[A rare cause of hepatic coma]

A 65-year-old female patient was admitted to the hospital in somnolent state. During physical examination, she had an increase in blood pressure and a positive bilateral Babinski's sign. Laboratory findings showed elevated liver enzymes, metabolic alkalosis and slightly elevated kidney values. 3 h hours later she lapsed into a hepatic coma (ammonia > 400 micrograms/dl). Subsequently, indirect anamnesis revealed the following affections: ureterosigmoidostomy in 1942, cystectomy in 1943, and right-sided nephrectomy in 1950.

This case presents with an uncommon origin of the hepatic encephalopathy: in the operated colon, bacterial overgrowth (bacteriogenic ureapoiesis) developed, which led to a hyperammonemia. Furthermore, in mild alcoholic liver disease--as in this case--ammonia cannot be metabolized to urea and leads to hepatic encephalopathy. We considered making this part of the colon poor in bacteria (by consequent administration of antibiotics), thus reducing the formation of ammonia.