الفهرس 
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Abstract
The present study was performed at Assiut University Children Hospital – Gastroenterology and hepatology unit during the period from the begining of March 2019 to the end of February 2020. In the present study 60 children were included (30 patients with chronic liver diseases and 30 control). The mean age of CLD childern was14.7±1.985 years, range from 12 years to 18 years.We found that there is no statistically significant difference about age in results of Psychometric hepatic encephalopathy score (PHES). This finding is in consistent with Anshu Srivastava et al., 2017 who studied prospectively 67 children with CLD their age mean was 13years and there was no statistically significant difference about age in results of PHES. In our study, 18 of the studied children were females (60%) and 12 of them were males (40%). We found that there is no statistically significant difference about sex predominance in PHES results. This finding is in consistant with Razek et al., 2014 who reported that PHES results not affected by sex. Our study results was supported by the study of Praveen Sharma et al., 2016 in adult in which authors reported that there was no statistically significant difference about age and sex in results of PHES. In the current study the mean of education years in children with CLD was 7.7±1.98 years . We found that education years did not impact the result of any psychometric test [p > 0.05] in the studied age categories. This finding is in consistent with Razek et al.,2014 study in which the mean of education years in CLD children was 7.2±1.5 years and the authors reportd that education years not affect PHES results . Contrary to this study results Mohammed eltaher et al.,2018 reported that all individual tests of PHES (psychometric hepatic encephalopathy score ) were influenced in CLD patients by educational years but this observation was absent in normal persons .This discrepancy can be explained by the fact that our cohorts age was 12 years and more and 60% of them received more than 6 years of education In our study patient and control undergo battery of neuropsychological tests. According to these tests we found that the prevelance of MHE represents 63.3% (19/30) of patients with CLD, with 46.7% abnormal NCTA, 56.7% abnormal NCTB, 50% abnormal DST, 36.7% abnormal CDT and 56.7% abnormal LTT as seen in (table 10). Our results were supported by study of Razek et al., 2014 as they reported that the used psychometric test battery were impaired in 56.7 % (17/30) of patients. But in their study, besides NPT, magnetic resonance spectroscopy (HMRS) was done for all patients. The NPT well correlated with metabolite changes in magnetic resonance spectroscopy (HMRS) denoting that altered metabolic changes were responsible for abnormalities in NPTs in these patients. Also our results is consistant with Srivastava et al., 2017 study in which psychometric test battery were impaired in 50.7 % (34/67) of children with CLD patients. The authors of this study evaluates multiple parameters that could potentially be associated with MHE, including blood ammonia, IL6 and TNFa levels. The children undergo neuropsychological tests (NPT), magnetic resonance spectroscopy (HMRS) to study brain metabolite changes (specifically glutamine, choline and myoinositol) and also undergo diffusion tensor imaging (DTI). On the basis of NPT testing and neuroimaging the authors found aprevalence of 50.7% for MHE. In the previous 2 studies childern with CLD undergoe Neuroimaging in additional to NPT to detect MHE and their results simulate our results although we used only NPT, we couldn’t do Neuroimaging for patients as it is expensive and we live in acountry of limited resources. The present study showed that most of our cases, about One third (33.3%) had portal hypertension, the consequences of portal hypertension include portosystemic shunting (PSS), direct entry of the intestinal blood with toxic substances such as ammonia into the systemic circulation and brain without passing on the liver, leading to manifestations of MHE.This finding is in contrast with Anshu Srivastava et al., 2017 who reported that autoimmune liver disease was the most common etiology of CLD in their study which represented (41.8%) of cases. This may be due to portal hypertension is common type and complication of chronic liver diseases in our community. In the current study there is no statistically significant difference about different causes of chronic liver diseases and PHES [P > 0.05], thus there is no difference in patients with MHE and no MHE in the cause of CLD. This finding in consistent with Anshu Srivastava et al 2017 study in which authors reported that MHE prevalence was similar in patients regardless the cause of liver disease. Also this finding is in consistent with the study of Assem Mahmoud et al., 2018 in adult who found that there is no statistically significant difference about different causes of chronic liver diseases and PHES. In the current study we used 5 neuropsychometric tests and MHE diagnosed when 2 or more NPT were positive (˂ 2 SD from mean of control performance). This finding is in contrast with Lorenzo D’Antiga et al.,2014 study in which the authors used awide battery of 26 psychometric tests for detecting MHE . This may be due to wide age range of the studied cases (4-18 years), two psychometric test batteries were used according to age (one battery for young children and one for older children) in their study. In our study two psychometric tests ( NCT-A and LTT) have high sensitivity for diagnosing MHE as there was a statistically significant difference in the mean (±SD) of these two tests between patient and control results (p˂0.05). This finding is in consistent with Weissenborn K et al., 2001 who reported that NCT-A was able to diagnose MHE with a sensitivity of 76.9% and a specificity of 96.3 %, as there is significant difference in results of patient and control in this test To the best of our knowledge this is the first study to examine the relation between duration of illness and PHES in children. We found that there is statistically significant difference between duration of illness and PHES , Childern with MHE had long duration of CLD compared to childern with no MHE. Inagreement with us, Mohammad Eltaher et al ., 2018 study in adult which reported that patients with minimal hepatic encephalopathy had long duration of liver disease compared to patients with no MHE The present study showed that poor scoring of psychometric tests was associated with impairment of hepatic function as reflected by AST, S.Albumin, S.Bilirubin and prothrombin time [P < 0.05].We found that AST, S.Bilirubin and prothrombin time have positive correlation with 4 NPT (NCTA, NCTB, CDT, LTT) and negative correlation with DST but, S.Albumin had positive correlation with DST and negative correlation with the other 4 NPT. Our results were supported by study of Assem Mahmoud et al., 2018 in which results display that poor scoring of psychometric tests was associated with impairment of liver function reflected by S.Ammonia, platelet count, S.Albumin, S.Bilirubin and INR [P < 0.05] for each variable . from this study, it can be concluded that Minimal hepatic encephalopathy (MHE) has high prevelance in children with chronic liver diseases. chronic liver diseased childern should be investigated properly for the presence of MHE so that we can diagnose and treat it well to avoid progression to overt hepatic encephalopathy. Neuropsychological tests are cheap and simple tests but considered golden tests for diagnosing MHE, high expensive investigations may be used in some cases only if indicated. Psychometric hepatic encephalopathy score only affected by duration of illness and impairment of liver fuction tests in children with CLD. There is need to improve follow up of children with MHE to detect improvement of cognitive function after treatment, to detect cases who remain unchanged and cases who progress to overt HE. There is a relatively small number of patients included in the study, so further studies are needed to analyze the same parameters on a larger sample. Highly expensive investigations may be taken in consideration e.g. Proton magnetic resonance spectroscopy (HMRS) if indicated and available. Hepatic encephalopathy (HE) consists of a spectrum of neuropsychiatric abnormalities seen in patients with advanced liver disease, and is diagnosed after the exclusion of other known brain diseases. Minimal hepatic encephalopathy (MHE) represents the mildest form of hepatic encephalopathy (HE) seen in patients with chronic liver diseases. It is characterized by defects in cognitive functions like attention and motor abilities. Daily life activities and emotional behavior were significantly decreased in patients with MHE, and those patients have a high risk of development of episodic HE. Studies done on childern with chronic liver diseases found MHE around 50% of cases. MHE patients have no obvious clinical symptoms of hepatic encephalopathy so it cannot be diagnosed on standard neurological examination. Neuropsychological testing (NPT) is the current gold standard for diagnosing MHE. Neuropsychological test score value of ˂ 2standard deviation from normal was considered abnormal. MHE was diagnosed in patients with two or more abnormal NPTs The diagnosis of MHE is essential because it can impair the daily functioning and quality of life and increases risk of developing overt HE, so early diagnosis and treatment of MHE in children is important for the preservation of brain function in which brain experiencing maturation and cognitive development. The study is aimed to determine the prevalence of minimal hepatic encephalopathy in children with chronic liver diseases by using non invasive Neuropsychological tests. This is a cross- sectional study, was carried out at Gastroenterology and hepatology unit at Assuit university children hospital. The duration of the study was one year and the age studied children from 12 year to 18 years . The main results of the study revealed that the mean age of our studied group was 14.7±1.98 years. 60% of them were females. There was no statistically significant difference between (age and sex) and PHES results. In the present study the mean of education years in children with CLD was 7.7±1.98 years . There was no statistically significant difference between education years and PHES in the studied age categories. In the current study the commonest cause of CLD was portal hypertension (33.3%) of patients, followed by liver cirrhosis (30%), chronic hepatitis (5%), Autoimmune hepatitis (5%) and congenital hepatic fibrosis (1%).There was no statistically significant difference between different causes of CLD and PHES The present study showed that there is statistically significant difference between duration of illness and PHES. Childern with MHE had long duration of CLD compared to childern with no MHE. In our study patient and control undergo battery of 5 neuropsychological tests. We found that the used psychometric test battery was impaired in 63.3% (19/30) of patients, with 46.7% abnormal NCTA, 56.7% abnormal NCTB, 50% abnormal DST, 36.7% abnormal CDT and 56.7% abnormal LTT. In the current study two psychometric tests ( NCT-A and LTT) have high sensitivity for diagnosing MHE as there was a statistically significant difference in the mean (±SD) of these two tests between patient and control results.
The present study showed that poor scoring of psychometric tests was associated with impairment of liver function as reflected by AST, S.Albumin, S.Bilirubin and prothrombin time.
from this study it can be concluded that it is important to investigate children with CLD for the presence of MHE, so we can diagnose and treat it early to avoid progression to overt hepatic encephalopathy, Neuropsychological tests are golden tool for diagnosing MHE,and we recommended to improve follow up of patients with MHE to detect the effect of treatment on cognitive functions.