To the Editor: We present the case of a 67-year-old man with a history of portal vein thrombosis due to chronic hepatitis B, presenting at the emergency room with acute confusion. Magnetic resonance imaging of the brain revealed hyperintensities in the basal ganglia bilaterally. Neuropsychological testing and electroencephalography confirmed an encephalopathic process. The patient was treated with lactulose and returned to normal. Minimal hepatic encephalopathy (MHE) is a newly-recognized syndrome that could cause episodes of confusion, with the patient being normal between them. Porto-systemic shunting may be the cause of elevated ammonia levels that affect the brain. Management of MHE includes reduction in the production and absorption of ammonia.