Deranged Liver Function Tests Research Articles

An Observational Study on Clinical and Liver Profile in Dengue Cases at a Tertiary Care Hospital in South India

Introduction: Dengue fever, the most common arthropod-borne viral illness in humans, is caused by the dengue virus, which is one of the world's most dangerous tropical infectious diseases. Dengue fever epidemics have been reported in India on various occasions. Liver involvement is known to occur in children with dengue fever. Liver dysfunction ranges from mild injury with elevated transaminase activity to severe injury with liver cell failure. Liver dysfunction varies in severity depending on the type of clinical presentation of dengue fever, but it is more common in children with severe dengue fever. Hence the following study was conducted to find out the range of liver dysfunction in children with dengue fever. Material and Methods: The study was conducted in a tertiary care hospital over a period of one year in a total of 100 patients who are serologically positive for dengue fever. Results: Patients were classified as dengue fever (DF)-48%, and dengue hemorrhagic fever (DHF)-52%. Liver function tests AST, ALT and ALP, bilirubin and albumin were deranged in children with dengue hemorrhagic fever. The mean total bilirubin, serum albumin, AST, ALT, ALP, PT, aPTT, INR, BT, CTwere 1.7 mg/dl, 2.9 mg/dl, 382 U/L, 240 U/L, 254.4 U/L, 39.8s, 56.8s, 1.5, 4.6 minutes and 2.5 minutes respectively. Derangement of liver function tests was significant among DHF as compared to DF. Conclusion: Liver dysfunction was very common in all forms of dengue fever, significantly deranged among DHF. AST levels raising significantly when compared to ALT.

UTILITY OF FIBROSCAN IN ULCERATIVE COLITIS?

Abstract INTRODUCTION Ulcerative colitis (UC) is associated with liver disorders due to various etiologies. Some are diagnosed on basis of deranged liver function tests, imaging, and/or histology. Data on fibroscan in UC is scarce. A previous study had shown no significant differences in liver stiffness (LS) on fibroscan between the inflammatory bowel disease (IBD) cases and non-IBD control groups. AIMS We aimed to evaluate UC patients for the prevalence of clinically significant liver disease which is defined by an increased liver stiffness measurement (LS) ≥8 kPa using transient elastography (TE) and to evaluate the effect of UC treatment on liver stiffness at 6 months. METHODS All individuals (UC and non-IBD) had their LS recorded using FibroScan® (EchoSense, Paris, France) by a single-blinded operator trained in TE. RESULTS 120 UC patients and 60 non-IBD control subjects were included. All demographic variables were comparable between the two groups. Thirty-five UC patients (29.9%) had an LS over 8 kPa at baseline and 24 had persistently elevated LS at 6 months after treatment. This suggests a significant reduction in TE values among 31.4% of cases after starting treatment. Four patients had LS in the cirrhotic range (>14 kPa). On fibroscan, difference in LS (mean ± standard deviation in group UC = 7.57 ± 2.77 vs non-IBD group = 5.37 ± 2.32, p < .001). CONCLUSION TE in UC at the time of diagnosis can detect clinically significant fibrosis. With treatment, TE values regress below <8 kpa in a significant proportion of patients.

UTILITY OF FIBROSCAN IN ULCERATIVE COLITIS?

Ulcerative colitis (UC) is associated with liver disorders due to various etiologies. Some are diagnosed on basis of deranged liver function tests, imaging, and/or histology. Data on fibroscan in UC is scarce. A previous study had shown no significant differences in liver stiffness (LS) on fibroscan between the inflammatory bowel disease (IBD) cases and non-IBD control groups.

Pattern of liver function test variations in COVID-19 infection & its clinical significance: A study from a dedicated COVID-19 tertiary care centre from India.

Coronavirus disease 2019 (COVID-19) affects respiratory, gastrointestinal, cardiovascular and other systems disease. Studies describing liver involvement and liver function test (LFT) abnormalities are sparse from our population. This study was undertaken to estimate the LFT abnormalities in patients with COVID-19 in a tertiary care set up in India. In this retrospective study conducted at a tertiary care centre in Mumbai, India, all consecutive patients with proven COVID-19 by reverse transcriptase-PCR from March 23 to October 31, 2020 were enrolled. Of the 3280 case records profiled, 1474 cases were included in the study. Clinical characteristics, biochemical parameters and outcomes were recorded. Overall 681 (46%) patient had deranged LFTs. Hepatocellular type of injury was most common (93%). Patients with deranged LFTs had more probability of developing severe disease (P<0.001) and mortality (P<0.001). Advanced age (P<0.001), male gender (P<0.001), diabetes mellitus (P<0.001), lower oxygen saturation levels at admission (P<0.001), higher neutrophil-lymphocyte ratio (P<0.001), history of diabetes mellitus and cirrhosiss were associated with deranged LFTs. Acute liver injury was seen in 65 (4.3%) cases on admission and 57 (3.5%) cases during hospital stay. On multivariate analysis for predicting mortality, age >60 yr serum creatinine >2 mg%, PaO2/FiO2 ratio ≤200 and raised AST >50 IU/l (OR: 2.34, CI: 1.59-3.48, P<0.001) were found to be significant. In COVID-19, LFT abnormalities were common, and derangement increased as severity progressed. The presence of deranged LFT worsens the clinical outcome and predicts in-hospital mortality.

Liver injury in COVID-19: prevalence and association with patient-centered outcomes- an analysis of the international severe acute respiratory and emerging infection consortium (ISARIC) database

Background and Aim: Extrapulmonary manifestations are common in COVID-19 and elevations in components of liver function tests have been reported. Multiple mechanisms may contribute to these derangements. Using a large clinical dataset, we evaluated the prevalence and severity of derangements in liver function tests and their association with patient-centered outcomes. Methods: Using information available on the International Severe Acute Respiratory and emerging Infection Consortium database, we included patients with laboratory confirmed or suspected SARS-COV2 infection admitted to the hospital. The main exposure was the baseline liver function and main outcomes were hospital mortality, admission to an intensive care unit (ICU), receipt of oxygen therapy, non-invasive ventilation (NIV) or invasive ventilation, inotropes/vasopressors, renal replacement therapy, and the durations of hospital and ICU stay. We used generalized linear models to determine the association between exposure variables and outcomes. Results: From 708052 patients in the database, we included 17531 after excluding those with missing baseline information on liver function tests and outcomes. Nearly14% of patients had stage 2 liver injury at baseline and over 75% of the cohort had stage 3 liver injury. Stage 2 and 3 were associated with higher odds of mortality [ Stage 2- OR 1.82 (95%CI: 1.47-2.25) p value<0.001 and Stage 3- OR 1.50 (95%CI: 1.24-1.82) p value<0.001]. Stage 2 was also associated with higher odds of mechanical ventilation [ Stage 2- OR 1.6 (95%CI:1.34-2.06) p value<0.001] and a higher odds of ICU admission [ OR 1.13 (95%CI:0.95-1.35) p value=0.17]. For stage 3, this association with a higher probability of mechanical ventilation [OR 0.84 (95% CI:0.69-1.02) p value 0.08] and ICU admission [OR 0.24 (95% CI:0.21-0.28) p value<0.001)] was not observed. Conclusion: Liver function abnormalities are common among COVID-19 patients and are associated with worse clinical outcomes.

Correlation between parasitemia and different complications of malaria – The clinical outlook

Background: Malaria is one of the most severe public health problems worldwide. India contributes a substantial burden of malaria. It can cause several complications. Aims and Objectives: This study was conducted to determine the association of parasitemia of current malaria with age of patients, hemoglobin level, liver function test (LFT), platelet count, previous history of malaria, and relapse/recrudescence of malaria up to 1 year. Materials and Methods: An observational study conducted in hospital settings included thin and thick smear preparation with Leishman’s staining to determine the parasitemia as per the WHO guidelines from the blood samples of 280 malaria parasite dual antigen (MPDA) kit positive patients and their details were taken during study period of 2 years. Hemoglobin, LFT, and platelet count were tested and they were correlated with parasitemia. The previous history of malaria was taken and follow-up was done up to 1 year for relapse/recrudescence and their association with parasitemia in current disease was evaluated. Statistical tool R was used for data analysis. Results: Age group 20–40 years was most commonly affected with maximum mean percentage parasitemia. Higher parasitemia was associated with higher grade of anemia, LFT derangement, and thrombocytopenia. Disease severity was maximum for mixed infection followed by falciparum and vivax malaria. About 9.28% of patients with the previous history of malaria developed lower parasitemia in current infection. Relapse rate in vivax malaria –2.325% and recrudescence rate in falciparum malaria–12.5%. Conclusion: Malaria parasitemia should be reported routinely as it carries prognostic importance.

An Unusual Case of Haemobilia

Introduction: Haemobilia a rare cause of acute abdomen presents with Quincke’s triad: right upper quadrant pain, jaundice and gastrointestinal bleeding. Hemorrhagic cholecystitis is a rare cause of haemobilia. Case Presentation: A 30 year-old gentleman presented with right upper quadrant pain for 5 days, associated with fever, vomiting and jaundice. Patient was pale and icteric and right hypochondrium was tender with palpable gallbladder. His hemoglobin was 7.7 gm/dl with deranged liver function test (LFT). Abdominal ultrasonography demonstrated edematous and contracted gallbladder wall with echogenic lesion within the lumen. Computed tomography (CT) scan of abdomen revealed a mildly distended gallbladder, bilateral intrahepatic biliary radical dilatation and dilated common bile duct (CBD) with hyperdense sludge in the gallbladder and CBD. Patient developed per rectal bleeding on the fourth day of admission. Upper GI endoscopy showed blood pooling from ampulla of Vater. Abnormal blushing of gallbladder wall with abnormal enhancement at neck of gallbladder arising from cystic artery, was noted on angiography, suggestive of hemorrhagic cholecystitis. During surgery thickened gallbladder wall, engorged cystic artery and blood mixed with clot was seen in the gallbladder lumen. Cholecystectomy with choledochoscopy was performed. Choledochoscopy demonstrated normal extrahepatic biliary channel. Post-operative period was uneventful, blood hemoglobin level was static and LFT improved. Patient was discharged on fourth post-operative day. Conclusions: Haemobilia can be fatal condition hence mandates urgent diagnosis and treatment. Hemorrhagic cholecystitis is not to be forgotten as a cause of haemobilia.

Maternal and Foetal Outcomes in Early and Late Intrahepatic Cholestasis of Pregnancy and their Association with Maternal Serum Bile Acid Levels: A Prospective Cohort Study

Introduction: Intrahepatic Cholestasis of Pregnancy (IHCP) also known as recurrent jaundice of pregnancy is a pregnancy specific benign liver disease presenting in the second and third trimester of pregnancy and is associated with increased perinatal morbidity and mortality. Aim: To study and compare the maternal and foetal outcomes in early and late IHCP and to evaluate the Serum Bile Acid (SBA) levels and its association with adverse maternal and foetal outcomes at a tertiary care hospital in New Delhi. Materials and Methods: This was an observational, prospective cohort study, conducted during September 2018 to March 2020 in the Department of Obstetrics and Gynaecology, ESI PGIMSR, Basaidarapur, New Delhi, India. A total of 196 antenatal women with clinical signs and symptoms suggestive of IHCP with deranged liver function tests were grouped on the basis of period of gestation as early IHCP ( diagnosed ≤32 weeks) comprising of 40 women, and late IHCP (diagnosed &gt;32 weeks). comprising of 156 women. They were further divided into four groups A, B, C, D on the basis of the maternal Serum Bile Acid (SBA) levels between 10-19 mmol/L, 20-29 mmol/L, 30-39 mmol/L and ≥ 40 mmol/L, respectively. Maternal outcomes such as caesarean rates, instrumental delivery, postpartum haemorrhage, blood transfusion, hospital stay and foetal outcomes such as preterm birth, birth weight, Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score, Neonatal Intensive Care Unit(NICU) admission, intrauterine foetal demise and neonatal death were noted and association was found by Pearson's chi-square test or Fisher’s-exact test. Results: A total of 196 women(mean age 25.64±3.8 years, 40 in Early IHCP and 156 in late IHCP) were analysed for foetomaternal outcomes and were further divided into group A (n=138),group B (n=27), group C (n=13), and group D (n=18) on basis of maternal SBA. Adverse maternal outcomes such as high caesarean rates, instrumental delivery, postpartum haemorrhage, blood transfusion, prolonged hospital stay and adverse foetal outcomes such as preterm birth, low birth weight, low APGAR score, NICU admission, intrauterine foetal demise and neonatal death was more common in early IHCP in comparison to late IHCP (p &lt; 0.05). It was also observed that risk of adverse foetomaternal outcomes increased with increasing maternal SBA levels with maximum adverse outcomes seen in women with SBA ≥30mmol/L i.e., Group C and D (p&lt;0.05). Conclusion: Women diagnosed with IHCP at an earlier gestation ≤ 32 weeks have more propensity towards adverse foetomaternal outcomes and significantly higher rate of adverse outcome was observed in patients with SBA level ≥30mmol/L.

Predictive Factors for Preoperative Diagnosis and Management of Cystic Liver Lesions: A Six Years Single Centre Experience

Introduction: Surgical management differs for different cystic lesions of liver. Various clinical, biochemical and radiological features are specific to a particular cystic liver lesion pathology and it’s associated complications. Preoperative diagnosis helps to select appropriate surgical approach and tailoring appropriate management. Aim: To evaluate the clinical, biochemical, radiological predictive factors to differentiate between hydatid diseases, simple cyst of liver and biliary cystadenoma. Also to evaluate appropriate management for hydatid disease with cystobiliary communication. Materials and Methods: A retrospective study was conducted at Institute of Surgical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India. Data were collected from 65 patients including 44 patients of hydatid disease, 13 patients of simple cyst, and 8 patients of biliary cystadenoma using a maintained database from January 2014 to December 2019 with a follow up period up to December 2020 (mean follow up of 47.06±24.37 months). Various parameters like presence of cholangitis, deranged liver function test, number of cystic lesion, presence of calcification, presence of septation with or without enhancement were assessed. Data were statistically analysed using Analysis of Variance (ANOVA) and Chi-square test. Results: There were 44 (67.69%) females and 21 (32.31%) males in this study with mean age of 50.44±12.23 years. Though multiseptation was associated with 27 (61.36%) of hydatid cysts and 1 (7.69%) of atypical simple cyst, it was more specifically present in biliary cystadenoma 8 (100%). Presence of daughter cyst (n=24, 54.55%) in hydatid disease and multilobulated appearance (n=5, 62.5%) in biliary cystadenoma were strong predictors of diagnosis. Radical surgery was associated with significantly less postoperative bile leak than conservative surgery in patients of hydatid disease with cystobiliary communication. Conclusion: Predictive factors can help to make preoperative diagnosis correctly. Radical surgery reduces postoperative bile leak in patients of hydatid disease with cystobiliary communication.

Management of Psychiatric Disorders in Patients with Hepatic and Gastrointestinal Diseases.

Management of Psychiatric Disorders in Patients with Hepatic and Gastrointestinal Diseases.

Tuberculosis presenting as immune thrombocytopenia

A 19-year-old male presented with chief complaints of generalised weakness and unintentional weight loss from 50 Kg to 45 Kg within a span of 1 month. He complained of fever for 15 days and had developed petechiae over bilateral upper limbs and bilateral subconjunctival haemorrhage. Laboratory investigations done elsewhere showed platelet count of 10,000/mm3. On further investigation, Widal test, dengue serology, and smear examination for malarial parasite, antinuclear antibodies, and viral markers were negative. Abdominal ultrasonography showed multiple conglomerative enlarged lymph nodes in peripancreatic, peripatetic and paracaval, with few of them showing necrosis and loss of hilum and minimal ascites. Bone marrow examination showed megakaryocytic hyperplasia features, suggestive of immune thrombocytopenic purpura (ITP). No improvement in the platelet count was noted with intravenous methylprednisolone. On examination, the patient had ecchymotic patches over bilateral upper limbs and bilateral subconjunctival haemorrhages. Bilateral supraclavicular lymph nodes were palpable, non-tender, mobile, measuring 3 cm × 3 cm in the right side and 2 cm × 2 cm in the left side and firm in consistency. Cervical lymph node biopsy showed caseous necrotising granulomatous inflammation. Contrast-enhanced computed tomography neck, chest and abdomen showed multiple enlarged conglomerated heterogeneous enhancing lymph nodes with central non-enhancing areas s/o necrosis noted in the neck, mediastinum and abdomen. Tuberculin skin test (Mantoux test) revealed induration of 20 mm. The patient was started on eltrombopag, and four doses of intravenous immunoglobulin were given without improvement. The patient was started on liver-friendly anti-tuberculosis treatment in view of deranged liver function tests with isoniazid, rifampicin, ethambutol and levofloxacin and later pyrazinamide was added. The platelet count increased after 1 month of ATT to 40,000, and after 2 months, the count was 100,000/mm3.

P-EGS29 Is an ambulatory emergency general surgery management pathway of biliary disease more cost effective than a traditional approach? A matched case series study

Abstract Background Patients presenting with biliary colic with or without deranged liver function tests (LFT’s) requiring surgery have traditionally been managed as inpatients or on an elective basis. Emergency surgery has previously been associated with higher costs in comparison to outpatient, elective management. Methods Thirteen patients presenting as an emergency with a diagnosis of cholecystitis, with or without deranged LFTs, who underwent different patient pathways resulting in laparoscopic cholecystectomy were identified randomly over 1 month period. They were then matched into groups to compare elective, inpatient and ambulatory care pathway management for patients with similar demographics and clinical picture. The costs of each patient’s journey, from acute presentation to discharge following laparoscopic cholecystectomy was calculated in conjunction with the patient level information costing team (PLICS). Results Three matched groups of patients were identified: 50-60M, 65-75F with normal LFTs, 60F with obstructive LFT’s. Each patient underwent an ultrasound scan of the upper abdomen, laparoscopic cholecystectomy with additional investigations dependent on the group and clinical picture. In each group, when elective, emergency inpatient or ambulatory care pathways were compared there was a consistent cost difference. The order from most expensive to cheapest was: inpatient management, elective management, ambulatory care. The difference in costs was primarily linked with emergency department assessment and inpatient bed stays with cost saving of up to £5000 in one group when comparing inpatient stay to ambulatory emergency care management. Conclusions The use of an ambulatory emergency general surgical pathway for patients with a variety of biliary colic presentations including those with deranged LFT’s is economically comparable and potentially advantageous to more traditional and established patient management pathway options in a number of patient demographics across age, gender and pathology. An ambulatory care pathway, when developed and used correctly can provide significant cost savings to a wide range of patients.

P-BN16 Gallbladder agenesis in a gentleman presenting with biliary sepsis: a case report and review of literature

Abstract Background Gallbladder agenesis (GBA) is a well-recognised, yet rare embryological malformation, that is thought to stem from a failure of the gallbladder and cystic duct to bud from the common bile duct in the 5th week of gestation. The anomaly has an estimated incidence of 10-65 per 100 000 and is often an incidental finding. A quarter of those affected are symptomatic, often presenting in a similar manner to cholecystitis or choledocholithiasis. There is a lack of awareness and guidance on its investigation and management, making GBA a diagnostic challenge, which often leads to unnecessary high-risk surgical exploration. Methods A 64-year-old man presented with right upper quadrant abdominal pain, fevers, jaundice and persistent vomiting. On examination he was confused, visibly jaundiced and septic with deranged liver function tests. An initial ultrasound scan of the abdomen revealed dilated common bile ducts, with no evidence of choledocholithiasis, however, a gallbladder could not be identified. Magnetic resonance cholangiopancreatography confirmed a ‘post-cholecystectomy’ picture, despite no history of abdominal surgery. This led us to the diagnosis of gallbladder agenesis. Results There are no dedicated guidelines regarding the investigation and management of GBA. Efforts have been made to stratify the diagnostic imaging of GBA. Malde et al suggest that if the gallbladder is not visualised on USS, the next most appropriate investigations in order of accuracy are MRCP, CT and ERCP, respectively. Interestingly, they further suggest that if results of imaging remain inconclusive, they should be repeated again once the acute phase of the illness or symptoms have resolved. Inadvertently, this suggestion was applied in our case, as the patient underwent a repeat MRCP following the resolution of his acute symptoms. In our case, MRCP allowed an effective final diagnosis, avoiding unnecessary investigations and exploratory surgery. It also provided a detailed anatomical picture, excluding the possibility of an ectopic gallbladder. Conclusions The present case accentuates the importance of non-invasive imaging such as MRCP in appropriately diagnosing this phenomenon and avoiding unnecessary operative exploration.

P-EGS23 Efficacy of Percutaneous Cholecystostomy and Timing of Tube Removal: An Observational Study from a busy District General Hospital

Abstract Background Percutaneous cholecystostomy (PC) has traditionally been reserved for high-risk patients with cholecystitis who are unfit for surgical intervention, or as a temporizing measure for septic biliary patients to relieve sepsis and symptoms. However, there are currently no guidelines regarding the timing of tube removal following PC. The aim of this study is to evaluate the timing of tube removal following resolving inflammation and patency of biliary ducts, and its associated risks. Methods Patient notes and imaging reports were retrospectively reviewed from those who underwent percutaneous cholecystostomy from January 2015-Dec 2020. Data collected included demographic details, symptom presentation, requirement of ITU admissions, details of cholecystostomy, post-operative complications from the tube, outcomes following PC, and mortality rates within 30 days of the procedure. Patients were graded by their severity of their cholecystitis according to the 2018 Tokyo Guidelines, and these were correlated with morbidity and mortality outcomes within 1 year of the procedure. Results There were 55 females and 65 males, with a mean age of 75.2 years (range 45-96 years). Approximately 45% of patients were diabetic and had comorbidities. On presentation, 54% (65/120) patients had elevated inflammatory markers (WCC/CRP), and 20% of patients had associated deranged liver function tests. Majority of patients had moderate or severe acute cholecystitis, with over 25% (31/120) of patients presenting with sepsis, and 6 required admission to intensive care. The median time from diagnosis of acute cholecystitis to percutaneous cholecystostomy was 8.5 days (range 1-64 days). Tube removal was performed after a median time of 31 days (range 1-142 days). Morbidity rate was observed to be 8-10%, comprising of complications such as tube displacement, leakage around the drain, bleeding and liver abscesses. Only 18.3% (22/120) of patients were deemed to be fit for further surgical intervention, of which 13 of those underwent a cholecystectomy thereafter. Unsurprisingly, 38% of these patients had recurrent biliary symptoms, and a 30% mortality rate. Conclusions Percutaneous cholecystostomy is a safe option in high-risk surgical patients for symptom relief, and is a crucial step in temporizing and de-escalating sepsis. However, this study suggests that timing of cholecystostomy removal is variable, and is associated with high morbidity. Consideration needs to be given to shorten the time to tube removal, to minimise risks, if certain criteria are met to ensure safety and efficacy.

A rare presentation of systemic lupus erythematosus with lupus hepatitis

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation and the presence of circulating autoantibodies directed against self-antigens. Prevalence of SLE in children and adolescents is 1-6 per 100,000 population. Liver dysfunction occurs in approximately in 50-60% of the patients with SLE.And the incidence of lupus hepatitis in diagnosed SLE patients is 9.3%. We are reporting a case of 11-year-old female child who presented with fever, skin rashes, oral ulcers, irritability and positive antinuclear antibody (ANA) with deranged liver function test (LFT) in the form of elevated transaminases, bilirubin level and altered coagulation profile. Hepatitis serology was negative, with low C3 levels, diagnosed as SLE with lupus hepatitis with lupus nephritis stage IV with psychosis. Clinical improvement along with improvement in terms of laboratory findings was seen on corticosteroids therapy. It is important to differentiate lupus hepatitis from autoimmune hepatitis (AIH) as AIH presents similar to lupus hepatitis, has poor prognosis. While lupus hepatitis being rare cause for mortality in patients with SLE has good response with early intervention with corticosteroids therapy.

A study of dengue encephalitis with laboratory and clinical parameters in Tertiary Center of North India.

Introduction:With expanding clinical spectrum of dengue fever, encephalitis has been documented with increasing frequency. The aim of this study was to investigate the incidence, predictors and prognostic factors of dengue encephalitis (DE) in the setting of dengue viruses (DENV) infection.Materials and Methods:A hospital-based prospective cohort study was carried out, which included laboratory confirmed dengue positive cases. All dengue cases were categorized into nonencephalitis or encephalitis group. We estimated DE incidence and analyzed clinical, laboratory and neuroimaging data on admission, discharge and follow-up for 3 months to assess its predictors and prognostic factors.Results:Out of the enrolled 540 confirmed dengue cases, 27 patients had DE, representing 5% incidence. Two third of the DE patients were 20 years of age or younger, with male preponderance (81.5%). Fever, headache, and altered sensorium were present in >90% on admission. Significant predictors of encephalitis were mean body temperature during fever (P < 0.001), headache (P = 0.015), secondary dengue (P = 0.005), dengue hemorrhagic fever (P < 0.001), elevated hematocrit (P < 0.001), liver function test derangement (P < 0.05), and low platelet count (P = 0.006). Poor outcome factors for DE patients were prolonged duration of fever (P < 0.001), seizure (P = 0.002), and cerebrospinal fluid (CSF) DENV positivity (P = 0.049). One third patients died and the remainder of them recovered. An increasingly higher incidence rate with high mortality of DE is reported.Conclusion:Clinical and laboratory parameter along with DENV positivity in CSF can predict and prognosticate dengue encephalitis.

SP6.1.3 Readmissions After Cholecystectomy in a Tertiary UK Center: Incidence, Causes and Burden

Abstract Context Although cholecystectomy is a widely performed procedure, postoperative readmissions place a heavy burden on healthcare facilities. Aims This study assesses the incidence, causes and burden of 30-day readmissions after cholecystectomy in a tertiary UK center. Settings and Design University Hospital, Retrospective Cohort Study. Methods and Material Information was obtained from our prospectively maintained database and hospital’s computerised records. Statistical analysis The encounters are expressed in numbers and percentages. The hospital stay, BMI and age are expressed in mean, standard deviation (SD), min-max and median. Microsoft Excel® was used to calculate the means, SD, min-max and median. Results Out of the 1,140 cholecystectomies performed over this time, there were 75 true readmissions and 29 revisits; thus, the actual readmission rate is 6.58%. Non-specific abdominal pain ± deranged liver function tests (LFT) is the most common cause of readmission at (38;36.54%) cases, followed by (18;17.31%) wound infections and (12;11.54%) collections/bile leaks/abscess. This costed the center 93 scans; 30 procedures and 295 days of hospital stay. Conclusions Non-specific abdominal pain ± deranged LFT is the most common cause of readmissions/revisits in the center. Readmissions after a cholecystectomy are a significant encumbrance.

EP.FRI.147 Abdominal Variant Lemierre’s Syndrome: A Case Study and literature review

Abstract Background Lemierre’s Syndrome (LS) is a rare condition with a prevalence of around 0.6-2.3 cases per million of population. Typically, LS starts with a Fusobacterium Necophorum oropharyngeal infection which spreads rapidly causing infective thrombophlebitis, classically of the internal jugular. This is a life-threatening condition which left untreated has a mortality of 90%. In less than 10% of LS cases thrombophlebitis occurs outside of the internal jugular vein. These atypical presentations can result in delay in diagnosis thus treatment and hence have an increased risk of mortality. Case Report Here we present a case report of a patient with Abdominal Variant Lemierre’s syndrome. A 47-year-old female with no past medical history was admitted to the emergency department with severe epigastric abdominal pain. The patient was stable, her National Early Warning Score (NEWS) was 2, blood tests on admission showed thrombocytopenia (Hb 121g/dl, Platelets 50x109/l, WCC 17.1x1012/l), raised CRP 299mg/l and deranged Liver Function Tests (Total protein 56g/l, Bilirubin 45mg/dl, ALT 94U/L, AlkPhos- 121U/L). A Venous Blood Gas was abnormal with Lactate 2.1mmol/l. A sepsis pathway was initiated. The blood cultures grew Fusobacterium Necophorum. MRI Imaging confirmed the diagnosis of Abdominal Variant Lemierre’s Syndrome. Haematology and Microbiology were consulted. The patient was treated with antibiotics and anticoagulation and was discharged 29 days later, she has made a full recovery. Conclusion This case highlights the importance of sepsis vigilance in Acute General Surgery admissions and emphasises that multidisciplinary teamwork is essential to achieve effective and prompt treatment for patients.

O23 A series of catastrophic events

Case report - IntroductionCatastrophic antiphospholipid syndrome (CAPS) is a rare, life-threatening disease occurring in up to 1% of antiphospholipid syndrome (APS) cases. It was first defined in 1992 and remains a difficult to treat entity with a mortality rate of 37%. We describe a patient with systemic lupus erythematosus (SLE) and CAPS presenting with simultaneous multi-organ injuries who was successfully managed with ‘triple’ therapy including cyclophosphamide.Case report - Case descriptionA 42-year-old female presented to her local hospital with chest pain and worsening vision. She had a background of SLE, triple antibody-positive APS (previous DVT, pregnancy loss and strokes), hypertension, a metallic mitral valve, a previous myocardial infarction and pre-existing visual impairment due to a prior intra-cerebral bleed related to anticoagulation. Examination revealed a faint malar rash, cortical blindness and long tract neurological signs. Her ECG showed ischaemic changes and the admission troponin was significantly raised (3773ng/L). An echocardiogram showed new left ventricular dysfunction and a subsequent cardiac MRI was in keeping with coronary artery disease. Investigations showed an acute kidney injury, newly deranged liver function tests and a raised INR (>11, with no bleeding). Complement was normal with a low dsDNA titre. Urinalysis revealed proteinuria and a protein creatinine ratio measured 176mg/mmol. MRI diffusion weighted brain imaging showed acute bilateral occipital and left fronto-parietal infarcts. She had symptoms of a lupus flare with arthralgia and a butterfly facial rash. COVID-19 PCR tests were negative and she had not been recently vaccinated. She was diagnosed with CAPS and transferred to St Thomas’ hospital intensive care.On arrival, she received 1mg intravenous vitamin K followed by triple therapy for CAPS: an unfractionated heparin infusion, oral prednisolone 40mg daily, 5 days of plasma exchange and, given her background of SLE, she was treated with intravenous cyclophosphamide (according to the EUROLUPUS regimen). Intravenous methylprednisolone was avoided due to a previous hypertensive encephalopathy reaction. She responded rapidly. Her troponin fell from a peak of 5054 to 294ng/L, her creatinine settled at a new baseline (232umol/L) and her liver function normalised. She was switched back to warfarin due to her metallic valve and started on aspirin for cardiovascular secondary prevention. She required physical and occupational therapy due to her strokes but recovered well.Case report - DiscussionAccording to the 2003 criteria, CAPS can be classified as definite when there is evidence of: ≥3 organs involved, development of manifestations simultaneously or within a week, confirmation by imaging and/or histopathology of small vessel occlusion and positive antiphospholipid antibodies. Probable CAPS is when 3 out of the 4 criteria are present. In this case, three organs were confirmed to be involved with imaging showing cerebral and cardiac ischaemia. Her creatinine rose from a base of 190 to 289umol/L coupled with a high protein creatinine ratio confirming renal involvement. A Budd-Chiari syndrome was also suspected due to deranged liver function tests and INR, though imaging performed after therapy did not confirm this. A biopsy of any of these four organs was not feasible given the severity of her presentation and coagulopathy. There are no randomised controlled trials but data from the CAPS registry guides treatment and management follows a logical approach: anticoagulation to treat thrombosis, glucocorticoids for inflammation and plasma exchange (or IVIG) to remove the circulating autoantibodies. Triple therapy was associated with a reduced mortality compared to no treatment (28.6% versus 75%, respectively).Following analyses from the CAPS registry we also chose to treat with cyclophosphamide, which is associated with improved survival in patients with SLE. This decision was based on the clinical features of an SLE flare as opposed to serological grounds. There have been reports of rituximab and eculizumab being used successfully in CAPS, though generally as a last resort. As complement activation is seen in animal models of antiphospholipid syndrome thrombosis and rituximab is often used in refractory SLE, they may prove to be promising agents for refractory CAPS.Case report - Key learning pointsPrompt recognition and early treatment is vital in managing CAPSTriple therapy with anticoagulation, glucocorticoids and plasma exchange / IVIG is associated with better survival in CAPSCyclophosphamide is associated with better survival in patients with CAPS and concomitant SLE

O11 Neisseria Meningitidis as a cause of isolated bilateral polyarticular native knee joint septic arthritis

O11 <i>Neisseria Meningitidis</i> as a cause of isolated bilateral polyarticular native knee joint septic arthritis