Elsevier

Clinics in Liver Disease

Volume 16, Issue 1, February 2012, Pages 133-146
Clinics in Liver Disease

Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt

https://doi.org/10.1016/j.cld.2011.12.008Get rights and content

Section snippets

Incidence of post-TIPS HE

The current knowledge about the incidence of post-TIPS HE derives from the prospective studies available. Some discrepancies, however, may arise due to the method used for classifying and staging the syndrome. In fact, some studies considered the overall episodes of HE, whereas others have only considered the new or worsened HE episodes. Some investigators have selected the episodes that occurred “without an evident precipitating cause”22, 23 and others only those leading the patients to

Characteristics of post-TIPS HE

When bare metal stents were used for TIPS insertion, HE tends to be particularly frequent during the first months after TIPS and less common with time. This behavior is thought to be due to the development of shunt stenosis, which, even when not clinically overt (in this case the shunt is usually revised), can progressively reduce the amount of the portal blood shunted.14, 15, 16, 19 With the new PTFE-covered endoprostheses, the number of shunt stenoses is considerably reduced.20 Thus, a

Predictors of post-TIPS HE

Previous HE was found to be a very strong predictor of post-TIPS; almost all patients who previously had recurrent HE presented with encephalopathy after TIPS, and, thus, this kind of HE should be probably considered as a contraindication to TIPS.42 However, it should be noted that patients with a single episode of HE due to variceal bleeding may not be at risk of HE after TIPS. Others predictors of post-TIPS HE identified were age,16, 26 low portacaval pressure gradient (PPG),16, 43 and high

Prevention of post-TIPS HE

Because patients submitted to TIPS are at high risk of developing post-TIPS HE, and because selecting only patients at low risk of developing this complication to undergo the procedure is not always possible, a pharmacologic treatment to prevent the occurrence of HE would be very much appreciated. However, to date, there is no evidence of efficacious prophylactic treatments of HE after a TIPS. The only randomized controlled trial performed for this aim failed to show any beneficial effect of

Episodic HE

Episodes of HE after TIPS can be treated traditionally. The cornerstones of the treatment of this type of HE are the identification and treatment of the precipitating event and the general support of the patients. This includes the prevention of falls or body injuries in disorientated patients, care of bladder and bowel functions, care of intravenous lines, monitoring of fluid balance, monitoring of blood glycemia and electrolyte levels such as of arterial blood gases, correction of acid/base

Summary

Post-TIPS HE still remains a major unresolved issue because no efficacious strategy has been able to reduce the incidence of this condition that to date so negatively affects patients’ quality of life. Thus, a careful and evidence-based indication to TIPS insertion remains mandatory. According to us, once the decision to perform a TIPS has been carefully taken, the patient should be informed that episodic HE is likely to occur at least once after the procedure and that, although infrequently,

First page preview

First page preview
Click to open first page preview

References (65)

  • M. Rossle et al.

    Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding

    Lancet

    (1997)
  • R. Jalan et al.

    A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices

    Hepatology

    (1997)
  • P. Sauer et al.

    Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding

    Gastroenterology

    (1997)
  • D. Lebrec et al.

    Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial

    J Hepatol

    (1996)
  • P. Ginès et al.

    Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis

    Gastroenterology

    (2002)
  • A.J. Sanyal et al.

    The North American study for the treatment of refractory ascites

    Gastroenterology

    (2003)
  • O. Riggio et al.

    Emerging issues in the use of transjugular intrahepatic portosystemic shunt (TIPS) for management of portal hypertension: time to update the guidelines?

    Dig Liver Dis

    (2010)
  • M. Casado et al.

    Clinical events after TIPS: correlation with hemodynamic findings

    Gastroenterology

    (1998)
  • O. Riggio et al.

    Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study

    J Hepatol

    (2005)
  • O. Riggio et al.

    Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial

    J Hepatol

    (2010)
  • M. Merli et al.

    Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS)

    Am J Gastroenterol

    (2002)
  • G. Maleux et al.

    Management of transjugular intrahepatic portosystemic shunt–induced refractory hepatic encephalopathy with the parallel technique: results of a clinical follow-up study

    J Vasc Interv Radiol

    (2007)
  • R.K. Kerlan et al.

    Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts

    J Vasc Interv Radiol

    (1995)
  • F. Salerno et al.

    Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data

    Gastroenterology

    (2007)
  • A. Escorsell et al.

    TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: a randomized controlled trial

    Hepatology

    (2002)
  • T.D. Boyer et al.

    AASLD practice guidelines: the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension

    Hepatology

    (2010)
  • A. DeGasperi et al.

    Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia

    J Clin Monit Comput

    (2009)
  • J. Rösch et al.

    Transjugular intrahepatic portosystemic shunt: present status, comparison with endoscopic therapy and shunt surgery, and future prospectives

    World J Surg

    (2001)
  • A. Watanabe

    Portal-systemic encephalopathy in non-cirrhotic patients: classification of clinical types, diagnosis and treatment

    J Gastroenterol Hepatol

    (2000)
  • B. Minguez et al.

    Noncirrhotic portal vein thrombosis exhibits neuropsychological and MR changes consistent with minimal hepatic encephalopathy

    Hepatology

    (2006)
  • J. Klempnaue et al.

    Review: surgical shunts and encephalopathy

    Metab Brain Dis

    (2001)
  • A.J. Sanjal et al.

    Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective controlled study

    Hepatology

    (1994)
  • Cited by (119)

    • North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

      2022, Clinical Gastroenterology and Hepatology
      Citation Excerpt :

      Severe refractory overt HE that requires shunt reduction occurs in approximately 8% of TIPS recipients.166 There is no consensus definition of refractory overt HE; however, shunt reduction should be considered when there is persistent HE refractory to medical therapy or at least 3 or more episodes of unprovoked HE requiring hospitalization in the past 3 months.201 Shunt reduction is effective at reducing post-TIPS HE; however, recurrence of portal hypertensive complications are likely.166,202–207

    View all citing articles on Scopus
    View full text