Abstract
A 42-year-old man presented with recurrent grade I and II portosystemic encephalopathy caused by a 10-year-old surgical side-to-side portocaval shunt for Budd-Chiari syndrome. Multiple spontaneous episodes required hospitalization. He was persistently hyperammonemic (170–300 μmol/L); his serum bilirubin level was also elevated at 1.73 mg/dL.
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