Peripheral Neuropathy in Liver Cirrhosis

Methods

Thirty-three patients with liver cirrhosis presenting to the department of Hepatology at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, were evaluated for the presence of neuro-pathy. A diagnosis of cirrhosis was made on the basis of clinical, biochemical, ultrasound and endoscopic evidence and, wherever possible, by liver biopsy when prothrombin time permitted it to be performed. It was considered alcohol-related if the patient had consumed more than 80 g of alcohol per day for more than 10 years. Seventeen patients had alcohol-related cirrhosis and 16 patients (five hepatitis B virus, four hepatitis C virus, seven cryptogenic) had non-alcohol-related cirrhosis. The severity of liver cirrhosis was graded using the Child-Pugh classification.^[17] Seventeen cases were in class B, 16 in class C and none in class A. There were 26 male and seven female patients. Eleven patients had histories of encephalopathy and 17 of gastrointestinal bleeding.

Patients having an identifiable cause of peripheral neuropathy, except alcohol, were excluded from the study that included patients with diabetes. Patients with evidence of vitamin B₁₂ deficiency were also excluded from the study. All patients underwent a standardized neurological evaluation, including a history and clinical examination. Nerve conduction study was conducted on a Nicolet Viking IV EMG/EP system (Nicolet Biomedical, Madison, WI, USA). Informed consent was obtained for all patients. The nerves studied included median and ulnar (motor and sensory), common peroneal (motor) and sural sensory. F-waves were recorded from the median nerve. The results were analyzed by comparing the values with an equal number of age- and sex-matched normal controls. Values beyond 'two standard deviations' from normal were taken as abnormal. 'Neuropathy' was defined by the presence of two or more abnormalities on electrophysiological testing of the above-mentioned nerves with regards to distal latency, conduction velocity, amplitude of action potentials and F-wave latency. The severity of neuropathy and its grading was assessed by a 'neuropathy score' (NS) ( Table 1 ), modified from the 'total neuropathy score' used by Chaudhryet al.^[18,19]

The results obtained were analyzed for statistical significance using X ² test for qualitative comparison and unpaired t-test for quantitative comparison.

The protocol for this research project was approved by the Ethics Committee of the Institute.

Cite this: Peripheral Neuropathy in Liver Cirrhosis - Medscape - Aug 01, 2003.

Table 1. Neuropathy score
Criteria	Score
Criteria	0	1	2	3
Clinical
Sensory symptoms	Normal	Limited to feet	Feet and hands	Disabling
Pin-prick or vibration sensation	Normal	Reduced up to wrist/ankle	Reduced up to elbow/knee	Reduced above elbow/knee
Motor power	Normal	Weakness at ankles	Weakness at ankle and hands	Generalized weakness
Tendon jerks	Normal	Ankle jerks reduced	Ankle jerks plus any other deep tendon jerks reduced	All reflexes absent
Nerve conduction
Peroneal motor amplitude	Normal or reduced by <5% of LLN	76-95% of LLN	51-75% of LLN	<50% of LLN
Median sensory amplitude	Normal or reduced by less than 5% of LLN	76-95% of LLN	51-75% of LLN	<50% of LLN

Table 2. Nerve-conduction study results
Nerve-conduction parameters	Abnormal (%)
No. of patients with abnormal study	73
Reduced conduction velocity
Median motor	63
Ulnar motor	58
Peroneal motor	66
Median sensory	63
Ulnar sensory	66
Sural sensory	57
Reduced amplitudes
Median motor CMAP	18
Ulnar motor CMAP	15
Peroneal motor CMAP	55
Median sensory SNAP	27
Ulnar sensory SNAP	30
Sural sensory SNAP	52
Prolonged median F-wave latency	57

Table 3. Relation of alcohol to nerve-conduction abnormalities and neuropathy score
Variable	Total patient no.	Patients with abnormal nerve conduction: n (%)	Neuropathy score (mean ± SEM)
Alcohol-related cirrhosis	17	15 (88^a)	3.0 ± 0.44^b
Non-alcohol-related cirrhosis	16	9 (56^a1)	1.7 ± 0.62^b1

Table 4. Relationship of Child-Pugh class to nerve-conduction abnormalities and neuropathy score
Variable	Total patient no.	Patients with abnormal nerve conduction: n (%)	Neuropathy score (mean ± SEM)
Child's B	17	12 (71^a)	2.3 ± 0.56^b
Child's C	16	12 (75^a1)	2.4 ± 0.59^b1

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Peripheral Neuropathy in Liver Cirrhosis

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