Episodic confusion and tremor associated with extrahepatic portacaval shunting in cirrhotic liver disease

In an elderly male patient with alcohol-related liver disease, who developed episodic confusion and tremor, we found a large extrahepatic portacaval shunt. He had no clinical or laboratory evidence of liver dysfunction except for an elevated serum ammonia level that increased Mher in response to an ammonium chloride challenge test. Extrahepatic portacaval shunting causing episodic confusion and tremor may occur with alcoholic liver disease without overt liver failure and may require abdominal angiography or a transhepatic portogram to demonstrate the shunt.