Severity Of Underlying Liver Disease Research Articles

Is There Really a Difference in Outcomes between Men and Women with Hepatocellular Cancer?

Hepatocellular carcinoma (HCC) is a male-dominated disease. Currently, gender differences remain incompletely defined. Data from the state tumor registry were used to investigate differences in demographics, comorbidities, treatment patterns, and cancer-specific survival (HSS) among HCC patients according to gender. Additional analyses were performed to evaluate racial differences among women with HCC. 2627 patients with HCC were included; 498 (19%) were women. Women were mostly white (58%) or African American (39%)-only 3.8% were of another or unknown race. Women were older (65.1 vs. 61.3 years), more obese (33.7% vs. 24.2%), and diagnosed at an earlier stage (31.7% vs. 28.4%) than men. Women had a lower incidence of liver associated comorbidities (36.1% vs. 43%), and more often underwent liver-directed surgery (LDS; 27.5% vs. 22%). When controlling for LDS, no survival differences were observed between genders. African American women had similar HSS rates compared to white women (HR 1.14 (0.91,1.41), p = 0.239) despite having different residential and treatment geographical distributions. African American race and age >65 were predictive for worse HSS in men, but not in women. Overall, women with HCC undergo more treatment options-likely because of the earlier stage of the cancer and/or less severe underlying liver disease. However, when controlling for similar stages and treatments, HCC treatment outcomes were similar between men and women. African American race did not appear to influence outcomes among women with HCC as it did in men.

Stationary Trend in Elevated Serum Alpha-Fetoprotein Level in Hepatocellular Carcinoma Patients

A recent study from the US showed a decreasing trend in the elevated serum alpha-fetoprotein (AFP) level (i.e., ≥20 ng/mL) in hepatocellular carcinoma (HCC) patients at the time of diagnosis. Furthermore, advanced tumor stage and severe underlying liver disease were associated with elevated AFP levels. We aimed to evaluate this issue in an area endemic for hepatitis B virus (HBV). Between 2011 and 2020, 4031 patients were newly diagnosed with HCC at our institution. After excluding 54 patients with unknown AFP data, the remaining 3977 patients were enrolled in this study. Elevated AFP level was defined as ≥20 ng/mL. Overall, 51.2% of HCC patients had elevated AFP levels; this proportion remained stationary between 2011 and 2020 (51.8% vs. 51.1%). Multivariate analysis showed that female gender (odds ratio (OR) = 1.462; p < 0.001), tumor size per 10 mm increase (OR = 1.155; p < 0.001), multiple tumors (OR = 1.406; p < 0.001), Barcelona Clinic Liver Cancer stages B-D (OR = 1.247; p = 0.019), cirrhosis (OR = 1.288; p = 0.02), total bilirubin > 1.4 mg/dL (OR = 1.218; p = 0.030), and HBV- or hepatitis C virus (HCV)-positive status (OR = 1.720; p < 0.001) were associated with elevated AFP levels. In conclusion, a stationary trend in elevated serum AFP level in HCC patients has been noted in the past 10 years. Advanced tumor stage, severe underlying liver disease, viral etiology, and female gender are associated with elevated AFP levels in HCC patients.

Health-related quality of life in Cuban patients with chronic liver disease: A real-world experience

Introduction and objectivesPatient-reported outcomes (PROs) are important for comprehensive assessment of chronic liver disease (CLD). Latin America and the Caribbean have a high burden of CLD, but PROs are lacking. We assessed health-related quality of life (HRQL) in Cuban patients with compensated CLD. Materials and methodsA cross sectional study performed of adult patients with a diagnosis of chronic viral infection B and C (HBV, HCV), non-alcoholic fatty liver diseases (NAFLD) and autoimmune liver diseases (AILD) including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC) and overlap syndrome (AIH+PBC). PROs were collected using: Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Work Productivity and Activity-Specific Health Problem (WPAI: SHP), and the Chronic Liver Disease Questionnaire (CLDQ)-disease-specific. Results543 patients enrolled, n=91 (HBV), n=188 (HCV), n=221 (NAFLD), n=43 (AILD). Of those with AILD, 22 had AIH, 14 PBC, and 7 overlap AIH/PBC. Mean age was 53.5 years, 64.1% female, 69.2% white, and 58.0% employed. Patients with HCV and AILD had more severe liver disease. A significant impairment in PROs was observed in HCV group whereas the AILD patients had more activity impairment. CLDQ-HRQL scores were significantly lower for patients with NAFLD and AILD compared to HBV. Male gender and exercising ≥90min/week predicted better HRQL. The strongest independent predictors of HRQL impairment were fatigue, abdominal pain, anxiety, and depression (p<0.05). ConclusionsHRQL for Cuban patients with compensated CLD differs according to the CLD etiology. Patients with HCV and AILD had the worst PRO scores most likely related to severe underlying liver disease and/or extrahepatic manifestations.

Comparative study between spontaneous fungal peritonitis (SFP) and spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease (ESLD)

Background: Bacterial infections in end stage liver disease are common and associated with increased mortality. Although extensive research has elucidated the impact of bacterial infections as the major precipitating event leads to increased frequency of liver-related complications and mortality in these patients. Objective: Evaluating the clinical and laboratory characters, risk factors, and outcome of fungal and bacterial peritonitis in cirrhotic patients with end stage liver disease (ESLD). Patients and Methods: This cross sctional study enrolled 60 patients with liver cirrhosis and ascites. Fifty patients were culture-positive spontaneous peritonitis, including 12 with spontaneous fungal peritonitis (SFP), and 38 culture-positive spontaneous bacterial peritonitis (SBP), and 10 patients without clinical or laboratory evidence of peritonitis as a control group, during the study period, between 1st February 2018 and 30th May 2019. We compared the clinical, laboratory findings, Child–Pugh scores, model for end stage liver disease (MELD) score, risk factors, and mortality rates between patients with spontaneous peritonitis associated with fungal culture-positive ascites, and those with spontaneous peritonitis associated with bacterial culture-positive ascites. Results: Patients of the current study were critically ill. The mean duration of ESLD in the studied patients was 4.75 ± 1.8 year, 57 patients (95.0%) were Child score C, and 3 patients (5%) were Child score B. The mean MELD score was 23.32 ± 5.49. All patients with evidence of peritonitis were Child C, and mean MELD scores were 22.6 ±5.7 and 26.1±4.5 in SBP and SFP groups respectively. Jaundice, GI bleeding and hepatic encephalopathy were significantly for clinical presentation and predictors of mortality in SFP group compared to SBP and control group. Lower levels of hemoglobin (Hb), S. albumin and platelets count and increased level of total leukocytic count (TLC), international normalized ratio (INR), and bilirubin were significantly higher in SFP group compared to SBP and control group. Duration of ESLD and hospital admission was significant in SFP compared to SBP and control group. HCC was evident in SFP group (66.7%) that was highly significant in comparison to SBP (28.9%), and control group (20%). Overall mortality rate among the studied groups was 45%, the mortality rate was significantly increased in SFP group (75%) compared to SBP (42.1%), and control group (20%).The mean MELD score significantly increased in non-survival group compared to survival group . The duration of ESLD significantly increased in non-survival group compared to survival group. Conclusion: Prolonged and severe underlying liver disease with a high Child- Pugh or MELD score, renal impairment, HCC, and onset of severe sepsis have been reported as risk factors in increased mortality in patients with SFP than in SBP. In SFP, mortality was associated not only with the severity of the underlying liver disease, but also with delay in diagnosis and initiation of antifungal therapy.

Comparative study between spontaneous fungal peritonitis (SFP) and spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease (ESLD)

Background: Bacterial infections in end stage liver disease are common and associated with increased mortality. Although extensive research has elucidated the impact of bacterial infections as the major precipitating event leads to increased frequency of liver-related complications and mortality in these patients. Objective: Evaluating the clinical and laboratory characters, risk factors, and outcome of fungal and bacterial peritonitis in cirrhotic patients with end stage liver disease (ESLD). Patients and Methods: This cross sctional study enrolled 60 patients with liver cirrhosis and ascites. Fifty patients were culture-positive spontaneous peritonitis, including 12 with spontaneous fungal peritonitis (SFP), and 38 culture-positive spontaneous bacterial peritonitis (SBP), and 10 patients without clinical or laboratory evidence of peritonitis as a control group, during the study period, between 1st February 2018 and 30th May 2019. We compared the clinical, laboratory findings, Child–Pugh scores, model for end stage liver disease (MELD) score, risk factors, and mortality rates between patients with spontaneous peritonitis associated with fungal culture-positive ascites, and those with spontaneous peritonitis associated with bacterial culture-positive ascites. Results: Patients of the current study were critically ill. The mean duration of ESLD in the studied patients was 4.75 ± 1.8 year, 57 patients (95.0%) were Child score C, and 3 patients (5%) were Child score B. The mean MELD score was 23.32 ± 5.49. All patients with evidence of peritonitis were Child C, and mean MELD scores were 22.6 ±5.7 and 26.1±4.5 in SBP and SFP groups respectively. Jaundice, GI bleeding and hepatic encephalopathy were significantly for clinical presentation and predictors of mortality in SFP group compared to SBP and control group. Lower levels of hemoglobin (Hb), S. albumin and platelets count and increased level of total leukocytic count (TLC), international normalized ratio (INR), and bilirubin were significantly higher in SFP group compared to SBP and control group. Duration of ESLD and hospital admission was significant in SFP compared to SBP and control group. HCC was evident in SFP group (66.7%) that was highly significant in comparison to SBP (28.9%), and control group (20%). Overall mortality rate among the studied groups was 45%, the mortality rate was significantly increased in SFP group (75%) compared to SBP (42.1%), and control group (20%).The mean MELD score significantly increased in non-survival group compared to survival group . The duration of ESLD significantly increased in non-survival group compared to survival group. Conclusion: Prolonged and severe underlying liver disease with a high Child- Pugh or MELD score, renal impairment, HCC, and onset of severe sepsis have been reported as risk factors in increased mortality in patients with SFP than in SBP. In SFP, mortality was associated not only with the severity of the underlying liver disease, but also with delay in diagnosis and initiation of antifungal therapy.

Liver resection is justified for multinodular hepatocellular carcinoma in selected patients with cirrhosis: A multicenter analysis of 1,066 patients

BackgroundThe role of liver resection for multinodular (≥3 nodules) hepatocellular carcinoma (HCC) remains unclear, especially among patients with severe underlying liver disease. We sought to evaluate surgical outcomes among patients with cirrhosis and multinodular HCC undergoing liver resection. MethodsUsing a multicenter database, outcomes among cirrhotic patients who underwent curative-intent resection of HCC were examined stratified according to the presence or absence of multinodular disease. Perioperative mortality and morbidity, as well as overall survival (OS) and recurrence-free survival (RFS) were compared between the two groups. ResultsAmong 1066 cirrhotic patients, 906 (85.0%) had single- or double-nodular HCC (the non-multinodular group), while 160 (15.0%) had multinodular HCC (the multinodular group). There were no differences in postoperative 30-day mortality and morbidity among non-multinodular versus multinodular patients (1.8% vs. 1.9%, P = 0.923, and 36.0% vs. 39.4%, P = 0.411, respectively). In contrast, 5-year OS and RFS of multinodular patients were worse compared with non-multinodular patients (34.6% vs. 58.2%, and 24.7% vs. 44.5%, both P < 0.001). On multivariable analyses, tumor numbers ≥5, total tumor diameter ≥8 cm and microvascular invasion were independent risk factors for decreased OS and RFS after resection of multinodular HCC in cirrhotic patients. ConclusionsLiver resection can be safely performed for multinodular HCC in the setting of cirrhosis with an overall 5-year survival of 34.6%. Tumor number ≥5, total tumor diameter ≥8 cm and microvascular invasion were independently associated with decreased OS and RFS after resection in cirrhotic patients with multinodular HCC.

Sa1000 Focal Liver Lesions Classification by Artificial Neural Networks and Support Vector Machines Employing Dynamic Imaging Data

RHH by pooling all available evidence in a systematic review and meta-analysis. Methods We conducted a comprehensive literature search using Ovid on MEDLINE (1946-2013), EMBASE (1988-2013), PubMed (1946-2013), Cochrane Library, and the Web of Science to identify studies on TIPS for RHH. Two reviewers independently screened article titles and abstracts for eligibility. Among information abstracted from each study was number of participants, outcomes of interest (mortality/survival, symptom response, HE and change in hepatic venous pressure gradient (HVPG)). Complete response was defined by resolution of HH without further need for thoracentesis, while a partial response was defined as improvement in symptoms and/or a decrease need for thoracentesis. New onset or worsening of baseline HE within 30 days of TIPS was considered a complication of the procedure. Data were pooled using a fixed-effects meta-analysis. Outcomes are expressed as proportions. Heterogeneity was assessed using the I2 and Cochrane Q test. Results Seven studies, involving 203 patients were included in the analyses. The mean age of the patients was 56.3 years, with 50.7% being male. The majority of patients were Child-Pugh Class C (56.9%), while 40.7% and 0.8% were Child-Pugh Class B and A, respectively. The mean follow up period was 11.9 ± 3.6 months. The mean preand post-TIPS HVPG was 20.14 mmHg (range: 17.4-26) and 7.37 mmHg (range: 5.7-10), respectively. Response to TIPS was complete in 55.8% (95% CI 44.7-66.9) and partial in 17.6% (95% CI 10.9-24.2). There was no response in 21.2% (95% CI 14.2-28.3) of patients. The incidence of post-TIPS HE was 11.7% (95% CI 6.3-17.2). The mortality within 30days of TIPS placement was 16.6% (95% CI 10.222.9), while the overall mortality was 49.1% (95% CI 38.8-59.5). The mean 1-year survival (reported by 2 studies) was 56%. Predictors of mortality included older age, severity of liver disease and non-response to TIPS. Conclusion TIPS is associated with symptomatic relief in approximately 75% of patients with RHH. Although TIPS increases the incidence of HE, response to treatment may be associated with improved survival. TIPS should be used cautiously in older patients with more severe underlying liver disease.

Estudio del paciente con sospecha de Osteoporosis

Introduction: Spider naevi are traditionally considered a sign of liver cirrhosis, particularly in patients with alcoholism. However, systematic evaluation of their diagnostic value in alcoholic patients has been scarcely performed. The aim of this study was to determine the diagnostic accuracy of the presence of spider neavi for liver disease detection in alcoholics using percutaneous liver biopsy as the reference standard. Methods: Cross-sectional study of 229 alcoholics admitted to the hospital (67% males) undergoing percutaneous liver biopsy. Results: Spiders were least prevalent in patients with fatty liver (4/104 cases, 4%). The prevalence of spiders was greater in patients with alcoholic hepatitis (15/80, 19%) than in patients with fatty liver (P=0.002). Prevalence was even higher in patients with cirrhosis (6/21, 29%, P<0.001), and was highest in patients with cirrhosis and superimposed alcoholic hepatitis (11/24, 46%, P<0.001). The presence of spiders had a sensitivity of 25% (95% CI 18-34%), a specificity of 95% (95% CI 90-99%), and a positive likelihood ratio of 6.6 (95% CI 2.4-18.2) for the diagnosis of severe underlying liver disease (alcoholic hepatitis, liver cirrhosis, or both). The presence of spiders was associated with biological markers of liver dysfunction and with additional cutaneous stigmata (facial telangiectasia and palmar erythema). Conclusion: The presence of spiders in an alcoholic patient strongly indicates the presence of severe underlying liver disease (liver cirrhosis and/or alcoholic hepatitis).

Surgical Therapy for Hepatocellular Carcinoma

Hepatocellular carcinoma is one of the most common malignancies worldwide, and its incidence continues to rise in the United States. Partial hepatectomy and liver transplantation remains the mainstay of treatment for localized disease and provides significant improvement in long-term survival, as well as the potential for cure. The indications and criteria for resection and transplantation are well established, but continue to undergo significant modification over time. Surgical resection is the primary therapeutic modality in patients with well-compensated liver disease, and transplantation is highly effective in early-stage tumors in patients with severe underlying liver disease. The relative role for each of these modalities must be tailored to individual patients based on a rational approach designed to balance quality of life, organ allocation, and patient survival.

Role of predisposition, injury, response and organ failure in the prognosis of patients with acute-on-chronic liver failure: a prospective cohort study.

IntroductionAcute deterioration of cirrhosis is associated with high mortality rates particularly in the patients who develop organ failure (OF), a condition that is referred to as acute-on-chronic liver failure (ACLF), which is currently not completely defined. This study aimed to determine the role of predisposing factors, the nature of the precipitating illness and inflammatory response in the progression to OF according to the PIRO (predisposition, injury, response, organ failure) concept to define the risk of in-hospital mortality.MethodsA total of 477 patients admitted with acute deterioration of cirrhosis following a defined precipitant over a 5.5-year period were prospectively studied. Baseline clinical, demographic and biochemical data were recorded for all patients and extended serial data from the group that progressed to OF were analysed to define the role of PIRO in determining in-hospital mortality.ResultsOne hundred and fifty-nine (33%) patients developed OF, of whom 93 patients died (58%) compared with 25/318 (8%) deaths in the non-OF group (P < 0.0001). Progression to OF was associated with more severe underlying liver disease and inflammation. In the OF group, previous hospitalisation (P of PIRO); severity of inflammation and lack of its resolution (R of PIRO); and severity of organ failure (O of PIRO) were associated with significantly greater risk of death. In the patients who recovered from OF, mortality at three years was almost universal.ConclusionsThe results of this prospective study shows that the occurrence of OF alters the natural history of cirrhosis. A classification based on the PIRO concept may allow categorization of patients into distinct pathophysiologic and prognostic groups and allow a multidimensional definition of ACLF.

617 RELATIONSHIP BETWEEN SMALL INTESTINAL BACTERIAL OVERGROWTH AND INTESTINAL PERMEABILITY IN CIRRHOSIS

s A.I.S.F. Annual Meeting (Rome, February 25th−26th, 2010) / Digestive and Liver Disease 42 Suppl. 1 (2010) S1–S51 S19 with normal spleen diameter (p 20 ppm or a rise by 12 ppm above baseline following glucose administration was considered as positive. IP was evaluated by the (51)Cr-EDTA permeability test. SIBO prevalence in LC was compared with healthy controls and correlated with LC severity and IP. Results: Twenty-nine out of 56 LC patients had SIBO vs 2 of the 48 healthy controls (51.8% vs 4%, p< 0.0001). SIBO prevalence correlated with the severity of LC (68.2% of Child C pts vs. 56.2% of Child B and 31.2% of Child A pts), with the presence of ascites (66% in ascitic pts vs. 27% in non-ascitic pts), and with a history of SBP (92% of patients with SBP vs. 48% of those without SBP). A significant correlation was found between presence of SIBO and altered IP: it was weak for Child A but significant for Child B and C pts (R = 0.07, NS; R = 0.35, p = 0.005; R = 0.29, p = 0.03, respectively). Conclusions: SIBO seems to have a higher prevalence in LC, correlates with LC severity and altered IP. This association suggests that SIBO may affect intestinal permeability of splancnic vessels and/or peritoneal membranes leading to SBP outbreak in LC. Future interventional studies are needed to confirm these preliminary data. T.N.13 PREDICTORS OF OUTCOME IN CIRRHOTICS ADMITTED TO INTENSIVE CARE UNIT (ICU); SURVIVORS EXHIBITED SIGNIFICANT RISE OF SERUM SODIUM LEVELS AND A FALL IN LACTATE LEVELS AT 48 HOURS M. Garcovich1,2, V. Vemala1, A. Davenport1, E. Dionigi1, S. Shaw1, B. Agarwal1, A.K. Burroughs1. Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK; Dipartimento di Medicina Interna, Universita Cattolica del Sacro Cuor, Rome, Italy Background: Critically ill cirrhotics admitted to ICU have poor prognosis. Factors known to portend worse outcome include mechanical ventilation, development of shock, renal failure and increasing number of organ failure. While a negative impact on mortality of low serum sodium level is observed in stable cirrhotics active on the waiting list for liver transplant, the impact of admission serum sodium and its changes during the course of an acute illness in these patients is not well known. Methods: We retrospective studied a cohort of cirrhotics admitted to ICU between 2005−08 at the Royal Free Hospital. Data were collected on demographic variables, aetiology of liver disease, liver-specific prognostic scores; Child–Turcotte–Pugh (CTP), Model for end-stage liver disease (MELD), United Kingdom model for end-stage liver disease (UKELD), acute physiological score and chronic health points (APACHE II) and sequential organ failure assessment score (SOFA). In addition, data were also collected for serum Na+ and Lactate levels at 0 (on admission) and at 48 hrs. Results: Currently 67 of 125 patients have been enrolled. 51/67 (76.1%) survived ICU. The non-survivors (16/67) had similar demographics as the survivors, had significantly higher mean MELD, UKELD, SOFA and APACHE II scores, and higher admission lactate. Total CTP score was not different between the groups but serum bilirubin level and prothrombin time were significantly higher in the non-survivors. Although the admission Na+ levels in survivors and non survivors were similar, a significant elevation was observed at 48 hrs in the survivors. The trend for serum lactate levels showed a similar pattern i.e., the survivors showed significant reductions at 48 hrs. Conclusions: The reasons for this observed rise in serum Na+ at 48 hrs in the survivors are not obvious. It may signify a better preserved water balance in patients with less severe underlying liver disease. T.N.14 COLLAGEN PROPORTIONATE AREA IN ASSESSING THE AMOUNT OF FIBROSIS IN CHRONIC LIVER DISEASE: DOES HIGH RESOLUTION COMPARED TO CONVENTIONAL IMAGE CAPTURING AND ANALYSIS ALTERS ITS RESULTS? L. Andreana1, G. Isgro1, M. Garcovich1, A. Hall2, F. Grillo2, A.P. Dhillon2, A.K. Burroughs1, T.V. Luong2. The Sheila Sherlock Liver Centre and University Dept. of Surgery, Royal Free Hospital, London, UK; Dept. of Histopathology, Royal Free Hospital,

T.N.14 COLLAGEN PROPORTIONATE AREA IN ASSESSING THE AMOUNT OF FIBROSIS IN CHRONIC LIVER DISEASE: DOES HIGH RESOLUTION COMPARED TO CONVENTIONAL IMAGE CAPTURING AND ANALYSIS ALTERS ITS RESULTS?

s A.I.S.F. Annual Meeting (Rome, February 25th−26th, 2010) / Digestive and Liver Disease 42 Suppl. 1 (2010) S1–S51 S19 with normal spleen diameter (p 20 ppm or a rise by 12 ppm above baseline following glucose administration was considered as positive. IP was evaluated by the (51)Cr-EDTA permeability test. SIBO prevalence in LC was compared with healthy controls and correlated with LC severity and IP. Results: Twenty-nine out of 56 LC patients had SIBO vs 2 of the 48 healthy controls (51.8% vs 4%, p< 0.0001). SIBO prevalence correlated with the severity of LC (68.2% of Child C pts vs. 56.2% of Child B and 31.2% of Child A pts), with the presence of ascites (66% in ascitic pts vs. 27% in non-ascitic pts), and with a history of SBP (92% of patients with SBP vs. 48% of those without SBP). A significant correlation was found between presence of SIBO and altered IP: it was weak for Child A but significant for Child B and C pts (R = 0.07, NS; R = 0.35, p = 0.005; R = 0.29, p = 0.03, respectively). Conclusions: SIBO seems to have a higher prevalence in LC, correlates with LC severity and altered IP. This association suggests that SIBO may affect intestinal permeability of splancnic vessels and/or peritoneal membranes leading to SBP outbreak in LC. Future interventional studies are needed to confirm these preliminary data. T.N.13 PREDICTORS OF OUTCOME IN CIRRHOTICS ADMITTED TO INTENSIVE CARE UNIT (ICU); SURVIVORS EXHIBITED SIGNIFICANT RISE OF SERUM SODIUM LEVELS AND A FALL IN LACTATE LEVELS AT 48 HOURS M. Garcovich1,2, V. Vemala1, A. Davenport1, E. Dionigi1, S. Shaw1, B. Agarwal1, A.K. Burroughs1. Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK; Dipartimento di Medicina Interna, Universita Cattolica del Sacro Cuor, Rome, Italy Background: Critically ill cirrhotics admitted to ICU have poor prognosis. Factors known to portend worse outcome include mechanical ventilation, development of shock, renal failure and increasing number of organ failure. While a negative impact on mortality of low serum sodium level is observed in stable cirrhotics active on the waiting list for liver transplant, the impact of admission serum sodium and its changes during the course of an acute illness in these patients is not well known. Methods: We retrospective studied a cohort of cirrhotics admitted to ICU between 2005−08 at the Royal Free Hospital. Data were collected on demographic variables, aetiology of liver disease, liver-specific prognostic scores; Child–Turcotte–Pugh (CTP), Model for end-stage liver disease (MELD), United Kingdom model for end-stage liver disease (UKELD), acute physiological score and chronic health points (APACHE II) and sequential organ failure assessment score (SOFA). In addition, data were also collected for serum Na+ and Lactate levels at 0 (on admission) and at 48 hrs. Results: Currently 67 of 125 patients have been enrolled. 51/67 (76.1%) survived ICU. The non-survivors (16/67) had similar demographics as the survivors, had significantly higher mean MELD, UKELD, SOFA and APACHE II scores, and higher admission lactate. Total CTP score was not different between the groups but serum bilirubin level and prothrombin time were significantly higher in the non-survivors. Although the admission Na+ levels in survivors and non survivors were similar, a significant elevation was observed at 48 hrs in the survivors. The trend for serum lactate levels showed a similar pattern i.e., the survivors showed significant reductions at 48 hrs. Conclusions: The reasons for this observed rise in serum Na+ at 48 hrs in the survivors are not obvious. It may signify a better preserved water balance in patients with less severe underlying liver disease. T.N.14 COLLAGEN PROPORTIONATE AREA IN ASSESSING THE AMOUNT OF FIBROSIS IN CHRONIC LIVER DISEASE: DOES HIGH RESOLUTION COMPARED TO CONVENTIONAL IMAGE CAPTURING AND ANALYSIS ALTERS ITS RESULTS? L. Andreana1, G. Isgro1, M. Garcovich1, A. Hall2, F. Grillo2, A.P. Dhillon2, A.K. Burroughs1, T.V. Luong2. The Sheila Sherlock Liver Centre and University Dept. of Surgery, Royal Free Hospital, London, UK; Dept. of Histopathology, Royal Free Hospital,

T.N.13 PREDICTORS OF OUTCOME IN CIRRHOTICS ADMITTED TO INTENSIVE CARE UNIT (ICU); SURVIVORS EXHIBITED SIGNIFICANT RISE OF SERUM SODIUM LEVELS AND A FALL IN LACTATE LEVELS AT 48 HOURS

s A.I.S.F. Annual Meeting (Rome, February 25th−26th, 2010) / Digestive and Liver Disease 42 Suppl. 1 (2010) S1–S51 S19 with normal spleen diameter (p 20 ppm or a rise by 12 ppm above baseline following glucose administration was considered as positive. IP was evaluated by the (51)Cr-EDTA permeability test. SIBO prevalence in LC was compared with healthy controls and correlated with LC severity and IP. Results: Twenty-nine out of 56 LC patients had SIBO vs 2 of the 48 healthy controls (51.8% vs 4%, p< 0.0001). SIBO prevalence correlated with the severity of LC (68.2% of Child C pts vs. 56.2% of Child B and 31.2% of Child A pts), with the presence of ascites (66% in ascitic pts vs. 27% in non-ascitic pts), and with a history of SBP (92% of patients with SBP vs. 48% of those without SBP). A significant correlation was found between presence of SIBO and altered IP: it was weak for Child A but significant for Child B and C pts (R = 0.07, NS; R = 0.35, p = 0.005; R = 0.29, p = 0.03, respectively). Conclusions: SIBO seems to have a higher prevalence in LC, correlates with LC severity and altered IP. This association suggests that SIBO may affect intestinal permeability of splancnic vessels and/or peritoneal membranes leading to SBP outbreak in LC. Future interventional studies are needed to confirm these preliminary data. T.N.13 PREDICTORS OF OUTCOME IN CIRRHOTICS ADMITTED TO INTENSIVE CARE UNIT (ICU); SURVIVORS EXHIBITED SIGNIFICANT RISE OF SERUM SODIUM LEVELS AND A FALL IN LACTATE LEVELS AT 48 HOURS M. Garcovich1,2, V. Vemala1, A. Davenport1, E. Dionigi1, S. Shaw1, B. Agarwal1, A.K. Burroughs1. Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK; Dipartimento di Medicina Interna, Universita Cattolica del Sacro Cuor, Rome, Italy Background: Critically ill cirrhotics admitted to ICU have poor prognosis. Factors known to portend worse outcome include mechanical ventilation, development of shock, renal failure and increasing number of organ failure. While a negative impact on mortality of low serum sodium level is observed in stable cirrhotics active on the waiting list for liver transplant, the impact of admission serum sodium and its changes during the course of an acute illness in these patients is not well known. Methods: We retrospective studied a cohort of cirrhotics admitted to ICU between 2005−08 at the Royal Free Hospital. Data were collected on demographic variables, aetiology of liver disease, liver-specific prognostic scores; Child–Turcotte–Pugh (CTP), Model for end-stage liver disease (MELD), United Kingdom model for end-stage liver disease (UKELD), acute physiological score and chronic health points (APACHE II) and sequential organ failure assessment score (SOFA). In addition, data were also collected for serum Na+ and Lactate levels at 0 (on admission) and at 48 hrs. Results: Currently 67 of 125 patients have been enrolled. 51/67 (76.1%) survived ICU. The non-survivors (16/67) had similar demographics as the survivors, had significantly higher mean MELD, UKELD, SOFA and APACHE II scores, and higher admission lactate. Total CTP score was not different between the groups but serum bilirubin level and prothrombin time were significantly higher in the non-survivors. Although the admission Na+ levels in survivors and non survivors were similar, a significant elevation was observed at 48 hrs in the survivors. The trend for serum lactate levels showed a similar pattern i.e., the survivors showed significant reductions at 48 hrs. Conclusions: The reasons for this observed rise in serum Na+ at 48 hrs in the survivors are not obvious. It may signify a better preserved water balance in patients with less severe underlying liver disease. T.N.14 COLLAGEN PROPORTIONATE AREA IN ASSESSING THE AMOUNT OF FIBROSIS IN CHRONIC LIVER DISEASE: DOES HIGH RESOLUTION COMPARED TO CONVENTIONAL IMAGE CAPTURING AND ANALYSIS ALTERS ITS RESULTS? L. Andreana1, G. Isgro1, M. Garcovich1, A. Hall2, F. Grillo2, A.P. Dhillon2, A.K. Burroughs1, T.V. Luong2. The Sheila Sherlock Liver Centre and University Dept. of Surgery, Royal Free Hospital, London, UK; Dept. of Histopathology, Royal Free Hospital,

Minor versus major hepatic resection for small hepatocellular carcinoma (HCC) in cirrhotic patients: A 20-year experience

The choice between minor versus major resection or anatomic versus nonantatomic resection for small (<5 cm) solitary hepatocellular carcinoma (HCC) in patients with cirrhosis is controversial. The aim of our study was to evaluate the long-term disease-free survival (DFS) and overall survival (OS) after minor or major hepatic resection for small solitary HCC in cirrhotic patients. Between January 1983 and December 2002, patients with solitary HCC of < or = 5 cm in size who had histologically proven liver cirrhosis and microscopically tumor-free margin were included. These selected patients underwent either minor (< or = 2 segments) or major (> or = 3 segments) hepatectomy. In 373 patients, 259 underwent minor and 114 underwent major hepatectomy. Patients in the minor resection group had more severe underlying liver disease (P = .005). Therefore, only 29.3% received anatomic resection in the minor resection group in comparison with 72.8% in the major hepatectomy group (P = .0001). No difference was found in postoperative morbidity (P = .105), mortality (P =.222), intrahepatic recurrence (P = .742), and 5-year DFS and OS (31.6% vs 31.8%, P = .932 and 50.7% vs 44.0%, P = .114) in both groups. The type of operative resection was not found to be a significant factor affecting survival in univariate analysis, but the preoperative liver function (alanine aminotransferase [AST] or alanine aminotransferase [ALT], serum albumin, or Child-Pugh status), tumor characteristics (alpha-feto protein, size, and presence of daughter nodules), and blood transfusion were found to be independent factors that affect the DFS and OS in a multivariate analysis. The severity of cirrhosis and tumor characteristics depicts long-term survival rather than the type of resection in HCC.

Patients’ Preferences for Treatment of Hepatitis C

The objective of this study was to ascertain patient preferences for treatment of hepatitis C virus (HCV). The authors recruited consecutive patients eligible for treatment of HCV and used adaptive conjoint analysis (ACA), a hybrid approach of conjoint analysis that uses both self-explicated ratings and pair-wise comparisons, to elicit preferences for pegylated-interferon and ribavirin. They examined the association between patient characteristics and treatment preferences using the Mann-Whitney U test and chi(2) statistic for continuous and categorical variables, respectively, and subsequently calculated adjusted odds ratios and 95% confidence intervals using logistic regression. A total of 140 subjects completed the ACA task. The mean (+/-SD) age of the sample was 51+/-8 y; 85% were male, and 59% were white. When described as being associated with mild side effects, 67% (n = 94) of subjects preferred treatment for HCV. The percentage of subjects preferring therapy decreased to 51% (n = 72) when it was described as being associated with severe side effects. Preferences for treatment of HCV were stronger among subjects with a higher perceived risk of developing cirrhosis, more severe underlying liver disease, and worse HCV-related quality of life. Subjects having more severe disease placed greater weight on the importance of expected benefits and less on the risk of toxicity compared with those with mild or no fibrosis. Whether to choose treatment for HCV is a difficult decision for many patients. Treatment is usually recommended for those with moderate to severe liver disease, and these results demonstrate that most patients' preferences are concordant with this practice.

Hepatocellular carcinoma and liver transplantation: Entering the area after the Milan and University of California at San Francisco criteria?

Hepatocellular carcinoma and liver transplantation: Entering the area after the Milan and University of California at San Francisco criteria?

Spontaneous Bacterial Peritonitis.

Spontaneous bacterial peritonitis (SBP) is the prototypical ascitic fluid infection occurring in patients with advanced liver disease and ascites. The key to successful treatment of SBP is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops, particularly those individuals at high risk for infection. A high index of suspicion should lead to early diagnostic paracentesis and ascitic fluid analysis. Treatment of SBP involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP. SBP typically involves infection with a single organism, with Escherichia coli, Klebsiella spp, and Streptococcus spp responsible for nearly three fourths of cases. The treatment of choice is cefotaxime 2 g given intravenously every 8 hours for a total of 5 days. The antibiotic regimen is adjusted based on the results of ascitic fluid cultures. Other antibiotic regimens for SBP are less well studied. Given the significant morbidity and mortality rates associated with SBP, efforts to prevent its development and recurrence with antibiotic prophylaxis are warranted. The most extensively studied form of prophylaxis involves selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin. Individuals with low-protein ascites (ascitic fluid total protein < 1g/dL) benefit from SID with norfloxacin 400 mg daily during times of hospitalization. Long-term primary prophylaxis during outpatient management of individuals awaiting liver transplantation with severe ascites and advanced liver failure should also be considered. Patients with cirrhosis and upper gastrointestinal bleeding should receive norfloxacin 400 mg twice daily for 1 week following their bleed. Those individuals surviving an episode of SBP should be treated with norfloxacin 400 mg daily until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery. Although the infection-related mortality associated with SBP has decreased to less than 10%, hospitalization-related mortality remains as high as 30% as a result of the severe underlying liver disease in which the infection arises and the marked generation of cytokines and nitric oxide resulting from the infection. Recently, the simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality. Further improvement in the outcomes of SBP will require treatments targeting this cytokine cascade rather than the development of more potent antibiotics.

Nonsurgical treatment of hepatocellular carcinoma

While surgical resection and tumor ablation are the preferred therapies for hepatocellular carcinoma (HCC), these are available or appropriate in only a minority of patients. This reflects the usual comorbidity of severe underlying liver disease that either precludes surgery or makes the surgical approach extremely dangerous. Nonetheless, regional control of HCC is highly relevant and many regional strategies have been explored, including hepatic intra-arterial chemotherapy transarterial chemoembolization, lipiodol chemoembolization, radiation therapy, cryosurgery, percutaneous ethanol injection, and radiofrequency ablation. In addition, a variety of systemic chemotherapeutic agents have been tested in HCC, including various combinations of 5-fluorouracil, doxorubicin, epirubicin, etoposide, cisplatin, and mitoxantrone, as well as interferon, tamoxifen, capecitabine, thalidomide, and octreotide. Published data regarding these regional and systemic therapies will be discussed in this review.

Primary prophylaxis of variceal bleeding in cirrhosis.

Variceal bleeding is the result of portal hypertension, which is a major complication of liver cirrhosis and carries a high mortality rate. Because of the mortality associated with variceal bleeding, strategies for prevention of the first bleed is important. Risk stratification is important in determining those at risk of bleeding from varices and current data suggest that patients with large varices with red signs, severe underlying liver disease and those who have a hepatic venous pressure gradient of greater than 12 mmHg are at high risk of bleeding. Surveillance for varices in patients with cirrhosis is therefore important. The current review evaluates the role of various treatments in the primary prophylaxis of variceal bleeding. The current first choice treatment is non-selective beta-blockers; which is cheap, easy to administer, and reduces the risk of first variceal haemorrhage significantly. Combination of beta-blockers and nitrates looks promising but needs further evaluation. Endoscopic variceal band ligation compares favourably with non-selective beta-blockers in preventing the first bleeding episode in cirrhotic patients and may be an alternative for patients who cannot tolerate, or have contraindications to beta-blockers. The role of monitoring the hepatic venous pressure gradient in those being treated with pharmacological agents, the role of newer drugs such as non-selective beta-blockers with intrinsic alpha-adrenergic activity and angiotensin receptor blockers require further evaluation.