COEXISTENCE OF HYPERAMMONEMIA AND METABOLIC ENCEPHALOPATHY IN NONCIRRHOTIC PATIENTS

SELCUK COSKUN¹, GUL PAMUKCU GUNAYDIN², GULHAN KURTOGLU CELIK³, TEOMAN ERSEN⁴, EKREM KADIR COSKUN⁵, ALP SENER⁶, SERVAN GOKHAN⁷

¹ Associate Professor Ankara Ataturk Training and Research Hospital, Department of emergency medicine, Bilkent Yolu, Cankaya/Ankara/Turkey - ² Ankara Ataturk Training and Research Hospital, Department of emergency medicine, Bilkent Yolu Cankaya /Ankara/Turkey - ³ Ankara Ataturk Training and Research Hospital, Department of emergency medicine, Bilkent Yolu Cankaya /Ankara/Turkey - ⁴ Ankara Ataturk Training and Research Hospital, Department of emergency medicine, Bilkent Yolu Cankaya /Ankara/Turkey - ⁵ TOBB-ETU Hospital, Department of Quality and Statistics, Yasam Sogutozu, Cankaya, Ankara/Turkey - ⁶ Ankara Ataturk Training and Research Hospital, Department of emergency medicine, Bilkent Yolu Cankaya /Ankara/Turkey - ⁷ Associate Professor, Chief Physician Ankara Ataturk Training and Research Hospital, Department of emergency medicine, Bilkent Yolu Cankaya /Ankara Turkey

Introduction: Most of the time hyperammonemia is seen in hepatic encephalopathy, but it can coexist with various other conditions. In this study, we investigated the causes of hyperammonemia in noncirrhotic patients with encephalopathy. The aims of this study were identifying risk groups of patients who can present with hyperammonemic metabolic encephalophaty.

Materials and methods: This retrospective, observational, descriptive, sectional clinic study was conducted in a tertiary level training and research hospital between July 2013 and October 2015. Blood ammonia levels were analyzed in metabolic encephalopathy patients who have presented to the emergency department (ED).

Results: Among 135 patients (54 patients had cirrhosis and 81 patients did not have cirrhosis) enrolled in this study Mean age was 57 years (range 18-88 years). 67 % of the patients were male (n= 90) and 33% of the patients were female (n= 45). In cirrhotic group although mean values of ammonia got higher as Child-Pugh class raised from A to C (164.2, 202 and 248 µg/dl respectively) the difference was not statistically significant. In noncirrhotic group we found remarkable increased ammonia level in the patients with epilepsy or patients who have seizure (n:37, ammonia level: 110,49 (18-687)), patients with urinary problems (n:27, ammonia level: 135,88 (18-687)), patients with sepsis (n:28, ammonia level: 133,09 (29-687)), and patients who have starvation or oral intake difficulty (n:24, 133,7 (20,90-687))

Conclusion: Blood ammonia levels are useful in differential diagnosis of adult patients who present to ED with new or acute mental status changes of unknown cause. Ammonia levels may be elevated in noncirrhotic patients. Urinary problems, epilepsy or seizure, starvation or oral intake difficulty can be the cause of hyperammonemia. In clinical practice when evalutating patients with hyperammonemia emergency physicians should be familiar with causes other than cirrhosis.