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Management of Hepatic Encephalopathy  [PDF]
G. Wright,A. Chattree,R. Jalan
International Journal of Hepatology , 2011, DOI: 10.4061/2011/841407
Abstract: Hepatic encephalopathy (HE), the neuropsychiatric presentation of liver disease, is associated with high morbidity and mortality. Reduction of plasma ammonia remains the central therapeutic strategy, but there is a need for newer novel therapies. We discuss current evidence supporting the use of interventions for both the general management of chronic HE and that necessary for more acute and advanced disease.
Management of Hepatic Encephalopathy  [PDF]
G. Wright,A. Chattree,R. Jalan
International Journal of Hepatology , 2011, DOI: 10.4061/2011/841407
Abstract: Hepatic encephalopathy (HE), the neuropsychiatric presentation of liver disease, is associated with high morbidity and mortality. Reduction of plasma ammonia remains the central therapeutic strategy, but there is a need for newer novel therapies. We discuss current evidence supporting the use of interventions for both the general management of chronic HE and that necessary for more acute and advanced disease. 1. Introduction There are a plethora of therapeutic approaches to targeting varying severities of hepatic encephalopathy (HE), the neuropsychiatric presentations of liver disease. There is a need for newer therapies for patients with advanced HE and worsening acute liver injury. Reduction of plasma ammonia remains the central strategy although novel strategies may be beneficial. We discuss current evidence supporting the use of therapeutic interventions for both the general management of chronic HE and that necessary for more acute and advanced disease. 2. General Management of Chronic Encephalopathy (Table 1) Table 1: Treatment stratagems used in HE. 2.1. Ammonia-Lowering Strategies 2.1.1. Dietary Protein Supplementation Patients with cirrhosis often have a poor nutritional reserve due to anorexia, poor diet, malabsorption, and altered metabolic state. Hospitalized patients are often hypermetabolic and hypercatabolic, worsened by complications such as gastrointestinal bleeding, continued anorexia, and fasting for tests. Yet dietary protein has the potential to drive further ammoniagenesis, and so previously dietary protein restriction was common practice. However, protein restriction is no longer advocated as does not improve HE and may be harmful [1]. In fact high-protein diets are well tolerated in cirrhotic patients [2], with consensus supporting the need for normal or high dietary protein (1–1.5?g/kg protein and 25–40?kcal/kg per day) [2, 3]. Rare exceptions arise occasionally with inborn errors of metabolism or acute liver failure (ALF) patients intubated for grade 3-4?HE associated with high circulating ammonia when protein restriction with maintained calorie intake (e.g., dextrose infusion) is necessary. 2.1.2. Branched-Chain Amino Acids (BCAAs) BCAAs are chiefly derived from dairy products and vegetables and account for 25% of total dietary protein. They are a good substrate for protein synthesis, both conserving and restoring muscle mass in advanced liver disease. In cirrhosis, poor dietary intake leads to a deficiency of BCAA and resultant accumulation of aromatic amino acids, both worsening protein-energy deficits and glutaminergic
An evidence-based update on hepatic encephalopathy  [cached]
Abdo Ayman
Saudi Journal of Gastroenterology , 2006,
Abstract: Hepatic encephalopathy (HE) is a disturbance of the central nervous system (CNS) function secondary to porto-systemic shunting. It usually occurs in the setting of advanced liver cirrhosis or acute fulminant hepatic failure. An extensive Medline search was undertaken and all relevant papers found were critically examined. Special emphasis was paid to clinical trials and meta-analyses. All guidelines and conference proceedings related to hepatic encephalopathy were also examined. HE presents with a spectrum of neuropsychiatric manifestations that may be quite subtle (minimal HE) or overt, ranging from disturbance of the sleep pattern to deep hepatic coma. Most patients with HE may be diagnosed on clinical grounds only after excluding other causes of neurological disease, but a wide variety of neuropsychological, neurophysiological, and neuroradiological tests may be utilized. The first step in the management of patients with HE should be supportive care. Following that, a significant effort must be exerted to find and correct possible exacerbating factors which may include: renal impairment, infection, constipation, drugs, gastrointestinal bleeding and other factors. Medications used to treat patients with encephalopathy aim to reduce toxin production, increase toxin elimination, and protect the brain from the harmful effects of these toxins. A critical analysis of the evidence concerning most of the available management modalities is presented. Ultimately, all patients with HE must be considered for liver transplantation. It is concluded that early recognition, positive diagnosis, and a multi-target management plan constitutes appropriate management of patients with HE.
Role of Nutrition in the Management of Hepatic Encephalopathy in End-Stage Liver Failure  [PDF]
Chantal Bémeur,Paul Desjardins,Roger F. Butterworth
Journal of Nutrition and Metabolism , 2010, DOI: 10.1155/2010/489823
Abstract: Malnutrition is common in patients with end-stage liver failure and hepatic encephalopathy, and is considered a significant prognostic factor affecting quality of life, outcome, and survival. The liver plays a crucial role in the regulation of nutrition by trafficking the metabolism of nutrients, their distribution and appropriate use by the body. Nutritional consequences with the potential to cause nervous system dysfunction occur in liver failure, and many factors contribute to malnutrition in hepatic failure. Among them are inadequate dietary intake, malabsorption, increased protein losses, hypermetabolism, insulin resistance, gastrointestinal bleeding, ascites, inflammation/infection, and hyponatremia. Patients at risk of malnutrition are relatively difficult to identify since liver disease may interfere with biomarkers of malnutrition. The supplementation of the diet with amino acids, antioxidants, vitamins as well as probiotics in addition to meeting energy and protein requirements may improve nutritional status, liver function, and hepatic encephalopathy in patients with end-stage liver failure. 1. Introduction Malnutrition is a common complication of end-stage liver failure (cirrhosis) and is an important prognostic indicator of clinical outcome (survival rate, length of hospital stay, posttransplantation morbidity, and quality of life) in patients with cirrhosis. Several studies have evaluated nutritional status in patients with liver cirrhosis of different etiologies and varying degrees of liver insufficiency [1, 2] leading to a consensus of opinion that malnutrition is recognizable in all forms of cirrhosis [3] and that the prevalence of malnutrition in cirrhosis has been estimated to range from 65%–100% [4, 5]. The causes of malnutrition in liver disease are complex and multifactorial. The present paper reviews the role of nutrition in relation to the management of hepatic encephalopathy (HE), a major neuropsychiatric complication of end-stage liver failure. Nutritional consequences of liver failure with the potential to cause central nervous system dysfunction are reviewed. In particular, the roles of dietary protein (animal versus vegetable), branched-chain amino acids, dietary fibre, probiotics, vitamins and antioxidants, minerals (zinc, magnesium) as well as L-carnitine in relation to HE are discussed. An update of the impact of nutritional supplementation on the management of HE is included. 2. Malnutrition in Liver Disease The functional integrity of the liver is essential for nutrient supply (carbohydrates, fat, and proteins), and the
Management of Hepatic Encephalopathy by Traditional Chinese Medicine
Chun Yao,Nong Tang,Guoxiang Xie,Xiaojiao Zheng,Ping Liu,Lei Fu,Wu Xie,Fan Yao,Houkai Li,Wei Jia
Evidence-Based Complementary and Alternative Medicine , 2012, DOI: 10.1155/2012/835686
Abstract: In spite of the impressive progress in the investigation of hepatic encephalopathy (HE), the complex mechanisms underlying the onset and deterioration of HE are still not fully understood. Currently, none of the existing theories provide conclusive explanations on the symptoms that link liver dysfunction to nervous system disorders and clinical manifestations. This paper summarized the diagnostic and therapeutic approaches used for HE in modern medicine and traditional Chinese medicine and provided future perspective in HE therapies from the viewpoint of holistic and personalized Chinese medicine.
HEPATIC ENCEPHALOPATHY
MANZAR ZAKARIA
The Professional Medical Journal , 2008,
Abstract: Introduction: Hepatic encephalopathy is a common complication of cirrhosis.Its development heralds a poor prognosis. Hepatic encephalopathy is often precipitated by an identifiable factor. Promptdiagnosis of precipitating factors is the key to management of this reversible complication of cirrhosis. Objective: Todetermine the frequency of precipitating factors for hepatic encephalopathy in patients diagnosed with cirrhosis. StudyDesign: Descriptive Study. Place and Duration of study: The study was carried out at Combined Military HospitalLahore from 18.6.07 to 18.12.2007. Patients and methods: Eighty Consecutive patients, 18 years and above of bothgenders suffering from hepatic encephalopathy were included in the study. Precipitating factors of hepaticencephalopathy were identified with the help of clinical examination and investigations. Results: Majority of patients(63.8%) had one precipitating factor; more than one factor was found in 27.5%. Upper gastrointestinal bleed (56%) andinfections (27%) (spontaneous bacterial peritonitis and urinary tract infections) were the leading precipitating factors.Use of diuretics/ electrolyte imbalance and constipation were found in 19% and 7% of patients respectively. Noprecipitating factor was detected in 9% of patients. Conclusion: In majority of patients with hepatic encephalopathy,precipitating factor/ factors could be easily identified.
Role of Nutrition in the Management of Hepatic Encephalopathy in End-Stage Liver Failure  [PDF]
Chantal Bémeur,Paul Desjardins,Roger F. Butterworth
Journal of Nutrition and Metabolism , 2010, DOI: 10.1155/2010/489823
Abstract: Malnutrition is common in patients with end-stage liver failure and hepatic encephalopathy, and is considered a significant prognostic factor affecting quality of life, outcome, and survival. The liver plays a crucial role in the regulation of nutrition by trafficking the metabolism of nutrients, their distribution and appropriate use by the body. Nutritional consequences with the potential to cause nervous system dysfunction occur in liver failure, and many factors contribute to malnutrition in hepatic failure. Among them are inadequate dietary intake, malabsorption, increased protein losses, hypermetabolism, insulin resistance, gastrointestinal bleeding, ascites, inflammation/infection, and hyponatremia. Patients at risk of malnutrition are relatively difficult to identify since liver disease may interfere with biomarkers of malnutrition. The supplementation of the diet with amino acids, antioxidants, vitamins as well as probiotics in addition to meeting energy and protein requirements may improve nutritional status, liver function, and hepatic encephalopathy in patients with end-stage liver failure.
Rifaximin in the treatment of hepatic encephalopathy  [cached]
Iadevaia MD,Del Prete A,Cesaro C,Gaeta L
Hepatic Medicine: Evidence and Research , 2011,
Abstract: Maddalena Diana Iadevaia, Anna Del Prete, Claudia Cesaro, Laura Gaeta, Claudio Zulli, Carmelina LoguercioDepartment of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, ItalyAbstract: Hepatic encephalopathy is a challenging complication in patients with advanced liver disease. It can be defined as a neuropsychiatric syndrome caused by portosystemic venous shunting, ranging from minimal to overt hepatic encephalopathy or coma. Its pathophysiology is still unclear, although increased levels of ammonia play a key role. Diagnosis of hepatic encephalopathy is currently based on specific tests evaluating the neuropsychiatric state of patients and their quality of life; the severity of hepatic encephalopathy is measured by the West Haven criteria. Treatment of hepatic encephalopathy consists of pharmacological and corrective measures, as well as nutritional interventions. Rifaximin received approval for the treatment of hepatic encephalopathy in 2010 because of its few side effects and pharmacological benefits. The aim of this work is to review the use and efficacy of rifaximin both in acute and long-term management of hepatic encephalopathy. Treatment of overt hepatic encephalopathy involves management of the acute episode as well as maintenance of remission in those patients who have previously experienced an episode, in order to improve their quality of life. The positive effect of rifaximin in reducing health care costs is also discussed.Keywords: acute hepatic encephalopathy, recurrent hepatic encephalopathy, rifaximin, lactulose, cost, health-related quality of life
Rifaximin in the treatment of hepatic encephalopathy
Iadevaia MD, Del Prete A, Cesaro C, Gaeta L, Zulli C, Loguercio C
Hepatic Medicine: Evidence and Research , 2011, DOI: http://dx.doi.org/10.2147/HMER.S11988
Abstract: ximin in the treatment of hepatic encephalopathy Review (3789) Total Article Views Authors: Iadevaia MD, Del Prete A, Cesaro C, Gaeta L, Zulli C, Loguercio C Published Date December 2011 Volume 2011:3 Pages 109 - 117 DOI: http://dx.doi.org/10.2147/HMER.S11988 Maddalena Diana Iadevaia, Anna Del Prete, Claudia Cesaro, Laura Gaeta, Claudio Zulli, Carmelina Loguercio Department of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, Italy Abstract: Hepatic encephalopathy is a challenging complication in patients with advanced liver disease. It can be defined as a neuropsychiatric syndrome caused by portosystemic venous shunting, ranging from minimal to overt hepatic encephalopathy or coma. Its pathophysiology is still unclear, although increased levels of ammonia play a key role. Diagnosis of hepatic encephalopathy is currently based on specific tests evaluating the neuropsychiatric state of patients and their quality of life; the severity of hepatic encephalopathy is measured by the West Haven criteria. Treatment of hepatic encephalopathy consists of pharmacological and corrective measures, as well as nutritional interventions. Rifaximin received approval for the treatment of hepatic encephalopathy in 2010 because of its few side effects and pharmacological benefits. The aim of this work is to review the use and efficacy of rifaximin both in acute and long-term management of hepatic encephalopathy. Treatment of overt hepatic encephalopathy involves management of the acute episode as well as maintenance of remission in those patients who have previously experienced an episode, in order to improve their quality of life. The positive effect of rifaximin in reducing health care costs is also discussed.
HEPATIC ENCEPHALOPATHY  [PDF]
Goran Bjelakovic,Violeta Grozdanovic,Aleksandar Nagorni,Ivanka Stamenkovic
Acta Medica Medianae , 2005,
Abstract: Chronic liver disease may cause broad spectrum of systemic manifestations that may influence the clinical course. Hepatic encephalopathy (HE) incorporates a spectrum of neuropsychiatric abnormalities seen in patients with liver dysfunction without brain disease. The exact patophysiological mechanisms are still not completely defined. Hepatic encephalopathy is predominantly seen in patients with chronic liver disease and portal hypertension with shunting of blood, bypassing the liver. The onset is often insidious characterized by subtle and sometimes intermittent memory changes, changes of one’s personality, concentration and reaction time. Manifestations of hepatic encephalopathy are nonspecific, and it is important to exclude alternative diagnosis before starting the therapy. The treatment of hepatic encephalopathy in patients with acute and chronic liver failure is quite distinct. Beside clinically manifested hepatic encephalopathy, there is also a subclinical stage defined as subtle or subclinical neuropsychological deficit present in patients with liver disease which cannot be detected by routine clinical examination.
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