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Probiotics Cut Risk for Hepatic Encephalopathy in Half

Probiotics Cut Risk for Hepatic Encephalopathy in Half

Daniel M. Keller, PhD
May 01, 2013

AMSTERDAM, the Netherlands — Probiotics were effective in helping to prevent a first episode of overt hepatic encephalopathy in patients with cirrhosis, compared with patients not receiving probiotics, according to a new study.

"The patients in the control group had 2 times the chance of developing overt hepatic encephalopathy in the follow-up period," lead author Manish Lunia, MD, from the G.B. Pant Hospital in New Delhi, India, told delegates here at the International Liver Congress 2013.

It is estimated that hepatic encephalopathy occurs in 30% to 45% of patients with cirrhosis, and the mortality rate is 20% to 30%. Because bacterial overgrowth in the small intestine leads to endotoxemia, the researchers reasoned that probiotics could prevent the condition.

For their open-label, prospective, randomized trial, they enrolled patients 18 to 80 years of age with cirrhosis and no history of overt hepatic encephalopathy. A battery of psychometric tests, the critical flicker frequency test, and the psychometric hepatic encephalopathy score were used to diagnose encephalopathy. Glucose hydrogen breath tests were used to identify small intestinal bacterial overgrowth and lactulose hydrogen breath tests were used to identify orocecal transit time.

Study participants were randomly assigned to the probiotic group (n = 86) or the control group (n = 74). The researchers used the commercially available VSL#3, which is a mixture of nonurease-producing organisms: Streptococcus thermophilus and various species of Bifidobacterium and Lactobacillus (110 billion colony-forming units, 3 times daily).

There were no significant differences between the probiotic and control groups in terms of baseline age (about 44 to 47 years), sex, cause of cirrhosis, proportion of Child–Turcotte–Pugh classes, and model for end-stage liver disease (MELD) score. The groups also did not differ in various baseline laboratory parameters, such as small intestinal bacterial overgrowth (38.4% vs 35.1%) and the proportion of patients with minimal hepatic encephalopathy, defined as a psychometric hepatic encephalopathy score of 5 or lower (48.8% and 44.6%).

Patients were followed monthly for signs of overt hepatic encephalopathy or death (mean follow-up time, 38 to 40 weeks). Every 3 months, they underwent psychometric, arterial ammonia level, critical flicker frequency, glucose hydrogen, and lactulose hydrogen breath tests. Six probiotic patients and 5 control subjects were lost to follow-up.

More patients in the probiotic group than in the control group developed overt hepatic encephalopathy (8.8% vs 20.3%). Kaplan–Meier analysis revealed a hazard ratio for developing overt hepatic encephalopathy of 2.1 (95% confidence interval, 1.31 - 6.53; P < .05). There were fewer deaths in the probiotic group than in the control group (7.5% vs 11.5%).

A significantly greater proportion of patients with Child class B and C cirrhosis than with class A cirrhosis developed overt hepatic encephalopathy, but patients with Child class A and Child class B did not differ from each other (P = .36).

In the probiotic group, there were significant improvements from baseline to 3 months in arterial ammonia (P = .04), small intestinal bacterial overgrowth (P = .006), orocecal transit time (P = .05), psychometric hepatic encephalopathy score (P = .01), critical flicker frequency test (P = .02), and minimal hepatic encephalopathy (P = .001). In the control group, there were no significant differences from baseline in any of these parameters.

Factors significantly associated with the development of overt hepatic encephalopathy were minimal hepatic encephalopathy (adjust odds ratio [aOR], 3.1), Child–Turcotte–Pugh score (aOR, 1.6), small intestinal bacterial overgrowth (aOR, 2.1), and critical flicker frequency (aOR, 1.44).

Dr. Lunia reported that 5 patients with minimal hepatic encephalopathy or 31 patients without minimal hepatic encephalopathy would need to be treated to prevent 1 case of overt hepatic encephalopathy.

This study involved patients with a low level of hepatic encephalopathy at worst, and was therefore for prevention, not treatment, session moderator Isabelle Colle, MD, from Gent University in Belgium, who was not involved with the study, told Medscape Medical News. She explained that the use of probiotics is "certainly not" standard for such patients at this point.

She also questioned whether the use of probiotics in these patients is completely benign. "The gut permeability...is increased, so you can imagine that these bacteria can go through the intestine and cause bacterial translocation.... Do you see infections with this treatment?" she asked. It was a short study, and Dr. Lunia did not present any data on infections, Dr. Colle pointed out.

Dr. Lunia and Dr. Colle have disclosed no relevant financial relationships.

International Liver Congress 2013: 48th Annual Meeting of the European Association for the Study of the Liver (EASL). Abstract 78. Presented April 26, 2013.

46 Responses
446474 tn?1446351282
"The researchers used the commercially available VSL#3, which is a mixture of nonurease-producing organisms: Streptococcus thermophilus and various species of Bifidobacterium and Lactobacillus (110 billion colony-forming units, 3 times daily)."

VSL#3 is available at CVS, Walgreens, Rite Aid and many grocery stores that sell vitamins and supplements.

4043517 tn?1374010173
Is this why I see objects in my peripheral vision in low light? In bed especially at night, see movements, floating sheet like things some might call them ghosts waving/shimmering to my side. Maybe I need these.
317787 tn?1473362051
Thank you so much for this article.  It really helped me quite a bit.
I am grateful to you and Hector for all of the information you share with the rest of us
Avatar universal
I'm very happy that it helped you.

Good luck,
1475202 tn?1536274577
Great article Mike, Thanks. I was doing some research after reading this and found another page that I think is a nice addition to this.


In this article though posted in 2009 it is said probiotics can greatly reduce the risk of bacterial infection from ascites (spontaneous bacterial peritonitis).

As always persons with cirrhosis should consult their hepatologist before starting any new medications.

317787 tn?1473362051
Thank you Randy.  After reading Mike's article I am on probiotics.  Of to read yours now :)
Avatar universal
My dad has been on theses probitotics for the last year. It was 1 year ago this week that I was told my dad had less then 6wks to live. His blood work defiantly showed that. We took a different approach to his cirrhosis. We have seen my dad go from near death and in and out of hospitals 5 times last year and bleeding. He could not walk he was blown up and it took 5 of us kids to put him in a blow up raft boat to give him detox baths. We also had him on depends. This man has gone from there to getting himself up out of a real bath tub by himself and  no more depends. I  also own a flower shop and he came in to do deliveries with my mom for mother’s day. He worked 8 hours and was amazing. We know the route that we took might not be for ever one but OMG please people ck into some different things and ck with your dr. My dad turned 78 a couple of months ago. And is living a different life then a year ago. . My dad’s blood work improves ever month. And so does he. I am glad we choose the path that we did. Please belive me it was a rough road to go but the change is amazing.
. I am a daughter that just was not ready to say goodbye to my dad. His life has changed my life also. I go to my dad’s everyday and do a 45 minute treatment on him to keep his blood flowing to all his organs. I also use avocado oil to keep arms and legs soft and smooth so he has no dry skin. This also helps with itching a little.  As of today the only RX med he is on is lactulose the rest are vitamins.  He also eats everything he wants and has no digestion or sodium problems. If you choose to go on probiotics make sure that you get ones safe on the liver. Multi-flora plus   is what we like. My dad will be going for his blood work in the next couple of days. He just had skin cancer surgery yesterday on his head  with over 25 stiches. Today I changed the bandage and they look great! This is something that I would never have done with him 5 months ago where his blood was no high enough nor was he stong enough.  Today  as always I realize what a truly an amazing man he is. And this is where I get my strenght from. I wish everyone a miracle like his.  As always we take one day at a time and breath. Jill
Avatar universal
Jill, of course I'm familiar with your dad's case - and his is really quite a remarkable 'comeback' story.  Thank you so much for continuing to provide this encouragement to us all..!!  My 'lessons learned' from your testimony (and a few other similar ones) are these:
Cirrhosis does not have to be a death sentence!
Every case really IS different!
Attitude IS so vitally important!
There's much that can be done to improve prognosis, often even if the liver has already gone into failure.
It's so important to "keep the blood moving"....with regular exercise and/or by other means (therapeutic massage, acupuncture/acupressure, or whatever works)!
Hopefully many folks - incl. newer ones - will see this and take heart -
You, your dad and family are blessed - and are a blessing!
Avatar universal
Thank you for saying it better then I can. You nailed it! You and Hector are so good at giving great advice. I  could only wish I had your wisdom. My heart goes out to all the families going thru this. I just hope that what we go thru may help someone else. jill
Avatar universal
I loved reading about your Dad. Yours is a very inspiring story.

Thank you for sharing.

1815939 tn?1377995399
Good articles, Mike and Randy.
1654058 tn?1407162666
Great news all. I'm watching this post just to have a reminder to read it again. These are amazing stories. What inspiration. I'm actually a little teary now thinking that the worst does NOT have to happen. xo Karen:)
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