Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 4, Number 1, January 2013, pages 56-60

Successful Surgical Rescue of Hepatic Encephalopathy due to Anal Fissure in the Case of Acute Myeloid Leukemia


Figure 1.
Figure 1. CT reveals anal fissure without a significant abscess formation.
Figure 2.
Figure 2. CT also demonstrates perirectal cellulitis without other abnormalities.
Figure 3.
Figure 3. Clinical course demonstrates a significant reduction in the level of ammnonia after surgery.
Figure 4.
Figure 4. Patients could experience severe heaptic encephalopathy primarily due to anal fissure.


Table 1. Laboratory Examination on Admission
PT: prothrombin time; APTT: activated partial thromboplastin time; HBs-Ag: hepatitis B surface antigen; HCV-Ab: hepatitis C virus antibody; HIV-Ab: human immunodeficiency virus antibody.
White blood cell107.9 × 109/L
Red blood cell3.42 × 1012/L
Hemoglobin11.0 g/dL
Platelet30 × 109/L
PT sec14.5 sec
APTT sec31.4 sec
Total protein7.8 g/dL
Albumin4.7 g/dL
Total Bilirubin0.6 mg/dL
Asparate aminotransferase26 IU/L
Alanine aminotransferase42 IU/L
Gamma glutamyl transpeptidase22 IU/L
Lactate dehydrogenase348 IU/L
Amylase42 IU/L
Blood urea nitrogen8.4 mg/dL
Creatinine0.56 mg/dL
Na142 mEq/L
K3.4 mEq/L
Cl103 mEq/L
Glucose104 mg/dL
Immunoglobulin G1,497 mg/dL
Immunoglobulin A176 mg/dL
Immunoglobulin M140 mg/dL


Table 2. West Heaven Criteria for Semiquantative Grading of Mental State
Grade 1Trivial lack of awareness, Euphoria or anxiety
  Shortened attention span
  Impaired performance of addition
Grade 2Lethargy or apathy
  Minimal disorientation for time or place
  Subtle personality change, Inappropriate behaviour
  Impaired performance of subtraction
Grade 3Somnolence to semistupor, but responsive to verbal stimuli
  Confusion, Gross disorientation
Grade 4Coma (unresponsive to verbal or noxious stimuli)


Table 3. Laboratory Examination on the Onset of Hepatic Encephalopathy
PT: prothrombin time; APTT: activated partial thromboplastin time.
White blood cell0.4 × 109/L
Red blood cell2.56 × 1012/L
Hemoglobin8.1 g/dL
Platelet37 × 109/L
PT sec16.5 sec
APTT sec37.7 sec
Total protein6.6 g/dL
Albumin3.0 g/dL
Total Bilirubin1.2 mg/dL
Asparate aminotransferase40 IU/L
Alanine aminotransferase148 IU/L
Lactate dehydrogenase92 IU/L
Amylase42 IU/L
Blood urea nitrogen14.3 mg/dL
Creatinine0.49 mg/dL
Na140 mEq/L
K4.6 mEq/L
Cl104 mEq/L
Glucose111 mg/dL
Ammonia235 µg/dL


Table 4. Hepatic Encephalopathy is Classified into 3 Types Based on the Disease State of the Liver
Classification and grading In the World Congress of Gastroenterology 1998 in Vienna.
Hepatic encephalopathy is subdivided in type A, B and C
  Type A (acute) describes hepatic encephalopathy associated with acute liver failure
  Type B (bypass) is caused by portal-systemic shunting without associated intrinsic liver disease
  Type C (cirrhosis) occurs in patients with cirrhosis