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1.
Z Gastroenterol ; 58(1): 49-56, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31931540

RESUMO

BACKGROUND: Hepatic encephalopathy (HE) is a severe complication of liver cirrhosis with impairment of quality of life and prognosis. Management patterns among physicians have not been investigated yet. METHODS: A questionnaire containing 17 questions was sent out to 1468 gastroenterologists and 120 general practitioners (GPs). It included questions regarding diagnostic, therapeutic, and management strategies used in patients with overt HE (OHE) and covert HE (CHE). RESULTS: The response rate was 12 % (n = 172) for gastroenterologists and 45 % (n = 54) for GPs. Of gastroenterologists, 26.7 % examine patients with an initial diagnosis of liver cirrhosis regarding HE. Gastroenterologists favored a combination of different testing strategies (27.9 %) and clinical examination (23.0 %), while the biggest part of the GPs use clinical examination (55.3 %); 63.7 % of gastroenterologists and 28.3 % of GPs give correct nutritional advices to patients with HE. Treatment strategies for acute bouts of OHE and secondary prophylaxis varied widely in both groups. Preferred medication was lactulose followed by rifaximin or a combination therapy. More than half of the GPs (53.7 %) were not familiar with minimal HE (MHE). About one-third of both groups never tried to diagnose MHE. CONCLUSION: Our data strongly indicate that management of HE is very heterogeneous among gastroenterologists as well as selected GPs working in Germany and not driven by evidence-based international guidelines. Thus, the national guideline is more than welcome.


Assuntos
Gastroenterologistas , Fármacos Gastrointestinais/uso terapêutico , Clínicos Gerais , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/terapia , Cirrose Hepática/complicações , Padrões de Prática Médica/estatística & dados numéricos , Gerenciamento Clínico , Alemanha , Encefalopatia Hepática/psicologia , Humanos , Lactulose/uso terapêutico , Cirrose Hepática/terapia , Qualidade de Vida , Rifaximina/uso terapêutico , Prevenção Secundária/métodos , Inquéritos e Questionários
2.
World J Gastroenterol ; 25(36): 5403-5422, 2019 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-31576089

RESUMO

The Chinese Society of Hepatology developed the current guidelines on the management of hepatic encephalopathy in cirrhosis based on the published evidence and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of hepatic encephalopathy (HE) including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy, emphasizing the importance on screening MHE in patients with end-stage liver diseases. The guidelines emphasized that early identification and timely treatment are the key to improve the prognosis of HE. The principles of treatment include prompt removal of the cause, recovery of acute neuropsychiatric abnormalities to baseline status, primary prevention, and secondary prevention as soon as possible.


Assuntos
Doença Hepática Terminal/complicações , Gastroenterologia/normas , Encefalopatia Hepática/terapia , Cirrose Hepática/complicações , Sociedades Médicas/normas , China , Consenso , Doença Hepática Terminal/terapia , Gastroenterologia/métodos , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Humanos , Cirrose Hepática/terapia , Prognóstico , Prevenção Secundária/métodos , Prevenção Secundária/normas , Fatores de Tempo
3.
N Engl J Med ; 381(21): 2043-2050, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31665575

RESUMO

Fecal microbiota transplantation (FMT) is an emerging therapy for recurrent or refractory Clostridioides difficile infection and is being actively investigated for other conditions. We describe two patients in whom extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli bacteremia occurred after they had undergone FMT in two independent clinical trials; both cases were linked to the same stool donor by means of genomic sequencing. One of the patients died. Enhanced donor screening to limit the transmission of microorganisms that could lead to adverse infectious events and continued vigilance to define the benefits and risks of FMT across different patient populations are warranted.


Assuntos
Bacteriemia/etiologia , Disbiose/terapia , Escherichia coli/isolamento & purificação , Transplante de Microbiota Fecal/efeitos adversos , Fezes/microbiologia , Idoso , Bacteriemia/microbiologia , Farmacorresistência Bacteriana , Disbiose/etiologia , Escherichia coli/efeitos dos fármacos , Escherichia coli/metabolismo , Evolução Fatal , Encefalopatia Hepática/complicações , Encefalopatia Hepática/terapia , Humanos , Masculino , Síndromes Mielodisplásicas/complicações , Síndromes Mielodisplásicas/terapia , beta-Lactamases/metabolismo
4.
World J Gastroenterol ; 25(33): 4933-4944, 2019 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-31543684

RESUMO

BACKGROUND: Proton pump inhibitors (PPIs) are widely prescribed, often without clear indications. There are conflicting data on its association with mortality risk and hepatic decompensation in cirrhotic patients. Furthermore, PPI users and PPI exposure in some studies have been poorly defined with many confounding factors. AIM: To examine if PPI use increases mortality and hepatic decompensation and the impact of cumulative PPI dose exposure. METHODS: Data from patients with decompensated liver cirrhosis were extracted from a hospital database between 2013 to 2017. PPI users were defined as cumulative defined daily dose (cDDD) ≥ 28 within a landmark period, after hospitalisation for hepatic decompensation. Cox regression analysis for comparison was done after propensity score adjustment. Further risk of hepatic decompensation was analysed by Poisson regression. RESULTS: Among 295 decompensated cirrhosis patients, 238 were PPI users and 57 were non-users. PPI users had higher mortality compared to non-users [adjusted HR = 2.10, (1.20-3.67); P = 0.009]. Longer PPI use with cDDD > 90 was associated with higher mortality, compared to non-users [aHR = 2.27, (1.10-5.14); P = 0.038]. PPI users had a higher incidence of hospitalization for hepatic decompensation [aRR = 1.61, (1.30-2.11); P < 0.001]. CONCLUSION: PPI use in decompensated cirrhosis is associated with increased risk of mortality and hepatic decompensation. Longer PPI exposure with cDDD > 90 increases the risk of mortality.


Assuntos
Insuficiência Hepática Crônica Agudizada/epidemiologia , Infecções Bacterianas/epidemiologia , Encefalopatia Hepática/epidemiologia , Cirrose Hepática/mortalidade , Peritonite/epidemiologia , Inibidores da Bomba de Prótons/efeitos adversos , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Idoso , Infecções Bacterianas/etiologia , Infecções Bacterianas/terapia , Progressão da Doença , Feminino , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Incidência , Fígado/efeitos dos fármacos , Fígado/patologia , Cirrose Hepática/complicações , Cirrose Hepática/patologia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Peritonite/etiologia , Peritonite/terapia , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo
5.
Emerg Med Clin North Am ; 37(3): 511-527, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262418

RESUMO

Patients with end-stage liver disease (ESLD) who require intensive care unit admission have high rates of mortality. This article reviews the pathophysiology and emergency department assessment and management of the most frequent conditions and complications encountered in critically ill ESLD patients including hepatic encephalopathy, gastrointestinal bleeding, sepsis and bacterial peritonitis, hepatorenal syndrome, severe coagulopathy, and hepatic hydrothorax.


Assuntos
Estado Terminal , Doença Hepática Terminal/complicações , Doença Hepática Terminal/terapia , Manuseio das Vias Aéreas/métodos , Coagulação Intravascular Disseminada/diagnóstico , Coagulação Intravascular Disseminada/etiologia , Coagulação Intravascular Disseminada/terapia , Medicina de Emergência , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Síndrome Hepatorrenal/diagnóstico , Síndrome Hepatorrenal/etiologia , Síndrome Hepatorrenal/terapia , Humanos , Hidrotórax/diagnóstico , Hidrotórax/etiologia , Hidrotórax/terapia , Hiperamonemia/etiologia , Hiperamonemia/terapia , Unidades de Terapia Intensiva , Transplante de Fígado , Peritonite/diagnóstico , Peritonite/etiologia , Peritonite/terapia , Medição de Risco , Índice de Gravidade de Doença
6.
World J Gastroenterol ; 25(26): 3426-3437, 2019 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-31341366

RESUMO

BACKGROUND: In patients with cirrhosis, hepatic encephalopathy (HE) indicates a poor prognosis despite the use of artificial liver and liver transplantation, presenting as frequent hospitalizations and increased mortality rate. AIM: To determine predictors of early readmission and mid-term mortality in cirrhotic patients discharged after the resolution of HE. METHODS: From January to February 2018, 213 patients were enrolled in this observational study assessing all the successive patients with cirrhosis discharged from Department of Gastroenterology and Department of Infectious and Liver Diseases, Second Affiliated Hospital of Chongqing Medical University after the resolution of HE. The patients were followed for 6 mo. For each subject, demographic, clinical, and laboratory variables were assessed at the time of diagnosis of HE, during hospital stay, at discharge, and during follow-up. The primary endpoints were incidence of early readmission and mid-term mortality. RESULTS: During follow-up, 65 (31%) patients experienced an early readmission. International normalized ratio (INR) [odds ratio (OR) = 2.40; P = 0.003) at discharge independently predicted early readmission. The incidence of early readmission was significantly higher in patients with an INR > 1.62 at discharge than in those with an INR ≤ 1.62 (44% vs 19%; P < 0.001). Model for End-stage Liver Disease (MELD) score (OR = 1.11; P = 0.048) at discharge proved to be an independent predictor of early readmission caused by HE. Hemoglobin (OR = 0.97; P = 0.005) at discharge proved to be an independent predictor of non-early readmission. During 6 months of follow-up, 34 (16%) patients died. Artificial liver use (hazard ratio = 6.67; P = 0.021) during the first hospitalization independently predicted mid-term mortality. CONCLUSION: INR could be applied to identify fragile cirrhotic patients, MELD score could be used to predict early relapse of HE, and anemia is a potential target for preventing early readmission.


Assuntos
Anemia/diagnóstico , Doença Hepática Terminal/mortalidade , Encefalopatia Hepática/mortalidade , Coeficiente Internacional Normatizado , Cirrose Hepática/mortalidade , Idoso , Anemia/sangue , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/terapia , Feminino , Seguimentos , Encefalopatia Hepática/sangue , Encefalopatia Hepática/terapia , Humanos , Tempo de Internação/estatística & dados numéricos , Cirrose Hepática/diagnóstico , Cirrose Hepática/terapia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Recidiva , Fatores de Risco , Índice de Gravidade de Doença
7.
Gastroenterol Nurs ; 42(3): 277-285, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31145253

RESUMO

Hepatic encephalopathy is a complication of liver failure characterized by neuropsychiatric dysfunction ranging from disorientation to coma. There is a need for more treatment options and preventive care interventions to reduce the incidence of hepatic encephalopathy and mitigate its socioeconomic impact on families and strain on healthcare resources. Currently, there is no consensus on a single pathophysiological mechanism responsible for the development of this neurocognitive disorder. Ammonia toxicity remains a significant factor, but there is now increased recognition that hyperammonemia acts synergistically with systemic inflammation, oxidative stress, and gut microbiota imbalance in the development of hepatic encephalopathy. This article provides an overview of current and emerging therapies that target these factors in the treatment and management of this condition. Because of its complex pathogenesis, a multipronged approach to treating hepatic encephalopathy may be highly beneficial.


Assuntos
Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/terapia , Fármacos Gastrointestinais/uso terapêutico , Encefalopatia Hepática/etiologia , Humanos , Hiperamonemia/complicações , Hiperamonemia/terapia , Lactulose/uso terapêutico
8.
Z Gastroenterol ; 57(5): 611-680, 2019 May.
Artigo em Alemão | MEDLINE | ID: mdl-31060080

RESUMO

This guideline provides evidence-based key recommendations for diagnosis and therapy of complications of liver cirrhosis and upgrades the 2011 version. An interdisciplinary team of medical experts and patient support groups developed the guideline following the AWMF recommendations for evidence based consensus guidelines. New chapters concerning diagnosis and therapy of hepatic encephalopathy were added.


Assuntos
Encefalopatia Hepática , Cirrose Hepática , Guias de Prática Clínica como Assunto , Consenso , Gastroenterologia , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/terapia , Humanos , Cirrose Hepática/diagnóstico , Cirrose Hepática/terapia
9.
Rev Gastroenterol Mex ; 84(2): 195-203, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31014748

RESUMO

Understanding of the pathophysiology of hepatic encephalopathy has conditioned new treatment options. Ammonia detoxification in hepatic encephalopathy is regulated by two enzymes: glutaminase or glutamine synthetase. The first produces ammonia and the second detoxifies the ammonia, which is why treatments are aimed at glutaminase inhibition or glutamine synthetase activation. At present, we know that both enzymes are found not only in the liver, but also in the muscle, intestine, kidney, and brain. Therefore, current treatments can be directed at each enzyme at different sites. Awareness of those potential treatment sites makes different options of approach possible in the patient with hepatic encephalopathy, and each approach should be personalized.


Assuntos
Encefalopatia Hepática/fisiopatologia , Encefalopatia Hepática/terapia , Amônia/metabolismo , Ativadores de Enzimas/uso terapêutico , Inibidores Enzimáticos/uso terapêutico , Glutamato-Amônia Ligase/efeitos dos fármacos , Glutaminase/antagonistas & inibidores , Humanos , Hiperamonemia/fisiopatologia , Hiperamonemia/terapia
10.
Dig Dis Sci ; 64(6): 1448-1457, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30863953

RESUMO

BACKGROUND: Hepatic encephalopathy (HE) is associated with substantial morbidity and mortality, contributing significant burden on healthcare systems. AIM: We aim to evaluate trends in clinical and economic burden of HE among hospitalized adults in the USA. METHODS: Using the 2010-2014 National Inpatient Sample, we identified adults hospitalized with HE using ICD-9-CM codes. Annual trends in hospitalizations with HE, in-hospital mortality, and hospital charges were stratified by the presence of acute liver failure (ALF) or cirrhosis. Adjusted multivariable regression models were evaluated for predictors of in-hospital mortality and hospitalization charges. RESULTS: Among 142,860 hospitalizations with HE (mean age 59.3 years, 57.8% male), 67.7% had cirrhosis and 3.9% ALF. From 2010 to 2014, total number of hospitalizations with HE increased by 24.4% (25,059 in 2010 to 31,182 in 2014, p < 0.001). Similar increases were seen when stratified by ALF (29.7% increase) and cirrhosis (29.7% increase). Overall in-hospital mortality decreased from 13.4% (2010) to 12.3% (2014) (p = 0.001), with similar decreases observed in ALF and cirrhosis. Total inpatient charges increased by 46.0% ($8.15 billion, 2010 to $11.9 billion, 2014). On multivariable analyses, ALF was associated with significantly higher odds of in-hospital mortality (OR 5.37; 95% CI 4.97-5.80; p < 0.001) as well as higher mean inpatient charges (122.6% higher; 95% CI + 115.0-130.3%; p < 0.001) compared to cirrhosis. The presence of ascites, hepatocellular carcinoma, and hepatorenal syndrome was associated with increased mortality. CONCLUSIONS: The clinical and economic burden of hospitalizations with HE in the USA continues to rise. In 2014, estimated national economic burden of hospitalizations with HE reached $11.9 billion.


Assuntos
Encefalopatia Hepática/epidemiologia , Hospitalização/tendências , Cirrose Hepática/epidemiologia , Falência Hepática Aguda/epidemiologia , Estudos Transversais , Bases de Dados Factuais , Feminino , Encefalopatia Hepática/economia , Encefalopatia Hepática/mortalidade , Encefalopatia Hepática/terapia , Preços Hospitalares/tendências , Custos Hospitalares/tendências , Mortalidade Hospitalar/tendências , Hospitalização/economia , Humanos , Pacientes Internados , Cirrose Hepática/economia , Cirrose Hepática/mortalidade , Cirrose Hepática/terapia , Falência Hepática Aguda/economia , Falência Hepática Aguda/mortalidade , Falência Hepática Aguda/terapia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
12.
Dig Liver Dis ; 51(2): 190-205, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30606696

RESUMO

Hepatic encephalopathy (HE) is a common, worrisome and sometimes difficult to manage complication of end-stage liver disease. HE is often recurrent, requiring multiple hospital admissions. It can have serious implications in terms of a patient's ability to perform complex tasks (for example driving), their earning capacity, their social and family roles. This guideline reviews current knowledge on HE definition, pathophysiology, diagnosis and treatment, both by general principles and by way of a summary of available drugs and treatment strategies. The quality of the published, pertinent evidence is graded, and practical recommendations are made. Where possible, these are placed within the Italian health service context, with reference to local diagnosis and management experience.


Assuntos
Doença Hepática Terminal/complicações , Encefalopatia Hepática , Administração dos Cuidados ao Paciente , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Itália , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/organização & administração
13.
J Gynecol Obstet Hum Reprod ; 48(2): 133-137, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30315885

RESUMO

Acute fatty liver of pregnancy (AFLP) continues to raise special concerns since its first post-mortem description by Sheehan in 1940. While early diagnosis and expedite delivery are the cornerstone of management, this condition remains fatal for both mother and fetus. Acute fulminant liver failure is the most serious and life-threatening AFLP-related complication and can require liver transplant despite aggressive supportive management. In lieu of transplant, therapeutic plasma exchange (PE) has emerged as a life-saving alternative and has, in few reports, demonstrated efficacy for the reversal of this dangerous condition. Here we present a case report of a patient diagnosed with fulminant liver failure complicating an AFLP and progressed to severe hepatic encephalopathy who was successfully treated with five rounds of plasma exchange.


Assuntos
Fígado Gorduroso/complicações , Falência Hepática Aguda/etiologia , Falência Hepática Aguda/terapia , Troca Plasmática/métodos , Adulto , Coma/etiologia , Fígado Gorduroso/diagnóstico , Fígado Gorduroso/terapia , Feminino , Morte Fetal , Idade Gestacional , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/terapia
14.
J Gastroenterol Hepatol ; 34(1): 215-223, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30070412

RESUMO

BACKGROUND AND AIM: This study aimed to identify predictors of model for end-stage liver disease sodium score reductions and improvements in vital prognoses following portosystemic shunt occlusion in portal hypertension patients. METHODS: Seventy cirrhotic patients with major portosystemic shunts and a mean model for end-stage liver disease sodium score of 10.5 underwent balloon-occluded retrograde transvenous obliteration between February 2008 and March 2017. We calculated the scores before and 1 month after shunt occlusion. The long-term outcomes were monitored, and vital prognoses were analyzed. RESULTS: The model for end-stage liver disease sodium score did not change significantly 1 month post-balloon-occluded retrograde transvenous obliteration, and the score decreased postoperatively in 31 (44.3%) patients. Univariate analyses showed that decline in the score after portosystemic shunt occlusion was strongly associated with hepatic encephalopathy as a procedural indication, lower liver volumes, and lower liver stiffness levels measured by transient elastography before treatment (P < 0.05). Multivariate logistic regression analysis identified preoperative liver stiffness level as an independent predictor of model for end-stage liver disease sodium score amelioration following balloon-occluded retrograde transvenous obliteration (P < 0.05), and receiver operating characteristic curve analysis determined a liver stiffness cutoff value of 21.6 kPa, with a sensitivity of 76.0% and specificity of 69.6%. The Kaplan-Meier method determined that overall survival rates after treatment in patients with liver stiffness < 21.6 kPa were significantly higher than in patients with liver stiffness ≥ 21.6 kPa (P < 0.05). CONCLUSIONS: Liver stiffness measured by transient elastography may predict improvements in model for end-stage liver disease sodium scores and in survival rates after portosystemic shunt occlusion in portal hypertension patients.


Assuntos
Oclusão com Balão , Elasticidade , Varizes Esofágicas e Gástricas/terapia , Encefalopatia Hepática/terapia , Cirrose Hepática/diagnóstico por imagem , Cirrose Hepática/fisiopatologia , Derivação Portossistêmica Cirúrgica , Adulto , Idoso , Idoso de 80 Anos ou mais , Técnicas de Imagem por Elasticidade , Doença Hepática Terminal/sangue , Varizes Esofágicas e Gástricas/etiologia , Feminino , Encefalopatia Hepática/etiologia , Humanos , Hipertensão Portal/complicações , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Sódio/sangue , Taxa de Sobrevida
15.
Indian J Gastroenterol ; 37(6): 559-562, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30474827

RESUMO

Experimental studies demonstrated that fecal microbiota transplant (FMT) may reverse intestinal microbial dysbiosis. In this retrospective case series, we share our experience of treating recurrent overt hepatic encephalopathy (HE) with single FMT treatment. A total of 10 patients, age ranged from 25 to 65 years, were treated with single FMT through colonoscopy using fecal material received from rigorously screened patient-identified donors. There was sustained clinical response with single FMT treatment in 6 patients at post-treatment week 20. Arterial ammonia concentration decreased considerably (96 [87.25-117.75] vs. 74 [70-82]; p = 0.024) at post-treatment week 20. Moreover, there was statistically significant decrease in Child-Turcotte-Pugh (CTP) score (9.5 [9-10.75] vs. 8 [7-8]; p = 0.005) and model for end-stage liver disease (MELD) score (18 [16.25-19] vs. 15 [14-16]; p = 0.008). Four patients experienced six adverse-events. Overt HE and re-hospitalization were observed in 3 and 2 patients, respectively. One patient (who also experienced overt HE) died within 2 months of the index procedure.


Assuntos
Transplante de Microbiota Fecal/métodos , Fezes/microbiologia , Microbioma Gastrointestinal , Encefalopatia Hepática/terapia , Adulto , Idoso , Disbiose/microbiologia , Disbiose/terapia , Transplante de Microbiota Fecal/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
16.
Semin Respir Crit Care Med ; 39(5): 523-537, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30485883

RESUMO

Hepatic encephalopathy (HE) is a severe complication of liver disease, describing a spectrum of neurological and psychiatric abnormalities ranging from subclinical alterations to coma. HE is the leading cause for hospital readmission, intensive care treatment, and mortality in patients with chronic liver disease. The complex and multifaceted pathogenesis is not yet fully understood, but hypotheses focus on ammonia and systemic inflammation, which are the main targets for currently available therapies in clinical practice. Nevertheless, the remaining high clinical relevance and healthcare burden of this syndrome underlines the emergence for further unraveling the full spectrum of pathomechanisms, as this provides the basis for the development of novel, highly targeted therapies. In this review, the most recent literature about current and future therapies for HE, relevant for intensive care management, will be discussed.


Assuntos
Coma/etiologia , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/terapia , Hipertensão Intracraniana/complicações , Cuidados Críticos , Humanos
17.
Ann Hepatol ; 17(5): 836-842, 2018 Aug 24.
Artigo em Inglês | MEDLINE | ID: mdl-30145570

RESUMO

INTRODUCTION AND AIMS: Serum electrolyte derangements are common in patients with decompensated cirrhosis hospitalized for hepatic encephalopathy. There are limited data describing the association between electrolyte levels and outcomes in hepatic encephalopathy. We assessed the association between initial serum electrolyte values and outcomes in patients with hepatic encephalopathy. MATERIAL AND METHODS: A total of 385 consecutive patients hospitalized with encephalopathy were included in the study. Baseline electrolyte levels (sodium, potassium, chloride, bicarbonate, calcium and phosphorus) were measured at the time of admission and assessed for association with outcomes, which included survival, admission to the intensive care unit, requirement for mechanical ventilation, and length of hospital stay. P-values ≤ 0.0083 were considered significant after adjustment for multiple testing. RESULTS: In unadjusted analysis, significant associations were identified regarding both bicarbonate and phosphorus (admission to intensive care unit), and calcium (mechanical ventilation); however these findings weakened and no longer approached statistical significance when adjusting for confounding variables. No other significant associations between serum electrolyte measurements and outcomes were observed. CONCLUSIONS: Our findings suggest that in patients hospitalized with encephalopathy, serum electrolyte measurements are not strong predictors of patient outcome.


Assuntos
Eletrólitos/sangue , Encefalopatia Hepática/sangue , Cirrose Hepática/complicações , Admissão do Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Mortalidade Hospitalar , Humanos , Tempo de Internação , Cirrose Hepática/sangue , Cirrose Hepática/diagnóstico , Cirrose Hepática/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
18.
BMJ Case Rep ; 20182018 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-30061127

RESUMO

A 31-year-old man was brought to Accident & Emergency after collapsing during a race. On presentation, the patient had a temperature of 41.7°C (rectal). External cooling was started immediately. The patient was intubated in view of a Glasgow Coma Scale of 7 and was transferred to theintensive therapy unit. Laboratory results revealed an acute kidney injury, rhabdomyolysis, disseminated intravascular coagulopathy and acute liver failure. The patient was encephalopathic, jaundiced and difficult to sedate. His liver function continued to deteriorate with alanine aminotransferase (ALT) levels reaching 9207 U/L. King's Hospital Liver Centre, London was contacted for a possible liver transplant, and they advised an infusion of N-acetylcysteine. The following day liver function tests improved; thus, transplantation was not performed. The patient failed multiple sedation holds and required a tracheostomy. He continued to spike a fever. Despite no source of sepsis being found, the patient remained on broad spectrum antibiotics to cover for any potential infective causes until day 27. After 15 days, the patient's encephalopathy gradually improved. He was weaned off the ventilator and underwent intense physiotherapy. The patient was discharged from hospital one month after admission.


Assuntos
Golpe de Calor/fisiopatologia , Encefalopatia Hepática/fisiopatologia , Falência Hepática Aguda/fisiopatologia , Rabdomiólise/fisiopatologia , Corrida/fisiologia , Adulto , Atletas , Tratamento Conservador/métodos , Escala de Coma de Glasgow , Golpe de Calor/terapia , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Falência Hepática Aguda/etiologia , Falência Hepática Aguda/terapia , Masculino , Rabdomiólise/etiologia , Rabdomiólise/terapia , Resultado do Tratamento
19.
Khirurgiia (Mosk) ; (8): 61-67, 2018.
Artigo em Russo | MEDLINE | ID: mdl-30113595

RESUMO

AIM: Here we analyze efficiency of the algorithm for intensive therapy of acute hepatic insufficiency in patients with cirrhosis after portosystemic shunting, based on the experience of the Republican Specialized Scientific and Practical Medical Center of Surgery named after academician V.V. Vakhidov and considering recommendations of the world's leading hepatology schools. MATERIAL AND METHODS: Algorithm efficiency was analyzed based on the results of portosystemic shunting of 556 patients with cirrhosis and acute liver insufficiency. Treatment effectiveness was assessed by presence and severity of postoperative complications, such as hepatic insufficiency and hepatic encephalopathy. Initial decompensation of liver cirrhosis significantly increases the risk of postoperative complications of portosystemic shunting due to edematous ascites syndrome - liver insufficiency (13.5% vs 6.9% in patients without ascites p≥0.05) and hepatic encephalopathy (64.9% vs. 51,7%, respectively, p≥0.05). In group of patients with preoperative ascites syndrome mortality rate was 3.8% (10 patients) and in the group without ascites - 2.3% (6 patients). The main cause of early postoperative lethality was anastomotic thrombosis development with recurrence of bleeding from esophagus and stomach varicose veins. To reduce the risk of postoperative complications and lethality, a therapeutic-tactical algorithm was developed which was effective in combination with a complex of conservative and biophysical methods of treatment and aimed at eliminating the 'resolving factors' of their developmen. RESULTS: One of the most important components of this algorithm is pharmacotherapy with hepatoprotective drugs use in patients with liver cirrhosis in the postoperative period to maintain liver functional state. Considering the antihypoxic, detoxifying and antioxidant properties of active components of remaxol and revealed positive effect of its use in patients (decrease in bilirubin level, increase in albumin fraction of total blood protein and decrease in activity of ALAT and ASAT in 2 times), this drug can be recommended for inclusion in the postoperative pathogenetic standard therapy in this category of patients.


Assuntos
Cuidados Críticos/normas , Encefalopatia Hepática/terapia , Hipertensão Portal/cirurgia , Cirrose Hepática/terapia , Falência Hepática/terapia , Derivação Portossistêmica Cirúrgica/efeitos adversos , Doença Aguda , Algoritmos , Ascite/etiologia , Ascite/mortalidade , Ascite/terapia , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/mortalidade , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Falência Hepática/etiologia , Falência Hepática/mortalidade , Derivação Portossistêmica Cirúrgica/mortalidade , Substâncias Protetoras/uso terapêutico , Succinatos/uso terapêutico
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