Papers
                      Dietary management of hepatic encephalopathy in
                      cirrhotic patients: survey of current practice in                                                                                                                          BMJ: first published as 10.1136/bmj.318.7195.1391 on 22 May 1999. Downloaded from 
                      United Kingdom
                      Clare T Soulsby, Marsha Y Morgan
                      In the early 1950s it was shown that some patients with             Dietary management of 1046 cirrhotic patients with hepatic           Editorial
                      cirrhosis given “nitrogenous substances,” including                                                                                      by Seymour
                      excess dietary protein, developed hepatic “precoma.” 1              encephalopathy. Values are numbers (percentages) of patients         Departmentof
                      These largely uncontrolled observations led to the                                                                       Dietitians’     Nutrition and
                                                                                          Dietary protein intake (g/day)      Diet instituted  preference      Dietetics, Royal Free
                      introduction of dietary protein restriction to treat                Unrestricted                          287 (27)        440 (42)       Hospital, London
                      hepatic encephalopathy.                                                                                                                  NW32QG
                          Recent research has shown, however, that protein                Moderately restricted (30-50)         419 (40)        499 (48)       Clare T Soulsby,
                                                                                          Seriously restricted (<30)            340 (33)        107 (10)       senior dietitian
                                                                          2
                      requirementsareincreasedinthesepatients, thathigh                                                                                        University
                      protein diets are well tolerated, and that their use, par-                                                                               Departmentof
                      ticularly   in   patients    who are malnourished, is               these patients received appropriate additional nutri-                Medicine,Royal
                      associated with sustained improvement in mental                                                                                          Free Hospital and
                      state.34 In     response, the European Society for                  tional support.                                                      School of Medicine,
                                                                                                                                                               LondonNW32QG
                      Parenteral and Enteral Nutrition has recommended                                                                                         MarshaYMorgan,
                      that traditional protein restriction should be aban-                                                                                     senior lecturer in
                      doned in patients with hepatic encephalopathy                       Comment                                                              medicine
                                                                                     5                                                                         Correspondence to:
                      particularly as other effective treatments are available.           This survey shows that despite clear recommendations                 DrMorgan
                      Weundertookthissurveytoreviewthecurrentdietary                                        5
                                                                                          to the contrary, most patients in the United Kingdom
                      managementofthesepatients in hospitals throughout                   with cirrhosis and hepatic encephalopathy have their                 BMJ 1999;318:1391
                      the United Kingdom.                                                 protein intake restricted, often for prolonged periods.
                                                                                          Protein restriction is also widespread in patients
                                                                                          thought to be at risk of developing hepatic encepha-
                      Methods and results                                                 lopathy, which has no justification. Many of these
                      Wedevised and piloted a questionnaire and then sent                 patients are anorexic and find the diets unpalatable
                      it to the 110 UK dietetic departments approved by the               andhenceunacceptable,yet few are given appropriate
                      British   Dietetic    Association for training student              nutritional support. In general, dietitians are less in
                                                                                          favour of restricting protein intake than the referring
                      dietitians. Information was requested on the referral,              doctors, but either their views are not expressed or                                                   http://www.bmj.com/
                      clinical assessment, and dietary management of all                  their advice is not heeded.
                      inpatients with cirrhosis and hepatic encephalopathy                     The widespread inappropriate dietary manage-
                      seen in the past 12 months. The questionnaires were                 mentofcirrhoticpatientswithhepaticencephalopathy
                      returned anonymously. Closed questions were ana-                    is likely to adversely affect outcome.Both dietitians and
                      lysed with descriptive statistics and open questions by             medical practitioners need to be made aware of recent
                      content analysis.                                                                5
                          Seventy one (65%) questionnaires were returned;                 guidelines, to change current practice, and to work
                                                                                          together effectively.
                      64 departments with relevant experience provided                                                                                                                            on 4 January 2023 by guest. Protected by copyright.
                      details of the dietary management of 1046 patients.                 We thank the participating dietitians for completing the
                      Overall, 759 (73%) patients had had their protein                   questionnaires.
                      intake restricted to some degree (table). In most of                    Contributors: CTS initiated the study, designed the original
                      these patients the diets were imposed for prolonged                 questionnaire, undertook the field work, analysed the data,
                      periods because treatment end points were not                       assisted in writing the paper, and secured the funding. MYM
                                                                                          refined the design of the study and the questionnaire,
                      specified    or poorly defined. Over half of the                    participated in the data analysis, wrote the paper, and is the
                      responding departments reported requests to restrict                guarantor.
                      protein prophylactically in cirrhotic patients who were                 Funding:ThestudywaspartlyfundedbytheBritishDietetic
                      neuropsychiatrically unimpaired.                                    Association.
                                                                                              Conflict of interest: None.
                          Overall, 261 (25%) patients were referred with a
                      prescriptive request to restrict protein intake; the                1  Phillips GB, Schwartz R, Gabuzda GJ Jr, Davidson CS. The syndrome of
                      remaining 758 were referred with a request for dietary                 impending hepatic coma in patients with cirrhosis of the liver given cer-
                      advice that allowed leeway for discussion.Nevertheless,                tain nitrogenous substances. N Engl J Med 1952;247:239-6.
                      the dietitians still felt that 153 (14%) patients had               2  NielsenK,KondrupJ,MartinsenL,DøssingH,LarssonB,StillingB,etal.
                                                                                             Long-term oral refeeding of patients with cirrhosis of the liver. BrJNutr
                      had their protein intake restricted inappropriately                    1995;74:557-67.
                      (table).                                                            3  Kearns PJ, Young H, Garcia G, Blaschke T, O’Hanlon G, Rinki M, et al.
                                                                                             Acceleratedimprovementofalcoholicliverdiseasewithenteralnutrition.
                          Difficulties were experienced in maintaining oral                  Gastroenterology 1992;102:200-5.
                      intake in many of these patients; 58 (91%) of the                   4  Morgan TR, Moritz TE, Mendenhall CL, Haas R, and VA Cooperative
                                                                                             StudyGroup#275.Proteinconsumptionandhepaticencephalopathyin
                      responding departments reported substantial prob-                      alcoholic hepatitis. J Am Coll Nutr 1995;14:152-8.
                      lems because of anorexia, 17 (27%) because patients                 5  Plauth M,Merli M,Kondrup J,Weimann A,Ferenci P,Müller MJ,ESPEN
                                                                                             Consensus Group. ESPEN guidelines for nutrition in liver disease and
                      were drowsy or confused, and 12 (19%) because the                      transplantation. Clin Nutr 1997;16:43-55.
                      diets were unpalatable. Nevertheless, less than 25% of                 (Accepted 27 August 1998)
                      BMJ VOLUME318 22MAY1999 www.bmj.com                                                                                                                   1391