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Re: Ammonia level

Posted By Bob Kovich on June 01, 1999 at 16:15:33
My mother is 82 years old and was diagnosed with cirrhosis 15 years ago. She quit drinking for 10 years and then slowly began again. One month ago she hurt her back and was hospitalized. She was then transferred to a nursing home and underwent therapy. She is now capable of walking without a cane even though she is told she must use it and wants to go home. Her ammonia level is reportedly 160 (I do not know the units) . I spent an afternoon with her 2 days ago and had a chance to tour the nursing home. My mom was able to walk around with me and converse normally for 2 hours. (basic chit chat, etc) The other residents of the home are vegetative and my mom has no one to talk to. She is not allowed out of her room even though she is able to get around. She is also on some medicine that makes her have bowel movements as soon as she eats so she feels like she is not getting any nourishment. It appears that her appetite is OK. She does get tired easily and naps frequently. Until this episode she has lived alone and taken care of herself and home for 10 years since my father died.
Her regular doctor will not see her now that she is in the home and the home doctor has not returned my calls. She has been prescribed Advil and Tylenol even though she says that she is not in any pain.
I am afraid that no one, including the doctor, is treating her as they should. From my observations it appears that no one is expected to ever return home from there.
1. How serious is the ammonia level and what are the consequences??
2. Should she be taking Advil and Tylenol ?? I thought that these where bad for the liver.
3. Can she be released from the nursing home and return home?? Meals on wheels will deliver to her house.

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Posted By HFHSM.D.-D.M. on June 08, 1999 at 18:04:22
Dear Bob Kovich:
I appreciate your concern for your mother and your questions.  
As the liver fails, ammonia and other chemicals (that are typically cleared by the liver) rise in the blood.  Many patients with high ammonia levels from liver disease develop a condition called hepatic encephalopathy and develop symptoms such as forgetfulness, confusion and lethargy.  However,  surprisingly, the level of the ammonia does not always correlate with the severity of someones hepatic encephalopathy.  Some individuals tolerate high ammonia levels with little confusion whereas others will have severe problems with only mildly elevated ammonia levels.  In fact, what we are much more concerned with is our clinical assessment of the patient. .  I am a liver specialist with access to a quality lab and I hardly ever get an ammonia level on my patients.  
If a patient appears fully oriented, alert and conversant at a high level, we dont necessarily get that concerned about a high ammonia level.  I would also point out that ammonia levels are relatively sophisticated tests to perform and I would be surprised that your nursing home can even obtain one accurately.  I would also point out that some patients have more subtle signs of hepatic encephalopathy including fatigue, trouble sleeping and inability to concentrate.  These symptoms sometimes respond to a relatively small doses of a drug called lactulose.  
Your question about advil and Tylenol are excellent ones.  Believe it or not Tylenol is a surprisingly safe drug for people with chronic liver disease provided it is used in prescribed doses and provided there is no alcohol use.  Advil is often safe in liver patients as well provided there is kidney disease, history or stomach ulcers or platelet or bleeding problems.  
The decision about leaving the nursing home is really one you will have to make in discussions with your mother and her physicians.  I dont know if she would be alone at home or if there will be other people to help her should she get into trouble.  You havent told me anything about her liver condition that suggests it would be an obstacle to not being in a nursing home.  
I hope this information is helpful to you.  Good luck with your situation.  If you have additional information or questions, I would invite you to post the material to MEDHELP .  The direct number to our Liver Clinic at Henry Ford is (313) 916-8865. We have an active group of liver specialists.
This response is being provided for general informational purposes only and should not be considered medical advice or consultation.  Always check with your personal physician when you have a question pertaining to your health.  

Follow Ups:

Ammonia level bob kovich 6/10/1999

Re: Ammonia level HFHSM.D.-D.M. 6/17/1999

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