Encephalopathy

The first step in managing encephalopathy (damage to the brain) is to treat any precipitating cause, if known, such as:

• High ammonia levels.
• Bleeding.
• Low oxygen.
• Dehydration.
• Infection.
• Use of sedatives.

Some studies indicate that manganese poisoning may be partially responsible for encephalopathy in cirrhosis. Studies are needed to determine if drugs that remove manganese improve this complication.

Eliminating Ammonia

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Ammonia is the leading toxin in causing encephalopathy related to cirrhosis. Mild encephalopathy is managed by directing therapy toward eliminating ammonia in the intestine:

• The first step is to restrict animal protein, substituting meats and dairy products with vegetable protein, such as soy, and amino acid supplements.
• Enemas, which clean out the intestine, may be effective.
• Lactulose (Cephulac, Chronulac, Constulose, Duphalac, Enulose) and lactitol, known as disaccharides, help lower blood ammonia levels and may be beneficial in mild encephalopathy.
• Antibiotics, such as metronidazole, rifamycin, or neomycin, are effective in reducing levels of ammonia-producing bacteria in the intestine, although long-term use of these drugs can cause toxic side effects.
• Adding non-ammonia producing bacteria to the intestine, including L. acidophilus and E. faecium, is showing promise as a safe and effective treatment.

Investigative Agents. Certain drugs, such as rifaximin (Xifaxan) and flumazenil (Mazicon, Romazicon), are under investigation for treating encephalopathy. Flumazenil is typically administered to counteract the effects of sedatives.