Peripheral Neuropathy in Liver Cirrhosis

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Abstract and Introduction

Background and Aims: Neuropathy in association with chronic liver disease, including cirrhosis, is recognized; however, there are differences in the incidence and type of neuropathy reported. The causal relationship of liver disease to neuropathy has been questioned. This study was designed to evaluate the incidence and character of peripheral neuropathy in patients with liver cirrhosis. The effect of alcohol consumption, severity of liver disease and encephalopathy on the incidence and severity of neuropathy were also studied.
Methods: Patients having an identifiable cause of peripheral neuropathy, except alcohol, were excluded from the study. Patients with evidence of vitamin B₁₂ deficiency or diabetes were also excluded from the study. In this study, 33 patients with liver cirrhosis were evaluated clinically and electrophysiologically to detect any evidence of peripheral neuropathy. Nerve conduction studies were performed in the upper and lower limbs using surface electrodes. These patients also underwent a detailed clinical examination.
Results: Clinical signs of peripheral neuropathy were found in seven (21%) patients. Nerve conduction studies were abnormal in 24 (73%) patients. The pattern of involvement was predominantly of an axonal sensory motor polyneuropathy. Neuropathy was found both in patients with alcohol-related and non-alcohol-related cirrhosis. The presence of encephalopathy did not have a significant bearing on the incidence and severity of neuropathy. The neuropathy was also not significantly related to the severity of liver disease.
Conclusions: The present study reveals that a significant number of patients with liver cirrhosis show evidence of peripheral neuropathy, which is present regardless of the etiology of cirrhosis, and is subclinical in a majority of these patients. The cause of neuropathy was probably the liver disease itself, as the incidence and severity of neuropathy in the alcohol-related cirrhosis, although higher, was not significantly different from the neuropathy in patients with non-alcohol-related cirrhosis.

Peripheral neuropathy has been reported in association with chronic liver disease, including liver cirrhosis and chronic hepatitis. However, the reports have varied regarding the incidence and characteristics of this neuropathy. Some authors have been reluctant to accept the existence of this neuropathy.^[1] The causal relationship of the liver disease with neuropathy has also been questioned.^[2,3] Others have reported an incidence of 19-100%.^[4,5,6,7,8] Histopathological studies have reported segmental demyelination in sural nerves, even in patients without clinical evidence of neuropathy.^[4,6] Autonomic neuropathy has also been reported in association with chronic liver disease.^{[9,10,11,12,13,14,15]} Despite various reports on the subject, there is still discordance regarding the type and extent of 'hepatic neuropathy'. While earlier reports postulated a predominantly demyelinating neuropathy, a recent study found predominant axonal sensory-motor polyneuropathy in chronic liver disease.^[16] This study was planned to: (i) ascertain the incidence of peripheral neuropathy in liver cirrhosis; (ii) characterize the type of involvement of the nerves; (iii) evaluate the effect of various complications of liver cirrhosis on neuropathy; and (iv) study the causal relationship of liver disease to neuropathy.

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

Abstract and Introduction

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