Semin Liver Dis 2008; 28(3): 328-336
DOI: 10.1055/s-0028-1085100
DIAGNOSTIC PROBLEMS IN HEPATOLOGY

© Thieme Medical Publishers

A 56-Year-Old Man with Sudden Onset of Portosystemic Encephalopathy Years after Severe Electrocution Trauma

Kirsten T. Weiser1 , Arief A. Suriawinata2 , Dirk J. van Leeuwen1
  • 1Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center/Dartmouth Medical School, Lebanon, New Hampshire
  • 2Section of Anatomic Pathology, Dartmouth-Hitchcock Medical Center/Dartmouth Medical School, Lebanon, New Hampshire
Further Information

Publication History

Publication Date:
23 September 2008 (online)

ABSTRACT

A 56-year-old white male painter, with a history of major electrocution and deep thermal injury, developed mental status changes initially ascribed to an acute neurological event. Unexpectedly, magnetic resonance imaging (MRI) of the head showed areas of high signal intensity in the basal ganglia, which can be observed in advanced liver disease. An electroencephalogram (EEG) suggested metabolic encephalopathy and coexistent elevation of ammonia, indicative of significant liver disease. The patient had had a long history of right upper quadrant pain and fluctuation in liver tests following the electrocution trauma. For these symptoms, he underwent surgery 7 years prior to his current presentation of portosystemic encephalopathy, and was found to have a gangrenous acalculous cholecystitis. Intraoperative cholangiogram suggested possible strictures within the right hepatic ducts. Multiple liver biopsies, however, showed only steatosis. Current evaluation including liver biopsy, MRI, magnetic resonance angiography (MRA), and magnetic resonance cholangiopancreatography (MRCP), revealed progression to biliary cirrhosis with large bile duct obstruction, and hepatic artery thrombosis/occlusion with evidence of left lobe atrophy and right lobe compensatory hypertrophy. The pathobiology of ischemic bile duct injury is discussed herein. The case is an example of serious late sequelae of an occupational injury.

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Dirk J van LeeuwenM.D. Ph.D. 

Section of Gastroenterology and Hepatology, Dartmouth Medical School/Dartmouth-Hitchcock Medical Center,

One Medical Center Drive, Lebanon, NH 03756

Email: Dirk.J.van.Leeuwen@Dartmouth.edu