Machine learning prediction of hepatic encephalopathy for long-term survival after transjugular intrahepatic portosystemic shunt in acute variceal bleeding

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is an effective intervention for managing complications of portal hypertension,particularly acute variceal bleeding(AVB).While effective in reducing portal pressure and preventing rebleeding,TIPS is associated with a considerable risk of overt hepatic encephalopathy(OHE),a complication that significantly elevates mortality rates.AIM To develop a machine learning(ML)model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset.METHODS This retrospective single-center study included 218 patients with AVB who underwent TIPS.The dataset was divided into training(70%)and testing(30%)sets.Critical features were identified using embedded methods and recursive feature elimination.Three ML algorithms-random forest,extreme gradient boosting,and logistic regression-were validated via 10-fold cross-validation.SHapley Additive exPlanations analysis was employed to interpret the model’s predictions.Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival(OS)between patients with and without OHE.RESULTS The median OS of the study cohort was 47.83±22.95 months.Among the models evaluated,logistic regression demonstrated the highest performance with an area under the curve(AUC)of 0.825.Key predictors identified were Child-Pugh score,age,and portal vein thrombosis.Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS(P=0.005).The 5-year survival rate was 78.4%,with an OHE incidence of 15.1%.Both actual OHE status and predicted OHE value were significant predictors in each Cox model,with model-predicted OHE achieving an AUC of 88.1 in survival prediction.CONCLUSION The ML model accurately predicts post-TIPS OHE and outperforms traditional models,supporting its use in improving outcomes in patients with AVB.

Gut microbiome composition in patients with liver cirrhosis with and without hepatic encephalopathy: A systematic review and metaanalysis

BACKGROUND The gut microbiome is associated with hepatic encephalopathy(HE),but research results on the gut microbiome characteristics of patients with liver cirrhosis with and without HE are inconsistent.AIM To study the gut microbiota characteristics of patients with liver cirrhosis with and without HE.METHODS We searched the PubMed,Web of Science,EMBASE,and Cochrane databases using two keywords,HE,and gut microbiome.According to the inclusion and exclusion criteria,suitable literature was screened to extract data on the diversity and composition of the fecal microbiota in patients with liver cirrhosis with and without HE.The data were analyzed using RevMan and STATA.RESULTS Seventeen studies were included:(1)A meta-analysis of 7 studies revealed that the Shannon index in liver cirrhosis patients with HE was significantly lower than that in patients without HE[-0.20,95%confidence interval(CI):-0.28 to-0.13,I2=20%];(2)The relative abundances of Lachnospiraceae(-2.73,95%CI:-4.58 to-0.87,I2=38%)and Ruminococcaceae(-2.93,95%CI:-4.29 to-1.56,I2=0%)in liver cirrhosis patients with HE was significantly lower than those in patients without HE;(3)In patients with HE,Enterococcus,Proteobacteria,Enterococcaceae,and Enterobacteriaceae proportions increased,but Ruminococcaceae,Lachnospiraceae,Prevotellaceae,and Bacteroidetes proportions decreased;(4)Differences in the fecal metabolome between liver cirrhosis patients with and without HE were detected;and(5)Differential gut microbiomes may serve as diagnostic and prognostic tools.CONCLUSION The gut microbiomes of patients with liver cirrhosis with and without HE differ.Some gut microbiomes may distinguish liver cirrhosis patients with or without HE and determine patient prognosis.

Innovative diagnostic tool aids screening for minimal hepatic encephalopathy in non-alcoholic cirrhosis patients

In this editorial we comment on the article by Jiang et al.We focus on the Ence-phalApp Stroop test which is an innovative,smartphone-based tool specifically designed for screening minimal hepatic encephalopathy(MHE)in cirrhosis patients.Traditional MHE screening methods,while highly sensitive and specific,are often complex,time-consuming,and require controlled environmental con-ditions,limiting their widespread clinical use.The EncephalApp Stroop test si-mplifies the screening process,enhances diagnostic efficiency,and is applicable across diverse cultural contexts.However,the combination of additional bio-markers could further improve diagnostic accuracy.Despite its promising po-tential,more multicenter clinical studies are required to validate its effectiveness and applicability on a global scale.

Portocaval shunts'role in gut microbiota and hepatic encephalopathy:The gut-to-brain pathway

I read the study by Zhao et al with great interest.Although the study design was quite complicated,it was successful in raising awareness of science and relevant researchers.Thirty patients with liver cirrhosis and portal hypertension secondary to chronic hepatitis B were included in the study.They were treated for variceal bleeding and underwent trans-jugular intrahepatic portosystemic shunt to prevent the recurrence of variceal bleeding and to reduce portal pressure.The authors evaluated the effects of changes in gut microbiota(GM)on hepatic encephalopathy secondary to portocaval bypass.The GM is greatly affected by local and general factors,including herbal and medical drugs,a person's dietary characteristics(carnivorous,vegan,vegetarian),supplementary foods,drinking water sources,and living in a city center or town.Therefore,I congratulate Zhao et al for their concise and comprehensive study on a multifactorial subject.

Spleen volume is associated with overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with portal hypertension

BACKGROUND Portal shunt and immune status related to the spleen are related to the occurrence of hepatic encephalopathy(HE).It is unknown whether spleen volume before transjugular intrahepatic portosystemic shunt(TIPS)is related to postoperative HE.AIM To investigate the relationship between spleen volume and the occurrence of HE.METHODS This study included 135 patients with liver cirrhosis who underwent TIPS,and liver and spleen volumes were elevated upon computed tomography imaging.The Kaplan-Meier curve was used to compare the difference in the incidence rate of HE among patients with different spleen volumes.Univariate and multivariate Cox regression analyses were performed to identify the factors affecting overt HE(OHE).Restricted cubic spline was used to examine the shapes of the dose-response association between spleen volumes and OHE risk.RESULTS The results showed that 37(27.2%)of 135 patients experienced OHE during a 1-year follow-up period.Compared with preoperative spleen volume(901.30±471.90 cm3),there was a significant decrease in spleen volume after TIPS(697.60±281.0 cm^(3))in OHE patients.As the severity of OHE increased,the spleen volume significantly decreased(P<0.05).Compared with patients with a spleen volume≥782.4 cm^(3),those with a spleen volume<782.4 cm^(3) had a higher incidence of HE(P<0.05).Cox regression analysis showed that spleen volume was an independent risk factor for post-TIPS OHE(hazard ratio=0.494,P<0.05).Restricted cubic spline model showed that with an increasing spleen volume,OHE risk showed an initial increase and then decrease(P<0.05).CONCLUSION Spleen volume is related to the occurrence of OHE after TIPS.Preoperative spleen volume is an independent risk factor for post-TIPS OHE.

Role of fecal microbiota transplant in management of hepatic encephalopathy: Current trends and future directions

Fecal microbiota transplantation(FMT)offers a potential treatment avenue for hepatic encephalopathy(HE)by leveraging beneficial bacterial displacement to restore a balanced gut microbiome.The prevalence of HE varies with liver disease severity and comorbidities.HE pathogenesis involves ammonia toxicity,gut-brain communication disruption,and inflammation.FMT aims to restore gut microbiota balance,addressing these factors.FMT's efficacy has been explored in various conditions,including HE.Studies suggest that FMT can modulate gut microbiota,reduce ammonia levels,and alleviate inflammation.FMT has shown promise in alcohol-associated,hepatitis B and C-associated,and non-alcoholic fatty liver disease.Benefits include improved liver function,cognitive function,and the slowing of disease progression.However,larger,controlled studies are needed to validate its effectiveness in these contexts.Studies have shown cognitive improvements through FMT,with potential benefits in cirrhotic patients.Notably,trials have demonstrated reduced serious adverse events and cognitive enhancements in FMT arms compared to the standard of care.Although evidence is promising,challenges remain:Limited patient numbers,varied dosages,administration routes,and donor profiles.Further large-scale,controlled trials are essential to establish standardized guidelines and ensure FMT's clinical applications and efficacy.While FMT holds potential for HE management,ongoing research is needed to address these challenges,optimize protocols,and expand its availability as a therapeutic option for diverse hepatic conditions.

Can rifaximin for hepatic encephalopathy be discontinued during broad-spectrum antibiotic treatment?

Hepatic encephalopathy(HE)is a formidable complication in patients with decompensated cirrhosis,often necessitating the administration of rifaximin(RFX)for effective management.RFX,is a gut-restricted,poorly-absorbable oral rifamycin derived antibiotic that can be used in addition to lactulose for the secondary prophylaxis of HE.It has shown notable reductions in infection,hospital readmission,duration of hospital stay,and mortality.However,limited data exist about the concurrent use of RFX with broad-spectrum antibiotics,because the patients are typically excluded from studies assessing RFX efficacy in HE.A pharmacist-driven quasi-experimental pilot study was done to address this gap.They argue against the necessity of RFX in HE during broad-spectrum antibiotic treatment,particularly in critically ill patients in intensive care unit(ICU).The potential for safe RFX discontinuation without adverse effects is clearly illuminated and valuable insight into the optimization of therapeutic strategies is offered.The findings also indicate that RFX discontinuation during broadspectrum antibiotic therapy was not associated with higher rates of delirium or coma,and this result remained robust after adjustment in multivariate analysis.Furthermore,rates of other secondary clinical and safety outcomes,including ICU mortality and 48-hour changes in vasopressor requirements,were comparable.However,since the activity of RFX is mainly confined to the modulation of gut microbiota,its potential utility in patients undergoing extensive systemic antibiotic therapy is debatable,given the overlapping antibiotic activity.Further,this suggests that the action of RFX on HE is class-specific(related to its activity on gut microbiota),rather than drug-specific.A recent double-blind randomized controlled(ARiE)trial provided further evidence-based support for RFX withdrawal in critically ill cirrhotic ICU patients receiving broad-spectrum antibiotics.Both studies prompt further discussion about optimal therapeutic strategy for patients facing the dual challenge of HE and systemic infections.Despite these compelling results,both studies have limitations.A prospective,multi-center evaluation of a larger sample,with placebo control,and comprehensive neurologic evaluation of HE is warranted.It should include an exploration of longer-term outcome and the impact of this protocol in non-critically ill liver disease patients.

Fecal microbiota transplantation in the treatment of hepatic encephalopathy:A perspective

Due to its complex pathogenesis,treatment of hepatic encephalopathy(HE)continues to be a therapeutic challenge.Of late,gut microbiome has garnered much attention for its role in the pathogenesis of various gastrointestinal and liver diseases and its potential therapeutic use.New evidence suggests that gut micro-biota plays a significant role in cerebral homeostasis.Alteration in the gut microbiota has been documented in patients with HE in a number of clinical and experimental studies.Research on gut dysbiosis in patients with HE has opened newer therapeutic avenues in the form of probiotics,prebiotics and the latest fecal microbiota transplantation(FMT).Recent studies have shown that FMT is safe and could be effective in improving outcomes in advanced liver disease patients presenting with HE.However,questions over the appropriate dose,duration and route of administration for best treatment outcome remains unsettled.

External validation of EncephalApp Stroop test to screen minimal hepatic encephalopathy patients with nonalcoholic cirrhosis

BACKGROUND Neurocognitive impairment,including minimal hepatic encephalopathy(MHE)and overt hepatic encephalopathy,is one of the most common complications of all types of primary liver diseases,such as hepatitis B,biliary cholangitis,and autoi-mmune hepatitis.The EncephalApp Stroop test is a smartphone application-based test that is time-saving for MHE screening.However,neurocognitive impairment is different between alcoholic cirrhosis patients and nonalcoholic cirrhosis pa-tients,so the cutoff value for MHE diagnosis might be inflated.AIM To validate the Stroop test in nonalcoholic cirrhosis patients.METHODS This external validation was performed at the National Center for Infectious Diseases(Beijing).Liver cirrhosis patients aged between 18 and 65 years who voluntarily enrolled in the study and provided signed informed consent were included.The Psychometric Hepatic Encephalopathy Score(PHES)test was used as the standard diagnostic criterion for MHE.The EncephalApp Stroop test was then performed on the iPad,including two sessions of tests(“off”and“on”)to measure patients’ability to differentiate between numbers and letters.We assessed the performance of the EncephalApp Stroop test in terms of the area under the curve(AUC),sensitivity,specificity,positive predictive value,and negative predictive value,with the PHES as the standard criterion.RESULTS A total of 160 nonalcoholic cirrhosis patients were included in this validation study,including 87(54.4%)patients without MHE and 73(45.6%)patients with MHE.Taking the PHES as the gold standard,the EncephalApp Stroop test performed well for nonalcoholic liver cirrhosis patients in terms of“off”time[AUC:0.85,95%confidence interval(CI):0.79-0.91]and“on+off”time(AUC:0.85,95%CI:0.80-0.91);however,total runs of“off”session(AUC:0.61,95%CI:0.52-0.69),total runs of“on”session(AUC:0.57,95%CI:0.48-0.65),and“on–off”time(AUC:0.54,95%CI:0.44-0.63)were comparatively low.The optimal cutoff points were“off”time>101.93 seconds and“on+off”time>205.86 seconds,with sensitivities of 0.84 and 0.90,specificities of 0.77 and 0.71,positive predictive values of 0.75 and 0.72,and false-positive values of 0.85 and 0.89,respectively.CONCLUSION Our results suggest that different cutoffs should be used for the EncephalApp Stroop tool for MHE screening between alcoholic and nonalcoholic living patients,which is a critical check before generalization to screen for neurocognitive impairment among the whole population of chronic liver diseases.

Rifaximin discontinuation during broad-spectrum antibiotic treatment in critically ill patients with hepatic encephalopathy

Hepatic encephalopathy(HE)is one of the main complications of cirrhosis,characterized by a wide spectrum of neuropsychiatric alterations that lead to an increase in mortality,morbidity and recurrent hospitalizations.Due to the central role in HE pathogenesis of ammonia and other neurotoxins primarily produced by the gut microbiota,the main therapeutic approaches for the treatment of HE are based on the modulation of the gut microbiota.Rifaximin is a non-absorbable broad-spectrum antibiotic,that is effective against ammonia-producing grampositive,gram-negative,and anaerobic species,approved for the treatment of HE in secondary prophylaxis.The chronic administration of rifaximin in this setting is associated with a lower risk of HE recurrence and mortality,while the role of rifaximin for the treatment of an overt-HE episode in inpatients is still unclear.Limited data exist about the coadministration of rifaximin and broad-spectrum antibiotics commonly used to treat concomitant infections,as patients receiving or recently treated with antibiotics were frequently excluded from clinical trials.In this editorial we comment on the article by Ward et al published in the recent issue of the World Journal of Hepatology.It is a single center,retrospective,quasiexperimental,pharmacist-driven protocol,with the aim to evaluate the feasibility and safety of rifaximin discontinuation in critically ill patients with HE and chronic liver disease receiving broad-spectrum antibiotic therapies in intensive care units.The study revealed no differences between the protocol and control group in terms of primary outcome(days alive and free of delirium and coma to day 14)and secondary outcomes which include:Intensive care mortality,intensive care length of stay,intravenous vasopressor requirement changes and adverse effects rate.Therefore,rifaximin discontinuation during broad-spectrum antibiotic therapy does not appear to negatively impact the clinical status of critically ill liver patients,with a similar safety profile and significant cost savings,as compared to the coadministration of rifaximin and broad-spectrum antibiotics.In agreement with Ward et al,a recently published double-blind,randomized controlled trial provided additional evidence to support the feasibility of withholding rifaximin during broad-spectrum antibiotic therapy in critically ill cirrhotic patients.However,given the limitations of these studies,further multicentric and prospective clinical trials,enrolling a larger sample of non-critically ill patients,are needed to better establish the role of rifaximin in this setting.

Progress in pathogenesis and treatment of type A hepatic encephalopathy in acute liver failure:a comprehensive review

Hepatic encephalopathy is a serious neuropsychiatric complication caused by liver failure,which is characterized by the development of cognitive and motor disorders into coma.Typically,hepatic encephalopathy can be divided into three types(A,B,and C)according to the etiology.Type A hepatic encephalopathy(AHE)caused by acute liver failure seriously affects the prognosis of patients,ranging from mild neuropsychological changes to coma,brain edema,and even death.So far,the research on the pathogenesis of AHE has focused on the toxic effects of ammonia on the central nervous system,metabolic disorders(glutamine and lactate accumulation),neurotransmission alteration,systemic inflammation,especially neuro-inflammation.All these mechanisms are not independent,but mutually have synergistic effects.In clinic,treatment of AHE based on only one mechanism is often ineffective.To clarify the pathogenesis and the interaction among the mechanisms will be beneficial to the effective treatment of AHE and reduce the mortality.The aim of this review is to provide comprehensive scientific evidence for the clinical treatment of AHE via collecting and analyzing the latest mechanism of AHE,and clarifying the relationship among these mechanisms combing the investigation of the latest research progress of drug treatment of acute liver failure.Consequently,we find that the pathogenesis of AHE is a complex neurocognitive disorder shaped by interactions among hyperammonemia,inflammation,and changes in neurotransmission,the signaling pathways thereby integrating the inflammatory and neurological inputs to impact pathophysiological or neurobehavioral outcomes.

Natural history of covert hepatic encephalopathy: An observational study of 366 cirrhotic patients

AIM To explore the natural history of covert hepatic encephalopathy(CHE) in absence of medication intervention.METHODS Consecutive outpatient cirrhotic patients in a Chinese tertiary care hospital were enrolled and evaluated for CHE diagnosis. They were followed up for a mean of 11.2 ± 1.3 mo. Time to the first cirrhosis-related complications requiring hospitalization, including overt HE(OHE), resolution of CHE and death/transplantation, were compared between CHE and no-CHE patients. Predictors for complication(s) and death/transplantation were also analyzed.RESULTS A total of 366 patients(age: 47.2 ± 8.6 years, male: 73.0%) were enrolled. CHE was identified in 131 patients(35.8%). CHE patients had higher rates of death and incidence of complications requiring hospitalization, including OHE, compared to unimpaired patients. Moreover, 17.6% of CHE patients developed OHE, 42.0% suffered persistent CHE, and 19.8% of CHE spontaneously resolved. In CHE patients, serum albumin < 30 g/L(HR = 5.22, P = 0.03) was the sole predictor for developing OHE, and blood creatinine > 133 μmol/L(HR = 4.75, P = 0.036) predicted mortality. Child-Pugh B/C(HR = 0.084, P < 0.001) and OHE history(HR = 0.15, P = 0.014) were predictors of spontaneous resolution of CHE.CONCLUSION CHE exacerbates, persists or resolves without medication intervention in clinically stable cirrhosis. Triage of patients based on these predictors will allow for more cost-effect management of CHE.

Relationship between pre-TIPS hepatic hemodynamics and postoperative incidence of hepatic encephalopathy

BACKGROUND: Hepatic encephalopathy (HE) is one of the complications that have limited the effectiveness of transjugular intrahepatic portosystemic shunt (TIPS) most significantly. Up to the present, the predicting factors of HE post-TIPS have been debated controversially. This study was undertaken to verify the relationship between pre-TIPS intrahepatic hemodynamics and the incidence of post-TIPS HE. METHODS: The hepatic blood dynamics was evaluated in 41 patients with liver cirrhosis before TIPS and at one month after TIPS by ultrasonography. The patients were divided into two groups according to Doppler findings before TIPS: group 1, patients with prograde portal flow, and group 2, patients with hepatofugal or back-forth portal flow. The clinical characteristics (age, sex, etiology of liver disease, pre-TIPS Child-Pugh score, incidence of pre-TIPS HE, and portacaval pressure gradient), incidence of post TIPS HE, and pre-/post-TIPS hepatic arterial resistant index (RI) in the two groups were compared. The independent prognostic value of pre-TIPS variables for the onset of HE after TIPS, including age, Child-Pugh score, presence of HE before TIPS, and the pattern of portal flow, was tested with a multiple-factor regression analysis. RESULTS: No significant difference in age, etiology of liver disease, indications of TIPS placement, incidence of HE before TIPS, and portacaval gradient before and after TIPS was observed between the two groups; but liver failure was more severe in group 2 (P<0.05). The incidence of post-TIPS HE in group 2 was significantly lower than that in group 1 (P<0.01). Pre-TIPS, the RI of the hepatic artery in group 1 was significantly higher than that in group 2 (P<0.01). However, TIPS induced a significantly decreased RI in group 1 (P <0.01), but not in group 2. Multiple-factor regression analysis demonstrated that the pattern of portal flow before TIPS was closely associated with the onset of post TIPS HE. CONCLUSIONS: Pre-TIPS intrahepatic hetnodynamics is closely related to the incidence of post-TIPS HE. Hepatic hetnodynamics of patients with hepatofugal portal blood flow only changes a little after TIPS and still provides compensatory blood supply of the hepatic artery, and the hepatic function is less affected. Hence HE is unlikely. Hepatic hemodynamics of patients with prograde portal blood flow changes a lot after TIPS, and dual blood supply of the portal vein and hepatic artery changes into compensatory blood supply of the hepatic artery, and hepatic function suffers greatly in a short time. Thus HE is mostly likely.

Clinical scenarios for the use of S100β as a marker of hepatic encephalopathy

AIM: To evaluate the association between serum concentrations of S100&#x003b2; in patients with cirrhosis and the presence of low grade hepatic encephalopathy (HE).METHODS: This was a cross-sectional study. The population was categorized into four groups healthy subjects, cirrhosis without HE, cirrhosis with covert hepatic encephalopathy (CHE) and cirrhosis with overt HE. Kruskal-Wallis, Mann Whitney&#x02019;s U with Bonferroni adjustment Spearman correlations and area under the ROC were used as appropriate.RESULTS: A total of 61 subjects were included, 46 cirrhotic patients and 15 healthy volunteers. S100&#x003b2; values were different among all groups, and differences remained significant between groups 1 and 2 (P &#x0003c; 0.001), and also between groups 2 and 3 (P = 0.016), but not between groups 3 and 4. In cirrhotic patients with HE S100&#x003b2; was higher than in patients without HE [0.18 (0.14-0.28) ng/mL vs 0.11 (0.06-0.14) ng/mL, P &#x0003c; 0.001]. There was a close correlation between serum concentrations of S100&#x003b2; and psychometric hepatic encephalopathy score in patients with cirrhosis without HE compared to the patients with cirrhosis with CHE (r = -0.413, P = 0.019). ROC curve analysis yielded &#x0003e; 0.13 ng/mL as the best cutoff value of S100&#x003b2; for the diagnosis of HE (sensitivity 83.3%, specificity 63.6%).CONCLUSION: Serum concentrations of S100&#x003b2; are higher in patients with cirrhosis than in healthy volunteers, and are further increased in the presence of hepatic encephalopathy. The results suggest that serum biomarkers such as S100&#x003b2; could help in the correct characterization of incipient stages of HE.

Advances in cirrhosis: Optimizing the management of hepatic encephalopathy

Hepatic encephalopathy(HE) is a major complication of cirrhosis resulting in significant socioeconomic burden, morbidity, and mortality. HE can be further subdivided into covert HE(CHE) and overt HE(OHE). CHE is a subclinical, less severe manifestation of HE and requires psychometric testing for diagnosis. Due to the time consuming screening process and lack of standardized diagnostic criteria, CHE is frequently underdiagnosed despite its recognized role as a precursor to OHE. Screening for CHE with the availability of the Stroop test has provided a pragmatic method to promptly diagnose CHE. Management of acute OHE involves institution of lactulose, the preferred first-line therapy. In addition, prompt recognition and treatment of precipitating factors is critical as it may result in complete resolution of acute episodes of OHE. Treatment goals include improvement of daily functioning, evaluation for liver transplantation, and prevention of OHE recurrence. For secondary prophylaxis, intolerance to indefinite lactulose therapy may lead to non-adherence and has been identified as a precipitating factor for recurrent OHE. Rifaximin is an effective add-on therapy to lactulose for treatment and prevention of recurrent OHE. Recent studies have demonstrated comparable efficacy of probiotic therapy to lactulose use in both primary prophylaxis and secondary prophylaxis.

Frontal assessment battery: A tool for screening minimal hepatic encephalopathy?

AIMTo apply the Frontal Assessment Battery to cirrhotic patients with or without overt hepatic encephalopathy (OHE) and controls. METHODSThe frontal assessment battery (FAB) was applied to 87 patients with liver cirrhosis (16 with and 71 without OHE) and 40 control subjects without cirrhosis treated at the alcohol and liver outpatient clinics and the gastroenterology ward of the Cassiano Antônio de Moraes University Hospital (Hospital Universit&aacute;rio Cassiano Antônio de Moraes - HUCAM), Esp&iacute;rito Santo, Brazil. RESULTSThe average FAB score was lower for the cirrhotic than for the non-cirrhotic patients (10.6 &plusmn; 3.67 vs 12.25 &plusmn; 2.72, P = 0.015). The FAB score was lower for the cirrhotic patients with OHE than for the patients without OHE (8.25 &plusmn; 4.55 vs 11.14 &plusmn; 3.25, P = 0.027). The total FAB score was lower for the cirrhotic patients without OHE than for the non-cirrhotic patients, although this difference was not significant (11.14 &plusmn; 3.25 vs 12.25 &plusmn; 2.72, P = 0.067). Nevertheless, the difference in the scores on the subtest that assessed the ability to inhibit a response previously conditioned to a stimulus was significant (1.72 &plusmn; 0.93 vs 2.2 &plusmn; 0.85, P = 0.011). CONCLUSIONThe present study indicates that the FAB is a promising tool for outpatient minimal HE screening and the assessment of HE severity.

Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy(HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.AIM To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.METHODS A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A(targeting left branch of portal vein, n = 937) and group B(targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.RESULTS The symptoms of ascites and variceal bleeding disappeared within a short time.By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B(P = 0.278, P = 0.561, respectively).Incidence of HE differed significantly between groups A and B at 1 mo(14.94% vs36.80%, χ~2 = 4.839, P = 0.028), 3 mo(12.48% vs 34.20%, χ~2 = 5.054, P = 0.025), 6 mo(10.03% vs 32.24%, χ~2 = 6.560, P = 0.010), 9 mo(9.17% vs 31.27%, χ~2 = 5.357, P =0.021), and 12 mo(8.21% vs 28.01, χ~2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years(6.61% vs 7.16%, χ~2 = 1.204, P =0.272) and 5 years(5.01% vs 6.18%, χ~2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B(χ~2 = 0.226, P = 0.634, log-rank test).CONCLUSION Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE but has no direct influence on prognosis of portalhypertension-related complications.

Portal hypertension exacerbates intrahepatic portosystemic venous shunt and further induces refractory hepatic encephalopathy: A case report

BACKGROUND Intrahepatic portosystemic venous shunt(IPSVS)is a rare hepatic disease with different clinical manifestations.Most IPSVS patients with mild shunts are asymptomatic,while the patients with severe shunts present complications such as hepatic encephalopathy.For patients with portal hypertension accompanied by intrahepatic shunt,portal hypertension may lead to hemodynamic changes that may result in exacerbated portal shunt and increased shunt flow.CASE SUMMARY A 57-year-old man,with the medical history of chronic hepatitis B and liver cirrhosis,was admitted to our hospital with abnormal behavior for 10 mo.He had received the esophageal varices ligation and entecavir therapy 1 year ago.Comparing with former examination results,the degree of esophageal varices was significantly reduced,while the right branch of the portal vein was significantly expanded and tortuous.Meanwhile,abdominal ultrasound presented the right posterior branch of portal vein connected with the retrohepatic inferior vena cava.The imaging findings indicated the diagnosis of IPSVS and hepatic encephalopathy.Instead of radiologic interventions or surgical therapies,this patient had only accepted symptomatic treatment.No recurrence of hepatic encephalopathy was observed during 1-year follow-up.CONCLUSION Hemodynamic changes may exacerbate intrahepatic portosystemic shunt.The intervention or surgery should be carefully applied to patients with severe portal hypertension due to the risk of hemorrhage.

Prevention and treatment of hepatic encephalopathy during the perioperative period of transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt(TIPS)is an established procedure for treating the complications of portal hypertension in liver cirrhosis.While the pathogenesis of postoperative TIPS-related hepatic encephalopathy(HE)has yet to be fully understood,intraoperative portosystemic shunts may provide a pathological basis for the occurrence of postope-rative HE in patients with liver cirrhosis.Studies at home and abroad have expressed mixed opinions about TIPSrelated HE.This study presents a literature review on the risk factors for and prevention and treatment of perioperative TIPS-related HE in patients with liver cirrhosis,aiming to optimize the procedure and reduce the incidence of postoperative HE.

Discrimination for minimal hepatic encephalopathy based on Bayesian modeling of default mode network

In order to classify the minimal hepatic encephalopathy （MHE） patients from healthy controls, the independent component analysis （ICA） is used to generate the default mode network （DMN） from resting-state functional magnetic resonance imaging （fMRI）. Then a Bayesian voxel- wised method, graphical-model-based multivariate analysis （GAMMA）, is used to explore the associations between abnormal functional integration within DMN and clinical variable. Without any prior knowledge, five machine learning methods, namely, support vector machines （SVMs）, classification and regression trees （ CART ）, logistic regression, the Bayesian network, and C4.5, are applied to the classification. The functional integration patterns were alternative within DMN, which have the power to predict MHE with an accuracy of 98%. The GAMMA method generating functional integration patterns within DMN can become a simple, objective, and common imaging biomarker for detecting MIIE and can serve as a supplement to the existing diagnostic methods.