April 26, 2019 0 Comment

J. Egypt. Soc. Parasitol. (JESP), 48(1), 2018: 19 – 23
Effect of Helicobacter Pylori Eradication
on the Pathogenesis of Minimal Hepatic Encephalopathy
in Egyptian Patients with Liver Cirrhosis
*Mohie Eldin Amer, *Mohamed Abdel Rasheed Abdel Khalik, **Mohamed Abdel Hammid
Bassyoni Khedr and *Safwat Ahmed Mohamed Ali Massoud*
*Department of Tropical Medicine,Al-AzharUniversity, Faculty of Medicine, Cairo.
** Department of Clinical Pathology,Al-Azhar University, faculty of Medicine, Cairo
Hepatic Encephalopathy is one of the complications of liver cirrhosis, Ammonia has
been implicated as a precipitating factor for HE, Minimal Hepatic Encephalopathy
cannot be detected clinically and impairs quality of life, it’s been suggested that H.
pylori infection is associated with high blood ammonia levels by urease enzyme and
can lead to causation of HE.
We aimed to evaluate the effect of H. pylori eradication therapy on MHE.
From in or out cirrhotic patients at al-Hussein university hospital 60 patients were
selected. On the base of number connection test, 2 equal groups were established
group-I; 30 patients with MHE and group-II; 30 patients without MHE.
For all patients, H. pylori stool antigen and blood ammonia level were done. Positive
H. pylori patients received triple therapy for 14 days, then 4 weeks later were
revaluated regarding, H. pylori stool antigen, serum ammonia level and NCT
Helicobacter pylori infection was found 63.3% of MHE group versus 40% in Non-MHE
group, Serum ammonia levels were significantly higher in patients with MHE and H.
pylori positive. Eradication therapy was successful in 78.9% of MHE patients versus
89.4% of nob-MHE. Number connection test and serum ammonia level were
significantly improved in patients of MHE and positive H. pylori after eradication
Helicobacter pylori infection is significantly associated with MHE and eradication
treatment leads to reduction in ammonia level and improvement of MHE.
Key words: Minimal Hepatic Encephalopathy, Serum Ammonia, Helicobacter pylori
Introduction: – Hepatic
Encephalopathy (HE) is a major
complication that develops in a
majority of patients with liver
cirrhosis. Minimal hepatic
encephalopathy (MHE), the mildest
form of hepatic encephalopathy is
characterized by subtle motor and
cognitive deficits and impairs
health related quality of life. 3
Minimal Hepatic Encephalopathy
(MHE) is not detectable by clinical
examination although it can be
detected by sensitive tests of
coordination like number
connection test (NCT), figure
connection test (FCT) and line
tracing test, electroencephalography
and visual,
auditory and somatosensory
evoked potentials. 1
Among the different risk factors
implicated in the pathogenesis of
HE, hyperammonemia was found
to be the most significant predictor
of progression of MHE and it was
widely concluded to be highly
correlated with MHE causation in
both adult and pediatric
populations. 4 13
Helicobacter pylori bacteria are
rich in urease enzyme and are
known to produce ammonia from
urea that is rapidly absorbed from
J. Egypt. Soc. Parasitol. (JESP), 48(1), 2018: 19 – 23
gastric lumen into circulation.
Infection with these bacteria has
been shown to be associated with
elevated blood ammonia levels.1
Patients and Methods: – This
study was carried out at Al-Azhar
University Hospitals on 60 cirrhotic
patients divided in to two groups;
Group I: 30 patients of MHE, as
recognized by positive NCT. Group
II: 30 patients did not have MHE.
Number connection test is a plain
paper with randomly scattered
number from 1-25 should be
connected in ascending manner
within 45 seconds, any patient with
NCT more than 45 second was
diagnosed as MHE.
Any patient with history of proton
pump inhibitors (PPI) use within
the last two weeks or presented
with other causes of
encephalopathy were excluded.
The selected patients were
subjected to written consent, full
clinical evaluation, routine
laboratory investigations and
ultrasonography. Fecal H. pylori
antigen and serum ammonia level
were done before and 4 weeks after
eradication therapy.
Eradication therapy was
levofloxacin 500mg/day,
omeprazole 20mg twice daily and
amoxicillin 1g twice daily for 14
days. 16
Results: – Our patient groups did
not differ regarding age and sex
From our 60 examined patients,
only 10 patients were child-B; 6
from MHE group and 4 from the
Non-MHE, no Child-C was
involved. No differences were
detected between the 2 groups
regarding, clinical presentation,
laboratory results or sonographic
Serum ammonia level was
significantly higher in patients of
MHE. H. Pylori was detected in 19
patients (63.3%) and 12 (40%) of
MHE and Non-MHE respectively.
H. Pylori was eradicated in 78.9%
of MHE patients and 75% of Non-
MHE with no significant
differences in between table. 2
Significant drop in ammonia level
after H. pylori eradication therapy
was seen among MHE and Non-
MHE groups. Eradication of
therapy of H. Pylori dramatically
improved the MHE as NCT was
improved in 89.4% of MHE
patients Table. 3
Table (1): The studied groups regarding Age and Sex.
Table 2: S. ammonia level, Positive H. Pylori and successful triple therapy in the
studied groups
MHE (n.30) Non-MHE (n. 30) P value
S. ammonia 94.6±14.25 61.13 ±7.5