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

Background and Aims: Poor patient-reported outcomes (PROs) are common in cirrhosis, including poor sleep and health-related quality of life (HRQOL). HE is a major driver of poor PROs. Many clinicians initiate lactulose therapy to address poor PROs. PRO-triggered therapy, however, has not been studied till date. Methods: We conducted a 28-day randomized trial of crystalline lactulose therapy (20 g BID) compared with no HE-directed therapy in 52 patients with cirrhosis, portal hypertension, no prior HE, and high Work Productivity and Activity Impairment scores (0–10) attributed to cirrhosis. The primary outcome was change in global HRQOL measured with Short Form-8 Health Survey. Secondary outcomes included change in Animal Naming Test score, Work Productivity and Activity Impairment, and sleep quality (scored “very bad” to “very good”). Approach and Results: Overall, 52 patients underwent randomization; 3 subjects withdrew from the crystalline lactulose arm (1 before medication initiation, 1 due to an unrelated condition, and 1 due to high baseline bowel movements). The average age was 60 years, the average Model for Endstage Liver Disease—Sodium score was 10.5, and 56% of the patients had ascites. Baseline bowel movements were 2.3/day, with 35% of the patients having Bristol Stool Scale >4. At 28 days, there was no improvement in HRQOL: patients receiving crystalline lactulose had an 8.1-point (95% CI: 3.7–12.4) increase compared with 6.6 (95% CI: 2.3–10.8) in the control group (p = 0.6). Lactulose was associated with a significantly (p = 0.002) increased Animal Naming Test score (3.7, 95% CI: 2.1–5.4) versus the control group (0.2, 95% CI: −1.7, 1.4). Lactulose users reported more good sleep (92% vs. 52%, p = 0.001) and lower activity impairment (3.0 vs. 4.8, p = 0.02). Conclusions: Lactulose improves sleep and activity impairment in patients with poor PROs. We did not observe any improvement in global HRQOL after 28 days using the Short Form-8 Health Survey instrument.

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“…Model 3 adjusts for Bristol Stool Scale at day 15 because this has been associated with response to lactulose in a retrospective study. [18]…”

Section: Discussionmentioning

confidence: 99%

Lactulose therapy for patients with cirrhosis, portal hypertension, and poor patient-reported outcomes: The Mi-Kristal trial

et al. 2023

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“…54 Branch-chain amino acids are specifically required and are frequently supplemented but may not be required in the setting of adequate protein supplementation. 53 Lactulose titrated to produce soft stools-specifically 2-3 bowel movements with Bristol stool scale 55 -remains first-line and is the only agent shown to improve quality of life and sleep quality among persons with covert HE. 56 Rifaximin has been approved for breakthrough episodes of HE on lactulose and its use is associated with reduced mortality and hospitalisations after incident HE.…”

Section: Hepatic Encephalopathymentioning

confidence: 99%

Review article: current and emerging therapies for the management of cirrhosis and its complications

Tapper

Ufere

Huang

et al. 2022

Aliment Pharmacol Ther

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Background Cirrhosis is increasingly common and morbid. Optimal utilisation of therapeutic strategies to prevent and control the complications of cirrhosis are central to improving clinical and patient‐reported outcomes. Methods We conducted a narrative review of the literature focusing on the most recent advances. Results We review the aetiology‐focused therapies that can prevent cirrhosis and its complications. These include anti‐viral therapies, psychopharmacological therapy for alcohol‐use disorder, and the current landscape of clinical trials for non‐alcoholic steatohepatitis. We review the current standard of care and latest developments in the management of hepatic encephalopathy (HE), ascites and hepatorenal syndrome. We evaluate the promise and drawbacks of chemopreventative therapies that have been examined in trials and observational studies which may reduce the risk of hepatocellular carcinoma and cirrhosis complications. Finally, we examine the therapies which address the non‐pain symptoms of cirrhosis including pruritis, muscle cramps, sexual dysfunction and fatigue. Conclusion The improvement of clinical and patient‐reported outcomes for patients with cirrhosis is possible by applying evidence‐based pharmacotherapeutic approaches to the prevention and treatment of cirrhosis complications.

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“…A recent study looked at incorporating Bristol Stool Scale (BSS) in the management of HE. 20 The BSS is an objective scale used by gastroenterologists to categorize stool from 1 to 7, with 1 being hard small stool that is difficult to pass and associated with constipation, to 7 which is watery stool with no solid components. Researchers found a higher 30-day HE readmission rate in patients in whom only stool frequency is used to determine therapy plans, compared to those in whom stool frequency and BSS are both considered.…”

Section: He Treatmentmentioning

confidence: 99%

“…Researchers found a higher 30-day HE readmission rate in patients in whom only stool frequency is used to determine therapy plans, compared to those in whom stool frequency and BSS are both considered. 20 Currently, additional therapy needs to be considered in recurrent OHE episodes, after failed outpatient treatment with lactulose. The nonsystemically absorbed antibiotic rifaximin is recommended in addition to lactulose, in patients with recurrent OHE.…”

Section: He Treatmentmentioning

confidence: 99%

“…It is also imperative to warn patients (especially those new to lactulose) that it will cause loose stools and possibly fecal urgency and to continue to foster medication adherence, as this prevents OHE. A recent study looked at incorporating Bristol Stool Scale (BSS) in the management of HE 20 . The BSS is an objective scale used by gastroenterologists to categorize stool from 1 to 7, with 1 being hard small stool that is difficult to pass and associated with constipation, to 7 which is watery stool with no solid components.…”

Section: He Treatmentmentioning

confidence: 99%

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Hepatic encephalopathy and strategies to prevent readmission from inadequate transitions of care

Rosenstengle

Kripalani

Rahimi

2022

Journal of Hospital Medicine

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One of the most costly and frequent causes of hospital readmissions in the United States is hepatic encephalopathy in patients with underlying liver cirrhosis. In this narrative review, we cover current practices in inpatient management, transitions of care, and strategies to prevent hospital readmissions. Bundled approaches using a model such as the “Ideal Transitions of Care” appear to be more likely to prevent readmissions and assist patients as they transition to outpatient care. Numerous strategies have been evaluated to prevent readmissions in patients with hepatic encephalopathy, including technologic interventions, involvement of nonphysician team members, early follow‐up strategies, and involvement of palliative care when appropriate.

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

Abstract: INTRODUCTION: Bowel movement (BM) frequency is used to titrate lactulose for hepatic encephalopathy (HE). However, stool consistency using the Bristol stool scale (BSS, 0-7) is often ignored.

Cited by 11 publications

References 22 publications

Lactulose therapy for patients with cirrhosis, portal hypertension, and poor patient-reported outcomes: The Mi-Kristal trial

Lactulose therapy for patients with cirrhosis, portal hypertension, and poor patient-reported outcomes: The Mi-Kristal trial

Review article: current and emerging therapies for the management of cirrhosis and its complications

Hepatic encephalopathy and strategies to prevent readmission from inadequate transitions of care

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