Portosystemic Encephalopathy without Liver Cirrhosis Masquerading as Depression

Area of Science:

• Medicine
• Radiology
• Gastroenterology

Background:

• A 69-year-old woman presented with progressive lethargy and hyperammonemia.
• She was previously diagnosed with depression and prescribed antidepressants.
• Abdominal CT revealed a portosystemic shunt between the left renal vein and inferior mesenteric vein.

Observation:

• The patient's symptoms of lethargy and hyperammonemia were initially attributed to depression.
• A portosystemic shunt, a connection between the portal vein and systemic circulation, was identified as the underlying cause.
• Elevated ammonia levels (hyperammonemia) can lead to neurological symptoms, including lethargy, confusion, and personality changes, mimicking psychiatric conditions.

Findings:

• Balloon-occluded retrograde transvenous obliteration of the portosystemic shunt was performed.
• The patient experienced significant clinical improvement following the interventional radiology procedure.
• This case demonstrates that portosystemic encephalopathy can occur even without apparent liver disease.

Implications:

• Portosystemic shunts should be considered in patients with hyperammonemia, regardless of liver disease presence.
• Measuring ammonia levels is crucial before diagnosing conditions like depression, especially when neurological symptoms are present.
• Interventional radiology offers a minimally invasive and effective treatment for portosystemic shunts, potentially reversing encephalopathy and improving patient outcomes.