Extrahepatic portosystemic shunts (EPS) are abnormal connections between the portal and systemic circulations. Acquired EPS occur most commonly in adults and are usually associated with portal hypertension due to cirrhosis. Acquired EPS cases can be further subdivided into two types: variceal (pre-existing) EPS and non-variceal EPS (NVEPS). Variceal EPS arise from originally small vessels with pre-existing dual portal and systemic drainage. Due to elevated portal pressure, these vessels dilate and undergo a reversal of flow, sending blood back to the systemic circulation. A much less common and, therefore, underappreciated subset of acquired EPS is NVEPS, which consists of aberrant connections that did not previously exist between the portal vein and large systemic vessels, usually in the presence of portal hypertension. Neoangiogenesis results in the development of abnormal anastomoses between the portal vein and other large veins, resulting in splenorenal, gastrorenal, portocaval, and mesocaval shunts. While not uncommon, they are frequently overlooked in the diagnosis and treatment of portal hypertension and can pose significant diagnostic and therapeutic challenges. Because the treatment of variceal EPS and NVEPS can differ markedly, it is important to correctly diagnose NVEPS and institute appropriate management. The aim of this article was to review acquired EPS, with particular attention to NVEPS, updating the pathogenesis, diagnosis, and treatment.

Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.

A woman in her sixties with portosystemic shunt and hepatic encephalopathy underwent open mesenteric vein ligation, resulting in improved portal flow and blood ammonia. In this case, 4D flow MRI was a valuable diagnostic and follow-up tool, visualizing and quantifying physiological portal hemodynamics with features distinct from those of contrast-enhanced CT and digital subtraction angiography. Our case study highlights the value of 4D flow MRI for managing portosystemic shunts.

This study addresses the effects of shunt embolization on the recurrence of hepatic encephalopathy (HE) in patients with major portosystemic shunts. MEDLINE via PubMed, Google Scholar, and Scopus was searched to find the relevant full-text articles published from inception until August 2024. The primary outcome was the degree of HE or mental state change determined by the West-Heaven classification system. Dichotomous data were compared using odds ratios (OR). 95% confidence (CI) intervals were provided for each outcome in the report. The random-effects model was used to analyze the data. Trim and fill, Egger's regression and funnel plot were employed to evaluate publication bias in this body of literature. A total of 7 articles and 254 patients were included in the present meta-analysis. It was found that shunt embolization significantly reduced the recurrence of HE in patients with portosystemic shunts due to liver cirrhosis. Overall analysis showed that the pooled OR was 0.253 and the overall heterogeneity of the data was substantial (95% CI: 0.117-0.550, I 2=60.52% and P=0.001). The funnel plot was reasonably symmetrical and no study was trimmed to either side of the mean. Begg's (P=0.229) and Egger's tests (P=0.273) showed no significant risk of publication bias. Quality assessment showed that the majority of the included studies were of low quality. In conclusion, the present meta-analysis indicates that shunt embolization after portosystemic shunt significantly reduces the recurrence of HE in patients with liver cirrhosis. However, the findings should be interpreted with caution due to the low quality and low number of the included studies. Future research should prioritize higher-quality trials to validate these results and explore long-term outcomes.

To compare the long-term efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with concurrent antegrade embolization in treating portal hypertension with oesophagogastric variceal bleeding in patients with and without large spontaneous portosystemic shunts (L-SPSSs).

We retrospectively analysed data from patients with portal hypertension who underwent TIPS from November 2015 to April 2022. The patients were screened according to the inclusion criteria and were divided into L-SPSSs group (L-S group) and Non L-SPSSs group (Non L-S group). The primary outcome was the 2-year liver transplantation-free survival (TFS) rate. Secondary outcomes contained the incidence of overt hepatic encephalopathy (OHE), ectopic embolization and the 2-year rebleeding rate.

A total of 259 patients were enrolled (64 patients in L-S group and 195 patients in Non L-S group). The average age was 57.2 years, and the success rate of procedure was 100%. Baseline data showed no significant differences between two groups. There was a statistically significant difference in the 2-year liver transplantation-free rate between two groups (L-S vs. Non L-S, 84.38% vs. 71.28%; p = 0.045). OHE occurred in 19 (29.69%) patients with L-SPSSs and 104 (53.33%) patients without L-SPSSs, with a statistically significant difference (p = 0.001). And no statistically significant difference was found in ectopic embolism incidence rate and the 2-year rebleeding rate between two groups. Multivariate Cox regression analysis identified male gender, portal vein thrombosis and preoperative high blood ammonia levels as independent risk factors for long-term survival.

Compared to Non L-S group, the patients in L-S group achieve longer liver transplantation-free survival and lower incidence rate of OHE without increasing the risk of 2-year rebleeding and ectopic embolization.

Acute-on-chronic liver failure (ACLF) is a specific, but complex and multifactorial form of acute decompensation (AD) of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure and high short-term mortality. In daily clinical practice, patients with liver cirrhosis and decompensation have indications for different medical procedures such as endoscopies, interventional treatments like transjugular intrahepatic portosystemic shunt (TIPS) or even surgical procedures. In these situations, clinicians often need to balance the expected benefits of such procedures with the risks of causing acute decompensation or ACLF. This review summarizes the evidence of medical procedures and their role in precipitating or preventing ACLF and highlights the aspects to consider during patient selection.

We report the case of a 70-year-old woman with advanced hepatic encephalopathy (HE) secondary to metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis who exhibited an excellent response to portosystemic shunt embolization. Four years earlier, she was diagnosed as having MASH-related cirrhosis accompanied by multiple mesenteric vein-inferior vena cava shunts. As her condition progressed, she suffered recurrent HE that was unresponsive to oral medication, prompting the decision to proceed with shunt embolization. The procedure was successful, with no ensuing HE recurrence. At the 1-year follow-up, she remained free from refractory ascites, and no new shunts were detected. Remarkably, her liver function and glucose metabolism also showed significant improvement after the embolization. This case demonstrates that shunt embolization may be an effective treatment option for refractory HE associated with cirrhosis not only in terms of encephalopathy, but also for ameliorating hepatic function and glycemic control.

Hepatic encephalopathy (HE) is traditionally associated with hepatic parenchymal diseases, such as acute liver failure and cirrhosis. Its prevalence in non-cirrhotic portal hypertension (NCPH) patients, extrahepatic portal vein obstruction (EHPVO), and non-cirrhotic portal fibrosis (NCPF) is less well described. HE in NCPH allows one to study the effect of portosystemic shunting and ammonia without significant hepatic parenchymal injury. The current review narrates the spectrum and management of hepatic encephalopathy in NCPH patients. We synthesized data from various studies on the occurrence and management of HE in NCPH, mainly EHPVO, idiopathic non-cirrhotic portal hypertension (INCPH), and porto-sinusoidal vascular disease (PSVD). The prevalence of minimal hepatic encephalopathy (MHE) in NCPH is reported from 12 to 60%, depending on the condition and diagnostic criteria. MHE was reported in nearly a third of EHPVO patients. Studies show that venous ammonia levels are significantly elevated in patients with MHE and spontaneous shunts (82.4 ± 20.3 vs. 47.1 ± 16.7 µmol/L, P = 0.001). Large portosystemic shunts substantially increase the risk of HE, with 46-71% of patients with persistent or recurrent HE having identifiable shunts. Management of HE in NCPH primarily focuses on reducing ammonia levels through lactulose, which has shown improvement in 53% of patients with MHE after three months (P = 0.001). Shunt occlusion in patients with large portosystemic shunts is helpful in selected cases. HE in NCPH, particularly in EHPVO, is associated with elevated ammonia levels and spontaneous shunts. Despite the high prevalence of HE in NCPH, this is still a neglected aspect in the care of NCPH. A high index of suspicion and the application of appropriate screening tools are crucial for timely diagnosis and management. HE screening tools that are well-studied in cirrhosis, are also valid in NCPH. Effective management strategies include lactulose, rifaximin, dietary modifications, and shunt embolisation in some cases. Future research should focus on the long-term natural history and efficacy of treatment strategies in this population.

Acute decompensation in cirrhotic patients signifies the onset of clinically evident events due to portal hypertension. The transition from compensated to decompensated cirrhosis involves hemodynamic changes leading to multiorgan dysfunction, managed predominantly in outpatient settings with regular monitoring. The mortality risk is elevated in decompensated patients. Therefore, diligent outpatient management should focus on regular medical follow-ups, medication adjustments, patient education, addressing emergent issues and evaluation for liver transplantation. The ultimate goal is to improve quality of life, prevent disease progression, reduce complications, and assess possible recompensation. This guide provides valuable recommendations for medical experts managing decompensated cirrhotic patients post-hospitalization.

Patients undergoing solid-organ transplantation (SOT) face a tumultuous journey. Prior to transplant, their medical course is characterized by organ dysfunction, diminished quality of life, and reliance on organ support, all of which are endured in hopes of reaching the haven of organ transplantation. Peritransplant altered mental status may indicate neurologic insults acquired during transplant and may have long-lasting consequences. Even years after transplant, these patients are at heightened risk for neurologic dysfunction from a myriad of metabolic, toxic, and infectious causes. This review provides a comprehensive examination of causes, diagnostic approaches, neuroimaging findings, and management strategies for altered mental status in SOT recipients. Given their complexity and the numerous etiologies for neurologic dysfunction, liver transplant patients are a chief focus in this review; however, we also review lesser-known contributors to neurological injury across various transplant types. From hepatic encephalopathy to cerebral edema, seizures, and infections, this review highlights the importance of recognizing and managing pre- and posttransplant neurological complications to optimize patient outcomes.

Hepatic encephalopathy (HE) is a common condition in patients with cirrhosis, representing the second most frequent cause of decompensation. Approximately 30-40% of patients with cirrhosis will experience overt HE during the clinical course of their illness. In most cases, it is possible to identify a precipitating or risk factor for HE. These are distinct concepts that play different roles in the development of this condition. While precipitating factors act acutely, risk factors are generally present over an extended period and contribute to the overall likelihood of developing HE. The two types of factors require different approaches, with risk factors being more susceptible to prevention. The aim of this review is to describe the most important risk factors (such as severity of liver disease, previous episode of HE, minimal/covert HE, spontaneous and iatrogenic shunt, malnutrition, chronic therapies, metabolic diseases) for the development of HE and how to prevent it.

To assess the technical and clinical outcomes of percutaneous embolization for high-flow mesenteric vein to gonadal vein (MGV) portosystemic shunts.

In this HIPPA-compliant, review board-approved study, patients who underwent embolization of MGV shunts between 2011 and 2023 were included. Patient demographic data, embolization technique, clinical outcomes, and complications were retrieved from the electronic health records. Technical success was defined as complete occlusion of the shunt on follow-up imaging. Clinical outcomes assessed were resolution/improvement of hepatic encephalopathy, improvement in liver function, changes to liver volumes, and occurrence of adverse events.

Eight patients (mean age 59.5, 75% female) with nine MGV shunts were included. The indications for shunt embolization included medically refractory hepatic encephalopathy, bleeding duodenal varices, and transplant liver dysfunction. The mean maximum shunt diameter was 23.3 mm. Embolization was most commonly performed with a combination of coils and N-butyl cyanoacrylate or vascular plugs. Complete MGV shunt thrombosis was achieved in 7/9 shunts post-embolization, and symptom improvement was noted in 7/8 patients. Child-Pugh scores improved post-embolization in 6/9 patients by a median of 3 points. Liver volumes also increased by a mean of 20.8 ± 17.7% post-embolization. Minor adverse events included new onset ascites, partial mesenteric/portal vein thrombosis, and new gastroesophageal varices without bleeding in four patients.

Embolization of MGV shunts is technically feasible and effective for treatment of hepatic encephalopathy and increasing hepatopetal portal perfusion. There was an improvement in Child-Pugh scores and an increase in liver volumes in the majority of patients post-embolization.

The objective of this study was to evaluate esophageal varices (EVs) as predictors of poor prognosis with low tolerability after balloon-occluded retrograde transvenous obliteration (BRTO) in patients with overt hepatic encephalopathy (HE).

This study retrospectively enrolled 107 patients who underwent BRTO for uncontrollable overt HE. The enrolled patients were divided into two groups based on the presence of EVs using propensity matching. The present study assessed the technical success rate and safety of BRTO in both the groups. Further, the event-free survival, HE-free survival, and the overall survival (OS) were compared between the two groups. Event-free survival was defined as the time period during which the patients did not developed complications related to portal hypertension, including EVs, hepatic ascites, and portal vein thrombosis.

After propensity matching, the EV and non-EV groups had 37 and 36 patients, respectively. Only 1 patient experienced an unsuccessful procedure in the EV group. Procedure-related adverse events in the EV group and non-EV group occurred in 11 and 7 patients, respectively (p = 0.417). The event-free survival after BRTO in the EV and non-EV group were 1,283 (95% CI: 798-1,767) days and 2,257 (1,722-2,792) days, respectively. Event-free survival was significantly worse in the EV group than in the non-EV group (p = 0.014). Furthermore, the EV group experienced worse OS than the non-EV group (p = 0.001 and p < 0.001, respectively).

The presence of EVs could potentially be associated with a higher risk of adverse outcomes or mortality after BRTO treatment in individuals with HE.

Hepatic encephalopathy is described by a broad spectrum of neurological and psychiatric aberrations resulting due to advanced liver dysfunction. It is a neurological disorder due to hepatic insufficiency and/or portosystemic shunts. Its clinical presentation includes neuropsychiatric dysfunction ranging from subclinical changes to comatose state. It is a sign of poor prognosis in cirrhotics with a high 1-year mortality. Each episode of hepatic encephalopathy leads to high hospitalization rate, poor prognosis and raised burden of healthcare. Primary prophylaxis is prevention of initial occurrence and secondary prophylaxis is prevention of reappearance of hepatic encephalopathy in subjects who had prior history. Early detection and management of triggers is very important in the treatment of hepatic encephalopathy. The initial choice of treatment is still lactulose, as it is effective in minimal, overt, and recurrent hepatic encephalopathy. Rifaximin is equally effective as lactulose in managing hepatic encephalopathy and is better tolerated. Branch chain amino acids are beneficial in subjects who are protein intolerant. L-ornithine L-aspartate and probiotics are also useful in the management of hepatic encephalopathy. Rifaximin along with lactulose is effective in managing overt and recurrent hepatic encephalopathy. Large portosystemic shunts embolization and liver transplant is efficacious in certain group of patients. Nutritional therapy and fecal microbiota transplantation are newer therapies for hepatic encephalopathy but the evidences are limited, more research is required to prove their efficacy. Involvement of hospital pharmacists, telemedicine, and providing education are also beneficial in managing hepatic encephalopathy.

Decompensated-cirrhosis encompasses several stages with different prognosis, such as bleeding, ascites and bleeding-plus-ascites. Development of further-decompensation worsens survival, while non-selective β-blockers (NSBBs) can modify the risk. However, how this applies to each stage is uncertain. We aimed to investigate, in each stage of decompensated-cirrhosis, the influence of further-decompensation on mortality and whether changes in portal-pressure (HVPG) under NSBBs influence these outcomes.

Patients with variceal bleeding were consecutively included differentiating those with bleeding-alone from those who also had ascites. Patients with ascites and high-risk varices referred for primary-prophylaxis were also investigated. A baseline haemodynamic study was performed and was repeated after 1-3-months under NSBBs. Outcomes were investigated by competing-risk.

Totally 103 patients had bleeding-alone, 186 bleeding-plus-ascites and 187 ascites-alone. Mean follow-up was 32-months (IQR, 12-60). Patients with bleeding-plus-ascites had higher HVPG and were more hyperdynamic than patients with ascites-alone and these than those with bleeding-alone. At each stage, the mortality risk was more than twice in patients developing further-decompensation vs. those without (p < .001). In each stage, HVPG-decrease under NSBBs showed better discrimination to predict further-decompensation than the baseline MELD, Child-Pugh or HVPG, by time-dependent ROC-curves (c-statistic >70%). At each stage, patients without HVPG-decreases, either ≥10% or ≥20% from the baseline, had higher risk of further-decompensation (sHR from 2.43 to 6.73, p < .01) and worse survival.

In each stage of decompensated cirrhosis, mortality risk significantly and very markedly increase with further-decompensation. HVPG-non-response to NSBBs may adequately stratify the risk of further decompensation and death, in each stage. This suggests potential benefit with pre-emptive therapies in HVPG-non-responders at each-stage.

Portal hypertension has cerebral consequences via its causes and complications, namely hepatic encephalopathy (HE), a common and devastating brain disturbance caused by liver insufficiency and portosystemic shunting. The pathogenesis involves hyperammonemia and systemic inflammation. Symptoms are disturbed personality and reduced attention. HE is minimal or grades I to IV (coma). Bouts of HE are episodic and often recurrent. Initial treatment is of events that precipitated the episode and exclusion of nonhepatic causes. Specific anti-HE treatment is lactulose. By recurrence, rifaximin is add-on. Anti-HE treatment is efficacious also for prophylaxis, but emergence of HE marks advanced liver disease and a dismal prognosis.

The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.

This study aimed to assess the safety and efficacy of interventional embolization in cirrhotic patients with refractory hepatic encephalopathy (HE) associated with large spontaneous portosystemic shunts (SPSS). Inverse probability of treatment weighting (IPTW) was employed to minimize potential bias. A total of 123 patients were included in this study (34 in the embolization group and 89 in the control group). In the unadjusted cohort, the embolization group demonstrated significantly better liver function, a larger total area of SPSS, and a higher percentage of patients with serum ammonia levels > 60 µmol/L and the presence of hepatocellular carcinoma (HCC) (all P < 0.05). In the IPTW cohort, baseline characteristics were comparable between the two groups (all P > 0.05). Patients in the embolization group exhibited significantly longer HE-free survival compared to the control group in both the unadjusted and IPTW cohorts (both P < 0.05). Subsequent subgroup analyses indicated that patients with serum ammonia level > 60 μmol/L, hepatopetal flow within the portal trunk, the presence of solitary SPSS, a baseline HE grade of II, and the absence of HCC at baseline showed statistically significant benefit from embolization treatment (all P < 0.05). No early procedural complications were observed in the embolization group. The incidence of long-term postoperative complications was comparable to that in the control group (all P > 0.05). Hence, interventional embolization appears to be a safe and effective treatment modality for cirrhotic patients with refractory HE associated with large SPSS. However, the benefits of embolization were discernible only in a specific subset of patients.

Overt hepatic encephalopathy remains a serious complication after TIPS. Concomitant SPSS is associated with an increased risk of HE in patients treated with TIPS.

To perform a systematic review and meta-analysis on the effectiveness and safety of the prophylactic embolization of SPSS at the time of TIPS creation.

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched up to April 2023 to identify studies on the association between antegrade embolized SPSS before TIPS placement and the incidence of post-TIPS HE. Odds ratios (ORs) and their corresponding 95% CIs were used to identify significant differences in the outcomes.

Four studies enrolling 1243 patients with cirrhosis who received TIPS for variceal bleeding were included. A meta-analysis revealed that TIPS without simultaneous SPSS embolization was associated with an increased risk of overt HE (OR 2.41, 95% CI 1.32-4.38; p = 0.004). The risks of mortality (0.79, 95% CI 0.58-1.07; p = 0.13), variceal rebleeding (0.94, 95% CI 0.66-1.34; p = 0.74) and shunt dysfunction (1.40, 95% CI 0.51-3.83; p = 0.51) did not significantly differ among the groups.

SPSS prevalence was associated with an increased risk of overt HE after TIPS. Concurrent antegrade SPSS embolization during TIPS creation reduced the risk for overt HE without increasing other complications.

Hepatic encephalopathy, either covert or overt, affects more than half of patients with cirrhosis and has lasting effects even after portal hypertension is corrected. Unfortunately, the current therapeutic options still result in high rates of relapse and progression, in part owing to cost barriers and side effects, leading to poor adherence. This review summarizes emerging treatment options, which could take advantage of alternative disease pathways to improve future care of those with hepatic encephalopathy.

Hepatic encephalopathy (HE) is a clinically severe and devastating complication of decompensated liver disease affecting mortality, quality of life for patients and families, hospital admission rates, and overall health-care costs globally. Depending on the cause of HE, several medical treatment options have been developed and become available. In some refractory HE, such as spontaneous portosystemic shunt-related HE (SPSS-HE) or posttransjugular intrahepatic portosystemic shunt HE (post-TIPS HE), advanced interventional radiology (IR) procedures have been used, and shown to be effective in these conditions. This review presents 2 effective IR procedures for managing SPSS-HE and post-TIPS HE.

Hepatic encephalopathy (HE) is a debilitating complication associated with both acute and chronic liver injury. It is associated with a greater risk of death than any other significant hepatic decompensation event. It manifests as a wide spectrum of neuropsychological abnormalities ranging from subtle impairments in higher cognitive function, to confusion and coma. The pathophysiological role of ammonia in the development of HE is well known, but there is increasing recognition that the gut microbiome, gut-derived systemic inflammation and development of infection can serve as drivers of HE in patients with cirrhosis. The development of HE portents to the severity of cirrhosis and the prognosis is poor without liver transplantation. A referral for liver transplantation should therefore be considered early in those who are eligible. This review covers the pragmatic assessment of HE in patients with cirrhosis, as well as the current evidence base for the best practice management of HE in such patients.

This retrospective case series assessed the early effectiveness of combined spontaneous portosystemic shunt (SPSS) embolization and preemptive transjugular intrahepatic portosystemic shunt (TIPS) creation for alleviation of medically refractory hepatic encephalopathy (HE) and prevention of portal hypertension complications in patients with liver cirrhosis. Eight patients with liver cirrhosis (5 men and 3 women; mean age, 61 years [SD ± 10]) and HE (overt [West-Haven Grade 2-4], n = 7; covert [West-Haven Grade 1], n = 1) refractory to lactulose and rifaximin therapy who underwent concurrent or staged SPSS embolization and TIPS creation between 2018 and 2022 were included in this study. The primary outcomes were 3-month improvement in HE and postprocedural HE-related hospitalizations. HE improvement was achieved in 7 (87.5%) of 8 cases. Among all patients, there was 1 HE-related hospitalization within 90 days that responded to repeat embolization with no further admissions. No patients developed new ascites, variceal hemorrhage, or other portal hypertension complications within 3 months.

Hepatic encephalopathy (HE) usually occurs in the end stages of cirrhosis. During these stages, portosystemic shunt (PSS) is one cause of severe HE. Previous reports have demonstrated that shunt embolization is effective in cases involving a large PSS. However, embolization is risky in some patients because severe ascites and esophageal varices may result from aggravation of portal hypertension. Herein, we report a case in which intentional flow reduction was repeatedly performed for spleno-renal shunt using 2 flow reduction methods, debranching and the rough coiling technique, for a patient with severe HE for whom embolization of the whole PSS pathway was risky. Complete embolization was finally achieved by repeated flow reduction over 5 sessions. The patient tolerated treatment well with no ascites for 4 years after total embolization. If embolization of the whole PSS puts the patient at risk for refractory HE, repeatable flow reduction might provide a good alternative path to single-step embolization.

Hepatic encephalopathy (HE) is a common complication of advanced liver disease and acute liver failure. It is a condition that features several neuropsychiatric symptoms that affect mortality, morbidity and the quality of patients' and caregivers' lives. An HE diagnosis is generally an exclusion diagnosis. Once the patient is admitted to the hospital, clinical examination, blood tests and eventually neuroimaging should be performed with the aim of ruling out other causes of acute brain dysfunction. Moreover, HE is recognized using various precipitants that can potentially promote its onset, alone or in combination, and must be identified. Once the diagnostic process is complete, a correct treatment should be started. The anti-HE treatment is based on a combination of the correction of precipitants; non-absorbable antibiotics, such as rifaximin; and non-absorbable disaccharides. Once the patient is discharged from the hospital, specific anti-HE therapy should be maintained in order to prevent other HE episodes.

Occlusion of spontaneous portosystemic shunts (SPSSs) in patients with cirrhosis may be required in recurrent or refractory hepatic encephalopathy. We describe a novel method for occlusion of SPSS using endoscopic ultrasound (EUS).

EUS-guided transgastric shunt obliteration was performed by injecting glue and coils directly into SPSS.

EUS-guided transgastric shunt obliteration was performed for 7 patients in 9 sessions. Complete cessation of Doppler flow was achieved in 6/7 cases. Adequate clinical response was observed in 6/7 patients. No procedure-related severe adverse events were seen.

This novel technique is a potentially effective and efficient method for shunt obliteration.

Spontaneous portosystemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis complications. This study was conducted to detect the prevalence of portosystemic shunts in liver cirrhosis patients and analyze its prognostic role.

We conducted a prospective observational study, where 92 patients with decompensated cirrhosis were evaluated based on history, physical examination, biochemical tests and abdominal computed tomography (CT) angiography findings. A follow-up was done after six months for the development of cirrhosis-related complications.

Of the 92 cirrhotic patients, 57.6% had SPSS (large SPSS + small SPSS) detected by multi-detector computed tomographic angiography. Overall, we found large SPSS in 24 (26.1%) patients, small SPSS in 29 (31.5%) patients and no shunt in 39 (42.4%) patients. Among the shunts, the splenorenal shunt is the most frequent type (25, 27.2%) followed by the paraumbilical shunt (20.7%). Previous decompensating events, including hepatic encephalopathy, ascites, spontaneous bacterial peritonitis and gastrointestinal bleed, were experienced more frequently by the large SPSS group followed by the small SPSS and without SPSS groups. Regarding follow-up, decompensating episodes of hepatic encephalopathy developed more frequently in patients with large SPSS (41.7%) than in patients with small SPSS (24.1%) followed by patients without SPSS (12.8%).

In summary, all cirrhotic patients should be studied with radiological imaging to detect the presence of portosystemic shunts. In several cases, patients with large SPSS had a more impaired liver function and more frequent complications of portal hypertension. So, these patients would probably benefit from a closer surveillance and more intensive therapy.

Hepatic encephalophathy (HE) is a neuropsychiatric syndrome with a prevalence in the cirrhotic population ranging from 20 to 80%. HE is a cause of inappropriate hospitalization, caregiver burdening and increased social costs. There is need to create dedicated care pathways to better manage patients and support family caregivers. The data used for the preparation of this diagnostic therapeutic assistance path (DTAP) are based on a detailed analysis of the scientific literature published before June 30, 2022 (PubMed, Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted in particular the guidelines/ position papers of International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN), Italian Association for the Study of the Liver (AISF), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), Italian Society on Alcohol (Società Italiana di Alcologia [SIA]) and other relevant papers. DTAP was created based on the most recent recommendations of the international scientific literature. The present DTAP highlight the need for a multidisciplinary activity integrated with territorial medicine in close connection with caregivers. This guarantees improved therapeutic adherence, hospital readmission reduction, improved quality of life for patients and caregivers and a significant reduction in costs.

The impact of spontaneous portosystemic shunt (SPSS) on decompensated events and mortality for patients with hepatitis B-related cirrhosis remains poorly investigated.

To evaluate the prevalence, clinical characteristics, and outcomes of SPSS among patients with hepatitis B-related cirrhosis.

Patients who were diagnosed with hepatitis B-related cirrhosis were retrospectively recruited. All eligible patients were classified into SPSS and non-SPSS groups and their clinical characteristics and outcomes were compared and analyzed.

Of the 1282 patients included in this study, SPSS was identified in 488 patients (38.1%). SPSS group had more severe liver function impairment, higher prevalence and severity of esophageal and gastric varices (EGV), and a higher prevalence of EGV bleeding (EGVB), portal vein thrombosis (PVT), hepatic encephalopathy (HE), ascites, and hepatocellular carcinoma (HCC, all P<0.05). During the follow-up period, SPSS group experienced a significantly higher incidence of EGVB, PVT, and HE (all P<0.05); however, there was no significant difference in the incidence of ascites, HCC, and mortality between the two groups (all P>0.05).

With hepatitis B-related cirrhosis, SPSS was common and characterized by severe liver damage and a high prevalence of decompensated events. Moreover, patients with SPSS had higher risks of EGVB, PVT, and HE.

Portosystemic shunt embolization (PSSE) is a promising treatment for hepatic encephalopathy (HEP) and gastric varix (GV) in cirrhotic patients with a spontaneous portosystemic shunt. However, PSSE may worsen portal hypertension causing hepatorenal syndrome, liver failure, and mortality. This study aimed to develop and validate a prognostic model that helps identify patients with a risk of poor short-term survival after PSSE.

We included 188 patients who underwent PSSE for recurrent HEP or GV at a tertiary center in Korea. To develop a prediction model for 6-month survival after PSSE, Cox proportional-hazard model was used. The developed model was validated in a separate cohort of 184 patients from two other tertiary centers.

In multivariable analysis, the 1-year overall survival after PSSE was significantly associated with baseline levels of serum albumin, total bilirubin, and international normalized ratio (INR). We therefore developed the albumin-bilirubin-INR (ABI) score by assigning 1 point each for albumin < 3.0 g/dL, total bilirubin ≥ 1.5 mg/dL, and INR ≥ 1.5. Time-dependent areas under the curve of the ABI score for predicting 3-month and 6-month survival were 0.85 and 0.85 in the development cohort and 0.83 and 0.78 in the validation cohort, indicating good discrimination performance. The ABI score showed a better discrimination and calibration performance than the model for end-stage liver disease and the Child-Pugh scores, especially in high-risk patients.

The ABI score is a simple prognostic model that helps decide whether to proceed with PSSE for the prevention of HEP or GV bleeding in patients with spontaneous portosystemic shunt.

We report a case of portosystemic encephalopathy treated by retrograde transvenous obliteration (RTO) with an antecubital vein approach using a steerable triaxial system. A 77-year-old female was referred to our department complaining of dizziness and tremor. Laboratory data showed hyperammonemia. Contrast-enhanced CT and 3D-CT reconstruction images demonstrated an inferior mesenteric vein (IMV)-left common iliac vein shunt and a splenorenal shunt. The former was treated as a responsible shunt. The spleen volume was 212 mL, and the liver volume was 757 mL; giving a spleen/liver volume ratio of 0.3. Partial splenic artery embolization (PSE) was employed to control portal venous pressure. The hepatic venous pressure gradient (HVPG) changed from 13.2 to 9.6 mm Hg and the spleen/liver volume ratio improved from 0.3 to 0.2 by PSE. Two months after PSE, RTO with an antecubital vein approach using a steerable triaxial system was performed. HVPG changed to 12.5 mm Hg after RTO. Contrast-enhanced CT and 3D-CT reconstruction images 3 days after the procedure demonstrated the thrombus in the IMV-left common iliac vein shunt. We conclude that the antecubital vein approach using a steerable triaxial system is a feasible and minimally invasive technique in RTO for portosystemic shunts.

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for treating the complications of portal hypertension in liver cirrhosis. While the pathogenesis of postoperative TIPS-related hepatic encephalopathy (HE) has yet to be fully understood, intraoperative portosystemic shunts may provide a pathological basis for the occurrence of postoperative HE in patients with liver cirrhosis. Studies at home and abroad have expressed mixed opinions about TIPS-related HE. This study presents a literature review on the risk factors for and prevention and treatment of perioperative TIPS-related HE in patients with liver cirrhosis, aiming to optimize the procedure and reduce the incidence of postoperative HE.

Hepatic encephalopathy (HE) is a frequent and severe complication of liver disease with poor patient outcomes. However, it is a poorly understood complication, with no consensus for diagnosis. Therefore, HE is often underdiagnosed. Differential diagnosis may be cumbersome because of non-specific symptoms, such as confusion, cognitive disorders, the aetiological factors of cirrhosis and comorbidities, which are often observed in cirrhotic patients. Therefore, an overt or covert form of HE should be systematically investigated. Advice is provided to drive patient work-up. Effective treatments are available to prevent or treat HE bouts, but the issue of single or combination therapy has not been resolved. Transjugular intrahepatic portosystemic shunt (TIPS) placement largely improved the prognosis of cirrhotic patients, but HE occurrence of HE is often a fear, even when post-TIPS HE can be avoided by a careful selection of patients and preventive treatment. HE is an indication of liver transplantation. However, its reversibility post-transplantation and the consequences of transplantation in patients with other causes of neurological disorders remain controversial, which supports the performance of an extensive work-up in expert centres for this subset of patients. The present guidelines assist clinicians in the diagnosis of the overt or covert form of HE to implement curative and preventive treatments and clarify which patients require referral to expert centres for consideration for liver transplantation. These guidelines are very clinically oriented and address different frequent clinical issues to help physicians make bedside decisions.

Spontaneous portosystemic shunt (SPSS) can cause refractory hepatic encephalopathy (HE) in cirrhotic patients. The embolization of the shunt (ES) can resolve the HE, while the selective embolization of the splenic vein (SESV) can treat splenorenal shunts related HE. The aim of this study was to compare the clinical outcomes of ES and SESV when applied for the treatment of SPSS-induced refractory HE in cirrhotic patients.

Patients with refractory HE who were treated with ES or SESV were retrospectively identified. The clinical outcomes were compared and analyzed.

The 6-month mortality after the ES procedure was significantly higher than that after the SESV procedure. During the 6-month follow-up, both the white blood cell and the platelet counts were significantly lower after the ES procedure than after the SESV procedure. There was a significant increase in aspartate aminotransferase levels after ES. However, the albumin levels as well as the Child-Pugh score and grade were found to be significantly improved at 6 months after the undertaking of an SESV (as compared with baseline).

The 6-month mortality was improved after SESV (as compared with ES) in the treatment of SPSS-induced refractory HE. A prospective multicenter study for validation is warranted.

Hepatic encephalopathy (HE) is a peculiar kind of brain dysfunction typical of liver cirrhosis characterized by nonspecific neurological and psychiatric manifestations. HE ranges from minimal hepatic encephalopathy (MHE) to the most severe form characterized by alteration of consciousness or coma (overt HE, OHE). Once the diagnosis of OHE is made, every effort to identify and correct the precipitating cause is essential for the resolution of symptoms. Clinical studies that assessed the prevalence and incidence of any type of HE (MHE and OHE) in patients affected by cirrhosis were included in this review. No language, publication date, or publication status restrictions were imposed. The studies were identified by searching electronic databases (PubMed and SCOPUS).

The most widely empirical pharmacological approach consists of non-absorbable antibiotics (rifaximin) and non-absorbable disaccharides (lactulose, lactitol per os and per enemas). Other agents (including branched-chain amino acids, probiotics, other antibiotics, or intravenous L-ornithine L-aspartate) are available, but the evidence supporting their efficacy remains under debate.

Gray areas and future needs remain the therapeutic approach to MHE and issues in the design of therapeutic studies for HE which have been extensively discussed in this review.

Patients with liver cirrhosis and portosystemic shunt occasionally develop reversed portal flow in the portal venous system. The factors contributing to reversed portal flow in these patients remain unclear. The aim of this study was to identify factors contributing to reversed portal flow in patients with portosystemic shunts based on four-dimensional computed tomography (4DCT), which visualized flow dynamics in the portal venous system.

Data from 34 consecutive patients with portosystemic shunts who had undergone 4DCT before interventional radiology procedures were retrospectively investigated in this study. Uni- and multivariate analyses were performed to identify factors contributing to reversed portal flow.

Flow dynamics could be visualized on 4DCT in 32 of the 34 patients. Fifteen patients had forward portal flow; 17 had reversed portal flow. The main portal, splenic, and superior mesenteric veins displayed reversed portal flow in five, 12, and five vessels, respectively. Portosystemic shunt originating from splenic and superior mesenteric veins, worse albumin-bilirubin score, and small main portal vein diameter were significant factors contributing to reversed portal flow in both univariate (p = 0.049, p = 0.027, and p = 0.002) and multivariate (odds ratio [OR] 6.345, p = 0.012; OR 4.279, p = 0.039; and OR 5.516, p = 0.019) analyses.

The reversed portal flow was visualized on 4DCT. Portosystemic shunt originating distant to the liver, worse albumin-bilirubin score, and small diameter of the main portal vein were factors contributing to reversed flow in the portal venous system.

Hepatic encephalopathy (HE) is a common complication in patients with advanced liver disease. It is a brain dysfunction characterized by neurological and psychiatric symptoms that significantly affects quality of life, morbidity and mortality of patients. HE has various precipitants that can potentially promote its onset, alone or in combination. Among the historically well-known precipitants, such as infections, gastrointestinal bleeding, dehydration, electrolyte disorders and constipation, recent studies have highlighted the role of malnutrition and portosystemic shunts as new precipitating factors of HE. The identification, management and correction of these factors are fundamental for effective HE treatment, in addition to pharmacological therapy with non-absorbable disaccharides and/or antibiotics.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is effective in treating the sequelae of decompensated liver cirrhosis-including medically refractory ascites and variceal bleeding-by decompressing the portal venous system through a manmade portosystemic conduit within the liver. However, the altered physiology in which splenomesenteric blood bypasses intrahepatic portal venous perfusion can precipitate varying degrees of hepatic encephalopathy (HE). While the majority of post-TIPS HE cases can be treated medically, some require escalated management strategies, including endovascular interventions to modify the indwelling TIPS and/or occlude competitive physiologic spontaneous portosystemic shunts. This review article details the epidemiology, risk factors, diagnosis, classification, and treatment of post-TIPS HE.

Hepatic encephalopathy (HE) is brain dysfunction secondary to liver insufficiency or portosystemic shunting. HE is a major burden on patients and caregivers, impairs quality of life and is associated with higher mortality. Overt HE is a clinical diagnosis while Covert HE, needs specialized diagnostic strategies. Mainstay of treatment of HE is nonabsorbable disaccharides such as lactulose as well as rifaximin; however, investigational therapies are discussed in this review. Better tools are needed to prognosticate which patients will go on to develop HE but microbiome and metabolomic-driven strategies are promising. Here we review methods to prevent the HE development and admissions.

To define technically Diff-LT.

Currently, there is no acknowledged definition of Diff-LT.

This retrospective study included all first consecutive liver-only transplantations performed in 2 centers from 2011 to 2015. Diff-LT was defined as the combination of the number of blood units transfused, cold ischemia time, and duration of operation, all at or above the median value of the entire population. The correlation of Diff-LT with short- (including the comprehensive complication index) and long-term outcomes was assessed. Outcomes were also compared to the 90-day benchmark cutoffs of LT. Predictors of Diff-LT were identified by multivariable analysis, first using only recipient data and then using all recipient, donor, graft, and surgical data.

The study population included 467 patients. The incidence of Diff- LT was 18.8%. Diff-LT was associated with short-term outcomes, including the comprehensive complication index and mortality, but not with patient or graft long-term survival. Previous abdominal surgery, intensive care unitbound at the time of LT, split graft use, nonstandard arterial reconstruction, and porto-systemic shunt ligation were independent predictors of Diff-LT. The proportion of variables below the corresponding LT 90-day benchmark cutoffs was 8/13 (61.5%) for non-Diff-LT, and 4/13 (30.8%) for Diff-LT.

Diff-LT, as defined, occurred frequently. Adjusting modifiable variables might decrease the risk of Diff-LT and improve the postoperative course. This definition of Diff-LT might be useful for patient information, comparison between centers and surgeons, and as a metric in future trials.