Portal-systemic encephalopathy

Zeneroli ML, Baraldi M, Ventura E, Vezzelli C, Tofanetti O, Germini M, Casciarri I Alterations of GABA-A and dopamine D2 brain receptors in dogs with portal-systemic encephalopathy. Life Sci 1991 48 37-50. 

Bircher J, Muller J, Guggenheim P, Haemmerli UP Treatment of chronic portal-systemic encephalopathy with lactulose. Lancet 1966 1 890-892. 

Conn HO, Leevy CM, Vlahcevic ZR, Rodgers JB, Maddrey WC, Seeff L, Levy LL Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. Gastroenterology 1977 72 573-583. 

Parini P, Cipolla A, Ronchi M, Salzetta A, Mazzella G, Roda E Effect of rifaximin and paromomycin in the treatment of portal-systemic encephalopathy. Curr Ther Res 1992 52 34-39. 

De Marco F, Santamaria Amato P, D Arienzo A Rifaximin in collateral treatment of portal-systemic encephalopathy A preliminary report. Curr Ther Res 1984 36 668-674. 

Pedretti G, CalzettiC, Missale G, FiaccadoriF Rifaximin versus neomycin on hyperammoni-emia in chronic portal systemic encephalopathy of cirrhotics. A double-blind, randomized trial. Ital J Gastroenterol 1991,23 175-178. 

After the submission of the manuscript three interesting papers [1-3] dealing with the management of hepatic encephalopathy have been published. A Cochrane systematic review [1] evaluating 30 randomized controlled trials did conclude that antibiotics appear to be superior to nonabsorbable disaccharides in improving symptoms of portal systemic encephalopathy. The authors also emphasized that there is insufficient high-quality evidence to support the use of lactulose or lactitol. A combination of a disaccharide and an antibiotic has been suggested, but not consistently demonstrated to be beneficial [2]. Finally, the use of probiotics has been proposed [3], whose administration could actually follow that of antibiotics. 

Art important drug in the therapy of portal systemic encephalopathy is... 

Lactulose (certain brands) Prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic precoma and coma. 

Cephulac, Cholac, Enclose - Prevent and treat portal-systemic encephalopathy... 

Adults - 30 to 45 mL 3 or 4 times daily. Adjust dosage every day or two to produce 2 or 3 soft stools daily. Hourly doses of 30 to 45 mL may be used to induce rapid laxation in the initial phase of therapy. When the laxative effect has been achieved, reduce dosage to recommended daily dose. Improvement may occur within 24 hours, but may not begin before 48 hours or later. Continuous long-term therapy is indicated to lessen severity and prevent recurrence of portal-systemic encephalopathy. 

Rectal Administer to adults during impending coma or coma stage of portal-systemic encephalopathy when the danger of aspiration exists or when endoscopic or intubation procedures interfere with oral administration. The goal of treatment is reversal of the coma stage so the patient can take oral medication. Reversal of coma may occur within 2 hours of the first enema. Start recommended oral doses before enema is stopped entirely. 

Portal-systemic encephalopathy PO Initially, 30-45 ml every hr. Then, 30-45 ml (20-30 g) 3-4 times a day. Adjust dose q 1-2 days to produce 2-3 soft stools a day. Rectal (as retention enema) 300 ml with 700 ml water or saline solution patient should retain 30-60 min. Repeat q4-6h. If evacuation occurs too promptly, repeat immediately. 

Treatment of hepatic encephalopathy (portal systemic encephalopathy) hepatic coma. 

Ferenci P, Grimm G, Meryn S, Gangl A. Successful long-term treatment of portal-systemic encephalopathy by the benzodiazepine antagonist flumazenil. Gastroenterology 1989 96 240-3. 

Conn, H.O. Trailmaking and number-connection tests in the assessment of mental state in portal systemic encephalopathy. Dig. Dis. 1977 ... 

Loguerdo, C., Del Vecchio-Blanco, C., Coltorti, M. Psychometric tests and latent portal-systemic encephalopathy. Brit. J. Clin. Pract. 1984 38 407-411... 

James, J.H., Zlparo, V., Jeppson, B., Fischer, J.E. Hyperammonaemia, plasma aminoacid imbalance, and blood- brain aminoacid transport a unified theory of portal- systemic encephalopathy Lancet 1979/II ... 

Joelsson, B., Asinnd, U., Hultberg, B., Alwmark, A., Gullstrand, P., Bengmark, S. Portal-systemic encephalopathy. Influence of shunt surgery and relations to serum amino acids. Scand. X Gastroenterol. 1986 21 900-906... 

Sndhamshn, K.C., Matsntanl, S., Marnyama, H., Fukamachi, T., No-moto, H., Aklike, T., Ebara, M., Saisho, H. Portal-systemic encephalopathy in two patients without liver cirrhosis and portal hypertension. Hepatol. Res. 2002 23 122-129... 

Wong, F., Blendis, L.M. Ascites and portal-systemic encephalopathy as complications of cirrhosis. Curr. Opin. Gastroenterol. 1993 9 391-396... 

Fenton, J.C.B., Knight, E.J., Humpherson, P.L. Milk-and-cheese diet in portal-systemic encephalopathy. Lancet 1966/1 164—166... 

Horst, D., Grace, N.D., Conn, H.O., Schiff, E., Schenker, S., Viteri, A., Law, D., Atterbury, C.E. 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 - 287... 

Keshavarzian, A., Meek, J., Sutton, C., Emery, V.M., Hughes, E.A., Hodgson, H.J.F. Dietary protein supplementation from vegetable sources in the management of chronic portal-systemic encephalopathy. Amer. X Gastroenterol. 1984 79 945-949... 

Uribe M., Garcia-Ramos, G., Ramos, M., Valverde, C., Marquez, MA., Farca, A., Guevara, L. Standard and higher doses of bromocriptine for severe chronic portal-systemic encephalopathy. Amer. J. Gastroenterol. 1983 78 517-522... 

Uribe-Esquivel, M., Moran, S., Poo, J.L., Munoz, R.M. Invitro and invivo lactose and lactulose effects on colonic fermentation and portal-systemic encephalopathy parameters. Scand. J. Gastroenterol. 1997 32 (Suppl. 222) 49- 52... 

Watanabe, A. Portal-systemic encephalopathy in non-cirrhotic patients classification of clinical types, diagnosis and treatment. J. Gastroenterol. Hepatol. 2000 15 969 — 979... 

Layrargues GP, et al. Role of manganese in the pathogenesis of portal-systemic encephalopathy. Metab Brain Dis 1998 13 311-317. 

A study by Rao et al." measured the levels of amino acids using in vivo cerebral microdialysis in the frontal cortex of portacaval-shunted rats administered ammonium acetate to precipitate severe portal-systemic encephalopathy. In comparison to sham-operated control rats, tryptophan levels increased by 63% along with those of other amino acids. However, the experimental animals did not have a significant increase in extracellular fluid concentration of tryptophan, suggesting that increased spontaneous release of tryptophan in cerebral cortex is not implicated in the pathogenesis of hepatic coma. 

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