Myth: Interpretation of a single ammonia level in patients with chronic liver disease can confirm or rule out hepatic encephalopathy

Although the exact pathophysiology of hepatic encephalopathy (HE) is not fully understood, for more than a century ammonia has been thought to play a critical role. However, the interpretation and utility of ammonia levels in patients with chronic liver disease (CLD) presenting with HE has been a long-standing source of confusion. It is a common belief in the emergency department and on the wards that a single elevated ammonia level in a patient with CLD can confirm the diagnosis of HE, and a normal level essentially rules it out. This confusion stems from the fact that early studies showed a correlation between degree of encephalopathy and the ammonia level, but numerous subsequent studies have shown that severely encephalopathic patients often have normal ammonia levels. This paper reviews the published literature on ammonia levels in patients with CLD in an attempt to clarify its value as a clinical decision-making tool in patients with suspected HE.

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Faculty Opinions recommendation of Comparison of once a day rifaximin to twice a day dosage in the prevention of recurrence of hepatic encephalopathy in patients with chronic liver disease.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725432284.793505982 ◽

2015 ◽

Author(s):

Philip Rosenthal

Keyword(s):

Liver Disease ◽

Hepatic Encephalopathy ◽

Chronic Liver Disease ◽

Chronic Liver ◽

Prevention Of Recurrence

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Role of Rifaximin for the Treatment of Hepatic Encephalopathy in Chronic Liver Disease

BIRDEM Medical Journal ◽

10.3329/birdem.v7i3.33781 ◽

2017 ◽

Vol 7 (3) ◽

pp. 205-211

Author(s):

Ranjit Kumar Paul ◽

Indrajit Kumar Datta ◽

Habib Ahmed ◽

Mohammad Reazul Karim ◽

Md Nazmul Haque ◽

...

Keyword(s):

Liver Disease ◽

Hepatic Encephalopathy ◽

Hospital Stay ◽

Chronic Liver Disease ◽

Chronic Liver ◽

Controlled Study ◽

End Of Treatment ◽

Group A ◽

Group B ◽

Ctp Score

Background: Hepatic encephalopathy (HE) is a common problem in patients with chronic liver disease (CLD) and is characterized by diminished mentation and neuromuscular abnormalities. Rifaximin has been reported to be effective for the treatment of hepatic encephalopathy (HE) in Europe and other countries. It is unknown whether rifaximin is effective for the treatment of hepatic encephalopathy in Bangladeshi patients.Methods: A prospective, randomized, single blind, placebo controlled study was conducted to evaluate the efficacy of rifaximin among patients with cirrhosis of liver with hepatic encephalopathy. A total sixty patients of HE fulfilling inclusion criteria were randomly enrolled among those admitted under Gastrointestinal, Hepatobiliary and Pancreatic Disorders (GHPD) department of BIRDEM General Hospital during August 2012 to April 2013. Patients were divided into two groups: group A (receiving Tab. rifaximin with lactulose), the total number of patients were 31(51.7%) and group B (receiving placebo with lactulose), it was 29(48.3%). Enrolled patients were followed up for 10 days or up to discharge from the hospital or death. At enrollment and at the end of treatment, gradation of HE and estimation of portosystemic encephalopathy (PSE) index was done.Results: In this study between two groups, mean age difference (p=0.404), gender difference (p=0.668) and CLD duration difference (p=0.555) were not statistically significant between two groups. At enrollment, prognostic scores e.g. Child-Turcotte-Pugh (CTP) score (p=0.489) and PSE index (p=0.934) were not significantly different between two groups. At the end of treatment, group A patients showed significantly lower HE grade (P=0.045) and PSE index (P<0.05) than group B. CTP score (p=0.552) was also lower in rifaximin treated group than placebo group but no significant difference was observed. The mean duration of hospital stay was significantly lower in group A than group B (p<0.05).Conclusions: Hepatic encephalopathy patients treated with rifaximin plus lactulose have better outcome and less hospital stay than those treated with placebo plus lactulose.Birdem Med J 2017; 7(3): 205-211

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Prevalence of minimal hepatic encephalopathy among patients with chronic liver disease in Ilorin, Nigeria

Ghana Medical Journal ◽

10.4314/gmj.v53i4.8 ◽

2020 ◽

Vol 53 (4) ◽

pp. 299

Author(s):

Opeyemi F Bamidele ◽

Abdulfatai B Olokoba ◽

Matthew O Bojuwoye ◽

Richard O. Akintayo ◽

Oluwakemi Bamidele

Keyword(s):

Liver Disease ◽

Hepatic Encephalopathy ◽

Chronic Liver Disease ◽

Minimal Hepatic Encephalopathy ◽

Chronic Liver

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Predictors of Mortality in Hepatic Encephalopathy in Acute and Chronic Liver Disease

Journal of Clinical Gastroenterology ◽

10.1097/01.mcg.0000225639.45157.ee ◽

2007 ◽

Vol 41 (10) ◽

pp. 922-926 ◽

Cited By ~ 13

Author(s):

N. Udayakumar ◽

K. Subramaniam ◽

L. Umashankar ◽

Joy Verghese ◽

V. Jayanthi

Keyword(s):

Liver Disease ◽

Hepatic Encephalopathy ◽

Chronic Liver Disease ◽

Chronic Liver ◽

Predictors Of Mortality

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Development and multicenter validation of FIB‐6; a novel, machine‐learning, simple bedside score to rule out liver cirrhosis and compensated advanced chronic liver disease in CHC patients

Hepatology Research ◽

10.1111/hepr.13729 ◽

2021 ◽

Author(s):

G Shiha ◽

R Soliman ◽

NNH Mikhail ◽

K Alswat ◽

AA Abdo ◽

...

Keyword(s):

Machine Learning ◽

Liver Cirrhosis ◽

Liver Disease ◽

Chronic Liver Disease ◽

Chronic Liver ◽

Simple Bedside ◽

Multicenter Validation ◽

Rule Out

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Hepatic encephalopathy

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0320 ◽

2020 ◽

pp. 3080-3089

Author(s):

Paul K. Middleton ◽

Debbie L. Shawcross

Keyword(s):

Liver Transplantation ◽

Liver Disease ◽

Hepatic Encephalopathy ◽

Chronic Liver Disease ◽

Wide Spectrum ◽

Chronic Liver ◽

Electrolyte Disorders ◽

The West ◽

Optimal Medical Management ◽

Type C

Hepatic encephalopathy (HE) is a significant complication of both acute and chronic liver disease, causing much morbidity and mortality. It is a complex neuropsychological condition, associated with hyperammonaemia and systemic inflammation, with a wide spectrum of symptoms. The West Haven criteria describe grades of severity from 0 (subclinical) and I (changes in awareness, mood, attention, cognition, and sleep pattern) through to IV (coma). It is further classified by the underlying aetiology: type A, due to acute liver failure; type B, secondary to portosystemic shunting; and type C, occurring in chronic liver disease in association with precipitating factors including infections, gastrointestinal bleeding, and electrolyte disorders, particularly hyponatraemia. There is no definitive test or set of diagnostic criteria to establish a diagnosis of HE, which remains primarily a clinical diagnosis of exclusion in patients with a history or clinical evidence of liver disease. Management depends on the type of HE, but for type C (the commonest type) typically includes lactulose and rifaximin. Patients with cirrhosis with ongoing overt HE despite optimal medical management have a dismal outlook and should be considered promptly for liver transplantation.

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Multiparametric MR mapping in clinical decision-making for diffuse liver disease

Abdominal Radiology ◽

10.1007/s00261-020-02684-3 ◽

2020 ◽

Vol 45 (11) ◽

pp. 3507-3522 ◽

Cited By ~ 3

Author(s):

Helena B. Thomaides-Brears ◽

Rita Lepe ◽

Rajarshi Banerjee ◽

Carlos Duncker

Keyword(s):

Liver Disease ◽

Liver Diseases ◽

Clinical Decision Making ◽

Clinical Care ◽

Clinical Decision ◽

Chronic Liver ◽

Diffuse Liver Disease ◽

Treatment Pathway ◽

Recent Developments ◽

Potential Applications

Abstract Accurate diagnosis, monitoring and treatment decisions in patients with chronic liver disease currently rely on biopsy as the diagnostic gold standard, and this has constrained early detection and management of diseases that are both varied and can be concurrent. Recent developments in multiparametric magnetic resonance imaging (mpMRI) suggest real potential to bridge the diagnostic gap between non-specific blood-based biomarkers and invasive and variable histological diagnosis. This has implications for the clinical care and treatment pathway in a number of chronic liver diseases, such as haemochromatosis, steatohepatitis and autoimmune or viral hepatitis. Here we review the relevant MRI techniques in clinical use and their limitations and describe recent potential applications in various liver diseases. We exemplify case studies that highlight how these techniques can improve clinical practice. These techniques could allow clinicians to increase their arsenals available to utilise on patients and direct appropriate treatments.

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