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

Background: The risk of exacerbating subclinical hepatic encephalopathy associated with the administration of sedative drugs in patients with cirrhosis undergoing diagnostic upper gastrointestinal (GI) endoscopy for portal hypertension remains to be determined. Methods: Ten adult patients with cirrhosis completed number connection tests before sedation for endoscopy and at discharge from the endoscopy unit 2 hours post-procedure. Control patients consisted of five patients with cirrhosis undergoing the same procedure for the same indication who did not receive sedation and 12 patients with no evidence of liver disease who received 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 cirrhosis who received sedation. Results: The mean (± SEM) age of patients with cirrhosis who received sedation was 59.6 ± 3.8 years. Seven of the ten (70%) were men. Their mean Child Pugh's score was 7.2 ± 1.5. Nine of the ten (90%) had abnormal baseline number connection tests results (mean for the group 52.3 ± 6.7 seconds) the extent of which correlated with Child Pugh's scores (p < 0.005). Individually, the baseline number connection tests results were normal in one (10%), mild in six (60%), moderate in one (10%), and severe in two (20%). After the procedure (before discharge) the mean number connection tests result was 61.5 ± 7.9 seconds (p = 0.01 when compared with baseline). The results were now normal in none (0%), mild in four (40%), moderate in four (40%), and severe; in two (20%). Pre- and post-procedure number connection tests results did not change in the non-sedated cirrhotic or sedated nonliver disease control patients. Conclusions: The results of this study indicate that (1) the majority of patients with cirrhosis and suspected portal hypertension have evidence of subclinical hepatic encephalopathy, (2) the extent of encephalopathy correlates with the Child Pugh's score, (3) sedation with midazolam for upper GI endoscopy exacerbates the encephalopathy, and (4) this adverse effect is still evident 2 hours after the procedure.