Secondary Prophylaxis of Hepatic Encephalopathy in Cirrhosis
Secondary Prophylaxis of Hepatic Encephalopathy in Cirrhosis
Hepatic encephalopathy (HE), a challenging complication of advanced liver disease, occurs in
 approximately 30-45% of patients with cirrhosis. The treatment of choice is non-absorbable
 disaccharides, such as lactulose and lactitol.Probiotics are effective in the treatment of
 minimal hepatic encephalopathy which precipitates hepatic encephalopathy. The investigators
 will assess the effects of lactulose and probiotics for the prevention of recurrence of HE
 (secondary prophylaxis) in patients after the recovery of an episode of overt hepatic
 encephalopathy.
Hepatic encephalopathy, a challenging complication of advanced liver disease, occurs in
 approximately 30-45% of patients with cirrhosis and 10-50% of patients with transjugular
 intrahepatic portosystemic shunt.Although the occurrence of episodes of hepatic
 encephalopathy appears to be unrelated to the cause of cirrhosis,increases in the frequency
 and severity of such episodes predict an increased risk of death.A small metaanalysis
 determined that lactulose and lactitol were equally effective in the treatment of
 HE.Probiotics alter the gut flora resulting in decreased ammonia production and absorption
 due to decreased intraluminal pH. Also shown to alter the short chain fatty acid production,
 & decrease intestinal permeability.Various studies have shown some improvement in either the
 prevalence of minimal hepatic encephalopathy or results in neuropsychological tests with the
 use of probiotics.Lactulose and probiotics improves minimal hepatic encephalopathy in
 cirrhotic patients and it has also been shown that minimal hepatic encephalopathy predisposes
 the cirrhotic patient to HE.We will assess the effects of lactulose and probiotics for the
 prevention of recurrence of hepatic encephalopathy (secondary prophylaxis) in patients after
 the recovery of an episode of overt hepatic encephalopathy.
Inclusion Criteria:

 -  Patients with cirrhosis and previous history of recovery from hepatic encephalopathy

 Exclusion Criteria:

 -  history of taking lactulose in the past 6 weeks.

 -  alcohol intake during the past 6 weeks or during follow up

 -  patients on secondary prophylaxis for spontaneous bacterial peritonitis

 -  previous TIPS or shunt surgery

 -  significant comorbid illness such as heart, respiratory, or renal failure

 -  any neurologic diseases such as alzheimer's disease, parkinson's disease and
 nonhepatic metabolic encephalopathies.