- Email: [email protected]
231 NOVEL NONINVASIVE MEASUREMENT OF HEPATIC VENOUS PRESSURE GRADIENT AND PORTAL PRESSURE FROM ANATOMIC CT ANGIOGRAPHY
POSTERS 230 COMPARISON OF SIX SERUM TESTS, LIVER STIFFNESS AND HVPG IN THE PREDICTION OF CLINICAL DECOMPENSATION IN CHRONIC LIVER DISEASES 3 B. Procopet1,2 , M.A. Robic3 , M. Grigorescu1,2 , S. Metivier ´ , 1,2 3,4 3,4 3,4 1 M. Tantau , J.M. Peron , J.P. Vinel , C. Bureau . Gastroenterology, University of Medicine and Pharmacy “Iuliu Hatieganu”, 2 Gastroenterology, Regional Institute of Gastroenterology and Hepatology “O Fodor”, Cluj-Napoca, Romania; 3 HepatoGastroenterology, Purpan Hospital, CHU Toulouse, 4 INSERM U858 and University of Toulouse, Toulouse, France E-mail: [email protected] Background and Aims: The prognosis of chronic liver diseases (CLD) is determined by the presence of portal hypertension (PHT). The standard method for PHT diagnosis is hepatic venous pressure gradient (HVPG). Recently, non-invasive methods were proposed to evaluate patients with CLD. The aim of this study is to compare non-invasive tests with HVPG in terms of diagnosis of clinical significant portal hypertension (CSPHT) and esophageal varices and, for their capacity of clinical decompensation prediction. Methods: Two hundred thirty-eight patients underwent HVPG measurement along with serological test (AST/ALT index, APRI, Lok, FIB-4, GUCI, Risk score) and liver stiffness (LS) measurement on the same day. A subgroup of 100 patients was followup for 2 year or until decompensation. Decompensation was defined as variceal haemorrhage, ascites, hepatic encephalopathy, hepatocellular carcinoma and/or sepsis. The patients were censored at 2 years or at the time of the first decompensation, liver transplantation, or death. PHT related complications (variceal bleeding and/or ascites) were also studied separately. Results: In the whole studied population, cirrhosis was found in 142 patients, from which 93 (65%) had EV and 103 (72%) had CSPH. At the time of inclusion all cirrhotic patients were compensated. For CSPHT and esophageal varices the Lok score was the best serum test, AUROC=0.86 and 0.83, respectively. However, LS is the best non-invasive methods for these end-points (AUROC=0.95 for CSPH and 0.90 for esophageal varices). The best correlation with CSPH was for LS (r = 0.769, p < 0.0001), followed by the Lok score (r = 0.616, p < 0.0001). Worse correlation was with APRI (r = 0.377, p < 0.0001). During the follow-up 41 patients suffered a clinical complication within a mean period of 491±282 [8–730] days. FIB-4 is the best serological test, which predicts clinical decompensation (AUROC=0.84), but Lok score predicts slightly better the occurrence of PHT related complications (AUROC=0.77). The worse performance had the AST/ALT index in predicting either clinical decompensation and PHT related complications. Conclusion: LS is the most efficient non-invasive method in diagnosis and prognosis of CLD. The Lok and FIB-4 scores are good non-invasive alternatives for diagnosis and prediction of clinical decompensation.
portal hypertension (PHT) and determining the treatment for cirrhotic patients. Invasive HVPG and PP measurements can not be performed routinely and repeatedly. This study intends to develop a novel noninvasive assessment of HVPG (HVPGni) and PP (PPni) computed from three dimensional (3D) hepatic portal venous models. Methods: HVPGni and PPni were calculated through 3D hepatic portal venous models reconstructed from CT angiography. Finite element and computational fluid dynamics in ANSYS software were applied to analyze the pressure distribution in vitro. Clinical data of a decompensated cirrhotic patient were calculated to test the feasibility and accuracy of the novel measurement with diagnostic results of Doppler ultrasound (DUS) and CT angiography as reference standards. Results: CT images showed that the diameter of portal venous was around 1.6cm and the average velocity measured by DUS was 12.5cm/s, both of which indicated a severe PHT. According to calculation through the novel assessment, HVPGni and PPni of the decompensated cirrhotic patient were 65.2Pa (Figure 1) and 3535.0Pa (Figure 2), which were generally consistent with the previous diagnosis of PHT. Besides, the pressure (Figure 3.I) and velocity (Figure 3.II) distribution of different cross-sections of portal venous were simulated in vitro.
Figure 1.
231 NOVEL NONINVASIVE MEASUREMENT OF HEPATIC VENOUS PRESSURE GRADIENT AND PORTAL PRESSURE FROM ANATOMIC CT ANGIOGRAPHY X. Qi1 , F. Zhou1 , H. Lv2 , H. Chen1 , W. Xu3 , S. Xing3 , D. Yang3 , G. Li4 , C. Yang1 . 1 Division of Gastroenterology and Hepatology, Tongji Hospital, Tongji University School of Medicine, 2 Division of Mathematics, Tongji University, 3 Division of Radiology, Tongji Hospital, Tongji University School of Medicine, 4 Tongji University School of Civil Engineering, Shanghai, China E-mail: [email protected] Background and Aims: Assessment of hepatic venous pressure gradient (HVPG) and portal pressure (PP) is significant in diagnosing
Figure 2.
Journal of Hepatology 2013 vol. 58 | S63–S227
S99
POSTERS Thrombin injection and 1 patient had ascites with no flow in parallel TIPSS 4 days post-procedure. Secondary patency was 82% by the end of follow-up period with a median number of interventions of 1.5 (IQR 1–3). Median follow-up was 30 months (range 0.5–120). 92% patients were alive at 1 month with 86% 1 year survival. Two patients were transplanted during follow-up. Conclusions: Parallel TIPSS is a safe and effective method to treat TIPSS insufficiency. The majority of patients not only had a good haemodynamic result, but also resolution of symptoms. 233 SOLUBLE VEGFR-2 SERUM MAY BE A PREDICTIVE FACTOR FOR PROGRESSION OF CHRONIC LIVER DISEASE AND HEPATOCELLULAR CARCINOMA N. Ratnasari, S. Nurdjanah. Internal Medicine, Faculty of Medicine/Dr. Sardjito General Hospital, Gadjah Mada University, Yogyakarta, Indonesia E-mail: [email protected]
Figure 3.
Conclusions: HVPGni and PPni were in vitro quantified successfully. Although comparisons of noninvasive index with invasive ones are still needed, the novel evaluation of PHT from anatomic hepatic portal venous models has made up deficiencies and provides a potentially noninvasive and repeatable approach for the diagnosis of PHT. 232 PARALLEL TIPSS FOR THE MANAGEMENT OF SHUNT INSUFFICIENCY IN PATIENTS WITH COMPLICATIONS OF PORTAL HYPERTENSION: A TERTIARY LIVER UNIT 19 YEAR EXPERIENCE N. Rajoriya1 , H. Mehrzad2 , K. Mangat2 , S. Oliff2 , D. Tripathi1 . 1 Liver Medicine, 2 Radiology, Queen Elizabeth Hospital, Birmingham, UK E-mail: [email protected] Background: Transjugular Intrahepatic Porto-Systemic Shunts (TIPSS) insufficiency can be addressed with a side placement of another TIPSS beside the original (“parallel” technique) thus improving portosystemic pressure gradient (PPG). There is a paucity of data assessing the efficacy of this technique. Aim: To assess the efficacy of parallel TIPSS in a large UK tertiary referral centre. Methods: A retrospective study was performed from patient electronic radiology and laboratory databases. Parallel TIPSS were performed over a 19 year period in a single centre. Results: 11 patients (8M:3F) were identified (2% of all TIPSS procedures). Mean age at time of parallel TIPSS was 48.6 (±13.7). Background aetiology of portal hypertension included: 5 ALD, 2 PSC, 2 PBC, 1 liver graft failure, 1 non-cirrhotic portal hypertension (NCPH). Indications for index TIPSS (5 covered stents) were: 4 Oesophageal variceal (OV) haemorrhage, 3 gastric variceal (GV) haemorrhage, 1 stomal variceal haemorrhage and 3 for refractory ascites. At time of 1st TIPSS, documented mean PPG was 16.6 (±7.71) and post TIPSS 10.8 (±7.35) mmHg. Median time between index TIPSS and parallel TIPSS insertion was 72 (IQR 4–1122) days. Prior to parallel stent placement, 7 patients had dilatation of the index TIPSS. At parallel TIPSS, the mean initial PPG was 16.0 (±7.40) post procedure 6 (±2.28) mmHg. 63% had covered stent as the parallel TIPSS. One patient had transient encephalopathy, but no other complications were encountered. Nine patients had a resolution in symptoms. One patient had ongoing GV bleeding requiring S100
Background: Angiogenesis process in chronic liver disease (CLD) is occurred as result from hypoxia of necro-inflammation hepatocyte. The alteration serum VEGF and sVEGFR-2 reflected intrahepatic neo-vascularization and induced hepatocellular carcinoma (HCC). The aim of study is to identify sVEGFR-2 serum as a predictor of severity diseases in CLD and HCC patients. Methods: A prospective study was conducted in LCD and HCC patients with un-matching consecutive sampling. Liver Cirrhotic (LC) and HCC patients were case subjects, and Chronic Hepatitis (CH) patients as control subject. Healthy subjects were participated for assessing normal range. All subjects were enrolled during 2 years study (2010–2012) at Dr. Sardjito General Hospital Yogyakarta Indonesia. Physical examination, liver function test, a-fetoprotein, viral sero-marker, ultrasound/CT imaging, and fine needle biopsy for HCC were performed to define the diagnosis. Serum of sVEGFR-2 was examined using Quantikine® HS kit human immunoassay (R & D System, Minneapolis, MN, USA). Data were analyzed by computer. ANOVA test, spearman correlation, ROC curve and OR were calculated with significant value p < 0.05 and 95% CI. Results: 113 subjects were enrolled (33 HCC; 32 LC; 20 CH; and 28 healthy), 70 (61.9%) male and 46 (38.1%) female, and no difference mean of age (52±11 yr.). By ANOVA and posthoc tests, there were significant difference between group for sVEGFR-2 level (HCC = 8016.51±1785.55 pg/mL; LC = 7117.84±1554.40 pg/mL; CH = 9225.67±2231.33 pg/mL; p < 0.001; Healthy = 10038.95±1827.12 pg/mL). There was significant correlation between sVEGFR-2 serum with platelet count (r = 0.34; r = 0.39) and CPT score (r = −0.31; r = 0.38) in HCC and LC subjects. Significant correlation was showed in FIB4 score (r = −0.29) and albumin level (r = −0.30) in LC subject. Based on AUCROC the cutoff sVEGF-2 level in HCC-LC was 7301.40 pg/mL; HCC-CH was 8177.45 pg/mL. Cutoff in LC-CH was used median level in CH (9192.15 pg/mL). The OR LC-HCC was 3.26, OR CH-HCC was 2.31, and OR CH-LC was 9.67. Conclusions: The sVEGFR-2 serum can be used as predictor factor of HCC and LC progression in chronic liver diseases. There were good correlation between level of sVEGFR-2 with severity diseases (albumin, platelet, CP-score and FIB4-score).
Journal of Hepatology 2013 vol. 58 | S63–S227
portal hypertension (PHT) and determining the treatment for cirrhotic patients. Invasive HVPG and PP measurements can not be performed routinely and repeatedly. This study intends to develop a novel noninvasive assessment of HVPG (HVPGni) and PP (PPni) computed from three dimensional (3D) hepatic portal venous models. Methods: HVPGni and PPni were calculated through 3D hepatic portal venous models reconstructed from CT angiography. Finite element and computational fluid dynamics in ANSYS software were applied to analyze the pressure distribution in vitro. Clinical data of a decompensated cirrhotic patient were calculated to test the feasibility and accuracy of the novel measurement with diagnostic results of Doppler ultrasound (DUS) and CT angiography as reference standards. Results: CT images showed that the diameter of portal venous was around 1.6cm and the average velocity measured by DUS was 12.5cm/s, both of which indicated a severe PHT. According to calculation through the novel assessment, HVPGni and PPni of the decompensated cirrhotic patient were 65.2Pa (Figure 1) and 3535.0Pa (Figure 2), which were generally consistent with the previous diagnosis of PHT. Besides, the pressure (Figure 3.I) and velocity (Figure 3.II) distribution of different cross-sections of portal venous were simulated in vitro.
Figure 1.
231 NOVEL NONINVASIVE MEASUREMENT OF HEPATIC VENOUS PRESSURE GRADIENT AND PORTAL PRESSURE FROM ANATOMIC CT ANGIOGRAPHY X. Qi1 , F. Zhou1 , H. Lv2 , H. Chen1 , W. Xu3 , S. Xing3 , D. Yang3 , G. Li4 , C. Yang1 . 1 Division of Gastroenterology and Hepatology, Tongji Hospital, Tongji University School of Medicine, 2 Division of Mathematics, Tongji University, 3 Division of Radiology, Tongji Hospital, Tongji University School of Medicine, 4 Tongji University School of Civil Engineering, Shanghai, China E-mail: [email protected] Background and Aims: Assessment of hepatic venous pressure gradient (HVPG) and portal pressure (PP) is significant in diagnosing
Figure 2.
Journal of Hepatology 2013 vol. 58 | S63–S227
S99
POSTERS Thrombin injection and 1 patient had ascites with no flow in parallel TIPSS 4 days post-procedure. Secondary patency was 82% by the end of follow-up period with a median number of interventions of 1.5 (IQR 1–3). Median follow-up was 30 months (range 0.5–120). 92% patients were alive at 1 month with 86% 1 year survival. Two patients were transplanted during follow-up. Conclusions: Parallel TIPSS is a safe and effective method to treat TIPSS insufficiency. The majority of patients not only had a good haemodynamic result, but also resolution of symptoms. 233 SOLUBLE VEGFR-2 SERUM MAY BE A PREDICTIVE FACTOR FOR PROGRESSION OF CHRONIC LIVER DISEASE AND HEPATOCELLULAR CARCINOMA N. Ratnasari, S. Nurdjanah. Internal Medicine, Faculty of Medicine/Dr. Sardjito General Hospital, Gadjah Mada University, Yogyakarta, Indonesia E-mail: [email protected]
Figure 3.
Conclusions: HVPGni and PPni were in vitro quantified successfully. Although comparisons of noninvasive index with invasive ones are still needed, the novel evaluation of PHT from anatomic hepatic portal venous models has made up deficiencies and provides a potentially noninvasive and repeatable approach for the diagnosis of PHT. 232 PARALLEL TIPSS FOR THE MANAGEMENT OF SHUNT INSUFFICIENCY IN PATIENTS WITH COMPLICATIONS OF PORTAL HYPERTENSION: A TERTIARY LIVER UNIT 19 YEAR EXPERIENCE N. Rajoriya1 , H. Mehrzad2 , K. Mangat2 , S. Oliff2 , D. Tripathi1 . 1 Liver Medicine, 2 Radiology, Queen Elizabeth Hospital, Birmingham, UK E-mail: [email protected] Background: Transjugular Intrahepatic Porto-Systemic Shunts (TIPSS) insufficiency can be addressed with a side placement of another TIPSS beside the original (“parallel” technique) thus improving portosystemic pressure gradient (PPG). There is a paucity of data assessing the efficacy of this technique. Aim: To assess the efficacy of parallel TIPSS in a large UK tertiary referral centre. Methods: A retrospective study was performed from patient electronic radiology and laboratory databases. Parallel TIPSS were performed over a 19 year period in a single centre. Results: 11 patients (8M:3F) were identified (2% of all TIPSS procedures). Mean age at time of parallel TIPSS was 48.6 (±13.7). Background aetiology of portal hypertension included: 5 ALD, 2 PSC, 2 PBC, 1 liver graft failure, 1 non-cirrhotic portal hypertension (NCPH). Indications for index TIPSS (5 covered stents) were: 4 Oesophageal variceal (OV) haemorrhage, 3 gastric variceal (GV) haemorrhage, 1 stomal variceal haemorrhage and 3 for refractory ascites. At time of 1st TIPSS, documented mean PPG was 16.6 (±7.71) and post TIPSS 10.8 (±7.35) mmHg. Median time between index TIPSS and parallel TIPSS insertion was 72 (IQR 4–1122) days. Prior to parallel stent placement, 7 patients had dilatation of the index TIPSS. At parallel TIPSS, the mean initial PPG was 16.0 (±7.40) post procedure 6 (±2.28) mmHg. 63% had covered stent as the parallel TIPSS. One patient had transient encephalopathy, but no other complications were encountered. Nine patients had a resolution in symptoms. One patient had ongoing GV bleeding requiring S100
Background: Angiogenesis process in chronic liver disease (CLD) is occurred as result from hypoxia of necro-inflammation hepatocyte. The alteration serum VEGF and sVEGFR-2 reflected intrahepatic neo-vascularization and induced hepatocellular carcinoma (HCC). The aim of study is to identify sVEGFR-2 serum as a predictor of severity diseases in CLD and HCC patients. Methods: A prospective study was conducted in LCD and HCC patients with un-matching consecutive sampling. Liver Cirrhotic (LC) and HCC patients were case subjects, and Chronic Hepatitis (CH) patients as control subject. Healthy subjects were participated for assessing normal range. All subjects were enrolled during 2 years study (2010–2012) at Dr. Sardjito General Hospital Yogyakarta Indonesia. Physical examination, liver function test, a-fetoprotein, viral sero-marker, ultrasound/CT imaging, and fine needle biopsy for HCC were performed to define the diagnosis. Serum of sVEGFR-2 was examined using Quantikine® HS kit human immunoassay (R & D System, Minneapolis, MN, USA). Data were analyzed by computer. ANOVA test, spearman correlation, ROC curve and OR were calculated with significant value p < 0.05 and 95% CI. Results: 113 subjects were enrolled (33 HCC; 32 LC; 20 CH; and 28 healthy), 70 (61.9%) male and 46 (38.1%) female, and no difference mean of age (52±11 yr.). By ANOVA and posthoc tests, there were significant difference between group for sVEGFR-2 level (HCC = 8016.51±1785.55 pg/mL; LC = 7117.84±1554.40 pg/mL; CH = 9225.67±2231.33 pg/mL; p < 0.001; Healthy = 10038.95±1827.12 pg/mL). There was significant correlation between sVEGFR-2 serum with platelet count (r = 0.34; r = 0.39) and CPT score (r = −0.31; r = 0.38) in HCC and LC subjects. Significant correlation was showed in FIB4 score (r = −0.29) and albumin level (r = −0.30) in LC subject. Based on AUCROC the cutoff sVEGF-2 level in HCC-LC was 7301.40 pg/mL; HCC-CH was 8177.45 pg/mL. Cutoff in LC-CH was used median level in CH (9192.15 pg/mL). The OR LC-HCC was 3.26, OR CH-HCC was 2.31, and OR CH-LC was 9.67. Conclusions: The sVEGFR-2 serum can be used as predictor factor of HCC and LC progression in chronic liver diseases. There were good correlation between level of sVEGFR-2 with severity diseases (albumin, platelet, CP-score and FIB4-score).
Journal of Hepatology 2013 vol. 58 | S63–S227