Reversibility of minimal hepatic encephalopathy following liver transplantation in Egyptian cirrhotic patients

AIM To evaluate the reversibility of minimal hepatic encephalopathy(MHE) following liver transplantation(LT) in Egyptian cirrhotic patients. METHODS This prospective study included twenty patients with biopsy-proven liver cirrhosis listed for LT and twenty ageand sex-matched healthy control subjects. All underwent neuro-psychiatric examination, laboratory investigations, radiological studies and psychometric tests including trail making test A(TMT A), TMT B, digit symbol test and serial dotting test. The psychometric hepatic encephalopathy score(PHES) was calculated for patients to diagnose MHE. Psychometric tests were repeated six months following LT in the cirrhotic patient group. RESULTS Before LT, psychometric tests showed highly significant deficits in cirrhotic patients in comparison to controls(P 0.001). There was a statistically significant improvement in test values in the patient group after LT; however, their values were still significantly worse than those of the controls(P 0.001). The PHES detected MHE in 16 patients(80%) before LT with a median value of -7 ± 3.5. The median PHES value was significantly improved following LT, reaching-4.5 ± 5(P 0.001), and the number of patients with MHE decreased to 11(55%). The pre-transplant model for end-stage liver disease(MELD) score ≥ 15 was significantly related to the presence of post-transplant MHE(P = 0.005). More patients in whom reversal of MHE was observed had a pre-transplant MELD score 15.CONCLUSION Reversal of MHE in cirrhotic patients could be achieved by LT, especially in those with a MELD score 15.     

Severity of hepatic encephalopathy before liver transplantation is associated with quality of life after transplantation.

BACKGROUND--Cirrhosis is associated with a chronic low-grade hepatic encephalopathy and disturbances in quality of life. This study investigated the extent to which severity of hepatic encephalopathy before orthotopic liver transplantation correlated with quality of life. METHODS--A battery of neuropsychological tests was administered to nonalcoholic patients to quantify severity of hepatic encephalopathy. The Sickness Impact Profile was administered before and after surgery to document quality of life across multiple health and psychosocial dimensions. RESULTS--There was substantial improvement from the pretransplant to the posttransplant periods across almost all dimensions of quality of life. Neuropsychological test scores explained up to 20% of the variance in magnitude of change from pre (before) to post (after) surgery. CONCLUSION--Severity of hepatic encephalopathy (particularly with respect to static ataxia and fine motor control) is associated with posttransplantation improvement in quality of life.     

Extent of reversibility of hepatic encephalopathy following liver transplantation

Although hepatic encephalopathy (HE) is prevalent in the cirrhotic population, it has also been considered a potentially reversible condition. Liver transplantation represents the ultimate reversal of the decompensated cirrhotic state and should provide the best option for the reversibility of HE. However, the neurologic compromise associated with HE in the cirrhotic patient may not be completely reversible. Theories regarding fixed structural and reversible metabolic deficits as well as persistence of the hyperdynamic state with continued portosystemic shunting have been proposed to explain this lack of complete reversibility. Whether this remnant neurologic deficit is clinically significant remains unclear.     

Reversibility of cachexia after bilateral lung transplantation

BACKGROUND: Cachexia is one of the terminating syndromes in pulmonary disease, and cachectic patients have an increased mortality even after lung transplantation (LTx). Our study assessed weight changes in cachectic patients after LTx compared to normal weight LTx recipients, and investigated differences in gender, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), and primary pulmonary hypertension (PPH). METHODS: We prospectively examined 46 patients before and serially 3, 6, 12 and 24 months after LTx (25 female, 21 male; median age at transplantation 46.9+/-13.9 years, n=17 COPD, n=8 CF, n=9 PPH, n=12 other origin). Patients were subgrouped as cachectic (BMI21, n=25). RESULTS: Body weight increase was restricted to underweight patients: at 3 months (+2.1% vs. pre-transplant weight, p=0.28), 6 (+6.2%), 12 (+8.8%), and 24 months (+11.4%, all p0.05). BMI pre LTx was correlated to weight gain after LTx (r=0.29 to 0.35; all p<0.05). Weight gain was not related to diagnosis (COPD, CF or PPH), gender or age. CONCLUSION: Weight gain after LTx is highest in underweight recipients and a continuous process from 3 months to 2 years after LTx. The weight gain is independent from the primary lung disease, and healing of this disease by LTx can make cachexia reversible. Weight increase after LTx is not affected by gender, immunosuppressive regimen, renal function before LTx, or age.     

Application of fecal microbial transplantation in hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

Rationale:Transjugular intrahepatic portosystemic shunt (TIPS) is mainly used to treat acute and chronic esophageal, gastric, and intestinal variceal bleeding and refractory ascites caused by portal hypertension. The most common complication of TIPS is the development of hepatic encephalopathy (HE). Fecal microbiota transplantation (FMT) is an emerging method for treating diseases by altering the intestinal flora. We present 2 cases of FMT that ameliorated liver function and HE after TIPS.Patient concerns:In this report, 2 patients with liver cirrhosis secondary to hepatitis B had recurrent Grade 2-3 HE after TIPS.Diagnosis:Two patients were diagnosed as having HE.Interventions:The 2 patients separately received 3 times of FMT.Outcomes:The liver function of both patients improved, the clinical symptoms were relieved, and the number of HE attacks decreased significantly after FMT.Lessons:FMT may be another effective way to treat HE, and is worthy of further research.     

Massive progression of diffuse hepatic lymphangiomatosis after liver resection and rapid deterioration after liver transplantation

Hepatic involvement is an exceptional presentation of lymphangiomatosis. In this case report we describe a patient who underwent liver transplantation secondary to progressive hepatic involvement, which occurred 2 yr after partial hepatectomy. Within 1 yr after liver transplantation the disease condition deteriorated, with rapid progression of pre-existing skeletal lesions and development of pulmonary disease. We conclude that liver transplantation may be a treatment option for hepatic lymphangiomatosis. In the presence of pre-existing extrahepatic lesions, however, liver transplantation seems to be contraindicated.     

冠状动脉支架放置术治疗肝移植术后肝动脉狭窄

目的评价肝移植术后肝动脉狭窄时冠状动脉支架应用的可行性和有效性。方法2003年11月至2005年9月,14例肝移植术后肝动脉狭窄患者接受肝动脉冠状动脉支架放置术治疗,其中早期治疗10例,延迟治疗4例。总结肝动脉冠状动脉支架放置术的技术结果、肝动脉通畅及患者临床转归等情况。结果冠状动脉支架放置术成功率达100％。中位随诊146d(9～345 d),2例患者分别于术后26 d和45 d出现再狭窄,其余患者肝动脉均保持通畅；10例早期介入治疗的患者中,2例分别于术后9 d和30 d死于败血症性多器官功能衰竭,1例患者由于反复胆道感染于术后147 d接受再次肝移植,其余患者术后肝功能指标正常且无症状生存。4例延迟治疗的患者中,1例生存至今已345 d,但肝功能反复出现异常,其余3例死于肝脓肿和胆道感染导致的多器官功能衰竭。结论肝动脉冠状动脉支架放置术可以成功治疗肝移植术后肝动脉狭窄,早期介入治疗是取得良好的临床疗效的关键。     

EBV-induced fulminant hepatic failure: favorable outcome after liver transplantation

Viral hepatitis are the leading cause of fulminant hepatitis. Epstein Barr virus is the viral agent involved in infectious mononucleosis, associated with a frequent and usually benign hepatitis, except in case of immunodeficiency, congenital or acquired. We report the case of an immunocompetent young woman who presented an EBV induced fulminant hepatic failure, requiring liver transplantation that was successful. This observation emphasizes that EBV must be known as a possible cause of fulminant hepatitis and that liver transplantation is probably the unique therapeutic option to avoid a usually fatal course.     

Wernicke encephalopathy in a patient after liver transplantation: A case report

Wernicke encephalopathy(WE) is an acute neurological disorder resulting from vitamin B1 deficiency, which is common in chronic alcoholism and is rare in acute liver failure. So far, there are 2 cases of WE reported after liver transplantation. Here, we report a case of a 45-year-old nonalcoholic male patient who developed psychiatric and neurological disturbance 15 d after receiving orthotopic liver transplantation because of hepatitis B-related cirrhosis and portal hypertension. Brain magnetic resonance imaging(MRI) showed symmetric high-signal intensities in the periaqueductal area. The patient was diagnosed with WE and given intravenous high-dose vitamin B1 immediately. His neurological disturbance resolved in 7 d after receiving the vitamin B1. Brain MRI after 5 mo showed nearly complete recovery. Most WE cases may be misdiagnosed in patients after liver transplantation, and we should pay more attention to its onset.     

肝炎肝硬化并发亚临床肝性脑病的诊断研究

目的探讨及评价亚临床性肝性脑病(SHE)早期诊断的方法。方法对116例肝炎肝硬化患者进行3项心理智能测试及3项脑电诱发电位(EP)检测,并与正常人群比较。结果心理智能测试异常率为58.6%,显著高于EP检测异常率25.9%,两者总异常率达68.0%(80/116例)。6项测试中以数字连接试验(NCT)异常率最高(50%);将患者按Child-Pugh进行肝功能分级,B/C级患者(90例)中心理智能测试异常率为68.9%,心理智能测试与EP检测总异常率为77.8%,显著高于A级患者(26例)心理智能测试异常率(23%,P<0.01)及心理智能测试与EP检测总异常率(38.5%,P<0.01)。结论心理智能测试比EP检测敏感,二者在SHE的诊断中有相互补充的作用;NCT是最敏感的单项测试方法;心理智能测试异常率及SHE发生率的高低与肝脏病变及肝功能损害的严重程度相一致。     

Pathogenesis of hepatic encephalopathy in acute liver failure

Hepatic encephalopathy (HE) in acute liver injury signifies a serious prognosis. Brain edema and intracranial hypertension are major causes of death in this syndrome. Comparison of HE in acute liver failure (ALF) with that of cirrhosis allows recognition of important differences and similarities. A key role for ammonia in the pathogenesis of both HE and brain edema is now firmly supported by clinical and experimental data. Additional factors, such as infection, products of the necrotic liver, and synergistic toxins, may contribute to an altered mental state. A low plasma osmolarity, high temperature, and both high and low arterial pressure may affect brain water content. A combined derangement of cellular osmolarity coupled with cerebral hyperemia can explain the development of brain edema in ALF. Increasingly, study of the mechanisms responsible for brain swelling provides critical information for understanding the pathogenesis of HE.     

Role of artificial liver support in hepatic encephalopathy

Hepatic encephalopathy (HE) refers to the reversible neuropsychiatric disorders observed in acute liver failure and as a complication of cirrhosis and/or portal hypertension. This review aims to describe the pathophysiology of HE, the rationale for the use of artificial liver support in the treatment of HE, the different concepts of artificial liver support and the results obtained. Ammonia has been considered central to its pathogenesis but recently an important role for its interaction with inflammatory responses and auto-regulation of cerebral hemodynamics has been suggested. Artificial liver support might be able to decrease ammonia and modulate inflammatory mediators and cerebral hemodynamics. Bioartificial liver support systems use hepatocytes in an extracorporeal device connected to the patient’s circulation. Artificial liver support is intended to remove protein-bound toxins and water-soluble toxins without providing synthetic function. Both systems improve clinical and biochemical parameters and can be applied safely to patients. Clinical studies have shown that artificial liver support, especially albumin dialysis, is able to improve HE in acute and acute-on-chronic liver failure. Further studies are required to better understand the mechanism, however, artificial liver support can be added to the therapeutic bundle in treating HE.     

Incidence and treatment of hepatic artery complications after orthotopic liver transplantation

AIM: To investigate the incidence and treatment of hepatic artery complications after orthotopic liver transplantation. METHODS: From February 1999 to May 2002, orthotopic liver transplantations (OLT) were performed in 72 patients with end-stage liver diseases with an average age of 40.2&#177;13.6 years (ranged from 11 to 68 years), 56 were males and 16 females. The preoperative evaluation for the 72 patients was performed using duplexsonography, abdominal CT scan, and angiography of the hepatic artery. All donor grafts were perfused and preserved in University of Wisconsin solution at 4℃. OLT was performed with standard techniques with or without a veno-venous bypass. Reconstructions of hepatic artery were performed between the branch patches of gastroduodenal/hepatic or splenic/common hepatic artery confluence of the donors and recipients, and an end-to-end anastomosis between other arterial vessels of the donors and recipients was done. Arterial anastomosis was performed with interrupted 7-0/8-0 monofilament polypropylene suture under 3.5 x Ioupe magnification. Diagnosis of the complications of hepatic artery after OLT was based on the clinical presentations, ultrasound findings and arterial angiography. All patients were followed up regularly for duplex ultrasound scan after discharge. RESULTS: The overall incidence of arterial complications in 72 patients after OLTs was 1.4% (1/72). One 3cm pseudoaneurysm at the side of anastomotic site of hepatic artery was found by urgent arteriogram due to hemoperitoneum secondary to bile leakage after OLT. Subsequently the pseudoaneurysm was successfully embolized and the blood flow toward the donor liver in hepatic artery remained. The overall postoperative 30day mortality rate was 8.33%. The one-year survival rate was 83.72% in 50 patients with benign diseases and was 71.43% in 22 patients with malignant diseases following OLT. No death associated with complications of hepatic artery occurred. CONCLUSION: Careful preoperative evaluations and intraoperative microsurgical technique for hepatic artery reconstructions are the keys in prevention of hepatic artery complications after OLT.     

Gazeous necrosis of the liver due to hepatic artery thrombosis after liver transplantation]

An emergency liver transplantation was performed in a 22 year-old female for fulminant hepatitis. The donor had had splenectomy with portal vein thrombosis which was diagnosed and removed during portoscopy. Nineteen days later, abdominal pain with shock and hepatic failure occurred. X-rays showed pneumoperitoneum and aeric images in the liver area. Laparotomy disclosed massive liver necrosis with gaz under the Glisson's capsula. The hepatic artery was thrombosed. In spite of emergency retransplantation, the patient died 8 days later, due to systemic aspergillosis. Thrombosis of hepatic artery was particular by the importance of gaz-forming infection, and emphasizes the role of rejection. The discovery of portal thrombosis allows to outline the precautions necessary in case of splenectomized donors. The severeness of aspergillosis is underscored.