The treatment of hepatic encephalopathy.
ABSTRACT Current recommendations for the treatment of hepatic encephalopathy are based, to a large extent, on open or uncontrolled trials, undertaken in very small numbers of patients. In consequence, there is ongoing discussion as to whether the classical approach to the treatment of this condition, which aims at reducing ammonia production and absorption using either non-absorbable disaccharides and/or antibiotics, should be revisited, modified or even abandoned. Pros and cons of present therapeutic strategies and possible future developments were discussed at the fourth International Hannover Conference on Hepatic Encephalopathy held in Dresden in June 2006. The content of this discussion is summarized.
SourceAvailable from: Marsha Yvonne Morgan[Show abstract] [Hide abstract]
ABSTRACT: Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly. Conclusion: Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE. (Hepatology 2013)Hepatology 07/2013; 58(1). DOI:10.1002/hep.26370 · 11.19 Impact Factor
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ABSTRACT: Rifaximin is a non-absorbable antibiotic which is approved for the treatment of hepatic encephalopathy (HE) in the United States. Our goal was to retrospectively assess this in patients with very advanced liver disease with our center data. Between 2003 and 2010, we examined a total of 286 consecutive patients from our center who were on a combination of rifaximin and lactulose, who had been evaluated or listed as eligible for a liver transplant. Patients who received less than 3 months of rifaximin and lactulose were excluded. Patients who had incomplete data; specifically, a lack of MELD score upon hospital admission were excluded from this analysis. The retrospective chart review was approved by the institutional review board. We observed a total of 723 hospitalizations among the patients. Of the 723 hospitalizations, 218 were due to portosystemic encephalopathy (PSE), whereas 505 were due to other causes. We observed that patients with a MELD < 20 had an average of 2.5 hospitalizations per 6 month period, and that those with a MELD > 20 had an average of 1.6 hospitalizations per 6 month period for HE. At the same time, patients who had a MELD score < 20 had 3.29 hospitalizations for HE unrelated causes and those whose MELD was >20 had 3.73 hospitalizations for causes not related to HE. In this cohort 65% of all hospitalizations from HE were in patients whose MELD was <20, and 35% of all hospitalizations were for patients with a MELD > 20. In our experience, HE related hospitalizations were lower in patients whose MELD > 20 who were on a combination of rifaximin and lactulose compared to patients with MELD < 20. In contrast, patients whose MELD > 20 had greater hospitalizations for non HE events which may be an expected result owing to the overall increased severity of their liver disease. The limitation of this study is its retrospective nature and single center experience. In conclusion, administration of rifaximin appears to significantly reduce hospitalizations from HE in patients with MELD > 20 and therefore is advocated in maintenance of remission of HE in patients with very advanced liver disease. Copyright © 2014 Elsevier Inc. All rights reserved.Transplantation Proceedings 12/2014; 46(10):3481-6. DOI:10.1016/j.transproceed.2014.10.021 · 0.95 Impact Factor
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ABSTRACT: It is now well known that intestinal microbiota exerts not only several physiological functions, but has also been implied in the mechanisms of many conditions, both intestinal and extraintestinal. These advances, to the best of our knowledge, have been made possible by the development of new ways of studying gut flora. Metagenomics, the study of genetic material taken directly from environmental samples, avoiding individual culture, has become an excellent tool to study the human microbiota. Therefore, it has demonstrated an association between an altered intestinal microbiota and inflammatory bowel disease or irritable bowel syndrome, perhaps the most extensively studied conditions associated with this particular subject. However, microbiota has a potential role in the development of other diseases; their manifestations are not confined to the intestine only. In this article, an extensive updated review is conducted on the role intestinal microbiota has in health and in different diseases. Focus is made on the following conditions: inflammatory bowel disease, irritable bowel syndrome, celiac disease, hepatic encephalopathy, and obesity.