Chronic Portal-SystemicShunt Encephalopathy in a Hemodialysis Patient Treated with Balloon-Occluded Retrograde Transvenous Obliteration

Abstract

We report a case of chronic portal-systemic shunt encephalopathy in a 79-year-old female hemodialysis patient with end-stage renal disease. Approximately 1 month before admission, she occasionally had a discrepant conversation. It was considered that hepatic encephalopathy was caused by an increase in the ammonia level in the blood flow of the shunt, which had been diagnosed 7 years previously between the splenic vein and the left renal vein. On admission, disturbed consciousness and an elevated serum ammonia level (221 μg/dl) were observed. No change in the shunt diameter was noted. Consciousness improved with conservative treatment, whereas hyperammonemia remained. Balloon-occluded retrograde transvenous obliteration (B-RTO) was performed on the shunt. As a result, hyperammonemia resolved immediately, and the level of ammonia was maintained at approximately 60 μg/dl. The patient often complained of drug-induced constipation; therefore, an increase in the intra-abdominal pressure in addition to ammonia production in the intestinal tract was suspected as the cause of encephalopathy. More than 23 months have passed since the B-RTO therapy, and no symptoms of encephalopathy have been observed yet.

Percutaneous transvenous embolization for portosystemic shunts associated with encephalopathy: Long‐term outcomes in 14 patients

“…PTE has been safely performed for PSE with almost complete eradication. At present, however, the majority of reports have been case reports or short‐term results . The long‐term outcome of more than 1 year after PTE has not yet been fully demonstrated.…”

“…1,2 PSE is caused by portosystemic shunts (PSS), including splenorenal (SR) shunts, gastrorenal (GR) shunts, superior mesenteric vein (SMV) systemic shunts, inferior mesenteric vein (IMV) systemic shunts and portal vein (PV) inferior vena cava (IVC) shunts. PSE can be treated with surgery or interventional radiology, [3][4][5][6][7][8] or medication. 9,10 Surgical treatment is ligation of shunts.…”

“…At present, however, the majority of reports have been case reports or short-term results. [4][5][6][7][8] The long-term outcome of more than 1 year after PTE has not yet been fully demonstrated.…”

Two Cases of Hemodialysis-associated Chronic Portal-systemic Shunt Encephalopathy (CPSE) with Opposite Changes in the Blood Ammonia Concentrations during Hemodialysis: A Case Report and Literature Review

“…It is difficult to diagnose CPSE because the serum transaminase level is normal, with the exception of hyperammonemia. Recently, CPSE has been recognized to be a cause of disturbance of consciousness in patients receiving dialysis (3)(4)(5)(6). Dialysis patients may develop CPSE for several reasons, including the growth of PSS due to fluid overload and an increase in back flow via the PSS as a result of hemodialysis-related fluid removal (7)(8)(9).…”

Hemodialysis-related Portal-Systemic Encephalopathy

“…We reviewed 13 cases of HRPSE (Table) (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15). Of these patients, nine were women and the average patient age was 62.2 years (range, 32-80 years).…”