S3271 Blame It on the Alcohol...or Not?

Abstract

INTRODUCTION: Hyperammonemia (HA) can cause cerebral edema and brain herniation leading to coma or death, making it a common cause to be considered in patients who present with altered mental status (AMS). However, the etiology of hyperammonemia must be determined to guide treatment. While alcohol-related liver disease is one of the most common causes of liver cirrhosis, there are many other causes of cirrhosis that can also lead to hyperammonemia. We aim to study whether the etiology of cirrhosis plays a role in the severity of hyperammonemia in patients who present with AMS. METHODS: We performed a retrospective chart review of 190 patients seen at community hospital between July to August 2019 with an ICD-10 code of altered mental status (R41.82), hepatic failure without coma (K72.90) and cirrhosis of liver (K74.60). Data points included history/etiology of cirrhosis, history of alcohol abuse, AMS, and ammonia level on presentation. HA was defined as an ammonia level > 45 µmol/L. Patients were separated by the etiology of cirrhosis with alcohol in one group and other etiologies, including autoimmune hepatitis, non-alcoholic steatohepatitis (NASH), and viral hepatitis leading malignancy, and unknown etiology, in another group. We compared the average ammonia level for each group. RESULTS: Out of a total 190 patients who met criteria, 143 presented with ammonia levels >45 µmol/L. Out of this cohort, 52% had cirrhosis due to alcohol, and 48% had cirrhosis due to other causes. The average ammonia level for patients who presented with hyperammonemia with a history of alcoholic cirrhosis and cirrhosis due to other etiologies were 139µmol/L and 110 µmol/L, respectively. CONCLUSION: Alcohol-related liver disease is one of the most common causes of liver cirrhosis, but there are many other etiologies for liver cirrhosis. Hyperammonemia is known to be associated with increasing severity of liver cirrhosis. Whether the etiology of liver cirrhosis plays a role in the level of hyperammonemia that a patient presents with is unknown. This study found that patients with cirrhosis due to alcohol-related liver disease presented with a higher level of hyperammonemia on average compared to those with other etiologies of cirrhosis. However, the significance of determining the etiology of liver cirrhosis and its relation to diagnosing and management of hyperammonemia is yet to be determined. Limitations included the exclusion of other causes of hyperammonemia and being a single-center retrospective study.