Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure frequently employed to manage portal hypertension associated conditions such as variceal bleeding, ascites, and hydrothorax. However, despite its benefits, TIPS placement is frequently complicated by post-TIPS hepatic encephalopathy (HE), a condition that can significantly impact patient outcomes and quality of life. Currently, there is a lack of consensus and robust evidence regarding the optimal prophylactic treatments for post-TIPS HE. There is a recommendation suggesting the use of rifaximin, which is based solely on a single randomized controlled trial^1,2. Thus, more data are needed to assess the efficacy of prophylactic therapies in a real-world clinical setting.

Aims & Methods

This work aims to compare the efficacy of different prophylactic treatments (lactulose, rifaximin or both) and identify predictive factors for post-TIPS HE.
A retrospective study was conducted at a tertiary TIPS referral centre, including all adult patients who undergone TIPS placement between January/2021 and June/2024. Clinical records were reviewed to collect demographic data, prior decompensations, analytical results, medication and episodes of post-TIPS HE. A minimum of 6 months of follow-up was required. Statistical analysis was performed using SPSS Statistics version 26®.

Results

We included 83 patients, most of them male (n=69;83.1%) with a mean age of 60.1±1.3 years old. Most patients had alcoholic liver disease (n=58; 69.9%), followed by metabolic dysfunction and alcohol-related liver disease (n=6;7.2%). Prior to the procedure 22 (26.5%) patients had previous episodes of HE: 12 (14.5%) were medicated with lactulose, 2 (2.4%) with rifaximin and 8 (9.6%) with both. The remaining 61 (73.5%) had no previous medication. The primary indications for TIPS placement were variceal haemorrhage (n=50; 60.2% [pre-emptive n=21;42.0%]) and refractory ascites or hepatic hydrothorax (n=27;32.5%). The mean pre-TIPS and post-TIPS direct portal pressure were 31.0±0.9 mmHg and 22.2±0.7 mmHg, respectively. After TIPS placement 19 (22.9%) were discharged with lactulose, 3 (3.6%) with rifaximin, 20 (24.1%) with both and 41 (49.4%) with no medication. The mean follow-up time after TIPS placement was 22.3±2.0 months. Twenty-five (30.1%) patients had post-TIPS HE and there were no differences between therapeutic strategies in preventing such episodes (lactulose: OR 2.6 (95%CI 0.7-9.2) p-value 0.14; rifaximin: OR 1.1 (95%CI 0.1-19.0) p-value 0.94; both OR 2.4 (95%CI 0.7-8.2) p-value 0.15). Those discharged with no medication had less post-TIPS HE (OR 0.2 (95%CI 0.1-0.6) p-value 0.008), although these had also less pre-TIPS HE (p-value 0,046). Previous variceal haemorrhage (OR 3.2 (95%CI 1.0-9.9) p-value 0.046) and lower glomerular filtration rate (OR 0.98 (95%CI 0.96-0.99) p-value 0.03) were associated with higher risk for post-TIPS HE.

Conclusion

Our study found no significant differences between prophylactic treatments for post-TIPS HE. Notably, patients who did not receive prophylaxis had lower incidence of post-TIPS HE, although they also had fewer pre-TIPS episodes of HE. This raises questions about the universal application of these treatments and suggests the need for a more individualized approach. The identification of risk factors such as a history of variceal haemorrhage and lower glomerular filtration rate may guide treatment decisions, emphasizing the need for tailored management strategies. Future studies with larger sample sizes and multicentre participation are needed to refine prophylactic recommendations.

References

1. Bureau C, Thabut D, Jezequel C, Archambeaud I, D’Alteroche L, Dharancy S, et al. The use of rifaximin in the prevention of overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled trial. Ann Intern Med. 2021;174:633-40;
2. Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology. 2024 Jan 1;79(1):224-250.

Clinical Case Summary

Case Description: A 62-year-old woman from Príncipe, residing in Portugal for 2 months, presented to the emergency department with fever and abdominal pain for one day. She had no acholic stools or dark urine. Her medical history included type 2 diabetes, obesity and dyslipidemia with no pharmacological treatment. Laboratory tests revealed neutrophilic leukocytosis and cholestasis (leukocytes 21.38×10⁹/L;AST 699 IU/L;ALT 527 IU/L;ALP 207 U/L;GGT 486 U/L;Total Bilirubin 1.60 mg/dL; Direct Bilirubin 1.17 mg/dL; CRP 3.2 mg/L). CT showed a thickened, distended gallbladder with radiodense endoluminal material and a dilated common bile duct (CBD),10 mm, without obstruction. The diagnosis of acute lithiasic cholangitis and cholecystitis was established. The patient was started on intravenous fluids and antibiotics and an endoscopic retrograde cholangiopancreatography (ERCP) was scheduled within 72 hours. After 48 hours, she remained in pain and tachycardic. Repeat laboratory tests indicated coagulopathy (INR 1.64), prompting urgent biliary drainage. ERCP revealed a 30 cm Ascaris lumbricoides in the duodenum, which was removed using forceps. A single dose of albendazole was administered. Cholangiography showed a normal CBD but a gallbladder with spherical content. A 7Fr×5cm plastic biliary stent was placed. One week later, a follow-up ERCP with sphincterotomy confirmed bile duct clearance, and the stent was removed. The patient was discharged after 9 days. One month later, the patient underwent cholecystectomy and the specimen report revealed foci of low-grade intraepithelial neoplasia.
Conclusion: In endemic regions, both biliary lithiasis and hepatobiliary parasitic infections are common. Imaging findings may be similar, but the absence of CBD stones and the presence of Ascaris near the papilla strongly suggest transient biliary obstruction due to the parasite, highlighting the importance of epidemiological factors in the evaluation of acute cholangitis.

References

Figure 1 (First ERCP): Duodenoscopy identifies a long, cylindrical parasite in the second portion of the duodenum, adjacent to the papilla.
Figure 2 (First ERCP): Cholangiography shows the CBD and intrahepatic bile ducts without filling defects. The gallbladder contains spherical content.
Figure 3 (Second ERCP): Cholangiography shows no abnormalities in the CBD or intrahepatic bile ducts. Sphincterotomy was performed with no biliary content drainage.

Disclosure

Nothing to declare

Introduction

ERCP can still represents a challenge for endoscopists. In a variable percentage of cases (about 15%), cannulation of the common bile duct (CBD) is defined as “difficult”. In these cases, various advanced techniques are used to ensure access to the biliary tract. These methods can be summarised as follows: when an accidental cannulation of the pancreatic duct (PD) has occurred, the double guidewire technique (DGW) or the transpancreatic sphincterotomy (TPBS) technique can be performed; when access to the PD has not been achieved, freehand precut (trans papillary or fistulotomy) can be performed.¹
It has been shown that these methods are burdened by higher complication rates (in particular post- ERCP pancreatitis [PEP]) compared to standard cannulation of the CBD.² In particular, TPBS carries a stigma of risk and complexity. The ESGE guidelines propose its use as a second line after failure of DGW technique and only by expert endoscopists.¹ Recent studies have shown a certain distrust among endoscopists towards TPBS.³

Aims & Methods

We conducted a one-year prospective study with the aim of evaluating the efficacy and safety of TPBS in cases of difficult cannulation, comparing it with the DGW technique and trans papillary precut. All patients undergoing ERCP in a secondary centre were enrolled. A total of 169 ERCPs were performed by three endoscopists (two seniors and one junior with experience < 200 ERCPs). The most frequent indication was lithiasis of the CBD (74% of cases). The protocol adopted in case of difficult cannulation was the following: in the case of failed access to the PD, trans papillary precut was attempted. In the case of access to PD, the endoscopist chose at his discretion to perform the DGW technique or TPBS. In the case of PD cannulation, no pancreatic stent placement was performed. Other measures were taken to prevent PEP (rectal indomethacin and intravenous hydration during ERCP). Patients were followed up until discharge and peri- and post-procedural complications were recorded.

Results

The overall cannulation rate for naive papillae was 92.8%. Advanced techniques were used in 19% of the cases to achieve cannulation of the bile duct: 73% were successful. TPBS achieved 100% cannulation of CBP, compared to 66.7% of DWS and 55.6% of pre-cutting, showing a statistically significant better performance (p=0.02). A total of five bleedings, two cholangitis, one cholecystitis and two PEP were recorded. Of all these, only three (respectively one PEP, one bleeding and one cholecystitis) occurred after the above-mentioned advanced CBD cannulation methods were used.

Conclusion

In conclusion, this single-centre prospective observational study, despite its limited sample size, demonstrates that TPBS is a safe and effective method in case of difficult bile duct cannulation when PD cannulation is achieved. In particular TPBS seems to be more efficient than DGW and precut, showing a similar security profile. This technique can also be performed safely by non-expert endoscopists.
Finally, it is important to underline that, despite not placing the pancreatic prosthesis after cannulation of the PD (24 patients) none of them presented PEP.

References

1.Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, Devière J, Dinis-Ribeiro M, Dumonceau JM, Giovannini M, Gyokeres T, Hafner M, Halttunen J, Hassan C, Lopes L, Papanikolaou IS, Tham TC, Tringali A, van Hooft J, Williams EJ. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. Epub 2016 Jun 14. PMID: 27299638.
2.Fung BM, tea TCTabibian JH. Difficult Biliary Cannulation in Endoscopic Retrograd2 Cholangiopancreatography: Definitions, Risk Factors, and Implications. Eur Med J Hepatol. 2021 Aug;9(1):64-72. Epub 2021 Aug 5. PMID: 34621527; PMCID: PMC8494185.
3.Kouanda A, Bayudan A, Hussain A, Avila P, Kamal F, Hasan MK, Dai SC, Munroe C, Thiruvengadam N, Arain MA. Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study. Endosc Int Open. 2023 Jun 21;11(6):E588-E598. doi: 10.1055/a-2085-4565. PMID: 37564727; PMCID: PMC10410689.

Introduction

Alternate day oral iron therapy is better than daily oral iron therapy in Iron deficiency anemia (IDA) as it increases the fractional absorption of iron. In Ulcerative colitis (UC) with IDA increased fractional absorption of iron with alternate day iron may not only be better in improvement of anemia but also results in reduced unabsorbed iron delivery to distal bowel and may hence reduce adverse effects.

Aims & Methods

In a randomized, open label trial, from February 2023 to December 2024 patients of UC in remission (Mayo ≤2 OR partial Mayo ≤1 with fecal calprotectin <150mcg/gm for last 3 months) with IDA (ferritin <30mcg/l, transferrin saturation <20%, Hb 8-12 gm/dl) were randomized to every other day 132mg (EOD group) or daily 66mg (OD group) elemental oral iron given as ferrous fumarate for 8 weeks. Primary outcome was the difference in mean change in Hemoglobin (Hb) at 8 weeks. Secondary outcomes were the difference in mean change in RBC indices, iron indices and adverse events at 8 weeks.

Results

54 patients were randomized between both groups. One patient in EOD and 2 in OD group withdrew before treatment initiation. Eleven patients had disease flare on oral iron therapy (5 in EOD and 6 in OD group) p= 0.62 and two patients in EOD group had intolerance requiring oral iron stoppage. Thirty-eight patients completed treatment. The mean change in Hb at 8 weeks in EOD and OD groups was 2.08±1.0gm/dl and 2.09±1.11gm/dl respectively in per protocol analysis (p=0.797). The mean change in serum ferritin, serum iron, transferrin saturation and total iron binding capacity in both the groups is not significant. Disease flare within 6 months prior to oral iron therapy correlated with increased incidence of flare on oral iron therapy. (P=0.04)

Conclusion

Alternate day oral iron is not better than daily oral iron in improving Hb levels, iron indices and with similar incidence of adverse events in patients of UC in remission. A recent flare has increased chances of disease flare with oral iron therapy

Introduction

Anastomotic leaks and fistulae following upper gastrointestinal (GI) surgery remain a serious clinical challenge, carrying high morbidity and mortality. Endoscopic vacuum therapy (EVT) has emerged as a promising minimally invasive treatment option for managing these complications. This study aimed to assess the efficacy and safety of EVT for postoperative anastomotic leaks in a high-volume tertiary referral center.

Aims & Methods

We conducted a retrospective analysis of all patients treated with EVT for anastomotic leakage following upper GI surgery between January 2022 and January 2025. The primary outcome was EVT success, defined as complete leak closure confirmed through both endoscopic and radiologic assessment. Secondary outcomes included procedure-related adverse events and all-cause mortality.

Results

Twenty-four patients were included (79.2% male; mean age: 64 ± 12 years). Of these, 16 patients underwent oesophagectomy and 8 total gastrectomy; only two surgeries were performed for benign conditions. EVT achieved leak closure in 20 patients (87%). One patient died due to hemorrhagic shock from a hepatic artery pseudoaneurysm, unrelated to EVT.
Among successful cases, the mean duration of EVT was 30 ± 19 days, with a median of four sponge exchanges (IQR = 5). Median hospital stay was 52 days (IQR = 41). EVT failure occurred in three patients, all of whom had cancer-related surgeries and defect sizes exceeding 30 mm. In these cases, adjunctive endoscopic treatment with self-expanding metallic stents led to successful leak closure.
A larger defect size was associated with a lower likelihood of closure (p = 0.067), suggesting a trend toward reduced efficacy in extensive leaks. Importantly, no EVT-related complications were observed throughout the study period.

Conclusion

EVT demonstrated a high success rate (87%) and an excellent safety profile for managing postoperative anastomotic leaks following upper GI surgery. Larger leak sizes showed a trend toward lower closure rates, highlighting the importance of early diagnosis and timely initiation of EVT when defects are smaller. Given its effectiveness and minimal risk, EVT should be considered a first-line endoscopic treatment for anastomotic leaks. Further studies are warranted to refine treatment protocols and establish standardized indications based on leak characteristics.

References

1. de Moura DTH, et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World JGastrointestEndosc. 2019 May 16;
2. Mastoridis S, et al. Endoscopic vacuum therapy (EVT) in the management of oesophageal perforations and post-operative leaks. Minim Invasive TherAllied Technol. 2022 Mar;
3. Livingstone I, et al. Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks. Clin Endosc. 2021 Nov;
4. Panneerselvam K,et al. Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects. Clin Endosc. 2023 Nov.