A patient with concurrent liver disease and hypothyroidism may present with what clinically appears to be hepatic encephalopathy. This can be a problem if the hypothyroidism goes undiagnosed.


Clinical presentation:

(1) history of chronic liver disease

(2) elevated blood ammonia

(3) elevated serum transaminases and bilirubin

(4) altered mental status


Hypothyroidism should be considered and thyroid studies (TSH, thyroid hormones) ordered if the patient fails to respond as expected to appropriate therapy for hepatic encephalopathy.


Confirmation of the diagnosis of hypothyroidism would be:

(1) elevated TSH

(2) positive clinical response to thyroid hormone replacement therapy


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