Refractory hepatic encephalopathy in a patient with hypothyroidism: Another element in ammonia metabolism

• Published in: World journal of gastroenterology : WJG 2017-07, Vol.23 (28), p.5246-5252
• Main Authors: Díaz-Fontenla, Fernando, Castillo-Pradillo, Marta, Díaz-Gómez, Arantxa, Ibañez-Samaniego, Luis, Gancedo, Pilar, Guzmán-de-Villoria, Juan Adan, Fernández-García, Pilar, Bañares-Cañizares, Rafael, García-Martínez, Rita
• Format: Article
• Language: English
• Subjects: Adrenergic beta-Antagonists - therapeutic use; Alcoholism - complications; Ammonia - blood; Ammonia - metabolism; Antithyroid Agents - therapeutic use; Brain - diagnostic imaging; Carbimazole - therapeutic use; Case Report; Diagnosis, Differential; Disorders of Excessive Somnolence - blood; Disorders of Excessive Somnolence - diagnostic imaging; Disorders of Excessive Somnolence - etiology; Drug Resistance; Dysarthria - blood; Dysarthria - diagnostic imaging; Dysarthria - etiology; Electroencephalography; Embolization, Therapeutic; Female; Goiter, Nodular - blood; Goiter, Nodular - complications; Goiter, Nodular - drug therapy; Goiter, Nodular - metabolism; Hepatic Encephalopathy - blood; Hepatic Encephalopathy - diagnosis; Hepatic Encephalopathy - drug therapy; Hepatic Encephalopathy - metabolism; Humans; Hyperammonemia - blood; Hyperammonemia - complications; Hypothyroidism - blood; Hypothyroidism - diagnosis; Hypothyroidism - drug therapy; Hypothyroidism - metabolism; Liver Cirrhosis, Alcoholic - blood; Liver Cirrhosis, Alcoholic - complications; Magnetic Resonance Imaging; Middle Aged; Portal Vein - abnormalities; Portal Vein - diagnostic imaging; Portasystemic Shunt, Transjugular Intrahepatic; Propranolol - therapeutic use; Renal Veins - abnormalities; Renal Veins - diagnostic imaging; Thyrotropin - blood; Thyroxine - therapeutic use; Tomography, X-Ray Computed; Vascular Malformations - blood; Vascular Malformations - complications; Vascular Malformations - therapy
• ISSN: 1007-9327; 2219-2840
• DOI: 10.3748/wjg.v23.i28.5246

Hepatic encephalopathy (HE) remains a diagnosis of exclusion due to the lack of specific signs and symptoms. Refractory HE is an uncommon but serious condition that requires the search of hidden precipitating events ( ., portosystemic shunt) and alternative diagnosis. Hypothyroidism shares clinical manifestations with HE and is usually considered within the differential diagnosis of HE. Here, we describe a patient with refractory HE who presented a large portosystemic shunt and post-ablative hypothyroidism. Her cognitive impairment, hyperammonaemia, electroencephalograph alterations, impaired neuropsychological performance, and magnetic resonance imaging and spectroscopy disturbances were highly suggestive of HE, paralleled the course of hypothyroidism and normalized after thyroid hormone replacement. There was no need for intervention over the portosystemic shunt. The case findings support that hypothyroidism may precipitate HE in cirrhotic patients by inducing hyperammonaemia and/or enhancing ammonia brain toxicity. This case led us to consider hypothyroidism not only in the differential diagnosis but also as a precipitating factor of HE.