title: Treating Every Needle in the Haystack: Hyperammonemic Encephalopathy and Severe Malnutrition After Bariatric Surgery-A Case Report and Review of the Literature.
abstract: Neurologic complications are not uncommon following bariatric surgery. Hyperammonemic encephalopathy (HAE) due to an acquired or unmasked urea cycle deficit is among the rarest of these. Pediatric nutrition support specialists are familiar with recognizing urea cycle deficits, but adult specialists may not be. Here we present a case of a patient initially misdiagnosed with cirrhosis who presented with recurrent HAE 4 years after Roux-en-Y gastric bypass. She was diagnosed with a proximal urea cycle deficit and severe protein calorie malnutrition. The patient recovered with specialized nutrition and medical support targeting this condition. A literature review indicates multiple fatalities from this condition, indicating the importance of early diagnosis and appropriate nutrition support.
authors.affiliation: Department of General Internal Medicine, Palliative Medicine and Medical Education, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky.
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Singh
authors.affiliation: Department of General Internal Medicine, Palliative Medicine and Medical Education, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky Department Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky.
authors.forename: Swetha
authors.initials: S
authors.lastname: Suresh
authors.affiliation: Department of General Internal Medicine, Palliative Medicine and Medical Education, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: McClave
authors.affiliation: Department of General Internal Medicine, Palliative Medicine and Medical Education, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky Department of Pharmacology & Toxicology, University of Louisville, Louisville, Kentucky Robley Rex Louisville VAMC, Louisville, Kentucky matt.cave@louisville.edu.
authors.forename: Matt
authors.initials: M
authors.lastname: Cave
mesh_terms: D000328:Adult; D000641:Ammonia / Q000097:blood*; D001928:Brain Diseases, Metabolic / Q000097:blood / Q000175:diagnosis* / Q000209:etiology; D003951:Diagnostic Errors; D005260:Female; D005355:Fibrosis / Q000175:diagnosis; D015390:Gastric Bypass / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D011502:Protein-Energy Malnutrition / Q000209:etiology*; D014508:Urea / Q000097:blood
chemical_list: D000641:Ammonia; D014508:Urea
keywords: OTC deficiency; bariatric surgery complications; hyperammonemic; noncirrhotic encephalopathy