Luis Guevara

Treatment of chronic portal-systemic encephalopathy with lactose in lactase-deficient patients

A controlled cross-over clinical comparison of lactose (50 g twice a day) versus neomycin (3 g/day) plus milk of magnesia, was carried out in ten cirrhotic patients with chronic portal-systemic encephalopathy and documented lactase deficiency. Serial semiquantitative assessments were done including: mental state, asterixis, number connection test, electroencephalogram, and blood ammonia levels. No patient developed deep coma while ingesting either lactose or neomycin plus milk of magnesia. However, a significant improvement of mental state, asterixis, number connection tests, and electroencephalograms was evident during lactose therapy. Apart from mild diarrhea and bloating, no severe side effects were noticeable during lactose treatment. Based on these results, we propose lactose as a valuable alternate treatment of portal-systemic encephalopathy in lactase-deficient populations.

Lactitol, a second-generation disaccharide for treatment of chronic portal-systemic encephalopathy: a double-blind, crossover, randomized clinical trial

A double-blind crossover trial was performed to test the therapeutic usefulness and safety of lactitol, a beta-galactoside sorbitol, against lactose in 18 patients with chronic portal-systemic encephalopathy (PSE). The study included four periods: two for washout and two for lactitol and lactose administration. During washout periods, which lasted two weeks each, patients were stabilized with neomycin plus milk of magnesia. Lactitol and lactose were administered during four weeks each. Ten patients were randomly assigned to receive lactose (group A) and eight patients to receive lactitol (group B) first. PSE parameters, ie, mental state, number connection test performance, asterixis and blood ammonia levels were assessed fortnightly. Electroencephalographic tracings and stool pHs were evaluated at the end of each study period. After the first administration of lactose and lactitol, no statistically significant differences in PSE parameters were found. At the same stage, a significant stool acidification (P<0.05) was detected. It is concluded that lactitol seems to be safe and efficacious in treating patients with chronic PSE.

Role of the distal splenorenal shunt in management of variceal bleeding in Latin America.

In the early 1970s, we began to perform selective shunts on a regular basis for the treatment of portal hypertension. In a 15-year period, 177 patients (155 with liver cirrhosis) were treated with 3 kinds of selective shunts: the Warren shunt (128 patients) the end-to-end splenorenal shunt (29 patients), and the splenocaval shunt (20 patients). One hundred sixty-seven of the procedures were elective. Operative mortality was 14%, and survival for the Childs class A group was 75% at 1 year, 69% at 5 years, and 65% at 15 years. Incapacitating encephalopathy was observed in 7% of the patients, rebleeding in 6%, and shunt thrombosis in 6%. Postoperative portal vein alterations included reduced venous diameter (13%) and thrombosis (21%). Experience with the Warren shunt in schistosomiasis, a disease in which normal liver function is the rule in Latin American countries, is discussed. We believe that, when feasible, the selective shunts are the treatment of choice for portal hypertension in Latin American countries.

Survival and quality of life after selective portasystemic shunts.

Selective portasystemic shunts were performed in 55 consecutive patients; 27 underwent end-to-end selective renosplenic shunt, 18 distal splenorenal shunt and 10 splenocaval shunt. Thirty-one patients were in Childs class A, 18 were in class B and 6 in class C. Hospital mortality for the whole group was 16 percent and occurred less frequently in class A than in class B and C patients. Five year predicted survival for the whole group was 59 percent. At the same period of follow-up, class A patients had a higher survival rate than those in class B and C (83 percent versus 36 percent; p < 0.01). No striking difference in 5 year survival was evident in alcoholics and nonalcoholics (52 percent versus 61 percent). After surgery, long-term portasystemic encephalopathy and bleeding were noted in 2 of 36 survivors. For class A patients, selective portal shunts offer an adequate and relative safe method for decreasing mortality due to variceal bleeding.