Nishi Akihiro, Kenzaka Tsuneaki, Sogi Misa, Nakaminato Shuichiro, Suzuki Takahiro
General Medicine, Awa Regional Medical Center, Tateyama 2940014, Chiba, Japan.
Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe 6500017, Hyogo, Japan.
World J Clin Cases. 2023 Feb 6;11(4):945-951. doi: 10.12998/wjcc.v11.i4.945.
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.
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.
Portosystemic shunt-borne hepatic encephalopathy must be considered in the differential diagnosis for consciousness disturbance, including abnormal behavior and speech.
高氨血症和肝性脑病在门体分流患者中很常见。手术分流闭塞一直是标准治疗方法，尽管最近侵入性较小的球囊闭塞逆行静脉闭塞术（B-RTO）受到越来越多的关注。迄今为止，尚无关于90岁以上患者使用B-RTO治疗门体分流的报道。在本研究中，我们报告了一例由左髂总静脉和肠系膜下静脉分流引起的肝性脑病患者，经B-RTO成功治疗。
一名97岁无肝病病史的女性因意识障碍入住我院。她没有黄疸、蜘蛛痣、肝掌、肝脾肿大或扑翼样震颤。血液检查显示高氨血症，腹部增强CT显示左髂总静脉和肠系膜下静脉之间存在门体分流。她被诊断为门体分流继发的肝性脑病。患者经乳果糖、利福昔明和低蛋白饮食等保守治疗后病情未改善。进行了B-RTO，导致分流闭塞，高氨血症和意识障碍得到改善。此外，未出现因并发症引起的腹痛或肝酶升高。患者出院时意识未进一步障碍。
在意识障碍的鉴别诊断中，包括异常行为和言语，必须考虑门体分流引起的肝性脑病。
