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Shunt occlusion for portosystemic shunt syndrome related refractory hepatic encephalopathy—A single-center experience in 21 patients from Kerala

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Abstract

Introduction

Large spontaneous portosystemic shunts (SPSS) are seen in a subset of patients with liver disease and medically refractory recurrent/persistent hepatic encephalopathy (MRHE). Shunt occlusion has been shown to improve clinical outcomes.

Methods

We retrospectively analyzed patient characteristics, SPSS attributes, procedural features, baseline clinical and investigational parameters, neurological outcomes, adverse effects (procedure and portal hypertension related), and risk factors predicting outcomes in liver disease patients undergoing shunt occlusion procedure for MRHE.

Results

Between October 2016 and July 2017, 21 patients (Child-Pugh score, CTP 6 to 13) with mean model of end-stage liver disease (MELD) and MELD-sodium scores 15.7 and 19.3 respectively with MRHE [3-cirrhotic Parkinsonism (CP)] were diagnosed to have single or multiple large SPSSs. A total of 29 shunts were occluded (1 surgical, 20 non-surgical). Recurrent and persistent HE and CP markedly improved in the short (n=20, 1 to 3 months), intermediate (n=12, 3 to 6 months), and long (n=7, 6 to 9 months) follow up. None had spontaneous or persistent HE at a median follow up 105 (30 to 329) days (p<0.05). Motor, speech, sleep abnormalities, daily activities of living, and liver disease severity scores improved significantly on follow up. Baseline arterial ammonia showed a statistically significant reduction in all time periods of follow up after shunt occlusion (p<0.05). CTP >11 predicted mortality post shunt occlusion (p=0.04). Embolization of large SPSS in liver disease patients with MRHE and modestly preserved liver function is safe and efficacious and associated with improved quality of life and can function as a bridge to liver transplantation in accurately selected patients.

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Authors and Affiliations

  1. Department of Hepatology and Liver Transplant Medicine, PVS Memorial Hospital, Kochi, 682 025, India

    Cyriac Abby Philips

  2. Department of Diagnostic and Interventional Radiology, PVS Memorial Hospital, Kochi, 682 025, India

    Lijesh Kumar

  3. Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 025, India

    Philip Augustine

Authors
  1. Cyriac Abby Philips
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  2. Lijesh Kumar
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  3. Philip Augustine
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Corresponding author

Correspondence to Cyriac Abby Philips.

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CAP, LK, and PA declare that they have no conflict of interests.

Ethics statement

All procedures performed in this study, with human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments.

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Supplementary Fig. 1

Area under the curve estimates of Child Pugh score and associated mortality (GIF 62 kb)

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Philips, C.A., Kumar, L. & Augustine, P. Shunt occlusion for portosystemic shunt syndrome related refractory hepatic encephalopathy—A single-center experience in 21 patients from Kerala. Indian J Gastroenterol 36, 411–419 (2017). https://doi.org/10.1007/s12664-017-0787-8

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  • DOI: https://doi.org/10.1007/s12664-017-0787-8

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