Maruyama Masahiro, Miyasaka Yoshiaki, Takano Atsushi, Inoue Masayuki, Furuya Kazushige, Sugai Hidemitsu, Hada Masao, Nakagomi Hiroshi
Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan.
Surg Case Rep. 2015 Sep 24;1:88. doi: 10.1186/s40792-015-0088-3. eCollection 2015 Dec.
Hyperammonemic encephalopathy is rarely caused by a urinary diversion. We herein experienced a case of rectal carcinoma with rectovesical and ileal fistulae that developed hyperammonemic encephalopathy. A 72-year-old man suffered from a fever, diarrhea, pneumaturia, and fecaluria beginning in April 2013 and was referred to our hospital in May 2013. He developed a loss of consciousness and whole body cramping on the first hospital day. The laboratory data indicated an inflammatory reaction and hyperammonemia with a highly elevated serum ammonia (NH3) level of 703 μg/dl. The patient was diagnosed to have rectal carcinoma with rectovesical and ileal fistulae according to computed tomography (CT) and a water-soluble contrast enema. We administered a solution of branched chain amino acids (BCAA) and antibiotics. Furthermore, we repeatedly irrigated bladder through the urethral catheter. The patient's symptoms recovered, and the serum ammonia levels on the second and third hospital day were decreased to 210 and 135 μg/dl, respectively. However, the symptoms of infection and confusion were suspected to repeat; we elected to perform surgical treatment. An ileal disconnection with ileocecal bypass and sigmoidostomy were effective for preventing hyperammonemic encephalopathy.
高氨血症性脑病很少由尿路改道引起。我们在此报告一例患有直肠膀胱和回肠瘘的直肠癌患者并发高氨血症性脑病的病例。一名72岁男性于2013年4月开始出现发热、腹泻、气尿和粪尿症状，并于2013年5月转诊至我院。入院第一天他出现意识丧失和全身抽搐。实验室检查数据显示有炎症反应和高氨血症，血清氨（NH3）水平高达703μg/dl。根据计算机断层扫描（CT）和水溶性造影灌肠检查，该患者被诊断为患有直肠膀胱和回肠瘘的直肠癌。我们给予了支链氨基酸（BCAA）溶液和抗生素治疗。此外，我们通过尿道导管反复冲洗膀胱。患者症状得到缓解，住院第二天和第三天的血清氨水平分别降至210μg/dl和135μg/dl。然而，怀疑感染和意识模糊症状会复发；我们选择进行手术治疗。回肠切断并进行回盲肠旁路吻合术和乙状结肠造口术对预防高氨血症性脑病有效。
