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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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Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis-Current Understanding and Future Prospects. Can J Gastroenterol Hepatol 2021; 2021:8795115. [PMID: 34422711 PMCID: PMC8376437 DOI: 10.1155/2021/8795115] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023] Open
Abstract
Portal hypertension (PHT) in cirrhosis results from increased resistance to splanchnic blood flow secondary to parenchymal and vascular changes within the liver. In an attempt to counteract the increased portal pressure, two mechanisms simultaneously occur: splanchnic vasodilatation and formation of spontaneous portosystemic shunts (SPSS). Long considered to be a compensatory mechanism to decompress the portal venous system, it is now well established that SPSS are not only inefficient in decreasing the portal pressure but also contribute to reduced hepatocyte perfusion and increased splanchnic blood flow and resistance, associated with worsening PHT. Recent studies have described a high prevalence of SPSS in cirrhosis patients, increasing with liver dysfunction, and observed an association between the presence of SPSS and worse clinical outcomes. In cirrhosis patients with preserved liver functions, the presence of SPSS independently increases the risk of hepatic encephalopathy, variceal bleeding, and ascites, and reduces transplant-free survival. Moreover, the presence of SPSS in patients undergoing transjugular intrahepatic portosystemic shunting and liver transplant has been shown to variably affect the postprocedural outcome. This article provides an overview of the current understanding of the role of SPSS in the natural history of liver cirrhosis and their status as a therapeutic target and an imaging biomarker to identify patients at higher risk of developing complications of PHT.
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Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis. J Hepatol 2020; 72:1140-1150. [PMID: 31954206 DOI: 10.1016/j.jhep.2019.12.021] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/12/2019] [Accepted: 12/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis. METHODS In this retrospective international multicentric study, CT scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. One-year survival was the primary endpoint and acute decompensation (oHE, variceal bleeding, ascites) was the secondary endpoint. RESULTS A total of 301 patients (169 male) were included in the training cohort. Thirty percent of all patients presented with >1 SPSS. A TSA cut-off of 83 mm2 was used to classify patients with small or large TSA (S-/L-TSA). Patients with L-TSA presented with higher model for end-stage liver disease score (11 vs. 14) and more commonly had a history of oHE (12% vs. 21%, p <0.05). During follow-up, patients with L-TSA experienced more oHE episodes (33% vs. 47%, p <0.05) and had lower 1-year survival than those with S-TSA (84% vs. 69%, p <0.001). Multivariate analysis identified L-TSA (hazard ratio 1.66; 95% CI 1.02-2.70, p <0.05) as an independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed that patients with L-TSA had lower 1-year survival (77% vs. 64%, p <0.001) and more oHE development (35% vs. 49%, p <0.001) than those with S-TSA. CONCLUSION This study suggests that TSA >83 mm2 increases the risk for oHE and mortality in patients with cirrhosis. Our results support the clinical use of TSA/SPSS for risk stratification and decision-making in the management of patients with cirrhosis. LAY SUMMARY The prevalence of spontaneous portosystemic shunts (SPSS) is higher in patients with more advanced chronic liver disease. The presence of more than 1 SPSS is common in advanced chronic liver disease and is associated with the development of hepatic encephalopathy. This study shows that total cross-sectional SPSS area (rather than diameter of the single largest SPSS) predicts survival in patients with advanced chronic liver disease. Our results support the clinical use of total cross-sectional SPSS area for risk stratification and decision-making in the management of SPSS.
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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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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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7
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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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8
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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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9
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Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO). Am J Gastroenterol 2013; 108:1612-9. [PMID: 23939627 DOI: 10.1038/ajg.2013.232] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/31/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the incidence of post-balloon-occluded retrograde transvenous obliteration (BRTO) ascites/hepatic hydrothorax and rebleeding rate (variceal and non-variceal) in the presence and absence of a transjugular intrahepatic portosystemic shunt (TIPS). METHODS A retrospective audit of consecutive patients undergoing BRTO was performed (August 2007-October 2010). The population was divided into two groups: patients who underwent BRTO only (BRTO-only group) and those who underwent BRTO in the presence of TIPS (BRTO+TIPS group). Post-BRTO rebleeding was categorized for the source of bleeding. Ascites and/or hepatic hydrothorax were categorized according to clinical severity. Comparisons, utilizing the Kaplan-Meier method, between both groups were made for patient survival, incidence of ascites/hydrothorax, and rebleeding. RESULTS Thirty-nine patients underwent BRTO (three technical failures of BRTO-only group). Of the 36 technically successful BRTO procedures, 27 patients (75%) underwent BRTO-only and 9 patients (25%) underwent BRTO in the presence of a TIPS. Pre-BRTO ascites/hydrothorax resolved in BRTO-only vs. BRTO+TIPS in 7% (N=2/27) and 56% (N=5/9), respectively (P=0.006). The ascites/hydrothorax free rate at 6, 12, and 24 months after BRTO for BRTO-only vs. BRTO+TIPS was 58%, 43%, 29%, and 100%, 100%, 100%, respectively (P=0.01). Recurrent hemorrhage for BRTO-only vs. BRTO+TIPS groups, and for the same time periods was 9%, 9%, 21% vs. 0%, 0%, 0%, respectively (P=0.03). The 1-year patient survival of both groups (80-88%) was similar (P>0.05). CONCLUSIONS This study concludes that the presence of TIPS has a protective value against the development of post-BRTO ascites/hydrothorax as well as recurrent hemorrhage but this does not translate to improved patient survival.
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Splenic Vein Embolization Using Coil Anchors and Prophylactic Occlusion of a Hepatofugal Collateral for Hepatic Encephalopathy due to Splenorenal Shunt: Technical Note and Literature Review. Case Rep Radiol 2013; 2013:160653. [PMID: 23607030 PMCID: PMC3623118 DOI: 10.1155/2013/160653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/28/2013] [Indexed: 02/04/2023] Open
Abstract
Purpose. Interventional treatment strategies for patients with encephalopathy due to splenorenal shunt remain controversial. Portosplenic blood flow separation by occluding the splenic vein could avoid the complication of severe portal hypertension, but it would require repeated reintervention due to recurrence of symptoms. This paper describes occlusion of the splenic vein using coil anchors and prophylactic embolization of a collateral hepatofugal vessel with no recurrence of hyperammonemia. Materials and Methods. A 51-year-old woman with severe cirrhosis had hepatic encephalopathy due to a large splenorenal shunt. The serum ammonia level was 132 μ g/dL. Via a transileocolic approach, the splenic vein was completely embolized with 0.035-inch metallic coils using coil anchors while preserving the splenorenal shunt. In addition, one of the collateral vessels of the portal vein, the retrogastric vein, was also embolized prophylactically. Results. After this procedure, the serum ammonia level decreased immediately to 24 μ g/dL. The portal venous pressure increased by only 1.5 mmHg. Hepatic encephalopathy had not been observed for 25 months after the procedure, and neither retention of ascites nor worsening of esophageal varices and liver function was observed. Conclusion. This procedure appears to be safe and effective for hepatic encephalopathy caused by a splenorenal shunt.
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Al hajjaj A, Bonatti H, Krishna M, Dickson R, Mark MJ, Nguyen J, Steers J, Aranda-Michel J. Percutaneous transfemoral embolization of a spontaneous splenorenal shunt presenting with ischemic graft dysfunction 18months post-transplant. Transpl Int 2008; 21:816-9. [DOI: 10.1111/j.1432-2277.2008.00691.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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12
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Holden A, Ng R, Gane E, Hill A, McCall J. A technique for controlled partial closure of a transjugular intrahepatic portosystemic shunt tract in a patient with hepatic encephalopathy. J Vasc Interv Radiol 2007; 17:1957-61. [PMID: 17185693 DOI: 10.1097/01.rvi.0000244850.39439.34] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A novel endovascular technique to reduce flow through a transjugular intrahepatic portosystemic shunt (TIPS) is described in a patient with severe hepatic encephalopathy. This technique allows controlled and potentially adjustable partial closure of the TIPS without thromboembolic risk. The patient experienced a dramatic clinical improvement after the procedure.
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Affiliation(s)
- Andrew Holden
- Department of Radiology, Auckland City Hospital, Park Road, Grafton, Auckland 9, New Zealand.
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13
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Madoff DC, Wallace MJ, Ahrar K, Saxon RR. TIPS-related hepatic encephalopathy: management options with novel endovascular techniques. Radiographics 2004; 24:21-36; discussion 36-7. [PMID: 14730033 DOI: 10.1148/rg.241035028] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy is a common complication that develops after creation of a transjugular intrahepatic portosystemic shunt (TIPS). Although most patients respond well to conservative medical therapy (ie, protein-restricted diet, nonabsorbable disaccharides, nonabsorbable antibiotics), a small percentage of patients (3%-7%) do not benefit from these methods and require more invasive therapeutic approaches. One option is emergent liver transplantation, but the majority of patients are not suitable candidates. Recently, various percutaneous techniques have been described that alter the hemodynamics through the shunt by occluding it with coils or balloons or by reducing its diameter by inserting constrained stents or stent-grafts. Other techniques have been used for patients with TIPS-related hepatic encephalopathy in whom spontaneous splenorenal shunts are present. In many patients with refractory hepatic encephalopathy, these percutaneous techniques have produced symptomatic improvement, with either a complete resolution or a substantial reduction in hepatic encephalopathy symptoms that can be controlled with medical therapy. Unfortunately, despite all attempts, some patients remain incapacitated and ultimately die. Further research is necessary to improve our understanding of TIPS-related hepatic encephalopathy so that newer, less invasive and safer procedures can be developed to treat this difficult clinical problem.
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Affiliation(s)
- David C Madoff
- Division of Diagnostic Imaging, Section of Vascular and Interventional Radiology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 325, Houston, TX 77030-4009, USA.
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Lozeva V, Montgomery JA, Tuomisto L, Rocheleau B, Pannunzio M, Huet PM, Butterworth RF. Increased brain serotonin turnover correlates with the degree of shunting and hyperammonemia in rats following variable portal vein stenosis. J Hepatol 2004; 40:742-8. [PMID: 15094220 DOI: 10.1016/j.jhep.2004.01.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2003] [Revised: 11/13/2003] [Accepted: 01/07/2004] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Hepatic encephalopathy (HE) is a serious neuropsychiatric complication of chronic liver disease. Brain monoamines have been implicated in the pathogenesis of HE. We examined the relationship between monoamine dysfunction and the degree of portal-systemic shunting (PSS) in rats with varying degrees of PSS. METHODS Concentrations of catecholamines, serotonin, histamine, precursors and metabolites in frontal cortex of rats with varying degrees of PSS (9-99.8%) were measured by HPLC. RESULTS The concentrations of the serotonin precursor, tryptophan, and its metabolite, 5-HIAA were increased up to 4-fold in brains of rats with various degrees of PSS and were significantly correlated with the degree of shunting and with arterial ammonia levels. Brain levels of histamine, its precursor, l-histidine, and metabolite, tele-methylhistamine were significantly increased only following total shunting. Concentrations of catecholamines and their metabolites were not significantly correlated with degree of PSS or hyperammonemia. CONCLUSIONS Given the established role of the serotonin system in the regulation of sleep, circadian rhythmicity and locomotion these findings suggest that selective alterations of this system could be implicated in the pathogenesis of HE. Therapeutic approaches aimed at the normalization of serotonin turnover could be beneficial in the prevention and treatment of early neuropsychiatric symptoms of HE.
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Affiliation(s)
- Violina Lozeva
- Neuroscience Research Unit, Hopital Saint-Luc CHUM, 1058 St-Denis St., Montreal, Que., Canada H2X 3J4
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Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003; 4:109-16. [PMID: 12845306 PMCID: PMC2698068 DOI: 10.3348/kjr.2003.4.2.109] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To assess the feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) in active gastric variceal bleeding, and to compare the findings with those of transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHDOS: Twenty-one patients with active gastric variceal bleeding due to liver cirrhosis were referred for radiological intervention. In 15 patients, contrast-enhanced CT scans demonstrated gastrorenal shunt, and the remaining six (Group 1) underwent TIPS. Seven of the 15 with gastrorenal shunt (Group 2) were also treated with TIPS, and the other eight (Group 3) underwent BRTO. All patients were followed up for 6 to 21 (mean, 14.4) months. For statistical inter-group comparison of immediate hemostasis, rebleeding and encephalopathy, Fisher's exact test was used. Changes in the Child-Pugh score before and after each procedure in each group were statistically analyzed by means of Wilcoxon's signed rank test. RESULTS One patient in Group 1 died of sepsis, acute respiratory distress syndrome, and persistent bleeding three days after TIPS, while the remaining 20 survived the procedure with immediate hemostasis. Hepatic encephalopathy developed in four patients (one in Group 1, three in Group 2, and none in Group 3); one, in Group 2, died while in an hepatic coma 19 months after TIPS. Rebleeding occurred in one patient, also in Group 2. Except for transient fever in two Group-3 patients, no procedure-related complication occurred. In terms of immediate hemostasis, rebleeding and encephalopathy, there were no statistically significant differences between the groups (p > 0.05). In Group 3, the Child-Pugh score showed a significant decrease after the procedure (p = 0.02). CONCLUSION BRTO can effectively control active gastric variceal bleeding, and because of immediate hemostasis, the absence of rebleeding, and improved liver function, is a good alternative to TIPS in patients in whom such bleeding, accompanied by gastrorenal shunt, occurs.
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Affiliation(s)
- Young Ho Choi
- Department of Radiology, Seoul City Boramae Hospital, Seoul, Korea
| | - Chang Jin Yoon
- Department of Radiology, Seoul National University College of Medicine and Institute of Radiation Medicine, Seoul National University Medical Research Center and Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jae Hyung Park
- Department of Radiology, Seoul National University College of Medicine and Institute of Radiation Medicine, Seoul National University Medical Research Center and Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University College of Medicine and Institute of Radiation Medicine, Seoul National University Medical Research Center and Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jong Won Kwon
- Department of Radiology, Seoul National University College of Medicine and Institute of Radiation Medicine, Seoul National University Medical Research Center and Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Guk Myung Choi
- Department of Radiology, Cheju National University College of Medicine, Jeju-do, Korea
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Shen B, Younossi ZM, Dolmatch B, Newman JS, Henderson JM, Ong JP, Gramlich T, Yamani M. Patent ductus venosus in an adult presenting as pulmonary hypertension, right-sided heart failure, and portosystemic encephalopathy. Am J Med 2001; 110:657-60. [PMID: 11382375 DOI: 10.1016/s0002-9343(01)00701-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- B Shen
- Department of Gastroenterology, the Cleveland Clinic Foundation, Ohio, USA
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Haskal ZJ. Embolization of varices. Tech Vasc Interv Radiol 2000. [DOI: 10.1053/tvir.2000.9678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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