Precipitating Factors For Hepatic Encephalopathy In Cirrhosis Of Liver-A One Year Cross Sectional Study

Abstract

Purpose: Hepatic encephalopathy(HE) describes a spectrum of potentially reversible neuropsychiatric abnormalities in patients of cirrhosis of liver. HE is a well recognised clinical complication of cirrhosis of liver and the prompt identification of well defined precipitating factors is extremely important in diagnosis and treatment of this fatal condition Objectives: To study precipitating factors for hepatic encephalopathy in cirrhosis of liver. Methodology: A cross sectional study was conducted in patients presenting to Department of Internal medicine at KLES Dr Prabhakar Kore Hospital & MRC, Belgaum fulfilling inclusion criteria, for hepatic encephalopathy with cirrhosis of liver and subjected to detailed history, examination and processed through necessary investigations with informed consent Results: In this study infection (SBP + other infections) 41.66%(35) is the commonest precipitating factor for HE, followed by electrolyte imbalance34.52(29), upper GI bleeding with 32.14%(27) of patients and constipation 4.76%(4). Among the infections spontaneous bacterial peritonitis 21.43%(18) is the commonest precipitating factor followed by other infections 20.41%(17) like cellulitis of extremities and abdominal wall 9.52%(8) , 5.95%(5) cases are pneumonia, 2 are of acute gastroenteritis and other 2 are undiagnosed but presented with fever and raised leucocyte count. In electrolyte imbalance hyponatremia16.67%(14) is the most commonest electrolyte disturbance causing HE. In our study hypomagnesaemia 8.33%(7 cases) is seen as precipitating factor for HE. Among the participants (N=84) Grade I HE is seen in only 2 cases, 58.33%(49 patients have grade II hepatic encephelopathy, 34.52%(29) have grade III HE, 4.76%(4) have grade IV HE. Grade I HE showing equal association with single and multiple precipitating factors, Grade II HE,43 (83.67%) were having single precipitating factor. 65.5% of patients of Grade III HE had single precipitating factor. All Grade IV, were assosciated with single precipitating factor. There is no correlation of Grade of HE to number of precipitating factors. Among 2 patients of Grade I, one was having infection. Among 49 patients of Grade II 23(46.94%) were having infection. Among 29 patients of Grade III 10(34.48%) were having infection. Among 4 patients of Grade IV only 1 patient was having infection. In 84 patients of HE,35(41.67%) were precipitated by infection,. in which Grade II was common. In our study 27 patients had upper GI bleed. 19 patients (out of 27) had Grade III HE. 29 patients had electrolyte imbalance. 21 patients (out of 29) had Grtade II HE. In our study 57.14%(48) patients had Child Pugh class B and 42.86%(36) had Child Pugh class C. As grade of HE increases so does child Pugh score and child Pugh class is directly proportional to grade of HE. Conclusion: Infection is the commonest risk factor for hepatic encephalopathy, followed by electrolyte imbalance, upper GI bleeding, HRS, and constipation. Grade II HE is the most common presentation seen in this study.There is no correlation of Grade of HE to number of precipitating factors. There is no correlation of Grade of HE to infection. Upper GI bleeding patients had presented mostly with Grade III HE. Electrolyte imbalance had presented mostly with Grade II HE. In our study we observed that hypomagnesemia is a precipitating factor for HE. Role of magnesium in causing HE in patients of CL is important as correction of it shows a dramatic response. So monitoring of serum magnesium level is important in a patient with HE. As sample size of present study is small larger studies are required to confirm the role of magnesium as a precipitating factor for HE in cirrhosis of liver patients. Limitations:  Sample size was small to generalize the study result.  This study was done in a short period, so all factors in relation to precipitating factors for HE in CL cannot be studied.  Study was conducted only in single centre . So this study result would not be generalized for the entire country.