Introduction

Hepatic encephalopathy (HE) is a group of neuropsychiatric disorders caused by liver dysfunction or portosystemic shunting, and it is a common complication in the progression of liver cirrhosis. Pathophysiologically, there is an imbalance between the hepatic production and clearance of ammonia, leading to an increase in serum ammonium levels, which can lead to neurological dysfunction, intracranial hypertension, cerebral oedema and ultimately death (1). There are multiple triggering factors; one of the most well-known is upper gastrointestinal bleeding (UGIB) (2). Therefore, we suggest that the coexistence of UGIB and HE is associated with an increased risk of in-hospital mortality and prolonged hospital stay. This study aims to analyse the risk factors for HE during an episode of UGIB and its impact on the patient's prognosis.

Aims & Methods

Retrospective analysis of a prospective registry of patients with UGIB treated at the Hospital Universitario Virgen de las Nieves (2013-2022). Statistical analysis was performed using R v4.3.2. Categorical variables were compared using the Chi-square or Fisher's exact test. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using the Woolf-Haldane formula for significant variables. Continuous variables were assessed using the Shapiro-Wilk test for normality, and Levene's test was used to check for homogeneity of variances. The t-test for independent samples, with or without Welch's correction, and the Mann-Whitney U test were used for hypothesis testing. Multivariate analysis is performed to identify independent risk factors for variables with statistically significant differences, calculating Odds Ratios (OR) and their 95% confidence intervals (95%CI).

Results

A total of 343 patients with liver cirrhosis and UGIB were analysed, of whom 260 were male and 83 were female, with an overall mean age of 61.51 ± 12.38, developing HE in a total of 66 patients.
After comparing the cirrhotic population that developed HE with those that did not, we observed a series of variables that correlated significantly, as shown in Table 1. Subsequently, after performing multivariate analysis, we noticed that only four variables had a significant independent relationship: bilirubin with an OR (95% CI) of 1.07 (1-1.16) with p0.064; albumin with an OR (95%CI) of 0.41 (0.23-0.7) with p0.0017; ascites with an OR (95%CI) of 1.65(1.01-2.71) with p0.04; and urea on admission with an OR (95% CI) of 1.01 (1-1.102) with p0.0005.

Conclusion

We conclude that patients with cirrhosis admitted for UGIB and who develop HE have higher mortality rates during admission without an apparent increase in hospital stay. Our study indicates that bilirubin, albumin, ascites, and urea are the most accurate predictors of HE development. These findings aligns with Rattanasupar et al. (2), concluding that the Child-Pugh score, which also considers the abovementioned variables, best predicts hepatic encephalopathy after UGIB. Further research is necessary to explore additional risk factors that aid in predicting and modelling the disease based on our findings.

References

1. Elsaid MI, Rustgi VK. Epidemiology of Hepatic Encephalopathy. Clinics in Liver Disease. 2020 May;24(2):157–74.
2. Rattanasupar A, Tiawijit N, Rachatapantanakorn B. Predictive factor for hepatic encephalopathy in cirrhotic patients who presented with acute variceal bleeding. J Med Assoc Thai. 2014 Jun;97(6):567–73.