A naturally occurring TIPS?

Abstract

Portal-systemic encephalopathy in both cirrhosis and non-cirrhotic patients can occur when a large portal-systemic shunt forms within the venous system. Though most commonly found in patients with portal hypertension, after trauma, surgical intervention, and liver biopsy, one can also be idiopathic. A 78-year-old Latino male developed worsening confusion and lethargy during a hospitalization for bridging of his anticoagulation. An extensive laboratory and radiologic workup did not initially reveal the etiology of his delirium and decreased state of consciousness. On exam, he had tremulousness and fetor hepaticus without corresponding liver function abnormalities in his laboratory testing. An ultrasound of the liver demonstrated a large veno-venous shunt between the right portal vein and the right hepatic vein. After multiple episodes of encephalopathy and progressive heart failure from significant right ventricular overload, the shunt was closed by interventional radiology. This treatable cause of encephalopathy may not be evident without radiologic studies.