prabin kumar bam, introduction of hepatic encephalopathy, treatment measures, drugs used in hepatic encephalopathy, management of hepatic encephalopathy, role of lactulose, role of antibiotics (Rifaximin), nutrition, liver transplantation, prophylaxis,

1. DRUGS USED IN HEPATIC
ENCEPHALOPATHY
Prabin Kumar Bam
Chitwan Medical College
Bharatpur, Nepal
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2. Hepatic Encephalopathy
• Hepatic encephalopathy is a brain dysfunction
caused by liver insufficiency and/or
portosystemic shunt.
• In this disorder, nitrogenous waste products
(chiefly ammonia) accumulates in systemic
circulation. Then they cross blood-brain barrier,
enter brain and affect it.
• Symptoms: Personality changes, intellectual
impairment, decresed consciousness and coma in
the advanced stage.
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3. Treatment measures
Hospitalization
Maintain ABC
Remove the cause and precipitating factor.
IV dextrose, saline and Inj. Thiamine.
Reduce ammonia load.
Proper nutrition
Inj. Vitamin K
Liver transplantation.
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4. Non absorbable disaccharides
• Lactulose
• Lactilol
• First line drug
therapy.
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5. • Mechanism of Action:
Disaccharides → monosaccharides → volatile
fatty acid (VFA) + H ions.
VFA : promotes bacterial growth, which form
bulk.
H ions: decrease pH which causes;
1. ↓ synthesis & absorption of ammonia.
2. ↑movement of ammonia from blood to GIT.
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6. • Dose: 15- 30 ml given twice a day to induce
2-3 soft bowel movements daily.
Can be given as rectal enema.
• Adverse effects: Bloating, hypokalemia,
aspiration and dehydration.
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7. Antibiotics - Rifaximin
• MOA: Selectively eliminates urease producing
bacteria.
• It is given in combination with lactulose.
• Dose: 550mg/ 12hr.
• AE: abdominal pain, flatulence, headache and
constipation.
• Other antibiotics like Metronidazole and
Neomycin can also be used.
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8. Oral branched-chain amino acids
(BCCAs)
• Increase the manifestations of episodic HE.
• Leucine → stimulate liver regeneration.
• They increase albumin synthesis and improve
immunity.
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9. L- ornithine L- aspartate (LOLA)
• Can be given IV (preferred) or oral.
• They help in detoxification of ammonia by
promoting metabolic pathways and urea cycle.
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10. Zinc supplementation
• Zn deficiency is common in patients with liver
cirrhosis.
• Zinc increases the activity of an enzyme in the
urea cycle (ornithine transcarbamylase). And
hence helps in improvement of HE.
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11. Other ammonia lowering agents
• Probiotics
• Sodium benzoate
• Glycerol phenyl butyrate
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12. • Approximately 75% of patients with HE suffer
moderate to severe protein-calorie
malnutrition.
• So, vegetable proteins should be given (60-
80g/day). They are well tolerated than animal
proteins.
• High glucose diet (35-40kcal/kg wght.).
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Nutrition

13. Liver transplantation
• Recommended in recurrent HE and treatment
resistant cases.
• It results in complete resolution of HE.
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14. Prophylaxis
 Combined Lactulose and Rifaximin should be
used.
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15. References
• Harrison’s Principles of Internal Medicine.
• Davidson’s Principles and Practice of
Medicine.
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