- Email: [email protected]
New Approaches to the Diagnosis and the Symptomatic Treatment of Hepatic Encephalopathy
POSTER PRESENTATIONS no difference in GFR between patients with AI and those with normal adrenal function (82 vs. 70 mL/min). There was no difference in the use of beta-blockers. All patients had preserved left ventricular (LV) systolic function, and there was no difference in ejection fraction. Patients with AI had significantly higher LV end-diastolic diameter (55.3 vs. 49.3 mm; p = 0.004), left atrial diameter (47.1 vs. 41.8 mm; p = 0.007) and E/E′ ratio (12.4 vs. 9.1; p = 0.005). There were no differences in interventricular septal thickness, right ventricular systolic function or pulmonary artery systolic pressure. More patients with AI had grade II/III diastolic dysfunction (44.4% vs. 19.2%). There was no difference in QTc duration. Conclusions: AI in cirrhosis as diagnosed using conventional criteria was associated with more advanced liver disease, but not with renal dysfunction. AI was associated with LV dilatation without LV systolic impairment, as well as with indices of LV diastolic dysfunction. The results of this study indicate a potential association between the hepato-adrenal syndrome and CCM as suggested by inverse LV remodeling and impaired diastolic filling. THU-034 NEW APPROACHES TO THE DIAGNOSIS AND THE SYMPTOMATIC TREATMENT OF HEPATIC ENCEPHALOPATHY E. Manzhalii1, V. Kondratiuk1, M. Scherbinina2, O. Baka3. 1Department of Propedeutics of Internal Medicine II, Bogomolets National Medical University, Kiev; 2Faculty of Medicine, Dnepropetrovsk National University, Dnepropetrovsk; 3Gastroenterology, Hospital for Scientists of the National Academy of Science of Ukraine, Kiev, Ukraine E-mail: [email protected] Background and Aims: Taking into account the crucial role of the neurotrophic factors in the formation and functioning of the nervous system, it is possible to assume that autoimmune reactions in the form of autoantibodies (AAB) production, in particular to nonspecific protein (NSP) can contribute to the development of pathological processes of these diseases. The treatment of Hepatic Encephalopathy (HE) involves various drugs that may lead to recovery of consciousness and thinking but their therapeutic options are often limited. Our aim were: 1) to assess the levels of AAB to NSP: neurospecific enolaza (NE), protein S100 (PS100), myelin basic protein (MBP), cerebral antigen (CA); 2) to assess the efficacy of Choline Alphoscerate for the treatment of HE. Methods: For this prospective study we included 51 patients with liver cirrhosis and HE, stage I-II, latent. The patients of the main group (MG) (n = 34) received L – ornithine- L – aspartate (LOLA), Rifaximin, lactulose. In addition to basic treatment (BT) we appointed Choline Alphoscerate. The patients of the CG (n-17) received only BT. Results: After the treatment the patients in the MG demonstrated a statistically significant decrease in CA-15,1, PS100- 12.01, NE – 7.17, MBP-12.57 ( p < 0.05) in relation to the CG. The level of AAB to NSP in the patients with HE had been high before the treatment In healthy people, this index was standard. Assessment of the neurological status of MG and CG demonstratedpseudobulbar disorders such as reflexes of oral automatism 63%, anisoreflexia 32%, staticolocomotory ataxia symptoms 51%, sensitivity disorders in 43%. After the treatment in the MG vs. CG pathological neurological symptoms eliminated in 64%, cognitive function improved in 73%, speech and memory improved in 52% ( p < 0.01). The correlation between the levels of PS100, MBP, CA and neurological status the examined patients was respectively 0.67, 0.62 and 0.66 ( p < 0.05). The patients of the MG showed a marked EEG with cognitive evoked potentials improvement correlating with the levels of AAB changes. Conclusions: Determination of the levels of autoantibodies gives us a reason to associate increase in these parameters with the process of destruction of brain tissue, which allows to predict the course of the disease and develop treatment tactics. Choline Alphoscerate eliminates pathological neurological symptoms, improves cognitive function, speech and memory in patients with HE.
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THU-035 TREATMENT WITH RIFAXIMIN HIGH DOSE PLUS LACTULOSE VS RIFAXIMIN STANDARD DOSE PLUS LACTULOSE FOR ACUTE HEPATIC ENCEPHALOPATHY IN ED E. Crisafulli1, S. Demma1,2, G. Rigano1, G. Bertino1. 1Clinical and Experimental Medicine, Internal and Emergency Medicine DepartmentLiver Unit, University Hospital “G. Rodolico” of Catania, Catania, Italy; 2 UCL Institute of Liver and Digestive Health, Royal Free NHS Foundation Trust, London, United Kingdom E-mail: [email protected] Background and Aims: Hepatic encephalopathy (HE) is a debilitating complication of hepatic cirrhosis and a main presentation of liver failure. The efficacy of rifaximin, a minimally absorbed antibiotic, is well documented in the treatment of acute hepatic encephalopathy, but even by guidelines its mode of use is not well codified. In our study we wanted to find a solution that was able to act quickly on HE resolving the symptoms and quickly stabilizing the patient condition even diminuishing his permanence in emergency department (ED) Methods: In this randomized controlled trial, were randomly assigned 77 patients to receive either rifaximin, at a dose of 400 mg four times a day plus lactulose (39), or RFX at 400 mg three times daily plus lactulose (38). The primary efficacy end point was the time to the resolution of episode of encephalopathy or the downgrading of 2 grade in West haven Score. The key secondary end point was the time of hospitalization involving hepatic encephalopathy. Tertiary endpoint was to evaluate a lower incidence of infectious/ inflammatory phase in the immediacy of AD/ACLF and a more rapid and lasting channeling of the alvus Results: Patients who received the high-dose treatment (GROUP A) have a more rapid reversion encephalopathy (3.35 ± 1.16 vs. 5.41 ± 1.41 days p < 0.05) and less time of hospitalization (5.7 ± 3.8 vs. 8.2 ± 4.1 days, p < 0.05). In addition, patients in group A showed a more significant decrease of ammonium respect to admission in the first 24 h, 35.23% ± 8.56 vs 18.53% ± 8.045%, p < 0.005. Also if we limit the analysis to the patients with ammonia >100 the difference between the two arms is more significant at p < 0.001 with a percentage reduction of blood ammonia in the first 24 hours of 40.57% ± 6.12% vs 20.74% ± 6.56, p < 0.001.
Conclusions: Considering our we can say that the treatment with rifaximin, both at the normal then at high dose, is safe and effective and that it works well in co-administration with lactulose as first-line therapy. Also from our data it seems reasonable to adopt a high-dose therapy of rifaximin in patients who have acute encephalopathy at admission to ED especially if have high WH score and/or hyperammoniaemia and problems with hive. Even more reasonable if patients have a value of blood ammonia greater than 100 mg/dL, the cut off value, beyond which the difference in results between the two treatments becomes decidedly more marked.
Journal of Hepatology 2016 vol. 64 | S213–S424
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THU-035 TREATMENT WITH RIFAXIMIN HIGH DOSE PLUS LACTULOSE VS RIFAXIMIN STANDARD DOSE PLUS LACTULOSE FOR ACUTE HEPATIC ENCEPHALOPATHY IN ED E. Crisafulli1, S. Demma1,2, G. Rigano1, G. Bertino1. 1Clinical and Experimental Medicine, Internal and Emergency Medicine DepartmentLiver Unit, University Hospital “G. Rodolico” of Catania, Catania, Italy; 2 UCL Institute of Liver and Digestive Health, Royal Free NHS Foundation Trust, London, United Kingdom E-mail: [email protected] Background and Aims: Hepatic encephalopathy (HE) is a debilitating complication of hepatic cirrhosis and a main presentation of liver failure. The efficacy of rifaximin, a minimally absorbed antibiotic, is well documented in the treatment of acute hepatic encephalopathy, but even by guidelines its mode of use is not well codified. In our study we wanted to find a solution that was able to act quickly on HE resolving the symptoms and quickly stabilizing the patient condition even diminuishing his permanence in emergency department (ED) Methods: In this randomized controlled trial, were randomly assigned 77 patients to receive either rifaximin, at a dose of 400 mg four times a day plus lactulose (39), or RFX at 400 mg three times daily plus lactulose (38). The primary efficacy end point was the time to the resolution of episode of encephalopathy or the downgrading of 2 grade in West haven Score. The key secondary end point was the time of hospitalization involving hepatic encephalopathy. Tertiary endpoint was to evaluate a lower incidence of infectious/ inflammatory phase in the immediacy of AD/ACLF and a more rapid and lasting channeling of the alvus Results: Patients who received the high-dose treatment (GROUP A) have a more rapid reversion encephalopathy (3.35 ± 1.16 vs. 5.41 ± 1.41 days p < 0.05) and less time of hospitalization (5.7 ± 3.8 vs. 8.2 ± 4.1 days, p < 0.05). In addition, patients in group A showed a more significant decrease of ammonium respect to admission in the first 24 h, 35.23% ± 8.56 vs 18.53% ± 8.045%, p < 0.005. Also if we limit the analysis to the patients with ammonia >100 the difference between the two arms is more significant at p < 0.001 with a percentage reduction of blood ammonia in the first 24 hours of 40.57% ± 6.12% vs 20.74% ± 6.56, p < 0.001.
Conclusions: Considering our we can say that the treatment with rifaximin, both at the normal then at high dose, is safe and effective and that it works well in co-administration with lactulose as first-line therapy. Also from our data it seems reasonable to adopt a high-dose therapy of rifaximin in patients who have acute encephalopathy at admission to ED especially if have high WH score and/or hyperammoniaemia and problems with hive. Even more reasonable if patients have a value of blood ammonia greater than 100 mg/dL, the cut off value, beyond which the difference in results between the two treatments becomes decidedly more marked.
Journal of Hepatology 2016 vol. 64 | S213–S424