Hepatology and gastroenterology, Unité de Soins Intensifs d'Hépato-Gastro-Entérologie, Groupement Hospitalier APHP-Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France, Paris, France
Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
Gut. 2023 Apr;72(4):749-758. doi: 10.1136/gutjnl-2022-326975. Epub 2022 Sep 9.
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.
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.
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.
pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.
预防性经颈静脉肝内门体分流术（pTIPS）可降低伴有急性静脉曲张出血（AVB）的高风险肝硬化患者（Child-Pugh C/B+活动性出血）的死亡率。真实世界研究指出，由于担心肝性脑病（HE），只有不到 15%的适合 pTIPS 的患者最终接受了经颈静脉肝内门体分流术（TIPS）。接受 pTIPS 治疗伴有 HE 的患者的结局尚不清楚。我们旨在：（1）评估伴有 AVB 的患者中 HE 的发生率；（2）评估 pTIPS 后入院时出现 HE 的患者的结局；（3）确定入院时的 HE 是否是死亡和 pTIPS 后 HE 的危险因素。
这是一项观察性研究，纳入了 2011 年 10 月至 2015 年 5 月期间来自 34 个中心的 2138 例患者。pTIPS 的放置基于各个中心的政策。对患者进行了 1 年的随访，直至死亡或肝移植。
2138 例患者中 671 例被认为处于高危状态，66 例接受了 pTIPS 治疗，605 例接受了内镜+药物治疗。入院时，高危患者中 HE 的发生率明显高于低危患者（39.2% vs 10.6%，p<0.001）。在入院时伴有 HE 的高危患者中，pTIPS 治疗的 1 年死亡率低于内镜+药物治疗（HR 0.374，95%CI 0.166 至 0.845，p=0.0181）。接受 pTIPS 治疗和内镜+药物治疗的患者的 HE 发生率无差异（38.2% vs 38.7%，p=0.9721），甚至在入院时伴有 HE 的患者中也是如此（56.4% vs 58.7%，p=0.4594）。年龄>56 岁、休克、终末期肝病模型评分>15、内镜+药物治疗和入院时伴有 HE 是高危患者死亡的独立因素。
与内镜治疗相比，伴有入院时 HE 的肝硬化伴静脉曲张出血的高危患者接受 pTIPS 治疗的生存率更好。
