This document provides guidelines on hepatic encephalopathy from the American College of Gastroenterology. It summarizes that hepatic encephalopathy is caused by nitrogenous substances reaching the brain due to liver dysfunction. Ammonia is a key toxin implicated in altered mental states and neurological changes seen in both acute and chronic liver failure. The guidelines describe clinical subtypes, evaluation approaches, and staging classifications to standardize the diagnosis and management of hepatic encephalopathy.
This document discusses esophageal motor disorders, specifically primary motor disorders of the esophagus including achalasia, idiopathic diffuse esophageal spasm, and hypercontractile disorders. It defines motor disorders of the esophagus as alterations in the peristaltic activity of the esophageal body and/or operation of the sphincters. The document outlines the etiology, signs and symptoms, diagnosis, and treatment of primary esophageal motor disorders.
1. Esophageal motor disorders are alterations in the peristaltic activity of the esophageal body and/or functioning of the sphincters. There are primary motor disorders that affect the esophageal body and lower esophageal sphincter including achalasia, diffuse esophageal spasm, and hypercontractile disorders.
2. The etiology of spastic motor disorders is divided into primary and secondary causes. The primary causes include diffuse esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter. The pathophysiology involves alterations in nitric oxide synthesis and degradation affecting normal peristalsis.
3. Symptoms include chest pain, dysphagia
This document provides a review of the diagnostic and treatment strategies for hepatic encephalopathy (HE). It discusses the pathophysiology of HE, including the role of hyperammonemia and astrocyte swelling. It describes the clinical subtypes and spectrum of HE from minimal HE to overt HE. Regarding diagnosis, it covers the various diagnostic tools available, from clinical assessment and neuropsychological tests to neurophysiological tests. It notes there is no consensus on diagnosing minimal HE. The document also discusses current treatment strategies focused on reducing ammonia levels and new potential agents.
This document discusses primary angiitis of the central nervous system (PACNS), a rare disease that causes inflammation of blood vessels in the brain and spinal cord. Diagnosing PACNS is difficult due to non-specific symptoms. A diagnosis is typically made through a process of eliminating other potential causes using tests such as cerebral spinal fluid analysis, MRI imaging, angiograms, and brain biopsies. The cause of PACNS is unknown but may involve underlying infections that trigger an autoimmune response. Treatment typically involves steroids and immunosuppressive drugs. The disease cerebral amyloid angiopathy can mimic PACNS since it also involves blood vessel inflammation and damage from the accumulation of amyloid beta protein in the brain.
This study evaluated biomarkers in patients with immersion pulmonary edema (IPE) and decompression sickness (DCS) to better understand IPE pathophysiology and improve diagnosis. Biomarkers of cardiac function, kidney function, hypoxia and stress were measured in 19 IPE patients, 12 DCS patients, and 10 healthy divers as controls. Levels of copeptin (a stress marker), ischemia-modified albumin (a hypoxia marker), brain natriuretic peptide and cardiac troponin I (markers of heart failure and ischemia) were all significantly higher in IPE patients compared to DCS patients and controls. A combination of elevated brain natriuretic peptide and cardiac troponin I levels perfectly distinguished I
This document discusses the relationship between primary hyperparathyroidism (PHPT) and kidney stones. PHPT is caused by inappropriate overproduction of parathyroid hormone and can lead to hypercalciuria and nephrolithiasis. A recent study found that 7% of patients with mild PHPT experienced renal stones. Surgical removal of enlarged parathyroid glands is the primary treatment for PHPT and can reduce the risk of developing further kidney stones. For asymptomatic cases, surgery may be recommended based on factors like age and presence of complications.
This document discusses esophageal motor disorders, specifically primary motor disorders of the esophagus including achalasia, idiopathic diffuse esophageal spasm, and hypercontractile disorders. It defines motor disorders of the esophagus as alterations in the peristaltic activity of the esophageal body and/or operation of the sphincters. The document outlines the etiology, signs and symptoms, diagnosis, and treatment of primary esophageal motor disorders.
1. Esophageal motor disorders are alterations in the peristaltic activity of the esophageal body and/or functioning of the sphincters. There are primary motor disorders that affect the esophageal body and lower esophageal sphincter including achalasia, diffuse esophageal spasm, and hypercontractile disorders.
2. The etiology of spastic motor disorders is divided into primary and secondary causes. The primary causes include diffuse esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter. The pathophysiology involves alterations in nitric oxide synthesis and degradation affecting normal peristalsis.
3. Symptoms include chest pain, dysphagia
This document provides a review of the diagnostic and treatment strategies for hepatic encephalopathy (HE). It discusses the pathophysiology of HE, including the role of hyperammonemia and astrocyte swelling. It describes the clinical subtypes and spectrum of HE from minimal HE to overt HE. Regarding diagnosis, it covers the various diagnostic tools available, from clinical assessment and neuropsychological tests to neurophysiological tests. It notes there is no consensus on diagnosing minimal HE. The document also discusses current treatment strategies focused on reducing ammonia levels and new potential agents.
This document discusses primary angiitis of the central nervous system (PACNS), a rare disease that causes inflammation of blood vessels in the brain and spinal cord. Diagnosing PACNS is difficult due to non-specific symptoms. A diagnosis is typically made through a process of eliminating other potential causes using tests such as cerebral spinal fluid analysis, MRI imaging, angiograms, and brain biopsies. The cause of PACNS is unknown but may involve underlying infections that trigger an autoimmune response. Treatment typically involves steroids and immunosuppressive drugs. The disease cerebral amyloid angiopathy can mimic PACNS since it also involves blood vessel inflammation and damage from the accumulation of amyloid beta protein in the brain.
This study evaluated biomarkers in patients with immersion pulmonary edema (IPE) and decompression sickness (DCS) to better understand IPE pathophysiology and improve diagnosis. Biomarkers of cardiac function, kidney function, hypoxia and stress were measured in 19 IPE patients, 12 DCS patients, and 10 healthy divers as controls. Levels of copeptin (a stress marker), ischemia-modified albumin (a hypoxia marker), brain natriuretic peptide and cardiac troponin I (markers of heart failure and ischemia) were all significantly higher in IPE patients compared to DCS patients and controls. A combination of elevated brain natriuretic peptide and cardiac troponin I levels perfectly distinguished I
This document discusses the relationship between primary hyperparathyroidism (PHPT) and kidney stones. PHPT is caused by inappropriate overproduction of parathyroid hormone and can lead to hypercalciuria and nephrolithiasis. A recent study found that 7% of patients with mild PHPT experienced renal stones. Surgical removal of enlarged parathyroid glands is the primary treatment for PHPT and can reduce the risk of developing further kidney stones. For asymptomatic cases, surgery may be recommended based on factors like age and presence of complications.
Clinically inapparent adrenal masses which are incidentally detected have become a common problem in everyday practice. Approximately 5-20% of adrenal incidentalomas present subclini- cal cortisol hypersecretion which is characterized by subtle alterations of the hypothalamic- pituitary-adrenal axis due to adrenal autonomy. this disorder has been described as subclinical cushing’s syndrome, since there is no typical clinical phenotype. the diagnosis of subclinical cushing’s syndrome is based on biochemical evaluation; however, there is still no consensus for the biochemical diagnostic criteria. An abnormal 1mg dexamethasone suppression test (Dst) as initial screening test in combination with at least one other abnormal test of the hypothalamic-pituitary-adrenal axis has been advocated by most experts for the diagnosis of subclinical cushing’s syndrome. Dst is the main method of establishing the diagnosis, while there is inhomogeneity of the information that other tests provide. Arterial hypertension, diabetes mellitus type 2 or impaired glucose tolerance, central obesity, osteoporosis/vertebral fractures and dyslipidemia are considered as detrimental effects of chronic subtle cortisol excess, although there is no proven causal relationship between subclinical cortisol hyperse- cretion and these morbidities. therapeutic strategies include careful observation along with medical treatment of morbidities potentially related to subtle cortisol hypersecretion versus laparoscopic adrenalectomy. the optimal management of patients with subclinical cushing’s syndrome is not yet defined. the conservative approach is appropriate for the majority of these patients; however, the duration of follow-up and the frequency of periodical evaluation still remain open issues. surgical resection may be beneficial for patients with hypertension, diabetes mellitus type 2 or abnormal glucose tolerance and obesity.
Broken Heart Syndrome: A Stress Responseasclepiuspdfs
This case report describes a 76-year-old female who presented with symptoms of chest pain and dyspnea after experiencing recent physical stress from pneumonia. She underwent pre-operative testing in preparation for hiatal hernia repair surgery. During induction of anesthesia, she went into ventricular fibrillation but self-converted to sinus rhythm. She was diagnosed with Takotsubo cardiomyopathy after cardiac catheterization found no significant coronary artery blockages. Takotsubo cardiomyopathy, also known as broken heart syndrome, is a type of reversible left ventricular dysfunction that can mimic acute coronary syndrome. It is often preceded by physical or emotional stress and predominantly affects postmenopausal women.
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver
places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones
and hernia are more common in patients with cirrhosis http://www.jcehapatology.com
Pre operative assessment of patient with liver diseaseHan Naung Tun
The patient is a 55-year-old male with liver cirrhosis and a history of empyema gallbladder who is scheduled for an elective cholecystectomy. Pre-operative assessments found elevated liver enzymes and signs of portal hypertension on ultrasound. The patient's MELD score placed him at moderate to high risk for surgery. Pre-operative optimization and risk stratification were performed, and the cholecystectomy was carried out with monitoring and treatment for liver disease and infection.
Patient with chronic PE treatment options - dr Szymon Darochapiodof
This document discusses treatment options for a 52-year-old female patient with chronic thromboembolic pulmonary hypertension (CTEPH) who is not eligible for pulmonary endarterectomy surgery. It provides background on CTEPH, describes the patient's condition and past treatment history, and reviews the potential for balloon pulmonary angioplasty (BPA) as an alternative treatment approach. BPA involves using a balloon catheter to break up clots and scar tissue in the lungs and has shown promising results in some CTEPH patients who cannot undergo surgery. The document also shares early experience with BPA from another medical center and reviews its safety profile.
Diabetic control of ckd patient prof. megahed abo elmagdFarragBahbah
1) Diabetes is the leading cause of end-stage renal disease (ESRD), accounting for around 50% of new dialysis patients in the US. Strict control of blood sugar, blood pressure, and use of renin-angiotensin system (RAS) blockers can help slow the progression of diabetic kidney disease.
2) New antidiabetic drug classes like SGLT2 inhibitors and DPP-4 inhibitors have shown promising results in reducing kidney disease progression in patients with type 2 diabetes beyond glycemic control alone.
3) Lifestyle factors like smoking significantly increase the risk of diabetic kidney disease progression. Maintaining good control of blood sugar, blood pressure, cholesterol, and
The document discusses chronic thromboembolic pulmonary hypertension (CTEPH) and its pathophysiology. It describes the core pathologic process as an imbalance between prothrombotic factors and disturbed thrombus resolution, leading to in situ thrombosis over thromboembolic lesions. It also discusses the BENEFIT trial which found that treatment with bosentan improved exercise capacity and hemodynamics in inoperable CTEPH patients. The CHEST trial then evaluated riociguat, a soluble guanylate cyclase stimulator, in inoperable or recurrent CTEPH patients and found improvements in pulmonary vascular resistance and other outcomes.
Successful management of massive intra-operative pulmonary embolism Apollo Hospitals
Acute Pulmonary Embolism has a high rate of mortality (26%) due to blockade of the pulmonary artery leading to acute increase in right ventricular pressure causing sudden cardiac decompensation. Lack of specific tests for early diagnosis is one of the causes for high rate of mortality but timely diagnosis and active intervention can save the life of the patient.
Soluble Lectin-Like Oxidized LDL Receptor-1 and High-Sensitivity Troponin T a...Nagi Abdalla
This study evaluated soluble lectin-like oxidized LDL receptor-1 (sLOX-1) and high-sensitivity troponin T (hs-TnT) as diagnostic biomarkers for acute coronary syndrome (ACS). sLOX-1 levels and hs-TnT levels were measured in 200 patients and found to be higher in ACS patients compared to those with non-ACS conditions. Both biomarkers showed diagnostic value for ACS, with sLOX-1 detecting some early-stage ACS cases that hs-TnT missed. However, neither biomarker was fully specific, as elevated levels were also seen in some non-ACS conditions. The combination of sLOX-1 and hs
A 30-year-old female presented with sinus tachycardia (130 bpm) shortly after induction of anesthesia with propofol, sufentanil, and rocuronium. Other potential causes of tachycardia were ruled out. Tachycardia resolved two minutes after administration of sugammadex, supporting the hypothesis that the rocuronium induced the tachycardia, likely through cardiac muscarinic M2 receptor blockade. The patient had an uneventful recovery with no further cardiovascular or neurological issues.
New class of therapeutic agents called soluble guanylate cyclase (sGC) stimulators.
Impairment of NO synthesis and signaling through the NO-sGC–cGMP pathway is involved in the pathogenesis of pulmonary hypertension.
Dual mode of action,
Directly stimulating sGC independently of NO, and
Increasing the sensitivity of sGC to NO.
vasorelaxation , antiproliferative and antifibrotic effects
This study evaluated the outcomes of hepatic resection (HR) versus percutaneous tube drainage (PD) for patients with pyogenic liver abscesses and an APACHE II score ≥15. The study found that patients who underwent HR had significantly lower mortality, failure, and double treatment rates compared to those who only underwent PD. HR patients also had significantly shorter hospital stays, shorter duration of antibiotic use, and fewer procedure-related complications. The study concludes that aggressive HR may produce better clinical outcomes than PD alone for patients with severe liver abscesses as indicated by high APACHE II scores.
This document discusses the importance of pre-operative liver function assessment prior to liver surgery. It outlines several methods of evaluating liver function, including clinical scoring systems like the Child-Turcotte-Pugh score, dynamic tests that measure hepatic uptake and excretion such as indocyanine green retention and nuclear scintigraphy, and volumetric measurements using CT scans. No single test can fully assess liver function, so a combination is recommended, along with surgical judgment, to determine the severity of any underlying liver disease, tumor extent, predicted post-operative liver remnant, and risk of hepatic failure. This helps select appropriate patients and procedures to optimize surgical outcomes.
Takayasu arteritis is a rare large vessel vasculitis that predominantly involves the aorta and its major branches. It was first described in 1908 by Mikito Takayasu and has various names including pulseless disease. It most commonly affects the subclavian and carotid arteries in women under 50 years old. Diagnosis is based on imaging and clinical criteria as there are no definitive diagnostic tests. Treatment involves steroids and steroid-sparing immunosuppressants, with TNF inhibitors being widely used biologic therapies. Ongoing management focuses on preventing arterial progression and complications like hypertension.
anaesthesia for lung transplant. indication and contra indication for lung transplant. intra-op and post op complications of lung transplant,
post op pain relief for lung transplant. patient selection for lung transplant. donor criteria for lung donor
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic). The most appropriate first
This study analyzed early postoperative complications in 145 adult patients who received total intravenous anesthesia (TIVA) with propofol and remifentanil for elective neurosurgery. The authors found:
1) The overall incidence of shivering was 30.3%, postoperative nausea and vomiting (PONV) was 16.6%, and postoperative hypertension (blood pressure over 25% of preoperative value) was 35.2%.
2) 51% of patients experienced at least one of these complications. Complication rates varied significantly between surgical groups.
3) The intracranial vascular surgery group had the highest rates of shivering (58.8%) and PONV (29.4
Acs0006 Risk Stratification, Preoperative Testing, And Operative Planningmedbookonline
This document discusses risk stratification, preoperative testing, and operative planning. It outlines tools for assessing surgical risk such as the American Society of Anesthesiologists physical status classification system. Factors that affect cardiac risk are identified, such as smoking, alcohol abuse, and previous cardiovascular disease. Guidelines for preoperative testing are presented, noting the need for selective testing. The importance of identifying clinical risk factors and optimizing modifiable factors is discussed.
Review (ca 2007) of Uremic Toxins Accumulating in Patients with Chronic and End Stage Renal Disease modified from a presentation I gave in Fellow's Grand rounds.
Relied heavily on publications from the EU Toxin Work Group Work, which provides more up to date information:
http://www.uremic-toxins.org/
This document summarizes modern management options for the uraemic syndrome in chronic kidney disease. It discusses the pathophysiology of the uraemic syndrome and how it affects multiple organ systems. Traditional and non-traditional risk factors for cardiovascular disease are examined. Over 150 uraemic retention products have been identified and are divided into small water-soluble compounds, protein-bound compounds, and larger middle molecules. Progression of chronic kidney disease depends on the underlying cause and risk factors, leading to loss of kidney function over time. Management options aim to target modifiable factors like cardiovascular risk simultaneously.
Movement disorders: A complication of chronic Hyperglycemia? A case reportApollo Hospitals
This case report describes a 77-year-old man who presented with bilateral choreic movements that were predominantly on the right side, along with some dystonic movements. He had long-standing type 2 diabetes that was poorly controlled, with an HbA1c of 17.3%. Brain imaging showed hyperdensity in the putamen and lenticular nucleus. His symptoms improved with insulin treatment and a neuroleptic medication. The report discusses that uncontrolled diabetes can rarely cause movement disorders like chorea due to metabolic disturbances in the basal ganglia from hyperglycemia. Prompt treatment of the hyperglycemia typically leads to resolution of the neurological symptoms.
Clinically inapparent adrenal masses which are incidentally detected have become a common problem in everyday practice. Approximately 5-20% of adrenal incidentalomas present subclini- cal cortisol hypersecretion which is characterized by subtle alterations of the hypothalamic- pituitary-adrenal axis due to adrenal autonomy. this disorder has been described as subclinical cushing’s syndrome, since there is no typical clinical phenotype. the diagnosis of subclinical cushing’s syndrome is based on biochemical evaluation; however, there is still no consensus for the biochemical diagnostic criteria. An abnormal 1mg dexamethasone suppression test (Dst) as initial screening test in combination with at least one other abnormal test of the hypothalamic-pituitary-adrenal axis has been advocated by most experts for the diagnosis of subclinical cushing’s syndrome. Dst is the main method of establishing the diagnosis, while there is inhomogeneity of the information that other tests provide. Arterial hypertension, diabetes mellitus type 2 or impaired glucose tolerance, central obesity, osteoporosis/vertebral fractures and dyslipidemia are considered as detrimental effects of chronic subtle cortisol excess, although there is no proven causal relationship between subclinical cortisol hyperse- cretion and these morbidities. therapeutic strategies include careful observation along with medical treatment of morbidities potentially related to subtle cortisol hypersecretion versus laparoscopic adrenalectomy. the optimal management of patients with subclinical cushing’s syndrome is not yet defined. the conservative approach is appropriate for the majority of these patients; however, the duration of follow-up and the frequency of periodical evaluation still remain open issues. surgical resection may be beneficial for patients with hypertension, diabetes mellitus type 2 or abnormal glucose tolerance and obesity.
Broken Heart Syndrome: A Stress Responseasclepiuspdfs
This case report describes a 76-year-old female who presented with symptoms of chest pain and dyspnea after experiencing recent physical stress from pneumonia. She underwent pre-operative testing in preparation for hiatal hernia repair surgery. During induction of anesthesia, she went into ventricular fibrillation but self-converted to sinus rhythm. She was diagnosed with Takotsubo cardiomyopathy after cardiac catheterization found no significant coronary artery blockages. Takotsubo cardiomyopathy, also known as broken heart syndrome, is a type of reversible left ventricular dysfunction that can mimic acute coronary syndrome. It is often preceded by physical or emotional stress and predominantly affects postmenopausal women.
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver
places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones
and hernia are more common in patients with cirrhosis http://www.jcehapatology.com
Pre operative assessment of patient with liver diseaseHan Naung Tun
The patient is a 55-year-old male with liver cirrhosis and a history of empyema gallbladder who is scheduled for an elective cholecystectomy. Pre-operative assessments found elevated liver enzymes and signs of portal hypertension on ultrasound. The patient's MELD score placed him at moderate to high risk for surgery. Pre-operative optimization and risk stratification were performed, and the cholecystectomy was carried out with monitoring and treatment for liver disease and infection.
Patient with chronic PE treatment options - dr Szymon Darochapiodof
This document discusses treatment options for a 52-year-old female patient with chronic thromboembolic pulmonary hypertension (CTEPH) who is not eligible for pulmonary endarterectomy surgery. It provides background on CTEPH, describes the patient's condition and past treatment history, and reviews the potential for balloon pulmonary angioplasty (BPA) as an alternative treatment approach. BPA involves using a balloon catheter to break up clots and scar tissue in the lungs and has shown promising results in some CTEPH patients who cannot undergo surgery. The document also shares early experience with BPA from another medical center and reviews its safety profile.
Diabetic control of ckd patient prof. megahed abo elmagdFarragBahbah
1) Diabetes is the leading cause of end-stage renal disease (ESRD), accounting for around 50% of new dialysis patients in the US. Strict control of blood sugar, blood pressure, and use of renin-angiotensin system (RAS) blockers can help slow the progression of diabetic kidney disease.
2) New antidiabetic drug classes like SGLT2 inhibitors and DPP-4 inhibitors have shown promising results in reducing kidney disease progression in patients with type 2 diabetes beyond glycemic control alone.
3) Lifestyle factors like smoking significantly increase the risk of diabetic kidney disease progression. Maintaining good control of blood sugar, blood pressure, cholesterol, and
The document discusses chronic thromboembolic pulmonary hypertension (CTEPH) and its pathophysiology. It describes the core pathologic process as an imbalance between prothrombotic factors and disturbed thrombus resolution, leading to in situ thrombosis over thromboembolic lesions. It also discusses the BENEFIT trial which found that treatment with bosentan improved exercise capacity and hemodynamics in inoperable CTEPH patients. The CHEST trial then evaluated riociguat, a soluble guanylate cyclase stimulator, in inoperable or recurrent CTEPH patients and found improvements in pulmonary vascular resistance and other outcomes.
Successful management of massive intra-operative pulmonary embolism Apollo Hospitals
Acute Pulmonary Embolism has a high rate of mortality (26%) due to blockade of the pulmonary artery leading to acute increase in right ventricular pressure causing sudden cardiac decompensation. Lack of specific tests for early diagnosis is one of the causes for high rate of mortality but timely diagnosis and active intervention can save the life of the patient.
Soluble Lectin-Like Oxidized LDL Receptor-1 and High-Sensitivity Troponin T a...Nagi Abdalla
This study evaluated soluble lectin-like oxidized LDL receptor-1 (sLOX-1) and high-sensitivity troponin T (hs-TnT) as diagnostic biomarkers for acute coronary syndrome (ACS). sLOX-1 levels and hs-TnT levels were measured in 200 patients and found to be higher in ACS patients compared to those with non-ACS conditions. Both biomarkers showed diagnostic value for ACS, with sLOX-1 detecting some early-stage ACS cases that hs-TnT missed. However, neither biomarker was fully specific, as elevated levels were also seen in some non-ACS conditions. The combination of sLOX-1 and hs
A 30-year-old female presented with sinus tachycardia (130 bpm) shortly after induction of anesthesia with propofol, sufentanil, and rocuronium. Other potential causes of tachycardia were ruled out. Tachycardia resolved two minutes after administration of sugammadex, supporting the hypothesis that the rocuronium induced the tachycardia, likely through cardiac muscarinic M2 receptor blockade. The patient had an uneventful recovery with no further cardiovascular or neurological issues.
New class of therapeutic agents called soluble guanylate cyclase (sGC) stimulators.
Impairment of NO synthesis and signaling through the NO-sGC–cGMP pathway is involved in the pathogenesis of pulmonary hypertension.
Dual mode of action,
Directly stimulating sGC independently of NO, and
Increasing the sensitivity of sGC to NO.
vasorelaxation , antiproliferative and antifibrotic effects
This study evaluated the outcomes of hepatic resection (HR) versus percutaneous tube drainage (PD) for patients with pyogenic liver abscesses and an APACHE II score ≥15. The study found that patients who underwent HR had significantly lower mortality, failure, and double treatment rates compared to those who only underwent PD. HR patients also had significantly shorter hospital stays, shorter duration of antibiotic use, and fewer procedure-related complications. The study concludes that aggressive HR may produce better clinical outcomes than PD alone for patients with severe liver abscesses as indicated by high APACHE II scores.
This document discusses the importance of pre-operative liver function assessment prior to liver surgery. It outlines several methods of evaluating liver function, including clinical scoring systems like the Child-Turcotte-Pugh score, dynamic tests that measure hepatic uptake and excretion such as indocyanine green retention and nuclear scintigraphy, and volumetric measurements using CT scans. No single test can fully assess liver function, so a combination is recommended, along with surgical judgment, to determine the severity of any underlying liver disease, tumor extent, predicted post-operative liver remnant, and risk of hepatic failure. This helps select appropriate patients and procedures to optimize surgical outcomes.
Takayasu arteritis is a rare large vessel vasculitis that predominantly involves the aorta and its major branches. It was first described in 1908 by Mikito Takayasu and has various names including pulseless disease. It most commonly affects the subclavian and carotid arteries in women under 50 years old. Diagnosis is based on imaging and clinical criteria as there are no definitive diagnostic tests. Treatment involves steroids and steroid-sparing immunosuppressants, with TNF inhibitors being widely used biologic therapies. Ongoing management focuses on preventing arterial progression and complications like hypertension.
anaesthesia for lung transplant. indication and contra indication for lung transplant. intra-op and post op complications of lung transplant,
post op pain relief for lung transplant. patient selection for lung transplant. donor criteria for lung donor
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic). The most appropriate first
This study analyzed early postoperative complications in 145 adult patients who received total intravenous anesthesia (TIVA) with propofol and remifentanil for elective neurosurgery. The authors found:
1) The overall incidence of shivering was 30.3%, postoperative nausea and vomiting (PONV) was 16.6%, and postoperative hypertension (blood pressure over 25% of preoperative value) was 35.2%.
2) 51% of patients experienced at least one of these complications. Complication rates varied significantly between surgical groups.
3) The intracranial vascular surgery group had the highest rates of shivering (58.8%) and PONV (29.4
Acs0006 Risk Stratification, Preoperative Testing, And Operative Planningmedbookonline
This document discusses risk stratification, preoperative testing, and operative planning. It outlines tools for assessing surgical risk such as the American Society of Anesthesiologists physical status classification system. Factors that affect cardiac risk are identified, such as smoking, alcohol abuse, and previous cardiovascular disease. Guidelines for preoperative testing are presented, noting the need for selective testing. The importance of identifying clinical risk factors and optimizing modifiable factors is discussed.
Review (ca 2007) of Uremic Toxins Accumulating in Patients with Chronic and End Stage Renal Disease modified from a presentation I gave in Fellow's Grand rounds.
Relied heavily on publications from the EU Toxin Work Group Work, which provides more up to date information:
http://www.uremic-toxins.org/
This document summarizes modern management options for the uraemic syndrome in chronic kidney disease. It discusses the pathophysiology of the uraemic syndrome and how it affects multiple organ systems. Traditional and non-traditional risk factors for cardiovascular disease are examined. Over 150 uraemic retention products have been identified and are divided into small water-soluble compounds, protein-bound compounds, and larger middle molecules. Progression of chronic kidney disease depends on the underlying cause and risk factors, leading to loss of kidney function over time. Management options aim to target modifiable factors like cardiovascular risk simultaneously.
Movement disorders: A complication of chronic Hyperglycemia? A case reportApollo Hospitals
This case report describes a 77-year-old man who presented with bilateral choreic movements that were predominantly on the right side, along with some dystonic movements. He had long-standing type 2 diabetes that was poorly controlled, with an HbA1c of 17.3%. Brain imaging showed hyperdensity in the putamen and lenticular nucleus. His symptoms improved with insulin treatment and a neuroleptic medication. The report discusses that uncontrolled diabetes can rarely cause movement disorders like chorea due to metabolic disturbances in the basal ganglia from hyperglycemia. Prompt treatment of the hyperglycemia typically leads to resolution of the neurological symptoms.
This document provides an overview of biochemical investigation and diagnosis of inborn errors of metabolism (IEM) that present with adult-onset neurological disease. It discusses the types of IEM that can present in adulthood, including lysosomal storage diseases, peroxisomal disorders, mitochondrial disorders, urea cycle disorders, and organic acidurias. It describes appropriate first-line biochemical tests for these disorders, including tests of intermediary metabolism, peroxisomal function, and lysosomal function. It emphasizes the importance of obtaining samples during acute attacks or illnesses when symptoms are present. The document also notes that some IEM diagnosed in childhood may only be recognized as causing neurological problems in adulthood.
This document provides an overview of nephrotic syndrome, including its diagnostic criteria, differential diagnosis, clinical signs, appropriate investigations, treatment principles, and common types. It defines nephrotic syndrome as having proteinuria, edema, hypoalbuminemia, and hypercholesterolemia. The main types discussed are minimal change disease, focal segmental glomerulosclerosis, and membranous nephropathy. Treatment involves controlling blood pressure and cholesterol, minimizing risk factors, immunosuppression for primary causes, and supportive care like fluid management and nutrition.
1) Autonomic neuropathies can be caused by a variety of factors including autoimmune disorders, metabolic conditions like diabetes, infections, toxins and genetic factors.
2) Autoimmune autonomic ganglionopathy is an immune-mediated disorder characterized by diffuse autonomic failure and is heterogeneous in its presentation and response to treatment.
3) Testing like autonomic function tests, serum autoantibody tests and skin biopsies are important for diagnosis, but treatment is often symptomatic while immunosuppressants may help in some cases of autoimmune etiology.
Motor disorders can involve the muscles of the pharyngoesophageal region or the esophageal body and lower esophageal sphincter. Proximal disorders cause oropharyngeal dysphagia while distal disorders produce vague symptoms. Diagnosis of proximal disorders involves endoscopy and videofluoroscopy while distal disorders are diagnosed using endoscopy, barium swallow, and manometry. Achalasia is caused by loss of inhibitory neurons and treated initially with pneumatic dilation or botulinum toxin injection. Minimally invasive techniques are becoming more common for treating proximal disorders like Zenker's diverticulum.
This guideline presents recommendations for the management of acute pancreatitis (AP). Key recommendations include: assessing hemodynamic status upon presentation and providing resuscitation as needed; admitting patients with organ failure to intensive care; providing aggressive intravenous hydration within the first 12-24 hours; using ERCP within 24 hours for patients with AP and cholangitis; not routinely using prophylactic antibiotics for severe AP or sterile necrosis; considering infected necrosis in patients not improving after 7-10 days and using antibiotics known to penetrate pancreatic necrosis; and providing enteral nutrition for severe AP to prevent infectious complications while avoiding parenteral nutrition.
Reply to the following 2 posts. In your reply posts, include how th.docxchris293
Reply to the following 2 posts. In your reply posts, include how the information you learned from your peer’s initial post will help you to provide care to a patient.
POST 1
lomerulonephritis
Glomerulonephritis (acute poststreptococcal glomerulonephritis, APSGN), is a representative form of nephritic disease, that occurs following an infection of streptococcal with strains of group A beta-hemolytic streptococcus. According to the National kidney foundation (2020), there are two types, acute and chronic. (NKF, 2020). I will be focusing this discussion on the acute type APSGN. This occurs following an infection in the upper respiratory tract, middle ear infections or strep throat. Whenever there are infections with strains of streptococcus, the immune response is usually initiated in the kidney. This condition develops 10 days up to two weeks following exposure to the strep strain and occurs in children between the ages of 3-7 years, mostly affecting boys. (Hubert & VanMeter, 2018).
Pathophysiology
When persons become infected with the streptococcal strain, subsequent infections causes the body to form antistreptococcal antibodies, thus creating an antigen-antibody complex (type 3 hypersensitivity reaction). When this occurs, the complement systemin becomes activated, which causes the glomeruli of both kidneys to develop an inflammatory response. The inflammatory responses further leads to increase permeability and cell proliferation, where protein and erythrocytes infiltrates and leak into the system. Immunoglobulin G and C3 becomes present in the glomerular tissue and reduction of the serum C3 is noted. If the inflammatory response is severe, and causes reduction in the filtration of the kidney, the glomerular filtration rate (GFR) will decrease and a build up of waste and fluids will occur in the body. If there is impairment in the blood flow, then acute renal failure can occur, increased renin secretion occurs which cause edema and high blood pressure. When these changes are over a prolonged period, scarring of the kidneys can occur. (Hubert et al, (2018).
Signs and symptoms
Edema of the face and periorbital region, generalized edema, due to the retention of fluid and sodium, and the fall in the osmotic pressure, blood pressure elevated, urine color is dark and cloudy, flank or back pain, oliguria results from the decrease in the GFR, and generalized signs of inflammation such as headache, malaise, anorexia and nausea. (Hubert et al, 2018).
Diagnostic testing
The diagnostic tests are blood test (serum urea, creatinine) these will be elevated. GFR will decrease. Blood levels to measure anti-DNase B, streptococcal antibodies. ASO (antistreptolysin O) and ASK (antistreptokinase) will be elevated. Urinalysis will be done to confirm the presence of protein, hematuria and erythrocyte casts. Serum bicarbonate levels and pH will be done same will be decreased, and metabolic acidosis will be present. The patients complement level.
Safety pharmacology aims to identify potential adverse effects of new drugs prior to clinical trials. It involves evaluating a drug's effects on major organ systems like the cardiovascular, central nervous, and respiratory systems. Biomarkers and newer approaches can provide mechanistic insight. Renal safety assessment is important and may involve in vivo, in vitro, and in silico models. Biomarkers of kidney injury like KIM-1 and clusterin are being used. Safety pharmacology helps predict hazards, identify risks, and facilitate risk management of new drugs.
Cirrhosis results from fibrosis and nodular regeneration of the liver. It leads to increased resistance to blood flow within the liver and portal hypertension. Common complications include variceal bleeding, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. Treatment focuses on managing the complications through medications, dietary changes, paracentesis, and sometimes transplantation. Prognosis depends on disease severity and presence of complications.
Prof. a. el sebaeii.fluid management in patients with akiwessam1071
Acute renal failure (ARF) is common in intensive care units (ICUs) and is associated with high mortality. Early fluid management is important to prevent and treat ARF. While aggressive hydration and maintaining adequate blood pressure can help prevent ARF, both overhydration and underhydration should be avoided as they can worsen renal function. No intravenous fluid is ideal, and fluid choice and management should be tailored to the individual patient based on their fluid status and needs. Early initiation of renal replacement therapy should be considered for patients with complications from ARF such as fluid overload or electrolyte abnormalities.
dr Mohammed Hussien ( assistant Lecturer of Gastroenterologist and Hepatology at Kaferelsheik University Egypy) illusterating one of Major complication of Cirrhosis --H.E
Metabolic disoders internal medicine and neuroscienceNeilVincentDeAsis
This document discusses acquired metabolic disorders of the nervous system that result from failure of other organ systems. It focuses on hypoxic-ischemic encephalopathy, where lack of oxygen and blood flow to the brain causes global disturbance of cerebral function. The main causes are discussed as well as the clinical features and progression from confusion to stupor and coma. Laboratory tests that can help identify potential causes are also outlined.
DIRI with commercial available agents ,,,.pdfMOHITROCK1
review articles 7th semester b pharm final year
topic: Drug Induced Renal Injury (DIRI): Alarming indication towards the
catastrophic behavior of drugs
Materials and Methods of DIRI
Renal manifestations of recrea
Nephrotoxicity of Ciprofloxaci
Herbal Nephropathy (Cranberry)
B PHARM
1) The document discusses how the structure-specific effects of alcohol in the brain depend on the ability of different brain structures to metabolize ethanol and its metabolite, acetaldehyde.
2) Local accumulation or deficiencies of these metabolites can lead to selective disturbances in brain structures and involvement in alcohol-related behaviors and alcoholism pathogenesis.
3) The enzymes that metabolize ethanol and acetaldehyde have different roles - ethanol-metabolizing enzymes produce acetaldehyde, which mediates reinforcing and toxic effects, while the acetaldehyde-metabolizing enzyme protects against excess acetaldehyde but may also initiate addiction in some brain structures.
This document discusses the evaluation of autonomic functions. It begins with an overview of the central control of autonomic functions through the central autonomic network and various hypothalamic and extra-hypothalamic nuclei. It then covers the peripheral autonomic system, classification of dysautonomia, clinical features of autonomic involvement, and approaches to assessing autonomic functions. Specific tests are described including heart rate variation with deep breathing, Valsalva maneuver, and orthostatic blood pressure recordings. Autonomic disorders and neuropathies are also categorized.
This document provides a review of hyponatremia. It discusses that hyponatremia is the most common electrolyte abnormality seen in hospitalized patients and the ICU. While associated with increased mortality, the degree of risk depends on severity and underlying comorbidities. Symptoms vary based on chronicity and rate of onset. Treatment involves determining the cause and correcting the sodium level appropriately to avoid complications like osmotic demyelination.
Hepatic encephalopathy is a reversible neuropsychiatric impairment that ranges from subtle mental status changes to deep coma in patients with acute or chronic liver disease. There are several proposed mechanisms for hepatic encephalopathy, including the ammonia, inflammation, oxidative stress, and manganese theories. The pathogenesis involves toxic substances bypassing the liver and affecting astrocyte function in the brain, which can lead to cerebral edema. Clinical examination is needed to diagnose hepatic encephalopathy and exclude other potential causes of altered mental status in cirrhotic patients.
Similar to Hepatic Encephalopathy - Medicina Interna II (20)
Prevalencia de Alteraciones Electrocardiograficas en Deportistas Profesionale...Matias Fernandez Viña
Este documento resume un estudio sobre la prevalencia de alteraciones electrocardiográficas en deportistas profesionales de un club en San Nicolás, Argentina. El estudio evaluó 124 deportistas de alto rendimiento utilizando electrocardiogramas y encuestas. Encontró que el 59% de los deportistas tenían electrocardiogramas normales, mientras que el 41% mostró alteraciones como bloqueo incompleto de rama derecha (22%), bradicardia sinusal leve (11%) y trastorno de repolarización precoz (10%). Las alteraciones vari
El electrocardiograma (ECG) registra la actividad eléctrica del corazón a través de electrodos colocados en la piel. El ECG proporciona información sobre el ritmo cardíaco, posibles problemas de corazón como infartos o arritmias, y cómo los medicamentos afectan el corazón. Al colocar electrodos en ubicaciones específicas, el ECG puede obtener 12 derivaciones que muestran la actividad eléctrica del corazón desde diferentes ángulos.
La disfagia se refiere a una sensación de atascamiento al pasar los alimentos a través del esófago. Puede ser funcional o orgánica, dependiendo de si es causada por una lesión o alteración funcional. Las causas incluyen enfermedades generales, paraesofágicas o esofágicas. La evaluación incluye el interrogatorio, radiografía esofágica de doble contraste y endoscopia para determinar la causa.
El documento describe la anatomía del corazón. El corazón es un órgano muscular ubicado en el centro del pecho que bombea sangre a través del cuerpo. Tiene cuatro cámaras y cuatro válvulas que controlan el flujo sanguíneo. El sistema de conducción eléctrica coordina las contracciones del corazón.
1) Las náuseas son la sensación de deseo inminente de vomitar y se describen como una sensación desagradable en la garganta y epigastrio. 2) Pueden ser causadas por factores orgánicos como problemas gastrointestinales o fármacos, o factores funcionales como estímulos desagradables o alteraciones emocionales. 3) Los vómitos son la expulsión violenta del contenido gástrico por la boca precedida o no de náuseas, controlados por el centro del vómito en el bulbo raqu
Las bacterias de la familia Mycoplasmataceae son procariotas sin pared celular que son resistentes a antibióticos como los betalactámicos. Incluyen los géneros Mycoplasma y Ureaplasma, que pueden causar infecciones respiratorias y del tracto genital. Mycoplasma pneumoniae causa neumonía atípica transmitida por gotas de Flügge, mientras que Mycoplasma hominis y Ureaplasma urealyticum forman parte de la flora genital asintomática pero pueden caus
El documento resume varias colagenopatías, incluyendo Sjögren, esclerodermia, polimiositis, dermatomiositis, enfermedad mixta del tejido conectivo y vasculitis. Describe los síntomas, criterios de diagnóstico, clasificaciones y opciones de tratamiento para cada una.
La monartritis es una inflamación de una sola articulación que puede ser causada por infecciones, depósitos de cristales o enfermedades autoinmunes. Los síntomas incluyen dolor, hinchazón y calor en la articulación afectada. El diagnóstico se basa en el examen físico, rayos X y análisis del líquido articular. El tratamiento depende de la causa subyacente e incluye antibióticos, drenaje de la articulación y descanso para aliviar la inflamación.
El documento presenta los resultados de una encuesta realizada a 1.958 mujeres con artritis reumatoide en varios países europeos y Estados Unidos. Encontró que la mayoría experimentaba dolor diario a pesar del tratamiento, y que el dolor era un tema importante en las discusiones con sus médicos. Casi un tercio consideraba un "buen día" como uno con alivio rápido del dolor y sin rigidez matutina.
El documento proporciona información sobre las enfermedades de la glándula tiroides. Describe las hormonas producidas por la glándula tiroides, las causas y manifestaciones clínicas del hipotiroidismo y hipertiroidismo, y los valores de laboratorio normales para evaluar las enfermedades tiroideas.
El documento proporciona información sobre el tratamiento de la diabetes. Describe las medidas generales como la educación, dieta, ejercicio y control de factores de riesgo. Explica los tratamientos farmacológicos como la insulina, sulfonilureas, biguanidas, glitazonas y alfa-glucosidasas. También cubre temas como la detección de complicaciones, tipos de insulina y dispositivos de administración.
1) La diabetes es un grupo de trastornos metabólicos caracterizados por la hiperglucemia debido a defectos en la secreción o acción de la insulina.
2) Existen dos tipos principales de diabetes: la tipo 1 causada por destrucción autoinmune de las células beta que producen insulina, y la tipo 2 asociada con resistencia a la insulina.
3) Las complicaciones de la diabetes incluyen problemas cardiovasculares, renales, oculares, neurológicos y de la piel.
Las leucemias y los linfomas son grupos de enfermedades neoplásicas caracterizadas por la proliferación anormal de células de la sangre. Las leucemias involucran las células madre hematopoyéticas en la médula ósea y pueden afectar las series mieloide o linfoide, mientras que los linfomas se originan a partir de los linfocitos B o T. Estas enfermedades pueden causar síntomas como fiebre, hemorragias, infecciones y dolor óseo y su diagnóstico
Las leucemias y los linfomas son grupos de enfermedades neoplásicas caracterizadas por la proliferación anormal de células de la sangre y la médula ósea. Presentan síntomas como fiebre, hemorragias, infecciones y dolor óseo. Su diagnóstico requiere exámenes de sangre y médula ósea para identificar las células anormales. Existen diferentes tipos que varían en su tratamiento y pronóstico.
Las leucemias y los linfomas son grupos de enfermedades neoplásicas caracterizadas por la proliferación anormal de células de la sangre y la médula ósea. Presentan síntomas como fiebre, hemorragias, infecciones y dolor óseo. Su diagnóstico requiere exámenes de sangre y médula ósea para identificar las células anormales. Existen diferentes tipos que varían en su tratamiento y pronóstico.
El documento describe el síndrome purpúrico y los mecanismos de hemostasia primaria y secundaria. Explica cómo evaluar a pacientes con síndrome purpúrico mediante interrogatorio, examen físico y pruebas de laboratorio como recuento de plaquetas, tiempo de sangrado y pruebas de coagulación. También clasifica los tipos de púrpuras y analiza casos clínicos de pacientes con púrpuras trombocitopénicas.
El documento describe diferentes tipos de anemia. Define la anemia y sus manifestaciones clínicas. Explica cómo clasificar las anemias según su causa, como la pérdida de sangre, la disminución de producción o las anemias hemolíticas. Describe en detalle la anemia ferropénica, la anemia megaloblástica, la esferocitosis y otras anemias hemolíticas. Explica los estudios necesarios para diagnosticar cada tipo y los tratamientos correspondientes.
Este documento trata sobre el enfoque del paciente con síndrome anémico. Define la anemia, clasifica los tipos de anemia según su etiología, morfología y otros criterios. Describe las características y causas de las anemias microcíticas, normocíticas y macrocíticas. Explica los exámenes de laboratorio importantes, las manifestaciones clínicas y el enfoque para evaluar y tratar a un paciente con síndrome anémico.
Este documento describe la clasificación y evaluación de la ascitis, así como su tratamiento. La ascitis puede ser no complicada, complicada con infección o síndrome hepatorrenal, o refractaria. La evaluación incluye análisis de sangre, orina y líquido ascítico. El gradiente albúmina sérica-ascítico ayuda a identificar la causa. El tratamiento consiste en restricción de sodio, diuréticos como espironolactona y furosemida, y paracentesis con expansores plasmáticos. La cirugía
El documento describe la cirrosis hepática, una enfermedad crónica del hígado caracterizada por la fibrosis masiva y la formación de nódulos de regeneración. Se clasifica según criterios morfológicos, clínicos y etiológicos. Las causas más frecuentes son el alcoholismo y la hepatitis viral. Los síntomas varían desde leves en la etapa compensada hasta graves complicaciones en la descompensada como hemorragias o insuficiencia hepática. El diagnóstico se realiza mediante análisis de laboratorio, ecografía e hist
We recently hosted the much-anticipated Community Skill Builders Workshop during our June online meeting. This event was a culmination of six months of listening to your feedback and crafting solutions to better support your PMI journey. Here’s a look back at what happened and the exciting developments that emerged from our collaborative efforts.
A Gathering of Minds
We were thrilled to see a diverse group of attendees, including local certified PMI trainers and both new and experienced members eager to contribute their perspectives. The workshop was structured into three dynamic discussion sessions, each led by our dedicated membership advocates.
Key Takeaways and Future Directions
The insights and feedback gathered from these discussions were invaluable. Here are some of the key takeaways and the steps we are taking to address them:
• Enhanced Resource Accessibility: We are working on a new, user-friendly resource page that will make it easier for members to access training materials and real-world application guides.
• Structured Mentorship Program: Plans are underway to launch a mentorship program that will connect members with experienced professionals for guidance and support.
• Increased Networking Opportunities: Expect to see more frequent and varied networking events, both virtual and in-person, to help you build connections and foster a sense of community.
Moving Forward
We are committed to turning your feedback into actionable solutions that enhance your PMI journey. This workshop was just the beginning. By actively participating and sharing your experiences, you have helped shape the future of our Chapter’s offerings.
Thank you to everyone who attended and contributed to the success of the Community Skill Builders Workshop. Your engagement and enthusiasm are what make our Chapter strong and vibrant. Stay tuned for updates on the new initiatives and opportunities to get involved. Together, we are building a community that supports and empowers each other on our PMI journeys.
Stay connected, stay engaged, and let’s continue to grow together!
About PMI Silver Spring Chapter
We are a branch of the Project Management Institute. We offer a platform for project management professionals in Silver Spring, MD, and the DC/Baltimore metro area. Monthly meetings facilitate networking, knowledge sharing, and professional development. For more, visit pmissc.org.
Joyce M Sullivan, Founder & CEO of SocMediaFin, Inc. shares her "Five Questions - The Story of You", "Reflections - What Matters to You?" and "The Three Circle Exercise" to guide those evaluating what their next move may be in their careers.
Learnings from Successful Jobs SearchersBruce Bennett
Are you interested to know what actions help in a job search? This webinar is the summary of several individuals who discussed their job search journey for others to follow. You will learn there are common actions that helped them succeed in their quest for gainful employment.
Success is often not achievable without facing and overcoming obstacles along the way. To reach our goals and achieve success, it is important to understand and resolve the obstacles that come in our way.
In this article, we will discuss the various obstacles that hinder success, strategies to overcome them, and examples of individuals who have successfully surmounted their obstacles.
A Guide to a Winning Interview June 2024Bruce Bennett
This webinar is an in-depth review of the interview process. Preparation is a key element to acing an interview. Learn the best approaches from the initial phone screen to the face-to-face meeting with the hiring manager. You will hear great answers to several standard questions, including the dreaded “Tell Me About Yourself”.
In the intricate tapestry of life, connections serve as the vibrant threads that weave together opportunities, experiences, and growth. Whether in personal or professional spheres, the ability to forge meaningful connections opens doors to a multitude of possibilities, propelling individuals toward success and fulfillment.
Eirini is an HR professional with strong passion for technology and semiconductors industry in particular. She started her career as a software recruiter in 2012, and developed an interest for business development, talent enablement and innovation which later got her setting up the concept of Software Community Management in ASML, and to Developer Relations today. She holds a bachelor degree in Lifelong Learning and an MBA specialised in Strategic Human Resources Management. She is a world citizen, having grown up in Greece, she studied and kickstarted her career in The Netherlands and can currently be found in Santa Clara, CA.
2. AJG – July, 2001 Hepatic Encephalopathy 1969
resulting in a series of neurochemical events caused by the and fluctuating long-tract signs are helpful clues, albeit
functioning alteration of this cell (8). nonspecific. The absence of such clinical signs does not
Other gut-derived toxins have been proposed. Benzodi- exclude the diagnosis of HE.
azepinelike substances (9) have been postulated to arise Measurement of venous ammonia blood levels may be
from a specific bacterial population in the colon (10). Other helpful in the initial evaluation when there is doubt about the
products of colonic bacterial metabolism (11), such as neu- presence of significant liver disease or of other causes for an
rotoxic short- and medium-chain fatty acids, phenols, and abnormality in consciousness. Follow-up with repeated am-
mercaptans, have received less attention in recent years. monia levels is unnecessary and does not replace the eval-
Manganese may deposit in basal ganglia and induce extra- uation of the patient’s mental state. A relation between
pyramidal symptomatology (12). All of these compounds ammonia levels and the risk of cerebral edema in cirrhosis
may interact with ammonia and result in additional neuro- (17) has not been examined. Ammonia levels should be
chemical changes. For example, ammonia activates periph- promptly assayed in an experienced laboratory to avoid
eral-type benzodiazepine receptors with subsequent stimu- pitfalls in its determination (18).
lation of the GABA-ergic system, an effect also induced Tools to exclude other causes of an abnormal mental state
directly by ammonia (13). include automated electroencephalogram analysis (19),
brain imaging (especially in patients in stupor and coma),
Clinical Subtypes and lumbar puncture (for patients with unexplained fever,
Under the auspices of the World Congress of Gastroenter- leukocytosis, or other symptoms suggestive of meningeal
ology, a consensus terminology has been proposed to nor- irritation). Alterations of the electroencephalogram are not
malize the designation of the different clinical presentations specific for HE and are subject to variability in interpreta-
of HE (14). The most distinctive presentation is the devel- tion; automated analysis of the tracings simplifies the diag-
opment of an acute confusional state that can evolve into nosis (19).
coma (acute encephalopathy). Patients with FHF and sub- Neuropsychological testing can range from an extensive
jects with cirrhosis can present with acute encephalopathy. battery to a single test office-based screening approach. The
In patients with cirrhosis, acute encephalopathy is most Number Connection Test, parts A and B; the Digit Symbol
Test; and the Block Design Test have been the tests most
commonly associated with a precipitating factor that trig-
frequently employed (15, 16).
gers the change in mental state.
In cirrhosis, recurrent episodes of an altered mental state
Staging
may occur in the absence of precipitating factors (recurrent
In patients with cirrhosis and overt encephalopathy, two
encephalopathy) or neurological deficits may not com-
staging classifications have been used for patients with HE.
pletely reverse (persistent encephalopathy). The most fre-
quent neurological disturbance is not evident on clinical
1. The West Haven criteria of altered mental state in HE (20)
examination: mild cognitive abnormalities only recogniz-
(numerous studies have employed variations of these crite-
able with psychometric or neurophysiologic tests (minimal ria).
or subclinical encephalopathy).
The therapeutic imperative in the first three subtypes is Stage 0. Lack of detectable changes in personality or
clear. Considerable controversy still exists regarding the behavior. Asterixis absent.
definition and clinical implications of a diagnosis of mini-
Stage 1. Trivial lack of awareness. Shortened attention
mal encephalopathy (15, 16).
span. Impaired addition or subtraction. Hypersomnia,
insomnia, or inversion of sleep pattern. Euphoria or
Diagnosis
depression. Asterixis can be detected.
Hepatic encephalopathy is a diagnosis of exclusion.
Other metabolic disorders, infectious diseases, intra- Stage 2. Lethargy or apathy. Disorientation. Inappropriate
cranial vascular events, and intracranial space– occupying behavior. Slurred speech. Obvious asterixis.
lesions can present with neuropsychiatric symptomatol- Stage 3. Gross disorientation. Bizarre behavior. Semistu-
ogy. Knowledge of the existence of acute or chronic liver por to stupor. Asterixis generally absent.
disease, the existence of a precipitating factor, and/or a Stage 4. Coma.
prior history of HE are clinical elements needed for
diagnosis. 2. Evaluation of the level of consciousness with the Glas-
Intrinsically linked to the diagnosis of HE is an evaluation gow Scale (21) (Table 1): although the Glasgow coma scale
of the degree of liver dysfunction and possible alterations of has not been rigorously evaluated in patients with HE, its
the hepatic circulation (thrombosis, large spontaneous por- widespread use in structural and metabolic disorders of
tal-systemic shunt, transjugular intrahepatic portal-systemic brain function justifies its application in acute and chronic
shunt [TIPS]). The detection of asterixis, fetor hepaticus, liver disease.
3. 1970 Blei et al. AJG – Vol. 96, No. 7, 2001
Table 1. Level of Consciousness With the Glasgow Scale
Eyes Open Best Motor Response Best Verbal Response
Spontaneously 4 Obeys verbal orders 6 Oriented, conversant 5
To command 3 Localizes painful stimuli 5 Disoriented, conversant 4
To pain 2 Painful stimulus, flexion 3 Inappropriate words 3
No response 1 Painful stimulus, extension 2 Inappropriate sounds 2
No response 1 No response 1
To obtain the score, the best ocular, verbal, and motor responses are summed. The best score is 15 and the worst 3. Severe encephalopathy is defined as a score of 12.
TREATMENT GOALS Precipitating events should also be sought with the
development of encephalopathy after placement of a
1. Provision of Supportive Care TIPS for control of portal hypertension (22).
Adequate supportive care is critical during all stages of HE
and may involve other professionals in the provision of Spontaneous encephalopathy (no precipitant factor iden-
patient care. tified) should raise the suspicion of an abnormal collateral
Standard measures for hospitalized patients are applicable circulation (see Manipulation of the Splanchnic Circula-
to subjects with HE. Special considerations include a critical tion).
role for the nursing staff in the management of these indi-
viduals. The mental state can change rapidly, and disorien- 3. Reduction of Nitrogenous Load From the Gut
tation can result in bodily harm. Prevention of falls in Measures to reduce the nitrogenous load from the gut
disoriented patients at earlier stages of HE may require should be implemented.
special measures. In deeper stages of HE, the need for These include catharsis and the use of nonabsorbable
prophylactic tracheal intubations needs to be considered. disaccharides and/or antibiotics. Treatment options are dis-
Adequate nutrition should be provided during the period of cussed in detail in Drugs That Affect Neurotransmission.
altered mental state (see Treatment Options). Surgical exclusion of the colon (23), via ileorectal anasto-
mosis, is rarely performed in a nontransplant candidate.
2. Identification and Removal of Precipitating Factors
A vigorous search to identify and eliminate a precipitating 4. Assessment of the Need for Long Term Therapy
factor or factors should be immediately instituted. Patients with cirrhosis are at risk of developing new epi-
In most cases of cirrhosis with acute or chronic HE, a sodes of encephalopathy. At discharge, three factors need to
precipitating factor is found, such as the following: be considered:
GI hemorrhage. Exploration requires stool analysis
and/or placement of a nasogastric tube. Control of potential precipitating factors. These include
avoidance of constipation; prophylaxis of bleeding
Infections. This factor requires culture of all appropriate from gastroesophageal varices, when indicated; pro-
body fluids, especially ascites when present. Sponta- phylaxis of spontaneous bacterial peritonitis, when in-
neous bacterial peritonitis and pneumonia may present dicated; judicious use of diuretics; and avoidance of
with HE. psychoactive medication.
Renal and electrolyte disturbances. These include renal Higher likelihood of recurrent encephalopathy. The de-
failure, metabolic alkalosis, hypokalemia, dehydration, velopment of HE in the absence of a precipitating
and diuretic effects. factor or the development of HE in patients with poor
Use of psychoactive medication. This factor may require liver function (Child B/C) is such a situation. Preven-
a urine screen for benzodiazepines, narcotics, and other tion of a first episode of HE in subjects who have
sedatives. undergone a TIPS procedure is done in some centers,
Constipation though no controlled data are available.
Excessive dietary protein. In many cases, an adequate Assessment of the need for liver transplantation. The
clinical history can be best provided by the patient’s development of overt HE carries a poor prognosis (24),
relatives. with a 1-yr survival of 40%. Appropriate candidates
Acute deterioration of liver function in cirrhosis. In con- should be referred to transplant centers after the first
trast to the situation in FHF, HE in cirrhosis seldom episode of overt encephalopathy of any type.
reflects the acute impact of liver failure. Exceptions
include the presence of superimposed alcoholic hepa- TREATMENT OPTIONS
titis, the development of an acute circulatory distur-
bance (e.g., portal vein thrombosis), and the impair- Treatment of HE is based on several, non–mutually exclu-
ment of liver function seen after surgery in cirrhosis. sive options.
4. AJG – July, 2001 Hepatic Encephalopathy 1971
1. Nutritional Management Background. Because the toxins responsible for HE arise
Patients with HE should avoid prolonged periods of dietary from the gut, bowel cleansing is a mainstay of therapy.
protein restriction and receive the maximum tolerable pro- In addition, HE itself may result in a slow transit time
tein intake, aiming at 1.2 g of protein/kg/day (range 1–1.5). (34). Colonic cleansing reduces the luminal content of
ammonia, decreases colonic bacterial counts, and low-
BACKGROUND. Restriction of dietary protein at the time ers blood ammonia in cirrhotic patients (35).
of acute encephalopathy with subsequent increments to as-
Implementation. Various laxatives may be used, but non-
sess clinical tolerance is a classic cornerstone of therapy.
absorbable disaccharides are preferred, as they result in
Protracted nitrogen restriction may contribute to malnutri-
additional effects that potentiate the elimination or
tion and aggravate the prognosis (25). On the other hand, a
reduce the formation of nitrogenous compounds (see
positive nitrogen balance will have positive effects on en-
below). Administration of enemas may be necessary in
cephalopathy by promoting hepatic regeneration and in-
the patient with a severe impairment of consciousness.
creasing the capacity of muscle to detoxify ammonia. Thus,
Alternatively, bowel cleansing can also be achieved
nutritional management includes intrinsic effects of dietary
after irrigation of the gut via a p.o. tube. Irrigation with
components as well as long term effects on organs whose
a 5-L isotonic solution of mannitol, 1 g/kg, has been
dysfunctions contribute to the pathogenesis of HE.
shown in a controlled trial to prevent encephalopathy
The increased catabolic rate of cirrhosis leads to a rec-
after a GI hemorrhage (36).
ommendation of 1–1.5 g protein/kg/day (26). Provision of
an adequate nitrogen intake is difficult. Vegetable and dairy B. NONABSORBABLE DISACCHARIDES. Lactulose
sources are preferable to animal protein (27), as they pro- is a first-line pharmacological treatment of HE.
vide a higher calorie to nitrogen ratio and, in the case of
vegetable protein, provide nonabsorbable fiber, a substrate Background. Careful scrutiny of the clinical trials that are
for colonic bacteria and subsequent colonic acidification. the basis for the use of lactulose (galactosido-fructose)
Zinc, a cofactor of urea cycle enzymes, may be deficient can lead to the conclusion that current standards of
in cirrhotic patients, especially if associated with malnutri- evidence-based medicine are not met (37, 38). Pooled
tion. Zinc supplementation improves the activity of the urea analysis of the results of controlled studies is not pos-
cycle in experimental models of cirrhosis (28). One trial has sible because of methodological differences between
evaluated the effects of zinc over a short period (up to a trials. A summary of controlled studies is provided in
week), without major improvement (29). A positive study the Appendix. In fact, a critical reappraisal of the use of
administered zinc for 3 months, though the study was not lactulose, especially in the management of acute en-
randomized (30). Zinc deficiency precipitated encephalop- cephalopathy in cirrhosis, would require a new clinical
athy in a well-described patient (31). Patients with zinc trial. This would be of interest, as in one double-blind
deficiency should receive oral zinc supplements. study the combination of lactulose and neomycin was
not better than a placebo in the management of acute
IMPLEMENTATION encephalopathy when the precipitant factor was simul-
Acute encephalopathy. Protein feeding can be withdrawn taneously corrected (39). On the other hand, extensive
for the first day. Short term (4 days) enteral nutrition data point at the potential mechanism of action of
has not been shown to benefit hospitalized cirrhotic lactulose (40). Lactulose is not broken down by intes-
patients (32). tinal disaccharidases and thus reaches the colon, where
bacteria will metabolize the sugar to acetic acid and
Chronic management. An increase in protein tolerance
lactic acid. The acidification of the colon may underlie
can be achieved by increasing protein intake in com-
its cathartic effect. Passage of ammonia into the co-
bination with other therapeutic measures, such as non-
lonic lumen results in its incorporation into bacteria
absorbable disaccharides. Substitution of animal pro-
with the resulting decrease of portal blood ammonia.
tein with vegetable and/or dairy protein should be
As a result, peripheral levels of ammonia are reduced
reviewed, a process facilitated by a consultation with a
and the total body pool of urea decreases. An exces-
nutritional expert. Oral formulation of branched chain
sively sweet taste, flatulence, and abdominal cramping
amino acids may provide a better tolerated source of
are the most frequent subjective complaints with this
protein in patients with chronic encephalopathy and
drug. If diarrhea develops, the drug should be stopped
dietary protein intolerance (33). Zinc acetate can be
and reinstituted at a lower dose. Protracted diarrhea
administered as 220 mg b.i.d. It may reduce the ab-
may result in hypertonic dehydration with hypernatre-
sorption of other divalent cations (e.g., copper).
mia (41); the resulting hyperosmolarity may aggravate
2. Reduction in the Nitrogenous Load Arising From the the patient’s mental state.
Gut Implementation. For acute encephalopathy, lactulose (in-
A. BOWEL CLEANSING. Bowel cleansing is a stan- gested or via nasogastric tube), 45 ml p.o., is followed
dard therapeutic measure in HE. by dosing every hour until evacuation occurs. Then
5. 1972 Blei et al. AJG – Vol. 96, No. 7, 2001
dosing is adjusted to an objective of two to three soft 3. Drugs That Affect Neurotransmission
bowel movements per day (generally 15– 45 ml every Flumazenil and bromocriptine administration may have a
8 –12 h). Only one study examined in a controlled therapeutic role in selected patients.
fashion the effectiveness of Lactitol enemas (42). Lac-
tulose by enema (300 ml in 1 L of water) is retained for BACKGROUND. Flumazenil and bromocriptine exert
1 h, with the patient in the Trendelenburg position (to their effects directly on the brain. An enhanced GABA-ergic
increase the possibility of access to the right colon). tone was postulated to contribute to the development of
For chronic encephalopathy, oral dosing of lactulose encephalopathy (50). It has been proposed that “endogenous
does not require the hourly initial administration. Lac- benzodiazepines” may be present in patients with HE and
tose can be used in patients with lactase deficiency. exert neuroinhibitory effects via binding to the GABAA
Lactitol, more palatable, is available in Europe but not receptor (51). Antagonism of their effect with flumazenil
the United States. has been tested in patients with acute encephalopathy and
severe changes in mental state. In a large clinical trial of 560
C. ANTIBIOTICS. Antibiotics are a therapeutic alter- patients, an i.v. bolus of flumazenil improved mental state in
native to nonabsorbable disaccharides for treatment in approximately 15% of patients, as compared to 3% of pla-
acute and chronic encephalopathy and cirrhosis. cebo-treated controls (52). Although these results are not
striking, flumazenil may be administered to patients with
Background. Benefits from neomycin, the most widely HE and suspected benzodiazepine ingestion. An oral prep-
used drug, are attributed to effects on colonic bacteria. aration is unfortunately not available for chronic long term
However, neomycin will also affect the small bowel administration.
mucosa and may impair the activity of glutaminase in Alterations of dopaminergic neurotransmission were ini-
intestinal villi (43). Metronidazole, affecting a different tially postulated 2 decades ago as the basis for the “false
bacterial population than neomycin, will also improve neurotransmitter” hypothesis (53). The tenets of this theory,
encephalopathy (44). Infection with Helicobacter py- where the imbalance between aromatic and branched-chain
lori was proposed as a mechanism responsible for amino acids favored the entry into the brain of the former,
encephalopathy, in view of the generation of ammonia were subsequently challenged by the unconvincing results
by this urease-containing organism (45). A careful with branched-chain amino acids for the therapy of HE (54,
assessment of its eradication failed to show a distinct 55). The recent observation of manganese accumulation in
impact on mental states or blood ammonia levels in basal ganglia of patients with cirrhosis has rekindled the
patients with minimal encephalopathy (46). At this possible alteration of dopamine neurotransmission (56).
time, eradication of H. pylori cannot be recommended These changes may underlie the frequent finding of extra-
as a therapeutic strategy. Associated toxicity may ham- pyramidal symptomatology in patients with liver disease.
per the use of antibiotics for a prolonged period. De- Improvements of extrapyramidal signs have been reported
spite its poor absorption, chronic neomycin, as other when bromocriptine was added to conventional therapy
aminoglycosides, can cause auditory loss and renal (57).
failure. Patients require annual auditory testing if main-
tained on chronic neomycin. Intestinal malabsorption IMPLEMENTATION. At this time, a formal recommenda-
can result in a spruelike diarrhea. Staphylococcal su- tion on the use of these drugs cannot be made on the basis
perinfection can also supervene. Metronidazole neuro- of evidence-based data. Flumazenil (1 mg bolus i.v.) is
toxicity can be severe in patients with cirrhosis, where indicated for patients with HE and suspected benzodiaz-
impaired clearance of the drug may be present (47). epine intake. Although flumazenil has been reported to
occasionally cause seizures, such findings have not been
Implementation. For acute encephalopathy, neomycin
described in patients with HE. Bromocriptine (30 mg p.o.
(3– 6 g/day p.o.) should be given for a period of 1–2
b.i.d.) is indicated for the treatment of chronic encephalop-
wk. For chronic encephalopathy, neomycin (1–2 g/day
athy in patients unresponsive to other therapy. Bromocrip-
p.o.) should be given, with periodic renal and annual
tine may result in elevation of prolactin levels.
auditory monitoring. Neomycin can be combined with
oral lactulose in problematic cases. Metronidazole 4. Manipulation of the Splanchnic Circulation
should be started at a dose of 250 mg b.i.d. The presence of large spontaneous portal-systemic shunts
should be sought in selected patients with recurrent epi-
D. OTHER THERAPIES. Ornithine aspartate drug is not sodes of encephalopathy despite medical therapy, where a
available in the United States. It provides substrates for the precipitating factor is not found.
urea cycle (ornithine) as well as for the synthesis of glu-
tamine (aspartate, via transamination to glutamate). It is BACKGROUND. Large splenorenal or gastrorenal com-
available in oral and i.v. formulations. Preliminary experi- munications have been associated with episodes of “spon-
ence in both acute (48) and chronic (49) encephalopathy has taneous” encephalopathy (absence of a precipitating factor)
been encouraging. (58). Visualization of the collaterals can be obtained with
6. AJG – July, 2001 Hepatic Encephalopathy 1973
ultrasound techniques and confirmed with visceral angiog- For problematic encephalopathy (nonresponsive to therapy),
raphy. These shunts may be amenable to occlusion via consider imaging of splanchnic vessels to identify large
radiological techniques, including placement of occlusive spontaneous portal-systemic shunts potentially amenable to
coils (59). Access to the portal circulation is best obtained radiological occlusion. In addition, consider the combina-
through the transhepatic route. In this limited experience, no tion of lactulose and neomycin, addition of oral zinc, and
increased risk of variceal hemorrhage was observed after invasive approaches, such as occlusion of TIPS or surgical
occlusion of the shunt. shunts, if present.
IMPLEMENTATION. Occlusion of portal-systemic collat- Minimal or Subclinical Encephalopathy
erals should be undertaken only in centers with experienced Treatment can be instituted in selected cases. The most
interventional radiologists and after all other medical mea- characteristic neuropsychological deficits in patients with
sures have failed. cirrhosis are in motor and attentional skills (60). Although
these may impact the ability to perform daily activities,
SUMMARY many subjects can compensate for these defects. Recent
studies suggest a small but significant impact of these ab-
1. Acute Encephalopathy in Cirrhosis normalities on patients’ quality of life (61), including dif-
A. GENERAL MEASURES. Tracheal intubation in pa- ficulties with sleep (62). In patients with significant deficits
tients with deep encephalopathy should be considered. A or complaints, a therapeutic program based on dietary ma-
nasogastric tube is placed for patients in deep encephalop- nipulations and/or nonabsorbable disaccharides may be
athy. Avoid sedatives whenever possible. Correction of the tried. Benzodiazepines should not be used for patients with
precipitating factor is the most important measure. sleep difficulties.
B. SPECIFIC MEASURES
Reprint requests and correspondence: Andres T. Blei, M.D.,
i. Nutrition. In case of deep encephalopathy, oral Lakeside VA Medical Center, 333 East Huron Street, Chicago, IL
intake is withheld for 24 – 48 h and i.v. glucose is 60611.
provided until improvement. Enteral nutrition can Received Mar. 12, 2001; accepted Mar. 16, 2001.
be started if the patient appears unable to eat after
this period. Protein intake begins at a dose of 0.5
g/kg/day, with progressive increase to 1–1.5 g/kg/ REFERENCES
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Appendix. Controlled Trials in Cirrhotic Patients
No. of
Treatment Comparison Trial Patients Time* Design Effect
Acute encephalopathy†
Lactulose Placebo (glucose) Simmons et al. (63) 21‡ 10 days
Lactitol Lactulose Morgan et al. (64) 28‡ 5 days
Lactitol Lactulose Heredia et al. (65) 40‡ 5 days
Lactitol/lactulose enemas Cleansing enemas Uribe et al. (42)§ 20‡ To clinical improvement
Lactitol enemas Lactose enemas Uribe et al. (42) 40‡ 4 days
Lactose enemas Neomycin starch Uribe et al. (66) 18‡ 5 days
placebo enemas
Neomycin Placebo Strauss et al. (67) 39‡ To maximal improvement
Neomycin sorbitol Lactulose Atterbury et al. (20) 45‡ To maximal improvement
Neomycin lactulose Placebo Blanc et al. (39) 80‡ 5 days
Sodium benzoate Lactulose Sushma et al. (68) 74‡ To maximal improvement
Flumazenil Placebo Pomier-Layrargues 21‡ 1h
et al. (69)
Flumazenil Placebo Cadrenel et al. (70) 14‡ 10 min
Flumazenil Placebo Gyr et al. (71)¶ 49‡ 8 h
Flumazenil Placebo Barbaro et al. (52) 527‡ 24 h
Omithine-aspartate Placebo Kircheis et al. (48) 126‡ 7 days
Chronic encephalopathy#
Lactulose Placebo (sorbitol) Elkington et al. (72) 7 Crossover **
Lactulose Placebo (saccarose) Germain et al. (73) 18 Parallel **
Lactitol Lactulose Blanc et al. (74) 77 Meta-analysis **
Lactitol Lactulose Camma et al. (75) 72 Meta-analysis **
Neomycin sorbitol Lactulose Conn et al. (76) 33 Crossover **
Neomycin MgSO4 Lactulose Orlandi et al. (77) 173 Parallel **
Zinc lactulose Lactulose Bresci et al. (78) 90 Parallel **
Zinc lactulose Placebo lactulose Reding et al. (79) 22 Parallel **
Zinc lactulose Placebo lactulose Riggio et al. (29) 15 Crossover **
Bromocriptine Placebo Uribe et al. (57) 7 Crossover **
Bromocriptine lactulose Placebo lactulose Morgan et al. (80) 6 Crossover **
Adapted from Riggio et al. (28).
* Period of time from initiation of treatment to measurement of outcome.
† Branched-chain amino acids not included.
‡ Total number of patients included in the study.
§ Analysis of the first 20 patients of the study.
All patients received only lactulose.
¶Only patients with encephalopathy grades I–III included. Additional treatment with lactulose was permitted. Twenty-four patients were excluded from the analysis. For
patients with clinically relevant improvement (n 5), flumazenil was associated with a better response.
# Branched-chain amino acids not included. Four additional controlled trials, including less than 10 patients, compared neomycin and lactulose (81).
** Effect on encephalophathy: , clinical improvement with treatment; , treatment associated with improvement in psychometric tests; , no differences between treatment
and control.