Joan CordobaUniversitat Autònoma de Barcelona
TRACTAMENT DE L’ENCEFALOPATIA HEPATICA
58 a varon confusion
Antecedentes
- Cirrosis VHCAscitis 2 años antes, control con espironolactoneVarices tt propranolol
- Infeccion orina 2 semanas antes. Cipro x 7 d.
CASO CLINICO
Enf actual
Progresivamente 4 dias somnolencia, temblor, incapacidad funcional (comer, beber, control estínteres….)
Temp 36ºC, TA 98/60, FC 60, pulsi: 99%
No ascitis, no edemas, no deshidratacion, no melenas (examen rectal)
Estuporoso, responde estimulos verbales, emitiendo un habla no comprensible
Flapping tremor, no deficit motor, reflejos simétricos
Diagnostico: Episodio Encefalopatia Hepática
Severity and duration
Bajaj APT 2010
ACUTE CHRONICSUBCLINICAL
OR LATENT
Severity and duration of neurological manifestations in cirrhosis
Bajaj APT 2010
MANAGEMENT OF THE EPISODE OF HEDiagnosisExclusion of other neurological diseases
Search of precipitating factorsGI bleeding, constipation, high protein loadinfection uremia, dehydration, hyponatremia sedatives
Assessment of liver function
Hb 13 g/dL, Leukocytes 5100, Platelets 68000creatinine 1 mg/dL Na 126 K 5.3 AST 105 ALT 73 NH3 129INR 1.6 bilirubin 2.4 mg/dL albumin 2.4 mg/dLUrine: 3 wc/f, 6 rc/f Chest x-ray: normalBlood and urinary cultures: negative
HE precipitated by hyponatremia/diuretics
Hyponatremia: risk factor for HE
Guevara M et al, AJG 2009;104:1382-9
Treatment of HETherapy: iv saline, stop diuretics, lactuloseImprovement in sodium (to 133 in 4 days)
Terminal liver failure: without jaundice? Additional anti-encephalopathy therapies: diet? drugs?Undiagnosed precipitating factor: additional tests?
Non-response at 1 week
2- Treatment HE: enema + neomycine + precipitating fact
0 g 12 g 24 g48 g 1,2 g.kg
1.2 g.kg.d1- DietNG tube30 Kcal.kg.d14 days
NORMAL PROTEIN
LOW PROTEIN
Cordoba, J Hepatology 2004
Oral intake of proteins during episodic HE
DAY0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
HE
PAT
IC E
NC
EPH
ALO
PAT
HY
STA
GE
0
1
2
3
4HYPOPROTEIC DIETNORMOPROTEIC DIET 30 patients randomized
10 patients finished before day 14 (died, GI bleeding, withdraw consent..)
No differences in the outcome
CT-scanPersistent HE = large porto-systemic shunts
Riggio O, Hepatology 2005
Cava
Left renal vein
Coils
Spleno-renal shunt
Occlusion of shunts improves HE for MELD<11
Laleman W 2012
Hepatology 2013
CT of the patient
Esophageal and paraesophageal varices
Lack of large portosytemic shunts
Additional information given by the CT
Hidden prostatic abscess
Drainage + culture: E Coli resistant to quinolones & sensitive to cotrimoxazol
Disappearance of HE
MANAGEMENT OF OVERT HEAmmonia and inflammation key factors in precipitating HE Unresolved episode of HE without severe liver failure and without comorbidities: keep on searching (shunts? hidden infections? benzodiacepines?)
ANTI-ENCEPHALOPATHY DRUGSPlacebo-controlled studies in overt HE are “old” (management of cirrhosis has changed, standard of care not established)
- Non-absorbable disaccharides (lactulose, lactitol)some evidences suggest that are better than cathartics- Non-absorbable antibiotics (neomycin, rifaximin)several studies suggest that are better than disaccharides- Benefits of combination for overt HE not demonstrated- Alternative pathways for ammonia disposal: L-Ornithine L-Aspartate iv. improves mental status in persistent HE
Sharma BJ, Gastroenterology 2009
Lactulose prevents recurrence
Bass NM, NEJM 2010
2 episodes of HE in the previous 6 months90% on lactulose
Rifaximin improves lactulose
N=299
Canditato a trasplante
Alta con medicación preventiva: lactulosa
Tratamiento tras el alta
Author Agent Duration Improved MHE?
Testing of clinicallyrelevant outcomes
Watanabe Lactulose 8 weeks Yes _
Li Probiotic 24 weeks Yes _
Horsmans Lactulose 2 weeks Yes _
Prasad Lactulose 90 days Yes Improved quality of life
Morgan Rifaximin 8 weeks Yes _
Bajaj Yogurt 60 days Yes Trend: reduced OHE
Liu Synbiotic 60 days Yes CTP improvement
Malguanera Probiotic 90 days Yes _
Sidhu Rifaximin 90 days Yes Improved quality of life
Bajaj Rifaximin 60 days Yes Improved driving
Objetivo: evitar descompensaciones y evitar riesgos, mejorar calidad devida, llegar al trasplante
Trabajo: carpintero en baja hasta trasplante
Conducción 2-3 veces por semana
Conyugue: nota empeoramiento conducción (varios golpes carroceria), se le pide no conduzca
Solicitamos pruebas psicométricas para convencerle
Tratamiento tras el alta
Tratamiento multifactorial EH
Cordoba J, Sem Liv Dis 2008
SNC
MUSCULO
INTESTINO
RIÑON
HIGADO
Fuentes amoniacoInfeccionesFunción renalExpansión volemia
Despres d’un primer episodi d’encefalopatia es recomana
¿Que no es recomana?1. Avaluar el risc d’accidents2. Indicar tractament amb lactulosa o lactitol3. Fer una dieta normoproteica4. Emplear dosis baixes de diurètics, o
evitarlos5. Fer tractament amb yogurt
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