Other therapies have limited data to support their
use. One theory of hepatic encephalopathy is that an
increased ratio of aromatic to branched-chain amino
acids may serve to increase the level of false neurotransmitters, which may inhibit neurotransmission.
Branched-chain amino acid supplements have been
studied, with a potential benefit detected, though
further research is needed to establish this therapy
as effective.119 Another theory is that zinc deficiency
contributes to hepatic encephalopathy, as zinc may
modulate neurotransmission and zinc deficiency is
common in patients with cirrhosis.120 There is limited
evidence for the effectiveness of zinc supplementa-tion for hepatic encephalopathy.121 Because of the
importance of GABA neurotransmission in hepatic
encephalopathy, the benzodiazepine receptor antagonist flumazenil has also been studied for hepatic
encephalopathy.122 Although it does improve hepatic
encephalopathy, the effects are short-lived, and the
medication can precipitate seizures. It is therefore not
recommended for routine use in this setting.
The traditional teaching that protein restriction
would reduce nitrogenous substrate for ammonia
production has not played out in clinical studies. Protein restriction does not reduce hepatic encephalopathy, but does result in more protein breakdown.123
Malnutrition is common in advanced liver disease,
and can be worsened with protein restriction. For
those who have hepatic encephalopathy sensitive
to protein intake, substitution of animal proteins with
vegetable proteins may be beneficial.124
CONCLUSION
The chief complications of cirrhosis and portal
hypertension are ascites, varices, and hepatic encephalopathy. These complications are highly morbid and require careful monitoring and treatment to
improve the quality and duration of patients’ lives.
Adherence to evidence-based therapies offers the
best chance of obtaining favorable outcomes. Most
importantly, the development of these complications
heralds a poor prognosis, and liver transplantation
should be considered for those who are eligible.
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