Anoxic Brain Injury From Hepatic Encephalopathy in Acute on Chronic Liver Failure: A Case Report (original) (raw)

2019, American Journal of Gastroenterology

diarrhea with 5-6 bowel movements/day from last 2-3 months, 30 pound unintentional weight loss in last 2 months, occasional night sweats. He denied any episodes of flushing. On presentation, vitals were stable. Other labs included CBC-wnl, BUN-25 mg/dl with creatinine of 3 (baseline 2), albumin-2.4, AST-19u/l, ALT-26u/l, ALP-210 u/l, total bilirubin 0.9 mg/dl. Clostridium difficle screen and GI panel were negative. Last colonoscopy, done one month prior to presentation was normal. He was started on Imodium without any relief. Gastroenterology service was consulted for further management. His chromogranin A was found to be 782 (, 93), 5HIAAA was 50 (, 8). He underwent ultrasound of the abdomen for this acute kidney injury which revealed 5.9 3 5.9 3 5.9 cm hyperechoic mass with central decreased echogenicity located within the liver. AFP was 1.1 ng/ml (, 8 ng/ ml), CEA 7.4 ng/ml (3 ng/ml). Meanwhile, he was started on sandostatin which helped a lot with his diarrhea. Further imaging of this abdomen was deferred due to kidney injury. He had previous PET scan done 3-4 years ago revealed increased uptake in liver but were inconsistent of any metastatis. His last abdominal CT scan done 2-3 years ago was negative of any metastasis. Two weeks after his discharge, he was readmitted to intensive care unit (ICU) with septic shock and unfortunately he passed away. DISCUSSION: Carcinoid tumors are relatively slow growing compared to adenocarcinomas of the same site and have a tendency for recurrence. The NANETS Consensus Guideline for the Diagnosis and Management of Neuroendocrine Tumors recommends an office follow up every 6 to12 months for 7 years. Either radiographic (CT/MRI) or endoscopic methods could be used for surveillance. The secretory tumors can be followed up by monitoring the levels of urinary 5-HIAA and serum chromogranin A.