1201
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Elwir S, Hal H, Veith J, Schreibman I, Kadry Z, Riley T. Radiographical findings in patients with liver cirrhosis and hepatic encephalopathy. Gastroenterol Rep (Oxf) 2015; 4:221-5. [PMID: 26463277 PMCID: PMC4976681 DOI: 10.1093/gastro/gov049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/23/2015] [Indexed: 01/28/2023] Open
Abstract
Background and aims: Hepatic encephalopathy is a common complication encountered in patients with liver cirrhosis. Hepatic encephalopathy is not reflected in the current liver transplant allocation system. Correlation was sought between hepatic encephalopathy with findings detected on radiographic imaging studies and the patient’s clinical profile. Methods: A retrospective analysis was conducted of patients with cirrhosis, who presented for liver transplant evaluation in 2009 and 2010. Patients with hepatocellular carcinoma, ejection fraction less than 60% and who had a TIPS (transjugular intrahepatic portosystemic shunting) procedure or who did not complete the evaluation were excluded. Statistical analysis was performed and variables found to be significant on univariate analysis (P < 0.05) were analysed by a multivariate logistic regression model. Results: A total of 117 patients met the inclusion criteria and were divided into a hepatic encephalopathy group (n = 58) and a control group (n = 59). Univariate analysis found that a smaller portal vein diameter, smaller liver antero-posterior diameter, liver nodularity and use of diuretics or centrally acting medications showed significant correlation with hepatic encephalopathy. This association was confirmed for smaller portal vein, use of diuretics and centrally acting medications in the multivariate analysis. Conclusion: A decrease in portal vein diameter was associated with increased risk of encephalopathy. Identifying patients with smaller portal vein diameter may warrant screening for encephalopathy by more advanced psychometric testing, and more aggressive control of constipation and other factors that may precipitate encephalopathy.
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Affiliation(s)
- Saleh Elwir
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania (PA), USA
| | - Hassan Hal
- Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joshua Veith
- Penn State Milton S. Hershey Medical Center and School of Medicine, Hershey, PA, USA
| | - Ian Schreibman
- Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Zakiyah Kadry
- Division of Transplant Surgery, Penn State Milton S. Hershey Medical Center, Hershey PA, USA
| | - Thomas Riley
- Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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1202
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Lauridsen MM, Schaffalitzky de Muckadell OB, Vilstrup H. Minimal hepatic encephalopathy characterized by parallel use of the continuous reaction time and portosystemic encephalopathy tests. Metab Brain Dis 2015; 30:1187-92. [PMID: 26016624 DOI: 10.1007/s11011-015-9688-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/22/2015] [Indexed: 12/11/2022]
Abstract
Minimal hepatic encephalopathy (MHE) is a frequent complication to liver cirrhosis that causes poor quality of life, a great burden to caregivers, and can be treated. For diagnosis and grading the international guidelines recommend the use of psychometric tests of different modalities (computer based vs. paper and pencil). To compare results of the Continuous Reaction time (CRT) and the Portosystemic Encephalopathy (PSE) tests in a large unselected cohort of cirrhosis patients without clinically detectable brain impairment and to clinically characterize the patients according to their test results. The CRT method is a 10-minute computerized test of a patient's motor reaction time stability (CRTindex) to 150 auditory stimuli. The PSE test is a 20-minute paper-pencil test evaluating psychomotor speed. Both tests were performed at the same occasion in 129 patients. Both tests were normal in only 36% (n = 46) of the patients and this group had the best quality of life, a normal CRP, a low risk of subsequent overt HE, and a low short term mortality. Either the CRT or the PSE test was abnormal in a total of 64% of the patients (n = 83), the CRT in 53% (n = 69) and the PSE in 34% (n = 44). All these patients had a poorer quality of life, low-grade CRP elevation, moderate risk for subsequent overt HE, and a higher than 20% short term mortality. Both tests were abnormal in 23% (n = 30) of the patients and this group had more advanced cirrhosis and a 40 % short-term mortality. One of the tests was abnormal in the majority of the patients but concordant in only 60%. Most cirrhosis patients seem to have impairments of different cognitive domains and more domains with advancing disease. Two abnormal tests identified patients with an increased risk of overt HE and death.
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Affiliation(s)
- M M Lauridsen
- Department of Gastroenterology, Hospital of South West Jutland, Finsensgade 35, 6700, Esbjerg, Denmark,
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1203
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Gluud LL, Dam G, Les I, Córdoba J, Marchesini G, Borre M, Aagaard NK, Vilstrup H. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev 2015:CD001939. [PMID: 26377410 DOI: 10.1002/14651858.cd001939.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hepatic encephalopathy is a brain dysfunction with neurological and psychiatric changes associated with liver insufficiency or portal-systemic shunting. The severity ranges from minor symptoms to coma. A Cochrane systematic review including 11 randomised clinical trials on branched-chain amino acids (BCAA) versus control interventions has evaluated if BCAA may benefit people with hepatic encephalopathy. OBJECTIVES To evaluate the beneficial and harmful effects of BCAA versus any control intervention for people with hepatic encephalopathy. SEARCH METHODS We identified trials through manual and electronic searches in The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index (August 2015). SELECTION CRITERIA We included randomised clinical trials, irrespective of the bias control, language, or publication status. DATA COLLECTION AND ANALYSIS The authors independently extracted data based on published reports and collected data from the primary investigators. We changed our primary outcomes in this update of the review to include mortality (all cause), hepatic encephalopathy (number of people without improved manifestations of hepatic encephalopathy), and adverse events. The analyses included random-effects and fixed-effect meta-analyses. We performed subgroup, sensitivity, regression, and trial sequential analyses to evaluate sources of heterogeneity (including intervention, and participant and trial characteristics), bias (using The Cochrane Hepato-Biliary Group method), small-study effects, and the robustness of the results after adjusting for sparse data and multiplicity. We graded the quality of the evidence using the GRADE approach. MAIN RESULTS We found 16 randomised clinical trials including 827 participants with hepatic encephalopathy classed as overt (12 trials) or minimal (four trials). Eight trials assessed oral BCAA supplements and seven trials assessed intravenous BCAA. The control groups received placebo/no intervention (two trials), diets (10 trials), lactulose (two trials), or neomycin (two trials). In 15 trials, all participants had cirrhosis. We classed seven trials as low risk of bias and nine trials as high risk of bias (mainly due to lack of blinding or for-profit funding). In a random-effects meta-analysis of mortality, we found no difference between BCAA and controls (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.69 to 1.11; 760 participants; 15 trials; moderate quality of evidence). We found no evidence of small-study effects. Sensitivity analyses of trials with a low risk of bias found no beneficial or detrimental effect of BCAA on mortality. Trial sequential analysis showed that the required information size was not reached, suggesting that additional evidence was needed. BCAA had a beneficial effect on hepatic encephalopathy (RR 0.73, 95% CI 0.61 to 0.88; 827 participants; 16 trials; high quality of evidence). We found no small-study effects and confirmed the beneficial effect of BCAA in a sensitivity analysis that only included trials with a low risk of bias (RR 0.71, 95% CI 0.52 to 0.96). The trial sequential analysis showed that firm evidence was reached. In a fixed-effect meta-analysis, we found that BCAA increased the risk of nausea and vomiting (RR 5.56; 2.93 to 10.55; moderate quality of evidence). We found no beneficial or detrimental effects of BCAA on nausea or vomiting in a random-effects meta-analysis or on quality of life or nutritional parameters. We did not identify predictors of the intervention effect in the subgroup, sensitivity, or meta-regression analyses. In sensitivity analyses that excluded trials with a lactulose or neomycin control, BCAA had a beneficial effect on hepatic encephalopathy (RR 0.76, 95% CI 0.63 to 0.92). Additional sensitivity analyses found no difference between BCAA and lactulose or neomycin (RR 0.66, 95% CI 0.34 to 1.30). AUTHORS' CONCLUSIONS In this updated review, we included five additional trials. The analyses showed that BCAA had a beneficial effect on hepatic encephalopathy. We found no effect on mortality, quality of life, or nutritional parameters, but we need additional trials to evaluate these outcomes. Likewise, we need additional randomised clinical trials to determine the effect of BCAA compared with interventions such as non-absorbable disaccharides, rifaximin, or other antibiotics.
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Affiliation(s)
- Lise Lotte Gluud
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Kettegaards Alle, Hvidovre, Denmark, 2650
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1204
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Role of local and distant functional connectivity density in the development of minimal hepatic encephalopathy. Sci Rep 2015; 5:13720. [PMID: 26329994 PMCID: PMC4556960 DOI: 10.1038/srep13720] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/27/2015] [Indexed: 02/07/2023] Open
Abstract
The progression of functional connectivity (FC) patterns from non-hepatic encephalopathy (non-HE) to minimal HE (MHE) is not well known. This resting-state functional magnetic resonance imaging (rs-fMRI) study investigated the evolution of intrinsic FC patterns from non-HE to MHE. A total of 103 cirrhotic patients (MHE, n = 34 and non-HE, n = 69) and 103 healthy controls underwent rs-fMRI scanning. Maps of distant and local FC density (dFCD and lFCD, respectively) were compared among MHE, non-HE, and healthy control groups. Decreased lFCD in anterior cingulate cortex, pre- and postcentral gyri, cuneus, lingual gyrus, and putamen was observed in both MHE and non-HE patients relative to controls. There was no difference in lFCD between MHE and non-HE groups. The latter showed decreased dFCD in inferior parietal lobule, cuneus, and medial frontal cortex relative to controls; however, MHE patients showed decreased dFCD in frontal and parietal cortices as well as increased dFCD in thalamus and caudate head relative to control and non-HE groups. Abnormal FCD values in some regions correlated with MHE patients’ neuropsychological performance. In conclusion, lFCD and dFCD were perturbed in MHE. Impaired dFCD in regions within the cortico-striato-thalamic circuit may be more closely associated with the development of MHE.
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1205
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Sharma P, Sharma BC. Management Patterns of Hepatic Encephalopathy: A Nationwide Survey in India. J Clin Exp Hepatol 2015; 5:199-203. [PMID: 26628837 PMCID: PMC4632100 DOI: 10.1016/j.jceh.2015.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 06/30/2015] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION AND AIM Hepatic encephalopathy (HE) is a common complication of cirrhosis. There is no standard practice for its management. This survey was done to determine the diagnostic and therapeutic practices of physicians treating patients with HE in patients with cirrhosis. MATERIAL AND METHOD We designed a 21-item questionnaire, which was given to physicians working in academic and non-academic institutes and regularly treating patients with HE. RESULTS Of 500 printed questionnaires, we received 451 questionnaires [323 (72%) general physicians and 128 (28%) gastroenterologists] from academic and non-academic institutes. Commonest precipitating event of HE was upper gastrointestinal bleed (47%), constipation (18%) and spontaneous bacterial peritonitis (12%). Arterial ammonia was always measured at admission by 156 (35%) physicians, never measured by 128 (28%) and sometimes by 167 (37%). Prophylactic antibiotics were used by 54% of physicians on the day of admission irrespective of any precipitating event, and 13% used antibiotics only if cultures were positive while others used antibiotics only if patient needs intubation or had variceal bleed as the cause of precipitation of HE. Disaccharides remained the mainstay of treatment in the management of HE and were always used by 87% (n = 391) followed by LOLA (n = 297, 66%) and rifaximin (n = 276, 61%). Combination of therapy was used by 84% of respondents. Lactulose enema was used in patients with HE by 280 (62%) physicians and was thought to be as good as giving lactulose by mouth or nasogastric tube in the treatment of HE. Regarding the recovery of HE with the present mode of therapy, of 451 responses, only 11% (n = 49) got 90-100% response to present therapy for the recovery of HE, while 70-90% response was seen by n = 152 (34%) and 50-70% response was seen by n = 183 (41%). Lactulose was prescribed as secondary prophylaxis agent more by gastroenterologists than non-gastroenterologists (76% vs 41%, P = 0.001). Similarly, rifaximin was more prescribed by gastroenterologists at discharge compared to non-gastroenterologists (32% vs 17%, P = 0.001). CONCLUSION Non-absorbable disaccharides are the most commonly prescribed treatment for HE and for secondary prophylaxis of HE. Combination of therapy (lactulose and LOLA or lactulose and rifaximin) was commonly used by treating physicians.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
- Address for correspondence: Praveen Sharma, Associate Professor, GRIPMER and Sir Ganga Ram Hospital, New Delhi, India. Tel.: +91 9810365151.
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1206
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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1207
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Abstract
Chronic liver disease results from a wide range of conditions, for which individual management is beyond the scope of this article. General education, counseling, and harm reduction practices are important to the primary care of these patients, as are monitoring for cirrhosis and management of its complications. For patients with advanced liver disease, comprehensive care includes considering referral for liver transplantation, educating and empowering patients to prioritize goals of care, and optimizing symptom relief.
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Affiliation(s)
- Jocelyn James
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Box 359892, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Iris W Liou
- Division of Gastroenterology, Department of Medicine, University of Washington, Box 356175, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
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1208
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Cox‐North P. Issues in the end-stage liver disease patient for which palliative care could be helpful. Clin Liver Dis (Hoboken) 2015; 6:33-36. [PMID: 31040983 PMCID: PMC6490644 DOI: 10.1002/cld.492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 05/14/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Paula Cox‐North
- Liver Clinic at Harborview Medical CenterUniversity of Washington School of NursingSeattleWA
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1209
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Endovascular Management of Refractory Hepatic Encephalopathy Complication of Transjugular Intrahepatic Portosystemic Shunt (TIPS): Comprehensive Review and Clinical Practice Algorithm. Cardiovasc Intervent Radiol 2015; 39:170-82. [PMID: 26285910 DOI: 10.1007/s00270-015-1197-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/23/2015] [Indexed: 12/17/2022]
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1210
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Abstract
Hepatic encephalopathy (HE) is defined by an altered mental status in the setting of portosystemic shunting, with or without cirrhosis. The basis of HE is probably multi-factorial, but increased ammonia delivery to the brain is thought to play a pivotal role. Medical therapies have typically focused on reducing blood ammonia concentrations. These measures are moderately effective, but further improvements will require identification of new therapeutic targets. Two medications, lactulose and rifaximin, are currently approved for the treatment of HE in the USA - new compounds are available off-label, and are in clinical trials. The presence of HE is associated with a higher risk of death in cirrhotic patients. Liver transplantation typically cures HE, but HE does not increase the MELD score, and therefore does not contribute to the likelihood of liver transplantation.
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Affiliation(s)
- Norman L Sussman
- Baylor College of Medicine and Baylor-St. Luke's Medical Center, Division of Abdominal Transplantation, 6620 Main Street #1425, Houston, TX 77030, USA.
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1211
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Abstract
Normal regulation of total body and circulating ammonia requires a delicate interplay in ammonia formation and breakdown between several organ systems. In the setting of cirrhosis and portal hypertension, the decreased hepatic clearance of ammonia leads to significant dependence on skeletal muscle for ammonia detoxification; however, cirrhosis is also associated with muscle depletion and decreased functional muscle mass. Thus, patients with diminished muscle mass and sarcopenia may have a decreased ability to compensate for hepatic insufficiency and a higher likelihood of developing physiologically significant hyperammonemia and hepatic encephalopathy.
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Affiliation(s)
- Catherine Lucero
- Division of Digestive and Liver Diseases, Department of Medicine, Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 14-105, New York, NY 10032, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 14-105, New York, NY 10032, USA.
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1212
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Matoori S, Leroux JC. Recent advances in the treatment of hyperammonemia. Adv Drug Deliv Rev 2015; 90:55-68. [PMID: 25895618 DOI: 10.1016/j.addr.2015.04.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/30/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023]
Abstract
Ammonia is a neurotoxic agent that is primarily generated in the intestine and detoxified in the liver. Toxic increases in systemic ammonia levels predominantly result from an inherited or acquired impairment in hepatic detoxification and lead to potentially life-threatening neuropsychiatric symptoms. Inborn deficiencies in ammonia detoxification mainly affect the urea cycle, an endogenous metabolic removal system in the liver. Hepatic encephalopathy, on the other hand, is a hyperammonemia-related complication secondary to acquired liver function impairment. A range of therapeutic options is available to target either ammonia generation and absorption or ammonia removal. Therapies for hepatic encephalopathy decrease intestinal ammonia production and uptake. Treatments for urea cycle disorders eliminate ammoniagenic amino acids through metabolic transformation, preventing ammonia generation. Therapeutic approaches removing ammonia activate the urea cycle or the second essential endogenous ammonia detoxification system, glutamine synthesis. Recent advances in treating hyperammonemia include using synergistic combination treatments, broadening the indication of orphan drugs, and developing novel approaches to regenerate functional liver tissue. This manuscript reviews the various pharmacological treatments of hyperammonemia and focuses on biopharmaceutical and drug delivery issues.
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1213
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Abstract
Hepatic encephalopathy (HE) is associated with cerebral edema (CE), increased intracranial pressure (ICP), and subsequent neurologic complications; it is the most important cause of morbidity and mortality in fulminant hepatic failure. The goal of therapy should be early diagnosis and treatment of HE with measures to reduce CE. A combination of clinical examination and diagnostic modalities can aid in prompt diagnosis. ICP monitoring and transcranial Doppler help diagnose and monitor response to treatment. Transfer to a transplant center and intensive care unit admission with airway management and reduction of CE with hypertonic saline, mannitol, hypothermia, and sedation are recommended as a bridge to liver transplantation.
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1214
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Abstract
Both covert hepatic encephalopathy (CHE) and overt hepatic encephalopathy (OHE) impair the ability to operate machinery. The legal responsibilities of US physicians who diagnose and treat patients with hepatic encephalopathy vary among states. It is imperative that physicians know the laws regarding reporting in their state. OHE represents a neuropsychiatric impairment that meets general reporting criteria. The medical advisory boards of the states have not identified OHE as a reportable condition. In the absence of validated diagnostic guidelines, physicians are not obligated to perform tests for CHE. There is a need for explicit guidance from professional associations regarding this issue.
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1215
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DuPont HL. Therapeutic Effects and Mechanisms of Action of Rifaximin in Gastrointestinal Diseases. Mayo Clin Proc 2015; 90:1116-24. [PMID: 26162610 DOI: 10.1016/j.mayocp.2015.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 04/27/2015] [Accepted: 04/29/2015] [Indexed: 02/06/2023]
Abstract
Emerging preclinical and clinic evidence described herein suggests that the mechanism of action of rifaximin is not restricted to direct antibacterial effects within the gastrointestinal tract. Data from this study were derived from general and clinical trial-specific PubMed searches of English-language articles on rifaximin available through December 3, 2014. Search terms included rifaximin alone and in combination (using the Boolean operation "AND") with travelers' diarrhea, hepatic encephalopathy, liver cirrhosis, irritable bowel syndrome, inflammatory bowel disease, and Crohn's disease. Rifaximin appears to reduce bacterial virulence and pathogenicity by inhibiting bacterial translocation across the gastrointestinal epithelial lining. Rifaximin was shown to decrease bacterial adherence to epithelial cells and subsequent internalization in a bacteria- and cell type-specific manner, without an alteration in bacterial counts, but with a down-regulation in epithelial proinflammatory cytokine expression. Rifaximin also appears to modulate gut-immune signaling. In animal models of inflammatory bowel disease, rifaximin produced therapeutic effects by activating the pregnane X receptor and thereby reducing levels of the proinflammatory transcription factor nuclear factor κB. Therefore, for a given disease state, rifaximin may act through several mechanisms of action to exert its therapeutic effects. Clinically, rifaximin 600 mg/d significantly reduced symptoms of travelers' diarrhea (eg, time to last unformed stool vs placebo [32.0 hours vs 65.5 hours, respectively; P=.001]). For the prevention of hepatic encephalopathy recurrence, data indicate that treating 4 patients with rifaximin 1100 mg/d for 6 months would prevent 1 episode of hepatic encephalopathy. For diarrhea-predominant irritable bowel syndrome, a significantly greater percentage (40.7%) of patients treated with rifaximin 1650 mg/d for 2 weeks experienced adequate global irritable bowel syndrome symptom relief vs placebo (31.7%; P<.001). Rifaximin may be best described as a gut microenvironment modulator with cytoprotection properties, and further studies are needed to determine whether these putative mechanisms of action play a direct role in clinical outcomes.
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Affiliation(s)
- Herbert L DuPont
- Center for Infectious Diseases, The University of Texas School of Public Health, Baylor College of Medicine, Baylor St. Luke's Medical Center, Kelsey Research Foundation, Houston, TX.
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1216
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Understanding the Complexities of Cirrhosis. Clin Ther 2015; 37:1822-36. [DOI: 10.1016/j.clinthera.2015.05.507] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/25/2015] [Accepted: 05/08/2015] [Indexed: 12/13/2022]
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1217
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Abstract
Chronic injury to the liver from a variety of different sources can result in irreversible scarring of the liver, known as cirrhosis. Cirrhosis is a major cause of morbidity and mortality in the USA, and according to the Centers for Disease Control and Prevention was responsible for 31,903 deaths in 2010 alone. It is thus of the utmost importance to appropriately manage these patients in the inpatient and outpatient setting to improve morbidity and mortality. In this review, we address four major areas of cirrhosis management: outpatient management of portal hypertension with decompensation, hepatic encephalopathy, hepatorenal syndrome, and bleeding/coagulation issues. Outpatient management covers recommendations for health care maintenance and screening. Hepatic encephalopathy encompasses a brief review of pathophysiology, treatment in the acute setting, and long-term prevention. Hepatorenal syndrome is discussed in regards to pathophysiology and treatment in the hospital setting. Finally, a discussion of the assessment of coagulation profiles in cirrhosis and recommendations for bleeding and thrombosis complications is included. These topics are not all encompassing with regard to this complicated population, but rather an overview of a few medical problems that are commonly encountered in their care.
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Affiliation(s)
- Neeral L Shah
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | | | | | - Scott L Cornella
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
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1218
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Roggeri DP, Roggeri A, Rossi E, Cinconze E, Gasbarrini A, Monici Preti P, De Rosa M. Overt hepatic encephalopathy in Italy: clinical outcomes and healthcare costs. Hepat Med 2015. [PMID: 26203290 PMCID: PMC4506032 DOI: 10.2147/hmer.s87594] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Hepatic encephalopathy (HE) is a recurrent severe complication of progressive hepatic cirrhosis. The aim of this study is to evaluate the average annual direct healthcare costs for the treatment of patients with overt HE in Italy. PATIENTS AND METHODS This retrospective, observational study analyzed information from the database of ARNO Observatory. Patients with at least one hospitalization due to overt HE in the period from January 1, 2011 to December 31, 2011, were selected and observed during the year following the hospitalization. Costs for drugs, diagnostic and therapeutic procedures, and hospitalizations were estimated from the Italian National Health Service perspective. RESULTS Out of a population of 2,678,462 subjects, 381 patients were identified, of whom, 21.5% died during the first hospitalization and 5.8% during the follow-up; the survival rate was 72.7% at the end of the observation period. The direct healthcare costs per patient amounted to €13,393/year (15,295 USD) (88% for hospitalizations, 8% for drugs, and 4% for diagnostic procedures). During the follow-up, 42.5% of patients had at least one rehospitalization due to HE. Patients readmitted for HE had an average annual cost of €21,272 (24,293 USD), almost doubled if compared to patients without readmissions (€12,098 [13,816 USD]). CONCLUSION This analysis showed that patients with HE had relevant direct healthcare costs, in which hospitalizations were the most important cost drivers.
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Affiliation(s)
| | | | - Elisa Rossi
- CINECA, Interuniversity Consortium, Bologna, Italy
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1219
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Abstract
Minimal hepatic encephalopathy (mHE) is diagnosed in patients with severe liver disease but no clinical symptoms of encephalopathy if either neuropsychological or neurophysiological tests indicate cerebral dysfunction and other possible causes of brain dysfunction have been excluded. mHE is characterized by deficits in attention, visuospatial orientation, visuoconstructive abilities and motor function. Accordingly, mHE can be expected to interfere with a subject's working ability, especially in those occupations that require handiwork, and driving ability. Indeed, about 60% of blue-collar workers with mHE have been shown to be assessed as unfit for work compared to only 20% of white-collar workers, and about 50% of patients with mHE have been judged unfit to drive a car in several studies. mHE interferes with a patient's quality of life and is associated with an increased risk of developing overt HE as well as increased mortality. Whether mHE is of importance for cognitive function after liver transplantation has still to be clarified.
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1220
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Abstract
Minimal hepatic encephalopathy (mHE) is common among patients with cirrhotic liver disease and causes significant morbidity and mortality. It may present as cognitive impairment, behavioural changes and, less frequently, with neurological symptoms which make diagnosis of the disease challenging. A history of falls and accidents may also be suggestive of mHE. Diagnosis primarily relies on at least two positive psychometric tests of which the psychometric hepatic encephalopathy score (PHES) is essential. Alternatively, PHES and an electroencephalogram may be used to establish a diagnosis. Biochemical markers of encephalopathy currently have no role in the diagnosis of mHE. Treatment is not always advocated for a diagnosis of mHE but is dependent on the degree of impairment caused by the symptoms. After treatment of other metabolic abnormalities and co-morbidities associated with cirrhosis, more specific treatment for mHE largely relies on therapies used to lower ammonia levels. Laxatives and rifaximin are commonly used in treatment and work through decreasing ammonia absorption from the gut. Other therapies, such as BCAA, LOLA, L-carnitine and phenylbutyrate, modify responses to ammonia as well as enhancing metabolism and excretion. mHE resulting from spontaneous portosystemic shunts or transhepatic intraportal systemic shunts may require ablation or reduction of the shunt. Early detection and appropriate treatment of mHE is important to prevent significant cognitive impairments and progression to overt HE.
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Affiliation(s)
- Shamindra Direkze
- Royal Free Hospital NHS Foundation Trust, University College London, London, UK
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1221
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Hepatic encephalopathy treatment and its effect on driving abilities: A continental divide. J Hepatol 2015; 63:287-8. [PMID: 25796480 DOI: 10.1016/j.jhep.2015.03.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 12/23/2022]
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1222
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Zhang YD, Zhu FP, Xu X, Wang Q, Wu CJ, Liu XS, Shi HB. Classifying CT/MR findings in patients with suspicion of hepatocellular carcinoma: Comparison of liver imaging reporting and data system and criteria-free Likert scale reporting models. J Magn Reson Imaging 2015; 43:373-83. [PMID: 26119393 DOI: 10.1002/jmri.24987] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/15/2015] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To compare the Liver Imaging Reporting and Data System (LI-RADS) and a criteria-free Likert scale (LS) reporting models for classifying computed tomography/magnetic resonance imaging (CT/MR) findings of suspicious hepatocellular carcinoma (HCC). MATERIALS AND METHODS Imaging data of 281 hepatic nodules in 203 patients were retrospectively included. Imaging characteristics including diameter, arterial hyperenhancement, washout, and capsule were reviewed independently by two groups of readers using LI-RADS and LS (range, score 1-5). LS is primarily based on the overall impression of image findings without using fixed criteria. Interreader agreement (IRA), intraclass agreement (ICA), and diagnostic performance were determined by Fleiss, Cohen's kappa (κ), and logistic regression, respectively. RESULTS There were 167 contrast-enhanced CT (CECT) versus 114 MR data. Overall, IRA was moderate (κ = 0.47, 0.52); IRA was moderate-to-good for arterial hyperenhancement, washout, and capsule (κ = 0.56-0.69); excellent for diameter and tumor embolus (κ = 0.99). Overall, ICA between LI-RADS and LS was moderate (κ = 0.44-0.50); ICA was good for scores 1-2 (κ = 0.71-0.90), moderate for scores 3 and 5 (κ = 0.41-0.52), but very poor for score 4 (κ = 0.11-0.19). LI-RADS produced significantly lower accuracy (78.6% vs. 87.2%) and sensitivity (72.1% vs. 92.8%), higher specificity (97.3% vs. 71.2%) and positive likelihood ratio (+LR: 26.32 vs. 3.23) in diagnosis of HCC. CECT produced relatively low IRA, ICA, and diagnostic ability against MR. CONCLUSION There were substantial variations in liver observations between LI-RADS and LS. Further study is needed to investigate ICA between CECT and MR.
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Affiliation(s)
- Yu-Dong Zhang
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Fei-Peng Zhu
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Xun Xu
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Qing Wang
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Chen-Jiang Wu
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Xi-Sheng Liu
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Hai-Bin Shi
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
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1223
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Vaquero J, Bañares R. A gut solution for hepatic encephalopathy. Hepatology 2015; 61:2107-009. [PMID: 25777043 DOI: 10.1002/hep.27784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Javier Vaquero
- Hepatología-Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Bañares
- Hepatología-Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
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1224
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Abstract
In patients with cirrhosis and portal hypertension, it is largely the frequency and severity of complications relating to the diseased liver, degree of portal hypertension and hemodynamic derangement that determine the prognosis. It can be considered as a multiple organ failure that apart from the liver involves the heart, lungs, kidneys, the immune systems and other organ systems. Progressive fibrosis of the liver and subsequent metabolic impairment leads to a systemic and splanchnic arteriolar vasodilatation. With the progression of the disease development of portal hypertension leads to formation of esophageal varices and ascites. The circulation becomes hyperdynamic with cardiac, pulmonary as well as renal consequences for dysfunction and reduced survival. Infections and a changed cardiac function known as cirrhotic cardiomyopathy may be involved in further aggravation of other complications such as renal failure precipitating the hepatorenal syndrome. Patients with end-stage liver disease and related complications as for example the hepatopulmonary syndrome can only radically be treated by liver transplantation.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine 239, Faculty of Health Sciences, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, University of Copenhagen , Hvidovre , Denmark
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1225
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Solinas A, Piras MR, Deplano A. Cognitive dysfunction and hepatitis C virus infection. World J Hepatol 2015; 7:922-925. [PMID: 25954475 PMCID: PMC4419096 DOI: 10.4254/wjh.v7.i7.922] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 02/23/2015] [Accepted: 03/18/2015] [Indexed: 02/06/2023] Open
Abstract
Cognitive dysfunction in patients with chronic hepatitis C virus (HCV) infection is a distinct form of minimal hepatic encephalopathy (MHE). In fact, the majority of HCV-positive patients, irrespective of the grading of liver fibrosis, display alterations of verbal learning, attention, executive function, and memory when they are evaluated by suitable neuropsychological tests. Similarities between the cognitive dysfunction of HCV patients and MHE of patients with different etiologies are unclear. It is also unknown how the metabolic alterations of advanced liver diseases interact with the HCV-induced cognitive dysfunction, and whether these alterations are reversed by antiviral therapies. HCV replication in the brain may play a role in the pathogenesis of neuroinflammation. HCV-related brain dysfunction may be associated with white matter neuronal loss, alterations of association tracts and perfusion. It is unclear to what extent, in patients with cirrhosis, HCV triggers an irreversible neurodegenerative brain damage. New insights on this issue will be provided by longitudinal studies using the protocols established by the diagnostic and statistical manual of mental disorders fifth edition for cognitive disorders. The domains to be evaluated are complex attention; executive functions; learning and memory; perceptual motor functions; social cognition. These evaluations should be associated with fluorodeoxyglucose positron emission tomography and magnetic resonance imaging (MRI) protocols for major cognitive disorders including magnetic resonance spectroscopy, diffusion tensor imaging, magnetic resonance perfusion, and functional MRI. Also, the characteristics of portal hypertension, including the extent of liver blood flow and the type of portal shunts, should be evaluated.
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1226
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Saab S. Evaluation of the impact of rehospitalization in the management of hepatic encephalopathy. Int J Gen Med 2015; 8:165-73. [PMID: 25999756 PMCID: PMC4427083 DOI: 10.2147/ijgm.s81878] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Overt hepatic encephalopathy (HE), which is associated with neuropsychiatric symptoms and neuromuscular dysfunction in patients with liver cirrhosis, is often managed in the hospital setting. Approximately 60% of eligible patients do not receive prophylactic therapy after an overt HE episode. Objective The aim of this review is to evaluate the impact of rehospitalization on costs and clinical outcomes in HE. Methods A PubMed search of English-language articles through July 9, 2014 was conducted, and bibliographies of identified publications were reviewed. Abstracts from relevant professional society meetings from 2010 to 2014 were searched. The selected references and abstracts reported on the prevalence, costs, or clinical consequences of rehospitalization in adults with HE. Data synthesis HE is a key reason for readmission among patients hospitalized for complications of cirrhosis. Almost 40% of patients previously hospitalized for HE may be readmitted within 1 year for HE-related reasons. Furthermore, in-hospital US mortality for patients admitted for HE is about 7% to 15%. Recurrent HE and hospitalization for cirrhosis complications are associated with impaired quality of life. In addition, recurrences (especially those requiring hospitalization) may contribute to persistent cognitive deficits (eg, impairments in reaction time, attention, and working memory) after resolution of an acute episode of overt HE. Conclusion The economic and clinical consequences of rehospitalization for patients with overt HE underscore the importance of secondary prevention and highlight the need to identify reasons for the undertreatment of patients after hospitalization for overt HE.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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1227
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Abstract
OBJECTIVE To provide an understanding of the detrimental impact of cirrhosis and its complications, strengths and weaknesses of current treatment options for the management of these complications, and new developments in this rapidly changing field. RESEARCH DESIGN AND METHODS Relevant publications were identified via PubMed and Cochrane databases, with additional references obtained by reviewing bibliographies from selected articles. RESULTS Cirrhosis, a progressive liver disease, is characterized by fibrosis caused by chronic liver injury. Liver fibrosis impairs hepatic function and causes structural changes that result in portal hypertension. Most patients with cirrhosis remain asymptomatic until they develop decompensated cirrhosis. At this stage, patients experience complications associated with portal hypertension (i.e., the abnormal increase in portal vein pressure), including ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), hepatorenal syndrome, portopulmonary hypertension, or variceal bleeding. In addition, intestinal microbial translocation in patients with cirrhosis might also cause SBP and HE. Because the survival rate for patients with cirrhosis substantially decreases once complications develop, the key goals in treating patients with cirrhosis include both managing the underlying liver disease and preventing and treating related complications. In patients with compensated cirrhosis, the management strategy is to prevent variceal bleeding and other complications that can lead to decompensated cirrhosis. Patients with decompensated cirrhosis are typically referred for liver transplantation, and the main focus of pre-transplant management is to eliminate the cause of cirrhosis (e.g., excess alcohol consumption, hepatitis virus) and prevent the recurrence of each decompensating complication. CONCLUSIONS Although substantial progress has been made to prevent the complications and mortality associated with cirrhosis, liver transplantation in combination with resolution of the etiology of cirrhosis remains the only curative option for most patients. Emerging therapies such as anti-fibrotic agents hold promise in potentially halting or reversing the progression of cirrhosis, even in patients with decompensated cirrhosis.
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Affiliation(s)
- Fred F Poordad
- The Texas Liver Institute, University of Texas Health Science Center , San Antonio, TX , USA
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1228
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Abstract
Liver disease results in over four million physician visits and over 750,000 hospitalizations per year in the USA. Those with chronic liver disease frequently progress to cirrhosis, end-stage liver disease (ESLD), and death. Patients with ESLD experience numerous complications, including muscle cramps, confusion (hepatic encephalopathy), protein calorie malnutrition, muscle wasting, fluid overload (ascites, edema), bleeding (esophagogastric variceal hemorrhage), infection (spontaneous bacterial peritonitis), fatigue, anxiety, and depression. Despite significant improvements in palliation of these complications, patients still suffer reduced quality of life and must confront the fact that their disease will often inexorably progress to death. Liver transplantation is a valid option in this setting, increasing the duration of survival and palliating many of the symptoms. However, many patients die waiting for an organ or are not candidates for transplantation due to comorbid illness. Others receive a transplant but succumb to complications of the transplant itself. Patients and families must struggle with simultaneously hoping for a cure while facing a life-threatening illness. Ideally, the combination of palliative care with life-sustaining therapy can maximize the patients' quality and quantity of life. If it becomes clear that life-sustaining therapy is no longer an option, these patients are then already in a system to help them with end-of-life care.
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Affiliation(s)
- Anne M Larson
- Swedish Liver Center, 1101 Madison Street #200, Seattle, WA, 98104, USA,
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1229
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Shawcross DL. Is it time to target gut dysbiosis and immune dysfunction in the therapy of hepatic encephalopathy? Expert Rev Gastroenterol Hepatol 2015; 9:539-42. [PMID: 25846450 DOI: 10.1586/17474124.2015.1035257] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The development of overt hepatic encephalopathy (HE) in a patient with cirrhosis confers a damning prognosis with a 1-year mortality approaching 64%. This complex neuropsychiatric syndrome arises as a consequence of a dysfunctional gut-liver-brain axis. HE has been largely neglected over the past 30 years, with the reliance on therapies aimed at lowering ammonia production or increasing metabolism following the seminal observation that the hepatic urea cycle is the major mammalian ammonia detoxification pathway and is key in the pathogenesis of HE. The relationship with ammonia is more clear-cut in acute liver failure; but in cirrhosis, it has become apparent that inflammation is a key driver and that a disrupted microbiome resulting in gut dysbiosis, bacterial overgrowth and translocation, systemic endotoxemia and immune dysfunction may be more important drivers. Therefore, it is important to re-focus our efforts into developing therapies that modulate the disrupted microbiome or alleviating its downstream consequences.
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Affiliation(s)
- Debbie L Shawcross
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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1230
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Allampati S, Mullen KD. Nomenclature and definition of hepatic encephalopathy - An update. Clin Liver Dis (Hoboken) 2015; 5:68-70. [PMID: 31040953 PMCID: PMC6490462 DOI: 10.1002/cld.449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 12/04/2014] [Accepted: 12/28/2014] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sanath Allampati
- MetroHealth Medical Center, Liver Research SectionCase Western Reserve UniversityClevelandOH
| | - Kevin D. Mullen
- MetroHealth Medical Center, Liver Research SectionCase Western Reserve UniversityClevelandOH
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1231
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Munk Lauridsen M, Vilstrup H. Diagnosing covert hepatic encephalopathy. Clin Liver Dis (Hoboken) 2015; 5:71-74. [PMID: 31040954 PMCID: PMC6490466 DOI: 10.1002/cld.451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/05/2015] [Accepted: 01/18/2015] [Indexed: 02/04/2023] Open
Abstract
NOTE: Could not find interview file for this one by Lauridsen and Vilstrup; thought we had this, but it was just LAU, so mistakenly saw this as Lauridsen when I scan files. Can you confirm they were filmed at AASLD 2014?
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Affiliation(s)
| | - Hendrik Vilstrup
- Department of Hepatology and GastroenterologyAarhus University HospitalAarhusDenmark
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1232
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Dhiman RK. Impact of minimal/covert hepatic encephalopathy on patients with cirrhosis. Clin Liver Dis (Hoboken) 2015; 5:75-78. [PMID: 31040955 PMCID: PMC6490468 DOI: 10.1002/cld.452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/18/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Radha K. Dhiman
- Department of HepatologyPostgraduate Institute of Medical Education & ResearchChandigarhIndia
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1233
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Riggio O, Nardelli S, Gioia S, Lucidi C, Merli M. Management of hepatic encephalopathy as an inpatient. Clin Liver Dis (Hoboken) 2015; 5:79-82. [PMID: 31040956 PMCID: PMC6490467 DOI: 10.1002/cld.457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/20/2015] [Accepted: 01/24/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Oliviero Riggio
- Dept. of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension“Sapienza” University of RomeRomeItaly
| | - Silvia Nardelli
- Dept. of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension“Sapienza” University of RomeRomeItaly
| | - Stefania Gioia
- Dept. of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension“Sapienza” University of RomeRomeItaly
| | - Cristina Lucidi
- Dept. of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension“Sapienza” University of RomeRomeItaly
| | - Manuela Merli
- Dept. of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension“Sapienza” University of RomeRomeItaly
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1234
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Xu R, Chang J. Progress in treatment of hepatic encephalopathy. Shijie Huaren Xiaohua Zazhi 2015; 23:1755-1762. [DOI: 10.11569/wcjd.v23.i11.1755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a common complication of severe liver disease and a common cause of mortality. Clinical features range from clinically imperceptible symptoms in minimal HE which require neuropsychological testing to identify, to abnormal behavior, mental deterioration, and even coma or death. It is a reversible progressive neuropsychiatric disorder that is associated with a decrease in quality of life and an increase in rate of hospitalization and consequent costs because patients are at risk for recurrence. Unfortunately, the prevalence of HE continues to rise for several reasons. For one, patients with viral hepatitis are now developing cirrhosis. Additionally, we are currently in the midst of a global obesity epidemic, which fuels the metabolic syndrome and nonalcoholic fatty liver disease, and these patients are now presenting in larger numbers with complications of chronic liver disease such as HE. The high morbidity and mortality combined with the costs underline the importance to search the effective treatment for HE. This article reviews the progress in the treatment of HE.
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1235
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Marafioti V, Benetti V, Montin U, Carbone V, Petrosino A, Tedeschi U, Rossi A. QTc interval prolongation and hepatic encephalopathy in patients candidates for liver transplantation: A valid inference? Int J Cardiol 2015; 188:43-4. [PMID: 25885747 DOI: 10.1016/j.ijcard.2015.04.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/03/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Vincenzo Marafioti
- Cardiovascular and Thoracic Department, University Hospital of Verona, Italy.
| | - Valentina Benetti
- Cardiovascular and Thoracic Department, University Hospital of Verona, Italy
| | - Umberto Montin
- Institute of General Surgery, University Hospital of Verona, Italy
| | - Vincenzo Carbone
- Department of Medicine and Pharmacology, University Hospital of Messina, Italy
| | | | - Umberto Tedeschi
- Institute of General Surgery, University Hospital of Verona, Italy
| | - Andrea Rossi
- Cardiovascular and Thoracic Department, University Hospital of Verona, Italy
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1236
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Lim N, Lidofsky SD. Impact of physician specialty on quality care for patients hospitalized with decompensated cirrhosis. PLoS One 2015; 10:e0123490. [PMID: 25837700 PMCID: PMC4383455 DOI: 10.1371/journal.pone.0123490] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/27/2015] [Indexed: 12/13/2022] Open
Abstract
Background Decompensated cirrhosis is a common precipitant for hospitalization, and there is limited information concerning factors that influence the delivery of quality care in cirrhotic inpatients. We sought to determine the relation between physician specialty and inpatient quality care for decompensated cirrhosis. Design We reviewed 247 hospital admissions for decompensated cirrhosis, managed by hospitalists or intensivists, between 2009 and 2013. The primary outcome was quality care delivery, defined as adherence to all evidence-based specialty society practice guidelines pertaining to each specific complication of cirrhosis. Secondary outcomes included new complications, length-of-stay, and in-hospital death. Results Overall, 147 admissions (59.5%) received quality care. Quality care was given more commonly by intensivists, compared with hospitalists (71.7% vs. 53.1%, P = .006), and specifically for gastrointestinal bleeding (72% vs. 45.8%, P = .03) and hepatic encephalopathy (100% vs. 63%, P = .005). Involvement of gastroenterology consultation was also more common in admissions in which quality care was administered (68.7% vs. 54.0%, P = .023). Timely diagnostic paracentesis was associated with reduced new complications in admissions for refractory ascites (9.5% vs. 46.6%, P = .02), and reduced length-of-stay in admissions for spontaneous bacterial peritonitis (5 days vs. 13 days, P = .02). Conclusions Adherence to quality indicators for decompensated cirrhosis is suboptimal among hospitalized patients. Although quality care adherence appears to be higher among cirrhotic patients managed by intensivists than by hospitalists, opportunities for improvement exist in both groups. Rational and cost-effective strategies should be sought to achieve this end.
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Affiliation(s)
- Nicholas Lim
- Division of Gastroenterology and Hepatology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
- University of Vermont Medical Center, Burlington, Vermont, United States of America
| | - Steven D. Lidofsky
- Division of Gastroenterology and Hepatology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
- University of Vermont Medical Center, Burlington, Vermont, United States of America
- * E-mail:
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1237
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Zhu GQ, Shi KQ, Huang S, Wang LR, Lin YQ, Huang GQ, Chen YP, Braddock M, Zheng MH. Systematic review with network meta-analysis: the comparative effectiveness and safety of interventions in patients with overt hepatic encephalopathy. Aliment Pharmacol Ther 2015; 41:624-35. [PMID: 25684317 DOI: 10.1111/apt.13122] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 10/21/2014] [Accepted: 01/26/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Interventional treatment for overt hepatic encephalopathy (OHE), includes non-absorbable disaccharides, neomycin, rifaximin, L-ornithine-L-aspartate and branched chain amino acids (BCAA). However, the optimum regimen remains inconclusive. AIM To compare interventions in terms of patients' adverse events and major clinical outcomes. METHODS Literature search of PubMed, Embase, Scopus, and Cochrane Library studies published up to July 31 2014. RCTs of above interventions in OHE patients were included. Network meta-analysis combined direct and indirect evidence to estimate odds ratios (ORs) and mean difference (MD) between treatments and the probabilities of ranking for treatment based on clinical outcomes. RESULTS Twenty eligible RCTs were included. When compared with observation, only L-ornithine-L-aspartate (OR 3.71, P < 0.001) and BCAA (OR 3.37, P < 0.001) improved clinical efficacy significantly. However, when L-ornithine-L-aspartate was compared with BCAA, non-absorbable disaccharides and neomycin, there was a trend suggesting that L-ornithine-L-aspartate may be the most effective intervention with respect to clinical improvement (OR 1.10), rifaximin (OR 1.31), non-absorbable disaccharides (OR 2.75), neomycin (OR 2.22). In addition, L-ornithine-L-aspartate (MD -20.18, 95% CI -40.12 to -0.27) provided a significant reduction in blood ammonia concentration compared with observation. Neomycin appeared to be associated with more adverse events in comparison with non-absorbable disaccharides (OR 10.15), rifaximin (OR 17.31), L-ornithine-L-aspartate (OR 3.16) or BCAA (OR 7.69). CONCLUSIONS L-ornithine-L-aspartate treatment may show a trend in superiority for clinical efficacy among standard interventions for OHE. Rifaximin shows the greatest reduction in blood ammonia concentration, and treatment with neomycin demonstrates a higher probability in causing adverse effects among the five compared interventions.
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Affiliation(s)
- G-Q Zhu
- Department of Infection and Liver Diseases, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; School of the First Clinical Medical Sciences, Wenzhou Medical University, Wenzhou, China
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1238
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Abstract
During the assessment of a patient with liver disease, finding the patient has decompensated cirrhosis, as defined by the presence of jaundice, ascites, variceal haemorrhage or hepatic encephalopathy, has major implications regarding management and prevention of cirrhosis-related complications, as well as consideration for a referral for liver transplantation evaluation. Prognosis is markedly worse in patients with decompensated compared with compensated cirrhosis. In general, any patient with decompensated cirrhosis should receive evaluation and medical care by a hepatologist. Since patients frequently present with more than one facet of liver decompensation, such cases pose a complex management challenge requiring input from a multidisciplinary team and close liaison with a liver transplant centre.
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1239
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Pinto RB, Schneider ACR, da Silveira TR. Cirrhosis in children and adolescents: An overview. World J Hepatol 2015; 7:392-405. [PMID: 25848466 PMCID: PMC4381165 DOI: 10.4254/wjh.v7.i3.392] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 12/10/2014] [Accepted: 01/09/2015] [Indexed: 02/06/2023] Open
Abstract
Several conditions, especially chronic liver diseases, can lead to cirrhosis in children and adolescents. Most cases in clinical practice are caused by similar etiologies. In infants, cirrhosis is most often caused by biliary atresia and genetic-metabolic diseases, while in older children, it tends to result from autoimmune hepatitis, Wilson's disease, alpha-1-antitrypsin deficiency and primary sclerosing cholangitis. The symptoms of cirrhosis in children and adolescents are similar to those of adults. However, in pediatric patients, the first sign of cirrhosis is often poor weight gain. The complications of pediatric cirrhosis are similar to those observed in adult patients, and include gastrointestinal bleeding caused by gastroesophageal varices, ascites and spontaneous bacterial peritonitis. In pediatric patients, special attention should be paid to the nutritional alterations caused by cirrhosis, since children and adolescents have higher nutritional requirements for growth and development. Children and adolescents with chronic cholestasis are at risk for several nutritional deficiencies. Malnutrition can have severe consequences for both pre- and post-liver transplant patients. The treatment of cirrhosis-induced portal hypertension in children and adolescents is mostly based on methods developed for adults. The present article will review the diagnostic and differential diagnostic aspects of end-stage liver disease in children, as well as the major treatment options for this condition.
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Affiliation(s)
- Raquel Borges Pinto
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
| | - Ana Claudia Reis Schneider
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
| | - Themis Reverbel da Silveira
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
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1240
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Kimer N, Krag A, Bendtsen F, Møller S, Gluud LL. Rifaximin for people with hepatic encephalopathy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nina Kimer
- Medical Division, Copenhagen University Hospital Hvidovre; Gastrounit; Kettegaards Alle 30 Hvidovre Denmark
| | - Aleksander Krag
- Odense University Hospital; Department of Gastroenterology S; Sdr. Boulevard 29, indgang 126 Odense C Denmark 5000
| | - Flemming Bendtsen
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Kettegårds alle 30 Hvidovre Denmark DK-2650
| | - Søren Møller
- Centre for Functional and Diagnostic Imaging and Research; Department of Clinical Physiology and Nuclear Medicine; Copenhagen University Hospital Hvidovre Copenhagen Denmark
| | - Lise Lotte Gluud
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Kettegårds alle 30 Hvidovre Denmark DK-2650
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1241
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Abstract
The history of hepatic encephalopathy (HE) is briefly reviewed since the beginning of western medicine by Hippocrates. For about 2000 years the main evidence was the mere association between jaundice, fever and delirium. A clear link between delirium and cirrhosis was proven in the 17th century by Morgagni. In subsequent times the focus was manly the descriptions of symptoms and the only pathophysiological improvement was the evidence that jaundice, per se, does not alter brain function. Only at the end of the 19th century Hann et al proved the role of portal-systemic shunt and pf nitrogenous derivates in the pathophysiology of the syndrome. A terrific development of knowledge occurred in the last 60 years, after the works of Sherlock in London. Nowadays some consensus about HE was reached, so that new developments will likely occur.
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1242
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Barone M. Neurophysiologic and psychometric tests in the diagnosis of low-grade encephalopathy. Gastroenterology 2015; 148:663. [PMID: 25622786 DOI: 10.1053/j.gastro.2014.10.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/02/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Michele Barone
- Chief of Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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1243
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1244
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Abstract
Hepatic encephalopathy (HE) can manifest with a broad range of neuropsychiatric abnormalities of varying severity, acuity and time course with significant clinical implications. Lack of precise nomenclature and classification had hampered research in this complex clinical problem. A multiaxial classification system based on underlying etiology, clinical severity, time course and presence or absence of precipitating factors has been developed over the recent years and has been fully incorporated in the newly published AASLD-EASL guidelines on HE management. This multiaxial classification is expected to bring uniformity in describing and categorizing of HE across centers and nations, foster clinical research and improve patient care and outcome.
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1245
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Ferenci P, Litwin T, Seniow J, Czlonkowska A. Encephalopathy in Wilson disease: copper toxicity or liver failure? J Clin Exp Hepatol 2015; 5:S88-95. [PMID: 26041965 PMCID: PMC4442862 DOI: 10.1016/j.jceh.2014.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 09/01/2014] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a complex syndrome of neurological and psychiatric signs and symptoms that is caused by portosystemic venous shunting with or without liver disease irrespective of its etiology. The most common presentation of Wilson disease (WD) is liver disease and is frequently associated with a wide spectrum of neurological and psychiatric symptoms. The genetic defect in WD leads to copper accumulation in the liver and later in other organs including the brain. In a patient presenting with Wilsonian cirrhosis neuropsychiatric symptoms may be caused either by the metabolic consequences of liver failure or by copper toxicity. Thus, in clinical practice a precise diagnosis is a great challenge. Contrary to HE in neurological WD consciousness, is very rarely disturbed and pyramidal signs, myoclonus dominate. Asterixis and many other clinical symptoms may be present in both disease conditions and are quite similar. However details of neurological assessment as well as additional examinations could help in differential diagnosis.
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Key Words
- AHD, acquired hepatocerebral-degeneration
- Cho, choline
- EEG, electroencephalography
- Glx, glutamine and glutamate
- HE, hepatic encephalopathy
- MHE, minimal hepatic encephalopathy
- MI, myoinositol
- MRI, magnetic resonance imaging
- MRS, magnet resonance spectroscopy
- NAA, N-acetyl-aspartate
- WD, Wilson disease
- Wilson disease
- ammonia
- copper
- hepatic encephalopathy
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Affiliation(s)
- Peter Ferenci
- Internal Medicine 3, Department of Gastroenterology and Hepatology, Medical University of Vienna, Austria,Address for correspondence: Peter Ferenci, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria, Waehringer Guertel 18-20, 1090 Vienna, Austria. Tel.: +43 1 40400 4741; fax: +43 1 40400 4735.
| | - Tomasz Litwin
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Joanna Seniow
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
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1246
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Rai R, Saraswat VA, Dhiman RK. Gut microbiota: its role in hepatic encephalopathy. J Clin Exp Hepatol 2015; 5:S29-36. [PMID: 26041954 PMCID: PMC4442863 DOI: 10.1016/j.jceh.2014.12.003] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/09/2014] [Indexed: 02/08/2023] Open
Abstract
Ammonia, a key factor in the pathogenesis of hepatic encephalopathy (HE), is predominantly derived from urea breakdown by urease producing large intestinal bacteria and from small intestine and kidneys, where the enzyme glutaminases releases ammonia from circulating glutamine. Non-culture techniques like pyrosequencing of bacterial 16S ribosomal ribonucleic acid are used to characterize fecal microbiota. Fecal microbiota in patients with cirrhosis have been shown to alter with increasing Child-Turcotte-Pugh (CTP) and Model for End stage Liver Disease (MELD) scores, and with development of covert or overt HE. Cirrhosis dysbiosis ratio (CDR), the ratio of autochthonous/good bacteria (e.g. Lachnospiraceae, Ruminococcaceae and Clostridiales) to non-autochthonous/pathogenic bacteria (e.g. Enterobacteriaceae and Streptococcaceae), is significantly higher in controls and patients with compensated cirrhosis than patients with decompensated cirrhosis. Although their stool microbiota do not differ, sigmoid colonic mucosal microbiota in liver cirrhosis patients with and without HE, are different. Linkage of pathogenic colonic mucosal bacteria with poor cognition and inflammation suggests that important processes at the mucosal interface, such as bacterial translocation and immune dysfunction, are involved in the pathogenesis of HE. Fecal microbiome composition does not change significantly when HE is treated with lactulose or when HE recurs after lactulose withdrawal. Despite improving cognition and endotoxemia as well as shifting positive correlation of pathogenic bacteria with metabolites, linked to ammonia, aromatic amino acids and oxidative stress, to a negative correlation, rifaximin changes gut microbiome composition only modestly. These observations suggest that the beneficial effects of lactulose and rifaximin could be associated with a change in microbial metabolic function as well as an improvement in dysbiosis.
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Key Words
- CDR, cirrhosis dysbiosis ratio
- HE, hepatic encephalopathy
- IL, interleukin
- LGG, Lactobacillus GG strain
- LPO, left parietal operculum
- MELD, model for end stage liver disease
- MHE, minimal hepatic encephalopathy
- MRS, magnetic resonance spectroscopy
- PAMPs, pathogen-associated molecular patterns
- PCR, polymerase chain reaction
- RCT, randomized controlled trial
- RNA, ribonucleic acid
- SBP, spontaneous bacterial peritonitis
- SIBO, small intestinal bacterial overgrowth
- SIRS, systemic inflammatory response syndrome
- TNF, tumor necrosis factor
- cirrhosis
- dysbiosis
- fMRI, functional MRI
- gut microbiome
- inflammation
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Affiliation(s)
- Rahul Rai
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India,Address for correspondence: Radha K. Dhiman, Tel.: +91 9914209337; fax: +91 1722744401.
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1247
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Gluud LL, Dam G, Les I, Córdoba J, Marchesini G, Borre M, Aagaard NK, Vilstrup H. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev 2015:CD001939. [PMID: 25715177 DOI: 10.1002/14651858.cd001939.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hepatic encephalopathy is a brain dysfunction with neurological and psychiatric changes associated with liver insufficiency or portal-systemic shunting. The severity ranges from minor symptoms to coma. A Cochrane systematic review including 11 randomised clinical trials on branched-chain amino acids (BCAA) versus control interventions has evaluated if BCAA may benefit people with hepatic encephalopathy. OBJECTIVES To evaluate the beneficial and harmful effects of BCAA versus any control intervention for people with hepatic encephalopathy. SEARCH METHODS We identified trials through manual and electronic searches in The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index on 2 October 2014. SELECTION CRITERIA We included randomised clinical trials, irrespective of the bias control, language, or publication status. DATA COLLECTION AND ANALYSIS The authors independently extracted data based on published reports and collected data from the primary investigators. We changed our primary outcomes in this update of the review to include mortality (all cause), hepatic encephalopathy (number of people without improved manifestations of hepatic encephalopathy), and adverse events. The analyses included random-effects and fixed-effect meta-analyses. We performed subgroup, sensitivity, regression, and trial sequential analyses to evaluate sources of heterogeneity (including intervention, and participant and trial characteristics), bias (using The Cochrane Hepato-Biliary Group method), small-study effects, and the robustness of the results after adjusting for sparse data and multiplicity. We graded the quality of the evidence using the GRADE approach. MAIN RESULTS We found 16 randomised clinical trials including 827 participants with hepatic encephalopathy classed as overt (12 trials) or minimal (four trials). Eight trials assessed oral BCAA supplements and seven trials assessed intravenous BCAA. The control groups received placebo/no intervention (two trials), diets (10 trials), lactulose (two trials), or neomycin (two trials). In 15 trials, all participants had cirrhosis. Based on the combined Cochrane Hepato-Biliary Group score, we classed seven trials as low risk of bias and nine trials as high risk of bias (mainly due to lack of blinding or for-profit funding). In a random-effects meta-analysis of mortality, we found no difference between BCAA and controls (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.69 to 1.11; 760 participants; 15 trials; moderate quality of evidence). We found no evidence of small-study effects. Sensitivity analyses of trials with a low risk of bias found no beneficial or detrimental effect of BCAA on mortality. Trial sequential analysis showed that the required information size was not reached, suggesting that additional evidence was needed. BCAA had a beneficial effect on hepatic encephalopathy (RR 0.73, 95% CI 0.61 to 0.88; 827 participants; 16 trials; high quality of evidence). We found no small-study effects and confirmed the beneficial effect of BCAA in a sensitivity analysis that only included trials with a low risk of bias (RR 0.71, 95% CI 0.52 to 0.96). The trial sequential analysis showed that firm evidence was reached. In a fixed-effect meta-analysis, we found that BCAA increased the risk of nausea and vomiting (RR 5.56; 2.93 to 10.55; moderate quality of evidence). We found no beneficial or detrimental effects of BCAA on nausea or vomiting in a random-effects meta-analysis or on quality of life or nutritional parameters. We did not identify predictors of the intervention effect in the subgroup, sensitivity, or meta-regression analyses. In sensitivity analyses that excluded trials with a lactulose or neomycin control, BCAA had a beneficial effect on hepatic encephalopathy (RR 0.76, 95% CI 0.63 to 0.92). Additional sensitivity analyses found no difference between BCAA and lactulose or neomycin (RR 0.66, 95% CI 0.34 to 1.30). AUTHORS' CONCLUSIONS In this updated review, we included five additional trials. The analyses showed that BCAA had a beneficial effect on hepatic encephalopathy. We found no effect on mortality, quality of life, or nutritional parameters, but we need additional trials to evaluate these outcomes. Likewise, we need additional randomised clinical trials to determine the effect of BCAA compared with interventions such as non-absorbable disaccharides, rifaximin, or other antibiotics.
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Affiliation(s)
- Lise Lotte Gluud
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Kettegaards Alle, Hvidovre, Denmark, 2650.
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1248
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Hepatic encephalopathy in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure. J Hepatol 2015; 62:437-47. [PMID: 25218789 DOI: 10.1016/j.jhep.2014.09.005] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy in a hospitalized cirrhotic patient is associated with a high mortality rate and its presence adds further to the mortality of patients with acute-on-chronic liver failure (ACLF). The exact pathophysiological mechanisms of HE in this group of patients are unclear but hyperammonemia, systemic inflammation (including sepsis, bacterial translocation, and insulin resistance) and oxidative stress, modulated by glutaminase gene alteration, remain as key factors. Moreover, alcohol misuse, hyponatremia, renal insufficiency, and microbiota are actively explored. HE diagnosis requires exclusion of other causes of neurological, metabolic and psychiatric dysfunction. Hospitalization in the ICU should be considered in every patient with overt HE, but particularly if this is associated with ACLF. Precipitating factors should be identified and treated as required. Evidence-based specific management options are limited to bowel cleansing and non-absorbable antibiotics. Ammonia lowering drugs, such as glycerol phenylbutyrate and ornithine phenylacetate show promise but are still in clinical trials. Albumin dialysis may be useful in refractory cases. Antibiotics, prebiotics, and treatment of diabetes reduce systemic inflammation. Where possible and not contraindicated, large portal-systemic shunts may be embolized but liver transplantation is the most definitive step in the management of HE in this setting. HE in patients with ACLF appears to be clinically and pathophysiologically distinct from that of acute decompensation and requires further studies and characterization.
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1249
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Su YY, Yang GF, Lu GM, Wu S, Zhang LJ. PET and MR imaging of neuroinflammation in hepatic encephalopathy. Metab Brain Dis 2015; 30:31-45. [PMID: 25514861 DOI: 10.1007/s11011-014-9633-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/17/2014] [Indexed: 12/11/2022]
Abstract
Neurological or psychiatric abnormalities associated with hepatic encephalopathy (HE) range from subclinical findings to coma. HE is commonly accompanied with the accumulation of toxic substances in bloodstream. The toxicity effect of hyperammonemia on astrocyte, such as the alteration in neurotransmission, oxidative stress, astrocyte swelling, is considered as an important factor in the pathogenesis of HE. Besides, neuroinflammation has captured more attention in the process of HE, but the mechanism of neuroinflammation leading to HE remains unclear. Molecular imaging techniques such as positron emission tomography (PET) and magnetic resonance imaging (MRI) targeting activated microglia and/ or other mediators appear to be promising noninvasive approaches to assess HE. This review focuses on novel imaging and therapy strategies of neuroinflammation in HE.
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Affiliation(s)
- Yun Yan Su
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nangjing, Jiangsu Province, 210002, China
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1250
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Courson A, Jones GM, Twilla JD. Treatment of Acute Hepatic Encephalopathy: Comparing the Effects of Adding Rifaximin to Lactulose on Patient Outcomes. J Pharm Pract 2015; 29:212-7. [PMID: 25586470 DOI: 10.1177/0897190014566312] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Rifaximin is approved for the reduction of hepatic encephalopathy (HE) recurrence in patients with chronic liver disease (CLD); however, few studies have evaluated the benefit of adding rifaximin to lactulose for treatment of acute HE. The aim of this study was to determine the impact of combination therapy with lactulose and rifaximin on hospital length of stay (LOS) and readmission rates. METHODS A retrospective study of patients admitted to an adult hospital within the Methodist LeBonheur Healthcare (MLH) System in Memphis, Tennessee, between 2007 and 2012 was conducted. Patients were identified via International Classification of Diseases, Ninth Revision (ICD-9) coding for liver cirrhosis. RESULTS Of the 173 patients included, 87 (50%) received lactulose monotherapy and 62 (36%) combination therapy, while 24 (14%) underwent therapy escalation. Median LOS was 6 days in monotherapy group and 8 days in combination group (P = .9). At 180 days, patients receiving combination therapy had fewer readmissions for HE than those receiving monotherapy (2.4% vs 16.2%, P = .02). CONCLUSION Addition of rifaximin to lactulose for treatment of acute HE did not reduce hospital LOS; however, it did result in lower readmission rates for HE at 180 days.
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Affiliation(s)
- Alesa Courson
- New York Presbyterian Hospital, Department of Pharmacy, New York, NY, USA
| | - G Morgan Jones
- Methodist University Hospital, Department of Pharmacy, Memphis, TN, USA University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
| | - Jennifer D Twilla
- Methodist University Hospital, Department of Pharmacy, Memphis, TN, USA University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
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