Protein loss results in hypoproteinemia, decreased oncotic pressure, fluid transudation into the extravascular space and finally edema development. Such edema are the most common symptoms of PLE. Patients usually present with swollen legs or generalized peripheral edema. Gastrointestinal disorders are furthermore associated with abdominal pain and diarrhea, possibly hemorrhagic diarrhea. Prolonged illness also results in malnutrition and weight loss.

In patients suffering from PLE due to lymphatic obstruction, lymphopenia and reduced levels of immunoglobulins provoke immune deficiency and increase susceptibility to infection. In this line, recurring infections may be reported [11].

Of note, the underlying disease may not only affect the gastrointestinal tract and may indeed provoke more severe symptoms than PLE. For instance, patients suffering from tuberculosis, amyloidosis or heart failure most likely present with a variety of symptoms that may overlap with those of PLE [12].

• Malnutrition

  These conditions lead to nutrient deficiencies and malnutrition. [symptoma.com]

  We present a young woman who suffered from chronic abdominal pain and diarrhea, developed severe malnutrition, and was eventually diagnosed with systemic lupus erythematosus and associated protein losing enteropathy. [ncbi.nlm.nih.gov]

  The diagnosis of PLE should be considered in patients with hypoproteinemia after other causes, such as malnutrition, proteinuria, and impaired protein synthesis due to cirrhosis, have been excluded. [mayoclinic.pure.elsevier.com]

  Investigations [ 1 ] The initial step in the evaluation of any patient with hypoproteinaemia and/or hypoalbuminaemia is to exclude other, more common causes, such as malnutrition, liver and renal diseases. [patient.info]

• Amyloidosis

  Amyloidosis of the gastrointestinal tract is usually a systemic disease. Localized gastrointestinal amyloidosis without evidence of extraintestinal involvement or an associated plasma cell dyscrasia is uncommon and does not usually cause death. [ncbi.nlm.nih.gov]

  […] pericarditis, superior vena cava thrombosis, Ménétrier's disease, eosinophilic gastroentropathy, sarcoidosis, Whipple's disease, infections–giardiasis, bacterial overgrowth, viral enteritis, schistosomiasis, C difficile, pulmonary artery stenosis, SLE, amyloidosis [medical-dictionary.thefreedictionary.com]

  […] disease Celiac disease Tropical sprue Connective tissue disorders like SLE Neurofibromatosis Angioedema Henoch-Schönlein purpura Allergic gastroenteritis Eosinophilic gastroenteritis Small intestinal bacterial overgrowth (SIBO) Intestinal parasites Amyloidosis [healthhype.com]

• Whipple Disease

  eosinophilic gastroentropathy, sarcoidosis, Whipple's disease, infections–giardiasis, bacterial overgrowth, viral enteritis, schistosomiasis, C difficile, pulmonary artery stenosis, SLE, amyloidosis Clinical Diarrhea, weight loss, peripheral edema Imaging [medical-dictionary.thefreedictionary.com]

  […] interstitial pressure or lymphatic obstruction due to : Tuberculosis Sarcoidosis Retroperitoneal fibrosis Lymphoma Intestinal endometriosis Lymphoenteric fistula Whipple disease Heart disease (constrictive pericarditis or congestive heart failure) Intestinal [healthhype.com]

  Infectious agents AIDS Cytomegalovirus infection Dientamoeba fragilis and a great variety of other intestinal parasites Pseudomembranous colitis (Clostridium difficile) Small intestinal bacterial overgrowth (SIBO) Tropical sprue Tuberculosis Whipple disease [symptoma.com]

  Intestinal lymphangiectasia [7] Nonerosive upper gastrointestinal diseases include the following: Cutaneous burns [8] Whipple disease Connective tissue disorders Acquired immunodeficiency syndrome (AIDS) [2] Enteropathy, such as angioedema (idiopathic [emedicine.com]

• Anemia

  Investigations revealed iron deficiency anemia which was treated with intravenous iron sucrose leading to resolution of both the anemia as well as symptoms of protein-losing enteropathy. [ncbi.nlm.nih.gov]

  The anemia was due to her chronic blood loss and chronic disease. [kjim.org]

  Full blood count showed an anemia of 9.6 g/dL and a lymphopenia of 0.8 (normal, 1.5–4 × 10 9 /L). [journals.lww.com]

• Weight Gain

  In these patients, failure to thrive, poor weight gain, and deficiencies in the fat-soluble vitamins (ie, A, D, E, K) can also occur. [emedicine.medscape.com]

• Diarrhea

  Diarrhea resolved rapidly after surgery. He remained well after six months following biliary diversion, with normal stool output and no protein loss. [ncbi.nlm.nih.gov]

  Homepage Rare diseases Search Search for a rare disease Congenital chronic diarrhea with protein-losing enteropathy Disease definition Congenital chronic diarrhea with protein-losing enteropathy is a rare, genetic, intestinal disease characterized by [orpha.net]

• Gastropathy

  Schindler R: On hypertrophic glandular gastritis, hypertrophic gastropathy and parietal cell mass. Gastroenterology 1963, 45 :77–83. PubMed Google Scholar 54. Scharschmidt BF: The natural history of hypertrophic gastropathy. [link.springer.com]

  Fecal clearance of alpha1-antitrypsin with lansoprazole can detect protein-losing gastropathy. Dig Dis Sci 1999; 44 :2313–2318. 28. Wang SJ, Tsai SC, Lan JL. [nature.com]

  Protein-losing gastropathy (PLG) behaves somewhat differently from the general group of PLE, marked by excellent responses to elimination of Helicobacter pylori, antisecretory therapy, and surgical resection. [ncbi.nlm.nih.gov]

  […] protein Malabsorption due to intolerance to soya protein Malabsorption, drug induced Milk intolerance Milk protein enteropathy Non-gluten sensitive enteropathy syndrome Protein losing enteropathy Protein malabsorption Protein-losing enteropathy Reactive gastropathy [icd9data.com]

  Cytomegalovirus-associated protein-losing gastropathy in childhood. Eur J Pediatr 2008; 167: 1217–20. 13. Urganci N, Arapoglu M, Telhan L, Kayaalp N. [caribbean.scielo.org]

• Chronic Diarrhea

  Homepage Rare diseases Search Search for a rare disease Congenital chronic diarrhea with protein-losing enteropathy Disease definition Congenital chronic diarrhea with protein-losing enteropathy is a rare, genetic, intestinal disease characterized by [orpha.net]

  We herein describe a 69-year-old man suffering from chronic diarrhea caused by lansoprazole (LPZ)-induced collagenous colitis (CC) accompanied with protein-losing enteropathy (PLE), diagnosed by increased fecal alpha-1 antitrypsin clearance and the findings [ncbi.nlm.nih.gov]

  Chronic diarrhea and protein-losing gastroenteropathy caused by Dientamoeba fragilis. J Gastroenterol. 2004 Nov. 39(11):1117-9. [Medline]. Murali A, Narasimhan D, Krishnaveni J, Rajendiran G. [emedicine.com]

• Intestinal Disease

  […] absorption of nutrients in damaged small intestine) Various infections (due to lowered immunity ) Causes Main causes of protein losing enteropathy: Stomach : Giant hypertrophic gastritis (Ménétrier disease); Small intestine : Crohn’s disease Celiac disease [healthhype.com]

  This case is considered to be common type of MALT lymphoma at an uncommon site and is distinct from immunoproliferative small intestinal disease (IPSID). [ncbi.nlm.nih.gov]

  Homepage Rare diseases Search Search for a rare disease Congenital chronic diarrhea with protein-losing enteropathy Disease definition Congenital chronic diarrhea with protein-losing enteropathy is a rare, genetic, intestinal disease characterized by [orpha.net]

  Diseases Protein-Losing Enteropathies Bronchial Diseases Respiratory Tract Diseases Lung Diseases, Obstructive Lung Diseases Respiratory Tract Infections Gastrointestinal Diseases Digestive System Diseases Vasoactive Intestinal Peptide Gastrointestinal [clinicaltrials.gov]

• Failure to Thrive

  Presenting signs and symptoms of PLE include abdominal bloating, diarrhea, edema, pleural effusions, ascites, and failure to thrive. [ncbi.nlm.nih.gov]

  Patients typically present severe, intractable diarrhea, failure to thrive, recurrent infections and edema. [orpha.net]

  In these patients, failure to thrive, poor weight gain, and deficiencies in the fat-soluble vitamins (ie, A, D, E, K) can also occur. [emedicine.medscape.com]

• Angioedema

  […] to lowered immunity ) Causes Main causes of protein losing enteropathy: Stomach : Giant hypertrophic gastritis (Ménétrier disease); Small intestine : Crohn’s disease Celiac disease Tropical sprue Connective tissue disorders like SLE Neurofibromatosis Angioedema [healthhype.com]

  Dientamoeba fragilis and a great variety of other intestinal parasites Pseudomembranous colitis (Clostridium difficile) Small intestinal bacterial overgrowth (SIBO) Tropical sprue Tuberculosis Whipple disease Immune-related diseases Allergic gastroenteritis Angioedema [symptoma.com]

  […] congestive heart failure) Intestinal lymphangiectasia [7] Nonerosive upper gastrointestinal diseases include the following: Cutaneous burns [8] Whipple disease Connective tissue disorders Acquired immunodeficiency syndrome (AIDS) [2] Enteropathy, such as angioedema [emedicine.com]

• Purpura

  Main causes of protein losing enteropathy: Stomach : Giant hypertrophic gastritis (Ménétrier disease); Small intestine : Crohn’s disease Celiac disease Tropical sprue Connective tissue disorders like SLE Neurofibromatosis Angioedema Henoch-Schönlein purpura [healthhype.com]

  Tuberculosis Whipple disease Immune-related diseases Allergic gastroenteritis Angioedema Celiac disease Connective tissue disorders like systemic lupus erythematosus Crohn disease Eosinophilic gastroenteritis Graft-versus-host disease Henoch-Schönlein purpura [symptoma.com]

  Nonerosive upper gastrointestinal diseases include the following: Cutaneous burns [8] Whipple disease Connective tissue disorders Acquired immunodeficiency syndrome (AIDS) [2] Enteropathy, such as angioedema (idiopathic or hereditary) and Henoch-Schönlein purpura [emedicine.com]

Patients presenting with peripheral edema of unknown origin should be examined for possible PLE. Laboratory analyses of blood samples generally provide valuable information and reveal hypoalbuminemia and hypoglobulinemia. Additionally, lymphopenia may be observed. Fat malabsorption entails reduced levels of liposoluble vitamins, i.e., vitamins A, D, E and K.

Differential diagnoses for low protein levels are reduced intake or malnutrition, decreased protein synthesis due to hepatic dysfunctions, and protein losing nephropathy [13]. Cutaneous lesions, particularly extended burns, may also account for decreased protein levels. These possible causes may be ruled out when anamnesis, hepatic and renal parameters do not point at such pathologies.

Diagnosis of PLE may be verified by intravenous application of labeled human serum albumin and quantification of the respective isotope in stool samples [14]. The presence of α1-antitrypsin in stool samples results from malabsorption and thus further supports the diagnosis of PLE. This test may, however, not be used in patients suffering from hyperacidity because of α1-antitrypsin degradation in acid environments. Occult blood in stool samples points at gastrointestinal lesions, too. Furthermore, stool samples may be examined for intestinal parasites.

Different, more or less specific tests are required to identify the underlying disease. Serologic tests may be helpful to detect infections. Positive hydrogen breath tests indicate intestinal bacterial overgrowth. Radiography and computed tomography may be applied to detect possibly present neoplasms; the latter is also used to visualize lymphatic obstruction. However, lymphangiography is more sensitive in this regard. Cardiac pathologies are often discernible in radiographic images, but echocardiography may reveal even better results.

The gold standard for diagnosis of gastrointestinal disorders is an endoscopic examination with mucosal biopsy sampling and subsequent pathohistological analysis of these tissue samples.

• Hypoalbuminemia

  This clinical condition should be suspected in the presence of persistent hypoalbuminemia despite normal liver function, adequate protein intake, and no significant proteinuria. [ncbi.nlm.nih.gov]

• Hypogammaglobulinemia

  It is characterized by dilation and leakage of intestinal lymph vessels leading to hypoalbuminemia, hypogammaglobulinemia and lymphopenia. [ncbi.nlm.nih.gov]

  Congenital chronic diarrhea with protein-losing enteropathy is a rare, genetic, intestinal disease characterized by early-onset, chronic, non-infectious, non-bloody, watery diarrhea associated with protein-losing enteropathy which results in hypoalbuminemia, hypogammaglobulinemia [orpha.net]

  DISCUSSION PLE is a disease characterized by excessive loss of proteins by the gastrointestinal tract, leading to hypoproteinemia (hypoalbuminemia), hypogammaglobulinemia, and hypocalcemia. [revespcardiol.org]

• Albumin Decreased

  After 8 weeksBCAA supplementation, the ratio of oxidized albumin within total albumin decreased significantly and that of reduced albumin increased significantly (P < 0.05, respectively). [forum.bodybuilding.com]

PLE therapy aims at eliminating the underlying disease, compensating for nutrient deficiencies and promoting gastrointestinal recovery.

Certain underlying diseases may be cured with easy and straightforward therapeutic approaches. Antiparasitic agents, for instance, will relieve the intestines from their parasitic burden. Recovery processes are initiated and protein loss will decrease to physiological levels. ACE inhibitors and diuretics are usually administered to those suffering from cardiac insufficiency and heart failure. In most cases, cardiac function will be improved and venous pressure will be reduced. Several autoimmune disorders are treated with immunosuppressive corticosteroids.

On the other hand, surgical interventions may be required to resect neoplasms and to cure associated diseases, e.g. giant hypertrophic gastritis [15]. Of note, patients suffering from giant hypertrophic gastritis may benefit from therapies aimed at elimination of Helicobacter pylori. Not all neoplasms that entail PLE are easily resectable. This may be the case for lymphoma. Chemotherapy and/or irradiation are indicated then. Surgical approaches may be the method of choice to resolve lymphatic obstruction or to bypass impassable lymphatic vessels by means of lymphovenous anastomosis.

Dietary adjustments are recommended for certain PLE cases. In this context, low-fat diets supplemented with medium-chain triglycerides are suggested to improve the condition of patients with lymphangiectasias. Its effect is, however, controversially discussed [16]. Celiac disease requires a gluten-free diet.

Prognosis largely depends on the underlying disease. If it is potentially curable, prognosis improves considerably. Due to the availability of better therapeutics, morbidity and mortality of PLE are decreasing [10].

PLE may result from excessive protein loss into the stomach, the small intestine or the large intestine. PLE may result from local or systemic pathologies and may effect one or more of the aforementioned parts of the gastrointestinal tract. As has been mentioned before, erosive and non-erosive gastrointestinal disorders may account for protein loss as well as those diseases associated with increased lymphatic or central venous pressure. This classification is based on the pathogenesis of PLE but does not reflect its actual triggers. Here, infectious, immune-related, neoplastic and idiopathic causes may be distinguished. Of note, some triggers may belong to more than one category.

Infectious agents

• AIDS
• Cytomegalovirus infection
• Dientamoeba fragilis and a great variety of other intestinal parasites
• Pseudomembranous colitis (Clostridium difficile) [4]
• Small intestinal bacterial overgrowth (SIBO)
• Tropical sprue
• Tuberculosis
• Whipple disease

Immune-related diseases

• Allergic gastroenteritis
• Angioedema
• Celiac disease
• Connective tissue disorders like systemic lupus erythematosus
• Crohn disease
• Eosinophilic gastroenteritis
• Graft-versus-host disease
• Henoch-Schönlein purpura
• Microscopic colitis
• Sarcoidosis
• Ulcerative colitis

Neoplasms affecting the gastrointestinal tract

• Carcinoid syndrome
• Giant hypertrophic gastritis
• Kaposi sarcoma
• Lymphoma
• Neurofibromatosis

Idiopathic causes

• Idiopathic ulcerative jejunoileitis

Others

• Amyloidosis [5]
• Heart insufficiency and heart failure [6] [7]
• Intestinal endometriosis
• Intestinal lymphangiectasia
• Lymphoenteric fistula
• Retroperitoneal fibrosis

Due to the large variety of underlying diseases, no reliable data regarding incidence and prevalence of PLE can be provided. Despite the long list of possible triggers, it is considered to be a rare disease.

There is no unique pathogenesis to PLE, but the above mentioned underlying diseases result in either intestinal mucosal erosion or ulceration, epithelial cell dysfunction without macroscopic evidence for mucosal damage, or increased lymphatic or central venous pressure. The precise link between the underlying disease and intestinal damage could not be identified for each cause of PLE. Such is the case with Fontan heart surgery. To date, there is no conclusive evidence regarding the pathophysiological events leading to PLE after realizing the Fontan procedure [8]. Postoperative increases of venous pressure, reduced pulmonary vascular compliance and augmented levels of serum hepatocyte growth factor have been proposed as potential triggers of PLE [9].

Gastrointestinal disorders with or without macroscopic evidence for mucosal lesions may contribute to protein loss in the form of detached enterocytes or infiltrating inflammatory cells, as well as blood and lymph that may pour out of lesioned vessels. With regards to increased lymphatic or central venous pressure, these conditions most commonly result from cardiac insufficiency. In patients suffering from cardiac insufficiency, a reduced stroke volume entails increased end-diastolic ventricular pressure, preload and venous pressure. The hydrostatic pressure in intestinal veins increases significantly, may even damage blood vessels and provoke remodelling processes, and protein-rich exudate is pressed into the intestine. Similarly, PLE triggered by increased lymphatic pressure results in lymph stasis, augmented hydrostatic pressure and protein-rich exudates. Mesenterial lymphatic obstruction may evoke these pathophysiological events. Contrary to blood, lymph also contains high concentrations of liposoluble molecules such as lipids, cholesterol and liposoluble vitamins. Thus, not only are nutrients poorly absorbed by the damaged intestine, but proteins as well as lipids are lost into the intestinal lumen. These conditions lead to nutrient deficiencies and malnutrition.

Recently published studies have proposed heparan sulfate proteoglycans, which can be found on the basolateral surface of intestinal epithelial cells and in the extracelluar matrix, as key factors in PLE. Presumably, inflammatory processes as well as increased pressure impair proteoglycan function, thus evoking an increased epithelial permeability and protein loss. Furthermore, loss of proteoglycans seems to potentiate the detrimental effects of pro-inflammatory cytokines and elevated lymphatic pressure. The hypothesis of heparan sulfate proteoglycans as mediators of epithelial protein permeability is further supported by the fact that patients suffering from genetic disorders that cause loss of proteoglycans also present with increased intestinal permeability and secondary PLE.

Preventive measures can be recommended to avoid certain diseases associated with PLE, e.g., infectious diseases and cardiac insufficiency. However, this is not the case for PLE itself.

Patients suffering from protein-losing enteropathy (PLE) lose increased amounts of plasma protein into different parts of the intestine. Physiologically, intestinal loss of plasma protein is very limited. It mainly results from enterocyte detachment due to mucosal regeneration and distinct secretions. Less than 2% of the entire amount of plasma protein and less than 10% of the entire amount of albumin are lost daily in healthy individuals [1]. These values are by far exceeded in PLE patients and here, up to 60% of the overall amount of albumin may be lost enterically in a single day. Moreover, lymphocytes, lipids, dietary minerals and trace elements may be lost. There are several diseases that may evoke PLE, especially gastrointestinal disorders that may or may not involve mucosal erosion and those diseases that cause increased lymphatic or central venous pressure [2]. Because lymph has a particularly high protein content, obstruction of mesenterial lymphatic vessels and subsequent leakage of lymph may result in protein loss as severe as that observed due to intestinal erosions and ulcers.

PLE results in hypoproteinemia and thus entails pleural effusion and ascites, pericardial effusion and peripheral edema development. Although protein anabolism will be stimulated in order to restore physiological protein levels, concentrations of those proteins with longer half-lives will be decreased for longer periods of time. This applies to albumin, the majority of immunoglobulins and ceruloplasmin. In contrast, levels of proteins with shorter half-lives, e.g., prealbumin, immunoglobulin E and insulin, may be elevated [3]. Additionally, lost protein is no longer available for nutrition and chronic PLE is therefore associated with malnutrition.

The condition of protein-losing enteropathy (PLE) describes excessive loss of plasma protein into the intestinal tract. Thus, it is a symptom rather than its own pathologic entity.

Causes

There are many diseases that may cause PLE. In general, such diseases may either directly lead to intestinal lesions, mucosal erosion and ulceration, or impair enterocyte functionality without provoking visible mucosal damage, or increase lymphatic or venous pressure. Infectious agents, autoimmune disorders, tumors as well as cardiovascular diseases are worth considering.

Common pathological conditions associated with PLE are bacterial or parasitic infections of the gastrointestinal tract, AIDS, celiac disease, Crohn disease, ulcerative colitis, lymphoma, cardiac insufficiency and intestinal lymphangiectasia.

Symptoms

Excessive loss of plasma protein mainly affects albumin and immunoglobulin pools. Albumin fulfills a myriad of functions, one of them being the maintenance of intravascular oncotic pressure. If there is less protein inside the vessel than outside this also means there is more water inside than outside. To compensate for this apparent imbalance, water diffuses into the surrounding tissues. Edema develops. Indeed, swollen legs are the most common symptom of PLE. On the other hand, immunoglobulins are key factors of the immune system. Low immunoglobulin levels weaken the immune system and leave the patient more susceptible to infections.

Gastrointestinal lesions may cause abdominal pain and diarrhea. Stool properties may change and blood may be detected in stool samples.

In the long term, PLE patients will probably suffer weight loss. Not only does the body lose essential proteins and even fat into the intestinal lumen, the lesioned intestinal mucosa is also unable to absorb nutrients. Subsequent malnutrition leads to weight loss.

Diagnosis

If patients present with the above described symptoms, the physician will obtain blood samples and verify albumin and immunoglobulin levels. Because hepatic and renal pathologies may trigger symptoms similar to those of PLE, additional parameters will be measured to assess the functionality of these organs.

There are specific tests that may prove intestinal protein loss. For instance, a patient may be intravenously administered labeled albumin. If this labeled albumin is lost into the intestinal lumen, it will appear in stool samples that are subsequently obtained. Also, certain substances should never be secreted into the intestine or readily be absorbed after oral intake. If their concentration in stool samples exceeds reference values, this finding points at limited absorption of nutrients.

In order to evaluate the actual condition of the intestine, endoscopic examination, biopsy sampling and histopathological evaluation may be required.

Additional diagnostic measures may be taken to identify the underlying disease.

Treatment

If at all possible, treatment aims at eliminating the source of PLE. If the underlying disease can be cured, protein levels and nutrient absorption usually normalize. Any therapy has to be adjusted to the underlying disease and therapeutic options range from antibiotics, antiparasitic drugs, immunosuppressive medication and ACE inhibitors to chemotherapy, irradiation and surgical intervention.

Dietary adjustments are often necessary and in some cases sufficient to control PLE. Such is the case for celiac disease, a very common autoimmune disorder that requires a gluten-free diet.

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