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A 31-year-old Asian man with hepatitis C cirrhosis complicated by variceal hemorrhage and ascites underwent an inpatient evaluation for orthotopic liver transplantation. He was a graduate student who was doing well until he developed decompensated cirrhosis with variceal hemorrhage. When he first presented, he had hypovolemic shock from acute blood loss related to variceal hemorrhage that was treated with many blood transfusions and variceal banding procedures. When he was transferred to the liver unit on hospital day 25, his liver test abnormalities had mostly recovered and he had no further gastrointestinal bleeding. He had a serum ammonia level measured as part of the routine liver transplant evaluation. He did not have any confusion, insomnia, or decreased mental alertness. Jaundice was noted on the physical examination but he was alert and oriented with normal cognitive function. No tenderness was noted on his abdominal examination and he had mild ascites. During the inpatient liver transplant evaluation, his cognitive capacity and mental status remained stable and he had no symptoms of encephalopathy. He received oral diuretics for the management of his ascites. The Table lists results of laboratory analyses performed at admission and on hospital days 25 and 38.
Ge PS, Runyon BA. Serum Ammonia Level for the Evaluation of Hepatic Encephalopathy. JAMA. 2014;312(6):643-644. doi:10.1001/jama.2014.2398