Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study

Department of Clinical Medicine, Sapienza University of Rome, Roma, Latium, Italy
Journal of Hepatology (Impact Factor: 10.4). 05/2005; 42(5):674-9. DOI: 10.1016/j.jhep.2004.12.028
Source: PubMed

ABSTRACT Hepatic encephalopathy is a frequent event after transjugular-intrahepatic-portosystemic-shunt (TIPS), especially during the first months. Aim of this study was to compare two different treatments (lactitol 60 g/day, rifaximin 1200 mg/day) with no-treatment in the prevention of post-TIPS hepatic encephalopathy.
Seventy-five consecutive cirrhotics submitted to TIPS were randomized to receive either one of the above treatments or no-treatment. The main end-point was the occurrence of an episode of overt hepatic encephalopathy during the first month post-TIPS. Before the procedure and weekly thereafter the patients were evaluated by examining their mental status, asterixis, ammonia and trail-making-test Part-A (TMT-A).
The three groups were comparable for age, sex, etiology, Child-Pugh-score, post-TIPS porto-systemic gradient, previous hepatic encephalopathy, basal values of ammonia and psychometric performance. Twenty-five patients developed hepatic encephalopathy (33%, CI 95%=22-45%). One-month incidence was similar in the three groups (P=0.97). Previous hepatic encephalopathy (Relative Hazard=3.79;1.27-11.31) and basal-TMT-A Z-score>1.5 (RH=3.55;1.24-10.2) were predictors of post-TIPS encephalopathy at multivariate analysis. A <5 mmHg porto-systemic gradient was also significantly related to the occurrence of encephalopathy.
Our data show that treatment with lactitol or rifaximin is not effective in the prophylaxis of hepatic encephalopathy during the first month after a TIPS.

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    • "Prevention of HE is difficult. Riggio et al. found no improvement when lactitol and rifaximin were used as HE prophylaxis [10]. Based on this trial, guidelines do not recommend using nonabsorbable disaccharides or antibiotics prophylactically for preventing post-TIPS HE. "
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    ABSTRACT: Purpose. The purpose of this study was to determine the incidence and predictors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic therapy (ET) in the elective treatment of recurrent variceal hemorrhage. Methods. Seventy patients were treated with elective TIPS and fifty-six patients with ET. Median observation time was 46.28 months in the TIPS group and 42.31 months in the ET group. Results. 30 patients (42.8%) developed clinically evident portosystemic encephalopathy in TIPS group and 20 patients (35.6%) in ET group. The difference between the groups was not statistically significant (P = 0.542; χ (2) test). The incidence of new or worsening portosystemic encephalopathy was 24.3% in TIPS group and 10.7% in ET group. Multivariate analysis showed that ET treatment (P = 0.031), age of >65 years (P = 0.022), pre-existing HE (P = 0.045), and Child's class C (P = 0.051) values were independent predictors for the occurrence of HE. Conclusions. Procedure-related HE is a complication in a minority of patients treated with TIPS or ET. Patients with increased age, preexisting HE, and higher Child-Pugh score should be carefully observed after TIPS procedure because the risk of post-TIPS HE in these patients is higher.
    Gastroenterology Research and Practice 03/2013; 2013:398172. DOI:10.1155/2013/398172 · 1.75 Impact Factor
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    • "A number of assessment tools are available the majority of which are easily applied and readily accessible [19] [20] [21]. This study by Riggio and colleagues [10] highlights further the issue of the efficacy of treatment for hepatic encephalopathy. Calls for further studies should not be heeded until the body of data already available has been fully appraised, and should not be implemented, even where indicated, until methods for assessing neuropsychiatric status have been standardised, appropriate study end-points agreed and study designs established which take into account the need to maintain blinding without compromising the integrity of the therapeutic regimens under test. "
    Journal of Hepatology 06/2005; 42(5):626-8. DOI:10.1016/j.jhep.2005.03.001 · 10.40 Impact Factor
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    ABSTRACT: Transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiology technique that has shown a 90% success rate to decompress the portal circulation. As a non-surgical intervention, without requirement for anesthesia and very low procedure-related mortality, TIPS is applicable to severe cirrhotic patients, who are otherwise untreatable, for example, nonsurgical candidates. TIPS constitutes the most frequently employed tool to achieve portosystemic shunting. TIPS acts by lowering portal pressure, which is the main underlying pathophysiologic determinant of the major complications of cirrhosis. Regarding esophagogastric variceal bleeding, TIPS has excellent hemostatic effect (95%) with low rebleeding rate (<20%). TIPS is an accepted rescue therapy for first line treatment failures in 2 settings (1) acute variceal bleeding and (2) secondary prophylaxis. In addition, TIPS offers 70% to 90% hemostasis to patients presenting with recurrent active variceal bleeding. TIPS is more effective than standard therapy for patients with hepatic venous pressure gradient >20mm Hg. TIPS is particularly useful to treat bleeding from varices inaccessible to endoscopy. TIPS should not be applied for primary prophylaxis of variceal bleeding. Portosystemic encephalopathy and stent dysfunction are TIPS major drawbacks. The weakness of the TIPS procedure is the frequent need for endovascular reintervention to ensure stent patency. The circulatory effects of TIPS are an attractive approach for the treatment of refractory ascites and hepatorenal syndrome, yet TIPS is not considered first line therapy for refractory ascites owing to unacceptable incidence of portosystemic encephalopathy. Pre-TIPS evaluation taking into account predictors of outcome is mandatory. The improved results achieved with covered-stents might expand the currently accepted recommendations for TIPS use.
    Journal of Clinical Gastroenterology 01/2007; 41 Suppl 3:S344-51. DOI:10.1097/MCG.0b013e318157e500 · 3.19 Impact Factor
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