Aim: To find frequence of common precipitating factors for Hepatic brain disorder in chronic liver disease.
Topographic point and Duration of survey: This survey was conducted at Civil Hospital Karachi over a period of six months from June 2009 to December 2009.
Patients and Methods: This cross sectional survey was conducted in Medical wards of Civil Hospital Karachi over a period of six months from June to December 2009. One hundred and 90 ( n=190 ) grownups including 98 ( 51.6 % ) male and 92 ( 48.1 % ) females, diagnosed instances of chronic liver disease were included in this survey. Hepatic brain disorder was diagnosed clinically on the footing of history, physical scrutiny and relevant research lab and radiological probes, on clinical scrutiny. Data was analyzed on SPSS 16 and consequences were tabulated.
Consequences: A entire figure of 190 grownup diagnosed instances of chronic liver disease, irrespective of cause were included in this survey. Ninety eight ( n= 98, 51.6 % ) were male and 90 two ( 92, 48.1 % ) were females. The average age was 52.35 old ages with STD ± 13.6. The common precipitating factors identified in this survey were as follows. Ninety four ( n= 94, seventy four ( n=74, 49.5 % ) had irregularity, , seventy four ( n=74, 38.9 % ) had infection, seventy four ( n=74, 38.9 % ) had electrolyte instability, 70 ( n=70, 36.8 % ) were on diuretic therapy, 60 two ( n=62, 32.6 % ) had haematemesis and melaena, 50 two ( n= 52, 27.4 % ) had desiccation, , twenty two ( n=22, 11.6 % ) were on high protein diet and 20 ( n= 20, 10.5 % ) used depressants.
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Decision: This survey concludes that most common precipitating factors of hepatic brain disorder in our set up are Constipation, Infection, Electrolyte instability and upper gastrointestinal hemorrhage… These factors are potentially preventable. A proper instruction and intervention program in these patients can cut down the hospitalizations and overall morbidity and mortality.
Cardinal Wordss: Chronic Liver disease, Hepatic brain disorder, precipitating factors.
Common PRECIPITATING FACTORS OF HEPATIC ENCEPHALOPATHY IN PATIENTS OF CHRONIC LIVER DISEASE AT CIVIL HOSPITAL KARACHI
Chronic liver disease is really common universe broad and intoxicant is the taking cause of chronic liver disease in western societies 1 while hepatitis B and C viruses are the major cause of chronic liver disease in Pakistan. World Health Organization ( WHO ) estimates that about 170 million people are infected with HCV 2. The prevalence of chronic hepatic C in Asia Pacific part is variable between 4 to 12 % . 1-3
The serious presentations of chronic liver disease are ascites, icterus, hepatic brain disorder and GI bleed 4.
Hepatic brain disorder is good recognized clinical complication of ague or chronic liver disease1 transporting high morbidity and mortality. About 30 % patients of chronic liver disease dice of hepatic encephalopathy 5-6. Hepatic Encephalopathy could be acute, sub ague, or chronic or it may be clinical or subclinical7. Those patients who suffer from chronic liver disease may hold a chronic neuropsychiatric province due to portosystemic shunting or have an acute onslaught with precipitating factors labeled as hepatic encephalopathy 6-8.
Hepatic Encephalopathy could hold different clinical presenting characteristics such as cognitive damage and coma with intellectual hydrops 7. Patients with chronic liver disease experiences frequent episodes of hepatic brain disorder precipitated by different factors 9.
The Common precipitating factors of hepatic brain disorders are irregularity, electrolyte instability, self-generated bacterial peritoneal inflammation, GI bleed, depressants, infection and self medicines 10-11. Other factors that could be responsible for precipitating hepatic brain disorder are purging, diarrhoea, over diueresis 12, high protein diet and inordinate peritoneal abdominocentesis.
In Pakistan few surveies have been done looking into assorted hazard factors for hepatic brain disorder. We at Civil Hospital Karachi have noticed increasing figure of people being admitted with Chronic liver disease and its complications in past old ages. Since this infirmary caters to a big figure of patients coming from the rural countries of Sindh and Balochistan, with really low socio economic category and from different civilizations and cultural backgrounds, the precipitating factors may differ in nature and frequence. There forward this survey was conducted to place the different precipitating factors for the proper direction every bit good as for the instruction of the patients to forestall farther episodes.
Patients AND METHODS
This survey was conducted in Medical wards of Civil Hospital Karachi from June 2009 to December 2009. One hundred and 90 ( n=190 ) grownup patients of chronic liver disease antecedently and diagnosed on clinical, biochemical and radiological bases who presented with the hepatic brain disorder were included.
Biodata and elaborate history was taken. A proper clinical scrutiny was carried out and biochemical, and haematological trials were requested which included complete blood image, urea, creatinine and electrolytes, liver map trials, prothrombin clip and international normalized ratio, serum protein, albumen and globulin ratio, hepatitis B and C serology by ELISA technique. Urine analysis was besides done.
Ultrasound scan of venters was done to asses the size and echo texture of the liver, to mensurate the size of the portal vena, lien and to see the presence of ascites. Abdominal abdominocentesis was done where it was needed and all the information was tabulated on printed performa.
Hepatic brain disorder was diagnosed on clinical scrutiny such as crossness restlessness, altered province of consciousness and asterixis and graded from I to IV as shown in Table 1. Constipation was defined as failure to go through stool in 48 hours, infection as presence of temperature of & A ; gt ; 99 F and raised leucocyte count, electrolyte instability as high or low degree of serum Na or serum K as per the mention degree, upper GI bleed as history of hemetemesis or melaena, desiccation as presence of dry lingua and loss of skin turgor, high protein diet as recent unrestricted and high consumption of proteins in any signifier,
Data was analyzed on SPSS 16 and consequences were tabulated to measure frequence of common precipitating factors.
Consequences: A entire figure of One hundred and 90 ( n=190 ) grownups diagnosed instances of chronic liver disease who presented with hepatic encephalopathy irrespective of cause were included. Ninety eight ( n=98, 51.6 % ) were males and 90 two ( n=92, 48.1 % ) were females. The average age was 52.35 with STD ± 13.6. The cause of chronic liver disease is mentioned in Graph 1.
Ninety four patients ( n=94, 49.5 % ) had irregularity, Seventy four ( n= 74, 38.9 % ) had electrolyte instability, seventy four ( n=74, 38.9 % ) had infection, 70 patients ( n= 70, 36.8 % ) were on diuretic therapy. sixty two ( n=62 32.6 % ) had GI bleed, 50 two ( n= 52, 27.4 % ) had desiccation, twenty two ( n= 22, 11.6 % ) were on high protein diet and 20 ( n=20, 10.5 % ) used depressants. ( Table 3 )
Hepatic brain disorder is a serious complication of chronic liver disease. Patients with chronic liver disease experiences frequent episodes of hepatic brain disorder precipitated by different factors 9. These factors may change depending upon the disease position, bing co-morbid, instruction and consciousness about the disease, socioeconomic status and handiness of the health care installations to the patients. It is really of import to place these precipitating factors in an person for a proper direction of hepatic brain disorder and to forestall farther episodes, failure of that would increase the morbidity and mortality in these instances.
The importance of gut factors in pathogenesis of hepatic brain disorder is suggested by the betterment of hepatic brain disorder associated with emptying of intestine and dietetic proteins limitation 13. For decennary ammonium hydroxide has been thought to play an of import function in pathogenesis of hepatic encephalopathy 14. It is good recognized that ammonium hydroxide modulates neural map and is a pro-convulsant 15. The GI piece of land and skeletal musculuss are major beginning of plasma ammonium hydroxide. In liver failure degree of ammonium hydroxide in plasma tends to increase 14 and plasma ammonia readily enters the brain16 Lactulose is a normally prescribed agent to alleviate irregularity in patients with chronic liver disease. It has an added advantage as a non absorbable disaccharide suppressing enteric ammonium hydroxide production by figure of mechanisms 17-18.
In our survey about half of the patients ( 49.5 % ) who presented with hepatic brain disorder had a anterior history of irregularity. The old surveies have shown the figures from 18.3 % – 38 % 6-10-19. The higher figures in our survey may be explained on the footing of different dietetic wonts of the survey population who belonged to really hapless socioeconomic position, deficiency of instruction sing the function of diet in chronic liver disease and perchance inability to take lactulose on a regular basis and in required doses because of fiscal constrains.
Infection was the 2nd common precipitating factor in our survey, present in 38.9 % of patients, more common in males than females. Previous local surveies have shown infection as a precipitating factor in 24- 44 % . In AKUH study Spontaneous bacterial peritoneal inflammation was noted in 20.5 % and urinary piece of land infection was noted in 15.3 % ( Table 3 ) .
Nephritic damage is the commonest precipitating factor in western population 20. However this factor was non independently assessed in our survey nor in any other local survey. Renal damage is by and large associated with desiccation and electrolyte instability which independently are risk factors for hepatic brain disorder and as such were assessed individually.
In our survey we found that more than one tierce of our patients ( 38.9 % ) had electrolyte instability as a precipitating cause of hepatic brain disorder. Most of them ( 70/74 ) were on diuretic therapy. These figures are lower than antecedently reported. ( Lady reading, PIMS ) . Dehydration perchance due to diuretic therapy contributed to development of brain disorder in 27.8 % patients.
High protein intake ( without farther inside informations of the content and sum of protein ) was noted in our patients in merely 11.6 % . Protein limitation is by and large considered as an indispensable portion of standard direction of chronic liver disease patients although protein limitation may decline the nutritionary position of the patient. A Spanish survey 21 concluded that diet with normal content of protein can be administered safely to cirrhotic patients with episodic hepatic brain disorder. This determination may be really relevant in our apparatus where the dietetic protein content of our patients belonging to hapless socioeconomic position is already really hapless. More so these patients are already badly malnourished and protein limitation may farther decline the nutritionary position without ensuing in any important betterment of hepatic brain disorder.
CONCLUSION AND RECOMMENDATIONS:
Hepatic brain disorder is precipitated by many factors. Constipation, infection electrolyte instability and upper gastrointestinal hemorrhage are the common causes in our apparatus. These are potentially preventable and reversible. A proper instruction and direction program of these patients in this respect may forestall many hospitalizations and cut down the overall morbidity and mortality in patients with chronic liver disease.
Table 1. Rating of the Hepatic Encephalopathy
Mild confusion, euphory, anxiousness or depression, reversed sleep beat, slurred address.
Drowsiness, lassitude, gross shortages in ability to execute mental undertakings, comparatively moderate confusion.
Somnolent but arousable, terrible confusion, inability to execute mental Tasks.
Coma with ( IVa ) or without ( IVb ) response to painful stimulations.
Hepatitis B = 30 four ( 17.9 % ) Hepatitis C = one 30 eight ( 72.6 % ) Mixed Hepatitis B and C = 18 ( 9.5 % )
Entire Male and Female patient. Ninety eight ( n=98, 51.6 % ) were males and 90 two ( n=92, 48.1 % ) were females
Table 2. Precipitating Factors of Hepatic Encephalopathy
94/190 ( 49.5 % )
74/190 ( 38.9 % )
74/190 ( 38.9 % )
70/190 ( 36.8 % )
62/190 ( 32.6 % )
High Protein Diet
22/190 ( 11.6 % )
20/190 ( 10.5 % )
Table No. 3. Comparison of Common precipitating factors of Hepatic Encephalopathy in Civil Hospital with other surveies.
Common Precipitating factors of Hepatic Encephalopahty
Civil Hospital Karachi
( n=190 )
Aga Khan Hospital Karachi
( n= 404 )
Lady Reading Hospital Peshawar
( n= 50 )
Pakistan Institute of Medical Sciences Islamabad
( n=50 )
Spontaneous Bacterial Peritonitis
Urinary Tract Infection
50 % ( Hyponatremia )
High Protein Diet