A 72-year-old female patient, known with cirrhosis Child Pugh B secondary to non-alcoholic steatohepatitis (NASH) and
alcohol abuse, was admitted repeatedly since April 2020 due to hepatic encephalopathy (HE), with several episodes of
deep coma requiring intubation and observation on the intensive care unit (ICU). Further history included hypothyroidism
and type 2 diabetes mellitus. Apart from signs of cirrhosis physical examination was not contributive. Active, though
minimal, alcohol consumption was reported during the initial hospitalization. Minimal ascites not amenable to aspiration,
was noted by ultrasound. Infection, gastro-intestinal bleeding and portal vein thrombosis were actively and repeatedly
excluded. Imaging, lumbar puncture and EEG ruled out central causes of encephalopathy. There was no evidence of
hepatocellular carcinoma. Glucose levels were normal, although there was poor metabolic control of type 2 diabetes
mellitus. Micronutrient deficiency were excluded. Because of hypothyroidism thyroid substitution was increased
accordingly. Vitamin B1 substitution, diuretics and lactulose were initiated in hospital and continued upon discharge.
Because of the recurrent episodes rifaximin was added. During a subsequent admission for HE levetiracetam was started
because of epileptic activity on EEG. A transfer to a service residence was arranged to improve compliance to treatment.
Nevertheless, 2 weeks later, the patient was readmitted for the fourth episode of altered mental state. An abdominal
contrast-enhanced CT-scan identified recanalization of the umbilical vena with presence of a shunt between the portal
and the deep venous system via the right iliac vena. Partial embolization was performed with subsequent improvement
of mental state.
HE is a feature of decompensated cirrhosis. It is associated with significant morbidity and mortality. In cases refractory
to treatment, assessment of a portosystemic shunt is recommended. Around 60 % of patients remain free of hepatic
encephalopathy three months after embolization, and 49-55 % after 1-2 years.
Originele taal-2English
TijdschriftActa Gastro-Enterologica Belgica
Nummer van het tijdschriftS1
StatusPublished - 2021


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