Abstract
The pathogenesis of hepatic encephalopathy (HE) is unknown. Many theories have been proposed. Most established therapies are based on such theories but since no theory has have ever been proved, therapies have to be considered empiric. The spectrum of HE ranges from minimal cerebral functional deficits, which can only be found by sensitive psychometric tests, to coma with signs of decerebration. HE has arbitrarily been divided into stages. A number of precipitating factors are known and the first line of therapy should always be the elimination of these factors. The differential diagnosis includes all states of impaired consciousness and deficits in cerebral function in patients with chronic liver disease, and clinical and biochemical tests to differentiate are indicated.
The therapeutic options for HE include: protein restriction only for a limited time in comatous patients; nonabsorbable antibiotics (aminoglycosides), which because of adverse effects are also limited to higher grades of HE; intestinal cleansing which is applicable in all degrees of HE; lactulose, branched chain aminoacids and ornithin aspartate which have been proven to be effective and can be applied long term in patients with lower grades of HE.
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References
Schomerus H. The disease picture of hepatic encephalopathy [in German]. Infusionstherapie Klin Ernahr 1987; 14 Suppl. 5: 50–2
Butterworth RF, Giguere JF, Michaud J, et al. Ammonia: key factor in the pathogenesis of hepatic encephalopathy. Neurochem Pathol 1987; 6: 1–12
Gerok W, Häussinger D. Ammonia detoxication and glutamine metabolism in severe liver disease and its role in the pathogenesis of hepatic encephalopathy. In: Häussinger D, Sies H, editors. Glutamin metabolism in mammalian tissues. Heidelberg: Springer, 1984: 257–77
Raabe W. Neuronal effects of ammonia. In: Soeters PD, Wilson J, Meijer AF, editors. Advances in ammonia metabolism and hepatic encephalopathy. New York: Elsevier Science Publishing, 1988: 349–55
Hindfelt B, Plum F, Duffy TE. The effect of acute ammonia intoxication on cerebral metabolism in rats with portocaval shunts. J Clin Invest 1977; 59(3): 386–96
Häussinger D, Laubenberger J, vom Dahl S, et al. Proton magnetic resonance spectroscopy studies on human brain myo-inositol in hypo-osmolarity and hepatic encephalopathy. Gastroenterology 1994; 107: 1475–80
Stahl J. Studies of the blood ammonia in liver disease: its diagnostic, prognostic and therapeutic significance. Ann Intern Med 1963; 58: 1–24
Aggarwal A, Kreiger D, Arroliga A, et al. Arterial ammonia levels in haptic encephalopathy: utility in diagnosis [abstract]. Turk J Gastroenterol 1999; 10: 18
Zieve L, Doizaki WM, Zieve J. Synergism between mecaptans and ammonia or fatty acids in the production of coma: a possible role for mercaptans in the pathogenesis of hepatic encephalopathy. J Lab Clin Med 1974; 83: 16–28
Blom HJ, Ferenci P, Grimm G, et al. The role of methanethiol in the pathogenesis of hepatic encephalopathy. Hepatology 1991; 13: 376–9
Windus-Podehl G, Lyftogt L, Zieve L. Encephalopathic effect of phenol in rats. J Lab Clin Med 1983; 101: 586–92
Häussinger D. Hepatogene encephalopathie. In: Gerok W, editor. Hepatologie. München: Urban & Schwarzenberg, 1987:612–24
Zaki AEO, Wardle EN, Canalese J, et al. Potential toxins of acute liver failure and their effects on blood-brain barrier permeability. Experientia 1983; 39: 988–91
Horowitz ME, Schafer DF, Molnar P, et al. Increased blood-brain transfer in a rabbit model of acute liver failure. Gastro-enterology 1983; 84: 1003–11
Ede RJ, Williams R. Hepatic encephalopathy and cerebral edema. Semin Liver Dis 1986; 6: 107–18
Mans AM, Biebuyck JF, Shelly K, et al. Regional blood-brain barrier permeability to amino acids after portocaval anastomosis. J Neurochem 1982; 38: 705–17
Cangiano C, Cardelli-Cangiano P, James JH. Brain microvessels take up large neutral amino acids in exchange for glutamine: cooperative role of Na+-dependent and Na+-independent systems. J Biol Chem 1983; 258: 8949–54
Fischer JE, Baldessarini RJ. False neurotransmitter in hepatic failure. Lancet 1971; II: 75–80
Fischer JE, Funovics A, Aguirre A. The role of plasma amino acid in hepatic encephalopathy. Surgery 1975; 78: 276–90
James JH, Zipparo V, Jeppson B, et al. Hyperammonemia, plasma amino acid imbalance and blood-brain amino acid transport: a unified theory of portal-systemic encephalopathy. Lancet 1979; II: 772–5
Manghani KK, Lunzer MR, Billing BH. Urinary and serum octopamine in patients with portosystemic encephalopathy. Lancet 1975; II(7942): 943–6
Baraldi M, Zeneroli ML. Experimental hepatic encephalopathy: changes in the binding of gamma amonibutyric acid. Science 1982; 216: 427–9
Bakti G, Fisch HU, Karlaganis G, et al. Mechanism of the excessive sedative response of cirrhotics to benzodiazepines: model experiments with triazolam. Hepatology 1987; 7(4): 629–38
Grippon P, Le Poncin-Lafitte M, Bosch ATM. Evidence for the role of ammonia in the intercerebral transfer and metabolism of tryptophan. Hepatology 1986; 6(4): 682–6
Zieve L, Olsen RL. Can hepatic coma be caused by a reduction of brain noradrenaline or dopamine? Gut 1977; 18(9): 688–91
Henriksen JH, Ring-Larsen H, Christensen NJ. Circulating noradrenaline and central haemodynamics in patients with cirrhosis. Scand J Gastroenterol 1985; 20: 1185–90
Van der Rijt CC, Schalm SW, Schat H, et al. Overt hepatic encephalopathy precipitated by zinc deficiency. Gastroenterology 1991; 100: 1114–8
Krieger D, Krieger S, Jansen S, et al. Manganese and chronic hepatic encephalopathy. Lancet 1995; 346: 270–4
Conn HO, Lieberthal MM. The hepatic coma syndromes and lactulose. Baltimore: Williams and Williams, 1979
Schomerus H, Hamster W, Blunck H, et al. Latent portasystemic encephalopathy: I. Nature of cerebral functional defects and their effect on fitness to drive. Dig Dis Sci 1981; 26: 622–30
Cordoba J, Cabrera J, Lataif L, et al. High prevalence of sleep disturbance in cirrhosis. Hepatology 1998; 27(2): 339–45
Adams RD, Foley JM. The disorder of movement in the more common varieties of liver disease. Electroencephalogr Clin Neurophysiol 1953; 3: 51
Read AF, Laidlaw J, Haslam RM, et al. Neuro-psychiatric complications following chlorothiazide therapy in patients with hepatic cirrhosis: possible relation to hypokalaemia. Clin Sci 1959; 18: 409
Sanyal AT, Freedman AM, Shiffman ML, et al. Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective controlled study. Hepatology 1994; 20(1): 46–55
Rössle M, Piotraschke J. Transjugular intrahepatic portosystemic shunt and hepatic encephalopathy. Dig Dis 1996; 14(1): 12–9
Siegerstetter V, Rossle M. The role of TIPS for the treatment of portal hypertension: effects and efficacy. Acta Gastroenterol Belg 1997; 60(3): 233–7
Nolte W, Wiltfang J, Schindler C, et al. Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: clinical, laboratory, psychometric and electroencephalographic investigations. Hepatology 1998; 28(5): 1215–25
Somberg KA, Riegler JL, La Berge JM, et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunts: incidence and risk factors. Am J Gastroenterol 1995; 90: 549–55
Rössle M, Siegerstetter V, Huber M, et al. The first decade of the transjugular intrahepatic portosystemic shunt: state of the art. Liver 1998; 18(2): 73–89
Kraas E. Portale hypertension. In: Schumpelick V, Bleese N, Mommsen U, editors. Chirurgie. Stuttgart: Enke Verlag, 1989: 565–74
Ito S, Miyaji H, Azuma T. Hyperammonaemia and helicobacter pylori. Lancet 1995; 346: 124–5
Wiedemann B, Kircheis G, Klauk S, et al. The influence of helicobacter pylorion protein-induced hyperammonaemia in cirrhotic patients without hepatic encephalopathy [abstract]. Hepatology 1996; 24: 453A
Farinati F, De Bona M, Floreani F, et al. Helicobacter pylori and liver: any relationship? Ital J Gastroenterol Hepatol 1998; 30: 124–8
Vasconez C, Elizalde JI, Llach J, et al. Helicobacter pylori, hyperammonaemia and subclinical portosystemic encephalopathy: effects of eradication. J Hepatol 1999; 30(2): 260–4
Kuhlbusch R, Enck P, Häussinger D. Hepatic encephalopathy: neuropsychological and neurophysiological diagnosis [in German]. Z Gastroenterol 1998; 36: 1075–83
Rikkers L, Jenko P, Rudman D, et al. Subelinical hepatic encephalopathy: detection, prevalence and relationship to nitrogen metabolism. Gastroenterology 1978; 75: 462–9
Gillen W The diagnosis and prevalence of subelinical hepatic encephalopathy in apparently ambulant non-shunted patients with cirrhosis. J Hepatol 1986; 3: 75–82
Loguercio C, Del Vecchio-Blanco C, Coltorti M. Psychometric test and latent portosystemic encephalopathy. Br J Clin Pract 1999; 407–11
Yen CL, Liaw YF. Somatosensory evoked potentials and number connection test in the detection of subelinical hepatic encephalopathy. Hepatogastroentrology 1990; 37: 332–4
Schomerus H, Hamster W Neuropsychological aspects of portal-systemic encephalopathy [abstract]. Metab Brain Dis 1998; 13: 361–77
Reitan RM. Validity of the trailmaking test as an indicator of organic brain damage. Percept Mot Skills 1958; 8: 271–6
Conn HO. Trailmaking and number connection test in the assessment of mental state in portal systemic encephalopathy. Am J Dig Dis 1977; 22: 541–50
Schomerus H, Weissenborn K, Hamster W, et al.PSE-Syndrom-Test manual. Frankfurt: Swets & Zeitlinger, 1999
Heaton RK, Grant I, Metthews C. Differences in neuropsychological test performance associated with age, education and sex. In: Grant J, Adams K, editors. Neuropsychological assessment of neuropsychiatrie disorders. New York: Oxford University Press, 1986: 100–20
Johannson U, Andersson T, Persson A, et al. Visual evokes potentials: a tool in the diagnosis of hepatic encephalopathy. J Hepatol 1989; 9: 227–33
Parsons-Smith BG, Summerskill WHJ, Dawson AM. The electroencephalograph in liver disease. Lancet 1957; II: 867–71
Demedts M, Pillen E, de Grote J, et al. Hepatic encephalopathy: comparative study of EEG abnormalities, neuropsychic disturbances and blood ammonia. Acta Neurol Belg 1973; 73: 281–8
Van der Rijt CC, Schalm SW, De Groot GH, et al. Objective measurement of hepatic encephalopathy by means of automated EEG analysis. Electroencephalogr Clin Neurophysiol 1984; 57: 423–6
Kullmann F, Hollerbach S, Holstege A, et al. Subelinical hepatic encephalopathy: the diagnostic value of evoked potentials. J Hepatol 1999; 22(1): 101–10
Teijeira JM, Montes C, Diaz E, et al. Visual evoked potentials: current perspectives. Rev Neurol 1998; 26(151): 451–8
Davies MG, Rowam MJ, Feely J. Flash visual evoked responses in the early encephalopathy of chronic liver disease. Scand J Gastroenterol 1990; 25: 1205–14
Kügler G, Lotterer E, Petter J, et al. Visual event-related P300 potentials in early portosystemic encephalopathy. Gastroenterology 1992; 103: 302–10
Davies MG, Rowan JM, McMathuina P, et al. The auditory P300 event-related potential: an objective marker of the encephalopathy of chronic liver disease. Hepatology 1990; 12: 688–94
Hollerbach S, Kullmann F, Frund R, et al. Auditory event-related cerebral potentials (P300) in hepatic encephalopathy: topographic distribution and correlation with clinical and psychometric assessment. Hepatogastroentrology 1997; 44(16): 1002–12
Watanabe E. Cerebral changes in hepatic encephalopathy. J Gastroenterol Hepatol 1998; 13(7): 752–60
Zeneroli ML, Cioni G, Vezzelli C, et al. Prevalence of brain atrophy in liver cirrhosis patients with chronic persistent encephalopathy: evaluation by computed tomography. J Hepatol 1987; 4: 283–92
Weissenborn K, Kolbe H. The basal ganglia and portal systemic encephalopathy. Metab Brain Dis 1998; 13(4): 261–7
Lockwood A, Weissenborn K, Burchert W, et al. Correlations between neuropsychological test performance and brain metabolism in cirrhotics [abstract]. Turk J Gastroenterol 1999; 10: 18
Macdonald GA, Frey KA, Agranoff BW, et al. Cerebral benzodiazepine receptor binding in vivo in patients with recurrent hepatic encephalopathy. Hepatology 1997; 26(2): 277–82
Zeneroli ML, Cioni G, Vezzelli C, et al. Brain magnetic resonance imaging in liver cirrhosis patients with encephalopathy. Hepatology 1990; 10: 26
Krieger S, Jauss M, Jansen O, et al. Neuropsychiatric profile and hyperintensive globus pallidus on Tl-weighted magnetic resonance images in liver cirrhosis. Gastroenterology 1996; 111: 147–55
Kato A, Kaneta H, Obara H, et al. Cerebral glucose metabolism and hyperintense on T1-weighted magnetic resonance images on globus pallidus in patients with liver cirrhosis [abstract]. Turk J Gastroenterol 1999; 10: 6
Krieger S, Jauss M, Jansen O, et al. MRI findings in chronic hepatic encephalopathy depend on portosystemic shunt: results of a controlled prospective clinical investigation. J Hepatol 1997; 27(1): 121–6
Nolte W, Wiltfang J, Schindler C, et al. Bright basal ganglia in T1-weighted magnetic resonance images are frequent in patients with portal vein thrombosis without liver cirrhosis and not suggestive of hepatic encephalopathy. J Hepatol 1998; 29(3): 443–9
Ross BD, Danielsen ER, Blttml S. Proton magnetic resonance: the new gold standard for diagnosis of clinical and subclinical hepatic encephalopathy. Dig Dis 1996; 14(1): 30–9
Zwingmann C, Brand A, Richter-Landsberg C, et al. Multinu-clear NMR spectroscopy studies on NH4Cl-induced metabolic alterations and detoxification processes in primary astrocytes and glioma cells. Dev Neurosci 1998; 20(4–5): 417–26
Uribe M, Conn HO. Dietary management of portal-systemic encephalopathy. In: Conn HO, Bircher J, editors. Hepatic encephalopathy syndromes and therapies. Bloomington: Medi Ed Press, 1994; 331–49
Bianchi GP, Marchesini G, Fabbri A, et al. Vegetable versus animal protein diet in cirrhotic patients with chronic encephalopathy: a randomized cross-over comparison. J Intern Med 1993; 233: 385–92
Uribe M, Marquez MA, Ramos GG, et al. Treatment of chronic portal systemic encephalopathy with vegetable and animal protein diets. Dig Dis Sci 1982; 27: 1109–16
Greenberger NJ, Carley J, Schenker S, et al. Effect of vegetable and animal protein diets in chronic hepatic encephalopathy. Dig Dis 1977; 22: 845–55
Naylor CD, O ’Rourkee K, Detsky AS, et al. Parenteral nutrition with branched-chain amino acids in hepatic encephalopathy: a meta-analysis. Gastroenterology 1989; 97: 1033–42
Egberts ER, Schomerus H, Hamster W, et al. Branched chain amino acids in the treatment of latent portosystemic encephalopathy. Gastroenterology 1985; 88: 887–95
Plauth M, Egberts ER, Hamster W, et al. Long-term treatment of latent portosystemic encephalopathy with branched-chain amino acids. J Hepatol 1993; 17: 308–14
Horst D, Grace ND, Conn HO. 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: 279–87
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 portalsystemic encephalopathy: a double-blind randomized trial. Hepatology 1987; 7: 629–34
Huchzermeyer H, Schumann C. Lactulose: a multifaceted substance. Z Gastroenterol 1997; 35: 945–55
Bircher J, Müller J, Guggemheim P, et al. Treatment of chronic portalsystemic encephalopathy with lactulose. Lancet 1966; I: 890–3
Orlandi F, Brunelli E, Benedetti A, et al. Clinical trials of non-absorbable disaccharide therapy in hepatic encephalopathy. In: Conn HO, Bircher J, editors. Hepatic encephalopathy: syndromes and therapies. Bloomington: Medi-Ed Press, 1994: 209–18
Fredrick L, Weber J. Lactulose and combination therapy of hepatic encephalopathy: the role of the intestinal microflora. Dig Dis Sci 1996; 14: 53–63
Blanc P, Daures JP, Rouillon JM, et al. Lactilol or lactulose in the treatment of chronic hepatic encephalopathy: results of a meta-analysis. Hepatology 1992; 15: 222–8
Morgan MY, Hawley KE. Lactilol versus lactulose in the treatment of acute hepatic encephalopathy in cirrhotic patients: a double-blind randomised trial. Hepatology 1987; 7: 1278–84
Camma C, Fiorello F, Tine F, et al. Lactilol in treatment of chronic hepatic encephalopathy: a meta-analysis. Dig Dis Sci 1993; 38: 916–22
Uribe M, Marquez MA, Gargaramos G. Treatment of chronic portal systemic encephalopathy with lactose in lactase-deficient patients. Dig Dis Sci 1980; 25: 914–28
Uribe M, Moran S, Poo JL, et al. Beneficial effect of carbohydrate maldigestion induced by a disaccharidase inhibitor (AO-128) in the treatment of chronic portal-systemic encephalopathy: a double-blind, randomized controlled trial. Scand J Gastroenterol 1998; 33(10): 1099–106
Conn HO, Leevy CM, Vlahceviz, ZR, et al. Comparison of lactulose and neomycin in the treatment of chronic portalsystemic encephalopathy. Gastroenterology 1977; 72: 573–83
Soeters PB, van Leeuwen PA. Ammonia and glutamine metabolism of the intestine: the effect of lactulose and neomycin [in German]. Infusionsther Klin Ernahr 1986; 13(4): 186–90
Atterbury CE, Maddrey WC, Conn HO. Neomycin-sorbitol and lactulose in the treatment of acute portal-systemic encephalopathy: a controlled double-blind clinical trial. Am J Dig Dis 1978; 23: 398–406
Berk DP, Chalmers T. Deafness complicating antibiotic therapy of hepatic encephalopathy. Ann Intern Med 1970; 73: 393–6
Morgan MH, Read AF, Speller DCE. Treatment of hepatic encephalopathy with metronidazole. Gut 1982; 23: 1–7
Bucci L, Palmieri GC. Double-blind, double-dummy comparison between treatment with rifaximin and lactulose in patients with medium to severe degree hepatic encephalopathy. Curr Med Res Opin 1993; 13: 109–18
Tarao K, Ikeda T, Hayashi K. Successful use of vancomycin hydrochloride in the treatment of lactulose-resistent chronic hepatic encephalopathy. Gut 1990; 31: 702–6
Mullen KD, Martin JV, Mendelson WB. Could an endogenous benzodiazepine ligand contribute to hepatic encephalopathy? Lancet 1988; I: 457–9
Basile AS, Pandl L, Jaouni T. Brain concentrations of benzodiazepines are elevated in an animal model of hepatic encephalopathy. Proc Natl Acad Sci U S A 1990; 87: 5263–7
Basile AS, Hughes RD, Harrison IM. Elevated brain concentrations of 1,4-bezodiazepines in fulminant hepatic failure. N Engl JMed 1991; 325: 473–8
Olasmaa M, Rothstein JD, Guidotto A. Endogenous benzodiazepine receptor ligands in human and animal hepatic encephalopathy. J Neurochem 1990; 55: 2015–23
Jalan R, Turjanski N, Teijeira JM, et al. Increased availability of central benzodiazepine receptors in patients with chronic hepatic encephalopathy and alcohol relate cirrhosis. Gut 2000; 46(4): 546–52
Cadranel JF, el Younsi M, Pidoux B, et al. Flumazenil therapy for hepatic encephalopathy in cirrhotic patients: a double-blind pragmatic randomized placebo study. Eur J Gastroenterol Hepatol 1995; 7(4): 325–9
Groeneweg M, Gyr K, Amrein R, et al. Effect of flumazenil on the electroencephalogram of patients with portosystemic encephalopathy: results of a double-blind randomized, placebo-controlled multicenter trial. Electroencephalogr Clin Neurophysiol 1996; 98: 29–34
Pomier-Layrargues JF, Giguere JF, Lavoie S, et al. Flumazenil in cirrhotic patients in hepatic coma. a randomized double-blind placebo controlled crossover trial. Hepatology 1994; 19: 32–7
Barbaro G, Di Lorenzo G, Soldini M, et al. Flumazenil for hepatic encephalopathy grade III and IVa in patients with cirrhosis: an Italian multicentre double-blind placebo-controlled crossover study. Hepatology 1998; 28(2): 374–8
Michel H, Solere M, Grainer P. Treatment of cirrhotic hepatic encephalopathy with L-dopa: a controlled trial. Gastroenterology 1980; 79: 207–11
Morgan MH, Jakobovits AW, James M, et al. Successful use of bromocriptine in the treatment of hepatic encephalopathy. Gastroenterology 1980; 78: 663–70
Uribe M, Farca A, Marquez MA, et al. Treatment of chronic portal systemic encephalopathy with bromocriptine. Gastroenterology 1979; 76: 1347–51
Ferenci P, Herneth A, Püspök A, et al. Neuropharmacologic modulation of hepatic encephalopathy: experimental and clinical data. Adv Exp Med Biol 1994; 368: 103–12
Yurdaydin C, Karavelioglu D, Onaran O, et al. Opoid receptor ligands in human hepatic encephalopathy. J Hepatol 1998; 29(5): 796–801
Meuret G, Beck K, Keul J, et al. On therapy of hepatic coma with metabolites of the urea cycle, glutamate and alpha-ketoglutarate. Dtsch Med Wochenschr 1968; 93(24): 1194–7
Staedt U, Leweling H, Gladisch R, et al. Effects of ornithine aspartate on plasma ammonia and plasma amino acids in patients with cirrhosis: a double-blind, randomized study using a four-fold crossover design. J Hepatol 1993; 19: 424–30
Kircheis G, Nilius R, Held C, et al. Therapeutic efficacy of L-ornithine-L-aspartate infusions in patients with cirrhosis and hepatic encephalopathy: results of a placebo-controlled, double-blind study. Hepatology 1997; 25: 1351–60
Kircheis G, Quack GEH. Ornithine-L-aspartate in the treatment of hyperammonemia and hepatic encephalopathy. In: Conn HO, Bircher J, editors. Hepatic encephalopathy: syndromes and therapies. Bloomington: Medi-Ed Press, 1994: 373–83
Mendelhall CL, Rouster S, Marshall L, et al. A new therapy for portal systemic encephalopathy. Am J Gastroenterol 1986; 81: 540–3
Sushama S, Dasarathy S, Tandon RK, et al. Sodium benzoate in the treatment of acute hepatic encephalopathy: a double-blind randomized trial. Hepatology 1992; 16: 138–44
Riordan SM, Wiliams R. Treatment of hepatic encephalopathy. N Engl J Med 1997; 337: 473–9
Tokluoglu S, Degertekin H, Yavuz Ö, et al. The effect of maintenance zinc treatment in liver cirrhosis with hepatic encephalopathy [abstract]. Turk J Gastroenterol 1999; 10: 20
Marchetti P, Amodio P, Del Piccolo F, et al. Prognostic value of plasma zinc value in cirrhotic patients [abstract]. Turk J Gastroenterol 1999; 10: 14
Robert L, Carithers Jr RL. Liver transplantation, AASLD Practice Guidelines. Hepatology 2000; 6(1): 122–35
Naegele T, Grodd W, Viebahn R, et al. MR imaging and (1) H spectroscopy of brain metabolites in hepatic encephalopathy: time-course of renormalization after liver transplantation. Radiology 2000; 216(3): 683–91
Dagenais MH, Bernard D, Marleau D, et al. Surgical treatment of severe postshunt hepatic encephalopathy. World J Surg 1991; 15: 109–13
Cotzias GC. Manganese in health and disease. Physiol Rev 1958; 38: 503–32
Pujol A, Pujol J, Graus F, et al. Hyperintense globus pallidus on T1-weighted MRI in cirrhotic patients associated with severe of liver failure. Neurology 1993; 43: 65–9
Hauenstein KH, Haag K, Ochs A, et al. The reducing stent: treatment for transjugular intrahepatic portosystemic shunt-induced refractory hepatic encephalopathy and liver failure. Radiology 1995; 194: 175–9
Read AF, McCarthy CF, Heaton KW, et al. Lactobacillus acidophilus in treatment of hepatic encephalopathy. BMJ 1996; 1: 1267–9
Macbeth WAAG, Kaas EH, McDermott WV. Treatment of hepatic encephalopathy by alterations of intestinal flora and Lactobacillus acidophilus. Lancet 1965; I: 399–403
Loguercio C, Abbiati R, Rinaldi M, et al. Long-term effects of enterococcus faecium SF68 versus lactulose in the treatment of patients with cirrhosis and grade 1–2 hepatic encephalopathy. J Hepatol 1995; 23: 39–46
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Gerber, T., Schomerus, H. Hepatic Encephalopathy in Liver Cirrhosis. Drugs 60, 1353–1370 (2000). https://doi.org/10.2165/00003495-200060060-00008
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DOI: https://doi.org/10.2165/00003495-200060060-00008