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Maharshi S, Sharma BC. Prophylaxis of hepatic encephalopathy: current and future drug targets. Hepatol Int 2024; 18:1096-1109. [PMID: 38492132 DOI: 10.1007/s12072-024-10647-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/18/2024] [Indexed: 03/18/2024]
Abstract
Hepatic encephalopathy is described by a broad spectrum of neurological and psychiatric aberrations resulting due to advanced liver dysfunction. It is a neurological disorder due to hepatic insufficiency and/or portosystemic shunts. Its clinical presentation includes neuropsychiatric dysfunction ranging from subclinical changes to comatose state. It is a sign of poor prognosis in cirrhotics with a high 1-year mortality. Each episode of hepatic encephalopathy leads to high hospitalization rate, poor prognosis and raised burden of healthcare. Primary prophylaxis is prevention of initial occurrence and secondary prophylaxis is prevention of reappearance of hepatic encephalopathy in subjects who had prior history. Early detection and management of triggers is very important in the treatment of hepatic encephalopathy. The initial choice of treatment is still lactulose, as it is effective in minimal, overt, and recurrent hepatic encephalopathy. Rifaximin is equally effective as lactulose in managing hepatic encephalopathy and is better tolerated. Branch chain amino acids are beneficial in subjects who are protein intolerant. L-ornithine L-aspartate and probiotics are also useful in the management of hepatic encephalopathy. Rifaximin along with lactulose is effective in managing overt and recurrent hepatic encephalopathy. Large portosystemic shunts embolization and liver transplant is efficacious in certain group of patients. Nutritional therapy and fecal microbiota transplantation are newer therapies for hepatic encephalopathy but the evidences are limited, more research is required to prove their efficacy. Involvement of hospital pharmacists, telemedicine, and providing education are also beneficial in managing hepatic encephalopathy.
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G.B. Pant Hospital, Room No. 201, Academic Block, New Delhi, 110002, India.
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2
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Yang M, Qiu Y, Wang W. Concurrent spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A systematic review and meta-analysis. Dig Liver Dis 2024; 56:978-985. [PMID: 37926635 DOI: 10.1016/j.dld.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Overt hepatic encephalopathy remains a serious complication after TIPS. Concomitant SPSS is associated with an increased risk of HE in patients treated with TIPS. PURPOSE To perform a systematic review and meta-analysis on the effectiveness and safety of the prophylactic embolization of SPSS at the time of TIPS creation. MATERIALS AND METHODS The PubMed, Embase, Cochrane Library, and Web of Science databases were searched up to April 2023 to identify studies on the association between antegrade embolized SPSS before TIPS placement and the incidence of post-TIPS HE. Odds ratios (ORs) and their corresponding 95% CIs were used to identify significant differences in the outcomes. RESULTS Four studies enrolling 1243 patients with cirrhosis who received TIPS for variceal bleeding were included. A meta-analysis revealed that TIPS without simultaneous SPSS embolization was associated with an increased risk of overt HE (OR 2.41, 95% CI 1.32-4.38; p = 0.004). The risks of mortality (0.79, 95% CI 0.58-1.07; p = 0.13), variceal rebleeding (0.94, 95% CI 0.66-1.34; p = 0.74) and shunt dysfunction (1.40, 95% CI 0.51-3.83; p = 0.51) did not significantly differ among the groups. CONCLUSION SPSS prevalence was associated with an increased risk of overt HE after TIPS. Concurrent antegrade SPSS embolization during TIPS creation reduced the risk for overt HE without increasing other complications.
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Affiliation(s)
- Ming Yang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yiwen Qiu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wentao Wang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.
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Kothari R, Khanna D, Kar P. To evaluate the prevalence of spontaneous portosystemic shunts in decompensated cirrhosis patients and its prognostic significance. Indian J Gastroenterol 2023; 42:677-685. [PMID: 37642937 DOI: 10.1007/s12664-023-01393-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 05/10/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Spontaneous portosystemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis complications. This study was conducted to detect the prevalence of portosystemic shunts in liver cirrhosis patients and analyze its prognostic role. METHOD We conducted a prospective observational study, where 92 patients with decompensated cirrhosis were evaluated based on history, physical examination, biochemical tests and abdominal computed tomography (CT) angiography findings. A follow-up was done after six months for the development of cirrhosis-related complications. RESULTS Of the 92 cirrhotic patients, 57.6% had SPSS (large SPSS + small SPSS) detected by multi-detector computed tomographic angiography. Overall, we found large SPSS in 24 (26.1%) patients, small SPSS in 29 (31.5%) patients and no shunt in 39 (42.4%) patients. Among the shunts, the splenorenal shunt is the most frequent type (25, 27.2%) followed by the paraumbilical shunt (20.7%). Previous decompensating events, including hepatic encephalopathy, ascites, spontaneous bacterial peritonitis and gastrointestinal bleed, were experienced more frequently by the large SPSS group followed by the small SPSS and without SPSS groups. Regarding follow-up, decompensating episodes of hepatic encephalopathy developed more frequently in patients with large SPSS (41.7%) than in patients with small SPSS (24.1%) followed by patients without SPSS (12.8%). CONCLUSION In summary, all cirrhotic patients should be studied with radiological imaging to detect the presence of portosystemic shunts. In several cases, patients with large SPSS had a more impaired liver function and more frequent complications of portal hypertension. So, these patients would probably benefit from a closer surveillance and more intensive therapy.
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Affiliation(s)
- Rishabh Kothari
- Department of Gastroenterology, Max Super Speciality Hospital, Vaishali, Ghaziabad, 201 012, India
| | - Deepanshu Khanna
- Department of Gastroenterology, Max Super Speciality Hospital, Vaishali, Ghaziabad, 201 012, India
| | - Premashis Kar
- Department of Gastroenterology, Max Super Speciality Hospital, Vaishali, Ghaziabad, 201 012, India.
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Lv Y, Chen H, Luo B, Bai W, Li K, Wang Z, Xia D, Guo W, Wang Q, Li X, Yuan J, Cai H, Xia J, Yin Z, Fan D, Han G. Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A randomized controlled trial. Hepatology 2022; 76:676-688. [PMID: 35266571 DOI: 10.1002/hep.32453] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Large spontaneous portosystemic shunt (SPSS) is associated with increased risk of HE in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). This study aimed to evaluate whether prophylactic embolization of large SPSS at the time of TIPS creation could reduce the incidence of post-TIPS HE in patients with cirrhosis and variceal bleeding. APPROACH AND RESULTS From June 2014 to August 2017, 56 patients with cirrhosis and large SPSS planning to undergo TIPS for the prevention of variceal bleeding were randomly assigned (1:1) to receive TIPS alone (TIPS group, n = 29) or TIPS plus simultaneous SPSS embolization (TIPS+E group, n = 27). The primary endpoint was overt HE. TIPS placement and SPSS embolization was successful in all patients. During a median follow-up of 24 months, the primary endpoint was met in 15 patients (51.7%) in the TIPS group and six patients (22.2%) in the TIPS+E group (p = 0.045). The 2-year cumulative incidence of overt HE was significantly lower in the TIPS+E group compared with the TIPS group (21.2% vs. 48.3%; HR, 0.38; 95% CI, 0.15-0.97; p = 0.043). The 2-year incidence of recurrent bleeding (TIPS+E vs. TIPS, 15.4% vs. 25.1%; p = 0.522), shunt dysfunction (12.3% vs. 18.6%, p = 0.593), death (15.0% vs. 6.9%, p = 0.352), and other adverse events was not significantly different between the two groups. CONCLUSIONS In patients with cirrhosis treated with TIPS for variceal bleeding, concurrent large SPSS embolization reduced the risk for overt HE without increasing other complications. Concurrent large SPSS embolization should therefore be considered for prophylaxis of post-TIPS HE.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Hongwei Cai
- Department of Technology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jielai Xia
- Department of Medical Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
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Zhou Y, Ma J, Ju S, Zhang Z, Zhang W, Yang M, Zhou X, Yan Z, Luo J. Efficacy of puncturing different portal vein branch during transjugular intrahepatic portosystemic shunt with 8 mm covered stent: a propensity-score analysis. Eur J Gastroenterol Hepatol 2021; 33:1110-1116. [PMID: 33741800 DOI: 10.1097/meg.0000000000002133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) remains an unsolved problem; therefore, this study aimed to compare the efficacy of shunting different portal vein branch during TIPS with 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients. METHODS Between November 2015 and December 2018, the medical records of consecutive cirrhotic patients who received TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding were analyzed retrospectively. Shunting the left and right branches of the portal vein was performed in 58 (group A) and 104 patients (group B), respectively. Afterwards, 54 patients in each group were produced by the PSM method. The incidence of overt hepatic encephalopathy (OHE), shunt patency, variceal rebleeding and survival were compared between two groups by using Kaplan-Meier analysis and log-rank test. RESULTS The median follow-up time was 37 months (range 0.3-50 months). The 6-,12- and 24-months cumulative OHE free rates in groups A and B were 92.5, 86.2, 83.6% and 74.1, 70.2, 67.6%, respectively (P = 0.042; hazard ratio = 0.469; 95% CI, 0.223-0.988). Two (3.7%) and eight (14.8%) patients experienced severe OHE in groups A and B, respectively (P = 0.042). There were no significant differences between the two groups in terms of shunt patency, variceal rebleeding and survival. CONCLUSION Shunting the left portal vein branch during TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients might decrease the occurrence of OHE significantly. The prospective trial is needed to further provide evidence of this results in future.
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Affiliation(s)
- Yongjie Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Shuai Ju
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Zihan Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Wen Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Minjie Yang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Xin Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Zhiping Yan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Jianjun Luo
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
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6
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Comparison of transjugular intrahepatic portosystemic shunt for treatment of variceal bleeding in patients with cirrhosis with or without spontaneous portosystemic shunt. Eur J Gastroenterol Hepatol 2019; 31:853-858. [PMID: 30633039 DOI: 10.1097/meg.0000000000001349] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications in cirrhosis. Spontaneous portosystemic shunts (SPSSs) may increase the risk of post-TIPS complications and mortality. This study was done to evaluate the safety and efficacy of TIPS for treating variceal bleeding between patients with and without SPSSs. PATIENTS AND METHODS The clinical data of 467 consecutive patients with cirrhosis who received TIPS for variceal bleeding from January 2012 to January 2018 were screened. A total of 33 patients with coexisting SPSSs were included as the SPSS group, and 33 patients without SPSSs were randomly selected as control. The procedure-related complications and long-term outcomes were compared between the two groups. RESULTS Both groups were successfully treated with TIPS. SPSSs were antegradely embolized before TIPS placement. In terms of safety, one patient in the SPSS group experienced an asymptomatic pulmonary embolism, and another patient experienced serious gastric ulcer bleeding. Overall, 23 (70.0%) patients in the SPSS group and 16 (51.5%) patients in the control group experienced different mild complications (P=0.131). During a median follow-up of more than 2 years, the rebleeding rates (7.1 vs. 3.7% at 1 year, P=0.508), overt hepatic encephalopathy occurrence rates (34.4 vs. 39.4% at 2 years, P=0.685), and orthotopic liver transplantation-free survival rates (73.2 vs. 70.7% at 2 years, P=0.557) were not significantly different between the two groups. CONCLUSION TIPS combined with antegrade embolization is safe, effective, and feasible for patients with SPSSs, with safety and long-term outcomes comparable to patients without SPSSs.
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He C, Lv Y, Wang Z, Guo W, Tie J, Li K, Niu J, Zuo L, Yu T, Yuan X, Chen H, Wang Q, Liu H, Bai W, Wang E, Xia D, Luo B, Li X, Yuan J, Han N, Zhu Y, Wang J, Yin Z, Fan D, Han G. Association between non-variceal spontaneous portosystemic shunt and outcomes after TIPS in cirrhosis. Dig Liver Dis 2018; 50:1315-1323. [PMID: 29960900 DOI: 10.1016/j.dld.2018.05.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/26/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Whether pre-existing nonvariceal spontaneous portosystemic shunts (SPSSs) in cirrhotic patients affect outcomes after transjugular intrahepatic portosystemic shunt (TIPS) and whether they need to be closed remains unclear. AIM To assess the effects of the presence or embolization of SPSSs on outcomes after TIPS for cirrhosis. METHODS From January 2004 to December 2014, 903 consecutive cirrhotic patients who underwent TIPS in a tertiary-care center were included, of which 715 patients had no SPSS (N-SPSS group), 144 patients had an SPSS without embolization (SPSS group), and 44 had an SPSS with embolization (SPSS + E group). RESULTS During a median follow-up period of 27.7 months, 368 (41%) patients experienced overt hepatic encephalopathy (OHE), 256 (28%) experienced clinical relapse, 164 (18%) developed shunt dysfunction, and 379 (42%) died. The SPSS group had a higher risk of OHE compared with the N-SPSS and SPSS + E groups (adjusted HR [95%CI]: N-SPSS vs SPSS vs SPSS + E: 1 vs 1.36 [1.06-1.75] vs 0.77 [0.46-1.29]; p = 0.027). In stratification analysis, a higher risk of OHE was only observed in patients with a large SPSS (SPSS diameter ≥6 mm) but not a small SPSS. Additionally, SPSS embolization was associated with a lower risk of OHE among patients with a large SPSS (adjust HR = 0.51; 95% CI: 0.29-0.91; p = 0.034). The risks of clinical relapse (p = 0.584), shunt dysfunction (p = 0.267), and mortality (p = 0.4743) did not significantly differ among groups. CONCLUSIONS Among cirrhotic patients undergoing TIPS, a pre-existing large SPSS was associated with a higher risk of OHE, which could be decreased by SPSS embolization. There was no clear association between the presence/embolization of an SPSS and post-TIPS clinical relapse, shunt dysfunction or mortality.
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Affiliation(s)
- Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jun Tie
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jing Niu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Luo Zuo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tianlei Yu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xulong Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Haibo Liu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Enxing Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianhong Wang
- Department of Ultrasound, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
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Vidal-González J, Simón-Talero M, Genescà J. Should prophylactic embolization of spontaneous portosystemic shunts be routinely performed during transjugular intrahepatic portosystemic shunt placement? Dig Liver Dis 2018; 50:1324-1326. [PMID: 30005961 DOI: 10.1016/j.dld.2018.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 06/18/2018] [Accepted: 06/18/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Judit Vidal-González
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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9
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Guillaume M, Bureau C. Should the Presence of Spontaneous Portosystemic Shunts Be Implemented to the Model for End-Stage Liver Disease Score for a Better Prediction of Outcome? Gastroenterology 2018; 154:1569-1571. [PMID: 29601827 DOI: 10.1053/j.gastro.2018.03.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maeva Guillaume
- Service d'Hépatologie et Gastro-entérologie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, Université Toulouse III, Institut CARDIOMET, Toulouse, France
| | - Christophe Bureau
- Service d'Hépatologie et Gastro-entérologie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, Université Toulouse III, Institut CARDIOMET, Toulouse, France.
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10
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Trebicka J. Emergency TIPS in a Child-Pugh B patient: When does the window of opportunity open and close? J Hepatol 2017; 66:442-450. [PMID: 27984174 DOI: 10.1016/j.jhep.2016.10.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/22/2016] [Accepted: 10/23/2016] [Indexed: 12/14/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of cirrhosis such as variceal bleeding and refractory ascites, but it also bears the risk of liver failure, overt hepatic encephalopathy (HE) and cardiac decompensation. Variceal bleeding may be controlled using endoscopic and medical treatment in patients with compensated cirrhosis; in decompensated patients, however, TIPS improves survival. Therefore, an early TIPS (within 72h or if later, still early after bleeding) might improve the survival of patients by preventing an inflammatory response and bacterial translocation. Both these processes mediate an impaired immunological and hemodynamic response, thereby facilitating the development of acute-on-chronic liver failure (ACLF) and/or death. Similarly, in patients with refractory ascites, TIPS should be used early in treatment to prevent acute kidney injury (AKI) and hepatorenal syndrome (HRS) after precipitating events induced by complications of portal hypertension. Whether TIPS and/or embolization should be used to treat portal vein thrombosis and spontaneous shunts is still a matter of debate and should be further investigated. In summary, the careful selection of patients for TIPS is crucial. New biomarkers, especially those evaluating systemic inflammation and bacterial translocation, might improve the predictive value of established clinical parameters such as bilirubin and overt HE. However, a significant amount of further research must be carried out.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; Institute of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
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11
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Wu W, Han G. Which approach is appropriate for spontaneous portosystemic shunt embolization in patients with post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy: Antegrade or retrograde? Hepatology 2016; 64:315-6. [PMID: 26566969 DOI: 10.1002/hep.28346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Wenbin Wu
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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12
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Doshi M, Pereira K, Carrion A, Martin P. Antegrade embolization of spontaneous splenorenal shunt for post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Hepatology 2016; 64:314-5. [PMID: 26566759 DOI: 10.1002/hep.28343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Mehul Doshi
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Keith Pereira
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Andres Carrion
- Department of Hepatology, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Paul Martin
- Department of Hepatology, Jackson Memorial Hospital, University of Miami, Miami, FL
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13
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Borentain P, Soussan J, Resseguier N, Botta-Fridlund D, Dufour JC, Gérolami R, Vidal V. The presence of spontaneous portosystemic shunts increases the risk of complications after transjugular intrahepatic portosystemic shunt (TIPS) placement. Diagn Interv Imaging 2016; 97:643-50. [PMID: 26947721 DOI: 10.1016/j.diii.2016.02.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/29/2016] [Accepted: 02/07/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE The goal of this study was to identify clinical and imaging variables that are associated with an unfavorable outcome during the 30 days following transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIAL AND METHODS Fifty-four consecutive patients with liver cirrhosis (Child-Pugh 6-13, Model for End-stage Liver Disease 7-26) underwent TIPS placement for refractory ascites (n=25), recurrent or uncontrolled variceal bleeding (n=23) or both (n=6). Clinical, biological and imaging variables including type of stent (covered n=40; bare-stent n=14), presence of spontaneous portosystemic shunt (n=31), and variations in portosystemic pressure gradient were recorded. Early severe complication was defined as the occurrence of overt hepatic encephalopathy or death within the 30days following TIPS placement. RESULTS Sixteen patients (30%) presented with early severe complication after TIPS placement. Child-Pugh score was independently associated with complication (HR=1.52, P<0.001). Among the imaging variables, opacification of spontaneous portosystemic shunt during TIPS placement but before its creation was associated with an increased risk of early complication (P=0.04). The other imaging variables were not associated with occurrence of complication. CONCLUSION Identification of spontaneous portosystemic shunt during TIPS placement reflects the presence of varices and is associated with an increased risk of early severe complication.
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Affiliation(s)
- P Borentain
- Service d'hépato-gastro-entérologie, centre hospitalier universitaire Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France; UMR 911, université de la Méditerranée, 27, boulevard Jean-Moulin, 13005 Marseille, France.
| | - J Soussan
- Service de radiologie, centre hospitalier universitaire Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - N Resseguier
- Aix-Marseille université, UMRS 912 (SESSTIM), IRD, 13385 Marseille, France; Service de santé publique et d'information médicale, centre hospitalier universitaire Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - D Botta-Fridlund
- Service d'hépato-gastro-entérologie, centre hospitalier universitaire Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - J-C Dufour
- Aix-Marseille université, UMRS 912 (SESSTIM), IRD, 13385 Marseille, France; Service de santé publique et d'information médicale, centre hospitalier universitaire Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - R Gérolami
- Service d'hépato-gastro-entérologie, centre hospitalier universitaire Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France; UMR 911, université de la Méditerranée, 27, boulevard Jean-Moulin, 13005 Marseille, France
| | - V Vidal
- Service de radiologie, centre hospitalier universitaire Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
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14
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Qi X, Ye C, Hou Y, Guo X. A large spontaneous intrahepatic portosystemic shunt in a cirrhotic patient. Intractable Rare Dis Res 2016; 5:58-60. [PMID: 26989653 PMCID: PMC4761588 DOI: 10.5582/irdr.2016.01000] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A spontaneous portosystemic shunt is a rare malformation of the vessels supplying the liver. This condition often leads to the development of hepatic encephalopathy due to excessive shunting of blood from the portal vein to the inferior vena cava. Some studies have suggested that the presence of spontaneous portosystemic shunts is inversely associated with the appearance of large esophageal varices. Spontaneous intrahepatic portosystemic shunts (SIPSS) are far less frequently observed than extrahepatic portosystemic shunts, which include spleno-gastric-renal shunts, mesenteric-caval shunts, and a large patent umbilical vein. Reported here is a case of decompensated liver cirrhosis with a large SIPSS without any incidence of overt hepatic encephalopathy.
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Affiliation(s)
- Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- Address correspondence to: Drs. Xiaozhong Guo and Xingshun Qi, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang 110840, China. E-mail: (XG), (XQ)
| | - Chun Ye
- Department of General Surgery, General Hospital of Shenyang Military Area, Shenyang, China
| | - Yue Hou
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- Address correspondence to: Drs. Xiaozhong Guo and Xingshun Qi, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang 110840, China. E-mail: (XG), (XQ)
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15
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Pereira K, Carrion AF, Martin P, Vaheesan K, Salsamendi J, Doshi M, Yrizarry JM. Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Liver Int 2015; 35:2487-94. [PMID: 26332169 DOI: 10.1111/liv.12956] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/24/2015] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt has evolved into an important option for management of complications of portal hypertension. The use of polytetrafluoroethylene covered stents enhances shunt patency. Hepatic encephalopathy (HE) remains a significant problem after TIPS placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for TIPS requires careful evaluation of risk factors for HE. TIPS procedure-related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. Liver transplantation is, however, the ultimate treatment.
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Affiliation(s)
- Keith Pereira
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Andres F Carrion
- Division of Hepatology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Paul Martin
- Division of Hepatology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Kirubahara Vaheesan
- Department of Interventional Radiology, Saint Louis University School of medicine, St Louis, MO, USA
| | - Jason Salsamendi
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Mehul Doshi
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Jose M Yrizarry
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
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16
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Endovascular Management of Refractory Hepatic Encephalopathy Complication of Transjugular Intrahepatic Portosystemic Shunt (TIPS): Comprehensive Review and Clinical Practice Algorithm. Cardiovasc Intervent Radiol 2015; 39:170-82. [PMID: 26285910 DOI: 10.1007/s00270-015-1197-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/23/2015] [Indexed: 12/17/2022]
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