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Su1477 The Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Obscure Gastrointestinal Bleeding in Patients With Portal Hypertension
Su1478 Balloon-Assisted Enteroscopy in Portal Hypertensive Enteropathy Chung-Jyi Tsai, Madhusudhan R. Sanaka, KV Narayanan Menon, John J. Vargo Background & aim: The small bowel represents the largest part of gastrointestinal tract. Little is known about its mucosal changes in portal hypertension, which is mainly due to limited accessibility of small bowel by conventional endoscopy. Balloon-assisted enteroscopy (BAE) provides higher-resolution of imaging and allows both diagnosis and treatment in the small intestine. However, the role of BAE in portal hypertensive enteropathy (PHE) is not clear. The purpose of this study is to define BAE findings and its utility in patients with PHE. Methods: This study included 20 cirrhotic patients with PHE and 20 control patients, matched by age and gender, who underwent BAE. The indications were to investigate the cause of obscure gastrointestinal bleeding and to achieve a diagnosis in patients with abnormal video capsule endoscopy and/or abnormal radiological imaging. The presence of hepatic cirrhosis and portal hypertension was confirmed by compatible clinical and radiological findings. We evaluated the diagnostic yield and safety of BAE in PHE. For comparison, patients who did not have chronic liver disease or portal hypertension and underwent BAE for investigating obscure gastrointestinal blood loss or abnormal radiological small bowel imaging studies during the same period of time, matched by age and gender, were selected as controls. Results: 36 BAE procedures (28 antegrade and 8 retrograde BAE) were carried out in twenty patients (7 men and 13 women). Seven patients underwent both antegrade and retrograde BAE procedures. BAE revealed significantly abnormal small bowel mucosa including angiodysplasia-like lesions, friability, edema, erythema, and punctate hemorrhage in PHE. There was a significantly higher prevalence of small bowel angiodysplasia-like lesions (65%) in the cirrhotic patients as compared with that (10%) in the controls (p = 0.01). Among the patients with small bowel angiodysplasia-like lesions (65%), seven patients (35%) exhibited a diffuse pattern, which was not found in the control group (p = 0.008). We found that the small bowel angiodysplasia-like lesions were not related to patient's age, severity of chronic liver disease, splenomegaly, presence of ascites, presence of varices, or the presence of PHG, GAVE, or PHC. In addition, there was no relationship between small bowel angiodysplasia-like lesions and prior TIPS procedures. Conclusions: Our study has shown that the abnormal small bowel mucosal pattern observed during BAE, including angiodysplasia-like lesions, friability, edema, erythema, and punctate hemorrhage, may represent PHE. Small bowel angiodysplasia-like lesion, particularly, the diffuse form of the lesion, is the dominant mucosal abnormality in PHE. The occurrence of small bowel angiodysplasialike lesions may be unrelated to portal hypertension.
Su1476 Efficacy of Combined Balloon-Occluded Retrograde Transvenous Obliteration With Ethanol and Endoscopic Injection Sclerotherapy for Gastric Varices Wataru Sato, Takashi Goto, Kentaro Kamada, Shigetoshi Ohshima, Kouichi Miura, Takahiro Dohmen, Ryo Kanata, Toshitaka Sakai, Mitsuru Chiba, Yuko Sugimoto, Shinichiro Minami, Hirohide Ohnishi BACKGROUND & AIMS: Though many recent developments have improved the outcome of treatments for gastric varices (GVs), no consensus has been reached on the optimum treatment. We evaluated the efficacy and safety of balloon-occluded retrograde transvenous obliteration (B-RTO) with absolute ethanol with ethyl ester of iodinated poppy-seed oil fatty acid (ET+LPD) and simultaneous endoscopic injection sclerotherapy (EIS) with cyanoacrylate (CA) for GVs. METHODS & PATIENTS: From January 2007 to July 2012, 16 consecutive patients proven endoscopically high-risk GVs and treated by combined B-RTO and simultaneous EIS were enrolled. RESULTS: Patients were 12 males and 4 females. Average age of patients was 64.7 years old (42-82 years). In the course of GVs, 10 cases were alcoholic liver cirrhosis, 4 cases were HCV cirrhosis, a case was primary biliary cirrhosis, and a case was portal vein thrombus. In Child-Pugh score, 10 cases were grade A and 6 cases were grade B. GVs involved both the cardia and fundus were 12 cases, fundal varices were 2 cases, and cardiac varices were 2 cases. Flow vein was left gastric vein in 13 cases and posterior gastric vein in 3 cases. Drainage rout was splenorenal shunt in all cases. Average dose of ET+LPD was 12.0 (8-21) mL. Average dose of CA was 2.45 (1.4-4.2) mL. All of the complications were transient, and included abdominal pain (6/16), liver dysfunction (1/ 16), pleural effusion (1/16) and ascites (1/16). No major complications, such as renal failure, pulmonary embolism, or liver failure, occurred after the procedure. None of the patients have experienced rebleeding and recurrence of the GVs during 38.3 (8-74) months, average period of observation. CONCLUSIONS: Combined B-RTO with ET+LPD and EIS with CA is useful technique for GVs, because all of the complications were transient, there were no major complications, the volumes of sclerosant were a little, the catheter could be removed after 1 to 2 hours of balloon occlusion safely, and none of the patients have experienced rebleeding and recurrence of the GVs.
Su1479 Rifaximin Treatment in Hepatic Encephalopathy (HE) - Marked Reduction in Hospital Admissions and Hospital Bed Day Occupancy in a UK District General Hospital Anurag Goel, Neena Patel, Rebecca Blackwell, Sandra Crompton, Kieran J. Moriarty Background: Rifaximin is a minimally absorbed, gut-selective antibiotic, which is safe and effective in the prevention and treatment of Hepatic Encephalopathy (HE). However, it is expensive and there is debate regarding its cost effectiveness. Aim: The present study examines the impact of Rifaximin treatment on hospital admissions and hospital bed day occupancy in patients with recurrent HE, due to chronic liver disease. Methods: Medical records of all 30 hospital patients with HE, commenced on Rifaximin between November 2011 and May 2013, in a UK District General Hospital, were evaluated. Data were collected on patient demographics, MELD scores, number of hospital admissions, bed day occupancy for each admission, and concomitant therapy for HE. We compared the clinical features and diagnoses for the number of, and length of each hospital admission for the 6 months before, and 6 months after, commencing Rifaximin treatment. Results: 30 patients with HE (18 men, 12 women), median age 64 (Inter-quartile range (IQR) 51-67), were commenced on Rifaximin. 83% had Alcohol-related liver disease, 10% NASH and 7% Hepatitis C. Median MELD score was 15.5 (IQR 13.5-21). All patients were prescribed lactulose. Of the 30 patients, 5 died within 6 months of commencing Rifaximin. One patient was discontinued, due to noncompliance. 24 patients were included in the final analysis. We compared the outcomes for the 6 months prior to, and the 6 months after commencing Rifaximin treatment. Median hospital admissions were reduced from 2 admissions (IQR 1-3, Range 1-5) to 1 admission (IQR 0-2, Range 0-4, Wilcoxon p<0.05). Median number of bed days was reduced from 27.5 (IQR 16.0-35.3, Range 2-129) to 2.5 (IQR 0-23.5, Range 0-55, Wilcoxon p<0.05). No patient developed Clostridium difficile-associated diarrhea in the 6 months after commencing Rifaximin. Summary and Conclusions: In our hospital, the basic cost of a hospital bed day is £300 (480 US dollars). A 6 month course of Rifaximin costs £1688 (2700 US dollars). This study demonstrates that Rifaximin treatment in patients with HE, due to chronic liver disease, produced a marked reduction in hospital admissions and hospital bed day occupancy in a UK District General Hospital, with major cost savings and improved clinical outcomes.
Su1477 The Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Obscure Gastrointestinal Bleeding in Patients With Portal Hypertension Mina Shaker, Naim Alkhouri, Natalie Mansour, Mohammed Eyad Yaseen Alsabbagh, Nizar N. Zein Background: Obscure gastrointestinal bleeding (OGIB) is blood loss from an unknown source that persists or recurs after a negative initial endoscopic & radiological evaluation. This is not uncommon problem in patients with underlying cirrhosis and portal hypertension. We aimed to investigate the role of TIPS in managing OGIB in patients with portal hypertension. Methods: Retrospective medical records review of patients who presented with OGIB with underlying cirrhosis and portal hypertension and underwent TIPS placement as a last attempt to control the bleeding and minimize frequency of blood transfusions. Endpoints to assess effectiveness of TIPS were; 1) frequency of blood transfusions per month, 2) number of monthly packed red blood cells (PRBCs) transfused and 3) severity of the bleeding episodes reflected by lowest hemoglobin levels during a bleeding episode. Results: Total of 5 patients were identified to fulfill the definition of OGIB with underlying portal hypertension and underwent TIPS to control the recurrent bleeding episodes. All of them were females with mean age at time of TIPS was a 53.2±16.2 year. Etiology of cirrhosis was non alcoholic steatohepatitis (n= 2), alcoholic (n = 2) and cryptogenic (n = 1). EGD was normal repeatedly in three of them while it showed portal hypertensive gastropathy and gastric varix in one and a duodenal varix in another, neither showed any signs of bleeding. Colonoscopy was normal in two; showed non-bleeding hemorrhoids in two patients, and evidence of old blood without identified source in one. Small bowel evaluation was obtained in all patients using capsule endoscopy, push or double balloon enteroscopy. Images were unremarkable in three of them while showed old blood in one patient and old blood with distal small non-bleeding AVMs in another. Mean MELD score at time of TIPS was 14.6±4.6. Mean hepatic venous pressure gradient before TIPS insertion was 16.6±4 mmHg, and decreased to 5.4±1.5 after TIPS. As highlighted in table 1, TIPS placement was associated with significant reduction in monthly frequency and amount of PRBCs transfusion. Also there was significant reduction in severity of bleeding episodes. Conclusion: TIPS placement for OGIB in patients with portal hypertension significantly reduced frequency, severity of bleeding and amount of blood transfusions needed even when a source of blood loss could not be identified. More studies are needed for further evaluation of TIPS role in OGIB. Table 1
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AGA Abstracts
AGA Abstracts
Patients on beta-blockers or nitrates or previous surgery for portal hypertension were excluded. Several clinical, biological, ultrasonographic, with Doppler study, and endoscopic data were collected and used to calculate the APRI score (AST to platelets ratio index) and congestion index (CI) of the portal vein (calculated by dividing portal vein cross-sectional area by portal blood velocity). All statistical analysis was performed with SPSS v. 18.0 and a p value of less than 0,05 was considered statistically significant. The performance of the scores was evaluated by the area under the receiver operating characteristic curve (AUROC). Results: 36 patients were included, 64% males, with mean age 60±8,6 years. On On endoscopy, 12 patients (33%) had no EV, 14 patients (39%) had small EV and 10 patients (28%) had large EV. Portal vein diameter was higher in patients with EV than those without EV, while platelet count and portal blood velocity were lower, however with no statistical difference, (p>0,05). APRI score and CI were good predictors for the presence of EV (AUROC 0.74 and 0,635 respectively). The combination of the APRI score for liver fibrosis and CI as a surrogate of portal hypertension resulted in an even more powerful predictor of the presence of EV (AUROC 0,797) and the best cutoff value was 0,075 (sensitivity 79,2%, specificity 75%, positive predictive value 86,4% and negative predictive value 64,3). Conclusions: APRI score and CI of the portal vein are good noninvasive tests to predict esophageal varices. The combination of both models is even more powerful to be used as a method to select cirrhotic patients who need to undergo upper GI endoscopy.
Su1476 Efficacy of Combined Balloon-Occluded Retrograde Transvenous Obliteration With Ethanol and Endoscopic Injection Sclerotherapy for Gastric Varices Wataru Sato, Takashi Goto, Kentaro Kamada, Shigetoshi Ohshima, Kouichi Miura, Takahiro Dohmen, Ryo Kanata, Toshitaka Sakai, Mitsuru Chiba, Yuko Sugimoto, Shinichiro Minami, Hirohide Ohnishi BACKGROUND & AIMS: Though many recent developments have improved the outcome of treatments for gastric varices (GVs), no consensus has been reached on the optimum treatment. We evaluated the efficacy and safety of balloon-occluded retrograde transvenous obliteration (B-RTO) with absolute ethanol with ethyl ester of iodinated poppy-seed oil fatty acid (ET+LPD) and simultaneous endoscopic injection sclerotherapy (EIS) with cyanoacrylate (CA) for GVs. METHODS & PATIENTS: From January 2007 to July 2012, 16 consecutive patients proven endoscopically high-risk GVs and treated by combined B-RTO and simultaneous EIS were enrolled. RESULTS: Patients were 12 males and 4 females. Average age of patients was 64.7 years old (42-82 years). In the course of GVs, 10 cases were alcoholic liver cirrhosis, 4 cases were HCV cirrhosis, a case was primary biliary cirrhosis, and a case was portal vein thrombus. In Child-Pugh score, 10 cases were grade A and 6 cases were grade B. GVs involved both the cardia and fundus were 12 cases, fundal varices were 2 cases, and cardiac varices were 2 cases. Flow vein was left gastric vein in 13 cases and posterior gastric vein in 3 cases. Drainage rout was splenorenal shunt in all cases. Average dose of ET+LPD was 12.0 (8-21) mL. Average dose of CA was 2.45 (1.4-4.2) mL. All of the complications were transient, and included abdominal pain (6/16), liver dysfunction (1/ 16), pleural effusion (1/16) and ascites (1/16). No major complications, such as renal failure, pulmonary embolism, or liver failure, occurred after the procedure. None of the patients have experienced rebleeding and recurrence of the GVs during 38.3 (8-74) months, average period of observation. CONCLUSIONS: Combined B-RTO with ET+LPD and EIS with CA is useful technique for GVs, because all of the complications were transient, there were no major complications, the volumes of sclerosant were a little, the catheter could be removed after 1 to 2 hours of balloon occlusion safely, and none of the patients have experienced rebleeding and recurrence of the GVs.
Su1479 Rifaximin Treatment in Hepatic Encephalopathy (HE) - Marked Reduction in Hospital Admissions and Hospital Bed Day Occupancy in a UK District General Hospital Anurag Goel, Neena Patel, Rebecca Blackwell, Sandra Crompton, Kieran J. Moriarty Background: Rifaximin is a minimally absorbed, gut-selective antibiotic, which is safe and effective in the prevention and treatment of Hepatic Encephalopathy (HE). However, it is expensive and there is debate regarding its cost effectiveness. Aim: The present study examines the impact of Rifaximin treatment on hospital admissions and hospital bed day occupancy in patients with recurrent HE, due to chronic liver disease. Methods: Medical records of all 30 hospital patients with HE, commenced on Rifaximin between November 2011 and May 2013, in a UK District General Hospital, were evaluated. Data were collected on patient demographics, MELD scores, number of hospital admissions, bed day occupancy for each admission, and concomitant therapy for HE. We compared the clinical features and diagnoses for the number of, and length of each hospital admission for the 6 months before, and 6 months after, commencing Rifaximin treatment. Results: 30 patients with HE (18 men, 12 women), median age 64 (Inter-quartile range (IQR) 51-67), were commenced on Rifaximin. 83% had Alcohol-related liver disease, 10% NASH and 7% Hepatitis C. Median MELD score was 15.5 (IQR 13.5-21). All patients were prescribed lactulose. Of the 30 patients, 5 died within 6 months of commencing Rifaximin. One patient was discontinued, due to noncompliance. 24 patients were included in the final analysis. We compared the outcomes for the 6 months prior to, and the 6 months after commencing Rifaximin treatment. Median hospital admissions were reduced from 2 admissions (IQR 1-3, Range 1-5) to 1 admission (IQR 0-2, Range 0-4, Wilcoxon p<0.05). Median number of bed days was reduced from 27.5 (IQR 16.0-35.3, Range 2-129) to 2.5 (IQR 0-23.5, Range 0-55, Wilcoxon p<0.05). No patient developed Clostridium difficile-associated diarrhea in the 6 months after commencing Rifaximin. Summary and Conclusions: In our hospital, the basic cost of a hospital bed day is £300 (480 US dollars). A 6 month course of Rifaximin costs £1688 (2700 US dollars). This study demonstrates that Rifaximin treatment in patients with HE, due to chronic liver disease, produced a marked reduction in hospital admissions and hospital bed day occupancy in a UK District General Hospital, with major cost savings and improved clinical outcomes.
Su1477 The Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Obscure Gastrointestinal Bleeding in Patients With Portal Hypertension Mina Shaker, Naim Alkhouri, Natalie Mansour, Mohammed Eyad Yaseen Alsabbagh, Nizar N. Zein Background: Obscure gastrointestinal bleeding (OGIB) is blood loss from an unknown source that persists or recurs after a negative initial endoscopic & radiological evaluation. This is not uncommon problem in patients with underlying cirrhosis and portal hypertension. We aimed to investigate the role of TIPS in managing OGIB in patients with portal hypertension. Methods: Retrospective medical records review of patients who presented with OGIB with underlying cirrhosis and portal hypertension and underwent TIPS placement as a last attempt to control the bleeding and minimize frequency of blood transfusions. Endpoints to assess effectiveness of TIPS were; 1) frequency of blood transfusions per month, 2) number of monthly packed red blood cells (PRBCs) transfused and 3) severity of the bleeding episodes reflected by lowest hemoglobin levels during a bleeding episode. Results: Total of 5 patients were identified to fulfill the definition of OGIB with underlying portal hypertension and underwent TIPS to control the recurrent bleeding episodes. All of them were females with mean age at time of TIPS was a 53.2±16.2 year. Etiology of cirrhosis was non alcoholic steatohepatitis (n= 2), alcoholic (n = 2) and cryptogenic (n = 1). EGD was normal repeatedly in three of them while it showed portal hypertensive gastropathy and gastric varix in one and a duodenal varix in another, neither showed any signs of bleeding. Colonoscopy was normal in two; showed non-bleeding hemorrhoids in two patients, and evidence of old blood without identified source in one. Small bowel evaluation was obtained in all patients using capsule endoscopy, push or double balloon enteroscopy. Images were unremarkable in three of them while showed old blood in one patient and old blood with distal small non-bleeding AVMs in another. Mean MELD score at time of TIPS was 14.6±4.6. Mean hepatic venous pressure gradient before TIPS insertion was 16.6±4 mmHg, and decreased to 5.4±1.5 after TIPS. As highlighted in table 1, TIPS placement was associated with significant reduction in monthly frequency and amount of PRBCs transfusion. Also there was significant reduction in severity of bleeding episodes. Conclusion: TIPS placement for OGIB in patients with portal hypertension significantly reduced frequency, severity of bleeding and amount of blood transfusions needed even when a source of blood loss could not be identified. More studies are needed for further evaluation of TIPS role in OGIB. Table 1
S-479
AGA Abstracts
AGA Abstracts
Patients on beta-blockers or nitrates or previous surgery for portal hypertension were excluded. Several clinical, biological, ultrasonographic, with Doppler study, and endoscopic data were collected and used to calculate the APRI score (AST to platelets ratio index) and congestion index (CI) of the portal vein (calculated by dividing portal vein cross-sectional area by portal blood velocity). All statistical analysis was performed with SPSS v. 18.0 and a p value of less than 0,05 was considered statistically significant. The performance of the scores was evaluated by the area under the receiver operating characteristic curve (AUROC). Results: 36 patients were included, 64% males, with mean age 60±8,6 years. On On endoscopy, 12 patients (33%) had no EV, 14 patients (39%) had small EV and 10 patients (28%) had large EV. Portal vein diameter was higher in patients with EV than those without EV, while platelet count and portal blood velocity were lower, however with no statistical difference, (p>0,05). APRI score and CI were good predictors for the presence of EV (AUROC 0.74 and 0,635 respectively). The combination of the APRI score for liver fibrosis and CI as a surrogate of portal hypertension resulted in an even more powerful predictor of the presence of EV (AUROC 0,797) and the best cutoff value was 0,075 (sensitivity 79,2%, specificity 75%, positive predictive value 86,4% and negative predictive value 64,3). Conclusions: APRI score and CI of the portal vein are good noninvasive tests to predict esophageal varices. The combination of both models is even more powerful to be used as a method to select cirrhotic patients who need to undergo upper GI endoscopy.