RESUMO
The first clinical guidelines on hepatic encephalopathy were published in 2009. Almost 14 years since that first publication, numerous advances in the field of diagnosis, treatment, and special condition care have been made. Therefore, as an initiative of the Asociación Mexicana de Gastroenterología A.C., we present a current view of those aspects. The manuscript described herein was formulated by 24 experts that participated in six working groups, analyzing, discussing, and summarizing the following topics: Definition of hepatic encephalopathy; recommended classifications; epidemiologic panorama, worldwide and in Mexico; diagnostic tools; conditions that merit a differential diagnosis; treatment; and primary and secondary prophylaxis. Likewise, these guidelines emphasize the management of certain special conditions, such as hepatic encephalopathy in acute liver failure and acute-on-chronic liver failure, as well as specific care in patients with hepatic encephalopathy, such as the use of medications and types of sedation, describing those that are permitted or recommended, and those that are not.
Assuntos
Encefalopatia Hepática , Lactulose , Rifaximina , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/tratamento farmacológico , Rifaximina/uso terapêutico , Lactulose/uso terapêuticoRESUMO
Minimal hepatic encephalopathy (MHE) corresponds to the earliest stage of hepatic encephalopathy (HE). MHE does not present clinically detectable neurological-psychiatric abnormalities but is characterized by imperceptible neurocognitive alterations detected during routine clinical examination via neuropsychological or psychometrical tests. MHE may affect daily activities and reduce job performance and quality of life. MHE can increase the risk of accidents and may develop into overt encephalopathy, worsening the prognosis of patients with liver cirrhosis. Despite a lack of consensus on the therapeutic indication, interest in finding novel strategies for prevention or reversion has led to numerous clinical trials; their results are the main objective of this review. Many studies address the treatment of MHE, which is mainly based on the strategies and previous management of overt HE. Current alternatives for the management of MHE include measures to maintain nutritional status while avoiding sarcopenia, and manipulation of intestinal microbiota with non-absorbable disaccharides such as lactulose, antibiotics such as rifaximin, and administration of different probiotics. This review analyzes the results of clinical studies that evaluated the effects of different treatments for MHE.
Assuntos
Encefalopatia Hepática , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Lactulose/uso terapêutico , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Cirrose Hepática/terapia , Qualidade de Vida , Rifaximina/uso terapêuticoRESUMO
Background: Among the bacterial dermopathy the canine leproid granuloma (CLG) is a nodular pyogranulomatous disorder that affects the skin or subcutaneous tissue mainly in the dorsal face of ear pinna, head, and extremity of memberscaused by Mycobacterium spp. The pathogenicity is still not well clarified regarding the causative agent, which has notyet been completely typified, but phylogenetically, it is related to Mycobacterium tilburgii, M. simiae, and M. genavense,in Brazil, by the species M. murphy. The objective of this study is to report a case of canine leproid granuloma, throughcytology and histopathology, and present the therapeutic procedures until the regression of cutaneous lesion.Case: A 5-year-old Boxer breed, intac male weighing 32 kg, was assisted at the Veterinary Clinic of UNIFIMES, in MineirosCity, Mid-West Region of Brazil, GO, Brazil. The animal had 4 nodules in the ears with evolution of 30 days, with nopruritus and without previous treatment. During the physical exam, the animal had normal physiological parameters. Thecutaneous lesions were characterised by papules and alopecic nodules of firm to fibroelastic consistency, with progressiveincrease, located in the convex face of the ears. The fine needle aspiration puncture technique (FNAP) and histopathologyfor a definitive diagnosis was used, allowing the differentiation between inflammatory processes, infectious and neoplastic. Furthermore, blood was collected for hemogram and biochemical analysis for the assessment of renal and hepaticfunctions. In cytology, the stained blades by the Diff-quick stain in the microscopic exam had elevated cellularity, withseveral macrophages, and bacilliform structures in the negative image. Staining was also conducted....
Assuntos
Masculino , Animais , Cães , Cães/microbiologia , Granuloma/veterinária , Infecções por Mycobacterium/veterinária , Dermatopatias/veterinária , Doxiciclina/uso terapêutico , Enrofloxacina/uso terapêutico , Rifaximina/uso terapêuticoRESUMO
Background: Among the bacterial dermopathy the canine leproid granuloma (CLG) is a nodular pyogranulomatous disorder that affects the skin or subcutaneous tissue mainly in the dorsal face of ear pinna, head, and extremity of memberscaused by Mycobacterium spp. The pathogenicity is still not well clarified regarding the causative agent, which has notyet been completely typified, but phylogenetically, it is related to Mycobacterium tilburgii, M. simiae, and M. genavense,in Brazil, by the species M. murphy. The objective of this study is to report a case of canine leproid granuloma, throughcytology and histopathology, and present the therapeutic procedures until the regression of cutaneous lesion.Case: A 5-year-old Boxer breed, intac male weighing 32 kg, was assisted at the Veterinary Clinic of UNIFIMES, in MineirosCity, Mid-West Region of Brazil, GO, Brazil. The animal had 4 nodules in the ears with evolution of 30 days, with nopruritus and without previous treatment. During the physical exam, the animal had normal physiological parameters. Thecutaneous lesions were characterised by papules and alopecic nodules of firm to fibroelastic consistency, with progressiveincrease, located in the convex face of the ears. The fine needle aspiration puncture technique (FNAP) and histopathologyfor a definitive diagnosis was used, allowing the differentiation between inflammatory processes, infectious and neoplastic. Furthermore, blood was collected for hemogram and biochemical analysis for the assessment of renal and hepaticfunctions. In cytology, the stained blades by the Diff-quick stain in the microscopic exam had elevated cellularity, withseveral macrophages, and bacilliform structures in the negative image. Staining was also conducted....(AU)
Assuntos
Animais , Masculino , Cães , Cães/microbiologia , Granuloma/veterinária , Infecções por Mycobacterium/veterinária , Enrofloxacina/uso terapêutico , Doxiciclina/uso terapêutico , Rifaximina/uso terapêutico , Dermatopatias/veterináriaRESUMO
Hepatic encephalopathy (HE) is a complication occurring in patients with cirrhosis and is associated with neuropsychiatric and motor abnormalities. Symptomatic HE episodes almost always require hospitalization and the frequent recurrence of episodes is associated with poor prognosis and increased medical costs. The utilization of existing therapies for management of HE and adherence to them has yet to be evaluated using real-world claims data.The aim of this study was to evaluate HE drug regimens and adherence and their association with hospital readmissions in Medicare Advantage plan patients.This was a retrospective cohort study of patients discharged from a HE-related hospitalization or emergency room visit. Based on subsequent enrollment in the plan they were categorized into cohorts of 1 month, 3, and 6 months follow-up, and medication regimen was evaluated within the first month. The drugs evaluated included lactulose, rifaximin, and neomycin. Multivariable logistic regression was conducted to evaluate the association of drug regimen and medication adherence measured as proportion of days covered with HE readmissions.There were 347 patients hospitalized for HE with 184 patients having 30-day enrollment and either a drug refill or an outpatient visit in this duration. Medications were not refilled by 67 (36.4%) patients. Various drug regimens had different adherence with mean (standard deviation) proportion of days covered ranging from 0.56 (0.29) to 0.82 (0.16) at 3 months and 0.48 (0.3) to 0.77 (0.15) at 6 months. The results of logistic regression at 3 and 6 months did not show a significant association of medication use or medication adherence with hospital readmissions.Despite availability of therapy, medication utilization was alarmingly low after discharge of patients from HE-related hospitalization. Medication adherence was also low, which may affect the rate of recurrence and costs associated with readmissions. Efforts are needed in both care coordination of these patients to ensure they are prescribed appropriate medications and to enhance adherence to them.
Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Encefalopatia Hepática/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Demandas Administrativas em Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/estatística & dados numéricos , Antibacterianos/uso terapêutico , Quimioterapia Combinada , Feminino , Seguimentos , Fármacos Gastrointestinais/uso terapêutico , Humanos , Lactulose/uso terapêutico , Masculino , Medicare Part C , Pessoa de Meia-Idade , Neomicina/uso terapêutico , Recidiva , Estudos Retrospectivos , Rifaximina/uso terapêutico , Estados UnidosRESUMO
Hepatic encephalopathy is a frequent complication in patients with cirrhosis of the liver and is associated with a high mortality rate. Costs attributed to the management of patients with cirrhosis are especially high due to complications, such as hepatic encephalopathy, given that they increase the number of days of hospital stay. Different drugs are currently used to treat hepatic encephalopathy, and the main ones are lactulose, L-ornithine L-aspartate (LOLA), and certain antibiotics, especially rifaximin-α (RFX). Even though many of them have been shown to be effective to greater or lesser degrees, it is important to understand the differences between them, so that every patient receives individualized treatment and the best option is chosen, in accordance with the different clinical scenarios. Thus, the aim of the present study was to analyze the evidence on the advantages and disadvantages of the individual or combined use of the 3 main treatments for hepatic encephalopathy, specifically taking into consideration their different degrees of efficacy, their impact on quality of life, prophylaxis, and cost reduction.
Assuntos
Antibacterianos/uso terapêutico , Encefalopatia Hepática/tratamento farmacológico , Rifaximina/uso terapêutico , Ácido Aspártico/uso terapêutico , Quimioterapia Combinada , Fármacos Gastrointestinais/uso terapêutico , Encefalopatia Hepática/diagnóstico , Humanos , Lactulose/uso terapêutico , Qualidade de Vida , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
OBJECTIVES: Small intestinal bacterial overgrowth (SIBO) is challenging to treat and diagnose and is associated with diagnosis of irritable bowel syndrome (IBS). Although no FDA-approved medications exist for treatment of SIBO, rifaximin has recently received approval to treat diarrhea-predominant IBS and patients with methane-positive SIBO breath tests. The aim of this study is to evaluate patient response to rifaximin for SIBO based on breath test results. MATERIALS AND METHODS: All patients underwent breath testing to evaluate for SIBO during a 42-month period. Patients were defined as having a positive glucose breath test for SIBO based on an increase of ≥ 20 ppm of hydrogen and/or ≥ 10 ppm of methane 90 minutes after ingesting glucose. Patient demographic and symptom data, antibiotic treatment regimens, symptomatic response to therapy, and repeat treatments were recorded. Institutional review board approval was obtained. RESULTS: A total of 53 of 443 patients had positive breath testing for SIBO. Response rates to rifaximin (550 mg three times daily for 14 days) were 47.4% for hydrogen positivity alone and 80% for both hydrogen and methane positivity. CONCLUSIONS: Rifaximin was the most commonly prescribed antibiotic regimen for SIBO therapy. Patients with hydrogen or hydrogen and methane positive breath tests responded well to rifaximin therapy. For patients with hydrogen-positive SIBO, rifaximin may prove a highly effective therapy in providing symptom relief from the effects of SIBO.
Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Intestino Delgado/microbiologia , Rifaximina/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/metabolismo , Testes Respiratórios , Feminino , Humanos , Hidrogênio/análise , Hidrogênio/metabolismo , Masculino , Metano/análise , Metano/metabolismo , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Objectives: Small intestinal bacterial overgrowth (SIBO) is challenging to treat and diagnose and is associated with diagnosis of irritable bowel syndrome (IBS). Although no FDA-approved medications exist for treatment of SIBO, rifaximin has recently received approval to treat diarrhea-predominant IBS and patients with methane-positive SIBO breath tests. The aim of this study is to evaluate patient response to rifaximin for SIBO based on breath test results. Materials and methods: All patients underwent breath testing to evaluate for SIBO during a 42-month period. Patients were defined as having a positive glucose breath test for SIBO based on an increase of ≥ 20 ppm of hydrogen and/or ≥ 10 ppm of methane 90 minutes after ingesting glucose. Patient demographic and symptom data, antibiotic treatment regimens, symptomatic response to therapy, and repeat treatments were recorded. Institutional review board approval was obtained. Results: A total of 53 of 443 patients had positive breath testing for SIBO. Response rates to rifaximin (550 mg three times daily for 14 days) were 47.4% for hydrogen positivity alone and 80% for both hydrogen and methane positivity. Conclusions: Rifaximin was the most commonly prescribed antibiotic regimen for SIBO therapy. Patients with hydrogen or hydrogen and methane positive breath tests responded well to rifaximin therapy. For patients with hydrogen-positive SIBO, rifaximin may prove a highly effective therapy in providing symptom relief from the effects of SIBO.
Objetivos: El sobrecrecimiento bacteriano de intestino delgado es una entidad difícil de diagnosticar y tratar, frecuentemente asociada con el síndrome de intestino irritable. A pesar que la FDA no ha aprobado medicamentos para tratar el sobrecrecimiento bacteriano, la rifaximina ha sido recientemente aprobada para tratar el intestino irritable tipo diarrea y en pacientes con test de aliento metano positivo en sobrecrecimiento bacteriano. El objetivo del estudio fue evaluar la respuesta a rifaximina de los pacientes con sobrecremiento bacteriano con prueba de aliento positiva. Material y métodos: Todos los pacientes que se realizaron prueba de aliento por sobrecrecimiento bacteriano durante un periodo de 42 meses. Se definió un paciente con sobrecrecimiento bacteriano positivo si tenía un incremento mayor a 20 ppm de hidrógeno y/o 10 ppm de metano luego de 90 minutos de la ingesta de glucosa. Se registraron los datos demográficos, síntomas, tratamiento antibióticos recibidos, respuesta a la terapia, y repetición de tratamientos. Resultados: Un total de 53 de 443 pacientes tuvieron prueba de aliento positiva para sobrecrecimiento bacteriano. La tasa de respuesta a rifaximina (550 mg tres veces x día x 14 días) fue 47.4% para pacientes con sólo test de hidrógeno positivo, y 80% para pacientes con tanto test de hidrógeno como metano positivos. Conclusiones: La rifaximina es el régimen antibiótico más frecuentemente utilizado en sobrecrecimiento bacteriano. Los pacientes con prueba de aliento de hidrógeno o hidrógeno y metano positivos respondieron bien a la rifaximina. Para pacientes con sobrecrecimiento bacteriano prueba de hidrógeno positiva, la rifaximina puede ser una terapia efectiva en mejorar síntomas.
Assuntos
Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Infecções Bacterianas/tratamento farmacológico , Rifaximina/uso terapêutico , Intestino Delgado/microbiologia , Antibacterianos/uso terapêutico , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/metabolismo , Testes Respiratórios , Estudos Retrospectivos , Resultado do Tratamento , Hidrogênio/análise , Hidrogênio/metabolismo , Metano/análise , Metano/metabolismoRESUMO
Crohn's disease (CD) is an immune-mediated condition characterized by the transmural inflammation of the gut tissue, associated with progressive bowel damage often leading to surgical intervention. As operative resection of the damaged segment is not curative, a majority of patients undergoing intestinal resections for complicated CD present disease recurrence within 3 years after the intervention. Postoperative recurrence can be defined as endoscopic, clinical, radiological or surgical. Endoscopic recurrence rates within 1 year exceed 60% and the severity, according to the Rutgeerts' score, is associated with worse prognosis and can predict clinical recurrence (in up to 1/3 of the patients). Most importantly, about 50% of patients will undergo a reoperation after 10 years of their first intestinal resection. Therefore, the prevention of postoperative recurrence in CD remains a challenge in clinical practice and should be properly managed. We aim to summarize the most recent data on the definition, risk factors, assessment and treatment of postoperative CD recurrence.
Assuntos
Colite Ulcerativa/cirurgia , Pouchite/prevenção & controle , Proctocolectomia Restauradora/efeitos adversos , Ciprofloxacina/uso terapêutico , Humanos , Metronidazol/uso terapêutico , Assistência Centrada no Paciente , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Rifaximina/uso terapêuticoRESUMO
Background and Aim: Variceal bleeding is the second most important precipitating factor related to the development of episodic hepatic encephalopathy; but to date there are no recommendations to prevent this complication. The aim of this study was to compare if primary prophylaxis with lactulose or L-ornithine L-aspartate or rifaximin, in cirrhotic patients with variceal bleeding, is better than placebo for avoiding the development of hepatic encephalopathy. Methods: A randomized, double-blind, placebo-controlled clinical trial (ClinicalTrials.gov identifier: NCT02158182) which included cirrhotic patients with variceal bleeding, without minimal or clinical hepatic encephalopathy at admission. Findings: 87 patients were randomized to one of four groups. The basal characteristics were similar between groups. Comparatively with placebo, the frequency with regard to the development of hepatic encephalopathy was as follows: lactulose (54.5% versus 27.3%; OR = 0.3, 95% CI 0.09-1.0; P = 0.06); L-ornithine L-aspartate (54.5% versus 22.7%, OR = 0.2, 95% CI 0.06-0.88; P = 0.03); rifaximin (54.5% versus 23.8%; OR = 0.3, 95% CI 0.07-0.9; P = 0.04). There was no significant difference between the three groups receiving any antiammonium drug (P = 0.94). In the group receiving lactulose, 59.1% had diarrhea, and 45.5% had abdominal discomfort, bloating, and flatulence. Two patients (10%) treated with lactulose and a patient (4.5%) in the placebo group developed spontaneous bacterial peritonitis due to E. coli; one of them died due to recurrent variceal bleeding. There were no other adverse effects. Conclusions: Antiammonium drugs, particularly L-ornithine L-aspartate and rifaximin, proved to be effective in preventing the development of hepatic encephalopathy in those cirrhotic patients with variceal bleeding.