- Email: [email protected]
Coronary artery disease in patients with end-stage liver disease
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Shahram Agah Mehrdohkt, Najafi Sahar Tavakolli, Hajar Nikbakht Colorectal Research Center, Rasool-akram Hospital, Tehran University of Medical Sciences, Iran
Background and Aim: About 10% of cirrhotic patients are unresponsive to sodium restriction and diuretics and develop refractory ascites. Such patients usually require recurrent large volume paracentesis and lots of hospital admissions. Hereby, we introduce a method applying a central vein (CV) catheter for large volume paracentesis in patients with refractory ascites. Methods: Non-tunneled triple lumen central vein catheter was used to drainage the ascites fluid of 30 cirrhotic patients. After precise percussion the point of highest fluid accumulation was marked for puncture. Then, the skin and subcutaneous tissue were anesthetized. CV catheter set guide-wire was entered into the peritoneal cavity and the dilator of the CV catheter set was passed through the guide wire and extracted after some rotations around its insertion site on the skin. The catheter was passed over the guide wire; the guide wire was extracted gradually from one of the lumens and fixed to the skin. Results: Nineteen males and 11 females with mean age of 59.4 11.7 year old underwent the procedure. A minimum of 9 and maximum of 29 liters (12 6.6 L) ascites fluid drained during a minimum of 2 and maximum of 5 days of hospital stay. None of the patients develop hemodynamic instability. Number of rehospitalizations for paracentesis was 1.9 times during the following year. No complication occurred. Conclusions: This technique seems to be a simple noninvasive method that can be performed in the endoscopy unit or even at patient's bedside and may reduce the need for repeated admissions. Corresponding author. Shahram Agah Mehrdohkt. E-mail: [email protected]
NORADRENALINE IS EQUALLY EFFECTIVE AS TERLIPRESSIN IN REVERSAL OF TYPE 1 HEPATORENAL SYNDROME: A RANDOMIZED PROSPECTIVE STUDY Reyaz Ahmad Indrabi, Gul Javid, Showkat Ali Zargar, Bashir Ahmad Khan, Gul Nabi Yattoo, Showkat Hussain Shah, Bashir Mohamad Gulzar, Gul Singh, Mushtaq Ahmad Khan, Shaheen Parveen, Mohamad Yaseen Mugoo
Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences Srinagar Kashmir, India
Background and Aims: Hepatorenal syndrome occurs in decompensated liver disease and carries high mortality. Vasoconstrictors are the drug of choice. Terlipressin is widely used and is expensive. In this study, we compared noradrenalin with terlipressin in the management of hepatorenal syndrome. Methods: Sixty consecutive patients with type 1 hepatorenal syndrome were managed with noradrenaline and albumin (group A, n=30) or terlipressin and albumin (group B, n=30) in a randomized controlled trial. Results: Reversal of hepatorenal syndrome was achieved in 16 (53%) in group A and 17 (57%) in group B (P =0.797). There was statistically insignificant difference between the two groups (P =0.766) in decreasing serum creatinine and increase in urinary output. On Univariate analysis, Child Pugh score, serum sodium, serum urea, serum albumin, prothombine time, International normalized ratio, serum alanine aspartase, ascitic fluid protein and history of bleeding were associated with response to treatment (nor adrenaline/terlipressin). However on multivariate analysis only baseline child Pugh score, serum urea, serum albumin and prothombine time were independent predictors of response. Only I patent (6%) survived at 90 days in group A compared to 2 (35%)patients in group B. Mean survival time in group A was 37.749.9 days while in group B it was 45.6 44.1 (P =0.257) Two patients (6%) developed recurrence of HRS, one each from nor adrenaline and terlipressin group. Only one patient was retreated. Three patients under went liver transplant and are surviving till date. Nor adrenaline was cheaper than terlipressin (P<0.05). Conclusion: There is no difference in outcome of patients of hepatorenal syndrome treated with noradrenaline or terlipressin, thus noradrenalin which is cheaper can be used instead of terlipressin. Corresponding author. Showkat Ali Zargar. E-mail: [email protected]
CORONARY ARTERY DISEASE IN PATIENTS WITH END-STAGE LIVER DISEASE Arikichenin Olithselvan, Dinesh Jothimani, Vivekanandan Shanmugam, Gomathy Narashimhan, Mohamed Rela Global Hospitals and Health City, Chennai, India
Background: There has been debate over the years regarding the protective effect of cirrhosis on the coronary arteries. Coronary artery disease (CAD) occurs at younger age and with increased frequency in Indians. Prevalence of angiogram proven CAD in western patients over 45 years being evaluated for liver transplant is around 20%.
Journal of Clinical and Experimental Hepatology | March 2013 | Vol. 3 | No. 1S | S82–S100
S97
Cirrhosis & Complications
NON-TUNNELED CENTRAL VEIN CATHETER FOR REFRACTORY ASCITES DRAINAGE: 30 PATIENTS WITH RECURRENT PARACENTESIS
ABSTRACTS
Cirrhosis & Complications
Objectives: The aim of the study was to study the incidence of CAD in the Indian patients with end-stage liver disease undergoing liver transplant work up. Methods: We conducted a Retrospective study and analyzed recipient transplant work up data from 11/4/10 to 9/7/12 over a 25 months period. Pediatrics (<18) and foreign nationals excluded .Only Indian Patients undergoing pre-transplant work up for liver transplant were included. 152 pts were indentified and 90(59.2%) of these underwent coronary angiogram as part of the cardiac pre-transplant work up according to our institute protocol. These patients were subsequently taken for the study. Significant CAD was defined as > 50% block (diameter). Results: Significant CAD was seen in 21 patients (23%) and Normal or in-significant CAD in 69 patients. The prevalence of undiagnosed significant CAD was noted in 19 patients. The Mean age was 51 (range: 18-72) with a predominant male ratio (85:5). The mean age, sex ratio and Body mass index were similar in both the CAD and the Normal. Risk factors for CAD were analyzed in both the groups and presence of type 2 diabetes, previous history of ischaemic heart disease, smoking and NASH cirrhosis were factors associated with significant CAD. Hyper tension and previous hyperlipidemia were not significant risk factors. Conclusion: CAD does occur in the cirrhotic population in Indian patients with the same frequency as westerners and end-stage liver disease does not seem to protect these patients from CAD. The prevalence of undiagnosed CAD is also high in this cohort. Corresponding author. Olithselvan. E-mail: [email protected]
SAFETY AND EFFICACY OF ENDOSCOPIC VARICEAL LIGATION FOR PRIMARY PROPHYLAXIS OF VARICEAL BLEEDING IN CHILDREN
21ST ANNUAL CONFERENCE —2013
done by a multiband ligator with six bands and sedation was used in small or uncooperative patients only. EVL sessions were performed at 4–8 week interval. The end point was taken as disappearance or presence of small varices, not amenable for EVL. Results: Seventy children (52 boys; median age 11, range 3-21 years) underwent 172 sessions of EVL. Of these, 49 children (27 EHPVO, 21 CLD) achieved the end point with a median of 2 (1-6) sessions. A median of 4 bands (2–6) were applied in the first session and a total of 9 (2–29) bands overall. Eight percent (4/49) cases had EVL ulcer and one child developed ulcer related upper gastrointestinal bleeding which settled with medical therapy. No other serious complications were seen and there was no mortality. The patients were followed up for a median duration of 13 (1–70) months and 8/49 (16.3%) had recurrence of varices over 10 (2–29) months and required repeat EVL. Conclusions: EVL is feasible even in small children of 3-5 years age. It is safe and efficacious for primary prophylaxis of VB in children with both intra and extra- hepatic portal hypertension. It is associated with mild complications in 8% cases and a recurrence rate of 16% over 1 year follow-up. Corresponding author. Anshu Srivastava. E-mail: [email protected]
NON-INVASIVE PREDICTION TOOL FOR OESOPHAGEAL VARICEAL HAEMORRHAGE: MODIFICATION OF PLATELET COUNT TO SPLEEN DIAMETER RATIO TO PRECISELY DETERMINE THE RISK PROGNOSIS I. Rankovic,1 D. Miletic,1 M. Lj. Stojkovic,1 D. Tomic,12 A. Pavlovic-Markovic,12 D. Culafic,12 I. Jovicic,1 T. Alempijevic,12 J. Bogdanovic,6 D. Mijac,12 Z. Vlaisavljevic,1 V. Milivojevic,4 T. Dragisic,5 M. Krstic,12 Z. Rajic,3 T. Milosavljevic12
Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
1 Clinical Center of Serbia, Clinic for Gastroenterology, Serbia, 2School of Medicine, University of Belgrade, Serbia, 3Clinical Center of Serbia, Clinic for Hematology, Serbia, 4Special Hospital for Endemic Nephropathy Lazarevac, Lazarevac, Serbia, 5Clinical Center of Serbia, Emergency Center, Belgrade, Serbia, 6Clinical Center of Serbia, Clinic for Endocrinology, Diabetes and Metabolic disorders, Belgrade, Serbia
Background and Aims: Endoscopic variceal ligation (EVL) is the preferred treatment modality for primary prophylaxis for variceal bleeding (VB) in adults with cirrhosis. Data on role of EVL for primary prophylaxis of VB is scarce in children. This study assessed the safety and efficacy of prophylactic EVL in children with high-risk varices but without a history of bleed. Material and Methods: Clinical, laboratory and endoscopy records of children subjected to EVL for primary prophylaxis of VB from 2005 to 2011 were reviewed. EVL was
Background and Aims: Currently, platelet count to spleen diameter ratio (PC/SD ratio) is used to predict the presence of oesophagel varices in patients with decompensated liver cirrhosis. Although this index is validated in numerous trials, when trying to assess the risk from variceal haemorrhage this index is inept and heavy-handed. Thus, we are proposing the modification of this ratio with INR value. With it we can closely and more precisely evaluate the variceal haemorrhage incidence in this category of patients.
Upendra Shava, Anshu Srivastava, Barath Jagdisan, Surender Kumar Yachha, Ujjal Poddar
S98
© 2013, INASL
Shahram Agah Mehrdohkt, Najafi Sahar Tavakolli, Hajar Nikbakht Colorectal Research Center, Rasool-akram Hospital, Tehran University of Medical Sciences, Iran
Background and Aim: About 10% of cirrhotic patients are unresponsive to sodium restriction and diuretics and develop refractory ascites. Such patients usually require recurrent large volume paracentesis and lots of hospital admissions. Hereby, we introduce a method applying a central vein (CV) catheter for large volume paracentesis in patients with refractory ascites. Methods: Non-tunneled triple lumen central vein catheter was used to drainage the ascites fluid of 30 cirrhotic patients. After precise percussion the point of highest fluid accumulation was marked for puncture. Then, the skin and subcutaneous tissue were anesthetized. CV catheter set guide-wire was entered into the peritoneal cavity and the dilator of the CV catheter set was passed through the guide wire and extracted after some rotations around its insertion site on the skin. The catheter was passed over the guide wire; the guide wire was extracted gradually from one of the lumens and fixed to the skin. Results: Nineteen males and 11 females with mean age of 59.4 11.7 year old underwent the procedure. A minimum of 9 and maximum of 29 liters (12 6.6 L) ascites fluid drained during a minimum of 2 and maximum of 5 days of hospital stay. None of the patients develop hemodynamic instability. Number of rehospitalizations for paracentesis was 1.9 times during the following year. No complication occurred. Conclusions: This technique seems to be a simple noninvasive method that can be performed in the endoscopy unit or even at patient's bedside and may reduce the need for repeated admissions. Corresponding author. Shahram Agah Mehrdohkt. E-mail: [email protected]
NORADRENALINE IS EQUALLY EFFECTIVE AS TERLIPRESSIN IN REVERSAL OF TYPE 1 HEPATORENAL SYNDROME: A RANDOMIZED PROSPECTIVE STUDY Reyaz Ahmad Indrabi, Gul Javid, Showkat Ali Zargar, Bashir Ahmad Khan, Gul Nabi Yattoo, Showkat Hussain Shah, Bashir Mohamad Gulzar, Gul Singh, Mushtaq Ahmad Khan, Shaheen Parveen, Mohamad Yaseen Mugoo
Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences Srinagar Kashmir, India
Background and Aims: Hepatorenal syndrome occurs in decompensated liver disease and carries high mortality. Vasoconstrictors are the drug of choice. Terlipressin is widely used and is expensive. In this study, we compared noradrenalin with terlipressin in the management of hepatorenal syndrome. Methods: Sixty consecutive patients with type 1 hepatorenal syndrome were managed with noradrenaline and albumin (group A, n=30) or terlipressin and albumin (group B, n=30) in a randomized controlled trial. Results: Reversal of hepatorenal syndrome was achieved in 16 (53%) in group A and 17 (57%) in group B (P =0.797). There was statistically insignificant difference between the two groups (P =0.766) in decreasing serum creatinine and increase in urinary output. On Univariate analysis, Child Pugh score, serum sodium, serum urea, serum albumin, prothombine time, International normalized ratio, serum alanine aspartase, ascitic fluid protein and history of bleeding were associated with response to treatment (nor adrenaline/terlipressin). However on multivariate analysis only baseline child Pugh score, serum urea, serum albumin and prothombine time were independent predictors of response. Only I patent (6%) survived at 90 days in group A compared to 2 (35%)patients in group B. Mean survival time in group A was 37.749.9 days while in group B it was 45.6 44.1 (P =0.257) Two patients (6%) developed recurrence of HRS, one each from nor adrenaline and terlipressin group. Only one patient was retreated. Three patients under went liver transplant and are surviving till date. Nor adrenaline was cheaper than terlipressin (P<0.05). Conclusion: There is no difference in outcome of patients of hepatorenal syndrome treated with noradrenaline or terlipressin, thus noradrenalin which is cheaper can be used instead of terlipressin. Corresponding author. Showkat Ali Zargar. E-mail: [email protected]
CORONARY ARTERY DISEASE IN PATIENTS WITH END-STAGE LIVER DISEASE Arikichenin Olithselvan, Dinesh Jothimani, Vivekanandan Shanmugam, Gomathy Narashimhan, Mohamed Rela Global Hospitals and Health City, Chennai, India
Background: There has been debate over the years regarding the protective effect of cirrhosis on the coronary arteries. Coronary artery disease (CAD) occurs at younger age and with increased frequency in Indians. Prevalence of angiogram proven CAD in western patients over 45 years being evaluated for liver transplant is around 20%.
Journal of Clinical and Experimental Hepatology | March 2013 | Vol. 3 | No. 1S | S82–S100
S97
Cirrhosis & Complications
NON-TUNNELED CENTRAL VEIN CATHETER FOR REFRACTORY ASCITES DRAINAGE: 30 PATIENTS WITH RECURRENT PARACENTESIS
ABSTRACTS
Cirrhosis & Complications
Objectives: The aim of the study was to study the incidence of CAD in the Indian patients with end-stage liver disease undergoing liver transplant work up. Methods: We conducted a Retrospective study and analyzed recipient transplant work up data from 11/4/10 to 9/7/12 over a 25 months period. Pediatrics (<18) and foreign nationals excluded .Only Indian Patients undergoing pre-transplant work up for liver transplant were included. 152 pts were indentified and 90(59.2%) of these underwent coronary angiogram as part of the cardiac pre-transplant work up according to our institute protocol. These patients were subsequently taken for the study. Significant CAD was defined as > 50% block (diameter). Results: Significant CAD was seen in 21 patients (23%) and Normal or in-significant CAD in 69 patients. The prevalence of undiagnosed significant CAD was noted in 19 patients. The Mean age was 51 (range: 18-72) with a predominant male ratio (85:5). The mean age, sex ratio and Body mass index were similar in both the CAD and the Normal. Risk factors for CAD were analyzed in both the groups and presence of type 2 diabetes, previous history of ischaemic heart disease, smoking and NASH cirrhosis were factors associated with significant CAD. Hyper tension and previous hyperlipidemia were not significant risk factors. Conclusion: CAD does occur in the cirrhotic population in Indian patients with the same frequency as westerners and end-stage liver disease does not seem to protect these patients from CAD. The prevalence of undiagnosed CAD is also high in this cohort. Corresponding author. Olithselvan. E-mail: [email protected]
SAFETY AND EFFICACY OF ENDOSCOPIC VARICEAL LIGATION FOR PRIMARY PROPHYLAXIS OF VARICEAL BLEEDING IN CHILDREN
21ST ANNUAL CONFERENCE —2013
done by a multiband ligator with six bands and sedation was used in small or uncooperative patients only. EVL sessions were performed at 4–8 week interval. The end point was taken as disappearance or presence of small varices, not amenable for EVL. Results: Seventy children (52 boys; median age 11, range 3-21 years) underwent 172 sessions of EVL. Of these, 49 children (27 EHPVO, 21 CLD) achieved the end point with a median of 2 (1-6) sessions. A median of 4 bands (2–6) were applied in the first session and a total of 9 (2–29) bands overall. Eight percent (4/49) cases had EVL ulcer and one child developed ulcer related upper gastrointestinal bleeding which settled with medical therapy. No other serious complications were seen and there was no mortality. The patients were followed up for a median duration of 13 (1–70) months and 8/49 (16.3%) had recurrence of varices over 10 (2–29) months and required repeat EVL. Conclusions: EVL is feasible even in small children of 3-5 years age. It is safe and efficacious for primary prophylaxis of VB in children with both intra and extra- hepatic portal hypertension. It is associated with mild complications in 8% cases and a recurrence rate of 16% over 1 year follow-up. Corresponding author. Anshu Srivastava. E-mail: [email protected]
NON-INVASIVE PREDICTION TOOL FOR OESOPHAGEAL VARICEAL HAEMORRHAGE: MODIFICATION OF PLATELET COUNT TO SPLEEN DIAMETER RATIO TO PRECISELY DETERMINE THE RISK PROGNOSIS I. Rankovic,1 D. Miletic,1 M. Lj. Stojkovic,1 D. Tomic,12 A. Pavlovic-Markovic,12 D. Culafic,12 I. Jovicic,1 T. Alempijevic,12 J. Bogdanovic,6 D. Mijac,12 Z. Vlaisavljevic,1 V. Milivojevic,4 T. Dragisic,5 M. Krstic,12 Z. Rajic,3 T. Milosavljevic12
Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
1 Clinical Center of Serbia, Clinic for Gastroenterology, Serbia, 2School of Medicine, University of Belgrade, Serbia, 3Clinical Center of Serbia, Clinic for Hematology, Serbia, 4Special Hospital for Endemic Nephropathy Lazarevac, Lazarevac, Serbia, 5Clinical Center of Serbia, Emergency Center, Belgrade, Serbia, 6Clinical Center of Serbia, Clinic for Endocrinology, Diabetes and Metabolic disorders, Belgrade, Serbia
Background and Aims: Endoscopic variceal ligation (EVL) is the preferred treatment modality for primary prophylaxis for variceal bleeding (VB) in adults with cirrhosis. Data on role of EVL for primary prophylaxis of VB is scarce in children. This study assessed the safety and efficacy of prophylactic EVL in children with high-risk varices but without a history of bleed. Material and Methods: Clinical, laboratory and endoscopy records of children subjected to EVL for primary prophylaxis of VB from 2005 to 2011 were reviewed. EVL was
Background and Aims: Currently, platelet count to spleen diameter ratio (PC/SD ratio) is used to predict the presence of oesophagel varices in patients with decompensated liver cirrhosis. Although this index is validated in numerous trials, when trying to assess the risk from variceal haemorrhage this index is inept and heavy-handed. Thus, we are proposing the modification of this ratio with INR value. With it we can closely and more precisely evaluate the variceal haemorrhage incidence in this category of patients.
Upendra Shava, Anshu Srivastava, Barath Jagdisan, Surender Kumar Yachha, Ujjal Poddar
S98
© 2013, INASL