pTIPS Improves Survival in Patients With Hepatic Encephalopathy at Admission

Hepatic encephalopathy at admission should not be considered a contraindication to pre-emptive TIPS.

Pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) improves survival in patients with cirrhosis and acute variceal bleeding who present with hepatic encephalopathy (HE) at admission, according to study findings published in Gut.

Real-world evidence indicates that less than 15% of eligible patients receive pTIPS because of concerns that the procedure is contraindicated due to the presence of HE at admission.

Researchers conducted an observational analysis and identified 2138 patients with cirrhosis and acute variceal bleeding; 671 patients were considered at high risk for variceal rebleeding, of which 256 presented with HE at admission.

Clinicians diagnosed HE more frequently in high-risk patients than low-risk patients at admission (39.2% vs 10.6%; P <.001). HE also occurred more frequently in high-risk patients (n=35/66) who received pTIPS than those (n=221/605) who underwent endoscopy and drug treatment (53.0% vs 36.5%; P =.009). Patients who received pTIPS demonstrated a decreased 1-year mortality risk compared with those who received endoscopy and drug treatment (hazard ratio [HR], 0.374; 95% CI, 0.166-0.845; P =.0181).

We believe that pTIPS must be considered in high-risk patients with AVB and HE at admission.

The researchers observed no significant difference between HE incidence in the 2 treatment groups, either at admission (pTIPS, 56.4% vs endoscopic treatment, 58.7%; P =.4594) or after treatment (pTIPS, 38.2% vs endoscopic treatment, 38.7%; P=.9721)

“In high-risk patients with HE at admission, pTIPS placement improved survival without increasing the risk of HE, as compared with standard treatment,” the study authors wrote. “Hence, we believe that pTIPS must be considered in high-risk patients with AVB [acute variceal bleeding] and HE at admission.”

Study limitations include small sample sizes, possible differences in modalities used for HE diagnosis, and an inability to distinguish between patients experiencing their first episode of HE or a recurrent episode.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Rudler M, Hernández-Gea V, Procopet BD, et al; 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. Published online September 9, 2022. doi:10.1136/gutjnl-2022-326975.