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Abstract
Type C hepatic encephalopathy (HE) is a brain dysfunction caused by severe hepatocellular failure or presence of portal-systemic shunts in patients with liver cirrhosis. In its subclinical form, called “minimal hepatic encephalopathy (MHE), only psychometric tests or electrophysiological evaluation can reveal alterations in attention, working memory, psychomotor speed and visuospatial ability, while clinical neurological signs are lacking. The term “covert” (CHE) has been recently used to unify MHE and Grade I HE in order to refer to a condition that is not unapparent but also non overt. “Overt” HE (OHE) is characterized by personality changes, progressive disorientation in time and space, acute confusional state, stupor and coma. Based on its time course, OHE can be divided in Episodic, Recurrent or Persistent. Episodic HE is generally triggered by one or more precipitant factors that should be found and treated. Unlike MHE, clinical examination and clinical decision are crucial for OHE diagnosis and West Haven criteria are widely used to assess the severity of neurological dysfunction. Primary prophylaxis of OHE is indicated only in the patient with gastrointestinal bleeding using non-absorbable antibiotics (Rifaximin) or non-absorbable disaccharides (Lactulose). Treatment of OHE is based on the identification and correction of precipitating factors and starting empirical ammonia-lowering treatment with Rifaximin and Lactulose (per os and enemas). The latter should be used for secondary prophylaxis, adding Rifaximin if HE becomes recurrent. In recurrent/persistent HE, the treatment options include fecal transplantation, TIPS revision and closure of eventual splenorenal shunts. Treatment of MHE should be individualized on a case-by-case basis.
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Siddiqui MT, Cresci GAM. Microbiota reprogramming for treatment of alcohol-related liver disease. Transl Res 2020; 226:26-38. [PMID: 32687975 DOI: 10.1016/j.trsl.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/01/2020] [Accepted: 07/13/2020] [Indexed: 02/08/2023]
Abstract
In the past decade knowledge has expanded regarding the importance of the gut microbiota in maintaining intestinal homeostasis and overall health. During this same time, we have also gained appreciation for the role of the gut-liver axis in the development of liver diseases. Alcohol overconsumption is one of the leading causes of liver failure globally. However, not all people with alcohol use disorder progress to advanced stages of liver disease. With advances in technology to investigate the gut microbiome and metabolome, we are now beginning to delineate alcohol's effects on the gut microbiome in relation to liver disease. This review presents our current understanding on the role of the gut microbiota during alcohol exposure, and various therapeutic attempts that have been made to reprogram the gut microbiota with the goal of alleviating alcoholic-related liver disease.
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3
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Abstract
Alcoholic liver disease (ALD) encompasses a broad spectrum of disorders including steatosis, steatohepatitis, fibrosis, and cirrhosis. Despite intensive research in the last two decades, there is currently no Food and Drug Administration-approved therapy for treating ALD. Several studies have demonstrated the importance of the gut-liver axis and gut microbiome on the pathogenesis of ALD. Alcohol may induce intestinal dysbiosis and increased intestinal permeability, which in turn result in increased levels of pathogen-associated molecular patterns such as lipopolysaccharide (LPS) and translocation of microbial products from the gut to the liver (bacterial translocation). LPS is an inflammatory signal that activates toll-like receptor 4 on Kupffer cells, contributing to the inflammation observed in ALD. Recently, probiotics have been shown to be effective in reducing or preventing the progression of ALD. A potential mechanism is that the probiotics transforms the composition of intestinal microbiota, which leads to reductions in alcohol-induced dysbiosis, intestinal permeability, bacterial translocation, endotoxemia, and consequently, the development of ALD. While transformation of intestinal microbiota by probiotics appears to be a promising therapeutic strategy for the treatment of intestinal barrier dysfunction, there is a scarcity of research that studies probiotics in the context of ALD. In this review, we discuss the potential therapeutic applications of probiotics in the treatment of ALD.
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Shen YC, Chang YH, Fang CJ, Lin YS. Zinc supplementation in patients with cirrhosis and hepatic encephalopathy: a systematic review and meta-analysis. Nutr J 2019; 18:34. [PMID: 31279342 PMCID: PMC6612144 DOI: 10.1186/s12937-019-0461-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/25/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Low serum zinc level is associated with hepatic encephalopathy (HE), but the efficacy of zinc supplementation remains uncertain. This study aimed to investigate the effects of zinc supplementation on HE treatment in patients with cirrhosis. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (Cochrane CENTRAL) and Scopus from inception to December 2018; without publication date or language restrictions. Randomized controlled trials of zinc supplementation versus placebo or other treatment for the management of HE in adult patients with cirrhosis were selected. The primary outcome was the degree of HE as assessed by clinical signs or specialized psychometric tests. The secondary outcomes included serum ammonia levels, adverse events, or the length of hospital stay and costs. We carried out a meta-analysis with random effects model and summarized continuous outcomes using standardized mean differences (SMD) or mean differences (MD) with 95% confidence intervals (95% CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence for each outcome was evaluated with the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS Four trials with 247 patients were included. In patients with cirrhosis who had mild HE (≤ grade II), the available evidence suggested that the combination treatment of zinc supplementation and lactulose over 3 to 6 months significantly improved performance in the number connection test (SMD: -0.97; 95% CI: - 1.75 to - 0.19; P = 0.01; moderate certainty), reported in three trials (n = 227). However, compared with lactulose therapy alone, additional zinc supplementation demonstrated no significant difference in the digit symbol test (SMD: 0.44; 95% CI: - 0.12 to 1.00; P = 0.12; very low certainty) or serum ammonia levels (MD: -10.86; 95% CI: - 25.73 to 4.01; P = 0.15; very low certainty), reported in two trials (n = 137). None of the included trials reported adverse events or effects on hospitalization. CONCLUSIONS In conclusion, a combination of zinc supplementation and lactulose over 3 to 6 months may improve the number connection test in cirrhotic patients with low grade HE, compared with lactulose only. TRIAL REGISTRATION PROSPERO: CRD42017080955 . Registered 23 November 2017.
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Affiliation(s)
- Ying-Chi Shen
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Ya-Hui Chang
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan.,Department of Pharmacy, MacKay Memorial Hospital, Taipei, Taiwan.,School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Ching-Ju Fang
- Medical Library, National Cheng Kung University, Tainan, Taiwan.,Department of Secretariat, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yang-Sheng Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan. .,MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan. .,Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Evidence-Based Medicine Center, MacKay Memorial Hospital, Taipei, Taiwan. .,Division of Gastroenterology and Hepatology, Department of Internal Medicine and Deputy Director, Evidence-Based Medicine Center, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei City, 104, Taiwan, Republic of China.
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5
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Abstract
Sleep-wake disturbances are common in liver cirrhosis and associated with impaired quality of life. The most common abnormalities are insomnia (difficulties falling asleep and maintaining sleep, or unrefreshing sleep), excessive daytime sleepiness, and sleep-wake inversion (disturbances of circadian rhythmicity). The underlying pathophysiological mechanisms for sleep disturbances in cirrhosis are complex and may include disturbed metabolism of melatonin and glucose, alterations in thermoregulation, and altered ghrelin secretion profiles. Sleep-wake 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 sleep-wake abnormalities have been tried with encouraging results for hydroxyzine and modafinil. However, due to the potential for medication toxicity in these disabled patients, further studies are needed to address the potential role of non-drug therapies in this population (eg, cognitive behavioral therapy, mindfulness, yoga) that have demonstrated usefulness in insomnia disorders.
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Affiliation(s)
- Marie Bruyneel
- Sleep Unit, Department of Pneumology, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium,
| | - Thomas Sersté
- Department of Hepato-gastroenterology, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
- Liver Transplantation Unit, Department of Hepato-gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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6
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Abstract
Decompensated cirrhosis is characterized by high hospitalization rates and costs, frequent readmissions, and poor short-term survival. Patients admitted to the hospital with acute variceal bleeding and/or hepatic encephalopathy and/or renal dysfunction are at serious risk for developing infection and/or sepsis; in turn, this renders them highly susceptible to the development of multi-system organ failure. The lack of standardized intensive care unit management protocols in patients with cirrhosis along with only few data reports from longitudinal clinical trials makes it difficult for hepatologists and critical care specialists to provide uniform evidence for clinical practice that could safely consolidate favorable outcomes such as lower hospitalization rates and/or mortality. Based on a rigorous online search of the scientific literature as well as a longtime clinical experience of the authors in the field of hepatology and critical care medicine, this work represents a focused effort to elucidate the specific bio-morbidity of advanced liver diseases in relation to the aforementioned challenges in clinical management. Further meta-analyses and/or systematic reviews are needed to enable clinicians to develop more effective strategies to bridge patients with decompensated liver disease to recompensation or liver transplantation.
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Affiliation(s)
- Antonios Katsounas
- Department for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Ali Canbay
- Department for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
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Nath A, Haktanirlar G, Varga Á, Molnár MA, Albert K, Galambos I, Koris A, Vatai G. Biological Activities of Lactose-Derived Prebiotics and Symbiotic with Probiotics on Gastrointestinal System. ACTA ACUST UNITED AC 2018; 54:medicina54020018. [PMID: 30344249 PMCID: PMC6037253 DOI: 10.3390/medicina54020018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/23/2018] [Accepted: 04/04/2018] [Indexed: 02/07/2023]
Abstract
Lactose-derived prebiotics provide wide ranges of gastrointestinal comforts. In this review article, the probable biochemical mechanisms through which lactose-derived prebiotics offer positive gastrointestinal health are reported along with the up-to-date results of clinical investigations; this might be the first review article of its kind, to the best of our knowledge. Lactose-derived prebiotics have unique biological and functional values, and they are confirmed as ‘safe’ by the Food and Drug Administration federal agency. Medical practitioners frequently recommend them as therapeutics as a pure form or combined with dairy-based products (yoghurt, milk and infant formulas) or fruit juices. The biological activities of lactose-derived prebiotics are expressed in the presence of gut microflora, mainly probiotics (Lactobacillus spp. in the small intestine and Bifidobacterium spp. in the large intestine). Clinical investigations reveal that galacto-oligosaccharide reduces the risks of several types of diarrhea (traveler’s diarrhea, osmotic diarrhea and Clostridium difficile associated relapsing diarrhea). Lactulose and lactosucrose prevent inflammatory bowel diseases (Crohn’s disease and ulcerative colitis). Lactulose and lactitol reduce the risk of hepatic encephalopathy. Furthermore, lactulose, galacto-oligosaccharide and lactitol prevent constipation in individuals of all ages. It is expected that the present review article will receive great attention from medical practitioners and food technologists.
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Affiliation(s)
- Arijit Nath
- Department of Food Engineering, Faculty of Food Science, Szent István University, Ménesi st 44, H-1118 Budapest, Hungary.
- Soós Ernő Water Technology Research Centre, Faculty of Engineering, University of Pannonia, Zrínyi M. u. 18, H-8800 Nagykanizsa, Hungary.
| | - Gokce Haktanirlar
- Department of Food Engineering, Faculty of Food Science, Szent István University, Ménesi st 44, H-1118 Budapest, Hungary.
| | - Áron Varga
- Department of Food Engineering, Faculty of Food Science, Szent István University, Ménesi st 44, H-1118 Budapest, Hungary.
| | - Máté András Molnár
- Department of Food Engineering, Faculty of Food Science, Szent István University, Ménesi st 44, H-1118 Budapest, Hungary.
| | - Krisztina Albert
- Department of Food Engineering, Faculty of Food Science, Szent István University, Ménesi st 44, H-1118 Budapest, Hungary.
| | - Ildikó Galambos
- Soós Ernő Water Technology Research Centre, Faculty of Engineering, University of Pannonia, Zrínyi M. u. 18, H-8800 Nagykanizsa, Hungary.
| | - András Koris
- Department of Food Engineering, Faculty of Food Science, Szent István University, Ménesi st 44, H-1118 Budapest, Hungary.
| | - Gyula Vatai
- Department of Food Engineering, Faculty of Food Science, Szent István University, Ménesi st 44, H-1118 Budapest, Hungary.
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Ridola L, Cardinale V, Riggio O. The burden of minimal hepatic encephalopathy: from diagnosis to therapeutic strategies. Ann Gastroenterol 2018; 31:151-164. [PMID: 29507462 PMCID: PMC5825945 DOI: 10.20524/aog.2018.0232] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/29/2017] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is the mildest form of hepatic encephalopathy (HE). It affects the performance of psychometric tests focused on attention, working memory, psychomotor speed, and visuospatial ability, as well as electrophysiological and other functional brain measures. MHE is a frequent complication of liver disease, affecting up to 80% of tested patients. By being related to falls, an impairment in fitness to drive and the development of overt HE, MHE severely affects the lives of patients and caregivers by altering their quality of life and their socioeconomic status. MHE is detected in clinically asymptomatic patients using appropriate psychometric tests and neurophysiological methods that highlight neuropsychological alterations, such as video-spatial orientation deficits, attention disorders, memory, reaction times, electroencephalogram slowing, prolongation of latency-evoked cognitive potentials, and reduction in the critical flicker frequency. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics such as rifaximin, probiotics and branched-chain amino acids. However, because of the multiple diagnosis methods, the various endpoints of treatment trials and the variety of agents used in trials, the treatment of MHE is not currently recommended as routine, but only on a case-by-case basis.
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Affiliation(s)
- Lorenzo Ridola
- Department of Medico-Surgical Sciences and Biotechnologies (Lorenzo Ridola, Vincenzo Cardinale), Sapienza University of Rome, Italy
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies (Lorenzo Ridola, Vincenzo Cardinale), Sapienza University of Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine (Oliviero Riggio), Sapienza University of Rome, Italy
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9
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Abstract
Alcohol consumption remains one of the predominant causes of liver disease and liver-related death worldwide. Intriguingly, dysregulation of the gut barrier is a key factor promoting the pathogenesis of alcoholic liver disease (ALD). A functional gut barrier, which consists of a mucus layer, an intact epithelial monolayer and mucosal immune cells, supports nutrient absorption and prevents bacterial penetration. Compromised gut barrier function is associated with the progression of ALD. Indeed, alcohol consumption disrupts the gut barrier, increases gut permeability, and induces bacterial translocation both in ALD patients and in experimental models with ALD. Moreover, alcohol consumption also causes enteric dysbiosis with both numerical and proportional perturbations. Here, we review and discuss mechanisms of alcohol-induced gut barrier dysfunction to better understand the contribution of the gut-liver axis to the pathogenesis of ALD. Unfortunately, there is no effectual Food and Drug Administration-approved treatment for any stage of ALD. Therefore, we conclude with a discussion of potential strategies aimed at restoring the gut barrier in ALD. The principle behind antibiotics, prebiotics, probiotics and fecal microbiota transplants is to restore microbial symbiosis and subsequently gut barrier function. Nutrient-based treatments, such as dietary supplementation with zinc, niacin or fatty acids, have been shown to regulate tight junction expression, reduce intestinal inflammation, and prevent endotoxemia as well as liver injury caused by alcohol in experimental settings. Interestingly, saturated fatty acids may also directly control the gut microbiome. In summary, clinical and experimental studies highlight the significance and efficacy of the gut barrier in treating ALD.
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Affiliation(s)
- Zhanxiang Zhou
- Center for Translational Biomedical Research, School of Health and Human Sciences, University of North Carolina at Greensboro, Kannapolis, NC, USA
- Department of Nutrition, School of Health and Human Sciences, University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Wei Zhong
- Center for Translational Biomedical Research, School of Health and Human Sciences, University of North Carolina at Greensboro, Kannapolis, NC, USA
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Singh J, Sharma BC, Puri V, Sachdeva S, Srivastava S. Sleep disturbances in patients of liver cirrhosis with minimal hepatic encephalopathy before and after lactulose therapy. Metab Brain Dis 2017; 32:595-605. [PMID: 28070704 DOI: 10.1007/s11011-016-9944-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 12/26/2016] [Indexed: 12/11/2022]
Abstract
Sleep disturbances are common in patients of cirrhosis with minimal hepatic encephalopathy (MHE) and affect health related quality of life (HRQOL). No study has evaluated effect of lactulose on sleep disturbances and correlation with HRQOL in patients with MHE. We assessed sleep disturbances in cirrhosis with MHE and effect of lactulose on sleep disturbances and HRQOL. One hundred patients of cirrhosis [MHE; (n = 50, age 45.3 ± 11.2 years, 45 males) no-MHE (n = 50, age 46.3 ± 10.4 years, 44 males)] were included. MHE was diagnosed with psychometric hepatic encephalopathy score (PHES) ≤ -5. All patients underwent laboratory parameters including arterial ammonia and critical flicker frequency (CFF) Sleep disturbances were measured with Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS) and polysomnography. HRQOL was measured with SF-36(v2) questionnaire. Patients with MHE were given lactulose therapy for 3 months and all the parameters were repeated. Poor quality of sleep and excessive day time sleepiness were more common in patients with MHE, compared to without MHE. With lactulose therapy there was improvement in MHE in 21 patients and arterial ammonia levels (93.74 ± 14.8 vs. 71.44 ± 18.8 μmol/L: p < 0.001), CFF (34.83 ± 3.54 vs. 39.44 ± 4.95 Hz: p < 0.001), PHES (-7.64 ± 2.1 vs. -5.58 ± 2.09: p < 0.001), PSQI (8.6 ± 3.3 vs. 5.2 ± 1.5: p < 0.001), ESS (12.52 ± 3.01 vs. 9.24 ± 2.27: p < 0.001) and HRQOL (p = 0.01). Excessive day time sleepiness and impaired sleep quality are common in patients with MHE and correlate with neuropsychiatric impairment. Improvement in MHE with lactulose also leads to improvement in sleep disturbances and HRQOL.
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Affiliation(s)
- Jatinderpal Singh
- Department of Gastroenterology, G. B. Pant Institute of Postgraduate Medical Education and Research, JLN Marg, New Delhi, 110002, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G. B. Pant Institute of Postgraduate Medical Education and Research, JLN Marg, New Delhi, 110002, India.
| | - Vinod Puri
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, JLN Marg, New Delhi, 110002, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, G. B. Pant Institute of Postgraduate Medical Education and Research, JLN Marg, New Delhi, 110002, India
| | - Siddharth Srivastava
- Department of Gastroenterology, G. B. Pant Institute of Postgraduate Medical Education and Research, JLN Marg, New Delhi, 110002, India
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El-Karaksy HM, Afifi O, Bakry A, Kader AA, Saber N. A pilot study using lactulose in management of minimal hepatic encephalopathy in children with extrahepatic portal vein obstruction. World J Pediatr 2017; 13:70-75. [PMID: 27878780 DOI: 10.1007/s12519-016-0066-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/20/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Minimal hepatic encephalopathy (MHE) is not associated with overt neuropsychiatric symptoms but rather with subtle changes in psychometric and/or neurophysiologic tests. We aimed to diagnose MHE in children with extrahepatic portal vein obstruction (EHPVO) and to evaluate the effect of lactulose on MHE. METHODS A prospective study was carried out on 30 patients with EHPVO (21 males; mean age 10±2.5 years). The study was carried out in the Pediatric Hepatology Unit, Cairo University Pediatric Hospital, Cairo, Egypt, between 2011 and 2013. All patients were subjected to clinical and laboratory assessment, neuropsychmetric testing using the arabic version of Wechsler intelligence tests, neurophysiological testing by visual electroencephalogram and P300 event related potentials (ERP). RESULTS The prevalence of MHE among children with EHPVO was 20% (6/30). After randomization to treatment and no-treatment groups using lactulose, all tests were repeated after three months. Among four patients with MHE who received lactulose, three (75%) improved. On the other hand, one of the patients in the no-treatment group developed MHE. Only one patient in the treatment arm had to discontinue lactulose because of severe diarrhea. CONCLUSIONS This pilot study revealed that the prevalence of MHE was 20%. Improvement on psychometic tests was seen in 75% of our patients (3/4) after treatment with lactulose. Lactulose treatment was well tolerated.
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Affiliation(s)
- Hanaa Mostafa El-Karaksy
- Department of Pediatrics, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt. .,, 44 Mohei El-Deen Abu El-Ezz Street, Dokki, Cairo, 12311, Egypt.
| | - Omneya Afifi
- Department of Pediatrics, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt
| | - Azza Bakry
- Department of Psychiatry, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt
| | - Ann Abdel Kader
- Department of Neurophysiology, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt
| | - Noha Saber
- Department of Psychiatry, Kasr Alainy School of Medicine, Cairo University, Giza, Egypt
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12
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Naderian M, Akbari H, Saeedi M, Sohrabpour AA. Polyethylene Glycol and Lactulose versus Lactulose Alone in the Treatment of Hepatic Encephalopathy in Patients with Cirrhosis: A Non-Inferiority Randomized Controlled Trial. Middle East J Dig Dis 2017; 9:12-19. [PMID: 28316761 PMCID: PMC5308129 DOI: 10.15171/mejdd.2016.46] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In this clinical trial, polyethylene glycol (PEG) solution was compared with lactulose in the treatment of hepatic encephalopathy in patients with cirrhosis. METHODS This randomized controlled trial was performed on 40 patients in two groups. The patients in the lactulose group received either 20-30 grams of lactulose orally or by a nasogastric tube, or 200 grams of lactulose enema by a rectal tube. The patients in the PEG-lactulose group received the same amount of oral or rectal lactulose, plus 280 grams of PEG in 4 liters of water orally as a single dose in 30-120 minutes. Serial physical examinations, hepatic encephalopathy scoring algorithm (HESA), blood level of ammonia, and serum biochemical studies were used to evaluate the severity of hepatic encephalopathy. RESULTS In comparison with lactulose alone, PEG-lactulose could improve HESA score in 24 hours more effectively (p =0.04). Overall, PEG-lactulose regimen was associated with a decrease in length of hospital stay compared with lactulose treatment (p =0.03) but in subgroup analysis we found that PEG-lactulose regimen could only decrease the length of hospital stay in women significantly (p =0.01). CONCLUSION The use of PEG along with lactulose in comparison with lactulose alone is more effective in the treatment of hepatic encephalopathy in patients with cirrhosis and results in more rapid discharge from hospital.
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Affiliation(s)
- Mohammadreza Naderian
- Liver and Pancreaticobilliary Disease Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Heshmatollah Akbari
- Liver and Pancreaticobilliary Disease Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Saeedi
- Department of Emergency Medicine, Pre-Hospital Emergency Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ali Sohrabpour
- Liver and Pancreaticobilliary Disease Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Subasinghe SKCE, Nandamuni Y, Ranasinghe S, Niriella MA, Miththinda JKND, Dassanayake A, de Silva AP, de Silva HJ. Association between road accidents and low-grade hepatic encephalopathy among Sri Lankan drivers with cirrhosis: a prospective case control study. BMC Res Notes 2016; 9:303. [PMID: 27296988 PMCID: PMC4907045 DOI: 10.1186/s13104-016-2106-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/31/2016] [Indexed: 01/18/2023] Open
Abstract
Background Low-grade hepatic encephalopathy (LGHE) comprises minimal hepatic encephalopathy (MHE) and grade 1 hepatic encephalopathy. LGHE has no or minimal recognizable symptoms but has mild cognitive and psychomotor deficits. Studies in Western countries have demonstrated increased road accidents (RA) among patients with MHE. Our objective was to investigate the association between Sri Lankan LGHE phenotype and RA. Study design and methods A prospective, case–control study was conducted in the University Medical Unit, North Colombo Teaching Hospital, Ragama Sri Lanka. Patients with cirrhosis of any aetiology, without OHE, who had been driving during previous 1 month were included. A similar number of age matched, healthy control drivers were also enrolled. Both groups were subjected to five pencil-paper based psychometric tests used to detect LGHE in cirrhotics. Self-reported RA during the previous 1 month were recorded: categorized as ‘major’ when resulted in hospitalization of the involved, ‘minor’ when there were injuries, but not serious enough for hospitalization of the involved and ‘other’ when limited to damages to vehicle or environment without injuries. Results Among 55 drivers with cirrhosis and LGHE [males, median age 53 years (range 30–60)], 7 (12.7 %) reported RA compared to 6 (10.9 %) among 55 controls [males; median age 51 years (range 30–60)]. There were no ‘major’ accidents in either group. 2/55 (3.6 %) cases and 2/55 (3.6 %) controls reported ‘minor’ accidents. Conclusion There was no increased frequency of RA among Sri Lankan drivers with LGHE compared to healthy controls. This is with the limitation of the study based only on self reported RA.
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Affiliation(s)
- S K C E Subasinghe
- Professorial Medical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - Y Nandamuni
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Thalagolla Road, PO Box 6, Ragama, GQ 11010, Sri Lanka
| | - S Ranasinghe
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Thalagolla Road, PO Box 6, Ragama, GQ 11010, Sri Lanka
| | - M A Niriella
- Professorial Medical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka. .,Department of Medicine, Faculty of Medicine, University of Kelaniya, Thalagolla Road, PO Box 6, Ragama, GQ 11010, Sri Lanka.
| | - J K N D Miththinda
- Professorial Medical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - A Dassanayake
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - A P de Silva
- Professorial Medical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Kelaniya, Thalagolla Road, PO Box 6, Ragama, GQ 11010, Sri Lanka
| | - H J de Silva
- Professorial Medical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Kelaniya, Thalagolla Road, PO Box 6, Ragama, GQ 11010, Sri Lanka
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14
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Gluud LL, Vilstrup H, Morgan MY. Non-absorbable disaccharides versus placebo/no intervention and lactulose versus lactitol for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Cochrane Database Syst Rev 2016; 2016:CD003044. [PMID: 27153247 PMCID: PMC7004252 DOI: 10.1002/14651858.cd003044.pub4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Non-absorbable disaccharides (lactulose and lactitol) are recommended as first-line treatment for hepatic encephalopathy. The previous (second) version of this review included 10 randomised clinical trials (RCTs) evaluating non-absorbable disaccharides versus placebo/no intervention and eight RCTs evaluating lactulose versus lactitol for people with cirrhosis and hepatic encephalopathy. The review found no evidence to either support or refute the use of the non-absorbable disaccharides and no differences between lactulose versus lactitol. OBJECTIVES To assess the beneficial and harmful effects of i) non-absorbable disaccharides versus placebo/no intervention and ii) lactulose versus lactitol in people with cirrhosis and hepatic encephalopathy. SEARCH METHODS We carried out electronic searches of the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 10), MEDLINE, EMBASE, and Science Citation Index Expanded to 19 October 2015; manual searches of meetings and conference proceedings; checks of bibliographies; and correspondence with investigators and pharmaceutical companies. SELECTION CRITERIA We included RCTs, irrespective of publication status, language, or blinding. DATA COLLECTION AND ANALYSIS Two review authors, working independently, retrieved data from published reports and correspondence with investigators. The primary outcomes were mortality, hepatic encephalopathy, and serious adverse events. We presented the results of meta-analyses as risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI). We assessed the quality of the evidence using 'Grading of Recommendations Assessment Development and Evaluation' (GRADE) and bias control using the Cochrane Hepato-Biliary Group domains. Our analyses included regression analyses of publication bias and other small study effects, Trial Sequential Analyses to detect type 1 and type 2 errors, and subgroup and sensitivity analyses. MAIN RESULTS We included 38 RCTs with a total of 1828 participants. Eight RCTs had a low risk of bias in the assessment of mortality. All trials had a high risk of bias in the assessment of the remaining outcomes. Random-effects meta-analysis showed a beneficial effect of non-absorbable disaccharides versus placebo/no intervention on mortality when including all RCTs with extractable data (RR 0.59, 95% CI 0.40 to 0.87; 1487 participants; 24 RCTs; I(2) = 0%; moderate quality evidence) and in the eight RCTs with a low risk of bias (RR 0.63, 95% CI 0.41 to 0.97; 705 participants). The Trial Sequential Analysis with the relative risk reduction (RRR) reduced to 30% confirmed the findings when including all RCTs, but not when including only RCTs with a low risk of bias or when we reduced the RRR to 22%. Compared with placebo/no intervention, the non-absorbable disaccharides were associated with beneficial effects on hepatic encephalopathy (RR 0.58, 95% CI 0.50 to 0.69; 1415 participants; 22 RCTs; I(2) = 32%; moderate quality evidence). Additional analyses showed that non-absorbable disaccharides can help to reduce serious adverse events associated with the underlying liver disease including liver failure, hepatorenal syndrome, and variceal bleeding (RR 0.47, 95% CI 0.36 to 0.60; 1487 participants; 24 RCTs; I(2) = 0%; moderate quality evidence). We confirmed the results in Trial Sequential Analysis. Tests for subgroup differences showed no statistical differences between RCTs evaluating prevention, overt, or minimal hepatic encephalopathy. The evaluation of secondary outcomes showed a potential beneficial effect of the non-absorbable disaccharides on quality of life, but we were not able to include the data in an overall meta-analysis (very low quality evidence). Non-absorbable disaccharides were associated with non-serious (mainly gastrointestinal) adverse events (very low quality evidence). None of the RCTs comparing lactulose versus lactitol evaluated quality of life. The review found no differences between lactulose and lactitol for the remaining outcomes (very low quality evidence). AUTHORS' CONCLUSIONS This review includes a large number of RCTs evaluating the prevention or treatment of hepatic encephalopathy. The analyses found evidence that non-absorbable disaccharides may be associated with a beneficial effect on clinically relevant outcomes compared with placebo/no intervention.
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Affiliation(s)
- Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards AlleHvidovreDenmark2650
| | - Hendrik Vilstrup
- Aarhus KommunehospitalDepartment of Hepatology and GastroenterologyNørrebrogade 44Aarhus CDenmarkDK‐8000
| | - Marsha Y Morgan
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
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15
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Abstract
OPINION STATEMENT The main issue with treating covert hepatic encephalopathy (HE) is to establish whether it is cost effective to reverse the neuropsychiatric abnormalities that define this mild form of HE. Until fairly recently, covert HE was rarely diagnosed, but advances in computerized psychometric testing have greatly simplified its detection. The many consequences of covert HE are now being identified, and most have been shown to be reversible with standard HE treatment. Perhaps the most enticing possibility will be the potential that standard HE therapies will postpone the onset of overt HE. This will require further evaluation with large placebo-controlled randomized trials.
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Affiliation(s)
- Nisheet Waghray
- Division of Gastroenterology, MetroHealth Medical Center/Case Western Reserve University, Cleveland, USA,
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16
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Sharma K, Pant S, Misra S, Dwivedi M, Misra A, Narang S, Tewari R, Bhadoria AS. Effect of rifaximin, probiotics, and l-ornithine l-aspartate on minimal hepatic encephalopathy: a randomized controlled trial. Saudi J Gastroenterol 2014; 20:225-32. [PMID: 25038208 PMCID: PMC4131305 DOI: 10.4103/1319-3767.136975] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Minimal hepatic encephalopathy (MHE) implies subtle impairment of cognitive functions in the absence of features of overt encephalopathy. We aimed to determine the prevalence of MHE in patients with liver cirrhosis and to find out the effect of rifaximin, probiotics, and l-ornithine l-aspartate (LOLA) individually in reversal of MHE by comparing it with placebo group. PATIENTS AND METHODS This study was carried out in two phases. Phase I included the recruitment of 250 apparently healthy controls and extraction of normative data utilizing three neuropsychometric tests (NPTs) and critical flicker frequency (CFF) test. Phase II consisted of screening and recruitment of patients of MHE followed by drugs trial. A total of 317 cirrhotics were screened; 111 were excluded and the remaining 206 cirrhotics were screened for MHE using NPTs and/or CFF test. Of these, 124 patients with MHE were randomized to receive LOLA (n = 31), rifaximin (n = 31), probiotics (n = 32), for 2 months and were compared with patients who were given placebo (n = 30). RESULTS Out of 206 cirrhotics, 124 (60.19%) had MHE. Among these 124 MHE patients, 87 (70.16%) patients had CFF <39Hz, 112 (90.32%) patients with MHE had two or more abnormal NPTs, and 75 (60.48%) patients had abnormality on both the CFF values and more than two abnormal NPTs. Intention-to-treat analysis showed the number of patients who improved after giving treatment were 67.7% (21/31), 70.9% (22/31), 50% (16/32), and 30% (9/30) for LOLA, rifaximin, probiotics, and placebo, respectively. CFF scores and improvement in psychometric tests after treatment were significantly higher (P < 0.05) for LOLA, rifaximin, and probiotics as compared with placebo group. CONCLUSIONS Prevalence of MHE is high in patients with cirrhosis of liver. Rifaximin, LOLA, and probiotics are better than giving placebo in patients with MHE.
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Affiliation(s)
- Kapil Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India,Address for correspondence: Dr. Kapil Sharma, Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi – 110 070, India. E-mail:
| | - Sanjay Pant
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Sriprakash Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Manisha Dwivedi
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Alok Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Sushil Narang
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Reshu Tewari
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Ajeet S. Bhadoria
- Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
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17
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Abstract
Management of hepatic encephalopathy (HE) primarily involves avoidance of precipitating factors and administration of various ammonia-lowering therapies such as nonabsorbable disaccharides and antimicrobial agents like rifaximin. The nonabsorbable disaccharides which include lactulose and lactitol are considered the first-line therapy for the treatment of HE and minimal hepatic encephalopathy (MHE). Lactulose significantly improves cognitive function and health-related quality of life in patients with MHE. Lactitol is comparable to lactulose in the treatment of HE with fewer side effects. Lactulose has also shown to be effective in primary and secondary prophylaxis of HE. Disaccharides were found to be comparable to rifaximin in recent systemic reviews in the treatment of HE however conclusion was based on inclusion of some poor quality trials. Combination therapy of disaccharides either with rifaximin, L-ornithine L-aspartate,probiotics for the treatment of HE needs further validation in large studies.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology, G.B.Pant Hospital, Academic Block Room - 203, New Delhi, India
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18
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Abstract
There is a strong relationship between liver and gut; while the portal venous system receives blood from the gut, and its contents may affect liver functions, liver in turn, affects intestinal functions through bile secretion. There is robust evidence that the pathogenesis of hepatic encephalopathy (HE) is linked to alterations in gut microbiota and their by-products such as ammonia, indoles, oxindoles, endotoxins, etc. In the setting of intestinal barrier and immune dysfunction, these by-products are involved in the pathogenesis of complications of liver cirrhosis including HE and systemic inflammation plays an important role. Prebiotics, probiotics and synbiotics may exhibit efficacy in the treatment of HE by modulating the gut flora. They improve derangement in flora by decreasing the counts of pathogenic bacteria and thus improving the endotoxemia, HE and the liver disease. Current evidence suggest that the trials evaluating the role of probiotics in the treatment of HE are of not high quality and all trials had high risk of bias and high risk of random errors. Therefore, the use of probiotics for patients with HE cannot be currently recommended. Further RCTs are required. This review summarizes the main literature findings about the relationships between gut flora and HE, both in terms of the pathogenesis and the treatment of HE.
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Affiliation(s)
- Radha K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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19
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Teperman LW. Impact of pretransplant hepatic encephalopathy on liver posttransplantation outcomes. Int J Hepatol 2013; 2013:952828. [PMID: 24324895 DOI: 10.1155/2013/952828] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/01/2013] [Indexed: 12/14/2022] Open
Abstract
Patients with cirrhosis commonly experience hepatic encephalopathy (HE), a condition associated with alterations in behavior, cognitive function, consciousness, and neuromuscular function of varying severity. HE occurring before liver transplant can have a substantial negative impact on posttransplant outcomes, and preoperative history of HE may be a predictor of posttransplant neurologic complications. Even with resolution of previous episodes of overt or minimal HE, some patients continue to experience cognitive deficits after transplant. Because HE is one of the most frequent pretransplant complications, improving patient HE status before transplant may improve outcomes. Current pharmacologic therapies for HE, whether for the treatment of minimal or overt HE or for prevention of HE relapse, are primarily directed at reducing cerebral exposure to systemic levels of gut-derived toxins (e.g., ammonia). The current mainstays of HE therapy are nonabsorbable disaccharides and antibiotics. The various impacts of adverse effects (such as diarrhea, abdominal distention, and dehydration) on patient's health and nutritional status should be taken into consideration when deciding the most appropriate HE management strategy in patients awaiting liver transplant. This paper reviews the potential consequences of pretransplant HE on posttransplant outcomes and therapeutic strategies for the pretransplant management of HE.
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20
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Acikgöz A, Giri S, Bader A. Detection of nanolevel drug metabolites in an organotypic culture of primary human hepatocytes and porcine hepatocytes with special reference to a two-compartment model. Int J Nanomedicine 2012; 7:5859-72. [PMID: 23226017 PMCID: PMC3512542 DOI: 10.2147/ijn.s29651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The quantification of drug metabolites produced during drug metabolism is a growing concern for the pharmaceutical industry, regulatory agencies such as the US Food and Drug Administration, the European Medicines Agency, and others. As 70% of drugs are known reactive metabolites and have black box warnings, they are a major cause of drug-induced injury and lead to drug attrition in early or late clinical stages. According to a 2006 survey report of pharmaceutical companies, drug-induced liver injury was ranked first in terms of adverse events, and it remains the most common reason for restriction or withdrawal of a drug from the market by the Food and Drug Administration. Although there are many reasons underlying drug-induced liver injury, one of the most important is liver failure induced by drug metabolites. Generally, a drug produces metabolites that may bind to cellular molecules and trigger a toxicological effect, cause serious adverse drug reactions, or alter cellular functions. Experimental cellular models that attempt to qualify drug metabolites from cell cultures rely on human plasma and urine obtained from clinical trials and supernatant during early in vitro experiments. However, there is a lack of information about the quantification of drug metabolites inside human hepatocytes, where the drug is extensively metabolized. To overcome this limitation, we used the highly accepted, gold standard organotypic cellular model of primary human hepatocytes to investigate and quantify the parent drug, as well as drug metabolites inside human hepatocytes and outside human hepatocytes to evaluate the quantity of drug metabolites, which are assumed to have remained inside the primary human hepatocytes. We refer to this as a two-compartment model, where one compartment is supernatant compared with in vivo hepatic blood circulation, and the other is inside the hepatocyte cell compared with the inside of in vivo human liver. We detected the nanoconcentrations of all major metabolites (desmethyldiazepam, temazepam, and oxazepam) of the diazepam drug, both inside the cells (matrix) and outside the hepatocyte cells (supernatant) at different time points (primary human hepatocytes: 0, 1, 2, 4, 8, and 24 hours; primary porcine hepatocytes: 0, 1, 2, 5, and 24 hours) during biotransformation in an organotypic sandwich cellular model. Although it is difficult to detect tissue distribution of metabolites in humans, we strongly recommend testing in a two-compartment model of primary human hepatocytes, as nonhuman models may not reflect human metabolism. Preclinical drug screening assessment tests that use this two-compartment strategy may facilitate safer registration of new drug candidates.
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Affiliation(s)
- Ali Acikgöz
- Center for Biotechnology and Biomedicine, Cell Techniques and Applied Stem Cell Biology, Universität Leipzig, Germany
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21
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Abstract
Hepatic encephalopathy (HE) is a broad spectrum of neuropsychiatric manifestations usually affecting individuals with end-stage liver disease. The presence of HE is a poor prognostic sign, with 1-year mortality rates of almost 60%. There is much debate about the underlying mechanisms that result in this syndrome; however, elevated plasma and central nervous system ammonia levels are considered key factors in its pathogenesis. Initial evaluation of the patient presenting with overt HE should include a careful search for predisposing factors, including underlying infection, gastrointestinal (GI) bleeding, electrolyte disturbances, hepatocellular carcinoma, dehydration, hypotension, and excessive use of benzodiazepines, psychoactive drugs, or alcohol. The mainstay of treatment for many years has been nonabsorbable disaccharides, particularly lactulose. Alternative treatments, which usually are second line in patients who do not respond to lactulose, include zinc, antibiotics (neomycin, metronidazole, and rifaximin), ornithine aspartate, sodium benzoate, probiotics, and surgical intervention. Accepted treatments for HE are associated with significant unpleasant side effects, including diarrhea, renal failure, neuropathy, and other GI disturbance. Newer therapies are still in development, and most are awaiting human trials in order to confirm their benefit. These include manganese chelators, L-carnitine, N-methyl-d-aspartate receptor antagonists, blood purification dialysis system, and an intravenous combination of sodium benzoate and phenylacetate.
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Affiliation(s)
- Nader Dbouk
- University of Alabama at Birmingham, Department of Medicine, 1530 Third Avenue South, MCLM 262A, Birmingham, AL 35294-0005, USA.
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22
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Kawaguchi T, Taniguchi E, Sata M. Motor vehicle accidents: How should cirrhotic patients be managed? World J Gastroenterol 2012; 18:2597-9. [PMID: 22690067 PMCID: PMC3369995 DOI: 10.3748/wjg.v18.i21.2597] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 05/18/2012] [Accepted: 05/23/2012] [Indexed: 02/06/2023] Open
Abstract
Motor vehicle accidents (MVAs) are serious social issues worldwide and driver illness is an important cause of MVAs. Minimal hepatic encephalopathy (MHE) is a complex cognitive dysfunction with attention deficit, which frequently occurs in cirrhotic patients independent of severity of liver disease. Although MHE is known as a risk factor for MVAs, the impact of diagnosis and treatment of MHE on MVA-related societal costs is largely unknown. Recently, Bajaj et al demonstrated valuable findings that the diagnosis of MHE by rapid screening using the inhibitory control test (ICT), and subsequent treatment with lactulose could substantially reduce the societal costs by preventing MVAs. Besides the ICT and lactulose, there are various diagnostic tools and therapeutic strategies for MHE. In this commentary, we discussed a current issue of diagnostic tools for MHE, including neuropsychological tests. We also discussed the advantages of the other therapeutic strategies for MHE, such as intake of a regular breakfast and coffee, and supplementation with zinc and branched chain amino acids, on the MVA-related societal costs.
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23
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Zhan T, Stremmel W. The diagnosis and treatment of minimal hepatic encephalopathy. Dtsch Arztebl Int 2012; 109:180-7. [PMID: 22470407 DOI: 10.3238/arztebl.2012.0180] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 09/01/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND The subtype of hepatic encephalopathy (HE) called minimal hepatic encephalopathy (MHE) is highly prevalent (22-74%) among patients with liver dysfunction. MEH is defined as HE without grossly evident neurologic abnormalities, but with cognitive deficits that can be revealed by psychometric testing. METHODS This article is based on relevant original publications and reviews in English and German (1970-2011) that were retrieved by a selective key-word-based search in the Medline and PubMed databases. RESULTS Despite its mild manifestations, MHE impairs patients' quality of life and their ability to work. It impairs driving ability and is associated with a higher rate of motor vehicle accidents. Furthermore, patients with MHE fall more often and are more likely to undergo progression to overt HE. The main pathophysiological mechanism of MHE is hyperammonemia leading to astrocyte dysfunction. Psychometric tests are the standard instruments for establishing the diagnosis; further, supportive diagnostic tools include neurophysiological tests and imaging studies. Recent randomized and controlled trials have revealed that treatment with lactulose or rifaximin therapy improves the quality of life of patients with MHE. Rifaximin was also found to improve driving performance in a simulator. A combination of these two drugs prevents the recurrence of episodic HE over a 6-months follow-up period. Moreover, small-scale trials have revealed that some dietary supplements can improve the cognitive deficits of MHE. CONCLUSION Clinical trials have shown that patients with MHE and patients who have had an episode of overt HE in the past can benefit from drug treatment.
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Affiliation(s)
- Tianzuo Zhan
- Department of Gastroenterology and Hepatology, Heidelberg University Hospital, Germany
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24
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Abstract
BACKGROUND/AIMS Minimal hepatic encephalopathy (MHE) is common in patients with extrahepatic portal vein obstruction (EHPVO). There is no study on the treatment of MHE using lactulose in patients with EHPVO. PATIENTS AND METHODS Consecutive EHPVO patients were assessed by psychometric (number connection test (NCT-A and B), digit symbol test (DST), serial dot test (SDT), line tracing test (LTT)), and critical flicker frequency (CFF) at inclusion. Patients diagnosed as MHE were treated with lactulose and psychometric tests, CFF, and were reassessed after 3 months. RESULTS Of the 70 patients screened, the prevalence of abnormal psychometric test was as follows: NCT-A (41%), NCT-B (53%), DST (38%), SDT (40%), and LTT (44%). Thirty patients (43%) had two or more than two abnormal (>2 SD) psychometry tests. Lactulose improved MHE in 16/30 (53%) of patients after 3 months of treatment. Arterial ammonia decreased after lactulose treatment compared to baseline (83.7±19.1 vs. 65.1±19.3 μmol/l, P=0.001). A total of 9 (75%) of 12 patients with large spontaneous shunt and 7 (39%) of 18 patients without spontaneous shunt improved with lactulose (P=0.07). CFF in patients with MHE (n=30) was significantly lower than those without MHE (n=40) (38.1±2.4 vs. 41.5±3.1 Hz, P=0.01). CFF was less than 38 Hz in 21 (70%) of 30 patients before treatment and in 10 (33%) patients after lactulose therapy in MHE patients. All patients could tolerate lactulose without any significant side effects. Four patients (13%) developed transient diarrhea in whom dose needed reduction, 3 (10%) did not like its taste but have continued, and 2 (6%) developed abdominal bloating sensation. CONCLUSIONS Lactulose is effective in the treatment of MHE in patients with EHPVO.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology, G. B. Pant Hospital, New Delhi, India.
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25
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Abstract
BACKGROUND/AIM Minimal hepatic encephalopathy (MHE) impairs patient's daily functioning of life. Predictors of MHE in cirrhotic patients have not been evaluated. PATIENTS AND METHODS A total of 200 cirrhotic patients (Child A, 74 [37%]; Child B, 72 [36%]; Child C, 54 [27%]) were evaluated by psychometry, P300 auditory event-related potential (P300ERP) and critical flicker frequency (CFF). MHE was diagnosed by abnormal psychometry (>2 S.D.) and P300ERP (>2.5 S.D.). Univariate and multivariate logistic regression analyses were performed to determine the predictors of MHE. RESULTS Eighty-two (41%) patients were diagnosed to have MHE - 26/74 (35%) in Child A, 26/72 (36%) in Child B and 30/54 (56%) in Child C. Ninety-seven (48.5%) patients had abnormal psychometric tests, and 96 (48%) had prolonged P300ERP (>358 ms). Sixteen (16.5%) patients with abnormal psychometry had P300ERP < 358 ms, and 15 (14.5%) patients with normal psychometry results had P300ERP > 358 ms. One hundred and three patients had CFF value < 39 Hz with specificity of 86.6% and sensitivity of 72.9% for MHE. Model for end-stage liver disease (MELD) (17.9 +/- 5.7 vs. 13.4 +/- 4.2, P = 0.005), Child-Turcotte-Pugh (CTP) score (8.4 +/- 2.5 vs. 7.7 +/- 2.2, P = 0.02), ammonia (104.8 +/- 37.9 vs. 72.5 +/- 45.2 micromol/L, P = 0.001) and CFF (37.0 +/- 2.8 vs. 41.0 +/- 3.4 Hz, P = 0.001) were significantly higher in MHE as compared to non-MHE patients. Ninety-one (45.5%) patients had MELD > 15.5, 115 (57.5%) had CTP score > 7.5, while 93 (46.5%) had venous ammonia > 84.5 micromol/L. On univariate analysis, MELD (8.52 [95% CI, 4.46-16.26; P = 0.001]), CFF (17.34 [95% CI, 8.16-36.85; P = 0.001]) and venous ammonia (7.80 [95% CI, 4.11-14.81; P = 0.003]) were associated with MHE; while CTP score (1.51 [95% CI, 0.85-2.69; P = 0.30]) was not significant. On multivariate analysis, MELD, CFF and venous ammonia were predictive of MHE. CONCLUSION Prevalence of MHE in this study was 41%; and MELD > 15.5, CFF < 39 Hz and venous ammonia > 84.5 micromol/L were predictive of MHE.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology, G. B. Pant Hospital, New Delhi, India
| | - Barjesh C. Sharma
- Department of Gastroenterology, G. B. Pant Hospital, New Delhi, India,Address for correspondence: Dr. Barjesh Chander Sharma, Department of Gastroenterology, Room 203, Academic Block, G. B. Pant Hospital, New Delhi - 110 002, India. E-mail:
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26
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27
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Abstract
Minimal hepatic encephalopathy is a neuro-cognitive dysfunction which occurs in an epidemic proportion of cirrhotic patients, estimated as high as 80% of the population tested. It is characterized by a specific, complex cognitive dysfunction which is independent of sleep dysfunction or problems with overall intelligence. Although named “minimal”, minimal hepatic encephalopathy (MHE) can have a far-reaching impact on quality of life, ability to function in daily life and progression to overt hepatic encephalopathy. Importantly, MHE has a profound negative impact on the ability to drive a car and may be a significant factor behind motor vehicle accidents. A crucial aspect of the clinical care of MHE patients is their driving history, which is often ignored in routine care and can add a vital dimension to the overall disease assessment. Driving history should be an integral part of care in patients with MHE. The lack of specific signs and symptoms, the preserved communication skills and lack of insight make MHE a difficult condition to diagnose. Diagnostic strategies for MHE abound, but are usually limited by financial, normative or time constraints. Recent studies into the inhibitory control and critical flicker frequency tests are encouraging since these tests can increase the rates of MHE diagnosis without requiring a psychologist. Although testing for MHE and subsequent therapy is not standard of care at this time, it is important to consider this in cirrhotics in order to improve their ability to live their life to the fullest.
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28
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Paik YH, Lee KS, Han KH, Song KH, Kim MH, Moon BS, Ahn SH, Lee SJ, Park HJ, Lee DK, Chon CY, Lee SI, Moon YM. Comparison of rifaximin and lactulose for the treatment of hepatic encephalopathy: a prospective randomized study. Yonsei Med J 2005; 46:399-407. [PMID: 15988813 PMCID: PMC2815818 DOI: 10.3349/ymj.2005.46.3.399] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rifaximin has been reported to be effective for the treatment of hepatic encephalopathy (HE) in Europe. However, it is unknown whether Rifaximin is effective for the treatment of HE in Koreans, therefore we conducted a open-label prospective randomized study to evaluate the efficacy of rifaximin versus lactulose in Korean patients. Fifty-four patients with liver cirrhosis and hepatic encephalopathy were enrolled. Thirty-two patients were randomized to receive rifaximin and 22 to receive lactulose both over a 7-day periods. Before and at the end of treatment, gradation of blood ammonia, flapping tremor, mental status, number connection test (NCT) were performed and estimation of HE indexes determined. Both rifaximin and lactulose were effective in the majority of patients (84.4% and 95.4%, respectively, p = 0.315). Blood NH3, flapping tremor, mental status, and NCT was significantly improved by rifaximin and lactulose, and the post- treatment levels of these measures were similar for the rifaximin and lactulose-treated groups, as was the HE index (rifaximin group (10.0 --> 4.2, p = 0.000); lactulose group (11.3 --> 5.0, p = 0.000)). One patient treated with rifaximin complained of abdominal pain, which was easily controlled. There was no episode of renal function impairment in either treatment group. Rifaximin proved to be as safe and as effective as lactulose for the treatment of Korean patients with hepatic encephalopathy.
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Affiliation(s)
- Yong-Han Paik
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwan Sik Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hyub Han
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Kun Hoon Song
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Myoung Hwan Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soo Moon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Se Joon Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Jin Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Chae Yoon Chon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang In Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Myoung Moon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Abstract
OBJECTIVE To assess the effects of non-absorbable disaccharides (lactulose and lactitol) in patients with hepatic encephalopathy. DATA SOURCES Cochrane Hepato-Biliary Group controlled trials register, Cochrane Library, Medline, and Embase until March 2003; reference lists of relevant articles; authors and pharmaceutical companies. REVIEW METHODS Randomised trials that compared non-absorbable disaccharides with placebo, no intervention, or antibiotics for hepatic encephalopathy were included. The primary outcome measures were no improvement of hepatic encephalopathy and all cause mortality. RESULTS 22 trials were included. Compared with placebo or no intervention, non-absorbable disaccharides seemed to reduce the risk of no improvement in patients with hepatic encephalopathy (relative risk 0.62, 95% confidence interval 0.46 to 0.84, six trials). However, high quality trials found no significant effect (0.92, 0.42 to 2.04, two trials). Compared with placebo or no intervention, non-absorbable disaccharides had no significant effect on mortality (0.41, 0.02 to 8.68, four trials). Non-absorbable disaccharides were inferior to antibiotics in reducing the risk of no improvement (1.24, 1.02 to 1.50, 10 trials) and lowering blood ammonia concentration (weighted mean difference 2.35 micromol/l, 0.06 micromol/l to 13.45 micromol/l, 10 trials). There was no significant difference in mortality (0.90, 0.48 to 1.67, five trials). CONCLUSIONS There is insufficient evidence to support or refute the use of non-absorbable disaccharides for hepatic encephalopathy. Antibiotics were superior to non-absorbable disaccharides in improving hepatic encephalopathy, but it is unclear whether this difference is clinically important. Non-absorbable disaccharides should not serve as comparator in randomised trials on hepatic encephalopathy.
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Affiliation(s)
- Bodil Als-Nielsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Department 7102, H:S Rigshospitalet, DK-2100 Copenhagen, Denmark.
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30
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de Bruyn G, Graviss EA. A systematic review of the diagnostic accuracy of physical examination for the detection of cirrhosis. BMC Med Inform Decis Mak 2001; 1:6. [PMID: 11806763 PMCID: PMC64783 DOI: 10.1186/1472-6947-1-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2001] [Accepted: 12/18/2001] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We conducted a review of the diagnostic accuracy of clinical examination for the diagnosis of cirrhosis. The objectives were: to identify studies assessing the accuracy of clinical examination in the detection of cirrhosis; to summarize the diagnostic accuracy of reported physical examination findings; and to define the effects of study characteristics on estimates of diagnostic accuracy. METHODS Studies were identified through electronic literature search of MEDLINE (1966 to 2000), search of bibliographic references, and contact with authors. Studies that evaluated indicants from physical examination of patients with known or suspected liver disease undergoing liver biopsy were included. Qualitative data on study characteristics were extracted. Two-by-two tables of presence or absence of physical findings for patients with and without cirrhosis were created from study data. Data for physical findings reported in each study were combined using Summary Receiver Operating Characteristic (SROC) curves or random effects modeling, as appropriate. RESULTS Twelve studies met inclusion criteria, including a total of 1895 patients, ranging in age from 3 to 90 years. Most studies were conducted in referral populations with elevated aminotransferase levels. Ten physical signs were reported in three or more studies and ten signs in only a single study. Signs for which there was more study data were associated with high specificity (range 75-98%), but low sensitivity (range 15-68%) for histologically-proven cirrhosis. CONCLUSIONS Physical findings are generally of low sensitivity for the diagnosis of cirrhosis, and signs with higher specificity represent decompensated disease. Most studies have been undertaken in highly selected populations.
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Affiliation(s)
- Guy de Bruyn
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Edward A Graviss
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
- Department of Pathology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
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