Portosystemic Encephalopathy without Liver Cirrhosis Masquerading as Depression

Abstract

A 69-year-old woman was hospitalized due to progressive lethargy with hyperammonemia. Five months before the current admission, she was diagnosed with depression based on her low level of daily physical activity and thus began taking antidepressants. Abdominal computed tomography revealed a portosystemic shunt running between the left renal vein and inferior mesenteric vein. Balloon-occluded retrograde transvenous obliteration of the shunt vessel was performed, and the patient showed a remarkable clinical improvement. The possibility of a portosystemic shunt should be considered in the presence or absence of underlying liver disease and the ammonia level should be measured before diagnosing depression, as portosystemic encephalopathy may be reversible with interventional radiology treatment.

Abernethy malformation: beware in cases of unexplained hepatic encephalopathy in adults—case report and review of the relevant literature

“… 43 , 44 It seems, however, that embolization of portosystemic shunts may be more effective in patients without underlying cirrhosis. 38 , 39 , 45 …”

Transhepatic embolization of a congenital intrahepatic portosystemic shunt for the treatment of hepatic encephalopathy in a noncirrhotic patient using Amplatzer vascular plug device

“…One study in Japan reported 47 cases of hepatic encephalopathy in the absence of underlying liver disease in the year 2000 [9]. Another study found that an additional 24 cases have been reported worldwide through 2015 [10].…”

“…Time to occlusion is also very short with use of Amplatzer device as compared to coils alone allowing for thorough evaluation of the shunt occlusion during the procedure. It is also superior to embolization with ethanol because you do not risk hemolysis and pulmonary edema [10].…”

“…One literature review found that embolization of portosystemic shunts may be more effective in patients without underlying cirrhosis and noted that of the patients undergoing embolization for shunts without underlying liver disease, all remained symptom free at 12 months [10]. A European study reported 41% recurrence rate of hepatic encephalopathy after embolization of portosystemic shunts in patients with underlying liver disease [12], and a more recent US study showed a recurrence rate of 8% at 1 year [11].…”

Recommendation of Repeated Ammonia Tests for Intrahepatic Portal-Systemic Shunt Without Cirrhosis in Elderly Patients With Psychiatric Symptoms

“…5 Encephalopathy from IPSSwoC intermittently occurs in the elderly, probably because of the irregular susceptibility of the brain to ammonia by aging. 6,7 To understand the correlation between blood ammonia levels and the PSE, we extracted Japanese congenital or idiopathic PSS without cirrhosis cases from the National Center for Biotechnology Information literature search sites 3,8–20 and estimated grades of PSE based on the symptoms described in them according to the guideline 21 (Table 2). There was a moderate correlation between blood ammonia levels and the estimated grades of PSE of PSS without cirrhosis (Figure 2, r 2 = 0.495).…”