Wright State University Boonshoft School of Medicine TIPP CITY, OH, United States
Ammar Ahmad, MD, Padmini Krishnamurthy, MD Wright State University Boonshoft School of Medicine, Dayton, OH
Introduction: Hepatic encephalopathy is a known complication of transjugular intrahepatic porta-systemic shunt (TIPS) procedure. It occurs in up to 50% of patients following TIPS procedure. About 10% of patients develop refractory hepatic encephalopathy after TIPS and do not respond to conventional treatments such as oral lactulose, rifaximin, or dietary modifications. We present a case of 64-year-old male who developed refractory hepatic encephalopathy following TIPS which was successfully treated with reduction of TIPS and simultaneous embolization of a splenorenal shunt by interventional radiology.
Case Description/Methods: A 64-year-old male with history of cirrhosis due to non-alcoholic steatohepatitis (NASH) had poor nocturnal sleep, daytime sleepiness, periods of confusion, reduced memory, and changes in behavior. Symptoms started after he underwent TIPS procedure due to elevated portal pressure (26 mmHg) and had been going on for almost a year. He was hospitalized multiple times and was treated with maximum tolerated dose of lactulose and rifaximin, along with modified diet without any significant clinical improvement. Other causes of these symptoms were excluded, and a diagnosis of refractory hepatic encephalopathy was made. A liver doppler ultrasound and CT scan of the abdomen was obtained which showed patent TIPS and prominent shunt between the splenic vein and left renal vein. This was treated with reduction of TIPS by placement of a covered stent in an hourglass shape within the original stent and simultaneous embolization of the splenorenal shunt by amplatzer plug. The patient had complete resolution of symptoms following the procedure.
Discussion: TIPS procedure is used to treat refractory ascites due to cirrhosis and as a salvage procedure in patients with bleeding due to gastroesophageal varices. About 8 to 10% of patients develop refractory hepatic encephalopathy after TIPS and do not respond to conventional treatments such as oral lactulose, rifaximin, or dietary modifications. Large portosystemic shunts can also develop in these patients and are thought to contribute to refractory hepatic encephalopathy. Hence, proper evaluation should be performed in these patients to diagnose portosystemic shunts as embolization can improve outcomes as was demonstrated in this case.
Ammar Ahmad indicated no relevant financial relationships.
Padmini Krishnamurthy indicated no relevant financial relationships.
Ammar Ahmad, MD, Padmini Krishnamurthy, MD. P2945 - Successful Treatment of Refractory Hepatic Encephalopathy With Embolization of Splenorenal Shunt, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.