PDF (5 MB) - Jurnalul de Chirurgie

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,