2001 INFO: Natl Guidelines - Practice Parameters Am College Gastroenterology - Heptic Encephalopathy - ....... Nutritional Management

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1. Nutritional Management Patients with HE should avoid prolonged periods of dietary protein restriction and receive the maximum tolerable protein intake, aiming at 1.2 g of protein/kg/day (range 1–1.5). BACKGROUND. Restriction of dietary protein at the time of acute encephalopathy with subsequent increments to assess clinical tolerance is a classic cornerstone of therapy. Protracted nitrogen restriction may contribute to malnutrition and aggravate the prognosis (25). On the other hand, a positive nitrogen balance will have positive effects on encephalopathy by promoting hepatic regeneration and increasing the capacity of muscle to detoxify ammonia. Thus, nutritional management includes intrinsic effects of dietary components as well as long term effects on organs whose dysfunctions contribute to the pathogenesis of HE. The increased catabolic rate of cirrhosis leads to a recommendation of 1–1.5 g protein/kg/day (26). Provision of an adequate nitrogen intake is difficult. Vegetable and dairy sources are preferable to animal protein (27), as they provide a higher calorie to nitrogen ratio and, in the case of vegetable protein,

provide nonabsorbable fiber, a substrate for colonic bacteria and subsequent colonic acidification. Zinc, a cofactor of urea cycle enzymes, may be deficient in cirrhotic patients, especially if associated with malnutrition. Zinc supplementation improves the activity of the urea cycle in experimental models of cirrhosis (28). One trial has evaluated the effects of zinc over a short period (up to a week), without major improvement (29). A positive study administered zinc for 3 months, though the study was not randomized (30). Zinc deficiency precipitated encephalopathy in a well-described patient (31). Patients with zinc deficiency should receive oral zinc supplements. IMPLEMENTATION Acute encephalopathy. Protein feeding can be withdrawn for the first day. Short term (4 days) enteral nutrition has not been shown to benefit hospitalized cirrhotic patients (32). Chronic management. An increase in protein tolerance can be achieved by increasing protein intake in combination with other therapeutic measures, such as nonabsorbable disaccharides. Substitution of animal protein with vegetable and/or dairy protein should be reviewed, a process facilitated by a consultation with a nutritional expert. Oral formulation of branched chain amino acids may provide a better tolerated source of protein in patients with chronic encephalopathy and dietary protein intolerance (33). Zinc acetate can be administered as 220 mg b.i.d. It may reduce the absorption of other divalent cations (e.g., copper). National Guidelines Practice Parameters Committee of the American College of GastroenterologyHepatic encephalopathy http://www.clevelandclinicmeded.com/diseasemanagement/gastro/henceph/henceph.htm