Reply.

Abstract

We appreciate the interest of Lo in our recent study published in Hepatology.1 First, the indication of TIPS in our trial was gastroesophageal variceal bleeding occurring within the past 6 to 42 days despite the endoscopic plus nonselective beta blockers for secondary prophylaxis, which is in agreement with current practice guidelines.2 Second, we agree with Lo that the prior history of HE (hepatic encephalopathy) could increase the risk of HE after TIPS. Thus, we conducted a sensitivity analysis excluding patients with previous HE (Figure 3B in the original study).1 Nevertheless, the conclusion that concurrent embolization of large spontaneous portosystemic shunt reduced the incidence, severity and frequency of post-TIPS overt HE is not changed. Third, the survival was not significantly different in our trial. However, it should be noted that the sample size was calculated based on the primary endpoint (overt HE) and our study is not powerful enough to detect the differences of survival.1 Finally, showed that rifaximin reduced the risk of HE after TIPS when administered 15 days before the procedure and maintained 6 months after,3 while an earlier trial showed that lactulose had no such protective effect.4 In our opinion, the impact of lactulose on the post-TIPS HE merits more investigation.