POST-GASTRIC BYPASS HYPERAMMONEMIC ENCEPHALOPATHY: A RARE AND POTENTIALLY FATAL CAUSE OF ENCEPHALOPATHY IN THE ICU

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: In the US prevalence of obesity has risen to 39.8% and affected about 93.3 million adults in 2015. Morbidly obese patients are increasingly pursuing bariatric surgery. While benefits surgery numerous, it is important recognize understand short term long postoperative complications. Hyperammonemic syndrome an uncommon but severe complication gastric bypass CASE PRESENTATION: A 43 year old woman with history non-alcoholic fatty liver disease prior sleeve which was followed by Roux-en-Y Gastric Bypass (RYGB) admitted for shortness breath altered mental status. On hospital day number 10 patient transferred ICU status, worsening hypoxia, retroperitoneal bleed septic shock. Patient subsequently intubated, given transfusions, placed on vasopressors, broad-spectrum antibiotics. After 72 hours her overall shock resolved ventilator requirements were minimal, she remained a comatose state. Initial workup including CT head brain MRI unremarkable. routine EEG consistent low voltage delta frequencies could be seen setting encephalopathy. Ammonia level had 169 umol/L, significantly elevated from 81 umol/L admission (Table 1). addition aggressive treatment lactulose rifaximin, multiple supplements added, including: Zinc, multivitamin, L-carnitine. Subsequent revealed myoclonic status epilepticus antiepileptic drugs given. Repeat increased diffusion-weighted signal intensity within cortex subcortical white matter suggesting hypoxic anoxic injury. DISCUSSION: related characterized hyperammonemia, plasma glutamine, hypoalbuminemia, reactive hypoglycemia, nutritional deficiencies essential amino acids, zinc levels, absence overt fibrosis or evidence significant hepatocellular injury (1). The mortality rate approaches 50% tends occur at high women Patients may present irritability, vomiting, ataxia, retardation, lethargy, eventually alteration consciousness coma There genetic nongenetic hypothesized mechanisms 2). Treatment strategies hyperammonemia include: lactulose, repletion deficient zinc, micro nutrients, prevention seizures cerebral edema (2). CONCLUSIONS: It consider as potential etiology neurologic changes bypass, especially where etiologies can cause encephalopathy hyperammonemia. REFERENCE #1: Fenves, A. et al. "Hyperammonemic Syndrome Roux-En-Y Bypass." Obesity Journal. Volume 23. Number 4. #2: Krishnan P, Ramdas Landsberg. "Bariatric Surgery causing hyperammonemia." Cureus 11 (7): e5098. DOI 10.7759/cureus.5098. July 8, 2019 DISCLOSURES: No relevant relationships SOHAIB KHAN, source=Web Response Jessica Nash, Mehul Patel, Mena Tawfik,