Glycine Induced Hyperammonemia After Bladder Rupture During Transurethral Resection of a Bladder Tumor

Abstract

Glycine is widely used as an irrigation fluid for transurethral procedures and rarely causes glycine toxicity. We report a case of profound hyperammonemia occurring from complications of a transurethral resection of a bladder tumor in a female. To our knowledge, no previously published report documents such a high serum ammonia level. A 76-year-old female with a past medical history included hypertension and hyperlipidemia underwent transurethral resection of the bladder tumor (TURBT). During her operative procedure the patient was found to have an invasive bladder tumor, which was resected using a resectoscope. During the procedure she received 24 liters of 1.5% glycine irrigation fluid. After the procedure the patient was found to have a distended lower abdomen. A retrograde cystogram confirmed that a rupture of the bladder occurred with extravasation of large amounts of fluid, thought to be glycine irrigation fluid. While in the recovery room the intubated patient was following simple commands. Her initial post-operative serum sodium level was 120 mmol/L. The patient was treated with normal saline continuous bladder saline irrigation and CT guided percutaneous drainage of the fluid collection. Twenty hours after the procedure the patient had an episode of tonic-clonic muscular activity. She was treated successfully with phenytoin and midazolam. The sodium decreased to a low of 109 mmol/L and the ammonia level peaked at 1,592 mol/L. The patient underwent hemodialysis on post-operative day one. Three days after the procedure the patient was extubated and at her baseline mental status. Her ammonia levels returned to normal by day two. She was discharged from the hospital without neurological sequelae. Severe hyperammonemia is possible after massive pelvic and intraperitoneal glycine absorption. Such toxicity is survivable and can be associated with altered mental status and seizures.




J Med Cases. 2013;4(4):250-253
doi: https://doi.org/10.4021/jmc1054w