What are the Transjugular Intrahepatic Portosystemic Shunt (TIPS) indications for hepatic hydrothorax with hepatic encephalopathy?

From the Guidelines

TIPS can be considered for hepatic hydrothorax with concurrent hepatic encephalopathy, but requires careful patient selection and management. For patients with refractory hepatic hydrothorax who also have hepatic encephalopathy, TIPS may still be performed but with additional precautions, as supported by a strong recommendation and moderate-quality evidence from the 2020 study published in Gut 1. Prior to TIPS, optimize encephalopathy management with lactulose (15-30 mL orally 2-4 times daily, titrated to 2-3 soft bowel movements daily) and rifaximin (550 mg twice daily). Post-TIPS, encephalopathy may worsen in 10-50% of patients, requiring vigilant monitoring and aggressive management. The procedure involves creating a shunt between the portal and hepatic veins to reduce portal pressure, typically using an 8-10 mm covered stent, which effectively reduces ascites and hydrothorax in 70-80% of cases, as reported in the 2020 study published in Gut 1. However, the portosystemic shunting can exacerbate encephalopathy by increasing ammonia delivery to the systemic circulation. Consider using smaller diameter stents (8 mm rather than 10 mm) to minimize encephalopathy risk while still achieving portal pressure reduction, as suggested by the 2014 study published in Hepatology 1. Post-procedure, maintain strict encephalopathy prophylaxis, monitor ammonia levels, and be prepared to adjust lactulose dosing. In severe cases of post-TIPS encephalopathy unresponsive to medical therapy, stent reduction or occlusion may be necessary. TIPS should be avoided in patients with severe encephalopathy (grade 3-4), active infection, heart failure, or severe liver dysfunction (Child-Pugh score >12 or MELD >18), as recommended by the 2022 study published in Clinical Gastroenterology and Hepatology 1 and the 2010 study published in Journal of Hepatology 1.

Some key points to consider when evaluating the use of TIPS for hepatic hydrothorax with concurrent hepatic encephalopathy include:

• Careful patient selection is critical to minimize the risk of post-TIPS complications, including hepatic encephalopathy, as emphasized by the 2022 study published in Clinical Gastroenterology and Hepatology 1.
• Optimization of encephalopathy management prior to TIPS is essential to reduce the risk of post-TIPS encephalopathy, as supported by the 2014 study published in Hepatology 1.
• The use of smaller diameter stents may help minimize the risk of post-TIPS encephalopathy, as suggested by the 2014 study published in Hepatology 1.
• Close monitoring and aggressive management of post-TIPS encephalopathy are crucial to prevent severe complications, as recommended by the 2022 study published in Clinical Gastroenterology and Hepatology 1.

Overall, the decision to use TIPS for hepatic hydrothorax with concurrent hepatic encephalopathy should be made on a case-by-case basis, taking into account the individual patient's risk factors, liver function, and overall clinical condition, as emphasized by the 2020 study published in Gut 1.

From the Research

TIPS for Hepatic Hydrothorax with Hepatic Encephalopathy

• TIPS (Transjugular Intrahepatic Portosystemic Shunt) is a procedure used to treat refractory hydrothorax, a complication of portal hypertension 2.
• The efficacy of TIPS in treating refractory hydrothorax has been shown to be around 73.3% 2.
• However, TIPS is associated with a high risk of portosystemic encephalopathy, which was recorded in 66.6% of cases 2.
• Hepatic encephalopathy is a common complication of TIPS, and its recurrence can be prevented with a combination of lactulose and rifaximin 3.
• The use of TIPS in patients with hepatic hydrothorax and hepatic encephalopathy requires careful consideration of the risks and benefits, as well as close monitoring for complications 2, 4.

Management of Hepatic Hydrothorax

• The management of hepatic hydrothorax typically involves a multi-disciplinary approach, including dietary salt restriction, diuretic therapy, and liver transplantation 5, 6.
• TIPS is considered a valid option for refractory cases of hepatic hydrothorax, despite the high risk of portosystemic encephalopathy and mortality 2, 4.
• Other treatment options for hepatic hydrothorax include chest tube drainage, pleurodesis, and surgical intervention 6.

Prevention of Hepatic Encephalopathy Recurrence

• The combination of lactulose and rifaximin has been shown to be effective in preventing the recurrence of hepatic encephalopathy after TIPS 3.
• Higher age and previous episodes of hepatic encephalopathy are risk factors for recurrence after TIPS 3.
• The use of lactulose and rifaximin as prophylactic medication regimens can reduce the risk of hepatic encephalopathy recurrence after TIPS 3.