Bozon-Rivière Pauline, Rudler Marika, Weiss Nicolas, Thabut Dominique
Liver Intensive Care Unit, Hepatogastroenterology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.
Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Hôpital de la Pitié Salpétrière, INSERM UMR_S 938, CDR Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France.
Metab Brain Dis. 2025 Feb 4;40(2):117. doi: 10.1007/s11011-025-01541-w.
Despite a better understanding in its prognosis and pathogenesis, hepatic encephalopathy (HE) remains one of the major complications of Transjugular Intrahepatic Portosystemic Shunt (TIPS) with a prevalence ranging from 35 to 50%. Its epidemiology differs according to the indication for TIPS (salvage/rescue TIPS, preemptive (pTIPS) or elective TIPS). In salvage/rescue TIPS, the prognosis is linked to that of bleeding, and HE should not be a contraindication to TIPS, especially as bleeding is a common precipitating factor of HE. In pTIPS, i.e. TIPS performed within the 72 h after stabilization of acute variceal bleeding in high-risk patients, the risk rebleeding and HE is reduced, when compared to endoscopic and drugs treatment. As a consequence, the Baveno VII recommendations state that HE at admission should not be considered as a contraindication to pTIPS placement. In elective situations, such as refractory (intractable ascites (intolerance to diuretics) or resistant ascites (i.e. despite optimal diuretic treatment (spironolactone 400 mg/d and Furosemide 160 mg/d combined with low-salt treatment (< 5.2 g/day) or recurrent ascites (the need for at least 3 paracenteses per year) and secondary prophylaxis of variceal bleeding, it is recommended to systematically look for risk factors for HE, and chronic or refractory HE remain not recommended to TIPS in most centers. Chronic HE involves persistent neurological symptoms with fluctuating acute episodes. Recurrent HE refers to repeated episodes occurring within 6 months, while refractory HE is resistant to standard treatments, often requiring more aggressive management (Vilstrup et al. 2014). A careful selection of patients is mandatory before elective TIPS decision. Risk factors must be identified and corrected if possible before any TIPS decision is made. Management of HE after TIPS is based on identification of precipitating factors, curative treatment with lactulose as first-line therapy and rifaximin as second-line therapy, and nutritional management. In elective TIPS, prophylactic administration of rifaximin is recommended in order to decrease the risk of further HE development in selected patients (not in everyone, at least according to Baveno VII). Liver transplantation (LT) should be discussed with a multidisciplinary team as an alternative option to TIPS in case of high-risk of post-TIPS HE, and in case of refractory HE after TIPS.
尽管对肝性脑病（HE）的预后和发病机制有了更深入的了解，但它仍然是经颈静脉肝内门体分流术（TIPS）的主要并发症之一，患病率在35%至50%之间。其流行病学因TIPS的适应证（挽救性/抢救性TIPS、预防性（pTIPS）或选择性TIPS）而异。在挽救性/抢救性TIPS中，预后与出血相关，HE不应成为TIPS的禁忌证，尤其是因为出血是HE常见的诱发因素。在pTIPS中，即在高危患者急性静脉曲张出血稳定后72小时内进行的TIPS，与内镜和药物治疗相比，再出血和HE的风险降低。因此，巴韦诺VII共识指出，入院时的HE不应被视为pTIPS置入的禁忌证。在选择性情况下，如难治性（顽固性腹水（对利尿剂不耐受）或抵抗性腹水（即尽管进行了最佳利尿剂治疗（螺内酯400mg/天和呋塞米160mg/天并联合低盐治疗（<5.2g/天））或复发性腹水（每年至少需要进行3次腹腔穿刺）以及静脉曲张出血的二级预防，建议系统地寻找HE的危险因素，大多数中心仍不建议对慢性或难治性HE进行TIPS。慢性HE包括持续的神经症状伴急性发作波动。复发性HE是指在6个月内反复出现的发作，而难治性HE对标准治疗有抵抗性，通常需要更积极的治疗（Vilstrup等人，2014年）。在做出选择性TIPS决策之前，必须仔细选择患者。在做出任何TIPS决策之前，必须识别并尽可能纠正危险因素。TIPS后HE的管理基于识别诱发因素、以乳果糖作为一线治疗和利福昔明作为二线治疗的根治性治疗以及营养管理。在选择性TIPS中，建议预防性使用利福昔明，以降低特定患者（并非所有人，至少根据巴韦诺VII共识）进一步发生HE的风险。对于TIPS后HE高危患者以及TIPS后难治性HE患者，应与多学科团队讨论肝移植（LT）作为TIPS的替代选择。
