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Preliminary experience with a simple bedside technique using an inexpensive portable ultrasound for liver biopsies
AJG – September, Suppl., 2003
272 PRELIMINARY EXPERIENCE WITH A SIMPLE BEDSIDE TECHNIQUE USING AN INEXPENSIVE PORTABLE ULTRASOUND FOR LIVER BIOPSIES Raja Mohi-ud-din, M.D., Christian Noguera, M.D., David Novak, M.D., Louis Korman, M.D.*. Veterans Affairs Medical Center, Washington, DC and Georgetown University, Washington, DC. Purpose: The real and percieved risks of bedside percutaneous liver biopsies have reduced the number of biopsies performed by gastroenterologists and increased the number of image guided biopsies referred to the radiologists.The study was designed to evaluate a simple bedside technique using an inexpensive multipurpose portable ultrasound device (SITERITE3, 3.5mhz) to localize the liver biopsy site. Methods: The xiphoid process and mid axillary line were identified and the intercostal space corresponding to the intersection of these two planes was marked as the potential liver biopsy site. The ultrasound probe was placed in the identified intercostal space and the liver parenchyma, vessels, and adjacent structures (i.e. gallbladder) were identified. The probe was repositioned if the landmarks were not clearly identified. Using the ultrasound machine, the distance from the skin to the liver and vessels was calculated. A 16-gauge spring loaded biopsy gun (Tru-Cut type needle) was inserted into the skin at the biopsy site and with the patient holding their breath in end-expiration, the tip was advanced to the the measured liver margin. The needle was then deployed such that the distance of the deployed needle was 1 cm less than the nearest measured parenchymal vessel. Results: Thirty consecutive liver biopsies were performed between August and October 2002 using the ultrasound guided bedside technique. Indications were: chronic hepatiits C-23/30, and abnormal liver enzymes with unclear etiology-7/30. The average time to complete the procedure was 19.4 minutes. Liver biopsy could not be performed in only one patient because of the inability to identify the appropriate site. Two patients required more than one pass to obtain a good core specimen. A successful liver biopsy defined by the pathologist as an adequate specimen for interpretation was achieved in 28/30 patients. Two complications were encountered: severe RUQ pain requiring an ultrasound-no subcapsular hematoma or other abnormalities were found; and biopsy site pain requiring an oral analgesic. Both patients were discharged home the same day without any further intervention. Conclusions: An inexpensive simple portable ultrasound device combined with a standard localization protocol appears to be a safe and effective method of performing a liver biopsy in the outpatient setting. This technique could improve the safety and reduce the number of procedures referred to imaging services for liver biopsies.
273 DIFFERENTIATING ACUTE VIRAL HEPATITIS B FROM FIRST EPISODE OF REACTIVATION OF CHRONIC HEPATITIS B Manoj Kumar, M.D., Sanjay Jain, M.D., Brijesh C. Sharma, D.M., Shiv K. Sarin, D.M.*. G.B. Pant Hospital, New Delhi, India. Purpose: In countries with intermediate or high endemicity for chronic HBV infection, reactivation presenting as acute hepatitis B is not uncommon. We studied the clinical, biochemical and virological characteristics of patients presenting as acute hepatitis B to differentiate between acute viral hepatitis B(AVH-B) and first episode of reactivation of chronic hepatitis B(R-CHB). Methods: We retrospectively analysed 79 patients [mean age 35.4 ⫾ 14 years; M:F⫽60:19] presenting within 4 weeks of onset of symptoms suggestive of acute viral hepatitis. Patients who on followup cleared HBsAg and/or did not develop clinical, radiological or histological evidence of chronic liver disease(CLD) were categorized as AVH-B. Patients who had persistence of HBsAg and developed clinical, biochemical, radiological or histological evidence of CLD were diagnosed as R-CHB.
Abstracts
S93
Results: 49 patients satisfied criteria for AVH-B and 30 for RCH-B. The two groups were comparable with respect to prodrome, and onset of jaundice. Biochemical parameters [median (range)] including S bilirubin [8.0(2.7–72.9) vs 9.6(3.0 –37.2) mg/dl], ALT [1085(400 – 6920) vs 923(400 –2900) IU/L], PT prolongation [2.9(0 –32) vs 3.0(0 –16) seconds], S albumin [3.8(2.9 – 4.6) vs 3.9(2.7– 4.5) g/dl] and A/G ratio [1.2(1.0 –1.8) vs 1.2(0.8 –2.0)] were similar in the two groups [p⫽ ns]. Serological pattern and HBV DNA levels are shown in the table. HBV DNA levels ⬎0.5 pg/ml had sensitivity, specificity, positive and negative predictive value of 81.3%, 95%, 98.6% and 86.4% respectively for diagnosis of R-CHB. IgM antiHBc titres ⬍1:1000 (including negative IgM anti-HBc) had sensitivity, specificity, positive and negative predictive value of 70%, 77.6%, 65.6% and 80.9% respectively for diagnosing R-CHB. Of 49 AVH-B patients, 48 became HbsAg negative. In RCH-B liver biopsies were done after a mean of 13.7⫾2.4 mo after onset of symptoms and showed mean HAI of 7.3 ⫾2.6 and fibrosis score of 3.1⫾1.0. Virological features of AVH-B and R-CHB Parameter
AVH-B (nⴝ49)
HBeAg ⫹ve Anti-HBe ⫹ve HBeAg ⫹ve Anti-HBe HBeAg –ve Anti-HBe HBeAg ⫹ve AntiHBe IgM anti-HBc -ve IgM anti-HBc ⬍1:1000 HBV DNA ⬎0.5 pg/ml
41 (83.7%) 0 0 0 41 (83.7%) 0 11 (22.5%) 1/20
Reactivation (nⴝ30) 19 (63.3%) 25 (83.3%) 16 (53.3%) 9 (30%) 5 (16.7%) 7 (23.3%) 14 (46.7%) 13/16
Conclusions: Quantitative HBV DNA and IgM anti-HBc titres can differentiate the first episode of reactivation from acute viral hepatitis B. Clinical and biochemical features do not help in differentiating the two.
274 INTERMEDIATE TERM MORBIDITY AND MORTALITY OF 90 RECIPIENTS OF LIVING DONOR LIVER TRANSPLANTATION AT THE UNIVERSITY OF ROCHESTER Bradford Sampson, M.D., Parvez S. Mantry, M.D., Uma Sundaram, M.D.*. University of Rochester, Rochester, NY. Purpose: A critical shortage of cadaveric organs for adults in need of liver transplants has lead to the development of living donor liver transplantation (LDLT) using the right lobe. We report a study of recipients of 90 LDLT performed at the University of Rochester between 2001 and 2002. Methods: We studied the electronic and paper records of 92 patients who underwent LDLT and studied various parameters such as demographics, indications, complications, number of rejection episodes and mortality after transplantation. Results: In terms of gender distribution, 54% of the living donor recipients were male. 85% of the living donor recipients were Caucasian. The mean age of the recipients was 50 years in LDLT recipients. Chronic Hepatitis C (including hepatoma resulting from it) was the leading indication for transplantation accounting for 40% of LDLT. Laennec’s cirrhosis accounted for 18% of LDLT. The other indications included cryptogenic cirrhosis (12%), primary biliary cirrhosis (5%), hepatitis B (4%), primary sclerosing cholangitis (3%), NASH (3%), autoimmune liver disease (2%), polycystic liver disease (2%), chronic rejection (2%), hemochromatosis (1%) and miscellaneous causes including metabolic and storage disorders (8%). Significant complications occurred in 14 % of the LDLT recipients. These included re-transplantation (8 patients), Biliary leak (6) Hepatic artery thrombosis (2), post-operative bleeding (1), Intraabdominal abscess (3) and biliary abscess (1). No complications of OLT as post transplant lymphoproliferative disorder, biliary stricture, CMV colitis or ampullary dysfunctions were seen in LDLT recipients. Significant rejection episodes (Rejection activity index ⬎⫽ 4) were seen in 5 LDLT recipients. The intraoperative mortality of LDLT recipients was 0. The median follow up
272 PRELIMINARY EXPERIENCE WITH A SIMPLE BEDSIDE TECHNIQUE USING AN INEXPENSIVE PORTABLE ULTRASOUND FOR LIVER BIOPSIES Raja Mohi-ud-din, M.D., Christian Noguera, M.D., David Novak, M.D., Louis Korman, M.D.*. Veterans Affairs Medical Center, Washington, DC and Georgetown University, Washington, DC. Purpose: The real and percieved risks of bedside percutaneous liver biopsies have reduced the number of biopsies performed by gastroenterologists and increased the number of image guided biopsies referred to the radiologists.The study was designed to evaluate a simple bedside technique using an inexpensive multipurpose portable ultrasound device (SITERITE3, 3.5mhz) to localize the liver biopsy site. Methods: The xiphoid process and mid axillary line were identified and the intercostal space corresponding to the intersection of these two planes was marked as the potential liver biopsy site. The ultrasound probe was placed in the identified intercostal space and the liver parenchyma, vessels, and adjacent structures (i.e. gallbladder) were identified. The probe was repositioned if the landmarks were not clearly identified. Using the ultrasound machine, the distance from the skin to the liver and vessels was calculated. A 16-gauge spring loaded biopsy gun (Tru-Cut type needle) was inserted into the skin at the biopsy site and with the patient holding their breath in end-expiration, the tip was advanced to the the measured liver margin. The needle was then deployed such that the distance of the deployed needle was 1 cm less than the nearest measured parenchymal vessel. Results: Thirty consecutive liver biopsies were performed between August and October 2002 using the ultrasound guided bedside technique. Indications were: chronic hepatiits C-23/30, and abnormal liver enzymes with unclear etiology-7/30. The average time to complete the procedure was 19.4 minutes. Liver biopsy could not be performed in only one patient because of the inability to identify the appropriate site. Two patients required more than one pass to obtain a good core specimen. A successful liver biopsy defined by the pathologist as an adequate specimen for interpretation was achieved in 28/30 patients. Two complications were encountered: severe RUQ pain requiring an ultrasound-no subcapsular hematoma or other abnormalities were found; and biopsy site pain requiring an oral analgesic. Both patients were discharged home the same day without any further intervention. Conclusions: An inexpensive simple portable ultrasound device combined with a standard localization protocol appears to be a safe and effective method of performing a liver biopsy in the outpatient setting. This technique could improve the safety and reduce the number of procedures referred to imaging services for liver biopsies.
273 DIFFERENTIATING ACUTE VIRAL HEPATITIS B FROM FIRST EPISODE OF REACTIVATION OF CHRONIC HEPATITIS B Manoj Kumar, M.D., Sanjay Jain, M.D., Brijesh C. Sharma, D.M., Shiv K. Sarin, D.M.*. G.B. Pant Hospital, New Delhi, India. Purpose: In countries with intermediate or high endemicity for chronic HBV infection, reactivation presenting as acute hepatitis B is not uncommon. We studied the clinical, biochemical and virological characteristics of patients presenting as acute hepatitis B to differentiate between acute viral hepatitis B(AVH-B) and first episode of reactivation of chronic hepatitis B(R-CHB). Methods: We retrospectively analysed 79 patients [mean age 35.4 ⫾ 14 years; M:F⫽60:19] presenting within 4 weeks of onset of symptoms suggestive of acute viral hepatitis. Patients who on followup cleared HBsAg and/or did not develop clinical, radiological or histological evidence of chronic liver disease(CLD) were categorized as AVH-B. Patients who had persistence of HBsAg and developed clinical, biochemical, radiological or histological evidence of CLD were diagnosed as R-CHB.
Abstracts
S93
Results: 49 patients satisfied criteria for AVH-B and 30 for RCH-B. The two groups were comparable with respect to prodrome, and onset of jaundice. Biochemical parameters [median (range)] including S bilirubin [8.0(2.7–72.9) vs 9.6(3.0 –37.2) mg/dl], ALT [1085(400 – 6920) vs 923(400 –2900) IU/L], PT prolongation [2.9(0 –32) vs 3.0(0 –16) seconds], S albumin [3.8(2.9 – 4.6) vs 3.9(2.7– 4.5) g/dl] and A/G ratio [1.2(1.0 –1.8) vs 1.2(0.8 –2.0)] were similar in the two groups [p⫽ ns]. Serological pattern and HBV DNA levels are shown in the table. HBV DNA levels ⬎0.5 pg/ml had sensitivity, specificity, positive and negative predictive value of 81.3%, 95%, 98.6% and 86.4% respectively for diagnosis of R-CHB. IgM antiHBc titres ⬍1:1000 (including negative IgM anti-HBc) had sensitivity, specificity, positive and negative predictive value of 70%, 77.6%, 65.6% and 80.9% respectively for diagnosing R-CHB. Of 49 AVH-B patients, 48 became HbsAg negative. In RCH-B liver biopsies were done after a mean of 13.7⫾2.4 mo after onset of symptoms and showed mean HAI of 7.3 ⫾2.6 and fibrosis score of 3.1⫾1.0. Virological features of AVH-B and R-CHB Parameter
AVH-B (nⴝ49)
HBeAg ⫹ve Anti-HBe ⫹ve HBeAg ⫹ve Anti-HBe HBeAg –ve Anti-HBe HBeAg ⫹ve AntiHBe IgM anti-HBc -ve IgM anti-HBc ⬍1:1000 HBV DNA ⬎0.5 pg/ml
41 (83.7%) 0 0 0 41 (83.7%) 0 11 (22.5%) 1/20
Reactivation (nⴝ30) 19 (63.3%) 25 (83.3%) 16 (53.3%) 9 (30%) 5 (16.7%) 7 (23.3%) 14 (46.7%) 13/16
Conclusions: Quantitative HBV DNA and IgM anti-HBc titres can differentiate the first episode of reactivation from acute viral hepatitis B. Clinical and biochemical features do not help in differentiating the two.
274 INTERMEDIATE TERM MORBIDITY AND MORTALITY OF 90 RECIPIENTS OF LIVING DONOR LIVER TRANSPLANTATION AT THE UNIVERSITY OF ROCHESTER Bradford Sampson, M.D., Parvez S. Mantry, M.D., Uma Sundaram, M.D.*. University of Rochester, Rochester, NY. Purpose: A critical shortage of cadaveric organs for adults in need of liver transplants has lead to the development of living donor liver transplantation (LDLT) using the right lobe. We report a study of recipients of 90 LDLT performed at the University of Rochester between 2001 and 2002. Methods: We studied the electronic and paper records of 92 patients who underwent LDLT and studied various parameters such as demographics, indications, complications, number of rejection episodes and mortality after transplantation. Results: In terms of gender distribution, 54% of the living donor recipients were male. 85% of the living donor recipients were Caucasian. The mean age of the recipients was 50 years in LDLT recipients. Chronic Hepatitis C (including hepatoma resulting from it) was the leading indication for transplantation accounting for 40% of LDLT. Laennec’s cirrhosis accounted for 18% of LDLT. The other indications included cryptogenic cirrhosis (12%), primary biliary cirrhosis (5%), hepatitis B (4%), primary sclerosing cholangitis (3%), NASH (3%), autoimmune liver disease (2%), polycystic liver disease (2%), chronic rejection (2%), hemochromatosis (1%) and miscellaneous causes including metabolic and storage disorders (8%). Significant complications occurred in 14 % of the LDLT recipients. These included re-transplantation (8 patients), Biliary leak (6) Hepatic artery thrombosis (2), post-operative bleeding (1), Intraabdominal abscess (3) and biliary abscess (1). No complications of OLT as post transplant lymphoproliferative disorder, biliary stricture, CMV colitis or ampullary dysfunctions were seen in LDLT recipients. Significant rejection episodes (Rejection activity index ⬎⫽ 4) were seen in 5 LDLT recipients. The intraoperative mortality of LDLT recipients was 0. The median follow up