From the Guidelines
The initial management for encephalopathy after a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure should focus on medical management with lactulose and rifaximin, as recommended by current guidelines. The management approach includes:
- Starting with lactulose at a dose of 25-30 mL orally every 1-2 hours until the patient has 2-3 soft bowel movements per day, then adjusting to a maintenance dose of 15-30 mL 2-3 times daily 1
- Adding rifaximin 550 mg twice daily as an adjunctive therapy 1
- Temporarily implementing protein restriction to 0.8-1.0 g/kg/day, but avoiding prolonged restriction to prevent malnutrition
- Correcting any precipitating factors such as dehydration, electrolyte abnormalities, infection, or gastrointestinal bleeding
- Ensuring adequate hydration while avoiding excessive fluid administration
- Considering reducing the diameter of the TIPS or complete TIPS occlusion in severe cases where encephalopathy is refractory to medical management
This approach is based on the most recent and highest quality study available, which recommends medical management of post-TIPS overt hepatic encephalopathy (HE) with lactulose and rifaximin 1. The study highlights the importance of careful case selection to reduce the incidence of severe HE post-TIPS, and notes that shunt diameter reduction can reverse HE in some cases 1. However, the primary focus should be on medical management with lactulose and rifaximin, as recommended by current guidelines 1.
From the FDA Drug Label
The usual adult, oral dosage is 2 to 3 tablespoonfuls (30 mL to 45 mL, containing 20 grams to 30 grams of lactulose) three or four times daily. Hourly doses of 30 mL to 45 mL of lactulose solution may be used to induce the rapid laxation indicated in the initial phase of the therapy of portal-systemic encephalopathy.
The initial management for encephalopathy after a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure is lactulose therapy. The recommended dose is 2 to 3 tablespoonfuls (30 mL to 45 mL) three or four times daily, or hourly doses of 30 mL to 45 mL to induce rapid laxation in the initial phase of therapy.
- Key points:
- Lactulose dose: 2 to 3 tablespoonfuls (30 mL to 45 mL) three or four times daily
- Rapid laxation: Hourly doses of 30 mL to 45 mL of lactulose solution
- Therapy goal: Reversal of coma stage and prevention of recurrence of portal-systemic encephalopathy 2
From the Research
Initial Management for Encephalopathy after TIPS Procedure
The initial management for encephalopathy after a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure involves several strategies, including:
- Conservative medical therapy, such as a protein-restricted diet, nonabsorbable disaccharides, and nonabsorbable antibiotics, which is effective in most patients 3
- Pharmacological prophylaxis, such as lactulose, rifaximin, albumin, and l-ornithin-l-aspartate, which can reduce the incidence of hepatic encephalopathy (HE) after TIPS 4
- Percutaneous techniques, such as occluding the shunt with coils or balloons, or reducing its diameter by inserting constrained stents or stent-grafts, which can produce symptomatic improvement in patients with refractory HE 3
Predictive Factors and Prevention Strategies
Predictive factors for HE after TIPS placement include:
- Patient selection and pre-procedural risk stratification, which are crucial in preventing HE 5
- The use of drugs after TIPS, which can reduce the incidence of HE 4
- The presence of prior HE, which can increase the risk of HE after TIPS 4
Management Options
Management options for HE after TIPS placement include:
- Medical therapy, such as lactulose and rifaximin, which can reduce the incidence and severity of HE 4
- Percutaneous techniques, such as shunt occlusion or reduction, which can produce symptomatic improvement in patients with refractory HE 3
- Liver transplantation, which can be considered in patients with severe and refractory HE 3, 6