Ammonia is not the driver for HE; there is strong evidence for other drivers such as systemic inflammation, electrolyte imbalance, and microbial

dysbiosis. It has been shown that patients with HE are occupied with potentially pathogenic bacteria. Current conventional therapy changes

microbial function and milieu. The considerable amount of patients with HE are unresponsive to current conventional therapy, our patient was one

of them. We tried a novel clinical approach for management of persistent HE by microbiota modulation through fecal microbiota transplantation

(FMT) from sibling stool donor. The patient improved his sensorium, cognitive function and reduced ammonia level after single FMT. No adverse

events or infectious complications related to FMT were observed after transplantation.