Metabolic Brain Disease

, Volume 22, Issue 1, pp 45–50 | Cite as

Hepatic encephalopathy following transjugular intrahepatic portosystemic shunt (TIPS): Management with l-ornithine-l-aspartate and stent reduction

  • Vanessa Stadlbauer
  • Josef Tauss
  • Horst R. Portugaller
  • Philipp Stiegler
  • Florian Iberer
  • Rudolf E. Stauber
Original Paper

Abstract

Hepatic encephalopathy (HE) is a common problem after insertion of a trans-jugular intrahepatic portosystemic shunt (TIPS), which may be difficult to manage. We present a case of severe post-TIPS HE unresponsive to high doses of l-ornithine-l-aspartate (LOLA) despite reduction of venous ammonia levels in a dose-dependent fashion. Ultimately, high-grade HE was successfully treated by a reduction stent and the patient subsequently underwent successful liver transplantation.

Keywords

Hepatic encephalopathy Venous ammonia levels Transjugular intrahepatic portosystemic shunt l-ornithine-l-aspartate Stent reduction 

Abbreviations

HE

hepatic encephalopathy

TIPS

transjugular intrahepatic portosystemic shunt

LOLA

l-ornithine-l-aspartate

References

  1. Als-Nielsen B, Gluud LL, Gluud C (2004) Non-absorbable disaccharides for hepatic encephalopathy: systematic review of randomised trials. BMJ 328:1046–1052PubMedCrossRefGoogle Scholar
  2. Blei AT, Olafsson S, Therrien G, Butterworth RF (1994) Ammonia-induced brain edema and intracranial hypertension in rats after portacaval anastomosis. Hepatology 19:1437–1444PubMedCrossRefGoogle Scholar
  3. Conn HO, Leevy CM, Vlahcevic ZR, Rodgers JB, Maddrey WC, Seeff L, Levy LL (1977) Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. Gastroenterology 72:573–583PubMedGoogle Scholar
  4. Cordoba J, Dupuis J, Gottstein J, Blei AT (1997) Stenosis of a portacaval anastomosis affects circadian locomotor activity in the rat: A multivariable analysis. Am J Physiol 273:G1218–G1225PubMedGoogle Scholar
  5. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT (2002) Hepatic encephalopathy–definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 35:716–721PubMedCrossRefGoogle Scholar
  6. Fleig WE, Kircheis G, Spengler U, Zeuzem ST, Gortelmeyer R, The German-Austrian-Swiss Multicenter Study Group (1999) Placebo-controlled, double-blind evaluation of L-ornithine–L-aspartate (LOLA) granules in patients with cirrhosis and subclinical (SHE) or mild overt hepatic encephalopathy (HE). J Hepatol 30:65 (abstract)CrossRefGoogle Scholar
  7. Gines P, Uriz J, Calahorra B, Garcia-Tsao G, Kamath PS, Del Arbol LR, Planas R, Bosch J, Arroyo V, Rodes J (2002) Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 123:1839–4187PubMedCrossRefGoogle Scholar
  8. Hauenstein KH, Haag K, Ochs A, Langer M, Rossle M (1995) The reducing stent: treatment for transjugular intrahepatic portosystemic shunt-induced refractory hepatic encephalopathy and liver failure. Radiology 194:175–179PubMedGoogle Scholar
  9. Kircheis G, Nilius R, Held C, Berndt H, Buchner M, Gortelmeyer R, Hendricks R, Kruger B, Kuklinski B, Meister H, Otto HJ, Rink C, Rosch W, Stauch S (1997) Therapeutic efficacy of l-ornithine-l-aspartate infusions in patients with cirrhosis and hepatic encephalopathy: results of a placebo-controlled, double-blind study. Hepatology 25:1351–1360PubMedCrossRefGoogle Scholar
  10. Klempnauer J, Schrem H (2001) Review: surgical shunts and encephalopathy. Metab Brain Dis 16:21–25CrossRefGoogle Scholar
  11. Lebrec D, Giuily N, Hadengue A, Vilgrain V, Moreau R, Poynard T, Gadano A, Lassen C, Benhamou JP, Erlinger S (1996) Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: A randomized trial French Group of Clinicians and a Group of Biologists. J Hepatol 25:135–144PubMedCrossRefGoogle Scholar
  12. Leonhardt H, Bungert HJ (1972) Therapie der schweren Hyperammoniaemie. Med Klin 67:1052–1056PubMedGoogle Scholar
  13. Lozeva V, Montgomery JA, Tuomisto L, Rocheleau B, Pannunzio M, Huet PM, Butterworth RF (2004) Increased brain serotonin turnover correlates with the degree of shunting and hyperammonemia in rats following variable portal vein stenosis. J Hepatol 40:742–748PubMedCrossRefGoogle Scholar
  14. Luca A, D’Amico G, La Galla R, Midiri M, Morabito A, Pagliaro L (1999) TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials. Radiology 212:411–421PubMedGoogle Scholar
  15. Madoff DC, Wallace MJ, Ahrar K, Saxon RR (2004) TIPS-related hepatic encephalopathy: Management options with novel endovascular techniques. Radiographics 24:21–36PubMedGoogle Scholar
  16. Ochs A, Rossle M, Haag K, Hauenstein KH, Deibert P, Siegerstetter V, Huonker M, Langer M, Blum HE (1995) The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med 332:1192–1197PubMedCrossRefGoogle Scholar
  17. Olde Damink SW, Jalan R, Redhead DN, Hayes PC, Deutz NE, Soeters PB (2002) Interorgan ammonia and amino acid metabolism in metabolically stable patients with cirrhosis and a TIPSS. Hepatology 36:1163–1171PubMedCrossRefGoogle Scholar
  18. Quiroga J, Sangro B, Nunez M, Bilbao I, Longo J, Garcia-Villarreal L, Zozaya JM, Betes M, Herrero JI, Prieto J (1995) Transjugular intrahepatic portal systemic shunt in the treatment of refractory ascites: Effect on clinical, renal, humoral, and hemodynamic parameters. Hepatology 21:986–994PubMedCrossRefGoogle Scholar
  19. Riggio O, Merli M, Pedretti G, Servi R, Meddi P, Lionetti R, Rossi P, Bezzi M, Salvatori F, Ugolotti U, Fiaccadori F, Capocaccia L (1996) Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt Incidence and risk factors. Dig Dis Sci 41:578–584PubMedCrossRefGoogle Scholar
  20. Rose C, Michalak A, Pannunzio P, Therrien G, Quack G, Kircheis G, Butterworth RF (1998) L-ornithine-L-aspartate in experimental portal-systemic encephalopathy: Therapeutic efficacy and mechanism of action. Metab Brain Dis 13:147–57PubMedCrossRefGoogle Scholar
  21. Rose C, Michalak A, Rao, KV, Quack G, Kircheis G, Butterworth RF (1999) L-ornithine-L-aspartate lowers plasma and cerebrospinal fluid ammonia and prevents brain edema in rats with acute liver failure. Hepatology 30:636–640PubMedCrossRefGoogle Scholar
  22. Rose C, Butterworth RF, Zayed J, Normandin L, Todd K, Michalak A, Spahr L, Huet PM, Pomier-Layrargues G (1999) Manganese deposition in basal ganglia structures results from both portal-systemic shunting and liver dysfunction. Gastroenterology 117:640–644PubMedCrossRefGoogle Scholar
  23. Rossle M, Ochs A, Gulberg V, Siegerstetter V, Holl J, Deibert P, Olschewski M, Reiser M, Gerbes AL (2000) A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 342:1701–1707PubMedCrossRefGoogle Scholar
  24. Saab S, Nieto J, Ly, D, Runyon B (2004) TIPS versus paracentesis for cirrhotic patients with refractory ascites. Cochrane Database Syst Rev 3:CD004889PubMedGoogle Scholar
  25. Salerno F, Merli M, Riggio O, Cazzaniga M, Valeriano V, Pozzi M, Nicolini A, Salvatori F (2004) Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 40:629–635PubMedCrossRefGoogle Scholar
  26. Sanyal AJ, Genning C, Reddy KR, Wong F, Kowdley KV, Benner K, McCashland T (2003) North American study for the treatment of refractory ascites group the North American study for the treatment of refractory ascites. Gastroenterology 124:634–641PubMedCrossRefGoogle Scholar
  27. Somberg KA, Riegler JL, LaBerge JM, Doherty-Simor MM, Bachetti P, Roberts JP, Lake JR (1995) Hepatic encephalopathy after transjugular intrahepatic portosystemic shunts: Incidence and risk factors. Am J Gastroenterol 90:549–555PubMedGoogle Scholar
  28. Stauch S, Kircheis G, Adler G, Beckh K, Ditschuneit H, Gortelmeyer R, Hendricks R, Heuser A, Karoff C, Malfertheiner P, Mayer D, Rosch W, Steffens J (1998) Oral L-ornithine-L-aspartate therapy of chronic hepatic encephalopathy: Results of a placebo-controlled double-blind study. J Hepatol 28:856–864PubMedCrossRefGoogle Scholar
  29. Ter Borg PC, Hollemans M, Van Buuren HR, Vleggaar FP, Groeneweg M, Hop WC, Lameris JS (2004) Transjugular intrahepatic portosystemic shunts: long-term patency and clinical results in a patient cohort observed for 3–9 years. Radiology 231:537–545PubMedGoogle Scholar
  30. Wong F, Sniderman K, Liu P, Allidina Y, Sherman M, Blendis L (1995) Transjugular intrahepatic portosystemic stent shunt: effects on hemodynamics and sodium homeostasis in cirrhosis and refractory ascites. Ann Intern Med 122:816–822PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Vanessa Stadlbauer
    • 1
    • 4
  • Josef Tauss
    • 2
  • Horst R. Portugaller
    • 2
  • Philipp Stiegler
    • 3
  • Florian Iberer
    • 3
  • Rudolf E. Stauber
    • 1
  1. 1.Department of Internal Medicine, Division of Gastroenterology and HepatologyMedical University of GrazGrazAustria
  2. 2.Department of Radiology, Division of Interventional RadiologyMedical University of GrazGrazAustria
  3. 3.Department of Surgery, Division of Transplantation SurgeryMedical University of GrazGrazAustria
  4. 4.Department of Medicine, Liver Failure Group, UCL Institute of HepatologyUniversity College LondonLondonUK

Personalised recommendations