Case reports in gastrointestinal medicine · 2026
Refractory Post-TIPS Hepatic Encephalopathy Complicated by Small Bowel Obstruction: A Therapeutic Dilemma.
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Ismail Ammar, Alnakeb Amira, Altarawneh Saba, Depasquale Joseph
Аннотация
INTRODUCTION: Refractory hyperammonemic encephalopathy in cirrhosis presents a therapeutic challenge, particularly in post-TIPS patients or with contraindications to standard therapies. We report a fatal case complicated by small bowel obstruction (SBO), highlighting the limitations of current management strategies.
CASE PRESENTATION: A 69-year-old male with decompensated NASH cirrhosis and recent TIPS revision for shunt stenosis developed SBO. He presented with severe encephalopathy (GCS 5), seizures, and MRI-confirmed cerebral edema. Due to SBO, lactulose and rifaximin were not effective. Despite aggressive dialysis with continuous venovenous hemodialysis (CVVHD) reducing ammonia from 447 to 160 μmol/L, he progressed to irreversible cerebral edema and met brain death criteria.
DISCUSSION: Post-TIPS hyperammonemia carries high mortality, especially when compounded by SBO. CVVHD effectively lowers ammonia but may fail to prevent neurologic injury if initiated late.
CONCLUSION: This case underscores the need for proactive RRT and novel ammonia-lowering strategies in high-risk patients, especially when gut decontamination is not feasible.
CASE PRESENTATION: A 69-year-old male with decompensated NASH cirrhosis and recent TIPS revision for shunt stenosis developed SBO. He presented with severe encephalopathy (GCS 5), seizures, and MRI-confirmed cerebral edema. Due to SBO, lactulose and rifaximin were not effective. Despite aggressive dialysis with continuous venovenous hemodialysis (CVVHD) reducing ammonia from 447 to 160 μmol/L, he progressed to irreversible cerebral edema and met brain death criteria.
DISCUSSION: Post-TIPS hyperammonemia carries high mortality, especially when compounded by SBO. CVVHD effectively lowers ammonia but may fail to prevent neurologic injury if initiated late.
CONCLUSION: This case underscores the need for proactive RRT and novel ammonia-lowering strategies in high-risk patients, especially when gut decontamination is not feasible.