Diagnostic Tap Research Articles

Screening Options in Autism Telediagnosis: Examination of TAP, M-CHAT-R, and DCI Concordance and Predictive Value in a Telediagnostic Model.

Tele-assessment of autism in early childhood has increased. However, it is unclear how autism screening tools (M-CHAT-R, DCI) function as part of tele-assessment and relate to a commonly used tele-assessment instrument, the TAP. 361 families from a clinically referred sample of children (mean age: 27.63 months, sd = 4.86 months) completed the M-CHAT-R and DCI prior to a tele-assessment visit utilizing the TAP. Data was collected on demographic background, measure scores, and diagnostic outcome. No significant differences in measure scores or diagnostic findings emerged in age at referral, age group, age at diagnosis, or child sex, ethnicity, or racial background. The M-CHAT-R and DCI correlated strongly and positively. Older age was associated with lower risk scores on screening instruments. Children with autism had significantly higher scores on all screener and subdomain scores, with the exception of DCI Behavior. Subdomains of the DCI emerged as the strongest predictor of diagnostic outcome. Both the DCI total score and the M-CHAT-R significantly related to diagnostic outcome and TAP score in this tele-assessment model, regardless of child age or sex. Findings also support use of the DCI for children under 24 months of age.

Strongyloides stercoralis infection masquerading as malignant ascites in a case of angiosarcoma.

Strongyloides stercoralis is a parasitic nematode that infects millions of people worldwide. It primarily infects humans but can also be found in domestic animals and primates. The severity of infection varies from asymptomatic to life-threatening complications. We present a case of a 56-year-old male with a known case of angiosarcoma liver with massive ascites and low-grade fever. He was clinically diagnosed as having malignant ascites and was planned for chemotherapy. During therapeutic cum diagnostic ascitic tap, cell block sections revealed the presence of cross sections of nematode S. stercoralis gravid uterus with eggs. Later, stool for ova and cysts also revealed multiple larval forms of the nematode. S. stercoralis hyperinfection is often accompanied by sepsis or meningitis with enteric organisms. Patient was started on tab. ivermectin 12 mg once a day for two days (in the standard dosage of 200 mcg/kg) was then repeated in the same dosage for another two days after two weeks, and gradually the ascites settled. Post-treatment ascitic tap cell block preparations did not show any parasites. Patient has been on follow-up for 6 months, and he remains asymptomatic.

SFM Fetal Therapy Practice Guidelines: Fetal Shunts

AbstractFetal shunt is placed into the fetus in order to drain fluid from a fluid-filled fetal area into the amniotic cavity. The main indications are hydrothorax, congenital pulmonary airway malformation (CPAM) with dominant cyst, and lower urinary tract obstruction.Fetal shunt is indicated if the hydrothorax is primary or hypertensive. In case of re-accumulation after a diagnostic tap or if the primary hydrothorax has led to a secondary nonimmune hydrops provided the primary nature is clearly established and in cases where gestational age is less than 34 weeks.A shunt in CPAM is indicated in case of CPAM with a dominant cyst where the CPAM volume ratio (CVR) is greater than 1.6, where macrocysts are visible within the lesion, where the diameter of the dominant cyst is more than one-third of the largest diameter of the lesion and where presence of hydrops is not a contraindication for shunting. In case of lower urinary tract obstruction, fetal shunt may be indicated if the following conditions are met. The etiology of lower urinary tract obstruction is posterior urethral valve with oligohydramnios and fetal urinalysis is favorable.

Frequency of uremic and tuberculous pleuritis having exudative lymphocytic pleural effusion in patients with advanced renal disease

Pleural effusion is a common occurrence in patients with late-stage chronic kidney disease. In developing countries like Pakistan, many effusions remain undiagnosed after pleural fluid analysis and patients are empirically treated with anti-tubercular therapy. Objective: To determine the frequency of uremic and tuberculosis pleuritis in patients with advanced renal disease. Study Design: Cross-sectional study Study Duration: The study was conducted within 6 months after approval of synopsis i.e. from 2nd December, 2020 till 1st June, 2021. Methodology:150 patients who fulfilled the inclusion criteria were enrolled Informed consent was taken from each patient. Demographic information (name, age, sex, BMI and duration of renal disease) was noted. Then diagnostic pleural tap was done and exudates sample was taken. All exudative samples were further assessed by pleural 2 biopsy and sample was sent to the laboratory of the hospital for histological assessment of uremic or tuberculous pleuritis Results: The mean age (in years), BMI (kg/m2) and duration of disease (in months) of the patients was 39.5±14.2, 27.6±4.19 and 35.8±14.6. There were 55.3% males and 44.7% females. Uremic pleuritis was present in 69.4% and tuberculous pleuritis was seen in 30.6% patients. Age, gender and duration of disease was significantly associated with uremic and tuberculous pleuritis as indicated by a p value of 0.026, 0.048 and 0.007 respectively. Conclusion:Uremic pleuritis was more frequently seen as compared to tuberculous pleuritis in patients with advanced renal disease.

Endogenous endophthalmitis in post-COVID-19 patients: a case report.

Two patients who were hospitalized and received treatment for COVID-19 pneumonia with remdesivir and systemic steroids presented with decreased vision. The first case had a severe anterior chamber reaction with a hypopyon and dense exudates in the vitreous. The second case had cells and flare in the anterior chamber and exudates in the vitreous. They were diagnosed with EE and underwent a diagnostic vitreous tap followed by pars plana vitrectomy and intravitreal antibiotic and steroid. The culture of vitreous fluid was negative for any bacteria and fungus in both cases. However, the first case demonstrated Escherichia coli in urine culture. The follow-up visual acuity was no perception of light and only perception of light in the first and second case, respectively. Severe COVID-19 patients who are hospitalized, receive systemic steroid and have associated comorbidities like diabetes mellitus are at high risk of EE. Delay in diagnosis and appropriate treatment in these patients leads to poor visual outcome.

S2945 Check Point SOS! A Case of Cemiplimab-Associated Sinusoidal Obstruction Syndrome

Introduction: Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS), is a clinical syndrome characterized by hepatomegaly, right-upper quadrant pain, and ascites that occurs most commonly in the setting of high-dose chemotherapy or hematopoietic stem cell transplantation (HSCT). The diagnosis can be confirmed on biopsy. Cemiplimab is an immune checkpoint inhibitor recently approved for the treatment of cutaneous squamous cell carcinoma. There are currently no known reports of immune checkpoint inhibitor-related VOD/SOS. Case Description/Methods: A 58-year-old female with a history of locally advanced basal cell carcinoma of the left eye treated with six months of Cemipilimab presented with ascites. On admission, labs were notable for a total bilirubin of 1.2, mildly elevated liver function tests, alkaline phosphatase 884, and international normalized ratio 2.1. A diagnostic tap revealed a high SAAG ascites that was negative for infection. A comprehensive serological workup for viral, metabolic and autoimmune causes was unrevealing. A transjugular liver biopsy demonstrated a hepatic venous pressure gradient of 18mmHg, nodular regenerative hyperplasia (NRH), and portal venopathy. The patient was discharged on steroids but returned one month later for recurrent ascites and worsening bilirubin to 12.6 (direct 7.3); COVID PCR was negative. A full rheumatologic and vasculitis workup was unremarkable. Repeat biopsy (Figure 1) demonstrated moderate NRH changes, prominent central vein sclerosis with fibrous obliteration, signs of SOS/VOD and central venulitis with fibrotic changes with sinusoidal portal hypertension. Discussion: VOD occurs most often with hematopoietic stem cell transplantation, and chemotherapeutic agents. Here we present the first case of checkpoint inhibitor-induced VOD/SOS. Despite discontinuation of the offending agent and a trial of steroids, the patient’s clinical course continued to deteriorate. She eventually developed refractory ascites and portosystemic encephalopathy. She was deemed not a candidate for liver transplant given her underlying malignancy. She was transitioned to home hospice before further treatment, such as Defibrotide could have been pursued. VOD associated with immune checkpoint inhibition should be considered in the differential of patients who develop new onset liver dysfunction and ascites while receiving these medications.Figure 1.: Sinusoidal dilatation and congestion alongside central vein sclerosis. These are common findings of sinusoidal obstruction syndrome on liver biopsy.

Cecal Perforation: Gastrointestinal Menifestation of Acute Lymphoblastic Leukemia

Background: Hematological malignancies present with gastrointestinal manifestations in the form of typhlitis, colitis and bowel perforation. Prompt diagnosis and appropriate treatment of these entities is essential because they are associated with high morbidity and mortality. Case report: We present a case report of a young female patient who was diagnosed with acute lymphoblastic leukemia and while being on induction chemotherapy started having fever, pneumonia, positive blood culture and was started for that on broad spectrum antibiotics after which she developed abdominal pain and loose motion and was found to have clostridial difficile a toxin positive in blood. Surgical consult was taken for non-settling abdominal pain. It was a challenging diagnosis as patient was having loose motion with positive clostridial difficile further more ct scan abdomen done with contrast showed only bowel thickening which was in favor of colitis along with ascites. She was initially managed conservatively and ascitic diagnostic tap also was done which showed serous fluid. However, her persistent abdominal pain which was not settling led her to go another ct scan abdomen after 3 days of initial ct scan and showed specks of free air around cecum based on which she was taken to operation theatre and was found to have big cecal perforation with fecal peritonitis, she ended up having right hemicolectomy and ileo transverse stoma formation. She had prolonged Intensive Care Unit (ICU) stay but eventually recovered fully and was shifted to general ward where after wound healing was taken over by hematology department for continuation of her chemotherapy. Final histopathology of right hemicolectomy specimen showed focal marked mucosal ulcerations/erosions with patchy submucosal neutrophilic abscesses with fibrinosuppurative necrosis, and marked serositis with dense acute (fibrinopurulent) inflammation, all bowel layers mucosa, sub mucosa, muscularis and serosa showed neutrophilic infiltrates, there was no evidence of pseudomembranous colitis, granuloma or malignancy. Conclusion: Patients on chemotherapy for hematological malignancies are neutropenic and are at high risk of bowel ischemia and perforation emanating to there primary disease, immunocompromised status and direct and indirect side effects of chemotherapeutic agents. A high index of suspicion is needed to diagnose these cases accurately and treat accordingly to prevent mortality.

Treatment Patterns and Health Care Resource Utilization of Iatrogenic Spinal Cerebrospinal Fluid Leaks in the United States.

Retrospective cohort study. We aimed to characterize the treatment patterns and the associated costs in patients with cerebrospinal fluid (CSF) leak after spine procedures in the United States. CSF leak is a common complication after spinal procedures. However, there is a little data regarding the national patterns of treatment choice and the associated health care resource utilization. We utilized the IBM MarketScan Research databases to retrospectively analyze adult US patients diagnosed with CSF leak within 30 days of spine procedures between 2001 and 2018. Treatment prevalence, treatment failure, and health care resource utilization data within 30 days of the CSF leak were collected. A subanalysis was performed on patients who received epidural blood patches (EBP) to better understand health care utilization attributable to this treatment modality. Twenty one thousand four hundred fourteen patients were identified. The most common causes of CSF leak were diagnostic spinal tap (59.2%) and laminectomy/discectomy (18.7%). With regard to treatment prevalence, 40.4% of the patients (n=8651) had conservative medical management, 46.6% (n=9987) received epidural blood patch repair, 9.6% required surgical repair (n=2066), and 3.3% (n=710) had lumbar drain/puncture. Nine hundred sixty-seven (9.7%), 150 (21.1%), and 280 (13.5%) patients failed initial EBP, lumbar drain, and surgery, respectively, and the overall failure rate was 10.9% (n=1397). The median 30-day total cost across all groups was $5,101. Patients who received lumbar drain ($22,341) and surgical repair ($30,199) had higher 30-day median total costs than EBP ($8,140) or conservative management ($17,012). The median 30-day total cost for patients whose EBP failed ($8,179) was substantially greater than those with a successful EBP repair ($3,439). National treatment patterns and costs for CSF leaks were described. When used in the correct patient cohort, EBP has the lower failure rates and costs than comparable alternatives. EBP may be considered more often in situations where conservative management or lumbar drains are currently being used.

Isolated gallbladder perforation in paediatric blunt abdominal injury: A case report and review of literature

Gallbladder injury in blunt abdominal trauma is rare, around 2% of all abdominal traumas. Vague symptoms and inconclusive imaging make it an elusive diagnosis, more so in children. Only 30 pediatric cases have been reported worldwide till date. We report a case of a 7yrs old boy presenting 2 weeks after a road accident with a gallbladder rupture which was eventually discovered on a diagnostic laparoscopy. This is the second such case being reported from India. The injury is most often identified at exploration and although cholecystectomy is the preferred treatment, there are occasions when the gallbladder may be left in situ. The classification system of Losanoff and Kjossev has merit in guiding treatment. The various presentations, mechanisms and modes of injury have been highlighted along with the clinical and imaging findings. Despite the developments in modern radiology, identifying gallbladder perforation has always been difficult because of the rarity of the condition. In a child with blunt abdominal trauma and intra-abdominal free fluid without any solid organ injury, a diagnostic peritoneal tap may be helpful. Based on the current evidence, we advocate a low threshold for performing a diagnostic laparoscopy in all such cases.

Opaque Hemithorax in a Child

Background: Children with acute febrile respiratory illnesses are commonly seen in the emergency department. Apart from the initial stabilization, they need to be assessed for the underlying cause, and clinicians should formulate differential diagnoses to start treatment. Radiological investigations including x-ray and ultrasonography are often used to narrow down the initial possibilities based on history and examination. A child presenting with an opaque hemithorax is one such scenario. Clinical Description: A 3-year-old boy presented with a short duration of fever, cough and respiratory distress. Examination showed rightward mediastinal shift with dull percussion note and reduced breath sounds over the left hemithorax, along with congested neck veins, stridor and left sided wheeze. Chest x-ray showed an opacified left hemithorax and ultrasonography suggested moderate pleural effusion. Management: Complicated pneumonia with parapneumonic effusion (or empyema) was considered, but a diagnostic pleural tap was dry. The possibilities were revised to include cystic space occupying lesions with mediastinal compression. Computed tomography of the chest confirmed a mass lesion with predominantly cystic components. The patient underwent surgical excision, and histopathology showed pleuropulmonary blastoma. Conclusion: Although respiratory infections are common in childhood, clinical evaluation and judicious use of imaging modalities can uncover less common conditions. Although bedside ultrasonography is a handy tool in the emergency department, it is not infallible.

Kappa Index Versus CSF Oligoclonal Bands in Predicting Multiple Sclerosis and Infectious/Inflammatory CNS Disorders.

Background: Cerebrospinal fluid (CSF) kappa free light chains (KFLC) are gaining increasing interest as markers of intrathecal immunoglobulin synthesis. The main aim of this study was to assess the diagnostic accuracy (AUC) of the kappa index (CSF/serum KFLC divided by the CSF/serum albumin ratio) compared to CSF oligoclonal IgG bands (OCB) in predicting Multiple Sclerosis (MS) or a central nervous system infectious/inflammatory disorder (CNSID). Methods: We enrolled patients who underwent a diagnostic spinal tap throughout two years. KFLC levels were determined using a Freelite assay (Binding Site) and the turbidimetric Optilite analyzer. Results: Of 540 included patients, 223 had a CNSID, and 84 had MS. The kappa index was more sensitive (0.89 versus 0.85) and less specific (0.84 versus 0.89), with the same AUC (0.87) as OCB for MS diagnosis (optimal cut-off: 6.2). Adding patients with a single CSF IgG band to the OCB-positive group slightly increased the AUC (0.88). Likewise, the kappa index (cut-off: 3.9) was more sensitive (0.67 versus 0.50) and less specific (0.81 versus 0.97), with the same AUC (0.74) as OCB, for a CNSID diagnosis. Conclusion: The kappa index and CSF OCB have comparable diagnostic accuracies for a MS or CNSID diagnosis and supply the clinician with useful, complementary information.

Clinico-immunological profile in a case of hepatic tubercular abscess: A rare manifestation of extrapulmonary TB in an immunocompetent child

Tubercular liver abscess is a rare entity even in an endemic area for TB. We report here a rare case of pediatric tuberculous liver abscess, the etiology of which was established using recently introduced Cartridge based nucleic acid amplification test (CBNAAT). A 7 years old male child presented with vomiting, pain abdomen and fever. Hepatomegaly was found on examination. Ultrasound of abdomen revealed two liver abscesses in the right lobe. Patient remained symptomatic even after empirical antimicrobial therapy. On diagnostic tap Gram stained smear of the pus showed polymorphs with negative culture. CBNAAT was positive for Mycobacterial tuberculosis and sensitive to rifampicin. Subjecting difficult extrapulmonary specimens to relevant microbiological investigations along with CBNAAT and other newer methods may improve diagnosis of tuberculosis in such rare cases thus leading to an early management and decrease in morbidity.

Pleural effusion with rapid refill: A diagnostic dilemma-series of five cases

Background: A rare complication of acute or chronic pancreatitis is the formation of a mediastinal pancreatic pseudocyst (MPP). Inflammatory injury causes pancreatic ductal disruption leading to leakage of amylase rich pancreatic secretions along the paths of minimum resistance. Thoracopancreatic fistulae are caused by the posterior disruptions while anterior disruptions can cause pancreatic ascites. Patients of pancreatitis can present with symptoms like chest pain, respiratory distress, dysphagia and in extreme cases with pericardial effusion and tamponade. High index of suspicion is needed in diagnosing this condition. Here, we report the imaging characteristics of five such cases. Our results revealed three features in common: (i) extension of pancreatic pseudocyst into the mediastinum; (ii) rapid refill of pleural effusions; and (iii) imaging findings consistent with pancreatitis. Aims: 1) To evaluate the cause of rapid refill of pleural effusion in cases of acute or chronic pancreatitis with pseudocysts. 2) To evaluate the mediastinal extension of the pseudocyst.Materials and Methods: Patients with rapid refill of pleural effusion were sent to the department of surgery and subsequently to radiology for further evaluation. Chest radiographs, diagnostic and therapeutic tap, abdominal ultrasonography, barium swallow and contrast enhanced CT scans of thorax and abdomen were done. Result: All our five patients of pancreatitis with rapid refill of pleural collection were found to have mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula.Conclusion: Mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula is a rare complication following acute or chronic pancreatitis. Detailed radiological investigations are a useful adjunct to surgical management.

Pleural Tap-Guided Antimicrobial Treatment for Pneumonia with Parapneumonic Effusion or Pleural Empyema in Children: A Single-Center Cohort Study.

Parapneumonic effusion or pleural empyema (PPE/PE) is a frequent complication of community-acquired pneumonia (CAP) in children. Different management approaches exist for this condition. We evaluated a 14-day treatment with amoxicillin (AMX) with/without clavulanic acid (AMC) confirmed or modified by microbiological findings from pleural tap. Children ≤16 years of age with radiologically diagnosed PPE/PE and initial diagnostic pleural tap were included at University Children’s Hospital Zurich from 2001–2015. AMX/AMC was given for 14 days and rationalized according to microbiological pleural tap results. Clinical and radiological follow-up was scheduled until six months or full recovery. In 114 of 147 (78%) children with PPE/PE a pathogen was identified by culture, polymerase chain reaction (PCR), and/or antigen testing. Streptococcus pneumoniae was detected in 90 (79%), S. pyogenes in 13 (11%), and Staphylococcus aureus in seven cases (6%), all but two cultured pathogens (96%) were sensitive to AMX/AMC. One-hundred two of 147 (69%) patients received treatment with AMX/AMC for 14 days. They recovered more rapidly than patients with a different management (p = 0.026). Of 139 children with follow-up, 134 (96%) patients fully recovered. In conclusion, 14-day AMX/AMC treatment confirmed and rarely modified by microbiological findings from pleural tap resulted in full recovery in >95% of children with PPE/PE.

Changes in Cognitive Function Scores After Cerebrospinal Fluid Tap Testing in Patients with Suspected Idiopathic Normal-Pressure Hydrocephalus.

In patients suspected of having idiopathic normal-pressure hydrocephalus (iNPH), improvement in impaired cognition is common after a diagnostic cerebrospinal fluid tap test (CSFTT). Measures used to evaluate cognitive function before and after a CSFTT include the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Trail Making Test (TMT). However, the time point at which cognitive function should be reevaluated after a CSFTT remains controversial. To investigate differences in cognitive function 1 day and 1 week after a CSFTT (versus baseline) in patients with suspected iNPH. This retrospective study, conducted between October 2012 and January 2017, involved 39 patients with suspected iNPH. We analyzed their MMSE, FAB, and TMT scores on tests conducted before and 1 day and 1 week after the CSFTT. Changes in MMSE scores were negligible 1 day after the CSFTT but began to appear 1 week later. Changes in FAB scores were observed from 1 day to 1 week after the CSFTT. Although no statistically significant differences in TMT scores were observed at either time point, the execution time for the test tended to be shorter on the day after the CSFTT. Changes in cognitive function were not associated with demographic or morphological parameters. More severe impairments at baseline, however, were associated with greater changes in cognitive function. Performing several reevaluations using each test may enable more accurate assessment of cognitive function in patients with suspected iNPH. Our results highlight the need for long-term follow-up, regardless of the severity of cognitive impairment.

Lumbar Puncture Test in Normal Pressure Hydrocephalus: Does the Volume of CSF Removed Affect the Response to Tap?

There is limited evidence to support the use of high-volume lumbar taps over lower-volume taps in the diagnosis of normal pressure hydrocephalus. The purpose of this study is to detect whether the volume of CSF removed from patients undergoing high-volume diagnostic lumbar tap test for normal pressure hydrocephalus is significantly associated with post-lumbar tap gait performance. This retrospective study included 249 consecutive patients who underwent evaluation for normal pressure hydrocephalus. The patients were analyzed both in their entirety and as subgroups that showed robust response to the lumbar tap test. The volume of CSF removed was treated as both a continuous variable and a discrete variable. Statistical tests were repeated with log-normalized volumes. This study found no evidence of a relationship between the volume of CSF removed during the lumbar tap test and subsequent gait test performance in the patient population (Pearson coefficient r = 0.049-0.129). Log normalization of the volume of CSF removed and controlling for age and sex failed to yield a significant relationship. Subgroup analyses focusing on patients who showed greater than 20% improvement in any of the gait end points or who were deemed sufficiently responsive clinically to warrant surgery also yielded no significant relationships between the volume of CSF removed and gait outcomes, but there were preliminary findings that patients who underwent tap with larger-gauge needles had better postprocedure ambulation among patients who showed greater than 20% improvement in immediate time score (P = .04, n = 62). We found no evidence to support that a higher volume of CSF removal impacts gait testing, suggesting that a high volume of CSF removal may not be necessary in a diagnostic lumbar tap test.

Comparison of outcomes following a cytological or histological diagnosis of malignant mesothelioma

Background:Survival with the epithelioid subtype of malignant mesothelioma (MM) is longer than the biphasic or sarcomatoid subtypes. There is concern that cytology-diagnosed epithelioid MM may underdiagnose the biphasic subtype. This study examines survival differences between patients with epithelioid MM diagnosed by cytology only and other subtypes diagnosed by histology.Methods:Demographics, diagnosis method, MM subtype and survival were extracted from the Western Australia (WA) Mesothelioma Registry, which records details of all MM cases occurring in WA.Results:A total of 2024 MM cases were identified over 42 years. One thousand seven hundred forty-four (86.2%) were male, median (IQR) age was 68.6 (60.4–77.0) years. A total of 1212 (59.9%) cases were identified as epithelioid subtype of which 499 (41.2%) were diagnosed using fluid cytology only. Those with a cytology-only diagnosis were older than the histology group (median 70.2 vs 67.6 years, P<0.001), but median survival was similar (cytology 10.6 (5.5–19.2) vs histology 11.1 (4.8–19.8) months, P=0.727) and Cox regression modelling adjusting for age, sex, site and time since first exposure showed no difference in survival between the different diagnostic approaches.Conclusions:Survival of cytologically and histologically diagnosed epithelioid MM cases does not differ. A diagnostic tap should be considered adequate to diagnose epithelioid MM without need for further invasive testing.

PTU-084 Decompensated Cirrhosis in the Acute Medical Unit – A Neglected Group?

Introduction Decompensated chronic liver disease (DCLD) is a medical emergency with high mortality, usually managed by non-specialists in emergency (ED) and acute medical (AMU) departments in critical early stages. A recently introduced BSG/BASL care bundle 1 (CB) highlights crucial investigations, which can influence outcome if performed early ( We audited performance against CB recommendations and impact on outcome. Methods Data was reviewed retrospectively using electronic records. Adherence to 4 key CB investigations (blood tests/cultures, ultrasound (US) and ascitic tap in Results All patients admitted over 3 months with DCLD were included (n = 25 patients/33 total AMU admissions). Ascites (51.5%) and jaundice (24.2%) were the commonest presenting complaints. Most (57.6%) had Childs C disease (Childs A 6%; B 36.4%). LOS was variable (mean 11 days; median 7 [1–60]), and 7 people were readmitted within 1 month. In-patient mortality was 16% (12.1% of admissions) in keeping with national data, and 80% were alive at 3 months. No-one had all 4 investigations performed within 6 hr of admission. 81.8% had routine blood tests performed (usually by ED), but only 15.1% had blood cultures, despite early identification of sepsis being a critical aspect of DCLD care. All cultures were taken for other reasons (e.g. cellulitis, pyrexia/rigour) suggesting sepsis risk in DCLD is under-appreciated by non-specialists. 39.4% had US requested within 6 hr and there was a lack of awareness of hepatoma/venous thrombosis as DCLD precipitants. Just 24.1% of those with ascites had a diagnostic tap within 6 hr, with most not performed until under gastroenterology care. Data suggests this was due to inexperience of the admitting doctor, both in understanding importance of excluding/treating sepsis early, and technical capability to perform the test. Slow patient flow added considerable delay to assessment/investigation, with 35% arriving in AMU > 6 hr post ED arrival (mean 4.5; median 5.5 [0.3–16 hr]), closing the window of opportunity for early intervention. There was a non-significant trend towards long waits in those who subsequently died (mean 7.5 hr; median 5.9 [3.6–14.5]), but no correlation between delay and LOS. Conclusion Patients with DCLD were under-investigated and experienced considerable delay in assessment and investigation, possibly impacting mortality. CB awareness was limited, and we identified failure of non-specialists to appreciate causes of DCLD and importance of rapid and robust assessment, compounded by delays in patient flow. We arranged talks for AMU staff on DCLD, and have commenced enhanced gastroenterology in-reach for ED/AMU, to identify and treat patients more rapidly. Reference 1 http://www.bsg.org.uk/images/stories/docs/decomp_cirrhosis_care_bundle.doc Disclosure of Interest None Declared

PWE-103 Implementation and impact of a care bundle for the management of patients with decompensated liver disease: Abstract PWE-103 Table 1

Introduction The 2013 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘ Measuring the Units ’ 1 and a regional audit 2 suggested significant deficiencies in the management of patients with decompensated liver disease. As a result, on behalf of the BSG and BASL, we developed a ‘care bundle’ to optimise and standardise the care of patients with decompensated liver disease in the first 24 h. 3 Our aim was to audit the implementation of the care bundle in our Trust. Method A retrospective audit was conducted on the management of consecutive patients admitted with decompensated liver disease to our general medical admissions unit over 4 time periods (1 pre- and 3 post-introduction of the care bundle) to assess the effect of bundle implementation. Direct admissions to the tertiary liver unit were excluded as twice daily consultant ward rounds might confound results for those patients. Results Since the care bundle was introduced in March 2014, there has been a significant stepwise increase in completion rates (6/25 (24%) for Jun/Jul 14; 5/11 (36%) for Nov 14 and 7/8 (88%) for Dec 14/Jan 15). Table 1shows a comparison of patient management prior to bundle implementation and post-implementation in those with and without a completed bundle. Overall, patients with a completed care bundle were more likely to have appropriate management compared with patients pre-implementation and subjects post-implementation without a completed bundle. The most striking improvement was in performing a diagnostic tap to exclude spontaneous bacterial peritonitis (SBP) which increased to 100% in patients with a completed bundle compared with 46% in those without a bundle completed (p = 0.008). Conclusion Uptake of the care bundle was initially slow, but with perseverance completion rates have increased from 24% to 88% over 9 months. The ‘care bundle’ appears to improve patient care, particularly by increasing the proportion of patients having a diagnostic ascitic tap. Ongoing audit will assess the impact of the care bundle on other aspects, such as management of variceal haemorrhage, length of hospital stay and mortality. Disclosure of interest None Declared. References http://www.ncepod.org.uk/2013arld.htm Dyson, et al . PTU-113. BSG, 2014 McPherson, et al . Frontline Gastroenterol. 2014 doi:10.1136/flgastro-2014-100491

Spontaneous gangrene and perforation of choledochal cyst: a rare presentation

Choledochal cyst is a rare entity. It generally presents in children with pain, jaundice and the occasional finding of a lump in right hypochondriac region. A very rare presentation is biliary peritonitis resulting from a perforated choledochal cyst. It is usually seen in younger children. Our patient was a 14 year old female who presented with an acute abdomen. Clinically she had signs of peritonitis. Chest radiograph did not show free gas under diaphragm. The USG showed a dilated CBD of 4.1cm with a calculus at its lower end of 2 x 2.6cm, USG guided diagnostic tap revealed bile. Emergency exploration was done, a gangrenous patch of size 3 * 2cm in the anteromedial wall of large choledochal cyst was found with a perforation in it. No calculous was found. The gangrenous wall of choledochal cyst was excised and primary suturing of choledochal cyst was done with a T-tube placed through separate incision in choledochal cyst. As there is no facility for intra-operative cholangiogram in the emergency setting in our institute, a post-operative cholangiogram was done on day 7. It revealed a dilated CBD, CHD as well as right and left hepatic ducts (choledochal cyst type IA). The patient was discharged and asked to follow-up electively for excision of choledochal cyst at a later date. A rare possibility of a perforated choledochal cyst should be kept in mind in cases of biliary peritonitis, especially in younger age groups. Bile drainage would be a safer procedure in emergency condition, especially when patient presented late to hospital with hemodynamic unstability and edematous wall.