Hepatic encephalopathy chronic

Chronic hepatitis (disease lasting longer than 6 months) is usually associated with hepatitis B, C, and D. Chronic viral hepatitis may lead to the development of cirrhosis, which may induce end-stage liver disease (ESLD). Complications of ESLD include ascites, edema, jaundice, hepatic encephalopathy, infections, and bleeding esophageal varices. Therefore, prevention and treatment of viral hepatitis may prevent ESLD. 

Lanthier PL, Morgan MY Lactitol in the treatment of chronic hepatic encephalopathy An open comparison with lactulose. Gut 1985 26 415-420. 

Tarao K, Ikeda T, Hayashi K, Sakurai I A Successful use of vancomycin hydrochloride in the treatment of lactulose-resistant chronic hepatic encephalopathy. J Gastroenterol Hepatol 1989 4 284-286. 

Puxeddu A, Quartini M, Massimetti A, Ferrieri A Rifaximin in the treatment of chronic hepatic encephalopathy. Curr Med Res Opin 1995 13 274-281. 

Loguercio C, Federico A, De Girolamo V, Ferrieri A, Del Vecchio Blanco C Cyclic treatment of chronic hepatic encephalopathy with rifaximin. Minerva Gastroenterol Dietol 2003 49 53-62... 

Treatment Goals Acute and Chronic Hepatic Encephalopathy... 

Portal hypertension most commonly occurs as a consequence of chronic liver disease. Portal hypertension Is caused by Increased blood flow within the portal venous system and increased resistance to portal flow within the liver. Splanchnic blood flow is increased in patients with cirrhosis due to low arteriolar resistance that is mediated by increased circulating vasodilators and decreased vascular sensitivity to vasoconstrictors. Intrahepatic vascular resistance is increased in cirrhosis due to fixed fibrosis within the spaces of Disse and hepatic veins as well as reversible vasoconstriction of hepatic sinusoids and venules. Among the consequences of portal hypertension are ascites, hepatic encephalopathy, and the development of portosystemic collaterals—especially gastric or esophageal varices. Varices can rupture, leading to massive upper gastrointestinal bleeding. 

Lactulose (Constulose, Generlac, Enulose, Others) [Laxative/ Osmotic] Uses Hepatic encephalopathy constipation Action Acidifies the colon, allows ammonia to diffuse into colon Dose Acute hepatic encephalopathy. 30-45 mLPO qlh until soft stools, then tid-qid Chronic laxative therapy 30-45 mL... 

A 70-year-old woman with a 2-year history of primary biliary cirrhosis confirmed by histological and immunological criteria took colestyramine sachets twice daily for 2 months and developed lethargy, confusion, and drowsiness (3). She had signs of chronic liver disease, portal hypertension, and hepatic encephalopathy. Laboratory investigations confirmed a metabolic acidosis (pH 7.15) and hyperchloremia. Multiple cultures failed to reveal sepsis, and a urinary pH of 4.85 together with tests of renal acidification excluded renal tubular acidosis. No other cause was found and she responded to 600 mmol of sodium bicarbonate intravenously over 36 hours. 

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>. 

Kreis, R., Ross, B.D., Farrow, N.A., Ackerman, Z. (1992). Metabolic disorders of the brain in chronic hepatic encephalopathy detected with H-NMR spectroscopy. Radiology 182, 19-27. 

The relationship between drug concentration and response also can be altered in patients with advanced liver disease. Of greatest concern is the fact that customary doses of sedatives may precipitate the disorientation and coma that are characteristic of portal-systemic or hepatic encephalopathy. Experimental hepatic encephalopathy is associated with increased y-aminobutyric acid-mediated inhibitory neurotransmission, and there has been some success in using the benzodiazepine antagonist flumazenil to reverse this syndrome (50). This provides a theoretical basis for the finding that brain hypersensitivity, as well as impaired drug elimination, is responsible for the exaggerated sedative response to diazepam that is exhibited by some patients with chronic liver disease (51). Bakti et al. (52) conducted a particularly well-controlled... 

Hepatic encephalopathy (HE) is defined as a functional, potentially reversible disorder of the brain in the wake of severe (either acute or chronic) liver disease. The term comprises all neurological and mental symptoms. 

Kullmann, F., Hollerbach, S., Lock, G., Holstege, A., Dierks, T., Scholmerich, J. Brain electrical activity mapping of EEG for the diagnosis of (sub)clinical hepatic encephalopathy in chronic Hver disease. Eur. J. Gastroenterol. Hepatol. 2001 13 513-522... 

Levy, L.J., Bolton, R.R, Losowsky, M.S. The visual evoked potential in clinical hepatic encephalopathy in acute and chronic liver disease. Hepato-Gastroenterol. 1990 (Suppl. II) 37 66-73... 

Rehnstrom, S., Simert, G., Hansson, J.A., Johnson, G., Vang, J. Chronic hepatic encephalopathy. A psychometrical study. Scand. X Gastroenterol. 1977 12 305-311... 

The occurrence of hepatic encephalopathy (HE) is only possible under the following conditions (1.) a serious (acute or chronic) liver disease, in which the detoxification function is significantly restricted, has to be present, and/or (2.) a functional or anatomic portosystemic collateral circulation must exist — this can be placed surgically or in the form of a TIPS (72, 90) -through which the nondetoxified portal blood bypasses the liver, so that toxic substances can reach the brain. 

L-dopa, a precursor of the neurotransmitters norepinephrine and dopamine, was introduced into HE therapy by J.D. Parkes et al. in 1970. The results were good. As yet, there is still no accepted opinion on the use of this substance. Piracetam, as a nootropic substance, led to a clear improvement in typical electrical brain activities in animals displaying hepatic damage and symptoms of encephalopathy. Similarly, a double-blind randomized cross-over study with the nootropic agent centropheno-xine partly showed positive effects in psychometric testing. Bromocriptine, an agonist of the dopamine receptor, was also used in 1980 for chronic hepatic encephalopathy. (146,163) Application of L-carnitine (6 g/day orally, divided into two doses, for 4 weeks) leads to a marked reduction of hyperammonaemia and a clear improvement in clinical symptoms of HE in cirrhotic patients. (119) (s. p.49)... 

Cabre, E., Periago, J.L., Gonzalez, J., Gonzalez-Huix, F., Abad-Lacruz, A., Gil, A., Sancbez-Medina, F., Esteve- Comas, M., Fernandez-Ban-ares, F., Planas, R., Gassull, M.A. Plasma polyunsaturated fatty acids in liver cirrhosis with or without chronic hepatic encephalopathy a preliminary study. X. Parenter. Enter. Nutr. 1992 16 359-363... 

Jalan, R., Seery, J.P., Taylor-Roblnson, S.D. Review article pathogenesis and treatment of chronic hepatic encephalopathy Aliment. Pharmacol. Ther. 1996 10 681-697... 

Strauss, E., Ferreira da Costa, M. The importance of bacterial infections as precipitating factors of chronic hepatic encephalopathy in cirrhosis. Hepato-Gastroenterol. 1998 45 900—904... 

Thirlby, R.C., Fenster, L.F., Coatsworth, J.J., Petty, F. Reversal of chronic hepatic encephalopathy by colonic exclusion poor correlation with blood GABA levels. Amer. J. Gastroenterol. 1990 85 1637-1641... 

Freund, H., Yoshimura, N., Fischer, J.E. Chronic hepatic encephalopathy. Long-term therapy with a branched-chain amino-acid-enriched elemental diet. X. Amer. Med. Ass. 1979 242 347-349... 

Greenberg, N.J., Carley, J., Schenker, St., Bettinger, I., Stamness, C., Beyer, R Effect of vegetable and animal protein diets in chronic hepatic encephalopathy. Dig. Dis. 1977 22 845-855... 

Riggio, O., Balducci, G., Ariosto, F., Merli, M., Tremlterra, S., Ziparo, V., Capocaccia, L. Lactitol in the treatment of chronic hepatic encephalopathy — a randomized cross-over comparison with lactulose. Hepato-Gastroenterol 1990 37 524-527... 

Stauch, S., Kircheis, G., Adler, G., Becker, K., Ditschuneit, H., Gortelmeyer, R., Hendricks, R., Heuser, A., Karoff, C., Malfertheiner, R, Mayer, D., Rosch, W, Steffens, J. Oral L-ornithine-L-aspartate therapy of chronic hepatic encephalopathy results of a placebo-controlled double-blind study. X. Hepatol 1998 28 856-864... 

---