Late presentation of fatal hyperammonemic encephalopathy after Roux-en-Y gastric bypass

Hyperammonaemic encephalopathy: a remarkably rare complication after bariatric surgery

Hyperammonaemia is a metabolic disorder with elevated blood ammonia levels. Here we describe a case of hyperammonaemia associated encephalopathy as an incredibly rare, potentially fatal and treatable complication associated with bariatric surgery. This case highlights the importance of longer-term follow-up after bariatric surgery.

MiR-200c-3p Regulates DUSP1/MAPK Pathway in the Nonalcoholic Fatty Liver After Laparoscopic Sleeve Gastrectomy

AIM

Non-alcoholic fatty liver disease (NAFLD) is a health burden worldwide, which is closely related to obesity. The effect of sleeve gastrectomy (SG) on NAFLD is efficient, and the underlying mechanism remains unknown. Our study sought to investigate the mechanism of dual-specificity protein phosphatase 1 (DUSP1) expression regulation following the SG procedure in NAFLD patients and C57BL/6J mice via miR-200c-3p.

METHODS

The serum was extracted from NAFLD patients who underwent laparoscopic sleeve gastrectomy (LSG) and volunteers. Next, the correlation between miR-200c-3p and DUSP1 was identified in vitro. NAFLD mice were modelled by high-fat diets (HFD). The hepatic tissue expression levels of miR-200c-3p, DUSP1, phospho-extracellular regulated protein kinases1/2 (p-ERK1/2), phospho -p38 mitogen-activated protein kinases (p-p38), and phospho-c-Jun N-terminal kinases (p-JNK) induced by SG procedure were evaluated.

RESULTS

The SG procedure contributed to significant weight loss, reduced lipids in NAFLD patients and mice. The increased expression level of miR-200c-3p and reduced expression of DUSP1 were observed in NAFLD patients and mice (p<0.05). The reduced expression levels of miR-200c-3p and increased expression of DUSP1 were observed in patients and mice with NAFLD who underwent SG procedure. DUSP1 is a potential target of miR-200c-3p.

CONCLUSIONS

A novel mechanism was identified in which miR-200c-3p regulates the MAPK-dependent signals that are linked to the promotion of hepatosteatosis via DUSP1 after sleeve gastrectomy. The findings suggested that miR-200c-3p should be further explored as a potential target for the treatments of NAFLD.

Hyperammonemia in the setting of Roux-en-Y gastric bypass presenting with osmotic demyelination syndrome

Hyperammonemia can lead to serious outcomes including brain herniation, coma and death. It is often attributed to liver disease, specifically in association with alcohol use. However, in the absence of liver pathology, it can be difficult to diagnose the etiology. We present a case of a patient with a history of remote alcohol use disorder in remission and Roux-en-Y gastric bypass (RYGB) 20 years prior who was admitted for altered mental status, found to have hyperammonemia with normal liver function tests and a normal liver biopsy. An extensive workup was unremarkable until several weeks into her admission, where she was found to have osmotic demyelination syndrome on head MRI, which was obtained after she developed persistent myoclonus and opsoclonus. Her osmotic demyelination was speculated to be secondary to hyperammonemia, which itself was correlated to her history of RYGB. There have been multiple case reports on the association of late onset hyperammonemic encephalopathy after RYGB; however, no significant correlation has yet to be made between osmotic demyelination syndrome and hyperammonemia.

Russian Consensus “Hyperammonemia in Adults” (Version 2021)

Justification Given the large number of reports on the peculiarities of liver lesions during the Sars-Cov-2 infection [1], a team of experts who participated in the 23rd Congress of the Scientific Society of Gastroenterologists of Russia and 15 National Congress of Therapists of November 19, 2020 decided to make additions to the Russian Consensus of “Hyperammonemia in Adults” published early 2020 [2, 3].

A retrospective study of adult patients with noncirrhotic hyperammonemia

Adult-onset noncirrhotic hyperammonemia (NCH) is poorly understood and has a high morbidity and mortality. To elucidate the etiology and management of NCH, we performed a retrospective analysis of 23 adults (median age 51) with NCH treated between 2014 and 2020 at two academic medical centers. Hyperammonemia was diagnosed in all cases during the evaluation of altered mental status, with 22% presenting with seizures. Peak ammonia levels were >200 μmol/L in 70% of cases. Defects in ammonia metabolism were assessed using urea cycle biochemical testing, germline genetic testing, and testing for urease-producing infectious agents. Ammonia metabolism defects in these cases appear attributable to four major sources: (a) infection with urease-producing organism (n = 5); (b) previously undiagnosed inborn errors of metabolism (IEMs) (n = 4); (c) clinical exposures causing acquired urea cycle dysfunction (n = 6); and (d) unexplained acquired urea cycle dysfunction (uaUCD) (n = 8), as evidenced by biochemical signatures of urea cycle dysfunction without a genetic or clinical exposure. Severe protein malnutrition appeared to be a reversible risk factor for uaUCD. Overall, 13% of our cohort died prior to resolution of hyperammonemia, 26% died after hyperammonemia resolution, 57% survived after having reversible neurological changes, and 4% survived with irreversible neurological changes. Renal replacement therapy for ammonia clearance was often utilized for patients with an ammonia level above 250 μmol/L and patients were frequently empirically treated with antibiotics targeting urea-splitting organisms. Our study demonstrates that acquired urea cycle dysfunction, IEMs and urease-producing infections are major sources of adult-onset NCH and highlights successful management strategies for adult-onset NCH.

Nonfatal Hyperammonemic Encephalopathy as a Late Complication of Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is the most common weight loss procedure performed in the US. Gastric bypass–related hyperammonemia (GaBHA) is a potentially fatal entity, characterized by encephalopathy associated with hyperammonemia and various nutritional deficiencies, which can present at variable time intervals after RYGB. Twenty-five cases of hyperammonemic encephalopathy after bariatric surgery have been previously reported in the literature. We describe the case of a 48-year-old Hispanic woman with no prior history of liver disease, presenting with nonfatal hyperammonemic encephalopathy as a late postoperative complication 20 years after undergoing a RYGB. Hyperammonemic encephalopathy in the absence of known hepatic dysfunction presents a diagnostic dilemma. An early diagnosis and intervention are crucial to decrease morbidity and mortality.

Postbariatric Surgery Hyperammonemia: A Rare Cause of Encephalopathy

Hyperammonemic encephalopathy is an under-recognized and potentially fatal complication of Roux-en-Y gastric bypass surgery. We present a case of a 42-year-old woman with no known history of liver disease who experienced worsening encephalopathy 1 year after bariatric surgery. She presented with elevated ammonia and severe encephalopathy requiring intubation. A complete workup led to the diagnosis of a urea cycle disorder. The patient was managed with lactulose, ammonia scavenging agents, and nutritional supplementation with a favorable outcome. We report this case to increase awareness of this condition and urge providers to maintain a high clinical suspicion in the appropriate setting.

Treatment of Severe Protein Malnutrition After Bariatric Surgery

BACKGROUND

Severe protein malnutrition, with a serum albumin < 25 g/L, is one of the complications that may develop after bariatric surgery. It is associated with increased morbidity and mortality and requires timely diagnosis and appropriate treatment to prevent rapid clinical deterioration. However, evidence-based recommendations for a specific treatment approach are currently not available. The present study describes the efficacy of a newly developed treatment regimen for post-bariatric patients presenting with severe hypoalbuminemia.

METHODS

A single-centre, retrospective analysis of eleven post-bariatric patients presenting with severe hypoalbuminemia, treated with continuous 24 h nasal-jejunal tube feeding of a medium chain triglyceride (MCT) formulation in combination with pancreatic enzyme supplementation every 3 h.

RESULTS

Duration of tube feeding ranged from 25 to 156 days (median 64 days) and pancreatic enzyme was supplemented for 22-195 days (median 75 days). An increase in serum albumin levels of 5 g/L and 10 g/L was achieved after a median period of 20 (range 6-26 days) and 36 days (range 21-57 days), respectively. Albumin levels were > 35 g/L after a median period of 58 days (range 44-171 days).

CONCLUSION

In this case series, a continuous 24-h nasal-jejunal MCT tube feed combined with frequent pancreatic enzyme supplementation was effective in all patients presenting with severe post-bariatric hypoalbuminemia and was not associated with adverse effects.

Pathophysiology and Management of Hyperammonemia in Organ Transplant Patients

Neurologic complications are common after solid-organ transplantation, occurring in one-third of patients. Immunosuppression-related neurotoxicity (involving calcineurin inhibitors and corticosteroids), opportunistic central nervous system infections, seizures, and delirium are some of the causes of neurologic symptoms following solid-organ transplantation. An uncommon often missed complication posttransplantation involves buildup of ammonia levels that can lead to rapid clinical deterioration even when treated. Ammonia levels are not routinely checked due to the myriad of other explanations for encephalopathy in a transplant recipient. A treatment of choice for severe hyperammonemia involves renal replacement therapy (RRT), but there are no guidelines on the mode or parameters of RRT for reducing ammonia levels. Hyperammonemia in a transplant recipient poses specific challenges beyond the actual condition because the treatment (RRT) involves significant hemodynamic fluctuations that may affect the graft. In this review, we describe a patient with posttransplantation hyperammonemia and discuss the pathways of ammonia metabolism, potential factors underlying the development of hyperammonemia posttransplantation, and choice of appropriate therapeutic options in these patients.

An overview of complications affecting the Central Nervous System following bariatric surgery

Bariatric surgery has been considered as an effective treatment for morbid obesity. Apart from procedures related complications, a broad spectrum of neurological disorders affecting any part of neuraxis has been reported following BS. Central nervous system complications, although less common than peripheral nervous system complications, carry significant morbidity and potential mortality. Encephalopathy, behavioral and psychiatric disorders, myelopathy and optic neuropathy are the most frequently reported CNS complications. Early detection and prompt management may improve or completely reverse these neurological complications. It is essential that the treating physicians must be aware of their clinical manifestations and management, so early diagnosis and treatment can prevent patients from suffering significant neurological deficits and even death. This review discusses the clinical manifestations of these complications in detail which will help concerned physician in earlier recognition and hence prevent the delay in specific treatment.