Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt
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,
References (65)
- et al.
Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension
J Hepatol
(2010) - et al.
Role of transjugular intrahepatic portosystemic shunt treatment of portal hypertension and its complication: conference sponsored by the National Digestive Diseases Advisory Board
Hepatology
(1995) - et al.
New non-operative treatment for variceal haemorrhage
Lancet
(1989) - et al.
Hepatic encephalopathy: definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998
Hepatology
(2002) - et al.
Intrahepatic portal-hepatic venous anastomosis: a portal-systemic shunt with neurological repercussions
Am J Gastroenterol
(2000) - et al.
Induced hyperammonemia alters neuropsychology, brain MR spectroscopy and magnetization transfer in cirrhosis
Hepatology
(2003) - et al.
Reversal of hepatic encephalopathy after occlusion of total portosystemic shunts
Am J Surg
(1981) - et al.
Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study
Gastroenterology
(2004) - et al.
TIPS vs. sclerotherapy in the elective treatment of variceal hemorrhage
Gastroenterology
(1996) - et al.
Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt for variceal hemorrhage
J Hepatol
(1995)
Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding
Lancet
A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices
Hepatology
Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding
Gastroenterology
Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial
J Hepatol
Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis
Gastroenterology
The North American study for the treatment of refractory ascites
Gastroenterology
Emerging issues in the use of transjugular intrahepatic portosystemic shunt (TIPS) for management of portal hypertension: time to update the guidelines?
Dig Liver Dis
Clinical events after TIPS: correlation with hemodynamic findings
Gastroenterology
Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study
J Hepatol
Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial
J Hepatol
Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS)
Am J Gastroenterol
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
Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts
J Vasc Interv Radiol
Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data
Gastroenterology
TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: a randomized controlled trial
Hepatology
AASLD practice guidelines: the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension
Hepatology
Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia
J Clin Monit Comput
Transjugular intrahepatic portosystemic shunt: present status, comparison with endoscopic therapy and shunt surgery, and future prospectives
World J Surg
Portal-systemic encephalopathy in non-cirrhotic patients: classification of clinical types, diagnosis and treatment
J Gastroenterol Hepatol
Noncirrhotic portal vein thrombosis exhibits neuropsychological and MR changes consistent with minimal hepatic encephalopathy
Hepatology
Review: surgical shunts and encephalopathy
Metab Brain Dis
Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective controlled study
Hepatology
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