Bariatric surgery including sleeve is one of the recently growing weight reduction methods. The need of this kind of surgery is increasing recently. Despite the good outcome in term of weight loss and subsequent improvement of the metabolic status it can lead to fatal complications. These complications are variable, individually dependent, mild or severe, causing irreversible damage. Steatohepatitis can be present at any time during the course or after surgery and is usually discovered late as the patient presents with vague nonspecific symptoms. This type of steatohepatitis can lead to hyperammonemic state with severe brain cortical damage and variable degree of encephalopathy leading to seizure, coma or even death.

Case

A 23- years- old female, morbidly obese, underwent sleeve gastrectomy. 2 month later, she developed abdominal pain and vomiting. She was found to have severe liver injury with high ammonia level. Ultrasound and Magnetic resonance cholangiopancreatography showed evidence of steatohepatitis. Within 1 week she started developing abnormal behavior, agitation followed by recurrent seizures requiring intubation, sedation and antiepileptic treatment. Brain MRI showed evidence of diffuse cytotoxic edema, symmetrical cortical diffusion restriction sparing the subcortical areas suggestive of hyperammonemic state. Lactulose, hypertonic saline was a started, sedative agent gradually tapered off; EEG showed extremely low voltage activity, due probably to cortical damage and likely compatible with severe encephalopathy. Following normalization of her ammonia level, the second brain MRI performed 10 days later showed significant improvement in her diffusion restriction. Despite the radiological and biochemical improvement, she remained comatose with very low voltage EEG suggesting severe encephalopathy.  

Post sleeve steatohepatitis is one of the severe complications leading to toxic brain injury due to hyperammonemic state. It needs prompt diagnosis, high index of suspension and urgent treatment to decrease morbidity and mortality.