S3435 The Masked Face of Constipation

Abstract

INTRODUCTION: Parkinson disease is the most common type of hypokinetic movement disorder. This progressive neurodegenerative disease, involves gradual loss of dopamine-producing neurons in the substantia nigra pars compacta. It has four cardinal signs: tremor at rest, bradykinesia, rigidity, and gait/balance impairment. It may have atypical (non-motor) presentations, with symptoms associated to cognition, the musculoskeletal system, or the autonomic system. These non-motor symptoms have gained attention, and are now considered among the hallmark criteria of this disease. CASE DESCRIPTION/METHODS: A 66-year-old male with alcoholic cirrhosis and chronic hepatitis B was admitted for treatment of decompensated chronic liver disease (CLD), due to altered mental status. Once stable, he was discharged with lactulose for constipation. Five days later, was readmitted due to recurrent altered mental status, non-bloody emesis, and unrelenting constipation. He was lethargic, icteric, and had a flapping tremor of his hands upon extension of his wrists. Labs revealed hyperammonemia, hyperbilirubinemia, thrombocytopenia, and lactic acidosis. He was diagnosed with hepatic encephalopathy secondary to constipation. Treatment was initiated with lactulose enemas to no avail. Additional physical evaluation revealed masked facies, cogwheel rigidity, bradykinesia, resting hand tremors, and dysmetria. A complete neurological evaluation confirmed the clinical diagnosis of PD. Treatment with carbidopa-levodopa and lubiprostone was started, which led to gradual resolution of the patient’s constipation and altered mental status and motor symptoms. On discharge, he was passing 4 bowel movements per day, and remained free of motor symptoms. DISCUSSION: Recognizing constipation as a non-motor symptom of PD is important. It is a common complaint among PD patients, but an unusual presenting symptom, because it is non-specific. The presentation of PD can be masked by other signs associated to hepatic encephalopathy and CLD. Treatment of constipation in PD includes lubiprostone, which is expensive. An effective, affordable alternative is polyethylene glycol, available over the counter. Recognizing constipation as a presenting symptom of Parkinson’s disease was critical in this patient, to resolve both his hepatic encephalopathy and altered mental status. Awareness, a high degree of suspicion, and adequate treatment of non-motor presentations of Parkinson’s disease can lead to timely diagnosis and prevention of psychophysical morbidity.