S Gupta, F Wong, K Sniderman, S Ryan, C Tsien
2020 Journal of the Canadian Association of Gastroenterology  
Background Hepatic encephalopathy (HE) is a common complication of cirrhosis with a spectrum of neuropsychiatric manifestations. In patients with medically refractory HE (i.e. after a trial of Lactulose with or without Rifaximin), it is warranted to investigate and manage underlying spontaneous portosystemic shunts (SPS) as a cause of chronic or recurrent HE in the absence of precipitants. Aims Here we present a case report of a patient with non-decompensated cirrhosis who underwent mesocaval
more » ... unt embolization as a treatment for medically refractory HE (grade III) in the absence of underlying precipitants. Methods The patient's chart was reviewed and radiological images pre- and post- shunt embolization were obtained. A literature review was performed on the treatment of SPS for HE in cirrhosis. Results Mr. H is a 56-year-old man with alcohol-related cirrhosis who was admitted to the hospital with a reduced level of consciousness. On examination he was arousable but nonverbal. Asterixis was observed with no focal neurologic findings. Laboratory, infectious and toxicology results were negative. His MELD-Na score was 11. Computed tomography (CT) of his head and ultrasound of his abdomen were normal. The patient did not improve with lactulose and rifaximin. A CT of his abdomen/pelvis revealed a large SPS arising from the superior mesenteric vein (SMV) to the infrarenal inferior vena cava (IVC). A decision was made to attempt partial occlusion of the shunt. A 22-mm Amplatzer™ Vascular Plug II and two 8mm x 59mm Atrium balloon expandable covered stents were deployed in the right gonadal vein. Partial occlusion was subsequently demonstrated with contrast injection. The patient had gradual improvement of his HE and became independent for his ADLs six months post-procedure. Conclusions Between 45–70% of patients with cirrhosis and medically refractory HE have SPS as a result of chronic liver injury and increased portal venous pressures. AASLD guidelines recommend screening for SPS in cirrhotic patients with medically refractory HE or in HE with compensated liver disease. Shunt embolization in patients with MELD < 11 has been shown to reverse chronic or recurrent HE as well as improve hepatic outcomes for at least a two-year follow-up, as shown by a recent multicentre survey done by Laleman et al. Further studies have shown that portosystemic shunt embolization can result in reversal of HE in over 75% of cases. The most frequently encountered shunt in these studies is the splenorenal shunt. Our case, however, offers insight into the less commonly experienced mesocaval shunt, which accounts for only 5% of large SPS. We have shown that mesocaval shunts, when discovered, have the potential for successful treatment with embolization that can lead to reversal and long-term clinical remission of HE. Funding Agencies None
doi:10.1093/jcag/gwz047.070 fatcat:dz22picmpnbyxchkeasi2jcrga