The study is a cross-sectional comparative study for evaluation and screening of minimal hepatic encephalopathy in road traffic accident victims attending the emergency departments in the Suez Canal University Hospital. Seventy-four consecutive patients were included in the study according to the inclusion and exclusion criteria.
We included all patients involved in road traffic accidents (drivers, history of fall, pedestrians whom accidents occur during crossing the road); patients with clinically proven hepatic cirrhosis, without clinical manifestation of HE; and patients with age range between 18 and 65 years.
We excluded patient with grade1, 2, 3, or 4 HE; patients presented with head trauma, fracture of the dominant hand used in writing, and recent GIT bleeding (within the previous 4 weeks); and patients with renal disease (serum creatinine > 1.5 mg/dl), respiratory disease, congestive heart failure, diabetes, hypertension, and severe malnutrition. Patients with neurological disease and psychiatric problems (e.g., Alzheimer’s disease, Parkinson’s disease, depression) which may affect mental functions or ophthalmological disorders were also excluded. No patients had been prescribed lactulose or neomycin in the previous 6 weeks, and none was receiving antibiotic or sedatives in the week prior to the study. Patients with psychoactive drugs, anti-depressants, or sedatives in the last 6 weeks were excluded. Patients with a history of alcohol intake were excluded. Patients with hepatocellular carcinoma, transjugular intrahepatic portosystemic shunt (TIPS), or shunt surgery were excluded. Patients receiving antiviral treatment before or during the study were excluded. Patients with serum sodium < 130 mmol/L and serum potassium < 3.2 mmol/L or > 5 mmol/L were excluded. Pregnant females and illiterate subjects ere excluded.
Thorough history taking and neurological examinations were done for the exclusion of patients with neurological disease and psychiatric problems (e.g., Parkinson’s disease, depression). Mental state examination using standardized mini-mental state examination (SMMSE) was done for the exclusion of patients with Alzheimer’s disease.
Laboratory investigations include routine laboratory investigations (complete blood count (CBC), liver function tests, hepatitis markers, kidney function tests, random blood sugar, serum sodium, serum potassium, and serum calcium) and determination of interleukin-6 (IL-6) in serum and ammonia in blood.
Imaging done in the ER includes pelvi-abdominal ultrasound for the exclusion of patients with hepatocellular carcinoma and pregnant females and brain CT for the exclusion of patients with traumatic brain injury.
Psychometric hepatic encephalopathy score
Psychometric hepatic encephalopathy score (PHES) was the base for diagnosis of MHE; it includes “digit symbol test (DST), number connection test-A (NCT-A), number connection test-B (NCT-B), serial dotting test (SDT), and line drawing test (LDT).” A score is defined as “the number of standard deviations of the difference between the two values for each test”; MHE was diagnosed with the sum of all scores less than or equal to − 4 points . According to the guidelines of the International Society for Hepatic Encephalopathy and Nitrogen Metabolism , “the results of NCT-A will be considered abnormal when the test scores are more than the mean + 2 standard deviations (SD) from the age-matched normal values, and DST will be considered abnormal when the test scores are less than the mean − 2 SD from the age-matched normal values.”
The number connection test
The NCT-A is the “testing of visuo-spatial orientation and psychomotor speed.” The patient is given a paper with 25 numbered circles randomly spread on the paper. The patient is asked to connect the circles from 1 to 25 as quick as possible. The test result is “the time needed by the subject including error correction time” . The NCT-B is nearly like the NCT-A. The numbers from 1 to 13 and the letters from A to L were included in the circles. “The patients are asked to connect the numbers and letters in an alternating manner, that means go from 1-A-2-B-3-C and so on.” The test result represents the time needed including error correction time .
The digit symbol test
The patients take a series of double boxes with a number given in the upper part. “The task is to draw a symbol pertinent to this number into the lower part of the boxes. Nine fixed pairs of numbers and symbols are given at the top of the test sheet.” The number of boxes correctly filled within 90 s is the test result .
The line drawing test
The patients are asked to track a route in a labyrinth without borderline crossing or touching. The route is divided into small sections, and when the patient touches or crosses the border in a certain section, this is counted. The test results include mistake number and the time required to go through the labyrinth .
The circle dotting test
This test is the testing of pure motor speed and considered the simplest test of the battery. The patient is given a sheet composed of 100 circles, and the patient is asked to put a dot in each circle; the patient is prepared by dotting the 20 circles at the top of the sheet, and the time needed is the test result .
IBM SPSS statistics (V. 21.0, IBM Corp., USA, 2012) was used for data analysis. Quantitative data was expressed as median or means ± standard deviation (SD) as appropriate. Qualitative data was expressed as frequency (numbers) and percentages. The results of all categorical variables were given in the form of rates (%). Student t test will be used to test the significance of difference for quantitative variables that follow a normal distribution. Chi-squares and Fisher’s exact tests were used to test the significance of difference for qualitative variables.
The independent data of the study was conducted and analyzed. Definitive statistics will be used for the analysis of the sociodemographic and other variables. Firstly, the relation between the dependent and independent variables was studied using the chi-square test and the t test. Second, the significant variables were subjected to multivariate logistic regression analysis.
Data had been collected without any harm to the patients and after explaining the aim of the study to the patients, and an informed written consent was obtained; they did are not exposed to any harm or additional invasiveness.
The study was approved by the ethical committee of Faculty of Medicine, Suez Canal University on 18 June 2013 (Research# 996).