Q: All of the following have shown possible beneficial effect in hepatic encephelopathy except?

A) Plasma aromatic amino acids (AAA)
B) Branched chain amino acids (BCAA)
C) Sodium benzoate 
D) Flumazenil 
E) Zinc


Answer: A

Objective of above question is to highlight the role of Amino Acids in hepatic encephelopathy. Evidence is still weak so this should not be used as standard of treatment, but should be kept in mind if situation requires intervention.

It has been suggested that hepatic failure/insufficiency increases the ratio of plasma aromatic amino acids (AAA) to branched-chain amino acids (BCAA), and can be a contributing cause of hepatic encephalopathy. Increasing the BCAA level may reverse this ratio and helps in preventing or improving hepatic encephelopathy. 

 BCAA is also available as an oral supplement, and may helpful as an adjuvant treatment.

So answer to above question is "A" as Aromatic Amino acid (AAA) can be detrimental. All other choices are of benefits in hepatic encephelopathy. 


References:

1. Gluud LL, Dam G, Les I, et al. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev 2017; 5:CD001939. 

2.  Naylor CD, O'Rourke K, Detsky AS, Baker JP. Parenteral nutrition with branched-chain amino acids in hepatic encephalopathy. A meta-analysis. Gastroenterology 1989; 97:1033. 

3. Marchesini G, Dioguardi FS, Bianchi GP, et al. Long-term oral branched-chain amino acid treatment in chronic hepatic encephalopathy. A randomized double-blind casein-controlled trial. The Italian Multicenter Study Group. J Hepatol 1990; 11:92. 

4. Horst D, Grace ND, Conn HO, et al. Comparison of dietary protein with an oral, branched chain-enriched amino acid supplement in chronic portal-systemic encephalopathy: a randomized controlled trial. Hepatology 1984; 4:279. 

5. Les I, Doval E, García-Martínez R, et al. Effects of branched-chain amino acids supplementation in patients with cirrhosis and a previous episode of hepatic encephalopathy: a randomized study. Am J Gastroenterol 2011; 106:1081.