SlideShare ist ein Scribd-Unternehmen logo
1 von 32
Downloaden Sie, um offline zu lesen
PROF DR NASIR KHOKHAR MD FACP FACG
PROFESSOR OF MEDICINE AND AND
DIRECTOR, DIVISION OF
GASTROENTEROLOGY
SHIFA INTERNATIONAL HOSPITAL
ISLAMABAD
Portosystemic Encephalopathy:
Towards improved management
Spectrum of HE
Shapes of HE
Forms of HE
West Haven classification
Stages of Hepatic Encephalopathy
Management of hepatic encephalopathy
Ammonia effects
Management of hepatic encephalopathy
Ammonia Management
 Clean the bowel bacteria: Lactulose
 Kill the bowel bacteria: antibiotics
 Improve ammonia clearance: L-ornithine
L-aspartate
 Muscular metabolism
 Save brain
Empiric therapy of HE
 Correction of underlying factor(s)
 Reducing production and absorption of
ammonia in gut
Precipitating causes of HE
 Sepsis
 Gastrointestinal hemorrhage
 Constipation
 Dietary protein overload
 Sedatives
 Hypokalemia/diuretics/diarrhea
 Poor compliance with lactulose
 Anesthesia
Ahmed H, et al. Factors precipitating Hepatic Encephalopathy in Cirrhosis Liver
J Postgrad Med Inst Jan 2001;15(1):91-7.
Hepatic Encephalopathy Precipitants
Inadequate clinical response
 Improvement in 24-48 hours of treatment
 If HE persists after 72 hours then consider:
 Other causes of encephalopathy
 Precipitating factor missed, inadequately
treated
 Effective treatment not instituted
 Effects of therapy ?lactulose
Non-absorbable diasaccharides
 Lactulose is a non-absorbable disaccharide that is
fermented in the colon.
 The exact mechanism of action remains unclear;
acidification of colonic contents and mass
evacuation of bacteria have been proposed.
 Associated with improvement in mental status
Mullen KD, Amodio P, Morgan MY. Therapeutic studies in hepatic
encephalopathy. Metab Brain Dis 2007; 22: 407–23.
Als-Nielsen B, et al. Nonabsorbable disaccharides for hepatic encephalopathy.
Cochrane Database Syst Rev 2004; 2: CD003044.
Efficacy of Lactulose and Protein Restriction
 Lactulose has no significant effect on mortality in
patients with hepatic encephalophathy compared with
placebo
 Protein restriction offers no apparent benefit
 May create protein levels insufficient for maintaining positive
nitrogen balance needed in cirrhosis
Shawcross D, Jalan R. Lancet. 2005;365:431-433.
Actions Of Lactulose
Antibiotics
 Neomycin
 Vancomycin
 Metronidazole
 Rifaximin
 Quinolones
Non-absorbable antibiotics
 Rifaximin is a non-absorbable antibiotic
 Cochrane review recommends the use of non-
absorbable antibiotics.
 Given up to 1200 mg/day.
 Reduced hospitalization rates after rifaximin therapy
compared with that of lactulose.
 The drug expense remains a concern
Alcorn J. Review: rifaximin is equally or more effective than other antibiotics
and lactulose for hepatic encephalopathy. ACP J Club 2008; 149: 11.
Rifaximin Study Design
Bass NM, et al. N Engl J Med. 2010;362:1071-1081.
Patients with recurrent HE,
currently inremission
(N = 299)
Rifaximin 550 mg BID*
(n = 140)
Placebo*
(n = 159)
Mo 6
*Concomitant lactulose permitted.
Main Findings
 Significantly fewer breakthrough HE episodes and significantly
lower rate of hospitalizations involving HE observed among
patients treated with rifaximin vs placebo
 Number needed to treat for 6 mos to prevent 1 overt HE episode: 4
 Number needed to treat for 6 mos to prevent 1 hospitalization
involving HE: 9
Bass NM, et al. N Engl J Med. 2010;362:1071-1081.
Outcome at Mo 6 Rifaximin, n (%)
(n = 140)
Placebo, n (%)
(n = 159)
HR for Time to
First Event
(95% CI)
P Value
Breakthrough HE 31 (22.1) 73 (45.9) 0.42 (0.28-0.64) < .001
Hospitalization 19 (13.6) 36 (22.6) 0.50 (0.29-0.87) .01
Summary of Key Conclusions
 Rifaximin significantly more effective than placebo at preventing
additional episodes of HE over 6-mo period in patients with
recurrent HE in remission
 Risk of breakthrough HE reduced by 58%
 Risk reduction consistent across nearly all patient subgroups
 Majority of patients (> 90%) in both arms received concomitant
lactulose
 Rifaximin also resulted in significant 50% reduced risk of
hospitalization due to HE
 Rifaximin well tolerated with no increased incidence of adverse
events, serious adverse events, or infections compared with
placebo
Bass NM, et al. N Engl J Med. 2010;362:1071-1081.
L ornithine L aspartate
 LOLA can improve overt HE I or II patients
 Hospital stay was reduced.
 Data do not support the use of LOLA for patients
with subclinical hepatic encephalopathy.
 Trials detecting efficacy and safety were of high
quality.
Abid S, et al. Efficacy of infusion of L-ornithine L-aspartate in cirrhotic patients
with portosystemic encephalopathy: a placebo controlled study.
J. Hepatol. 2005; 42 (Suppl. 2): 84.
Sodium benzoate
 Sodium benzoate and sodium phenylacetate bind
with ammonia substrates and thus take them out of
the circulation.
 One small study reported that sodium benzoate was
as effective as lactulose in reducing ammonia levels
and improving cognitive function.
 Severe accidental overdose has been reported
Sushma S, et al. Sodium benzoate in the treatment of acute hepatic
encephalopathy: a double-blind randomized trial. Hepatology 1992;16:138–44.
Zinc
 Zinc deficiency is common in cirrhosis.
 Zinc administration has the potential to improve
hyperammonemia by increasing the activity of
ornithine transcarbamylase, an enzyme in the urea
cycle.
 Zinc sulfate and zinc acetate have been used at a
dose of 600 mg orally every day in clinical trials.
 Hepatic encephalopathy improved in 2 studies
Bresci G, et al. Management of hepatic encephalopathy with oral
zinc supplementation: a long-term treatment. Eur J Med. 1993;2(7):414-6.
Detoxification systems
 The molecular adsorbant recirculating system
(MARS) removes protein-bound and water-soluble
toxins.
 A short-term (5-day), multicenter, randomized study
compared the use of MARS with standard medical
therapy.
 Significantly more rapid improvement in mental
status was observed in the MARS group (p=0.044).
 The role of albumin dialysis unclear.
Hassanein TI, et al. Randomized controlled study of extracorporeal albumin
dialysis for hepatic encephalopathy. Hepatology 2007;46: 1853–62.
Probiotics
 Probiotics are live, microbiologic dietary
supplements (e.g., yogurt).
 Work by depriving pathogenic bacteria of substrates
and providing fermentation products for beneficial
bacteria.
 Two small studies reported neuropsychological
improvement in patients with MHE.
Malaguarnera M, et al. Bifidobacterium longum with fructo-oligosaccharide (FOS)
treatment in minimal hepatic encephalopathy: a randomized, double-blind,
placebocontrolled study. Dig Dis Sci 2007;52:3259–65.
Bajaj JS, et al. Probiotic yogurt for the treatment of minimal hepatic
encephalopathy. Am J Gastroenterol 2008;103:1707–15.
BRAIN
KIDNEY
GUT
LIVER
MUSCLE
NH3
Glutamin
e
Lactulose
Acarbose
ABX
LOLA
UREA
Mechanism of Action of Drugs
Other Management
 Alternative targets for ammonia reduction
 Kidneys produce, excrete significant ammonia
 Volume expansion promotes excretion, reduces plasma ammonia
 Muscle converts ammonia to glutamine in hyperammonemia
 L-ornithin L-aspartate (LOLA) increases muscle detoxification
 Reduction in inflammation and potential infection
 Targets: nitric oxide, proinflammatory cytokines, free radicals
 Liver detoxicification via liver support systems
 Reduction in cerebral hyperemia, intracranial
hypertension
 Moderate hypothermia treatment reduces cerebral blood flow
Shawcross D, Jalan R. Lancet. 2005;365:431-433.
Liver transplant
 The ultimate management goal for OHE is
the replacement of the diseased liver.
 Therefore, liver transplant work-up is
crucial for the management of OHE after
correction of the acute insult and prevention
of recurrences.
Management of hepatic encephalopathy
THANK YOU FOR YOUR ATTENTION

Weitere ähnliche Inhalte

Was ist angesagt?

Renal tubular acidosis
Renal tubular acidosisRenal tubular acidosis
Renal tubular acidosisZaheen Zehra
 
Acute kidney injury
Acute kidney injury Acute kidney injury
Acute kidney injury anoop k r
 
20 hepatic enchephalopathy
20 hepatic enchephalopathy20 hepatic enchephalopathy
20 hepatic enchephalopathyinternalmed
 
Hepatic encephalopathy final
Hepatic encephalopathy finalHepatic encephalopathy final
Hepatic encephalopathy finalbiplave karki
 
Autoimmune Hepatitis
Autoimmune HepatitisAutoimmune Hepatitis
Autoimmune HepatitisPratap Tiwari
 
Autoimmune hepatitis rajesh
Autoimmune hepatitis rajeshAutoimmune hepatitis rajesh
Autoimmune hepatitis rajeshMohit Aggarwal
 
Tubulointerstitial Nephritis
Tubulointerstitial NephritisTubulointerstitial Nephritis
Tubulointerstitial Nephritisautumnpianist
 
Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)Tauhid Bhuiyan
 
Cirrosis of liver and its complication and traetment of hep b and c
Cirrosis of liver and its complication and traetment of hep b and cCirrosis of liver and its complication and traetment of hep b and c
Cirrosis of liver and its complication and traetment of hep b and cAdrija Hajra
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathyRINA7373
 
Primary Biliary Cholangitis
Primary Biliary CholangitisPrimary Biliary Cholangitis
Primary Biliary CholangitisPratap Tiwari
 
Approach to Rapidly Progressive Glomerulonephritis RPGN
Approach to Rapidly Progressive Glomerulonephritis RPGNApproach to Rapidly Progressive Glomerulonephritis RPGN
Approach to Rapidly Progressive Glomerulonephritis RPGNGarima Aggarwal
 
Approach to a Patient with Acute kidney injury
Approach to a Patient with Acute kidney injury Approach to a Patient with Acute kidney injury
Approach to a Patient with Acute kidney injury AIIMS, New Delhi, India
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathyArun George
 
Cholestatic syndromes
Cholestatic syndromes Cholestatic syndromes
Cholestatic syndromes Gautam Nath
 

Was ist angesagt? (20)

Renal tubular acidosis
Renal tubular acidosisRenal tubular acidosis
Renal tubular acidosis
 
Acute kidney injury
Acute kidney injury Acute kidney injury
Acute kidney injury
 
20 hepatic enchephalopathy
20 hepatic enchephalopathy20 hepatic enchephalopathy
20 hepatic enchephalopathy
 
Hepatic encephalopathy final
Hepatic encephalopathy finalHepatic encephalopathy final
Hepatic encephalopathy final
 
Autoimmune Hepatitis
Autoimmune HepatitisAutoimmune Hepatitis
Autoimmune Hepatitis
 
Autoimmune hepatitis rajesh
Autoimmune hepatitis rajeshAutoimmune hepatitis rajesh
Autoimmune hepatitis rajesh
 
Tubulointerstitial Nephritis
Tubulointerstitial NephritisTubulointerstitial Nephritis
Tubulointerstitial Nephritis
 
Ckd mbd
Ckd mbdCkd mbd
Ckd mbd
 
Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)
 
Cirrosis of liver and its complication and traetment of hep b and c
Cirrosis of liver and its complication and traetment of hep b and cCirrosis of liver and its complication and traetment of hep b and c
Cirrosis of liver and its complication and traetment of hep b and c
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathy
 
Acute kidney injury
Acute kidney injuryAcute kidney injury
Acute kidney injury
 
Renal anemia
Renal anemiaRenal anemia
Renal anemia
 
Dyspepsia
Dyspepsia Dyspepsia
Dyspepsia
 
Primary Biliary Cholangitis
Primary Biliary CholangitisPrimary Biliary Cholangitis
Primary Biliary Cholangitis
 
Approach to Rapidly Progressive Glomerulonephritis RPGN
Approach to Rapidly Progressive Glomerulonephritis RPGNApproach to Rapidly Progressive Glomerulonephritis RPGN
Approach to Rapidly Progressive Glomerulonephritis RPGN
 
Approach to a Patient with Acute kidney injury
Approach to a Patient with Acute kidney injury Approach to a Patient with Acute kidney injury
Approach to a Patient with Acute kidney injury
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathy
 
Acute kidney injury
Acute kidney injuryAcute kidney injury
Acute kidney injury
 
Cholestatic syndromes
Cholestatic syndromes Cholestatic syndromes
Cholestatic syndromes
 

Andere mochten auch

Hepatic encephalopathy, short review & update
Hepatic encephalopathy, short review & updateHepatic encephalopathy, short review & update
Hepatic encephalopathy, short review & updateRushdanZakariah
 
Hepatic encephalopathy presentation latest aspect
Hepatic encephalopathy presentation latest aspectHepatic encephalopathy presentation latest aspect
Hepatic encephalopathy presentation latest aspectJuned Khan
 
[2015] hepatic encephalopathy
[2015] hepatic encephalopathy[2015] hepatic encephalopathy
[2015] hepatic encephalopathyAyman Alsebaey
 
Copy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel Kareem
Copy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel KareemCopy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel Kareem
Copy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel KareemAhmed-shedeed
 
Hepato encephalopathy
Hepato encephalopathyHepato encephalopathy
Hepato encephalopathyRs Naraa
 
Hepatic encephalopathy by dreams
Hepatic encephalopathy by dreamsHepatic encephalopathy by dreams
Hepatic encephalopathy by dreamsDreams Higher
 
Pelvic fracture by Dr.Ushma saini
Pelvic fracture by Dr.Ushma sainiPelvic fracture by Dr.Ushma saini
Pelvic fracture by Dr.Ushma sainiushma Saini
 
Hepatic encephalopathy by Dr: Mohammed Hussien Ahmed
Hepatic encephalopathy by Dr: Mohammed Hussien AhmedHepatic encephalopathy by Dr: Mohammed Hussien Ahmed
Hepatic encephalopathy by Dr: Mohammed Hussien AhmedKafrelsheiekh University
 
Hepatic encephalopathy: biochemical basis
Hepatic encephalopathy: biochemical basisHepatic encephalopathy: biochemical basis
Hepatic encephalopathy: biochemical basisPrabhash Bhavsar
 
Liver Diseases And Hepatic Encephalopathy
Liver Diseases And Hepatic EncephalopathyLiver Diseases And Hepatic Encephalopathy
Liver Diseases And Hepatic Encephalopathyyushu zhang
 
Hepatic encephalopathy 2012 presentation
Hepatic encephalopathy  2012 presentationHepatic encephalopathy  2012 presentation
Hepatic encephalopathy 2012 presentationIko Musa
 
Rifaximin treatment in hepatic encephalopathy
Rifaximin treatment in hepatic encephalopathyRifaximin treatment in hepatic encephalopathy
Rifaximin treatment in hepatic encephalopathyPratap Tiwari
 

Andere mochten auch (17)

Hepatic encephalopathy, short review & update
Hepatic encephalopathy, short review & updateHepatic encephalopathy, short review & update
Hepatic encephalopathy, short review & update
 
Hepatic encephalopathy presentation latest aspect
Hepatic encephalopathy presentation latest aspectHepatic encephalopathy presentation latest aspect
Hepatic encephalopathy presentation latest aspect
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathy
 
[2015] hepatic encephalopathy
[2015] hepatic encephalopathy[2015] hepatic encephalopathy
[2015] hepatic encephalopathy
 
Copy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel Kareem
Copy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel KareemCopy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel Kareem
Copy of pelvic_fractures_o6th_u_presentation by dr. mahmoud Abdel Kareem
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathy
 
Hepato encephalopathy
Hepato encephalopathyHepato encephalopathy
Hepato encephalopathy
 
Hepatic Encephalopathy
Hepatic EncephalopathyHepatic Encephalopathy
Hepatic Encephalopathy
 
Hepatic encephalopathy by dreams
Hepatic encephalopathy by dreamsHepatic encephalopathy by dreams
Hepatic encephalopathy by dreams
 
Pelvic fracture by Dr.Ushma saini
Pelvic fracture by Dr.Ushma sainiPelvic fracture by Dr.Ushma saini
Pelvic fracture by Dr.Ushma saini
 
Hepatic encephalopathy by Dr: Mohammed Hussien Ahmed
Hepatic encephalopathy by Dr: Mohammed Hussien AhmedHepatic encephalopathy by Dr: Mohammed Hussien Ahmed
Hepatic encephalopathy by Dr: Mohammed Hussien Ahmed
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathy
 
Hepatic encephalopathy: biochemical basis
Hepatic encephalopathy: biochemical basisHepatic encephalopathy: biochemical basis
Hepatic encephalopathy: biochemical basis
 
Liver Diseases And Hepatic Encephalopathy
Liver Diseases And Hepatic EncephalopathyLiver Diseases And Hepatic Encephalopathy
Liver Diseases And Hepatic Encephalopathy
 
Hepatic encephalopathy 2012 presentation
Hepatic encephalopathy  2012 presentationHepatic encephalopathy  2012 presentation
Hepatic encephalopathy 2012 presentation
 
Rifaximin treatment in hepatic encephalopathy
Rifaximin treatment in hepatic encephalopathyRifaximin treatment in hepatic encephalopathy
Rifaximin treatment in hepatic encephalopathy
 
Cirrhosis of liver
Cirrhosis of liverCirrhosis of liver
Cirrhosis of liver
 

Ähnlich wie Management of hepatic encephalopathy

REVIEW ARTICLE ON CHRONIC KIDNEY DISEASE
REVIEW ARTICLE ON CHRONIC KIDNEY DISEASEREVIEW ARTICLE ON CHRONIC KIDNEY DISEASE
REVIEW ARTICLE ON CHRONIC KIDNEY DISEASEDhiraj Dhira
 
ANEMIA_IN_CKD.pptx
ANEMIA_IN_CKD.pptxANEMIA_IN_CKD.pptx
ANEMIA_IN_CKD.pptxboscokiuria
 
Alkalinization induced inotropic enhancement
Alkalinization induced inotropic enhancementAlkalinization induced inotropic enhancement
Alkalinization induced inotropic enhancementCosmin Balan
 
Primary pulmonary hypertension
Primary pulmonary hypertensionPrimary pulmonary hypertension
Primary pulmonary hypertensiondrvasudev007
 
Antiepileptic in systemic disorder
Antiepileptic in  systemic disorderAntiepileptic in  systemic disorder
Antiepileptic in systemic disorderNeurologyKota
 
Update on the Management of Pulmonary Hypertension
Update on the Management of Pulmonary HypertensionUpdate on the Management of Pulmonary Hypertension
Update on the Management of Pulmonary HypertensionSarfraz Saleemi
 
Brazilian Red Propolis Attenuates Hypertension and Renal Damage
Brazilian Red Propolis Attenuates Hypertension and Renal DamageBrazilian Red Propolis Attenuates Hypertension and Renal Damage
Brazilian Red Propolis Attenuates Hypertension and Renal DamageBee Healthy Farms
 
Managing hep enceph in out ptn settings
Managing hep enceph in out ptn settingsManaging hep enceph in out ptn settings
Managing hep enceph in out ptn settingsarnab ghosh
 
Hidrasec Bongs Lecture
Hidrasec Bongs LectureHidrasec Bongs Lecture
Hidrasec Bongs LectureRodolfo Rafael
 
Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...
Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...
Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...LucyPi1
 
Alcohol Induce Liver Injury
Alcohol Induce Liver InjuryAlcohol Induce Liver Injury
Alcohol Induce Liver InjuryZulcaif Ahmad
 
Eletro Stimulation of Lower Esophageal Sphincter on GERD treatment
Eletro Stimulation of Lower Esophageal Sphincter  on GERD treatment  Eletro Stimulation of Lower Esophageal Sphincter  on GERD treatment
Eletro Stimulation of Lower Esophageal Sphincter on GERD treatment Manoel Galvao Neto
 
Geriatric%20 Medicine%20 %20 Dr.%20 Cefalu
Geriatric%20 Medicine%20 %20 Dr.%20 CefaluGeriatric%20 Medicine%20 %20 Dr.%20 Cefalu
Geriatric%20 Medicine%20 %20 Dr.%20 CefaluFlavio Guzmán
 

Ähnlich wie Management of hepatic encephalopathy (20)

PAH management
PAH managementPAH management
PAH management
 
ALCOHOLIC hepatitis.pptx
ALCOHOLIC hepatitis.pptxALCOHOLIC hepatitis.pptx
ALCOHOLIC hepatitis.pptx
 
REVIEW ARTICLE ON CHRONIC KIDNEY DISEASE
REVIEW ARTICLE ON CHRONIC KIDNEY DISEASEREVIEW ARTICLE ON CHRONIC KIDNEY DISEASE
REVIEW ARTICLE ON CHRONIC KIDNEY DISEASE
 
Pulmonary hypertension
Pulmonary hypertensionPulmonary hypertension
Pulmonary hypertension
 
ANEMIA_IN_CKD.pptx
ANEMIA_IN_CKD.pptxANEMIA_IN_CKD.pptx
ANEMIA_IN_CKD.pptx
 
Alkalinization induced inotropic enhancement
Alkalinization induced inotropic enhancementAlkalinization induced inotropic enhancement
Alkalinization induced inotropic enhancement
 
Primary pulmonary hypertension
Primary pulmonary hypertensionPrimary pulmonary hypertension
Primary pulmonary hypertension
 
ni3
ni3ni3
ni3
 
Antiepileptic in systemic disorder
Antiepileptic in  systemic disorderAntiepileptic in  systemic disorder
Antiepileptic in systemic disorder
 
Update on the Management of Pulmonary Hypertension
Update on the Management of Pulmonary HypertensionUpdate on the Management of Pulmonary Hypertension
Update on the Management of Pulmonary Hypertension
 
Brazilian Red Propolis Attenuates Hypertension and Renal Damage
Brazilian Red Propolis Attenuates Hypertension and Renal DamageBrazilian Red Propolis Attenuates Hypertension and Renal Damage
Brazilian Red Propolis Attenuates Hypertension and Renal Damage
 
Fibrosis[1]
Fibrosis[1]Fibrosis[1]
Fibrosis[1]
 
Managing hep enceph in out ptn settings
Managing hep enceph in out ptn settingsManaging hep enceph in out ptn settings
Managing hep enceph in out ptn settings
 
ppt
pptppt
ppt
 
Hidrasec Bongs Lecture
Hidrasec Bongs LectureHidrasec Bongs Lecture
Hidrasec Bongs Lecture
 
Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...
Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...
Jian-Gan-Xiao-Zhi decoction ameliorates high-fat high-carbohydrate diet-induc...
 
Alcohol Induce Liver Injury
Alcohol Induce Liver InjuryAlcohol Induce Liver Injury
Alcohol Induce Liver Injury
 
Eletro Stimulation of Lower Esophageal Sphincter on GERD treatment
Eletro Stimulation of Lower Esophageal Sphincter  on GERD treatment  Eletro Stimulation of Lower Esophageal Sphincter  on GERD treatment
Eletro Stimulation of Lower Esophageal Sphincter on GERD treatment
 
60180538 case-study
60180538 case-study60180538 case-study
60180538 case-study
 
Geriatric%20 Medicine%20 %20 Dr.%20 Cefalu
Geriatric%20 Medicine%20 %20 Dr.%20 CefaluGeriatric%20 Medicine%20 %20 Dr.%20 Cefalu
Geriatric%20 Medicine%20 %20 Dr.%20 Cefalu
 

Mehr von drnkhokhar

Outcome of abscess treatment in Crohn's disease
Outcome of abscess treatment in Crohn's diseaseOutcome of abscess treatment in Crohn's disease
Outcome of abscess treatment in Crohn's diseasedrnkhokhar
 
Management of Inflammatory Bowel Disease
Management of Inflammatory Bowel DiseaseManagement of Inflammatory Bowel Disease
Management of Inflammatory Bowel Diseasedrnkhokhar
 
Update on acid peptic disease
Update on acid peptic disease Update on acid peptic disease
Update on acid peptic disease drnkhokhar
 
Challenges in HCV Management
Challenges in HCV Management Challenges in HCV Management
Challenges in HCV Management drnkhokhar
 
Update on Chronic Hepatitis B
Update on Chronic Hepatitis BUpdate on Chronic Hepatitis B
Update on Chronic Hepatitis Bdrnkhokhar
 
Alcoholic liver disease in Pregnancy
Alcoholic liver disease in PregnancyAlcoholic liver disease in Pregnancy
Alcoholic liver disease in Pregnancydrnkhokhar
 
Peg hcv karachi
Peg hcv karachiPeg hcv karachi
Peg hcv karachidrnkhokhar
 
Management of non responders khi
Management of non responders khiManagement of non responders khi
Management of non responders khidrnkhokhar
 
Management of hepatitis c pma
Management of hepatitis c pmaManagement of hepatitis c pma
Management of hepatitis c pmadrnkhokhar
 

Mehr von drnkhokhar (9)

Outcome of abscess treatment in Crohn's disease
Outcome of abscess treatment in Crohn's diseaseOutcome of abscess treatment in Crohn's disease
Outcome of abscess treatment in Crohn's disease
 
Management of Inflammatory Bowel Disease
Management of Inflammatory Bowel DiseaseManagement of Inflammatory Bowel Disease
Management of Inflammatory Bowel Disease
 
Update on acid peptic disease
Update on acid peptic disease Update on acid peptic disease
Update on acid peptic disease
 
Challenges in HCV Management
Challenges in HCV Management Challenges in HCV Management
Challenges in HCV Management
 
Update on Chronic Hepatitis B
Update on Chronic Hepatitis BUpdate on Chronic Hepatitis B
Update on Chronic Hepatitis B
 
Alcoholic liver disease in Pregnancy
Alcoholic liver disease in PregnancyAlcoholic liver disease in Pregnancy
Alcoholic liver disease in Pregnancy
 
Peg hcv karachi
Peg hcv karachiPeg hcv karachi
Peg hcv karachi
 
Management of non responders khi
Management of non responders khiManagement of non responders khi
Management of non responders khi
 
Management of hepatitis c pma
Management of hepatitis c pmaManagement of hepatitis c pma
Management of hepatitis c pma
 

Kürzlich hochgeladen

SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?Ryan Addison
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfMedicoseAcademics
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingAnonymous
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxkitati1
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 

Kürzlich hochgeladen (20)

SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdf
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_Wellbeing
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptx
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 

Management of hepatic encephalopathy

  • 1. PROF DR NASIR KHOKHAR MD FACP FACG PROFESSOR OF MEDICINE AND AND DIRECTOR, DIVISION OF GASTROENTEROLOGY SHIFA INTERNATIONAL HOSPITAL ISLAMABAD Portosystemic Encephalopathy: Towards improved management
  • 6. Stages of Hepatic Encephalopathy
  • 10. Ammonia Management  Clean the bowel bacteria: Lactulose  Kill the bowel bacteria: antibiotics  Improve ammonia clearance: L-ornithine L-aspartate  Muscular metabolism  Save brain
  • 11. Empiric therapy of HE  Correction of underlying factor(s)  Reducing production and absorption of ammonia in gut
  • 12. Precipitating causes of HE  Sepsis  Gastrointestinal hemorrhage  Constipation  Dietary protein overload  Sedatives  Hypokalemia/diuretics/diarrhea  Poor compliance with lactulose  Anesthesia Ahmed H, et al. Factors precipitating Hepatic Encephalopathy in Cirrhosis Liver J Postgrad Med Inst Jan 2001;15(1):91-7.
  • 14. Inadequate clinical response  Improvement in 24-48 hours of treatment  If HE persists after 72 hours then consider:  Other causes of encephalopathy  Precipitating factor missed, inadequately treated  Effective treatment not instituted  Effects of therapy ?lactulose
  • 15. Non-absorbable diasaccharides  Lactulose is a non-absorbable disaccharide that is fermented in the colon.  The exact mechanism of action remains unclear; acidification of colonic contents and mass evacuation of bacteria have been proposed.  Associated with improvement in mental status Mullen KD, Amodio P, Morgan MY. Therapeutic studies in hepatic encephalopathy. Metab Brain Dis 2007; 22: 407–23. Als-Nielsen B, et al. Nonabsorbable disaccharides for hepatic encephalopathy. Cochrane Database Syst Rev 2004; 2: CD003044.
  • 16. Efficacy of Lactulose and Protein Restriction  Lactulose has no significant effect on mortality in patients with hepatic encephalophathy compared with placebo  Protein restriction offers no apparent benefit  May create protein levels insufficient for maintaining positive nitrogen balance needed in cirrhosis Shawcross D, Jalan R. Lancet. 2005;365:431-433.
  • 18. Antibiotics  Neomycin  Vancomycin  Metronidazole  Rifaximin  Quinolones
  • 19. Non-absorbable antibiotics  Rifaximin is a non-absorbable antibiotic  Cochrane review recommends the use of non- absorbable antibiotics.  Given up to 1200 mg/day.  Reduced hospitalization rates after rifaximin therapy compared with that of lactulose.  The drug expense remains a concern Alcorn J. Review: rifaximin is equally or more effective than other antibiotics and lactulose for hepatic encephalopathy. ACP J Club 2008; 149: 11.
  • 20. Rifaximin Study Design Bass NM, et al. N Engl J Med. 2010;362:1071-1081. Patients with recurrent HE, currently inremission (N = 299) Rifaximin 550 mg BID* (n = 140) Placebo* (n = 159) Mo 6 *Concomitant lactulose permitted.
  • 21. Main Findings  Significantly fewer breakthrough HE episodes and significantly lower rate of hospitalizations involving HE observed among patients treated with rifaximin vs placebo  Number needed to treat for 6 mos to prevent 1 overt HE episode: 4  Number needed to treat for 6 mos to prevent 1 hospitalization involving HE: 9 Bass NM, et al. N Engl J Med. 2010;362:1071-1081. Outcome at Mo 6 Rifaximin, n (%) (n = 140) Placebo, n (%) (n = 159) HR for Time to First Event (95% CI) P Value Breakthrough HE 31 (22.1) 73 (45.9) 0.42 (0.28-0.64) < .001 Hospitalization 19 (13.6) 36 (22.6) 0.50 (0.29-0.87) .01
  • 22. Summary of Key Conclusions  Rifaximin significantly more effective than placebo at preventing additional episodes of HE over 6-mo period in patients with recurrent HE in remission  Risk of breakthrough HE reduced by 58%  Risk reduction consistent across nearly all patient subgroups  Majority of patients (> 90%) in both arms received concomitant lactulose  Rifaximin also resulted in significant 50% reduced risk of hospitalization due to HE  Rifaximin well tolerated with no increased incidence of adverse events, serious adverse events, or infections compared with placebo Bass NM, et al. N Engl J Med. 2010;362:1071-1081.
  • 23. L ornithine L aspartate  LOLA can improve overt HE I or II patients  Hospital stay was reduced.  Data do not support the use of LOLA for patients with subclinical hepatic encephalopathy.  Trials detecting efficacy and safety were of high quality. Abid S, et al. Efficacy of infusion of L-ornithine L-aspartate in cirrhotic patients with portosystemic encephalopathy: a placebo controlled study. J. Hepatol. 2005; 42 (Suppl. 2): 84.
  • 24. Sodium benzoate  Sodium benzoate and sodium phenylacetate bind with ammonia substrates and thus take them out of the circulation.  One small study reported that sodium benzoate was as effective as lactulose in reducing ammonia levels and improving cognitive function.  Severe accidental overdose has been reported Sushma S, et al. Sodium benzoate in the treatment of acute hepatic encephalopathy: a double-blind randomized trial. Hepatology 1992;16:138–44.
  • 25. Zinc  Zinc deficiency is common in cirrhosis.  Zinc administration has the potential to improve hyperammonemia by increasing the activity of ornithine transcarbamylase, an enzyme in the urea cycle.  Zinc sulfate and zinc acetate have been used at a dose of 600 mg orally every day in clinical trials.  Hepatic encephalopathy improved in 2 studies Bresci G, et al. Management of hepatic encephalopathy with oral zinc supplementation: a long-term treatment. Eur J Med. 1993;2(7):414-6.
  • 26. Detoxification systems  The molecular adsorbant recirculating system (MARS) removes protein-bound and water-soluble toxins.  A short-term (5-day), multicenter, randomized study compared the use of MARS with standard medical therapy.  Significantly more rapid improvement in mental status was observed in the MARS group (p=0.044).  The role of albumin dialysis unclear. Hassanein TI, et al. Randomized controlled study of extracorporeal albumin dialysis for hepatic encephalopathy. Hepatology 2007;46: 1853–62.
  • 27. Probiotics  Probiotics are live, microbiologic dietary supplements (e.g., yogurt).  Work by depriving pathogenic bacteria of substrates and providing fermentation products for beneficial bacteria.  Two small studies reported neuropsychological improvement in patients with MHE. Malaguarnera M, et al. Bifidobacterium longum with fructo-oligosaccharide (FOS) treatment in minimal hepatic encephalopathy: a randomized, double-blind, placebocontrolled study. Dig Dis Sci 2007;52:3259–65. Bajaj JS, et al. Probiotic yogurt for the treatment of minimal hepatic encephalopathy. Am J Gastroenterol 2008;103:1707–15.
  • 29. Other Management  Alternative targets for ammonia reduction  Kidneys produce, excrete significant ammonia  Volume expansion promotes excretion, reduces plasma ammonia  Muscle converts ammonia to glutamine in hyperammonemia  L-ornithin L-aspartate (LOLA) increases muscle detoxification  Reduction in inflammation and potential infection  Targets: nitric oxide, proinflammatory cytokines, free radicals  Liver detoxicification via liver support systems  Reduction in cerebral hyperemia, intracranial hypertension  Moderate hypothermia treatment reduces cerebral blood flow Shawcross D, Jalan R. Lancet. 2005;365:431-433.
  • 30. Liver transplant  The ultimate management goal for OHE is the replacement of the diseased liver.  Therefore, liver transplant work-up is crucial for the management of OHE after correction of the acute insult and prevention of recurrences.
  • 32. THANK YOU FOR YOUR ATTENTION