Hepatic encephalopathy: treatment

Treatment of hepatic encephalopathy can be divided into three main points:

1. Establishment and elimination of factors contributing to the development of hepatic encephalopathy.
2. Measures aimed at reducing the formation and absorption of ammonia and other toxins that form in the large intestine. These include reducing the amount and modification of food proteins, altering the intestinal microflora and intestinal

Treatment of hepatic precoma and coma

Acute hepatic encephalopathy:

1. Identify factors that contribute to the development of encephalopathy.
2. Purify the intestine from nitrogen-containing substances:
   1. stop rotting
   2. make a phosphate enema
3. Assign a protein-free diet and, as you recover, slowly increase the protein content of the food
4. Assign lactulose or lactitol
5. Assign neomycin inside 1 g 4 times a day for 1 week
6. Maintain calorie content of food, amount of liquid and electrolyte balance
7. They cancel diuretics, control the level of electrolytes in the blood serum

Chronic hepatic encephalopathy:

1. Avoid the use of nitrogen-containing drugs
2. Limit the protein content in food within the tolerated - about 50 g per day, recommending that you consume mainly plant proteins
3. Ensure bowel evacuation at least 2 times a day
4. Assign lactulose or lactitol
5. If worsened, they switch to treatment used in acute encephalopathy of the environment (antibiotics, lactulose or lactitol), stimulation of emptying of the large intestine (enema, lactulose or lactitol).
6. Appointment of drugs that modify the ratio of neurotransmitters direct (bromocriptine, flumazemil) or indirect (branched-chain amino acids) by. Currently, in clinical practice, these methods are used little.

The choice of method of treatment depends on the clinical picture: subclinical, acute or persistent chronic encephalopathy

Diet

In acute liver encephalopathy, the amount of food proteins must be reduced to 20 g per day. Caloric content of food is maintained at the level of 2000 kcal per day or higher with ingestion or parenteral nutrition.

During recovery, the protein content is increased by 10 grams every other day. If relapse occurs, the encephalopathy returns to the previous level of protein in the food. In patients recovering from an acute episode of coma, the protein content in food is soon brought to normal. With chronic encephalopathy patients need to constantly limit the amount of food proteins in order to avoid the development of psychopathological symptoms. The usual protein content in food is 40-60 g per day.

Vegetable proteins are transported better than animals. They have a less ammonogenic effect and they contain little methionine and aromatic amino acids. In addition, vegetable proteins have a more pronounced laxative effect, when they are used, the intake of dietary fiber increases; this leads to an increase in the binding and excretion of nitrogen contained in the bacteria of the large intestine. Taking plant foods can be difficult because of the development of flatulence, diarrhea and bloating.

In acute cases, it is possible to completely exclude proteins from food for a period of several days to several weeks - this will not harm the patient. Even with chronic encephalopathy in patients who have consumed food proteins for many months, there are rarely clinical signs of protein deficiency. The protein restriction is shown only to patients with signs of encephalopathy. In other cases, liver disease can be successfully prescribed a high-protein diet; this is achieved by the simultaneous use of lactulose or lactitol.

Antibiotics

Orally administered neomycin successfully reduces the formation of nitrogen compounds in the intestine. Despite the fact that only a small amount of this drug is absorbed from the intestine, it can be found in the blood of patients, therefore prolonged use of neomycin can lead to hearing loss or deafness. It should be prescribed only in acute cases at 4-6 g / day in several doses for 5-7 days. At the same time, the improvement in the clinical state of patients is difficult to relate to changes in the fecal microflora.

Metronidazole at a dose of 200 mg 4 times a day orally, apparently acts as effectively as neomycin. It should not be used for a long time because of a dose-dependent toxic effect on the central nervous system. In acute hepatic coma, lactulose is prescribed, and if its action occurs slowly or is incomplete, neomycin is added. These two drugs are synergistic, probably because they affect different groups of bacteria.

Lactulose and lactitol

The mucous membrane of the human intestine does not contain enzymes that break down these synthetic disaccharides. Accepted orally, lactulose reaches the cecum, in which it is cleaved by bacteria with the formation of predominantly lactic acid; The pH of the stool is reduced. This promotes the growth of bacteria that break down lactose; while the growth of ammonogenic microorganisms, such as bacteroides, is suppressed. Lactulose can "detoxify" fatty acids with a short chain, formed in the presence of blood and proteins. In the presence of lactulose and blood, large intestine bacteria generally break down lactulose. This is of particular importance in hepatic encephalopathy caused by bleeding. When using lactulose, osmotic pressure in the colon increases.

The mechanism of action of this drug is not exactly known. The acid reaction of stale masses can reduce ionization and, consequently, absorption of ammonia, as well as amines and other toxic nitrogen-containing compounds; while the ammonia content in the stool does not increase. In the large intestine lactulose more than 2 times increases the formation of bacteria and soluble nitrogen compounds. As a result, nitrogen is not absorbed in the form of ammonia and urea formation decreases.

When lactulose is prescribed, it is necessary to strive for the formation of an acid feces in the patient without diarrhea. The drug is prescribed in a dose of 10-30 ml 3 times a day, which leads to a double stool with a semi-liquid feces.

The effectiveness of lactitol in comparison with lactulose

• Similar action in the large intestine
• Equally effective in hepatic encephalopathy
• Acts more quickly
• More convenient in use (powdery)
• Less Sweet
• To a lesser degree causes diarrhea and flatulence

Side effects include flatulence, diarrhea and intestinal pain. Diarrhea can be so strong that the level of sodium in the blood serum exceeds 145 mmol / l, the level of potassium decreases and alkalosis develops. The volume of circulating blood decreases, resulting in impaired renal function. Such complications develop especially often if the daily dose of the drug exceeds 100 ml. Some side effects may be associated with an impurity in other lactulose syrup syrups. Crystalline lactulose can be less toxic.

Lactitol (beta-galactosidosorbitol) is the second generation of disaccharides. It is easy to obtain in a chemically pure crystalline form, from which powder can be prepared. This drug is not inactivated and not absorbed in the small intestine, but is broken down by bacteria of the large intestine. Powdered lactitol is more convenient to use than liquid lactulose, and can be used as a sweetener. It is more pleasant to taste and less luscious. The daily dose is approximately 30 g.

Lactitol is also effective in the treatment of chronic and acute portosystemic encephalopathy, as well as lactulose. Lactitol acts faster than lactulose and to a lesser extent causes diarrhea and flatulence.

Lactulose and lactitol are used to treat subclinical forms of hepatic encephalopathy. When they are applied, the results of psychometric tests are improved. At a dose of 0.3-0.5 g / kg per day lactitol is well tolerated by patients and is quite effective.

Purification of the intestines with laxatives. Hepatic encephalopathy develops against a background of constipation, and remission is associated with the resumption of normal bowel action. Therefore, in patients with hepatic encephalopathy, special attention should be paid to the role of enemas and the purification of the intestine by magnesium sulfate. You can use enemas with lactulose and lactose, and after them - with clean water. All enemas should be neutral or acidic in order to lower the absorption of ammonia. Enemas with magnesium sulfate can lead to a dangerous hypermagnesemia for the patient. Phosphate enemas are safe.

[1], [2], [3], [4], [5],