Nutritional assessment in cirrhotic patients with hepatic encephalopathy

Table 1 Possible causes of malnutrition in patients with cirrhosis and hepatic encephalopathy

Possible causes	Clinical manifestation
Reduced ingestion of foods	Anorexia
	Early satiety
	Ascites
	Confusion and/or excessive somnolence
	Frequent hospitalizations
Impaired absorption of	Alterations in enterohepatic circulation
nutrients	Impaired biliary excretion
	Small intestinal bacterial overgrowth
	Portosystemic shunts
Metabolic disturbances	Protein hypercatabolism/BCAA depletion
	Decreased glycogen stores and gluconeogenesis
	Insulin resistance and enhanced ketogenesis
	Increased lipolysis and fatty acid oxidation
Other factors	Restricted diets (e.g., low sodium diets)
	Protein loss during large volume paracentesis
	Abdominal distention during lactulose therapy

BCAA: Branched chain amino acids.

Table 2 Advantages and disadvantages of the main methods of nutritional assessment for cirrhotic patients with hepatic encephalopathy

Method	Advantages	Disadvantages
SGA	Quick application	Requires patient comprehension and collaboration
	Low cost	Subjectivity (the only objective measure used is weight)
	Can identify patients under risk of malnutrition	Can underestimate malnutrition
	upon hospital arrival	Cannot be used as a follow-up method
	Can be applied in hospital rooms
Anthropometry	Quick application	Some measures (body weight, body mass index, AC, TSF) can be highly influenced by water retention and overweight/obesity
	Low cost	Interobserver variation decreases the data reproducibility
	Demands little collaboration	Can underestimate malnutrition
	Can be applied in hospital rooms
	Some measures (CAMA, MAMC, APMT) are less influenced by water retention and overweight/obesity
	MAMC is widely recommended for liver disease patients
	MAMC and TSF are associated with outcomes in cirrhotic patients and are related to the presence of HE
Handgrip strength	Quick application	Cannot identify muscle wasting anatomically
	Low cost	Is not so suitable for evaluating cirrhotic women, because skeletal
	Can be applied in hospital rooms	muscle function correlates with muscle mass only in men
	Identify impaired muscle function
	Is not influenced by either water retention or overweight/obesity
	Is an independent predictor of cirrhosis decompensation
Bioelectrical impedance analysis	Quick application	Controversial applicability in patients with fluid retention
	Can be applied in hospital rooms when portable equipment is used	Requires patient removal to the equipment room when non-portable equipment is used
	PA and BCM are associated with outcomes in cirrhotic patients	Can underestimate malnutrition
Dual-energy X-ray absorptiometry	Adequate accuracy to identify muscle depletion	High cost
	Excellent reproducibility	Requires patient removal to the equipment room
	Can also identify bone mass reduction as a screening tool	Exposure to ionizing radiation makes routine use less attractive as a follow up method
	Gives detailed analyses of body composition (segmental results), obtaining measures that have prognostic impact in cirrhotic patients
	FFMI is an independent predictor of HE
	AMMI can be used to diagnose sarcopenia
Computed tomography scan	Adequate accuracy to identify muscle depletion	High cost
	Excellent reproducibility	Requires patient removal to the equipment room
	Can be performed retrospectively from images previously obtained	Exposure to ionizing radiation makes routine use less attractive as a follow-up method
	Can also identify hepatic nodules, portosystemic shunts and other abnormalities
	Skeletal muscle thickness in cross-sectional images has prognostic impact in cirrhotic patients
	L3 SMI can be used to diagnose sarcopenia

The bedside techniques are presented at the top and can be valuable even in conditions of restricted access to technology. The more complex methods are shown at the bottom, and should also be used when technology is unrestrained, providing more accuracy. Methods used only for research purposes and those not applied to patients with hepatic encephalopathy are not included. AC: Arm circumference; AMMI: Appendicular muscle mass index; APMT: Adductor pollicis muscle thickness; BCM: Body cell mass; CAMA: Corrected arm muscle area; FFMI: Fat-free mass index; HE: Hepatic encephalopathy; L3 SMI: Third lumbar vertebrae skeletal muscle index; MAMC: Mid-arm muscle circumference; PA: Phase angle; TSF: Triceps skinfold; SGA: Subjective Global Assessment.