19 It is tempting to speculate that tumor-derived ANG2 and engagement CP-673451 cell line of the TIE2 receptor on endothelial cells and monocytes may promote angiogenesis in HCC and, possibly, also limit HCC sensitivity to sorafenib. In mouse models of mammary carcinogenesis, systemic ANG2

neutralization or Tie2 gene knockdown in TEMs inhibited tumor angiogenesis, suggesting that the ANG2/TIE2 axis modulates the proangiogenic activity of TEMs, at least in mouse models of cancer.20 In summary, Matsubara et al.3 report interesting new findings that provide further evidence that BMDCs may serve as biomarkers for HCC. Furthermore, the data also suggest that BMDCs could be involved in the pathogenesis of HCC. Indeed, CEPs,4 mononuclear MDSCs,8 and TEMs3 may all have the potential to regulate HCC angiogenesis

and progression, possibly by releasing proangiogenic growth factors or molecules that Galunisertib mouse blunt the endothelial- or cancer-cell killing activity of cytotoxic T cells.7 Thus, inhibiting the proangiogenic and/or immunosuppressive functions of these BMDCs may represent a promising strategy to improve the efficacy of current treatments for HCC. “
“Background and Aim:  Nocturnal gastro-esophageal reflux causes heartburn and sleep disturbances impairing quality of life. Lifestyle modifications, like bed head elevation during sleep, are thought to alleviate the symptoms of gastroesophageal reflux. We tested the hypothesis that bed head selleck kinase inhibitor elevation might decrease recumbent acid exposure compared to sleeping in a flat bed. Methods:  Patients of symptomatic nocturnal reflux and documented recumbent (supine) reflux verified by esophageal pH test entered the trial. On day 1, baseline pH was measured while the patient slept on a flat bed. Then patients

slept on a bed with the head end elevated by a 20-cm block for the next 6 consecutive days from day 2 to day 7. The pH test was repeated on day 2 and day 7. Each patient acted as his own control. Results:  Twenty of 24 (83.3%) patients with mean age of 36 ± 5.5 years completed the trial. The mean (± SD) supine reflux time %, acid clearance time, number of refluxes 5 min longer and symptom score on day 1 and day 7 were 15.0 ± 8.4 and 13.7 ± 7.2; P = 0.001, 3.8 ± 2.0 and 3.0 ± 1.6; P = 0.001, 3.3 ± 2.2 and 1.0 ± 1.2; P = 0.001, and 2.3 ± 0.6 and 1.5 ± 0.6; P = 0.04, respectively. The sleep disturbances improved in 13 (65%) patients. Conclusions:  Bed head elevation reduced esophageal acid exposure and acid clearance time in nocturnal (supine) refluxers and led to some relief from heartburn and sleep disturbance.

In chronic hepatitis C therapy, ribavirin improves the SVR rates in both IFN-containing and all-oral, IFN-free regimens. Although multiple mechanisms of action have been suggested for ribavirin, the main antiviral mechanism in hepatitis C has not yet been

clearly elucidated. Objective: To understand the molecular mechanism of ribavirin antiviral action in hepatitis C virus infection. Methods and Results: Gene expression analysis of uninfected hepatoma (Huh7) cells treated with ribavirin (100 μg/mL) for 24 hours showed that the expression of genes implicated in IFN responses, Fulvestrant in vivo including TLR7, IRF7, IRF9, GBP1 and IFIT2, was induced see more by ribavirin administration. Using the subgenomic genotype 1 b replicon Con-1 in Huh7.5 cells, ribavirin exerted dose-dependent antiviral activity against HCV, reducing the amount of intracellular HCV RNA and the level of NS5A protein after 24 and 48 hours of exposure.

To investigate how ribavirin affects gene transcription in the context of viral infection, we first investigated whether the promoter of IRF7 was modulated by ribavirin. Hepatoma cells expressing the subgenomic genotype 1 b replicon Con-1 and one or both functional interferon-sensitive response elements (ISRE/IRF-E) from different reporter plasmids were treated with different doses of ribavirin, alone or in combination with IFN. Ribavirin activated the IRF7 promoter via IRF-E in a dose-dependent manner. In contrast to IFN, ribavirin had no effect on ISRE, regardless of the ribavirin dose. In addition, IRF7 dominant negative-mediated inhibition of IRF7 resulted in a significant reduction of HCV replication

inhibition. Although IRF7 may be of particular importance because of its role in amplifying the IFN selleck compound signaling cascade, IFN production is initiated by the recognition of TLR, one of the two best-known pattern-recognition receptors. Ribavirin had an effect on TLR7 mRNA expression and, using cells expressing human TLR and an inducible reporter gene, ribavirin selectively activated TLR7 in a dose-dependent manner. In addition, co-incubation of imiquimod or loxoribin (potent activators of TLR7) with ribavirin significantly increased activity of both compounds on TLR7 expressing HEK cells. TLR7 stimulation by ribavirin induced cytokine secretion, hepatoma cells. Conclusion: Ribavirin is a selective TLR7 agonist that increases cytokine secretion by promoting the activation of IRF7, a key factor because of its direct antiviral effect and its role in amplifying the IFN signaling cascade.

2).42, 43 CD16+ monocytes in blood showed homogenous intermediate levels of CX3CR1, whereas mDCs isolated from the liver included CX3CR1high cells and a population that expressed levels comparable to blood CD16+ monocytes. CD16+ monocytes lost CX3CR1 surface expression during the Selleckchem Tanespimycin process of transmigration and as a consequence of receptor engagement by CX3CL1. Exposure to soluble CX3CL1

in vitro resulted in a profound but transient loss of cell surface CX3CR1 and could explain why prior exposure to soluble CX3CL1 prevents transendothelial migration; a similar effect has been reported for other chemokine receptors.44 Thus, CX3CL1 must be appropriately retained and presented on endothelium to function efficiently. Re-expression of CX3CR1 after cells have been recruited to the liver parenchyma could be important for their onward migration to areas of portal or lobular inflammation, where CX3CL1 is also strongly expressed42 (Fig. 2). In addition to CX3CL1 and VCAM-1, VAP-1 was involved in CD16+ monocyte transendothelial migration under flow. VAP-1 belongs to an expanding family of ectoenzymes involved in cellular trafficking.45 VAP-1 is present on liver sinusoidal endothelium,

where it has been implicated in lymphocyte recruitment in humans and rodents.27, 35, 36 Soluble VAP-1 is detected at high levels in the serum of patients with selleck chemicals chronic liver disease, but not other inflammatory conditions such as rheumatoid arthritis.46, 47 VAP-1 can mediate sialic acid-dependent Selleckchem Luminespib tethering and transendothelial migration of lymphocytes on sinusoidal endothelium.27, 48 This is the first

time that VAP-1 has been implicated in monocyte transendothelial migration, although reduced monocyte recruitment to inflammatory sites has been reported in mice after VAP-1 blockade.49 We found that VAP-1 was involved in both adhesion and transendothelial migration. The combination of immobilized CX3CL1 and VAP-1 proteins on their own failed to support significant levels of adhesion, suggesting that VAP-1 operates in conjunction with other receptors to mediate transendothelial migration, consistent with data showing that enzymatic activity of VAP-1 modulates the expression of other adhesion molecules34 (Fig. 5). These findings add to an evolving body of literature that implicates VAP-1 as an important molecule in leukocyte transmigration across hepatic sinusoidal endothelium in vitro and in vivo and provide further evidence that the sinusoidal bed uses distinct combinations of molecules to recruit leukocytes to the liver parenchyma.25, 34-36, 50 The role of VAP-1 in transendothelial migration is particularly interesting.

To test whether DCs may contribute to HSC activation and liver fibrogenesis, we first performed Selleck Carfilzomib a coculture of DCs and HSCs. Similar to HMs, DCs did not activate HSCs but rather up-regulated the expression of NF-κB–dependent genes, and NF-κB–driven luciferase reporter activity through an IL-1– and TNF-dependent manner (Fig. 6B). However, activation of NF-κB was considerably lower than the induction we observed in HM coculture. Based on these

results, we next determined whether DC ablation may have contributed to the reduced fibrogenesis in clodronate-treated mice. In our first approach, we performed BDL in diphtheria toxin-treated or PBS-treated bone marrow–chimeric CD11c-DTR-eGFP mice. Bone marrow chimerism avoids the known side effects of diphtheria toxin treatment observed after long-term Selleckchem Dinaciclib treatment in global CD11c-DTR-eGFP mice.[26] We did not observe a significant difference in BDL-induced fibrosis as determined by sirius red staining and qRT-PCR

for the fibrogenic genes α-SMA, Col1a1, and TIMP1 (Fig. 6C-D). We confirmed these data employing CCl4 injection for induction of liver fibrosis, again using bone marrow-chimeric CD11c-DTR-eGFP mice. Similar to the BDL model, we did not observe significant differences in liver fibrosis between PBS and diphtheria toxin-treated mice (Fig. 6E). As a third approach, we used antibody-mediated ablation of pDC. Again, we did not observe a reduction of CCl4-induced liver fibrosis (Fig. 6F). Importantly, we achieved considerable selleck kinase inhibitor depletion of cDC and pDC using the above methods (Supporting Fig. 8). Similar to previous studies,[27] we observed neutrophilia in CD11c-DTR mice (Supporting Fig. 9) but consider this unlikely to exert a profound effect on fibrosis based on previous studies.[28] Thus, our data suggest that neither class of DC significantly contributes to liver fibrogenesis in vivo. Hepatic fibrogenesis involves multiple resident and recruited cell populations. HSCs represent the center component of this wound healing response, but

other populations, including macrophages, are known positive modulators of fibrogenesis. Here, we uncover a novel function of macrophages, the promotion of HSC/myofibroblast survival. A second novel finding of our study lies in the discovery that DCs do not contribute to liver fibrosis. Employing microarray and pathway analysis, we discovered that NF-κB, the best-characterized antiapoptotic signaling pathway[29, 30] and an important regulator of liver injury and fibrosis,[31] was a key pathway activated in HSCs by HMs. The relevance and physiologic nature of the employed in vitro coculture system is validated by the finding that this system achieves HSC gene expression patterns highly similar to those found in in vivo–activated HSCs, and that all gene expression changes and functional consequences of NF-κB activation were confirmed in vivo.

To test whether DCs may contribute to HSC activation and liver fibrogenesis, we first performed CH5424802 order a coculture of DCs and HSCs. Similar to HMs, DCs did not activate HSCs but rather up-regulated the expression of NF-κB–dependent genes, and NF-κB–driven luciferase reporter activity through an IL-1– and TNF-dependent manner (Fig. 6B). However, activation of NF-κB was considerably lower than the induction we observed in HM coculture. Based on these

results, we next determined whether DC ablation may have contributed to the reduced fibrogenesis in clodronate-treated mice. In our first approach, we performed BDL in diphtheria toxin-treated or PBS-treated bone marrow–chimeric CD11c-DTR-eGFP mice. Bone marrow chimerism avoids the known side effects of diphtheria toxin treatment observed after long-term NVP-LDE225 order treatment in global CD11c-DTR-eGFP mice.[26] We did not observe a significant difference in BDL-induced fibrosis as determined by sirius red staining and qRT-PCR

for the fibrogenic genes α-SMA, Col1a1, and TIMP1 (Fig. 6C-D). We confirmed these data employing CCl4 injection for induction of liver fibrosis, again using bone marrow-chimeric CD11c-DTR-eGFP mice. Similar to the BDL model, we did not observe significant differences in liver fibrosis between PBS and diphtheria toxin-treated mice (Fig. 6E). As a third approach, we used antibody-mediated ablation of pDC. Again, we did not observe a reduction of CCl4-induced liver fibrosis (Fig. 6F). Importantly, we achieved considerable selleck depletion of cDC and pDC using the above methods (Supporting Fig. 8). Similar to previous studies,[27] we observed neutrophilia in CD11c-DTR mice (Supporting Fig. 9) but consider this unlikely to exert a profound effect on fibrosis based on previous studies.[28] Thus, our data suggest that neither class of DC significantly contributes to liver fibrogenesis in vivo. Hepatic fibrogenesis involves multiple resident and recruited cell populations. HSCs represent the center component of this wound healing response, but

other populations, including macrophages, are known positive modulators of fibrogenesis. Here, we uncover a novel function of macrophages, the promotion of HSC/myofibroblast survival. A second novel finding of our study lies in the discovery that DCs do not contribute to liver fibrosis. Employing microarray and pathway analysis, we discovered that NF-κB, the best-characterized antiapoptotic signaling pathway[29, 30] and an important regulator of liver injury and fibrosis,[31] was a key pathway activated in HSCs by HMs. The relevance and physiologic nature of the employed in vitro coculture system is validated by the finding that this system achieves HSC gene expression patterns highly similar to those found in in vivo–activated HSCs, and that all gene expression changes and functional consequences of NF-κB activation were confirmed in vivo.

6-8 Nevertheless, correlations are not always found between tumor stage and the actual prognosis, and this phenomenon is more common in patients with early HCC than in those with advanced HCC. Considering that HCC is increasingly diagnosed and resected at an early stage and that current staging systems have some limitations in the prognostic evaluation of early HCC,4, 9, 10 efforts have been made to investigate prognostic molecules.11-13 To date, no easily measurable biomarker that has strong correlations with

clinical outcomes has been identified. Human aspartyl-(asparaginyl)-β-hydroxylase (AAH) is abundantly expressed in proliferating trophoblastic cells of the placenta and is rarely expressed in normal adult tissues.14 Overexpression of AAH can promote the malignant transformation of biliary epithelial cells, enhance the metastasis of cholangiocarcinoma cells,14-17 Vadimezan research buy and increase the mobility of neuroblastoma.18 Wands and colleagues14, 19 have reported that AAH is highly expressed in HCCs and that overexpression of AAH significantly increases motility and invasiveness of HepG2 and Huh-7 cells.20, 21 Our previous study also showed enhanced AAH immunostaining in HCC when compared with that in nontumorous tissue, which was associated with poor differentiation of HCC cells.22 However, the learn more significance of AAH expression level in the prognostic evaluation of patients undergoing surgical resections

has not been reported. The purpose of this prospective study was to examine whether AAH expression level is an effective prognostic factor for HCC patients who undergo hepatectomy. selleck products Differential expression levels of AAH in HCCs and nontumorous tissues were analyzed through hybridization with complementary DNA (cDNA) microarray, reverse-transcription polymerase chain reaction (RT-PCR), and immunohistochemical staining in tissue microarray (TMA). We found that AAH expression level in tumor tissue was well-correlated with multiple malignant clinico-pathological

characteristics and was strongly associated with tumor recurrence and patient survival. Moreover, AAH overexpression predicted a worse surgical outcome in patients with early stage HCC according to Barcelona Clinic Liver Cancer (BCLC) staging classification. AAH, aspartyl-(asparaginyl)-β-hydroxylase; AFP, AFP, α-fetoprotein; BCLC, Barcelona Clinic Liver Cancer; cDNA, complementary DNA; CI, confidence interval; HCC, hepatocellular carcinoma; HR, hazard ratio; mRNA, messenger RNA; PVTT, portal vein tumor thrombosis; RT-PCR, reverse-transcription polymerase chain reaction; TMA, tissue microarray; TTR, time to recurrence. A total of 281 adult patients with HCC undergoing hepatectomy by three independent surgical teams at Eastern Hepatobiliary Surgery Hospital between January 1 and June 30, 2004, were enrolled in the study. The preoperative clinical diagnosis of HCC met the diagnostic criteria of the American Association for the Study of Liver Diseases.

6-8 Nevertheless, correlations are not always found between tumor stage and the actual prognosis, and this phenomenon is more common in patients with early HCC than in those with advanced HCC. Considering that HCC is increasingly diagnosed and resected at an early stage and that current staging systems have some limitations in the prognostic evaluation of early HCC,4, 9, 10 efforts have been made to investigate prognostic molecules.11-13 To date, no easily measurable biomarker that has strong correlations with

clinical outcomes has been identified. Human aspartyl-(asparaginyl)-β-hydroxylase (AAH) is abundantly expressed in proliferating trophoblastic cells of the placenta and is rarely expressed in normal adult tissues.14 Overexpression of AAH can promote the malignant transformation of biliary epithelial cells, enhance the metastasis of cholangiocarcinoma cells,14-17 AZD8055 nmr and increase the mobility of neuroblastoma.18 Wands and colleagues14, 19 have reported that AAH is highly expressed in HCCs and that overexpression of AAH significantly increases motility and invasiveness of HepG2 and Huh-7 cells.20, 21 Our previous study also showed enhanced AAH immunostaining in HCC when compared with that in nontumorous tissue, which was associated with poor differentiation of HCC cells.22 However, the click here significance of AAH expression level in the prognostic evaluation of patients undergoing surgical resections

has not been reported. The purpose of this prospective study was to examine whether AAH expression level is an effective prognostic factor for HCC patients who undergo hepatectomy. selleck chemicals llc Differential expression levels of AAH in HCCs and nontumorous tissues were analyzed through hybridization with complementary DNA (cDNA) microarray, reverse-transcription polymerase chain reaction (RT-PCR), and immunohistochemical staining in tissue microarray (TMA). We found that AAH expression level in tumor tissue was well-correlated with multiple malignant clinico-pathological

characteristics and was strongly associated with tumor recurrence and patient survival. Moreover, AAH overexpression predicted a worse surgical outcome in patients with early stage HCC according to Barcelona Clinic Liver Cancer (BCLC) staging classification. AAH, aspartyl-(asparaginyl)-β-hydroxylase; AFP, AFP, α-fetoprotein; BCLC, Barcelona Clinic Liver Cancer; cDNA, complementary DNA; CI, confidence interval; HCC, hepatocellular carcinoma; HR, hazard ratio; mRNA, messenger RNA; PVTT, portal vein tumor thrombosis; RT-PCR, reverse-transcription polymerase chain reaction; TMA, tissue microarray; TTR, time to recurrence. A total of 281 adult patients with HCC undergoing hepatectomy by three independent surgical teams at Eastern Hepatobiliary Surgery Hospital between January 1 and June 30, 2004, were enrolled in the study. The preoperative clinical diagnosis of HCC met the diagnostic criteria of the American Association for the Study of Liver Diseases.

The fact that three patients with elevated sIgG4 had abnormal pancreatic imaging suggests that some patients could have had undiagnosed IAC. However, none of the resected bile ducts Roscovitine clinical trial showed evidence of IAC despite staining for IgG4, which would

argue against this hypothesis. Finally, we found no association of elevated sIgG4 levels with stricture distribution (intra- or extrahepatic) and no correlation between sIgG4 and CA19-9 level in CCA patients. We also found no evidence of association of an overlap syndrome of autoimmune hepatitis in conjunction with PSC with elevated sIgG4 levels in CCA patients. In summary, we have demonstrated the following findings relating to sIgG4 in cholangiocarcinoma: (1) sIgG4 is elevated in a subset of patients with CCA; (2) CCA patients with concomitant PSC (CCA+PSC) are more likely to exhibit higher sIgG4 levels than those without PSC (CCA-PSC); (3) in order to more

reliably distinguish IAC from CCA based on sIgG4 alone, an IgG4 cutpoint of at least twice the upper limit of normal is required. However, at approximately four times the upper limit of normal, sIgG4 is 99%-100% specific for distinguishing IAC from CCA. In view of the similar clinical and radiologic features of CCA and IAC, CCA should be carefully ruled out in patients with suspected IAC whose sIgG4 is only mildly elevated, particularly when they do not fully meet the HISORt criteria required to diagnose IAC. This distinction FG-4592 molecular weight is important in view of the use of steroids to manage IAC, which may result in delays in administering appropriate treatment of CCA. Secretarial

assistance: Victoria L. Campion and Erin Fairchild. Author contributions: Abdul M Oseini: Study concept and design; acquisition of data; analysis and interpretation of data; drafting of the article; statistical analysis. Roongruedee Chaiteerakij: Study concept and design; acquisition of data; analysis and interpretation of data; drafting of the article; statistical analysis. Abdirashid M. Shire: Acquisition of data; critical revision of the article for important intellectual content. Amaar Ghazale: Study concept and design; acquisition of data; critical selleckchem revision of the article for important intellectual content. Kaiya Joseph: Acquisition of data; critical revision of the article for important intellectual content. Catherine D Moser: Acquisition of data; critical revision of the article for important intellectual content. Ileana Aderca: Acquisition of data; critical revision of the article for important intellectual content. Teresa A Mettler: Acquisition of data; critical revision of the article for important intellectual content. Terry M Therneau: Statistical analysis and interpretation of data; critical revision of the article for important intellectual content. Lizhi Zhang: Tissue staining and pathological analysis; critical revision of the article for important intellectual content.

41, 95% confidence interval = 1.16–5.00, P = 0.02). Serum FST levels are significantly associated with HCC prognosis and could represent a predictive C646 biomarker in this disease. “
“The role of autophagy in disease pathogenesis following viral infection is beginning to be elucidated. We have previously reported that hepatitis C virus (HCV) infection in hepatocytes induces autophagy. However, the biological significance of HCV-induced autophagy has not been clarified. Autophagy has recently been identified as a novel component of the innate immune system against viral infection. In this study, we found that knockdown of autophagy-related protein

beclin 1 (BCN1) or autophagy-related protein 7 (ATG7) in immortalized human hepatocytes (IHHs) inhibited HCV growth. BCN1- or ATG7-knockdown IHHs, when they were infected with HCV, exhibited increased

expression of interferon-β, 2′,5′-oligoadenylate synthetase 1, interferon-α, and interferon-α–inducible protein 27 messenger RNAs of the interferon signaling pathways in comparison with infected control IHHs. A subsequent study Selleck 3-deazaneplanocin A demonstrated that HCV infection in autophagy-impaired IHHs displayed caspase activation, poly(adenosine diphosphate ribose) polymerase cleavage, and apoptotic cell death. Conclusion: The disruption of autophagy machinery in HCV-infected hepatocytes activates the interferon signaling pathway and induces apoptosis. Together, these results suggest that HCV-induced autophagy impairs the innate immune selleck chemicals llc response. (HEPATOLOGY 2011;53:406-414) Hepatitis C virus (HCV) infection affects nearly 3.3 million people and is the most common cause of cirrhosis and hepatocellular carcinoma in the United States.1 The currently approved therapy for the treatment of HCV is pegylated interferon

in combination with ribavirin.2, 3 Although several advances have shown promise in improving the management of HCV infection, nevertheless, it remains a major health problem.4-6 HCV is a member of the Flaviviridae family, and its genome contains a positive-strand RNA approximately 9.6 kb long. The HCV genome encodes a polyprotein precursor of approximately 3000 amino acids that is cleaved by both viral and host proteases into structural (core, E1, E2, and p7) and nonstructural proteins [nonstructural protein 2 (NS2), NS3, NS4A, NS4B, NS5A, and NS5B]. HCV-infected cells accumulate lipid droplets and play an important role in the assembly of virus particles.7-9 Autophagy is a catabolic process by which cells remove their own damaged organelles and long-lived proteins for the maintenance of cellular homeostasis. During autophagy, the double-membrane vesicles engulf the damaged organelles and eventually fuse with the lysosomes for degradation.

23. Neomycin is an alternative choice for treatment of OHE (GRADE II-1, B, 2). 24. Metronidazole is an alternative choice for treatment of OHE (GRADE II-3, B, 2). There are no randomized, placebo-controlled trials of lactulose for maintenance Regorafenib datasheet of remission from OHE. However, it is still widely recommended and practiced. A single-center, open-label RCT of lactulose demonstrated less recurrence

of HE in patients with cirrhosis.[33] A recent RCT supports lactulose as prevention of HE subsequent to upper gastrointestinal (GI) bleeding.[110] Rifaximin added to lactulose is the best-documented agent to maintain remission in patients who have already experienced one or more bouts of OHE while on lactulose treatment after their initial episode of OHE.[101] Once TIPS was popularized to treat complications of PH, its tendency to cause the appearance of HE, or less commonly, intractable persistent HE, was noted. Faced with severe HE as a complication of a TIPS procedure, physicians had a major dilemma. Initially, it was routine to use standard HE treatment to prevent post-TIPS HE. However, one study illustrated that neither rifaximin nor lactulose prevented post-TIPS HE any better than GW-572016 placebo.[111] Careful case selection has reduced the incidence

of severe HE post-TIPS. If it occurs, shunt diameter reduction can reverse HE.[112] However, the original cause for placing TIPS may reappear. Another important issue with TIPS relates to the desired portal pressure (PP) attained after placement of stents. Too low a pressure because of large stent diameter can lead to intractable HE, as noted above. There is a lack of consensus on whether to aim to find more reduce PP by 50% or below 12 mmHg. The latter is associated with more bouts of encephalopathy.[113] It is widely

used to treat post-TIPS recurrent HE as with other cases of recurrent HE, including the cases that cannot be managed by reduction of shunt diameter. Recurrent bouts of overt HE in patients with preserved liver function consideration should lead to a search for large spontaneous PSSs. Certain types of shunts, such as splenorenal shunts, can be successfully embolized with rapid clearance of overt HE in a fraction of patients in a good liver function status, despite the risk for subsequent VB.[114] 25. Lactulose is recommended for prevention of recurrent episodes of HE after the initial episode (GRADE II-1, A, 1). 26. Rifaximin as an add-on to lactulose is recommended for prevention of recurrent episodes of HE after the second episode (GRADE I, A, 1). 27. Routine prophylactic therapy (lactulose or rifaximin) is not recommended for the prevention of post-TIPS HE (GRADE III, B, 1). There is a nearly uniform policy to continue treatment indefinitely after it has successfully reversed a bout of OHE. The concept may be that once the thresholds for OHE is reached, then patients are at high risk for recurrent episodes.