Cases Of Hepatic Encephalopathy Research Articles

Determine the Frequency of Factors Leading to Hepatic Encephalopathy in Patients with Liver Cirrhosis

Aim: To determine the frequency of factors leading to hepatic encephalopathy in patients with liver cirrhosis. Study design: Retrospective study Place and duration of study: Department of Internal Medicine, Rawalpindi Medical Universityfrom 01-07-2021 to 30-06-2022 Methodology: One hundred patients were included and divided into two groups. One group was those which developed hepatic encephalopathy while the other group was of those which did not develop any hepatic encephalopathy. Various risk factors and their frequencies were measured through a modelled hepatic encephalopathy pharmacological, clinical as well as demographic data. Comparison on the frequency of the variable seen in hepatic encephalopathy patients with non-hepatic encephalopathy was conducted for better assessment of the frequency of risk factors. Results: Seventy patients did not develop hepatic encephalopathy while 30 patients did develop hepatic encephalopathy. Fifteen patients had developed alcoholic liver cirrhosis followed by hepatitis C and non-alcoholic cirrhosis. Age greater than 60 years had a percentage of 60% within cases of hepatic encephalopathy only. Prevalence of hepatitis C cirrhosis in 36.6%, diabetes in 49%, cardiovascular disease in 51%, hepatocellular carcinoma in 6.6%, use of proton pump inhibitor in 63.3% were presented and were higher than who did not develop hepatic encephalopathy. Benzodiazepines, gamma aminobutyric acid [GABA]ergics, opioids and proton pump inhibitors each of them was associated with increased chances of hepatic encephalopathy. Conclusion: Hepatic encephalopathy was more commonly observed in older patients (60%) and more specifically in male population. Higher frequency of comorbidities (hypertension, diabetes, cardiovascular disease, ascites, alcoholic cirrhosis), CCI score and pharmacological drugs were identifiable risk factors for hepatic encephalopathy. Key words: Neurotoxicity; Cirrhosis, Complications, Hepatitis C, Deteriorate

Development of a New Index to Distinguish Hepatic Encephalopathy through Automated Quantification of Globus Pallidal Signal Intensity Using MRI.

Hyperintensities within the bilateral globus pallidus on T1-weighted magnetic resonance images were present in some liver cirrhosis patients with hepatic encephalopathy. The symptoms of covert hepatic encephalopathy are similar to those of mild dementia. We aimed to develop a new diagnostic index in which to distinguish hepatic encephalopathy from dementia. The globus pallidus signal hyperintensity was quantified using three-dimensional images. In addition, the new index value distribution was evaluated in a cohort of dementia patients. Signal intensity of globus pallidus significantly increased in liver cirrhosis patients with hepatic encephalopathy compared to those without hepatic encephalopathy (p < 0.05), healthy subjects (p < 0.05) or dementia patients (p < 0.001). Only 12.5% of liver cirrhosis patients without hepatic encephalopathy and 2% of dementia patients exceeded the new index cut-off value of 0.994, which predicts hepatic encephalopathy. One dementia patient in our evaluation had a history of liver cancer treatment and was assumed to have concomitant hepatic encephalopathy. The automatic assessment of signal intensity in globus pallidus is useful for distinguishing liver cirrhosis patients with hepatic encephalopathy from healthy subjects and liver cirrhosis patients without hepatic encephalopathy. Our image analyses exclude possible cases of hepatic encephalopathy from patients with neurocognitive impairment, including dementia.

Outcomes of Hepatitis E in Pregnancy

Introduction: Hepatitis E virus infection is an emerging challenge of the developing world. During pregnancy, hepatitis E Virus results in devastating effects endangering the life of both mother and fetus. Hepatitis E contribute to 19% to 25% of maternal and 7-13% of all neonatal deaths. Purpose of this study is to see the association between hepatitis E virus infection and feto-maternal outcomes in pregnancy. Material &amp; Methods: A prospective study design was used. Study was conducted in a tertiary health care sector for a period of March 2018 to January 2021 with sample size of 60 pregnant women. Study was conducted after getting institutional approval and informed consent was taken from all the study participants. Ethical considerations were followed throughout the study period. Data was analyzed using SPSS version 23.0 and descriptive statistics was used. Results: Out of 60 pregnancies, 19 (30%) suffered with PPH, 14 (23.33%) had history of DIC and 16 (26.66%) cases of hepatic encephalopathy were evident. Preterm SVD was a majority reason seen for ending the pregnancy. Results showed that hepatitis E virus caused multiple fetal morbidities. Conclusion: High mortality rate was evident in hepatitis E virus infection affected pregnancies in this study. There is a need to educate pregnant ladies regarding preventive measures to avoid fulminant consequences. Emphasis should be given to follow hygienic practices during pregnancy and proper antenatal visits are mandatory to educate the women. Keywords: Hepatitis E, Fetus Outcomes, Pregnancy, Maternal.

Hepatic Encephalopathy Linked to COVID-19 in a Pediatric Case: A Rare Presentation of COVID-19

Introduction: Coronavirus disease 2019 (COVID-19) has been identified as an emerging disease in 2019. Complications of the disease remain unknown, and extensive research has been conducted to investigate it. Due to the way the disease is transmitted through ACE2, the virus affects many organs. So far, no cases of hepatic encephalopathy following the virus have been reported. Case Presentation: A 3-year-old boy referred to Ali-Ibn-Abitaleb Hospital in Zahedan, Iran was hospitalized with icterus and decreased level of consciousness. After examinations and evaluation, the patient was diagnosed with hepatic encephalopathy following COVID-19. Unfortunately, despite the treatments, the patient was finally expired. Conclusions: To the best of our knowledge, this is the first case report demonstrating COVID-19 related hepatic encephalopathy. This case is a useful reminder for doctors to be much more vigilant and cautious about possible side effects of COVID-19.

Performance of albumin-bilirubin score in prediction of hepatic encephalopathy in cirrhotic patients with acute variceal bleeding

BackgroundHepatic encephalopathy exacerbates the morbidity, delays hospital discharge, and increases the rate of readmissions of cirrhotic patients, particularly those are admitted by acute variceal bleeding. We evaluated the performance of albumin-bilirubin score in prediction of hepatic encephalopathy in cirrhotic patients with acute variceal bleeding, in comparison to Child-Pugh and MELD scores. This prospective cohort study was conducted on 250 cirrhotic patients who were consecutively presented by acute variceal bleeding in the period from January to December 2020 at Tanta university emergency hospital. Albumin-bilirubin, Child-Pugh, and MELD scores were measured at admission, and then all patients were followed up for 4 weeks after endoscopic bleeding control for possible occurrence of hepatic encephalopathyResultsAlbumin-bilirubin, Child-Pugh, and MELD scores had significant performances in prediction of hepatic encephalopathy in cirrhotic patients with acute variceal bleeding; in this regard, albumin-bilirubin score had the highest accuracy (AUC 0.858, CI 0.802-0.914, sig 0.000) followed by Child-Pugh score (AUC 0.654, CI 0.574–0.735, sig 0.001) and then MELD score (AUC 0.602, CI 0.519–0.686, sig 0.031). The cumulative incidence of hepatic encephalopathy in cirrhotic patients with albumin-bilirubin grade 3 was found to be significantly more than that present in albumin-bilirubin grade 2; most of these hepatic encephalopathy cases occurred in the first 2 weeks of follow-up period.ConclusionsAlbumin-bilirubin score has a significant performance in risk prediction of hepatic encephalopathy in cirrhotic patients with acute variceal bleeding better than Child-Pugh and MELD scores. Albumin-bilirubin grades could be used as a risk stratifying tool to triage cirrhotic patients who will benefit from early discharge after bleeding control and those patients who will benefit from prophylactic measures for hepatic encephalopathy.

Efficacy of Lactulose Vs Lactulose with Rifaxamin in patients with Hepatic Encephalopathy: A Randomized Control Trial

Introduction: Hepatic encephalopathy (HE) is one of the deadliest complications of cirrhosis. The basic underlying pathophysiology is the increased production of ammonia which can cross the blood brain barrier and can influence in multiple ways. For managing HE various therapeutic regime have been tried in the past with varying degree of success grate and side effect profiles. Neomycin, Enema, Lactulose, Metronidazole, Vancomycin, Rifaxamin etc. are the various modalities used. Lactulose is the most widely used and Rifaxamin; an antibiotic is recently used with good success rate.&#x0D; Objective: To compare the outcome of lactulose alone versus lactulose with Rifaxamin in cases with hepatic encephalopathy.&#x0D; Methodology: A randomized control trial was conducted on indoor patients of medical departments, Mayo Hospital. Lahore from June 2017 to December 2017. The cases of hepatic encephalopathy of any grade within last 7 days of its onset with age range of 20-60 years were included. The cases with end stage cardiac or renal failure were excluded. The cases were divided into two groups; A and B. The group A was treated with lactulose alone in a dose to 20 to 100 ml per day to maintain stool frequency of at least 2 per day and the group B was treated with same amount of lactulose along with Rifaxamin in a dose of 550 mg thrice a day. The efficacy was assessed daily till there were no signs and symptoms of hepatic encephalopathy till day 7 where final outcome was seen to label efficacy or mortality as Yes or No.&#x0D; Results: In the present study, 100 cases of hepatic encephalopathy were included. Out of these 50 were in each group. The maximum cases were in Child Pugh class in both groups comprising 26 (52%) and 25 (50%) in group A and B respectively. The mean age at presentation was 46.73± 9.13 years in A as compared to 51.25± 9.04 years in group B with p= 0.54. The efficacy in group A was seen in 28 (56%) of cases and in group B as 38 (76%) of cases with p= 0.01. This difference was also statistically significant in terms of mortality which was seen I n 22 (44%) of cases in group A and 12 (24%) in group B (p=0.01).&#x0D; Conclusion: Combination of lactulose plus Rifaxamin is significantly better as compared to lactulose alone for the treatment as well as to reduce mortality in cases of hepatic encephalopathy.&#x0D; &#x0D; Key words: Lactulose, Rifaxamin, Cirrhosis, Encephalopathy

Phenotype and genotype of twelve Chinese children with mitochondrial DNA depletion syndromes

Objective: To explore the phenotype and genotype of mitochondrial DNA depletion syndromes (MDS) in Chinese children. Methods: The clinical and genetic data of 12 MDS patients (8 were boys and 4 were girls) diagnosed in the Department of Neurology in Beijing Children's Hospital, Capital Medical University from October 2010 to April 2018 were retrospectively collected and analyzed. Results: The developmental milestones were normal or mildly retardated before disease onset. The age of onset ranged from 0 to 2.9-year-old. Most cases developed postnatal or after infection. The most common initial symptoms were feeding difficulty, seizure, muscle weakness, psychomotor regression and hepatic dysfunction. At the last evaluation, all the patients had developmental retardation, failure to thrive, muscle weakness, and dysphagia. Other clinical features were weight loss (9 cases), hearing impairment (7 cases), ptosis (6 cases), seizure (5 cases), dyspnea (4 cases), visual impairment (1 case), hirsutism (1 case), lactic acidosis (7 cases), elevated hepatic enzymes (4 cases) and creatine kinase (2 cases), elevated protein in cerebrospinal fluid (3 cases), abnormalities on screening for inborn error of metabolism (10 cases) and brain magnetic resonance imaging (MRI) (10 cases), abnormal electromyogram (including neurogenic or myogenic injury) (5 cases). Five patients died of infection or multiple organ failure. A total of 18 novel mutations presented below were detected in these patients. Among the 6 cases of encephalomyopathy, there were 3 with SUCLG1 mutation (c. 916G>T, c. 619T>C, c. 980dupT were novel), 2 with SUCLA2 mutation (c. 851G>A, c.971G>A were novel), and one with RRM2B mutation (c.456-2A>G, c.212T>C were novel). All the cases of hepatic encephalopathy all had POLG mutations (c. 3151G>A, c. 2294C>T, c. 2858G>C, c. 680G>A and c. 150_158delGCAGCAGCA were novel). Two cases of infantile-onset spinocerebellar ataxia had TWNK mutations (c. 1163C>T, c. 1319T>C, c. 1388G>A and c. 257_258delAG were novel). One case of myopathy had TK2 mutations (c.557C>G and c.341A>T were novel). Conclusions: The clinical and genetic features of MDS were heterogeneous. Eighteen novel mutations in six MDS related genes were reported, which expanded the genetic spectrum of MDS in Chinese children.

Posterior Reversible Encephalopathy Syndrome (PRES) in Adult Multi-Visceral Transplant patients- Cambridge University Hospital experience

Introduction: Neurological dysfunction after intestinal or multivisceral transplant (MVT) can arise due to drug toxicity, delerium due to sepsis, renal failure, stroke or central nervous system (CNS) infection. Less well known is posterior reversible encephalopathy syndrome (PRES).[1] We report here cases of PRES at a UK adult intestinal transplant centre. Methods: Data is collected prospectively on a database which was interrogated retrospectively to identify cases. Following this, case notes and radiology reports were reviewed. Results: We report three cases of PRES in our MVT cohort. Two females and one male with a median age of 42 years old. All patients were diagnosed by consistent imaging findings on magnestic resonance imaging (MRI) and exclusion of other causes. The time to diagnosis of PRES post transplant was 44 days, 9 days and 7 days (delayed in the first case as the initial MRI was normal but a further scan 7 days later showed consistent features of PRES). Patients presented with headache and confusion, partial status epilepticus and headache and visual hallucinations, resectively. All patients responded to withdrawal of tacrolimus and all were successfully rechallenged with tacrolimus at a later date. Two patients required temporary anti-hypertensive treatment. Interestingly, all patients had pre-transplant encephalopathy (2 cases of hepatic encephalopathy and one case of D-lactic encephalopathy). Conclusion: PRES was first Described by Hinchey et al in 1996.[2] There are variety of presenting symptoms including headache, visual disturbace, confusion, and hemianopia. The diagnosis of this condition in the setting of MVT can be challenging, characteristic features are best seen on T2-weighted FLAIR MRI sequences. The mechanism of PRES is unknown, however, there are proposed theories including cerebral autoregulation failure and hypoperfusion, immunologic theory through T cell/Endothelial cell interaction and circulating cytotoxic hypothesis.[3] PRES is uncommon but the prognosis of this reversable neurologic condition is good if recognised in a timley manner. The diagnosis of PRES can be challenging. Our data would suggest that there should be a particularly high level of suspicion in patients who were encephalopathic pre-transplant. Complete recovery with immunosuppression switching is possible and once there has been complete neurologica recovery, tacrolimus can be successfully reintroduced.

Hepatic encephalopathy: early diagnosis in pediatric patients with cirrhosis.

As acute liver failure (ALF) and chronic liver disease (cirrhosis) continue to increase in prevalence, we will see more cases of hepatic encephalopathy. Primary care physician are often the first to suspect it, since they are familiar with the patient's usual physical and mental status. This serious complication typically occurs in patients with severe comorbidities and needs multidisciplinary evaluation and care. Hepatic encephalopathy should be considered in any patient with acute liver failure and cirrhosis who presents with neuropsychiatric manifestations, decrease level of consciousness (coma), change of personality, intellectual and behavioral deterioration, speech and motor dysfunction. Every cirrhotic patient may be at risk; potential precipitating factors should be addressed in regular clinic visits. The encephalopathy of liver disease may be prominent, or can be present in subtle forms, such as decline of school performance, emotional outbursts, or depression. "Subtle form" of hepatic encephalopathy may not be obvious on clinical examination, but can be detected by neurophysiologic and neuropsychiatric testing.

Spleno-adrenal shunt: A novel alternative for portosystemic decompression in children with portal vein cavernous transformation

PurposeChildren with portal vein cavernous transformation (PVCT) can develop life-threatening variceal hemorrhage from progressive portal hypertension. While spleno-renal shunt±splenectomy is the most common portosystemic decompression surgery performed in children, we have adopted a modified spleno-adrenal (SA) shunt for complicated PVCT. We describe our 10year experience focusing on technique evolution and treatment efficacy. MethodsBetween 2001 and 2011, 15 children (9 girls and 6 boys, ages 3–11years, median: 6years) with PVCT, portal hypertension, and hypersplenism were treated with SA shunt with splenectomy in Shanghai Children's Medical Center. All children in the study had endoscopy proven active esophageal variceal bleeding requiring multiple transfusions (mean: 4.2 units) with failed sclerotherapy (mean: 2.6 times). Greater omental vein pressure (GVP) approximating portal venous pressure was measured pre- and post-SA shunt. Pre- and post-operative ammonia levels were obtained. Follow-up ranged from 6months to 10years (mean: 4.2±2years). ResultsIntra-operative adrenal vein diameter and length ranged from 0.7 to 1.8cm and 2 to 3cm, respectively. Intra-operative GVPs pre-and post-SA shunt were (30±11) and (22±7) mmHg, respectively (p<0.01). On follow-up, there have been no recurrences of GI bleeding. Liver function tests remained normal in all children with the exception of elevated post-operative mean blood ammonia levels [Pre (18±7) mmol/L, post (60±17) mmol/L (p<0.05)] in all children. Ammonia levels normalized in all cases on outpatient follow-up. There have been no cases of hepatic encephalopathy, and all have normal age appropriate neurodevelopment (Bayley's assessment). Barium swallow and/or upper endoscopy showed interval resolution of esophageal varices in all children, and vascular ultrasound showed patent shunt anastomosis without stricture in 14 (93%). ConclusionsThe left adrenal vein is a viable conduit for effective selective portosystemic decompression. Similar to the more traditional spleno-renal shunt, SA appears also to have the advantage of preventing hepatic encephalopathy preserving neurodevelopment, although the rise in post-operative ammonia levels was unexpected. Longer follow-up is needed to look for late signs of encephalopathy assessing neurodevelopment long term.

Precipitating factors of Hepatic Coma

Objective: The objective of this study was to: Find the age and gender distribution and frequency of preci-pitating factors of hepatic coma in chronic liver dise-ase. Study Design: Comparative cross - sectional study. Material and Methods: In the Gastroenterology Unit and East Medical Ward KEMU. The study duration was one year and started in May 2005. Fifty cases of hepatic encephalopathy due to chronic liver disease were selected. It was probability sampl-ing and random table was used. The complete record of the patients was maintained on the structured pro-forma. After informed consent all record was kept con-fidential. Results: Constipation, upper gastrointestinal bleed-ing, and infection were the common precipitating fac-tors. It was found that constipation was more in old age group (75%) and the difference was found signifi-cant (p< 0.05). The upper gastrointestinal bleeding was found more in young group (44%) and this was found significant (p < 0.05). Conclusions: The precipitating factors of hepatic encephalopathy should be early recogonized and awa-reness should be created. Lifestyle modifications like exercise, low fat diet, high fibre diet and active work should be encouraged to prevent constipation. Emer-gency endoscopic facilities should be made available. Keywords: Cirrhosis, encephalopathy, hepatic.

Hepatic encephalopathy: Suspect it early in patients with cirrhosis

As viral hepatitis and nonalcoholic fatty liver disease continue to increase in prevalence, we will see more cases of hepatic encephalopathy. Primary care physicians are often the first to suspect it, as they are familiar with the patient's usual mental and physical status. This serious complication typically occurs in patients with severe comorbidities and requires multidisciplinary evaluation and care.

Favorable clinical outcome using a covered stent following transjugular intrahepatic portosystemic shunt in patients with portal hypertension

To compare retrospectively the clinical outcomes in patients treated with transjugular intrahepatic portosystemic shunt (TIPS) using the novel polytetrafluoroethylene-covered stents (Fluency) and bare stents. Sixty consecutive patients with portal hypertension treated with TIPS from April 2007 to April 2009 were included. TIPS creation was performed with Fluency stent grafts in 30 patients (group A) and with bare stents in 30 patients (group B). Liver function, TIPS patency and clinical outcomes were evaluated every 3 months after procedures. During hospitalization, there were no cases of hepatic encephalopathy (HE) and recurrence of variceal bleedings. Acute shunt occlusion was found in one patient in each group. Follow-ups were performed in group A with average time of 6.16 +/- 3.89 months and in group B with 8.34 +/- 4.42 months. The rates of recurrent bleeding, shunt occlusion, HE and mortality were 0.03, 0.0, 16.7 and 0% in group A, and 20.0, 30.0, 20.0 and 13.3% in group B, respectively. There was no difference of HE between group A and group B. The decrease of portal pressure and portosystemic pressure gradient, and the increase of portal flow were 34.1 and 23.3%, 60.0 and 52.8%, and 189.5 and 111.1% in group A and B, respectively. There were no differences of liver function between group A and B. The Fluency stent graft is relatively safe and effective in TIPS creation, with a high patency rate compared with bare stents.

Promyelocytic leukemia protein is redistributed during the formation of intranuclear inclusions independent of polyglutamine expansion: an immunohistochemical study on Marinesco bodies.

Marinesco bodies (MBs) are ubiquitinated intranuclear inclusions observed in nigral pigmented neurons. They increase in number during aging, and their formation is considered to represent a cellular reaction to stress, but is not always associated with neuronal degeneration. We conducted immunohistochemical studies on MBs abundant in myotonic dystrophy brains and compared their nature with that of neuronal intranuclear inclusions (NIIs) in polyglutamine diseases. First, we examined the relationship between MBs and polyglutamine proteins and demonstrated that one of the polyglutamine proteins, ataxin-3, as well as a 19S proteasomal protein, was preferentially recruited into MBs even in the absence of expanded polyglutamine. This indicates that an alternative mechanism during the formation of MBs that is not related to polyglutamine expansion or neuronal degeneration may recruit ataxin-3 into nuclear inclusions in a protein-specific manner. Secondly, we investigated the relationship between MBs and promyelocytic leukemia protein (PML), a nuclear matrix-associated protein that is normally localized to intranuclear punctate structures (PML nuclear bodies) and is known to reorganize itself in association with polyglutamine aggregation. In nigral pigmented neurons in myotonic dystrophy, spherical, hemispherical or rod-like PML-immunoreactive structures, in addition to punctate structures, were observed in their nuclei. Similar PML redistribution was also observed in nigral pigmented neurons in aged controls and cases of hepatic encephalopathy, 2 other conditions in which abundant MBs are formed. Double immunofluorescence study revealed that these PML-positive structures undergo morphological changes in association with ubiquitin accumulation during MB formation. It is therefore indicated that PML reorganization does not represent a specific nuclear event involved in the pathogenesis of polyglutamine diseases, but may commonly occur during the formation of intranuclear inclusions as a reaction against various stresses that involve the ubiquitin-proteasome pathway.

Percutaneous vascular intervention after surgical shunting for portal hypertension.

Twenty percutaneous transluminal angioplasty (PTA) procedures and 13 percutaneous venous embolization (PVE) procedures were performed in 23 patients who either had or were at risk for the development of recurrent bleeding, hepatic encephalopathy, or both after surgical shunt placement for portal hypertension. PTA, performed in 12 patients with significant shunt stenoses, resulted in reduction or elimination of gradients in all patients; rebleeding has occurred in only one patient. Complications consisted of one fatal rupture of a mesocaval interposition vein graft and one balloon rupture requiring surgical removal. PVE, performed in 11 patients, resulted in measurable improvement in four of seven encephalopathic patients and temporary control in the two patients with intractable bleeding. Three patients underwent PVE prophylactically. PTA of graft strictures is a valuable treatment modality. Embolization may be helpful in selected cases of hepatic encephalopathy.

Severe depression of serum cholinesterase activity associated with two cases of hepatic encephalopathy.

Journal Article Severe depression of serum cholinesterase activity associated with two cases of hepatic encephalopathy. Get access T Z Liu, T Z Liu Search for other works by this author on: Oxford Academic Google Scholar C Y Yuan C Y Yuan Search for other works by this author on: Oxford Academic Google Scholar Clinical Chemistry, Volume 31, Issue 9, 1 September 1985, Pages 1570–1571, https://doi.org/10.1093/clinchem/31.9.1570a Published: 01 September 1985

Measurement of GFAP in hepatic encephalopathy by ELISA and transblots.

Basal ganglia, cerebral cortex and subcortical white matter were studied for glial fibrillary acidic protein (GFAP) in four cases of hepatic encephalopathy (HE) with Alzheimer II gliosis and five age-matched controls. GFAP was measured by enzyme-linked immunosorbent assay (ELISA) and reflectance densitometry of immunoperoxidase-stained western blots. Both methods revealed a 70% decrease in the average amount of GFAP in the cerebral cortex and a 60% decrease in the basal ganglia in HE cases. GFAP in white matter was not significantly changed. In contrast to GFAP, the average protein content was not significantly different for HE and controls. These findings support the view that HE is a neurological disease in which there is a selective loss of GFAP from the grey matter.

Hirano bodies in myelinated fibers of hepatic encephalopathy.

Inclusions, essentially identical to Hirano bodies, were observed in the substantia nigra, dentate nuclei, and frontal lobes in three autopsy cases of hepatic encephalopathy. Similar inclusions were not observed in these areas in nine controls. The inclusions were mainly seen in the inner loops of the myelinated fibers, between the myelin lamellae, and among degenerated myelin sheaths. The same inclusions were rarely observed in postsynaptic terminals.

70 GLIAL FIBRILLARY ACIDIC PROTEIN IN HEPATIC ENCEPHALOPATHY

Basal ganglia, thalamus, cerebral cortex, and subcortical white matter were studied in ten cases of hepatic encephalopathy (HE), including three cases of acquired hepatocerebral degeneration (HCD), and in thirteen age-matched controls using the peroxidase-antiperoxidase immunohistochemical staining technique for glial fibrillary acidic (GFA) protein. HE cases all had pronounced Alzheimer type II astrocytosis. The perikarya and processes of Alzheimer type II glia did not stain for GFA protein. Staining of perivascular endfeet was evaluated by first selecting blood vessels throughout the gray and white matter in hematoxylin and eosin-stained slides to eliminate bias. The vessels were then identified in sections stained for GFA protein and graded as to complete circumferential, partial circumferential, or absence of staining. Both the degree and frequency of staining in the basal ganglia, thalamus, and cerebral cortex were significantly decreased in cases of HE; no statistically significant differences were found for the white matter. There were no significant differences in staining between HCD and other HE cases. These findings show that the Alzheimer II change is associated with a loss of immunohistochemically detectable GFA protein in cerebral gray matter.

Hepatic Encephalopathy Treated With L-Dopa, Recovery Followed for 18 Months

Six cases of hepatic encephalopathy (HE) treated with L-Dopa have been described in the literature1-3 but no substantial follow-up is available regarding the surviving patients. We treated a young girl in HE with L-Dopa and have had an 18-month follow-up to date. Case Report A. 13-year-old Negro girl with a one-year history of recurrent urinary tract infections was admitted with anasarca and ascites. She was normotensive and neurologically stable. Hematuria was observed but serum electrolytes, blood urea nitrogen (BUN) and creatinine levels were normal.