Acil Serviste hepatik ensefalopati tanısı alan hastalarda santral görüntülemenin gerekliliği
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Tarih
2023
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Yayıncı
Necmettin Erbakan Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Giriş
Hepatik ensefalopati (HES), kronik karaciğer fonksiyon bozukluğu olan hastaların %50-70'inde ortaya çıkan geçici ve potansiyel olarak geri dönüşümlü nöropsikiyatrik anormallikler spektrumunu tanımlar. Hastaların semptomları oldukça değişkenlik göstermesine rağmen, en sık izlenen semptomlar bilinç bozukluğu veya değişikliğidir. Kronik karaciğer yetmezliği olan hastalardın acil servise bilinç bozukluğu nedeniyle kabulü sonrasında belirgin bir fokal nörolojik defisit olmadığında dahi kraniyal bilgisayarlı tomografi (BT) veya diffüzyon manyetik rezonans görüntüleme (MR) planlanmaktadır. Ancak HES şüphesi olan hastalarda kraniyal görüntüleme yapılması gerektiği hakkında uzlaşı sağlanmış rehberler bulunmamaktadır. Bu çalışmanın amacı acil servise başvuran ve HES tanısı alan siroz hastalarında santral görüntüleme bulgularının değerlendirilmesi ve santral görüntülemede izlenen patolojilerle ilişkili demografik, klinik ve laboratuvar verilerinin değerlendirilmesi amaçlanmıştır.
Gereç ve yöntem
Nisan 2018 ila Haziran 2022 tarihleri arasında acil servise başvuran, kraniyal BT ve diffüzyon MR görüntüleme tetkiki olan 216 HES hastası çalışmaya dahil edildi. Bu retrospektif çalışmaya santral görüntülemesi olmayan hastalar dahil edilmedi. Tanımlayıcı özellikler arasından yaş ve cinsiyet değerlendirildi. Acil servis başvuruş sırasındaki semptom, fizik muayene bulguları ve vital bulgular analizlere dahil edildi. Hasta dosyalarından siroz etiyolojileri değerlendirildi. Hastaların tanısı veya ayırıcı tanısı için istenen laboratuvar sonuçları çalışmaya dahil edildi. Bu laboratuvar testleri arasında glukoz, üre, kreatinin, sodyum, potasyum, C-reaktif protein, amonyak, beyaz küre sayısı, hemoglobin, platelet, INR, pH ve laktat seviyesi yer almaktaydı.
Bulgular
Hastaların yaş ortalaması 63,9 ± 11,1 yıl idi (23-90 yaş). Hastaların %50,9’u kadın, %49,1’i erkekti. Kadın/erkek oranı 1,03/1 idi. En sık izlenen semptomlar sırasıyla bilinç bozukluğu (%97,2), konuşma bozukluğu/yavaşlığı (%34,7), uyku hali (%27,8) ve yorgunluk
(%12) yer almaktaydı. Hastaların fizik muayenesinde en sık izlenen bulgular sırasıyla oryantasyon ve kooperasyon bozukluğu (%83,3), konfüzyon (%51,4), letarji (%29,6), motor yavaşlama (%17,1) ve flapping tremor (%11,6) idi. Siroz etiyolojileri arasından en sık izlenenler sırasıyla kriptojenik (%36,6), HBV (%21,3), malignite (%9,7), HCV (%7,4), alkolik (%7,4) ve otoimmün (%7,4) siroz ve NASH (%6,9) idi. Yeni gelişen bir patoloji veya olay için santral görüntüleme istenen hastaların %6’sında difüzyon MR’da, %3,7’sinde kraniyal BT’de patoloji izlenmiştir. Her iki görüntüleme yöntemi birlikte dikkate alındığında ise hastaların sadece %7,4’ünde santral patoloji izlenmişti. Santral patoloji izlenen ve izlenmeyen hastalar arasında demografik, klinik özellikler ve laboratuvar sonuçları karşılaştırıldı, ancak santral patoloji varlığıyla ilişkili herhangi bir parametre izlenmedi.
Sonuç
Acil servise kabul edilen HES hastalarında santral görüntülemede nadiren patoloji izlenmektedir. Hastaların demografik ve klinik özellikleri kraniyal görüntülemelerin planlanmasında yol gösterici olmayabilir. Gereksiz görüntülemelerin özlenmesi ve görüntüleme yöntemleriyle ilişkili sağlık maliyetlerinin azaltılması için hekimlerin HES’e karşı farkındalığı arttırılabilir, görüntüleme tekniklerin planlanması için algoritmalar oluşturulabilir.
Introduction The term hepatic encephalopathy (HES) describes the spectrum of transient and potentially reversible neuropsychiatric abnormalities that occur in 50-70% of patients with chronic liver dysfunction. Patients present with a variety of symptoms. The most common are confusion or changes in mental status. Many patients with liver disease and altered mental status have a CT scan or diffusion-weighted MR of the head during admission of emergency unit. This is often done even if there are no obvious signs of neurological problems. Currently, there are no universally accepted protocols for deciding whether patients with suspected HES in emergency medicine should receive a central imaging. The aim of this study is to evaluate the central imaging results of patients diagnosed with HES who have applied to the emergency department with cirrhosis and to assess the demographic, clinical and laboratory data associated with pathologies observed in central imaging. Material and methods The study involved 216 patients who were diagnosed with HES in the emergency department and also had a head CT and diffusion-weighted MR scan between April 2018 and June 2022. Patients without central imaging were not included in this retrospective study. Among the descriptive characteristics, age and gender were evaluated. The symptoms, findings and vital signs at the time of emergency department admission were included in the analyses. Cirrhosis etiologies were evaluated by patient files. Laboratory tests requested from the patients for diagnosis and differential diagnosis were included in our study. These laboratory tests included glucose, urea, creatinine, sodium, potassium, C-reactive protein, ammonia, white blood cell count, haemoglobin, platelet, INR, pH and lactate level. Results The mean age of the patients was 63.9 ± 11.1 years (23-90 years). 50.9% of the patients were female and 49.1% were male. The female/male ratio was 1.03/1. The most common symptoms were impaired consciousness (97.2%), abnormal speech (34.7%), somnolence (27.8%) and fatigue (12.0%) The most common findings on physical examination were disorientation and co-operation (83.3%), confusion (51.4%), lethargy (29.6%), slowing in motor functions (17.1%) and flapping tremor (11.6%). The frequent causes of cirrhosis were cryptogenic (36.6%), HBV (21.3%), malignancy (9.7%), HCV (7.4%), alcoholic (7.4%) and autoimmune (7.4%) cirrhosis and NASH (6.9%), respectively. In patients who undergo brain imaging for newly developing central pathology or event, pathology was detected in diffusion MRI in 6% of cases and in cranial CT in 3.7%. When both imaging methods were evaluated together, central pathology was observed in only 7.4% of cases. Demographic and clinical characteristics and laboratory results of patients with and without central pathology were compared. However, no variable associated with the presence of central pathology was found. Conclusion Pathology is rarely observed on central imaging in HES patients admitted to emergency unit. Demographic and clinical features alone may not be guiding in the planning of cranial imaging. In order to prevent unnecessary imaging and reduce health costs associated with imaging, physicians' awareness of HES should be increased and imaging planning algorithms can be established. Key words: Hepatic encephalopathy, Cranial imaging, Head CT, Diffusion-weighted MR, Emergency department
Introduction The term hepatic encephalopathy (HES) describes the spectrum of transient and potentially reversible neuropsychiatric abnormalities that occur in 50-70% of patients with chronic liver dysfunction. Patients present with a variety of symptoms. The most common are confusion or changes in mental status. Many patients with liver disease and altered mental status have a CT scan or diffusion-weighted MR of the head during admission of emergency unit. This is often done even if there are no obvious signs of neurological problems. Currently, there are no universally accepted protocols for deciding whether patients with suspected HES in emergency medicine should receive a central imaging. The aim of this study is to evaluate the central imaging results of patients diagnosed with HES who have applied to the emergency department with cirrhosis and to assess the demographic, clinical and laboratory data associated with pathologies observed in central imaging. Material and methods The study involved 216 patients who were diagnosed with HES in the emergency department and also had a head CT and diffusion-weighted MR scan between April 2018 and June 2022. Patients without central imaging were not included in this retrospective study. Among the descriptive characteristics, age and gender were evaluated. The symptoms, findings and vital signs at the time of emergency department admission were included in the analyses. Cirrhosis etiologies were evaluated by patient files. Laboratory tests requested from the patients for diagnosis and differential diagnosis were included in our study. These laboratory tests included glucose, urea, creatinine, sodium, potassium, C-reactive protein, ammonia, white blood cell count, haemoglobin, platelet, INR, pH and lactate level. Results The mean age of the patients was 63.9 ± 11.1 years (23-90 years). 50.9% of the patients were female and 49.1% were male. The female/male ratio was 1.03/1. The most common symptoms were impaired consciousness (97.2%), abnormal speech (34.7%), somnolence (27.8%) and fatigue (12.0%) The most common findings on physical examination were disorientation and co-operation (83.3%), confusion (51.4%), lethargy (29.6%), slowing in motor functions (17.1%) and flapping tremor (11.6%). The frequent causes of cirrhosis were cryptogenic (36.6%), HBV (21.3%), malignancy (9.7%), HCV (7.4%), alcoholic (7.4%) and autoimmune (7.4%) cirrhosis and NASH (6.9%), respectively. In patients who undergo brain imaging for newly developing central pathology or event, pathology was detected in diffusion MRI in 6% of cases and in cranial CT in 3.7%. When both imaging methods were evaluated together, central pathology was observed in only 7.4% of cases. Demographic and clinical characteristics and laboratory results of patients with and without central pathology were compared. However, no variable associated with the presence of central pathology was found. Conclusion Pathology is rarely observed on central imaging in HES patients admitted to emergency unit. Demographic and clinical features alone may not be guiding in the planning of cranial imaging. In order to prevent unnecessary imaging and reduce health costs associated with imaging, physicians' awareness of HES should be increased and imaging planning algorithms can be established. Key words: Hepatic encephalopathy, Cranial imaging, Head CT, Diffusion-weighted MR, Emergency department
Açıklama
Anahtar Kelimeler
Hepatik ensefalopati, Kraniyal görüntüleme, Kraniyal BT, Difüzyon MR, Acil servis, Hepatic encephalopathy, Cranial imaging, Head CT, Diffusion-weighted MR, Emergency department
Kaynak
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Scopus Q Değeri
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Sayı
Künye
Yılmaz, S. (2023). Acil Serviste hepatik ensefalopati tanısı alan hastalarda santral görüntülemenin gerekliliği. (Yayınlanmamış tıpta uzmanlık tezi) Necmettin Erbakan Üniversitesi, Tıp Fakültesi Dahili Tıp Bilimleri Bölümü Acil Tıp Anabilim Dalı, Konya.
