TRACTAMENT DE L’ENCEFALOPATIA · PDF file- Non-absorbable disaccharides (lactulose,...
Transcript of TRACTAMENT DE L’ENCEFALOPATIA · PDF file- Non-absorbable disaccharides (lactulose,...
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Joan CordobaUniversitat Autònoma de Barcelona
TRACTAMENT DE L’ENCEFALOPATIA HEPATICA
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58 a varon confusion
Antecedentes
- Cirrosis VHCAscitis 2 años antes, control con espironolactoneVarices tt propranolol
- Infeccion orina 2 semanas antes. Cipro x 7 d.
CASO CLINICO
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
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Severity and duration
Bajaj APT 2010
ACUTE CHRONICSUBCLINICAL
OR LATENT
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Severity and duration of neurological manifestations in cirrhosis
Bajaj APT 2010
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MANAGEMENT OF THE EPISODE OF HEDiagnosisExclusion of other neurological diseases
Search of precipitating factorsGI bleeding, constipation, high protein loadinfection uremia, dehydration, hyponatremia sedatives
Assessment of liver function
Hb 13 g/dL, Leukocytes 5100, Platelets 68000creatinine 1 mg/dL Na 126 K 5.3 AST 105 ALT 73 NH3 129INR 1.6 bilirubin 2.4 mg/dL albumin 2.4 mg/dLUrine: 3 wc/f, 6 rc/f Chest x-ray: normalBlood and urinary cultures: negative
HE precipitated by hyponatremia/diuretics
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Hyponatremia: risk factor for HE
Guevara M et al, AJG 2009;104:1382-9
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Treatment of HETherapy: iv saline, stop diuretics, lactuloseImprovement in sodium (to 133 in 4 days)
Terminal liver failure: without jaundice? Additional anti-encephalopathy therapies: diet? drugs?Undiagnosed precipitating factor: additional tests?
Non-response at 1 week
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2- Treatment HE: enema + neomycine + precipitating fact
0 g 12 g 24 g48 g 1,2 g.kg
1.2 g.kg.d1- DietNG tube30 Kcal.kg.d14 days
NORMAL PROTEIN
LOW PROTEIN
Cordoba, J Hepatology 2004
Oral intake of proteins during episodic HE
DAY0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
HE
PAT
IC E
NC
EPH
ALO
PAT
HY
STA
GE
0
1
2
3
4HYPOPROTEIC DIETNORMOPROTEIC DIET 30 patients randomized
10 patients finished before day 14 (died, GI bleeding, withdraw consent..)
No differences in the outcome
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CT-scanPersistent HE = large porto-systemic shunts
Riggio O, Hepatology 2005
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Cava
Left renal vein
Coils
Spleno-renal shunt
Occlusion of shunts improves HE for MELD<11
Laleman W 2012
Hepatology 2013
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CT of the patient
Esophageal and paraesophageal varices
Lack of large portosytemic shunts
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Additional information given by the CT
Hidden prostatic abscess
Drainage + culture: E Coli resistant to quinolones & sensitive to cotrimoxazol
Disappearance of HE
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MANAGEMENT OF OVERT HEAmmonia 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 DRUGSPlacebo-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
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Sharma BJ, Gastroenterology 2009
Lactulose prevents recurrence
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Bass NM, NEJM 2010
2 episodes of HE in the previous 6 months90% on lactulose
Rifaximin improves lactulose
N=299
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Canditato a trasplante
Alta con medicación preventiva: lactulosa
Tratamiento tras el alta
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Author Agent Duration Improved MHE?
Testing of clinicallyrelevant outcomes
Watanabe Lactulose 8 weeks Yes _
Li Probiotic 24 weeks Yes _
Horsmans Lactulose 2 weeks Yes _
Prasad Lactulose 90 days Yes Improved quality of life
Morgan Rifaximin 8 weeks Yes _
Bajaj Yogurt 60 days Yes Trend: reduced OHE
Liu Synbiotic 60 days Yes CTP improvement
Malguanera Probiotic 90 days Yes _
Sidhu Rifaximin 90 days Yes Improved quality of life
Bajaj Rifaximin 60 days Yes Improved driving
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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 tras el alta
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Tratamiento multifactorial EH
Cordoba J, Sem Liv Dis 2008
SNC
MUSCULO
INTESTINO
RIÑON
HIGADO
Fuentes amoniacoInfeccionesFunción renalExpansión volemia
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Despres d’un primer episodi d’encefalopatia es recomana
¿Que no es recomana?1. Avaluar el risc d’accidents2. Indicar tractament amb lactulosa o lactitol3. Fer una dieta normoproteica4. Emplear dosis baixes de diurètics, o
evitarlos5. Fer tractament amb yogurt