Jawaban pertanyaan kuis kuliah IPD 1 .

The mainstay of treatment for encephalopathy, in addition to correcting precipitating factors, is to use lactulose, a nonabsorbable disaccharide, which results in colonic acidification. Catharsis ensues, contributing to the elimination of nitrogenous products in the gut that are responsible for the de elopment of encephalopathy. The goal of lactulose therapy is to promote !"# soft stools per day. Patients are asked to titrate their amount of ingested lactulose to achie e the desired effect. Poorly absorbed antibiotics are often used as ad$uncti e therapies for patients who ha e had a difficult time with lactulose. %&nthony '. (auci, !))*. +arrison,s Internal -edicine, 1* th. .dition, /'&,. -c0raw " +ill1
&lthough it is not licensed for use in the /nited 'tates at present, oral lactitol at a dose of #) to 23 g daily is as effecti e as lactulose for treating hepatic encephalopathy and has the ad antage of being more palatable and associated with a lower incidence of side effects, such as flatulence. 4ral lactose at a dose of 1)) g daily is another pro ed alternati e in lactase5deficient patients. %Treatment of +epatic .ncephalopathy, 'tephen -. 6iordan, -.D., and 6oger 7illiams, -.D8 1

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The indications set for aspirations were9 5not responding to antibiotic therapy, 5si:e morethan 1) cm % ;ong5term follow5up of pyogenic li er abscess by ultrasound ' <C, D 'harma 5 .uropean $ournal of radiology, !)1) " .lse ier1

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'ometimes hydration and correction of electrolyte imbalance is all that is necessary. In the past, restriction of dietary protein was considered for patients with encephalopathy8 howe er, the negati e impact of that maneu er on o erall nutrition is thought to outweigh the benefit when treating encephalopathy, and it is thus discouraged. There may be some benefit to replacing animal5based protein with egetable5based protein in some patients with encephalopathy that is difficult to manage. %&nthony '. (auci, !))*. +arrison,s Internal -edicine, 1* th. .dition, /'&,. -c0raw " +ill1
Pro ision of 25= small meals daily with a nighttime snack may impro e +. by a oiding protein loading and distributing protein e>ually. & late5e ening meal has been shown to ha e a positi e effect on nitrogen balance in patients with cirrhosis when compared with an e>uica?loric diet without a late5e ening meal. %'wart 06, @illikens -C, an Auure J<, et al. .ffect of a late e ening meal on nitrogen balance in patients with cirrhosis of the li er. Br -ed J. 1C*C8!CC91!)!51!)#.1

DVegetable and Casein Protein

7ith low le els of methionine, aromatic amino acids, and ammoniagenic amino acids, egetable protein is presum5ably better tolerated than animal proteins in patients with ad anced li er disease and cirrhosis. In a random5i:ed, crosso er comparison study, Bianchi et al pro ed egetable protein to impro e nitrogen balance, increase a erage daytime integrated blood glucose, and impro e clinical grading of +.. Aegetable protein with an abun?dance of dietary fiber can increase nitrogen incorporation and elimination in gut by decreasing the intestinal transit time and increasing the intraluminal p+ and fecal ammo?nia eEcretion. Patients eating increased amounts of egetable proteins ha e increased plasma arginine and citrulline concentrations, which may facilitate ammonia remo al ia the <rebs5+enseleit cycle. In patients with +., dairy %casein1 proteins may be better tolerated than are proteins from miEed sources. 0heorghe et al reported impro ement of +. using a modified high5calorie, high5protein diet. Aegetable5 and milk5deri ed protein was initiated to ensure that an ade?>uate energy re>uirement of #) kcalFkgFd and protein re>uirement of 1.! protein gFkgFd were met. This high5calorie, high5protein diet impro ed mental status in about *)G of the study population.

Use of Probiotics and Synbiotics

Probiotics are li ing microorganisms, prebiotics are indigestible carbohydrates that stimulate the growth and acti ity of beneficial bacteria within the intestinal flora, and synbiotics are a combination of the two. Probiotic or prebiotic treatment aims to augment the intestinal content of lactic acid"type bacteria at the eEpense of other species

with more pathogenic poten?tial and thus reduce the incidence of sepsis. There is also e idence that synbioticFprobiotic supplementation impro es hepatic function in -+.. The data suggest that in addition to lactulose and antibiotics, dietary inter ention with probiotic yogurt can be an effecti e strategy for -+. therapy.

Micronutrients
&nimal protein restriction, diuretic use leading to urinary :inc losses, and increased needs lead to :inc defi?ciency in cirrhosis. @inc deficiency is a near5constant finding in patients with ad anced stages of li er disease. Distortion or decrease in taste sensation %dysgeusia1 associated with :inc or magnesium deficiency is well described in the literature and may contribute to reduced intake and malnutrition. @inc is essential for the function of H#)) en:ymes, including those of the urea cycle. The effects of :inc defi?ciency on the acti ity of hepatic ornithine carbamoyltrans?ferase %4CT1 and plasma ammonia were studied in rats by 6abbani et al. I-+.%-inimal +epatic .ncelohepatic1J

(Rajagopal Chadalavada, MD; Raja Shekhar Sappati Biyyani, MD; John Maxwell, MD; and Kevin Mullen, MD !utrition in "epati# $n#ephalopathy; %&'&( 2 .

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