Management of Covert Hepatic Encephalopathy

Waghray, Abhijeet; Waghray, Nisheet; Mullen, Kevin D.

doi:10.1016/j.jceh.2014.02.007

Cited by 18 publications

(15 citation statements)

References 69 publications

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“…Historically, patients with post-TIPS HE were treated with a low-protein diet as well as nonabsorbable antibiotics and disaccharides to reduce intestinal neurotoxin production and absorption, which is increasingly being questioned today [11,12]. However, up to 8% of patients develop refractory HE after TIPS and there is only limited evidence about specific predictive risk factors for this purpose [13][14][15][16].…”

Section: Introductionmentioning

confidence: 99%

TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

Schindler

Seifert

Masthoff

et al. 2020

JCM

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Purpose: To evaluate predictive parameters for the development of Hepatic Encephalopathy (HE) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement and for success of shunt modification in the management of shunt-induced HE. Methods: A retrospective analysis of all patients with TIPS (n = 344) has been performed since 2011 in our university liver center. n = 45 patients with HE after TIPS were compared to n = 48 patients without HE after TIPS (case-control-matching). Of n = 45 patients with TIPS-induced HE, n = 20 patients received a reduction stent (n = 18) or TIPS occlusion (n = 2) and were differentiated into responders (improvement by at least one HE grade according to the West Haven classification) and non-responders (no improvement). Results: Older patient age, increased serum creatinine and elevated International Normalized Ratio (INR) immediately after TIPS placement were independent predictors for the development of HE. In 11/20 patients (responders, 55%) undergoing shunt modification, the HE grade was improved compared with nine non-responders (45%), with no relevant recurrence of refractory ascites or variceal bleeding. A high HE grade after TIPS insertion was the only positive predictor of treatment response (p = 0.019). A total of 10/11 responders (91%) survived the 6 months follow-up after modification but only 6/9 non-responders (67%) survived. Discussion: Older patient age as well as an increased serum creatinine and INR after TIPS are potential predictors for the development of HE. TIPS reduction for the treatment of TIPS-induced HE is safe, with particular benefit for patients with pronounced HE.

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Section: Introductionmentioning

confidence: 99%

TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

Schindler

Seifert

Masthoff

et al. 2020

JCM

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“…5 Beneficial effects of LOLA for the management and treatment of HE have been reported in over 20 Randomized Clinical Trials (RCTs) in patients with cirrhosis. However, while recent reviews provide a consensus of opinion that LOLA is of benefit for the treatment of OHE, 6,7 evidence regarding its use in MHE has been questioned. 8,9 In the current AASLD-EASL Guidelines, recommendations relating to the use of LOLA for the treatment of HE in cirrhosis were based upon the results of a single RCT of intravenous LOLA while the oral formulation was deemed to be ineffective.…”

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confidence: 99%

Efficacy of l-Ornithine l-Aspartate for the Treatment of Hepatic Encephalopathy and Hyperammonemia in Cirrhosis: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Butterworth

Kircheis

Hilger

et al. 2018

Journal of Clinical and Experimental Hepatology

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Background/objectives: L-Ornithine L-Aspartate (LOLA) is a mixture of two endogenous amino acids with the capacity to fix ammonia in the form of urea and/or glutamine. Its' efficacy for the treatment of Hepatic Encephalopathy (HE), a known hyperammonemic disorder, remains the subject of debate. This study quantitatively analyzed the efficacy of LOLA in patients with cirrhosis and HE. Methods: Efficacy was defined as the extent of lowering of blood ammonia and improvement of mental state assessed in clinically overt HE (OHE) by Westhaven criteria or psychometric testing for assessment of Minimal HE (MHE). Appropriate keywords were used for electronic and/or manual searches of databases to identify RCTs for inclusion. Study quality and risk of bias were assessed using the Jadad Composite Scale together with The Cochrane Scoring Tool. Random Effects Models were used to express pooled Risk Ratio (RR) or Mean Difference (MD) with associated 95% Confidence Intervals (CI). Results: 10 RCTs (884 patients) were included. Regression analysis showed no evidence of publication bias or other small study effects. Eight RCTs had low risk of bias by Jadad/Cochrane criteria. Comparison with placebo/no intervention controls revealed that LOLA was significantly more effective for improvement of mental state in all types of HE (

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“…There is a reduction in Veillonellaceae (gram negative cocci) and an increase in Eubacteriaceae (gram positive cocci). 40,41 Rifaximin is effective and well tolerated, with minimal systemic absorption. A meta-analysis comparing rifaximin with lactulose found that patients taking rifaximin fared better than those on lactulose.…”

Section: Correct Answers: C and Ementioning

confidence: 99%