1. EMedicine - Portal-Systemic Encephalopathy : Article By Blake A Jones, MD portalsystemic encephalopathy. Last Updated January 8, 2003 http://www.emedicine.com/med/topic1890.htm

(advertisement) Home Specialties CME PDA ... Patient Education Articles Images CME Patient Education Advanced Search Link to this site Back to: eMedicine Specialties Medicine, Ob/Gyn, Psychiatry, and Surgery Gastroenterology Portal-Systemic Encephalopathy Last Updated: January 8, 2003 Rate this Article Email to a Colleague Synonyms and related keywords: portosystemic encephalopathy, PSE, hepatic encephalopathy, HE, liver disease, advanced liver disease, portosystemic shunt, portal-systemic shunt, neurotoxicity, neuropsychosis, hyperammonemia, transjugular intrahepatic portosystemic shunt, TIPS, nonselective portocaval shunts AUTHOR INFORMATION Section 1 of 10 Author Information Introduction Clinical Differentials ... Bibliography Author: Blake A Jones, MD , Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Blake A Jones, MD, is a member of the following medical societies: American Association for the Study of Liver Diseases American College of Gastroenterology American Gastroenterological Association American Medical Association ... Royal College of Physicians and Surgeons of Canada , and Texas Medical Association Editor(s): Ann Ouyang, MBBS

2. EMedicine - Portal-Systemic Encephalopathy : Article Excerpt By: Blake A Jones, Excerpt from portalsystemic encephalopathy. Synonyms, Key Words, and Related Terms portosystemic encephalopathy, PSE, http://www.emedicine.com/med/byname/portal-systemic-encephalopathy.htm

(advertisement) Excerpt from Portal-Systemic Encephalopathy Synonyms, Key Words, and Related Terms: portosystemic encephalopathy, PSE, hepatic encephalopathy, HE, liver disease, advanced liver disease, portosystemic shunt, portal-systemic shunt, neurotoxicity, neuropsychosis, hyperammonemia, transjugular intrahepatic portosystemic shunt, TIPS, nonselective portocaval shunts Please click here to view the full topic text: Portal-Systemic Encephalopathy Background: Portosystemic encephalopathy (PSE) is a neuropsychiatric syndrome associated with advanced liver disease. Portosystemic shunting of ill-defined substances is suspected to result in neurotoxicity. This has led to many investigative and therapeutic efforts aimed at identifying and eliminating the putative poisons that originate from the gut lumen. A fluctuating level of consciousness is common, and progression to coma may occur rapidly. A high index of clinical awareness is critical for anticipating and recognizing complications. A precipitating cause usually is discovered after clinical and laboratory evaluation. Although elevated plasma ammonia levels often are seen and therapy based on this observation generally is effective, poor correlation exists between plasma ammonia levels and the degree of encephalopathy. Multiple mechanisms contribute to the pathogenesis of this disorder. Discrete neuropathological features are described in PSE but may represent epiphenomena. Treatment with lactulose is the mainstay of therapy, but novel developmental approaches show promise.

3. THE MERCK MANUAL, Sec. 4, Ch. 38, Clinical Features Of Liver toxic substances from the intestine gain direct access to the systemic circulation,a critical factor in the pathogenesis of portalsystemic encephalopathy. http://www.merck.com/pubs/mmanual/section4/chapter38/38d.htm

4. Portal-Systemic Encephalopathy By Sanjay Sandhir, MD, Frederick LPortal-Systemic Pathogenesis and treatment of portalsystemic encephalopathy an update. http://www.medicus.bip.ru/gastro/hepar.html

5. THE MERCK MANUAL, Sec. 4, Ch. 38, Clinical Features Of Liver Disease Ascites. portalsystemic encephalopathy. Other Symptoms And Signs Of Liver Disease. Portal-SystemicEncephalopathy (Hepatic Encephalopathy; Hepatic Coma). http://www.merck.com/pubs/mmanual/section4/chapter38/38f.htm

This Publication Is Searchable The Merck Manual of Diagnosis and Therapy Section 4. Hepatic And Biliary Disorders Chapter 38. Clinical Features Of Liver Disease Topics [General] Jaundice Hepatomegaly Portal Hypertension ... Other Symptoms And Signs Of Liver Disease Portal-Systemic Encephalopathy (Hepatic Encephalopathy; Hepatic Coma) A neuropsychiatric syndrome caused by liver disease and usually associated with portal-systemic shunting of venous blood. "Portal-systemic encephalopathy" is a more descriptive term of the pathophysiology than "hepatic encephalopathy" or "hepatic coma," but clinically all three are used interchangeably. Etiology Portal-systemic encephalopathy may occur in fulminant hepatitis caused by viruses, drugs, or toxins, but it more commonly occurs in cirrhosis or other chronic disorders when extensive portal-systemic collaterals have developed as a result of portal hypertension. The syndrome also follows portacaval shunt or similar portal-systemic anastomoses. In patients with chronic liver disease, encephalopathy is usually precipitated by specific, potentially reversible causes (eg, GI bleeding; infection; electrolyte imbalance, especially hypokalemia; alcoholic debauches) or iatrogenic causes (tranquilizers, sedatives, analgesics, diuretics).

6. Treatment Of Chronic Portal-systemic Encephalopathy With Lactose In Lactase-defi was carried out in ten cirrhotic patients with chronic portalsystemic encephalopathy and documented lactase deficiency. http://www.maaloxan-welt.de/science/1980/1980_7004808.htm

Dig Dis Sci 1980 Dec;25(12):924-8 Treatment of chronic portal-systemic encephalopathy with lactose in lactase-deficient patients. Uribe M, Marquez MA, Garcia-Ramos G, Escobedo V, Murillo H, Guevara L, Lisker R. A controlled cross-over clinical comparison of lactose (50 g twice a day) versus neomycin (3 g/day) plus milk of magnesia, was carried out in ten cirrhotic patients with chronic portal-systemic encephalopathy and documented lactase deficiency. Serial semiquantitative assessments were done including: mental state, asterixis, number connection test, electroencephalogram, and blood ammonia levels. No patient developed deep coma while ingesting either lactose or neomycin plus milk of magnesia. However, a significant improvement of mental state, asterixis, number connection tests, and electroencephalograms was evident during lactose therapy. apart from mild diarrhea and bloating, no severe side effects were noticeable during lactose treatment. Based on these results, we propose lactose as a valuable alternate treatment of portal-systemic encephalopathy in lactase-deficient populations. Publication Types: Clinical Trial Randomized Controlled Trial Impressum Gesundheit (Sodbrennen, Magen)

7. Treatment Of Chronic Portal--systemic Encephalopathy With Vegetable And Animal P on 10 cirrhotic patients with mild chronic portalsystemic encephalopathy. The 40-g vegetable protein diet had a http://www.maaloxan-welt.de/science/1982/1982_6756833.htm

Dig Dis Sci 1982 Dec;27(12):1109-16 Treatment of chronic portalsystemic encephalopathy with vegetable and animal protein diets. A controlled crossover study. Uribe M, Marquez MA, Garcia Ramos G, Ramos-Uribe MH, Vargas F, Villalobos A, Ramos C. Publication Types: Clinical Trial Controlled Clinical Trial Impressum Gesundheit (Sodbrennen, Magen)

8. PROFESSIONAL REFERENCE Allergy Immunlogy Cardiology Dermatology portalsystemic encephalopathy by Sanjay Sandhir, MD and Fredrick L Weber, Jr.,MD, Best Practice of Medicine. January 2000. Last modified October 12, 2001. http://merck.praxis.md/index.asp?page=bpm_brief&chapter=CPM02HP377

9. Best Practice Of Medicine - Portal-systemic Encephalopathy - article url /bpm.asp?page= CPM02HP377. Best Practice of Medicine Hepatology PortalsystemicEncephalopathy by Sanjay Sandhir , MD and Fredrick L . Weber, Jr. http://merck.praxis.md/bpm/bpmviewall.asp?page=CPM02HP377

10. EFFECTS OF MANGANESE IN ASTROCYTES ROLE IN PORTAL - SYSTEMIC EFFECTS OF MANGANESE IN ASTROCYTES ROLE IN Alan S. Hazell Department of Medicine, Hôpital SaintLuc (CHUM), University of Montreal, Montreal, Quebec, Canada H2X 3J4 portal-systemic encephalopathy (PSE) resulting from chronic liver http://www.cac.es/fundacion/articles/alan_hazell.pdf

11. Portal-systemic Encephalopathy In Non-cirrhotic Patients: Classification portalsystemic encephalopathy in non-cirrhotic patients Classificationof clinical types, diagnosis and treatment. Date Fri, 1 http://archive.mail-list.com/hbv_research/msg01824.html

hbv_research archives Portal-systemic encephalopathy in non-cirrhotic patients: Classification of clinical types, diagnosis and treatment Date: Fri, 1 Dec 2000 06:34:21 -0500 From hbv_research-list-owners@mail-list.com Subject Portal-systemic encephalopathy in non-cirrhotic patients: Classification of clinical types, diagnosis and treatment mailto:martins@zoomnet.net http://dispatch.mail-list.com/archives/hbv_research Prev by Date: Pregnancy After Liver Transplantation Next by Date: Lamivudine-high dose interferon combination therapy for chronic hepatitis B patients co-infected with the hepatitis D virus Return to Table of Contents:

12. Portal-Systemic Encephalopathy portalsystemic encephalopathy. Date Sat, 24 Jun 2000 091732 -0700; From hbv_research-list-owners@mail-list.com;Subject portal-systemic encephalopathy. http://archive.mail-list.com/hbv_research/msg01287.html

hbv_research archives Portal-Systemic Encephalopathy Date: Sat, 24 Jun 2000 09:17:32 -0700 From hbv_research-list-owners@mail-list.com Subject Portal-Systemic Encephalopathy http://www.merck.com/pubs/mmanual/section4/chapter38/38f.htm Prev by Date: Ascites Next by Date: Portal Hypertension Return to Table of Contents:

13. Cátedra Santiago Grisolía Alan Hazell Effects of manganese in astrocytes role in portalsystemic encephalopathy.Alberto Verotti Valproate-induced hyperammonemic encephalopathy. http://www.cac.es/fundacion/symposium_abstracts.htm

14. LU:research - Lund University Institutional Archive G., and Bengtsson F. (1996) Acute effects of Ltryptophan on brain extracellular5-HT and 5-HIAA in chronic experimental portal-systemic encephalopathy. Metab. http://eprints.lub.lu.se/archive/00009671/

About Bergqvist, Peter B. F. UNSPECIFIED Thesis or Dissertation Tryptophan-related Neurotransmission in the Brain: Disturbances Associated with Experimental Hepatic Encephalopathy Ammonia UNSPECIFIED link UNSPECIFIED No Faculty of Medicine Department of Laboratory Medicine (ILM), Lund Clinical Pharmacology UNSPECIFIED UNSPECIFIED I. Bergqvist P.B.F., Heyes M.P., Bugge M., and Bengtsson F. (1995) Brain quinolinic acid in chronic experimental hepatic encephalopathy: Effects of an exogenous ammonium acetate challenge. J. Neurochem. 65(5), 2235-2240. II. Bergqvist P.B.F., Heyes M.P., Apelqvist G., Butterworth R.F., and Bengtsson F. (1996) Brain extracellular quinolinic acid in chronic experimental hepatic encephalopathy as assessed by in vivo microdialysis: Acute effects of L-tryptophan. Neuropsychopharmacology 15(4), 382-389. III. Bergqvist P.B.F., Vogels B.A.P.M., Bosman D.K., Maas M.A.W., Hjorth S., Chamuleau R.A.F.M., and Bengtsson F. (1995) Neocortical dialysate monoamines of rats after acute, subacute, and chronic liver shunt. J. Neurochem. 64(3), 1238-1244. IV. Bergqvist P.B.F., Hjorth S., Apelqvist G., and Bengtsson F. (1996) Acute effects of L-tryptophan on brain extracellular 5-HT and 5-HIAA in chronic experimental portal-systemic encephalopathy. Metab. Brain Dis. 11(3), 269-278.

15. Hepatic Encephalophaty Hepatic encephalopathy for healthcare personel (contains medical terms).portal-systemic encephalopathy - (Hepatic Encephalopathy; Hepatic Coma). http://home3.inet.tele.dk/omni/encephalopathy.htm

The Danish Hepatitis C website Hepatic encephalopathy (for patients and relatives): The typical symptoms of hepatic encephalopathy include The typical symptoms of hepatic encephalopathy include ... Ascites Hepatic encephalopathy (for patients and relatives): Hepatic encephalopathy refers to the changes in the brain that occur in patients with advanced acute or chronic liver disease. If liver cells are damaged, certain substances that are normally cleansed from the blood by the healthy liver are not removed (ammonia mainly, and other toxins). A patient with chronic hepatic encephalopathy may develop progressive loss of memory, disorientation, untidiness, and muscular tremors, leading to a form of chronic dementia. The ingestion of protein invariably aggravates these symptoms. The treatment of hepatic encephalopathy involves, first, the removal of all drugs that require detoxification in the liver and, second, the reduction of the intake of protein. Restricting the amount of protein in the diet will generally lower the levels of amino acids and ammonia in the bloodstream and brain. Most physicians advise their patients with this condition to eat only about 40 grams of protein a day, and will prescribe lactulose or neomycin to lower amino acid production. Non-meat proteins, such as those found in vegetables and milk, are preferred. Certain amino acids are used in treatment, since they are considered less likely to cause mental impairment. A dietary supplement rich in these amino acids is used at many liver treatment centers.

16. Hepatitis Central, References, Subclinical Hepatic Encephalopathy Impairs Daily 1. Butterworth RF. Pathogenesis and treatment of portalsystemic encephalopathyan update. 3. Gitlin N. Subclinical portal-systemic encephalopathy. http://hepatitis-central.com/hcv/symptoms/encephalopathy/references.html

References Subclinical Hepatic Encephalopathy Impairs Daily Functioning 1. Butterworth RF. Pathogenesis and treatment of portal-systemic encephalopathy: an update. Dig Dis Sci 1992; 37: 321-327[Medline]. 2. Parsons-Smith BG, Summerskill WHJ, Dawson AM, Sherlock S. The electroencephalograph in liver disease. Lancet 1957; 2: 867-871. 3. Gitlin N. Subclinical portal-systemic encephalopathy. Am J Gastroenterol 1988; 82: 8-11. 4. Zeegen R, Drinkwater JE, Dawson AM. Method for measuring cerebral dysfunction in patients with liver disease. Br Med J 1970; 2: 633-636[Medline]. 5. Rikkers L, Jenko P, Rudman D, Freides D. Subclinical hepatic encephalopathy: detection, prevalence, and relationship to nitrogen metabolism. Gastroenterology 1978; 75: 462-469[Medline]. 6. Gilberstadt SJ, Gilberstadt H, Zieve L, Buegel B, Collier RO, McClain CJ. Psychomotor performance defects in cirrhotic patients without overt encephalopathy. Arch Intern Med 1980; 140: 519-521[Medline]. 7. Gitlin N, Lewis DC, Hinkley L. The diagnosis and prevalence of subclinical hepatic encephalopathy in apparently healthy ambulant, non-shunted patients with cirrhosis. J Hepatol 1986; 3: 75-82[Medline].

17. References Dietary management of portalsystemic encephalopathy. In Conn HO, BircherJ, editors. Hepatic encephalopathy syndromes and therapies. http://www.medscape.com/content/2001/00/40/65/406524/406524_ref.html

References for: Hepatic Encephalopathy - Effective Treatments Available Once Acute Precipitants Have Been Eliminated Gerber T, Schomerus H. Hepatic encephalopathy in liver cirrhosis.Drugs 2000; 60 (6): 1353-70 Yen CL, Liaw YF. Somatosensory evoked potentials and number connection test in the detection of subclinical hepatic encephalopathy. Hepatogastroenterology 1990; 37: 332-4 Uribe M, Conn HO. Dietary management of portal-systemic encephalopathy. In: Conn HO, Bircher J, editors. Hepatic encephalopathy syndromes and therapies. Bloomington: Medi-EdPress, 1994; 331-49 Egberts ER, Schomerus H, Hamster W, et al. Branched chain amino acids in the treatment of latent portosystemic encephalopathy.Gastroenterology 1985; 88: 887-95 Kersh ES, Rifkin H. Lactulose enemas. Ann Intern Med 1973; 78: 81-4 Uribe M, Campollo O, Vargas F. Acidifying enemas (lactilol and lactulose) vs nonacidifying enemas (tap water) to treat acute portal systemic encephalopathy: a double-blind randomized trial.Hepatology 1987; 7: 629-34 Camma C, Fiorello F, Tine F. Lactilol in treatment of chronic hepatic encephalopathy: a meta-analysis. Dig Dis Sci 1993; 38: 916-22

18. Lactulose containing both lactose and galactose; causes a decrease in the blood concentrationof ammonia in clients suffering from portalsystemic encephalopathy. http://www.nursespdr.com/members/database/ndrhtml/lactulose.html

Lactulose Lactulose (Chronulac, Duphalac) Lactulose LAK -tyou-lohs) Pregnancy Category: B Acilac Cephulac Cholac Chronulac Constilac Constulose Duphalac Gen-Lac Enulose Evalose Heptalac Lactulax Laxilose PMS Lactulose (Rx) Classification: Ammonia detoxicant, laxative Action/Kinetics: A disaccharide containing both lactose and galactose; causes a decrease in the blood concentration of ammonia in clients suffering from portal-systemic encephalopathy. Due to bacteria-induced degradation of lactulose in the colon, resulting in an acid medium. Ammonia will then migrate from the blood to the colon to form ammonium ion, which is trapped and cannot be absorbed. A laxative action due to increased osmotic pressure from lactic, formic, and acetic acids then expels the trapped ammonium. The decrease in blood ammonia concentration improves the mental state, EEG tracing, and diet protein tolerance of clients. The increased osmotic pressure also results in a laxative effect, which may take up to 24 hr. Partly absorbed from the GI tract. Onset: 24-48 hr.

19. Chapter 2 - Workbook: First Principles Of Gastroenterology Section 6 Dietary Therapy in Liver Disease 6.1 Discuss appropriate dietarytherapy for a. Ascites b. portalsystemic encephalopathy c. Cirrhosis. http://gastroresource.com/GITextbook/En/chapter2/workbook.htm

- Select a chapter - 1. Symptoms and Signs 2. Nutrition 3. Ethics 4. Research/Clinical Trials 5. Esophagus 6. Stomach and Duodenum 7. Small Intestine 8. Intestinal Ischemia 9. H.I.V. 10. Inflammatory Bowel 11. Colon 12. Pancreas 13. Biliary System 14. Liver 15. Paediatrics 16. Video Endoscopic Images Search Chapter 2: Nutrition Sections: 1. Introduction 2. Essential Pysiologic Concepts in Nutrition 3. Clinical and Laboratory Features of Protein-Energy Malnutrition 4. Effects of Malnutrition on the Gastrointestinal Tract and Pancreas ... Acknowledgements Chapter 2 Workbook LEARNER OBJECTIVES At the completion of this chapter, the learner will be able to: Section 2: Essential Physiologic Concepts 2.1 Describe the essential physiologic concepts in nutrition. 2.2 Identify hormonal regulation of nutrition metabolism by: a. Listing the regulatory hormones b. Describing each regulatory hormone's metabolic action Section 3: Clinical and Lab Features of Protein-Energy Malnutrition 3.1 Identify the clinical and laboratory features of protein-energy

20. Ausgabe 13 3. Butterworth RF portalsystemic encephalopathy a disorder of neuron-astrocyticmetabolic trafficking. Dev Neurosci 1993;15313-318. http://www.medvis.de/fernkolleg/ausgabe13/8.htm

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