Deranged Liver Function Research Articles

Peg- Asparaginase induced hepatic injury-A concern for hepatologist

Background and Aim: Peg-L Asparaginase is an important chemotherapeutic agent prescribed in Acute Lymphoblastic Leukaemia (ALL). L Asparaginase is a recognised cause of liver toxicity and patient presenting with deranged liver function should be investigated for this cause apart from primary liver infiltration. Case summary: We report a case of 48-year-old male known case of DM, diagnosed with Early T Cell Precursor (ETP) ALL, treated with BFM 2002 protocol with Daunorubicin, Vincristine, L asparaginase and Methotrexate. He presented with right upper quaant pain with anorexia and jaundice in 4th week of induction. On investigation his peak bilirubin reached uptil 14 mg/dl of which 11 mg/dl was direct component. The peak INR reached till 1.45 and SGOT and SGPT reached upto 350 IU/L and 380 IU/L respectively. Imaging was done suggestive of hepatomegaly with fatty liver infiltration. Rest all other liver specific tests were negative. He was started on symptomatic treatment and with UDCA. The drug was stopped and he improved symptomatically. Conclusions: L asparaginase can cause liver toxicity which may be improved after drug stoppage.

Review of Liver Enzymes Abnormalities in Patients with SARS-CoV-2 Infection

<i>Background</i>: Liver function derangements have been reported in COVID-19, but reported rates are variable. Treatment in intensive care units (ICU) has become a major challenge; therefore, early recognition of severe and critical cases is absolutely essential for timely triaging of patients. Objectives: to review incidence of acute liver injury in patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). <i>Patients and methods</i>: obtaining clinical records and laboratory results prospectively from one hundred patients with PCR-confirmed or radiography-confirmed COVID-19, who are admitted to the isolation wards and emergency departments of three different hospitals in Baghdad from 1st of December 2020 to 31st of March 2021. <i>Results</i>: The mean age group of study sample was (61.2±12.36) years, males formed 59%. GI manifestations were recorded in 47% of total cases, and were statistically correlated with disease severity (P value 0.001). Wide range of LFT abnormalities are found in patients with COVID-19, but none of which showed statistical significance in relation to disease severity. When LFT results were reviewed in relation to previous comorbidities, GGT was found to be statistically correlated with the underlying CLD (P value 0.001), and ALP with both underlying CLD and DM (P values <0.001 and 0.029, respectively) and even in the absence of underlying comorbidity (P value 0.006). <i>Conclusion</i>: Liver enzyme derangements are increasingly reported in patients with COVID-19, but are not necessarily correlate with disease severity. Cholestatic picture of liver enzyme derangement is a more commonly recorded manifestation.

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.

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.

Angiographic Correlates of Acute ST Elevation Inferior Wall Myocardial Infarction with or Without Right Ventricular Involvement

Objectives: Right ventricular infarction (RVI) poses as an added risk factor in patients presenting with acute ST elevation inferior wall myocardial infarction (IWMI) with considerable high mortality. An early interventional therapeutic strategy after a prompt and accurate non-invasive investigative correlate is needed. Material and methods: We sampled 104 patients diagnosed with inferior wall infarction presenting with angina within 12 hours of angina. Investigations included routine blood investigation, 12 lead and right precordial lead electrocardiography, right ventricular (RV) systolic echocardiographic indices, and coronary angiography. Results: Majority of the patients had angiographic evidence of a dominant distal right coronary artery (RCA) culprit lesion. Those patients having ST elevation in RV4 lead had significantly higher incidences of RVI and high-grade atrio-ventricular (AV) blocks. Elderly diabetic patients with azotemia and deranged liver function predicted RVI among the study population. RV systolic indices like TAPSE was most accurate and S’ was found to be most specific in detecting RVI. Chi square test and multivariate regression analysis of echocardiographic parameters like RVDD, RVMPI, and S’ proved excellent surrogate non-invasive surrogate markers for specific angiographic culprit lesions. Conclusion: RV systolic echocardiographic indices shows a diagnostic accuracy of variable degrees in detecting right ventricular involvement in IWMI patients and also act as a surrogate marker in predicting the culprit lesion.

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.

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

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

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.

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.

Liver Function Derangement and Bleeding Morbidity in Dengue Fever and Dengue Haemorrhagic Fever in a tertiary Hospital in Bangladesh

Background: Dengue is a major international health concern that is prevalent in tropical and sub tropical countries. Study of dengue infection and its Liver complications are scarce from countries like India. This study was done to assess the frequency and spectrum of liver dysfunction and bleeding morbidity in Dengue infection patients. Methods: A Cross sectional prospective observational study was performed in the of Department of Medicine Sir Salimullah Medical College Mitford Hospital. All the inpatients who were diagnosed with dengue infection between July 2015 to July 2016 were included in this study. A total of 70 patients were included in the study. Results: Patients were classified as classical dengue fever (DF) 61.5.% dengue haemorrhagic fever (DHF) 38.5%. The mean age was 28.607±10.45 years in DF group and 26.78±11.78 years in DHF group and male: female ratio was 3:1. Deranged serum glutamic-oxaloacetic transaminase (SGOT) and/or Serum glutamic pyruvic transaminase (SGPT) was present in most of the patients. Elevation of ALT level occured more in DHF group patient (81%) than DF group (46%). Out of 70 patient 28(40%) patient were within normal value. 42 (60%) patient had elevated ALT level which is statistically significant (p value-&lt;0.05)..The degree of rise of SGOT, SGPT,and Bilirubin was significantly more in DHF and DSS, as compared to DF. About bleeding morbidity, purpura was a mentionable finding 29(41%) but gum bleeding 15(21%), echymosis 14(20%), are less in both DF and DHF group. Major bleeding like hematomesis 5 (7%), melaena 4 (5%) and haematuria 1 (1%) also occured in both group of patients. Conclusion: Liver dysfunction in the form of raised SGPT was seen in almost all patients. Preferentially high SGOT may serve as an early indicator of dengue infection while high values of bilirubin, SGOT, SGPT,may be an indicator of severe disease and poor prognosis. Bangladesh J Medicine July 2022; 33(1) : 44-51

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.

Real World Experience on the Use of Ibrutinib Monotherapy in Waldenström Macroglobulinemia

BACKGROUNDIbrutinib is approved as a second line treatment option for Waldenström Macroglobulinemia (WM) patients in the United Kingdom and for patients unsuitable for chemo-immunotherapy. In a clinical trial setting, Ibrutinib monotherapy produced a major response rate (MRR) of 79.4% and a predicted five-year overall survival (OS) rate of 87%1. Valuable insights can be gained on the response and tolerability outcomes of Ibrutinib monotherapy in WM outside of the clinical trial setting. This study aimed to evaluate these outcomes in a large specialist centre which receives referrals from across the UK.METHODSA retrospective analysis was performed on consecutive patients with WM who commenced Ibrutinib between December 2014 and February 2021; all included patients were treated for at least 3 months. Data were collated from the WMUK Rory Morrison Registry. The primary outcomes were depth of response, event free survival (EFS, defined as time from commencement to permanent ibrutinib discontinuation due to toxicity, disease progression or death), duration of response (time from best response to progressive disease, PD), progression free survival (PFS) and overall survival (OS). Response was determined in accordance with the Sixth International Workshop on WM (IWWM) response criteria 2. Baseline characteristics and toxicity data were also collated.RESULTSOf the 84 patients who had commenced ibrutinib, sufficient data was available for 62 patients; median age was 69 years (range 44 - 85) and 40 (64.5%) were male. Among the 50 patients for whom International Prognostic Scoring System for WM (IPSSWM) data were available, the IPSSWM risk score at the time of ibrutinib initiation was low (n=8, 16%), intermediate (n=25, 50%) and high (n=17, 34%). The median number of prior therapy lines was 2 (range 1 - 7). The median time from diagnosis to commencement of ibrutinib was 70 months (Range 2 - 243).The median follow-up was 29 months (Range 3 - 71). Objective response rate (≥MR) was 79% (n=49) and MRR was 62.9% (n=39). Best response achieved was CR in 12.9%, VGPR in 24.2%, PR in 25.8%, MR in 16.1% and SD in 11.2%; 9.7% of patients experienced PD. The median time to best response was 5 months (Figure 1A) and the median EFS was 37 months (Range 3 - 71). Of the 49 patients who achieved an objective response, the median PFS was not reached and the two-year predicted PFS rate was 73.5%. At the time of analysis, 15 patients (24.2%) had discontinued ibrutinib due to disease progression, 5 (8.1%) due to adverse effects and 4 (6.5%) due to death. The median OS was not reached, and the predicted two-year OS rate was 87.8% (Figure 1B).The most common adverse effects were diarrhoea (14.5%), atrial fibrillation (AF, 9.7%) and rash (9.7%). Six of the seven patients who developed treatment-emergent AF continued ibrutinib with concurrent anticoagulants and either rate or rhythm control. Ibrutinib was permanently discontinued due to heart failure/AF (n=1), intracranial haemorrhage whilst taking ibrutinib and warfarin concurrently for brittle antiphospholipid syndrome and WM (n=1), significant liver function derangement (n=2) and intractable diarrhoea (n=1). Ibrutinib dose was reduced to 280 mg daily (n=13) and 140 mg daily (n=4) due to adverse reactions.CONCLUSIONIn a real-world setting, ibrutinib produces clinically meaningful objective responses in patients with relapsed WM; these response rates are comparable to those achieved in a clinical trial setting. Ibrutinib can produce durable disease control with long remission intervals. The toxicity profile is acceptable.REFERENCES1. Treon, S., Meid, K., Gustine, J., Yang, G., Xu, L., & Liu, X. et al. (2021). Long-Term Follow-Up of Ibrutinib Monotherapy in Symptomatic, Previously Treated Patients With Waldenström Macroglobulinemia. Journal Of Clinical Oncology, 39(6), 565-575. doi: 10.1200/jco.20.005552. Owen, S., Kyle, R., Stone, M., Rawstron, A., Leblond, V., Merlini, G. et al. (2013). Response assessment in Waldenström Macroglobulinemia: updated from the VIth International Workshop. British Journal of Haematology, 60, 171-176. doi: 10.1111/bjh.12102 [Display omitted] DisclosuresD'Sa: Sanofi: Honoraria; BeiGene: Honoraria, Research Funding; Janssen Cilag: Honoraria, Research Funding.

AN OBSERVATIONAL STUDY OF THE CLINICAL PROFILE AND OUTCOMES OF PATIENTS WITH MILIARY TUBERCULOSIS (TB).

Objectives: This study aimed to evaluate the clinical prole and outcome of the patients with miliary tuberculosis (TB). Methods: This was a retrospective observational study which involved evaluation of medical records of 44 patients with miliary TB in the department of respiratory medicine and internal medicine from 2016-2019. Miliary TB in these patients had been diagnosed on the basis of clinical symptoms, radiology and microbiology. The clinical prole of the patients in terms of age, gender, clinical presentations were recorded. Time duration for resolution of symptoms was noted. Radiological outcome was also studied. Final outcome was treatment success and mortality. Results: The mean age of the patients were 37.07 years with 27 males. Most common complaints were fever (86.36%), cough (72.73%), expectoration (65.91%) and anorexia (45.45%). Laboratory ndings showed hypertransaminasemia, anemia, and hyponatremia in 75.00%, 70.45%, and 43.18% patients, respectively. Standardized treatment (RHEZ) was given in 70.45% patients, and non-standardized treatment in 29.55% patients. Median duration of fever was relieved in 15 days. Mortality rate was 11.36% and drug induced liver injury (DILI) was seen in 4(9.09%) patients. Radiological resolution was seen in almost all of the patients except in 3 and in majority of patients clearing was seen within the rst two months of initiation of treatment. Among all variables, hyperbilirubinemia showed signicant association with mortality (OR=14.6, 95% CI 1.86 to 114.615, P=0.013). Conclusion: In conclusion, in our series miliary TB presents most commonly in the third decade of life and is predominant among males. The clinical features were similar to pulmonary tuberculosis. There was frequent association with derangements in liver function, electrolyte, and hemoglobin. Hyperbilirubinemia was associated with signicantly increased the odds of mortality. Non-standardized treatment regimens were associated with poorer outcome. Mortality rate in miliary TB was as high as 11.3% in our series.

EP.TU.581Cholecysto-colonic fistula – A rare complication of gallstone

Abstract We present a 90year old male patient presenting to the emergency department with complaints of PR bleed for a month with no associated abdominal pain. He described that the blood was mixed with stools and dark in colour. He has a significant past medical history with multiple comorbidities. The patient is known to have gallstones and had ERCP with sphincterotomy in 2017 as a definitive treatment, as he wasn’t a fit candidate for surgical intervention. On clinical examination, his abdomen was soft and non-tender and per rectal examination showed stools mixed with the blood but no active bleeding or fresh blood. His haemoglobin was 72 g/L, inflammatory markers were significantly elevated with deranged liver enzymes and normal bilirubin. The medical team were involved in the management of this patient because of pneumonia and extensive medical issues. A gastroscopy was performed as there was a suspicion of UGI bleed, which was normal. Given a deranged liver function and there was a suspicion of biliary sepsis patient had MRCP and Computed tomography of the abdomen which confirmed that there is haematoma in the gallbladder with gas in the biliary tree, with possible cholecysto-colonic fistula, with a large gall stone (2.7cm lamellated structure within rectum) in the rectum. As the patient was not a surgical candidate decision was made to manage him conservatively with antibiotics under medical care. The cholecysto-colonic fistula is a rare complication of gallstone disease, and very few cases have been reported in the literature.

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