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  • Closure of a distal splenorenal shunt as a therapy for refractory hyperammonaemia in setting of neuropsychiatric symptoms

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Case Reports: Unusual association of diseases/symptoms
Closure of a distal splenorenal shunt as a therapy for refractory hyperammonaemia in setting of neuropsychiatric symptoms
  1. Alexander Miller1,
  2. Michelle Bernshteyn1,
  3. Basit Achakzai2 and
  4. Rebekah Macfie3
  1. 1Department of Gastroenterology, Guthrie Robert Packer Hospital, Sayre, PA, USA
  2. 2Department of Interventional Radiology, Guthrie Robert Packer Hospital, Sayre, PA, USA
  3. 3Department of Surgical Oncology, Guthrie Robert Packer Hospital, Sayre, PA, USA
  1. Correspondence to Dr Alexander Miller; alexander.miller{at}guthrie.org

Abstract

Before the widespread use of the transjugular intrahepatic portosystemic shunt, portal hypertension was addressed by the creation of an operative distal splenorenal shunt (DSRS). DSRS was largely regarded as a safe and effective therapy, though it did have a risk of precipitating hyperammonaemia and hepatic encephalopathy.

A woman suffered a gunshot wound to the abdomen. This trauma led to portal vein thrombosis, cavernous transformation of the vein and eventually bleeding oesophageal varices from portal hypertension. A DSRS was created to decrease portal hypertension. Years later, she had profound depression with psychomotor slowing in the setting of hyperammonaemia. To reduce hepatic encephalopathy as a contributor to her neuropsychiatric condition, her shunt was closed. The hyperammonaemia resolved and neuropsychiatric symptoms improved.

This case highlights several interesting clinical features, including portal hypertension due to chronic portal vein occlusion, cavernous transformation, a surgical DSRS causing hyperammonaemia and hepatic encephalopathy manifesting as neuropsychiatric symptoms.

  • Interventional radiology
  • Depressive disorder
  • Liver disease

https://doi.org/10.1136/bcr-2023-255610

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    Footnotes

    • Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: AM, MB, BA and RM. The following authors gave final approval of the manuscript: AM, MB, BA and RM.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.