TRACTAMENT DE L`ENCEFALOPATIA HEPATICA

TRACTAMENT DE L’ENCEFALOPATIA
HEPATICA
Joan Cordoba
Universitat Autònoma de Barcelona
CASO CLINICO
58 a varon confusion
Antecedentes
- Cirrosis VHC
Ascitis 2 años antes, control con espironolactone
Varices tt propranolol
- Infeccion orina 2 semanas antes. Cipro x 7 d.
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
ACUTE
CHRONIC
SUBCLINICAL
OR LATENT
Bajaj APT 2010
Severity and duration of neurological
manifestations in cirrhosis
Bajaj APT 2010
MANAGEMENT OF THE EPISODE OF HE
Diagnosis
Exclusion of other neurological diseases
Search of precipitating factors
GI bleeding, constipation, high protein load
infection
uremia, dehydration, hyponatremia
sedatives
Assessment of liver function
Hb 13 g/dL, Leukocytes 5100, Platelets 68000
creatinine 1 mg/dL Na 126 K 5.3 AST 105 ALT 73 NH3 129
INR 1.6 bilirubin 2.4 mg/dL albumin 2.4 mg/dL
Urine: 3 wc/f, 6 rc/f Chest x-ray: normal
Blood 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 HE
Therapy: iv saline, stop diuretics, lactulose
Improvement in sodium (to 133 in 4 days)
Non-response at 1 week
Terminal liver failure: without jaundice?
Additional anti-encephalopathy therapies: diet? drugs?
Undiagnosed precipitating factor: additional tests?
Oral intake of proteins during episodic HE
NORMAL PROTEIN 1.2 g.kg.d
1- Diet
NG tube
30 Kcal.kg.d
14 days
LOW PROTEIN
0g
12 g
24 g
48 g
1,2 g.kg
HEPATIC ENCEPHALOPATHY STAGE
2- Treatment HE: enema + neomycine + precipitating fact
4
HYPOPROTEIC DIET
NORMOPROTEIC DIET
30 patients randomized
3
2
10 patients finished before day 14 (died, GI
bleeding, withdraw consent..)
1
No differences in the outcome
0
0
1
2
3
4
5
6
7
DAY
8
9 10 11 12 13 14
Cordoba, J Hepatology 2004
CT-scan
Persistent HE = large porto-systemic shunts
Riggio O, Hepatology 2005
Occlusion of shunts improves HE for MELD<11
Cava
Coils
Spleno-renal
shunt
Left renal
vein
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 HE
Ammonia 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 DRUGS
Placebo-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
Lactulose prevents recurrence
Sharma BJ, Gastroenterology 2009
Rifaximin improves lactulose
2 episodes of HE in the previous 6 months
90% on lactulose
N=299
Bass NM, NEJM 2010
Tratamiento tras el alta
Canditato a trasplante
Alta con medicación preventiva: lactulosa
Author
Agent
Watanabe Lactulose
Duration Improved MHE?
Testing of clinically
relevant outcomes
8 weeks
Yes
_
Li
Probiotic
24 weeks
Yes
_
Horsmans
Lactulose
2 weeks
Yes
_
Prasad
Lactulose
90 days
Yes
Morgan
Rifaximin
8 weeks
Yes
Improved quality of life
_
Bajaj
Yogurt
60 days
Yes
Trend: reduced OHE
Liu Synbiotic
60 days
Yes
CTP improvement
Malguanera Probiotic
90 days
Yes
_
Improved quality of life
Improved driving
Sidhu Rifaximin
90 days
Yes
Bajaj
Rifaximin
60 days
Yes
Tratamiento tras el alta
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 multifactorial EH
SNC
MUSCULO
HIGADO
INTESTINO
RIÑON
Fuentes amoniaco
Infecciones
Función renal
Expansión volemia
Cordoba J, Sem Liv Dis 2008
Despres d’un primer episodi
d’encefalopatia es recomana
¿Que no es recomana?
1. Avaluar el risc d’accidents
2. Indicar tractament amb lactulosa o lactitol
3. Fer una dieta normoproteica
4. Emplear dosis baixes de diurètics, o
evitarlos
5. Fer tractament amb yogurt