Multistrain probiotic and lactulose in the treatment of minimal hepatic encephalopathy

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. materials and 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. conclusion: 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.