SHM Converge Scientific Abstract ePoster Gallery-Osmotic Demylination Syndrome With Lactulose Enema

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This case describes a fatal episode of Osmotic Demyelination Syndrome (ODS), also known as central pontine myelinolysis, in a 66-year-old woman with NASH-related decompensated cirrhosis. She had a recent hospitalization for hepatic encephalopathy and was discharged with normal mentation. She returned one day later with confusion, initially attributed to oxycodone, gabapentin, and lactulose nonadherence. Lactulose was restarted and her sedating medications were held, leading to temporary improvement.<br /><br />Her mental status later worsened, and her ammonia level rose further. She was treated with frequent rectal lactulose enemas, which produced multiple bowel movements over several days. Following this aggressive bowel regimen, she developed hypernatremia that rapidly progressed from 148 to 172 overnight, accompanied by worsening somnolence and neurological decline. CT imaging was negative for acute intracranial pathology, but MRI later showed diffuse cortical and pontine hyperintensity consistent with ODS. Despite attempts to correct sodium and supportive ICU care, her condition deteriorated, she required intubation, and ultimately she transitioned to comfort care and died.<br /><br />The report emphasizes several key lessons: ODS can occur not only with hyponatremia correction but also with rapid rises in sodium from normal baseline levels. Lactulose used for hepatic encephalopathy should be carefully titrated to achieve 2–3 bowel movements per day, because overuse can cause dehydration, hypernatremia, aspiration, and worsening encephalopathy. Patients with cirrhosis or other volume-overload states require close monitoring of fluid and electrolyte balance when receiving diuretics or laxatives. It also highlights that CT cannot diagnose ODS, making MRI essential, though diagnosis often occurs after irreversible injury has already happened.

Asset Subtitle

Katherine E. Whalen

Meta Tag

Author List Abdul Chaudry, Amith Skandhan, Bailee Keefe, Katherine E. Whalen, Sai Avula

Category Clinical Vignettes

Concept Osmotic Demyelination Syndrome

Concept Rapid Sodium Change

Concept Hypernatremia

Concept Magnetic Resonance Imaging

Concept Sodium Level

Distinguished Non-Finalist

Presenter Organization South East Health

Presenting Author Katherine E. Whalen

Track Adult

Keywords

osmotic demyelination syndrome

central pontine myelinolysis

hypernatremia

lactulose

hepatic encephalopathy

cirrhosis

NASH

MRI

electrolyte imbalance

decompensated cirrhosis

Osmotic Demyelination Syndrome

Rapid Sodium Change

Hypernatremia

Magnetic Resonance Imaging

Sodium Level