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EASL 2013: Probiotics May Help Manage Hepatic Encephalopathy in Patients with Cirrhosis


Probiotics that change the population of organisms in the gut can help improve neurocognitive function and prevent hepatic encephalopathy in people with liver cirrhosis, according to a presentation last month at the EASL International Liver Congress (EASL 2013) in Amsterdam.

Hepatic encephalopathy occurs when a damaged liver is no longer able to carry out its essential processing and filtering functions, allowing toxins such as ammonia -- produced by some types of gut bacteria -- to build up in the body. It is characterized by aspectrum of neuropsychiatric abnormalities including personality changes, intellectual impairment, and reduced levels of consciousness.

Manish Lunia and colleagues from G.B. Pant Hospital in Delhi conducted a study to evaluate whether probiotics -- which can alter gut flora by substituting non-urease producing organisms that decrease ammonia production -- would help prevent hepatic encephalopathy in people with cirrhosis.

The analysis included 160 participants with various stages of advanced liver disease (16% with Child-Pugh Class A, 32% with Class B, and 53% with Class C). About half had minimal hepatic encephalopathy at study entry and about 35% had small intestine bacterial overgrowth. Participants were randomly assigned to receive a probiotic preparation known as VSL#3 once-daily for 3 months or to an untreated control group.


  • After an average 9 months of follow-up, people who received probiotics showed significant improvements in arterial ammonia levels, bacterial overgrowth, and intestinal transit time.
  • In addition, patients in the probiotic group had significantly improved psychometric hepatic encephalopathy scores and performance on a critical flicker frequency test.
  • 7 people (9%) in the probiotic group developed overt hepatic encephalopathy during follow-up, compared with 14 (20%) in the control group (hazard ratio 2.1).
  • Among participants without minimal hepatic encephalopathy at study entry, the absolute risk reduction was 8% and the number needed to treat to prevent a case was 31.0.
  • Among patients with minimal hepatic encephalopathy at baseline, however, risk reduction rose to 24% and the number needed to treat fell to 5.1.
  • The probiotic preparation was generally well-tolerated with no serious adverse events.
  • Similar proportions of patients died in the probiotic and control arms (7% vs 8%, respectively).

Based on these findings, the researchers concluded, "Probiotics are effective in primary prophylaxis of hepatic encephalopathy."

"Hepatic encephalopathy is an insidious disease that's caused by an accumulation of toxins in the blood that are normally removed by the liver," EASL treasurer Mauro Bernardi explained in an EASL press release. "Treatment normally involves the use of antibiotics or laxatives to suppress the production of toxic substances in the intestine, but there is still a great deal of room for improvement, so it will be exciting to see the results of further studies to determine if clinicians have a new form of treatment on the cards." 



MK Lunia, BC Sharma, S Sachdeva, and S Srivastava. An open label randomised controlled trial of probiotics for primary prophylaxis of hepatic encephalopathy in patients with cirrhosis. 48th Annual Meeting of the European Association for the Study of the Liver (EASL 2013). Amsterdam. April 24-28, 2013. Abstract 78.

Other Source

EASL. Probiotics Found to Reduce Hepatic Encephalopathy in Cirrhotic Patients. Press release. April 25, 2013.