Internal Medicine

0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:12

Hepatic Encephalopathy 679

specific therapy

Indication

■clinical HE (uncertain if treating subclinical HE is beneficial)

Treatment Options

■lactulose: via nasogastric tube for comatose patients until loose

bowel movements are achieved; retention enema is a less effective

route for patients in coma; orally if patient is sufficiently conscious,

titrated to 3 bowel movements daily

■neomycin

■metronidazole: orally; only short-term use recommended because

of adverse effects

■dietary protein restriction: <40 g daily

■flumazenil (benzodiazepine antagonist), given intravenously as

boluses; costly; short duration of action; clinical utility limited to

overt HE

■promising medications not yet approved in the United States

➣lactitol: nonabsorbable synthetic disaccharide with efficacy

equivalent to that of lactulose; absence of sweet taste enhances

compliance

➣rifaximin: poorly absorbed macrolide; shows great promise

➣sodium benzoate: may cause dyspepsia and fluid retention;

Side Effects and Contraindications

■lactulose

➣side effects: dehydration, hypernatremia, flatulence, and abdo-

minal cramps

■neomycin

➣side effects: ototoxicity, nephrotoxicity, peripheral neuropathy

➣contraindications

absolute: tinnitus, renal failure

relative: serum creatinine >1.5 mg/dL

■metronidazole

➣side effects: peripheral neuropathy, carcinogenicity, metallic

taste, disulfiram-like reaction

■dietary protein restriction

➣side effects: protein-calorie malnutrition (negative nitrogen bal-

ance and obligatory endogenous protein breakdown)

follow-up

During Treatment

■monitor neurologic status