#GUT Blog: Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding

Professor El-Omar has chosen Dr Marika Rudler and Professor Dominique Thabut to do the next #GUTBlog on behalf of the International Variceal Bleeding Observational Study Group: a Baveno Cooperation.  Dr Rudler and Professor Thabut are from the Hopitaux Universitaires Pitie Salpetriere-Charles Foix, Paris, France. The #GUTBlog focusses on the paper “Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding” (1) which was published in paper copy in GUT in April 2023.

Dr Rudler & Professor Dominique                  Thabut and team


Dr Marika Rudler and Professor Dominique Thabut write:

“We are delighted to be invited by Professor Emad El Omar, the Editor in Chief of Gut to write a #GUTBlog on our recent publication “Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding” (1). This publication comes from the International Variceal Bleeding Observational Group, a Baveno cooperation, in which we decided to perform an ancillary study on hepatic encephalopathy (HE) in a multicentric cohort of patients with cirrhosis and variceal bleeding (VB).

In Paris, France, our 10-bed intensive care unit is dedicated to the management of portal hypertension-related complications, especially VB. About 10 years ago, our team created a unique study group to phenotype the neurologic complications of liver diseases at the Pitié-Salpêtrière University Hospital in Paris: The Brain Liver Pitié-Salpêtrière Study (BLIPS) group (2). This group includes all sorts of specialists (hepatologists, neurologists, liver surgeons, liver transplant specialists, neuroradiologists, neurophysiologists, etc), and follows both outpatients and inpatients, from patients with Minimal HE (MHE) to patients with Overt HE (OHE) in the intensive care unit (ICU).

We first evaluated to prognosis value of HE in VB and found that HE was an independent factor associated with a higher mortality in VB (3), whatever the liver function was. Since 2010, the Baveno recommendations state that a pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) should be performed in high-risk patients and VB. We chose to apply the pTIPS policy since March 2011 (4). Nevertheless, we had the feeling that all the physicians were not completely convinced by the therapeutic benefit of pTIPS. Then, we first evaluated the pTIPS policy in France (5). We noticed that less that 10% of patients with an indication of pTIPS effectively received this treatment. Speaking with our unconvinced colleagues, we found that this phenomenon was first related to the relative difficulties to have access to an expert centre performing TIPS placement 24/24 and that many of them were feared to place a pTIPS in patients with clinical HE. That said, we had the clinical feeling that VB was a frequent precipitating factor of HE, and that the better control of bleeding thanks to pTIPS placement would induce a better resolution of HE and a good secondary prophylaxis, as patients would be less prone to present rebleeding during the follow-up. pTIPS had already shown to be more effective in the most severe patients (6), the idea came to us to perform this ancillary study evaluating the impact of pTIPS on the prognosis of high-risk patients with VB and HE. We found, in this non randomized study, that: 1) pTIPS was associated with a significant improvement of survival in high-risk patients with HE; 2) that HE during follow-up was not higher is this subgroup of patients, when compared to patients without HE that were performed pTIPS.

This allowed us to conclude that HE should not be considered as a contra indication for pTIPS placement. The Baveno VII recommendations include this statement (7). Next step is to prospectively validate these results and also to consider the role of minimal HE.”


(1) Rudler M, Hernández-Gea V, Procopet BD, Giráldez A, Amitrano L, Villanueva C, Ibañez L, Silva-Junior G, Genesca J, Bureau C, Trebicka J, Bañares R, Krag A, Llop E, Laleman W, Palazon JM, Castellote J, Rodrigues S, Gluud LL, Noronha Ferreira C, Canete N, Rodríguez M, Ferlitsch A, Mundi JL, Gronbaek H, Hernandez-Guerra M, Sassatelli R, Dell’era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Larrue H, Primignani M, Nevens F, Calleja JL, Schwarzer R, Jansen C, Robic MA, Conejo I, Martínez Gonzalez J, Catalina MV, Albillos A, Alvarado E, Guardascione MA, Mallet M, Tripon S, Casanovas G, Bosch J, Garcia-Pagan JC, Thabut D; for International Variceal Bleeding Observational Study Group: a Baveno Cooperation. Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding. Gut. 2023 Apr;72(4):749-758.

(2) Rudler M, Weiss N, Bouzbib C, Thabut D. Diagnosis and Management of Hepatic Encephalopathy. Clin Liver Dis. 2021 May;25(2):393-417.

(3) Rudler M, Bureau C, Carbonell N, Mathurin P, Saliba F, Mallat A, Massard J, Golmard JL, Bernard-Chabert B, Dib N, Thabut D; French Club for the Study of Portal Hypertension (CFEHTP). Recalibrated MELD and hepatic encephalopathy are prognostic factors in cirrhotic patients with acute variceal bleeding. Liver Int. 2018 Mar;38(3):469-476.

(4) Rudler M, Cluzel P, Corvec TL, Benosman H, Rousseau G, Poynard T, Thabut D. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther. 2014 Nov;40(9):1074-80.

(5) Thabut D, Pauwels A, Carbonell N, Remy AJ, Nahon P, Causse X, Cervoni JP, Cadranel JF, Archambeaud I, Bramli S, Ehrhard F, Ah-Soune P, Rostain F, Pariente A, Vergniol J, Dupuychaffray JP, Pelletier AL, Skinazi F, Guillygomarc’h A, Vitte RL, Henrion J, Combet S, Rudler M, Bureau C; des Hépato-Gastroentérologues des Hôpitaux Généraux (ANGH); Club Francophone pour l’Etude de l’Hypertension Portale (CFETHTP); CHOC Study Group collaborators:. Cirrhotic patients with portal hypertension-related bleeding and an indication for early-TIPS: a large multicentre audit with real-life results. J Hepatol. 2017 Dec 14;68(1):73-81.

(6) Lv Y, Zuo L, Zhu X, Zhao J, Xue H, Jiang Z, Zhuge Y, Zhang C, Sun J, Ding P, Ren W, Li Y, Zhang K, Zhang W, He C, Zhong J, Peng Q, Ma F, Luo J, Zhang M, Wang G, Sun M, Dong J, Bai W, Guo W, Wang Q, Yuan X, Wang Z, Yu T, Luo B, Li X, Yuan J, Han N, Zhu Y, Niu J, Li K, Yin Z, Nie Y, Fan D, Han G. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut. 2019 Jul;68(7):1297-1310.

(7) de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII – Renewing consensus in portal hypertension. J Hepatol. 2022 Apr;76(4):959-974.

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