Luminary Learning Gastrointestinal Disorder- Issue 1

Latest Concepts in Inpatient Hepatic Encephalopathy Management •  9 to embolization. Multiple retrospective studies have reported the efficacy and safety of the embo- lization of large portosystemic shunts in refractory HE [52–55]. In a European multicenter study ( n = 37), 59% and 49% were free of HE at 100 days and 2 years, respectively. The HE recurrence was less in those with MELD score of 11 or less [52]. In a US series ( n = 20), 100% (20/20) achieved immediate improvement and durable benefit was achieved in 92% (11/12) at 6–12 months after the procedure [55]. The overall procedural complication rate was 10%. One patient had bacterial cholangitis and another patient required readmission from pain at the puncture site. Importantly, 35% (7/20) developed evidence of worsening portal hypertension at some point within 12-month follow-up time [55]. In a Korean case-control series ( n = 17), the 2-year HE recurrence rate was lower in the embolization group (40% vs. 80%, P = 0.02) but there was no difference in the 2-year overall survival rates (65% vs. 53%, P = 0.98). In addition, they observed an improvement in overall survival in the embolization group (100% vs. 60%, P = 0.03) in the subgroup analysis of only patients without hepatocellular carcinoma and with MELD score < 15 [54]. Molecular Adsorbent Recirculating System Albumin has been shown to be a multifunctional protein with antioxidant, immunomodulatory, and detoxification functions [56]. Molecular adsorbent recirculating system (MARS) was intro- duced in 1999 and is based on the concept of albumin dialysis. MARS was designed to remove protein- and albumin-bound toxins, such as bilirubin, bile acids, nitrous oxide, and endogenous benzodiazepines. In addition, MARS also removes non-protein-bound ammonia that accumulates in liver failure [57]. Although there was no survival benefit observed in previous trials, MARS did show a beneficial effect on HE treatment. In a study designed specifically to evaluate the effect of MARS on HE, 70 patients with grades 3–4 HE were enrolled. The MARS-treated patients were found to have a higher proportion of patients with a 2-grade improvement in HE when compared to standard treatment alone. The MARS-treated patients were also found to have more rapid improvement [58]. The RELIEF trial enrolled 189 patients with ACLF and showed higher propor- tion of patients with HE grade 3 or 4 improvement to HE grade 0 or 1 in MARS-treated patients (15 of 24; 62.5%) compared with standard therapy (13 of 34; 38.2%), which trended toward signif- icance ( P = 0.07) [59]. In a small study, MARS had a statistically significant effect on improvement of HE in nine patients with alcoholic hepatitis and HE [60]. The FDA initially approved the use of MARS for grade 3–4 HE related to decompensation of chronic liver disease but has since retracted its approval. In summary, MARS is a reasonable option for patients with severe HE refractory to standard medical therapy. Liver Transplantation Liver transplantation (LT) is the most definitive treatment option for HE. Therefore, cirrhotic patients with HE and MELD ≥15 should be evaluated for liver transplantation. It is important to distinguish other conditions such as neurodegenerative diseases like Alzheimer’s, and Wernicke’s encephalopathy, which would not improve after liver transplant. Although HE should improve