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E
fficacy
of
lactulose
in
the
prophylaxis
of
hepatic
encephalopathy
in
cirrhotic
patients
presenting
gastrointestinal
bleeding
R
ev
A
ssoc
M
ed
B
ras
2016; 62(3):243-247
243
ORIGINAL ARTICLE
Efficacy of lactulose in the prophylaxis of hepatic encephalopathy in
cirrhotic patients presenting gastrointestinal bleeding
F
elipe
T
oyama
A
ires
1
*, P
aola
T
eruya
R
amos
2
, W
anderley
M
arques
B
ernardo
3
1
Medical degree from Faculdade de Ciências Médicas de Santos. Resident Physician in General Surgery at Hospital Ana Costa, Santos, SP, Brazil
2
Medical degree from Faculdade de Ciências Médicas de Santos, Santos, SP, Brazil
3
PhD from Universidade de São Paulo. Coordinator of the Diretrizes Project, Associação Médica Brasileira and the Conselho Federal de Medicina, São Paulo, SP, Brazil
S
ummary
Study conducted at Núcleo Acadêmico
de Estudos e Pesquisas em Medicina
Baseada em Evidências da Faculdade
de Ciências Médicas de Santos,
Santos, SP, Brazil
Article received:
10/1/2014
Accepted for publication:
10/17/2014
*Correspondence:
Address: Rua Oswaldo Cruz, 179,
Boqueirão
Santos, SP – Brazil
Postal code: 11045-101
Phone: +55 13 3221-3252
ft_aires@hotmail.com http://dx.doi.org/10.1590/1806-9282.62.03.243Introduction:
Hepatic encephalopathy (HE) is a bad prognostic factor in pa-
tients with liver cirrhosis and its incidence is associated with several triggering
factors being the most prevalent gastrointestinal bleeding. Lactulose, despite its
questionable efficacy in the literature, is considered a first line treatment in pa-
tients with HE.
Objective:
To evaluate the effectiveness of lactulose in preventing HE in cirrhot-
ic patients with gastrointestinal bleeding.
Method:
A systematic review of the literature using the Medline scientific data-
base. Only randomized controlled clinical trials evaluating the efficacy of lactu-
lose for HE prophylaxis in cirrhotic patients with gastrointestinal bleeding were
included.
Results:
The incidence of HE in the intervention group was 7%, while the con-
trol group was 26% (p=0.01). There was no significant difference in the incidence
of mortality in the group treated with lactulose compared to the group that was
not treated (p=0.48).
Conclusion:
Administering lactulose to cirrhotic patients with upper gastroin-
testinal bleeding reduces the incidence of hepatic encephalopathy.
Keywords:
hepatic encephalopathy, gastrointestinal hemorrhage, lactulose, liver
cirrhosis.
I
ntroduction
Hepatic encephalopathy (HE) is a potentially reversible
metabolically-induced neuropsychiatric disorder, charac-
terized by changes in personality and intellect, sleep dis-
turbances and depressed level of consciousness. It is a com-
plication of patients with acute or chronic liver failure,
especially in cases of cirrhosis, and is generally associated
with triggering factors such as gastrointestinal bleeding,
bacterial infections and electrolyte disturbances.
1,2
The main mechanisms responsible for the develop-
ment of HE are severe intrinsic liver dysfunction and the
presence of portosystemic shunts leading to portal blood
deviation to the systemic circulation before the removal
of intestinal toxic substances.
2,3
Non-absorbable disaccharides, including lactulose as
their main representative, are considered first-line treat-
ment in patients with HE despite their questionable effi-
cacy in the literature. These substances act by reducing
the concentration of aminogenic substrate in the intes-
tinal lumen, decreasing the pH of the colon through the
production of organic acids by bacterial fermentation
and osmotic cathartic mechanism.
4,5
The aim of this study is to evaluate the effectiveness
of non-absorbable disaccharides for HE prophylaxis in
cirrhotic patients with gastrointestinal bleeding.
M
ethod
Selection criteria
Only randomized controlled clinical trials evaluating the ef-
ficacy of non-absorbable disaccharides for HE prophylaxis
in cirrhotic patients with gastrointestinal bleeding were in-
cluded. To be included in the review, the trial should ade-
quately describe the methods of randomization and blind-
ing of patients, as well as the loss of patients to follow-up,
according to the Jadad score criteria.
6
The internal validity
of each study was based on Consort
7
recommendations.