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Cirrhosis
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Doctors are advocating an alternative treatment approach
for minimal hepatic encephalopathy (MHE), a liver condition that can also
cause brain dysfunction in some patients. MHE can cause changes in
behavior, intelligence, consciousness and neuromuscular function, experts
say. Minimal hepatic encephalopathy is a more subtle version of the overt
form, causing only minimal dysfunction. Since ammonia has been shown to
play a key part in the development of overt hepatic encephalopathy,
treatment options for MHE have also focused on reducing ammonia levels.
Synbiotics: An Alternative for MHE? Flora is the medical term for the various microorganisms that exist in the body. When MHE occurs, the liver cannot properly detoxify and metabolize toxic substances in the body. As a result, these toxic substances, like ammonia, build up in the bloodstream. This ammonia can also be created by intestinal bacteria.2 What Are Synbiotics? To evaluate the effects of synbiotics and fermentable fiber on microorganisms living in the intestinal tract, as well as MHE, the scientists conducted a pilot study of 55 patients with the disease. Twenty of them were treated for a month with a daily synbiotic preparation, another 20 took fermentable fibers for 30 days, and the remaining 15 received a placebo for a month. At the 1-month mark, all patients were re-screened for MHE, and the researchers also evaluated the levels of intestinal flora in three separate fecal samples. Those were compared with the findings of intestinal flora of 20 healthy volunteers. Comparing Notes There were benefits for cirrhotic patients in the study, as well. Both treatments appeared to have significantly altered the intestinal flora of patients with cirrhosis, said the study investigators. At the start of the study, the cirrhotic patients with MHE were found to have significant fecal overgrowths of E. coli and Staphylococcus. Treatment with the synbiotic preparation reduced these levels to those of the healthy individuals. Treatment with placebo did not change the counts of any of the intestinal flora, the investigators found. "Our study is the first to examine the impact of synbiotics and fermentable fiber on MHE and other aspects of hepatic function in patients with cirrhosis," the study authors reported. "We conclude that treatment with synbiotics or fermentable fiber alone is an alternative to use of non-absorbable disaccharides, such as lactulose, for the management of MHE in patients with cirrhosis. Significant reductions in viable counts of potentially pathogenic [disease-causing] gut flora occur with both treatments." Lactulose is a laxative that is used to prevent bacteria in the intestines from making toxic ammonia.2 'Impressive and Exciting'
"We expect this research to stimulate further interest in the study of gut flora therapy, and the 'gut-liver' axis, because the liver does, indeed, care about the gut," they wrote. 1. Liu Q, Duan ZP, Ha da K et al. Synbiotic modulation
of gut flora: Effect on minimal hepatic encephalopathy in patients with
cirrhosis. Hepatology 2004 May;39(5):1441-9. John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include coverage of health news for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
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Anemia Is a Major Determinant of Fatigue in Patients with Cirrhosis
Fatigue is a common complaint among patients with cirrhosis with many possible contributing factors, including severity of liver disease, anemia, and cardiopulmonary complications. In this study, researchers determined the relationship between fatigue and quality of life in cirrhotic patients and the factors that contribute to fatigue. One hundred ambulatory cirrhotic patients attending a liver transplant clinic underwent a comprehensive clinical evaluation for severity of liver disease, anemia (Hemoglobin (Hgb) < 11 gm/dl) and the presence of cardiopulmonary disease. Patients with renal failure were excluded. Fatigue was assessed with the Fisk Fatigue Severity Scale (FFSS) and the 6-Minute Walk Test (6MWT), a standardized exercise test that measures distance walked in 6 minutes. Quality of life (QOL) was assessed with the NIDDK-QA. Severity of fatigue was correlated with quality of life scores. Multivariate analyses were performed to identify independent factors associated with fatigue and poor performance on the 6MWT. Then the additional influence of anemia was tested for each. Results Fatigue was a common complaint. Mean FFSS was 60.2 ± 40.8 (range 0 to 158), and 6MWT was 266 ± 99 m (range 50 to 450). Increased FFSS was correlated with impaired 6MWT (r = -0.46; p < 0.0001). Mean QOL score was 129.9 ± 41.8 (range 35.6 to 213.9). Increased fatigue score correlated with poor quality of life (r = -0.79; p < 0.0001). Mean Hgb level was 12.4 ± 2.0 gm/dl (range 7.3 to 16.5), and 34 patients were anemic. After controlling for age (p < 0.0019), ascites (p < 0.0389), BMI (p < 0.0093), 02 Sat (p < 0.0093) and MELD (p < 0.0205) anemia significantly reduced exercise tolerance expressed as distance walked on 6MWT (p < 0.0006). Anemia was also associated with severe fatigue on the FFSS (p < 0.06) after controlling for ascites (p < 0.0217), 02 saturation (p < 0.0402) and encephalopathy grade (p < 0.0193). Conclusions
05/26/04
Reference DALLAS - In less than an hour, tiny radioactive glass beads traveled through Mike Chapman's bloodstream, toward the grapefruit-sized tumor on his liver. Once trapped inside the small blood vessels of the tumor, the SIR-Spheres began to shrink the tumor. If Chapman is lucky, the tumor will shrink enough to make him a transplant candidate. It's the only real shot at long-term survival for Chapman, who went decades without knowing the hepatitis C virus was destroying his liver. For Chapman, 51, the therapy also allows him to get on with his life without debilitating side effects. "I could have gone back to work the next day," he said. "But I blocked off a couple of days just to be on the safe side." Chapman, of Irving, is the first person in North Texas to undergo the new therapy to treat liver cancer, according to officials at the Liver Institute at Methodist Dallas Medical Center. His doctors imported the spheres from Australia, where the treatment is being used in clinical trials. Hepatitis C, which Chapman contracted from a blood transfusion after a motorcycle accident in 1971, is the most common cause of primary liver cancer, said Dr. Reem Ghalib, medical director at the Liver Institute at Methodist Dallas Medical Center. In the United States, an estimated 3.9 million people have hepatitis C, according to the Centers for Disease Control and Prevention. Of the 5,670 liver transplants in the United States last year, 1,873 were for people with hepatitis C; 435 people had liver cancer, according to the United Network for Organ Sharing. The antiviral drugs interferon and ribavirin have been successful in the treatment of hepatitis C and may also prevent cancer. But many people who were exposed to the virus in the 1960s and 1970s -- most often through blood transfusions or IV drug use -- don't know that they've been infected until it's too late. "The challenge is finding people when they are asymptomatic and in the early stages," said Ghalib, also a physician at Methodist Health System. "Cirrhosis can be prevented if we treat hepatitis C early, before scarring develops." Chapman learned that he had the virus three years ago when his esophagus started bleeding. Like 80 percent of those infected with the virus, he had no symptoms. "One day I was feeling fine," he said. "The next day a vein burst and I was bleeding profusely." Chapman's liver was badly scarred. He went on with his life, working as an aircraft electronics technician for Honeywell, but he often felt fatigued and worried about his health. "The year after I knew I had hepatitis I ended up in the emergency room twice thinking I was dying," he said. In January, Chapman learned he had liver cancer. Although treatment options include chemotherapy, surgery is considered the best way to treat this type of cancer. In many cases, a patients' liver has deteriorated to the point where it's not possible to cut out part of the organ, and a transplant offers the best chance of survival. In the 1980s, doctors began performing transplants on people with liver cancer. Only about 30 percent of patients survived five years, according to the American Cancer Society. Today, about 60 percent survive that long. Each transplant center has its own criteria for organ recipients. People with liver cancer are considered for a transplant based on the individual circumstances, said Pam Silvestri, a spokeswoman for Southwest Transplant Alliance. On a transplant list, cancer patients are often classified as having an urgent need. Chapman's tumor could not be surgically removed. That's the case for about 80 percent of liver cancer patients, according to the American Cancer Society. But he could qualify for a liver transplant if the tumor is smaller than 5 centimeters, about 2 inches, and the malignancy has not spread. During the therapy that Chapman is undergoing, the spheres are slowly injected into the artery that supplies blood to the tumor, said Dr. Travis Van Meter, an intervention radiologist for Methodist Health System and one of Chapman's doctors. For a short period, the patient has a little radioactivity in his body, but the tumor is exposed to a higher dose, he said. As the tumor tissue dies, patients might get fatigued or have a low-grade fever. But Chapman, who had the procedure April 18 at Methodist Dallas Medical Center, did not experience those effects. He won't know for three to six months whether the therapy shrank the tumor, but he's optimistic. "I'm hopeful that this is going to take care of it," he said. Facts about Hepatitis C Hepatitis C is the most common chronic blood-borne viral infection in the United States. • Symptoms include jaundice, fatigue, dark urine, abdominal pain, loss of appetite and nausea; but 80 percent of those infected have no symptoms. • The risk is highest for injecting drug users and recipients of clotting factors made before 1987. Recipients of blood or organs before 1992 have an intermediate risk. • The virus is treated with a combination of interferon and ribavirin. • The hepatitis C virus is the most common reason for liver transplantation among adults. • An estimated 3.9 million Americans have the hepatitis C virus; of those, 2.7 million have a chronic infection. Source: Centers for Disease Control and Prevention
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Reviewed May 29 2004
