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

Abstract

Anal fissures and other anorectal complications are relatively common conditions, which are rarely fatal. However, it is important to understand that these conditions could progress to lethal infections in immunocompromised patients. On the other hand, Hepatic encephalopathy (also known as portosystemic encephalopathy) is a potentially-reversible, life-threatening, systemic, neuropsychiatric disorder, which occurs in the setting of liver failure. Hepatic encephalopathy can occur in either acute or chronic liver disease, or, in the case of portal-systemic shunting, without associated intrinsic liver disease. Hepatic encephalopathy due to anal fissure is relatively rare. In cases of perirectal cellulitis caused by Escherichia Coli (E. Coli) or other enteric bacteria large amounts of NH3 are produced, especially in immunocompromised patients. This NH3 is subsequently drained by the middle or lower rectal veins from the rectal venous plexus to the systemic circulation. Consequently, patients can experience severe hepatic encephalopathy in spite of normal liver function. To our knowledge, this is the first published case of an anal fissure presenting with hepatic encephalopathy during therapy-related neutropenia in a patient with AML. Surgical intervention with sigmoid colostomy and perirectal drainage is the procedure of choice to treat life-threatening hepatic encephalopathy in immunocompromised patients with anorectal cellulitis not responding to conservative therapy. For this reason, we also chose to perform a sigmoid colostomy with drainage of the perirectal cellulitis.