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Evaluation and Predictors of Mortality in Patients with Liver Abscess. An Analysis of 943 Consecutive Patients
POSTER PRESENTATIONS FRI-352 EVALUATION AND PREDICTORS OF MORTALITY IN PATIENTS WITH LIVER ABSCESS. AN ANALYSIS OF 943 CONSECUTIVE PATIENTS A. Jindal1, A. Kumar1, S.K. Sarin1. 1Department of Hepatology, ILBS, New Delhi, India E-mail: [email protected] Background and Aims: Liver abscess (LA) is the most common inflammatory space occupying liver lesion with a highly variable presentation and if left inadequately treated, complicated LA has high morbidity and mortality. Methods: Retrospective analysis of a prospective cohort of 943 LA patients at ILBS (2009–2015) were analysed for baseline clinical/lab parameters, abscess characteristics (number, size and location), local and systemic complications, Interventions (aspiration, PCD and surgery) and predictors of mortality. Results: Among 943 patients (mean age-47.40 ± 15.66 years, M:F6.2:1), main etiologies of LA were amoebic (ALA) (80.8%), pyogenic (PLA) (6.2%), malignant (1.5%) and eosinophilic LA (0.9%) and most frequent presentation(s) was abdominal pain (83.6%), fever (82.1%) and jaundice (9.1%) (Symptom duration-12(7–20) days) 28.8% had concomitant alcoholism, 45.8% were diabetic. Right lobe (84.4%), subcapsular (63%) and multiple (57.6%) LA were common [mean diameter 6.59 ± 2.65 cm]. Patients with ALA had more frequent fever, abdominal pain and alcoholism while PLA had more jaundice and prolonged hospitalization. 32 patients (3.4%) had cirrhosis and had high mortality (HR: 20.2). 602 patients (71.2%) required intervention [single time aspiration (SA) alone10.4%, SA + PCD (42.6%), multiple aspirations (MA) + PCD-13.5%, PCD alone- 2.3%, surgery-0.6%]. Main indications for intervention were large (>5 cm) abscess, left lobe abscess, subcapsular location or abscess complicated by rupture. 26(3.1%) had ERCP (biliary rupture-16 or cholangitic abscess-10). Median duration of hospitalization was 8(5–12) days and PCD was 5(3–8) days. Overall in-hospital mortality was 1.18%. Presence of septic encephalopathy (HR: 29.2) and AKI (S.cr >2 mg/dL) (HR: 5.4) were independent predictors of mortality. Conclusions: Liver abscess should be carefully assessed especially in cirrhotics and in presence of systemic complications such as encephalopathy and acute kidney injury. Besides antibiotics, most patients require intervention with aspiration and percutaneous drainage. FRI-353 BEZAFIBRATE ALLEVIATES PRURITUS AND DECREASES SPECIFIC CIRCULATING METABOLITES IN PATIENTS WITH PRIMARY BILIARY CHOLANGITIS A. Reig1, M. Pérez-Cormenzana1, P. Sesé1, R. Mayo1, A. Castro1, A. Pares1. 1Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain E-mail: [email protected] Background and Aims: Pruritus is a common and distressing symptom in patients with primary biliary cholangitis (PBC), and when uncontrollable it is an indication for liver transplantation. Recent observations have reported that fibrates may improve cholestatic itching, although no specific studies have been carried out. Therefore, we have assessed the effects of fibrates on pruritus and the changes in the metabolomic profiling in patients PBC. Methods: 46 PBC patients (43 females, age 54.3 ± 1.5 years) with suboptimal biochemical response to UDCA were treated with bezafibrate (400 mg/d). Apart from clinical and biochemical changes, pruritus severity was assessed by a specific questionnaires (PBC-40 and pruritus score) and with a visual analogue scale (VAS) (form 0 to 10), at baseline and after a mean of 29 ± 4 months. Moreover in 14 patients with pruritus, samples were obtained before, during and after bezafibrate discontinuation for metabolic profiling using 3 different UPLC-MS analytical platforms.
Results: Twenty-seven patients (58.7%) experienced pruritus. Bezafibrate therapy resulted in a significant alleviation of pruritus (VAS from 4.4 ± 0.5 to 0.8 ± 0.2, < 0.001). Itch disappeared completely or partly in 17 and 7 patients, respectively. No marked changes in pruritus were reported by three patients (11%). Bezafibrate discontinuation in patients who have no pruritus or minimum pruritus under therapy, resulted in an increase or recurrence of pruritus (within 19–120 days) in all cases (mean VAS from 0.8 ± 0.3 to 5.7 ± 0.6, p < 0.001). In these patients, itching decreased or disappeared again after resuming bezafibrate therapy. Thirty-eight metabolites decreased significantly after treatment, particularly phosphatidylcholines (PC) PC(18:3/18:3), PC(18:0/20:4), PC(38:5), PC(16:0/22:6), PC(14:0/20:4), TG(56:5), and PC(15:0/22:6). The omega 6 arachidonic acid, 20:4n-6, several PC with the 20:4 fatty acyl chain esterified to them together with ChoE (20:4) were in lesser amount in the samples from patients treated with bezafibrate. Twenty-two of these metabolites increased again after bezafibrate discontinuation, mainly PC and lysophosphatidylcholines ( p < 0.001) and androsterone sulfate and related isomers ( p < 0.02). Conclusions: Bezafibrate therapy is associated with a clear relief of pruritus in patients with primary biliary cholangitis, presumably resulting from a decrease of certain circulating metabolites especially phosphatidylcholines and some sterols. FRI-354 THE ALT/AST RATIO AND TOTAL PROTEIN LEVEL IDENTIFY THE AUTOIMMUNE ETIOLOGY IN PATIENTS WITH FULMINANT HEPATITIS A. Reig1, V. Prado1, H. Uchima1, A. Mas1, A. Parés1. 1Liver Unit, Hospital Clínic, IDIBAPS; CIBERehd, University of Barcelona, Barcelona, Spain E-mail: [email protected] Background and Aims: The incidence of autoimmune hepatitis has increased in recent years, but the clinical features and course of the fulminant presentation (FAIH) is not well established. Moreover, the diagnosis of this presentation may be complex and delayed by the lack of early complete analytical and histologic procedures. This is critical for therapy and consequently prognosis and survival. Therefore, we have assessed the differential features of FAIH as compared with other etiologies of fulminant hepatitis. Methods: 77 patients (58% women; age 41 ± 2 years old) diagnosed with acute liver failure (fulminant hepatitis) between 2003 and 2013. Patients were divided according to the etiology into viral, toxic, autoimmune and miscellaneous (Wilson, associated with pregnancy, ischemic and idiopathic) etiologies. Clinical, biochemical, immunological and histological features were assessed, as well as the incidence of each etiology among three periods of similar duration. Results: 17 patients (22%) had FAIH, while toxic, viral and miscellaneous etiologies were diagnosed in 36%, 23%, and 17% of patients, respectively. The incidence of FAIH increased over the three time periods being 16%, 20% and 33% respectively. Age and female gender were similar in all etiologies except for those of viral origin (25% women, p = 0.02; age 36 ± 3 years, p < 0.05). The clinical features were comparable in all different etiologies, but the duration between the first sign of liver disease and the diagnosis of fulminant hepatitis was longer in FHAI (48 ± 16 vs 17.2 ± 7.4 days, p < 0.01). Moreover, AST/ALT ratio over 1 (OR: 5.17, 95% CI 1.6–16.8, p < 0.01) and total protein levels ≥50 g/L (OR: 6.1, 95% CI 1.6–23.5, p < 0.002) were mainly observed in patients with FAIH as compared with the other etiologies, while no significant changes were found in other liver biochemistries. The combination of these two variables (AST/ALT ratio and total protein concentration) were associated with the autoimmune etiology (OR: 12.9, 95% CI 3.6–46.4, p = 0.001). The outcome was similar among all etiologies except for FAIH patients who had better early survival (76%) although most of them (70%) were transplanted.
Journal of Hepatology 2016 vol. 64 | S425–S630
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Results: Twenty-seven patients (58.7%) experienced pruritus. Bezafibrate therapy resulted in a significant alleviation of pruritus (VAS from 4.4 ± 0.5 to 0.8 ± 0.2, < 0.001). Itch disappeared completely or partly in 17 and 7 patients, respectively. No marked changes in pruritus were reported by three patients (11%). Bezafibrate discontinuation in patients who have no pruritus or minimum pruritus under therapy, resulted in an increase or recurrence of pruritus (within 19–120 days) in all cases (mean VAS from 0.8 ± 0.3 to 5.7 ± 0.6, p < 0.001). In these patients, itching decreased or disappeared again after resuming bezafibrate therapy. Thirty-eight metabolites decreased significantly after treatment, particularly phosphatidylcholines (PC) PC(18:3/18:3), PC(18:0/20:4), PC(38:5), PC(16:0/22:6), PC(14:0/20:4), TG(56:5), and PC(15:0/22:6). The omega 6 arachidonic acid, 20:4n-6, several PC with the 20:4 fatty acyl chain esterified to them together with ChoE (20:4) were in lesser amount in the samples from patients treated with bezafibrate. Twenty-two of these metabolites increased again after bezafibrate discontinuation, mainly PC and lysophosphatidylcholines ( p < 0.001) and androsterone sulfate and related isomers ( p < 0.02). Conclusions: Bezafibrate therapy is associated with a clear relief of pruritus in patients with primary biliary cholangitis, presumably resulting from a decrease of certain circulating metabolites especially phosphatidylcholines and some sterols. FRI-354 THE ALT/AST RATIO AND TOTAL PROTEIN LEVEL IDENTIFY THE AUTOIMMUNE ETIOLOGY IN PATIENTS WITH FULMINANT HEPATITIS A. Reig1, V. Prado1, H. Uchima1, A. Mas1, A. Parés1. 1Liver Unit, Hospital Clínic, IDIBAPS; CIBERehd, University of Barcelona, Barcelona, Spain E-mail: [email protected] Background and Aims: The incidence of autoimmune hepatitis has increased in recent years, but the clinical features and course of the fulminant presentation (FAIH) is not well established. Moreover, the diagnosis of this presentation may be complex and delayed by the lack of early complete analytical and histologic procedures. This is critical for therapy and consequently prognosis and survival. Therefore, we have assessed the differential features of FAIH as compared with other etiologies of fulminant hepatitis. Methods: 77 patients (58% women; age 41 ± 2 years old) diagnosed with acute liver failure (fulminant hepatitis) between 2003 and 2013. Patients were divided according to the etiology into viral, toxic, autoimmune and miscellaneous (Wilson, associated with pregnancy, ischemic and idiopathic) etiologies. Clinical, biochemical, immunological and histological features were assessed, as well as the incidence of each etiology among three periods of similar duration. Results: 17 patients (22%) had FAIH, while toxic, viral and miscellaneous etiologies were diagnosed in 36%, 23%, and 17% of patients, respectively. The incidence of FAIH increased over the three time periods being 16%, 20% and 33% respectively. Age and female gender were similar in all etiologies except for those of viral origin (25% women, p = 0.02; age 36 ± 3 years, p < 0.05). The clinical features were comparable in all different etiologies, but the duration between the first sign of liver disease and the diagnosis of fulminant hepatitis was longer in FHAI (48 ± 16 vs 17.2 ± 7.4 days, p < 0.01). Moreover, AST/ALT ratio over 1 (OR: 5.17, 95% CI 1.6–16.8, p < 0.01) and total protein levels ≥50 g/L (OR: 6.1, 95% CI 1.6–23.5, p < 0.002) were mainly observed in patients with FAIH as compared with the other etiologies, while no significant changes were found in other liver biochemistries. The combination of these two variables (AST/ALT ratio and total protein concentration) were associated with the autoimmune etiology (OR: 12.9, 95% CI 3.6–46.4, p = 0.001). The outcome was similar among all etiologies except for FAIH patients who had better early survival (76%) although most of them (70%) were transplanted.
Journal of Hepatology 2016 vol. 64 | S425–S630
S429