Hepatic Myelopathy in a Patient with Decompensated Alcoholic Cirrhosis and Portal Colopathy

Cirrhotic or hepatic myelopathy is a rare neurological complication of chronic liver disease usually seen in adults and presents as a progressive pure motor spastic paraparesis which is usually associated with overt liver failure and a surgical or spontaneous systemic portocaval shunt. We describe the development of progressive spastic paraparesis, in a patient with alcoholic cirrhosis with portal hypertension and portal colopathy who presented with the first episode of hepatic encephalopathy. The patient had not undergone any shunt procedure. 1. Introduction Hepatic myelopathy (HM) is an insidious onset pure motor spastic paraparesis without sensory or bladder or bowel involvement in patients with liver disease in which the neurological dysfunction cannot be attributed to another disorder. A progressive spastic paraparesis in patients with hepatic failure was first described by Leigh and Card [1], followed by a detailed description of HM？？by other authors who observed this rare neurological complication of cirrhosis, especially in patients with portosystemic shunts [2–4]. In India, HM was reported for the first time by Pant et al. who described two cases of spastic paraparesis in patients with liver cirrhosis, one with a spontaneous portocaval shunt and the other with a surgical portocaval anastamosis [5]. The typical clinical presentation of this disorder is of a patient with underlying chronic liver disease, developing progressive pure motor spastic paraparesis with minimal or no sensory deficit and without bowel and bladder involvement. Most patients report prior episodes of hepatic encephalopathy, and in many cases, the development of myelopathy follows the creation of surgical shunts [6–8]. Early and accurate diagnosis of？？HM？？is important because patients with early stages of the disease can recover following liver transplantation [9]. Neuropathological studies show demyelination in the lateral corticospinal tracts, with varying degrees of axonal loss [2]. Motor-evoked potential studies may be suitable for the early diagnosis of？？hepatic？？myelopathy, even in patients with preclinical stages of the disease [10]. 2. Case Presentation A 45-year-old male farmer, hailing from Uttar Pradesh, north India, presented to us with complaints of difficulty in walking due to stiffness of lower limbs for 2 years, associated with weakness. Initially, the weakness was only present on activities like standing from the squatting position or climbing stairs which over a period of a couple of months progressed to noticing slippage of footwear and dragging of feet