Deng Dan, Liao Ming-Song, Qin Jian-Ping, Li Xiao-An
Department of Ultrasonography, General Hospital, Chengdu Military Command, Chengdu 610083, China.
Hepatobiliary Pancreat Dis Int. 2006 May;5(2):232-6.
Hepatic encephalopathy (HE) is one of the complications that have limited the effectiveness of transjugular intrahepatic portosystemic shunt (TIPS) most significantly. Up to the present, the predicting factors of HE post-TIPS have been debated controversially. This study was undertaken to verify the relationship between pre-TIPS intrahepatic hemodynamics and the incidence of post-TIPS HE.
The hepatic blood dynamics was evaluated in 41 patients with liver cirrhosis before TIPS and at one month after TIPS by ultrasonography. The patients were divided into two groups according to Doppler findings before TIPS: group 1, patients with prograde portal flow, and group 2, patients with hepatofugal or back-forth portal flow. The clinical characteristics (age, sex, etiology of liver disease, pre-TIPS Child-Pugh score, incidence of pre-TIPS HE, and portacaval pressure gradient), incidence of post TIPS HE, and pre-/post-TIPS hepatic arterial resistant index (RI) in the two groups were compared. The independent prognostic value of pre-TIPS variables for the onset of HE after TIPS, including age, Child-Pugh score, presence of HE before TIPS, and the pattern of portal flow, was tested with a multiple-factor regression analysis.
No significant difference in age, etiology of liver disease, indications of TIPS placement, incidence of HE before TIPS, and portacaval gradient before and after TIPS was observed between the two groups; but liver failure was more severe in group 2 (P<0.05). The incidence of post-TIPS HE in group 2 was significantly lower than that in group 1 (P<0.01). Pre-TIPS, the RI of the hepatic artery in group 1 was significantly higher than that in group 2 (P<0.01). However, TIPS induced a significantly decreased RI in group 1 (P<0.01), but not in group 2. Multiple-factor regression analysis demonstrated that the pattern of portal flow before TIPS was closely associated with the onset of post TIPS HE.
Pre-TIPS intrahepatic hemodynamics is closely related to the incidence of post-TIPS HE. Hepatic hemodynamics of patients with hepatofugal portal blood flow only changes a little after TIPS and still provides compensatory blood supply of the hepatic artery, and the hepatic function is less affected. Hence HE is unlikely. Hepatic hemodynamics of patients with prograde portal blood flow changes a lot after TIPS, and dual blood supply of the portal vein and hepatic artery changes into compensatory blood supply of the hepatic artery, and hepatic function suffers greatly in a short time. Thus HE is mostly likely.
肝性脑病（HE）是最显著限制经颈静脉肝内门体分流术（TIPS）疗效的并发症之一。迄今为止，TIPS术后HE的预测因素一直存在争议。本研究旨在验证TIPS术前肝内血流动力学与TIPS术后HE发生率之间的关系。
通过超声检查对41例肝硬化患者在TIPS术前及术后1个月进行肝脏血流动力学评估。根据TIPS术前的多普勒检查结果将患者分为两组：第1组为门静脉血流正向的患者，第2组为门静脉血流离肝或来回流动的患者。比较两组的临床特征（年龄、性别、肝病病因、TIPS术前Child-Pugh评分、TIPS术前HE发生率和门腔压力梯度）、TIPS术后HE发生率以及两组TIPS术前/术后肝动脉阻力指数（RI）。采用多因素回归分析检验TIPS术前变量（包括年龄、Child-Pugh评分、TIPS术前HE的存在情况和门静脉血流模式）对TIPS术后HE发生的独立预后价值。
两组在年龄、肝病病因、TIPS置入指征、TIPS术前HE发生率以及TIPS术前和术后的门腔梯度方面均未观察到显著差异；但第2组的肝功能衰竭更严重（P<0.05）。第2组TIPS术后HE的发生率显著低于第1组（P<0.01）。TIPS术前，第1组肝动脉的RI显著高于第2组（P<0.01）。然而，TIPS使第1组的RI显著降低（P<0.01），而第2组则未降低。多因素回归分析表明，TIPS术前的门静脉血流模式与TIPS术后HE的发生密切相关。
TIPS术前肝内血流动力学与TIPS术后HE的发生率密切相关。门静脉血流离肝的患者TIPS术后肝血流动力学变化较小，仍能提供肝动脉的代偿性供血，肝功能受影响较小。因此不太可能发生HE。门静脉血流正向的患者TIPS术后肝血流动力学变化较大，门静脉和肝动脉的双重供血转变为肝动脉的代偿性供血，肝功能在短时间内受到很大影响。因此最有可能发生HE。
