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Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.109 n.6 Madrid Jun. 2017




Recurrent hyperammonemic encephalopathy. Embolization of the portosystemic shunt

Encefalopatía hiperamoniémica recurrente. Embolización de shunt portosistémico



Goizalde Solano-Iturri1, Alfonso Gutiérrez-Macías1, Borja Peña-Baranda2 and Miguel González-de-Garay-Sanzo2

Services of 1Internal Medicine and 2Radiology. Hospital Universitario de Basurto. Bilbao, Vizcaya. Spain



Case report

We present the case of a 74-year-old woman with a history of hypertension, diabetes, bariatric surgery (Scopinaro technique), secondary chronic diarrhea with severe malnutrition and cirrhosis with portal hypertension. After bariatric surgery, she presented recurrent and self-limited episodes of trembling, confusion and dysarthria with an unclear triggering factor. Laboratory tests indicated hyperammonemia. Thus, hyperammonemic hepatic encephalopathy was diagnosed. The main causes include acute hepatitis (not in this case), cirrhosis (present in our patient but without improvement despite medical treatment), uncommon urea cycle disorders (specific studies were negative) and portosystemic shunts (1). An abdominopelvic computed tomography (CT) showed a tortuous and dilated vein that originated from the right gonadal vein to the inferior mesenteric vein, just before draining into the portal vein. This was compatible with a portosystemic shunt (Fig. 1). Therefore, we considered this case to be compatible with cirrhosis secondary to nonalcoholic steatohepatitis which was aggravated by bariatric surgery. There was no evidence of drugs, viral hepatitis or autoimmune disease.



Embolization of the shunt (collateral mesenterico-caval) was performed with the Amplatzer® vascular plug, confirming the complete occlusion of the vein in the control phlebography and diminishing episodes of hyperammonemic encephalopathy (Fig. 2).




This technique compared to coils, has several advantages such as higher accuracy in implantation, possibility of removal if necessary, lower risk of migration, quicker occlusion time, and compatibility with magnetic resonance (1). Thus, we recommend that the technique described here be taken into account in similar situations to that described here (2,3).



1. Ramírez-Polo A, Márquez-Guillén E, González-Aguirre AJ, et al. Persistent hepatic encephalopathy secondary to portosystemic shunt occluded with Amplatzer device. Ann Hepatol 2014;13(4):456-60.         [ Links ]

2. Laleman W, Simon-Talero M, Maleux G, et al. Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: A multicenter survey on safety and efficacy. Hepatol 2013;57(6):2448-57. DOI: 10.1002/hep.26314.         [ Links ]

3. Boixadera H, Tomasello A, Quiroga S, et al. Successful embolization of a spontaneous mesocaval shunt using the Amplatzer Vascular Plug II. Cardiovasc Intervent Radiol 2010;33(5):1044-8. DOI: 10.1007/s00270-009-9739-8.         [ Links ]