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Cerebral Edema and Hyperammonemia After Transjugular Intrahepatic Portosystemic Shunt Placement in a Cirrhotic Patient

https://doi.org/10.1016/j.cgh.2008.04.020Get rights and content

Transjugular intrahepatic portosystemic shunt (TIPS) placement has been widely performed for nearly two decades and has been shown to alleviate refractory ascites in patients with cirrhosis. Hepatic encephalopathy after TIPS is rarely severe; however, a risk of cerebral edema resulting from hyperammonemia after TIPS does exist. Here we describe a case demonstrating the development of severe hepatic encephalopathy with cerebral edema caused by hyperammonemia as a complication of TIPS in a patient with chronic liver disease with relatively preserved liver function.

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Clinical Course

The patient was a 46-year-old man with a history of hepatitis C cirrhosis diagnosed 13 years prior, with refractory ascites and a right-sided pleural effusion consistent with hepatic hydrothorax. He had a history of hypertension, chronic kidney disease, and portal hypertension with grade III esophageal varices. As an outpatient he had been undergoing therapy with peginterferon alfa-2a and propranolol and was listed for liver transplantation with a Model for End-Stage Liver Disease (MELD) score

Discussion

This case demonstrates the development of severe hepatic encephalopathy with cerebral edema caused by hyperammonemia as a complication of TIPS in a patient with chronic liver disease with relatively preserved liver function. The development of hepatic encephalopathy after TIPS is common, occurring with a frequency of 10%–44%, although these data are primarily obtained for TIPS performed for refractory variceal hemorrhage.5, 6, 7, 8 In a series of 50 patients who underwent TIPS for refractory

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