B0519 - The Use of Prophylactic Treatment in the Prevention of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt

Monday, October 24, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

BN

Benjamin Nunley, MD

University of Alabama at Birmingham
Birmingham, Alabama

Benjamin Nunley, MD¹, Tyler Colvin, MD¹, David Fettig, MD², Mark Beasley, PhD¹
¹University of Alabama at Birmingham, Birmingham, AL; ²UAB, Birmingham, AL

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are indicated in the treatment of refractory ascites or variceal bleeding in patients with end-stage liver disease. Hepatic encephalopathy (HE) is a major complication of the procedure as ammonia is able to bypass the liver. Previous studies have shown prophylactic use of rifaximin to have significant benefit in primary prevention of HE. The purpose of our study was to evaluate how frequently primary HE prophylaxis medications were prescribed and to assess if this led to decreased incidence of HE.

Methods: We performed a retrospective chart review of 231 patients who received TIPS over the past 10 years at our institution that also had at least one follow up visit. Patient demographics were recorded including age, race, cirrhosis etiology, cirrhotic decompensations, MELDNa, BMI, pre/post TIPS gradients, and use of HE prophylaxis medications. Diagnosis of hepatic encephalopathy was performed through chart review by reviewing both Hepatology clinic notes and all hospital admissions. Variables were analyzed using Chi-Squared test, two sample T test, and multivariate analysis for incidence of hepatic encephalopathy.

Results: Our cohort included 231 patients with 95 females (41.1%) and the majority being elective cases (62.8%). Common indications for TIPS included esophageal varices (51.9%), ascites (35.5%), and hepatic hydrothorax (7.8%). There were 111 patients that were discharged with lactulose, 9 patients discharged with rifaximin, 55 patients discharged with a combination of lactulose and rifaximin, and 57 patients were discharged without HE prophylaxis. Multivariate analysis showed the incidence of HE was significantly reduced in the group of patients discharged with lactulose [Adjusted Odds Ratio (OR): 0.48, 95% CI (0.23-0.99), p=0.049] and a near significant difference in patients discharged with a combination of lactulose and rifaximin [Odds Ratio (OR): 0.48, 95% CI (0.20-1.15), p=0.100].

Discussion: Lactulose as prophylaxis following TIPS procedure was associated with significantly decreased likelihood of developing HE. Lactulose provides a cost effective alternative to rifaximin.

Variable	Unadjusted OR	95% CI	p-value	Adjusted OR	95% CI	p-value
Age	1.019	0.993, 1.045	0.1482	1.027	0.997, 1.058	0.0781
BMI	0.994	0.959, 1.030	0.7428	0.998	0.959, 1.038	0.9097
Pre-TIPS Gradient	1.009	0.954, 1.068	0.7515	0.977	0.906, 1.053	0.5428
Post-TIPS Gradient	1.079	0.970, 1.200	0.1616	1.076	0.937, 1.236	0.2967
Gradient Change	1.016	0.953, 1.082	0.6283	NA
Gender
Female	ref			ref
Male	1.459	0.854, 2.493	0.1664	1.300	0.700, 2.413	0.4066
Ethnicity
White	ref			ref
Black	0.491	0.169, 1.426	0.1908	0.373	0.105, , 1.322	0.1265
Other	0.510	0.097, 2.689	0.4274	0.388	0.0622.428	0.3115
TIPS Indication
EV	ref			ref
Ascites	0.692	0.388, 1.234	0.2118	0.599	0.285, 1.261	0.1775
Hydrothorax	1.011	0.373, 2.741	0.9823	1.130	0.369, 3.462	0.8301
Volume Overload	NC
Prior HE
No	ref			ref
Yes	0.810	0.4411.489	0.4971	1.380	0.636, 2.992	0.4147
Unknown	0.634	0.1832.190	0.4710	0.804	0.186, 3.469	0.7699
Prior Hep Visit
No	ref			ref
Yes	1.103	0.619, 1.966	0.7390	1.064	0.5042.245	0.8701
HE Prophylaxis Meds
None	ref			ref
Lactulose	0.491	0.257, 0.939	0.0316	0.484	0.235, 0.996	0.0486
Rifaximin	1.048	0.255, 4.313	0.9478	1.326	0.234, 7.503	0.7495
Both	0.518	0.244, 1.100	0.0871	0.476	0.197, 1.153	0.1000
Surgery
Elective	ref			ref
Emergent	1.483	0.867, 2.538	0.1503	1.523	0.729, 3.180	0.2632

Disclosures:

Benjamin Nunley indicated no relevant financial relationships.

Tyler Colvin indicated no relevant financial relationships.

David Fettig indicated no relevant financial relationships.

Mark Beasley indicated no relevant financial relationships.

Benjamin Nunley, MD¹, Tyler Colvin, MD¹, David Fettig, MD², Mark Beasley, PhD¹. B0519 - The Use of Prophylactic Treatment in the Prevention of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.