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S1835 Short-Term Prognostic Factors of Alcoholic Liver Disease Presented with Jaundice
among any of the four diagnostic categories (p=NS, Fisher's exact test). Other endoscopic findings (i.e. other than GEVs) were similar between deaths and survivors. When GEVs were considered with specific endoscopic lesions, we found that GEV plus esophagitis was significantly associated with increased mortality (p=0.0270); none of the other endoscopic dx with GEV predicted outcome. Conclusions: 36 of 267 unique cirrhotic patients identified ultimately died as an in-patient after presenting with UGIB. When classified as deaths and compared to patients who survived, endoscopic findings did not differ between the two groups. In this high-risk patient population, factors besides the etiology of bleeding appear to be the most important predictors of outcome.
(32.5%) were deceased. Total number of patients with ascites was 96 (78%), hepatic encephalopathy was 51 (41.5%), spontaneous bacterial peritonitis was 9 (7.3%), hepatorenal syndrome was 37 (30.1%), and bleeding was 10 (8.1%). The area under the receiver operating characteristic curve in predicting in-hospital mortality was 0.748 for initial DF, 0.744 for initial MELD, 0.702 for initial MELD-sodium, and 0.664 for initial CTP scores (P=.000, .000, .000 and .003, respectively); the area was 0.782, 0.762, 0.760, and 0.620 for 1 dayMELD, DF, MELD-sodium, and delta-MELD scores (P=.000, .000, .000, .031, respectively); the area was 0.854, 0.835, 0.824, and 0.734 for 3 day-MELD, MELD-sodium, DF, and delta-MELD scores (P=.000, all), respectively; and the area was 0.853, 0.839, 0.820, and 0.733 for 7 day-MELD, DF, MELD-sodium, and delta-MELD scores (P=.000, all), respectively. Upon multivariate analysis (Cox model), high 3 day-MELD score (≥20), presence of hepatorenal syndrome, and high polymorphonuclear neutrophil counts (≥9000/mm3) at presentation were independent short-term prognostic predictors with a risk ratio of 7.206 (95% confidential interval (CI): 1.183-43.905, P=.032), 5.393 (95% CI: 1.315-22.117, P=.019), and 2.515 (95% CI: 1.155-5.476, P=.020), respectively. In conclusion, MELD score which was derived from the laboratory findings of 3 days after presentation was objective predictor of in-hospital mortality for the patients of alcoholic liver disease presented with significant jaundice. S1836
S1834
Serial Pulse Oximetry in Hepatopulmonary Syndrome Rajan Kochar, Rajasekhar Tanikella, Sreelatha Meleth, Huichien Kuo, Keith M. Wille, Michael B. Fallon
AASLD Abstracts
Esophageal Variceal Band Ligation (EVL) Plus Beta-Blocker (BB) Treatment in the Primary Prophylaxis of Esophageal Variceal Bleeding Lance L. Stein, Sameer M. Mazhar, Charles Gabbert, Tarek Hassanein, David Kravetz
Background: Hepatopulmonary syndrome (HPS) affects 10-30% of patients with cirrhosis and is associated with increased mortality. The natural history of HPS is poorly characterized. Single measurement of arterial oxygen saturation (SaO2) with pulse oximetry is useful in detecting hypoxemia in HPS. However, whether changes in pulse oximetry measurements over time are similar in HPS and non-HPS patients is unknown. Aim: To monitor pulse oximetry over time in a cohort of advanced liver disease patients with and without HPS. Methods: A retrospective analysis of data from a prospective cohort of patients evaluated for liver transplantation at a US academic center (Pulmonary vascular complications of liver disease: PVCLD) was performed. HPS patients defined by an increased alveolar-arterial oxygen gradient (A-aPO2) with intrapulmonary vasodilation on contrast echocardiography (+CE) in the absence of significant cardiopulmonary disease were compared to those without HPS (normal A-aPO2, - or + CE).Linear statistical models were used to compare the change in pulse oximetry over time in HPS and non-HPS patients. Results: 22 patients with HPS and 32 patients without HPS (18 + CE) were compared over a mean duration of 20 months (2-50) and mean of 4 SaO2 measurements (2-24). Demographic data was similar between the groups; however, more non-HPS patients were males (P=0.03). HPS patients had significantly lower baseline SaO2 (32% vs. 9% SaO2 ≤ 96%) and higher A-aPO2 (30.9 mmHg vs. 6.1 mmHg, P=0.0001) compared to non-HPS patients. Patients with HPS had a significantly more rapid decline in SaO2 over time (P = 0.0007) relative to non-HPS patients (with or without + CE). 8/22 (36%) HPS patients compared to 3/32 (9%) non-HPS patients had a ≥2% net reduction in SaO2. There was no significant difference in changes in serial SaO2 measurements over time between the 2 non-HPS subgroups (- or + CE). Overall survival in the HPS group was lower than in non-HPS patients (68% vs 88%, P<0.05). However, within the HPS group neither baseline SaO2/A-aPO2 or the decline in SaO2 over time differed between those who survived and those who died. Conclusions: HPS patients have a more rapid rate of decline and a higher net reduction in SaO2 over time compared to non-HPS patients. However, in HPS patients, decline in SaO2 over time is not associated with increased mortality. A reduction in SaO2 is uncommon in non-HPS patients. Serial monitoring of SaO2 with pulse oximetry, particularly in non-HPS patients, may be useful in detecting HPS.
Background: Esophageal variceal hemorrhage (EVH) has a high mortality rate and different strategies for the prevention of this complication have been assessed. It has been shown that primary prophylaxis with EVL or BB is more effective than placebo treatment. However, the data evaluating the efficacy of combined therapy are based on studies with small sample sizes and exclude patients with renal dysfunction, hepatocellular carcinoma, and noncirrhotic portal hypertension. Our aim was to evaluate our liver center experience in the prevention of initial EVH using EVL and BB versus either strategy alone. Methods: We retrospectively analyzed all upper endoscopies performed on patients at our center with cirrhosis or non-cirrhotic portal hypertension between June 1, 2005, and May 31, 2007. We included patients without a previous history of EVH, with medium or large esophageal varices (EV), or small EV with Child's Class B or C. Patients with a history of gastric varices, TIPS or surgical shunt, or those who did not receive prophylaxis were excluded. Medical charts were reviewed to identify patient characteristics and EV prophylaxis protocols (EVL + BB versus either strategy alone). The rates of EVH among patients receiving combined therapy and monotherapy were assessed. A chi-square two-tailed test was used to assess the difference in EVH rates. Results: Diagnostic upper endoscopy was performed on 625 patients during the recruitment period, 213 of whom were included. Mean follow-up time was 29.2 +/- 9.8 months. 75 patients (35%) received EVL and BB, compared to 99 patients (46%) treated with either EVL (10) or BB (89) alone. 39 patients (18.3%) were excluded from further analysis due to not receiving EV prophylaxis. Data characteristics are listed in the table. The prevalence of medium or large EV was significantly higher in combined versus monotherapy. In the combined treatment group 6 (8%) patients presented with EVH and only 4 (4.6%) patients had this complication in the monotherapy group (p=0.345). Conclusion: This study shows that combined therapy with EVL and BB was not superior to monotherapy in the primary prophylaxis of EVH. However, in our practice, we found that patients with medium or large EV were more likely to receive combination therapy.
S1837 The Point of Care 13C Methacetin Breath Test Accurately Predicts Long Term Prognosis in Patients with Chronic Liver Disease: A Non Invasive Liver Function Test Gadi Lalazar, Beat Müllhaupt, Tomer Adar, Oliver Goetze, Meir Mizrahi, Ehud Zigmond, Nilla Hemed, Mina Rowe, Yaron Ilan Values are means. ± = Standard Deviation. *p< 0.05
Patients with chronic liver disease have variable rates of disease progression. Estimating the prognosis of individual patients is an important goal for both patient and physician. In cirrhotic patients, prognosis based stratification is crucial for organ allocation. Currently, prognosis is determined by a combination of clinical, laboratory parameters and liver biopsy. Since blood tests and physical examination may be normal in patients with significant liver disease, and prognosis varies widely even in the presence of cirrhosis, current tests lack the ability to accurately assess hepatic reserve. The point-of-care non-invasive BreathID® 13CMethacetin breath test (MBT, Exalenz Ltd.) has been used to assess liver function in acute and chronic liver disease. Aim: To assess the ability of MBT for predicting survival in patients with chronic liver disease. Methods: 575 patients with chronic liver disease (363 M, 212 F, age 48±14), from 2 tertiary hospitals (Jerusalem,Zurich) performed MBT after ingestion of 75mg of Methacetin. After following patients for up to 2 years, survival data was collected. A Cox regression model was used to develop a survival model, incorporating age and breath test parameters PDR15 (percent dose of 13C recovered at 15 minutes) and CPDR15 (cumulative PDR). Results: MBT parameters accurately predicted survival. Out of 575 patients (209 with cirrhosis) 25 died during follow up (15 M, 10 F; age 60±14). The risk of dying increased with the age (hazard ratio (HR) 1.06,p=0.0009), and decreased with PDR15 (HR 0.744,p<0.0001) and CPDR15 (HR 0.657,p=0.03). Using the MBT survival model score patients were grouped into 3 risk levels, each containing one third of the patients. A Kaplan Meier curve and log rank test showed the MBT score correlated with survival (p<0.0001) with 19, 3 and 1 deaths in the high, medium and low risk groups, respectively. While prognosis was excellent (99%) for patients in the low risk group at 24 months, this dropped to 90% and 73% in the medium and high risk groups, respectively. In cirrhotic patients survival rates were lower at 97%, 85% and 70% at 24 months respectively. Cirrhotic patients and their MBT survival model scores were divided into low, medium and high risk groups
S1835 Short-Term Prognostic Factors of Alcoholic Liver Disease Presented with Jaundice Jinmo Yang, Jin Dong Kim, Chang Nyol Paik, Woo Chul Chung, Uim Chang, Kang-Moon Lee : The prognosis of patients with severe alcoholic liver disease is associated with a high risk of short-term mortality. Early identification of the patients with high risk and prediction of prognosis are important. The aim of present study was to examine and compare the ability of model for end-stage liver disease (MELD) score, delta-MELD score, MELD-sodium score, discriminant function (DF), and Child-Turcotte-Pugh (CTP) score to predict in-hospital mortality in patients with alcoholic liver disease presented with jaundice. One hundred and twenty-three consecutive patients diagnosed as alcoholic hepatitis with or without cirrhosis between January 2000 and December 2006 were evaluated. All patients were initially presented with jaundice (serum bilirubin >10mg/dL). The patients who deceased within 48 hours after hospital visit were excluded. Alcohol behavior, presence of decompensated complications, and laboratory data were analyzed retrospectively. The CTP score was calculated at presentation, and DF, MELD, MELD-sodium, and delta-MELD scores were calculated at presentation, 1, 3, 7, and 14 days after presentation, respectively. Total 40 patients
AASLD Abstracts
A-826
(32.5%) were deceased. Total number of patients with ascites was 96 (78%), hepatic encephalopathy was 51 (41.5%), spontaneous bacterial peritonitis was 9 (7.3%), hepatorenal syndrome was 37 (30.1%), and bleeding was 10 (8.1%). The area under the receiver operating characteristic curve in predicting in-hospital mortality was 0.748 for initial DF, 0.744 for initial MELD, 0.702 for initial MELD-sodium, and 0.664 for initial CTP scores (P=.000, .000, .000 and .003, respectively); the area was 0.782, 0.762, 0.760, and 0.620 for 1 dayMELD, DF, MELD-sodium, and delta-MELD scores (P=.000, .000, .000, .031, respectively); the area was 0.854, 0.835, 0.824, and 0.734 for 3 day-MELD, MELD-sodium, DF, and delta-MELD scores (P=.000, all), respectively; and the area was 0.853, 0.839, 0.820, and 0.733 for 7 day-MELD, DF, MELD-sodium, and delta-MELD scores (P=.000, all), respectively. Upon multivariate analysis (Cox model), high 3 day-MELD score (≥20), presence of hepatorenal syndrome, and high polymorphonuclear neutrophil counts (≥9000/mm3) at presentation were independent short-term prognostic predictors with a risk ratio of 7.206 (95% confidential interval (CI): 1.183-43.905, P=.032), 5.393 (95% CI: 1.315-22.117, P=.019), and 2.515 (95% CI: 1.155-5.476, P=.020), respectively. In conclusion, MELD score which was derived from the laboratory findings of 3 days after presentation was objective predictor of in-hospital mortality for the patients of alcoholic liver disease presented with significant jaundice. S1836
S1834
Serial Pulse Oximetry in Hepatopulmonary Syndrome Rajan Kochar, Rajasekhar Tanikella, Sreelatha Meleth, Huichien Kuo, Keith M. Wille, Michael B. Fallon
AASLD Abstracts
Esophageal Variceal Band Ligation (EVL) Plus Beta-Blocker (BB) Treatment in the Primary Prophylaxis of Esophageal Variceal Bleeding Lance L. Stein, Sameer M. Mazhar, Charles Gabbert, Tarek Hassanein, David Kravetz
Background: Hepatopulmonary syndrome (HPS) affects 10-30% of patients with cirrhosis and is associated with increased mortality. The natural history of HPS is poorly characterized. Single measurement of arterial oxygen saturation (SaO2) with pulse oximetry is useful in detecting hypoxemia in HPS. However, whether changes in pulse oximetry measurements over time are similar in HPS and non-HPS patients is unknown. Aim: To monitor pulse oximetry over time in a cohort of advanced liver disease patients with and without HPS. Methods: A retrospective analysis of data from a prospective cohort of patients evaluated for liver transplantation at a US academic center (Pulmonary vascular complications of liver disease: PVCLD) was performed. HPS patients defined by an increased alveolar-arterial oxygen gradient (A-aPO2) with intrapulmonary vasodilation on contrast echocardiography (+CE) in the absence of significant cardiopulmonary disease were compared to those without HPS (normal A-aPO2, - or + CE).Linear statistical models were used to compare the change in pulse oximetry over time in HPS and non-HPS patients. Results: 22 patients with HPS and 32 patients without HPS (18 + CE) were compared over a mean duration of 20 months (2-50) and mean of 4 SaO2 measurements (2-24). Demographic data was similar between the groups; however, more non-HPS patients were males (P=0.03). HPS patients had significantly lower baseline SaO2 (32% vs. 9% SaO2 ≤ 96%) and higher A-aPO2 (30.9 mmHg vs. 6.1 mmHg, P=0.0001) compared to non-HPS patients. Patients with HPS had a significantly more rapid decline in SaO2 over time (P = 0.0007) relative to non-HPS patients (with or without + CE). 8/22 (36%) HPS patients compared to 3/32 (9%) non-HPS patients had a ≥2% net reduction in SaO2. There was no significant difference in changes in serial SaO2 measurements over time between the 2 non-HPS subgroups (- or + CE). Overall survival in the HPS group was lower than in non-HPS patients (68% vs 88%, P<0.05). However, within the HPS group neither baseline SaO2/A-aPO2 or the decline in SaO2 over time differed between those who survived and those who died. Conclusions: HPS patients have a more rapid rate of decline and a higher net reduction in SaO2 over time compared to non-HPS patients. However, in HPS patients, decline in SaO2 over time is not associated with increased mortality. A reduction in SaO2 is uncommon in non-HPS patients. Serial monitoring of SaO2 with pulse oximetry, particularly in non-HPS patients, may be useful in detecting HPS.
Background: Esophageal variceal hemorrhage (EVH) has a high mortality rate and different strategies for the prevention of this complication have been assessed. It has been shown that primary prophylaxis with EVL or BB is more effective than placebo treatment. However, the data evaluating the efficacy of combined therapy are based on studies with small sample sizes and exclude patients with renal dysfunction, hepatocellular carcinoma, and noncirrhotic portal hypertension. Our aim was to evaluate our liver center experience in the prevention of initial EVH using EVL and BB versus either strategy alone. Methods: We retrospectively analyzed all upper endoscopies performed on patients at our center with cirrhosis or non-cirrhotic portal hypertension between June 1, 2005, and May 31, 2007. We included patients without a previous history of EVH, with medium or large esophageal varices (EV), or small EV with Child's Class B or C. Patients with a history of gastric varices, TIPS or surgical shunt, or those who did not receive prophylaxis were excluded. Medical charts were reviewed to identify patient characteristics and EV prophylaxis protocols (EVL + BB versus either strategy alone). The rates of EVH among patients receiving combined therapy and monotherapy were assessed. A chi-square two-tailed test was used to assess the difference in EVH rates. Results: Diagnostic upper endoscopy was performed on 625 patients during the recruitment period, 213 of whom were included. Mean follow-up time was 29.2 +/- 9.8 months. 75 patients (35%) received EVL and BB, compared to 99 patients (46%) treated with either EVL (10) or BB (89) alone. 39 patients (18.3%) were excluded from further analysis due to not receiving EV prophylaxis. Data characteristics are listed in the table. The prevalence of medium or large EV was significantly higher in combined versus monotherapy. In the combined treatment group 6 (8%) patients presented with EVH and only 4 (4.6%) patients had this complication in the monotherapy group (p=0.345). Conclusion: This study shows that combined therapy with EVL and BB was not superior to monotherapy in the primary prophylaxis of EVH. However, in our practice, we found that patients with medium or large EV were more likely to receive combination therapy.
S1837 The Point of Care 13C Methacetin Breath Test Accurately Predicts Long Term Prognosis in Patients with Chronic Liver Disease: A Non Invasive Liver Function Test Gadi Lalazar, Beat Müllhaupt, Tomer Adar, Oliver Goetze, Meir Mizrahi, Ehud Zigmond, Nilla Hemed, Mina Rowe, Yaron Ilan Values are means. ± = Standard Deviation. *p< 0.05
Patients with chronic liver disease have variable rates of disease progression. Estimating the prognosis of individual patients is an important goal for both patient and physician. In cirrhotic patients, prognosis based stratification is crucial for organ allocation. Currently, prognosis is determined by a combination of clinical, laboratory parameters and liver biopsy. Since blood tests and physical examination may be normal in patients with significant liver disease, and prognosis varies widely even in the presence of cirrhosis, current tests lack the ability to accurately assess hepatic reserve. The point-of-care non-invasive BreathID® 13CMethacetin breath test (MBT, Exalenz Ltd.) has been used to assess liver function in acute and chronic liver disease. Aim: To assess the ability of MBT for predicting survival in patients with chronic liver disease. Methods: 575 patients with chronic liver disease (363 M, 212 F, age 48±14), from 2 tertiary hospitals (Jerusalem,Zurich) performed MBT after ingestion of 75mg of Methacetin. After following patients for up to 2 years, survival data was collected. A Cox regression model was used to develop a survival model, incorporating age and breath test parameters PDR15 (percent dose of 13C recovered at 15 minutes) and CPDR15 (cumulative PDR). Results: MBT parameters accurately predicted survival. Out of 575 patients (209 with cirrhosis) 25 died during follow up (15 M, 10 F; age 60±14). The risk of dying increased with the age (hazard ratio (HR) 1.06,p=0.0009), and decreased with PDR15 (HR 0.744,p<0.0001) and CPDR15 (HR 0.657,p=0.03). Using the MBT survival model score patients were grouped into 3 risk levels, each containing one third of the patients. A Kaplan Meier curve and log rank test showed the MBT score correlated with survival (p<0.0001) with 19, 3 and 1 deaths in the high, medium and low risk groups, respectively. While prognosis was excellent (99%) for patients in the low risk group at 24 months, this dropped to 90% and 73% in the medium and high risk groups, respectively. In cirrhotic patients survival rates were lower at 97%, 85% and 70% at 24 months respectively. Cirrhotic patients and their MBT survival model scores were divided into low, medium and high risk groups
S1835 Short-Term Prognostic Factors of Alcoholic Liver Disease Presented with Jaundice Jinmo Yang, Jin Dong Kim, Chang Nyol Paik, Woo Chul Chung, Uim Chang, Kang-Moon Lee : The prognosis of patients with severe alcoholic liver disease is associated with a high risk of short-term mortality. Early identification of the patients with high risk and prediction of prognosis are important. The aim of present study was to examine and compare the ability of model for end-stage liver disease (MELD) score, delta-MELD score, MELD-sodium score, discriminant function (DF), and Child-Turcotte-Pugh (CTP) score to predict in-hospital mortality in patients with alcoholic liver disease presented with jaundice. One hundred and twenty-three consecutive patients diagnosed as alcoholic hepatitis with or without cirrhosis between January 2000 and December 2006 were evaluated. All patients were initially presented with jaundice (serum bilirubin >10mg/dL). The patients who deceased within 48 hours after hospital visit were excluded. Alcohol behavior, presence of decompensated complications, and laboratory data were analyzed retrospectively. The CTP score was calculated at presentation, and DF, MELD, MELD-sodium, and delta-MELD scores were calculated at presentation, 1, 3, 7, and 14 days after presentation, respectively. Total 40 patients
AASLD Abstracts
A-826