Intrahepatic Portosystemic Shunt Causing Hepatic Encephalopathy in a Non-cirrhotic Patient

A 60-year-old woman presented with persistent nausea, new-onset tremulousness, and altered mental status. Abdominal and pelvic computed tomography (CT) revealed a large intrahepatic portosystemic connection, suspicious for a portal venous malformation. She underwent two image-guided embolization procedures. The first, via a transcaval approach, reduced shunt flow and improved ammonia levels. The second, using combined transhepatic and transfemoral access, achieved complete occlusion and led to sustained clinical improvement. This case underscores the importance of considering hepatic encephalopathy in non-cirrhotic patients with altered mental status and recognizing portosystemic shunts as a potential underlying cause.