Department of Gastroenterology Hepatobiliary and Pancreatic Disorders,BIRDEM General Hospital,122, Kazi Nazrul Islam Avenue, Dhaka-1000
Background and objectives:
Minimal hepatic encephalopathy (MHE) impairs health related quality of life and
predicts overt hepatic encephalopathy (HE) in cirrhotic patients. Lactulose is
effective in the treatment of MHE. But the response to lactulose treatment
depends on several factors. This study was aimed to find out the contributing
factors to non-response to lactulose therapy.
Materials and methods: The study was carried out at the BIRDEM general hospital from September,
2013 to March, 2015. Sixty patients were enrolled to assess the response of
lactulose therapy in cirrhotic patients with MHE. MHE was diagnosed based on abnormal
psychometric tests namely, number connection test (NCT), digit symbol test
(DST) and high serum ammonia level. A daily dose of 30-60 ml of lactulose was given to
all patients for one month. The response to treatment with regard to MHE was
determined after one month using
defined criteria. The response was graded as responder and non-responder.
Results: The mean age of the study
population was 57.0±10.3 years. Out of 60 cases, 46 (77%) were male and 39
(65%) had diabetes. Out of 60 enrolled MHE cases, 16 (27%) had Child-Turcotte-Pugh-A
(CTP-A) score and 44 (73%) belonged to CTP-B & C category.
Out of 60 MHE cases, 23 (38.3%) showed
improvement in their MHE status based on normalization of psychometric
tests and reduction of serum ammonia level to ≤32 µmol/L. Age,
gender and diabetes were not associated with the response to lactulose therapy.
Low baseline arterial pressure was significantly
(p=0.003) associated with non-response to lactulose treatment. The mean
baseline ammonia level was higher significantly among the non-responders
compared to the responders (83.6±21.4 µmol/L vs 58.8±19.8 µmol/L, p<0.001). Compared to
responders, low serum sodium and potassium and raised serum bilirubin levels of
non-responders at baseline were found significantly (p<0.05) associated with
non-response to one month of lactulose treatment. Initial hemoglobulin,
peripheral leucocyte and platelet counts did not have any effect on the
response to lactulose treatment in MHE cases.
Conclusions:The status of MHE in patients with
cirrhosis improved by one-month treatment with lactulose. Baseline low arterial
pressure, hyperammonemia, hypokalemia and hyponatremia were major contributors
to non-response to lactulose therapy. The findings of the study would be useful
in treating patients of cirrhosis with MHE.
IMC J Med Sci 2018; 12(1): 15-21
Correspondence: Dr. Shireen Ahmed, Registrar, Department
of Gastroenterology Hepatobiliary and Pancreatic Disorders, BIRDEM General
Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh. E-mail: