Ammonia: The Old and the New
Experimental evidence relating increased blood ammonia to cerebral dysfunction dates back to 1877 when Eck first created a portocaval shunt. In the 1930’s Van Caulert and Kirk described mental disturbances in cirrhotics receiving ammonium salts.1 However, it wasn’t until 1952 that Gabuzda, Phillips, Schwartz, and Davidson2,3 recognized that symptoms and EEG changes indistinguishable from hepatic encephalopathy could be produced in cirrhotics given ammonium-containing cation-exchange resins, ammonium salts, urea, or protein orally. Two years later a patient with a normal liver who had a portocaval shunt following a Whipple procedure for carcinoma of the pancreas was reported by McDermoff and Adams4 to have recurrent episodes of irrationality, confusion, disorientation, incontinence, drowsiness, apathy, stupor, and sometimes coma Blood ammonia and EEG abnormalities were correlated with the manifestations, which were reproducible by feeding the patient meat, urea, ammonium-containing cation-exchange resin, or ammonium chloride. Such observations in cirrhotics and in patients with portacaval shunts have been confirmed many times since these early reports, so a relationship between ammonia and the clinical syndrome of hepatic coma is well established.
KeywordsHepatic Encephalopathy Blood Ammonia Hepatic Coma Portacaval Shunt Glutamine Synthesis
Unable to display preview. Download preview PDF.
- 1.G. J. Gabuzda, Hepatic coma: Clinical consideration, pathogenesis, and management, in “Advances in Internal Medicine:’ Dock, W. and Snapper I. eds., Vol. II, Chicago Year Book, pp. 1173 (1962).Google Scholar
- 2.G. J. Gabuzda, G. B. Phillips, and C. S. Davidson, Reversible toxic manifestations in patients with cirrhosis of the liver given cation-exchange resins, New Eng. J. Med. 246: 124 (1952).Google Scholar
- 6.H. O. Conn and M. M. Lieberthal, The hepatic coma syndromes and lactulose. William and Wilkins, Baltimore (1979).Google Scholar
- 18.R. T. Hourani, E. M. Hamlin, and T. B. Reynolds, Cerebrospinal fluid glutamine as a measure of hepatic encephalopathy, Arch. Int. Med. 127: 1033 (1971).Google Scholar
- 19.T. E. Duffy, F. Vergara, and F. Plum, a-ketoglutaramate in hepatic encephalopathy, in: “Brain Dysfunction in Metabolic Disorders,” F. Plum ed., Res. Publ. Assoc. Nerv. Ment. Dis. 53: 39 (1974).Google Scholar
- 20.F. Plum and B. Hindfelt, The neurological complications of liver disease, in: “Handbook of Clinical Neurology,” P. H. Vinken and G..W. Bruyn, Vol. 27, Metabolic and Deficiency Diseases of the Nervous System, Part I. American Elsevier, New York Publishing Co. Inc., pp. 349–377 (1976).Google Scholar