title: Postshunt hepatic encephalopathy in liver transplant recipients.
abstract: BACKGROUND
  Preexisting spontaneous portosystemic shunts increase the risk of posttransplantation portal vein thrombosis. Portosystemic shunts may also be placed surgically to manage posttransplant portal vein stenosis/thrombosis. Both types may be complicated by hepatic encephalopathy.
  
  
  METHODS
  The database of a major tertiary medical center from 1999 to 2006 was searched for liver transplant recipients with hepatic encephalopathy and stable liver function. The medical and imaging files were reviewed for risk factors, management, and outcome.
  
  
  RESULTS
  Of the 244 patients who underwent liver transplantation during the study period, four (1.6%) met the inclusion criteria. Median age at transplantation was 49 years (range 39-54); median time to the first episode of hepatic encephalopathy after transplantation was 23 months (range 2-40). In two patients, a distal splenorenal shunt placed at 1 and 7 months after transplantation to treat portal vein thrombosis led to hepatic encephalopathy at 1 and 33 months later. Both responded to medical therapy. The other two patients had spontaneous splenorenal shunts, and hepatic encephalopathy appeared 33 months and 12 months after transplantation. Treatment consisted of transhepatic percutaneous portal vein dilatation with stent insertion in the first patient and interposition of a venous graft between the superior mesenteric and left intrahepatic portal veins to reroute splanchnic flow in the second patient.
  
  
  CONCLUSIONS
  Portosystemic shunts in liver transplant recipients with stable graft function may be associated with hepatic encephalopathy. Pretransplant assessment to detect unknown spontaneous shunts is important. Restoration of portal flow is the preferred procedure in this setting.
authors.affiliation: Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
authors.forename: Marius M
authors.initials: MM
authors.lastname: Braun
authors.forename: Nathan
authors.initials: N
authors.lastname: Bar-Nathan
authors.forename: Ezra
authors.initials: E
authors.lastname: Shaharabani
authors.forename: Sigal
authors.initials: S
authors.lastname: Aizner
authors.forename: Ran
authors.initials: R
authors.lastname: Tur-Kaspa
authors.forename: Alexander
authors.initials: A
authors.lastname: Belenky
authors.forename: Eitan
authors.initials: E
authors.lastname: Mor
authors.forename: Ziv Z
authors.initials: ZZ
authors.lastname: Ben-Ari
mesh_terms: D001706:Biopsy; D006501:Hepatic Encephalopathy / Q000209:etiology*; D006801:Humans; D006975:Hypertension, Portal / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects* / Q000473:pathology; D018810:Magnetic Resonance Angiography; D011169:Portal Vein / Q000473:pathology; D011170:Portasystemic Shunt, Surgical / Q000009:adverse effects*; D011172:Portography; D013157:Splenic Artery / Q000000981:diagnostic imaging / Q000473:pathology; D013164:Splenorenal Shunt, Surgical; D013927:Thrombosis / Q000473:pathology