BMJ Case Reports 2017; doi:10.1136/bcr-2017-221458
  • Reminder of important clinical lesson

Hyperammonaemic encephalopathy following an uncomplicated surgery

  1. Sara Sexton1
  1. 1Plastic Surgery Department, NHS Grampian, Aberdeen, UK
  2. 2Department of Biochemistry, NHS Grampian, Aberdeen, UK
  1. Correspondence to Dr Stuart McIntosh, stuartmcintosh10{at}
  • Accepted 7 August 2017
  • Published 16 August 2017


A 59-year-old woman who underwent an uncomplicated exploratory laparotomy, adhesiolysis, small bowel resection and anterolateral thigh flap had a complicated postoperative period characterised by wound dehiscence and poor nutritional intake. 29 days postoperatively, a tremor developed in her upper limbs associated with weakness. Her Glasgow Coma Scale (GCS) fell to 4 and she was transferred to the intensive care unit. The patient was reviewed by multiple specialists and multiple differentials were considered and eliminated. Eventually, investigations revealed hyperammonaemic encephalopathy, being a result of low arginine and potentially small intestinal bacterial overgrowth. Following treatment with sodium benzoate, sodium phenylbutyrate and arginine along with haemodialysis and rifaximin, GCS and hyperammonaemia rapidly improved. She was stepped down to surgical high-dependency unit, continued arginine therapy with total parenteral nutrition and percutaneous endoscopic gastrostomy feeds. She was discharged with regular follow-up from surgeons and biochemistry and continues oral arginine therapy.


  • Contributors SM: involved with requesting of patient notes, interpretation of medical notes, collection of blood results. Writing of report and revising drafts of report. KM: involvement in planning of report, collection of data from medical records, interpretation of blood results and notes on postoperative care. Also involved in writing of report and revising drafts for finalisation. KD: chiefly involved in the gathering of biochemical data for patient and providing information on the treatment of the patient; involved in writing of treatment section and reviewing report for finalisation. SS: involved in the collection of patient blood results, interpretation of results and literature searching; reviewed and approved final draft.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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