Randomized Controlled Trial Comparing Effects of Sedation for Upper Gastrointestinal Endoscopy with Propofol Versus Midazolam on Psychometric Tests and Critical Flicker Frequency in Cirrhotics

© 2011, INASL 14 Randomized Controlled Trial Comparing Effects of Sedation for Upper Gastrointestinal Endoscopy with Propofol Versus Midazolam on Psychometric Tests and Critical Flicker Frequency in Cirrhotics A Agrawal*, P Sharma*, BC Sharma*, R Uppal**, SK Sarin* Department of *Gastroenterology and **Anesthesia, GB Pant Hospital, New Delhi Background: Cirrhotics are at increased risk of development of complications related to sedation. Aim: To compare effects of sedation for upper gastrointestinal endoscopy with propofol and midazolam on psychometric test and critical flicker frequency (CFF) in cirrhotics. Methods: Ninety cirrhotic patients were randomized into 3 groups, propofol group (n = 28), midazolam group (n = 30) and no sedation (n = 32). All patients underwent CFF test and combination of psychometry (number connection test-A and B (NCT-A,B); digit symbol test (DST), line tracing test (LTT) and serial dotting test (SDT) CFF done at 30 min and repeated every 30 mins for 2 hours. Psychometry repeated at 2 hours. Results: 59/90 cirrhotics (65.5%) had minimal hepatic encephalopathy before the endoscopy. In propofol group there was no significant deterioration in psychometry [NCT-A (56.0 ± 20.7 vs. 57.6 ± 21.7 sec), NCT-B (100.6 ± 36.5 vs. 100.0 ± 36.1 sec), DST (26.7 ± 6.5 vs. 26.1 ± 6.4), LTT (117.1 ± 38.9 vs. 118.7 ± 40.9 sec), SDT (99.9 ± 36.7 vs. 98.3 ± 38.1 sec)]. Baseline CFF was 39.5 ± 2.6 Hz. Significant deterioration from baseline was seen in CFF at 30 min (38.5 ± 2.2 Hz) and 1 hour (38.9 ± 2.3 Hz) but no difference thereafter. In midazolam group significant deterioration was observed on psychometry [NCT-A (58.3 ± 20.0 vs. 61.4 ± 21.3 sec), NCT-B (100.1 ± 29.9 vs. 105.9.6 ± 30.3 sec), DST (26.3 ± 5.7 vs. 25.1 ± 5.4), LTT (132.4 ± 35.8 vs. 135.9 ± 35.3 sec), SDT (98.4 ± 34.7 vs. 100.8 ± 35.9 sec)]. Significant deterioration from baseline was seen in CFF at 30 min, 1 hour, and 2 hours after midazolam. No patient developed overt HE after sedation. No deterioration observed in psychometry and CFF in cirrhotics without sedation. Conclusion: Propofol sedation for upper gastrointestinal endoscopy is safe and associated with improved recovery in cirrhotics compared to midazolam and does not precipitate hepatic encephalopathy. Conflict of Interest: None Randomized Controlled Trial Comparing Effects of Lactulose Versus No Lactulose on Arterial Ammonia, TNF Alpha and Magnetic Resonance Spectroscopy in Minimal Hepatic Encephalopathy Patients with Cirrhosis L Jain*, A Agrawal*, P Sharma*, BC Sharma*, SK Puri**, SK Sarin* Department of *Gastroenterology and **Radiology, GB Pant Hospital, New Delhi Background: Minimal hepatic encephalopathy (MHE) represents the mildest form of hepatic encephalopathy (HE), in which patients have abnormal neuropsychologic findings. On magnetic resonance spectroscopy, improvement of metabolic ratios after liver transplantation suggests an important role of Myo-inositol and Choline in the development of MHE. Aims: To study effects of lactulose on arterial ammonia, TNF alpha and magnetic resonance spectroscopy (MRS) in MHE patients with cirrhosis. Methods: Sixty patients of MHE, diagnosed by PHES score were randomized into 2 groups, lactulose (group-L, n = 30) and No-lactulose (group-NL, n = 30). Arterial ammonia, TNF alpha and MRS were performed in all patients at baseline and at 3 months. For comparison, 30 patients of cirrhosis without MHE were examined for arterial ammonia, TNF alpha and underwent MRS. Results: Mean PHES score improved significantly after 3 months in Group-L (−6 ± 1 vs. −5 ± 1), but not in Group-NL (−7.5 ± 1 vs. −7 ± 1). Mean arterial ammonia (69.43 ± 8 vs. 52.73 ± 4.7 μg/dL), significantly decreased in Group-L while not decreased significantly in Group-NL (71.6 ± 7.6 vs. 69.93 ± 11.4 μg/dL). Mean TNF alpha levels significantly decreased in Group-L patients compared to baseline (229 ± 22.5 pg/mL vs. 159 ± 14.8 pg/mL) but not in Group-NL (223 ± 19.3 pg/mL vs. 214 ± 19.1 pg/mL). On MR spectroscopy, compared to healthy controls, MI/Cr, Cho/Cr ratios was significantly reduced and Glx/Cr ratio was significantly increased in both groups After 3 months, MI/Cr and Cho/Cr ratios increased and Glx/Cr decreased significantly in Group-L but not in Group-NL patients. Conclusion: Arterial ammonia and inflammatory mediators (TNF alpha) reduce and metabolic parameters improve after treatment with lactulose in MHE patients. Conflict of Interest: None 03_JCEH-Abstract.indd 14 3/18/2011 11:13:04 AM