Assessment of Reversibility of Minimal Hepatic Encephalopathy in Cirrhotic Patient after Liver Transplantation

Abstract

SUMMARY H epatic encephalopathy (HE) is a common complication in patient with liver cirrhosis. It comprises of a broad spectrum of neuropsychiatric abnormalities of varying severity, and affected patients usually suffer from psychomotor, cognitive, emotional, behavioural, and motor coordination dysfunctions. Patients with minimal HE (MHE), a subclinical form of HE, usually have a normal mental and neurological status upon routine clinical examination. The subtle deficits in patients with MHE can only be elicited by specialized neuropsychological tests. Despite the subclinical presentation of MHE, MHE patients are a significant burden on society and are burdened themselves, because they are more likely to suffer from car accidents, falls, a lower quality of life. Liver transplantation is considered the optimal therapy for end stage liver disease. It represents the treatment of choice for the HE syndrome, Because HE is a metabolic disturbance, complete reversibility is expected after removal of the diseased liver. However, while clinical signs may disappear, subtle neurological impairment may persist after LT. Our conducted study was a prospective case control study carried on 20 adult patients and 20 age matched control. All were recruited from Liver transplantation unit of Ain Shams Specialised Hospital from June 2014 to December 2014. The aim of this study is to assess the improvement of cognitive function and the reversibility of MHE after liver transplantation. All subjects enrolled in the study were subjected to detailed history taking, full physical examination, neuropsychiatric assessment, laboratory investigations, imaging studies which included pelvi-abdominal ultrasonography, CT brain and psychometric tests for detection of MHE using specially DST, TMT A, TMT B and SDT. A Total score of the four tests was calculated. A total score of -4 or less or 2 or more tests having a score equal or lower than 2 SD was used to diagnose MHE. Patients with Significant cortical atrophy or other structural brain changes, also subjects on Regular use of psychotropic substances or with known major psychiatric disorder or shows signs of acute graft rejection or Overt hepatic encephalopathy at time of test were completely excluded. The patients were assessed before undergoing LT and one month post transplantation. Also MELD score was calculated before and after LT. All data were statistically analysed. Results were compared to results of similar researches. Our study found that there is significant improvement in the score of each of the four psychometric tests in patient post transplantation compared to scores before transplantation. Comparing patients post transplantation with control as regards the 4 psychometric tests and the Total score: there is still statistical significance between the 2 groups. This means that MHE improved in patients after liver transplantation, but still could not reach the normal level of a healthy individual. So MHE is not fully reversible after LT. Further studies may be needed in the future with larger number of patients, different etiologies and longer period of follow up.