Transjugular Intrahepatic Portosystemic Shunt In Patients Research Articles

Predictive Power of Liver Maximum Function Capacity Test in Transjugular Intrahepatic Portosystemic Shunt Patients: A Pilot Study

Background: Transjugular intrahepatic shunt (TIPSS) is placed in patients with variceal bleeding, refractory ascites, and for other indications. Postprocedural liver function-associated complications (LFAC), including hepatic encephalopathy (HE) and liver failure, represent a major setback. Current methods to predict complications are insufficient. Objectives: We investigated in a pilot study of patients prior TIPSS placement whether the risk of LFAC correlates with the functional reserve of the liver, as assessed by liver maximum function capacity (LiMAx) test. Methods: Prospectively we included patients prior TIPSS placement between June 2016 and November 2017 at Saarland University Medical Center. LiMAx was conducted before and after TIPSS placement. Patients with HE prior TIPSS, as well as other factors predisposing to HE, including concomitant sedative drugs, current bacterial infections and sepsis, were excluded. Overt HE (OHE), LiMAx, and laboratory values were assessed before and after TIPSS placement. Data were analyzed in multivariate regression and AUROC models. Results: Mean age was 60 ± 8 years. Patients (n = 20) were mainly men (65%), and presented predominantly with Child-Pugh class B (90%). Indications for TIPSS were most commonly refractory ascites or recurrent variceal bleeding. In total, 40% of the patients developed LFAC after TIPSS placement. Expectedly, LiMAx decreased and serum bilirubin increased after TIPSS. LiMAx drop ≥20% was the only parameter predicting the development of LFAC after TIPSS in multivariate regression and AUROC analysis. Conclusions: In multivariate regression models and AUROC analysis, a drop in LiMAx predicted the development of LFAC after TIPSS placement. Additional larger studies assessing OHE and early liver failure separately are warranted.

Combined diffusion tensor imaging and magnetic resonance spectroscopy to predict neurological outcome before transjugular intrahepatic portosystemic shunt.

Hepatic encephalopathy (HE) may occur after transjugular intrahepatic portosystemic shunt (TIPSS) placement. Multimodal magnetic resonance imaging (MRI), combining anatomical sequences, diffusion tensor imaging (DTI) and 1 H magnetic resonance spectroscopy, is modified in cirrhotic patients. To describe multimodal MRI images before TIPSS, to assess if TIPSS induces changes in multimodal MRI, and to find predictors of HE after TIPSS in patients with cirrhosis. Consecutive cirrhotic patients with an indication for TIPSS were prospectively screened. Diagnosis of minimal HE was performed using psychometric HE test score. Multimodal MRI was performed before and 3months after TIPSS placement. Twenty-five consecutive patients were analysed (median age=59, male gender 76%, median Child-Pugh score=8 [5-8], MELD score=12 [9-17], indication for TIPSS placement: ascites/secondary prophylaxis of variceal bleeding/other 20/3/2), no HE/minimal HE/overt HE: 21/4/0. 8/25 patients developed HE after TIPSS. Before TIPSS placement, metabolite concentrations were different in patients with or without minimal HE (lower myo-inositol, mI, higher glutamate/glutamine), but there were no differences in DTI data. TIPSS placement induced changes in metabolite concentrations even in asymptomatic patients, but not in DTI metrics. Baseline fractional anisotropy was significantly lower in patients who developed HE after TIPSS in five regions of interest. TIPSS placement induced significant changes in cerebral metabolites, even in asymptomatic patients. Patients who developed HE after TIPSS displayed lower fractional anisotropy before TIPSS. Brain MRI with DTI acquisition may help selecting patients at risk of HE.

Cardiac volume overload and pulmonary hypertension in long-term follow-up of patients with a transjugular intrahepatic portosystemic shunt.

Transjugular intrahepatic portosystemic shunt (TIPSS) cause haemodynamic changes in patients with cirrhosis, yet little is known about long-term cardiopulmonary outcomes. To evaluate the long-term cardiopulmonary outcome after TIPSS. We evaluated cardiopulmonary parameters including echocardiography during long-term follow-up after TIPSS. Results at 1-5 years after TIPSS were compared to those of cirrhotic controls. Pulmonary hypertension (PH) diagnoses rates were included. Endothelin 1, thromboxane B2 and serotonin were measured. We found significant differences 1-5 years after TIPSS compared to pre-implantation values: median left atrial diameter (LAD) increased from 37 mm [interquartile range (IQR): 33-43] to 40 mm (IQR: 37-47, P = 0.001), left ventricular end-diastolic diameter (LV-EDD) increased from 45 mm (range: 41-49) to 48 mm (IQR: 45-52, P < 0.001), pulmonary artery systolic pressure (PASP) increased from 25 mmHg (IQR: 22-33) to 30 mmHg (IQR: 25-36, P = 0.038). Comparing results 1-5 years post-implantation to the comparison cohort revealed significantly higher (P < 0.05) LAD, LV-EDD and PASP values in TIPSS patients. PH prevalence was higher in the shunt group (4.43%) compared to controls (0.91%, P = 0.150). Thromboxane B2 levels correlated with PASP in the TIPSS cohort (P = 0.033). There was no transhepatic gradient observed for the vasoactive substances analysed. TIPSS placement is accompanied by long-term cardiovascular changes, including cardiac volume overload, and is associated with an increased rate of pulmonary hypertension. The need for regular cardiac follow-up after TIPSS requires further evaluation.

Early transjugular intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a systematic review and meta-analysis of controlled trials.

There is conflicting evidence on the benefit of early transjugular intrahepatic portosystemic shunt (TIPSS) on the survival of patients with acute variceal bleeding (AVB). To assess the effect of early TIPSS on patient prognosis. We carried out a meta-analysis of trials evaluating early TIPSS in cirrhotic patients with AVB. Four studies were included. Early TIPSS was associated with fewer deaths [odds ratio (OR)=0.38, 95% confidence interval (CI)=0.17-0.83, P=0.02], with moderate heterogeneity between studies (P=0.15, I=44%). Early TIPSS was not significantly associated with fewer deaths among Child-Pugh B patients (OR=0.35, 95% CI=0.10-1.17, P=0.087) nor among Child-Pugh C patients (OR=0.34, 95% CI=0.10-1.11, P=0.074). There was no heterogeneity between studies in the Child-Pugh B analysis (P=0.6, I=0%), but there was a high heterogeneity in the Child-Pugh C analysis (P=0.06, I=60%). Early TIPSS was associated with lower rates of bleeding within 1 year (OR=0.08, 95% CI=0.04-0.17, P<0.001) both among Child-Pugh B patients, (OR=0.15, 95% CI=0.05-0.47, P=0.001) and among Child-Pugh C patients (OR=0.05, 95% CI=0.02-0.15, P<0.001), with no heterogeneity between studies. Early TIPSS was not associated with higher rates of encephalopathy (OR=0.84, 95% CI=0.50-1.42, P=0.5). Cirrhotic patients with AVB treated with early TIPSS had lower death rates and lower rates of clinically significant bleeding within 1 year compared with patients treated without early TIPSS. Additional studies are required to identify the potential risk factors leading to a poor prognosis after early TIPSS in patients with AVB and to determine the impact of the degree of liver failure on the patient's prognosis.

612 EARLY TIPS IN PATIENTS WITH ACUTE VARICEAL BLEEDING AND THE EFFECT ON THIRTY DAY AND SIX MONTH MORTALITY RATES – A SINGLE CENTRE EXPERIENCE

611 PORTAL HYPERTENSIVE GASTROPATHY IN LIVER CIRRHOSIS IN CHILDREN L. Bozomitu, B.A. Stana, A.N. Azoicai, E. Moraru. 5th Pediatrics Clinic, 2nd Pediatrics Clinic, ‘Gr. T. Popa’ University of Medicine and Pharmacy, Iasi, Romania E-mail: laura.bozomitu@gmail.com Introduction: Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) syndrome are recently characterized entities that may be associated with gastrointestinal bleeding in patients with and without liver cirrhosis. Up to 65% of patients with portal hypertension of cirrhosis will develop PHG, but it can also occur in the setting of non-cirrhotic portal hypertension. In patients with portal hypertension, PHG is often associated with the presence of esophageal aand/or gastric varices Mechanisms involved in the pathogenesis of PHG have not been fully elucidated. Aim of study: To assess the existence of PHG in children with liver cirrhosis and to make correlations between PHG and clinical parameters and evolution. Material and Methods: The study group consisted of 52 patients with liver cirrhosis (mean age 13 years), diagnosed and monitored during 8 years (2004–2011) in the Pediatric Clinics of Iasi. Upper digestive endoscopy was performed in all patients. Portal hypertensive gastropathy lesions have been described according to current criteria. Presence of Helicobacter pylori was also assessed. Statistical correlations were made between aspects revealed by endoscopy and clinical and biological parameters. Results and Discussions: PHG 1st grade was found in 36 patients and 2nd grade in 16 patients. There was no appearance of acute erosive gastritis or bleeding. Appearance of ‘snake skin’ gastric mucosa, PHG characteristic lesions arised in the natural history of portal hypertension in 10 cases, in a mean period of 48 months. Helicobacter pylori has been found in 24 patients, with higher prevalence in patients with 1 grade PHG (p =0.003). Statistical correlations were made, appearance of gastric mucosa suggestive of portalhypertensive gastropathy positively correlated with the presence of ascites and low albumin levels (p = 0.011 and 0.023, respectively). Conclusions: PHG is a common finding in upper endoscopy in children with liver cirrhosis, requiring careful evaluation in order to predict disease outcome and risk of gastrointestinal bleeding. Helicobacter pylori infection needs specific treatment, carefully conducted in the context of the main disease. 612 EARLY TIPS IN PATIENTS WITH ACUTE VARICEAL BLEEDING AND THE EFFECT ON THIRTY DAY AND SIX MONTH MORTALITY RATES – A SINGLE CENTRE EXPERIENCE E. Britton, S. Mahoney, S. Powell, R. McWilliams, U. Shaikh, A. Healy, J. Evans, P. Rowlands, P. Richardson. Hepatology, Interventional Radiology, Royal Liverpool University Hospital, Liverpool, UK E-mail: edward.britton@doctors.net.uk Background and Aims: The mainstay of treatment for variceal bleeding is pharmacotherapy and endoscopic band ligation (EBL), with TIPS reserved for patients failing conventional therapy. The use of a transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours for Childs Pugh C cirrhosis or Child Pugh B with active bleeding has been shown to improve survival when compared to pharmacotherapy and EBL. In light of the recent study early TIPS was adopted at the Royal Liverpool from Dec 2010. Here we report patient outcomes. Methods: All TIPS performed at the RLUH between December 2010 and August 2012 were reviewed. All patients fulfilling criteria were included. Data including time of bleed, index endoscopy, TIPS, aetiology of liver disease, Child–Pugh and MELD scores, abstinence rates, and mortality rates were obtained from the RLUH computer records and patient records. Results: Forty-seven TIPS were performed at the RLUH during the time period specified. 31 patients had early TIPS as management for variceal haemorrhage following index endoscopy, 58% (n =18) were from an ITU setting. The mean age was 50.9 and the aetiology of underlying liver disease was recorded as alcohol 68.8% (n =22), alcohol and hepatitis C 21.9% (n =7) and other 9.4% (n =3). Results are displayed in table 1.

Degree of hepatic dysfunction and improvement of renal function predict survival in patients with HRS type I: a retrospective analysis

Hepatorenal syndrome (HRS) is a frequent complication of end-stage liver cirrhosis. HRS type I has a very poor prognosis. From which of the more or less established therapies, such as use of vasoconstrictors together with albumin or placement of a Transjugular Intrahepatic Portosystemic Shunt patients might profit remains elusive. Therefore, it is important to define parameters that predict an improved outcome in respect to kidney function and survival. The clinical charts of 91 patients with cirrhosis and HRS type I were studied. The parameters associated with response to therapy, defined as a decrease in serum creatinine of more than 1.5 mg/dl on day 14 after diagnosis of HRS, and those associated with survival were assessed by multivariate analysis. The median survival was 2.7 (1.5-3.8) months. Three independent predictive factors for survival were identified: Child-Pugh score (P = 0.05), Model of End-Stage Liver Disease (MELD) score less than 20 (P = 0.01), and response to therapy (P = 0.02). The Child-Pugh score (P = 0.00) and MELD score less than 20 (P = 0.02) were the parameters independently associated with the response to therapy, which occurred in 26% of the patients. Our data of this large monocentric series with HRS type I confirm the poor prognosis in these patients, especially in those with high Child-Pugh and MELD scores, and in those in whom kidney function does not improve within 2 weeks.

MRI findings in chronic hepatic encephalopathy depend on portosystemic shunt: results of a controlled prospective clinical investigation

Background/Aims: Deterioration of hepatic encephalopathy is a major concern with the transjugular intrahepatic portosystemic shunt procedure. Symmetric hyperintense globus pallidus on T1-weighted cranial magnetic resonance imaging in patients with liver cirrhosis anticipates hepatocerebral disease. It is hypothesized that hepatic encephalopathy and basal ganglia signal intensity progress in patients with cirrhosis of the liver undergoing transjugular intrahepatic portosystemic shunt.Methods: Twenty-four patients were randomized to undergo either transjugular intrahepatic portosystemic shunt or elective sclerotherapy. At study entry and 6 months after randomization, neurologic assessment, psychometric tests, standard EEG, and magnetic resonance imaging were performed. The severity of liver failure was graded using Child-Pugh's classification. The signal intensity of the globus pallidus was determined on sagittal T1-weighted magnetic resonance imaging.Results: The T1-weighted signal intensity of the globus pallidus on magnetic resonance imaging significantly increased after transjugular intrahepatic portosystemic shunt placement (p<0.01), but not with elective sclerotherapy. At follow-up, neurological symptoms indicating decline of mental status and motor performance were somewhat more prevalent in transjugular intrahepatic portosystemic shunt patients. Significant deterioration of EEG abnormalities occurred in patients treated with transjugular intrahepatic portosystemic shunt as opposed to elective sclerotherapy (p<0.01).Conclusions: Transjugular intrahepatic portosystemic shunt procedure increases hyperresonant globus pallidus on magnetic resonance imaging. Neuropsychiatric evaluation shows advancing hepatic encephalopathy, in particular with transjugular intrahepatic portosystemic shunt; however, it does not parallel the augmentation of pallidal signal intensity on magnetic resonance imaging.