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The effects of probiotics and symbiotics on risk factors for hepatic encephalopathy

Viramontes H�rner, Daniela; Avery, Amanda; Stow, Ruth

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Daniela Viramontes H�rner

Ruth Stow


Alterations in the levels of intestinal microbiota, endotoxemia, and inflammation are novel areas of interest in the pathogenesis of hepatic encephalopathy (HE). Probiotics and symbiotics are a promising treatment option for HE due to possible beneficial effects in modulating gut microflora and might be better tolerated and more cost-effective than the traditional treatment with lactulose, rifaximin or L-ornithine-L-aspartate. A systematic search of the electronic databases PubMed, ISI Web of Science, EMBASE, and Cochrane Library was conducted for randomized controlled clinical trials in adult patients with cirrhosis, evaluating the effect of probiotics and symbiotics in changes on intestinal microflora, reduction of endotoxemia, inflammation, and ammonia, reversal of minimal hepatic encephalopathy (MHE), prevention of overt hepatic encephalopathy (OHE), and improvement of quality of life. Nineteen trials met the inclusion criteria. Probiotics and symbiotics increased beneficial microflora and decreased pathogenic bacteria and endotoxemia compared with placebo/no treatment, but no effect was observed on inflammation. Probiotics significantly reversed MHE [risk ratio, 1.53; 95% confidence interval (CI): 1.14, 2.05; P=0.005] and reduced OHE development (risk ratio, 0.62; 95% CI: 0.48, 0.80; P=0.0002) compared with placebo/no treatment. Symbiotics significantly decreased ammonia levels compared with placebo (15.24; 95% CI: −26.01, −4.47; P=0.006). Probiotics did not show any additional benefit on reversal of MHE and prevention of OHE development when compared with lactulose, rifaximin, and L-ornithine-L-aspartate. Only 5 trials considered tolerance with minimal side effects reported. Although further research is warranted, probiotics and symbiotics should be considered as an alternative therapy for the treatment and management of HE given the results reported in this systematic review.


Viramontes Hörner, D., Avery, A., & Stow, R. (2017). The effects of probiotics and symbiotics on risk factors for hepatic encephalopathy. Journal of Clinical Gastroenterology, 51(4), 312-323.

Journal Article Type Article
Acceptance Date Nov 28, 2016
Publication Date Apr 30, 2017
Deposit Date May 3, 2017
Publicly Available Date May 3, 2017
Journal Journal of Clinical Gastroenterology
Print ISSN 0192-0790
Electronic ISSN 1539-2031
Publisher Lippincott, Williams & Wilkins
Peer Reviewed Peer Reviewed
Volume 51
Issue 4
Pages 312-323
Keywords probiotics, symbiotics, hepatic encephalopathy, hepatic
Public URL
Publisher URL
Related Public URLs
Additional Information This is a non-final version of an article published in final form in: Viramontes Hörner, Daniela, Avery, Amanda, Stow, Ruth, The effects of probiotics and symbiotics on risk factors for hepatic encephalopathy, Journal of Clinical Gastroenterology, 51(4), p. 312-323 (April 2017)
Contract Date May 3, 2017


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