The most common are the following: Metabolic stress (eg, infection; electrolyte imbalance, especially hypokalemia; dehydration; use of diuretic drugs) Conditions that increase gut protein (eg, gastrointestinal bleeding, high-protein diet) Nonspecific cerebral depressants (eg, alcohol, sedatives, analgesics) Pathophysiology of Portosystemic Encephalopathy In portosystemic shunting, absorbed products that would otherwise be detoxified by the liver enter the systemic circulation and reach the brain, causing toxicity, particularly to the cerebral cortex.