Hepatic Encephalopathy

Brain organization and specialization in deep-sea chondrichthyans

Chondrichthyans occupy a basal place in vertebrate evolution and offer a relatively unexplored opportunity to study the evolution of vertebrate brains. This study examines the brain morphology of 22 species of deep-sea sharks and holocephalans, in relation to both phylogeny and ecology. Both relative brain size (expressed as residuals) and the relative development of the five major brain areas (telencephalon, diencephalon, mesencephalon, cerebellum, and medulla) were assessed. The cerebellar-like structures, which receive projections from the electroreceptive and lateral line organs, were also examined as a discrete part of the medulla. Although the species examined spanned three major chondrichthyan groupings (Squalomorphii, Galeomorphii, Holocephali), brain size and the relative development of the major brain areas did not track phylogenetic groupings. Rather, a hierarchical cluster analysis performed on the deep-sea sharks and holocephalans shows that these species all share the common characteristics of a relatively reduced telencephalon and smooth cerebellar corpus, as well as extreme relative enlargement of the medulla, specifically the cerebellar-like lobes. Although this study was not a functional analysis, it provides evidence that brain variation in deep-sea chondichthyans shows adaptive patterns in addition to underlying phylogenetic patterns, and that particular brain patterns might be interpreted as 'cerebrotypes'.

M, Lucchesi L, Kondo M, Tufik S. Avaliação dos potenciais evocados relacionados a eventos (ERP-P300) em pacientes com cirrose hepática sem encefalopatia

RACIONAL: Na cirrose hepática ocorrem alterações na estrutura do fígado, levando à perda das funções do órgão, com conseqüências neuropsiquiátricas, como disfunções cognitivas. Um dos meios mais efetivos para avaliar objetivamente as funções cognitivas é medir a atividade eletrofisiológica do sistema nervoso central através do potencial evocado relacionado a eventos (ERP-P300). OBJETIVO: Estudar a utilidade do potencial evocado relacionado a eventos (ERP), para avaliar distúrbios cognitivos em pacientes com cirrose hepática e como auxiliar no diagnóstico da encefalopatia hepática mínima. MÉTODO: Foram selecionados 50 pacientes, diagnosticados com cirrose hepática sem sinais clínicos de encefalopatia hepática e 35 voluntários saudáveis de idades e sexo semelhantes. Em todos os pacientes foram realizados exames clínico-neurológico e laboratoriais. Para identificação do prejuízo cognitivo foi utilizado o ERP-P300 e obtida a média da latência da onda P300. RESULTADOS: Houve diferença significativa entre as médias da latência do ERP-P300 do grupo cirrótico e controle. CONCLUSÃO: A realização do ERP-P300 é simples, depende de fatores controláveis de variação e tem fácil reprodutibilidade, podendo ser útil para o rastreio de distúrbios cognitivos em pacientes com cirrose e auxiliar no diagnóstico de encefalopatia hepática mínima.

Use of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation in children: initial clinical experience

Four children, three boys and one girl, with a median age of 9 years 8 months, underwent transjugular intrahepatic portosystemic shunt creation with an expanded polytetrafluoroethylene (e-PTFE)-covered nitinol stent. The stent-graft was successfully placed in all four patients without any complication. Clinical and biochemical improvement was noted in all four patients during follow-up. Radiological follow-up with use of duplex ultrasound showed a recurrent stenosis of the shunt 180 days after stent-graft implantation in one patient. This was treated with placement of an additional stent-graft, re-expanding completely the recurrent stenosis. In the other three patients, the stent-graft remained fully patent until the end of the study or until orthotopic liver transplantation. These preliminary results suggest that use of the Viatorr ePTFE-covered stent-graft in children is safe and feasible, with potentially the same high patency rate and improved clinical outcome as reported in adult patients.

[Medical therapy of complications in liver cirrhosis]

Patients with liver cirrhosis bear a considerable risk of a variety of complications that involve virtually all organ systems. They can be addressed with a wide spectrum of drugs for acute interventions as well as for prophylactic purposes. At the same time treatment of the underlying disease, the identification and treatment of triggering factors and the possibility of liver transplantation should be kept in mind.

Bifidobacterium longum with fructo-oligosaccharide (FOS) treatment in minimal hepatic encephalopathy: a randomized, double-blind, placebo-controlled study

Minimal hepatic encephalopathy (MHE) describes patients with chronic liver disease or cirrhosis who have no clinical symptoms of brain dysfunction but perform worse on psychometric tests compared with healthy subjects. The pathogenesis of hepatic encephalopathy is controversial although ammonia has been found to induce cerebral dysfunction. Increased intestinal ammonia production is due to bacterial urease activity and the production of other toxin methabolities, such as mercaptans, thioles. This study assesses the clinical efficacy of Bifidobacterium longum plus fructo-oligosaccharides (FOS) in the treatment of MHE. A total of 60 cirrhotic patients were randomly and equally divided into two groups receiving Bifidobacterium+FOS (17 males, 13 females; mean age, 46+/-11 years) or placebo (16 males, 14 females; mean age, 45+/-12 years), respectively. All patients underwent clinical and laboratory assessment psychometric tests and automated EEG analysis: neurophysiological assessment, liver function assessment, amd neuropsychological assessment. After 90 days of treatment, fasting NH(4) serum levels were significantly decreased (P=0.003), performance on Trail Making Test-A was significantly decreased (P=0.000), performance on Trail Making Test-B was significantly decreased (P=0.000), performance on the symbol digit modalities test was significantly improved (P<0.05), performance on block design was significantly improved (P=0.000), and performance on the MMSE test was significantly improved (P=0.000). We conclude that the improvement in biochemical and neuropsychological tests of the group treated with Bifidobacterium longum+FOS are interesting and merit further, close examination.

Spatial memory alterations in three models of hepatic encephalopathy

A behavioural evaluation was carried out on three chronic models of hepatic encephalopathy: two models of type B HE, portacaval shunt (PCS) and portal hypertension (PH) and one of type C HE with cirrhosis and portal hypertension from thioacetamide intoxication (TAA). The tasks selected cover a wide range of behaviours related to: locomotion (rotarod-accelerod test), anxiety (open field and elevated plus maze) and memory (Morris water maze). The results indicate that neither locomotor activity nor anxiety was affected in our models, in comparison with their respective controls. However, this is not the case for the mnesic tasks. Hence, the PCS and TAA groups displayed a severe alteration in spatial reference memory and cannot correctly perform the Morris maze task, while this alteration is less severe in the PH group. On the contrary, the PH group revealed a deficit in spatial working memory, like the TAA group, but this does not occur in subjects with PCS. These results reveal a double dissociation in spatial reference memory and spatial working memory between the PCS and PH groups, which would be of great interest to study about cerebral causes and substrates of the alterations accompanying HE.

Beef meat promotion of dimethylhydrazine-induced colorectal carcinogenesis biomarkers is suppressed by dietary calcium

Red meat consumption is associated with increased risk of colorectal cancer. We have previously shown that haemin, Hb and red meat promote carcinogen-induced preneoplastic lesions: aberrant crypt foci (ACF) and mucin-depleted foci (MDF) in rats. We have also shown that dietary Ca, antioxidant mix and olive oil inhibit haemin-induced ACF promotion, and normalize faecal lipoperoxides and cytotoxicity. Here we tested if these strategies are effective also against red meat promotion in dimethylhydrazine-induced rats. Three diets with 60 % beef meat were supplemented with calcium phosphate (31 g/kg), antioxidant agents (rutin and butylated hydroxyanisole, 0.05 % each) and olive oil (5 %). ACF, MDF, faecal water cytotoxicity, thiobarbituric acid reactive substances (TBARS) and urinary 1,4-dihydroxynonane mercapturic acid (DHN-MA) were measured. Beef meat diet increased the number of ACF (+30 %) and MDF (+100 %) (P < 0.001), which confirms our previous findings. Promotion was associated with increased faecal water TBARs ( x 4) and cytotoxicity ( x 2), and urinary DHN-MA excretion ( x 15). Ca fully inhibited beef meat-induced ACF and MDF promotion, and normalized faecal TBARS and cytotoxicity, but did not reduce urinary DHN-MA. Unexpectedly, high-calcium control diet-fed rats had more MDF and ACF in the colon than low-Ca control diet-fed rats. Antioxidant mix and olive oil did not normalize beef meat promotion nor biochemical factors. The results confirm that haem causes promotion of colon carcinogenesis by red meat. They suggest that Ca can reduce colorectal cancer risk in meat-eaters. The results support the concept that toxicity associated with the excess of a useful nutrient may be prevented by another nutrient.

The cost-effectiveness and budget impact of competing therapies in hepatic encephalopathy - a decision analysis

BACKGROUND

Treatment options for hepatic encephalopathy have disparate risks and benefits. Non-absorbable disaccharides and neomycin are limited by uncertain efficacy and common dose-limiting side effects. In contrast, rifaximin is safe and effective in hepatic encephalopathy, but is more expensive.

METHODS

We conducted a decision analysis to calculate the cost-effectiveness of six strategies in hepatic encephalopathy: (i) no hepatic encephalopathy treatment, (ii) lactulose monotherapy, (iii) lactitol monotherapy, (iv) neomycin monotherapy, (v) rifaximin monotherapy and (vi) up-front lactulose with crossover to rifaximin if poor response or intolerance of lactulose ('rifaximin salvage'). The primary outcome was cost per quality-adjusted life-year gained.

RESULTS

Under base-case conditions, 'do nothing' was least effective and rifaximin salvage was most effective. Lactulose monotherapy was least expensive, and rifaximin monotherapy was most expensive. When balancing cost and effectiveness, lactulose monotherapy and rifaximin salvage dominated alternative strategies. Compared to lactulose monotherapy, rifaximin salvage cost an incremental US$2315 per quality-adjusted life-year-gained. The cost of rifaximin had to fall below US$1.03/tab in order for rifaximin monotherapy to dominate lactulose monotherapy.

CONCLUSIONS

Rifaximin monotherapy is not cost-effective in the treatment of chronic hepatic encephalopathy at current average wholesale prices. However, a hybrid salvage strategy, reserving rifaximin for lactulose-refractory patients, may be highly cost-effective.

Development of a clinical hepatic encephalopathy staging scale

AIM

To develop a scale to assess the severity of hepatic encephalopathy using simple dichotomic items.

METHODS

A list of 48 items was created by selecting items that are simple to recognize and categorize; it was applied to thirty-six cirrhotic in-patients with episodic encephalopathy, in addition to the adapted-West-Haven Criteria and the Glasgow Coma Score. The list underwent an item reduction process and principal component analysis; the metric characteristics were evaluated.

RESULTS

Multiple neurological abnormalities were observed and a Clinical Hepatic Encephalopathy Staging Scale of nine items was constructed. The principal component analysis of the Clinical Hepatic Encephalopathy Staging Scale obtained two factors that explained 77% of the variance. The Clinical Hepatic Encephalopathy Staging Scale exhibited adequate internal consistency and reproducibility. The scores of the Clinical Hepatic Encephalopathy Staging Scale correlated to those of adapted-West-Haven Criteria and the Glasgow Coma Score.

CONCLUSIONS

This study confirms that the evaluation of multiple neurological manifestations is not necessary to classify hepatic encephalopathy adequately, which can be simply undertaken by an assessment of the patient's orientation, alertness, ability to respond to commands and to talk. A list of nine items is proposed as a linear scale from normality (Clinical Hepatic Encephalopathy Staging Scale = 0) to deep coma (Clinical Hepatic Encephalopathy Staging Scale = 9).

Laparoscopic disconnection of a huge paraumbilical vein shunt for portosystemic encephalopathy

Chronic portosystemic encephalopathy (CPSE) resulting from portosystemic shunts (PSS) is a devastating clinical problem. When CPSE is refractory to medical treatment, occlusion of the PSS should be considered. We report a case of CPSE due to a huge paraumbilical vein shunt that was successfully treated with laparoscopic disconnection. A 54-year-old woman diagnosed with liver cirrhosis was referred to our department for treatment of hepatic encephalopathy. She had repeatedly experienced episodes of disturbance of consciousness, and had hyperammoniemia refractory to medical treatment. Computed tomography showed a huge patent paraumbilical vein connected to the systemic circulation through the round ligament. Laparoscopic disconnection of the paraumbilical vein shunt was performed. The postoperative course was uncomplicated and there has been no recurrence of hepatic encephalopathy in the 2 years since, nor has there been a need for further medical treatment. We believe this is the first case report of CPSE treated laparoscopically, and it demonstrates that laparoscopic disconnection of PSS, especially paraumbilical vein shunts, can be a safe and effective procedure to treat CPSE.

Zinc and the liver: an active interaction

Zinc is an essential trace element, exerting important antioxidant, anti-inflammatory, and antiapoptotic effects. It affects growth and development and participates in processes such as aging and cancer induction. The liver is important for the regulation of zinc homeostasis, while zinc is necessary for proper liver function. Decreased zinc levels have been implicated in both acute and chronic liver disease states, and zinc deficiency has been implicated in the pathogenesis of liver diseases. Zinc supplementation offers protection in experimental animal models of acute and chronic liver injury, but these hepatoprotective properties have not been fully elucidated. In the present review, data on zinc homeostasis, its implication in the pathogenesis of liver diseases, and its effect on acute and chronic liver diseases are presented. It is concluded that zinc could protect against liver diseases, although up to now the underlying pathophysiology of zinc and liver interactions have not been defined.

Diagnosis and Management of Cirrhosis in Coinfected Patients

HIV coinfection is associated with faster progression of liver disease resulting from hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. Thus, liver complications have become a major cause of illness and death in coinfected patients. Controlling HIV through highly active antiretroviral therapy may slow disease progression to nearly the rate of HIV-negative persons. Several antiretroviral regimens have been associated with drug-induced liver injury, however, which is more common in patients coinfected with hepatitis B or C. After development of cirrhosis and decompensation, survival is shorter in coinfected patients. Diagnosis and management of cirrhosis should be the same for coinfected and monoinfected HBV/HCV patients. The main complications of cirrhosis are ascites, spontaneous bacterial peritonitis, bleeding esophageal varices, hepatic encephalopathy, the hepatorenal syndrome, and hepatocellular carcinoma. Liver transplantation is feasible in patients with HIV infection, and early evaluation for this option is crucial because of the accelerated course of complications in HIV coinfection.

A novel endovascular adjustable polytetrafluoroethylene-covered stent for the management of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is frequently complicated by hepatic encephalopathy. When medical therapy fails, TIPS narrowing and resultant increase in the portosystemic pressure gradient and blood flow to the liver is performed in order to reverse the encephalopathy. We present a method for reducing the TIPS using a polytetrafluoroethylene-covered balloon expandable stent placed over a self-expanding stent. This results in a narrowed TIPS that not only rapidly increases the portosystemic gradient but also can be adjusted by dilating the balloon expandable stent. This method was successful in narrowing the patient's TIPS, acutely increasing the portosystemic gradient and reversing the hepatic encephalopathy.

Preoperative evaluation of patients with liver disease

Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child-Turcotte-Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.

Endovascular shunt reduction in the management of transjugular portosystemic shunt-induced hepatic encephalopathy: preliminary experience with reduction stents and stent-grafts

OBJECTIVE

The purpose of this study was to retrospectively evaluate the safety, feasibility, and midterm clinical outcome of the use of three types of reduction stents inserted to manage transjugular intrahepatic portosystemic shunt (TIPS)-induced hepatic encephalopathy refractory to medical treatment.

CONCLUSION

The use of a covered reduction stent-graft results in a greater increase in portosystemic gradient immediately after reduction than does use of a bare reduction stent. Relief of TIPS-induced hepatic encephalopathy tends to be greater in patients with reduction stent-grafts than in those with bare reduction stents.

Histamine H1 blocker hydroxyzine improves sleep in patients with cirrhosis and minimal hepatic encephalopathy: a randomized controlled pilot trial

OBJECTIVES

Sleep difficulty is common in minimal hepatic encephalopathy (HE) and the mechanisms are not fully elucidated. Dysregulated histamine neurotransmission is associated with an altered circadian rhythmicity that is partially restored following central histamine H1 receptor blockade in cirrhotic animals. We studied the effects of the histamine H1 blocker hydroxyzine in sleep alterations in patients with cirrhosis in a double-blind, randomized controlled fashion.

METHODS

A total of 35 patients (age 56 yr [36-69], Pugh's score 9 [7-12], portosystemic shunt: N = 7) with minimal HE and long-standing sleep difficulties (8 months [4-48]) and free from benzodiazepines were randomized to hydroxyzine 25 mg at bedtime (N = 17) or placebo (N = 18) for a 10-day period. Measurements of sleep behavior using visual analog scale and wrist actigraphy, neuropsychological tests, and protein s100beta serum levels were performed at baseline and at day 10.

RESULTS

Subjective improvement in sleep was observed in 40% of hydroxyzine-treated patients but in none receiving placebo (P < 0.04). Objectively, 65% of hydroxyzine-treated patients versus 25% of patients under placebo had a >or=30% increase in sleep efficiency as measured by wrist actigraphy (P < 0.04). Neuropsychological tests (Z scores) and protein s100beta levels remained statistically unchanged in both groups. One patient developed an acute episode of encephalopathy reversible upon cessation of hydroxyzine.

CONCLUSIONS

In contrast to placebo, hydroxyzine 25 mg at bedtime improved sleep behavior (subjectively and using wrist actigraphy) in patients with cirrhosis and minimal HE. The risk of precipitating overt HE warrants some caution when prescribing this drug.

Review article: the current pharmacological therapies for hepatic encephalopathy

Effective treatment options for hepatic encephalopathy are limited. Based on the principle that intestinal-derived ammonia contributes to the pathogenesis of hepatic encephalopathy, current therapeutic approaches are directed at reducing bacterial production of ammonia and enhancing its elimination. Non-absorbable disaccharides are first-line therapy for hepatic encephalopathy, but published clinical studies evaluating their safety and efficacy are limited. Alternative therapies such as benzodiazepine receptor antagonists, branched-chain amino acids, and l-ornithine-l-aspartate also have limited clinical data supporting their use. Studies of antibiotics indicate that they are effective in the treatment of hepatic encephalopathy, but adverse effects and concerns about long-term safety have limited the widespread use of most. Rifaximin is a minimally absorbed antibiotic that concentrates in the gastrointestinal tract and is excreted mostly unchanged in faeces. It has been studied extensively in the treatment of hepatic encephalopathy and appears to confer therapeutic benefits greater than those of placebo and non-absorbable disaccharides and at least comparable with those of systemic antibiotics. Rifaximin was also well tolerated in patients with hepatic encephalopathy and is not associated with clinical drug interactions or clinically relevant bacterial antibiotic resistance. In conclusion, non-absorbed antibiotics such as rifaximin offer a favourable benefit-risk ratio in the treatment of hepatic encephalopathy and may help to improve patient outcomes.

Review of the final report of the 1998 Working Party on definition, nomenclature and diagnosis of hepatic encephalopathy

The heterogeneity and variability of the manifestations of hepatic encephalopathy among patients and in individual patients over time make the condition difficult to diagnose and to categorize with respect to severity. Recognizing these challenges, the World Congress of Gastroenterology formed a Working Party of hepatologists, neurologists and basic scientists in 1998 to develop consensus recommendations regarding key issues relevant to the diagnosis and grading of hepatic encephalopathy in clinical research and practice. This paper discusses the Working Party recommendations, which warrant re-examination in the context of the absolute need for consistency in diagnosis and grading of hepatic encephalopathy and in approaches to its clinical study. The Working Party recommendations provide a framework for achieving this consistency and can serve as a springboard for further refinements in diagnostic tests and procedures and in clinical-trial methodology.

Acute liver failure in children

OBJECTIVE

To review the incidence, etiologies, pathophysiology, and treatment of acute liver failure (ALF) in children. Emphasis will be placed on the initial management of the multiple organ system involvement of ALF.

METHOD

MEDLINE search from 1970 to March 2005 was performed. Search headings were as follows: acute liver failure, fulminant liver failure, pediatric liver failure, hepatic encephalopathy, and liver transplantation. Studies written in English were selected. Pediatric studies were emphasized. Adult studies were referenced if there were no pediatric studies available in regard to a specific aspect of liver failure.

CONCLUSIONS

Pediatric acute liver failure is a rare but life-threatening disease. The common etiologies differ for given age groups. Management includes treating specific causes and supporting multiple organ system failure. Commonly associated disorders that require initial recognition and treatment include energy production deficiencies (hypoglycemia), coagulation abnormalities, immune system dysfunctions, encephalopathy, and cerebral edema. Criteria used to determine the need for liver transplant are reviewed as well as the difficulties associated with predicting which patients will meet these criteria and how rapidly liver transplant will become the only option. Finally, experimental procedures that may provide additional time for the liver to recover are briefly reported.

Nutrition in alcoholic liver disease

Liver disease secondary to alcohol ranges from alcoholic fatty liver disease to acute hepatitis to cirrhotic liver disease. It is imperative that alcohol be discontinued to allow for any potential improvement in liver function, with most benefit being seen in the early stages of the disease. Alcoholic liver disease has a profound effect on nutrient intake, nutrition status, and metabolism, contributing to a high prevalence of malnutrition in this population. Early intervention with nutrition therapy may improve response to treatment, alleviate symptoms, and improve quality and quantity of life. In this review, nutrition assessment parameters and medical nutrition therapy goals for alcoholic liver disease are discussed.

Advances in critical care management of hepatic failure and insufficiency

BACKGROUND

Chronic liver disease is becoming an increasingly frequent diagnosis for patients in the intensive care setting with such diagnoses as symptomatic ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, or fulminant hepatic failure.

OBJECTIVE

To review frequent diagnoses for patients with chronic liver disease admitted to the intensive care unit and discuss current concepts in management and investigational modalities.

RESULTS

Patients with new-onset ascites in the intensive care setting should undergo immediate ultrasound to rule out acute thrombosis. A transjugular intrahepatic portosystemic shunt is indicated when control of the refractory ascites or hepatic hydrothorax is required. In patients with hepatorenal syndrome, hemodialysis can be used as a bridge to liver transplantation. Otherwise, hepatorenal syndrome carries a high mortality. When hepatic encephalopathy is present, a precipitating cause should be sought and treated, if identified. Although bioartificial support systems are under active investigation, standard treatment for hepatic encephalopathy is lactulose and alteration of gut flora. Patients with fulminant hepatic failure should be stabilized and transferred to the intensive care unit of a liver transplant center and supported with appropriate airway management, close neurologic evaluation, glucose monitoring, and correction of coagulopathy when there is overt bleeding or an invasive procedure is planned. Intracranial pressure monitoring is recommended to maintain an adequate cerebral perfusion pressure of >60 mm Hg.

CONCLUSION

Review of the literature demonstrates that certain critically ill patients with chronic liver disease may benefit from invasive modalities such as transjugular intrahepatic portosystemic shunting, hemodialysis, and in some cases, liver transplantation, which may be offered only at tertiary care centers.

Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation

OBJECTIVE

To assess the usefulness of dialysis with the molecular adsorbent recirculating system (MARS) in patients with acute liver failure who fulfil criteria for liver transplantation.

DESIGN

Observational cohort study.

SETTING

ICU at a liver transplantation centre.

PATIENTS

Twenty-two patients (23 episodes) received MARS dialysis. They were either listed for LT (n=14), delayed (n=1), or not listed (contra-indication, n=7).

INTERVENTIONS

A total of 56 MARS treatments (median per patient 2; mean duration 7.6+/-2.6h) were performed on haemodialysis.

MEASUREMENTS AND RESULTS

Clinical and biological variables were assessed before and 24[Symbol: see text]h after MARS therapy. The rate of recovery of liver function without transplantation was compared with an expected rate and survival was analysed. Following MARS dialysis, we observed an improvement in the grade of hepatic encephalopathy (P=0.02) and the Glasgow coma score (P=0.02), a decrease in conjugated bilirubin (P=0.05) and INR (P=0.006), and an increase in prothrombin index (P=0.005). Overall, liver function improved in seven patients (32%): four listed patients in whom transplantation could be avoided and three patients among those not listed due to contra-indications. The transplant-free recovery rate in listed patients was 29% (vs. expected 9%, P=0.036). Listed patients (n=14) had a higher 30-day survival rate [86% (12/14) vs 38% (3/8), P=0.05] and a higher long-term survival rate (P=0.02).

CONCLUSIONS

A statistically significant improvement of liver function was observed after MARS therapy. Transplant-free recovery was more frequent than expected. The apparent benefit of MARS dialysis to treat acute liver failure needs to be confirmed by a controlled study.

An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist

Liver disease is a common cause of morbidity and mortality in the United States and elsewhere. Arising from infectious, hereditary, or toxin-induced sources, the detection of liver disease often requires a high index of suspicion. Clinical presentations are highly variable and are often accompanied by neuropsychiatric symptoms. This fact, along with an increased incidence of liver disease among patients with primary psychiatric disorders and the presence of varied drug use, complicates the tasks of providing care to patients with liver disease. To assist the consultation-liaison psychiatrist, the authors present the first of a two-part series focused on psychiatric issues in liver disease.

Formal heparin anticoagulation protocol improves safety of charcoal-based liver-assist treatments

Extracorporeal devices have had limited effectiveness in liver failure due to consequences of inadequate anticoagulation. The purpose of this study was to evaluate an anticoagulation protocol developed for Liver Dialysis Unit (LDU) treatments. Twelve patients underwent 19 LDU treatments for acetaminophen overdose (n = 1), subacute liver failure (n = 1), and refractory encephalopathy in cirrhosis (n = 10). The initial 6 patients (group 1) were treated according to the manufacturer's recommendations. The subsequent 6 patients (group 2) were treated using a formal heparin anticoagulation protocol that included 2000 units in prime solution and 30 units/kg induction, activated clotting time (ACT) measurements, and heparin administered by dose-response curve to maintain 300-second ACT. Protamine reversal was used. Treatments were well tolerated and equally effective in both groups. Adequate (ACT > or = 250 seconds) and therapeutic (ACT 250-350 seconds) anticoagulation was maintained more consistently in group 2 (90.9% vs 50.0%, p < 0.0001; and 77.4% vs 45.8%, p < 0.001). There was less consumption of fibrinogen (12.1% vs 43.3%, p < 0.005) and platelets (13.8% vs 29.9%, p < 0.05) and a trend for less blood product used (8.3 vs 15.8 units/patient, p = 0.13) and fewer complications (16.7% vs 66.7%, p = 0.15) in group 2. Anticoagulation using ACT monitoring, heparin dose-response curves, and a target ACT of 300 seconds improves the safety of LDU treatments.

[Diagnosis and treatment of hepatic encephalopathy in Spain: results of a survey of hepatologists]

INTRODUCTION

Hepatic encephalopathy is a common complication of cirrhosis. Recent studies have challenged the efficacy of nonabsorbable disaccharides and have reported that protein restriction may pose risks to patients with cirrhosis and hepatic encephalopathy.

AIM

To determine the diagnostic and therapeutic practices of physicians treating patients with hepatic encephalopathy.

MATERIAL AND METHODS

We designed a 20-item questionnaire, which was mailed to the members of the Spanish Society for the Study of the Liver.

RESULTS

We received 128 questionnaires, completed by physicians with wide clinical experience. They reported that the most common precipitating factors in episodic encephalopathy were infections (22%), diuretics (21%), and gastrointestinal bleeding (21%). The usual treatment of episodic encephalopathy was administration of nonabsorbable disaccharides (90%) and protein restriction (52%). Patients with chronic encephalopathy were also usually treated with nonabsorbable disaccharides (94%) and protein restriction (40%). Fifty-nine percent of the hepatologists never carried out neurophysiologic or neuropsychologic assessment for the diagnosis of minimal hepatic encephalopathy.

CONCLUSION

Although their efficacy has been questioned, nonabsorbable disaccharides and protein restriction are the most commonly prescribed treatments for hepatic encephalopathy. Future studies are needed to assess the efficacy and risks of these treatments. Most hepatologists never assess minimal hepatic encephalopathy in patients with cirrhosis.

Palliative care for patients with end-stage liver disease ineligible for liver transplantation

The proportion of patients with ESLD who will be managed without liver transplantation will increase in the near future, largely as a result of the increasing age of the population. Patients with ESLD are subject to many physical and psychosocial symptoms that negatively affect health-related quality of life. Sleep quality should be maximized by controlling pruritus and leg cramps. Many frequently used therapies are not supported by a strong evidence base. Advance directives should be addressed with all patients with ESLD, preferably in the outpatient setting before an acute deterioration. Medicare provides a hospice benefit for patients with ESLD, and referral to a hospice is appropriate for patients with an expected survival of 6 months or less.

Management of patients with cirrhosis in Southern California: results of a practitioner survey

INTRODUCTION

Cirrhosis is an important medical and public health concern. A paucity of data exists on how patients with cirrhosis are managed. Our aims were to determine how cirrhosis is managed and whether current management practices follow established recommendations.

METHODS

A questionnaire was mailed to Southern California Society of Gastroenterology members. Most had practiced for more than 15 years (67%) in a private practice setting (69%). Proportions of physicians who followed established guidelines versus those who had not were compared using chi test.

RESULTS

Hepatitis A, hepatitis B, influenza, and pneumococcus vaccinations were recommended by most respondents. Ninety-one percent of respondents routinely screened patients for hepatocellular carcinoma. A significantly greater proportion of respondents screened for hepatocellular carcinoma using either alpha-fetoprotein or ultrasound every 6 months (P < 0.05). Seventy-six percent recommended antibiotic prophylaxis in patients with prior spontaneous bacterial peritonitis, whereas less than half recommended prophylaxis in patients with ascitic protein fluid <1 g/dL, current variceal bleed, and those on the liver transplant list. Sixty-seven percent of respondents performed screening esophagogastroduodenoscopy upon diagnosis of cirrhosis. Most respondents did not recommend repeating endoscopy in 1 to 2 years if a patient was found to have small varices (P < 0.05), and would repeat an endoscopy if large varices were found (P < 0.05).

CONCLUSION

The management of patients with cirrhosis in the community varied and did not always conform to established guidelines. These results should be confirmed in a larger group of physicians, and the rationales for physicians accepting or rejecting established guidelines should be further assessed.

Influence of recent advances in medical management on clinical outcomes of cirrhosis

Cirrhosis and its disease-related complications are the 12th leading cause of mortality among U.S. adults and are the 5th leading cause of death for individuals aged 45 to 54 years. Hospitalization costs for disease-related complications are estimated at 18,000 dollars per episode of care, and 10% of admitted patients die. Despite these ominous findings, the survival rate of patients with cirrhosis has improved during the past 2 decades. This observation coincides with the conducting and reporting of high-quality randomized controlled trials and observational studies. Therefore, the improved prognosis in cirrhosis may be related to the effective translation of research findings to clinical practice for this patient population. Although explicit data to support this claim are not available, this article reviews the reported trends in clinical outcomes for patients with cirrhosis and the existence of evidence-based medical information that is available to care for these chronically ill patients.

Breath ammonia testing for diagnosis of hepatic encephalopathy

Measurement of arterial ammonia has been used as a diagnostic test for hepatic encephalopathy, but obtaining an arterial specimen is an invasive procedure. The aim of this study was to evaluate the ability of a minimally invasive, highly sensitive optical sensing device to detect ammonia in the breath of patients with end-stage liver disease and to evaluate the correlation of breath ammonia levels, arterial ammonia levels, and psychometric testing. Fifteen subjects with liver cirrhosis and clinical evidence of hepatic encephalopathy underwent mini-mental status examination, number connection test, focused neurological examination, and arterial ammonia testing. On the same day, breath ammonia testing was performed using an apparatus that consists of a sensor (a thin membrane embedded with a pH-sensitive dye) attached to a fiberoptic apparatus that detects optical absorption. Helicobacter pylori testing was performed using the 14C urea breath test. A positive correlation was found between arterial ammonia level and time to complete the number connection test (r = 0.31, P = 0.03). However, a negative correlation was found between breath ammonia level and number connection testing (r = -0.55, P = 0.03). Furthermore, no correlation was found between breath and arterial ammonia levels (r = -0.005, P = 0.98). There is a significant correlation between the trailmaking test and arterial ammonia levels in patients with cirrhosis. However, no correlation was found between breath and arterial ammonia levels using the fiberoptic ammonia sensor apparatus in this small study.

Preoperative assessment of the patient with liver disease

Patients with liver disease are at appreciable risk when undergoing anesthesia and surgery. Attempts to quantify this risk have been thwarted by the diversity of disease states and illness severity that such patients bring to the operating theater and the myriad of procedures they may undergo. This review discusses the indications and contraindications for surgery in patients with liver disease and attempts to give specific recommendations for optimizing the clinical status of a patient with hepatic dysfunction prior to operative intervention.

Distinguishing between clinical and minimal hepatic encephalopathy on the basis of specific cognitive impairment

It is well-known that liver cirrhosis is frequently accompanied by a wide range of neuropsychiatric abnormalities, including general and specific cognitive impairment. The aim of this study was to investigate which cognitive functions are selectively compromised in Hepatic Encephalopathy (HE) and to clarify the relationship between clinically overt or nonovert HE and the different forms and degrees of decay in cognitive deficits. Twenty-two patients without overt HE and 12 patients who showed overt HE at the first level of severity, along with matched control subjects, were compared in several cognitive domains. The results showed significant differences in some measures of attention between patients with minimal HE (mHE) and patients with overt HE. There were also notable differences in verbal short-term memory between patients with mHE and healthy subjects. Thus, we can hypothesize that there is a linear diminution in short-term memory and attentional performance starting from healthy patients, moving toward patients with mHE, and finally progressing toward patients with the first grade of overt HE. There are two types of diminution that we noted: between patients with mHE and the overt form, the decline in the attentional domain was more evident, while between healthy subjects and mHE patients, short-term memory showed a more evident decline.

Comparison of rifaximin and lactulose for the treatment of hepatic encephalopathy: a prospective randomized study

Rifaximin has been reported to be effective for the treatment of hepatic encephalopathy (HE) in Europe. However, it is unknown whether Rifaximin is effective for the treatment of HE in Koreans, therefore we conducted a open-label prospective randomized study to evaluate the efficacy of rifaximin versus lactulose in Korean patients. Fifty-four patients with liver cirrhosis and hepatic encephalopathy were enrolled. Thirty-two patients were randomized to receive rifaximin and 22 to receive lactulose both over a 7-day periods. Before and at the end of treatment, gradation of blood ammonia, flapping tremor, mental status, number connection test (NCT) were performed and estimation of HE indexes determined. Both rifaximin and lactulose were effective in the majority of patients (84.4% and 95.4%, respectively, p = 0.315). Blood NH3, flapping tremor, mental status, and NCT was significantly improved by rifaximin and lactulose, and the post- treatment levels of these measures were similar for the rifaximin and lactulose-treated groups, as was the HE index (rifaximin group (10.0 --> 4.2, p = 0.000); lactulose group (11.3 --> 5.0, p = 0.000)). One patient treated with rifaximin complained of abdominal pain, which was easily controlled. There was no episode of renal function impairment in either treatment group. Rifaximin proved to be as safe and as effective as lactulose for the treatment of Korean patients with hepatic encephalopathy.

Clinical significance of extrapyramidal signs in patients with cirrhosis

BACKGROUND/AIMS

Extrapyramidal signs have been described in cirrhosis and there is little information about their clinical significance. The aims of this study have been to investigate the relationship between extrapyramidal signs and cognitive impairment, and what is their influence on quality of life.

METHODS

46 patients with cirrhosis were evaluated for cognitive impairment with psychometric tests (Trail-Making Test part A, Grooved-Pegboard, Block-Design, Oral Symbol Digit and Stroop Test) and cognitive evoked potentials (P300). Extrapyramidal signs were evaluated using the UPDRS scale. Health-related quality of life (HRQL) was measured using SF-36 scale and the Chronic Liver Disease Questionnaire (CLDQ).

RESULTS

Twenty-two patients had extrapyramidal signs, and these patients scored worse in all psychometric tests, except Block-Design. Patients with extrapyramidal signs also showed a longer P300 latency. Moreover, patients with extrapyramidal signs had the worst score in all the HRQL scales used. A multivariate analysis disclosed that the only variable showing an independent relationship to the mental component summary of SF-36 and with CLDQ was UPDRS score.

CONCLUSIONS

We have found a clear relationship between the presence of extrapyramidal signs and cognitive impairment. Moreover, patients with extrapyramidal signs have worse scores in quality of life scales.

Effect of antibiotics, prebiotics and probiotics in treatment for hepatic encephalopathy

In order to reduce ammonia production by urease-positive bacteria Solga recently hypothesised (S.F. Solga, Probiotics can treat hepatic encephalopathy, Medical Hypotheses 2003; 61: 307-13), that probiotics are new therapeutics for hepatic encephalopathy (HE), and that they may replace antibiotics and lactulose. This influenced our view of the effect of antibiotics, prebiotics, e.g., lactulose, and probiotics on intestinal bacteria in the treatment of HE. Intestinal ammonia arises from aminoacids after bacterial de-amination and not from urea making urease-positive bacteria irrelevant. Antibiotics are not preferred in the treatment of HE, since ammonia-producing antibiotic-resistant bacteria may survive and replace ammonia-producing antibiotic-susceptible bacteria. Intestinal prebiotics are carbohydrate-like compounds, such as lactulose and resistant starch, that beneficially affects host's health in a different manner than normal food. In the small bowel prebiotics are not absorbed and digested, but are fermented in the colon by colonic bacteria. Fermentation of prebiotics yields lactic, acetic and butyric acids, as well as gas especially hydrogen (H2). The massive H2 volumes cause rapid intestinal hurry and thus massive amounts of colonic bacteria, not only urease-positive bacteria, but also deaminating bacteria, are removed and intestinal uptake of toxic bacterial metabolites, e.g., ammonia, reduced. As living non-pathogenic micro-organisms, probiotics beneficially affect the host's health by fermenting non-absorbed sugars, especially in the small bowel. Thus, they reduce the substrate of the other bacteria, and simultaneously they create a surplus of fermentation products which may affect the non-probiotic flora. Regarding the fermentation products (lactic acid, ethanol, acetic acid and CO2) five groups of probiotic micro-organisms are known. It is argued that probiotic, CO2-producing (facultatively) heterolactic lactobacilli, i.e., lactobacilli, that produce both lactic acid and CO2 from sugars, such as glucose, are preferred in the treatment of HE. Our ideas concur with the practice guidelines regarding HE as formulated by Blei, Cordoba and the Practice Parameters Committee of the American College of Gastroenterology, and does not alter the final conclusion of Solga as regards the beneficial use in future treatment of HE.

Comparison of probiotics and lactulose in the treatment of minimal hepatic encephalopathy in rats

AIM: To compare the efficacy of probiotic preparation Golden Bifid and lactulose on rat experimental model of minimal hepatic encephalopathy (MHE) induced by thioactamide (TAA).

METHODS: MHE was induced by intraperitoneal injection of TAA (200 mg/kg) every 24 h for two consecutive days. Thirty-six male MHE models were then randomly divided into 3 groups: TAA group (n = 12) received tap water ad libitum only; lactulose group (n = 12) and probiotics group (n = 12) were gavaged, respectively with 8 mL/kg of lactulose and 1.5 g/kg of probiotic preparation Golden Bifid (highly concentrated combination of probiotic) dissolved in 2 mL of normal saline, once a day for 8 d (from the 5^th d before the experiment to the 3^rd d of the experiment). The latency of brainstem auditory evoked potentials (BAEP) I was used as an objective index of MHE. The incidence of MHE, the level of serum endotoxin, ammonia, liver function and histological grade of hepatic injury of rats were examined individually.

RESULTS: There were no overt HE and rat deaths in 3 groups. The incidence of MHE, the levels of blood ammonia and endotoxin in TAA group, which were 83.3% (10/12), 168.33±15.44 mg/dL and 0.36±0.04 EU/mL, respectively, were significantly higher than those in lactulose group, which were 33.3% (4/12), 110.25±7.39 mg/dL and 0.19±0.02 EU/mL, and probiotics group, which were 33.3% (4/12), 108.58±10.24 mg/dL and 0.13±0.03 EU/mL respectively (P <0.001). It showed that either probiotics or lactulose could significantly lower the level of hyperammonemia and hyper-endotoxemia, lighten centrolobular necrotic areas as well as inflammatory reaction in the liver of rats, normalize the latency of BAEP, and decrease the incidence of MHE. However, no significant differences were observed between these two groups (P >0.05).

CONCLUSION: Probiotic compound Golden Bifid is at least as useful as lactulose for the prevention and treatment of MHE. Probiotic therapy may be a safe, natural, well-tolerated therapy appropriate for the long-term treatment of MHE.

Long-term management of alcoholic liver disease

Despite the epidemics of viral hepatitis C and nonalcoholic fatty liver disease, alcohol remains one of the major causes of liver disease. Commonly, hepatitis C and other liver diseases are found in association with alcohol consumption. This association in many instances is noted to accelerate the progression of liver disease. In many respects, the long-term management of alcoholic liver disease is not dissimilar from the long-term management of patients with cirrhosis from other etiologies. One major element is the abstinence of alcohol use. The ability to maintain sobriety has a major impact on the outcome of patients with alcoholic cirrhosis because maintaining abstinence can lead to significant regression of fibrosis and possibly early cirrhosis. Similarities in managing patients with cirrhosis due to alcohol or cirrhosis from other causes include vaccination to prevent superimposed viral hepatitis and screening for esophageal varices and hepatocellular carcinoma with subsequent appropriate therapy.

Cognition in liver disease

BACKGROUND

Cognitive dysfunction has been observed in a range of liver diseases including chronic hepatitis C virus, alcoholic liver disease, primary biliary cirrhosis and Wilson's disease. Such dysfunction may range from mild cognitive changes to overt hepatic encephalopathy, and represents a significant complication of liver disease that may negatively impact the patient's quality of life, and normal activities of daily living (e.g., driving).

METHOD

This article reviews the published evidence relating to cognitive dysfunction in liver disease.

OUTCOME

Issues of definition, diagnosis, epidemiology, aetiology, treatment and outcome are discussed. Particular attention is devoted to identifying the mild cognitive changes that occur in liver diseases of different aetiology.

Neostigmine for the treatment of acute hepatic encephalopathy with acute intestinal pseudo-obstruction in a cirrhotic patient

We treated a 49-yr-old man with neostigmine, who had liver cirrhosis, acute hepatic encephalopathy, and acute intestinal pseudoobstruction. He was admitted in a state of hepatic confusion. On physical examination, the abdomen was distended; and bowel sound was absent. Plain abdomen film revealed multiple air-fluid levels and distention of bowel loops. Initially, we gave him lactulose enemas every 6 hr for one day without improvement in his mental state. Furthermore, he became to a state of coma. Therefore, we gave him 0.5 mg of neostigmine subcutaneously to improve his peristaltic movement, and 2 L of polyethylene glycol electrolyte solution through a nasogastric tube for 4 hr to reduce the production and absorption of gut-derived toxins of nitrogenous compounds. After these treatments, the venous ammonia level decreased to the normal range within 12 hr, and the coma disappeared after 2 days. We suggest that neostigmine may be one of the most effective treatments to initiate peristaltic movement and bowel cleansing in cirrhotic patients with acute hepatic encephalopathy and acute intestinal pseudoobstruction.

Bridges to transplantation

The definitive treatment of patients with acute liver failure is liver transplantation. Organ Procurement and Transplantation Network status 1 patients receive priority, but the median waiting time in 2002 was 11 days. Patients who are small or have an unusual blood type are expected to wait even longer. Because cerebral edema and death may occur before a liver is available, numerous methods of bridging patients to transplantation by artificial means have been proposed. To date, no system of hepatic support has been proven effective at delaying the onset of cerebral edema in controlled trials.

Relationship between tumor necrosis factor-alpha and ammonia in patients with hepatic encephalopathy due to chronic liver failure

BACKGROUND

We have recently demonstrated that in humans, circulating levels of tumor necrosis factor-alpha (TNF) correlate positively with severity of hepatic encephalopathy (HE) due to chronic liver failure.AIM. The main aim of this larger population study is to determine the relationship between TNF and ammonia in patients with HE and chronic liver failure due to liver cirrhosis.

METHODS

Circulating levels of TNF and ammonia were measured in 108 patients with liver cirrhosis due to various etiologies in various clinical grades of HE (grades 0-4). TNF concentrations were measured in venous serum using commercially available solid-phase high sensitivity enzyme-linked immunosorbent assay. Ammonia levels were determined in venous plasma by the enzymatic method, using the glutamate dehydrogenase reaction.

RESULTS

The mean+/-SEM values of circulating levels of TNF and ammonia at presentation in patients with grade 0 of HE (n = 30) were 3.89+/-0.2 pg/mL and 49.8+/-2.8 microg/mL respectively, in patients with grade 1 of HE (n = 26) were 8.56+/-0.34 pg/mL and 101.6+/-6.5 microg/mL respectively, in patients with grade 2 of HE (n = 22) were 11.59+/-0.48 pg/mL and 160.3+/-10.7 microg/mL respectively, in patients with grade 3 of HE (n = 20) were 19.98+/-0.94 pg/mL and 228.8+/-16.1 microg/mL respectively, and in patients with grade 4 of HE (n = 10) were 51.53+/-8.59 pg/mL and 284.2+/-20.3 microg/mL respectively. A significant positive correlation was found between circulating levels of TNF and those of ammonia (r = 0.62, P< 0.0001), and also between circulating levels of both substances and severity of HE in these patients (r = 0.95, P<0.0001, and r = 0.9, P<0.0001 respectively). TNF and ammonia were both significant independent predictors of severity of HE (P<0.0001 for both variables).

CONCLUSION

The results of this study demonstrate a significant relationship between TNF and ammonia in patients with chronic liver failure and HE, and so strengthen the suggestion that TNF could be strongly involved in the pathogenesis of HE in these patients. Hence, we suggest a new theory in the pathogenesis of HE, the "TNF theory".

Characteristics of minimal hepatic encephalopathy

The term minimal hepatic encephalopathy refers to the subtle changes in cognitive function, electrophysiological parameters, cerebral neurochemical/neurotransmitter homeostasis, cerebral blood flow, metabolism, and fluid homeostasis that can be observed in patients with cirrhosis who have no clinical evidence of hepatic encephalopathy. Use of this term emphasizes the fact that the entity of hepatic encephalopathy is a single syndrome with quantitatively distinct features relating to severity. The absence of clinical evidence of hepatic encephalopathy is key to the diagnosis and can only be determined by a detailed assessment of the patients' history and a comprehensive neurological assessment of consciousness, cognitive, and motor function. The neuropsychological features of minimal hepatic encephalopathy point to a disorder of executive functioning, particularly selective attention and psychomotor speed, but other abnormalities may be observed. Alterations in electrophysiological variables have been described; endogenous evoked potentials are, in principle, more likely to reflect the presence of minimal hepatic encephalopathy, since they reflect cognitive phenomena rather than mere stimulus conduction but the specificity of the changes observed is unclear at present. Changes have also been described in the execution of diadochokinetic movements and in the capacity to discriminate flickering light, both of which may have diagnostic potential. The changes observed in cerebral blood flow and metabolism in SPET, PET, and 1H and 31P MRS studies reflect the pathogenic process that underlies the condition rather than providing diagnostic information. Similarly, the morphological brain abnormalities identified in this population, including mild brain oedema, hyperintensity of the globus pallidus and other subcortical nuclei observed in cerebral MR studies, and the central and cortical atrophy observed in neural imaging studies, are unlikely to have diagnostic utility. The presence of minimal hepatic encephalopathy is not without clinical consequence; it has a detrimental effect on health-related quality of life, the ability to perform complex tasks such as driving, and on outcome.

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