Hepatic encephalopathy - a physostigmine-reactive central anticholinergic syndrome ?

This report describes an association between hepatic encephalopathy and cen tral anticholinergic syndrome (CAS). A 60-year-old anaemic woman was admitt ed unconscious and with a delayed reaction to pain but with no focal neurol ogical deficits. She had signs of portal hypertension and a history of non- alcoholic liver cirrhosis grade Child B. Suspecting upper gastrointestinal bleeding, she was intubated for gastroeduodenoscopy and a fibrin-covered ul cer was revealed. Raised intra-abdominal pressure resulting from ascites ca used cardiopulmonary failure, which required mechanical ventilation for 24 h, but extubation was possible after drainage of the ascites and blood volu me replacement therapy. However, her neurological state remained unchanged despite normal blood ammonia concentration and no sedation. CAS was conside red and physostigmine injected with immediate effect. The patient opened he r eyes immediately and was fully orientated to personal and medical history . We suggest that hepatic encephalopathy may trigger CAS, although the sign ificance of physostigmine in the treatment of hepatic encephalopathy remain s to be addressed by controlled investigations.