TRACTAMENT DE L`ENCEFALOPATIA HEPATICA
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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
