Comparison of the Efficacy of Lactobacillus rhamnosus GG and Lactulose Treatments in Minimal Hepatic Encephalopathy

Zerin  Günel; Sezgin Barutçu; Abdullah Emre Yıldırım

doi:10.5152/EurJTher.2022.22011

Authors

Zerin Günel Division of Internal Medicine, Selahattin Cizrelioğlu Public Hospital, Şırnak, Turkey https://orcid.org/0000-0002-6534-0562
Sezgin Barutçu Department of Internal Medicine, Division of Gastroenterology, Gaziantep University, Faculty of Medicine, Gaziantep, Turkey https://orcid.org/0000-0003-0823-3215
Abdullah Emre Yıldırım Department of Internal Medicine, Division of Gastroenterology, Gaziantep University, Faculty of Medicine, Gaziantep, Turkey https://orcid.org/0000-0002-4386-9297

DOI:

https://doi.org/10.5152/EurJTher.2022.22011

Keywords:

Critical flicker frequency, lactobacillus rhamnosus, lactulose, minimal hepatic encephalopathy

Abstract

Objective: Minimal hepatic encephalopathy is a condition characterized by decreased perception and consequently deterioration in quality of life, and there is still limited data on its treatment. The aim of this study is to compare the efficacy of lactulose and Lactobacillus rhamnosus GG treatments by critical flicker frequency test in minimal hepatic encephalopathy patients.

Methods: Patients with a critical flicker frequency test result of <39 Hz were considered to have minimal hepatic encephalopathy. Eighty-four minimal hepatic encephalopathy patients were divided into 3 groups as lactulose, Lactobacillus rhamnosus GG, and control group. Critical flicker frequency control was performed 4 weeks after treatment. Critical flicker frequency values before and after treatment were compared according to the treatment groups and evaluated.

Results: Minimal hepatic encephalopathy was detected in 84 (54.5%) of 154 cirrhosis patients. Of the patients with minimal hepatic encephalopathy, 31 (36.9%) received lactulose, 31 (36.9%) Lactobacillus rhamnosus GG treatment, and 22 (26.2%) did not receive any treatment. In patients with minimal hepatic encephalopathy compared to those without minimal hepatic encephalopathy, there were statistically significant differences in terms of age (P=.003), body mass index (BMI) (P=.019), albumin (P < .001), sodium (P = .010), model for end-stage liver diseases score (P < .001), and Child Pugh Classification (CHILD) score (P < .001).There was no significant difference between cirrhosis etiology and treatment response (P=.535). Statistically significant increase was found in critical flicker frequency values in the lactulose (P=.011) and Lactobacillus rhamnosus GG (P=.007) groups after treatment. No statistically significant difference was found in the placebo group (P=.804). There was no statistically significant difference between lactulose and Lactobacillus rhamnosus GG (P=.576).

Conclusion: In the treatment of minimal hepatic encephalopathy, Lactobacillus rhamnosus GG treatment is as effective like lactulose treatment and can be used safely

Metrics

Metrics Loading ...

References

Wijdicks EF. Hepatic encephalopathy. N Engl J Med. 2016;375(17): 1660-1670.

Ferenci P, Lockwood A, Mullen K, Tarter R,Weissenborn K, Blei AT. Hepatic encephalopathy definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology. 2002;35(3):716-721.

Bao ZJ, Qiu DK, Ma X, et al. Assessment of health-related quality of life in Chinese patients with minimal hepatic encephalopathy. World J Gastroenterol. 2007;13(21):3003-3008.

Özel Coşkun BD, Özen M. Critical flicker frequency test for diagnosing minimal hepatic encephalopathy in patients with cirrhosis. Turk J Gastroenterol. 2017;28(3):191-196.

Nabi E, Bajaj JS. Useful tests for hepatic encephalopathy in clinical practice. Curr Gastroenterol Rep. 2014;16(1):362.

Ampuero J, Simón M, Montoliú C, et al. Minimal hepatic encephalopathy and critical flicker frequency are associated with survival of patients with cirrhosis. Gastroenterology. 2015;149(6):1483-1489.

Bajaj JS, Schubert CM, Heuman DM, et al. Persistence of cognitive impairment after resolution of overt hepatic encephalopathy. Gastroenterology. 2010;138(7):2332-2340.

Henderson PK, Herrera JL. Should we treat minimal/covert hepatic encephalopathy, and with what? Clin Liver Dis. 2015;19(3):487-495.

Prasad S, Dhiman RK, Duseja A, Chawla YK, Sharma A, Agarwal R. Lactulose improves cognitive functions and health-related quality of life in patients with cirrhosis who have minimal hepatic encephalopathy. Hepatology. 2007;45(3):549-559.

Agrawal A, Sharma BC, Sharma P, Sarin SK. Secondary prophylaxis of hepatic encephalopathy in cirrhosis: an open-label, randomized controlled trial of lactulose, probiotics, and no therapy. Am J Gastroenterol. 2012;107(7):1043-1050.

Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362(12):1071-1081.

Nardone R, Taylor AC, Höller Y, Brigo F, Lochner P, Trinka E. Minimal hepatic encephalopathy: a review. Neurosci Res. 2016;111:1-12.

American Association for the Study of Liver Diseases, European Association for the Study of the Liver. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. J Hepatol. 2014;61(3):642-659.

Ridola L, Nardelli S, Gioia S, Riggio O. Quality of life in patients with minimal hepatic encephalopathy. World J Gastroenterol. 2018;24(48):5446-5453.

Ridola L, Cardinale V, Riggio O. The burden of minimal hepatic encephalopathy: from diagnosis to therapeutic strategies. Ann Gastroenterol. 2018;31(2):151-164.

Weissenborn K. Diagnosis of minimal hepatic encephalopathy. J Clin Exp Hepatol. 2015;5(suppl 1):S54-S59.

Kircheis G, Wettstein M, Timmermann L, Schnitzler A, Häussinger D. Critical flicker frequency for quantification of lowgrade hepatic encephalopathy. Hepatology. 2002;35(2):357-366.

Sharma P, Sharma BC, Puri V, Sarin SK. Critical flicker frequency: diagnostic tool for minimal hepatic encephalopathy. J Hepatol. 2007;47(1):67-73.

Romero-Gómez M, Córdoba J, Jover R, et al. Value of the critical flicker frequency in patients with minimal hepatic encephalopathy. Hepatology. 2007;45(4):879-885.

Sharma K, Pant S, Misra S, et al. Effect of Rifaximin, probiotics, and l-ornithine l-aspartate on minimal hepatic encephalopathy: a randomized controlled trial. Saudi J Gastroenterol. 2014;20(4):225-232.

Kircheis G, Hilger N, Häussinger D. Value of critical flicker frequency and psycometric hepatic encephalopathy score in diagnosis of lowgrade hepatic encephalopathy. Gastroenterology. 2014;146(4):961-969.

Dhiman RK, Saraswat VA, Sharma BK, et al. Indian national association for study of the liver. Minimal hepatic encephalopathy: consensus statement of a working party of the Indian National Association for the Study of the Liver. J Gastroenterol Hepatol. 2010;25(6):1029-1041.

Cao Q, Yu CB, Yang SG, et al. Effect of probiotic treatment on cirrhotic patients with minimal hepatic encephalopathy: A meta-analysis. Hepatobiliary Pancreat Dis Int. 2018;17(1):9-16.

Moran S, López-Sánchez M, Milke-García MDP, Rodríguez-Leal G. Current approach to treatment of minimal hepatic encephalopathy in patients with liver cirrhosis. World J Gastroenterol. 2021;27(22):3050-3063.

Xia X, Chen J, Xia J, et al. Role of probiotics in the treatment of minimal hepatic encephalopathy in patients with HBV-induced liver cirrhosis. J Int Med Res. 2018;46(9):3596-3604.

Goyal O, Sidhu SS, Kishore H. Minimal hepatic encephalopathy in cirrhosis- how long to treat? Ann Hepatol. 2017;16(1):115-122.