Su1297 Preventing Osteoporosis in Patients With Cirrhosis: How Well Do We Follow British Society of Gastroenterology Guidelines?

cirrhotic patients with recurrent HE. Methods: Maintenance of remission and tolerability data were pooled from a 6-month, randomized, controlled trial (RCT) and a long-term, open-label trial of RFX 550 mg BID in cirrhotic patients (n=392) with recurrent HE. Breakthrough overt HE was defined as an increase in Conn Score (CS) to ≥2, an increase in both CS and asterixis score of 1 grade each for patients entering with a CS of 0, or an increase in CS to ≥3 for patients entering with a CS of 2. The incidence and rate (number of patients ÷ person-years of exposure [PYE]) of adverse events (AEs) were reported. Results: In this post-hoc analysis, 40 (10.2%) patients took RFX alone and 352 (89.8%) took RFX+LAC. MELD scores were somewhat lower in the RFX alone (mean=10.2) vs. RFX+LAC (mean=13.1) group. Breakthrough HE events occurred in 10% (4 of 40 patients) of RFX alone patients vs. 44.6% (157 of 352) of RFX+LAC patients, corresponding to an 82.2% reduction in relative risk of a breakthrough HE episode (Figure, P=0.0001). The most commonly reported AEs were related to the gastrointestinal (GI) system, and the incidence was lower in patients treated with RFX alone vs. RFX+LAC (47.5% vs. 69.6%). Most commonly reported GI-related AEs were nausea, abdominal pain, and ascites, all occurring at a lower rate in the RFX alone (7.5-12.5% of patients;0.05-0.09 events/PYE) vs. RFX+LAC (17.6-24.1%;0.15-0.23 events/PYE) group. Conclusions: RFX monotherapy appears to be more efficacious and better tolerated than combination therapy with RFX+LAC. A limitation of these findings is that baseline MELD scores were somewhat lower in the monotherapy group. Randomized, controlled, prospective studies are ongoing to verify these findings.

Su1296 Co-Existence of Pancreatic and Liver Disease in Alcoholics: A Prospective and Retrospective Analysis Kartar Singh, Karam Romeo Singh, Ashim Das, Kaushal K. Prasad, Virendra Singh, Sreekanth Appasani, Jahangeer Basha, Rakesh Kochhar INTRODUCTION: Alcoholism in developing countries is on rapid rise. On genetic basis co-existence of alcoholic pancreatitis (ALP) and alcoholic liver disease (ALD) was considered rare. Fibroscan and endoscopic ultrasound (EUS) have revolutionized fibrosis detection in liver and pancreas respectively. AIM: To prospectively evaluate pattern of liver and pancreatic involvement prospectively using fibroscan and EUS and retrospectively on autopsy data in alcoholics. MATERIALS & METHODS: Daily alcohol consumption was evaluated. Patients with BMI>40, HBV, HCV, HIV, gallstones and diabetes mellitus were excluded. In group A, 68 ALD patients (mean age 42yrs, all males) were classified as alcoholic hepatitis/cirrhosis based on signs of portal hypertension, biochemistry and imaging. Pancreatic parenchymal and ductal changes were characterized using Rosemont's classification on EUS. In group B, 70 symptomatic ALP patients with imaging features on USG/CT/EUS/ERCP were fibroscanned for liver stiffness and graded per protocol. In group |C autopsy specimens of liver and pancreas of 51 alcoholics(mean age=46yrs, all males) who died of alcohol related liver and pancreatic diseases from Jan 2008-Dec 2010 were analyzed. RESULTS: Of 68 ALD patients (group A), 40%(27) had pancreatic involvement on EUS (chronic pancreatitis(CP)-7%, suggestive CP-12%, indeterminate CP-21%). Of 70 ALP patients (group B), 26(37%) had liver involvement on fibroscan (cirrhosis-6%, severe fibrosis-13%, significant fibrosis-19%). Altered liver function with raised bilirubin, AST, ALT, ALP and low albumin were observed in 23(30%), 39(51%), 24(32%), 27(35%) and 27(35%) patients respectively. Of 51 autopsy patients (group C), 82%(42) had ALD and 18%(9) had ALP. Of these 42 ALD patients, 25(60%) had some form of pancreatitis (CP-31%, acute on CP-17% and acute pancreatitis12%). Of these 9 ALP patients, 44%(4) had liver injury (fatty liver-33%, steatohepatitis11%). There was no difference in age, type, frequency and pattern of alcohol consumption in both groups. Amount and duration of alcohol intake in ALD(211gm, 21yrs) was more than in patients with ALP(183gm, 13yrs)(p=0.038, p=0.003). CONCLUSIONS: Our study shows that 37% ALP had evidence of liver disease on fibroscan and 40% ALD had evidence of pancreatic disease on EUS. High degree of co-existence of ALD and ALP (60%) was noted in our autopsy data. ALD patients consumed more alcohol and for longer periods than ALP. This is the first study of its kind.

Rifaximin alone vs. Rifaximin + Lactulose Su1299 Vitamin D Deficiency in Cirrhotics and Its Relation to FibroScan Score, Severity of Liver Disease and Bone Mineral Density Rajoo S. Chhina, Arshdeep Singh, Omesh Goyal, Rajdeep S. Chhina, Suresh K. Sharma Background: Vitamin-D deficiency is highly prevalent in cirrhotics. However, data on the relationship between vitamin D deficiency and severity of liver disease in cirrhotics is scarce, and it is not clear whether vitamin-D deficiency in cirrhotics is associated with low bone mineral density (BMD). This prospective study was planned to assess the relationship between vitamin D deficiency and severity of liver disease, Fibroscan score and bone mineral density in cirrhotics. Methods: Between November 2011 and August 2012 (10 months), 125 patients of cirrhosis underwent testing for 25-hydroxyvitamin-D (25OHD) levels, Parathyroid hormone (PTH) levels, Fibroscan (Echosens, Paris), dual-energy-X-ray-absorptiometry (DEXA) at same time point. Low bone mineral density (BMD) was defined as BMD ≥ 2 standard deviations lower than age, sex, and race-matched controls (Z-score ≤ -2.0) at the hip or lumbar spine. Patients in whom Fibroscan could not be performed (ascites, morbid obese, hepatocellular carcinoma etc) were excluded. Child Turcotte Pugh Score (CTP) and Model for End stage Liver Disease (MELD) scores were calculated. Results are expressed as median with 95% confidence interval (CI). Correlation analysis was performed using the Pearson Correlation method. Results: The median age was 50 years (95% CI, 41-59) and there were 86.4% males. Etiology of cirrhosis was alcohol in 60.8%, alcohol and HCV in 14.4%, HCV in 11.2%, NAFLD/cryptogenic in 11.2%, and HBV in 2.4%. Median CTP and MELD scores were 12 (95% CI, 11-13) and 20 (95% CI, 17-23) respectively. The median Fibroscan score was 48 (95% CI, 44.3-53.9). Fibroscan score showed significant positive correlation with both CTP (r=0.348; p= 0.003) and MELD scores (r=0.525; p=0.000). The median 25OHD value was 23.8 ng/mL (95% CI 18.7-29.5), and hypovitaminosis D (25OHD ,20 ng/ml) was present in 60.8% (76/125). The median 25OHD level in patients with alcoholic cirrhosis (22 ng/mL) was not significantly different from those in patients with non-alcoholic cirrhosis (27 ng/mL). Also, there was no significant correlation between 25OHD levels and Fibroscan score (p=0.119), CTP score (p=0.9) or MELD score (p=0.383). The median PTH level was 32.5 (95% CI, 25.8- 41.1). Low BMD (Z-score , -2) at the spine and hip were present in 28.2% and 11.3% respectively. 25OHD levels did not show any significant correlation with PTH (p=0.288) levels or BMD scores (p=0.818). Conclusion: Vitamin-D deficiency is common in hospitalized cirrhotics in northern India. Vitamin-D deficiency is not related liver disease severity, liver fibrosis, or etiology of cirrhosis. There is lack of correlation between VitaminD levels, bone mineral density or PTH levels.

Su1297 Preventing Osteoporosis in Patients With Cirrhosis: How Well Do We Follow British Society of Gastroenterology Guidelines? Kamran Gaba, Bradley Porter Background: Osteoporosis is an important complication of chronic liver disease, associated with significant morbidity due to resulting fractures, deformity and immobility. British Society of Gastroenterology guidelines advocate the need for bone protection in cirrhotic patients. This audit aimed to evaluate how well the Oxford Hepatology Unit adhered to these guidelines. Methods and Materials: The notes of all patients with cirrhosis discharged from the Oxford Hepatology Unit between May - September 2012 were audited retrospectively to ascertain whether they had been prescribed Calcium and Vitamin D supplements on discharge and whether a bone mineral density (BMD) assessment had been performed. Depending on the BMD (T score on DEXA scan), it was then further examined whether the BMD had been repeated within 2 years or whether a diagnostic work-up had been performed with additional treatment and a repeat BMD after the end of the treatment period. Results: Fifty patients (n=50) with cirrhosis were discharged from the Oxford Hepatology Unit during the study period. The age range was 22-84 years. There were 28 (56%) with alcoholic cirrhosis, 6 (12%) with Hepatitis C, 1 (2%) with Hepatitis B, 3 (6%) with Non-alcoholic Steatohepatitis, 3 (6%) with Cryptogenic cirrhosis and 9 (18%) with other aetiologies. 6 (12%) were prescribed daily Calcium and Vitamin D on discharge and, of these, 2 (4%) had undergone BMD assessment. Of these 2 patients who had followed the initial stage of the guideline, neither had undergone a repeat BMD or a diagnostic work-up for osteoporosis. Additionally, 4 (8%) had undergone a BMD assessment but were not prescribed Calcium and Vitamin D supplements on discharge. Conclusions: No patient's management adhered fully to the British Society of Gastroenterology guidelines for preventing osteoporosis in patients with cirrhosis and only a minority were given Calcium and Vitamin D supplementation. More attention is required to this aspect of patient management to prevent the potentially devastating complications of osteoporosis in this vulnerable population of patients. Su1298

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Improved Outcomes in Hepatic Encephalopathy Using Rifaximin Monotherapy Compared to Rifaximin and Lactulose Combination Therapy Guy W. Neff, Steven L. Flamm, Kevin D. Mullen, Andrew C. Barrett, Enoch Bortey, Craig Paterson, William P. Forbes

Efficacy and Tolerability of Rifaximin in Hepatitis C Patients With Recurrent Hepatic Encephalopathy Guy W. Neff, Andrew C. Barrett, Enoch Bortey, Craig Paterson, William P. Forbes

Background and aims: Treatment protocols for hepatic encephalopathy (HE) will continue to evolve as the prevalence of cirrhosis increases worldwide. Rifaximin (RFX), a minimally absorbed, gut-targeted antibiotic, is often used in combination with nonabsorbable disaccharides such as lactulose (LAC). The objective of this analysis was to examine the comparative efficacy and tolerability of RFX alone vs. RFX+LAC, using data from 2 clinical trials of

Background and aims: Hepatitis C virus (HCV) is the most frequent cause of chronic liver disease. Many patients suffering from prolonged HCV develop cirrhosis that may lead to decompensation events, such as hepatic encephalopathy (HE). Rifaximin (RFX), a minimally absorbed, gut-targeted antibiotic, has demonstrated efficacy and safety in a heterogenous group of cirrhotic patients with recurrent HE, although the profile in specific subgroups of

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AGA Abstracts

AGA Abstracts

(49.7% versus 15.1%, OR 5.6, 95%CI 5.4 - 5.8), all p ,0.0001. After adjusting for age, sex and comorbidities, in patients with liver cirrhosis, CDI was independently associated with an increased LOS (adjusted mean difference, 5.2 days, 95% CI, 4.6 - 5.8), higher all-cause in-hospital mortality (OR 1.4, 95% CI, 1.3 - 1.5), and higher DTCF (3.9, 95% CI, 3.7 4.0), all p,0.0001. Conclusions: CDI is a major complication in liver cirrhosis patients, and is independently associated with poor outcomes, including increased LOS, in-hospital mortality and DTCF.