Table of Contents Author Guidelines Submit a Manuscript
International Journal of Hepatology
Volume 2013 (2013), Article ID 952828, 9 pages
http://dx.doi.org/10.1155/2013/952828
Review Article

Impact of Pretransplant Hepatic Encephalopathy on Liver Posttransplantation Outcomes

Division of Transplant Director, Mary Lea Johnson Richards Organ Transplantation Center, New York University Langone Medical Center, Rivergate 3, 403 E 34th Street, New York, NY 10016, USA

Received 16 July 2013; Accepted 1 October 2013

Academic Editor: Matthias Bahr

Copyright © 2013 Lewis W. Teperman. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Linked References

  1. G. Garcia-Tsao and J. Lim, “Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program,” American Journal of Gastroenterology, vol. 104, no. 7, pp. 1802–1829, 2009. View at Publisher · View at Google Scholar · View at Scopus
  2. K. F. Murray and R. L. Carithers Jr., “AASLD practice guidelines: evaluation of the patient for liver transplantation,” Hepatology, vol. 41, no. 6, pp. 1407–1432, 2005. View at Publisher · View at Google Scholar · View at Scopus
  3. Organ Procurement and Transplantation Network, “Organ distribution—allocation of livers,” 2012, http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_8.pdf.
  4. S. Saab, A. B. Ibrahim, A. Shpaner et al., “MELD fails to measure quality of life in liver transplant candidates,” Liver Transplantation, vol. 11, no. 2, pp. 218–223, 2005. View at Publisher · View at Google Scholar · View at Scopus
  5. F. F. Poordad, “Review article: the burden of hepatic encephalopathy,” Alimentary Pharmacology and Therapeutics, vol. 25, supplement 5, pp. 3–9, 2007. View at Publisher · View at Google Scholar · View at Scopus
  6. M. Stepanova, A. Mishra, C. Venkatesan et al., “In-hospital mortality and economic burden associated with hepatic encephalopathy in the United States from 2005 to 2009,” Clinical Gastroenterology and Hepatology, vol. 10, no. 9, pp. 1034–1041, 2012. View at Publisher · View at Google Scholar
  7. P. Ferenci, A. Lockwood, K. Mullen, R. Tarter, K. Weissenborn, and A. T. Blei, “Hepatic encephalopathy—definition, nomenclature, diagnosis, and quantification: final report of the Working Party at the 11th World Congresses of Gastroenterology, Vienna, 1998,” Hepatology, vol. 35, no. 3, pp. 716–721, 2002. View at Publisher · View at Google Scholar · View at Scopus
  8. M. R. Arguedas, T. G. DeLawrence, and B. M. McGuire, “Influence of hepatic encephalopathy on health-related quality of life in patients with cirrhosis,” Digestive Diseases and Sciences, vol. 48, no. 8, pp. 1622–1626, 2003. View at Publisher · View at Google Scholar · View at Scopus
  9. G. Kircheis, A. Knoche, N. Hilger et al., “Hepatic encephalopathy and fitness to drive,” Gastroenterology, vol. 137, no. 5, pp. 1706–1715, 2009. View at Publisher · View at Google Scholar · View at Scopus
  10. J. S. Bajaj, M. Hafeezullah, Y. Zadvornova et al., “The effect of fatigue on driving skills in patients with hepatic encephalopathy,” American Journal of Gastroenterology, vol. 104, no. 4, pp. 898–905, 2009. View at Publisher · View at Google Scholar · View at Scopus
  11. J. S. Bajaj, J. B. Wade, D. P. Gibson et al., “The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers,” American Journal of Gastroenterology, vol. 106, no. 9, pp. 1646–1653, 2011. View at Publisher · View at Google Scholar · View at Scopus
  12. A. Said, J. Williams, J. Holden et al., “Model for end stage liver disease score predicts mortality across a broad spectrum of liver disease,” Journal of Hepatology, vol. 40, no. 6, pp. 897–903, 2004. View at Publisher · View at Google Scholar · View at Scopus
  13. A. Pujol, F. Graus, A. Rimola et al., “Predictive factors of in-hospital CNS complications following liver transplantation,” Neurology, vol. 44, no. 7, pp. 1226–1230, 1994. View at Google Scholar · View at Scopus
  14. S. Mechtcheriakov, I. W. Graziadei, M. Mattedi et al., “Incomplete improvement of visuo-motor deficits in patients with minimal hepatic encephalopathy after liver transplantation,” Liver Transplantation, vol. 10, no. 1, pp. 77–83, 2004. View at Publisher · View at Google Scholar · View at Scopus
  15. F. Lazeyras, L. Spahr, R. DuPasquier et al., “Persistence of mild parkinsonism 4 months after liver transplantation in patients with preoperative minimal hepatic encephalopathy: a study on neuroradiological and blood manganese changes,” Transplant International, vol. 15, no. 4, pp. 188–195, 2002. View at Publisher · View at Google Scholar · View at Scopus
  16. R. E. Tarter, J. Switala, A. Arria, J. Plail, and D. H. Van Thiel, “Subclinical hepatic encephalopathy. Comparison before and after orthotopic liver transplantation,” Transplantation, vol. 50, no. 4, pp. 632–637, 1990. View at Google Scholar · View at Scopus
  17. A. Huda, B. H. Guze, M. A. Thomas et al., “Clinical correlation of neuropsychological tests with 1H magnetic resonance spectroscopy in hepatic encephalopathy,” Psychosomatic Medicine, vol. 60, no. 5, pp. 550–556, 1998. View at Google Scholar · View at Scopus
  18. M. Guevara, M. E. Baccaro, B. Gómez-Ansón et al., “Cerebral magnetic resonance imaging reveals marked abnormalities of brain tissue density in patients with cirrhosis without overt hepatic encephalopathy,” Journal of Hepatology, vol. 55, no. 3, pp. 564–573, 2011. View at Publisher · View at Google Scholar · View at Scopus
  19. D. J. Bronster, S. Emre, P. Boccagni, P. A. Sheiner, M. E. Schwartz, and C. M. Miller, “Central nervous system complications in liver transplant recipients—incidence, timing, and long-term follow-up,” Clinical Transplantation, vol. 14, no. 1, pp. 1–7, 2000. View at Publisher · View at Google Scholar · View at Scopus
  20. R. Dhar, G. B. Young, and P. Marotta, “Perioperative neurological complications after liver transplantation are best predicted by pre-transplant hepatic encephalopathy,” Neurocritical Care, vol. 8, no. 2, pp. 253–258, 2008. View at Publisher · View at Google Scholar · View at Scopus
  21. E. U. Sotil, J. Gottstein, E. Ayala, C. Randolph, and A. T. Blei, “Impact of preoperative overt hepatic encephalopathy on neurocognitive function after Liver transplantion,” Liver Transplantation, vol. 15, no. 2, pp. 184–192, 2009. View at Publisher · View at Google Scholar · View at Scopus
  22. J. S. Bajaj, C. M. Schubert, D. M. Heuman et al., “Persistence of cognitive impairment after resolution of overt hepatic encephalopathy,” Gastroenterology, vol. 138, no. 7, pp. 2332–2340, 2010. View at Publisher · View at Google Scholar · View at Scopus
  23. S. Prasad, R. K. Dhiman, A. Duseja, Y. K. Chawla, A. Sharma, and R. Agarwal, “Lactulose improves cognitive functions and health-related quality of life in patients with cirrhosis who have minimal hepatic encephalopathy,” Hepatology, vol. 45, no. 3, pp. 549–559, 2007. View at Publisher · View at Google Scholar · View at Scopus
  24. H. Schomerus and W. Hamster, “Quality of life in cirrhotics with minimal hepatic encephalopathy,” Metabolic Brain Disease, vol. 16, no. 1-2, pp. 37–41, 2001. View at Publisher · View at Google Scholar · View at Scopus
  25. M. Groeneweg, J. C. Quero, I. De Bruijn et al., “Subclinical hepatic encephalopathy impairs daily functioning,” Hepatology, vol. 28, no. 1, pp. 45–49, 1998. View at Publisher · View at Google Scholar · View at Scopus
  26. M. Guevara, M. E. Baccaro, A. Torre et al., “Hyponatremia is a risk factor of hepatic encephalopathy in patients with cirrhosis: a prospective study with time-dependent analysis,” American Journal of Gastroenterology, vol. 104, no. 6, pp. 1382–1389, 2009. View at Publisher · View at Google Scholar · View at Scopus
  27. M. J. McPhail, J. S. Bajaj, H. C. Thomas, and S. D. Taylor-Robinson, “Pathogenesis and diagnosis of hepatic encephalopathy,” Expert Review of Gastroenterology and Hepatology, vol. 4, no. 3, pp. 365–378, 2010. View at Publisher · View at Google Scholar · View at Scopus
  28. R. F. Butterworth, “Pathophysiology of hepatic encephalopathy: a new look at ammonia,” Metabolic Brain Disease, vol. 17, no. 4, pp. 221–227, 2002. View at Publisher · View at Google Scholar · View at Scopus
  29. S. M. Riordan and R. Williams, “Treatment of hepatic encephalopathy,” New England Journal of Medicine, vol. 337, no. 7, pp. 473–479, 1997. View at Publisher · View at Google Scholar · View at Scopus
  30. G. Ardizzone, A. Arrigo, M. M. Schellino et al., “Neurological complications of liver cirrhosis and orthotopic liver transplant,” Transplantation Proceedings, vol. 38, no. 3, pp. 789–792, 2006. View at Publisher · View at Google Scholar · View at Scopus
  31. F. H. Saner, J. Gensicke, S. W. M. O. Damink et al., “Neurologic complications in adult living donor liver transplant patients: an underestimated factor?” Journal of Neurology, vol. 257, no. 2, pp. 253–258, 2010. View at Publisher · View at Google Scholar · View at Scopus
  32. R. Moreno and M. Berenguer, “Post-liver transplantation medical complications,” Annals of Hepatology, vol. 5, no. 2, pp. 77–85, 2006. View at Google Scholar · View at Scopus
  33. R. Blanco, U. De Girolami, R. L. Jenkins, and U. Khettry, “Neuropathology of liver transplantation,” Clinical Neuropathology, vol. 14, no. 2, pp. 109–117, 1995. View at Google Scholar · View at Scopus
  34. A. J. Martinez, C. Estol, and A. A. Faris, “Neurologic complications of liver transplantation,” Neurologic Clinics, vol. 6, no. 2, pp. 327–348, 1988. View at Google Scholar · View at Scopus
  35. N. Ghaus, S. Bohlega, and M. Rezeig, “Neurological complications in liver transplantation,” Journal of Neurology, vol. 248, no. 12, pp. 1042–1048, 2001. View at Publisher · View at Google Scholar · View at Scopus
  36. F. Saner, Y. Gu, S. Minouchehr et al., “Neurological complications after cadaveric and living donor liver transplantation,” Journal of Neurology, vol. 253, no. 5, pp. 612–617, 2006. View at Publisher · View at Google Scholar · View at Scopus
  37. M. Guarino, A. Stracciari, P. Pazzaglia et al., “Neurological complications of liver transplantation,” Journal of Neurology, vol. 243, no. 2, pp. 137–142, 1996. View at Publisher · View at Google Scholar · View at Scopus
  38. O. Riggio, L. Ridola, C. Pasquale et al., “Evidence of persistent cognitive impairment after resolution of overt hepatic encephalopathy,” Clinical Gastroenterology and Hepatology, vol. 9, no. 2, pp. 181–183, 2011. View at Publisher · View at Google Scholar · View at Scopus
  39. K. Mattarozzi, A. Stracciari, L. Vignatelli, R. D'Alessandro, M. C. Morelli, and M. Guarino, “Minimal hepatic encephalopathy: longitudinal effects of liver transplantation,” Archives of Neurology, vol. 61, no. 2, pp. 242–247, 2004. View at Publisher · View at Google Scholar · View at Scopus
  40. D. K. Atluri, M. Asgeri, and K. D. Mullen, “Reversibility of hepatic encephalopathy after liver transplantation,” Metabolic Brain Disease, vol. 25, no. 1, pp. 111–113, 2010. View at Publisher · View at Google Scholar · View at Scopus
  41. T. Naegele, W. Grodd, R. Viebahn et al., “MR imaging and 1H spectroscopy of brain metabolites in hepatic encephalopathy: time-course of renormalization after liver transplantation,” Radiology, vol. 216, no. 3, pp. 683–691, 2000. View at Google Scholar · View at Scopus
  42. R. Garcia-Martinez, A. Rovira, J. Alonso et al., “Hepatic encephalopathy is associated with posttransplant cognitive function and brain volume,” Liver Transplantation, vol. 17, no. 1, pp. 38–46, 2011. View at Publisher · View at Google Scholar · View at Scopus
  43. B. Als-Nielsen, L. L. Gluud, and C. Gluud, “Non-absorbable disaccharides for hepatic encephalopathy: systematic review of randomised trials,” British Medical Journal, vol. 328, no. 7447, pp. 1046–1050, 2004. View at Google Scholar · View at Scopus
  44. S. Shukla, A. Shukla, S. Mehboob, and S. Guha, “Meta-analysis: the effects of gut flora modulation using prebiotics, probiotics and synbiotics on minimal hepatic encephalopathy,” Alimentary Pharmacology and Therapeutics, vol. 33, no. 6, pp. 662–671, 2011. View at Publisher · View at Google Scholar · View at Scopus
  45. M. Luo, L. Li, C. Lu, and W. Cao, “Clinical efficacy and safety of lactulose for minimal hepatic encephalopathy: a meta-analysis,” European Journal of Gastroenterology and Hepatology, vol. 23, no. 12, pp. 1250–1257, 2011. View at Publisher · View at Google Scholar · View at Scopus
  46. P. Sharma, B. C. Sharma, A. Agrawal et al., “Primary prophylaxis of overt hepatic encephalopathy in patients with cirrhosis: an open labeled randomized controlled trial of lactulose versus no lactulose,” Journal of Gastroenterology and Hepatology, vol. 27, no. 8, pp. 1329–1335, 2012. View at Publisher · View at Google Scholar
  47. Q. Jiang, X. H. Jiang, M. H. Zheng, L. Jiang, Y. Chen, and L. Wang, “Rifaximin versus nonabsorbable disaccharides in the management of hepatic encephalopathy: a meta-analysis,” European Journal of Gastroenterology and Hepatology, vol. 20, no. 11, pp. 1064–1070, 2008. View at Publisher · View at Google Scholar · View at Scopus
  48. O. Riggio, G. Balducci, F. Ariosto et al., “Lactitol in prevention of recurrent episodes of hepatic encephalopathy in cirrhotic patients with portal-systemic shunt,” Digestive Diseases and Sciences, vol. 34, no. 6, pp. 823–829, 1989. View at Google Scholar · View at Scopus
  49. B. C. Sharma, P. Sharma, A. Agrawal, and S. K. Sarin, “Secondary prophylaxis of hepatic encephalopathy: an open-label randomized controlled trial of lactulose versus placebo,” Gastroenterology, vol. 137, no. 3, pp. 885–891, 2009. View at Publisher · View at Google Scholar · View at Scopus
  50. D. Heredia, J. Teres, N. Orteu, and J. Rodes, “Lactitol vs. lactulose in the treatment of chronic recurrent portal-systemic encephalopathy,” Journal of Hepatology, vol. 7, no. 1, pp. 106–110, 1988. View at Google Scholar · View at Scopus
  51. A. Agrawal, B. C. Sharma, P. Sharma et al., “Secondary prophylaxis of hepatic encephalopathy in cirrhosis: an open-label, randomized controlled trial of lactulose, probiotics, and no therapy,” The American Journal of Gastroenterology, vol. 107, no. 7, pp. 1043–1050, 2012. View at Publisher · View at Google Scholar
  52. Lactulose (Lactulose Solution) [Package Insert], Apotex Inc., Ontario, Canada, 2005.
  53. A. Watanabe, T. Sakai, S. Sato et al., “Clinical efficacy of lactulose in cirrhotic patients with and without subclinical hepatic encephalopathy,” Hepatology, vol. 26, no. 6, pp. 1410–1414, 1997. View at Google Scholar · View at Scopus
  54. J. Polson and W. M. Lee, “AASLD position paper: the management of acute liver failure,” Hepatology, vol. 41, no. 5, pp. 1179–1197, 2005. View at Publisher · View at Google Scholar · View at Scopus
  55. L. W. Teperman and V. P. Peyregne, “Considerations on the impact of hepatic encephalopathy treatments in the pretransplant setting,” Transplantation, vol. 89, no. 7, pp. 771–778, 2010. View at Publisher · View at Google Scholar · View at Scopus
  56. B. W. Shaw Jr., R. P. Wood, R. D. Gordon, S. Iwatsuki, W. P. Gillquist, and T. E. Starzl, “Influence of selected patient variables and operative blood loss on six-month survival following liver transplantation,” Seminars in Liver Disease, vol. 5, no. 4, pp. 385–393, 1985. View at Google Scholar · View at Scopus
  57. M. Merli, M. Giusto, F. Gentili et al., “Nutritional status: its influence on the outcome of patients undergoing liver transplantation,” Liver International, vol. 30, no. 2, pp. 208–214, 2010. View at Publisher · View at Google Scholar · View at Scopus
  58. S. A. McCluskey, K. Karkouti, D. N. Wijeysundera et al., “Derivation of a risk index for the prediction of massive blood transfusion in liver transplantation,” Liver Transplantation, vol. 12, no. 11, pp. 1584–1593, 2006. View at Publisher · View at Google Scholar · View at Scopus
  59. G. Fusai, P. Dhaliwal, N. Rolando et al., “Incidence and risk factors for the development of prolonged and severe intrahepatic cholestasis after liver transplantation,” Liver Transplantation, vol. 12, no. 11, pp. 1626–1633, 2006. View at Publisher · View at Google Scholar · View at Scopus
  60. G. N. Ioannou, “Development and validation of a model predicting graft survival after liver transplantation,” Liver Transplantation, vol. 12, no. 11, pp. 1594–1606, 2006. View at Publisher · View at Google Scholar · View at Scopus
  61. S. W. Biggins, H. J. Rodriguez, P. Bacchetti, N. M. Bass, J. P. Roberts, and N. A. Terrault, “Serum sodium predicts mortality in patients listed for liver transplantation,” Hepatology, vol. 41, no. 1, pp. 32–39, 2005. View at Publisher · View at Google Scholar · View at Scopus
  62. H. Selcuk, I. Uruc, M. A. Temel et al., “Factors prognostic of survival in patients awaiting liver transplantation for end-stage liver disease,” Digestive Diseases and Sciences, vol. 52, no. 11, pp. 3217–3223, 2007. View at Publisher · View at Google Scholar · View at Scopus
  63. A. J. Sanchez and J. Aranda-Michel, “Nutrition for the liver transplant patient,” Liver Transplantation, vol. 12, no. 9, pp. 1310–1316, 2006. View at Publisher · View at Google Scholar · View at Scopus
  64. M. Merli, M. Caschera, C. Piat, G. Pinto, M. Diofebi, and O. Riggio, “The effect of lactulose and lactitol administration on fecal fat excretion in patients with liver cirrhosis,” Journal of Clinical Gastroenterology, vol. 15, no. 2, pp. 125–127, 1992. View at Google Scholar · View at Scopus
  65. K. R. Lawrence and J. A. Klee, “Rifaximin for the treatment of hepatic encephalopathy,” Pharmacotherapy, vol. 28, no. 8, pp. 1019–1032, 2008. View at Publisher · View at Google Scholar · View at Scopus
  66. S. S. Sidhu, O. Goyal, B. P. Mishra, A. Sood, R. S. Chhina, and R. K. Soni, “Rifaximin improves psychometric performance and health-related quality of life in patients with minimal hepatic encephalopathy (the RIME trial),” American Journal of Gastroenterology, vol. 106, no. 2, pp. 307–316, 2011. View at Publisher · View at Google Scholar · View at Scopus
  67. J. S. Bajaj, D. M. Heuman, J. B. Wade et al., “Rifaximin improves driving simulator performance in a randomized trial of patients with minimal hepatic encephalopathy,” Gastroenterology, vol. 140, no. 2, pp. 478–487, 2011. View at Publisher · View at Google Scholar · View at Scopus
  68. R. Testa, C. Eftimiadi, and G. S. Sukkar, “A non-absorbable rifamycin for treatment of hepatic encephalopathy,” Drugs under Experimental and Clinical Research, vol. 11, no. 6, pp. 387–392, 1985. View at Google Scholar · View at Scopus
  69. “FDA approves new use of Xifaxan for patients with liver disease,” 2010, http://www.drugs.com/newdrugs/fda-approves-new-xifaxan-patients-liver-2078.html.
  70. N. M. Bass, K. D. Mullen, A. Sanyal et al., “Rifaximin treatment in hepatic encephalopathy,” New England Journal of Medicine, vol. 362, no. 12, pp. 1071–1081, 2010. View at Publisher · View at Google Scholar · View at Scopus
  71. A. Sanyal, Z. M. Younossi, N. M. Bass et al., “Randomised clinical trial: rifaximin improves health-related quality of life in cirrhotic patients with hepatic encephalopathy-a double-blind placebo-controlled study,” Alimentary Pharmacology and Therapeutics, vol. 34, no. 8, pp. 853–861, 2011. View at Publisher · View at Google Scholar · View at Scopus
  72. H. Y. Sun, M. Wagener, T. V. Cacciarelli, and N. Singh, “Impact of rifaximin use for hepatic encephalopathy on the risk of early post-transplant infections in liver transplant recipients,” Clinical Transplantation, vol. 26, no. 6, pp. 849–852, 2012. View at Publisher · View at Google Scholar · View at Scopus
  73. E. Strauss, R. Tramote, E. P. S. Silva et al., “Double-blind randomized clinical trial comparing neomycin and placebo in the treatment of exogenous hepatic encephalopathy,” Hepato-Gastroenterology, vol. 39, no. 6, pp. 542–545, 1992. View at Google Scholar · View at Scopus
  74. H. O. Conn, C. M. Leevy, and Z. R. Vlahcevic, “Comparison of lactulose and neomycin in the treatment of chronic portal systemic encephalopathy. A double blind controlled trial,” Gastroenterology, vol. 72, no. 4, pp. 573–583, 1977. View at Google Scholar · View at Scopus
  75. C. E. Atterbury, W. C. Maddrey, and H. O. Conn, “Neomycin-sorbitol and lactulose in the treatment of acute portal-systemic encephalopathy. A controlled, double-blind clinical trial,” American Journal of Digestive Diseases, vol. 23, no. 5, pp. 398–406, 1978. View at Google Scholar · View at Scopus
  76. F. Orlandi, U. Freddara, and M. T. Candelaresi, “Comparison between neomycin and lactulose in 173 patients with hepatic encephalopathy. A randomized clinical study,” Digestive Diseases and Sciences, vol. 26, no. 6, pp. 498–506, 1981. View at Google Scholar · View at Scopus
  77. D. Festi, G. Mazzella, M. Orsini et al., “Rifaximin in the treatment of chronic hepatic encephalopathy; resultes of a multicenter study of efficacy and safety,” Current Therapeutic Research, vol. 54, no. 5, pp. 598–609, 1993. View at Publisher · View at Google Scholar · View at Scopus
  78. F. Miglio, D. Valpiani, S. R. Rossellini, A. Ferrieri, and N. Canova, “Rifaximin, a non-absorbable rifamycin, for the treatment of hepatic encephalopathy. A double-blind, randomised trial,” Current Medical Research and Opinion, vol. 13, no. 10, pp. 593–601, 1997. View at Google Scholar · View at Scopus
  79. M. H. Morgan, A. E. Read, and D. C. E. Speller, “Treatment of hepatic encephalopathy with metronidazole,” Gut, vol. 23, no. 1, pp. 1–7, 1982. View at Google Scholar · View at Scopus
  80. A. T. Blei and J. Córdoba, “Hepatic encephalopathy,” American Journal of Gastroenterology, vol. 96, no. 7, pp. 1968–1976, 2001. View at Publisher · View at Google Scholar · View at Scopus
  81. S. H. Cohen, D. N. Gerding, S. Johnson et al., “Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA),” Infection Control and Hospital Epidemiology, vol. 31, no. 5, pp. 431–455, 2010. View at Publisher · View at Google Scholar · View at Scopus
  82. K. M. Eltawil, M. Laryea, K. Peltekian, and M. Molinari, “Rifaximin vs conventional oral therapy for hepatic encephalopathy: a meta-analysis,” World Journal of Gastroenterology, vol. 18, no. 8, pp. 767–777, 2012. View at Publisher · View at Google Scholar · View at Scopus