Hyperammonemia-Induced Cerebral Edema Following Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Severe hepatic encephalopathy with elevated ammonia may occur following TIPS. Cerebral edema is a rare and potentially deadly complication. We present a rare case of severe hyperammonemia, cerebral edema, and seizure following TIPS procedure. Case Description/Methods: A 53-year-old man with alcoholic liver cirrhosis presents with gastrointestinal bleeding on apixaban. Evaluation reveals large gastric varices not amenable to endoscopic management for which he undergoes a TIPS procedure. Two months later, the patient presents with confusion, recurrent hematemesis and respiratory failure. The patient receives blood, ceftriaxone, and pantoprazole and undergoes an esophagogastroduodenoscopy (EGD) that shows acute gastritis and multiple small ulcers in the gastric antrum. Bleeding resolves, however the patient experiences severe agitation. Laboratory evaluation reveals significant hyperammonemia (highest > 1000 mcmol/L) and status epilepticus with tonic-clonic movements. The patient receives lactulose and rifaximin without improvement. Continuous renal replacement therapy (CRRT) is started and levetiracetam is administered. Electroencephalogram (EEG) shows generalized encephalopathy and left hemispheric focal disturbances. CT (computed tomography) head indicates cerebral edema with complete effacement to the cerebral sulci and ventricles. TIPS reversal is considered but not performed due to active seizures. Ammonia levels are brought down to normal limits but the patient continues to display acute episodes of jerking movements and posturing. Following discussion with family, care is withdrawn. Discussion: TIPS procedures create a connection between the portal vein and a hepatic vein via a bypass stent-graft that shunts blood away from the portal vein. The procedure is performed as a response to portal hypertension with refractory varices or ascites. Hepatic encephalopathy is a relatively common side effect from the procedure, developing in approximately 10%-44% of patients. Hyperammonemiainduced cerebral edema complicates this particular case. Hyperammonemia may rarely lead to astrocyte swelling due to glutamine accumulation. Cerebral edema is a rare, but serious complication that should be taken into consideration and monitored for following the TIPS procedure and TIPS reversal is suggested as soon as edema complications are discovered.

Volume

119

Issue

10

First Page

S2789

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