Recurrent hepatic encephalopathy caused by the persistent porto-systemic shunt in liver transplant recipients.

Introduction Hepatic encephalopathy (HE) caused by porto-systemic shunt is one of the representative complications of liver cirrhosis, but HE is an infrequent condition after the full restoration of portal flow through liver transplantation, despite the persistence of porto-systemic shunts. We report two cases with a normal functioning liver graft and patent portal flow that developed recurrent HE after liver transplantation. Methods We reviewed the medical record the two cases, liver transplant recipient represented HE with stable graft function. Results The one case received a living donor liver transplantation (LDLT) with inferior vena cava (IVC) replacement because of Budd-Chiari Syndrome. Two months after LDLT, recurrent HE occurred despite of well-functioning liver graft and patent portal vein. An abdominal computed tomography scan (CT) showed large port-systemic collaterals between mesenteric vein and IVC. The other case transferred for the further evaluation of recurrent HE. She received a deceased donor liver transplantation, 9 years ago, and a HE with hyperammonemia was repeated, despite of normal liver function test. Persistent meso-caval collateral veins were identified on CT. After the closure of shunt by the interventional angiographic embolization, hyperammonemia and HE were completely resolved. Conclusions Persistent porto-systemic shunts in liver transplant recipients with stable graft function may be the cause of HE. Therefore, when liver transplant patient with stable graft function represents HE, a more thorough evaluation is needed to identify the existence of persistent porto-systemic shunts that are very rare condition.