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Refractory Hepatic Encephalopathy — RACP Adult Medicine MCQ

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HardGastroenterology & HepatologyRefractory Hepatic EncephalopathyRACP Adult Medicine

A 55-year-old woman with chronic liver disease develops acute confusion. Her ammonia level is 95 µmol/L. She is on lactulose and rifaximin for secondary prophylaxis of hepatic encephalopathy. Despite optimal medical therapy, she has recurrent episodes. What intervention may be considered?

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Correct answer: A — Embolisation of portosystemic shunts

Recurrent hepatic encephalopathy despite optimal medical therapy (lactulose + rifaximin) may be driven by large spontaneous portosystemic shunts (variously termed splenorenal shunts, gastrorenal shunts) that divert portal blood directly into the systemic circulation. Embolisation of these shunts can dramatically reduce encephalopathy episodes. CT angiography should be performed to identify shunt anatomy. Liver transplant assessment should also be considered. Dietary protein restriction is NOT recommended.

Reference: eTG – 2025 – Gastrointestinal; EASL – 2022 – Hepatic Encephalopathy Guidelines