From the Guidelines
Encephalopathy post TIPS narrowing should be managed with shunt diameter reduction, as it can reverse the condition, and medical management with lactulose and rifaximin to reduce ammonia production, as recommended by the most recent and highest quality study 1.
Management Approach
The management of encephalopathy post TIPS narrowing involves a multi-faceted approach, including:
- Shunt diameter reduction to reverse the condition
- Medical management with lactulose 20-30g orally three to four times daily (titrated to achieve 2-3 soft bowel movements per day) and rifaximin 550mg twice daily to reduce ammonia production
- Protein restriction to 0.8-1.0 g/kg/day may be temporarily implemented
- Close monitoring for signs of worsening encephalopathy, including confusion, lethargy, and asterixis
- Identification and addressing of precipitating factors such as gastrointestinal bleeding, infection, electrolyte disturbances, and medication side effects
Risk Factors
Patient-specific risk factors for development of post-TIPS overt hepatic encephalopathy include:
- Prior history of overt HE
- Advanced age
- Advanced liver dysfunction (CTP Class C)
- Hyponatremia
- Renal dysfunction
- Sarcopenia, as noted in the study 1
Screening and Prevention
Screening for covert and overt encephalopathy should be performed in patients undergoing elective TIPS, using at least two of the following: psychometric hepatic encephalopathy score (PHES) testing, Stroop testing, Critical Flicker Frequency and Spectral Enhanced or quantitative EEG, as recommended by the study 1
From the Research
Encephalopathy Post TIPS Narrowing
- Encephalopathy is a significant complication of Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure, with a substantial collective experience gained in many centers around the world 2.
- The true rate of post-TIPS encephalopathy is significant and likely to be similar to that observed shortly after shunt surgery, with specific indications needing to be demonstrated using well-designed clinical trials 2.
- In many patients, the decreased incidence of post-TIPS HE observed during follow-up is related to progressive stenosis of the shunt, which is associated with the recurrence of portal hypertension and clinical complications such as ascites or variceal bleeding 2.
Risk Factors and Prophylaxis
- Higher age and previous hepatic encephalopathy (HE) are risk factors for post-TIPS HE 3, 4.
- Effective prophylaxis of HE is feasible via combination of lactulose and rifaximin, with no additional benefit from L-ornithine-L-aspartate (LOLA) 3.
- Lactulose monoprophylaxis has no prophylactic effect, while lactulose and rifaximin prevent HE recurrence at 1,3, and 12 months after TIPS 3.
Management of Refractory Hepatic Encephalopathy
- Shunt reduction with an hourglass-shaped balloon-expandable stent-graft is effective in reducing shunt flow and rapidly improving the patient's clinical condition 5.
- Shunt reduction can be modified on the basis of the patient's clinical condition, with symptoms of hepatic encephalopathy disappearing a mean of 22.3 hours after the procedure 5.
- Medical therapy typically addresses HE, and shunt reduction is necessary in only a few cases 4.
Incidence and Clinical Outcomes
- The incidence of post-TIPS HE is non-trivial, with symptoms typically mild and medically managed 4.
- HE rates are higher in older patients and those with worse liver function, and should be contemplated when counseling on expected TIPS outcomes and post-procedure course 4.
- Occurrence of de novo HE post-TIPS does not associate with 90-day mortality, in contrast to worsening HE 4.