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P.07.3 PATIENTS WITH ALCOHOLIC LIVER CIRRHOSIS (ALC), HEPATORENAL SYNDROME (HRS) AND HISTOLOGICAL EVIDENCE OF ACUTE ALCOHOLIC HEPATITIS (AAH) IN EXPLANTED LIVER
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Abstracts of the 20th National Congress of Digestive Diseases / Digestive and Liver Disease 46S (2014) S1–S144
P.07.3 PATIENTS WITH ALCOHOLIC LIVER CIRRHOSIS (ALC), HEPATORENAL SYNDROME (HRS) AND HISTOLOGICAL EVIDENCE OF ACUTE ALCOHOLIC HEPATITIS (AAH) IN EXPLANTED LIVER P. Borro ∗,1 , A. Sumberaz 1 , E. Andorno 2 , C. Ferro 3 , E. Scafato 4 , G. Testino 5 1 Centro
Alcologico Regionale-Liguria, IRCCS AOU San Martino-IST, Collaborative Centre, World Health Organization, Genova, Italy; 2 Unit of Hepato-Biliary Surgery, IRCCS AOU San Martino-IST, Genova, Italy; 3 Unit of Interventional Radiology, IRCCS AOU San Martino-IST, Genova, Italy; 4 Collaborative Centre, World Health Organization, Istituto Superiore di Sanità, Roma, Italy; 5 Centro Alcologico Regionale-Liguria, IRCCS AOU San Martino-IST, Collaborative Centre, World Health Organization, Genova, Italy Background and aim: Recently the Trieste Italian Conference of the Regions (www.mediofriuli, Ministero della Salute) has discussed on “six months rule” in patients with ALC. Therefore, we revised retrospectively again 9 consecutive patients (6 males, average age 49) affected by type I HRS (HCV and HBV negative) (5) (Child-Pugh score between 10 and 12, model end stage liver disease over 21) suitable for transjugular intrahepatic portosystemic stent shunt (TIPS). Material and methods: The diagnosis of HRS was based on the criteria elaborated by the International Ascites Club. For the intervention of TIPS written informed consent was obtained from all patients. In all patients we determined serum creatinine, blood urea nitrogen (BUN), serum sodium, sodium excretion and urine volume before the intervention, 7 days and 30 days after TIPS. The statistical analysis: paired Student’s test and ANOVA with Dunn’s test and Bonferroni comparison. Results: All stents were successfully established. Complications occurred in 4 patients and included temperature above 38 °C (3 patients) and in 1 patient vomiting after procedure. Causes of death were septicaemia in one patient and liver failure in one patients. Seven patients were transplanted within 3 months. The results concerning the renal functional parameters are in the Table 1: they indicate an improvement of renal function. Nevertheless the shorter prelisting liver transplantation (LT) abstinence, none patients relapsed after a period of 5 years. Table 1. Functional renal parameters before and after TIPS Serum Creatinine (mg/dL) BUN (mg/dL) Serum sodium (mEq/L) Urine sodium (mEq/d) Urine volume (mL/d)
Baseline
7 days
30 days
p
5.2±0.9 110±8 125±4 2.5±0.5 250±40
3.6±1.1 109±7 123+/3 7±3 840±170
1.6±0.6 51±11 135±4 10±3 1100±210
0.04 0.007 n.s. n.s. 0.003
P.07.4 HEPATIC ARTERY ABERRATION WITH BILIARY STENOSIS G. Ursini ∗,1 , A. Ferrara 1 , S. Caruso 1 , G. Ferrari 2 , M.L. Boella 2 , R.M. Ferrara 3 1 Ospedale Legnano, Gastroenterologia, Legnano, Italy; 2 Ospedale Legnano, Chirurgia Generale, Legnano, Italy; 3 Ospedale Legnano, Radiologia, Legnano, Italy
Background and aim: A 48 year-old patient was admitted into the accident and emergency for epigastric pain started 2 weeks ago. After detection of gastritis in EGDS, PPI therapy was administrated without clinical benefit. Because of the worsening of the painful symptoms the patient went to the emergency room/accident and emergency of another Hospital where he was hospitalized in the internal medicine department for jaundice. Under suspicion of acute hepatitis resulting from the sharp increase in hepatic cytolysis indexes associated with jaundice, the patient is transferred to the infectious diseases Department of our hospital. Abdominal ultrasound revealed the presence of about 14 mm gallstone to the hepatic hilum and dilation of intrahepatic biliary duct without cholelithiasis. The cholangio-RM has documented the presence of biliary gallstone and a short common hepatic duct strictures downstream, suspected for extrinsic compression. For the worsening of jaundice during hospitalization, it was performed an endoscopic retrograde cholangiography
with endoprothesis inserction. Abdomen CT has not allowed to clarify the nature of stenosis. In consideration of diagnosis, after improvement of jaundice, the patient has undergone surgery. Intraoperatively it was possible to document an abnormal course of the right hepatic artery which, compressing the common hepatic duct, conditioned the stenosis resulting in colestasis and stacking of gallstones in the previous tract. The intervention consisted of cholecystectomy, debridement of the right hepatic artery and choledochotomy with removal of the gallstones. More than 3 years after surgery the patient, asymptomatic, performed cholangio-RM that has documented regularity of the extrahepatic biliary tree with minimal scarring of the intrahepatic ducts due to previous intrahepatic cholangitis. 6 years after surgery the patient is still asymptomatic. Conclusions: 1) The vascular anomaly presented by our patient is an infrequent condition (20% of benign biliary strictures). The peculiarity of the case lies in the extent of the biliary stricture conditioning intrahepatic gallstones, situation never reported in literature. 2) The conservative surgical treatment of mobilisation of the hepatic artery with stenosis resolution and gallstones removal, proved to be the easiest and most effective way to perform in the long term.
P.07.5 INCIDENCE OF MICROANGIOPATHY IN PATIENTS WITH CHRONIC HEPATITIS C AND TYPE 2 DIABETES MELLITUS: RESULTS OF A PROSPECTIVE CONTROLLED COHORT STUDY C. Coppo 1 , D. Bonfanti 2 , S. Bo 2 , C. Giordanino 1 , M. Gallo 1 , G. Ciccone 3 , A. Smedile 4 , A. Ciancio 4 , E. Bugianesi 4 , R. Pellicano 4 , M. Rizzetto 4 , G.M. Saracco ∗,1 1 SCDU
Gastroenterologia, Dept. Oncologia, Università di Torino, Torino, Italy; 2 Clinica Medica, Dipartimento di Scienze Mediche, Università di Torino, Torino, Italy; 3 Epidemiologia Clinica e Valutativa, AO Città della Salute e della Scienza di Torino e CPO-Piemonte., Torino, Italy; 4 S.C.D.U. Gastroepatologia, Dipartimento di Scienze Mediche, Università di Torino, Torino, Italy Background and aim: Patients with chronic hepatitis C have an increased risk of type 2 diabetes (DM) but the incidence and type of diabetes-related complications have not yet been evaluated. Material and methods: In order to assess the incidence of diabetic microangiopathy in patients with chronic hepatitis C we prospectively recruited 57 HCV+ patients with new onset DM and without microangiopathy from January 2005 to December 2006; we prospectively collected 119 patients without chronic viral hepatitis with new onset DM and without microangiopathy. All the patients were followed-up every 6 months for liver and diabetic complications up to December 2012. Incidence of macroangiopathy was also investigated. Results: Of 612 HCV+ patients who referred to our Centers in 2005–2006, 118 (19.2%) were diabetic; 57 (48.3%) showed new-onset DM without baseline complication. Of 1213 diabetic patients who attended the Diabetologic Unit during the same period, 119 (9.8%) showed new-onset DM without microangiopathy. After 7.2 years of follow-up, 22.8% HCV+ and 29.4% HCV− diabetics showed at least one microangiopathic complication (p=0.37), 9.2% HCV+ and 10.8% HCV− diabetics reported CAD/stroke (p=0.2). “De novo” cirrhosis was observed in 9% HCV+ and 1.7% HCV− diabetics (p=0.0001); 24.5% HCV+ diabetics developed liver-related complication compared to no one among HCV− cohort (p=0.0003). One (1.7%) HCV+ diabetic died due to HCC, 1 (0.8%) HCV− patient died for myocardial infarction (p=0.3). HCV− patients showed a higher incidence of AH during follow-up (58.3% vs 7.5%, p=0.0001). On multivariable analysis, HCV− diabetics showed a trend towards a lower incidence of microangiopathy (HR=0.63, 95% CI: 0.28–1.40, p=0.255) while increasing age (in years) (HR= 1.03, 95% CI: 1.00–1.07) and being smoker (HR=3.63, 95% CI: 1.36–9.72) were positively associated to microangiopathy. Conclusions: Incidence of microangiopathy is not clearly different in diabetics with or without chronic hepatitis C but the clinical impact of diabetic complications in patients with chronic hepatitis C is probably obscurated by the natural history of concomitant liver disease.
Abstracts of the 20th National Congress of Digestive Diseases / Digestive and Liver Disease 46S (2014) S1–S144
P.07.3 PATIENTS WITH ALCOHOLIC LIVER CIRRHOSIS (ALC), HEPATORENAL SYNDROME (HRS) AND HISTOLOGICAL EVIDENCE OF ACUTE ALCOHOLIC HEPATITIS (AAH) IN EXPLANTED LIVER P. Borro ∗,1 , A. Sumberaz 1 , E. Andorno 2 , C. Ferro 3 , E. Scafato 4 , G. Testino 5 1 Centro
Alcologico Regionale-Liguria, IRCCS AOU San Martino-IST, Collaborative Centre, World Health Organization, Genova, Italy; 2 Unit of Hepato-Biliary Surgery, IRCCS AOU San Martino-IST, Genova, Italy; 3 Unit of Interventional Radiology, IRCCS AOU San Martino-IST, Genova, Italy; 4 Collaborative Centre, World Health Organization, Istituto Superiore di Sanità, Roma, Italy; 5 Centro Alcologico Regionale-Liguria, IRCCS AOU San Martino-IST, Collaborative Centre, World Health Organization, Genova, Italy Background and aim: Recently the Trieste Italian Conference of the Regions (www.mediofriuli, Ministero della Salute) has discussed on “six months rule” in patients with ALC. Therefore, we revised retrospectively again 9 consecutive patients (6 males, average age 49) affected by type I HRS (HCV and HBV negative) (5) (Child-Pugh score between 10 and 12, model end stage liver disease over 21) suitable for transjugular intrahepatic portosystemic stent shunt (TIPS). Material and methods: The diagnosis of HRS was based on the criteria elaborated by the International Ascites Club. For the intervention of TIPS written informed consent was obtained from all patients. In all patients we determined serum creatinine, blood urea nitrogen (BUN), serum sodium, sodium excretion and urine volume before the intervention, 7 days and 30 days after TIPS. The statistical analysis: paired Student’s test and ANOVA with Dunn’s test and Bonferroni comparison. Results: All stents were successfully established. Complications occurred in 4 patients and included temperature above 38 °C (3 patients) and in 1 patient vomiting after procedure. Causes of death were septicaemia in one patient and liver failure in one patients. Seven patients were transplanted within 3 months. The results concerning the renal functional parameters are in the Table 1: they indicate an improvement of renal function. Nevertheless the shorter prelisting liver transplantation (LT) abstinence, none patients relapsed after a period of 5 years. Table 1. Functional renal parameters before and after TIPS Serum Creatinine (mg/dL) BUN (mg/dL) Serum sodium (mEq/L) Urine sodium (mEq/d) Urine volume (mL/d)
Baseline
7 days
30 days
p
5.2±0.9 110±8 125±4 2.5±0.5 250±40
3.6±1.1 109±7 123+/3 7±3 840±170
1.6±0.6 51±11 135±4 10±3 1100±210
0.04 0.007 n.s. n.s. 0.003
P.07.4 HEPATIC ARTERY ABERRATION WITH BILIARY STENOSIS G. Ursini ∗,1 , A. Ferrara 1 , S. Caruso 1 , G. Ferrari 2 , M.L. Boella 2 , R.M. Ferrara 3 1 Ospedale Legnano, Gastroenterologia, Legnano, Italy; 2 Ospedale Legnano, Chirurgia Generale, Legnano, Italy; 3 Ospedale Legnano, Radiologia, Legnano, Italy
Background and aim: A 48 year-old patient was admitted into the accident and emergency for epigastric pain started 2 weeks ago. After detection of gastritis in EGDS, PPI therapy was administrated without clinical benefit. Because of the worsening of the painful symptoms the patient went to the emergency room/accident and emergency of another Hospital where he was hospitalized in the internal medicine department for jaundice. Under suspicion of acute hepatitis resulting from the sharp increase in hepatic cytolysis indexes associated with jaundice, the patient is transferred to the infectious diseases Department of our hospital. Abdominal ultrasound revealed the presence of about 14 mm gallstone to the hepatic hilum and dilation of intrahepatic biliary duct without cholelithiasis. The cholangio-RM has documented the presence of biliary gallstone and a short common hepatic duct strictures downstream, suspected for extrinsic compression. For the worsening of jaundice during hospitalization, it was performed an endoscopic retrograde cholangiography
with endoprothesis inserction. Abdomen CT has not allowed to clarify the nature of stenosis. In consideration of diagnosis, after improvement of jaundice, the patient has undergone surgery. Intraoperatively it was possible to document an abnormal course of the right hepatic artery which, compressing the common hepatic duct, conditioned the stenosis resulting in colestasis and stacking of gallstones in the previous tract. The intervention consisted of cholecystectomy, debridement of the right hepatic artery and choledochotomy with removal of the gallstones. More than 3 years after surgery the patient, asymptomatic, performed cholangio-RM that has documented regularity of the extrahepatic biliary tree with minimal scarring of the intrahepatic ducts due to previous intrahepatic cholangitis. 6 years after surgery the patient is still asymptomatic. Conclusions: 1) The vascular anomaly presented by our patient is an infrequent condition (20% of benign biliary strictures). The peculiarity of the case lies in the extent of the biliary stricture conditioning intrahepatic gallstones, situation never reported in literature. 2) The conservative surgical treatment of mobilisation of the hepatic artery with stenosis resolution and gallstones removal, proved to be the easiest and most effective way to perform in the long term.
P.07.5 INCIDENCE OF MICROANGIOPATHY IN PATIENTS WITH CHRONIC HEPATITIS C AND TYPE 2 DIABETES MELLITUS: RESULTS OF A PROSPECTIVE CONTROLLED COHORT STUDY C. Coppo 1 , D. Bonfanti 2 , S. Bo 2 , C. Giordanino 1 , M. Gallo 1 , G. Ciccone 3 , A. Smedile 4 , A. Ciancio 4 , E. Bugianesi 4 , R. Pellicano 4 , M. Rizzetto 4 , G.M. Saracco ∗,1 1 SCDU
Gastroenterologia, Dept. Oncologia, Università di Torino, Torino, Italy; 2 Clinica Medica, Dipartimento di Scienze Mediche, Università di Torino, Torino, Italy; 3 Epidemiologia Clinica e Valutativa, AO Città della Salute e della Scienza di Torino e CPO-Piemonte., Torino, Italy; 4 S.C.D.U. Gastroepatologia, Dipartimento di Scienze Mediche, Università di Torino, Torino, Italy Background and aim: Patients with chronic hepatitis C have an increased risk of type 2 diabetes (DM) but the incidence and type of diabetes-related complications have not yet been evaluated. Material and methods: In order to assess the incidence of diabetic microangiopathy in patients with chronic hepatitis C we prospectively recruited 57 HCV+ patients with new onset DM and without microangiopathy from January 2005 to December 2006; we prospectively collected 119 patients without chronic viral hepatitis with new onset DM and without microangiopathy. All the patients were followed-up every 6 months for liver and diabetic complications up to December 2012. Incidence of macroangiopathy was also investigated. Results: Of 612 HCV+ patients who referred to our Centers in 2005–2006, 118 (19.2%) were diabetic; 57 (48.3%) showed new-onset DM without baseline complication. Of 1213 diabetic patients who attended the Diabetologic Unit during the same period, 119 (9.8%) showed new-onset DM without microangiopathy. After 7.2 years of follow-up, 22.8% HCV+ and 29.4% HCV− diabetics showed at least one microangiopathic complication (p=0.37), 9.2% HCV+ and 10.8% HCV− diabetics reported CAD/stroke (p=0.2). “De novo” cirrhosis was observed in 9% HCV+ and 1.7% HCV− diabetics (p=0.0001); 24.5% HCV+ diabetics developed liver-related complication compared to no one among HCV− cohort (p=0.0003). One (1.7%) HCV+ diabetic died due to HCC, 1 (0.8%) HCV− patient died for myocardial infarction (p=0.3). HCV− patients showed a higher incidence of AH during follow-up (58.3% vs 7.5%, p=0.0001). On multivariable analysis, HCV− diabetics showed a trend towards a lower incidence of microangiopathy (HR=0.63, 95% CI: 0.28–1.40, p=0.255) while increasing age (in years) (HR= 1.03, 95% CI: 1.00–1.07) and being smoker (HR=3.63, 95% CI: 1.36–9.72) were positively associated to microangiopathy. Conclusions: Incidence of microangiopathy is not clearly different in diabetics with or without chronic hepatitis C but the clinical impact of diabetic complications in patients with chronic hepatitis C is probably obscurated by the natural history of concomitant liver disease.