STUDY OF PRECIPITATING FACTORS AND HOSPITAL OUTCOME OF HEPATIC ENCEPHALOPATHY PATIENTS WITH PRECIPITANTS

Abstract

Background: Hepatic encephalopathy is a complication of impaired liver functionand is manifested as
neuropsychiatric signs and symptoms associated with acute or chronic liverdisease in the absence of other
neurological disorders. The main objective of this study was to determine precipitants of hepatic
encephalopathy (HE) and different treatment regimens, and their impact on ICU stay and mortality.
Methods:from November 2009 to June 2010, 540 patients with cirrhosis of liver, manifesting signs
ofhepatic encephalopathy (HE) were included. Detailed history, clinical examination and thorough
investigations were doneto look for any precipitating factor.All patients were randomized to four
treatment groups, standard treatment, branched chain amino acids (BCAA), L-Ornithine-L-aspartate
(LOLA) and BCAA plus LOLA.
Results: Of the 540 patients 353 (65.4%) were males, and 187 (34.6%) were females. Mean age was 61 ±
8.4 years. Hepatitis C virus was the cause of cirrhosis in 465 (86.1%); Child-Pugh (C-P) class C was
present in 489 (90.6%) patients. On admission, 5.4% patients had grade 1 HE while30.4%, 41.5% and
22.4% had grades 2, 3 and 4 respectively. The most common precipitant of HE was infection in 159
(29.4%), gastrointestinal bleeding in 146 (27%), constipation in 47 (8.7%) patients,while no precipitant
was noted in 40 (7.4%) patients.Twenty-three percent died during ICU stay. Univariateanalysis identified
old age, hemodynamic instability, grades 3 or 4 HE, renal impairment, recurrent episodes of HE and
sepsis associated with ICU mortality. Mean ICU stay was 2.54 ± 1days. Shorter ICU stays (i.e. early
recovery) was associated with grade 1, 2 HE, Child class B, and treatment group IV (BCAA plus LOLA).
Longer ICU stay (i.e. late recovery) was associated with grade 3, 4 HE, Child class C, and treatment group
I (standard treatment).In the group treated with standard treatment, mean ICU stay was2.97±1.1 days vs.
2.1±0.9days in the group treated with BCAA plus LOLA.In the group treated with standard treatment,
ICU mortalitywas 36%vs. 15.4% in the group treated with BCAA plus LOLA.
Conclusion:Infections, gastrointestinal bleeding were identified as the major precipitants in this study.
Patients with old age, hemodynamic instability, grades 3 or 4 HE, renal impairment, and recurrent
episodes of HE on admission was associated with worse outcomes. Shorter ICU stays (i.e. early recovery)
was associated with grade 1, 2 HE, Child class B, and treatment group IV (BCAA plus LOLA). Patients
treated with group IV, which include BCAA and LOLA, had early recovery and lower mortality.
Keywords:Hepatic encephalopathy. Cirrhosis. Hepatitis C. Precipitant. Outcome.