Post-TIPS Hepatic Encephalopathy — FRCA Final MCQ

Instant feedback + full explanation. One question, done properly.

ModerateIntensive Care MedicinePost-TIPS Hepatic EncephalopathyFRCA Final

A 55-year-old man with cirrhosis undergoes transjugular intrahepatic portosystemic stent-shunt insertion. Following an initially normal recovery from general anaesthesia, he becomes disorientated and agitated 12 hours later and has a flapping tremor. Capillary glucose and renal function are unchanged, there is no focal neurological deficit, and his plasma ammonia concentration is 180 micromol/L. Which complication is most likely?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Hepatic encephalopathy

The correct answer is A, hepatic encephalopathy. TIPSS diverts portal blood away from hepatic detoxification, increasing systemic exposure to gut-derived neurotoxins, including ammonia. New disorientation, agitation and asterixis after TIPSS are characteristic; the raised ammonia supports the diagnosis but ammonia concentration alone does not determine clinical severity. Stent or portal vein thrombosis would more typically cause shunt dysfunction or recurrence of portal-hypertensive complications rather than an isolated neuropsychiatric syndrome. Intracranial haemorrhage remains an important differential but is less likely without focal signs. Contrast-associated acute kidney injury requires a rise in creatinine, which is absent. Management includes identifying precipitants and administering lactulose; rifaximin reduces recurrent overt episodes. Protein restriction should be avoided because it may worsen malnutrition and sarcopenia. Refractory post-TIPSS encephalopathy may require shunt reduction.

Reference: British Society of Gastroenterology, Best Practice Guidance: outpatient management of cirrhosis – part 2: decompensated cirrhosis, section on hepatic encephalopathy, 2023. https://fg.bmj.com/content/14/6/462