Bowel Movement Frequency Is Not Linked With Cognitive Function in Cirrhosis

Duong, Nikki; Reuter, Bradley; Saraireh, Hamzeh; Nadhem, Omar; Acharya, Chathur; Fagan, Andrew; Hassouneh, Ramzi; Bajaj, Jasmohan S.

doi:10.1016/j.cgh.2021.05.014

Cited by 8 publications

(8 citation statements)

References 8 publications

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“…However, our data fit with the international literature on serum ammonia ordering and its lack of utility in altering the management of hospitalised patients with chronic liver disease and cirrhosis 5,7,8 . Recent studies noted that management directed at ammonia levels or bowel motion frequency do not change patient outcomes 21,22 …”

Section: Discussionsupporting

confidence: 81%

“…5,7,8 Recent studies noted that management directed at ammonia levels or bowel motion frequency do not change patient outcomes. 21,22 It does need to be recognised that there are factors in the determination of serum ammonia levels that may affect the result. Clenched muscles and long tourniquet time can increase venous serum ammonia levels.…”

Section: Ammonia Level Testing and Hepatic Encephalopathymentioning

confidence: 99%

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Serum ammonia does not guide management and is overutilised in patients with cirrhosis in hospital settings

Hannah

Vasic

Kansal

et al. 2023

Internal Medicine Journal

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BackgroundHepatic encephalopathy is a confusional state associated with cirrhosis. Serum ammonia levels are neither sensitive nor specific for the diagnosis.AimsWe audited the ordering location and hospital unit whilst assessing the impact on management at a major Australian tertiary centre.MethodsWe conducted a single‐centre retrospective chart review of the ordering of serum ammonia levels between 1 March 2019 and 29 February 2020 at The Royal Melbourne Hospital, a tertiary‐referral centre in Melbourne, Victoria. Demographic, medication and pathology results, including serum ammonia measurements, were collected. The main outcomes assessed were ordering location, sensitivity, specificity and impact on management.ResultsA total of 1007 serum ammonia tests were ordered in 425 patients. Nearly all ammonia ordering was by non‐gastroenterologists, 24.2% by the intensive care unit, 23.1% by general medicine and 19.5% by the emergency department (ED). Only 21.6% of patients had a history of cirrhosis, with hepatic encephalopathy diagnosed in 13.6%. On subgroup analysis, 217 ammonia tests were performed in 92 patients with cirrhosis. Cirrhotic patients were older (64 vs 59 years, P = 0.012) and had higher median ammonia levels (64.46 vs 59 μmol/L, P < 0.001) compared with non‐cirrhotic patients. In cirrhotic patients, the sensitivity and specificity for serum ammonia and diagnosis of hepatic encephalopathy were 75% and 52.3% respectively.ConclusionWe affirm the poor utility of serum ammonia levels for guiding management of hepatic encephalopathy within the Australian context. ED and general medical units account for the majority of test ordering within the hospital. Understanding where ordering occurs provides a target for targeted education.

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Section: Discussionsupporting

confidence: 81%

Section: Ammonia Level Testing and Hepatic Encephalopathymentioning

confidence: 99%

Serum ammonia does not guide management and is overutilised in patients with cirrhosis in hospital settings

Hannah

Vasic

Kansal

et al. 2023

Internal Medicine Journal

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“…Patients with cirrhosis, especially those with HE, are prescribed lactulose under the assumption that achieving a set number of BMs implies efficacy (1,8). However, this dogma is being increasingly challenged with the recent publication from our group determining that regardless of HE or lactulose use, cognitive impairment was not associated with BM frequency (4). The focus on number of BMs and driving doses of lactulose beyond that would be tolerable to most Western patients often leads to readmissions due to nonadherence (3,9).…”

Section: Discussionmentioning

confidence: 99%

“…Thus, caution should be applied when using bowel frequency alone as an end point for lactulose therapy (3). Moreover, this one-size-fits-all policy does not consider baseline BM frequency or consistency and is not associated with objective cognitive performance data (4). Therefore, we need to amalgamate other criteria to potentially reduce admissions and reduce changes in medications.…”

Section: Introductionmentioning

confidence: 99%

Bristol Stool Scale as a Determinant of Hepatic Encephalopathy Management in Patients With Cirrhosis

et al. 2021

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“…Some patients will have no HE with two bowel movements per day, while others require four or more per day. In fact, there has been some recent controversy as to whether the frequency of bowel movements in cirrhosis is tied to cognitive function at all [ 23 •]. A different strategy is to intermix polyethylene glycol (PEG) with lactulose, especially when bloating is an issue.…”

Section: Liver-specific Symptomsmentioning

confidence: 99%

Symptom Management in Patients with Cirrhosis: a Practical Guide

Kaplan

Rosenblatt

2022

Curr Treat Options Gastro

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Purpose of the review Though it is well known that cirrhosis is associated with significant morbidity and mortality, management of symptoms in cirrhosis can be difficult. This review serves to offer practical guidance in the management of liver-specific symptoms of cirrhosis as well as other symptoms with special hepatic considerations. Recent findings We discuss liver-specific symptoms and management, including ascites and refractory ascites, hepatic encephalopathy, pruritus, and muscle cramping. We also discuss the challenges of treating more generalized symptoms in cirrhosis, including pain, depression/anxiety, appetite, and fatigue. Medication management is, especially complex in this population given the altered metabolism of drugs, and we consider some strategies to approach this. Summary With the right tools, provided throughout this review, hepatologists should be well equipped to manage the nuanced liver-specific and generalized symptoms in patients with cirrhosis.

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Bowel Movement Frequency Is Not Linked With Cognitive Function in Cirrhosis

Cited by 8 publications

References 8 publications

Serum ammonia does not guide management and is overutilised in patients with cirrhosis in hospital settings

Serum ammonia does not guide management and is overutilised in patients with cirrhosis in hospital settings

Bristol Stool Scale as a Determinant of Hepatic Encephalopathy Management in Patients With Cirrhosis

Symptom Management in Patients with Cirrhosis: a Practical Guide

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