显性肝性脑病缓解后认知障碍的持续存在。
Persistence of cognitive impairment after resolution of overt hepatic encephalopathy.
机构信息
Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia 23249, USA.
出版信息
Gastroenterology. 2010 Jun;138(7):2332-40. doi: 10.1053/j.gastro.2010.02.015. Epub 2010 Feb 20.
BACKGROUND & AIMS: In patients with cirrhosis, hepatic encephalopathy (HE) has acute but reversible as well as chronic components. We investigated the extent of residual cognitive impairment following clinical resolution of overt HE (OHE).
METHODS
Cognitive function of cirrhotic patients was evaluated using psychometric tests (digit symbol, block design, and number connection [NCT-A and B]) and the inhibitory control test (ICT). Improvement (reduction) in ICT lures and first minus second halves (DeltaL(1-2)) were used to determine learning of response inhibition. Two cross-sectional studies (A and B) compared data from stable cirrhotic patients with or without prior OHE. We then prospectively assessed cognitive performance, before and after the first episode of OHE.
RESULTS
In study A (226 cirrhotic patients), 54 had experienced OHE, 120 had minimal HE, and 52 with no minimal HE. Despite normal mental status on lactulose after OHE, cirrhotic patients were cognitively impaired, based on results from all tests. Learning of response inhibition (DeltaL(1-2) > or =1) was evident in patients with minimal HE and no minimal HE but was lost after OHE. In study B (50 additional patients who developed > or =1 documented OHE episode during follow-up), the number of OHE hospitalizations correlated with severity of residual impairment, indicated by ICT lures (r = 0.5, P = .0001), digit symbol test (r = -0.39, P = .002), and number connection test-B (r = 0.33, P = .04). In the prospective study (59 cirrhotic patients without OHE), 15 developed OHE; ICT lure response worsened significantly after OHE (12 before vs 18 after, P = .0003), and learning of response inhibition was lost. The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing.
CONCLUSIONS
In cirrhosis, episodes of OHE are associated with persistent and cumulative deficits in working memory, response inhibition, and learning.
背景与目的
在肝硬化患者中，肝性脑病（HE）既有急性但可逆转的成分，也有慢性成分。我们研究了显性肝性脑病（OHE）临床缓解后残留认知障碍的程度。
方法
使用心理测试（数字符号、积木和数字连接[NCT-A 和 B]）和抑制控制测试（ICT）评估肝硬化患者的认知功能。使用 ICT 诱饵的改善（减少）和第一减去第二半部分（DeltaL(1-2)）来确定反应抑制的学习。两项横断面研究（A 和 B）比较了有或无 OHE 既往史的稳定肝硬化患者的数据。然后，我们前瞻性评估了 OHE 首次发作前后的认知表现。
结果
在研究 A（226 例肝硬化患者）中，54 例患者发生过 OHE，120 例患者患有轻微 HE，52 例患者无轻微 HE。尽管在 OHE 后乳果糖治疗后精神状态正常，但所有测试均表明肝硬化患者存在认知障碍。在有轻微 HE 和无轻微 HE 的患者中可以观察到反应抑制的学习（DeltaL(1-2)≥1），但在 OHE 后则会丧失。在研究 B（50 例在随访期间发生≥1 次有记录的 OHE 发作的额外患者）中，OHE 住院次数与 ICT 诱饵的严重程度相关（r = 0.5，P =.0001）、数字符号测试（r = -0.39，P =.002）和数字连接测试-B（r = 0.33，P =.04）。在前瞻性研究（59 例无 OHE 的肝硬化患者）中，15 例发生 OHE；OHE 后 ICT 诱饵反应明显恶化（12 次治疗前 vs 18 次治疗后，P =.0003），反应抑制的学习能力丧失。44 例未发生 OHE 的患者在连续测试中认知功能没有恶化。
结论
在肝硬化中，OHE 发作与工作记忆、反应抑制和学习的持续和累积缺陷有关。
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