Resistant ascites and hepatic encephalopathy in a patient on the liver transplant waiting list

Introduction. Treatment of a patient with liver cirrhosis involves achieving maximum control over its complications.
Objective of the Study. To demonstrate a staged approach to the management of a patient on the liver transplantation waiting list using a clinical case example.
Discussion. Minimally invasive surgical techniques opens up new therapeutic opportunities for patients with liver cirrhosis. The implementation of TIPS (Transjugular Intrahepatic Portosystemic Shunt) has proven to be an effective method for managing refractory ascites. The exacerbation of hepatic encephalopathy in the postoperative period following TIPS is an anticipated adverse effect that must be considered when planning the intervention. Screening examinations for the diagnosis of hepatic encephalopathy should be regularly conducted for all patients who have undergone TIPS.
Treatment of TIPS-associated hepatic encephalopathy aims to reduce the production and absorption of ammonia or increase its elimination. It should be initiated in the early days following the procedure. Since intestinal sanitation is a pathogenetically justified objective of this therapy, the use of antibacterial agents to suppress excessive bacterial growth in these patients becomes the cornerstone of the treatment protocol.
Conclusions. TIPS is an effective treatment method for refractory ascites, while the risk of developing hepatic encephalopathy should be taken into account when implementing early postoperative period management interventions.

1. Pivovarova G.M., Zayarny D.S. Analysis of mortality from digestive diseases in the Russian Federation in 2011–2019. Profilakticheskaya Meditsina, 2020, № 6(2), рр. 141–148. (In Russian)

2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. Journal of Hepatology, 2018, Aug; № 69(2), рр. 406–460. https://doi.org/10.1016/j.jhep.2018.03.024

3. Ivashkin V.T., Maevskaya M.V., Zharkova M.S., Zhigalova S.B., Kitsenko E.A., Manukyan G.V., Trukhmanov A.S., Maev I.V., Tikhonov I.N., Deeva T.A. Clinical guidelines of the Russian Society for the Study of Liver and the Russian Gastroenterological Association for the diagnosis and treatment of liver fibrosis and cirrhosis and their complications. Russian Journal of Gastroenterology, Hepatology, and Coloproctology, 2021, № 31(6), рр. 56–102. (In Russian) https://doi.org/10.22416/1382-4376-2021-31-6-56-102

4. Gauthier S.V., Khomyakov S.M. Organ donation and transplantation in the Russian Federation in 2021. XIV message from the Register of the Russian Transplant Society. Bulletin of Transplantology and artificial organs, 2022, № 24(3), рр. 8–31. In Russian) https://doi.org/10.15825/1995-1191-2022-3-8-31

5. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. Journal of Hepatology, 2018 Aug; № 69(2), рр. 406–460. https://doi.org/10.1016/j.jhep.2018.03.024

6. De Franchis R., Bosch J., Garcia-Tsao G., Reiberger T., Ripoll C.; Baveno VII Faculty. Baveno VII – Renewing consensus in portal hypertension. Journal of Hepatology, 2022, Apr; № 76(4), рр. 959–974. https://doi.org/10.1016/j.jhep.2021.12.022

7. Khoronko Yu.V., Kosovtsev E.V., Kozyrevsky M.A., Khoronko E.Yu., Krivorotov N.A., Chesnokov V.V. Portosystem bypass surgery in complicated portal hypertension: modern possibilities of minimally invasive technologies. Annals of Surgical Hepatology, 2021, № 6(3), pp. 34–45. (In Russian) https:// doi: 10.16931/1995-5464.2021-3-34-45

8. Osipova S.V., Pavlov C.S., Drozdov P.A., Sorokoletov S.M., Levina O.N., Ivanova N.A., Mikhailyants G.S., Novikova A.A. Comparative effectiveness of treatment of hepatic encephalopathy in patients with cirrhosis of the liver after bypass surgery. Effective pharmacotherapy, 2025, № 21(22), рр. 24–32. (In Russian) https://doi.org/10.33978/2307-3586-2025-21-22-24-32

9. Rajesh S., George T., Philips C.A., Ahamed R., Kumbar S., Mohan N., Mohanan M., Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World Journal of Gastroenterology, 2020, № 26(37), рр. 5561–5596. https://doi.org/10.3748/wjg.v26.i37.5561

10. Masson S., Mardini H.A., Rose J.D., Record C.O. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion: a decade of experience. QJM: An International Journal of Medicine, 2008, № Jun;101(6), рр. 493–501. https://doi.org/10.1093/qjmed/hcn037

11. Radchenko V.G. Hepatic encephalopathy and colon dysbiosis: possible approaches to correction (advanced medical technology): methodological recommendations. Saint Petersburg: I.I. Mechnikov Saint Petersburg State Medical Academy, Ministry of Health and Social Development of the Russian Federation, Health Committee of the Government of Saint Petersburg, 2011, 52 p. (In Russian)

12. Yokoyama K., Sakamaki A., Takahashi K., Naruse T., Sato C., Kawata Y., Tominaga K., Abe H., Sato H., Tsuchiya A., Kamimura K., Takamura M., Yokoyama J., Terai S. Hydrogen-producing small intestinal bacterial overgrowth is associated with hepatic encephalopathy and liver function. PLoS One, 2022, Feb № 25;17(2), рр. e0264459. https://doi.org/10.1371/journal.pone.0264459

13. Feng X., Li X., Zhang X., Chen W., Tian Y., Yang Q., Yang Y., Pan H., Jiang Z. Hepatic Encephalopathy in Cirrhotic Patients and Risk of Small Intestinal Bacterial Overgrowth: A Systematic Review and Meta-Analysis. BioMed Research Inttrnatinal, 2022, № Oct 18, рр. 2469513. https://doi.org/10.1155/2022/2469513.

14. Wang L. J., Yao X., Qi Q., Qin J. P. Prevention and treatment of hepatic encephalopathy during the perioperative period of transjugular intrahepatic portosystemic shunt. World Journal of Gastrointestal Surgery, 2023, Aug 27; № 15(8), рр. 1564–1573. https://doi.org/10.4240/wjgs.v15.i8.1564