Review article: hyperammonaemic and catabolic consequences of upper gastrointestinal bleeding in cirrhosis

Summary Background  Upper gastrointestinal (UGI) bleeding in patients with cirrhosis of the liver induces hyperammonaemia and leads to a catabolic cascade that precipitates life‐threatening complications. The haemoglobin molecule is unique because it lacks the essential amino acid isoleucine and contains high amounts of leucine and valine. UGI bleed therefore presents the gut with protein of very low biologic value, which may be the stimulus to induce net catabolism. Aim  To describe the hyperammonaemic and catabolic consequences of UGI bleeding in cirrhosis. Methods  A semi‐structured literature search was performed using PubMed and article references. Results  It has recently been proven that (‘simulation of ’) a UGI bleed in patients with cirrhosis leads to impaired protein synthesis that can be restored by intravenous infusion of isoleucine. This may have therapeutic implications for the function of rapidly dividing cells and short half‐life proteins such as clotting factors. Renal and small bowel ammoniagenesis were shown to be the most prominent causes for the hyperammonaemia that resulted from a UGI bleed. This provides an explanation for the therapeutic failure of the current clinical therapies that are aimed at large bowel‐derived ammonia production. Isoleucine infusion did not diminish renal ammoniagenesis. Conclusions  New pharmacological therapies to diminish postbleeding hyperammonaemia should target the altered inter‐organ ammonia metabolism and promote ammonia excretion and/or increase the excretion of precursors of ammoniagenesis, e.g. l ‐ornithine–phenylacetate.