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Summary

Hyperammonaemic encephalopathy can occur without liver failure, posing diagnostic challenges. Prompt treatment involving dialysis and nutritional support is crucial for recovery in such cases.

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Area of Science:

Medicine
Biochemistry
Critical Care

Background:

Hyperammonaemic encephalopathy (HE) is a severe condition often linked to liver failure.
Diagnosis can be difficult when liver function tests are normal.
This case highlights HE in a patient with a history of gastric bypass surgery.

Purpose of the Study:

To present a case of non-hepatic hyperammonaemia (NHHA) in a post-gastric bypass patient.
To discuss the diagnostic challenges and management of NHHA.
To emphasize the importance of considering HE in critically ill patients with encephalopathy and normal liver function.

Main Methods:

A case report of a middle-aged woman admitted for weight loss, edema, and fatigue.
Initiation of enteral nutrition, followed by rapid deterioration and coma.
Treatment included intubation, ICU care, dialysis, medications (sodium benzoate, lactulose, rifaximin), and nutritional management.

Main Results:

The patient presented with severe hyperammonaemia (298 μmol/L) despite normal liver function tests.
Treatment led to normalization of ammonia levels and resolution of encephalopathy.
The patient was successfully extubated after nine days.

Conclusions:

NHHA can arise from increased ammonia production and impaired elimination, as seen in post-surgical undernutrition.
Clinicians should screen for hyperammonaemia in critically ill patients with unexplained encephalopathy, seizures, or vomiting.
Early recognition and intervention are vital for managing this potentially life-threatening condition.