Hepatic encephalopathy (HE) represents a spectrum of neuropsychiatric abnormalities resulting from hepatic dysfunction. This case report discusses the case of a 66-year-old woman with a known diagnosis of primary biliary cholangitis (PBC) who presented with a 10-day history of constipation, vomiting, and progressive cognitive decline. Cross-sectional imaging of the abdomen revealed a large ventral hernia in the anterior midline containing multiple loops of small bowel, consistent with adhesional small bowel obstruction. Laboratory investigations demonstrated elevated ammonia levels and deranged liver function tests (LFTs), consistent with the clinical picture of HE. The patient was managed conservatively with bowel decompression, and HE was successfully treated with rifaximin and, following the resolution of the obstruction, with lactulose. The patient made a good neurological recovery with normalization of biochemical markers and was discharged from the intensive care unit (ICU) in a stable condition. This case underscores the importance of recognizing and promptly addressing reversible precipitants of HE and illustrates the challenges of managing HE in the context of gastrointestinal obstruction.
Keywords: ammonia; hepatic encephalopathy; primary biliary cholangitis; rifaximin; small bowel obstruction.
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