Orthograde whole gut irrigation with mannite versus paromomycine plus lactulose as prophylaxis of hepatic encephalopathy in patients with cirrhosis and upper gastrointestinal bleeding: Results of a controlled randomized trial
A. Tromm et al., Orthograde whole gut irrigation with mannite versus paromomycine plus lactulose as prophylaxis of hepatic encephalopathy in patients with cirrhosis and upper gastrointestinal bleeding: Results of a controlled randomized trial, HEP-GASTRO, 47(32), 2000, pp. 473-477
Background/Aims: In patients with liver cirrhosis and upper gastrointestina
l bleeding development of hepatic encephalopathy is a major problem. The ai
m of the present study was to evaluate the efficacy of the mannite lavage i
n a controlled randomized trial with respect to the Child-Pugh classificati
on.
Methodology: After initial gastroscopy (+/- sclerotherapy) 39 patients with
cirrhosis (18 F, 21 M; age: 57.5+/-11.9yr; Child A: 6, Child B: 16, Child
C: 17) and upper gastrointestinal-bleeding were classified according to the
Child-Pugh-criteria (A,B,C) and randomized in 2 groups (A,B) for each Chil
d-Pugh level. Patients in group A (n=18) were initially treated with 2000mL
mannite solution (10%) during the first 2 hours using a naso-gastric tube.
Treatment was continued using 2000mL mannite solution (10%) per day until
no rectal blood could be observed. Patients in group B (n=21) were treated
with paromomycine ter in die (1g tid) and lactulose (10mL tid). There were
no statistical differences between both groups concerning age, sex, Child-P
ugh-scores, severity or source of bleeding, initial hemoglobin-levels, numb
er of given blood-transfusions or number of patients with sclerotherapy.
Results: Patients in group A were treated with a total of 3325+/-1897mL man
nite solution. The application was well tolerated. In addition, kinetics of
serum creatinine, potassium and sodium levels did not show any significant
changes. No significant differences between both groups could be shown wit
h respect to clinical criteria of encephalopathy according to O'Grady and t
he length of intensive care unit treatment. Moreover, kinetic of ammonia-le
vels showed a pronounced decrease (P=0.05) on day 2 versus day 1 in group A
(110.0+/-24.2 vs. 156.4+/-98mg/dL) as compared to group B (210.0+/-52.7 vs
. 162.0+/-45mg/dL). In group A, 6 patients (33.3%) died during the study as
compared to 3 patients (14.3%) in group B (P>0.05). The lethality rate was
strongly associated with the larger proportion of Child-C-patients in grou
p A.
Conclusions: The data indicate that whole gut irrigation with mannite is eq
ually efficacious as compared to standard treatment for prophylaxis of hepa
tic encephalopathy after upper gastrointestinal bleeding in liver cirrhosis
. In contrast to previously published controlled studies, no impact of the
lavage on the mortality rate or duration of intensive care unit treatment c
ould be shown: With respect to the lower costs for the mannite solution as
compared to paromomycine and lactulose (ROTE LISTE, Germany), the mannite l
avage should be recommended for the prophylaxis of hepatic encephalopathy a
fter upper gastrointestinal bleeding in patients with liver cirrhosis.