. R., Shah, S. Z., Devrajani, T., Kumar, D., 2009, Precipitating factors of hepatic encephalopathy at a tertiary care hospital in Jamshoro, Hyderabad. Journal of Pakistan Medical Association, 59(10), 683–686. https://jpma.org.pk/article-details/1880
16. Nayak, M., Anubhaw, N., Nayak, R., 2016, Incidence of hepatic encephalopathy in cirrhosis of the liver. International Journal of Contemporary Medical Research, 3(12), 3528–3532. https://www.ijcmr.com/uploads/7/7/4/6/77464738/_incidence_of_hepatic_encephalopathy_in_cirrhosis_of_liver.pdf
17. Kumar, S. K. K., Sarin, S. M., Valliyot, B., Joy, V., Beevi, K., Balakrishnan, S., 2017, Study to assess the changing pattern of clinical profile and determine the prognosis in hepatic encephalopathy. International Journal of Research in Medical Sciences, 5(2), 424–428. https://doi.org/10.18203/2320-6012.ijrms20170165
18. Faloon, W. W., Evans, G. L., 1970, Precipitating factors in the genesis of hepatic coma. New York State Journal of Medicine, 70, 2891–2894. https://pubmed.ncbi.nlm.nih.gov/5482147
19. Sharma, B. C., Sharma, P., Agrawal, A., Sarin, S. K., 2021, Secondary prophylaxis of hepatic encephalopathy: an open-label randomized controlled trial of lactulose versus placebo. Gastroenterology, 160(1), 191–200.e2. https://doi.org/10.1053/j.gastro.2020.08.059
20. Bajaj, J. S., Wright, G., Dasarathy, S., Bajaj, S., 2022, The modern management of hepatic encephalopathy. American Journal of Gastroenterology, 117(2), 245–261. https://doi.org/10.14309/ajg.0000000000001565
21. Conn, H. O., Leiberthal, M. M., 1980, The hepatic coma syndrome and lactulose. Baltimore: William & Wilkins, p. 106.
Article Sidebar
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles published in JPTCP are licensed under Copyright Creative Commons Attribution-NonCommercial 4.0 International License.
Rahul Tarigopula
Department of General Medicine, Meenakshi Medical College Hospital and Research Institute, Meenakshi Academy of Higher Education and Research (Deemed to be University), Kanchipuram, Tamil Nadu, India.
Jayannan Jayasenan
Department of General Medicine, Meenakshi Medical College Hospital and Research Institute, Meenakshi Academy of Higher Education and Research (Deemed to be University), Kanchipuram, Tamil Nadu, India.
Hareesh Arumugam
Department of General Medicine, Meenakshi Medical College Hospital and Research Institute, Meenakshi Academy of Higher Education and Research (Deemed to be University), Kanchipuram, Tamil Nadu, India.
Anbarasu Duraisamy
Professor and Head of the Department, Dept. Of General Medicine, Meenakshi Medical College Hospital and Research Institute, Meenakshi Academy of Higher Education and Research (Deemed to be University), Kanchipuram, Tamil Nadu, India.