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Mingpun W, Sobanska A, Nimworapan M, Chayanupatkul M, Dhippayom T, Dilokthornsakul P. Carvedilol and traditional nonselective beta blockers for the secondary prophylaxis of variceal hemorrhage and portal hypertension related complications among patients with decompensated cirrhosis: a systematic review and network meta-analysis. Hepatol Int 2025:10.1007/s12072-025-10812-8. [PMID: 40178720 DOI: 10.1007/s12072-025-10812-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2024] [Accepted: 01/31/2025] [Indexed: 04/05/2025]
Abstract
BACKGROUND Carvedilol has limited research on decompensated cirrhosis. This study compared the effects of carvedilol, traditional nonselective beta blockers (NSBBs), including propranolol and nadolol, and other interventions in patients using carvedilol or traditional NSBBs for secondary prophylaxis of variceal hemorrhage (VH) and portal hypertension (PH)-related complications. METHODS A systematic search of databases, including PubMed, Embase, Cochrane Library, and Scopus, was conducted through October 2023. Randomized controlled trials (RCTs) evaluating carvedilol or traditional NSBBs for secondary prophylaxis of VH were included. The outcomes were the occurrence of VH and portal PH-related complications, including new or worsening ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. A network meta-analysis was performed using a random-effects model. RESULTS A total of 60 RCTs involving 5,600 patients with a median Child Pugh score of 8.0 (range 6.8-10) were included. The risk of carvedilol plus variceal band ligation (VBL) on VH was lower than placebo (relative risk (RR) 0.24; 95% confidence interval (CI): 0.10-0.57), and the risk of carvedilol on new or worsening ascites was lower than placebo (RR = 0.10, 95%CI; 0.01-0.93). Traditional NSBBs plus VBL also had preventive effects on VH compared to placebo (RR = 0.31, 95%CI; 0.18-0.54). However, there were no differences between carvedilol and traditional NSBBs in other outcomes. CONCLUSION Carvedilol can prevent PH-related complications, including VH and new or worsening ascites, in cirrhosis patients with a history of VH. No significant differences were observed between the effects of carvedilol and traditional NSBBs, both combined with VBL.
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Affiliation(s)
- Warunee Mingpun
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | | | - Mantiwee Nimworapan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Maneerat Chayanupatkul
- Center of Excellence in Alternative and Complementary Medicine for Gastrointestinal and Liver Diseases, Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Teerapon Dhippayom
- The Research Unit of Evidence Synthesis (TRUES), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake, United States
| | - Piyameth Dilokthornsakul
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.
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Luo SH, Wang ZH, Chen J, Chen JY. Numerous liver abscesses after transjugular intrahepatic portosystemic shunt for decompensated liver cirrhosis: A case report. World J Radiol 2025; 17:101932. [DOI: 10.4329/wjr.v17.i2.101932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Revised: 12/16/2024] [Accepted: 01/23/2025] [Indexed: 02/26/2025] Open
Abstract
BACKGROUND Liver cirrhosis patients can develop various complications including bacteremia as the intestinal flora is heterologous. In those with low immunity, trauma, or following surgery, etc., the body is susceptible to concurrent systemic or local infections. Under these circumstances, even minimally invasive treatment methods such as interventional therapy like transjugular intrahepatic portosystemic shunt (TIPS) for liver cirrhosis patients can also result in complications such as infections.
CASE SUMMARY A male patient with decompensated cirrhosis experienced multiple episodes of gastrointestinal bleeding and hypersplenism. He was admitted to hospital due to voluntary remedial TIPS. The patient developed a numerous intrahepatic liver abscess postoperatively. Following initial conservative treatment with intravenous antibiotics and parenteral nutrition, three months after TIPS, the liver abscess had disappeared on imaging examination. At the 6-month postoperative follow-up, outpatient re-examination showed that the patient had recovered and the liver abscess had resolved.
CONCLUSION Attention should be paid to decreased blood cell counts, especially low leukocyte levels in patients with liver cirrhosis as the presence of intestinal microbiota dysregulation and portal pyemia can result in liver abscess and sepsis during invasive diagnostic and therapeutic procedures like TIPS. The addition of probiotics might reduce the risk in such patients.
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Affiliation(s)
- Shi-Hua Luo
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Zhao-Han Wang
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Jie Chen
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Jian-Yong Chen
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
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Luo SH, Zhang HF, Liu W, Chu JG, Chen JY. Comparison of clinical outcomes of transjugular intrahepatic portosystemic shunt for refractory ascites and recurrent nonrefractory ascites. World J Hepatol 2025; 17:100451. [PMID: 40027559 PMCID: PMC11866158 DOI: 10.4254/wjh.v17.i2.100451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Revised: 12/04/2024] [Accepted: 01/23/2025] [Indexed: 02/20/2025] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has an important role in the therapy of complications of portal-hypertension-related ascites. Various guidelines now indicate that TIPS is indicated for refractory ascites (RA), but TIPS for recurrent nonrefractory ascites (RNRA) achieved better clinical results. AIM To compare the clinical outcomes of TIPS for RA and RNRA in patients with complications related to portal hypertension. METHODS There were 863 patients divided into two main categories who underwent TIPS between September 2016 and September 2021. In category 1, patients had ascites without cirrhotic gastrointestinal bleeding. The patients were divided into group A (RNRA, n = 183) and group B (RA, n = 217). In category 2, patients had ascites and cirrhotic gastrointestinal bleeding. The patients were divided into group C (RNRA, n = 328) and group D (RA, n = 135). The clinical outcomes were probability of total hepatic impairment, incidence of hepatic encephalopathy (HE) and mortality. RESULTS The symptoms of ascites disappeared or were relieved within 1 week in group A compared with group B (P = 0.032), and in group C compared with group D (P = 0.027). By the end of follow-up, there were significant differences in the rate of RA in group A compared with group B (P = 0.016), and in group C compared with group D (P = 0.012). The probability of total hepatic impairment was significantly different in group A compared with group B (P = 0.024), and in group C compared with group D (P = 0.019). The total incidence of HE was significantly different in group A compared with group B (P = 0.008), and in group C compared with group D (P = 0.004). The 6-month, and 1-, 2- and 3-year survival rates were significantly different between groups A and B (all P < 0.05), and between groups C and D (all P < 0.05). CONCLUSION TIPS has a good therapeutic effect on ascites related to cirrhotic portal hypertension, and early TIPS for RNRA can prolong survival, and prevent progression to RA.
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Affiliation(s)
- Shi-Hua Luo
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Hui-Fang Zhang
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Wei Liu
- Department of Gastroenterology, The First Affiliated Hospital of Gannan Medical University, Ganzhou 341000, Jiangxi Province, China
| | - Jian-Guo Chu
- Department of Gastroenterology, Air Force Medical Center of PLA, Beijing 100142, China
| | - Jian-Yong Chen
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China.
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Shafiq M, Khan MA, Khan S. Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding. Cureus 2024; 16:e73101. [PMID: 39651005 PMCID: PMC11621572 DOI: 10.7759/cureus.73101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2024] [Indexed: 12/11/2024] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to reduce the risk of rebleeding among patients with recurrent esophageal variceal bleeding. However, the impact of TIPS on survival remains uncertain. This study took on this challenge to determine if TIPS has any impact on all-cause inpatient mortality during the hospitalization in which it is performed and if it impacts all-cause 30-day readmission rates when compared to patients who only undergo esophageal variceal banding (EVB) for recurrent esophageal variceal bleeding. Methods This was a retrospective cohort study using the Healthcare Cost and Utilization Project - National Readmission Database 2019. All adult patients who had a diagnosis of cirrhosis, were hospitalized once for esophageal variceal bleeding requiring EVB in 2019, and then were hospitalized again later in the year for recurrent esophageal variceal bleeding requiring either TIPS or EVB were included. This second hospitalization in which patients either received TIPS or EVB only was considered as the index hospitalization. Patients with missing data and patients who were discharged in December were excluded. The primary outcome was all-cause 30-day readmission rates among patients who either received TIPS or EVB only. The secondary outcomes included: (i) incidence of all-cause inpatient mortality; and (ii) length of hospital stay during index hospitalization. Patients who underwent TIPS were matched with patients who underwent EVB only on age, sex, and baseline comorbidities. After propensity score matching, survival analysis was performed to compare the all-cause 30-day readmission rates after the index hospitalization, between patients who either received TIPS or EVB only during the index hospitalization. χ2 test was used to compare the inpatient mortality. As the data did not have a normal distribution, the Wilcoxon signed-rank test was used to compare the length of index hospitalization between patients who either received TIPS or EVB only. The alpha criterion was set at 0.05 for all statistical tests. Results This study found no difference in all-cause 30-day readmission rates between patients who underwent either TIPS or EVB only for recurrent esophageal variceal bleeding (hazard ratio: 1.24, 95%CI: 0.73-2.12, P = 0.4). In the exploratory analysis, it was noted that the rate of recurrent esophageal variceal bleeding, among patients who were readmitted within 30 days was lower in the TIPS group (13.3%) when compared to the EVB group (50%) with a risk ratio of 0.27 (95%CI: 0.10-0.72, P = 0.003). Although it was not statistically significant, the inpatient mortality rate during the index hospitalization appeared to be lower in the TIPS group when compared to the EVB group (4.2% vs 10.08%, respectively). Patients who underwent TIPS were hospitalized three days longer than patients who underwent EVB only. Conclusion TIPS does not reduce all-cause 30-day readmission rates but is associated with reduced 30-day readmission rates secondary to recurrent esophageal variceal bleeding. TIPS shows a modest survival advantage during index hospitalization when compared to EVB only.
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Affiliation(s)
- Muhammad Shafiq
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | | | - Shahryar Khan
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
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Gangwani MK, Ahmed Z, Ishtiaq R, Aziz M, Rani A, Dahiya DS, Priyanka F, Arif SF, Lee-Smith W, Sohail AH, Inamdar S, Hassan M. Hepatic encephalopathy with proton pump inhibitor use in post tips patients: a systematic review and meta-analysis. Minerva Gastroenterol (Torino) 2024; 70:353-358. [PMID: 37889110 DOI: 10.23736/s2724-5985.23.03422-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Hepatic encephalopathy (HE) after Trans-jugular intrahepatic portosystemic shunt (TIPS) is a common clinical problem. According to recent studies, Proton pump inhibitor (PPI) use can serve as an independent risk factor for HE. We performed a systematic review and meta-analysis to analyze the association between HE with PPI use versus without PPI use in patients undergoing TIPS. EVIDENCE ACQUISITION We conducted a comprehensive literature search from inception through February 15th, 2022 on MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science databases. Odds ratio (OR) was calculated when comparing dichotomous variables of patients with HE vs. no HE in PPI use versus no PPI use in post TIPS patients. A 95% confidence interval (CI) and P values (<0.05 considered significant) were also generated. EVIDENCE SYNTHESIS The search strategy yielded a total of 27 articles. We finalized four studies with a total of 825 patients. There was statistically significant difference in TIPS patients with HE in PPI users versus non-PPI users (OR 3.39 [1.79-6.43], P<0.01, I2=55.5%). Pooled mean average days to hospitalization was 215.2 days to hospitalization for hepatic encephalopathy in non-PPI users compared to 139.5 days in PPI users. CONCLUSIONS Our study determines that there is a higher risk of post-TIPS HE in patients on PPI therapy vs. patients not receiving PPI therapy. We recommend using PPIs at a lower tolerable dose where necessary. Larger studies are needed to draw stronger conclusions.
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Affiliation(s)
- Manesh K Gangwani
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA -
| | - Zohaib Ahmed
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Rizwan Ishtiaq
- Department of Medicine, St. Francis Hospital, Hartford, CT, USA
| | - Muhammad Aziz
- Department of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Anooja Rani
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Dushyant S Dahiya
- Department of Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Fnu Priyanka
- Division of Medicine, Shaheed Mohtarma Benazir Bhutto University, Larkana, Pakistan
| | - Syeda F Arif
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Wade Lee-Smith
- Department of Medicine, Alleghany General Hospital, Pittsburgh, PA, USA
| | - Amir H Sohail
- University of Toledo Libraries, University of Toledo, Toledo, OH, USA
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mona Hassan
- Department of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH, USA
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Hu XG, Yang XX, Lu J, Li G, Dai JJ, Wang JM, Deng Y, Feng R. Correlation between serum markers and transjugular intrahepatic portosystemic shunt prognosis in patients with cirrhotic ascites. World J Gastrointest Surg 2024; 16:481-490. [PMID: 38463353 PMCID: PMC10921209 DOI: 10.4240/wjgs.v16.i2.481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/30/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Individuals with refractory ascites in the context of liver cirrhosis typically face an adverse prognosis. The transjugular intrahepatic portosystemic shunt (TIPS) is an efficacious intervention, but there is a lack of reliable tools for postoperative prognosis assessment. Previously utilized clinical biochemical markers, such as the serum albumin concentration (Alb), sodium (Na+) concentration, and serum creatinine (Scr), have limited predictive value. Therefore, the quest for novel, specific biomarkers to evaluate the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites holds significant practical importance. AIM To investigate the associations between the Child-Pugh score, model for end-stage liver disease (MELD) score, and serum cystatin C (Cys C) level and post-TIPS prognosis in patients with liver cirrhosis and refractory ascites. METHODS A retrospective analysis was conducted on 75 patients with liver cirrhosis and refractory ascites who underwent TIPS at our institution from August 2019 to August 2021. These patients were followed up regularly for two years, and the death toll was meticulously documented. The patients were allocated into a survival group (n = 45 patients) or a deceased group (n = 30 patients) based on their prognosis status. The clinical data of the two groups were collected, and Child-Pugh scores and MELD scores were calculated for analysis. Spearman correlation analysis was carried out to evaluate the correlation of prognosis with Child-Pugh grade, MELD score, and Cys C level. Additionally, a multiple-factor analysis utilizing the Cox proportional hazard model was used to identify independent risk factors affecting the post-TIPS prognosis of patients with liver cirrhosis and refractory ascites. The receiver operating characteristic curve (ROC) ascertained the predictive value of the Cys C concentration, Child-Pugh grade, and MELD score for the prognosis of liver cirrhosis with refractory ascites in post-TIPS patients. RESULTS During a 2-year follow-up period, among 75 patients with liver cirrhosis and refractory ascites who underwent TIPS treatment, 30 patients (40.00%) passed away. The deceased cohort exhibited heightened aspartate aminotransferase, alanine aminotransferase, total bilirubin, Scr, prothrombin time, Cys C, international normalized ratio, Child-Pugh, and MELD scores compared to those of the survival cohort, while Alb and Na+ levels were attenuated in the deceased group (P < 0.05). Spearman analysis revealed moderate to high positive correlations between prognosis and Child-Pugh score, MELD score, and Cys C level (r = 0.709, 0.749, 0.671, P < 0.05). Multivariate analysis using the Cox proportional hazard model demonstrated that the independent risk factors for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites were Cys C (HR = 3.802; 95%CI: 1.313-11.015), Child-Pugh (HR = 3.030; 95%CI: 1.858-4.943), and MELD (HR = 1.222; 95%CI: 1.073-1.393) scores. ROC analysis confirmed that, compared to those of the classic prognostic models for Child-Pugh and MELD scores, the predictive accuracy of Cys C for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites was slightly lower. This analysis yielded sensitivity and specificity values of 83.33% and 82.22%, respectively. The area under the curve value at this juncture was 0.883, with an optimal cutoff value set at 1.95 mg/L. CONCLUSION Monitoring the serum Cys C concentration is valuable for assessing the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites. Predictive models based on serum Cys C levels, as opposed to Scr levels, are more beneficial for evaluating the condition and prognosis of patients with ascites due to cirrhosis.
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Affiliation(s)
- Xiao-Gang Hu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Xiao-Xian Yang
- Medical College, Jinhua Polytechnic, Jinhua 321017, Zhejiang Province, China
| | - Jun Lu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Gang Li
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jian-Ji Dai
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jia-Min Wang
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Yi Deng
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Rui Feng
- Department of Interventional Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
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Friis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med 2023; 13:14. [PMID: 38202028 PMCID: PMC10779844 DOI: 10.3390/jcm13010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.
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Affiliation(s)
- Karina Holm Friis
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Sara Montagnese
- Department of Medicine, University of Padova, 35122 Padova, Italy
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
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Ahmed M, Islam M, Gogokhia L, Borz-Baba C, Wakefield D, Jakab SS. Hospital Utilization for Patients With Cirrhosis and Severe Ascites in a Model of Outpatient Paracentesis by Interventional Radiology. Cureus 2023; 15:e51397. [PMID: 38292997 PMCID: PMC10826452 DOI: 10.7759/cureus.51397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, there is usually no evaluation of patients' renal function or adjustment of their medications at the time of paracentesis. The objectives of this study were to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care. METHODS This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR between October 15, 2015, and October 15, 2018, at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracentesis dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post index paracentesis. Associations between categorical predictors and clinical outcomes were analyzed using the chi-square test. Associations between quantitative predictors and clinical outcomes were analyzed using the Wilcoxon rank sum test. RESULTS Our study included 69 unique patients who had at least one outpatient encounter for paracentesis by IR in the study period. Most patients were men (71%), had alcohol-related cirrhosis as primary etiology (53.6%), an average age of 60 years, and an average Model for End-Stage Liver Disease-sodium (MELDNa) score at baseline of 16. Within six months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient), 43 patients (62.3%) had ER visits (total 118 ER visits, 2.8/patient), 41 patients (59.4%) had hospital admissions (total 88 admissions, 2.2/patient), and 11 patients required ICU admission. Complications of cirrhosis noted during follow-up included hepatic encephalopathy (40.5%), acute kidney injury (38.2%), upper gastrointestinal (UGI) bleeding (16%), and spontaneous bacterial peritonitis (SBP) in 15%. The mortality rate at six months was 20%. On multivariate analysis, the predictive factors for mortality were older age (p = 0.03) and MELDNa score (p = 0.02). Baseline MELDNa was predictive of acute kidney injury (p = 0.02), UGI bleed (p < 0.01), and ICU admission (p < 0.01), but not of SBP, encephalopathy, ED visit, or hospital admissions. Among patients with more than one paracentesis (64%),six patients underwent transjugular portosystemic shunt (TIPS), but there was no documentation of TIPS consideration in 31 patients (70.4%). A total of 20 patients (29%) were waitlisted for liver transplantation. CONCLUSION In this contemporary cohort of patients with cirrhosis undergoing outpatient IR paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data are needed to identify specific gaps in care, but IR paracentesis should be integrated within a multidisciplinary management model, with emphasis on early TIPS in eligible patients, as recommended by the current practice guidelines.
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Affiliation(s)
- Mustajab Ahmed
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Masuma Islam
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Lasha Gogokhia
- Gastroenterology and Hepatology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, USA
| | | | - Dorothy Wakefield
- Statistics, Department of Research, Saint Francis Hospital & Medical Center, Hartford, USA
| | - Sofia S Jakab
- Gastroenterology and Hepatology, Yale School of Medicine, New Haven, USA
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Luo SH, Zhou MM, Cai MJ, Han SL, Zhang XQ, Chu JG. Reduction of portosystemic gradient during transjugular intrahepatic portosystemic shunt achieves good outcome and reduces complications. World J Gastroenterol 2023; 29:2336-2348. [PMID: 37124886 PMCID: PMC10134416 DOI: 10.3748/wjg.v29.i15.2336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/15/2023] [Accepted: 03/23/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is placed important role in the therapy of complications of portal hypertension, there is still no suitable criterion for a reduction in portosystemic gradient (PSG), which can both reduce PSG and maximize clinical results and minimize hepatic encephalopathy (HE).
AIM To compare the clinical outcomes and incidence of HE after one-third PSG reduction during TIPS in patients with variceal bleeding and refractory ascites.
METHODS A total of 1280 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2016 to January 2019 were analyzed retrospectively. Patients were divided into group A (variceal hemorrhage and PSG reduced by one third, n = 479); group B (variceal hemorrhage and PSG reduced to < 12 mmHg, n = 412); group C (refractory ascites and PSG reduced by one third, n = 217); and group D (refractory ascites and PSG reduced to < 12 mmHg of PSG, plus medication, n = 172). The clinical outcomes were analyzed.
RESULTS By the endpoint of follow-up, recurrent bleeding was no different between groups A and B (χ2 = 7.062, P = 0.374), but recurrent ascites did differ significantly between groups C and D (χ2 = 14.493, P = 0.006). The probability of total hepatic impairment within 3 years was significantly different between groups A and B (χ2 = 11.352, P = 0.005) and groups C and D (χ2 = 13.758, P = 0.002). The total incidence of HE differed significantly between groups A and B (χ2 = 7.932, P = 0.016), groups C and D (χ2 = 13.637, P = 0.007). There were no differences of survival rate between groups A and B (χ2 = 3.376, P = 0.369, log-rank test), but did differ significantly between groups C and D (χ2 = 13.582, P = 0.014, log-rank test).
CONCLUSION The PSG reduction by one third may reduce the risk of HE, hepatic function damage and achieve good clinical results.
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Affiliation(s)
- Shi-Hua Luo
- Department of Interventional Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Mi-Mi Zhou
- Department of Interventional Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Ming-Jin Cai
- Department of Interventional Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Shao-Lei Han
- Department of Liver Disease, Jinan Infectious Disease Hospital, Shandong University School of Medicine, Jinan 250021, Shandong Province, China
| | - Xue-Qiang Zhang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Jian-Guo Chu
- Department of Gastroenterology, Air Force Medical Center of PLA, Beijing 100142, China
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Right vs left portal branch puncture in TIPS creation with controlled expansion covered stent: comparison of hemodynamic and clinical outcomes. Eur Radiol 2023; 33:2647-2654. [PMID: 36454260 DOI: 10.1007/s00330-022-09280-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE To retrospectively compare outcomes of TIPS performed by puncturing left portal vein (LPV) vs right portal vein (RPV) to access the portal system. MATERIALS AND METHODS One hundred ninety-three consecutive patients underwent TIPS with controlled expansion covered stent by using the LPV (37 patients) or the RPV (156 patients). Patients were followed until the last clinical evaluation, liver transplantation, or death. RESULTS Demographics and clinical characteristics of the two groups were comparable. The median follow-up was 9.6 months (range 0.1-50.6). Portosystemic pressure gradient (PSG) before TIPS 15.7 mmHg ± 4.7 in RPV group (RPVG) vs 15.4 mmHg ± 4.5 in LPV group (LPVG) (p = 0.725). After TIPS, PSG 6.3 mmHg ± 2.8 in RPVG vs 6.2 mmHg ± 2.2 (p = 0.839). In LPVG, the stent was dilated to 8-mm in 95% of patients vs 77% of RPVG (p = 0.015). Two (5.4%) and 22 (14%) patients underwent TIPS revision in LPVG and RPVG (p = 0.15). The incidence of overt HE was 13% in LPVG and 24% in RPVG (p = 0.177). Rebleeding occurred in 3 of 49 patients (6%) with variceal bleeding as an indication: 2/41 patients (4.9%) in RPVG vs 1/8 patients (12.5%) in LPVG (p = 0.417). Among 126 patients with refractory ascites 20 patients (15.9%) needed paracentesis 3 months after the procedure: 18/101 patients (17.8%) in RPVG vs 2/25 patients (8%) in LPVG (p = 0.231). Thirty-seven patients (19%) died: 32 (21%) in RPVG and 5 (14%) in LPVG (p = 0.337). CONCLUSION Compared with RPV puncture, in TIPS created through the LPV, the targeted PSG was reached with a smaller stent diameter. However, no significant difference in clinical outcomes was observed. KEY POINTS • A LPV approach for TIPS creation does not lead to better control of complications of portal hypertension as compared to a RPV approach.
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Cannella R, Tselikas L, Douane F, Cauchy F, Rautou PE, Duran R, Ronot M. Imaging-guided interventions modulating portal venous flow: evidence and controversies. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100484. [PMID: 35677591 PMCID: PMC9168703 DOI: 10.1016/j.jhepr.2022.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/07/2022]
Abstract
Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.
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