Unusual Presentation of Confusion: Hyperammonaemic Hepatic Encephalopathy Due to Intrahepatic Portosystemic Venous Shunt.

PRESENTATION: A 75-year-old man presented to the emergency department with a 5-week history of confusion, daytime somnolence, and fatigue. His physical examination was unremarkable.

DIAGNOSIS: Investigations initially showed deranged Liver function tests. Extensive investigations were done following that including CT brain, MRI brain, septic screen, Arterial blood gas, and Lumbar puncture, which were all inconclusive. An Electroencephalogram was suggestive of Encephalopathy. His Ammonia level was high (123). Triphasic CT liver, revealed Intrahepatic portosystemic venous shunt and was diagnosed with hyperammonaemic hepatic encephalopathy due to Intrahepatic portosystemic venous shunt.

TREATMENT: Management included the commencement of Lactulose, Rifaximin, and L-ornithine L-aspartate (LOLA). An IR-guided embolisation of the porto-venous shunt was performed. At two-month review, the patient reported no further episodes of confusion.

DISCUSSION: Intrahepatic portosystemic venous shunts should be considered in the differential diagnosis of patients presenting with confusion or other unexplained neurological symptoms, especially in the presence of liver dysfunction. Early diagnosis and appropriate management are crucial for favourable outcomes.