•Alternative drugs are midodrine, octreotide, and norepinephrine; the doses are as follows:

–2.5–7 mg midodrine should be given orally three times daily, increasing to 12.5 mg three times daily if needed.

–100 mg octreotide should be given subcutaneously or intravenously three times daily, increasing to 200 mg three times daily if required.

–Norepinephrine titrated to 0.5–3 mcg/kg/min should be given as a continuous intravenous infusion.

–Contraindications include coronary artery disease, peripheral vascular disease, and/or cerebrovascular disease because of the potential risk of ischemic events.

•Concomitant intravenous albumin infusion (1 g/kg body weight on the first day, followed by 20–40 g per day) is recommended.

•The duration of therapy should be approximately 7–14 days.

Suggested Reading

1.Moriwaki H, Shiraki M, Iwasa J, Terakura Y. Hepatic encephalopathy as a complication of liver cirrhosis. An Asian perspective. J Gastroenterol Hepatol. 2010;25:658–63.

This study concluded hepatic encephalopathy remains a serious complication of liver cirrhosis. Establishment of truly effective prevention modalities and broader application of liver transplantation will help rescue patients suffering from this complication of liver cirrhosis in the near future.

2.Runyon B. Management of adult patients with ascites due to cirrhosis. An Update. Hepatology. 2009;49:2087–107.

European Association for the Study of the Liver (EASL) clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome

3.Gines P, Schrier R. Renal failure in cirrhosis. N Engl J Med. 2009;361:1279–90.

4.Ferenci P, Lockwood A, Mullen K, Tarter R, et al. Hepatic encephalopathy definition, nomenclature, diagnosis and quantification final report of the working party at the 11th World Congress of Gastroenterology, Vienna, 1998. Hepatology. 2002;35:716–21.

The working party has suggested a modification of current nomenclature for clinical diagnosis of hepatic encephalopathy, proposed guidelines for the performance of future clinical trials in hepatic encephalopathy, and felt the need for a large study to redefine neuropsychiatric abnormalities in liver disease.

Websites

1.www.aasld.org

2.www.easl.org

3.www.cco.org