Lactulose Therapy Research Articles

Prophylactic Lactulose Therapy in Patients with Cirrhosis and Upper Gastrointestinal Bleeding: A Meta-analysis of Randomized Trials.

Lactulose is the first-line drug for both treatment and secondary prophylaxis for overt hepatic encephalopathy (HE). The use of lactulose for the primary prophylaxis of HE in patients with cirrhosis and acute upper gastrointestinal bleeding (AUGIB) has been debated. Hence, we conducted this meta-analysis to assess the role of lactulose in HE prophylaxis in patients with cirrhosis and AUGIB. A comprehensive search of literature from inception to December 2022 was performed of three databases for randomized studies comparing lactulose and placebo in patients with cirrhosis and AUGIB. Risk ratios (RR) with 95% confidence intervals were calculated for all the dichotomous outcomes. A total of five studies were included in the final analysis, out of which three studies had a low risk of bias, and two had a moderate risk of bias. Lactulose therapy was associated with a significantly lower risk of OHE compared to placebo, with a RR of 0.38 (0.23-0.62) and a number needed to treat of 6. There was no difference in the risk of mortality between the groups, with a RR of 0.71 (0.29-1.76). The pooled incidence rates of overall adverse events (AEs) and diarrhea with the use of lactulose therapy were 53.2% (42.2- 64.2) and 34.7% (17.7-51.7), but a majority did not require drug discontinuation. The certainty of the evidence was moderate to low. Prophylactic lactulose reduces the incidence of HE after AUGIB but has no effect on mortality. Diarrhea and abdominal discomfort are common AEs but do not need drug discontinuation.

Role of Probiotics in Secondary Prophylaxis of Hepatic Encephalopathy

Aim: To determine the role of probiotics in combination with standard therapy in secondary prophylaxis of hepatic encephalopathy. Methods: This Randomized Controlled Trial was carried out in the Medical Wards of King Edward Medical University/Mayo Hospital, Lahore from 15th October, 2018 to 14th January, 2020. 166 patients selected via simple random sampling technique were divided into two groups. Group A received Lactulose whereas Group B received Lactulose plus Probiotic. A three months follow up for each patient was done. Absence of hepatic encephalopathy at the end of treatment was considered Effective treatment response. Primary end point was completion of three months or development of hepatic encephalopathy. Patients' responses were noted on a pre-designed proforma. Data analysis was done using SPSS version 23.0. Results: Out of a total of 166 patients comprising 83 males and 83 females, mean age of the patients was 54.11±7.76 years. A statistically significant difference was found between the study groups inserum ammonia levels(p-value=<0.001). At 3rd month follow up 79(47.59%) patients had no episode of hepatic encephalopathy as assessed on West Haven grading (grade 0) followed by hepatic encephalopathy noted in 56(33.73%) patients; 25(15.06%)ingrade 3, 22(13.25%)ingrade 4 and 9(5.42%)in grade 2 respectively. p-value between the study groups and end result of the patients demonstrated statistically significant difference(p-value=0.028) Practical Implication: Overt hepaticencephalopathy is a common and frequent complication in patients with decompensated chronic liver disease. Various treatment modalities have proven beneficial. In this study we have shown the adjuvant role of probiotics with the standard lactulose therapy in remission and secondary prophylaxis of overt hepatic encephalopathy. Conclusion: Probiotics in conjunction with conventional lactulose therapy is more effective than standard lactulose therapy alone in remission and maintenance of secondary prophylaxis of overt hepatic encephalopathy. Keywords: Hepatic Encephalopathy, Secondary prophylaxis, Standard therapy, Probiotic

SAT-545 - Administration of Lactulose, Rifaximin, or combination therapy for hepatic encephalopathy is associated with a reduction in gastrointestinal cancers

SAT-545 - Administration of Lactulose, Rifaximin, or combination therapy for hepatic encephalopathy is associated with a reduction in gastrointestinal cancers

Comparison of Dual Therapy, Rifaximin plus Lactulose with Monothrapy, Lactulose Alone in the Treatment of Portosystemic Encephalopathy

Objective: To compare the efficacy of dual therapy (rifaximin and lactulose) and lactulose monotherapy in the treatment of porto-systemic encephalopathy. Study Design: Randomized control trial. Place and Duration of Study: Department of Gastroenterology, PIMS Hospital, Islamabad from 1st July 2020 to 31st December 2020. Methodology: One hundred and fifty patients of both genders age ranges from 18-65 years with liver cirrhosis having hepatic encephalopathy grade II or above were included. They were divided in two groups; each group comprised 75 patients. Group A took lactulose and rifaximin, while lactulose alone was given to Group B. All patients were monitored for 5 days on the basis of Child Pugh Criteria. Results: The mean age was 40.02+24.4 years. One hundred twenty six (85.1%) of patients were above 50 years. Males were 60%, majority of patients were from the emergency department, while 17 were from OPD. HCV was identified as the major cause of cirrhosis (72.6%), while HBV (14.6%), alcohol (4%) and others (8.6%) contributed nominally. Constipation was major precipitating factor in 83 patients while sepsis and UGI Bleed was culprit in 31 and 19 patients respectively. Sixty patients (80%) of group A of both genders showed improvement in five days, while 42 patients (56%) of group B showed improvement in the same period of time (p=0.006). It was found more in males and elder patients. Practical implication: Dual therapy will reduce the morbidity, hospital stay and cost of treatment. It may also help in making local guidelines for treatment of hepatic encephalopathy. Conclusion: Rifaximin plus lactulose therapy was far superior to lactulose monotherapy in every age group and either gender. Keywords: Porto systemic encephalopathy, Decompensated chronic liver disease, Rifaximin lactulose therapy, Lactulose monotherapy

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

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. We conducted a 28-day randomized trial of crystalline lactulose therapy (20g 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"). 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). 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.

Reduction in Gastrointestinal Cancers in Cirrhotic Patients Receiving Rifaximin vs Lactulose Only Therapy for Hepatic Encephalopathy.

Background Rifaximin and/or lactulose therapy is widely used in cirrhotic patients for the prevention and treatment of hepatic encephalopathy. The incidence of gastrointestinal cancers in these patients on lactulose, rifaximin, and/or combination therapy is unknown. We investigated the possible effect of lactulose and rifaximin on cancer risk in patients with cirrhosis using the MarketScan database. Methods A retrospective cohort study was conducted using the Truven Health MarketScan Commercial Claims databases from 2007-2017. An index date was defined for each participant as the earliest date of cirrhosis diagnosis. A baseline period for each participant was defined as the 12 months prior to the first medication date while the study follow-up period represented the period from the initiation of the medication to its cessation. ANOVA was used to compare all continuous measures of age and duration of medication. Wald Chi-square tests were performed to test the associations between the study groups. Results A total of 12,409 patients were included in our study. The rifaximin only cohort had the greatest reduction in risk of developing colon cancer, esophageal cancer, and stomach cancer compared to the other groups. Rifaximin reduced the risk of colon cancer and esophageal cancer by 59.42% and 70.37%, respectively, compared to patients taking lactulose only. Patients in the lactulose plus rifaximin cohort had the highest rate of development of pancreatic cancer (lactulose plus rifaximin vs rifaximin only vs lactulose only, 0.45% vs 0.24% vs 0.21%; P < 0.0001) and liver and intrahepatic bile duct cancers (11.73% vs 5.84% vs 5.49%; P < 0.0001). Conclusion Colon, esophageal, and gastric cancers had a marked incidence reduction in the rifaximin only cohort compared to the other cohorts studied.

Hyperammonemia in a septic patient with Ureaplasma parvum arthritis: a case report

BackgroundSeptic arthritis requires prompt diagnosis and treatments. Rare pathogens should be considered when patients respond poorly to the initial antibiotic treatments. Ureaplasma parvum is an opportunistic pathogen that commonly resides in the human urogenital tract. Its infection commonly causes hyperammonemia. Hyperammonemia from Ureaplasma parvum septic arthritis has never been reported previously.Case presentationA 65-year-old male presented with fever and left lower leg pain and swelling for more than ten days. Septic arthritis and sepsis were considered after laboratory tests and arthrocentesis. However, he responded poorly to the antibiotic treatments, including cefoperazone-sulbactam, imipenem-cilastatin, and linezolid. His mental status deteriorated rapidly with elevated blood ammonia levels with unremarkable liver function test and sonogram examination results. Despite the treatments with lactulose, L-ornithine L-aspartate, mannitol, and hemodialysis therapy to lower his ammonia level, his blood ammonia level remained persistently high. Finally, metagenomic sequencing of the left knee synovial fluid reported Ureaplasma parvum, which was considered to contribute to his hyperammonemia.ConclusionUreaplasma parvum could cause septic arthritis with hyperammonemia. Genetic tests, such as polymerase chain reaction and next-generation sequencing techniques, could provide a sensitive and fast diagnosis of Ureaplasma parvum.

Cost-Effectiveness of Rifaximin-α versus Lactulose for the Treatment of Recurrent Episodes of Overt Hepatic Encephalopathy: A Meta-Analysis

Background. Hepatic encephalopathy (HE) is a frequent and debilitating complication of liver disease. Treatments include lactulose and rifaximin-α. The objective of this literature review and meta-analysis was to assess the overall cost-effectiveness of rifaximin-α in HE treatment. Methods. Electronic database searches were conducted in November 2020 to identify cost-effectiveness studies comparing rifaximin-α with other interventions in HE, published in English. Incremental net benefit (INB) was calculated for each study using difference in effectiveness, difference in costs, and the willingness-to-pay threshold, or gross domestic product per capita for each country, and 95% confidence intervals (CI) were constructed. Costs were standardised to 2019 US$. An intervention was considered cost-effective if the INB was positive. Meta-analysis was used to pool calculated INB across studies, using a fixed-effects model if there was no heterogeneity or a random-effects model. Results. Eleven studies were included in the meta-analysis. For rifaximin-α plus lactulose in the second-line setting, the pooled INB was estimated at $20,156 (95% CI: $13,593-$29,887) versus lactulose monotherapy. For rifaximin-α monotherapy in the first-line setting, the pooled INB was $4834 (95% CI: $1601-$14,596) versus lactulose monotherapy. Due to lack of available data, meta-analyses were not possible for rifaximin-α added to lactulose therapy versus lactulose monotherapy in the first-line setting or for rifaximin-α as salvage therapy in the second-line setting. Conclusions. Rifaximin-α as an add-on treatment to lactulose in the second-line setting or as monotherapy in the first-line setting would be a cost-effective treatment for HE compared with lactulose monotherapy.

S3415 Gastroenterological Manifestations in a Patient With Common Variable Immunodeficiency

Introduction: Gastrointestinal manifestation of common variable immunodeficiency (CVID) can present with protein-losing enteropathy (PLE). A wide spectrum of liver injuries can occur with CVID, including nodular regenerative hyperplasia (NRH). Case Description/Methods: 41 y.o. female with PMH of CVID on IgG, chronically elevated LFTs, and nutritional deficiencies. Patient presented with 8-year history of diarrhea, bloating, weight loss, abdominal pain, hepatic encephalopathy (HE), new ascites, and shock. Previously was diagnosed with celiac disease and has strictly followed a gluten-free diet with no improvement. EGD on the current presentation showed visible changes in duodenal mucosa including villous flattening. Biopsies this time revealed villous flattening and absence of plasma cells consistent with CVID enteropathy. Liver biopsy 5 years prior to admission showed no liver disease. Serologic workups, including anti-gp210 and anti-sp100, were negative. Biopsy showed nodular regenerative hyperplasia and non-cirrhotic portal hypertension, which was confirmed by reticulin stain. Patient was started on budesonide 9 mg daily for treatment of PLE, and marked improvement of diarrhea was noted. Non-cirrhotic portal hypertension was managed with furosemide and spironolactone. HE was managed with oral lactulose. The patient was started on enteral and parenteral supplements. Discussion: Duodenal villous atrophy which is a diagnostic criterion for celiac disease can be seen in multiple other conditions including immune disorders such as CVID. In CVID patients with gastrointestinal symptoms, up to 80% of biopsies from different sites in the GI tract will show histological abnormalities. Given their common presentation, celiac disease can be initially diagnosed. The absence of plasma cells and apoptosis presence in duodenal biopsy can suggest PLE diagnosis. Serological studies are not reliable for celiac disease diagnosis due to deficiency of immunoglobulin production in CVID. Steroids can be used for the treatment of PLE in CVID. Hepatic manifestations in CVID are extremely varied and often misdiagnosed given they can mimic other diseases. NRH is a potentially fatal complication of CVID. Recognition of this complication allowed for symptom resolution within two days of starting lactulose therapy. NRH in CVID represents an autoimmune-like liver disease that might be driven by a local vasculopathy, and thus severe cases can warrant a trial of immunosuppression.

Effects of adding interferential current (IFC) in standard therapy (Lactulose) in cerebral palsy children with constipation

To determine the addition of interferential current (IFC) in treating constipation in children with cerebral palsy (CP), is more effective than standard therapy (lactulose). An experimental study with a single blind randomized controlled trial. Prior to receiving therapy, the subjects examined the baseline data regarding the Constipation Scoring System (CSS). The total subjects were 18 children with CP who had constipation according to ROME IV criteria, which were divided into two groups, the control group who received standard therapy (lactulose) and the intervention group who received lactulose plus IFC therapy with a frequency of 4000-4100 Hz, duration 20 minutes, 3 times a week for 1 month. A week after the last IFC, CSS was re-evaluated to assess outcomes. Data were analyzed computerized with SPSS v20.0. There was an improvement of CSS in CP with constipation who received additional IFC (P= .002) and lactulose P= .014). There was no significant difference of CSS between the two groups after therapy (P= .917).

Interferential current therapy improved constipation and pelvic floor muscle activity in cerebral palsy children

Background: Objective: The aim of this case report was to evaluate interferential current (IFC) therapy as adjuvant in treating constipation and abnormal pelvic floor muscle activity in cerebral palsy (CP) children. Study design: Nine CP children aged between 4,5 to 13 years old who had constipation according to ROME IV criteria received pre post test examination. At the baseline we collected data regarding the Pediatric Incontinence and Constipation Score (PICS), Pediatric Quality of Life (PedsQL), and pelvic floor muscle activity at rest and during contraction. They received standard lactulose therapy and IFC therapy with a frequency of 4000-4100 Hz, duration 20 minutes, 3 times a week for 4 weeks. A week after the last IFC series, the parameters were re-evaluated to assess outcomes. Data were analyzed with SPSS v20.0. Results: PICS for constipation improved (P= 0,005), PedsQL improved at pain parameter (p = 0,008), and the pelvic floor muscle activity reduced significantly at rest (P= 0,036) in CP with constipation after received additional IFC therapy.

Stool microbiota show greater linkages with plasma metabolites compared to salivary microbiota in a multinational cirrhosis cohort.

Cirrhosis is associated with changes in gut microbiota in both saliva and stool. The relative linkage patterns of stool versus saliva microbiota with systemic metabolomics are unclear and may differ across countries. We hypothesized that stool microbiota have greater linkages with plasma metabolites than saliva microbiota, which may depend on country of origin. Age-balanced controls and outpatient patients with cirrhosis, compensated and decompensated, from the USA and Mexico (MX) underwent plasma collection and dietary recall. Plasma metabolomics were analysed using nuclear magnetic resonance spectroscopy. Microbiota in stool and saliva samples were analysed using 16S rRNA analyses. Correlation network differences between both saliva and stool gut microbiota and plasma metabolites were compared between subject groupings and within/between countries. A total of 313 age-balanced subjects-135 USA (47 control, 48 compensated and 40 decompensated) and 178 MX (71 control, 56 compensated and 51 decompensated)-were enrolled. Cirrhosis severity, including lactulose and rifaximin use, were comparable. Plasma metabolites differed with advancing cirrhosis, between countries and according to 90-day hospitalizations. Correlation networks demonstrated more microbiome-metabolite linkages in stool compared to saliva in both populations, although there were no salivary correlation metrics across decompensated subjects in either country. Stool Lactobacillus showed a positive correlation to plasma lactate in decompensated cirrhosis from MX but not USA. Stool microbiota were more extensively linked with systemic metabolites than were saliva microbiota, irrespective of cirrhosis severity and country. These changes were more prominent in decompensated cirrhosis and were centred around plasma lactate, which might reflect the interaction of diet and lactulose therapy.

Nutrition, defecation, and the lower gastrointestinal tract during critical illness.

The goal of this report is to delineate the correlation between constipation as a manifestation of impaired gastrointestinal transit with adverse clinical outcomes, to identify risk factors, which predispose to this condition, and outline a management scheme for prophylactic treatment. Constipation is common in the ICU, affecting upwards of 60-85% of critically ill patients. As suggested by case series and observational studies, constipation may be an independent prognostic factor identifying patients with greater disease severity, higher likelihood of organ dysfunction, longer duration of mechanical ventilation, prolonged hospital length of stay, and possibly reduced survival. Treating constipation is a low priority for intensivists often relegated to the nursing service, and few ICUs have well designed protocols in place for a bowel regimen. Small randomized controlled trials show improvement in certain outcome parameters in response to a daily lactulose therapy; hospital length of stay, sequential organ failure assessment scores, and duration of mechanical ventilation. However, aggregating the data from these studies in two separate meta-analyses showed that the effect of a bowel regimen on these three endpoints were not statistically different. No causal relationship can be determined between constipation and adverse outcomes. Nonetheless, a clinical correlation seems to exist. Whether constipation is an epiphenomenon or simply a reflection of greater severity of critical illness, at some point it may contribute to worsening morbidity in the ICU. A graded prophylactic bowel regimen should help reverse impairment of the gastrointestinal transit and aid in reducing its deleterious impact on the hospital course of the critically ill patient.

Evaluation of levocarnitine, lactulose, and combination therapy for the treatment of valproic acid-induced hyperammonemia in critically ill patients

IntroductionCritically ill patients treated with valproic acid are at risk for hyperammonemic encephalopathy. Both levocarnitine and lactulose, either alone or in combination, have been used for the treatment of hyperammonemia associated with valproic acid, however they have not been directly compared in the literature. The aim of this study was to compare the effect of levocarnitine, lactulose, and combination therapy for the treatment of valproic acid-induced hyperammonemia in critically ill patients. MethodsThis was a retrospective, system-wide, cohort study of critically ill patients who received valproic acid and levocarnitine, lactulose, or combination therapy from January 1, 2012 to October 31, 2019. The primary outcome of the study was the change in ammonia level from baseline to the lowest point within the first 48 h of treatment. Secondary outcomes included the change in ammonia levels within the first 7 days, the incidence of a clinically significant reduction, ICU length of stay, hospital length of stay, and hospital mortality. ResultsA total of 371 charts were reviewed and 114 patients (levocarnitine [n = 15], lactulose [n = 72], and combination [n = 27]) were included. No difference in the primary outcome was observed (levocarnitine [11umol/L] vs. lactulose [20 umol/L] vs. combination [23 umol/L], p = 0.605). The incidence of a clinically significant reduction in ammonia levels at 48 h did not differ between groups, nor did mortality. ConclusionIn critically ill patients with valproic acid-induced hyperammonemia, there was no significant difference in the reduction in ammonia levels in the first 48 h of treatment between levocarnitine, lactulose, and combination therapy.

Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases.

Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases.

S2668 Cortical Laminar Necrosis Due to Hyperammonemia: The Irreversible Side of Hepatic Encephalopathy

INTRODUCTION: Cortical laminar necrosis (CLN) is a specific pattern of neuronal death due to sparsity of glucose and oxygen. These lesions can cause persistent neurological deficits, even after treatment of the triggering etiology. Among various causes of CLN, data on hepatic encephalopathy manifesting as CLN is scarce. Here we report a case of acute hepatic encephalopathy presenting as CLN. CASE DESCRIPTION/METHODS: 63 years old lady with history of stroke, alcohol abuse and nonalcoholic steatohepatitis leading to cirrhosis, was brought in after being found unresponsive at home. She had a Glasgow Coma Score of 7 and was emergently intubated. Initial lab and imaging investigations led to a diagnosis of hepatic encephalopathy. Day 1 MRI (Figure 1) showed restricted diffusion in both cerebral hemispheres and multiple vascular territories suggesting hepatic encephalopathy. Patient’s condition kept deteriorating despite aggressive treatment with lactulose, rifaximin initially, plus renal replacement therapy from day 2. MRI done on day 6 (Figure 2) showed new patchy bright signal on FLAIR and T2 images and white matter of both cerebral hemispheres as well as the left pons. Asymmetry of hippocampal formations was seen and thought to be secondary to swelling and enlargement of left hippocampal guidance and suspected atrophy of right hippocampal formation. There was also a mass effect causing a 5 mm midline shift to the right which was related to suspected brain swelling on the left. These findings were consistent with cortical laminar necrosis. Palliative care team was taken on board and eventually the family decided to pursue a comfort pathway and patient was compassionately extubated. She passed away 8 days after admission on the day of extubation. DISCUSSION: One of the possible reasons for the mortality in our case could be that we were unable to sufficiently lower ammonia levels early in the course of acute illness until renal replacement therapy was started. There is scarcity of clear evidence in literature on whether early and aggressive medical therapy leads to better outcomes in these patients. Moreover, further studies are needed to define the “early” intervention and what would be the target level of ammonia before resorting to advanced therapies including renal replacement therapy in management of this disease.Figure 1.: Areas of restricted diffusion involving bilateral (left worse than right) temporal, frontal and parietal lobes. Old right temporal-parietal infarct.Figure 2.: Extension of restricted diffusion and development of extensive FLAIR changes in bilateral temporal, parietal and frontal lobes. Old right temporal-parietal infarct.

Lactulose withdrawal can potentiate breakthrough overt hepatic encephalopathy in patients controlled with rifaximin plus lactulose therapy: a post hoc analysis of a randomized controlled trial

Lactulose withdrawal can potentiate breakthrough overt hepatic encephalopathy in patients controlled with rifaximin plus lactulose therapy: a post hoc analysis of a randomized controlled trial

Lactulose may reduce Clostridium difficile-related diarrhea among patients receiving antibiotics.

Background and AimPrebiotics are nondigestible oligosaccharides that are metabolized by colonic bacteria, resulting in a change in the pH of the colonic milieu as well as modifying the microbiome of the colon. The purpose of this retrospective study was to determine whether concomitant lactulose administration affected the Clostridium difficile infection rate among hospitalized adult patients receiving antibiotics.MethodsWe retrospectively reviewed inpatient medical records of patients in a large teaching hospital admitted during a one‐year period. Individuals treated with antibiotic therapy during the course of their hospitalization were considered for inclusion in the study. Patients were evaluated for development of C. difficile infection, as well as concomitant lactulose therapy for hepatic encephalopathy. The incidence of C. difficile infection among patients who received lactulose and antibiotic therapy was compared with that among those who received antibiotic therapy alone.ResultsPatients who received lactulose and antibiotic therapy were slightly older (n = 87, mean age 67) than patients who received antibiotic therapy alone (n = 103, mean age 60). Similar numbers of patients were males in both groups (male/female: 50/53 and male/female: 46/41). Two (2.3%) patients who received lactulose and antibiotic therapy developed C. difficile infection during the course of hospitalization, compared with 10 (9.7%) patients who received antibiotic therapy alone (P = 0.04, Fisher exact test).ConclusionAdministration of lactulose may reduce the incidence of C. difficile‐related diarrhea among hospitalized adult patients receiving antibiotics.

Diagnosis and Successful Medical Management of a Colonic, Urate Enterolith in an Argentine Black and White Tegu (Salvator merianae)

A 5-yr-old female Argentine black and white tegu (Salvator merianae) was presented for a lack of fecal output, anorexia, and lethargy. Several weeks prior the tegu underwent a rapid diet change to whole rodents. Computed tomography revealed a mineral-dense calculus in the distal colon, causing gastrointestinal obstruction. Because of poor response to enteric fluid therapy alone, transcloacal enterolith removal was elected. Under sedation and neuraxial anesthesia, saline-infusion cloacoscopy was performed and the calculus visualized and destructed using a dental burr on a low-speed dental handpiece and grasping forceps. Recovery from the procedure was unremarkable. Fluid therapy and oral lactulose therapy were prescribed postoperatively. The tegu began to defecate several days later. Transcloacal calculus destruction with a low-speed drill under cloacoscopic guidance should be considered a noninvasive option for management of colonic and cloacal calculi in larger lizard species.

Ammonia Levels Do Not Guide Clinical Management of Patients With Hepatic Encephalopathy Caused by Cirrhosis.

Ammonia appears to play a major role in the pathophysiology of hepatic encephalopathy (HE), but its role in guiding management is unclear. We aimed to understand the impact of ammonia levels on inpatient HE management, hypothesizing that patients with elevated ammonia levels would receive more aggressive lactulose therapy than patients with normal ammonia or no ammonia level drawn. We examined patients with cirrhosis older than 18 years admitted for management of HE from 2005 to 2015. We additionally used propensity matching to control for confounding by the severity of underlying disease. Patients with an ammonia level taken at time of HE diagnosis were further separated into those with normal or elevated ammonia levels. The primary endpoint was the total lactulose (mL) amount (or dose) given in the first 48 hours of HE management. One thousand two hundred two admissions with HE were identified. Ammonia levels were drawn in 551 (46%) patients; 328 patients (60%) had an abnormal ammonia level (>72 μmol/L). There were no significant differences in the Child-Pugh score, MELD, or Charlson Comorbidity Index in those with and without ammonia levels drawn. The average total lactulose dose over 48 hours was 167 and 171 mL in the no ammonia vs ammonia groups, respectively (P = 0.42). The average lactulose dose in patients with an elevated ammonia level was 161 mL, identical to the lactulose dose in patients with a normal ammonia level. There was no correlation between lactulose dose and ammonia level (R = 0.0026). Inpatient management of HE with lactulose was not influenced by either the presence or level of ammonia level, suggesting that ammonia levels do not guide therapy in clinical practice.