Tuesday, 3 December 2013

Cirrhosis - Treatment of the complications of cirrhosis - Hepatic encephalopathy

Cirrhosis is defined as a condition of irreversible scarring liver as a result of liver tissue by fibrosis due to final phase of chronic liver diseases of that can lead to poor function of the liver and liver failure. According to the statistics, Number of discharges with chronic liver disease or cirrhosis as the first-listed diagnosis: 101,000 in 2009 and Deaths per 100,000 population: 10.3 in 2010(a). Hepatitis B infection cause of the disease is very prevalent in South-East Asia.
Treatment of the complications of cirrhosis
Hepatic encephalopathy a condition of liver failure causes of confusion, altered level of consciousness, and coma. 
A.2.4.1. In conventional medicine
1. Antibiotics
In the study to test Prominent antibiotics such as neomycin, metronidazole, vancomycin and rifaximin for the treatment of hepatic encephalopathy (HE), showed that despite its cost in the US, rifaximin may prove cost-saving by preventing hospitalizations for overt HE. In minimal/covert HE, rifaximin is the only systematically studied antibiotic. Rifaximin showed improvement in cognition, inflammation, quality-of-life and driving simulator performance but cost-analysis does not favor its use at the current time. Antibiotics, especially rifaximin, have a definite role in the management across the spectrum of HE.
However the limited numbers studied, adverse effects (neomycin oto- and nephrotoxicity, metronidazole neurotoxicity) and potential for resistance emergence (vancomycin-resistant enterococcus) has limited the use of most antibiotics, apart from rifaximin which has the greatest evidence base(97).

2. Combination therapy
In the study to evaluate the efficacy and safety of combination therapy for the treatment and prevention of hepatic encephalopathy (HE), showed that he evidence evaluating the use of combination therapy for the treatment of HE does not support its widespread use. The combination of rifaximin and lactulose may be considered in the treatment of HE and in patients refractory to monotherapy. The combination of rifaximin and lactulose should be considered for the prevention of HE, especially after the second episode of HE recurrence(98).

3. L-ornithine-L-aspartate (LOLA)
L-Ornithine-L-aspartate (LOLA) has been shown to reduce ammonia and improve psychometric function in patients with hepatic encephalopathy. In the study to assess the effect of LOLA in healthy patients with cirrhosis and no evidence of clinical encephalopathy after challenging the central nervous system by administration of oral glutamine, found that LOLA ameliorated the deleterious psychometric effects of glutamine in Child's grade B and C patients with cirrhosis without TIPS and supports its use in clinical practice in hepatic encephalopathy(99).

A.2.4.2. In herbal medicine
Morin is a bioflavonoid, a constituent of many herbs and fruits that are used as herbal medicines and also several biological activities. According to the study by Annamalai University, oxidative stress was effectively modulated by morin administration. Morin significantly improved the status of antioxidants and decreased the levels of ammonia, urea, TBARS, HP and liver markers enzymes, as compared to the AC-treated group. There is an evidence for the antihyperammonaemic, hepatoprotective and antioxidant effects of morin against oxidative stress induced by AC(100).

A.2.4.1. In traditional Chinese medicine
In the study to evaluate the efficacy, safety and recent survival rates of high-dose herbs Qingre Huayu with the function of clearing heat and resolving stasis, in patients with hepatitis B-related ACLF with heat toxin stagnation syndrome, found that high doses of Qingre Huayu herbs can significantly improve liver function and coagulation function, reduce complications, and reduce mortality in patients with hepatitis B-related ACLF(101). 

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(a) http://www.cdc.gov/nchs/fastats/liverdis.htm
(97) http://www.ncbi.nlm.nih.gov/pubmed/23389621
(98) http://www.ncbi.nlm.nih.gov/pubmed/23092866
(99) http://www.ncbi.nlm.nih.gov/pubmed/10986219
(100) http://www.ncbi.nlm.nih.gov/pubmed/18756351
(101) http://www.ncbi.nlm.nih.gov/pubmed/22313885
(102) http://www.ncbi.nlm.nih.gov/pubmed/23372315 

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