What are the treatment options for hepatic encephalopathy (HE) due to post-transjugular intrahepatic portosystemic shunt (TIPS)?

Updated: Apr 04, 2019
  • Author: David C Wolf, MD, FACP, FACG, AGAF, FAASLD; Chief Editor: BS Anand, MD  more...
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Answer

Hepatic encephalopathy is seen in about 1 in 3 patients who undergo the creation of a transjugular intrahepatic portosystemic shunt (TIPS). Typically, post-TIPS encephalopathy symptoms are well controlled with the use of rifaximin or lactulose. However, post-TIPS encephalopathy symptoms can be profound in some instances. In a study by Fanelli et al, 12 of 189 patients undergoing TIPS developed encephalopathy that was refractory to conventional therapy with lactulose. These patients subsequently underwent placement of an hourglass-shaped balloon-expandable polytetrafluoroethylene (ePTFE) stent-graft inside the original shunt. Encephalopathy symptoms resolved in all of the patients over the next 18-26 hours. [69] Of course, such a procedure is not expected to improve a patient's overall condition. At the end of a mean of 74 weeks of follow-up, only 5 of the 12 patients remained alive and in good clinical condition.

Trebicka et al studied the outcomes of diameter of covered, self-expandable nitinol stents in patients with a TIPS. Of 185 patients, 53 received 8 mm stents and the remaining received 10 mm stents. Patients who received 8 mm stents survived significantly longer than patients who received 10 mm stents, regardless whether they were fully dilated or underdilated. The authors concluded that a the 8 mm stent is associated with a prolonged survival compared to 10 mm stents, independent of liver specific prognostic criteria. [70]


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