TY - JOUR

T1 - Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding

AU - Rudler, Marika

AU - Hernández-Gea, Virginia

AU - Procopet, Bogdan Dumitru

AU - Giráldez, Alvaro

AU - Amitrano, Lucio

AU - Villanueva, Càndid

AU - Ibañez, Luis

AU - Silva-Junior, Gilberto

AU - Genesca, Joan

AU - Bureau, Christophe

AU - Trebicka, Jonel

AU - Bañares, Rafael

AU - Krag, Aleksander

AU - Llop, Elba

AU - Laleman, Wim

AU - Palazon, Jose Maria

AU - Castellote, Jose

AU - Rodrigues, Susana

AU - Gluud, Lise Lotte

AU - Noronha Ferreira, Carlos

AU - Canete, Nouria

AU - Rodríguez, Manuel

AU - Ferlitsch, Arnulf

AU - Mundi, Jose Luis

AU - Gronbaek, Henning

AU - Hernandez-Guerra, Manuel

AU - Sassatelli, Romano

AU - Dell'Era, Alessandra

AU - Senzolo, Marco

AU - Abraldes, Juan G

AU - Romero-Gómez, Manuel

AU - Zipprich, Alexander

AU - Casas, Meritxell

AU - Masnou, Helena

AU - Larrue, Hélène

AU - Primignani, Massimo

AU - Nevens, Frederik

AU - Calleja, Jose Luis

AU - Schwarzer, Remy

AU - Jansen, Christian

AU - Robic, Marie Angèle

AU - Conejo, Irene

AU - Gonzalez, Javier Martínez

AU - Catalina, Maria Vega

AU - Albillos, Agustín

AU - Alvarado, Edilmar

AU - Guardascione, Maria Anna

AU - Mallet, Maxime

AU - Tripon, Simona

AU - Casanovas, Georgina

AU - Bosch, Jaume

AU - Garcia-Pagan, Juan-Carlos

AU - Thabut, Dominique

N1 - Publisher Copyright: © Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

PY - 2023

Y1 - 2023

N2 - Background: A pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) reduces mortality in high-risk patients with cirrhosis (Child-Pugh C/B+active bleeding) with acute variceal bleeding (AVB). Real-life studies point out that <15% of patients eligible for pTIPS ultimately undergo transjugular intrahepatic portosystemic shunt (TIPS) due to concerns about hepatic encephalopathy (HE). The outcome of patients undergoing pTIPS with HE is unknown. We aimed to (1) assess the prevalence of HE in patients with AVB; (2) evaluate the outcome of patients presenting HE at admission after pTIPS; and (3) determine if HE at admission is a risk factor for death and post-TIPS HE. Patients and methods: This is an observational study including 2138 patients from 34 centres between October 2011 and May 2015. Placement of pTIPS was based on individual centre policy. Patients were followed up to 1 year, death or liver transplantation. Results: 671 of 2138 patients were considered at high risk, 66 received pTIPS and 605 endoscopic+drug treatment. At admission, HE was significantly more frequent in high-risk than in low-risk patients (39.2% vs 10.6%, p<0.001). In high-risk patients with HE at admission, pTIPS was associated with a lower 1-year mortality than endoscopic+drug (HR 0.374, 95% CI 0.166 to 0.845, p=0.0181). The incidence of HE was not different between patients treated with pTIPS and endoscopic+drug (38.2% vs 38.7%, p=0.9721), even in patients with HE at admission (56.4% vs 58.7%, p=0.4594). Age >56, shock, Model for End-Stage Liver Disease score >15, endoscopic+drug treatment and HE at admission were independent factors of death in high-risk patients. Conclusion: pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.

AB - Background: A pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) reduces mortality in high-risk patients with cirrhosis (Child-Pugh C/B+active bleeding) with acute variceal bleeding (AVB). Real-life studies point out that <15% of patients eligible for pTIPS ultimately undergo transjugular intrahepatic portosystemic shunt (TIPS) due to concerns about hepatic encephalopathy (HE). The outcome of patients undergoing pTIPS with HE is unknown. We aimed to (1) assess the prevalence of HE in patients with AVB; (2) evaluate the outcome of patients presenting HE at admission after pTIPS; and (3) determine if HE at admission is a risk factor for death and post-TIPS HE. Patients and methods: This is an observational study including 2138 patients from 34 centres between October 2011 and May 2015. Placement of pTIPS was based on individual centre policy. Patients were followed up to 1 year, death or liver transplantation. Results: 671 of 2138 patients were considered at high risk, 66 received pTIPS and 605 endoscopic+drug treatment. At admission, HE was significantly more frequent in high-risk than in low-risk patients (39.2% vs 10.6%, p<0.001). In high-risk patients with HE at admission, pTIPS was associated with a lower 1-year mortality than endoscopic+drug (HR 0.374, 95% CI 0.166 to 0.845, p=0.0181). The incidence of HE was not different between patients treated with pTIPS and endoscopic+drug (38.2% vs 38.7%, p=0.9721), even in patients with HE at admission (56.4% vs 58.7%, p=0.4594). Age >56, shock, Model for End-Stage Liver Disease score >15, endoscopic+drug treatment and HE at admission were independent factors of death in high-risk patients. Conclusion: pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.

KW - cirrhosis

KW - hepatic encephalopathy

KW - oesophageal varices

U2 - 10.1136/gutjnl-2022-326975

DO - 10.1136/gutjnl-2022-326975

M3 - Journal article

C2 - 36328772

AN - SCOPUS:85139230191

VL - 72

SP - 749

EP - 758

JO - Gut

JF - Gut

SN - 0017-5749

IS - 4

ER -