Comparison Of Treatment Groups
The 2 groups were similar with respect to demographics and clinical features . The precipitants of HE included a total of 80 potential contributing factors identified in 50 patients . Admission laboratory data were also similar in the 2 groups , with the exception of blood urea nitrogen level, which was higher in the PEG group . Admission ammonia levels were elevated in both groups . Nineteen patients in the lactulose group and 18 patients in the PEG group underwent head computed tomography scanning. No acute CT findings were identified in any patient.
Hepatic Encephalopathy Nursing Care Plan 4
Nursing Diagnosis: Risk for Deficient Fluid Volume related to third-space shift, excessive fluid losses through vomiting and diarrhea, and alteration in the clotting process secondary to hepatic encephalopathy.
- The patient will maintain adequate hydration, as evidenced by good skin turgor, stable vital signs, normal capillary refill time, strong peripheral pulses, and urinary output within the patientÃ¢s normal range.
- The patient will demonstrate absence of signs of hemorrhage with clotting times within the normal limits.
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How To Use Lactulose Solution
If you are taking this medication by mouth for liver disease, take it usually 3-4 times a day or as directed by your doctor. To improve the taste, you may mix it into fruit juice, water, milk, or a soft dessert. The goal is to have 2-3 soft stools each day. Dosage is based on your medical condition and response to therapy .
This medication can also be given rectally as an enema for liver disease. Mix the recommended amount of lactulose with 700 milliliters of water or normal saline. Give the solution into the rectum and keep the liquid inside for 30-60 minutes as directed by your doctor. If you keep the enema inside for less than 30 minutes, repeat the dose unless directed otherwise.
Use this medication regularly in order to get the most benefit from it. Remember to use it at the same time each day.
When this drug is given rectally for liver disease, an improvement in your mental status may occur in as little as 2 hours, but if you are taking this medication by mouth, it may take up to 24 to 48 hours. If you are using this medication for constipation, it may take up to 48 hours to have a bowel movement. Inform your doctor if your condition persists or worsens.
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What Are Warnings And Precautions For Lactulose
- This medication contains lactulose. Do not take Enulose, Kristalose, Constulose or Generlac, if you are allergic to lactulose or any ingredients contained in this drug.
- Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center immediately.
- See What Are Side Effects Associated with Using Lactulose?
- See What Are Side Effects Associated with Using Lactulose?
- Monitor for electrolyte imbalance when the drug is used for longer than 6 months or in patients predisposed to electrolyte abnormalities
- Avoid using other laxatives concomitantly
- Inadequate response possible when taken concomitantly with anti-infective
Pregnancy and Lactation
- Lactulose use during pregnancy may be acceptable. Either animal studies show no risk, or human studies are not available or animal studies showed minor risks, and human studies were done and showed no risk
- It is unknown if lactulose is distributed into breast milk use with caution
How To Take It
You can take lactulose with or without food.
The medicine comes with a plastic cup or spoon to measure your dose. If you do not have a cup or spoon, ask your pharmacist for one. Do not use a kitchen spoon as it will not measure the right amount.
Some people do not like the sweet taste of lactulose. To improve the taste, you can mix your dose with half a glass or water or fruit juice.
Aim to drink 6 to 8 glasses of water or other liquid during the day while you’re taking lactulose or your constipation may get worse.
What Dose Of Lactulose Should I Take For He
Lactulose dosage can vary, so ask your doctor about the best dose for you2. It is important not to overdose on lactulose, as you could end up experiencing severe diarrhea, which can lead to a dangerous loss of fluids and electrolytes. Overdose can also slow down the movement of your intestines the opposite effect of what you want in HE, so make sure you follow the advice of your healthcare team.1
Lactulose is a type of sugar that is commonly used as a treatment for constipation as well as for HE.
Alteration Of Intracolonic Ph Levels
Lactulose is not absorbed or hydrolyzed in the upper intestine and is metabolized by lower intestinal flora to acetic, lactic, and formic acids. It produces an osmotic diarrhea because it is unabsorbed, and its metabolites effectively change the pH of stool from a normal of 7.0 to as low as 5.0 to 5.5, without producing obvious changes in bowel flora. This fall in pH is effective in reducing the nonionic diffusion of ammonia from the colon into the portal system, and is probably the main beneficial effect of lactulose. When given in divided doses to a total of 25 to 75 g daily, enough to produce two to three stools per day, lactulose is as effective as neomycin in controlling encephalopathy . Except that it causes diarrhea and abdominal cramps at times, lactulose is essentially nontoxic. There is little reason to prefer it over neomycin in most cases of acute encephalopathy, although it is the drug of choice in patients with chronic encephalopathy and with renal disease. Occasionally patients who are not helped by neomycin or lactulose alone may be benefited by the simultaneous use of both drugs.
Joseph Jankovic MD, inBradley and Daroff’s Neurology in Clinical Practice, 2022
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Treatments To Increase Ammonia Clearance
Zinc. Low zinc concentrations are common in patients with cirrhosis of the liver, particularly those with HE. Even in patients who are not zinc deficient. Patients with fulminant hepatic failure and subacute hepatic failure have also been shown to have low serum zinc levels. Zinc deficiency also leads to alteration of neurotransmitters like GABA and norepinephrine. Zinc supplementation has been tried in HE. It may have a role in mild chronic HE, though further trials are necessary.
Unequivocal evidence of benefit of oral zinc therapy for treatment of acute HE is lacking. Zinc sulfate and zinc acetate have been used at a dose of 600 mg orally every day in clinical trials. HE improved in two studies there was no improvement in mental function in two other studies. However, an interesting study from Japan in 2010 showed zinc supplementation significantly improved patientsâ quality of life, as it improved the physical component scale but not the mental component scale. Zinc supplementation also significantly decreased HE grade and blood ammonia levels and improved Child-Pugh score and neuropsychological tests compared with standard therapy. Interestingly this study showed as well administration of zinc in combination with L-carnosine showed to enhance intestinal barrier and improve zinc plasma levels.
Some examples for probiotics available in USA that contains same species that showed some effect for HE include :
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What Is Lactulose And How Does It Work
Lactulose is a prescription drug used by mouth or rectally to treat or prevent complications of liver disease . It does not cure the problem, but may help to improve mental status. Lactulose is a colonic acidifier that works by decreasing the amount of ammonia in the blood. It is a man-made sugar solution.
- Lactulose is available under the following different brand names: Enulose, Kristalose, Constulose, and Generlac.
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Optic Nerve Sheath Diameter Sonography
The retrobulbar segment of the optic nerve is surrounded by meninges. The subarachnoid space surrounding the nerve sheath can expand when ICP is elevated and ultrasound measurements of optic nerve sheath diameter can therefore give an estimation of ICP. Optic nerve sheath diameter has been used to estimate ICP in pediatric acute liver failure patients . A diameter > 5 mm has a 88 %96 % sensitivity, 93 %94 % sensitivity to detect an ICP > 20 mm Hg . Like TCD, optic nerve sheath sonography does not provide a continuous measure of ICP, but rather a stochastic estimate.
- Standard procedure :
The optic nerve sheath is insonated with a linear array probe in the transverse position in the superior lateral portion of the globe over the closed eyelid. The measurement is taken 3 mm behind the globe encompassing the width of the entire nerve from the margins of the dura mater on either side. Hypoechoic shadowing behind the globe can sometimes obscure the margins of the optic nerve sheath and care must be taken to avoid this artifact .
- Contraindications :
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Treatments To Decrease Intestinal Ammonia Production
In the late 19th century, it was recognized that the feeding of a high-protein diet to dogs that had undergone portosystemic shunt surgery could produce symptoms of abnormal coordination and stupor in the treated animals.
In the 20th century, low-protein diets were routinely recommended for patients with cirrhosis, in the hope of decreasing intestinal ammonia production and in preventing exacerbations of hepatic encephalopathy. An obvious consequence was the worsening of preexisting protein-energy malnutrition. Protein restriction may be appropriate in some patients immediately following a severe flare of symptoms . However, protein restriction is rarely justified in patients with cirrhosis and persistent hepatic encephalopathy. Indeed, malnutrition is a more serious clinical problem than hepatic encephalopathy for many of these patients.
Diets containing vegetable proteins appear to be better tolerated than diets rich in animal proteins, especially proteins derived from red meats. This may be because of increased content of dietary fiber, a natural cathartic, and decreased levels of aromatic amino acids. Aromatic amino acids, as precursors of the false neurotransmitters tyramine and octopamine, are thought to inhibit dopaminergic neurotransmission and worsen hepatic encephalopathy.
In subsequent years, multiple randomized trials have reinvestigated the efficacy of lactulose.
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How To Use Lactulose For Hepatic Encephalopathy
There are two ways to use lactulose for H.E. You can either use it by mouth or rectally. However, we must clarify that lactulose is not a cure for H.E, but it can only improve your mental status.
Lactulose is an artificial sugar solution and an acidifier of the colon. It decreases how much ammonia can pass into your blood from your colon. But Lactulose has many uses. H.E is not the only condition that lactulose treats. So how you would use it will rely on what you are using it to treat.
If you are using lactulose to treat liver disease, you would have to take it like 3 to 4 times daily. But if your doctor recommends otherwise, follow his directions.
Lactulose may not have so much of a great taste. But you can improve its taste by mixing the drug into fruit juice, soft dessert, or even just water. The goal of using lactulose is for you to have about two to three soft stools daily.
Sometimes, your doctor will adjust your dosage with how you are responding to the therapy. This is determined by how many soft stools you are passing each day.
You can use lactulose as an enema to treat H.E or any other liver disease. You would mix the recommended amount with 24 ounces of normal saline or water. Then, you can pass the liquid into your rectum. Keep the solution inside for about 30 to 60 minutes, except your doctor directs otherwise.
Lactulose 33g/5ml Oral Solution
This information is intended for use by health professionals
Laevolac 3.3 g/5ml Oral Solution
Lactulose 3.3 g/5ml Oral Solution
5 ml contain 3.3 g lactulose
For a full list of excipients, see section 6.1.
Clear colourless to pale brownish yellow, viscous solution
Treatment of portal systemic encephalopathy
The posology should be adjusted according to the individual needs of the patient. The starting dose can be adjusted after adequate treatment effect individually . Several days of treatment may be needed in some patients before adequate treatment effect occurs. In case of single daily dose, this should be taken at the same time of the day, e.g. during breakfast. During the therapy with laxatives it is recommended to drink sufficient amounts of fluids .
corresponding to 10-30 g lactulose
corresponding to 10-20 g lactulose
corresponding to 10-30 g lactulose
corresponding to 10-20 g lactulose
corresponding to 10 g lactulose
corresponding to 7-10 g lactulose
corresponding to 3-7 g lactulose
corresponding to up to 3 g lactulose
If diarrhoea occurs, the dosing regimen should be reduced.
Treatment of portal systemic encephalopathy – for adults only:
Beginning with 30 – 50 ml 3 times daily . The dosage has to be adopted to get 2-3 soft stools daily, pH of the stools should be between 5.0 to 5.5.
Method of administration
Use in patients with galactosaemia.
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Hepatic Encephalopathy Versus Alcohol Withdrawal
Occasionally, in a patient with cirrhosis due to alcoholism there will be a question of sorting out hepatic encephalopathy versus alcohol withdrawal. These are fundamentally nearly opposite pathologies:
Generally, this differentiation can be made on the basis of history and physical examination. The importance of an accurate drinking history cannot be over-emphasized
Be careful about over-diagnosing patients with alcohol withdrawal, because the treatment for alcohol withdrawal can be disastrous in a patient who actually has hepatic encephalopathy:
- Patients with hepatic encephalopathy have excess GABA stimulation, so they are very sensitive to GABAergic medications .
- Administration of benzodiazepines or barbiturates to a patient with hepatic encephalopathy risks inducing a prolonged comatose state.
Neuropsychological Test In Mhe
Neuropsychological testing is useful methodology for quantifying cognitive impairment due to various forms of encephalopathy, including low-grade or MHE. Neuropsychological tests directly measure cognitive functions that are directly relevant to activities of daily living. They have been applied for the diagnosis of HE for more than 50 years.
The neuropsychological features of MHE point to a disorder of executive functioning, particularly selective attention, visuospatial abilities and fine motor skills. Although these domains are most commonly implicated in MHE, impairments of memory have also been reported.
The attention impairments in MHE are observed on a variety of measures. These include measures of cognitive processing speed involving psychomotor responding, such as the Number Connection tests , block design test ,the Digit Symbol test , line drawing test, circle-dotting test, serial-dotting test, figure connection test. Impairments on measures of cognitive processing speed and response inhibition that do not require a motor response have also been reported . Visuospatial impairments have been primarily reported on block design tasks , but also on more pure measures of visuospatial perception, such as line orientation or the Hooper test. Fine motor skill impairments have been noted on measures such as the grooved pegboard task, and on line tracing tasks .
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Signs And Symptoms Of Hepatic Encephalopathy
Hepatic encephalopathy symptoms vary from person-to-person and depend on the underlying cause of hepatic damage.
Portal Hypertension And Tips
Liver cirrhosis is the most common cause of portal hypertension . Complications of PH include ascites and oesophageal or gastric variceal bleedings. These complications are severe and result in hospital admissions and decreased survival. Moreover, cirrhotic patients undergo physical deterioration due to undernutrition and muscle wasting and are physically frail.
A transjugular intrahepatic portosystemic shunt reduces PH, by decompression of the portal system through an artificial shunt from a intrahepatic portal vein to a hepatic vein. TIPS can be considered as therapy for refractory ascites and variceal bleeding. TIPS treatment for refractory ascites has a response rate, defined as improvement of ascites, of up to 85%. A meta-analysis showed improved survival of cirrhotic patients receiving a TIPS, with a decreased risk of refractory ascites and hepatorenal syndrome. However, these patients have an increased risk of hepatic encephalopathy . Improvement of survival was confirmed in a recent randomised controlled trial : 1-year transplant-free survival was significantly higher in patients who received TIPS compared with patients who were treated with large volume paracentesis and albumin infusion and suggested that TIPS should be the first line of treatment of refractory ascites.
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Other Potential Treatment Options
Flumazenil, a benzodiazepine antagonist, which targets the GABA receptor-complex pathway has shown modest benefit in certain selected groups of patients such as those with severe hepatic coma and encephalopathy associated with bleeding . The restoration of central dopaminergic function seen in rats after administration of flumazenil is purported to be a contributing factor in the improvement of HE .
L-ornithine L-aspartate and Acetyl L-carnitine have made some headway in demonstrating reduction in serum ammonia levels and improved mental function . There were also improvements to serum prothrombin time, serum bilirubin, and fasting ammonia levels in patients that were randomised to ALC in a randomized, double-blind, and placebo-controlled study administering ALC in cirrhotic patients . However, there are concerns about the possibly transient ammonia lowering effects of LOLA with rebound hyperammonemia on cessation of the drug .
Sodium benzoate increases renal excretion of ammonia and has shown to be as effective as lactulose and cheaper alternative in acute portosystemic encephalopathy and in the treatment of inborn errors of urea synthesis .
Acarbose can be considered in patients with low-grade HE and concomitant diabetes mellitus requiring oral hypoglycemic agents. This alpha-1 glucosidase inhibitor inhibits intestinal glucose absorption and thereby reducing substrate for ammonia production .