A Head CT is Unnecessary in the Initial Evaluation of Hepatic Encephalopathy in Patients With Cirrhosis
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Rifaximin
Spontaneous bacterial peritonitis
Hepatic Encephalopathy
Hepatic encephalopathy is challenging complication of liver dysfunction. Therapeutic treatment options for hepatic encephalopathy are currently limited and have appreciable risks and benefits associated with their use. Rifaximin is a novel anti microbiological agent with wide spectrum of activity that has shown promise as an alternative option for hepatic encephalopathy.The present study was undertaken to compare the effectiveness of Rifaximin and Lactulose as a combination vs Lactulose alone, to compare the adverse effects and to study the rapidity of therapeutic effects of Rifaximin and Lactulose.It was a prospective observational study. 60 patients suffering from hepatic encephalopathy (HE) were studied. Patients were investigated and treated as per treating physician's decision. At the time of analysis, patients were divided into 2 groups, Rifaximin group who received Rifaximin+Lactulose (R+L) and Lactulose group(L), who received Lactulose only. Parameters such as mental status grade, Asterixis grade, Serum Ammonia grade, Number Connection Test grade (NCT grade), Hepatic Encephalopathy Index (HE index) were evaluated and compared in both groups. Clinical efficacy was determined using HE index improvement. Primary end points were decrease in HE index and reversal of HE grades. Secondary end points were mortality from HE or any other cause, decrease in mental status grade, asterixis grade, serum Ammonia grade, NCT grade.Out of 60 patients, 32 received Rifaximin+Lactulose combination and 28 patients received Lactulose alone. Mean Child-Turcotte-Pugh score (CTP score) was 10.6 in R+L group and 10.32 in L group. There was statistically significant improvement in mental status grade, Asterixis grade, Serum Ammonia grade, NCT grade, Hepatic encephalopathy index in both groups, p value <0.05 but no statistically significant difference between improvement in mental status grade, Asterixis grade, Serum Ammonia grade, NCT grade, HE index between the two groups. Rifaximin + Lactulose combination was effective in 31 out of 32 i.e.96.87% and Lactulose alone in 24 out of 28 patients, i.e. in 85.71%, which is not statistically different, p=0.3251.Rifaximin+ Lactulose combination is not superior to Lactulose alone in treatment of refractory hepatic encephalopathy. Addition of Rifaximin may help in the treatment of refractory hepatic encephalopathy.Rifaximin + Lactulose combination is effective, but not superior to Lactulose alone in treatment of hepatic encephalopathy.
Lactulose
Rifaximin
Hepatic Encephalopathy
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Rifaximin is a non-absorbable antibiotic used to prevent relapses of hepatic encephalopathy which may also be a candidate for prophylaxis of spontaneous bacterial peritonitis (SBP).
Rifaximin
Spontaneous bacterial peritonitis
Hepatic Encephalopathy
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According to a review article by Biecker et al published in a previous issue of World Journal of Gastroenterology in March 2011, intestinal decontamination with norfloxacin remains the mainstay of primary prophylaxis of spontaneous bacterial peritonitis (SBP) at the expense of development of quinolone-resistant bacteria after long-term use.In our research, the administration of a 4-wk regimen with rifaximin 1200 mg/d reduced significantly the ascitic neutrophil count in cirrhotic patients with sterile ascites in line with a significant decrease in plasma endotoxin levels.Our observations concur with recent findings, showing a significantly reduced 5-year probability of SBP in cirrhotic patients taking rifaximin.
Rifaximin
Spontaneous bacterial peritonitis
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Ascitic fluid
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Background Rifaximin is a non-absorbable antibiotic used to prevent relapses of hepatic encephalopathy which may also be a candidate for prophylaxis of spontaneous bacterial peritonitis (SBP). Aim To detect the impact of rifaximin on the occurrence and characteristics of SBP. Methods We prospectively studied all hospitalized patients that underwent a diagnostic paracentesis in our department from March 2012 to April 2013 for SBP and recorded all clinical data including type of SBP prophylaxis, prior use of rifaximin, concomitant complications of cirrhosis, as well as laboratory results and bacteriological findings. Patients were divided into the following three groups: no antibiotic prophylaxis, prophylaxis with rifaximin or with systemically absorbed antibiotic prophylaxis. Results Our study cohort comprised 152 patients with advanced liver cirrhosis, 32 of whom developed SBP during the study period. As expected, our study groups differed regarding a history of hepatic encephalopathy and SBP before inclusion into the study. None of the 17 patients on systemic antibiotic prophylaxis developed SBP while 8/27 patients on rifaximin and 24/108 without prophylaxis had SBP (p = 0.02 and p = 0.04 versus systemic antibiotics, respectively). In general, episodes of SBP were similar for patients treated with rifaximin and those without any prophylaxis. However, Escherichia coli and enterococci were dominant in the ascites of patients without any prophylaxis, while mostly klebsiella species were recovered from the ascites samples in the rifaximin group. Conclusion Rifaximin pretreatment did not lead to a reduction of SBP occurrence in hospitalized patients with advanced liver disease. However, the bacterial species causing SBP were changed by rifaximin.
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Spontaneous bacterial peritonitis
Hepatic Encephalopathy
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Purpose: Recent study showed that intestinal decontamination with rifaximin prevents spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites. However, it remains to be determined whether rifaximin prevents infections other than SBP in patients with liver cirrhosis. The aim of the present study is to determine whether rifaximin prevents infections other than SBP in cirrhotic patients. Methods: We identified all adult patients with liver cirrhosis who were referred to our institution between January, 2003 and June, 2007 (N=664), of whom 49 patients received rifaximin therapy and served as study group. A control group of patients with liver cirrhosis who were not on rifaximin was matched 1:1 with the study group based on age and MELD score using a greedy algorithm. Infections were defined by isolation of any bacterial organisms in the body fluids. The rates of infections were estimated by dividing the number of infections by the number of patient years-follow-up. In addition, time-to-infection analysis was performed. Results: A total of 98 patients were included in the study, of whom 49 were on rifaximin therapy and 49 were not. The two groups were comparable with regards to sex and race. The mean MELD and Child's Pugh scores of the entire cohort were 16.9±7.3 and 11.1±1.4, respectively. The median follow-up time was 8.2 months, during which 50% of patients had at least one infection other than SBP (24.5% had 1 infection and 25.5% had +2 infections). The rifaximin patients developed a total of 45 infections other than SBP (infection rate 0.77), as compared with 54 infections (infection rate 0.70) in the non-rifaximin group (p=0.65). After adjusting for Child-Pugh score, there was no reduction in the rate of non-SBP infections in the rifaximin group (hazard ratio=0.63; 95% confidence interval, 0.37-1.05; P=0.074). Conclusion: There is no evidence to suggest that intestinal decontamination with rifaximin causes a significant decrease in the rate of infections other than SBP in patients with liver cirrhosis.Figure
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Primary prophylaxis of spontaneous bacterial peritonitis (SBP) may provide a survival advantage in cirrhotic patients with ascites and has become an integral part of clinical practice. Rifaximin is a poorly absorbable antibiotic with a broad spectrum of antibacterial action and has low risk of introducing bacterial resistance.To determine whether rifaximin is associated with decreasing the risk of SBP and improving transplant-free survival in cirrhotic patients with ascites.The medical records of all adult patients with liver cirrhosis and large ascites justifying paracentesis evaluated in our clinic (2003 to 2007) were reviewed. Patients were stratified into 2 groups by the use of rifaximin. Patients were excluded if they had received another antibiotic for SBP prophylaxis or had a history of SBP before rifaximin therapy.A total of 404 patients were included, of whom 49 (12%) received rifaximin. The rifaximin and nonrifaximin groups were comparable with regards to age, sex, and race. The median follow-up time was 4.2 [1.0, 17.1] months. During this time period, 89% of patients on rifaximin remained SBP free compared with 68% of those not on rifaximin (P=0.002). After adjusting for Model of End-Stage Liver Disease score, Child-Pugh score, serum sodium, and ascitic fluid total protein, there was a 72% reduction in the rate of SBP in the rifaximin group (hazard ratio=0.28; 95% confidence interval, 0.11-0.71; P=0.007). The group treated with rifaximin also demonstrated a transplant-free survival benefit compared with those not on rifaximin (72% vs. 57%, P=0.045).Intestinal decontamination with rifaximin may prevent SBP in cirrhotic patients with ascites. Prospective randomized controlled trials are needed to confirm this finding.
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Objective. To review the effectiveness and safety of rifaximin for the treatment of hepatic encephalopathy. Methods. A literature search was conducted of MEDLINE (1966‐September 2007), the Cochrane Database of Systematic Reviews (1995–2007), and the Cochrane Hepato‐Biliary Group Reviews (2003–2007). English‐language articles identified from the data sources were evaluated. All available studies were reviewed, including placebo‐controlled, treatment comparison, and open label. Results. Rifaximin was effective in improving behavioral, laboratory, mental status, and intellectual abnormalities associated with hepatic encephalopathy. Some studies demonstrated superior and more rapid improvement in signs or symptoms of encephalopathy during treatment with rifaximin compared with nonabsorbable disaccharides (lactulose, lactitol). Patients treated with rifaximin also required less hospitalization, had shorter duration of hospitalization, and lower hospital charges compared with lactulose‐treated patients. Adverse effects of rifaximin were mostly minor gastrointestinal complaints; however, rifaximin was better tolerated than other pharmacologic treatments. Conclusion. Rifaximin was at least equally effective as and in some studies superior to nonabsorbable disaccharides and antimicrobials in relieving signs or symptoms observed in patients with mild‐to‐moderately severe hepatic encephalopathy. Future clinical trials should focus on using standardized methods of evaluating mental status and limiting enrollment to patients with mild‐to‐moderate, episodic, persistent, or minimal hepatic encephalopathy. Well‐designed studies are needed to fully delineate the efficacy of rifaximin and other pharmacologic treatments for patients with hepatic encephalopathy.
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Rifaximin
Lactulose
Hepatic Encephalopathy
Spontaneous bacterial peritonitis
Liver disease
Chronic liver disease
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In the study 52 patients with decompensated liver cirrhosis and "tense" ascites were included. According to the clinical picture, ascites cultures and the number of polymorphonuclears in cmm of the ascitic fluid, all patients were selected in one of the following groups: 1. group of patients with sterile ascites (28), 2. group of patients with spontaneous peritonitis (16), and 3. group of patients with bacterascites (8). The results have shown that the incidence of spontaneous peritonitis is much higher in the group of "tense" ascites patients than in the group of all patients with ascites, the ratio being 30.7% compared to 6% in all cirrhotic patients with ascites. Spontaneous bacterial peritonitis correlates with increased polymorphonuclears in the ascitic fluid (p less than 0.05), decreased pH values (p less than 0.0), and increased amounts of total proteins in the ascitic fluid (p less than 0.05). The lethality rate in the group of spontaneous peritonitis and sterile ascites was 43.7% and 7.1% respectively. Early diagnosis and, of course, adequate therapy are the main points in spontaneous bacterial peritonitis.
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Hepatic encephalopathy is one of the complications of liver cirrhosis. There are several pharmacological therapies that can be used to treat hepatic encephalopathy, which are Lactulose and antibiotics, such as Rifaximin. Currently, Lactulose is the standard treatment to reduce the level of ammonia circulating in the blood, however, there is still no enough evidence that Lactulose itself can prevent recurrence of hepatic encephalopathy. Combination therapy of Lactulose with antibiotic is a promising therapy to prevent recurrence of hepatic encephalopathy. Literature searching through four databases (PubMed ® , Cochrane Library ® , EBSCOHost ® , and SCOPUS ® ) were performed. Using the inclusion and exclusion criteria, there were three journals, which were two randomized control trials and one retrospective cohort study, that were selected and correlated with the clinical cast. All articles were appraised for validity, importance, and applicability. The studies show that giving Lactulose combined with Rifaximin significantly reduced the recurrence of hepatic encephalopathy with HR 0.42 (CI: 0.28 to 0.64, p < .001) and significantly lower readmission rate (p < .05) in 180 days. Giving Rifaximin in combination with Lactulose can prevent recurrence of hepatic encephalopathy and lowering the readmission rate in patients suffering from overt hepatic encephalopathy.
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Hyperammonemia
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