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ORIGINAL PAPER 373Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4DIETARY THERAPY IMPACT FOR CIRRHOTIC PATIENTSWITH HEPATIC ENCEPHALOPATHYAdriana Teiuşanu 1, , Mirela Ionescu 1 , S. Gologan 1 , Adriana Stoicescu 1 ,M. Andrei 1 , T. Nicolaie 1 , M. Diculescu 21) Gastroenterology, Hepatology and Digestive Endoscopy Clinic,Elias Emergency University Hospital2) Gastroenterology and Hepatology Centre, Fundeni Clinical InstituteDIETARY THERAPY IMPACT FOR CIRRHOTIC PATIENTS WITH HEPATICENCEPHALOPATHY (Abstract): BACKGROUND: Malnutrition is prevalent in all forms ofliver disease and it is associated with increased number of complications and increased short andlong term mortality. AIM: to evaluate the level of serum ammonia, recurrence of hepaticencephalopathy (HE), improvement of mental status and of the nutritional status after one monthof high protein high calorie (HPHC) diet the effect of a dietary therapy on cirrhotic patients withHE. MATERIALS AND METHODS: Our study was designed as a descriptive prospectiveanalysis of patients with cirrhosis and a previous episode of HE, admitted in GastroenterologyDepartment of Elias Emergency Hospital, during one year (January 2010 -January 2011). Thediagnosis of cirrhosis was based on the medical history, physical examination, biochemicalfindings and imagistic methods. It was evaluated mental status, serum level of ammonia andnutritional parameters, before and after one month diet. RESULTS: A significant decrease in theblood ammonia levels was observed. A significant number of patients showed an improvement oftheir mental status assessed by West Haven scale after diet. A significant improvement of numberconnection test (NCT) scores was also noted. Body weight was slightly but significantly increasedafter a month of diet. Mid-arm muscle circumference (MAMC) increased after one month diet,but not statistically significant. CONCLUSIONS: The HPHC diet has a beneficial effect on thepatients with cirrhosis and hepatic encephalopathy, more significant regarding the mental status,level of the serum ammonia and the body weight. It was noted an improvement of mid armmuscle circumference. Key words: hepatic encephalopathy, diet, malnutrition, liver cirrhosis.KEY WORDS: MALNUTRITION; HEPATIC ENCEPHALOPATHY; SERUM AMMONIA;HIGH PROTEIN HIGH CALORIE DIET.SHORT TITLE: Hepatic encephalopathy: dietary therapyHOW TO CITE: Teiuşanu A, Ionescu M, Gologan S, Stoicescu A, Andrei M, Nicolaie T, Diculescu M [Dietary therapyimpact for cirrhotic patients with hepatic encephalopathy] Jurnalul de chirurgie (Iaşi). 2012; 8(4): 373-378.INTRODUCTIONMalnutrition has a high prevalence inall forms of liver disease, ranging from 20%in compensated liver disease to more than80% in those patients with decompensatedliver disease and 100% in hospitalizedpatients with acute alcoholic hepatitissuperimposed on cirrhosis [1]. Patients withalcoholic cirrhosis have a higher incidenceof malnutrition than those with nonalcoholicliver disease.Protein-calorie malnutrition (PCM)can be identified in all clinical stages, but iseasier observed in advanced stages of liverdisease [2].There are a number of factors thatcontribute to malnutrition in patient withliver disease such as decreased caloriesReceived date: 15.06.2012Accepted date: 24.10.2012Correspondence to: Adriana Teiuşanu, MDGastroenterology, Hepatology and Digestive Endoscopy ClinicElias Emergency University Hospital,Bd. Mărăști, No. 17, 011461, Bucureşti, RomaniaPhone: 0040 (0) 745 98 07 16.e-mail: adrianateiusanu@yahoo.com
374 Teiuşanu A. et al.Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4intake, decreased nutrients absorption orimpaired metabolic absorption [3].Many descriptive studies have shownhigher rates of complications and mortalityin cirrhotic patients with proteinmalnutrition as well as reduced survivalwhen such patients undergo livertransplantation [4].Hepatic encephalopathy (HE) is aneuropsychiatric condition that leads tomental status changes and abnormalneuromuscular function in patients withacute and chronic liver failure [5].More than 35% of hospitalizations arerelated to HE, with lengths of stay between 5and 7 days [6].Two forms of HE are recognized:minimal hepatic encephalopathy (MHE) andovert hepatic encephalopathy (OHE).Patients with MHE have no clinicalsymptoms of HE, but subtle deficits incognitive function that can be detected bypsychometric or neurophysiologic testing.OHE is characterized by symptoms rangingfrom trivial lack of awareness to loss ofconsciousness, and is usually assessed usingthe West-Haven grading system [7].Multiple recent studies have shown theimportance of maintaining the positivenitrogen balance via increased protein andcaloric intake in cirrhotic patients [5].Negative nitrogen balance due to proteinrestriction leads to protein-caloriemalnutrition (PCM) [8], and decrease thesurvival rate in patients with liver cirrhosis[5].The end point was to evaluate the levelof serum ammonia, recurrence of HE,improvement of mental status and thenutritional status in patients with livercirrhosis before and after 1 month of highprotein high calories diet.MATERIALS AND METHODSOur study was designed as adescriptive prospective analysis of patientswith cirrhosis and a previous episode of HE,admitted in Elias Emergency Hospital,Gastroenterology Department, during oneyear (January 2010-January 2011).Inclusion criteria were: age between18 and 80 years, documented liver cirrhosisin a stable hemodynamic condition,compliance to dietary recommendations andmedical treatment, with a previous episodeof HE.Exclusion criteria were: overt hepaticencephalopathy (OHE) stage III or IV (WestHaven criteria), active gastrointestinalbleeding, ongoing alcoholism, sepsis, liverfailure, hepatocellular carcinoma or otherknown malignancies.The diagnosis of cirrhosis was basedon the medical history, physicalexamination, biochemical findings andimagistic methods (ultrasound and/orcomputed tomography).Assessment of the mental status wasperformed using West Haven scale. Thosewho were with no abnormalities detected(stage 0) had to perform a conventionalNumber Connection Test (NCT), usingcircles numbered from 1 to 25, used forpsychometric performance evaluation.Laboratory tests included cell bloodcount (CBC), bilirubin, albumin,prothrombin time (PT), serum ammonium,International Normalized Ratio (INR), urea,creatinine, which were used to calculateChild Pugh score and to laboratoryevaluation; all markers were measured bystandard laboratory methods.In order to evaluate the nutritionalstatus of the patients with cirrhosis we usedmid-arm muscle circumference (MAMC)[9,10], an anthropometric parameter werethat is not affected by the presence of ascitesor peripheral edema and body weight.Patients from this study receivedmedical treatment including lactulose inorder to obtain 2-3 semisolid stools dailyand rifaximin 1200 mg/day.They were followed for 1 month.During that period they received high calorichigh protein (HPHC) diet: 30kcal/kg/dayand 1.2g of proteins/kg/day. They wereallowed to eat only 100g of poultry meat orfish twice a week. The proteins were fromvegetables, cereals or milk products,approximately 20-25% vegetables and fruits,
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