[59] Stool culture studies in patients with cirrhosis show an overgrowth of pathogenic E. coli and Staphylococcus species.[60] Studies on ascitic fluid, portal blood, mesenteric lymph nodes, and ileal contents have shown that bacterial translocation was more frequent in rats with ascites

and SBP than in rats with ascites but no SBP or in healthy rats[61]; the bacterial species isolated in mesenteric nodes or ascites were similar to those in the rat intestine, suggesting translocation of bacteria from gut as the source of SBP.[61, 62] Further, cirrhosis is associated with numerous defects in immune response, including impaired leukocyte function,[63, 64] low ascitic fluid levels of components of the complement system,[65] reduced phagocytic activity of reticuloendothelial cells,[66] reduced antibody-mediated and complement-dependent Talazoparib price bacterial killing,[67] and reduced proliferation and γ-interferon synthesis by intraepithelial lymphocytes[68]; these could contribute through reduced clearance

of translocated bacteria. HE encompasses a wide spectrum of abnormalities, ranging from subclinical alterations in neuropsychiatric tests (minimal HE) to overt neuropsychiatric manifestations of varying severity (clinical HE grade I–IV) in patients with Selleck Roxadustat acute or chronic liver failure. Pathogenesis of HE is poorly understood and appears to be multifactorial; several pieces of evidence support a role for gut microbes in this process.[69] Intraperitoneal administration of LPS in a mouse model of cirrhosis is associated with induction of pre-coma and worsening of cytotoxic brain edema.[70] Bacterial overgrowth is more common in patients with liver cirrhosis and minimal HE than in those without the latter.[51] Liu et al. reported an overgrowth of pathogenic E. coli and Staphylococcus species in patients with cirrhosis and minimal HE.[60] Administration

of probiotics and fermentable fiber resulted in an increase of non-urease-producing Lactobacilli over pathogenic bacteria with a significant reduction in blood levels of ammonia MCE and endotoxin, reversal of minimal HE, and improvement of Child–Pugh score. A meta-analysis of the effect of prebiotics, probiotics, or synbiotics, which modulate gut flora, has shown significant improvement in minimal HE.[71] Increased blood ammonia, leading to astrocyte swelling followed by brain edema, is believed to play a central role in the pathogenesis of HE. Ammonia is produced from catabolism of glutamine in the small bowel and that of undigested proteins and urea in the colon. Several other products of bacterial metabolism also have neurotoxic effects, and their levels are increased in persons with cirrhosis; these include phenols produced from aromatic amino acids such as phenylalanine mercaptans produced from sulfur-containing amino acids such as methionine, and short- and medium-chain fatty acids.