Acute variceal bleeding is a known predisposing risk factor for hepatic encephalopathy in cirrhotic patients [1, 3]; this may exacerbate the morbidity and delay hospital discharge as well as increase the rate of hospital readmissions and mortality in those patients [1,2,3,4,5,6]; consequently, early administration of appropriate prophylactic measures for HE in risky patients with AVB may mitigate both morbidity and mortality burden as well as alleviate the possible shortage of hospital places especially in emergency situations.
In this respect, the risk stratification of those cirrhotic patients with AVB at hospital admissions could be helpful for early prediction of possible occurrence of HE even after bleeding control; these predictors were evaluated in many reports [15, 16]. One of these risk stratifying factors is the underlying liver function which is commonly assessed by Child-Pugh score ; however, this score may be limited by the interrelation between albumin and ascites and the subjective assessment of encephalopathy and ascites . In our study, we used the new ALBI score for the underlying liver functions as a risk stratifying factor for prediction of HE in cirrhotic patients with AVB; we hypothesized that this score has a better performance in comparison to Child-Pugh and MELD scores as it depends on only two objectively assessed parameters (serum albumin and serum bilirubin).
First of all, we found that the cumulative incidence of HE in our patients were about 18.3% within 4 weeks follow-up period, and the reported cumulative incidences of HE after AVB have great variability; it was reported as 16.9% by Win J et al. , 31.4% by Fouad TR et al. , 40% by Sharma P et al. , and 54.5% by Higuera-de-la-Tijera F et al. ; this wide discrepancy may be due to the wide variability of the underlying reserve liver functions, variability in follow-up periods, and variability in modalities of variceal bleeding control. Various prophylactic measures of HE in cirrhotic patients after acute upper GIT bleeding were studied in many reports and were found to significantly improve the incidence rates of HE in those patients; these measures aim to eliminate the blood from GIT to decrease the absorption of its toxic products which is the main mechanism of HE after AVB [17,18,19,20].
As regards the accuracy of ALBI score in prediction of HE in cirrhotic patients with AVB in comparison to both Child-Pugh and MELD scores, we found that all of these scores had a significant performance; however, we found that ALBI score had the highest performance followed by Child-Pugh score then MELD score. Fouad TR et al.  reported a similar conclusion to ours as they identified the possible risk prediction of HE for ALBI score in comparable to Child-Pugh and MELD scores.
In our study, we used ALBI grades for risk stratifying of our patients, and we found that the cumulative incidence function of HE in cirrhotic patients with ALBI grade 3 was significantly more than that present in ALBI grade 2; most of these HE cases occurred in the first 2 weeks of follow-up period, so we could suggest that early hospital discharge for those cirrhotic patients after good control of AVB could be possible in absence of ALBI grade 3; this is the same concept that was reported by Fouad TR et al. . At the same time, we could encourage the administration of prophylactic measures for those cirrhotic patients with ALBI grade 3 who are admitted with AVB.
Our study has some limitations; the first limitation is the uni-centericity of this study, and the second is that the methods of follow-up were not the same for all patients; however, we tried to select the most appropriate method for each patient; the third limitation is that we did not assess the possible hazard of rebleeding; however, we found only 11 cases (4.4%) of mild rebleeding episodes that were appropriately controlled. Lastly, we did not correlate between ALBI score and different stages of HE; however, we focused in our study on the possible predictive performance of ALBI score for possible occurrence of HE.