Spontaneous Bacterial Peritonitis in Cirrhotic Patients Hospitalized in the Tertiary Care Hospital

blot analysis of whole-liver homogenate and LCM-PCR of sinusoidal wall revealed overexpressions of apelin and APJ in Child's C-LC samples. Examination by IEM revealed immunogold particles, showing the presence of APJ, which had located particularly on hepatic stellate cells but which sparsely dispersed on sinusoidal endothelial cell (SEC)s in Child's C-LC tissue. Conclusions: Aberrant expression of Apelin in human cirrhotic liver indicates the proliferation of arterial capillaries directly connected to the sinusoids, increasing the sinusoidal microvascular resistance. Enhanced expression of APJ on HSCs in cirrhosis induces sinusoidal microremodeling.

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Background: Spontaneous bacterial peritonitis (SBP) is one of the most common complications associated with cirrhosis and associated with high mortality. Empiric Intravenous antibiotics are recommended once the diagnosis of SBP is made on the basis of ascitic fluid cell count. Aim: To characterize the microorganisms seen on ascitic fluid culture, patterns of antibiotic use, and the outcome of hospitalized cirrhotic patients with culture-positive SBP in a large tertiary care hospital. Methods: Retrospective chart review of all cirrhotic patients who were hospitalized with a diagnosis SBP at Indiana University Hospital between January 2005 and December 2009. Patient clinical, laboratory and microbiology data including organism identification and the use of antibiotics was collected and analyzed. Outcomes of interest were the trend towards gram positive organism and the choice of empiric antibiotic used. Results: A total of 123 patients were hospitalized with the diagnosis of SBP. Of these, 22(18%, age 55.4±7.7 yrs) had classical SBP, 97(79%, age 51.7 ± 10.6 yrs) had culture negative neutrocytic ascites (CNNA) and remaining 4 (3%) had monobacter ascites or polymicrobial ascites. 26 of 123 patients (21%) had positive ascitic fluid cultures on index paracentesis. There were no differences in baseline admission laboratories, MELD scores, and the length of hospital stay between the groups. Only 13.6% of classical SBP patients had a history of previous SBP and took prophylaxis with quinolones. Gram positive microorganisms were found in 13 of 22 (61%) of classical SBP cases. Fifty percent of these patients(11/22) received a 3rd generation cephalosporin as the empiric antibiotic. Sixty percent of patients started on empiric cephalosporins had clinical deterioration within 72 hours requiring change to a broader spectrum antibiotic. Overall 64 %( 14/22) of classical SBP patients required change of antibiotic after culture data became available. and these patients had a complication with renal failure or sepsis requiring higher level of care due to ineffective empiric antibiotic use. In-hospital mortality in classical SBP and CNNA patients was 9% and 22%, respectively (p < 0.05). Concomitant urinary tract infections were found in 47% (in classical SBP group) and 33% (in CNNA group). Inpatient mortality was higher in those with gram positive microorganisms in the ascitic fluid (28.5% vs. 11.1%). There was no association between the use of SBP prophylaxis/rifaximin and the presence of gram positive ascitic fluid cultures. Conclusions: The majority of hospitalized cases with SBP were CNNA. We found significantly higher prevalence of gram positive organisms in the ascitic fluid cultures in those with classical SBP. This was associated with improper choice of empiric antibiotic leading to higher complications and a trend towards higher mortality.

Mo1009 Modified Orientation-Log (MO-log) is an Objective Method to Predict Outcomes in Patients Admitted With Hepatic Encephalopathy Maher Salam, Imran S. Farooq, R. Todd Stravitz, Arun J. Sanyal, Douglas M. Heuman, Richard K. Sterling, Velimir A. Luketic, Michael Fuchs, Puneet Puri, Jasmohan S. Bajaj Background and Aims: The subjectivity of the West-Haven criteria (WHC) is a major challenge in the evaluation of hepatic encephalopathy (HE). The orientation log is a validated instrument to assess mental status in traumatic brain injury (www.tbims.org/combi/olog/ olog.pdf). This was modified to fit the situation in HE as Modified Orientation Log (MOlog) which has 8 simple questions and a score ranging from 0 through 24 (24 being normal). The aim was to validate the MO-log as a rapid quantitative measure of mental status assessment for inpatients with HE. Methods: Patients admitted with HE between July 2009 and November 2010 were administered the MO-log after house-staff had been trained on its administration. The following data was collected: demographics, cirrhosis severity, prior HE, HE therapy, precipitating factors, daily MO-logs, admission WHC grade (performed by another examiner), sodium and ammonia at admission and discharge, time to reach maximum MO-log score and length of stay (LOS). Outcomes analyzed were death and readmission for HE. The change in MO-log over the 1st 24 hours was evaluated as a predictor of outcomes. Results: Hospital course: 52 patients were included (age 54 yrs, 75% men, 42% HCV).69% of pts were admitted for their second HE episode (all on lactulose, 54% also on rifaximin). The median admission MELD was 20, mean ammonia 111±56 and sodium 135±7mg/dl. Leading precipitating factors were non-adherence in 39%, infection in 21% and bleeding in 8%. The median admission WHC grade was 3 and mean MO-log score was 11±8 (maximum possible is 24). The mean LOS was 8±5 days and 29% required ICU care. 10% died during the admission. Discharge MO-log was ≥23 in 84% and the mean time to reach this level was 3.3±2.3 days. 40% required re-admission for HE a median of 3 weeks post-discharge. MO-log face validity: there was a significant negative correlation between admission WHC grade and MO-log score (r=-0.4, p=0.012). MO-log predictive capability: within the 1st 24 hrs, MO-log improved in 71% of patients and improved by ≥5 points in 47% of patients. LOS was significantly shorter in patients with any improvement (6 vs 11 days, p=0.037) or those with >5 point improvement (5 vs 9 days, p=0.016) in MO-log in the 1st 24 hrs. Improvement within first 24 hrs also predicted in-hospital mortality; 80% of those who died did not improve within 24 hrs compared to only 27% who did not die (p=0.023). Discharge MO-log: MO-log on discharge was significantly lower in those who subsequently returned for HE admission compared to those who remained HE-free (19 vs 23, p=0.05). Conclusions: MO-log is an objective instrument to predict outcomes in patients admitted with HE.

Mo1012 Hepatic Venous Outflow Tract Obstruction is Associated With Poor Outcome of Pregnancy Anupam Mahapatra, Akash Shukla, Anumeet Singh Grover, Shobna J. Bhatia Introduction and Aim: There are limited data of effect of hepatic venous outflow tract obstruction (HVOTO) on fertility and none on fertility or pregnancy profile prior to onset of symptoms. A retrospective study of pregnancy in sixteen women with HVOTO showed that maternal and fetal outcome, beyond gestation week 20, are good [Rautou PE et al. J Hepatol 2009;51:47-54]. We evaluated the fertility and outcome of pregnancy prior to onset of symptoms and post intervention in women with HVOTO. Methods: Fifty-one consecutive married women (age 30.11 [5.6] years) with HVOTO, who were sexually active for at least 2 years and not using any contraception, were prospectively included. Their detailed obstetric history was obtained. Results: Twenty-nine women had isolated hepatic vein (HV) thrombosis, 6 had isolated inferior vena cava (IVC) obstruction and 11 had IVC + HV thrombosis. Portal vein was thrombosed in 4 patients. The median duration of symptoms was 3 months (range 0.5-48). Prothrombotic states were identified in 9 women (APLA-4, Factor V Leiden1, PNH-1, FVL+APLA-1, FVL+MTHFR mutation-1, JAK2 [V617F] mutation-1). Six patients had primary infertility. Forty-five women conceived 108 times - 29 patients had 52 live births, 19 had 28 first trimester abortions, 4 had 7 second trimester abortions and 6 had seven still births; medical termination of pregnancy was done in 4 patients. None conceived after onset of symptoms. Presence of prothrombotic state was associated with increased risk of second trimester abortion (3/4 Vs 2/14, p=0.04, OR=18.0 [95% CI 1.2-271.5]), but not with infertility, first trimester abortions or stillbirths. Women who had live births were older at the time of diagnosis (33.1 [6.1] vs 28.2 [3.8] years; p=0.008, OR 5.5 [1.6-9.4]) and had later onset of symptoms (32.4 [6.2] years vs 27.0 [3.9] years; p=0.023, OR 4.5 [1.217.1]), as compared to those who never had any live births. Treatment: Fourteen patients underwent a radiological procedure, and intervention was not feasible in 4 patients; 33 were treated with anticoagulation alone. Post intervention 4 patients conceived 6 times, 1 had a live birth, 1 had a first trimester abortion, 2 had 3 second trimester abortions and medical termination of pregnancy was done in 1 patient. Pregnancy outcome and infertility did not correlate with duration of symptoms, anatomy of HV or IVC obstruction or intervention. Conclusion: Women with HVOTO have poor outcome of pregnancy even before the onset of the symptoms.

Mo1010 Synergistic Roles of Hepatic Encephalopathy and Obstructive Sleep Apnea in Disturbance of Sleep Architecture in Patients With Cirrhosis Matthew Kappus, Leonard C. Moses, Douglas M. Heuman, Jasmohan S. Bajaj Background: Sleep disturbances in cirrhosis are often attributed to hepatic encephalopathy (HE). With the increasing prevalence of NASH, it is common to encounter cirrhotics with complications of obesity, including obstructive sleep apnea (OSA). Few previous studies have attempted to distinguish between effects of OSA and HE on sleep architecture. Normal sleep has early (N1/N2), deep (N3/N4) and REM phases. N3/N4 stages determine the restfulness and have physically and mentally restorative functions. Aim: To evaluate the interaction between OSA and HE on sleep architecture in cirrhosis. Methods: Cirrhotics who underwent polysomnography between 2007 and 2010 were included. Records were reviewed for MELD score, HE (defined by use of lactulose/rifaximin), OSA, symptoms necessitating the sleep study, details of the report including time spent in early stage (N1/ N2), deep (N3/N4) and REM sleep and periodic limb movements (PLM) were recorded. HE patients were compared to non-HE patients. Results: 46 cirrhotics (58 yrs, 93% men, BMI 34±4, MELD 8, 50% HCV, 19% alcohol, Diabetes 43%, HTN 93%) were included. All were referred for the sleep study due to subjective sleeping difficulties (41% snored, 32% had daytime sleepiness). 89% had OSA and 21% had controlled HE (all HE pts also had OSA). Sleep study results: Median sleep efficiency was 77% with 29 hypopneas, 5 apneas, 67 arousals and 23 PLMs. The mean latency to sleep was 23 min; the mean % of sleep that consisted of N1(11%), N2 (57%), N3 (3%), N4(0.4%) and REM (11%); indicating a severe disruption. N3/N4 were absent in 67% of pts. HE, MELD score and sleep architecture: There was a significant correlation between MELD score and PLM (r=0.45,p=0.04) and with % in N1 sleep (r=0.33, p=0.037) but not with other sleep phases. Since the majority had OSA, there was no significant difference in sleep efficiency (p=0.5), hypopneas(p=0.9), apneas (p=0.5) or arousal(p=0.7) in cirrhotics with or without HE. Compared to patients with OSA alone, patients with HE+OSA spent a significantly higher % time in early (N1+N2) sleep (77% vs. 65%, p=0.007) but not in REM. 100% of pts with HE+OSA had no demonstrable N3/N4 sleep compared to only 29% of non-HE cirrhotics(p=0.021). Conclusions: In cirrhotics with OSA, the added presence of HE significantly shifts the sleep architecture towards early, non-restorative sleep and impairs deep sleep.

Mo1013 Proinflammatory Cytokines Are Raised in Extrahepatic Portal Venous Obstruction Patients With Minimal Hepatic Encephalopathy Anshu Srivastava, Santosh K. Yadav, Surender K. Yachha, Michael A. Thomas, Vivek A. Saraswat, Rakesh K. Gupta Background and aims: Minimal hepatic encephalopathy and hyperammonemia is seen in extra-hepatic portal venous obstruction patients. Inflammation has been shown to play an important role in pathogenesis of hepatic encephalopathy in cirrhotics. This study assessed the serum proinflammatory cytokines and their correlation with hyperammonemia, 1H magnetic resonance spectroscopy (1H MRS) derived brain glutamine and diffusion tensor

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AASLD Abstracts

AASLD Abstracts

Spontaneous Bacterial Peritonitis in Cirrhotic Patients Hospitalized in the Tertiary Care Hospital Arslan Kahloon, Rodjawan Supakul, Paul Y. Kwo, Raj Vuppalanchi, Marwan Ghabril, Rakesh Vinayek, Marco A. Lacerda, Hwan Y. Yoo, Naga P. Chalasani, Suthat Liangpunsakul