- Email: [email protected]
The role of diagnostic laparoscopy and biopsy in differentiation between tuberculous peritonitis and malignancy
546A
AASLD ABSTRACTS
HEPATOLOGYO c t o b e r 2 0 0 1
1495
1496
T H E ROLE OF D I A G N O S T I C LAPAROSCOPY AND BIOPSY IN DIFFERENTIATION BETWEEN TUBERCULOUS PERITONITIS AND MALIGNANCY. Waleed A H a m e d Dr, Royal Infirmary Of Edinburgh, E d i n b u r g h United Kingdom; M a m o u n A s h o u r Prof., Mabarek Hussin ProL, M a h m o u d Massoud Prof, Abdelgany Bebers Prof, Ain Shams Univ Hospitals, Cairo Egypt; Peter C Hayes Prof, Royal Infirmary Of Edinburgh, Cairo United K i n g d o m
BACTERIAL INFECTIONS IN C I R R H O T I C PATIENTS W I T H GASTROINTESTINAL IIEMORRIKtGE (GII-I): HAS ANTIBIOTIC PROPHYLAXIS AFFECTED ITS INCIDENCE?. Suchat Wongcharatrawee, Yale University, New Haven, CT; Ron Vender, Yale U n i v e r s i t y / S t Raphael's Hospital, New Haven, CT; Guadalupe Garcia-Tsao, Yale University / VA Connecticut Healthcare System, New Haven, CT
Introduction a n d Aim: The clinical distinction between tuberculous peritonitis (TBP) a n d malignant infiltration of p e r i t o n e u m is difficult in m a n y instances. In this study, we assessed the role of laparoscopic examination a n d biopsy as a differentiating tool between b o t h conditions. Patients a n d Methods: This retrospective study involved 135 consecutive patients with ascites admitted to the Department of Tropical Medicine, Ain Shams University, Cairo, Egypt. Definitive diagnosis was made in 111 patients using clinical, laboratory a n d radiological examinations. In the remaining 24 patients (7 males a n d 17 females; m e a n -+ SEM age: 3 7 . 4 -Z-_2.2 years), the aetiology ofascites remained obscure. However, the clinical diagnosis in those patients was believed to be either TBP or malignant peritoneal infiltration. Laparoscopic examination a n d biopsy were performed in these patients. Results: Laparoscopic procedure was undertaken successfully in all cases with failure to obtain biopsy in one patient (due to adhesion). Macroscopic appearance revealed nodules, adhesion, a n d abnormal vasculature in 20 patients (83 %). A definitive diagnosis was reached in 22 cases (92%) b y microscopic examination of laparoscopic biopsy of the periton e u m and/or nodules b u t only in one patient non-specific inflammation was identified. Sixteen cases (67%) were diagnosed as TBP a n d 6 cases (25%) as m a l i g n a n c y of w h i c h 2 were primary (hepatoma a n d mesothelioma), a n d 4 were metastatic a d e n o c a r c i n o m a infiltration from primary t u m o u r s of colon a n d ovaries, w h i c h were confirmed later. Conclusion: Microscopic examination of laparoscopic biopsies of the p e r i t o n e u m and/or nodules is the investigation of choice in Egyptian patients with ascites of u n k n o w n cause.
Cirrhotic patients with GIH are at a high risk of nosocomial infections. Meta-analysisof 5 randomized controlled trials (RCT) demonstrated that prophylactic antibiotics in this setting reduce the incidence of infections from 45% to 15% (Bernard et aL Hepatology 1999; 29:1655-61). The efficacyof routine antibiotic prophylaxis outside RCTs has not been reported. With the aim of investigating the incidence and type of infections in the setting of antibiotic prophylaxis, cirrhotic patients admitted consecutively for G1Hwere prospectively followed until hospital discharge or death. Patients were participants in a RCT of a somatostatin analogue for varicealhemorrhage that required the use of prophylactic quinolones prior to diagnostic endoscopy and within 12 hours of admission. Appropriate tests, including diagnostic paracentesis, were obtained in the presence of clinical signs of infection. Infection was defined as a positive clinical picture and a confirmatory laboratory test (culture, radiology and/or cytology). Non-parametric statistics and the Fisher's exact test were used. Results are expressed as medians. Results: In the study period, 51 patients w~th GI hemorrhage were entered in the study. Eleven patieuts were excluded: 6 had an active infection at the time of GIH, 1 was on long-term prophylaxis and 4 left the hospital or died during the first 24-48 hours. Analysisis therefore based on 40 patients. In a median hospital stay of 6 days (range 5-38 days), 11 patients (28%) developed an infection. Microorganismswere isolated in 4 cases. Infectionswere i bacteremia due to methicillin-resistant S. aureus(MRSA) and vancomycinresistant enterococcus, 1 endocarditis due to enteroeoccus, 1 bacteremia due to S. epidermidis, and 1 MRSA pneumonia. Of the remaining 7 cases, 6 were pneumonias and 1 was a suppurative meningitis. There were no cases of spontaneous bacterial peritonitis or infections by gramnegative organisms. Admission characteristics of infected patients (vs non-infected patients) are summarized in the table. Conclusions: Incidence of bacterial infections in cirrhotic patients admitted with G1His elevatedin spite of antibiotic prophylaxis. The type ofinfections (mostly upper respiratory) and type of organisms isolated (all grampositive) are different from those historically observed in patients not on prophylaxis. Patients who develop infections have predominantly alcoholic etiology, tend to have a more impaired liver and renal function at admission and tend to have a higher in-hospital mortality. These observations need to be extended to a larger population.
n Age Male gender Alcoholicetiology Ascites Child-Pugh score Bilirubin (mg/dL) Albumin (g/dL) Creatinine(mg/dL) PT (INR) AST (lUlL) Mertality
Infected
Not Infected
p
11 5t 73% 64% 54% 1t 2.6 2.7 1.3 1.7 95 27%
29 47 67% 26% 41% 8 1A 3.0 0.9 1.7 81 7%
NS NS 0.03 NS NS NS NS 0,06 N$ NS NS
1497
1498
PREVALENCE AND RISK FACTORS OF SIGNIFICANT INTRAPULMONARY S H U N T IN C I R R H O T I C PATIENTS A W A I T I N G LIVER TRANSPLANTATION. M o o n Seok Choi, Ji-Min Lee, Sang-Chol Lee, Seung W o o Park, J o o n H y e o k Lee, K w a n g Cheol Koh, Senng W o o n Paik, Poong-Lyul Rhee, Jae J u n Kim, J o n g C h u l Rhee, Kyoo W a n Choi, Samsung Medical Ctr, Seoul South Korea
[lSC]METItACETIN BREATH TEST: A NON-INVASIVE QUANTITATIVE LIVER F U N C T I O N TEST F O R THE ASSESSMENT OF HEPATOCELLULAR DYSFUNCTION. Christoph Balzer, Erich Lotterer, Claudia Baum, Wolfg a n g E Fleig, Universitaetsklinik u Poliklinik f Inhere Medizin I, Halle/Saale Germany
Background/Aims: H e p a t o p u l m o n a r y s y n d r o m e is a condition of severe hypoxia with i n t r a p u l m o n a r y s h u n t in the setting of hepatic dysfunction. Liver transplantation has been suggested as a definite treatment for h e p a t o p u l m o nary s y n d r o m e with reversal of i n t r a p u l m o n a r y s h u n t in some patients. H o w ever, inconsistency of response a n d inability to predict reversibility still remained significant problems. W e performed this study to evaluate the prevalence of significant i n t r a p u l m o n a r y s h u n t in pretransplantation cirrhotic patients a n d to find a n y risk factors. Methods: Fifty-seven patients (M:F = 38:19, median age 49 years (range 18 - 71)) with liver cirrhosis awaiting liver transplantation were serially included. Their i n t r a p u l m o n a r y s h u n t status was evaluated using contrast-enhanced echocardiography a n d significant s h u n t was defined as a s h u n t of grade > 2. Results: Significant i n t r a p u l m o n a y s h u n t was detected in 30 (52.6%) a m o n g total 57 patients. Significant s h u n t was f o u n d in 24 (63.2%) of 38 Child-Pugh class C patients a n d in 6 (31.6%) of 19 Child-Pugh class A or B patients ( O R = 3 . 7 (95% C.I.= 1.2-12.0), p < 0 . 0 5 ) . No significant difference in prevalence of significant s h u n t was seen according to age, sex, presence or absence of hepatocellular carcinoma, ascites, hepatic encephalopathy, gastroesophageal varix, etc. Conclusion: Significant intrapulm o n a r y s h u n t is a c o m m o n finding in cirrhotic patients awaiting liver transplantation. Child-Pugh class C is the risk factor associated with high prevalence of significant shunt.
Background: [13C] - based breath tests can substitute for tests using radioactive substrates to quantify metaboliy liver function. The aim of this studywas to compare the results of the new [zSC]methacetin breath-test ([13C]MBT) with the Child-Pughscore and established quantitative liver function tests such as galactose elimination capacity (GEC), monoethylglycine test (MEGX), hepatic sorbitol clearance (SC1 hep) and indocyanine green clearance (ICG-C1). Patients and methods: 76 patients with histologically proven cirrhosis (Child-Pugh A: n = 24; B: n = 3 5 ; C: n = 17; alcohohc cirrhosis: n = 4 8 ; primary or secondary biliary cirrhosis: n = 17; autoimmune hepatitis: n = 5 ; cryptogenic cirrhosis: u = 6 ) were given tSC-methacetin (2mg/kgBW in 100rnl tea) after a 12-hour fasting period. Breath samples were collected performed before the test drink and 30, 60, 90 and 120 minutes thereafter. The isotope ratio of [13C] / [12C] was determined using isotope-selective nondispersive infrared spectrometry (IRIS; Fa. Wagner, Worpswede, Germany). The increase of exhaled [13CO2] was expressed as A over baseline (DOB), from which the maximal percentage rate (PDRmax) as well as the cumulative rate (cPDR) were calculated. Results: Spearman-coeffizient:GEK SCL hepICG-C1Child-Pugh DOB 30 0,57 0,49-0,79-0,68 cPDR 0,42 0,54 -0,8 -0,68 Conclusions: Results of [ zsC]MBT discriminate patients of different Child-Pugh status and correlate with the results of established quantitative liver function tests. [13C]MBT may serve as a non-radioactive test of microsomal liver function. Its prognostic significance remains to be established in prospective follow-up studies. Results
j~C-MBT
_Child A
_Child B
_Child C
_p
mean+_SD DOB 30 PDRrnax("/dh) _cPDR (%) _MEGX GEK (rag/rain) SCI hep (mllmin) ICC~Cl.
n=24 14,3+-6,4 19,3--+8 8,9~5,5 70:~36 307+_104 509!-_157 8,1+7,9
n=35 9_+6,3 12,2+8 4,4±4 61+_17 244+_78 374-+85 18,3+_12,1
n=17 2,4+-2,2 3,5+_3,1 0,9+_0,9 56+_27 22t+-62 317+_109 "~8.3-+12,1
~, b, d ~, b, d **, b, d n,s. *, b ~. b, c **, b, c
Child A vs. Child B: * p<0,05; ** p<0,005; Child A vs. Child C: a p<0,05; b p<0,005; Child B vs. Child C',"p<0,05; d p<0,005 $CL hep.: hepaticsorbito~Clearance
AASLD ABSTRACTS
HEPATOLOGYO c t o b e r 2 0 0 1
1495
1496
T H E ROLE OF D I A G N O S T I C LAPAROSCOPY AND BIOPSY IN DIFFERENTIATION BETWEEN TUBERCULOUS PERITONITIS AND MALIGNANCY. Waleed A H a m e d Dr, Royal Infirmary Of Edinburgh, E d i n b u r g h United Kingdom; M a m o u n A s h o u r Prof., Mabarek Hussin ProL, M a h m o u d Massoud Prof, Abdelgany Bebers Prof, Ain Shams Univ Hospitals, Cairo Egypt; Peter C Hayes Prof, Royal Infirmary Of Edinburgh, Cairo United K i n g d o m
BACTERIAL INFECTIONS IN C I R R H O T I C PATIENTS W I T H GASTROINTESTINAL IIEMORRIKtGE (GII-I): HAS ANTIBIOTIC PROPHYLAXIS AFFECTED ITS INCIDENCE?. Suchat Wongcharatrawee, Yale University, New Haven, CT; Ron Vender, Yale U n i v e r s i t y / S t Raphael's Hospital, New Haven, CT; Guadalupe Garcia-Tsao, Yale University / VA Connecticut Healthcare System, New Haven, CT
Introduction a n d Aim: The clinical distinction between tuberculous peritonitis (TBP) a n d malignant infiltration of p e r i t o n e u m is difficult in m a n y instances. In this study, we assessed the role of laparoscopic examination a n d biopsy as a differentiating tool between b o t h conditions. Patients a n d Methods: This retrospective study involved 135 consecutive patients with ascites admitted to the Department of Tropical Medicine, Ain Shams University, Cairo, Egypt. Definitive diagnosis was made in 111 patients using clinical, laboratory a n d radiological examinations. In the remaining 24 patients (7 males a n d 17 females; m e a n -+ SEM age: 3 7 . 4 -Z-_2.2 years), the aetiology ofascites remained obscure. However, the clinical diagnosis in those patients was believed to be either TBP or malignant peritoneal infiltration. Laparoscopic examination a n d biopsy were performed in these patients. Results: Laparoscopic procedure was undertaken successfully in all cases with failure to obtain biopsy in one patient (due to adhesion). Macroscopic appearance revealed nodules, adhesion, a n d abnormal vasculature in 20 patients (83 %). A definitive diagnosis was reached in 22 cases (92%) b y microscopic examination of laparoscopic biopsy of the periton e u m and/or nodules b u t only in one patient non-specific inflammation was identified. Sixteen cases (67%) were diagnosed as TBP a n d 6 cases (25%) as m a l i g n a n c y of w h i c h 2 were primary (hepatoma a n d mesothelioma), a n d 4 were metastatic a d e n o c a r c i n o m a infiltration from primary t u m o u r s of colon a n d ovaries, w h i c h were confirmed later. Conclusion: Microscopic examination of laparoscopic biopsies of the p e r i t o n e u m and/or nodules is the investigation of choice in Egyptian patients with ascites of u n k n o w n cause.
Cirrhotic patients with GIH are at a high risk of nosocomial infections. Meta-analysisof 5 randomized controlled trials (RCT) demonstrated that prophylactic antibiotics in this setting reduce the incidence of infections from 45% to 15% (Bernard et aL Hepatology 1999; 29:1655-61). The efficacyof routine antibiotic prophylaxis outside RCTs has not been reported. With the aim of investigating the incidence and type of infections in the setting of antibiotic prophylaxis, cirrhotic patients admitted consecutively for G1Hwere prospectively followed until hospital discharge or death. Patients were participants in a RCT of a somatostatin analogue for varicealhemorrhage that required the use of prophylactic quinolones prior to diagnostic endoscopy and within 12 hours of admission. Appropriate tests, including diagnostic paracentesis, were obtained in the presence of clinical signs of infection. Infection was defined as a positive clinical picture and a confirmatory laboratory test (culture, radiology and/or cytology). Non-parametric statistics and the Fisher's exact test were used. Results are expressed as medians. Results: In the study period, 51 patients w~th GI hemorrhage were entered in the study. Eleven patieuts were excluded: 6 had an active infection at the time of GIH, 1 was on long-term prophylaxis and 4 left the hospital or died during the first 24-48 hours. Analysisis therefore based on 40 patients. In a median hospital stay of 6 days (range 5-38 days), 11 patients (28%) developed an infection. Microorganismswere isolated in 4 cases. Infectionswere i bacteremia due to methicillin-resistant S. aureus(MRSA) and vancomycinresistant enterococcus, 1 endocarditis due to enteroeoccus, 1 bacteremia due to S. epidermidis, and 1 MRSA pneumonia. Of the remaining 7 cases, 6 were pneumonias and 1 was a suppurative meningitis. There were no cases of spontaneous bacterial peritonitis or infections by gramnegative organisms. Admission characteristics of infected patients (vs non-infected patients) are summarized in the table. Conclusions: Incidence of bacterial infections in cirrhotic patients admitted with G1His elevatedin spite of antibiotic prophylaxis. The type ofinfections (mostly upper respiratory) and type of organisms isolated (all grampositive) are different from those historically observed in patients not on prophylaxis. Patients who develop infections have predominantly alcoholic etiology, tend to have a more impaired liver and renal function at admission and tend to have a higher in-hospital mortality. These observations need to be extended to a larger population.
n Age Male gender Alcoholicetiology Ascites Child-Pugh score Bilirubin (mg/dL) Albumin (g/dL) Creatinine(mg/dL) PT (INR) AST (lUlL) Mertality
Infected
Not Infected
p
11 5t 73% 64% 54% 1t 2.6 2.7 1.3 1.7 95 27%
29 47 67% 26% 41% 8 1A 3.0 0.9 1.7 81 7%
NS NS 0.03 NS NS NS NS 0,06 N$ NS NS
1497
1498
PREVALENCE AND RISK FACTORS OF SIGNIFICANT INTRAPULMONARY S H U N T IN C I R R H O T I C PATIENTS A W A I T I N G LIVER TRANSPLANTATION. M o o n Seok Choi, Ji-Min Lee, Sang-Chol Lee, Seung W o o Park, J o o n H y e o k Lee, K w a n g Cheol Koh, Senng W o o n Paik, Poong-Lyul Rhee, Jae J u n Kim, J o n g C h u l Rhee, Kyoo W a n Choi, Samsung Medical Ctr, Seoul South Korea
[lSC]METItACETIN BREATH TEST: A NON-INVASIVE QUANTITATIVE LIVER F U N C T I O N TEST F O R THE ASSESSMENT OF HEPATOCELLULAR DYSFUNCTION. Christoph Balzer, Erich Lotterer, Claudia Baum, Wolfg a n g E Fleig, Universitaetsklinik u Poliklinik f Inhere Medizin I, Halle/Saale Germany
Background/Aims: H e p a t o p u l m o n a r y s y n d r o m e is a condition of severe hypoxia with i n t r a p u l m o n a r y s h u n t in the setting of hepatic dysfunction. Liver transplantation has been suggested as a definite treatment for h e p a t o p u l m o nary s y n d r o m e with reversal of i n t r a p u l m o n a r y s h u n t in some patients. H o w ever, inconsistency of response a n d inability to predict reversibility still remained significant problems. W e performed this study to evaluate the prevalence of significant i n t r a p u l m o n a r y s h u n t in pretransplantation cirrhotic patients a n d to find a n y risk factors. Methods: Fifty-seven patients (M:F = 38:19, median age 49 years (range 18 - 71)) with liver cirrhosis awaiting liver transplantation were serially included. Their i n t r a p u l m o n a r y s h u n t status was evaluated using contrast-enhanced echocardiography a n d significant s h u n t was defined as a s h u n t of grade > 2. Results: Significant i n t r a p u l m o n a y s h u n t was detected in 30 (52.6%) a m o n g total 57 patients. Significant s h u n t was f o u n d in 24 (63.2%) of 38 Child-Pugh class C patients a n d in 6 (31.6%) of 19 Child-Pugh class A or B patients ( O R = 3 . 7 (95% C.I.= 1.2-12.0), p < 0 . 0 5 ) . No significant difference in prevalence of significant s h u n t was seen according to age, sex, presence or absence of hepatocellular carcinoma, ascites, hepatic encephalopathy, gastroesophageal varix, etc. Conclusion: Significant intrapulm o n a r y s h u n t is a c o m m o n finding in cirrhotic patients awaiting liver transplantation. Child-Pugh class C is the risk factor associated with high prevalence of significant shunt.
Background: [13C] - based breath tests can substitute for tests using radioactive substrates to quantify metaboliy liver function. The aim of this studywas to compare the results of the new [zSC]methacetin breath-test ([13C]MBT) with the Child-Pughscore and established quantitative liver function tests such as galactose elimination capacity (GEC), monoethylglycine test (MEGX), hepatic sorbitol clearance (SC1 hep) and indocyanine green clearance (ICG-C1). Patients and methods: 76 patients with histologically proven cirrhosis (Child-Pugh A: n = 24; B: n = 3 5 ; C: n = 17; alcohohc cirrhosis: n = 4 8 ; primary or secondary biliary cirrhosis: n = 17; autoimmune hepatitis: n = 5 ; cryptogenic cirrhosis: u = 6 ) were given tSC-methacetin (2mg/kgBW in 100rnl tea) after a 12-hour fasting period. Breath samples were collected performed before the test drink and 30, 60, 90 and 120 minutes thereafter. The isotope ratio of [13C] / [12C] was determined using isotope-selective nondispersive infrared spectrometry (IRIS; Fa. Wagner, Worpswede, Germany). The increase of exhaled [13CO2] was expressed as A over baseline (DOB), from which the maximal percentage rate (PDRmax) as well as the cumulative rate (cPDR) were calculated. Results: Spearman-coeffizient:GEK SCL hepICG-C1Child-Pugh DOB 30 0,57 0,49-0,79-0,68 cPDR 0,42 0,54 -0,8 -0,68 Conclusions: Results of [ zsC]MBT discriminate patients of different Child-Pugh status and correlate with the results of established quantitative liver function tests. [13C]MBT may serve as a non-radioactive test of microsomal liver function. Its prognostic significance remains to be established in prospective follow-up studies. Results
j~C-MBT
_Child A
_Child B
_Child C
_p
mean+_SD DOB 30 PDRrnax("/dh) _cPDR (%) _MEGX GEK (rag/rain) SCI hep (mllmin) ICC~Cl.
n=24 14,3+-6,4 19,3--+8 8,9~5,5 70:~36 307+_104 509!-_157 8,1+7,9
n=35 9_+6,3 12,2+8 4,4±4 61+_17 244+_78 374-+85 18,3+_12,1
n=17 2,4+-2,2 3,5+_3,1 0,9+_0,9 56+_27 22t+-62 317+_109 "~8.3-+12,1
~, b, d ~, b, d **, b, d n,s. *, b ~. b, c **, b, c
Child A vs. Child B: * p<0,05; ** p<0,005; Child A vs. Child C: a p<0,05; b p<0,005; Child B vs. Child C',"p<0,05; d p<0,005 $CL hep.: hepaticsorbito~Clearance