Assessment of clinical, laboratory and endoscopic risk factors for hepatic encephalopathy development in cirrhotic patients with upper GIT bleeding

Fady Wadea


Aim: to assess risk factors for hepatic encephalopathy development in Egyptianpatients with gastrointestinal bleeding.Material and methods: 120 cirrhotic patients with upper gastrointestinal bleedingwere randomly assigned into: (group I) patients who complicated with hepaticencephalopathy (n=60) versus (group II) patients not complicated with hepaticencephalopathy (n=60). Clinical, laboratory and endoscopic features of all patientswere explored and compared between the 2 groups.Results: Patients with Child's class C, more ascites and spontaneous bacterialperitonitis were significantly more in group I (p<0.001), also diabetic patients(p=0.02). Total leucocytic count, total, direct bilirubin, INR, creatinine and blood ureanitrogen were significantly higher in group I (p<0.001), also AST (p=0.04), albuminwas significantly lower (p<0.001). Higher degrees of esophageal varices and portalhypertensive gastropathy were the significant cause of bleeding in group I (p= 0.001& 0.02 respectively). Degree of ascites, Child's score points, diabetes, andspontaneous bacterial peritonitis were significantly related to encephalopathy grade(p<0.001, <0.001, <0.001, 0.016 respectively), also total, direct bilirubin, INR, bloodurea nitrogen and Total leucocytic count (p 0.005, 0.002, 0.001, 0.02, 0.018respectively). Patients with advanced encephalopathy grades had significantly highervariceal and gastropathy grades (p=0.002&0.038).Conclusion: Upper gastrointestinal bleeding is not alone the main precipitating factorfor hepatic encephalopathy but other cofactors as advanced Child's classes andscore, presence of ascites, renal impairment, leucocytosis, diabetes , spontaneousbacterial peritonitis and higher vaiceal and gastropathy grades are needed. Specialmonitoring and early prophylactic interventions are advised in these patients.


esophageal and gastric Varices, liver cirrhosis, peritonitis, hepatic encephalopathy precipitating Factors.



Frederick R. T. Current concepts in pathophysiology and management of hepaticencephalopathy. Gastroenterol and Hepatol 2011; 7(4).

Guevara M , Baccaro ME, Ríos J, Martín-Llahí M, Uriz J, Ruiz del Arbol L et al.,

Risk factors for hepatic encephalopathy in patients with cirrhosis and refractory ascites: relevance of serum sodium concentration. Liver Intl 2010; 30(8): 1137– 42.

Naveed A, Sabeen F, Muhammad AN, Amina H. Upper Gastrointestinal Bleed, a Grave yet Precipitating Factor of Hepatic Encephalopathy in Cirrhotic patients. P J MH 2015; 9(2): 723-25.

Wen J, Liu Q, Song J, Tong M, Peng L, Liang H. Lactulose is highly potential in prophylaxis of hepatic encephalopathy in patients with cirrhosis and upper

gastrointestinal bleeding: results of a controlled randomized trial. Digestion 2013;87(2):132-8.

Welters CF, Deutz NE, Dejong CH, Soeters PB. Enhanced renal vein ammonia

efflux after a protein meal in the pig. J Hepatol 1999; 31: 489–96.

Durand F, Valla D. Assessment of the prognosis of cirrhosis: Child-Pugh versus MELD. J Hepatol 2005; 42: 100-7.

Blei AT, Córdoba J. Hepatic Encephalopathy. Am J Gastroenterol 2001;


Paquet KJ. prophlactic endoscopic sclerosing treatment of the esophageal wall in varices-a prospective controlled randomized trial.Endoscopy.1982;14(1):4-5.

Tanoue K, Hashizume M, Wada H, Ohta M, Kitano S, Sugimachi K. Effects of

endoscopic injection sclerotherapy on portal hypertensive gastropathy: a prospective study. Gastrointest Endosc 1992; 38:582-85.

Forrest JA, Finlayson ND, Shearman DJ. endoscopy in gastrointestinal


Conn H, Lieberthal M. The hepatic coma syndromes and lactulose. Baltimore MD): Williams & Wilkins; 1979.

Magiera M, Kucharz EJ, Chelmicka A. Hypothetical pathogenetic mechanisms of hepatic encephalopathy. Pol Arch Med Wewn 1998; 100:359-64.

Mumtaz K, Ahmed US, Abid S, Baig N, Hamid S, Jafri W. Precipitating

factors and the outcome of hepatic encephalopathy in liver cirrhosis. J Coll Physicians Surg Pak 2010;20(8):514-8.

Devrajani B R, Shah S Z A, Devrajani T. Precipitating factors of hepatic

encephalopathy at a tertiary care hospital Jamshoro, Hyderabad. J Pak Med Assoc 2009; 59: 683- 86.

Riggio O, Balducci G, Ariosto F, Merli M, Pieche U, Pinto G et al. Lactitol in

prevention of recurrent episodes of hepatic encephalopathy in cirrhotic patients with portal-systemic shunt. Dig. Dis. Sci 1989; 34: 823–9.

Sharma BC , Sharma P, Agrawal A, Sarin SK. Secondary prophylaxis of hepatic encephalopathy: an open-label randomized controlled trial of lactulose versus placebo.Gastroenterology 2009; 137: 885–91.

Rolachon A, Zarski JP, Lutz JM, Fournet J, Hostein J. Is the intestinal lavage with a solution of mannitol effective in the prevention of post-hemorrhagic hepatic encephalopathy in patients with liver cirrhosis? Results of a randomized prospective study. Gastroenterol Clin Biol 1994; 18: 1057–62.

Sharma P, Agrawal A, Sharma BC, Sarin SK. Prophylaxis of hepatic

encephalopathy in acute variceal bleed: a randomized controlled trialof lactulose versus no lactulose. J Gastroenterol Hepatol 2011; 26(6):996-1003.

Thuluvath PJ. Higher prevalence and severity of hepatic encephalopathy in

patients with HCV cirrhosis and diabetes mellitus: is presence of autonomic

neuropathy the missing part of the puzzle? Am J Gastroenterol 2006; 101 :2244-46.

El Soud Ali AA, Mohamed HI, Badr EA, Mohamed MA. Study of the relation

between diabetes mellitus and hepatic encephalopathy in patients with liver cirrhosis. Menoufia Medical Journal 2014; 27(2): 296-300.

Sherlock S, Dooley J. Hepatic Encephalopathy. Disease of the liver and biliarysystem. 11th edition. London: Blackwell Science; 2002. 93.

Fessel JM, Conn HO. An analysis of the causes and prevention of hepatic coma.Gastroenterolgy 1972; 62: 191.

Hung TH, Tseng CW, Tseng KC ,etal.Effect of renal function impairment onnthe mortality of cirrhotic patients with hepatic encephalopathy: a population-based 3-year follow-up study. Medicine(Baltimore). 2014; 93(14):e79.

Shawcross DL , Shabbir SS, Taylor NJ, Hughes RD. Ammonia and the

neutrophil in the pathogenesis of hepatic encephalopathy in cirrhosis. Hepatology 2010; 51: 1062–9.

Onuorah CE, Ayo AJ. Food taboos and their nutritional implications on

developing nations like Nigeria: a review. Nutr Food Sci 2003; 33:235-40.

Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner

C, etal.Norfloxacin vs. ceftriaxone inthe prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006; 131(4):1049-56.

Sumon SM , Sutradhar SR, Chowdhury M, Khan NA, Uddin MZ, Hasan MI, et

al. Relation of different grades of esophageal varices with Child-Pugh classes in cirrhosis of liver. Mymensingh Med J 2013; 22(1):37-41.

Toyonaga A, Iwao T. Portal-hypertensive gastropathy. J Gastroenterol Hepatol1998; 13:865-877.

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