Methods

This study was conducted in accordance to the Preferred Reporting Items For
Systematic Review and Meta-Analyses (PRISMA) Guidelines 2009. All studies were
identified and collected from a pool of available data. These studies did not require
ethics approval.

Search Strategy and study selection:

The search terms used were “Hepatic Encephalopathy, Lactulose, and
Probiotics”. These were applied to The Pubmed, Cochrane, Clinicaltrials.gov to
identify available published and unpublished research articles. The search was
restricted to human studies, randomized control trials and those done in the last 15
years. The filters ‘randomized clinical trials’, ‘ RCT’, ‘trials’ and ‘Efficacy' were used
to narrow researches .
Articles written in the English language were included. Searching and
examining of the articles were done by three reviewers to avoid bias. Duplicates of
studies were removed and shortlisted based on title and abstract, after which the full
text was read and assessed for eligibility. References of the included studies were
reviewed to avoid selection bias.
Eligibility Criteria

Randomized controlled trials were gathered and included in this study.The

Inclusion criteria are as follows: Adults > 18 years old, male and female, all races
with minimal hepatic encephalopathy irregardless of the etiology receiving probiotics
or standard therapy alone.

Exclusion Criteria: Patients with overt hepatic encephalopathy, known brain

lesions, active gastrointestinal bleeding, active ongoing infection, renal impairment ,
electrolyte abnormalities and those reated with lactulose, antibiotics ,
benzodiazepines, narcotics, opioids, or alcohol in the preceding 6 weeks were not
included into the trial. Participants who had alcohol intake within 6 weeks and those
with comorbrities such as heart failure, respiratory failure, renal failure or any
neurologic disease were also excluded.

Data collection and quality assessment

The article were gathered from PubMed, PubMed central, Clinical trials.gov
through searching of the chosen terms or keywords and related to the titles or abstract.
The terms or keywords that were used in this search were, Hepatic Encephalopathy,
Lactulose and Probiotics. Results within 15 years from 2008 to 2022 were selectef
urther d and narrowed down by selecting randomized control trials, or RCT.