this paper provides an overview for the clinician of common comorbidities contributing to poor sleep in patients with liver disease, mainly restless leg syndrome and obstructive sleep apnea. it is hoped that these new classifications of covert he and overt he will lead to a more standardized approach to these patients, in both their classification and their management. despite the fact that disturbance in sleep rhythm is one of the earliest signs of covert hepatic encephalopathy, there has been no correlation found between the degree of sleep disturbance and the presence of hepatic encephalopathy. restless leg syndrome is more commonly reported in patients with cirrhosis and sleep disturbances than the general population [34], although the evidence is still unclear as to whether it would be a treatable cause of fatigue and sleep disturbance [35, 36].
very few studies have looked at effectiveness of administering bright light in the morning in an attempt to synchronize daytime melatonin levels in liver cirrhosis patients and decrease daytime sleepiness [40]. it is important to note that these improvements are shown in patients with minimal hepatic encephalopathy and did not apply to all patients with liver cirrhosis. a reasonable approach to patients with known cirrhosis complaining of poor sleep quality or daytime sleepiness is to first and foremost rule out the presence of he, such as west haven criteria grade 1 or minimal he (covert he). lastly, use of the stimulant modafinil was effective in combating daytime somnolence in primary biliary cirrhosis (pbc), and perhaps it can be useful if applied to other conditions causing liver cirrhosis.
the combination of restless nights and excessive daytime sleepiness) in patients with severe overt hepatic encephalopathy (he) [3]. [9•] have proposed a model to explain the abnormal interaction between homeostatic and circadian components of sleep in cirrhotic patients. the prevalence of this well-recognized cause of sleep fragmentation and excessive daytime somnolence [32] is increased in obese patients [33]. in addition, the adverse effects of alcohol consumption on sleep are well characterised both in healthy individuals and alcohol misusers. the evaluation of sleep–wake behaviour in patients with cirrhosis comprises a heterogeneous mix of methodologies which can be distinguished into subjective and objective/semi-quantitative. [15] have confirmed a significant correlation between stsqs and psqi for the diagnosis of sleep disturbances in patients with cirrhosis. due to the aforementioned limitations, this technique is generally employed in the research field and currently not included in the routine assessment of sleep quality. these results are most likely in relation to the severity of disturbance at baseline, since sleep and circadian rhythms in hospitalized, decompensated patients with cirrhosis are extremely compromised [66•]. the timing of caffeine administration is also worthy of study in patients with cirrhosis. sleep disturbance and daytime sleepiness in patients with cirrhosis: a case control study. correlation between degree and quality of sleep disturbance and the level of neuropsychiatric impairment in patients with liver cirrhosis. this study analyses the relationship between night sleep disturbance/excessive daytime sleepiness and neuropsychiatric impairment in patients with cirrhosis. progressive reduction of sleep time and quality in rats with hepatic encephalopathy caused by portacaval shunts. sleep and circadian abnormalities in patients with cirrhosis: features of delayed sleep phase syndrome? induced hyperammonemia may compromise the ability to generate restful sleep in patients with cirrhosis. abnormalities in the polysomnographic, adenosine and metabolic response to sleep deprivation in an animal model of hyperammonemia.
on the origin and the consequences of circadian abnormalities in patients with cirrhosis. musso g, cassader m, olivetti c, rosina f, carbone g, gambino r. association of obstructive sleep apnoea with the presence and severity of non-alcoholic fatty liver disease. chronic intermittent hypoxia upregulates genes of lipid biosynthesis in obese mice. effects of obstructive sleep apnea on sleep quality, cognition, and driving performance in patients with cirrhosis. impact of alcoholism on sleep architecture and eeg power spectra in men and women. sockalingam s, abbey se, alosaimi f, novak m. a review of sleep disturbance in hepatitis c. j clin gastroenterol. extrahepatic manifestations of hepatitis c virus infection: a general overview and guidelines for a clinical approach. the pittsburgh sleep quality index: a new instrument for psychiatric practice and research. saleh k, javaheri s. sleep in ambulatory patients with stable cirrhosis of the liver. sleep and circadian rhythms in hospitalized patients with decompensated cirrhosis: effect of light therapy. bright times for patients with cirrhosis and delayed sleep habits: a case report on the beneficial effect of light therapy. changes in the 24-h plasma cortisol rhythm in patients with cirrhosis. improvement of sleep architecture parameters in cirrhotic patients with recurrent hepatic encephalopathy with the use of rifaximin. vigilance and wake eeg architecture in simulated hyperammonaemia: a pilot study on the effects of l-ornithine-l-aspartate (lola) and caffeine. buxton om, frank sa, l’hermite-balériaux m, leproult r, turek fw, van cauter e. roles of intensity and duration of nocturnal exercise in causing phase delays of human circadian rhythms. formentin, c., garrido, m. & montagnese, s. assessment and management of sleep disturbance in cirrhosis.
key contributors to sleep disturbance include hepatic encephalopathy (he) and circadian rhythm imbalance due to altered melatonin metabolism. although sleep disturbances can be an early sign of hepatic encephalopathy (he), many patients without he still complain of poor quality sleep. the pathophysiology and relation to hepatic encephalopathy. the origin of sleep–wake disturbances in cirrhosis is likely to be multifactorial. it, .
although sleep disturbances can be an early sign of hepatic encephalopathy (he), many patients without he still complain of poor quality sleep. the pathophysiology of these disturbances is not fully understood but is believed to be linked to impaired hepatic melatonin metabolism. sleepu2013wake abnormalities are related to the presence of hepatic encephalopathy (he) and improvement in sleep parameters can be observed when he is properly managed. a few non-specific treatments for sleepu2013wake abnormalities have been tried with encouraging results for hydroxyzine and modafinil. sleep disturbances occur in 27-70% of patients with cirrhosis hepatic encephalopathy must be considered in any patient with cirrhosis and excessive daytime hepatic encephalopathy (he) is a complex neuropsychiatric syndrome related to chronic/acute hepatic failure. sleep architecture is disturbed in this syndrome, sleep disturbance and excessive daytime sleepiness (eds) have been reported in patients with hepatic cirrhosis with no hepatic encephalopathy (he)., .
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