Wernicke encephalopathy after pancreaticoduodenectomy for pancreatic cancer

A case report of Wernicke Korsakoff syndrome in a patient with cholangiocellular carcinoma: An underestimated cause of encephalopathy in cancer patients

INTRODUCTION

Wernicke's encephalopathy, a disorder caused by thiamin deficiency, is characterized by a classical triad of encephalopathy, ataxia, and ophthalmoplegia. Although alcoholism is the most common predisposing factor, it can also be associated with nonalcoholic states (hyperemesis gravidarum, intestinal obstruction, bariatric surgery, and others). This work presents a case of nonalcoholic Wernicke-Korsakoff syndrome diagnosed in a cholangiocellular carcinoma patient and literature review.

CASE REPORT

A 65-year-old male patient with a history of cholangiocellular carcinoma (Klatskin tumor) was treated with radiotherapy at the operation site after Roux-en-Y hepaticojejunostomy. During follow-up, the patient developed gastric outlet obstruction and was diagnosed with peritoneal carcinomatosis after a palliative gastrojejunostomy. As the patient could not tolerate oral nutrition during hospitalization, total parenteral nutrition was administered. After 10 days of admission, the patient showed decreased response to verbal stimuli as well as bilateral horizontal nystagmus, lethargy, and disorientation. Furthermore, the patient displayed confabulation. Clinical and imaging findings were consistent with Wernicke's encephalopathy. Therefore, treatment with intravenous thiamin replacement was initiated. The patient's encephalopathy regressed on the second day after treatment, and he recovered the place-person-time orientation. In the following month, the abnormal imaging findings were almost entirely resolved.

CONCLUSION

In order to prevent irreversible brain damage induced by chronic thiamin deficiency, thiamin replacement therapy with parenteral nutrition solutions should be included as a treatment for hospitalized cancer patients unable to receive enteral nutrition for a long time.

Hyperemesis-induced Wernicke-Korsakoff Syndrome due to Hypergastrinemia during Long-term Treatment with Proton Pump Inhibitors

We herein report a patient with Wernicke-Korsakoff syndrome (WKS) who had neither a history of alcoholism or of history of gastric surgery. A 56-year-old woman was transferred to our hospital because of the loss of consciousness and she was diagnosed to have Wernicke encephalopathy. She showed proton pump inhibitor-induced refractory hypergastrinemia with the subsequent development of hyperemesis and a vitamin B1 deficiency.

Development of Wernicke's encephalopathy long after subtotal stomach-preserving pancreatoduodenectomy: a case report

BACKGROUND

Wernicke's encephalopathy (WE) is an acute neuropsychiatric disorder resulting from thiamine (vitamin B₁) deficiency, frequently associated with chronic alcoholism and total parenteral nutrition without thiamine. However, only a few reports have focused on the relationship between WE and subtotal stomach-preserving pancreatoduodenectomy (SSPPD).

CASE PRESENTATION

A 71-year-old woman underwent SSPPD for an adenocarcinoma of the ampulla of Vater. Although there had been no evidence of recurrence, the patient was treated with antibiotics for cholangitis at 12 and 31 months, respectively, post-surgery. Thereafter, the patient presented with vomiting and disorientation 33 months after surgery. Although she was admitted and underwent closer inspection by a neurologist and a psychiatrist, the exact cause of these syndromes remained unknown. The psychiatrist measured thiamine concentration to examine the cause of disorientation. After 6 days, her level of consciousness worsened. Magnetic resonance imaging of the head showed symmetrically multiple abnormal hyperintense signals on fluid-attenuated inversion-recovery and diffusion weighted image, compatible with WE. An administration of intravenous thiamine was immediately initiated. After 8 days of the measurement of the thiamine level, the patient's serum thiamine level was found to be 6 µg/mL (reference range, 24-66 µg/mL). Accordingly, the patient was diagnosed with WE. Shortly after starting the treatment, blood thiamine value reached above normal range with significant improvement of her confusional state. However, short-term memory and ataxia remained.

CONCLUSIONS

Development of WE after SSPPD is uncommon. However, to prevent an after-effect, the possibility of development of WE after SSPPD should be recognized.

Total parenteral nutrition-induced Wernicke's encephalopathy after oncologic gastrointestinal surgery

Carl Wernicke described the disease bearing his name in 1881 and reported three cases characterized by the presence of mental confusion, ataxia, and ophthalmoplegia. Wernicke's disease is mainly observed in alcoholic patients, due to decreased vitamin intake as a consequence of an unbalanced diet, and a reduction of absorption due to the effects of alcohol. Likewise, inadequate vitamin intake is prevalent in older patients. Wernicke's encephalopathy due to inappropriate total parenteral nutrition (TPN) occurs infrequently; recently, there is an increase in the literature concerning Wernicke's encephalopathy in patients after general and bariatric surgeries. We present two cases of Wernicke's encephalopathy after oncologic gastrointestinal surgery by failure to administer vitamin B1 during TPN; to our knowledge, these are the first two cases of Wernicke's encephalopathy after colorectal surgery for cancer. In our opinion, timely diagnosis and treatment are mandatory to avoid nonfunctional recovery and consequent malpractice legal actions as well as an increase in the health-care costs correlated with the prolonged hospital stay and with the nonfunctional recovery.

A case of Wernicke's encephalopathy following complicated laparoscopic pylorus-preserving pancreaticoduodenectomy

Laparoscopic pylorus-preserving pancreaticoduodenectomy (PPPD)/pancreaticoduodenectomy (PD) is cautiously regarded as a safe and effective approach in well-selected patients with periampullary cancer. However, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postoperative bleeding, and sepsis and detrimental complications that can follow PPPD/PD. These complications can result in poor oral intake for a significant period of nothing per oral (NPO) or deterioration of long-term function. A 65-year-old man underwent laparoscopic PPPD for ampulla of vater (AoV) cancer. After surgery, He experienced POPF, DGE, Postoperative bleeding and these complications result in poor oral intake for one month. Approximately 50 days after surgery, an abrupt confused state was noted. He had horizontal nystagmus and ataxia. Abnormal Brain magnetic resonance imaging tomography findings detected in the bilateral medial thalami, dorsal midbrain, and medulla. The association of confusion, ataxia, and horizontal nystagmus along with poor oral intake and the MRI findings suggested acute Wernicke's encephalopathy. After thiamine therapy, He recovered completely. Wernicke's encephalopathy is very rare, but it can progress coma and even death. Therefore, Wernicke's encephalopathy needs to be considered in patients with complicated PPPD/PD associated with malnutrition.

Wernicke encephalopathy following gastrojejunostomy: A case report and review of the literature

Introduction

Non-alcoholic Wernicke encephalopathy (WE) is a life-threatening condition, which is caused due to thiamine deficiency. We reported a case of non-alcoholic WE following gastrojejunostomy.

Case presentation

A 31-year-old woman was admitted to our tertiary care center complaining about intractable nausea and vomiting following her gastrojejunostomy. She had undergone gastrojejunostomy because of gastric outlet obstruction after a suicide attempt with scale-remover. Two weeks after gastrojejunostomy, the altered mental status and confusion were reported and she also had a reduced range of motion, dysarthria, generalized muscle weakness, and vertical nystagmus. She gradually became uninterested in surroundings. WE was considered a differential diagnosis, which was confirmed by magnetic resonance imaging (MRI). High-dose intravenous thiamine administration was done for the patient and her symptoms were improved. We also reviewed the PubMed to evaluate studies on WE following gastrointestinal surgeries conducted through the last 10 years.

Conclusion

WE is a rare presentation of gastrojejunostomy and it should be considered as differential diagnosis when patient had impaired mental status and other related WE symptoms following gastrojejunostomy. Early diagnosis and management of WE in the Emergency Department can reduce the mortality and morbidity of WE.

A patient with Korsakoff syndrome of psychiatric and alcoholic etiology presenting as DSM-5 mild neurocognitive disorder

Background: Wernicke's encephalopathy (WE) and Korsakoff syndrome (KS) are underdiagnosed. The DSM-5 has raised the diagnostic threshold by including KS in the major neurocognitive disorders, which requires that the patient needs help in everyday activities. Methods: We report clinical, neuropsychological, and radiological findings from a patient who developed Wernicke-Korsakoff syndrome as a result of alcohol use and weight loss due to major depression. We assess the diagnosis in the context of the scientific literature on KS and according to the DSM-IV and the DSM-5. Results: The patient developed ataxia during a period of weight loss, thus fulfilling current diagnostic criteria of WE. WE was not diagnosed, but the patient partially improved after parenteral thiamine treatment. However, memory problems became evident, and KS was considered. In neuropsychological examination, the Logical Memory test and the Word List test were abnormal, but the Verbal Pair Associates test was normal (Wechsler Memory Scale-III). There were intrusions in the memory testing. The Wisconsin Card Sorting Test was broadly impaired, but the other test of executive functions (difference between Trail Making B and Trail Making A tests) was normal. There was atrophy of the mammillary bodies, the thalamus, the cerebellum, and in the basal ganglia but not in the frontal lobes. Diffusion tensor imaging showed damage in several tracts, including the uncinate fasciculi, the cinguli, the fornix, and the corona radiata. The patient remained independent in everyday activities. The patient can be diagnosed with KS according to the DSM-IV. According to the DSM-5, the patient has major neurocognitive disorders. Conclusions: Extensive memory testing is essential in the assessment of KS. Patients with a history of WE and typical clinical, neuropsychological, and radiological KS findings may be independent in everyday activities. Strict use of the DSM-5 may worsen the problem of Wernicke-Korsakoff syndrome underdiagnosis by excluding clear KS cases that do not have very severe functional impairment.

Association between malignancy and non-alcoholic Wernicke's encephalopathy: a case report and literature review

Background

Wernicke's encephalopathy is a serious medical condition associated with high morbidity and mortality caused by deficiency of thiamine. This disease is classically associated with alcoholism, but is underappreciated in the nonalcoholic population. There is growing acknowledgement of the development of Wernicke's encephalopathy in patients with malignancies.

Methods

We conducted a literature review in PubMed for cases of Wernicke's encephalopathy occurring in patients with malignancy. We also present the case of a 47-year-old woman with recurrent laryngeal cancer and multiple hospital admissions for malnutrition. Neurological examination was notable for pendular nystagmus, severe gait ataxia, confusion, and poor memory consolidation. MRI of the brain was significant for T2-weighted fluid-attenuated inversion recovery hyperintensities in periaqueductal regions, medial thalami, and the tectal plate, typical for Wernicke's encephalopathy. She was treated with thiamine repletion, and had marked improvement in her mental status and some improvement in her vision problems and ataxia, although some nystagmus and significant short-term memory impairment persisted.

Results

The literature review yielded dozens of case reports of Wernicke's encephalopathy in patients with malignancy, dominated by cases of patients with malignancies of the gastrointestinal system, followed by those with hematologic malignancies.

Conclusions

Malignancy is an important risk factor for the development of Wernicke's encephalopathy. This diagnosis is underappreciated and difficult for the clinician to discern from multifactorial delirium. Clinicians should be aware to treat at-risk patients with thiamine immediately, especially if multiple risk factors are present.

Risk of thiamine deficiency and Wernicke's encephalopathy after gastrointestinal surgery for cancer

BACKGROUND

Cancer patients submitted to gastrointestinal surgery are at risk of thiamine deficiency (TD) and Wernicke's encephalopathy (WE). Although permanent neurological damage and death could be prevented by a timely replacement therapy, they often remain undiagnosed and untreated. We hypothesized that WE remains unrecognized because most cases may manifest several months after hospital discharge.

METHODS

WE frequency was investigated in a sample of cancer patients who underwent gastrointestinal surgery, by using the diagnostic criteria proposed to improve diagnosis among alcoholics. Patients were evaluated at discharge through the examination of medical records and 6 months after by telephonic interview.

RESULTS

Forty-five patients were selected. Signs of WE resulted in 4.4% at discharge. At 6 months, 21 patients were interviewed. Among them, 90.4% had signs of WE. The number of affected patients was significantly higher 6 months after discharge than at discharge (90.4 vs 9.5%, p < 0.0001).

CONCLUSIONS

Further studies with larger samples are needed to establish the prevalence of TD and related WE in cancer patients after gastrointestinal surgery. This study suggests that the problem is understated. Even in absence of symptoms of TD, the use of prophylactic thiamine supplementation should be taken in consideration, as consequences of misdiagnosis can be severe.

Wernicke's encephalopathy: expanding the diagnostic toolbox

Wernicke's encephalopathy (WE) is a life threatening neurological disorder that results from thiamine (Vitamin B1) deficiency. Clinical signs include mental status changes, ataxia, occulomotor changes and nutritional deficiency. The conundrum is that the clinical presentation is highly variable. WE clinical signs, brain imaging, and thiamine blood levels, are reviewed in 53 published case reports from 2001 to 2011; 81 % (43/53) were non-alcohol related. Korsakoff Syndrome or long-term cognitive neurological changes occurred in 28 % (15/53). Seven WE cases (13 %) had a normal magnetic resonance image (MRI). Four WE cases (8 %) had normal or high thiamine blood levels. Neither diagnostic tool can be relied upon exclusively to confirm a diagnosis of WE.