Associate Professor, Department of Medicine, R. K. D. F. Medical College Hospital & Research Centre, Bhopal (M. P.), Jatkhedi, Nh-12, Hosingabad Road, Bhopal, Madhya Pradesh, INDIA.

Email: drmanjirikulkarni1984@gmail.com

Table A:Clinical Grades of Hepatic Encephalopathy West Haven classification

Table B: Child-Pugh Score

RESULTS

Total 100 patients were studied. Mean age of the patient was 38 ± 2 years. Table 1 shows distribution of patients according to age. Majority of the patients were in the age group of 41- 50 years (36%) followed by 31-40 years (23%). Patients were less in the age group below 20 years (3%) and above 60 years (6%). Out of total 100 patients 73 were male and 27 were females. Male to female ratio was 2.7:1. Figure 1 shows clinical features among the patients. Jaundice and ascites were common clinical features in all patients. Anaemia was seen in 62% patients. Upper gastrointestinal bleed was seen in 30 % patients. Splenomegaly and hepatomegaly were seen in 64% and 35% patients respectively. Fever was observed in 42% patients. Constipation was observed in 35% patients. Common precipitating factors were Upper GI bleed (30%), fever indicating infection (42%) and constipation (35%). Among the patients with infection most commonly recorded was spontaneous Bacterial Peritonitis (SBP)(53%) followed by urinary tract infection (33%) and pneumonia and septicaemia (14%). In our study alcoholic liver disease was most common etiological factor (43%). Hepatitis B infection was seen in 33% and Hepatitis C infection in 12% patients. Six patients showed alcoholic liver disease with hepatitis B infection. Unknown etiology was observed in 6% patients. According to Child Pugh score, 58 % patients were in group A followed by Group B (34%) and Group C (8%). Table 4 showed distribution of patients according to West Haven classification. Majority of the patients were in Grade IV (36%), followed by Grade III (32%). Grade I included 20% patients and Grade II included 12%. Our study revealed majority patients were of type C (82%) Hepatic encephalopathy followed by type A (18%). All patients were followed up to discharge from hospital. Out of 100 patients 54 patients survived and 46 patients died. According to Child Pugh Score patients with Group A had 100% survival. Group B has 27% mortality and Group C has highest mortality of 73%. In our study we found that Grade I of West Haven classification has zero mortality. Mortality increases as the grade increases in the patients (Grade II : 28%, Grade III : 38% and Grade IV : 94%). All parameters like haemoglobin, serum Na, serum K and Liver enzymes were elevated in all patients. Parameters were elevated in patients who died as compared to those who survived.

Table 1: Distribution of patients according to age group

Figure 1: Distribution of patients according to clinical features

Table 2: Distribution of patients according to etiology

Table 3: Distribution of patients according to Child Pugh Score

Table 4: Distribution of patients according to West Haven classification

Table 5: Distribution of patients according to Type of hepatic encephalopathy

Figure 2: Distribution of patients according to outcome

DISCUSSION

Mean age of the patient was 38 ± 2 years. Similar findings were seen in Onyekwere CA et al..⁷Majority of the patients were in the age group of 41- 50 years (36%) followed by 31-40 years (23%). Similar findings were seen in Saira Afzal et al. ⁸(64%), Alam et al. ⁹(64%). Most commonly affected population was 41-60 years in a study by Bikham Devrajani et al.¹⁰. In our study Male to female ratio was 2.7:1. Similar findings were seen in various studies like Dhiman RK et al. ¹¹and Shivani Patel et al. where male preponderance was seen. Jaundice and ascites were common clinical features in all patients. Anaemia was seen in 62% patients. Upper gastrointestinal bleed was seen in 30 % patients. Splenomegaly and hepatomegaly were seen in 64% and 35% patients respectively. Similarily jaundice and ascites were found as commonest features in patients in studies like Alam et al.⁹ and Khurram et al..¹² Anaemia was seen in 85% of cases by Jadumani Nayak et al..¹³ In our study alcoholic liver disease was most common etiological factor (43%). It is in accordance with study by Medha Rao et al. where 58.1% patients showed alcohol associated cirrhosis. Hepatitis B infection was seen in 33% and Hepatitis C infection in 12% patients. In a study by Sarin SK et al.¹⁴ HBV was common prevalent factor for hepatic encephalopathy. Study by Mumtaz et al. ¹⁵ showed Anti HCV was positive in 70% patients. Hepatitis C virus was the commonest of Cirrhosis by Muhammad Khurram et al..¹²Unknown etiology was observed in 6% patients. In a study by Ashish et al.¹⁶ cryptogenic causes were 35% in chronic liver diseases. According to Child Pugh score, 58 % patients were in group A followed by Group B (34%) and Group C (8%). Majority of the patients were in Grade IV (36%), followed by Grade III (32%). Grade I included 20% patients and Grade II included 12%.Our study revealed majority patients were of type C (82%) Hepatic encephalopathy followed by type A (18%). Out of 100 patients 54 patients survived and 46 patients died. Similar findings were seen in study by Onyekwere CA et al.⁷(51%). According to Child Pugh Score patients with Group A had 100% survival. Group B has 27% mortality and Group C has highest mortality of 73%. In accordance with our study higher mortality was seen in Group C by Fakhar Ali Qazi Arisar et al.¹⁷ In our study we found that Grade I of West Haven classification has zero mortality. Mortality increases as the grade increases in the patients (Grade II : 28%, Grade III : 38% and Grade IV : 94%). Similar findings were seen in Alam et al. ⁹and Bikha Ram Devrajani et al. ¹⁰.

CONCLUSION

Factors affecting mortality in hepatic encephalopathy were Male sex, alcohol intake, Child-Pugh Class C, Grade III and IV hepatic encephalopathy HBsAg, HCV antibody, low haemoglobin and elevated liver and renal parameters

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