Risk of sedation for upper GI endoscopy exacerbating subclinical hepatic encephalopathy in patients with cirrhosis

Background: The risk of exacerbating subclinical hepatic encephalopathy ass ociated with the administration of sedative drugs in patients with:cirrhosi s undergoing diagnostic upper gastrointestinal (GI) endoscopy for portal hy pertension remains to be determined. Methods: Ten adult patients with cirrhosis completed number connection test s before sedation for endoscopy and at discharge from the endoscopy unit 2 hours post-procedure. Control patients consisted of five patients with cirr hosis undergoing the same procedure for the same indication who did not rec eive sedation and 12 patients with no evidence of liver disease who receive d sedation before diagnostic endoscopy for a variety of GI complaints. The control populations were age, gender, education level, and, in the case of patients with cirrhosis, Child Pugh's score matched to the patients with ci rrhosis who received sedation. Results: The mean (+/- SEM) age of patients with cirrhosis who received sed ation was 59.6 +/- 3.8 years. Seven of the ten (70%) were men. Their mean C hild Pugh's score was 7.2 +/- 1.5. Nine of the ten (90%) had abnormal basel ine number connection tests results (mean for the group 52.3 +/- 6.7 second s) the extent of which correlated with Child Pugh's scores (p < 0.005). Ind ividually, the baseline number connection tests results were normal in one (10%), mild in six (60%), moderate in one (10%), and severe in two (20%). A fter the procedure (before discharge) the mean number connection tests resu lt was 61.5 +/- 7.9 seconds (p = 0.01 when compared with baseline). The res ults were now normal in none (0%), mild in four (40%), moderate in Pour (40 %), and severe in two (20%). Pre- and post-procedure number connection test s results did not change in the non-sedated cirrhotic or sedated nonliver d isease control patients. Conclusions: The results of this study indicate that (1) the majority of pa tients with cirrhosis and suspected portal hypertension have evidence of,su bclinical hepatic encephalopathy, (2) the extent of encephalopathy correlat es with the Child Pugh's score, (3) sedation with midazolam for upper GI en doscopy exacerbates the encephalopathy, and (4) this adverse effect is stil l evident 2 hours after the procedure.