Abstract

INTRODUCTION: Hepatic encephalopathy (HE) is one of the major and frequent complications of liver diseases. HE comprises of 2 clinical patterns: Covert hepatic encephalopathy(CHE) and Overt hepatic encephalopathy (OHE). The lack of clinical signs makes CHE hard to diagnose and carrying risk to progress into OHE is vital. CHE is important to diagnose, even to interfere. Given the lack of diagnostic measures to use, we wanted to search the optimal diagnostic tool.

METHODS: In this study we evaluated cirrhotic patients, divided into two categories (cirrhotic patients with CHE and cirrotic patients without CHE) by using West Haven Criteria and compared them to healthy controls. We applied psychometric hepatic encephalopathy score (PHES) and Critical flicker frequency (CFF) test for both patient and control groups and took blood samples to measure plasma ammonia, serum 3-nitro tyrosine (3-NT), endotoxin, interleukin 6 (IL-6) and 18, tumor necrosis factor alpha (TNF-α) levels, prospectively. 

RESULTS: There were 40 female, 36 male cirrhotic patients and 13 healthy controls (6F, 7M). Twenty-one of females and 20 of males were diagnosed as CHE; 19 female and 16 male cirrhotics did not have CHE by using West Haven criteria. When CFF test was applied to patients and healthy volunteers, patients with CHE clinic according to West-Haven criteria, completed by reacting late compared to non-CHE patients (p<0.001). There were statistically significant differences in time to finish Line Tracing Test (LTT) (p=0.025), Serial Dotting Test (SDT) (p=0.045), Digit Symbol Test (DST) (p=0.034) among the patients with and without CHE. But there was no significant difference in time to finish Number Connection Test (NCT). Significant differences were found in IL-6, TNFα and endotoxin levels among healthy volunteers and cirrhotic patients (p<0.05). IL-6 (p= 0.032) and endotoxin levels (p=0.028) were higher in cirrhotic patients than healthy volunteers; whereas TNF-α levels were higher in volunteers than cirrhotic patients (p=0.019). But there was no statistically significant difference IL-6, TNF-α, IL-18, endotoxin, ammonia and 3-NT levels among cirrhotic patients with and without CHE. We analyzed whether inflammatory markers correlated with PHES, only TNF-α (p is 0.039 for NCT and 0.028 for LTT) and 3-NT (p is 0.029 for LTT and 0.026 for DST) levels correlated with some psychometric tests.

CONCLUSION: CFF and PHES tests are still gold standart (maybe except NCT) to detect CHE cirrhotic patients. Besides these tests; IL-6, TNF-α, endotoxin and probably 3-NT levels could be used for detecting CHE patients.