EASL Clinical Practice Guidelines on the management of hepatic encephalopathy

HEAR-MHE study: Automated speech analysis identifies minimal hepatic encephalopathy and may predict future overt hepatic encephalopathy

BACKGROUND AND AIMS

HE is a major cause of poor quality of life in patients with cirrhosis. A simple diagnostic test to identify minimal hepatic encephalopathy (MHE) and predict future overt HE (OHE) is lacking. We aimed to evaluate if analysis of speech patterns using a modern speech platform (1) correlates with validated HE tests, (2) correlates with MHE, and (3) predicts future OHE.

APPROACH AND RESULTS

In a two-center prospective cohort study of 200 outpatients with cirrhosis and 50 controls, patients underwent baseline speech recording and validated HE diagnostic testing with psychometric HE score. Patients were followed for 6 months to identify episodes of OHE. Seven hundred fifty-two speech variables were extracted using an automated speech analysis platform, reflecting the acoustic, lexical, and semantic aspects of speech. Patients with cirrhosis were median 63 years old (IQR 54, 68), 49.5% (99) were female. Over 100 speech variables were significantly associated with psychometric HE score ( p <0.05 with false discovery rate adjustment). A three-variable speech model (2 acoustic, 1 speech tempo variable) was similar to animal naming test in predicting MHE (AUC 0.76 vs. 0.69; p =0.11). Adding age and MELD-Na improved the accuracy of the speech model (AUC: 0.82). A combined clinical-speech model ("HEAR-MHE model") predicted time to OHE with a concordance of 0.74 ( p =0.06).

CONCLUSIONS

Automated speech analysis is highly correlated with validated HE tests, associated with MHE, and may predict future OHE. Future research is needed to validate this tool and to understand how it can be implemented in clinical practice.

Assessment of Access Barriers to Rifaximin Among Patients with Hepatic Encephalopathy Using Adjudicated Claims Data

INTRODUCTION

Continuous treatment with rifaximin 550 mg (hereafter rifaximin) is associated with lower hospitalization rates in patients with hepatic encephalopathy (HE); however, access barriers may exist. This study assessed gaps in rifaximin access and the impact of treatment gaps, particularly those resulting from claim rejections, on hospitalizations and healthcare costs among patients with HE in the United States.

METHODS

The IQVIA PharMetrics® Plus database linked with Longitudinal Access and Adjudicated Data (2015-2022) were used to identify adults with HE who had ≥ 1 paid rifaximin prescription fill. Rifaximin treatment gaps were assessed during the 12-month period from the first observed attempt at receiving rifaximin (index date). Adjusted number of overt HE (OHE) hospitalizations and healthcare costs were compared over the 6 months following the index date between Cohort 1, who had no gap due to claim rejection and had < 7 days of treatment gap due to other reasons, and Cohort 2, who had ≥ 1 rejection gap or had ≥ 7 days of non-rejection gap.

RESULTS

During the year following the index date, 94.7% of the 1711 patients experienced a treatment gap, including 34.8% with initiation gaps from first attempt at receiving rifaximin to first paid claim (77.7% of initiation gaps due to rejected claims) and 72.0% with gaps in access during active treatment (14.8% of active treatment gaps due to rejected claims). Compared with Cohort 1 (n = 432; mean age 56.3 years), Cohort 2 (n = 679; mean age 54.8 years) had 1.55 times the incidence rate of OHE hospitalizations [adjusted incidence rate ratio: 1.55 (95% confidence interval: 1.10-2.20)] and incurred US$1579 more in healthcare-associated costs per-patient-per-month (all p < 0.05).

CONCLUSION

Prescription claim rejections frequently led to delays in rifaximin initiation and gaps in access during active treatment. Access barriers to rifaximin were associated with increased hospitalizations and healthcare costs in patients with HE.

Efficacy and safety of rifaximin in preventing hepatic encephalopathy: A systematic review and meta-analysis

Rifaximin (RFX) is recommended for the treatment of hepatic encephalopathy (HE). However, evidence on whether RFX application could yield additional benefits for preventing HE in patients with cirrhosis is limited. In this study, we aimed to assess the safety and efficacy of RFX in preventing HE. We conducted a systematic search of randomized controlled trials to evaluate the use of RFX by analyzing HE incidence, hospitalization, all-cause mortality, and adverse events. Compared with the control group, RFX had a beneficial effect on the primary prevention of HE (RR = 0.58, 95% CI: 0.50-0.68), with noncomparable effects to NADs (including lactulose and lactitol, RR = 0.65, 95% CI: 0.38-1.11), but more effective than placebo (RR = 0.57, 95% CI: 0.47-0.69). After more than 1 month of RFX treatment, the risk of HE decreased significantly (RR = 0.55, 95% CI: 0.47-0.65). In secondary prevention of HE, RFX decreased the recurrence risk (RR = 0.49, 95% CI: 0.40-0.61). RFX helped to reduce the incidence of HE after transjugular intrahepatic portosystemic stent shunt (TIPSS) (RR = 0.70, 95% CI: 0.51-0.96). In terms of adverse effects, RFX was associated with a lower risk of diarrhea than NADs (RR = 0.04, 95% CI: 0.00-0.25). So, RFX therapy is effective and well-tolerated in preventing HE, and can be used as the first choice in the prophylaxis of HE after TIPSS.

Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) in liver transplant candidates with cirrhosis and complex portal anastomosis

BACKGROUND & AIMS

Portal vein (PV) thrombosis may represent a relative contraindication to liver transplantation (LT). Transjugular intrahepatic portosystemic shunt (TIPS) used in portal hypertension complications, may allow portal vein recanalization (PVR).

METHODS

We reported PVR-TIPS in patients who were candidates for LT for clinical conditions but deemed contraindicated because of PV anatomy. We included consecutive patients undergoing PVR-TIPS at our center from February 2014 to May 2024.

RESULTS

We identified 25 patients (19 males [76 %], mean age 56 years [IQR 51-62]) in which PVR-TIPS was offered because foreseen high complex PV anastomosis. Twelve (48 %) patients showed main PV thrombosis, 8 (32 %) had cavernoma and 5 (20 %) had PV with very small diameter. PVR-TIPS was successfully achieved in all but one patient. All patients were listed after PVR-TIPS, with a listing MELD-Na score higher than pre-PVR-TIPS values (19 [IQR 15-23] vs. 16 [IQR 13-18], p < 0.018). Overall, 3 patients (13 %) were delisted for clinical improvement, 2 (8 %) died on the waiting-list and 16 (66 %) underwent LT. LT was technically feasible in all patients, without immediate major vascular complication.

CONCLUSIONS

PVR-TIPS may be a strategy to enable LT in patients otherwise excluded due to PV anatomy. This needs high technical expertise and often at the expense of a worsening in liver function.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

New Simple and Fast Digital Screening Method for Minimal Hepatic Encephalopathy in Cirrhotic Patients

Covert hepatic encephalopathy (CHE) is a subtle yet significant neurological complication of liver diseases, especially in patients with cirrhosis. Although it lacks overt clinical signs, CHE severely impacts quality of life, increases accident risks, and has serious prognostic implications. It is characterized by neurocognitive symptoms detectable only through specialized neuropsychometric tests. CHE affects 30%-80% of cirrhotic patients and represents the early stage of hepatic encephalopathy, which is a predictor of mortality. Early diagnosis is essential to improve patient outcomes. The Psychometric Hepatic Encephalopathy Score (PHES) is the gold standard for diagnosing CHE, but it is time-consuming and requires specialized training. Other tests, like the Animal Naming Test (ANT), are simpler and more practical for screening minimal hepatic encephalopathy (MHE), though they lack specificity. The Stroop test shows promise as a quicker and reliable diagnostic tool, but still has limitations. Recent innovations include a smartphone-based self-screening method developed by Dobbermann et al., combining three digital tests: the Tip Test, Number Connection Test, and Modified Stroop Test. This approach correlates well with PHES, is independent of language skills, and is accessible for a diverse patient population, including those with color vision deficiencies. This tool offers a rapid and reliable way to screen for CHE even in home settings, potentially improving early detection and intervention. In conclusion, CHE is an underrecognized but critical condition that requires greater clinical attention. Current diagnostic tools have limitations, highlighting the need for more effective, practical methods. A multidisciplinary approach involving hepatologists, neurologists, and neuropsychologists is crucial to improve the diagnosis and management of CHE, ultimately enhancing patient outcomes.

Optimal Management of the Inpatient With Decompensated Cirrhosis

Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.

Endoscopic Glue Injection vs Glue Plus BRTO or TIPSS for Preventing Gastric Variceal Bleeding: A Randomized Controlled Trial

BACKGROUND AND AIMS

The study sought to compare the efficacy of endoscopic injection sclerotherapy with cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (RI) (either transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year.

METHODS

Consecutive cirrhosis patients with acute variceal bleeding from cardiofundal varices were randomized into 2 arms (45 in each) after primary hemostasis by EIS-CYA. In the endoscopic intervention (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6, and 12 months), while in the RI arm, patients underwent transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration followed by endoscopic surveillance.

RESULTS

GV rebleed rates at 1 year were higher in the EI arm compared with the RI arm: 11 (24.4%; 95% confidence interval [CI], 12.9%-39.5%) vs 1 (2.2%; 95% CI, 0.1%-11.8%) (P = .004; absolute risk difference: 22.2%; 95% CI, 8.4%-36.6%). GV rebleed-related mortality in the EI arm (8 [17.8%; 95% CI, 8.0%-32.1%]) was significantly higher than in the RI arm (1 [2.2%; 0.1%-11.8%]) (P = .030; absolute risk difference: 15.6; 95% CI, 2.9%-29.2%); however, there was no difference in all-cause mortality between the 2 groups (12 [26.7%; 95% CI, 14.6%-41.9%] vs 7 [15.6%; 95% CI, 6.5%-29.5%]). The number needed to treat to prevent 1 GV-related rebleed at 1 year was 4.5.

CONCLUSIONS

RI for secondary prophylaxis reduces rebleeding from GV and GV rebleeding-related mortality in patients with GV hemorrhage. (CTRI/2021/02/031396).

ACG Clinical Guideline: Malnutrition and Nutritional Recommendations in Liver Disease

Malnutrition, defined as deficiency, excess, or imbalance of nutrients, is a common complication in patients with liver disease, especially those with cirrhosis. Malnutrition may present as an isolated micronutrient deficiency, such as zinc deficiency, and it commonly presents as frailty and/or sarcopenia in patients with advanced liver disease. Patients with cirrhosis and/or alcohol-associated hepatitis should be assessed for malnutrition because it adversely affects patient outcomes including mortality, as well as waitlist and posttransplant outcomes among liver transplant candidates. The prevalence of malnutrition varies based on the method of assessment and disease severity, being higher in those with advanced liver disease. Among stable outpatients with cirrhosis, counseling should be done to eat small frequent meals, a night-time snack between 7 PM and 10 PM, and 2 or more cups of coffee daily. In selected patients with metabolic dysfunction-associated steatohepatitis, vitamin E 800 IU/d should be provided. Among hospitalized patients with cirrhosis, nutritional supplementation preferably by enteral route should be implemented in those with poor oral intake of daily requirements of proteins and/or calories. Protein intake should not be restricted including patients with decompensated cirrhosis and hepatic encephalopathy. A vegetable source of protein seems to be better tolerated than an animal source of protein in patients with hepatic encephalopathy. Branched chain amino acids augment the efficacy of lactulose and rifaximin in the treatment of hepatic encephalopathy. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the auspices of the American College of Gastroenterology Practice Parameters Committee.

Endoscopy Sedation Challenges in Patients With Hepatic Encephalopathy: A Focused Review on Propofol and Selective Use of Benzodiazepines

BACKGROUND

Hepatic encephalopathy (HE) presents a significant challenge in gastrointestinal endoscopy sedation due to impaired liver function, which alters drug metabolism and increases the risk of adverse effects. In the absence of clear guidelines and specific biomarkers for diagnosis and assessment of HE, there is insufficient evidence to formulate standardized protocols for management, diagnosis, and sedation during endoscopy.

AREAS OF UNCERTAINTY

Rigid protocols for sedation are difficult to implement due to wide variation in patient age, comorbidities, and disease severity, which creates a "gray zone." This leaves decisions heavily reliant on the clinician's preference or experience, patient characteristics, and institutional protocols. This review highlights the strengths and limitations of propofol, midazolam, and remimazolam in efforts to improve sedation strategies for endoscopic procedures in patients with HE.

DATA SOURCES

A review was conducted using PubMed and Scopus databases, keeping in view recent publications. Only primary research studies were considered for this review. Inclusion was based on the relevance of patient side effects, sedation outcomes, and safety profiles, with a particular focus on gastrointestinal endoscopy procedures and their implications in HE.

RESULTS

Propofol remains preferred in patients with HE, demonstrating manageable cardiovascular and respiratory events without worsening encephalopathy. However, its safety requires careful consideration in this high-risk population. The combination of propofol with adjuncts, such as esketamine, has shown potential in mitigating adverse effects and optimizing sedation protocols in challenging cases. Midazolam, though historically used, is not recommended in HE due to exacerbation of encephalopathy and unfavorable safety profiles. While remimazolam shows promise, no evidence in HE populations precludes definitive conclusions about its efficacy and safety.

CONCLUSIONS

Future research should focus on optimizing sedation protocols according to the needs of HE patients, including tools for risk stratification and guidelines considering individual patient profiles. Furthermore, studies must be performed to evaluate remimazolam's outcomes and safety profiles, both as a standalone sedative and in combination with other agents.

Rifaximin-α in Patients With Recurrent Episodes of Hepatic Encephalopathy Due to Cirrhosis Reduces Healthcare Utilization

BACKGROUND AND AIMS

Hepatic encephalopathy is a frequent complication of cirrhosis. Rifaximin-α has been included in guidelines for secondary prevention of hepatic encephalopathy, but there are few real-world data on its efficacy and impact on healthcare utilization. In this study, we aimed to assess the effect of rifaximin-α on healthcare utilization.

METHOD

We conducted a cohort analysis in patients from seven hospitals in the Netherlands, who received rifaximin-α as secondary prophylaxis for hepatic encephalopathy. Data were compared 6 months before and 6 months after the prescription of rifaximin-α. The primary endpoint was the effect of rifaximin-α on healthcare utilization. Secondary endpoint was the effect of rifaximin-α on healthcare costs.

RESULTS

We included 126 patients (65% male; median age 68) with a median Model for End-stage Liver Disease score of 15. The mean number of hepatic encephalopathy episodes after starting rifaximin-α was lower than before starting rifaximin-α (0.9 vs. 2.2; p < 0.001). Mean healthcare utilization decreased from 6.1 contacts in the 6 months before rifaximin-α to 3.3 contacts in the 6 months after starting rifaximin-α (p < 0.001). The mean number of hospital admissions decreased from 1.7 admissions per patient to 1.0 admissions after starting rifaximin-α (p < 0.001). The mean number of outpatient visits also decreased after starting rifaximin-α (2.4 visits per patient to 1.7; p = 0.001). Annual costs per patient before starting rifaximin-α were €13,320. This was similar to the costs after rifaximin-α was prescribed (€13,120).

CONCLUSION

Rifaximin-α significantly reduced the number of episodes of hepatic encephalopathy, the number of hospital admissions as well as the number of outpatient and emergency department visits, contributing to a reduction in healthcare utilization. There was no reduction in overall costs.

Endoscopic variceal ligation combined with carvedilol versus endoscopic variceal ligation combined with propranolol for the treatment of oesophageal variceal bleeding in cirrhosis: study protocol for a multicentre, randomised controlled trial

INTRODUCTION

Liver cirrhosis and its severe complication, oesophageal variceal bleeding (EVB), pose significant health risks. Standard treatment for EVB combines non-selective beta-blockers (NSBB) with endoscopic variceal ligation (EVL). Carvedilol, an NSBB with additional benefits, is preferred for compensated cirrhosis. However, no randomised controlled trial (RCT) has compared carvedilol with propranolol, a conventional NSBB, in combination with EVL for secondary prophylaxis. This study aims to compare the effectiveness and safety of these treatments in preventing variceal rebleeding or death in patients with cirrhosis and EVB.

METHODS AND ANALYSIS

This multicentre, RCT is scheduled to begin in December 2024, with recruitment and follow-up continuing until December 2026. Eligible participants are patients with liver cirrhosis and EVB. Participants are randomly assigned in a 1:1 ratio to receive EVL combined with either carvedilol or propranolol. The primary endpoint is the incidence of variceal rebleeding or all-cause death. Secondary endpoints include all-cause death, liver-related death, each of the complications of portal hypertension (overt ascites, overt hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, portal vein thrombosis), hepatocellular carcinoma, changes in liver function (assessed by Child-Pugh and Model for End-Stage Liver Disease scores), changes in liver stiffness, changes in spleen stiffness, and adverse events. Subgroup and sensitivity analyses will be conducted to evaluate the consistency and robustness of the treatment effects. A total sample size of 524 patients (262 per group) is required to detect a significant difference between the treatment arms.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethics committee of the First Hospital of China Medical University (No. 2024-656-2). The study will follow the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this trial will be disseminated through peer-reviewed publications, conference presentations and healthcare professionals to guide future clinical practice.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (Registration number: ChiCTR2400089692).

Sex differences in hepatic encephalopathy: addressing the knowledge gap

Hepatic encephalopathy (HE) is a brain dysfunction caused by liver insufficiency and/or portal-systemic shunting with a significant impact on patients' quality of life and healthcare systems. This narrative review was elaborated by the Special Interest Group (SIG) "Gender in Hepatology" of the Italian Association for the Study of the Liver (AISF) and addresses the underexplored area of sex differences in HE, examining epidemiological trends, clinical manifestations and potential underlying mechanisms. Current evidence suggests that men and women may experience different prevalence rates, risk factors and disease progression due to biological and psychosocial factors. However, these differences remain poorly understood, with limited research on sex-specific outcomes, treatment adherence and psychological effects. Emerging data on body composition, gut microbiota and experimental models highlight potential mechanisms contributing to these differences. Given the evolving epidemiology of liver disease, this review highlights the need for targeted studies and sex-specific approaches in the management of HE to advance personalised medicine and improve outcomes.

Management of hepatic encephalopathy following transjugular intrahepatic portosystemic shunts: Current strategies and future directions

Transjugular intrahepatic portosystemic shunts (TIPSs) are generally used for the management of complications of portal hypertension in patients with decompensated cirrhosis. However, hepatic encephalopathy (HE), which impairs neuropsychiatric function and motor control, remains the primary adverse effect of TIPS, limiting its utility. Prompt prevention and treatment of post-TIPS HE are critical, as they are strongly associated with readmission rates and poor quality of life. This review focuses on the main pathophysiological mechanisms underlying post-TIPS HE, explores advanced biomarkers and predictive tools, and discusses current management strategies and future directions to prevent or reverse HE following TIPS. These strategies include preoperative patient assessment, individualized shunt diameter optimization, spontaneous portosystemic shunt embolization during the TIPS procedure, postoperative preventive and therapeutic measures such as nutrition management, medical therapy, fecal microbiota transplantation, and stent reduction.

Decompensated cirrhosis: an update of the BSG/BASL admission care bundle

Acute decompensated cirrhosis (DC) and acute-on-chronic liver failure are common reasons for hospital admission that have a high in-hospital mortality rate (10%–20%). Patients require a detailed assessment for precipitating factors and management of complications such as infections, ascites, acute kidney injury and hepatic encephalopathy. Multiple reports have demonstrated unwarranted variability in the care of patients with DC. In 2014, the British Society of Gastroenterology (BSG)/British Association for the Study of the Liver (BASL) DC care bundle (DCCB) was introduced to provide a structured approach for the management of patients with DC in the first 24 hours. Usage of the DCCB has been shown to improve care of patients with DC. However, despite evidence indicating the beneficial impact of the DCCB, overall usage across the UK was only 11.4% in a national audit. Our aim was to update the DCCB to incorporate recent advances in care and improve its usability and develop a strategy to improve its usage nationally. The updated bundle was developed by a multidisciplinary group of specialists from BSG, BASL and the Society for Acute Medicine with the quality of evidence supporting the bundle recommendations assessed using the Grading of Recommendation Assessment Development and Evaluation tool. Proposed minimum standards for audit were also developed. Finally, a strategy to promote usage of the bundle including education/training at a national and local level, improving accessibility for the bundle, and promotion of frameworks for use at an institutional level to improve and monitor utilisation of DCCB.

Minimal Hepatic Encephalopathy in Cirrhotic Patients: A New Simple and Fast Digital Screening Method

BACKROUND

Minimal hepatic encephalopathy is a common and prognostically severe complication of cirrhosis with a significant impact on the quality of life. Detailed diagnostic work-up of minimal hepatic encephalopathy is time-consuming and difficult to integrate into daily clinical routine.

OBJECTIVE

We aimed to develop a new, simple, and easy-applicable smartphone-based self-assessment method for screening of minimal hepatic encephalopathy.

METHODS

92 patients with cirrhosis and 20 healthy controls were recruited to perform 3 different short digital tests on smartphones (Tip test (TT), number connection test (dNCT) and modified Stroop test (ST)). Results were correlated with the Psychometric Hepatic Encephalopathy Score (PHES) as the presumed gold standard for minimal hepatic encephalopathy. The impact of age, gender, education, CHILD and MELD scores was further investigated.

RESULTS

All 3 digital tests showed good correlation with PHES (TT r = -0.76, dNCT r = -0.58, and ST r = -0.65; all p < 0.001). Digital tests were performed significantly faster (TT median 41s (IQR 36-51s); dNCT median 21s (IQR 8-16s); ST median 76s (IQR 55-99s) than PHES (median 322s; IQR 261-434s); There were significant differences between age groups and different levels of education (p < 0.05). AUC for TT was 0.835 (95% confidence interval 0.747-0.922, p < 0.001) and highest among all digital tests.

CONCLUSION

All 3 digital tests proved to be suitable for screening of minimal hepatic encephalopathy. TT showed the highest correlation with reference PHES and was not affected by language skills or color blindness, and, thus, might represent a new and fast method for minimal hepatic encephalopathy detection. Intra-individually adjusted smartphone-based thresholds might further eliminate the influence of age, gender, educational level or training, to refine early app-based alerts in case of cognitive deterioration in cirrhotic patients.

Post-TIPS Overt Hepatic Encephalopathy Increases Long-Term but Not Short-Term Mortality in Cirrhotic Patients With Variceal Bleeding: A Large-Scale, Multicenter Real-World Study

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for managing portal hypertension in cirrhotic patients, but the impact of post-TIPS overt hepatic encephalopathy (OHE) on survival remains controversial. While its effect on short-term survival is well-documented, its long-term implications remain unclear.

AIMS

This study aims to investigate the long-term impact of post-TIPS OHE on mortality in cirrhotic patients for variceal bleeding, focusing on the timing and predictive value of OHE beyond the first year post-TIPS.

METHODS

A multicenter, retrospective cohort study was conducted involving 3262 cirrhotic patients who underwent TIPS for variceal bleeding at seven Chinese tertiary centers between January 2010 and June 2020. Clinical data, including demographics, procedure details, post-TIPS complications and survival outcomes, were collected. The primary endpoints were all-cause mortality and OHE, with follow-up until death, liver transplantation or 60 months. Propensity score matching minimised confounding effects, and multivariate Fine-Grey competing risk models identified independent mortality predictors.

RESULTS

During a median follow-up of 1077 days, 33.2% developed post-TIPS OHE, associated with higher MELD and Child-Pugh scores. Among these, 19.3% died, with a median time from OHE onset to death of 947 days. Post-TIPS OHE was not linked to early survival (within 12 months) but emerged as an independent predictor of long-term mortality beyond 24 months, consistent across various clinical scenarios.

CONCLUSION

Post-TIPS OHE does not affect short-term survival but significantly increases long-term mortality risk. These findings highlight the need for continuous monitoring and tailored interventions to improve long-term outcomes in post-TIPS patients.

Chinese Guidelines on the Management of Hepatic Encephalopathy in Cirrhosis (2024)

With progress in basic and clinical research on hepatic encephalopathy in cirrhosis worldwide, the Chinese Society of Hepatology of the Chinese Medical Association has invited experts in relevant fields to revise the 2018 "Chinese Guidelines on the Management of Hepatic Encephalopathy in Cirrhosis." The updated guidelines provide recommendations for the clinical diagnosis, treatment, and both primary and secondary prevention of hepatic encephalopathy in cirrhosis.

Smartphone-based Stroop Test, EncephalApp: What is the optimal cutoff for diagnosing minimal hepatic encephalopathy?

Jiang et al explored the diagnostic capabilities of EncephalApp, a smartphone-based Stroop Test, in patients with nonalcoholic liver disease. The study included 160 patients with nonalcoholic cirrhosis and utilized the psychometric hepatic encephalopathy score as a benchmark for diagnosing minimal encephalopathy. The identified optimal cutoff times were > 101.93 seconds for the "off" time and > 205.86 seconds for the combined "on + off" time, demonstrating sensitivities of 0.84 and 0.90, and specificities of 0.77 and 0.71, respectively. The findings suggest the necessity of employing different cutoffs for patients with alcoholic vs nonalcoholic liver cirrhosis, reflecting the distinct pathophysiologies underlying each condition. Additionally, alcohol consumption itself may influence Stroop test outcomes. Therefore, it is reasonable to establish separate benchmarks for alcoholic and nonalcoholic cirrhotic patients. Further validation in larger patient cohorts with clinical outcomes is essential. The demand for noninvasive liver disease assessments remains high in clinical practice.

A Qualitative Study on Cryptogenic Hepatic Encephalopathy Screening Cognition Among Hepatology Medical Care Personnel

Objective

In this study, we focused on gaining an in-depth understanding on the attitudes and perceptions of hepatology healthcare professionals toward screening for cryptogenic hepatic encephalopathy (CHE), with the goal of providing references for the scientific and standardized implementation of CHE screening.

Study Methods

Based on the phenomenological research method, semi-structured in-depth interviews with nine medical professionals were conducted in March 2023 at the department of hepatology of a tertiary hospital in Taizhou city. The collected data was then integrated and analyzed using the Colaizzi seven-step method.

Results

Three main themes and seven sub-themes were identified: Inadequate knowledge of relevant information (inadequate knowledge of CHE, inadequate knowledge of neuropsychological test tools for CHE); positive attitudes toward screening for cirrhosis CHE; and screening factors (limited human resources, lack of stringent rules from the management, inability to properly use neuropsychological test tools, lack of cooperation from patients and their families, and lack of auxiliary means of screening).

Conclusion

Hepatology medical care personnel had a favorable outlook on CHE screening, however there is room for improvement in both their level of knowledge and clinical work. As a result the administrative departments of hospitals should focus on the factors affecting the clinical work of hepatology medical care personnel and formulate corresponding countermeasures. Emphasis should be placed on the screening and management of CHE for early recognition, early intervention, improvement of quality of life, and effective prevention of hepatic encephalopathy.

Liver Cirrhosis: ancient disease, new challenge

Liver cirrhosis is a common cause of morbidity and mortality worldwide. Excessive alcohol consumption and metabolic associated steatotic liver disease are the most common etiological factors of cirrhosis in our region. Cirrhosis occurs in two well-differentiated phases, compensated and decompensated, depending on the absence or presence of complications, respectively. Current therapeutic strategies are aimed at controlling these complications (such as ascites, hepatic encephalopathy, bacterial infections, or digestive hemorrhage, among others) or performing a liver transplant if there are no contraindications. However, it is important to eliminate the etiological factor responsible for the disease, as this can lead to the disappearance of complications, a state known as recompensation. This article proposes an updated review of the epidemiology of cirrhosis and its main causes, and offers an overview of the clinical features and treatment of the disease's complications, in addition to outlining future lines of research in this field.

Prevalence of hepatic encephalopathy in non-cirrhotic portal hypertension: A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

The prevalence of hepatic encephalopathy (HE) in non-cirrhotic portal hypertension (NCPH) is not well established, despite evidence of its occurrence in both minimal (MHE) and overt forms (OHE). Accurate diagnosis and management of HE can reduce morbidity and improve patients' and their families' quality of life. This study aimed to systematically review the prevalence of HE in NCPH.

MATERIALS AND METHODS

Systematic research in five databases (MEDLINE, LILACS, MEDRXIV, SCIELO and Scopus) was carried out from January to April 2024 to detect studies that address the prevalence of MHE and OHE in patients with NCPH, using the terms: "Hepatic Encephalopathy" or "Psychometrics" or "Cognition Disorders" or "Cognition" and "Noncirrhotic Portal Hypertension".

RESULTS

Twelve studies were included, including 575 patients. The prevalence of HE in patients with NCPH is 12 % (95 % CI: 6-24; I2 83 %, p<0.01), with high heterogeneity, with the pooled prevalence in studies evaluating MHE being 21 % (95 % CI: 11-38; I2 73 %, p<0.01) and the prevalence of OHE being 4 % (95 %CI: 1-15; I2 83 %, p<0.01). The prevalence of HE by etiology of NCPH is as follows: EHPVO is 25 % (95 %CI: 11-45; I2 0 %; p=1), PVT 2 % (95 %CI: 0-15; I2 0 %, p=1), in PSVD 8 % (95 %CI: 5-14; I2 87 %; p<0.01) and idiopathic NCPH 9 % (95 %CI: 5-14; I2 68 %, p<0.01), with the last two analyzes showing high heterogeneity.

CONCLUSIONS

HE occurs in approximately 12 % of patients with NCPH, with MHE being more common than OHE. Etiology plays a significant role in HE prevalence.

Simvastatin and Rifaximin in Decompensated Cirrhosis: A Randomized Clinical Trial

Importance

There are no useful treatments to prevent the development of severe complications of liver cirrhosis. Simvastatin and rifaximin have shown beneficial effects in liver cirrhosis.

Objective

To assess whether simvastatin combined with rifaximin improves outcomes in patients with decompensated cirrhosis.

Design, Setting, and Participants

Double-blind, placebo-controlled, phase 3 trial conducted among patients with decompensated cirrhosis in 14 European hospitals between January 2019 and December 2022. The last date of follow-up was December 2022.

Interventions

Patients were randomly assigned to receive simvastatin, 20 mg/d, plus rifaximin, 1200 mg/d (n = 117), or identical-appearing placebo (n = 120) for 12 months in addition to standard therapy, stratified according to Child-Pugh class B or C.

Main Outcomes and Measures

The primary end point was incidence of severe complications of liver cirrhosis associated with organ failure meeting criteria for acute-on-chronic liver failure. Secondary outcomes included transplant or death and a composite end point of complications of cirrhosis (ascites, hepatic encephalopathy, variceal bleeding, acute kidney injury, and infection).

Results

Among the 237 participants randomized (Child-Pugh class B: n = 194; Child-Pugh class C: n = 43), 72% were male and the mean age was 57 years. There were no differences between the 2 groups in terms of development of acute-on-chronic liver failure (21 [17.9%] vs 17 [14.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 1.23; 95% CI, 0.65-2.34; P = .52); transplant or death (22 [18.8%] vs 29 [24.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.75; 95% CI, 0.43-1.32; P = .32); or development of complications of cirrhosis (50 [42.7%] vs 55 [45.8%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.93; 95% CI, 0.63-1.36; P = .70). Incidence of adverse events was similar in both groups (426 vs 419; P = .59), but 3 patients in the treatment group (2.6%) developed rhabdomyolysis.

Conclusions and Relevance

The addition of simvastatin plus rifaximin to standard therapy does not improve outcomes in patients with decompensated liver cirrhosis.

Trial Registration

ClinicalTrials.gov Identifier: NCT03780673.

Hepatic encephalopathy treatment after transjugular intrahepatic portosystemic shunt: a new perspective on the gut microbiota

Transjugular intrahepatic portosystemic shunt (TIPS) placement alleviates portal hypertension symptoms. Hepatic encephalopathy (HE) is a common complication of TIPS, impacting patient quality of life and the healthcare burden. Post-TIPS HE is associated with portosystemic shunting, elevated blood ammonia levels, and inflammation. Increasing attention has been given to the liver and intestinal circulation in recent years. An imbalance in intestinal microecology plays a role in the occurrence of HE and may be a new target for treatment. This review discusses the causes, diagnosis, and treatment strategies for post-TIPS HE and focuses on exploring treatment strategies and their relationships with the gut microbiota, suggesting an innovative approach to address this complication.

Current management and future perspectives of covert hepatic encephalopathy in Japan: a nationwide survey

BACKGROUND

Covert hepatic encephalopathy (CHE) leads to devastating outcomes in patients with cirrhosis. This study aims to elucidate the current management and future perspectives of CHE in Japan.

METHODS

A questionnaire-based cross-sectional study was conducted among physicians involved in managing cirrhosis in Japan. The primary aim was to elucidate the real-world management of CHE, including testing and treatment. Factors influencing the implementation of CHE testing were analyzed using a logistic regression model. Limitations and future perspectives for improving the management of CHE were also evaluated.

RESULTS

Of 511 physicians surveyed, 93.9% recognized CHE as a significant problem, and 86.9% agreed that it should be tested. Overall, 62.8% of physicians tested for CHE, whereas 37.2% did not. Multivariable analysis identified institutional factors and certifying board as significant determinants of CHE test implementation. The Stroop (68.2%) and neuropsychiatric tests (57.5%) were the most commonly used methods of identifying CHE. Among those who tested for CHE, 87.7% treated CHE; the most common treatments were lactulose (81.5%), rifaximin (76.3%), and branched-chain amino acids (70.4%). Among non-testers, the primary barrier was the time requirement for testing. Proposals to encourage CHE testing included the development of simple tests and integration of multidisciplinary teams.

CONCLUSIONS

Most physicians involved in cirrhosis care in Japan recognize CHE as a significant problem that warrants testing. However, testing for CHE remains limited by institutional factors and physician specialties. Time requirements for CHE testing are the primary barrier, and simple tests and multidisciplinary teams are recommended to enhance CHE management.

Hepatic encephalopathy: risk identification and prophylaxis approaches

Hepatic encephalopathy (HE) is a debilitating neurological condition associated with cirrhosis, characterized by cognitive impairment ranging from minimal to overt symptoms. It significantly impacts patients' quality of life and substantially burdens healthcare systems. This review examines current prophylactic strategies for HE, focusing on established treatments, emerging therapies, and predictive tools to identify high-risk patients. Traditional treatments such as lactulose and rifaximin remain the cornerstone of HE management, effectively reducing ammonia levels and preventing recurrence. However, novel approaches like L-ornithine L-aspartate, albumin infusions, and antioxidants like resveratrol show promise in further improving outcomes by addressing underlying pathophysiological mechanisms, including systemic inflammation and gut dysbiosis. Developing predictive models, such as the AMMON-OHE score and clinical-genetic risk assessments, enhances the ability to tailor preventive interventions to individual patient profiles. These advancements are crucial in mitigating the incidence of overt HE, reducing hospital admissions, and improving patient survival rates. The future of HE management lies in personalized medicine, targeting specific inflammatory and metabolic pathways, with the potential integration of genetic manipulation. Continued research is essential to refine these strategies, ultimately aiming to improve the prognosis and quality of life for cirrhotic patients at risk of HE.

Optimal timing for TIPS and PSE combination treatment in patients with cirrhosis-related variceal bleeding and hypersplenism

RATIONALE AND OBJECTIVES

A consensus has not yet been reached regarding the optimal timing for the combination of transjugular intrahepatic portosystemic shunt (TIPS) and partial splenic embolization (PSE) in patients with cirrhosis-related variceal bleeding and hypersplenism. This study aimed to compare the clinical outcomes of patients who underwent either an early or late combination of TIPS and PSE.

METHODS

A total of 84 consecutive patients with cirrhosis-related variceal bleeding and hypersplenism who underwent TIPS and PSE between September 2016 and April 2023 were included in this retrospective multicenter study. These patients were subsequently divided into early combination (n = 36) and late combination (n = 48) groups based on the timing of the combination therapy.

RESULTS

Kaplan-Meier curves revealed a significant increase in cumulative survival in the late combination group, compared with that in the early combination group (log-rank P = 0.018). Additionally, the late combination group exhibited a lower cumulative incidence of overt hepatic encephalopathy (OHE), compared with the early combination group (log-rank P = 0.002). In Cox regression models, noninfarcted splenic volume (hazard ratio [HR] = 0.995, 95% confidence interval [CI] = 0.991-0.999, P = 0.044) and grouping (HR = 0.101, 95% CI = 0.011-0.921, P = 0.034) were identified as independent risk factors for mortality. Furthermore, the independent risk factors for OHE were serum albumin (ALB) level (P = 0.032) and grouping (P = 0.028).

CONCLUSION

The early combination of TIPS and PSE was associated with higher risks of death and OHE than the late combination.

Hepatic encephalopathy in patients with cirrhosis: Key clinical considerations for the nurse practitioner and physician assistant

BACKGROUND

Hepatic encephalopathy (HE) is a common neurocognitive cirrhosis-related complication with a broad range of symptoms. Timely recognition and treatment of HE, including identifying precipitating factors, when possible, is critical for improving outcomes in patients with cirrhosis. Lactulose and rifaximin therapies, as appropriate, are recommended for patients with cirrhosis and a history of HE episode(s) to reduce risk of HE recurrence.

OBJECTIVES

To provide clinical considerations for nurse practitioners and physician assistants (PAs) on the diagnosis and management of patients with cirrhosis.

DATA SOURCES

A PubMed search of English-language articles published between January 1, 2008, and March 13, 2024, was performed to identify publications on the diagnosis and treatment of HE.

RESULTS

Important topics to address when discussing care with patients with cirrhosis and their caregivers include concomitant medication use, recent infection history, comorbid conditions (e.g., diabetes), fall and frailty risks, and sleep quality. In addition, ensuring treatment adherence is important for reducing the risk of future HE episodes and HE-related hospitalizations. Engaging and empowering caregivers helps reinforce the need for patient adherence to treatment and facilitates earlier identification of HE symptoms.

CONCLUSIONS

Early recognition of HE, treatment, and reduction in risk of recurrence are imperative to minimize patient morbidity and mortality.

IMPLICATIONS FOR PRACTICE

Nurse practitioners and PAs play an important role in supporting patients with cirrhosis who are at risk for developing HE, as well as their caregivers. Understanding and recognizing precipitating factors and clinical symptoms of HE and treating and preventing HE recurrence can improve patient outcomes.

Acute and non-acute decompensation of liver cirrhosis (47/130)

In the traditional view, the occurrence of cirrhosis-related complications, such as hepatic encephalopathy, formation of ascites or variceal haemorrhage, marks the transition to the decompensated stage of cirrhosis. Although the dichotomous stratification into a compensated and decompensated state reflects a prognostic water-shed moment and remains to hold its prognostic validity, it represents an oversimplification of clinical realities. A broadening understanding of pathophysiological mechanisms underpinning decompensation have led to the identification of distinct prognostic subgroups, associated with different clinical courses following decompensation. Data provided by the PREDICT study uncovered three distinct sub-phenotypes of acute decompensation (AD). Moreover, acute-on-chronic liver failure (ACLF) has been established as a distinct clinical entity for many years, which is associated with a high short-term mortality. Recently, non-acute decompensation (NAD) has been proposed as a distinct pathway of decompensation, complementing current concepts of the spectrum of decompensation. In contrast to AD, NAD is characterized by a slow and progressive development of complications, which are often presented at first decompensation and/or in patients in an earlier stage of chronic liver disease. Successful treatment of AD or NAD may lead to a clinical stabilization or even the concept of recompensation. This review aims to provide an overview on current concepts of decompensation and to delineate recent advances in our clinical and pathophysiological understanding.

Mechanisms and treatment approaches for ACLF

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome characterized by decompensation of cirrhosis, severe systemic inflammation and organ failures. ACLF is frequently triggered by intra- and/or extrahepatic insults, such as bacterial infections, alcohol-related hepatitis or flares of hepatic viruses. The imbalance between systemic inflammation and immune tolerance causes organ failures through the following mechanisms: (i) direct damage of immune cells/mediators; (ii) worsening of circulatory dysfunction resulting in organ hypoperfusion and (iii) metabolic alterations with prioritization of energetic substrates for inflammation and peripheral organ 'energetic crisis'. Currently, the management of ACLF includes the support of organ failures, the identification and treatment of precipitating factors and expedited assessment for liver transplantation (LT). Early LT should be considered in patients with ACLF grade 3, who are unlikely to recover with the available treatments and have a mortality rate > 70% at 28 days. However, the selection of transplant candidates and their prioritization on the LT waiting list need standardization. Future challenges in the ACLF field include a better understanding of pathophysiological mechanisms leading to inflammation and organ failures, the development of specific treatments for the disease and personalized treatment approaches. Herein, we reviewed the current knowledge and future perspectives on mechanisms and treatment of ACLF.

Hepatic decompensation is the major driver of mortality in patients with HCC treated with atezolizumab plus bevacizumab: The impact of successful antiviral treatment

BACKGROUND AND AIMS

Unlike other malignancies, hepatic functional reserve competes with tumor progression in determining the risk of mortality from hepatocellular carcinoma (HCC). However, the relative contribution of hepatic decompensation over tumor progression in influencing overall survival (OS) has not been assessed in combination immunotherapy recipients.

APPROACH AND RESULTS

From the AB-real observational study (n = 898), we accrued 571 patients with advanced/unresectable hepatocellular carcinoma, Child-Pugh A class treated with frontline atezolizumab + bevacizumab (AB). Hepatic decompensation and tumor progression during follow-up were studied in relationship to patients' OS using a time-dependent Cox model. Baseline characteristics were evaluated as predictors of decompensation in competing risks analysis. During a median follow-up of 11.0 months (95% CI: 5.1-19.7), 293 patients (51.3%) developed tumor progression without decompensation, and 94 (16.5%) developed decompensation. In multivariable time-dependent analysis, decompensation (HR: 19.04, 95% CI: 9.75-37.19), hepatocellular carcinoma progression (HR: 9.91, 95% CI: 5.85-16.78), albumin-bilirubin (ALBI) grade 2/3 (HR: 2.16, 95% CI: 1.69-2.77), and number of nodules >3(HR: 1.63, 95% CI: 1.28-2.08) were independently associated with OS. Pretreatment ALBI grade 2/3 (subdistribution hazard ratio [sHR]: 3.35, 95% CI: 1.98-5.67) was independently associated with decompensation, whereas viral etiology was protective (sHR: 0.55, 95% CI: 0.34-0.87). Among patients with viral etiology, effective antiviral treatment was significantly associated with a lower risk of decompensation (sHR: 0.48, 95% CI: 0.25-0.93).

CONCLUSIONS

Hepatic decompensation identifies patients with the worst prognosis following AB and is more common in patients with baseline ALBI >1 and nonviral etiology. Effective antiviral treatment may protect from decompensation, highlighting the prognostic disadvantage of patients with nonviral etiologies and the importance of multidisciplinary management to maximize OS.

Noninvasive assessment of hepatic decompensation

Noninvasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to the symptom-driven assessment of decompensation in patients with cirrhosis, NITs provide not only opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision-making based on validated cutoffs and standardized interpretations as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, HE, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to a waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation, from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.

QuickStroop for screening for minimal hepatic encephalopathy in patients with cirrhosis

Background & Aims

QuickStroop, a shortened version of the Stroop EncephalApp, has recently been proposed for screening for minimal hepatic encephalopathy (MHE) in patients with cirrhosis in the USA. At present, there are no data on its clinical utility for MHE screening in patients in Europe, and only limited data are available regarding its comparison to the Animal Naming Test (ANT).

Methods

In total, 242 patients with cirrhosis without signs of hepatic encephalopathy (HE) ≥ grade 1 and no history of overt HE were included as the development cohort. Another independent cohort comprising 104 patients with cirrhosis from a different center served as a validation set. MHE was defined using the psychometric hepatic encephalopathy score (PHES) (PHES-MHE). All patients were tested with the complete EncephalApp Stroop. A subset was also tested with the ANT. Regression formulas were fitted for patients above and below the age of 60 years, including the first two off-state runs, age, and school education (QuickStroop).

Results

PHES-MHE was detected in 76 (31%) patients. The first two off-state runs of the EncephalApp demonstrated a comparable discriminative ability to the complete Stroop test in distinguishing between patients with and without PHES-MHE. QuickStroop had a better discriminative ability in patients below than above the age of 60 years. The discriminative ability of QuickStroop (total cohort: AUC 0.88) was superior to ANT (AUC 0.70). QuickStroop predicted PHES-MHE with a sensitivity of 74% and a specificity of 89%, and took a median of only 34.5 s to complete. The acceptable discriminative ability of QuickStroop was confirmed in the validation cohort (AUC 0.81).

Conclusion

QuickStroop is a rapid screening tool to identify patients at risk for PHES-MHE, especially in patients below 60 years of age.

Impact and implications

QuickStroop, a shortened version of the Stroop EncephalApp, has recently been proposed for screening for MHE in patients with cirrhosis in the USA. In this study, we validated QuickStroop for patients in Germany with cirrhosis and demonstrate a good diagnostic accuracy for detecting MHE, especially in patients below 60 years of age. Additionally, QuickStroop might be superior to the ANT in patients below 60 years of age. The use of QuickStroop in clinical practice could facilitate screening for MHE.

The clinical relevance of acute-on-chronic liver failure in medical procedures: Endoscopy, interventions and surgery

Acute-on-chronic liver failure (ACLF) is a specific, but complex and multifactorial form of acute decompensation (AD) of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure and high short-term mortality. In daily clinical practice, patients with liver cirrhosis and decompensation have indications for different medical procedures such as endoscopies, interventional treatments like transjugular intrahepatic portosystemic shunt (TIPS) or even surgical procedures. In these situations, clinicians often need to balance the expected benefits of such procedures with the risks of causing acute decompensation or ACLF. This review summarizes the evidence of medical procedures and their role in precipitating or preventing ACLF and highlights the aspects to consider during patient selection.

Relationship between Sarcopenia and minimal hepatic encephalopathy in patients with cirrhosis: a prospective observational study

BACKGROUND

Sarcopenia, characterized by loss of muscle mass and function, has gained importance in the evaluation of cirrhotic patients. Evidence suggests its role in adverse clinical outcomes, including minimal hepatic encephalopathy (MHE). This study aimed to investigate the association between sarcopenia and MHE in patients with cirrhosis.

METHODS

We prospectively enrolled outpatients with cirrhosis to assess sarcopenia using the 2019 criteria from the Asian Working Group for Sarcopenia. MHE was diagnosed through the Psychometric Hepatic Encephalopathy Score.

RESULTS

Of the 210 cirrhotic patients (57.1% male, mean age 62.7 ± 9.6 years), 54 (25.7%) had sarcopenia, with 26 (12.3%) classified as severe. Thirty-seven patients (17.6%) were diagnosed with MHE. Sarcopenia prevalence was significantly higher in patients with MHE compared to those without MHE (45.9% vs. 21.4%). MHE was significantly associated with age, education level, Mini-Mental State Examination score, and a history of hepatic decompensation. No significant associations were found regarding gender, body mass index, comorbidities, sleep quality, and the etiology of cirrhosis. Multivariable logistic regression showed that MHE was significantly associated with age (adjusted odds ratio [aOR] 1.08, 95% CI 1.02-1.13), sarcopenia (aOR 3.29, 95% CI 1.44-7.50), history of overt hepatic encephalopathy (aOR 7.40, 95% CI 1.20-45.56), and variceal bleeding (aOR 3.13, 95% CI 1.38-7.10). Severe sarcopenia was also independently associated with MHE (aOR 3.64, 95% CI 1.32-10.05).

CONCLUSIONS

Sarcopenia is prevalent in cirrhotic patients and is associated with an increased risk of MHE. Our findings emphasize the importance of assessing sarcopenia to potentially mitigate MHE risk in managing patients with cirrhosis.

Impact of type 2 diabetes mellitus on results in the animal naming test in patients with and without liver cirrhosis

INTRODUCTION AND OBJECTIVES

Diabetes mellitus is a common comorbidity in patients with cirrhosis and is associated with the development of hepatic encephalopathy (HE) and cognitive dysfunction. The simplified Animal Naming Test (S-ANT1) has been established for detecting minimal HE (MHE). It is currently unknown whether S-ANT1 results are affected by diabetes mellitus in patients with and without cirrhosis.

MATERIALS AND METHODS

This study analyzed data from 268 patients with cirrhosis without signs of HE ≥ 1. MHE was defined using the psychometric hepatic encephalopathy score (PHES). All patients were also tested with S-ANT1. 14 patients with diabetes mellitus and diabetic foot syndrome but no cirrhosis, as well as 37 healthy controls, were also tested with S-ANT1 and served as controls.

RESULTS

Type 2 diabetes mellitus was present in 79 (29.5%) patients with cirrhosis and MHE according to PHES was detected in 81 (30.2%) patients. In the total cohort, results in S-ANT1 did not differ between patients with and without diabetes mellitus (19 vs. 20 animals, p = 0.108). In multivariable logistic regression analysis, the only variables independently associated with performance in S-ANT1 were PHES-MHE, school education, sodium, and age, while diabetes mellitus was not. Patients with diabetic foot syndrome but no cirrhosis performed poorer in S-ANT1 compared to healthy controls, while patients with cirrhosis and MHE performed poorer than patients with diabetic foot syndrome.

CONCLUSION

S-ANT1 seems to be usable for screening for MHE in patients with cirrhosis and type 2 diabetes mellitus, while one might be more cautious when interpreting results in patients with diabetes-related complications.

TIPS and hepatic encephalopathy in patients with cirrhosis

Despite a better understanding in its prognosis and pathogenesis, hepatic encephalopathy (HE) remains one of the major complications of Transjugular Intrahepatic Portosystemic Shunt (TIPS) with a prevalence ranging from 35 to 50%. Its epidemiology differs according to the indication for TIPS (salvage/rescue TIPS, preemptive (pTIPS) or elective TIPS). In salvage/rescue TIPS, the prognosis is linked to that of bleeding, and HE should not be a contraindication to TIPS, especially as bleeding is a common precipitating factor of HE. In pTIPS, i.e. TIPS performed within the 72 h after stabilization of acute variceal bleeding in high-risk patients, the risk rebleeding and HE is reduced, when compared to endoscopic and drugs treatment. As a consequence, the Baveno VII recommendations state that HE at admission should not be considered as a contraindication to pTIPS placement. In elective situations, such as refractory (intractable ascites (intolerance to diuretics) or resistant ascites (i.e. despite optimal diuretic treatment (spironolactone 400 mg/d and Furosemide 160 mg/d combined with low-salt treatment (< 5.2 g/day) or recurrent ascites (the need for at least 3 paracenteses per year) and secondary prophylaxis of variceal bleeding, it is recommended to systematically look for risk factors for HE, and chronic or refractory HE remain not recommended to TIPS in most centers. Chronic HE involves persistent neurological symptoms with fluctuating acute episodes. Recurrent HE refers to repeated episodes occurring within 6 months, while refractory HE is resistant to standard treatments, often requiring more aggressive management (Vilstrup et al. 2014). A careful selection of patients is mandatory before elective TIPS decision. Risk factors must be identified and corrected if possible before any TIPS decision is made. Management of HE after TIPS is based on identification of precipitating factors, curative treatment with lactulose as first-line therapy and rifaximin as second-line therapy, and nutritional management. In elective TIPS, prophylactic administration of rifaximin is recommended in order to decrease the risk of further HE development in selected patients (not in everyone, at least according to Baveno VII). Liver transplantation (LT) should be discussed with a multidisciplinary team as an alternative option to TIPS in case of high-risk of post-TIPS HE, and in case of refractory HE after TIPS.

The Misdiagnosis and Underdiagnosis of Hepatic Encephalopathy

Patients with cirrhosis are at risk of developing hepatic encephalopathy (HE), which can present with a wide range of symptoms, including confusion, lethargy, inappropriate behavior, and altered sleep patterns. In addition to HE, patients with cirrhosis are at risk of developing mild cognitive impairment, dementia, and delirium, which have features closely resembling HE. Given the similar presentation of these conditions, misdiagnosis can and does occur. Mild cognitive impairment is common in individuals aged 50 years and older and can progress to dementia in those affected. Dementia and HE are both characterized by sleep disturbance and cognitive dysfunction, thus differentiating these conditions can be difficult. Furthermore, delirium can disrupt sleep patterns, and liver disease is recognized as a risk factor for its development. As HE is a cirrhosis-related complication, determining if a patient has undiagnosed cirrhosis is critical, particularly given the large number of patients with asymptomatic, compensated cirrhosis. Separately, underdiagnosis of minimal HE can occur even in patients with diagnosed liver disease, related, in part, to lack of testing. Given the availability of effective therapies for managing symptoms and preventing future episodes, accurate diagnosis of HE is essential.

Transjugular Intrahepatic Portosystemic Shunt (TIPS): A Bridge to Bariatric Surgery in Morbidly Obese Patients with Cirrhosis and Clinically Significant Portal Hypertension

BACKGROUND

In cirrhotic patients, portal hypertension increases mortality after surgery. We evaluated the impact of pre-operative transjugular intrahepatic portosystemic shunt (TIPS) on the outcomes of bariatric surgery in cirrhosis.

METHODS

Multicentric retrospective cohort. The decision for TIPS placement has been made according to hepatic venous pressure gradient (HVPG) values and centers' policy. The primary outcome: 1-year decompensation-free survival; secondary outcomes: 1-year acute-on-chronic liver failure (ACLF) and survival.

RESULTS

Fifty-three patients were included (2010-2022): 92% Child-Pugh A, MELD score 8, age 55 years, BMI 38.3 ± 13 kg/m2, 9 (18%) had TIPS. At baseline, patients with TIPS had more esophageal varices (89% vs 10%, p < 0.001), more previous decompensations (22% vs 0%, p = 0.002), and a higher HVPG (14 vs 7 mmHg, p < 0.001). All patients in the TIPS group had clinically significant portal hypertension vs 11% of patients without TIPS, p < 0.001. One-year decompensation-free survival was 77.8% and 93.2% in patients with and without TIPS, p = 0.064. ALCF occurred in 3 patients (6.8%) without TIPS and none with TIPS. All patients were alive 1 year after surgery.

CONCLUSIONS

In patients with cirrhosis and clinically significant portal hypertension (CSPH) undergoing bariatric surgery, TIPS placement was safe and had similar outcomes after surgery as patients without TIPS.

Canadian Association of Radiologists Central Nervous System Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Central Nervous System Expert Panel is made up of physicians from the disciplines of radiology, emergency medicine, neurosurgery, and neurology, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 24 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 55 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 51 recommendation statements across the 24 scenarios. This guideline presents the methods of development and the referral recommendations for congenital disorders of the brain, cerebrovascular disease, multiple sclerosis and demyelinating disease, headache, concussion, pituitary and juxtasellar lesions, cranial neuropathy, brain stem symptoms, altered intracranial pressure (hypertension, hypotension, hydrocephalus suspected shunt malfunction, normal pressure hydrocephalus), vestibular and cochlear symptoms (hearing loss, vertigo), mental status change (acute, dementia/memory loss), visual loss, epilepsy and seizure, CNS infection, intracranial space-occupying lesions, suspected cerebral venous sinus thrombosis, vasculitis, movement disorders/Parkinsonism, metabolic and toxic encephalopathies, and aneurysm screening.

Drug Utilization of Rifaximin-α in Patients with Hepatic Encephalopathy: Evidence from Real Clinical Practice in Italy

Background and Objectives: This analysis described rifaximin utilization in Italian patients with hepatic encephalopathy (HE). Although rifaximin is effective in preventing HE relapses, therapeutic management and prescriptive attitudes might be improved. Materials and Methods: Between Oct-2020 and Sep-2021, approximately 12.7 million citizens, patients hospitalized for HE, were identified through the ICD-9-CM code 572.2. Among those discharged alive, utilization of rifaximin 550 mg vs. rifaximin 200 mg for two months post-admission was compared. Results: Of 634 patients hospitalized for HE, 447 (70.5%) were discharged alive. In the two following months, 276 (61.7%) received rifaximin, of whom 117 (26.2%) received rifaximin 550 mg (two daily tablets) and 159 (35.6%) received rifaximin 200 mg (six daily tablets); among 171 patients without rifaximin, 56 (32.7%) received lactulose/lactitol. One year after rifaximin initiation, patients on rifaximin 550 mg (vs. 200 mg) were more frequently persistent (i.e., did not interrupt therapy) (78.6% vs. 46.9%, p < 0.001), showed a lower switching proportion (21.4% vs. 40.7%, p < 0.050), and had a mean monthly dose closer to the recommendations of 36,000 mg/month (~33,000 mg/month vs. 11,629 mg/month, respectively). Conclusions: This analysis suggests suboptimal rifaximin utilization for HE management. Although rifaximin 550 mg is the only formulation with specific indication and reimbursability to prevent HE relapses in Italy, rifaximin 200 mg is more largely used. The need to improve rifaximin prescribing choices is supported by higher persistence, lower switching rates, and average doses aligned to recommendations in patients treated with rifaximin 550 mg.

Real-World Trends and Future Projections of the Prevalence of Cirrhosis and Hepatic Encephalopathy Among Commercially and Medicare-Insured Adults in the United States

INTRODUCTION

Describing cirrhosis and hepatic encephalopathy (HE) burden over time can inform clinical management and resource allocation. Using healthcare claims data, this observational study examined recent trends in the prevalence of cirrhosis and HE and associated healthcare resource utilization among commercially and Medicare-insured adults in the United States.

METHODS

Data from the MarketScan Commercial Claims and Encounters Database and 100% Medicare Research Identifiable Files were analyzed (2007-2020). Annual prevalence of cirrhosis, HE, overt HE (OHE) hospitalizations, and rifaximin ± lactulose use, and costs per hospitalization per year were calculated. Average year-over-year changes in prevalence of cirrhosis, and HE were estimated. Trends were extrapolated to 2030 using ordinary least-squares regression.

RESULTS

From 2007 to 2020, the prevalence of cirrhosis increased by an average of 4.6% year-over-year in the Commercial population and 8.1% in the Medicare population; the prevalence of HE increased by 4.3% and 2.5%, respectively. Rates of OHE hospitalizations decreased from 27.5% to 5.5% (Commercial) and from 26.2% to 9.5% (Medicare), and rates of liver transplantation increased. Average payer costs (Commercial) and provider charges (Medicare) per OHE hospitalization increased (from $40,881 to $77,699 and from $45,913 to $74,894, respectively). Use of rifaximin ± lactulose showed an increasing trend during the observation period, whereas lactulose use declined steadily.

DISCUSSION

The healthcare burden of cirrhosis and HE in the United States is increasing. Trends are projected to continue unless action is taken, such as improving medication access and developing policies addressing the contributing factors.

Ammonia and beyond - biomarkers of hepatic encephalopathy

Ammonia is a product of amino acid metabolism that accumulates in the blood of patients with liver cirrhosis, leading to neurotoxic effects and hepatic encephalopathy (HE). HE manifestations can range from mild, subclinical disturbances in cognition, or minimal HE (mHE) to gross disorientation and coma, a condition referred to as overt HE. Many blood-based biomarkers reflecting these neurotoxic effects of ammonia and liver disease can be measured in the blood allowing the development of new biomarkers to diagnose cirrhosis patients at risk of developing HE. The effect of ammonia on the brain is modulated by severity of systemic inflammation, and both hyperammonemia and inflammation can induce oxidative stress, which may mediate the neurological alterations associated to HE. This review aims to provide the latest evidence on biomarkers of HE beyond ammonia. We present different approaches to predict overt HE based on the combination of blood ammonia with some analytical and clinical parameters. Magnetic resonance analysis of brain images could also provide sensitive diagnostic biomarkers based on neuroimaging parameters. Some reports suggest that markers of systemic inflammation, oxidative stress, and central nervous system-derived components, may serve as additional biomarkers of HE. The involvement of extracellular vesicles and microbiota in the pathophysiology of mHE and HE has recently acquired importance and it would be interesting to explore their usefulness as early biomarkers of the disease. It is important to have a biomarker or a combination of them for early diagnosis of mHE to improve its treatment and prevent progression to overt HE.

Microbiota transplant for hepatic encephalopathy in cirrhosis: The THEMATIC trial

BACKGROUND & AIMS

Preventing hepatic encephalopathy (HE) recurrence in cirrhosis, which is associated with an altered gut-liver-brain axis, is an unmet need. Benefits of fecal microbiota transplantation (FMT) have been shown in phase I studies, but route and dose-related questions remain.

METHODS

We performed a phase II randomized, placebo-controlled, double-blind, clinical trial of capsule and enema FMT in patients with cirrhosis and HE on lactulose and rifaximin. Participants were randomized into four groups (3 active doses; 2 active and 1 placebo dose; 1 active and 2 placebo doses; 3 placebo doses). Each patient received two capsules and one enema (either placebo or FMT) and were followed for 6 months. The primary outcome was FMT-related (serious) adverse events ([s]AEs)/AEs using intention-to-treat analysis. Secondary outcomes were HE recurrence, all-cause hospitalizations, death, donor engraftment, and quality-of-life. FMT was from a vegan or omnivorous donor.

RESULTS

We enrolled 60 patients (15/group) with similar baseline characteristics. FMT was safe without any FMT-related SAEs/AEs. Overall SAEs (p = 0.96) or death (p = 1.0) were similar. There were significant differences in HE recurrence between groups (p = 0.035, Cramer's V = 0.39). On post hoc analysis, recurrence was highest in the all-placebo vs. any FMT group (40% vs. 9%; odds ratio 0.15, 95% CI 0.04-0.64). Within the FMT groups, HE recurrence rates were similar regardless of route, doses, or donor type. Quality of life improved in FMT-recipient groups. Engraftment was highest in those with high pre-FMT Lachnospiraceae and lower in those whose HE recurred.

CONCLUSIONS

In patients with cirrhosis and HE on maximal therapy, FMT regardless of dose, route, or donor was safe without any FMT-related AEs. On post hoc analysis, HE recurrence was highest in the placebo-only group and linked with lower baseline Lachnospiraceae and reduced donor engraftment.

IMPACT AND IMPLICATIONS

Patients with hepatic encephalopathy (HE) already on maximal therapy could have recurrences, which worsen prognosis and are not prioritized for liver transplant. In this phase II, double-blind, randomized, placebo-controlled trial in patients with cirrhosis and prior overt HE, we found that fecal microbiota transplant (FMT) was safe and well tolerated regardless of route of delivery (oral or enema), number of doses (1 through 3), or donor type (vegan or omnivorous). HE recurrence, which was a key secondary endpoint, was different between groups and, on post hoc analysis, lowest in groups that received any FMT. Donor engraftment was higher in those with higher relative abundance of Lachnospiraceae, which was associated with lower HE recurrence.

A real-world drug safety surveillance study from the FAERS database of hepatocellular carcinoma patients receiving pembrolizumab alone and plus lenvatinib

Pembrolizumab plus Lenvatinib is regarded as a significant treatment option for advanced unresectable hepatocellular carcinoma (HCC). This study aims to meticulously monitor and identify adverse events (AEs) related to this combined therapy, enhance patient safety, and offer evidence-based recommendations for the appropriate use of these drugs. We gathered adverse drug reactions (ADRs)-related data from the FAERS database for HCC patients who received Pembrolizumab, both alone and in combination with Lenvatinib from the first quarter of 2014 to the fourth quarter of 2023. ADRs signal detection was performed using the ROR, PRR, BCPNN, MHRA, and MGPS methods. We gathered data on 459 and 358 AEs from patients with HCC treated with pembrolizumab alone and in combination with lenvatinib, respectively. Using four signal quantification techniques, we identified 50 and 38 distinct AEs, which were classified into 15 different System organ class (SOC) categories. Notably, the most common AEs associated with pembrolizumab were gastrointestinal disorders and hepatobiliary disorders. In both patient groups, the most frequently reported AEs were hepatic encephalopathy, blood bilirubin increased and diarrhea. We also observed some unexpected significant AEs, such as dehydration, skin ulcers, and intestinal perforation. The countries reporting the highest number of AEs were the United States, followed by China, France, and Japan. The median onset time for AEs related to pembrolizumab alone and its combination with lenvatinib was 80.5 days (interquartile range 20.0-217.3 days) and 77.5 days (interquartile range 19.7-212.3 days), respectively. This study offers new insights into the monitoring and management of ADRs in HCC patients receiving pembrolizumab alone or in combination with lenvatinib. It is crucial to closely monitor the safety of this treatment regimen in HCC patients to avoid serious AEs.

Association between overt hepatic encephalopathy and liver pathology after transjugular intrahepatic portosystemic shunt creation in cirrhotic patients

To investigate the association between overt hepatic encephalopathy (OHE) and liver pathology after transjugular intrahepatic portosystemic shunt (TIPS) creation in cirrhotic patients. From July 2015 to April 2024, 73 patients from 4 hospitals in China who received TIPS creation and liver biopsy were retrospectively enrolled in this study. Based on whether OHE occurred within 3 months after TIPS creation, the patients were categorized into OHE (n = 29) and non-OHE (n = 44) groups. The liver pathology was assessed by hematoxylin-eosin (H&E), Sirius red staining, immunohistochemistry, and immunofluorescence. Liver pathology by H&E staining showed typical features of liver cirrhosis (including disordered structure and pseudolobule formation) in all the patients. No marked difference was observed in extracellular matrix (ECM) deposition between the OHE and non-OHE groups. However, the patients in the OHE group had a higher level of liver and systemic inflammation than in the non-OHE group. And there was a strong correction between intrahepatic macrophage infiltration and serum inflammatory indicators. Additionally, the OHE group had more liver neovascularization, which was consistent with liver inflammation. The emergence of OHE after TIPS creation is closely associated with liver pathology, especially in liver inflammation and angiogenesis, but not in ECM deposition.

Vitamin D Supplementation Is Associated with Inflammation Amelioration and Cognitive Improvement in Decompensated Patients with Cirrhosis

Background/Objectives: Decompensated cirrhosis is characterized by systemic inflammation and innate and adaptive immune dysfunction. Hepatic encephalopathy (HE) is a prevalent and debilitating condition characterized by cognitive disturbances in which ammonia and inflammation play a synergistic pathogenic role. Extraskeletal functions of vitamin D include immunomodulation, and its deficiency has been implicated in immune dysfunction and different forms of cognitive impairment. The aim was to assess changes in cognitive function and inflammation in decompensated patients with cirrhosis receiving vitamin D supplementation. Methods: Patients with cirrhosis discharged from decompensation in two tertiary hospitals in Spain (from September 2017 to January 2020) were assessed before, at 6 and 12 months after vitamin D supplementation. A comprehensive neuropsychological battery and neuroinflammatory markers were examined. In a subgroup of patients, peripheral immune blood cells were analyzed. Results: Thirty-nine patients were recruited. Of those, 27 completed the 6 months evaluation and were analyzed [age 62.4 ± 11.3 years; 22 men; Model for End-Stage Liver Disease (MELD) 11.7 ± 4.0; prior overt HE 33%; median 25-hydroxyvitamin D (25OHD) plasma level 12.7 µgr/L] and 22 achieved 12 months assessment. At baseline, learning and memory (R = 0.382; p = 0.049) and working memory (R = 0.503; p = 0.047) subtests correlated with plasma 25OHD levels. In addition, processing speed (R = -0.42; p = 0.04), attention (R = -0.48; p = 0.04), Tinnetti balance (R = -0.656; p < 0.001) and Tinnetti score (R = -0.659; p < 0.001) were linked to neuroinflammation marker IL-1β. Patients with lower 25OHD had a greater proportion of TH1cells at baseline and a larger amelioration of IL-1β and IL-6 following supplementation. An improvement in working memory was found after 25OHD replacement (46.7 ± 13 to 50 ± 11; p = 0.047). Conclusions: This study supports that vitamin D supplementation modulates low-grade inflammation in decompensated cirrhosis providing cognitive benefits, particularly in working memory.