P2938 - A Crippling Presentation of Cirrhosis

Navkiran Randhawa, DO¹, Es-Haq Hassanin, DO², Sukhbir Randhawa, DO³, Arshdeep Kaur, BS^4
1Franciscan St. James Hospital, Olympia Fields, IL; ²University of Texas Health Science Center at Tyler, Tyler, TX; ³Samaritan Medical Center, Watertown, NY; ⁴Seattle Pacific University, Seattle, WA

Introduction: Liver cirrhosis is commonly associated with hepatic encephalopathy manifesting as altered mentation. Hepatic encephalopathy with neurological symptoms mimicking stroke has rarely been cited in medical literature. We present a case of decompensated liver cirrhosis manifesting with initial signs of right sided hemiparesis.

Case Description/Methods: A 54 year-old, Hispanic male with no known past medical history presented to the emergency room with a chief complaint of sudden-onset right-sided weakness over the past 24 hours. Physical examination was remarkable for right sided facial droop as well as 1/5 strength in the right upper and lower extremities. Computed tomography (CT) of the head without contrast as well as magnetic resonance imaging (MRI) without contrast were negative for acute stroke. Lab values including urine drug screen and alcohol level were unremarkable except for elevated liver enzymes. Further investigation with right upper quadrant ultrasound suggested possible liver cirrhosis and his serum ammonia level was elevated at 140. CT abdomen and pelvis revealed a micronodular appearance of the liver with numerous scattered hypodensities (Figure 1). The patient was started on lactulose and rifaximin. His neurological symptoms resolved without residual neurological deficits about 36 hours after treatment.

Discussion: Cirrhosis is generally asymptomatic in around 40% of patients and is generally diagnosed during routine examinations. Cirrhosis manifesting with acute stroke-like symptoms is a rare entity. Our study highlights the importance of considering non-neurological pathologies in the setting of acute hemiparesis. The gastrointestinal system is often overlooked when it comes to these symptoms. We encourage initial evaluation with liver enzymes and further work up as indicated if a patient with hemiparesis is negative for acute stroke.


Figure: Figure 1. Micronodular appearance of the liver with numerous scattered hypodensities


Disclosures:
Navkiran Randhawa indicated no relevant financial relationships.
Es-Haq Hassanin indicated no relevant financial relationships.
Sukhbir Randhawa indicated no relevant financial relationships.
Arshdeep Kaur indicated no relevant financial relationships.


Navkiran Randhawa, DO¹, Es-Haq Hassanin, DO², Sukhbir Randhawa, DO³, Arshdeep Kaur, BS⁴. P2938 - A Crippling Presentation of Cirrhosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.