Patients with Autonomic Neuropathy Are More Likely to Develop Hepatic Encephalopathy

Abstract

Autonomic neuropathy (AN) is common in patients with chronic liver disease. For hitherto unknown reasons, in longitudinal studies, the presence of AN has been found to be an independent predictor of mortality in patients with cirrhosis. We hypothesized that patients with AN are more likely to develop hepatic encephalopathy (HE) due to prologed intestinal transit time. In this study, we examined the incidence of new-onset HE in patients with and without AN. Seventy-two patients (Child A/B/C = 35/31/6) without evidence of HE at the time of autonomic function testing (AFT) were followed for 39.5 +/- 27.3 months. The end point of the study was the development of new onset HE. Patients were followed until death or liver transplantation. Of the 72 patients, 42 (58%) patients did not develop HE (group A) while 30 (42%) developed HE (group B) during the follow-up. Both groups had similar baseline demographics. AN was more common in group B (27/30; 90%) compared to group A (28/42; 67%) (P = 0.02). Kaplan-Meier analysis showed a trend toward a higher incidence of HE in patients with AN. Mortality was higher in group B (12/30; 40%) compared to group A (8/42; 19%) (P = 0.04). Patients with AN were more likely to develop new onset HE. Although an independent effect of AN on HE was not established in this study, we speculate that delayed intestinal transit secondary to AN may explain the higher incidence of HE in patients with AN.

Decreased heart rate variability in patients with cirrhosis relates to the presence and degree of hepatic encephalopathy

“…Its presence may lead to prolongation of gastrointestinal transit time, small bowel bacterial overgrowth, bacterial translocation and endotoxemia, all of which may predispose to hepatic encephalopathy. Indeed, Maheshwari and colleagues (33) reported that patients with cirrhosis and evidence of an autonomic neuropathy are more likely to develop hepatic encephalopathy than those without. They did not, however, objectively quantify their patients' neuropsychiatric status.…”

Malnutrition and diabetes mellitus are related to hepatic encephalopathy in patients with liver cirrhosis

“…Autonomic dysfunction is also common in diabetics and it has been associated with delayed orocecal transit in these patients (36, 37). Autonomic dysfunction has been proposed to be a predictor of delayed orocecal transit (38) and development of HE in patients with cirrhosis (39). Thus, diabetes might be an additional risk factor for development of autonomic dysfunction and thereby delayed orocecal transit and HE in liver cirrhosis.…”

Role of small intestinal bacterial overgrowth and delayed gastrointestinal transit time in cirrhotic patients with minimal hepatic encephalopathy

“…Recently, Maheshwari and Thuluvath have shown that the presence of autonomic neuropathy was an independent predictor of delayed OCTT in patients with cirrhosis [40]. In a retrospective longitudinal study, cirrhotic patients with autonomic dysfunction were found to have a higher incidence of new onset of hepatic encephalopathy [41]. Second, metabolic derangements in cirrhotic patients as a consequence of porto-systemic venous shunting secondary to portal hypertension may be responsible for delayed OCTT [42].…”