Harjot Bath, MD, Mohammed Elhassan, MD St. Agnes Medical Center, Fresno, CA
Introduction: Hepatic encephalopathy (HE) is an acute neuropsychiatric syndrome complicating liver failure. Posturing is a medical emergency and an uncommon sign in the setting of hyperammonemia. Our report details a patient acutely progressing, within hours, from grade 0 HE to grade IV comatose HE with posturing and convulsions hours after revision of TIPS.
Case Description/Methods: A 62-year-old Hispanic man with past medical history of treated hepatitis C infection, decompensated liver cirrhosis secondary to previous excessive alcohol use, hepatocellular carcinoma on chemotherapy, type 2 diabetes mellitus and peptic ulcer disease. He was on oral lactulose as a home medication. He underwent TIPS placement due to recurrent variceal bleeding and had no previous history of hepatic encephalopathy. He presented due to hematemesis. At time of admission he was fully alert and oriented and without focal neurological findings. Esophagogastroduodenoscopy was done and varices were banded. Forty-eight hours later he was found to have a partial thrombus in the shunt on imaging and underwent TIPS revision. Overnight the patient became acutely altered, hypertensive, tachycardic and had witnessed convulsions. He was then upgraded to the intensive care unit. Both Stat CT head and abdomen/pelvis were ordered and both revealed no acute abnormalities. Labs were significant for ammonia 387 (upper limit 38 µmol/L), lactate 8 (upper limit 2 mmol/L) and bicarbonate 13 (range 23-30 mEq/L). Physical exam revealed jerking movements and decerebrate posturing (arms/legs extended at sides with head/neck arching back) with a fixed left upper gaze. EEG was indicative encephalopathy of severe nature. Given he was already on oral lactulose from admission additional treatment with lactulose enema was begun resulting in multiple bowel movements. He had improved mentation within 1 day, allowing him to be discharged home within 4 days.
Discussion: Fortunately our patient responded well to conservative therapy with lactulose. Variceal bleed and/or recent sedation could possibly be inciting factors for his HE, however we acknowledge it is impossible to pinpoint the exact cause. Globally a rising number of patients are developing cirrhosis and its complications. There is a possibility we may see an increasing number of patients presenting with this manifestation of HE. Early recognition of posturing as a rare sign in the setting of HE can improve both early diagnosis and treatment along with decreasing excessive workup and length of hospital stay.
Disclosures:
Harjot Bath indicated no relevant financial relationships.
Mohammed Elhassan indicated no relevant financial relationships.
Harjot Bath, MD, Mohammed Elhassan, MD. A0590 - Decerebrate Posturing and Convulsions: A Rare Hepatic Encephalopathy Presentation, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
