CASE REPORT Usefulness of Magnetic Resonance Spectroscopy for Diagnosis of Hepatic Encephalopathy in a Patient with Relapsing Confusional Syndrome JUAN CORDOBA,* CARMEN HINOJOSA,* FRANCESC SAMPEDRO,* JULI ALONSO,*† ALEX ROVIRA,† SERGI QUIROGA,‡ RAFAEL ESTEBAN,* and JAUME GUARDIA* KEY WORDS: hepatic encephalopathy; magnetic resonance spectroscopy; portosystemic shunt; transjugular liver biopsy. The diagnosis of hepatic encephalopathy is not diffi- cult (1). It relies on the exclusion of other causes of neurological disturbance in a patient with cirrhosis who exhibits a confusional syndrome or coma. In most cases, a detailed clinical history, physical exam, and standard blood tests are sufficient to exclude other neurological abnormalities. In patients in deep coma, with focal neurological signs or not responsive to therapy, a computed tomography of the brain is recommended to rule out structural lesions. When hepatic encephalopathy is present, other signs of se- vere liver failure are frequently detected and a pre- cipitating factor is found. The diagnosis of cirrhosis depends on the demonstration of clinical signs of liver impairment and portal hypertension, complemented with imaging techniques that reveal abnormal liver structure. In difficult cases, liver histology can be obtained to confirm the diagnosis. The diagnosis of hepatic encephalopathy may sometimes be difficult, however, especially in cases not showing clinical signs of cirrhosis or those asso- ciated with large portosystemic shunts (2). In this situation proton magnetic resonance ( 1 H-MR) spec- troscopy, a technique that has been proposed for the diagnosis of hepatic encephalopathy, may be helpful (3–5). We report the case of a patient with relapsing confusional syndrome who initially was not diagnosed with hepatic encephalopathy. The exclusion of he- patic encephalopathy was based on results of a tran- sjugular liver biopsy and the assessment of the hepatic venous pressure gradient. In this patient, 1 H-MR spectroscopy of the brain was very useful in establish- ing the final diagnosis of hepatic encephalopathy complicating cirrhosis of the liver. CASE REPORT A 52-year-old woman was admitted to our hospital on April 1999 because of clouding of consciousness and dys- arthria. She had a history of long-lasting obesity, type 2 diabetes mellitus diagnosed at age 32, and was currently on insulin therapy. Regular alcohol intake was denied by the patient. Her neurological symptoms began on January 1996, when she was assessed in the emergency room of another hospital. At that time, she presented with confusion and dysarthria that lasted for two days. A brain CT scan was normal. The symptoms improved during her stay in the emergency room, and she was discharged without a final diagnosis. The patient remained asymptomatic for almost three years until November 1998, when she was admitted to the same hospital for a relapse of confusion and dysarthria. Standard blood tests were unremarkable except for a low platelet count (97,000  10 9 /liter). An upper gastrointesti- nal endoscopy was normal, and a transjugular hepatic he- modynamic study showed a hepatic venous pressure gradi- ent of 6.5 mm Hg, which was considered normal. A transjugular liver biopsy was taken and interpreted as liver steatosis without signs of liver cirrhosis. The findings of the Manuscript received May 6, 2000; revised manuscript received March 19, 2001; accepted May 28, 2001. From the *Servicio de Medicina Interna-Hepatologı ´a, †Unidad de Resonancia Magne ´tica, and ‡Unidad de Tomografia Com- putada, del Servicio de Radiologia (Institut de Diagno `stic per la Imatge), Hospital Vall d’Hebron, Universitat Auto `noma de Bar- celona, Barcelona, Spain. This study was supported by a grant from Fondo de Investiga- ciones Sanitarias (FIS 98/231). Address for reprint requests: Dr. Juan Cordoba, Servicio de Medicina Interna-Hepatologı ´a, Hospital Vall d’Hebron, Paseo Vall d’Hebron 119, Barcelona 08035, Spain. Digestive Diseases and Sciences, Vol. 46, No. 11 (November 2001), pp. 2451–2455 (© 2001) 2451 Digestive Diseases and Sciences, Vol. 46, No. 11 (November 2001) 0163-2116/01/1100-2451$19.50/0 © 2001 Plenum Publishing Corporation