In contrast, rifaximin has not been shown to have a significant side-effect profile,16 certainly when compared to other previously utilized antibiotics, although long-term data are not yet available. Some of the adverse effects of lactulose can be minimized with the use of lactitol (an analog of lactulose);17 however, this is not available worldwide. Overtreatment of lactulose can lead to the more serious side-effects of marked dehydration, hyponatremia, and worsening of hepatic encephalopathy.5 The dosing regime of rifaximin can check details be either fixed daily or cyclical,15 whereas lactulose does rely on some degree of patient adjustment to ensure approximately two to three semiformed

stools daily. Costing considerations are

not straightforward. While the direct cost of rifaximin compared to lactulose is marked, approximately $US1120 as opposed to $150 per month in the USA,15 the total annual costing of rifaximin has been reported to be less than lactulose when hospital admissions are taken into account.18 The role of rifaximin in the prevention or treatment of hepatic encephalopathy following an acute variceal bleed remains to be elucidated. Even if no further conclusive studies confirming the beneficial effect of lactulose occur, it is difficult to conceive of it being substituted as first-line therapy for hepatic encephalopathy. Its routine prophylactic use in the setting of an acute variceal bleed LY2157299 (post-initial stabilization and endoscopic

control of bleeding) seems intuitive. Perhaps prophylactic lactulose therapy should be considered for incorporation into acute variceal bleed practice guidelines as the “standard of care. “
“Hereditary hemochromatosis (HH) is an autosomal recessive disease caused by mutations in the HFE gene leading to increased iron absorption and deposition of iron in various organs, including the liver. It is the most common hereditary disorder in White people with a prevalence as high as one in 140 although phenotypic expression is much less common. It typically presents as asymptomatic elevation in iron studies IMP dehydrogenase but can present with abnormal liver enzymes and hepatomegaly. Arthralgias, loss of libido, diabetes and heart failure can occur due to iron deposition in other organs. The diagnosis relies on demonstration of a high iron saturation and ferritin. Testing for HFE gene mutations and liver biopsy can also be helpful. Treatment is based on depletion of iron through phlebotomy and improves survival. “
“A woman, aged 76, was admitted to hospital with abdominal pain that had persisted for 24 hours. On examination, she had a smooth mass in the right upper quadrant of her abdomen. Seventeen years previously, she had been diagnosed with two hepatic cysts; one had been treated by percutaneous sclerotherapy while the other had been left untreated.