Hepatic encephalopathy management

Blei AT, Cordoba J, and the Practice Parameters Committee of the American College of Gastroenterology. Hepatic encephalopathy practice guidelines. Am J Gastroenterol 2001 96 1968-1976. Gines P, Cardena A, Arroyo V, Rodes J. Management of cirrhosis and ascites. N Engl J Med 2004 350 1646-1654. 

Managing viral hepatitis involves both prevention and treatment. Prevention of hepatitis A and B (and indirectly for hepatitis D) can be achieved with immune globulin or vaccines. There is no specific pharmacologic treatment for acute viral hepatitis A, B, C, D, or E only supportive care is available. Individuals with mild to moderate symptoms rarely require hospitalization. Occasionally, hospitalization is required in individuals experiencing significant nausea, vomiting, diarrhea, and encephalopathy. Liver transplantation may be required in rare instances if fulminant hepatitis develops. 

Zeneroli ML, Avallone R, Corsi L, Venturini I, Baraldi C, Baraldi M Management of hepatic encephalopathy Role of rifaximin. Chemotherapy 2005 51(suppl 1) 90—95. 

After the submission of the manuscript three interesting papers [1-3] dealing with the management of hepatic encephalopathy have been published. A Cochrane systematic review [1] evaluating 30 randomized controlled trials did conclude that antibiotics appear to be superior to nonabsorbable disaccharides in improving symptoms of portal systemic encephalopathy. The authors also emphasized that there is insufficient high-quality evidence to support the use of lactulose or lactitol. A combination of a disaccharide and an antibiotic has been suggested, but not consistently demonstrated to be beneficial [2]. Finally, the use of probiotics has been proposed [3], whose administration could actually follow that of antibiotics. 

Lactitol 40 is a disaccharide that has been used in the management of hepatic encephalopathy, a major neuropsychiatric complication of both acute and chronic liver failure. It has mild laxative properties and is used to reduce the production and absorption of gut-derived neurotoxic substances symptomatic of hepatic encephalopathy. Although long considered a first-line pharmacological treatment, there is a lack of sufficient evidence to support lactitol s efficacy and continued use when weighed against other suitable therapeutic alternatives such as oral antibiotics <2006MI94>. 

List two treatment options for the management of Mrs MW s hepatic encephalopathy. Describe the mechanism of action for one of these. 

Case study level 1 - Alcoholic cirrhosis alcohol withdrawal 338 Case study level 2 - Alcoholic cirrhosis management of bleeding risk and treatment for the maintenance of alcohol abstinence 339 Case study level 3 - Hepatic encephalopathy and ascites 341 Case study level Ma - Pulmonary tuberculosis 342 Case study level Mb - Liver failure 344... 

Eriksson, L.S., Conn, H.O. Branched-chain amino acids in the management of hepatic encephalopathy an analysis of variants. Hepatology 1989 10 228 - 246... 

Colquhoun S, Lipkin C, Connelly C. The pathophysiology, diagnosis, and management of acute hepatic encephalopathy Adv Intern Med 2001 46 155-76. 

Cirrhosis and the pathophysiologic abnormalities that cause it result in the commonly encountered problems of ascites, portal hypertension and esophageal varices, hepatic encephalopathy, and coagulation disorders. Other less commonly seen problems in patients with cirrhosis include hepatorenal syndrome, hepatopulmonary syndrome, and endocrine dysfunction, and these are discussed in the section dealing with management of complications. 

Prompt referral for liver transplantation is the therapy of choice for most patients with fulminant hepatic failure. Transplantation should be considered in all cases in which the patient demonstrates progressive clinical deterioration (encephalopathy, hypoglycemia, metabolic acidosis, renal failure, and coagulation defects)." Patients should be transferred at the first sign of altered mental status, because these patients often worsen very rapidly. One-year smvival rates with liver transplantation for fulminant hepatitis are 50% to 80% (as compared to <20% with medical management alone)."... 

There has been considerable interest in the use of vegetable-protein diets in the chronic management of patients with cirrhosis and hepatic encephalopathy. Enthusiasm for this therapy is based on the reduced amounts of AAAs and methionine in vegetable protein. The... 

Edge, J.A., et al., et al.2006b. The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children. Diabetologia, 49(9) pp. 2002-2009 Festi, D., et al., 2006. Management of hepatic encephalopathy Focus on antibiotic therapy. Digestion, 73(Suppl 1) pp. 94-101... 

Medical management of hepatic encephalopathy is mainly nsed for patients who do not yet meet the criteria for liver transplantation or for patients awaiting liver transplantation. It must be underscored that severe neuropsychiatric symptoms in patients with severe liver disease must not be considered as contraindications but instead as clear indications for liver transplantation. 

C12H24O11 344.315 Artificial sweetener used in foods. Monohydrate used in the management of hepatic encephalopathy. Bulking agent for cosmetics and pharmaceuticals. Laxative. Cryst. + 1, 2 or 3H2O. Mp 95-98° (monohydrate). Log P -6.86 (calc). A food additive petition for GRAS status has been filed with the FDA. 

---