title: Multistrain probiotic and lactulose in the treatment of minimal hepatic encephalopathy.
abstract: BACKGROUND
  Some evidence has shown benefits of probiotics in the management of minimal hepatic encephalopathy (MHE). We evaluated the efficacy of a multistrain probiotic compound, alone and in combination with lactulose, in the treatment of MHE.
  
  
  METHODS
  This study has two parts. First, consecutive adult patients with MHE were randomized to receive lactulose (30-60 mL/day) + probiotic (200 million colony forming units of seven bacteria species/day) (Gp-LPr) or lactulose + placebo (Gp-L). In second part, a non-randomized group of patients received probiotic alone (Gp-Pr). Medication duration was for 2 weeks and patients were followed-up for another 8 weeks. Improvement in MHE status was assessed by psychometric hepatic encephalopathy score (PHES). Development of overt encephalopathy, hospitalization, and death were considered as secondary outcomes.
  
  
  RESULTS
  Sixty patients (80% male, mean age 38.4 ± 9.6 years) completed the intervention. PHES significantly improved after medication in all the three groups (Gp-LPr: -3.8 ± 3.9 to -1.6 ± 3.0; Gp-L: -4.8 ± 4.1 to -1.6 ± 2.9; and Gp-Pr: -4.9 ± 3.7 to -2.1 ± 2.5, P < 0.001). After 8 weeks follow-up, improvement was maintained in Gp-LPr and Gp-Pr, but there was deterioration in those who did not receive probiotics (Gp-L: PHES score reversed to -4.8 ± 4.2). Two patients (one each in Gp-L and Gp-Pr) experienced overt encephalopathy. One patient was hospitalized due to worsening of ascites (Gp-LPr) and one due to spontaneous bacterial peritonitis (Gp-L). Side effects were mild and not significantly different among the groups.
  
  
  CONCLUSIONS
  Lactulose and probiotics are effective for the treatment of MHE; however, probiotics, but not lactulose, have long-term effects. More studies are required before suggesting probiotics for the standard treatment of MHE.
authors.affiliation: Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Shavakhi
authors.affiliation: Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Huriyeh
authors.initials: H
authors.lastname: Hashemi
authors.affiliation: Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Elham
authors.initials: E
authors.lastname: Tabesh
authors.affiliation: Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Zhaleh
authors.initials: Z
authors.lastname: Derakhshan
authors.affiliation: Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Somaye
authors.initials: S
authors.lastname: Farzamnia
authors.affiliation: Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Shirin
authors.initials: S
authors.lastname: Meshkinfar
authors.affiliation: Medical Students' Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Sara
authors.initials: S
authors.lastname: Shavakhi
authors.affiliation: Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Minakari
authors.affiliation: Medical Students' Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Ali
authors.initials: A
authors.lastname: Gholamrezaei
keywords: Hepatic encephalopathy; lactulose; prebiotics; probiotics; synbiotics