Clearing the Confusion over Hepatic Encephalopathy After TIPS Creation: Incidence, Prognostic Factors, and Clinical Outcomes

Casadaban, Leigh C.; Parvinian, Ahmad; Minocha, Jeet; Lakhoo, Janesh; Grant, Christopher; Ray, Charles E.; Knuttinen, M. Grace; Bui, James T.; Gaba, Ron C.

doi:10.1007/s10620-014-3391-0

Cited by 97 publications

(85 citation statements)

References 28 publications

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“…Overall, three patients died within one week after TIPSS creation, attributable to their limited general conditions (multiorgan failure, ARDS, pneumonia) rather than to the TIPSS creation. By and large, the rate of adverse effects was concordant with the rate of TIPSS-related complications already published in the literature (25, 26). Apparently, those side effects were procedure-related rather than graft-related.…”

Section: Discussionsupporting

confidence: 86%

Implantability, Complications, and Follow-Up After Transjugular Intrahepatic Portosystemic Stent-Shunt Creation With the 6F Self-Expanding Sinus-SuperFlex-Visual Stent

et al. 2016

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BackgroundThe transjugular intrahepatic portosystemic stent-shunt (TIPSS) builds a shortcut between the portal vein and a liver vein, and represents a sophisticated alternative to open surgery in the management of portal hypertension or its complications.ObjectivesTo describe clinical experiences with a low-profile nitinol stent system in TIPSS creation, and to assess primary and long-term success.Patients and MethodsTwenty-six patients (5 females, 21 males; mean age 54.6 years) were treated using a low-profile 6F self-expanding sinus-SuperFlex-Visual stent system. The indication for TIPSS creation was refractory bleeding in 9 of the 26 patients, refractory ascites in 18 patients, and acute thrombosis of the portal vein confluence in one patient. Portosystemic pressure gradients before and after TIPSS, periprocedural and long-term complications, and the time to orthotopic liver transplantation (OLT) or death were recorded.ResultsThe portosystemic pressure gradient was significantly reduced, from 20.9 ± 6.3 mmHg before to 8.2 ± 2.3 mmHg after TIPSS creation (P < 0.001). Procedure-related complications included acute tract occlusion (n = 2), liver hematoma (n = 1), hepatic encephalopathy (n = 1), and cardiac failure (n = 1). Three of the 26 patients had late-onset TIPSS occlusion (at 12, 12, and 39 months after TIPSS creation). Three patients died within one week after the procedure due to their poor general condition (multiorgan failure, acute respiratory distress syndrome, necrotizing pancreatitis, and aspiration pneumonia). Another four patients succumbed to their underlying advanced liver disease within one year after TIPSS insertion. Seven patients underwent OLT at a mean time of 9.4 months after TIPSS creation.ConclusionThe sinus-SuperFlex-Visual stent system can be safely deployed as a TIPSS device. The pressure gradient reduction was clinically sufficient to treat the patients’ symptoms, and periprocedural complications were due to the TIPSS procedure per se rather than to the particular stent system employed in this study.

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Section: Discussionsupporting

confidence: 86%

Implantability, Complications, and Follow-Up After Transjugular Intrahepatic Portosystemic Stent-Shunt Creation With the 6F Self-Expanding Sinus-SuperFlex-Visual Stent

et al. 2016

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“…However, this comes with the caveat of potentially elevating portal pressures and increasing the risk of variceal bleeding. In patients who have had transjugular intrahepatic portosystemic shunts (TIPS), the development of mHE is common, with one case series reporting that 46% of all patients who developed post-TIPS HE had WH grade I [35]. Treatment of HE post-TIPS responds well to medical treatments.…”

Section: Treatment Of Mhementioning

confidence: 99%

Diagnosis and Treatment of Low-Grade Hepatic Encephalopathy

Direkze

Jalan²

2015

Dig Dis

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Minimal hepatic encephalopathy (mHE) is common among patients with cirrhotic liver disease and causes significant morbidity and mortality. It may present as cognitive impairment, behavioural changes and, less frequently, with neurological symptoms which make diagnosis of the disease challenging. A history of falls and accidents may also be suggestive of mHE. Diagnosis primarily relies on at least two positive psychometric tests of which the psychometric hepatic encephalopathy score (PHES) is essential. Alternatively, PHES and an electroencephalogram may be used to establish a diagnosis. Biochemical markers of encephalopathy currently have no role in the diagnosis of mHE. Treatment is not always advocated for a diagnosis of mHE but is dependent on the degree of impairment caused by the symptoms. After treatment of other metabolic abnormalities and co-morbidities associated with cirrhosis, more specific treatment for mHE largely relies on therapies used to lower ammonia levels. Laxatives and rifaximin are commonly used in treatment and work through decreasing ammonia absorption from the gut. Other therapies, such as BCAA, LOLA, L-carnitine and phenylbutyrate, modify responses to ammonia as well as enhancing metabolism and excretion. mHE resulting from spontaneous portosystemic shunts or transhepatic intraportal systemic shunts may require ablation or reduction of the shunt. Early detection and appropriate treatment of mHE is important to prevent significant cognitive impairments and progression to overt HE.

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“…In one extensive, retrospective study, involving 254 patients, the HE incidence ranged up to 34% (86 patients), and it was successfully regulated by a medication-dietary approach in almost all patients, therefore the flow reduction in TIPS was necessary in just 2 cases. It has also been shown that the incidence of HE is higher in elderly patients (2). The incidence of HE may be associated with renal function as well as with HE episodes prior to placement of TIPS (3).…”

Section: Discussionmentioning

confidence: 99%

“…On one hand, patients with acute hepatic insufficiency may develop HE, although there is no port-system (PS) shunt, while patients with PS shunt, whether pathologic or iatrogenic, may develop HE, regardless the liver is not in an insufficient condition. HE occurs as a result of liver circumvention as a filter that reduces the concentration of nitrogenous substances absorbed from the gastrointestinal tract (2).…”

Section: Discussionmentioning

confidence: 99%

Application of Color Doppler ultrasound in monitoring the effect of reducing the transjugular portosystem shunt due to hepatic encephalopathy: Case report

Dulovic¹,

Rusović²,

Mihajlovic³

et al. 2017

Medicinski casopis

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Clearing the Confusion over Hepatic Encephalopathy After TIPS Creation: Incidence, Prognostic Factors, and Clinical Outcomes

Abstract: The incidence of post-TIPS HE is non-trivial, but symptoms are typically mild and medically managed. HE rates are higher in older patients and those with worse liver function and should be contemplated when counseling on expected TIPS outcomes and post-procedure course.

Cited by 97 publications

References 28 publications

Implantability, Complications, and Follow-Up After Transjugular Intrahepatic Portosystemic Stent-Shunt Creation With the 6F Self-Expanding Sinus-SuperFlex-Visual Stent

Implantability, Complications, and Follow-Up After Transjugular Intrahepatic Portosystemic Stent-Shunt Creation With the 6F Self-Expanding Sinus-SuperFlex-Visual Stent

Diagnosis and Treatment of Low-Grade Hepatic Encephalopathy

Application of Color Doppler ultrasound in monitoring the effect of reducing the transjugular portosystem shunt due to hepatic encephalopathy: Case report

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