Recurrent Hepatic Encephalopathy Research Articles

Efficacy and Safety of Nitazoxanide in Preventing Recurrence of Hepatic Encephalopathy

Efficacy and Safety of Nitazoxanide in Preventing Recurrence of Hepatic Encephalopathy

Prophylactic Antibiotics in Cirrhosis: Are They Promoting or Preventing Infections?

Prophylactic Antibiotics in Cirrhosis: Are They Promoting or Preventing Infections?

P: 47 Risk of Recurrent Hepatic Encephalopathy (HE) in Patients With Liver Cirrhosis: A German Registry Study

BACKGROUND: Patients with Hepatic Encephalopathy (HE) show a low quality of life, recurrent hospitalizations and an increased mortality. We aimed to assess the natural course of patients after a recent HE-episode under the conditions of the German health system, as respective data were not available. METHODS: Fifteen sites from Germany - 8 of them liver transplant (LT) centers - took part in an observational prospective study including cirrhotic patients who had been hospitalized due to an acute episode of HE within 3 months before recruitment. Age < 18 years, no liver cirrhosis, malignancies and current hospitalization were exclusion criteria. Demographic and clinical data, health related quality of life (HRQoL) score SF-36, psychometric hepatic encephalopathy score (PHES) and critical flicker frequency (CFF) were assessed and monitored quarterly for one year. Primary endpoint was a novel clinical manifestation of HE necessitating hospital admission. Secondary endpoints were the combined endpoint of hospital admission for a novel HE episode and/or death, the dynamics of the West Haven Criteria (WHC) as well as changes in CFF, PHES and SF-36. RESULTS: A total of 115 patients were recruited. Fourteen patients (12.4 %) died during the study period due to complications of liver cirrhosis other than HE. For 67 subjects follow-up data were available in accordance with the protocol. After a median of 113 days half of the per protocol cohort (N = 34) was re-admitted due to a recurrent manifestation of HE. The patient groups with and without re-hospitalization differed significantly regarding recruitment sites (LT centers vs no LT centers) (P = 0.005), interval from discharge to recruitment (P = 0.007), history of more than 4 HE relapses prior to recruitment (P = 0.029), SF-36 mental score (P = 0.046) and PHES ≤ −3 (P = 0.004), whereas CFF, clinical (e.g. MELD score, WHC grade) and laboratory data did not differ. Of note, CFF performance was correct only in about half of both, the total and the per protocol group. Patients with incorrect CFF performance had worse PHES results than those with valid CFF measurement. Multiple logistic regression analysis revealed a PHES test result of ≤−3 as an independent risk factor for re-hospitalization (P = 0.046). CONCLUSIONS: Mortality in our cohort is comparatively low. Despite advanced treatment strategies, patients with a history of HE are still sincerely jeopardized to develop recurrent clinical HE. The PHES test appears useful for detection, monitoring and stratification of recurrent HE. Patients with PHES ≤−3 at baseline had an increased risk of deterioration.

245 – Fecal Microbiota Capsular Transplant is Safe and Effective in Patients with Recurrent Hepatic Encephalopathy: A Randomized, Blinded, Placebo-Controlled Trial

245 – Fecal Microbiota Capsular Transplant is Safe and Effective in Patients with Recurrent Hepatic Encephalopathy: A Randomized, Blinded, Placebo-Controlled Trial

Su1519 – Rifaximin and Lactulose Combination Therapy Versus Lactulose Alone for Prevention of Overt Hepatic Encephalopathy Recurrence: A Pooled Analysis of Two Randomized Trials

Su1519 – Rifaximin and Lactulose Combination Therapy Versus Lactulose Alone for Prevention of Overt Hepatic Encephalopathy Recurrence: A Pooled Analysis of Two Randomized Trials

PS-087-Fecal microbiota capsules are safe and effective in patients with recurrent hepatic encephalopathy: A randomized, blinded, placebo-controlled trial

PS-087-Fecal microbiota capsules are safe and effective in patients with recurrent hepatic encephalopathy: A randomized, blinded, placebo-controlled trial

Portosystemic shunts and refractory hepatic encephalopathy: patient selection and current options.

Portosystemic shunt (PS) syndrome encompasses a spectrum of disease manifestations ranging from asymptomatic portal hypertension to recurrent and refractory hepatic encephalopathy, ultimately culminating in progressive hepatic failure in patients of cirrhosis and associated large PSs. PSs commonly seen in cirrhosis include splenorenal, gastrorenal, and dilated paraumbilical veins, all of which can present with recurrent or refractory hepatic encephalopathy. In this exhaustive review, we describe the anatomy of PSs, elucidate new theories on their pathophysiology, discuss the clinical implications of PSs in cirrhosis, provide details on different techniques (classical and novel) of shunt embolization, and explore all the pertinent current literature on shunt embolization for refractory and recurrent hepatic encephalopathy, all of which are enumerated with extensive images and illustrations.

Infantile onset diabetes mellitus and recurrent hepatic encephalopathy

We present a case with recurrent hepatic encephalopathy and infantile onset diabetes mellitus where a novel mutation was detected in the EIF2AK3 gene which confirmed the Wolcott Rallison syndrome (WRS) and also briefly review literature related to WRS. Insulin dependent diabetes mellitus (IDDM) diagnosed below the age of 6 months is often due to genetic mutations related to pancreatic development and insulin production. They need to be recognized as some respond to oral drugs like sulphonylureas and need recurrence risk evaluation for the next sibling.

Understanding the impact of neurologic complications in patients with cirrhosis.

Patients with cirrhosis may experience neurologic complications, including hepatic encephalopathy. Hepatic encephalopathy may be classified as covert (mild symptoms (e.g. lack of awareness)) or overt (moderate to severe symptoms (e.g. confusion or coma)), and symptoms may overlap with other neurologic conditions (e.g. epilepsy, stroke). Managing hepatic encephalopathy includes identifying and treating precipitating factors (e.g. dehydration). First-line treatment for patients with overt hepatic encephalopathy is typically lactulose; to reduce the risk of overt hepatic encephalopathy recurrence, lactulose plus the nonsystemic antibiotic rifaximin is recommended. Rifaximin reduced the risk of breakthrough overt hepatic encephalopathy by 58% versus placebo over 6 months (p < 0.001; 91% of patients in each group were on concomitant lactulose). However, neither pharmacologic hepatic encephalopathy treatment nor liver transplantation may completely reverse neurologic impairment in patients with hepatic encephalopathy. Additional neurologic considerations for patients with cirrhosis include preventing falls, as well as managing sleep-related issues, hyponatremia, and cerebral edema. Thus, monitoring neurologic impairment is an important component in the management of patients with cirrhosis.

Preliminary experience with single fecal microbiota transplant for treatment of recurrent overt hepatic encephalopathy-A case series.

Experimental studies demonstrated that fecal microbiota transplant (FMT) may reverse intestinal microbial dysbiosis. In this retrospective case series, we share our experience of treating recurrent overt hepatic encephalopathy (HE) with single FMT treatment. A total of 10 patients, age ranged from 25 to 65years, were treated with single FMT through colonoscopy using fecal material received from rigorously screened patient-identified donors. There was sustained clinical response with single FMT treatment in 6 patients at post-treatment week 20. Arterial ammonia concentration decreased considerably (96 [87.25-117.75] vs. 74 [70-82]; p = 0.024) at post-treatment week 20. Moreover, there was statistically significant decrease in Child-Turcotte-Pugh (CTP) score (9.5 [9-10.75] vs. 8 [7-8]; p = 0.005) and model for end-stage liver disease (MELD) score (18 [16.25-19] vs. 15 [14-16]; p = 0.008). Four patients experienced six adverse-events. Overt HE and re-hospitalization were observed in 3 and 2 patients, respectively. One patient (who also experienced overt HE) died within 2months of the index procedure.

Assessment and Management of Nutrition Status in the Hospitalized Patient With Cirrhosis.

Assessment and Management of Nutrition Status in the Hospitalized Patient With Cirrhosis.

Recurrent Hepatic Encephalopathy Due to Spontaneous Mesocaval Shunt

Spontaneous portosystemic shunting is a rare entity that can manifest as hepatic encephalopathy (HE) in longstanding liver disease. In cases of severe portal hypertension (pHTN) portal blood flow may reverse with shunting from the portal vein to the inferior vena cava through a portosystemic anastomosis. Shunting allows toxins to accumulate in the systemic circulation leading to encephalopathy. We present a case of spontaneous mesocaval shunting in a patient with recurrent HE. A 76 year old female with history of Hepatitis B cirrhosis, grade II varices, and multiple admissions for HE presented for acute altered mental status for 1 day. At baseline, she is functionally independent and takes lactulose, rifaxamin, nadolol, entecavir, spironolactone, furosemide, and omeprazole. On presentation, she was not alert or orientated, minimally responsive to voice, moving only to pain, eye-blink startle reflex present but without tracking. There were facial spider angiomas, but no jaundice, ascites or asterixis. She was hemodynamically stable with mild pan-elevation of liver tests, hyperammonemia, hypoalbuminemia, macrocytosis with thrombocytopenia and mild coagulopathy. Prior work-up was limited to head CT and abdominal ultrasound due to acute kidney injury, and negative infectious work-up. CT abdomen on presentation revealed stable appearance of cirrhotic liver, as well as pHTN including recanalization of the umbilical vein, esophageal and omental varices, and mesocaval shunt adjacent to the left portal vein consistent with AV shunting. Interventional radiology was consulted for closure of the shunt and after 3 days of medical therapy, her mental status improved to baseline. Initial attempt was unsuccessful in catheterizing the shunt through the inferior vena cava, while a second attempt through the transplenic portogram and embolization of mesocaval shunt was successful. Patient made a stable recovery after the intervention for discharge. Spontaneous mesocaval shunting is a rare collateral circulation that develops between the superior or inferior mesenteric veins and the inferior vena cava. Similar collateral vessels can manifest as patent paraumbical vessels arising from the left portal vein, as seen in this patient. A high index of suspicion in patients with HE with appropriate imaging is needed to make a diagnosis. Treatment of these shunts via occlusion is crucial in reducing the occurrence of recurrent HE in cirrhosis.2292_A Figure 1. Axial CT - Demonstrates large portosystemic shunt arising from the superior mesenteric vein with its confluence at the inferior vena cava. A transplenic approach was utilized to gain access into the portal system and the mesocaval shunt was subselected.2292_B Figure 2. Robust flow was noted on venograms through the shunt pre-embolization. The mesocaval shunt was embolized with multiple coils of varying sizes and with nBCA.2292_C Figure 3. Final venograms demonstrated complete occlusion of the shunt and preferential flow through to the portal vein post-procedure.

Transjugular intrahepatic portosystemic shunt for the prevention of recurrent esophageal variceal bleeding in patients with cavernous transformation of portal vein

Treatment options for patients with cavernous transformation of portal vein (CTPV) are limited. This study aimed to evaluate the feasibility, efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) to prevent recurrent esophageal variceal bleeding in patients with CTPV. We retrospectively analyzed 67 consecutive patients undergone TIPS from January 2011 to December 2016. All patients were diagnosed with CTPV. The indication for TIPS was a previous episode of variceal bleeding. The data on recurrent bleeding, stent patency, hepatic encephalopathy and survival were retrieved and analyzed. TIPS procedure was successfully performed in 56 out of 67 (83.6%) patients with CTPV. TIPS was performed via a transjugular approach alone (n = 15), a combined transjugular/transhepatic approach (n = 33) and a combined transjugular/transsplenic approach (n = 8). Mean portosystemic pressure gradient (PSG) decreased from 28.09 ± 7.28 mmHg to 17.53 ± 6.12 mmHg after TIPS (P < 0.01). The probability of the remaining free recurrent variceal bleeding was 87.0%. The probability of TIPS patency reached 81.5%. Hepatic encephalopathy occurrence was 27.8%, and survival rate was 88.9% until the end of follow-up. Four out of 11 patients who failed TIPS died, and 4 had recurrent bleeding. TIPS should be considered a safe and feasible alternative therapy to prevent recurrent esophageal variceal bleeding in patients with CTPV, and to achieve clinical improvement.

A Head CT is Unnecessary in the Initial Evaluation of A Cirrhotic Patient with Recurrent Hepatic Encephalopathy

Introduction and aim. The evaluation to determine the cause of hepatic encephalopathy consists primarily of laboratory testing to rule out infections and metabolic causes. Despite lack of evidence, it is a common practice amongst clinicians to obtain a head CT as part of their initial evaluation in a cirrhotic presenting with recurrent episodes of hepatic encephalopathy.Material and methods. Medical records of all cirrhotic adults admitted to a tertiary care hospital from 2007 to 2010 with hepatic encephalopathy were reviewed.Results. In 67 patients, there were 147 episodes of hepatic encephalopathy where a head CT was performed. Six CTs had intracranial findings explaining hepatic encephalopathy. Two patients had focal neurologic findings on physical exam with no history of trauma, one had a history of trauma with no focal neurologic deficits and two had both a history of trauma and focal neurologic findings. Only one case revealed an intracranial hemorrhage with neither a preceding history of trauma nor positive neurological signs. The overall prevalence of intracranial findings in hepatic encephalopathy was 4% (6/147) and 0.6% (1/142) in the absence of trauma or focal neurologic findings. Laboratory and clinical variables including mean levels of ammonia, sodium, creatinine, bilirubin, albumin, platelet count, INR, encephalopathy grade and MELD score did not have a statistically significant impact on head CT findings (P > .05).Conclusion. In conclusion, the yield of a head CT in determining the cause of change in mental status is extremely low in patients with cirrhosis who present with recurrent hepatic encephalopathy.

Lactulose and Rifaximin as Prevention for Recurrence Hepatic Encephalopathy

Hepatic encephalopathy is one of the complications of liver cirrhosis. There are several pharmacological therapies that can be used to treat hepatic encephalopathy, which are Lactulose and antibiotics, such as Rifaximin. Currently, Lactulose is the standard treatment to reduce the level of ammonia circulating in the blood, however, there is still no enough evidence that Lactulose itself can prevent recurrence of hepatic encephalopathy. Combination therapy of Lactulose with antibiotic is a promising therapy to prevent recurrence of hepatic encephalopathy. Literature searching through four databases (PubMed®, Cochrane Library®, EBSCOHost®, and SCOPUS®) were performed. Using the inclusion and exclusion criteria, there were three journals, which were two randomized control trials and one retrospective cohort study, that were selected and correlated with the clinical cast. All articles were appraised for validity, importance, and applicability. The studies show that giving Lactulose combined with Rifaximin significantly reduced the recurrence of hepatic encephalopathy with HR 0.42 (CI: 0.28 to 0.64, p &lt; .001) and significantly lower readmission rate (p &lt; .05) in 180 days. Giving Rifaximin in combination with Lactulose can prevent recurrence of hepatic encephalopathy and lowering the readmission rate in patients suffering from overt hepatic encephalopathy.

10. Transjugular intrahepatic porto-systemic shunt (TIPSS) – single tertiary care centre experience

Background and Aims: TIPSS is a life saving procedure in cirrhotic patients with recurrent portal hypertension bleed and a palliative procedure for resistant ascites and hydrothorax. Methods: Clinical data of concurrent patients who underwent TIPSS for various indications from 2014 to 2018 was analyzed retrospectively Results: Total 16 patients underwent TIPSS during this period. Mean age was 53 (12–71) years, predominantly males (M:F:: 11:5), most common cause of underlying cirrhosis was cryptogenic. Mean MELD score was 16 (10–24), most common indication was resistant ascites (RA-10), other indications were RA+ hydrothorax (3), budd chiari syndrome with failed venous plasty (1), hepato renal syndrome (2). One of the patient had partial portal vein thrombosis and one had chronic portal vein thrombosis with large collaterals. TIPSS was placed from right hepatic vein to a collateral. In most of the patients covered stent was used except in 5, all were started on dual antiplatelets and LMWH post procedure, however stent patency rate was similar in both the groups. Most of the patients improved after the procedure, 2 patients required recurrent ascitic tapping for 3 months post TIPSS however ascites responded. 5 patients out of 16 had recurrent hepatic encephalopathy requiring admission but all of them were managed with anti coma measures, none required stent size reduction. One of them underwent liver transplant, 1 had subdural hematoma. Mean survival of our group post TIPSS was 16.6 (0.2–48) months. TIPSS patency was 100% in the study period. Conclusions: TIPSS has good survival benefits in well-chosen patients with life threatening complications related to cirrhosis. TIPSS could provide a good quality of life in those who don’t have option of liver transplant. Anticoagulation may not be a must in all patients to maintain TIPSS patency. The authors have none to declare.

Spontaneous thrombosis of large splenorenal shunt during balloon-occluded retrograde transvenous obliteration in a patient with chronic persistent hepatic encephalopathy. Is this catheter assisted trans-venous occlusion?

Large spontaneous portosystemic shunts in cirrhosis are implicated in recurrent and/or chronic persistent hepatic encephalopathy. In long standing cases, these shunts lead to portal vein thrombosis and hepatic dysfunction. Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique that is usually employed for shunt closure in the patients manifesting the features of chronic hepatic encephalopathy. There are several reports documenting systemic and portal vein thrombosis as a part of the procedure. We report first time a patient in whom the difficult and partial BRTO procedure led to the extensive thrombosis of the large splenorenal shunt itself without sclerosant instillation.

Fecal microbiota transplant from a rational stool donor improves hepatic encephalopathy: A randomized clinical trial.

FMT from a rationally selected donor reduced hospitalizations, improved cognition, and dysbiosis in cirrhosis with recurrent HE. (Hepatology 2017;66:1727-1738).

Fecal microbiota transplantation for treating recurrent hepatic encephalopathy: Ready for clinical application?

Fecal microbiota transplantation for treating recurrent hepatic encephalopathy: Ready for clinical application?

Retrospective cross-sectional pilot study of rifaximin dosing for the prevention of recurrent hepatic encephalopathy.

Standard treatment for hepatic encephalopathy (HE) includes medications that reduce ammonia and bacterial translocation in the gut. Rifaximin can be used off-label for the reduction of overt HE. The study purpose was to determine efficacy of traditional rifaximin dosing (400mg three times daily) compared with newer dosing (550mg twice daily) via readmission rates for the prevention of recurrent HE. This was a retrospective, observational, cross-sectional pilot study conducted in a tertiary medical center. A total of 226 patients 18-89years of age with documentation of HE via ICD-9 code who started rifaximin therapy while inpatient between April 2009 and June 2014 were evaluated. Data collected included rifaximin dosing, other medications used to treat HE, duration of therapy, time to readmission, and various laboratory values. There were no differences in readmission rates at 30days, 60days, or 6months between treatment groups. Additionally, there was no difference in the odds of readmission between the treatment groups (OR=0.77, 95% CI: [0.201, 4.365], P=0.718). Patients had a low overall probability of readmission over the observational period. Based on average wholesale price data, the cost for a 9-day supply of rifaximin for the 400-mg dosing regimen is $952.56 versus $605.16 for the 550-mg dosing regimen. The rifaximin 550-mg dosing strategy should be utilized in hospitalized patients for the prevention of recurrent HE as there was no difference in readmission rate or time to readmission between dosing groups. The 550-mg regimen had a lower acquisition cost for a 9-day duration of treatment in the studied institution.