AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage

Left-sided portal hypertension: what an interventional radiologist can offer?

Left-sided portal hypertension (LPH) refers to increased splenic venous pressure caused by splenic vein stenosis or occlusion. Pancreatitis is the leading cause of LPH. Typically, LPH remains asymptomatic, but it can lead to life-threatening hemorrhage from ruptured fundal varices in about 10% of patients. Further, it may be complicated by hypersplenism. Interventional radiology plays an essential role in LPH patients with failed endoscopic treatment. Variceal embolization is an effective salvage measure in bleeding gastric varices, but it carries a risk of recurrence and worsening of hypersplenism. Considering the pathophysiology, splenic vein recanalization (SVR) appears to be the best treatment; nevertheless, its lower technical success rate limits its utility only to a subgroup of LPH patients. Partial splenic embolization (PSE), a non-surgical alternative to splenectomy, reduces the splenic volume and venous outflow, thereby lowering variceal pressure. PSE is technically easier, which may explain its widespread use. Nonetheless, PSE can be complicated by life-threatening sepsis and portal vein thrombosis. Despite all attempts, some LPH patients eventually require a splenectomy. Importantly, the choice of therapy requires multidisciplinary discussion and is often influenced by availability, expertise, and clinical context. This article discusses various interventional strategies for managing LPH with the available evidence. KEY POINTS: Question Pressure within the main portal vein is normal in left-sided portal hypertension; thus, transjugular intrahepatic portosystemic shunt is ineffective. Findings Splenic vein stent placement can restore hepatopetal splenic blood flow and decompress splenic venous pressure. Clinical relevance Partial splenic embolization (PSE) is the most widely used interventional approach to manage left-sided portal hypertension-related complications.

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.

Small Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Embolization for Gastric Varices: A Multicenter Cohort Study

BACKGROUND & AIMS

The effect of transjugular intrahepatic portosystemic shunt (TIPS) plus variceal embolization for treating gastric varices (GVs) remains controversial. This nationwide multicenter cohort study aimed to evaluate whether adding variceal embolization to a small diameter (8-mm) TIPS could reduce the rebleeding incidence in patients with different types of GVs.

METHODS

This retrospective cohort study involved 629 patients who underwent 8-mm TIPS for gastric varices at 7 medical centers. The primary endpoint was all-cause rebleeding, and the secondary endpoints included overt hepatic encephalopathy (OHE) and all-cause mortality.

RESULTS

A total of 629 patients were included. Among them, 429 (68.2%) had gastroesophageal varices type 1 (GOV1), 145 (23.1%) had gastroesophageal varices type 2 (GOV2), and 55 (8.7%) had isolated gastric varices type 1 (IGV1). In the entire cohort, adjunctive embolization reduced rebleeding (6.2% vs 13.6%; P = .005) and OHE (31.0% vs 39.4%; P = .02) compared with TIPS alone. However, no significant differences were found in mortality (12.0% vs 9.7%; P = .42). In patients with GOV2 and IGV1, TIPS plus variceal embolization reduced both rebleeding (GOV2: 7.8% vs 25.1%; P = .01; IGV1: 5.6% vs 30.8%; P = .03) and OHE (GOV2: 31.8% vs 51.5%; P = .008; IGV1: 11.6% vs 38.5%; P = .04). However, in patients with GOV1, adjunctive embolization did not reduce rebleeding (5.9% vs 8.7%; P = .37) or OHE (33.1% vs 35.3%; P = .60).

CONCLUSIONS

Compared with TIPS alone, 8-mm TIPS plus variceal embolization reduced rebleeding and OHE in patients with GOV2 and IGV1. These findings suggest that patients with GOV2 and IGV1, rather than GOV1, could benefit from embolization with TIPS.

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.

Risk Factors for Glue Extrusion Bleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Retrospective Study of 269 Patients

BACKGROUND

Glue extrusion bleeding is a major complication of endoscopic cyanoacrylate glue injection for the treatment of gastric varices. However, its risk factors remain unclear.

AIMS

This retrospective study aimed to evaluate the risk factors for bleeding associated with glue extrusion.

METHODS

This study analyzed the medical data of cirrhotic patients who underwent endoscopic obliteration for gastric varices using cyanoacrylate glue between January 2016 and December 2022. The data within 1 year after therapy were carried out with logistic regression. A nomogram model was constructed based on the factors.

RESULTS

269 patients were enrolled. Risk factors associated with glue extrusion bleeding included the volume of the glue (≥ 4 mL)(OR 1.289, 95% CI 1.051-1.580; P = 0.015), massive ascites (OR 5.645, 95% CI 2.260-14.097; P = 0.000), active hemorrhage during endoscopy (OR 2.830, 95% CI 1.284-6.234; P = 0.010), and the use of β-blockers was a protective factor (OR 0.185, 95% CI 0.07-0.485; P = 0.001). The nomogram model had good prediction accuracy, with an area under the curve of 0.74 (95% CI 0.658-0.822; P < 0.001).

CONCLUSION

Massive ascites, active hemorrhage during endoscopy, glue volume ≥ 4 mL, and the use of β-blockers are associated with glue extrusion bleeding. At-risk patients may benefit from controlling the volume of the glue, undergoing endoscopic ultrasound and using β-blockers.

Future of Endoscopy in Surveillance of Esophageal Varices

PURPOSE OF REVIEW

tTo assess the evolving role of endoscopy assessment for esophageal varices in cirrhosis.

RECENT FINDINGS

The approach to screening endoscopy for varices has significantly changed in the last 10 years with the refinement of non-diagnostic tests. Non-invasive diagnostic methods have reduced the need of upper endoscopies for variceal screening in patients with compensated cirrhosis, focusing primarily on those with ambiguous risk assessments or contraindications to non-selective beta-blockers (NSBBs). In contrast, decompensated cirrhosis patients require more frequent endoscopic evaluations due to their heightened risk of complications and the potential benefit of combination therapy (NSBBs + variceal ligation). In patients with hepatocellular carcinoma (HCC) the performance of non-invasive tests is suboptimal and most patients require endoscopy. Emerging applications of artificial intelligence (AI) can assist in patient triage and the interpretation of endoscopic findings, potentially improving care. Further research is essential to validate these technologies within clinical practice and optimize their integration into patient management strategies.

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.

Benefits of TIPS for Patients With Large Ascites Preceding Recurrent or Refractory ascites: A Multicenter Cohort Study

BACKGROUND AND AIM

Patients with recurrent or refractory ascites can benefit from transjugular intrahepatic portosystemic shunt (TIPS). However, the value of TIPS for patients with large ascites remains unclear.

METHODS

This retrospective multicenter study included patients who underwent TIPS or medicine plus large-volume paracentesis (medicine + LVP) for ascites between January 2014 and December 2022 at five centers. The primary endpoint was recurrence or worsening of ascites. The secondary endpoints were liver-related death, all-cause hemorrhage, overt hepatic encephalopathy (OHE), and shunt dysfunction.

RESULTS

Overall, 724 patients were evaluated, including 373 patients with large ascites preceding recurrent or refractory ascites received TIPS (the LA-TIPS group), 282 patients with recurrent and refractory ascites received TIPS (the RA-TIPS group), and 69 patients with large ascites preceding recurrent or refractory ascites received medicine + LVP (the LA-M group). Patients in the LA-TIPS group had significantly lower incidences of recurrence or worsening of ascites (37.4% vs. 45.3%, p < 0.001), liver-related death (44.8% vs. 62.0%, p < 0.001), and OHE (47.3% vs. 60.3%, p < 0.001) than those in the RA-TIPS group. Meanwhile, patients in the LA-TIPS group had significantly lower incidences of recurrence or worsening of ascites (37.4% vs. 44.6%, p = 0.006) and hemorrhage (38.3% vs. 47.2%, p = 0.042), but a higher incidence of OHE (34.2% vs. 4.5%, p < 0.001) than those in the LA-M group.

CONCLUSIONS

In terms of controlling ascites, the benefit of TIPS was greater in patients with large ascites preceding recurrent or refractory ascites, suggesting that TIPS might be considered in patients with large ascites before they progress to recurrent or refractory stages.

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.

Trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) of bleeding gastric varices associated with gastrorenal shunts in cirrhosis

Background & Aims

There is a lack of consensus on the optimal management of fundal gastric varices (GVs) in patients with cirrhosis due to varied anatomy and hemodynamics. In this study, we evaluate the safety and efficacy of trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) for preventing recurrent bleeding in fundal GVs associated with gastrorenal shunt (GRS).

Methods

In this 4-year study, patients with cirrhosis with GRS-associated GV bleeding, without prior esophageal variceal bleeding, ascites, or portal vein thrombosis, were eligible for TACATO. Trans-splenic access was achieved by puncturing a splenic venous branch using ultrasound/fluoroscopic guidance. A microcatheter was inserted into the varices for embolization with detachable microcoils and possibly N-butyl-cyanoacrylate-Lipiodol. Technical success was assessed by venography. All patients underwent follow-up endoscopy and decompensating events were recorded. A retrospective external control group of patients with cirrhosis and similar GRS-associated GVs treated by retrograde transvenous obliteration was enrolled as a comparative group.

Results

Twenty patients with cirrhosis underwent TACATO (17 GOV2, 6 IGV1 - median GRS size 23 mm, range 15-32 mm). Median occlusion of the shunt was 90% (complete in 14/20); complications included local abdominal pain and partial splanchnic thrombosis in two patients. Over a median follow-up of 23 (range 10-31) months, no rebleeding or further decompensation occurred; liver function remained stable and endoscopy showed reduced or resolved fundal GVs without worsening esophageal varices in all patients. The comparative group (18 patients - median GRS diameter 14 mm, range 6-23 mm) reported no rebleeding but worsening varices in two and ascites progression in two.

Conclusions

TACATO is a viable option for secondary prophylaxis of bleeding from GVs associated with GRS and may reduce hepatic decompensation risk. Further studies are needed to validate these results and determine TACATO's broader role in GV management.

Impact and implications

Gastric varices (GVs) affect 20% of patients with cirrhosis, with a 2-year bleeding risk of 25%. Fundal GVs, which account for 70% of cases, are associated with mortality rates of up to 55%, posing management challenges due to their complex anatomy and hemodynamics. Transjugular intrahepatic portosystemic shunt placement often fails to address fundal GV hemodynamics, leaving patients at a high risk of rebleeding. Balloon-occluded retrograde transvenous obliteration, while effective, is limited by complexity, logistical hurdles, and complications. TACATO (trans-splenic anterograde coil-assisted transvenous occlusion) provides effective secondary prophylaxis for fundal GV bleeding linked to gastrorenal shunts. It matches the efficacy of retrograde and anterograde techniques while offering faster execution, minimal side effects, and no need for specialized equipment or gastrorenal shunt size restrictions. Trans-splenic access ensured safe and straightforward access to the portal system and fundal GVs in all patients treated with TACATO.

Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt

This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.

Coil or plug-assisted retrograde transvenous obliteration (CARTO/PARTO) for treating portal hypertensive variceal bleeding: A multicenter, real-world 10-year retrospective study

BACKGROUND AND AIMS

Coil-assisted retrograde transvenous obliteration (CARTO) and plug-assisted retrograde transvenous obliteration (PARTO) are well-accepted treatments for gastric variceal bleeding. However, long-term (>2 y) clinical outcomes have yet to be studied. In this study, we investigated long-term clinical outcomes, including overall survival (OS) in 10 years.

APPROACH AND RESULTS

We performed a multinational, multicenter, retrospective study of CARTO/PARTO in gastric varices treatments between May 2012 and July 2024. The primary study outcomes were a long-term OS and prognostic factors of CARTO/PARTO. The secondary outcomes were long-term clinical/technical success, complications, and clinical changes including portal hypertensive symptoms. A total of 311 patients (41% female; 69% CARTO) from 13 centers in 5 countries were included. The cumulative 1-, 3-, 5-, 7-, and 10-year OS rates were 98%, 80%, 68%, 52%, and 33%, respectively, with a median OS of 99 months. Prophylactic CARTO/PARTO showed a better OS than CARTO/PARTO for active bleeding ( p =0.00035). The independent prognostic factors of OS were having high pre-MELD, concurrent HCC, treating GOV2, history of esophageal variceal bleeding, high pre-TBili, and ammonia levels. Notably, a high pre-MELD score >27 had a significantly higher mortality rate (92.6%) than a lower pre-MELD score ( p <0.001). The overall cumulative 1-, 3-, 5-, 7-, and 10-year recurrent gastric varices bleeding rates were 0.9%, 3.2%, 4.0%, 4.5%, and 5.4%, respectively. The overall technical and clinical success rates were 96.5% and 95.3%, respectively, with a 4.5% major complication rate over 10 years.

CONCLUSIONS

CARTO and PARTO have excellent long-term survival and clinical outcomes. However, these are negatively affected by high MELD scores, concomitant HCC, and coexisting esophageal varices.

Clinical application of subharmonic aided pressure estimation (SHAPE) in the assessment of portal hypertension in patients with decompensated cirrhosis: A pilot study

PurposeThe aim of the study was to explore the possibility of subharmonic aided pressure estimation (SHAPE) measurement for noninvasive evaluation of portal hypertension in patients with decompensated liver cirrhosis.Materials and MethodsPatients diagnosed with decompensated liver cirrhosis were prospectively enrolled. SHAPE measurement was performed by using an ultrasound system. A continuous infusion of sonazoid at a rate of 0.18 ml/kg/h and saline at 120 ml/h was performed. The hepatic venous pressure gradient (HVPG) value are the gold standard for evaluating portal hypertension. The Pearson coefficient and areas under the receiver operating characteristic curves (AUCs) were analyzed.ResultsFrom February 2023 to August 2023, 15 patients (mean age, 61.1 ± 8.3 years; eight men and seven women) were included. The correlation coefficient of the SHAPE gradient and HVPG was 0.33. The mean SHAPE gradient of patients with clinically significant portal hypertension (CSPH) (HVPG ≥ 10 mmHg) was significantly higher than that of patients with lower risk (0.5 ± 4.4 dB vs. -7.4 ± 5.1 dB, P = 0.01). Patients with increased risk for variceal hemorrhage (HVPG ≥ 12 mmHg) had a significantly higher mean SHAPE gradient than patients with lower risk (HVPG < 12 mmHg) (1.3 ± 4.4 dB vs. -5.9 ± 4.8 dB; P = 0.01). The optimal cut-off values of the SHAPE gradient for diagnosing patients with CSPH and at increased risk for variceal hemorrhage were -1.3 dB and -0.6 dB (both AUC = 0.89), respectively.ConclusionSHAPE measurement is a potential noninvasive, effective imaging method to evaluate portal hypertension among patients diagnosed with decompensated liver cirrhosis in clinical practice.

Novel subharmonic-aided pressure estimation for identifying high-risk esophagogastric varices

BACKGROUND

Subharmonic-aided pressure estimation (SHAPE) is a technique for determining changes in ambient pressure. We aimed to analyze a novel SHAPE integrated into ultrasound diagnostic equipment to predict patients with liver cirrhosis at high risk of esophagogastric varices (EV).

METHODS

This prospective study included 111 patients with liver cirrhosis diagnosed between 2020 and 2023. We obtained liver stiffness measurements (LSM) and spleen stiffness measurements (SSM) using shear wave elastography and hepatic vein-portal vein (HV-PV) gradient using the SHAPE method. The EV risk was determined either as null, low, or high by esophagoscopy and Child-Pugh stage.

RESULTS

HV-PV gradient increased concordantly with the increase in EV risk (- 7.0 dB in null-risk, - 4.4 dB in low-risk, and - 2.0 dB in high-risk) with statistically significant difference among any two groups. The most appropriate cut-off value of the HV-PV gradient was - 3.5 dB, and sensitivity, specificity, and positive and negative predictive values were 80.0%, 89.0%, 80.0%, and 88.0%, respectively. The areas under the curve values for predicting the high-risk EV were 0.920, 0.843, and 0.824 for the HV-PV gradient, LSM, and SSM, respectively.

CONCLUSIONS

The novel SHAPE system demonstrated high accuracy in identifying patients with liver cirrhosis at a high risk of EV.

Three-dimensional volumetric CT image fusion and trans-abdominal US: Adjunct guidance to portal vein cannulation for TIPS

PURPOSE

To describe portal vein cannulation under adjunct guidance for transjugular intrahepatic portosystemic shunts (TIPS).

METHODS

Medical records of 86 patients who underwent TIPS, including conventional TIPS, 3D volumetric CT image fusion (CT-fluoroscopy image fusion)-guided TIPS, and trans-abdominal ultrasound (US)-guided TIPS at our institute from March 2016 to June 2024 were reviewed. Baseline characteristics, clinical outcomes, and procedural data were analyzed.

RESULTS

Technical success was achieved in 35 conventional TIPS patients (92.11 %), 20 CT-fluoroscopy image fusion-guided TIPS patients (95.24 %), and 26 transabdominal US-guided TIPS patients (96.30 %). Among patients who underwent a successful procedure, the procedural time and contrast usage were lower in the CT-fluoroscopy image fusion-guided and trans-abdominal US-guided TIPS groups than in the conventional group. There was a statistical significance in the cumulative fluoroscopic time between CT-fluoroscopy image fusion-guided TIPS and conventional TIPS groups (43.19 ± 14.92 vs 63.05 ± 30.33 min, p = 0.012). No immediate experienced complications were observed. Furthermore, the incidence of post-procedural complications among the three groups was not statistically different during follow-up.

CONCLUSIONS

CT-fluoroscopy image fusion and trans-abdominal US-guided portal vein cannulation are feasible, safe, and effective adjunct methods for patients undergoing TIPS. These methods provide shorter procedural time and lower contrast usage for TIPS placement.

Identifying the optimal measurement timing and hemodynamic targets of portal pressure gradient after TIPS in patients with cirrhosis and variceal bleeding

BACKGROUND & AIMS

The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) placement remain unclear. This study aimed to identify the ideal moment for hemodynamic measurements and the optimal target of PPG in patients undergoing covered TIPS for variceal bleeding.

METHODS

Between May 2018 and December 2021, 466 consecutive patients with recurrent variceal bleeding treated with covered TIPS were prospectively included. Post-TIPS PPG was measured immediately (immediate PPG), 24-72 hours (early PPG), and again 1 month (late PPG) after TIPS placement. The agreement among PPGs measured at different time points was assessed by intra-class correlation coefficient (ICC) and Bland-Altman method. The unadjusted and confounder-adjusted effects of PPGs on clinical outcomes (portal hypertensive complications [PHCs], overt hepatic encephalopathy [OHE], further decompensation, and death) were assessed using Fine and Gray competing risk regression models.

RESULTS

The agreement between early PPG and late PPG (ICC: 0.34) was better than that between immediate PPG and late PPG (ICC: 0.23, p <0.001). Early PPG revealed an excellent predictive value for PHCs (early PPG≥ vs. <12 mmHg: adjusted hazard ratio 2.17, 95% CI 1.33-3.55, p = 0.002) and OHE (0.40, 95% CI 0.17-0.91, p = 0.030), while immediate PPG did not. Late PPG showed a predictive value for PHC risk but not OHE. By targeting the lowest risk of further decompensation, we identified an optimal hemodynamic target with early PPG ranging from 11 to 14 mmHg that was associated with a decreased risk of OHE and effective prevention of PHCs.

CONCLUSIONS

PPG measured 24 to 72 hours after TIPS correlates with long-term PPG and clinical outcomes, and a hemodynamic target PPG of 11-14 mmHg is associated with reduced encephalopathy but not compromised clinical efficacy.

IMPACT AND IMPLICATIONS

The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) remain unclear. Here we show that post-TIPS PPG measured at least 24 hours but not immediately after the procedure correlated with long-term PPG and clinical events. Thus, PPG measurements taken at least 24 hours after TIPS should be used to guide decision making in order to improve clinical outcomes. Targeting a post-TIPS PPG of 11-14 mmHg or a 20%-50% relative reduction from pre-TIPS baseline measured 24-72 hours after the procedure was associated with reduced encephalopathy but not compromised clinical efficacy. Thus, these criteria could be used to guide TIPS creation and revision in patients with cirrhosis and variceal bleeding undergoing covered TIPS.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, ID: NCT03590288.

Update on Hepatorenal Syndrome: From Pathophysiology to Treatment

Hepatorenal syndrome-acute kidney injury (HRS-AKI) occurs in the setting of advanced chronic liver disease, portal hypertension, and ascites. HRS-AKI is found in ∼20% of patients presenting to the hospital with AKI, but it may coexist with other causes of AKI and/or with preexisting chronic kidney disease, thereby making the diagnosis challenging. Novel biomarkers such as urinary neutrophil gelatinase-associated lipocalin may be useful. While HRS-AKI is a functional form of AKI related to circulatory and neurohormonal dysfunction, there is increasing recognition of the importance of systemic inflammation and the renal microenvironment. Early diagnosis and initiation of HRS-AKI-specific treatment can improve outcomes. The mainstay of therapy is a vasoconstrictor (terlipressin or norepinephrine) combined with albumin, which achieves resolution of HRS in 40-50% of cases. Liver transplantation is the only option for patients failing to respond to medical therapies.

Portal Hypertensive Gastropathy and MELD-Na Score Predict Recurrent Gastrointestinal Bleeding After TIPSS: An ALTA Group Study

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPSS) is highly effective for treatment of variceal bleeding; however, factors contributing to rebleeding complications remain unclear.

AIMS

In this study, we aim to determine risk factors for recurrent portal hypertensive gastrointestinal bleeding following TIPSS.

METHODS

Utilising the Advancing Liver Therapeutic Approaches multicentre database, we retrospectively identified adult patients who underwent TIPSS for secondary prophylaxis of variceal bleeding and had a gastrointestinal rebleeding event within 1 year. We developed multivariable logistic regression models to identify clinical/procedural characteristics associated with rebleeding.

RESULTS

We identified 476 patients, predominately middle-aged (mean age 57), male (62%) and White (65%), with mean MELD-Na 16. 16% (n = 77) had a rebleeding event; these patients were more likely to be male (p = 0.016), with higher serum creatinine (p = 0.005), MELD-Na (p = 0.0002), portal hypertensive gastropathy on pre-TIPSS upper endoscopy (p = 0.000) and with higher incidence of TIPSS revision (p = 0.000). There were no significant differences in type of TIPSS endoprosthesis, concurrent embolotherapy, and post-TIPSS pressure gradients between those who experienced rebleeding and those who did not. After adjusting for TIPSS revision, multivariable analysis revealed MELD-Na and presence of portal hypertensive gastropathy on pre-TIPSS endoscopy were independently associated with rebleeding.

CONCLUSIONS

In this retrospective analysis of a multicentre, nationally representative database, we found that apart from TIPSS-related factors, high MELD-Na and portal hypertensive gastropathy on pre-TIPSS endoscopy were independent predictors of rebleeding within 1 year following TIPSS. These variables may be used to identify high-risk patients who may require additional monitoring following TIPSS.

Transjugular intrahepatic portosystemic shunt for the patients on the liver transplant list

Patients with cirrhosis-associated and portal hypertension-associated complications may benefit from TIPS and/or liver transplantation. In many patients, the decision of whether or not TIPS should be placed prior to liver transplantation is fairly clear-cut. Nevertheless, there are some patients in whom the decision can be more complex. On one hand, TIPS is easily available in contrast to liver transplantation, and patients with TIPS may have clinical improvement. On the other hand, although TIPS may improve the situation of the patient, this improvement may not be sufficient to significantly improve the quality of life. Furthermore, TIPS malposition may be challenging for liver transplantation surgery. This review approaches the advantages and disadvantages of TIPS placement in patients who are candidates for liver transplantation and proposes decision pathways for patients with complications of portal hypertension on the liver transplant waiting list.

Nonalcohol-related Cirrhosis Leads to Higher 6-week Mortality After Acute Variceal Bleeding Than Alcohol-related Cirrhosis

BACKGROUND & AIMS

Acute variceal bleeding (AVB) portends significant 6-week mortality in patients with cirrhosis. It remains unclear if the correlation between liver prognostic scores and 6-week mortality are similar across different etiologies of liver cirrhosis, particularly alcohol-related liver disease (ALD) vs non-alcohol-related liver disease (non-ALD). This study aims to compare the 6-week mortality following AVB in these 2 patient populations.

METHODS

We assessed outcomes after AVB in 2 large multicenter cohorts from the United States and Singapore of patients with cirrhosis presenting with AVB. Using multivariable logistic regression, 6-week mortality between ALD and non-ALD cirrhosis was compared. Sensitivity analyses were performed with propensity-score matching analyses of the overall cohort.

RESULTS

A total of 1349 patients with AVB from the United States (n = 469) and Singapore (n = 880) cohorts were included. The aggregated cohort consisted of 379 patients (27.5%) with ALD cirrhosis. The overall 6-week mortality was 14.4%. Non-ALD cirrhosis was associated with a significantly higher 6-week mortality than ALD cirrhosis after accounting for Child-Turcotte-Pugh (CTP) score (adjusted odds ratio [aOR], 2.9; 95% confidence interval [CI], 1.5-5.3), Model of End-stage Liver Disease (MELD) score (aOR, 3.0; 95% CI, 1.6-5.6), and MELD 3.0 score (aOR, 3.3; 95% CI, 1.7-6.4). Addition of cirrhosis etiology (ALD vs non-ALD) to existing prognostic scores improved the prediction of 6-week mortality following AVB (MELD 3.0 c-statistic: 0.784 vs 0.770; P < .001). An etiology-adjusted updated MELD 3.0 model was the best prediction model for 6-week mortality after AVB.

CONCLUSION

Patients with non-ALD cirrhosis presenting with AVB had a higher risk of 6-week mortality, at each severity of liver disease by standard indices, than patients with ALD cirrhosis. Cirrhosis etiology (ALD vs non-ALD) should be incorporated into the risk stratification of patients with AVB.

CIRSE Standards of Practice on Transjugular Intrahepatic Portosystemic Shunts

BACKGROUND

Proposed in the early 1980s as a solution for managing complications of portal hypertension, the percutaneous creation of transjugular intrahepatic portosystemic shunt has consistently gained a central role. Increasingly lower complication rates have been observed thanks to improvements in both technologies and the skills of interventional radiologists.

PURPOSE

This document is aimed at interventional radiologists and provides best practice recommendations for transjugular intrahepatic portosystemic shunt creation, describing patient selection, intraprocedural management and follow-up, in addition to recommendations in paediatric settings.

METHODS

The CIRSE Standards of Practice Committee established a writing group consisting of seven European clinicians with recognised expertise in the creation of transjugular intrahepatic portosystemic shunt. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select relevant publications in the English language and involving human subjects, preferably published from 2009 to 2024. The final recommendations were developed by consensus.

RESULTS

TIPS creation has an established role in the successful management of portal hypertension and its complications. This Standards of Practice document provides up-to-date recommendations for patient selection, materials, its safe performance, and follow-up with complications management.

Comprehensive approach to esophageal variceal bleeding: From prevention to treatment

Esophageal variceal bleeding is a severe complication often associated with portal hypertension, commonly due to liver cirrhosis. Prevention and treatment of this condition are critical for patient outcomes. Preventive strategies focus on reducing portal hypertension to prevent varices from developing or enlarging. Primary prophylaxis involves the use of non-selective beta-blockers, such as propranolol or nadolol, which lower portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices. Endoscopic variceal ligation (EVL) may also be employed as primary prophylaxis to prevent initial bleeding episodes. Once bleeding occurs, immediate treatment is essential. Initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs such as octreotide or terlipressin to control bleeding. Endoscopic intervention is the cornerstone of treatment, with techniques such as EVL or sclerotherapy applied to directly manage the bleeding varices. In cases where bleeding is refractory to endoscopic treatment, transjugular intrahepatic portosystemic shunt may be considered to effectively reduce portal pressure. Long-term management after an acute bleeding episode involves secondary prophylaxis using beta-blockers and repeated EVL sessions to prevent rebleeding, complemented by monitoring and managing liver function to address the underlying disease. In light of new scientific evidence, including the findings of the study by Peng et al, this editorial aims to review available strategies for the prevention and treatment of esophageal varices.

Fatal acute pulmonary embolism following endoscopic cyanoacrylate injection for gastric fundal varices

Acute gastric variceal bleeding is a rare but serious complication of portal hypertension. Initial therapy for bleeding gastric varices focuses on acute hemostasis. In this regard, endoscopic cyanoacrylate injection (ECI) is the first-line approach. Cyanoacrylate diluted with Lipiodol acts as a tissue adhesive that polymerizes on contact with blood. Glue-induced pulmonary embolism is a very rare but severe complication of ECI. This paper describes a case of fatal glue pulmonary embolism during ECI for prevention of bleeding from gastric fundal varices in a patient with polycythemia vera and the presence of portosystemic shunts.

Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit

BACKGROUND AND AIMS

Acute variceal bleeding (AVB) is a major complication in patients with cirrhosis. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB.

APPROACH AND RESULTS

We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all 5 QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-week mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort.A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6 weeks (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) ( p <0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, nonadherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence to the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality.

CONCLUSIONS

Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.

Transjugular intrahepatic portosystemic shunt in patients with splanchnic vein thrombosis: Prevalence and management of patent foramen ovale

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the treatment of several complications of portal hypertension (PH), including non-neoplastic portal vein thrombosis (PVT). Selection criteria for TIPS in PVT are not yet well established. Despite anecdotal, cases of thromboembolic events from paradoxical embolism due to the presence of patent foramen ovale (PFO) after TIPS placement have been reported in the literature. Therefore, we aimed at describing our experience in patients with non-neoplastic splanchnic vein thrombosis (SVT) who underwent TIPS following PFO screening.

METHODS

We conducted a single-centre retrospective study, including consecutive patients who underwent TIPS for the complications of cirrhotic and non-cirrhotic portal hypertension (NCPH) and having SVT.

RESULTS

Of 100 TIPS placed in patients with SVT, 85 patients were screened for PFO by bubble-contrast transthoracic echocardiography (TTE) with PFO being detected in 22 (26%) cases. PFO was more frequently detected in patients with non-cirrhotic portal hypertension (NCPH) (23% in the PFO group vs. 6% in those without PFO, p = .04) and cavernomatosis (46% in the PFO group vs. 19% in those without PFO, p = .008). Percutaneous closure was effectively performed in 11 (50%) after multidisciplinary evaluation of anatomical and clinical features. No major complications were observed following closure.

CONCLUSIONS

PFO screening and treatment may be considered feasible for patients with SVT who undergo TIPS placement.

French guidelines on TIPS: Indications and modalities

Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.

Advances in the management of complications from cirrhosis

Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.

Radiological and Surgical Treatments of Portal Hypertension

Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.

Non-contrast-enhanced MR angiography of left gastric vein in patients with gastroesophageal varices: morphology and blood supply analysis

OBJECTIVES

To investigate the feasibility of non-contrast-enhanced MR angiography (NCE-MRA) in evaluating the morphology and blood supply of left gastric vein (LGV) in patients with gastroesophageal varices.

METHODS

Between March 2021 and October 2022, patients with gastroesophageal varices and who underwent NCE-MRA were retrospectively reviewed. In order to evaluate the blood supply of LGV, superior mesenteric vein (SMV) and splenic vein (SV) were visualized separately by using inflow-sensitive inversion recovery sequence. Two radiologists independently assessed the image quality, determined the origination and the blood supply of LGV, and measured the diameter of LGV. The origination and diameter of LGV were compared between NCE-MRA and contrast-enhanced CT. Differences in blood supply were compared between LGVs with different originations.

RESULTS

A total of 53 patients were enrolled in this study and the image quality was categorized as good or excellent in 52 patients. No significant differences were observed in visualizing the origination and the diameter of LGV between NCE-MRA and contrast-enhanced CT (p > .05). The blood supply of LGV was related to its origination (p < .001). Most LGVs with SV origination were supplied by SV. If LGV was originated from the portal vein (PV), about 70% of them were supplied by both SV and SMV. Compared with LGVs with SV origination, LGVs with PV origination showed more chance to receive blood from SMV (p < .001).

CONCLUSION

Non-contrast-enhanced MR angiography appears to be a reliable technique in evaluating the morphology and blood supply of LGV in patients with gastroesophageal varices.

CLINICAL RELEVANCE STATEMENT

Non-contrast-enhanced MR angiography provides valuable information for the management of gastroesophageal varices. Especially, it benefits patients with renal insufficiency.

KEY POINTS

• Non-contrast-enhanced MR angiography using inflow-sensitive inversion recovery technique can be used for evaluating not only morphology as CT but also blood supply of left gastric vein. • The blood supply of left gastric vein is related to its origination and left gastric vein with portal vein origination shows more chance to receive blood from superior mesenteric vein.

Milestones to optimize of transjugular intrahepatic portosystemic shunt technique as a method for the treatment of portal hypertension complications

This editorial describes the milestones to optimize of transjugular intrahepatic portosystemic shunt (TIPS) technique, which have made it one of the main methods for the treatment of portal hypertension complications worldwide. Innovative ideas, subsequent experimental studies and preliminary experience of use in cirrhotic patients contributed to the introduction of TIPS into clinical practice. At the moment, the main achievement in optimize of TIPS technique is progress in the qualitative characteristics of stents. The transition from bare metal stents to extended polytetrafluoroethylene-covered stent grafts made it possible to significantly prevent shunt dysfunction. However, the question of its preferred diameter, which contributes to an optimal reduction of portal pressure without the risk of developing post-TIPS hepatic encephalopathy, remains relevant. Currently, hepatic encephalopathy is one of the most common complications of TIPS, significantly affecting its effectiveness and prognosis. Careful selection of patients based on cognitive indicators, nutritional status, assessment of liver function, etc., will reduce the incidence of post-TIPS hepatic encephalopathy and improve treatment results. Optimize of TIPS technique has significantly expanded the indications for its use and made it one of the main methods for the treatment of portal hypertension complications. At the same time, there are a number of limitations and unresolved issues that require further randomized controlled trials involving a large cohort of patients.

Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management

BACKGROUND

Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes.

AIMS

To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases.

METHODS

We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals.

RESULTS

Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered.

CONCLUSIONS

Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.

Attitudes towards transjugular intrahepatic portosystemic shunt (TIPS) in Australia: a national survey of TIPS centres

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive therapeutic option to treat the sequelae of portal hypertension. It is unclear whether current international recommendations are reflected in current clinical practice across Australia and the extent of variations in care. This study aimed to address this gap in knowledge and benchmark the current landscape of TIPS services in Australia against international guidelines.

METHODS

We designed a 42-item questionnaire according to practice-based recommendations and standards of international guidelines to investigate current landscape of TIPS service across four key domains: (1) service provision, (2) patient selection and indications, (3) best procedure practice, and (4) postoperative care.

RESULTS

Gastroenterologist/hepatologists from 23 major liver centres (67.6%) across Australia currently performing TIPS completed the questionnaire. Between 2017 and 2020, there were 456 elective TIPS insertions. Units offering TIPS service had a low median number of TIPS insertions (n=7 per annum). More than half of respondents (56.5%) did not have institutional clinical practice protocols. There was marked variation in practices across institutions in terms of TIPS indications and patient selection. Despite variations, the success rate of elective TIPS was high at 91.7% (79-100%), with 86.6% (29-100%) for rescue TIPS. There was significant variation in postoperative follow-up and care.

CONCLUSION

Current TIPS practice in Australia varies significantly across institutions. There is a need for a national consensus clinical practice guidelines to improve access and minimise unwarranted variation. A national registry for TIPS could measure, monitor, and report on quality of clinical care and patient outcomes.

Challenges in the Management of Esophagogastric Varices and Variceal Hemorrhage in Cirrhosis - A Narrative Review

Over the past decade, significant advancements in pharmacological, endoscopic, and radiographic treatments have emerged in the management of patients with cirrhosis and esophagogastric varices or variceal hemorrhage. These advances have been in several areas, including the role of screening and primary prophylaxis (preventing an initial variceal bleed), evaluation and management of acute esophagogastric variceal hemorrhage, and in preventing variceal rebleeding. Therefore, we believe there is a need for an updated, evidence-based "narrative review" on this important clinical topic that will be relevant for internists, hospitalists, intensive care unit physicians, and those in training. We believe the guidance presented in this narrative review will enhance daily medical practice of health care professionals and has the potential to improve quality of care for these complex patients.

Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting

Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.

Development of a Liver Disease-Specific Large Language Model Chat Interface using Retrieval Augmented Generation

Background

Large language models (LLMs) have significant capabilities in clinical information processing tasks. Commercially available LLMs, however, are not optimized for clinical uses and are prone to generating incorrect or hallucinatory information. Retrieval-augmented generation (RAG) is an enterprise architecture that allows embedding of customized data into LLMs. This approach "specializes" the LLMs and is thought to reduce hallucinations.

Methods

We developed "LiVersa," a liver disease-specific LLM, by using our institution's protected health information (PHI)-complaint text embedding and LLM platform, "Versa." We conducted RAG on 30 publicly available American Association for the Study of Liver Diseases (AASLD) guidelines and guidance documents to be incorporated into LiVersa. We evaluated LiVersa's performance by comparing its responses versus those of trainees from a previously published knowledge assessment study regarding hepatitis B (HBV) treatment and hepatocellular carcinoma (HCC) surveillance.

Results

LiVersa answered all 10 questions correctly when forced to provide a "yes" or "no" answer. Full detailed responses with justifications and rationales, however, were not completely correct for three of the questions.

Discussions

In this study, we demonstrated the ability to build disease-specific and PHI-compliant LLMs using RAG. While our LLM, LiVersa, demonstrated more specificity in answering questions related to clinical hepatology - there were some knowledge deficiencies due to limitations set by the number and types of documents used for RAG. The LiVersa prototype, however, is a proof of concept for utilizing RAG to customize LLMs for clinical uses and a potential strategy to realize personalized medicine in the future.