P2542 - Status Epilepticus Secondary to Cerebral Edema After Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement

Samantha McPeck, MD, Rodolfo Valentini, BS, Daniyal Asad, MD
University of Connecticut, Farmington, CT

Introduction: TIPS has emerged as an efficacious treatment to manage the complications of portal hypertension, including bleeding varices. Benefits of TIPS are often weighed against the risk of hepatic encephalopathy. A rare but potentially devastating complication is cerebral edema. We describe a patient with nonalcoholic steatohepatitis (NASH) cirrhosis and acute variceal bleeding who developed status epilepticus within 24 hours of TIPS placement.

Case Description/Methods: A 62-year-old male with a past medical history of decompensated NASH cirrhosis with variceal bleeding and spontaneous bacterial peritonitis presented with hemorrhagic shock due to hematemesis. Upper endoscopy demonstrated grade III esophageal varices with active bleeding; seven bands were placed, but given high risk of rebleeding, the patient underwent urgent esophageal varix embolization and TIPS placement. Post-TIPS portal pressure gradient was 9 mmHg. Twelve hours post-procedure, the patient had rhythmic shaking of all four extremities and facial twitching. CT head showed no acute findings and he was placed on continuous electroencephalogram monitoring. Ammonia level rose from 263 mmol/L on admission to greater than 800 mmol/L. Continuous veno-venous hemodialysis was initiated. About 24 hours post-procedure, the patient developed status epilepticus requiring multiple antiepileptic drugs as well as midazolam and ketamine for clinical and electrographic suppression. Repeat CT head demonstrated global cerebral edema, and subsequent MRI demonstrated diffuse hypoxic ischemic brain injury. Given this irreversible injury, the patient was transitioned to a comfort-centered approach and passed away.

Discussion: Cerebral edema is a rare complication of liver disease, and more often seen in acute liver failure rather than chronic liver disease. It may not be radiographically detectable until after clinical manifestations occur, and its development post-TIPS is theorized to result from fluid shifts and cytotoxic damage associated with hyperammonemia. There are rare reports of seizures after TIPS placement, but to our knowledge none of status epilepticus. This case demonstrates the importance of closely monitoring patients’ neurologic status after TIPS placement, which can be a challenge in the intubated and sedated patient. More research is needed to evaluate risk factors for cerebral edema post-TIPS in order to guide practices on reduction in portal gradient post-TIPS and post-procedural monitoring.


Disclosures:


Samantha McPeck, MD, Rodolfo Valentini, BS, Daniyal Asad, MD. P2542 - Status Epilepticus Secondary to Cerebral Edema After Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.