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Gastroenterology
Published in Faye Hill, Sash Noor, Neel Sharma, Tiago Villanueva, Medical and Surgical Emergencies for Students and Junior Doctors, 2021
Faye Hill, Sash Noor, Neel Sharma
Management is dependent on the grade of encephalopathy. A CT brain scan should be performed to exclude intracranial pathology and the presence of oedema. Lactulose has been shown to be merited in such patients. Patients with grade III or IV encephalopathy should ideally be intubated, with the use of mannitol for severe elevation of intracranial pressure or herniation. Antibiotics as per hospital protocol should be prescribed to reduce risk of sepsis.
Rational Medical Therapy of Functional GI Disorders
Published in Kevin W. Olden, Handbook of Functional Gastrointestinal Disorders, 2020
Richard M. Sperling, Kenneth R. McQuaid
As a general rule, laxatives should be reserved for severe constipation, and are best avoided in patients with alternating constipation and diarrhea for obvious reasons. When using these agents, the smallest dose for the shortest period of time is prudent. Hyperosmotic laxatives such as oral lactulose or glycerin suppositories are reasonable choices given their relatively quick onset of action. However, lactulose may worsen bloating and flatulence, and electrolyte imbalance may occur with chronic use. Stool-softeners are safe agents, but have a slower onset of action.
Hepatic failure
Published in Michael JG Farthing, Anne B Ballinger, Drug Therapy for Gastrointestinal and Liver Diseases, 2019
A more recent synthetic disaccharide, lactilol has been used in the treatment of PSE. Its mechanisms of action are likely to be similar to those of lactulose. Clinical trials and meta-analysis28 have been unable to demonstrate a difference in efficacy between lactulose and lactilol, although its effects upon colonic microflora differ from those of lactulose.27 It may be better tolerated than lactulose by patients, since it is less sweet and consistently causes fewer untoward abdominal side-effects. Flatulence, which may occur independent of the dose of lactulose, tends only to occur at doses of greater than 40 g/day of lactilol.
Hyperammonemia in acetaminophen toxicity
Published in Clinical Toxicology, 2022
Ryan T. Marino, Alexander M. Sidlak
Another important observation drawn from the data in this cohort is that mental status did not worsen, and encephalopathy did not develop, in patients who were not treated for hyperammonemia. The same explanation for why hyperammonemia may develop in the absence of any clinical encephalopathy may also explain the lack of benefit for conventional therapies. Lactulose, which was initiated in a majority of those patients treated, provides its benefit in hepatic encephalopathy by reducing endogenous and dietary ammonia through a cathartic and pH-altering effect in the gut lumen. Rifaximin, the second most commonly used drug in this cohort reduces urease-producing bacteria in the gut lumen and thus endogenously produced ammonia [8]. The reduction in ammonia and other poorly metabolized molecules provided by lactulose or rifaximin may not benefit patients with acetaminophen toxicity given that these therapeutic targets may not be the main cause of hyperammonemia in toxicity and hyperammonemia may not be solely responsible for the encephalopathy that develops. Acetaminophen-induced hepatotoxicity can progress to hepatic failure, which may include encephalopathy, but using ammonia as an early marker of this possibility appears to be unwise. Using an ammonia concentration alone to initiate treatment for hepatic encephalopathy that has yet to develop may lead to patient discomfort or harm rather than any benefit [11].
Identifying areas of improvement in nursing knowledge regarding hepatic encephalopathy management
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Aalam Sohal, Victoria Green, Sunny Sandhu, Marina Roytman
- Lactulose and Rifaximin are the main medications used in management of hepatic encephalopathy. Lactulose reduces intestinal ammonia production and absorption. Lactulose leads to reduced intestinal pH which leads to conversion of ammonia produced by bacteria to ammonium ion which is unable to cross biological membranes and as a result leads to increased excretion of ammonia into the stool [13]. The dose of lactulose is titrated to the number of the bowel movements with a goal of achieving 2–3 soft bowel movements every day [14]. Adverse effects with more than 3 bowel movements include electrolyte abnormalities such as hypernatremia and hypokalaemia which can paradoxically worsen HE [15,16]. Given the need for titration of lactulose, partnership with nursing staff is critical to achieve optimal administration of this medication.
Plecanatide for the treatment of chronic idiopathic constipation in adult patients
Published in Expert Review of Clinical Pharmacology, 2019
Gabrio Bassotti, Paolo Usai Satta, Massimo Bellini
Concerning traditional laxatives, lactulose is an indigestible synthetic disaccharide passing unchanged into the colon. This saccharide is osmotically active and hence draws water to the lumen of the colon [12]. Polyethylene glycol with a molecular weight of 3500–4000 (macrogol) is a non-absorbable macromolecule that maintains isoosmolarity in the lumen of the gut while drawing water, and is well investigated [13,14], superior to placebo [15] and recommended as a first choice treatment for CIC patients [16]. Polyethylene glycol is more effective than lactulose in increasing stool frequency and decreasing stool consistency [17]. Overall, stimulating laxatives have less literature evidence compared to polyethylene glycol because adequate placebo-controlled trials are lacking [15], even though most traditionally used laxatives are more effective than placebo for the treatment of CIC [15].