Refractory Post-TIPS Hepatic Encephalopathy Complicated by Small Bowel Obstruction: A Therapeutic Dilemma.

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.