Author information

• ¹Hepatology and gastroenterology, Unité de Soins Intensifs d'Hépato-Gastro-Entérologie, Groupement Hospitalier APHP-Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France, Paris, France marika_rudler@yahoo.fr.
• ²Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
• ³Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), APHP-Sorbonne Université, Paris, France.
• ⁴Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain.
• ⁵Gastroenterology, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor', Cluj-Napoca, Romania.
• ⁶Gastroenterology, University of Medicine and Pharmacy 'Iuliu Hatieganu', Cluj-Napoca, Romania.
• ⁷Hepatology, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
• ⁸Gastroenterology, A. Cardarelli Hospital, Napoli, Italy.
• ⁹Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
• ¹⁰Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
• ¹¹Gastroenterology and Hepatology, Hospital Universitario Gregorio Marañon, Instituto de Investigacion Sanitaria Gregorio Marañon (IiSGM), Universidad Complutense de Madrid, Madrid, Spain.
• ¹²Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
• ¹³Internal Medicine-Liver Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
• ¹⁴Hepato-Gastroenterology, University Hospital, Toulouse, France.
• ¹⁵Translational Hepatology, Department of Internal Medicine I, Goethe-Universitat Frankfurt am Main, Frankfurt am Main, Germany.
• ¹⁶Gastroenterology, IRYCIS, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
• ¹⁷Department of Gastroenterology, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
• ¹⁸Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERehd, Barcelona, Spain.
• ¹⁹Division of Liver and Biliopancreatic Disorders, KU Leuven, University of Leuven, Leuven, Belgium.
• ²⁰Hospital General Universitario de Alicante, Alicante, Spain.
• ²¹Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain.
• ²²Department of Gastroenterology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal.
• ²³Gastrounit, Medical Division, University Hospital of Hvidovre, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
• ²⁴Gastroenterology, Hospital de Santa Maria, Lisbon, Portugal.
• ²⁵Liver Section, Gastroenterology Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
• ²⁶Department of Gastroenterology, Hospital Central de Asturias, Oviedo, Spain.
• ²⁷Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
• ²⁸Department of Gastroenterology, University Hospital San Cecilio, Grenada, Spain.
• ²⁹Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
• ³⁰Liver Unit, University Hospital of the Canary Islands, Santa Cruz de Tenerife, Spain.
• ³¹Endoscopy Unit, IRCCS Santa Maria Nuova, Reggio Emilia, Italy.
• ³²Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Milano, Italy.
• ³³UOC Gastroenterologia ed Endoscopia, Aziende Socio Sanitarie Territoriale Fatebenefratelli Sacco, Milano, Italy.
• ³⁴Department of Surgical and Gastroenterological Sciences, Multivisceral Transplant Unit, University of Padova, Padova, Italy.
• ³⁵Cirrhosis Care Clinic, University of Alberta, Edmonton, Alberta, Canada.
• ³⁶Unit for The Clinical Management of Digestive Diseases and CIBERehd, Hospital Universitario de Valme, Sevilla, Spain.
• ³⁷First Department of Internal Medicine, Martin-Luther-University, Halle, Germany.
• ³⁸Liver Unit, Department of Gastroenterology, Corporación Sanitaria Parc Taulí, Sabadell, Spain.
• ³⁹Hospital Universitari Germans Trias i Pujol, Universitat Autònoma Barcelona, Barcelona, Spain.
• ⁴⁰Service D'hepato-Gastro-Enterologie, CHU Purpan, Toulouse, France.
• ⁴¹Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy.
• ⁴²Hepatology, UZ Leuven, Leuven, Belgium.
• ⁴³Gastroenterology and Hepatology, IDIPHISA, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain.
• ⁴⁴(CIBERehd), Instituto de Salud Carlos III, Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas, Madrid, Spain.
• ⁴⁵Internal Medicine I, University of Bonn, Bonn, Germany.
• ⁴⁶Liver Unit, Hospital Universitario Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona and CIBERehd, Barcelona, Spain.
• ⁴⁷Department of Gastroenterology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, Madrid, Spain.
• ⁴⁸Servicio de Medicina de Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, CIBERehd, Barcelona, Spain.
• ⁴⁹Hepatology, Hospital Ramon y Cajal, Madrid, Spain.
• ⁵⁰Universidad de Alcala de Henares, Madrid, Spain.
• ⁵¹Gastroenterology, Hospital de la Santa Creu i Sant Pau Institut de Recerca, Barcelona, Spain.
• ⁵²Gastroenterology Unit, Ospedale A Cardarelli, Naples, Italy.
• ⁵³Hepatology and gastroenterology, Unité de Soins Intensifs d'Hépato-Gastro-Entérologie, Groupement Hospitalier APHP-Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France, Paris, France.
• ⁵⁴Biostatistics Unit, Faculty of Medicine, Universitat Autònoma Barcelona, Barcelona, Spain.
• ⁵⁵Department of Biomedical Research, Bern University, Hepatology, Inselspital, Bern, Switzerland.

Abstract

Background: 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.

Patients and methods: 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.

Results: 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.

Conclusion: pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.