TBA (25S165)

An uncommon portosystemic shunt causing refractory hepatic encephalopathy in ALD

Author(s)

Dr H Tyrrell, Dr B Kelleher, Professor S Stewart, Professor Lawler, Dr N Ramlaul

Department(s)/Institutions

Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7

Introduction

Hepatic encephalopathy (HE) is a serious complication of chronic liver disease that may persist despite optimal medical therapy. In a significant subset of patients, large spontaneous portosystemic shunts (SPSS) contribute to refractory HE by bypassing hepatic detoxification. Increasing evidence supports the role of targeted shunt embolization as an effective intervention in select patients, particularly those with preserved liver function and anatomically accessible shunts.

Aims/Background

To illustrate the therapeutic role of targeted portosystemic shunt embolization in a cirrhotic patient with persistent encephalopathy unresponsive to standard medical therapy

Method

We report the case of a 57-year-old man with alcoholic cirrhosis (Child-Pugh B7) who developed persistent grade 3 HE, based on the West-Haven criteria. Despite maximal medical therapy which included regular laxatives, rifaximin and optimisation of electrolytes and nutritional status, he remained encephalopathic. CT triple-phase revealed large portosystemic collaterals, most prominently via a recanalized umbilical vein. Targeted endovascular embolization was performed by interventional radiology

Results

Shunt embolization led to complete and sustained resolution of encephalopathy. The patient regained full neurological function, resumed independent activities, and remained clinically stable through discharge.

Conclusions

This case illustrates that portosystemic shunt embolization can effectively reverse refractory hepatic encephalopathy in selected cirrhotic patients. However, careful patient selection is essential. Factors such as liver functional reserve (e.g, Child-Pugh A/B), absence of active variceal bleeding or uncontrolled ascites, and confirmation of large SPSS on imaging should guide clinical decision-making. In appropriately selected patients, embolization offers a targeted, physiology-based intervention that may significantly reduce encephalopathy burden and improve quality of life.