Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.

Keywords: ascites; brain dysfunction; cognition; liver cirrhosis; portal hypertension; time trend; variceal bleeding.

Figure 1

Literature search flowchart.

Figure 2

Fifty studies published within the past decade reporting post-TIPS HE absolute risk at a given follow-up time, not including studies in non-cirrhosis cohorts and HCC. Studies are grouped according to mean follow-up time and within each time category ordered after the year in which recruitment began. Numbers give mean post-TIPS HE absolute risk and range in brackets. The studies are too few to conduct meaningful statistical calculations. Still, the mean post-TIPS HE risk is not significantly different between studies that started inclusion before and after 2013 or before or after 2016 (p = 0.8 and 0.9). # Only ascites indication, one week follow-up; * Viatorr controlled expansion stent 8 or 10 mm, n = 33.

Figure 3

Overview of the most well-documented risk factors for post-TIPS hepatic encephalopathy. Many are modifiable and should be addressed before elective TIPS.