Therapeutic targets
- Reduction of ammonia attack
- Symptomatic therapy, depending on severity.
Therapy recommendations
- Elimination of triggering factors:
- For gastrointestinal bleeding (bleeding in the gastrointestinal tract): hemostasis and bowel cleansing, and prophylactic antibiotic administration.
- Hydration in case of exsiccosis (dehydration).
- Discontinuation of diuretics (dehydrating drugs), sedatives (tranquilizers).
- Possibly short-term administration of benzodiazepine antagonists (flumazenil) for after-effects of benzodiazepines.
- Reduction of CNS-toxic (toxic to the nervous system) protein metabolites of the intestine such as ammonia, gamma-aminobutyric acid (GABA), mercaptans, etc.:
- I. v. administration (intravenous) of L-ornithine aspartate: lowers ammonia levels by accelerating the urea cycle; liver detoxification function is improved.
- Lactulose (synthetic (man-made) disaccharide/disaccharide of galactose and fructose (monosaccharides/simple sugars)), taken orally, and high intestinal enemas (with the addition of lactulose) are recommended to cleanse the intestine.
- Suppression of ammonia-forming intestinal flora:
- Disaccharide lactulose → is cleaved in the colon (large intestine) by intestinal bacteria with lactate formation (lactic acid formation) and lowering of the pH value into galactose and fructose → shift of the germ spectrum, inhibition of bacterial urease (bacterial enzyme that catalyzes (“sets in motion”) the hydrolysis (dissolution) of urea to carbon dioxide and ammonia) in the intestine; Prophylactic use is not advisable because of side effects (diarrhea, flatulence/flatulence, nausea/nausea).
- Alternative to Lactulose: Lactitol – Works like lactulose, but the side effects turn out to be weaker.
- Administration of poorly absorbable antibiotics: Rifaximin
- Effective in acute therapy and relapse prophylaxis (prevention of disease recurrence).
- Reduction of HE episode frequency by about 60%.
- Disaccharide lactulose → is cleaved in the colon (large intestine) by intestinal bacteria with lactate formation (lactic acid formation) and lowering of the pH value into galactose and fructose → shift of the germ spectrum, inhibition of bacterial urease (bacterial enzyme that catalyzes (“sets in motion”) the hydrolysis (dissolution) of urea to carbon dioxide and ammonia) in the intestine; Prophylactic use is not advisable because of side effects (diarrhea, flatulence/flatulence, nausea/nausea).
- If necessary, compensation for hypoglycemia (low blood sugar).
- If necessary, improvement of renal function
- Monitoring/correction of electrolyte and water balance – hypokalemia (potassium deficiency)? Zinc deficiency?
- If necessary, correction of the acid-base balance.
Possible further therapeutic measures
- Fecal microbiota transplantation (FMT); There were significantly fewer serious adverse events (SAEs) in the FMT group than in the standard therapy group during follow-up after FMT (2 vs. 11 in FMT vs. SOC, p=0.02).
