Nikitha Chellapuram, MD, Carolyn Tran, MD, Jonathan Hughes, , Amirmohsen Arbabi, MD, Saisree Reddy Adla Jala, MD, Evan Nick Vidar, MD, Adarsha Bajracharya, MD, Stephen Parnell, MD Centinela Hospital Medical Center, Los Angeles, CA
Introduction: Hepatic encephalopathy (HE) is less frequently reported among hospitalized patients with MAFLD-related complications. HE occurs in about 30-45% of cirrhosis cases overall, but specific data on MASH-cirrhosis is limited.
Case Description/Methods: A 60-year-old Hispanic woman with diabetes mellitus, dyslipidemia, and a recent CVA without lasting deficits was admitted for altered mental status. Her husband found her confused and mumbling incoherently, marking her third hospital admission in the past year for similar issues. She had intermittent forgetfulness, confusion, and occasional blood in her stools while taking Aspirin and Plavix for her CVA. Her husband denied any history of alcohol, tobacco, or illicit drug use.
Emergency medical services initially recorded her blood glucose at 118 mg/dL, with a repeat of 105 mg/dL. At the hospital, she was lethargic, responding only to painful stimuli with groaning. With an NIHSS score of 27, a stroke code was activated. A non-contrast CT scan of the head revealed no acute intracranial pathology. Lumbar puncture and CSF analysis were performed to check for possible encephalitis. A 10-panel drug screen and ethyl alcohol test were negative, but her serum ammonia level was elevated at 273 μmol/L. She was started on a Lactulose enema and IV broad-spectrum antibiotics while further workup for encephalopathy continued.
An abdominal ultrasound showed a heterogeneous liver and spleen with a nodular liver surface, indicating cirrhosis. Within 24 hours of starting Lactulose therapy, her mental status improved significantly, and she was cleared by physical and occupational therapy evaluations. Gastroenterology was consulted, and an endoscopic examination found grade-1 distal esophageal varices without recent bleeding, and no gastric varices. After ruling out other potential causes, she was diagnosed with cirrhosis secondary to metabolic dysfunction-associated steatohepatitis (MASH), with a FIB-4 Index of 6.04 indicating advanced fibrosis. She received conservative management with Lactulose and Rifaximin, was given an outpatient hepatology referral, and was discharged on day five.
Discussion: MAFLD, characterized by multifactorial pathologies, involves gut dysbiosis and an impaired brain-gut-liver axis, contributing to hepatic encephalopathy. This study highlights the need for enhanced resources for timely diagnosis to reduce the disease burden and improve quality of life in MAFLD-related neurological complications.
Figure: MAFLD (NAFLD -old nomenclature),often leads to increased insulin resistance and chronic inflammation, with symptoms including neuroinflammation, hyperammonemia, cognitive decline, dementia, gut dysbiosis, and cerebrovascular dysfunction. Cheon, S.Y., Song, J. Novel insights into non-alcoholic fatty liver disease and dementia: insulin resistance, hyperammonemia, gut dysbiosis, vascular impairment, and inflammation. Cell Biosci 12, 99 (2022). https://doi.org/10.1186/s13578-022-00836-0
Note: The table for this abstract can be viewed in the ePoster Gallery section of the ACG 2024 ePoster Site or in The American Journal of Gastroenterology's abstract supplement issue, both of which will be available starting October 27, 2024.
Disclosures:
Nikitha Chellapuram indicated no relevant financial relationships.
Carolyn Tran indicated no relevant financial relationships.
Jonathan Hughes indicated no relevant financial relationships.
Amirmohsen Arbabi indicated no relevant financial relationships.
Saisree Reddy Adla Jala indicated no relevant financial relationships.
Evan Nick Vidar indicated no relevant financial relationships.
Adarsha Bajracharya indicated no relevant financial relationships.
Stephen Parnell indicated no relevant financial relationships.
Nikitha Chellapuram, MD, Carolyn Tran, MD, Jonathan Hughes, , Amirmohsen Arbabi, MD, Saisree Reddy Adla Jala, MD, Evan Nick Vidar, MD, Adarsha Bajracharya, MD, Stephen Parnell, MD. P4832 - The Brain-Gut-Liver Axis: A Case Study Perspective on Gut Dysbiosis and Hepatic Encephalopathy in MAFLD, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
