Comparative Study of MELD Score and Glasgow Coma Scale in Patients with Hepatic Encephalopathy

Background and study aim: Hepatic encephalopathy occurs in approximately 30-45% of patients with cirrhosis and 10–50% of patients with transjugular intrahepatic Porto systemic shunt, while minimal hepatic encephalopathy affects approximately 20–60% of patients with liver disease. There are multiple prognostic scores that predict the mortality from chronic liver disease, of which the Child-Pugh score and the Model for End-stage Liver Disease (MELD) score are the most commonly used. The most widely used scale used to evaluate HE is the West-Haven (WH) scale, with scores ranging from 0 to 4. This study is designed to compare Glasgow coma scale to West-Haven scale in prediction of prognosis and survival of patients with hepatic encephalopathy. Patients and Methods: This study was conducted on 100 patients with liver cirrhosis and overt Hepatic Encephalopathy admitted to The Department of Hepatology, Gastroenterology and Infectious Diseases of Mansoura Health Insurance Hospital, divided into four groups according to the grade of encephalopathy by West-Haven Criteria.  Results: There was no difference in prediction of survival among the studied patients assessed by GCS, MELD score, uMELD score and Child score (all had the same results). Conclusion: Glasgow Coma Scale can be a prognostic tool for morbidity and mortality, as well as, follow-up in patients with HE


INTRODUCTION
Hepatic encephalopathy (HE) is a serious complication of decompensated cirrhosis that manifests as a wide range of neuropsychological clinical findings ranging from minimal HE to coma [1].HE can be classified as either 'overt' or 'minimal'.Overt He (oHE) is a syndrome of neurological and neuronpsychiatric abnormalities that can be detected by bedside clinical tests.By contrast, patients with minimal He (mHE) present with normal mental and neurological status upon clinical examination but specific psychometric tests yield abnormal results [2].Despite the important progresses of neuron imaging methods, clinical scales are commonly considered the best way to assess the degree of impairment and its impact on daily life activities for the majority of neurological diseases.
Previous studies recommended using clinical scales for grading hepatic encephalopathy and to report efficacy in therapeutic trials such as the West-Haven criteria and Glasgow Coma Scale to assess the severity of HE [3].
The model for end-stage liver disease (MELD) score was introduced to evaluate hepatic functions in cirrhotic patients.It has the advantage of using three objective and easily measured parameters: creatinine levels, international normalized ratio (INR) and total bilirubin [4].The Model for End-Stage Liver Disease (MELD) score has been adopted as an objective indicator of liver disease severity [1].
Aim of the work: this study aims at assessing the significance of Glasgow coma scale in evaluation of patients with hepatic encephalopathy in comparison to the standard West-Haven criteria and its ability to predict morbidity and mortality in patients with hepatic encephalopathy in comparison with MELD score.

PATIENTS AND METHODS
This study was carried out on 100 patients with liver cirrhosis and overt Hepatic Encephalopathy.They were 85 males (85%) and15 females (15%), and their ages ranged between 18 and 60 years.All cases were selected from the Department of Hepatology, Gastroenterology and Infectious Diseases, Mansoura Health Insurance Hospital, within the period between January 2014 to June 2014.
The exclusion criteria were severe cardio-pulmonary disease, sepsis, renal disease, hepatocellular carcinoma, diabetes mellitus, patients listed to undergo transplantation.
Patients were subjected to the following: Full history taking, thorough clinical examination.Routine laboratory investigations, that included: Complete blood picture.Liver profile tests: prothrombin time and concentration S. creatinine, viral markers, arterial blood ammonia.

Samples collection, preparation and handling:
A sample of arterial blood was sampled soon after admission under aseptic condition in preheparinized syringes from indwelling radial or femoral arterial catheters.Admission samples were taken within 24 hours of admission.Ammonia was measured with Ammonia Test Kit II for the PocketChem BA device (Arkay, Inc., Kyoto, Japan).

Abdominal Ultrasonography:
Liver was assessed for: size (span), echogenicity, surface, thickening of portal tracts, portal vein diameter, hepatic veins, inferior vena cava and presence or absence of focal lesions.
Spleen was assessed for: size, echogenicity, splenic vein diameter and presence or absence of collaterals.Other data concerning the gall bladder, both kidneys, pancreas, para aortic region as well as detection of ascites all were fulfilled.In the statistical comparison between the different groups, the significance of difference was tested using one of the following tests :

The severity of liver cirrhosis in Hepatic
A-Student's t-test:-Used to compare between mean of two groups of numerical (parametric) data.B-Mann Whitney U test: Used to compare between two groups of numerical (nonparametric) data.C-Kruskal Wallis test: Used to compare between more than two groups of numerical (non-parametric) data followed by Mann Whitney for multiple comparisons.
Significance level: For all above mentioned statistical tests done, the threshold of significance is fixed at 5% level (p-value).The results were considered: Non-significant when the probability of error is more than 5% (p > 0.05).Significant when the probability of error is less than 5% (p≤0.05).Highly significant when the probability of error is less than 0.1% (p ≤0.001).

RESULTS
The study was conducted on 100 patients (cases group) 85 males (85%), 15 females (15%).the age ranged between 47 and 77 years old in group (1) cases with the mean age being 60.28±7.54years in comparison with group (4), the age ranged between 50 and 66 years old with mean age 56.50±6.95years.Table (1) All patients complained from disturbed consciousness.
The mean value of Serum Creatinine was significantly higher in group (3) group than in other groups.No statistical significant difference between the four groups as regards ALT, AST, alkaline phosphatase, total bilirubin, prothrombin concentration, INR and albumin (Table 2).
As shown in table (2) there was statistical significant difference between the four groups as regards the arterial blood ammonia.It was significantly more predominant in group (4) cases (356.50±47.93)than in group (1) cases (90.73±18.42).
As shown in table (3) The most cases of Child A were in group (2), most cases of Child B were in group (1), and most cases of Child C were in group (3) with statistical significant difference between the four groups.The mean value of Child score was predominant in group (3) cases (10± 1.087) with highly statistical significant difference between the four groups.As regards the severity of liver disease, MELD score was predominantly high in group (3) cases (24.43± 6.45) in comparison with group (1) patients (18.52± 4.62).Also uMELD score was high in group (3) cases with statistically significant difference between the four groups.There was statistical significant difference between the four groups as regards the severity of neurological dysfunction assessed by Glasgow Coma Scale.The GCS was predominantly high in group (1) cases, and less in group (4) cases.
As shown in table (4) average cirrhotic liver was detected in 78.9% of group (1) cases in comparison with group (4) cases (25.0%).Enlarged cirrhotic liver was detected predominant in group (4) cases, while shrunken liver was present predominant in group (3) cases and was statistically significant.Splenomegaly was detected in 100% of group (1-3-4) cases compared to 97.1% of group (2) cases which was statistically not significant.Portal Vein Dilatation was detected predominant in group (4) cases (100%) in comparison with group (1) cases which was present in (63.1%) and was statistically significant.There was no statistically significant difference among the four groups as regards the portal vein dilatation, splenic vein dilatation, collaterals, and gall bladder.There was statistical significant difference between the four groups as regards ascites.Mild ascites was significantly more predominant in group (4) patients (50.0%) than in other groups.Moderate ascites was significantly more predominant in group (1) patients (63.2%) than in other groups.Severe ascites was significantly more predominant in group (3) patients (56.5%) than in other groups.
As shown in table (5) there was statistically significant difference as regards the mortality among the studied patients being more predominant in group (3) patients (87%) in comparison with group (1) cases (34.2%).West Haven Criteria had significant influence on overall survival of patients with hepatic encephalopathy .There was a longest survival time (mean 8.9 months) in the group (1), followed by a longer survival time (mean 4.13 months) in the group (2) and a shorter survival time (mean 2.8 months) in the group (4) and the shortest survival time (mean 2.11months) in the group (3) which was statistically significant.Table (6) GCS had significant influence on overall survival of patients with hepatic encephalopathy.After one year, survival was predominant in score (11.76±1.93)and death in score (9.24±2.95).MELD score had significant influence on overall survival of patients with HE.After one year, survival was predominantly high when MELD score was early (17.64±4.29)and death occurred when the score was advanced (23.10±6.52).Also uMELD score affected on overall survival of patients with HE.After one year, survival was high when uMELD score was early (3.94±.489) and death occurred when the score (4.57±.737) was advanced with high significant statistically difference.Child score affected on overall survival of patients with HE.Survival was high when score was small (8.38±1.04)and death occurred when the score increased (9.18±1.27)with significant statistically difference between all groups.Table (7) As shown in table (8) according to Cox regression, there was no difference in prediction of survival among the studied patients assessed by GCS, MELD score, uMELD score and Child score (all had the same results).

CONCLUSION
Glasgow coma scale can help assess patients with hepatic encephalopathy and can with great accuracy assess risk of one year mortality.

Conflicts of interest: None.
Ethical approval: A written informed consent was taken from all included patients, and the study was approved by the Ethical Committee of our insitution.

Table ( 3): The severity of liver cirrhosis assessed by Child-Pugh classification, MELD and Glasgow Coma Scale
* significant, ** highly significant Table (4): Ultrasonographic features of the studied patients * significant, ** highly significant Table (5): One year mortality among the studied patients

Table ( 6
): Means and Medians for Survival Time of patients with hepatic encephalopathy with reference to West Haven Criteria ** highly significant Table (7): Overall survival of patients with hepatic encephalopathy with reference to GCS, MELD score, uMELD score and Child score.

Table ( 8
[14]ox regression for prediction of survival among the studied patients.1%)andwasstatisticallysignificant.These results were in agreement with Stewart et al.[1]who documented nearly the same results.There was no statistically significant difference among the four groups as regards the portal vein dilatation, splenic vein dilatation, collaterals, and gall bladder.These results are in agreement with Stewart et al.[1] who reported nearly the same results.After one-year follow up of patients with HE, it was founded that (61%) of patients died.These results in agreement withFichet et al. [34]who reported nearly the same results (54%)[34], and Gildea et al. [35] who reported nearly that (69%) of patients died with a median survival of 1 month.Mortality from studies regarding patients with HE ranged from 33% to 91%, depending of severity of the underlying disease [36,37].West Haven Criteria had significant influence on overall survival of patients with hepatic encephalopathy.The longest survival time (mean 8.9 months) was in the group 1, followed by a longer survival time (mean 4.13 months) in the group 2and a shorter survival time (mean 2.80 months) in the group (4) and the shortest survival time (mean 2.11months) in the group 3category group .These results in agreement with Mouri et al. [14] which reported nearly the same results.In the present study, MELD score had significant influence on overall survival of patients with HE.The score was advanced in the most of patients group 3 category group with a shortest survival time, intermediate in the group (2-4) category group with a longer survival time, early in the group 1 with a longest survival time.These results in agreement with Stewart et al. [1] and Laferrière et al. [24] who documented nearly the same results.In the present study, Glasgow Coma Scale had a significant influence on overall survival of patients with HE, overall survival was shorter in patients with lower score and longer with higher score.This result was in agreement with Mouri et al.[14]who documented the same results.
[33]ho documented nearly the same results, and Laferrière et al.[33]who reported that 100% in the all groups had homogenous liver.In contrast, these results disagree withMouri etal.[14] who reported that 14% of cases had heterogeneous liver, and Lehner et al. [15] who reported