- Email: [email protected]
ALT ratio
Posters
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ERYTHROMYCIN IMPROVES GASTRIC LAVAGE IN ACUTE UPPER GASTROINTESTINAL BLEEDING: A RANDOMIZED CONTROLLED TRIAL
N. Carbonell 1. V Godard 1, L. Seffaty 1, N. Best 2, R. Poupon I . :Service
d'H@atologie Hdpital Saint-Antoine, Paris, France," 2Direction de la Recherche Clinique Assistance Publique Hopitaux de Paris, Paris, France Emergency endoscopy may be difficult in upper gastrointestinal bleeding because of persistent clots in tile stomach. We investigated whether erythromycin infusion associated with gastric lavage would improve gastric emptying. Patients and Method: Ninety-nine consecutive patients admitted for upper gastrointestinal bleeding in a single university hospital were randomly assigned to receive gastric lavage plus E (250 mg iv in 30 minutes) or gastric lavage plus placebo in a double blind way. Randomization was stratified according to tile presence or not of an portal hypertension. Tile primary endpoint was tile presence or not of clots in tile stomach during emergency endoscopy. Clots were strongly defined as clots which cannot be aspirated by tile operator channel of tile endoscope. We also used a visual analogical scale of 0 to 10: 0, very bad preparation, 10, excellent preparation. Secondary endpoints were duration of endoscopy, need for second-look in tile next 48 hours, number of blood units transfused. Results: Characteristics upon adrnission, source of bleeding, interval between tile onset of bleeding and endoscopy, were similar in both groups. Sixty-six patients had cirrhosis and were well matched in both groups. Persistent clots were more frequent in tile placebo group than in tile erythromycin group (52% and 30% respectively, p < 0.05). The analogic visual scale was better in the erythromycin than in the placebo group (4.2 versus 3.3, p < 0.05). There were no differences between the two groups for tile secondary endpoints. Erythromycin was well tolerated in all patients. The same results were observed in tile subgroups of cirrhotic patients. Conclusion: IV erythromycin prior to endoscopy improves gastric lavage in patients with upper gastrointestinal bleeding. This treatment is well tolerated but does not modify the prognosis of these patients.
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THE INFLUENCE OF GLUCOCORTICOIDS IN LOW DOSE IN CIRRHOTIC PATIENTS WITH INFECTION
O. Chelarescu I . I. Stratan I , D. Chelarescu 2. 1Anaesthesiology and Intensive Care, "Sf SpirMon" Hospital, Iasi, Romania; 2pharmacology, Univ. IVied Pharos. 'GI: Z Popa ; Iasi, Romania Background: Septic shock is often associated with relative adrenal insufficiency. A replacement therapy with low doses of cortJcosteroids might be beneficial. Is it tile same situation for cirrhotic patients? Aim: To pursue if low dose corticoids decrease mortality in cirrhotic patients with infection that evolved severe septic shock. Method: We observed for tile development of severe sepsis (sepsis and 2 organ dysfunctions) 37 patients with cirrhosis admitted in Intensive Care Unit (ICU) for encephalopathy. These patients had proven upper respiratory or urinary tract infections and were treated with antibiotics after antibiogram-tested susceptibility. Patients were randomly assigned at the moment of ICU admittance in 2 groups: Ist group (19 patients) treated with regular treatment and IInd group (18 patients) treated (besides regular treatment) with hydrocortisone hemisuccinate (HHC) 50 mg at 6 hours. Regular treatment consists in enteral/parenteral nutrition, lactnlose and colimycin on nasogastric probe, volemic support. Results: At 10 days of ICU hospitalization 13 patients (68.42%) in Ist group evolved severe sepsis vs. 6 patients (33.34%) in IInd group. Requirement o f noradrenaline in patients that developed severe sepsis was lower in group treated with HHC vs. Ist group (5.8 ~g/rnin and 13.3 gg/min, respectively, p < 0.01). Scoring systems for ICU and surgical patients was also significantly improved in groups with HHC (APACHE II
score: 10 in HHC vs. 31 in Ist group; SAPS, SOFA II). Mortality rate was (at 15 days after infection diagnosis): 52.63% (10 patients) in HHC group respectively 11.11% (2 patients) in Ist group. If we considered only patients with severe sepsis the mortality was 76.92% vs 33.34% in HHC group. Conclusions: We plead for the introduction of the HHC (due to adrenal dysfunction) from the moment of setting the liver failure diagnostic. ADMITTED TO INTENSIVE CARE UNIT: RISK 1•9] CIRRHOTICS FACTORS AFFECTING 6 W E E K SURVIVAL E. Cholon~tas 1, M. Senzolo I , K. Kwong I , D. Patch 1, V.N. Nikolopoulou 1, G. Leandro ~, S. Shaw 2, A.K. Burroughs I . :Liver
Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, UK; 2Department of Intensive Care, Royal Free Hospital, London, UK Background: There is a high mortality rate in cirrhofics admitted to an Intensive Care Unit (ICU). Most ICU scores are derived from populations without many cirrhotics. Aim: To evaluate the factors associated with 6 week survival in cirrhotics admitted to ICU and to assess established scores. Patients and Methods: 312 cirrhotics (182 M, mean age 49.6±11.5y) were consecutively admitted. At admission, 40 variables, including admission calendar year, were available to derive a multivariable logistic regression model. Chil&Pugh (CP), MELD, Apache II and SOFA scores on adrnission, were evaluated and compared by ROC curves. Complications and therapeutic interventions during ICU stay were recorded. Results: Cirrhosis was alcoholic in 65%; the major indication for ICU admission was respiratory failure in 35.6 %. Renal failure was present in 41% and mechanical ventilation was needed in 88%. Tile median length of ICU stay was 4 ( 1 4 8 ) days. The median CP, Apache II, MELD and SOFA scores were 11, 18, 24 and 11 respectively. Mortality was 65% (n 203) at 6 weeks and was significantly higher during the period 1989 1996 compared to 1997-2004 (73% vs 58%, p=0.006). The cause of death was multiple organ failure in 45%. Survivors, compared to non-survivors, had significantly lower CP (10 vs 12, p<0.001), Apache II (15 vs 21, p < 0.001), MELD (19 vs 27, p < 0.001) and SOFA (9 vs 12, p <0.001) scores. Mortality factors independendy associated with 6 week survival on admission were: fewer organs failing (<3 51.5%, >~3 10%) and per unit log, lower FiO2 (OR 0.04, 95%CI: 0.04 0.51), lactate (OR 0.76, 95%CI: 0.64-0.90), urea (OR=0.94, 95%CI: 0 . 9 0 - 0 . 9 9 ) a n d bilirubin (OR= 0.996, 95%CI: 0.992-0.999). Predictive value of outcome in terms of ROC was best for SOFA followed by MELD score. Conclusions: A specific prognostic score for cirrhotics adrnitted to ICU can be derived in this large cohort as key markers of organ function were prognostic: FiO2 (respiratory), bilirubin (hepatic), urea (renal, hepatic), lactate (hepatic, renal) as well as 3 or more failing organs (resulting in 90% mortality). The established ICU scores, SOFA and MELD, which contain the above variables, or their surrogates, offered better prediction than Apache II or CP scores.
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FIBROSIS EVALUATION IN CHRONIC LIVER DISEASES: COMPARISON OF FIBROSCAN ® WITH LIVER BIOPSY, FIBROTEST ®, FORNS SCORE, APRI, HYALURONAN, PROTHROMBIN TIME, AND ASTtALT RATIO
J. Foucher I , J. Vergniol I , L. Cast&a I , B. Le Bail 2, E. Chanteloup I , X. Adhoute 1, M. Darriet 3, J. Bertet I , R Couzigou I , V de Ledinghen 1,4.
: Hdpato-Gastroentdrologie, CHU, Bordeaux, France; 2AnatomiePathologique, CHU, Bordeaux, France," SBiochimie, CHU, Bordeaux, France; 4INSEPu~IE362 IFR66, Universitd Victor Segalen, Bordeaux, Fl~nc e
Transient elastography (FibroScan ®, Echosens, France) is a new noninvasive rapid and reproducible method allowing to evaluate liver fibrosis
Category 2b." Cirrhosis and Complications." Clinical Aspects by measurement of liver stiffness. The aim of this prospective study was to evaluate, in patienlts with chronic liver disease, the accuracy o f FibroScan®, Fibrotest®, Foms score, APRI, hyaluronan, AST/ALT ratio, and prothrombin time (PT) compared to liver biopsy, for the diag-nosis of fibrosis. 363 consecutive patients (216 males, mean age 51 years) with chronic liver disease [HCV (n = 190) or HBV infection (n = 13), alcoholic liver disease (n=43), others (n= 117)1 were included. Fibrosis score according to Metavir split as follow: F0-F1 n = 114, F2 n = 101, F3 n = 52, F4 n = 96. Liver stift'ness ranged from 2.7 to 75 kPa. For a positive predictive value >90%, cut-offvalues of FibroScan ® were 8.6 kPa for F ~>2, 13 kPa for F ~>3 and 17.6 kPa for F = 4. The AUROCs (95%CI) are shown in tile table.
F2 F3 F4
A~T/ALT
PT
Hyaluro nm~ APRI
Forns
b'ibrotest
Nbroscan
0,63 0,56-0.68 0,67 0.60-0.72
0,64 0,68-0.70 0,73 0,68-0.78
0,73 0,68-0 84 0,76 0,61-0 86
0.76 0,69-0 80 0,80 0.76-0 84
0.78 0,66-0.87 0,81 0.67-0.89
077 071-0.83 066 081-0.90
079 074-0.83 069 086-0.92
0.78 0,71-0.83
0,84 0,78-0.88
0,90 0,74-0 97
0.79 0.73-0 84
0.89 0.79-0.96
088 0 84-0.92
095 092-0.97
The best performances were obtained by combining Fibroscan® with Fibrotest® or Forns with AUROCs of 0.80 (0.74 0.85) and 0.81 (0.69 0.88) for F~>2, 0.89 (0.85 0.93) and 0.84 (0.71 0.91) for F~>3, 0.94 (0.90-0.96) and 0.95 (0.85-0.98) for F=4, respectively. When FibroScan® and Fibrotest® agreed, tile concordance with liver biopsy was 76% for F>~2, 93% for F~>3, and 98% for F 4. In chronic liver diseases, FibroScan® is an efficient non-invasive method for the diaguosis of fibrosis. Its performance is of the same order as that of serolo~cal markers o f fibrosis. Combining FibroScan ® and Fibrotest® or Forns score in tile assessment of fibrosis could avoid liver biopsy in tile majority of patients with chronic liver disease.
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propranolol and after chronic per oral propranolol HVPG was 18.7-4-4, 15.5+4.4 and 16.8±5 respectively (P <0.05). Sixteen patients (28.6%) responded to intravenous propranolol and 18 (32.1°/0) to oral propranolol (P=NS). Three patients responded in the first study, but did not respond in tile second test, and five patients did not respond in the first study but responded in the second test; there was no case of rebleeding in these eight patients. Eight patients (14.3%) rebled on follow-up, only 1 of them responded to propranolol (in both studies); this patient had portal vein thrombosis. Conclusions: A single early hemodynamic study using intravenous propranolol appears to be useful in order to select prophylactic treatment.
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AUROC values with 95%CI
M O N I T O R I N G OF HVPG DURING P H A R M A C O L O G I C A L THERAPY: A C O M P A R I S O N BETWEEN T W O M E T H O D S
E. de Madaria I , JM. Palazdn ~, J. S~nchez2, E de Espafia3, S. Gil 3, S. Pascual I , M. Pbrez-Mateo 1. ;Liver Unit, HGUA, Spain; 2Epidemiology,
HGUA, Spa#a," SRadiology, HGUA, Spain Background: Tile effective preventive treatment of variceal bleeding is mandatory in patients with cirrhosis who survive their first variceal hemorrhage or in patients with medium or large-sized varices. The response to medical therapy can be assessed by measuring the Hepatic Venous Pressure Gradient (HVPG): baseline value and after chronic medical treatment. Aims: To determine if tile decrease of the HVPG after tile adrnfifistration of intravenous propranolol (0.15 mg]kg) is as useful to guide prophylaxis of variceal bleeding as HVPG measurement after at least 3 months of per oral propranolol. Methods: We included prospectively cirrhotic patients with esophageal varices (primary and secondary prophylaxis). A first hemodynamic study was performed: basal HVPG and HVPG after a propranolol bolus (0.15mg/kg iv) were measured. Patients then received oral propranolol (heart rate titrated). Non-responders were inchided also in a variceal band ligation programme. After at least three months a second hemodynamic study was performed. Those patients who responded then received only oral propranolol and those non-responders received only variceal band ligation. In both studies the responder status was defined as a decrease of HVPG to 12mmHg or less, or more than 20% related to tile basal HVPG. Results: Fifty-six patients were included with a mean age of 56±9. The basal Child-Pugh score was: 20 patients Child-Pugh A, 23 B and 13 C. Mean follow-up was 4054-290 days. In 13 patients (23%) the second hemodynamic study was not performed. The basal, after intravenous
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E N D O S C O P I C V A R I C E A L B A N D LIGATION IN C O M P A R I S O N WITH P R O P R A N O L O L IN P R O P H Y L A X I S OF FIRST V A R I C E A L BLEEDING IN PATIENTS WITH LIVER C I R R H O S I S
P. Drastich 1, J. Lata 2, J. Petrtyl 3 , V Prochazka 4, T. Vanasek5, P. Zdenek 6, j. Spicak I" 1 Clinic of Hepatogastroenterology, Institute for Clinical and
Experimental Medicine, Prague, Czech Republic," 2Gastroenterology, Faculty of Medicine Masaryk University, Brno, Czech Republic," 3Gastroenterology, General University Hospital, Prague, Czech Republic'," 4Gastroenterology, Faculty of Medicine Palacky University, Olomouc, Czech Republic," 5Gastroenterology, Faculty of Medicine Charles University, Hradec Kralove, Czech Republic'," 6 Gastroenterolog)~. Faculty of Medicine Charles University, Plzen, Czech Republic" Introduction: Prophylaxis of the first variceal bleeding is one of the most important strategies in treatment of patients with liver cirrhosis. Endoscopic variceal ligation (EVL) and beta-blockers have been shown independently to decrease tile risk of first bleeding. A | m s and Methods: We conducted a prospective, multicentric, randomized trim to compare efficacy and safety of propranolol therapy vs. EVL for tile prophylaxis of tile first variceal bleeding. A total o f 73 consecutive patients with liver cirrhosis and high-risk varices (>5 m m in diameter) that had never bled, were inchlded in the study. The patients were randomized into 2 groups: 33 received propranolol at a dose sufficient to decrease the baseline heart rate by 25 percent, and 40 underwent EVL until eradication was reached. The primary end points were bleeding from the esophageal varices and death. Median follow-up period was 10 months (1-18). Results: The 18 months actuarial risk for first variceal bleed was 9% for EVL (95% confidence interval [CI]: 0 2 0 % ) and 20% for propranolol group (95%CI: 0-49%), P=NS. Three patients died, 1 in propranolol group (3%) and 2 in EVL group (5°/0), P=NS, one death occurred as a consequence of variceal bleeding (EVL group) and 2 because of liver failure. There were no serious complications except one bleeding related immediately to EVL, in the propranolol group no treatment withdrawal occurred clue to side effects. The mean (±SD) number of sessions needed to achieve variceal eradication was 2.2221.2, the mean close ofpropranolol required for adequate heart rate reduction was 66.70±30.6mg daily. Recurrence of varices without bleeding occurred in 3 patients after 6, 9 and 12 months in EVL group (10%). Conclusion: Both propranolol and EVL seem to be safe and effective in primary prophylaxis of bleeding in patients with high-risk esophageal varices and both treatment modalities have few side-effects. EVL is a good alternative treatment to propranolol with fast eradication rate of esophageal Varice8.
This study is supported by grant IGA MH CR NK/6947-3.
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ERYTHROMYCIN IMPROVES GASTRIC LAVAGE IN ACUTE UPPER GASTROINTESTINAL BLEEDING: A RANDOMIZED CONTROLLED TRIAL
N. Carbonell 1. V Godard 1, L. Seffaty 1, N. Best 2, R. Poupon I . :Service
d'H@atologie Hdpital Saint-Antoine, Paris, France," 2Direction de la Recherche Clinique Assistance Publique Hopitaux de Paris, Paris, France Emergency endoscopy may be difficult in upper gastrointestinal bleeding because of persistent clots in tile stomach. We investigated whether erythromycin infusion associated with gastric lavage would improve gastric emptying. Patients and Method: Ninety-nine consecutive patients admitted for upper gastrointestinal bleeding in a single university hospital were randomly assigned to receive gastric lavage plus E (250 mg iv in 30 minutes) or gastric lavage plus placebo in a double blind way. Randomization was stratified according to tile presence or not of an portal hypertension. Tile primary endpoint was tile presence or not of clots in tile stomach during emergency endoscopy. Clots were strongly defined as clots which cannot be aspirated by tile operator channel of tile endoscope. We also used a visual analogical scale of 0 to 10: 0, very bad preparation, 10, excellent preparation. Secondary endpoints were duration of endoscopy, need for second-look in tile next 48 hours, number of blood units transfused. Results: Characteristics upon adrnission, source of bleeding, interval between tile onset of bleeding and endoscopy, were similar in both groups. Sixty-six patients had cirrhosis and were well matched in both groups. Persistent clots were more frequent in tile placebo group than in tile erythromycin group (52% and 30% respectively, p < 0.05). The analogic visual scale was better in the erythromycin than in the placebo group (4.2 versus 3.3, p < 0.05). There were no differences between the two groups for tile secondary endpoints. Erythromycin was well tolerated in all patients. The same results were observed in tile subgroups of cirrhotic patients. Conclusion: IV erythromycin prior to endoscopy improves gastric lavage in patients with upper gastrointestinal bleeding. This treatment is well tolerated but does not modify the prognosis of these patients.
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THE INFLUENCE OF GLUCOCORTICOIDS IN LOW DOSE IN CIRRHOTIC PATIENTS WITH INFECTION
O. Chelarescu I . I. Stratan I , D. Chelarescu 2. 1Anaesthesiology and Intensive Care, "Sf SpirMon" Hospital, Iasi, Romania; 2pharmacology, Univ. IVied Pharos. 'GI: Z Popa ; Iasi, Romania Background: Septic shock is often associated with relative adrenal insufficiency. A replacement therapy with low doses of cortJcosteroids might be beneficial. Is it tile same situation for cirrhotic patients? Aim: To pursue if low dose corticoids decrease mortality in cirrhotic patients with infection that evolved severe septic shock. Method: We observed for tile development of severe sepsis (sepsis and 2 organ dysfunctions) 37 patients with cirrhosis admitted in Intensive Care Unit (ICU) for encephalopathy. These patients had proven upper respiratory or urinary tract infections and were treated with antibiotics after antibiogram-tested susceptibility. Patients were randomly assigned at the moment of ICU admittance in 2 groups: Ist group (19 patients) treated with regular treatment and IInd group (18 patients) treated (besides regular treatment) with hydrocortisone hemisuccinate (HHC) 50 mg at 6 hours. Regular treatment consists in enteral/parenteral nutrition, lactnlose and colimycin on nasogastric probe, volemic support. Results: At 10 days of ICU hospitalization 13 patients (68.42%) in Ist group evolved severe sepsis vs. 6 patients (33.34%) in IInd group. Requirement o f noradrenaline in patients that developed severe sepsis was lower in group treated with HHC vs. Ist group (5.8 ~g/rnin and 13.3 gg/min, respectively, p < 0.01). Scoring systems for ICU and surgical patients was also significantly improved in groups with HHC (APACHE II
score: 10 in HHC vs. 31 in Ist group; SAPS, SOFA II). Mortality rate was (at 15 days after infection diagnosis): 52.63% (10 patients) in HHC group respectively 11.11% (2 patients) in Ist group. If we considered only patients with severe sepsis the mortality was 76.92% vs 33.34% in HHC group. Conclusions: We plead for the introduction of the HHC (due to adrenal dysfunction) from the moment of setting the liver failure diagnostic. ADMITTED TO INTENSIVE CARE UNIT: RISK 1•9] CIRRHOTICS FACTORS AFFECTING 6 W E E K SURVIVAL E. Cholon~tas 1, M. Senzolo I , K. Kwong I , D. Patch 1, V.N. Nikolopoulou 1, G. Leandro ~, S. Shaw 2, A.K. Burroughs I . :Liver
Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, UK; 2Department of Intensive Care, Royal Free Hospital, London, UK Background: There is a high mortality rate in cirrhofics admitted to an Intensive Care Unit (ICU). Most ICU scores are derived from populations without many cirrhotics. Aim: To evaluate the factors associated with 6 week survival in cirrhotics admitted to ICU and to assess established scores. Patients and Methods: 312 cirrhotics (182 M, mean age 49.6±11.5y) were consecutively admitted. At admission, 40 variables, including admission calendar year, were available to derive a multivariable logistic regression model. Chil&Pugh (CP), MELD, Apache II and SOFA scores on adrnission, were evaluated and compared by ROC curves. Complications and therapeutic interventions during ICU stay were recorded. Results: Cirrhosis was alcoholic in 65%; the major indication for ICU admission was respiratory failure in 35.6 %. Renal failure was present in 41% and mechanical ventilation was needed in 88%. Tile median length of ICU stay was 4 ( 1 4 8 ) days. The median CP, Apache II, MELD and SOFA scores were 11, 18, 24 and 11 respectively. Mortality was 65% (n 203) at 6 weeks and was significantly higher during the period 1989 1996 compared to 1997-2004 (73% vs 58%, p=0.006). The cause of death was multiple organ failure in 45%. Survivors, compared to non-survivors, had significantly lower CP (10 vs 12, p<0.001), Apache II (15 vs 21, p < 0.001), MELD (19 vs 27, p < 0.001) and SOFA (9 vs 12, p <0.001) scores. Mortality factors independendy associated with 6 week survival on admission were: fewer organs failing (<3 51.5%, >~3 10%) and per unit log, lower FiO2 (OR 0.04, 95%CI: 0.04 0.51), lactate (OR 0.76, 95%CI: 0.64-0.90), urea (OR=0.94, 95%CI: 0 . 9 0 - 0 . 9 9 ) a n d bilirubin (OR= 0.996, 95%CI: 0.992-0.999). Predictive value of outcome in terms of ROC was best for SOFA followed by MELD score. Conclusions: A specific prognostic score for cirrhotics adrnitted to ICU can be derived in this large cohort as key markers of organ function were prognostic: FiO2 (respiratory), bilirubin (hepatic), urea (renal, hepatic), lactate (hepatic, renal) as well as 3 or more failing organs (resulting in 90% mortality). The established ICU scores, SOFA and MELD, which contain the above variables, or their surrogates, offered better prediction than Apache II or CP scores.
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FIBROSIS EVALUATION IN CHRONIC LIVER DISEASES: COMPARISON OF FIBROSCAN ® WITH LIVER BIOPSY, FIBROTEST ®, FORNS SCORE, APRI, HYALURONAN, PROTHROMBIN TIME, AND ASTtALT RATIO
J. Foucher I , J. Vergniol I , L. Cast&a I , B. Le Bail 2, E. Chanteloup I , X. Adhoute 1, M. Darriet 3, J. Bertet I , R Couzigou I , V de Ledinghen 1,4.
: Hdpato-Gastroentdrologie, CHU, Bordeaux, France; 2AnatomiePathologique, CHU, Bordeaux, France," SBiochimie, CHU, Bordeaux, France; 4INSEPu~IE362 IFR66, Universitd Victor Segalen, Bordeaux, Fl~nc e
Transient elastography (FibroScan ®, Echosens, France) is a new noninvasive rapid and reproducible method allowing to evaluate liver fibrosis
Category 2b." Cirrhosis and Complications." Clinical Aspects by measurement of liver stiffness. The aim of this prospective study was to evaluate, in patienlts with chronic liver disease, the accuracy o f FibroScan®, Fibrotest®, Foms score, APRI, hyaluronan, AST/ALT ratio, and prothrombin time (PT) compared to liver biopsy, for the diag-nosis of fibrosis. 363 consecutive patients (216 males, mean age 51 years) with chronic liver disease [HCV (n = 190) or HBV infection (n = 13), alcoholic liver disease (n=43), others (n= 117)1 were included. Fibrosis score according to Metavir split as follow: F0-F1 n = 114, F2 n = 101, F3 n = 52, F4 n = 96. Liver stift'ness ranged from 2.7 to 75 kPa. For a positive predictive value >90%, cut-offvalues of FibroScan ® were 8.6 kPa for F ~>2, 13 kPa for F ~>3 and 17.6 kPa for F = 4. The AUROCs (95%CI) are shown in tile table.
F2 F3 F4
A~T/ALT
PT
Hyaluro nm~ APRI
Forns
b'ibrotest
Nbroscan
0,63 0,56-0.68 0,67 0.60-0.72
0,64 0,68-0.70 0,73 0,68-0.78
0,73 0,68-0 84 0,76 0,61-0 86
0.76 0,69-0 80 0,80 0.76-0 84
0.78 0,66-0.87 0,81 0.67-0.89
077 071-0.83 066 081-0.90
079 074-0.83 069 086-0.92
0.78 0,71-0.83
0,84 0,78-0.88
0,90 0,74-0 97
0.79 0.73-0 84
0.89 0.79-0.96
088 0 84-0.92
095 092-0.97
The best performances were obtained by combining Fibroscan® with Fibrotest® or Forns with AUROCs of 0.80 (0.74 0.85) and 0.81 (0.69 0.88) for F~>2, 0.89 (0.85 0.93) and 0.84 (0.71 0.91) for F~>3, 0.94 (0.90-0.96) and 0.95 (0.85-0.98) for F=4, respectively. When FibroScan® and Fibrotest® agreed, tile concordance with liver biopsy was 76% for F>~2, 93% for F~>3, and 98% for F 4. In chronic liver diseases, FibroScan® is an efficient non-invasive method for the diaguosis of fibrosis. Its performance is of the same order as that of serolo~cal markers o f fibrosis. Combining FibroScan ® and Fibrotest® or Forns score in tile assessment of fibrosis could avoid liver biopsy in tile majority of patients with chronic liver disease.
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propranolol and after chronic per oral propranolol HVPG was 18.7-4-4, 15.5+4.4 and 16.8±5 respectively (P <0.05). Sixteen patients (28.6%) responded to intravenous propranolol and 18 (32.1°/0) to oral propranolol (P=NS). Three patients responded in the first study, but did not respond in tile second test, and five patients did not respond in the first study but responded in the second test; there was no case of rebleeding in these eight patients. Eight patients (14.3%) rebled on follow-up, only 1 of them responded to propranolol (in both studies); this patient had portal vein thrombosis. Conclusions: A single early hemodynamic study using intravenous propranolol appears to be useful in order to select prophylactic treatment.
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AUROC values with 95%CI
M O N I T O R I N G OF HVPG DURING P H A R M A C O L O G I C A L THERAPY: A C O M P A R I S O N BETWEEN T W O M E T H O D S
E. de Madaria I , JM. Palazdn ~, J. S~nchez2, E de Espafia3, S. Gil 3, S. Pascual I , M. Pbrez-Mateo 1. ;Liver Unit, HGUA, Spain; 2Epidemiology,
HGUA, Spa#a," SRadiology, HGUA, Spain Background: Tile effective preventive treatment of variceal bleeding is mandatory in patients with cirrhosis who survive their first variceal hemorrhage or in patients with medium or large-sized varices. The response to medical therapy can be assessed by measuring the Hepatic Venous Pressure Gradient (HVPG): baseline value and after chronic medical treatment. Aims: To determine if tile decrease of the HVPG after tile adrnfifistration of intravenous propranolol (0.15 mg]kg) is as useful to guide prophylaxis of variceal bleeding as HVPG measurement after at least 3 months of per oral propranolol. Methods: We included prospectively cirrhotic patients with esophageal varices (primary and secondary prophylaxis). A first hemodynamic study was performed: basal HVPG and HVPG after a propranolol bolus (0.15mg/kg iv) were measured. Patients then received oral propranolol (heart rate titrated). Non-responders were inchided also in a variceal band ligation programme. After at least three months a second hemodynamic study was performed. Those patients who responded then received only oral propranolol and those non-responders received only variceal band ligation. In both studies the responder status was defined as a decrease of HVPG to 12mmHg or less, or more than 20% related to tile basal HVPG. Results: Fifty-six patients were included with a mean age of 56±9. The basal Child-Pugh score was: 20 patients Child-Pugh A, 23 B and 13 C. Mean follow-up was 4054-290 days. In 13 patients (23%) the second hemodynamic study was not performed. The basal, after intravenous
79
E N D O S C O P I C V A R I C E A L B A N D LIGATION IN C O M P A R I S O N WITH P R O P R A N O L O L IN P R O P H Y L A X I S OF FIRST V A R I C E A L BLEEDING IN PATIENTS WITH LIVER C I R R H O S I S
P. Drastich 1, J. Lata 2, J. Petrtyl 3 , V Prochazka 4, T. Vanasek5, P. Zdenek 6, j. Spicak I" 1 Clinic of Hepatogastroenterology, Institute for Clinical and
Experimental Medicine, Prague, Czech Republic," 2Gastroenterology, Faculty of Medicine Masaryk University, Brno, Czech Republic," 3Gastroenterology, General University Hospital, Prague, Czech Republic'," 4Gastroenterology, Faculty of Medicine Palacky University, Olomouc, Czech Republic," 5Gastroenterology, Faculty of Medicine Charles University, Hradec Kralove, Czech Republic'," 6 Gastroenterolog)~. Faculty of Medicine Charles University, Plzen, Czech Republic" Introduction: Prophylaxis of the first variceal bleeding is one of the most important strategies in treatment of patients with liver cirrhosis. Endoscopic variceal ligation (EVL) and beta-blockers have been shown independently to decrease tile risk of first bleeding. A | m s and Methods: We conducted a prospective, multicentric, randomized trim to compare efficacy and safety of propranolol therapy vs. EVL for tile prophylaxis of tile first variceal bleeding. A total o f 73 consecutive patients with liver cirrhosis and high-risk varices (>5 m m in diameter) that had never bled, were inchlded in the study. The patients were randomized into 2 groups: 33 received propranolol at a dose sufficient to decrease the baseline heart rate by 25 percent, and 40 underwent EVL until eradication was reached. The primary end points were bleeding from the esophageal varices and death. Median follow-up period was 10 months (1-18). Results: The 18 months actuarial risk for first variceal bleed was 9% for EVL (95% confidence interval [CI]: 0 2 0 % ) and 20% for propranolol group (95%CI: 0-49%), P=NS. Three patients died, 1 in propranolol group (3%) and 2 in EVL group (5°/0), P=NS, one death occurred as a consequence of variceal bleeding (EVL group) and 2 because of liver failure. There were no serious complications except one bleeding related immediately to EVL, in the propranolol group no treatment withdrawal occurred clue to side effects. The mean (±SD) number of sessions needed to achieve variceal eradication was 2.2221.2, the mean close ofpropranolol required for adequate heart rate reduction was 66.70±30.6mg daily. Recurrence of varices without bleeding occurred in 3 patients after 6, 9 and 12 months in EVL group (10%). Conclusion: Both propranolol and EVL seem to be safe and effective in primary prophylaxis of bleeding in patients with high-risk esophageal varices and both treatment modalities have few side-effects. EVL is a good alternative treatment to propranolol with fast eradication rate of esophageal Varice8.
This study is supported by grant IGA MH CR NK/6947-3.