Treatment of portosystemic shunt-borne hepatic encephalopathy in a 97-year-old woman using balloon-occluded retrograde transvenous obliteration: A case report

Abstract

BACKGROUND

Hyperammonemia and hepatic encephalopathy are common in patients with portosystemic shunts. Surgical shunt occlusion has been standard treatment, although recently the less invasive balloon-occluded retrograde transvenous obliteration (B-RTO) has gained increasing attention. Thus far, there have been no reports on the treatment of portosystemic shunts with B-RTO in patients aged over 90 years. In this study, we present a case of hepatic encephalopathy caused by shunting of the left common iliac and inferior mesenteric veins, successfully treated with B-RTO.

CASE SUMMARY

A 97-year-old woman with no history of liver disease was admitted to our hospital because of disturbance of consciousness. She had no jaundice, spider angioma, palmar erythema, hepatosplenomegaly, or asterixis. Her blood tests showed hyperammonemia, and abdominal contrast-enhanced computed tomography revealed a portosystemic shunt running between the left common iliac vein and the inferior mesenteric vein. She was diagnosed with hepatic encephalopathy secondary to a portosystemic shunt. The patient did not improve with conservative treatment: Lactulose, rifaximin, and a low-protein diet. B-RTO was performed, which resulted in shunt closure and improvement in hyperammonemia and disturbance of consciousness. Moreover, there was no abdominal pain or elevated levels of liver enzymes due to complications. The patient was discharged without further consciousness disturbance.

CONCLUSION

Portosystemic shunt-borne hepatic encephalopathy must be considered in the differential diagnosis for consciousness disturbance, including abnormal behavior and speech.

Keywords: Hepatic encephalopathy; Hyperammonemia; Portosystemic shunt; Balloon-occluded retrograde transvenous obliteration; Elderly; Case report

Core Tip: Hyperammonemia and hepatic encephalopathy are common with portosystemic shunts. In this case, hepatic encephalopathy caused by shunting of the left common iliac and inferior mesenteric veins was successfully treated with balloon-occluded retrograde transvenous obliteration (B-RTO). A 97-year-old woman was diagnosed with hepatic encephalopathy secondary to a portosystemic shunt. The patient did not improve with conservative treatment: Lactulose, rifaximin, and a low-protein diet. B-RTO was performed, resulting in shunt closure and improvement in hyperammonemia and disturbance of consciousness. The patient was discharged without further consciousness disturbance.Portosystemic shunt-borne hepatic encephalopathy must be considered in the differential diagnosis for consciousness disturbance, including abnormal behavior and speech.