Arising from: Hanje AJ and Patel T (2007) Nat Clin Pract Gastroenterol Hepatol 4: 266–276

In their Review “Preoperative evaluation of patients with liver disease”, Hanje and Patel insist on the use of lactulose for the treatment of portosystemic encephalopathy (PSE). They state that “... lactulose ... has been shown to improve symptoms of PSE when compared with placebo.” To support this assumption, they cite Als-Nielsen et al.1 The exact conclusion of the study by Als-Nielsen et al., on the basis of 22 randomized trials (only 4 of good quality; a total of 57 patients), was that “There is insufficient evidence to support or refute the use of non-absorbable disaccharides for hepatic encephalopathy.” After 30 years of use, lactulose should no longer be part of standard care. The effect of lactulose is limited to adding to the nurse's aide's workload, such as changing bed sheets (unpublished observations).