Luminary Learning Gastrointestinal Disorder- Issue 1

6  • LUMINARY LEARNING: GASTROINTESTINAL DISORDERS In addition to the treatment of HE that is present at hospital admission, there is also a poten- tial benefit from preventing the progression of HE. In a study from 1,560 patients from the North American Consortium for Study of End-stage Liver Disease evaluating hospitalized patients with cirrhosis, the maximumHE grade and not the admission HE grade was found to be prognostic for mortality independently of the extrahepatic organ failures [6]. Direct Treatment at Precipitating Factors The most common precipitating factors of HE are diuretic use, bacterial infection, and alcohol use [14]. Any identifiable precipitating event should be promptly treated and early antibiotics admin- istration should be considered when infection is suspected. Specific Treatment Nonabsorbable Disaccharides Nonabsorbed disaccharides (e.g., lactulose and lactitol) and nonabsorbable antibiotics (e.g., neo- mycin and rifaximin) represent the mainstay of specific treatment for HE. Lactulose (b-galac- tosidofructose) and lactitol (b-galactosidosorbitol) reduce ammonia absorption in the colon by acidification of the colon resulting in the conversion of ammonia to ammonium, shifting the colonic flora from urease- to nonurease-producing bacterial species, and by their cathartic effect. Fig. 2: Management of hospitalized patients with hepatic encephalopathy. groups [ 14 ]. Prognostic scores including the chronic liver fail- ure-sequential organ failure assessment (CLIF-SOFA) score may be utilized to determine the severity of ACLF [ 8 ]. If HE Possible HE Confirm HE diagnosis Does patient also have ACLF? Treatment of HE precipitating factors Can we identify precipitating factors? HE specific treatment • Lactulose • Rifaximin • Shunt embolization if MELD score <15 Alternative treatment if rifaximin is not available • Neomycin, metronidazole and vancomycin Treatment that requires more study • Zinc • L-Ornithine L-Aspartate • Branched-chain amino acids • Molecular Adsorbent Recirculating System Liver transplant HE associated ACLF • Consider ICU admission • Organ supports Yes Yes No If HE persists If HE persists Fig. 6.2 Management of hospitalized patients with hepatic encephalopathy