الفهرس 
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Abstract
Hepatic encephalopathy (HE) is a brain dysfunction caused by liver insufficiency and/or Porto systemic shunts; it manifests as a wide spectrum of neurological or psychiatric abnormalities ranging from subclinical alterations to coma (Ferenci et al., 2002; Cordoba,2011).
HE is an important event in the natural progression of end-stage liver disease; it exerts a negative effect on quality of life for patients and their caregivers and increases hospitalization rates with a considerable economic impact (La devaia et al., 2011). It is seen in up to 30-45% of patients with cirrhosis and its latent or subclinical form (minimal hepatic encephalopathy) can affect up to 60%of patients with liver disease (Poordad, 2007).
Although controversy about the exact pathogenic mechanism exists, certain factors like hyper ammonia and increased blood-brain permeability to ammonia, increased brain concentration of manganese and inhibitory neurosteroids have been documented (Yergara-Gomez et al., 2006).
The most important aspect of HE management is prompt recognition and treatment of the precipitating factors (Al Sibae and Mcguire, 2009). Management of HE primarily involves avoidance of precipitating factors, limitation of dietary protein intake and administration of ammonia-lowering therapies such as non absorbable disaccharides and antimicrobial agents (Phongsamaran et al., 2010).
The prevention of production and absorption of gut-derived neurotoxins along with reduction in endotoxemia and inflammation underlie the rationale for antibiotic use in HE. Prominent antibiotics used in the treatment of HE are neomycin, metronidazole, vancomycin and rifaximin; however, extensive side-effect profiles and the potential for bacterial antimicrobial resistance have limited the utility of most of these antibiotics in treating HE apart from rifaximin (Patidar and Bajaj, 2013).
Aim of the work:
Comparison between the efficacy of metronidazole versus rifaximine in the management of overt hepatic encephalopathy.
Patients and methods:
Our study included 100 patients diagnosed to have liver cirrhosis, admitted to Tropical Medicine and Gastroenterology Department in Sohag University Hospital due to an acute episode of HE. We assessed patients clinically at time of admission before starting treatment and every other day for seven days.
The patients were divided into two groups:
-1st group: group M: includes 50 patients received oral metronidazole (in a dose of 1000 mg / daily) in addition to lactulose, L-ornithine L-aspartate, magnesium sulfate enema.
-2nd group: group R: includes includes 50 patients received oral rifaximin (in a dose of 1100 mg / daily) in addition to lactulose, L-ornithine L-aspartate, magnesium sulfate enema.
In our study, there was no significant difference in the clinical outcome of patients who received metronidazole compared to those who received rifaximin where 30 (60%) patients versus 33 (66%) patients respectively have been improved and survived without significant difference.
Our results showed that the prevalence of HE was more in males than females which may be due to high prevalence of HCV infection among males. The most common associated co-morbidity was diabetes mellitus (33%) followed by hypertension (16%). The most common precipitating factors were diuretics (54%), heamatemesis (29%), constipation (23%), chest infection (21%), SBP (14%), melena (10%) and UTI (4%).
However, in the present study all patients received oral non absorbable disaccharides, LOLA, magnesium sulfate enema in addition to metronidazole or rifaximin therefore improvement in conscious level can not be correlated to metronidazole or rifaximin alone and our results can be explained by the add on effect of both drugs in treatment of HE.
Conclusion:
Metronidazole is as effective as rifaximine in the management of patients with acute episode of OHE and the outcome in the 7 days study period between both groups was statistically insignificant (P =< 0.8).
Recommendations:
We recommend performing further large scale, double blinded, randomized control trial between rifaximin and metronidazole as a monotherapy for management of hepatic encephalopathy to assess their efficacy alone, also, to assess the side effects and cost-effectiveness of both drugs.