bluuebunny/crossref_metadata_2025 huggingface dataset:
1057 National Demographic and Economic Trends of Primary Malignant Liver Neoplasms in the United States From 2000-2015
Authors: Khiew Yii Chun , Tsoukas Stephen
Published: October 2019

INTRODUCTION:

Primary malignant liver neoplasms involve tumors arising from hepatocytes and biliary epithelium. Risk factors include host factors, co-morbid diseases, and environmental exposures. The purpose of this study is to analyze trends in demographics, mortality, inpatient costs, and risk factors.

METHODS:

The Nationwide Inpatient Sample (NIS) database generated from the Healthcare Cost and Utilization Project was used to obtain a subset of discharge level data obtained from every 3 years from 2000 to Q3 2015. All cases with primary ICD-9 diagnosis code of primary malignant liver neoplasm were identified. Analysis included patient and hospital demographics, total inpatient cost, inpatient mortality, and the presence of secondary diagnoses for known risk factors of hepatocellular carcinoma (chronic viral hepatitis, alcoholic liver disease, and non-alcoholic fatty liver diseases (NAFLD).

RESULTS:

A total of 79,200 discharges were recorded between 2000 and 2015. There was an initial 24.1% increase in prevalence between 2000 and 2009 (9949 to 16266 cases), with a subsequent plateau across 2012 and 2015. There was a consistent male predominance (approximate ratio of 2.4 to 1). While the majority of patients across all years were between the ages of 45-84, there were fewer cases of 18-44 year olds from 2000 to 2015. Rates have increased in Caucasian, African-American, and Hispanic populations, with regional predominance in the South. There was a concurrent increase in secondary diagnoses of chronic HCV and non-alcoholic liver diseases (59.1% and 49.4% relative increase from 2000 to 2015 respectively). Despite a reduction of in-hospital mortality, total charges per annum increased from $25,306 in 2000 to an extrapolated $100,581 in 2015.

CONCLUSION:

This study highlights the increasing burden of primary liver neoplasms in the United States. Despite reduction of in-hospital mortality, the annual cost has increased significantly. Further studies are required to elucidate factors contributing to increasing charges, and regional and racial variation. Future strategies should focus on the effect of risk factor reduction such as early detection and treatment of viral hepatitis and NAFLD.
1060 The Use of Albumin in Cirrhotics: Data From a Tertiary Care Center
Authors: Mishra Kajali , Ashraf Taha , Venkat Deepak
Published: October 2019

INTRODUCTION:

Human albumin solution is an expensive colloid preparation commonly used in cirrhotics’ management. Approved indications of albumin administration in cirrhotics include large volume paracentesis (LVP), hepatorenal syndrome (HRS), and spontaneous bacterial peritonitis (SBP). Albumin use is not routinely recommended in inflammatory and hypovolemic states. The aim of this study is to identify albumin utilization patterns in a tertiary care center and to assess potential areas of improvement in albumin prescribing strategies.

METHODS:

We performed a retrospective chart review of 342 cirrhotic patients who received 25% albumin solution during their admission from January 2016 to January 2018. Baseline demographics, etiology of cirrhosis, and severity was noted. Indications for albumin administration were reviewed and other clinical variables were gathered. Patients with and without indications for albumin were compared using chi-square tests for categorical variables and two-sample t-tests for continuous variables.

RESULTS:

There were 342 cirrhotic patients included in this study. 187 (55%) were male, 227 (66%) were Caucasian and the mean age was 59 ± 11 years. The most common cirrhotic etiologies were Alcohol (n = 95, 28%), Nonalcoholic steatohepatitis (NASH) (n = 84, 25%) and Hepatitis C (n = 72, 21%). There were 187 (55%) patients who had at least one approved indication for albumin; out of those patients, 167 (48.4%) had HRS, 66 (19%) had SBP, and 77 (23%) underwent LVP. African Americans were more likely to receive albumin in the absence of an indication, as compared to Caucasians (P = 0.047). Patients who received albumin without an indication had a higher incidence of septic shock (34% vs 21%, P = 0.008); sepsis with acute kidney injury (AKI) (22% vs 12% P = 0.017); and history of HRS (35% vs 19% P = 0.0005) or SBP (37% vs 25% P = 0.018). No differences were detected between the two groups for age, gender, BMI, MELD, MELD NA, and etiology.

CONCLUSION:

There is a high rate of non-indicated albumin administration in cirrhotic patients. Apart from approved indications which have mortality benefit, shock, hypovolemia, or a history of SBP/HRS are influencing physicians to use albumin in cirrhotics. It is important to establish clinical protocols for judicial use of this expensive and limited resource.
1076 Prevalence of Cirrhotic Cardiomyopathy and Its Correlation With Serum Pro-BNP Levels, HRS, SBP, and Mortality
Authors: Kapoor Neha , Mehta Vimal , Kumar Suresh , Kar Premashis
Published: October 2019

INTRODUCTION:

Cardiac dysfunction is common in patients with cirrhosis. This study aims at estimating the Prevalence of Cirrhotic Cardiomyopathy and its correlation with pro-BNP levels, Hepatorenal Syndrome (HRS), SBP (Spontaneous bacterial peritonitis) And Mortality.

METHODS:

This was a prospective study in which we used newer technique Doppler Echocardiography and also did conventional 2D and Doppler echocardiography in cirrhotic patients. Additionally, QTc interval, pro-BNP, Tropinin T levels were measured. Patients were followed up for 6 month to look for any new complications that developed like hepato-renal syndrome, Spontaneous bacterial peritonitis or any mortality.

RESULTS:

In our study 53 cirrhotic patients were compared with 30 controls whose age and sex was matched. The results in 53 cirrhotic patients: mean age 43.81 ± 12.31yr, M:F: 49:4)etiology:alcoholic-27,nonalcoholic-26,child score(A-0,B-15,C-38),MELD Score was 18.17 ± 1.69 in diastolic dysfunction group and 16.36 ± 1.70 in cirrhotic patients without diastolic dysfunction. Doppler Echocardiography showed mean early diastolic velocity of 11.6 ± 2.6 vs 19.8 ± 6 cm/sec(P < 0.01) and mean late diastolic velocity of 10.7 ± 2.9 vs 8.4 ± 3.1 cm/sec(P < .05).The mean Doppler E- velocity was 0.76 ± .16 vs 0.88 ± 0.14 (P < 0.05),A-velocity was 0.72 ± 0.25 vs 0.53 ± 0.11(P < 0.01), DT was 231 ± 49.60 vs 212.9 ± 61.9 (p-NS) and E/A ratio was 1.14 ± 0.34 vs 1.7 ± 0.43(P < 0.01). The troponin-T levels were <.01ng/ml(normal range).The mean pro-BNP level was 447.62 ± 225.72 pg/ml (normal for our lab < 125 pg/ml).Mean QTc interval was 509.37 ± 54.32 msec.

CONCLUSION:

The study showed that diastolic dysfunction is highly prevalent (56.6% of study population) in cirrhosis. QTc interval and BNP were also significantly raised. In addition Cirrhosis complications like Hepatorenal Syndrome (HRS), SBP (Spontaneous bacterial peritonitis), and Hepatic Encephalopathy were more common in cirrhotic cardiomyopathy group.
1082 N-Acetylcysteine: A Novel Agent for Patients With Ischemic Hepatopathy
Authors: Kothari Shana , Kalinowski Michael , Brindise Elizabeth , Kobeszko Matthew , Silva Rogelio
Published: October 2019

INTRODUCTION:

Acute ischemic hepatopathy is diffuse hepatic injury from hypoperfusion leading to a profound elevation in aminotransferases; it accounts for 1 to 2.5 percent of patients admitted to an intensive care unit. Recent studies showed that N-Acetylcysteine (NAC) provides mortality benefit and improves transplant-free survival in patients with non-acetaminophen induced liver injury, however no studies have shown its effects on ischemic hepatopathy. In studies utilizing murine models, NAC was found beneficial in ischemic injury given its anti-apoptotic, anti-inflammatory, and anti-oxidant properties. We aim to evaluate the trend of hepatic function tests, use of vasopressor requirements, and length of intensive care stay for patients admitted with ischemic hepatopathy who received the 72-hour-NAC protocol compared to those who did not.

METHODS:

In this retrospective single-center study, we identified adult patients with ischemic hepatopathy from cardiogenic, septic, or hypovolemic shock within a three year period. Chart review was performed and data trends in transaminases, bilirubin, coagulation tests, creatinine, vasopressor requirements, and the number of intensive care days were collected. Univariate analysis was performed.

RESULTS:

A total of 30 patients with ischemic hepatopathy were included; 15 patients received the 72-hour NAC protocol and 15 patients did not. No differences were found in median age or gender between both groups. A statistical improvement in the aspartate aminotransferase (AST) (-93.6% vs -72.8%, P = 0.003) and creatinine (-38.2% vs 19.3%, P = 0.000) was observed in the NAC group compared to the non-NAC group. Median vasopressor days were fewer and length of stay was higher in the NAC group compared to the control, but not statistically significant. There was no significant difference in mortality.

CONCLUSION:

Based on our data, NAC use is associated with improved renal function at 72 hours. The NAC group appeared to have a more rapid improvement of AST, alanine aminotransferase (ALT), and bilirubin compared to the control group; however, only AST reached statistical significance, likely due to the small sample size. This pilot study shows potential clinical benefit of NAC as a treatment modality for ischemic hepatopathy. Higher-powered, randomized controlled trials are needed to further validate these observations.
1083 Health-Related Quality of Life Decreases With Disease Progression From Chronic Liver Disease to Cirrhosis and Hepatocellular Carcinoma
Authors: Salcedo Juan , Viray Terilyn , Feun Lynn , Selvaggi Gennaro , Martin Paul M. , Jones Patricia D.
Published: October 2019

INTRODUCTION:

Health-related quality of life (HRQOL), an important outcome for cancer patients, is reliably measured by the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep). FACT-Hep predicts disease progression, treatment response and survival in HCC patients. This study aimed to evaluate HRQOL in diverse HCC patients compared to patients with chronic liver disease (CLD) and cirrhosis.

METHODS:

Since 2018, we have enrolled patients with CLD, cirrhosis and HCC from the University of Miami and Jackson Memorial Hospitals into an observational longitudinal cohort. Clinical data is extracted from the electronic medical record. Participants complete various surveys, including the FACT-Hep version 4.0. Descriptive statistics were used for demographics and disease-specific characteristics. Each FACT-HEP subscale was prorated and combined, if valid. Disease subgroups were compared using Pearson’s chi-squared or Kruskal-Wallis tests. In a subset of participants who completed the Perceived Stress Scale (PSS-10), stress was correlated with HRQOL.

RESULTS:

From 1/2018 to 3/2019, 333 patients enrolled; 103 have CLD, 131 have cirrhosis and, 99 have HCC (91 cirrhotic HCC and 8 noncirrhotic HCC). The sample is 4% Asian, 16% Black, 34% White and 42% Hispanic. Median age of the CLD group was 54 years vs. 58 years for cirrhotics and 65 years for HCC patients, P < 0.001. Table 1. The FACT-Hep was completed by 223; the prorated score was valid in 211. There were no significant differences in physical, social, or emotional well-being when comparing disease groups. In contrast, participants with cirrhosis or cirrhotic HCC had significantly worse functional well-being compared to those with CLD or noncirrhotic HCC, P 0.001. Patients with cirrhosis with or without HCC scored lowest (worst) on the hepatobiliary subscale. HRQOL was best in non-cirrhotic HCC patients, then CLD patients, then cirrhotic patients followed by cirrhotic-HCC patients, P 0.004. Table 2. The PSS-10 was administered to 38 participants who completed the FACT-Hep. There was a correlation between stress and HRQOL; as stress increased from low to moderate to high, HRQOL decreased significantly, P 0.003. Significant racial differences in HRQOL, P 0.05, disappeared when stratified by disease group.

CONCLUSION:

Low HRQOL in HCC patients is likely driven by cirrhosis; non-cirrhotic HCC patients had the highest HRQOL. Therefore, alleviation of cirrhosis symptoms may improve HRQOL for most HCC patients.
1092 Referral Trends Show Low Linkage-to-Care of NAFLD Patients at a Tertiary Care Academic Center in Northern California
Authors: Leung Marcia , Piao Cindy , Frank Darren M. , Kuo Alexander , Sarkar Souvik
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) has emerged as the most common cause of chronic liver disease. NAFLD affects ∼1/3rd of the US population, with ∼70% prevalence in diabetics of whom 4-5% have advanced fibrosis. Despite its prevalence, NAFLD is under-recognized by physicians. Defining at-risk NAFLD patients is a cost-effective strategy. There is limited data on the referral process of NAFLD patients to help incorporate changes within health systems. In this study we queried referral trends for NAFLD, with specific focus on diabetes patients and non-invasive fibrosis score.

METHODS:

This is a retrospective analysis of referrals to gastroenterology at a tertiary care referral center for a large part of Northern California, for fatty liver disease between Jan 1, 2017 – December 31, 2018. Demographics, laboratory data, imaging (Fibroscan, MR elastography), comorbidities and liver biopsy, if available, were recorded. Well-validated FIB-4 score was calculated.

RESULTS:

Of 435,739 active patients at the center, 31,934 (7%) were diabetics. In 2 years, 188 referrals were made for NAFLD of whom 23% had diabetes, 67% did not have diabetes, 8% were unknown. Primary care providers made 86% referrals; there were no referrals from endocrinology. Approximately half of referrals (46%) had elevated ALT. Among them, 40% were referred for chief complaint of abnormal labs. As noted in the Table 1, FIB-4 >2.67 was seen in 14% of diabetics and 12% non-diabetics, while FIB-4< 1.3 was 39% and 57% of diabetics and non-diabetics. Nearly half of the referred patients underwent fibroscan, MRE or liver biopsy with the tests primarily in those with higher FIB-4 (66% of those with FIB-4≥1.3). Based on biopsy and/or imaging, 45% had stage 0-1 fibrosis while 24% and 6% were stages 2-3 or 4, respectively. Of those with FIB-4< 1.3, 84% had fibrosis 0-1 on further imaging/biopsy, while in those with FIB-4 1.3- 2.67 or >2.67 had stage 2-4 fibrosis in 29% and 54%, respectively.

CONCLUSION:

In the span of two years, only a handful of diabetic patients with NAFLD have been linked to care, with a notable lack of referrals from endocrinology. Majority of the referrals were for those with low FIB-4 scores, potentially missing a large percentage of advanced fibrosis patients. Our data shows a significant need for systems change and provider education to link-to-care patients at high risk of advanced NAFLD, with FIB-4 as a starting point.
1095 Presence of Acute Kidney Injury (AKI) at Admission in Severe Alcoholic Hepatitis (SAH) Patients Predicts Mortality: A Single Centre Experience
Authors: Singh Shivaram Prasad , Khatua Chitta Ranjan , Barik Rakesh Kumar , Sahu Saroj Kanta , Pradhan Subhasis , Meher Dinesh , Nath Gautam
Published: October 2019

INTRODUCTION:

Severe Alcoholic Hepatitis (SAH) is a life-threatening condition. There are different models to prognosticate patients with SAH. However, the impact of presence of acute kidney injury (AKI), defined as per AKIN criteria in patients with SAH has not been assessed for this region of Asia. Hence we performed a prospective study to evaluate the spectrum of SAH including outcome in hospitalized patients and the impact of AKI on outcome of patients with SAH.

METHODS:

This study was conducted on consecutive alcoholic hepatitis (AH) patients hospitalised in Gastroenterology Department, SCB Medical College, Cuttack, India between October 2016 and October 2018. On diagnosis of AH, modified Maddrey discriminant function (mDF) was used to detect SAH (mDF score ≥32).Demographic, clinical and laboratory parameters were recorded and survival was compared between patients with and without AKI (as per AKIN criteria) during hospitalisation and also at 28 days and 90 days.

RESULTS:

339 patients of AH were included in the study. Out of them, 236 (70%) patients had SAH (DF ≥ 32) and 103 patients (30%) had DF < 32.All patients with SAH were males. 164 (69%) patients with SAH had AKI and72 (31%) did not have AKI at hospitalisation. On comparison between SAH patients with or without AKI, age was comparable between the two groups. However, patients with SAH and AKI had higher MELD UNOS (28.69 ± 8.36 vs 19.50 ± 3.83; P < 0.001), MELD Na+ (30.44 ± 7.56 vs 22.97 ± 4.56; P < 0.001), CTP score (12.46 ± 1.84 vs 11.93 ± 1.50; P = 0.033), DF ((71.18 vs 53.24,IQR; P < 0.001) and ABIC score (3.37 ± 1.47 vs 2.26 ± 0.61; P < 0.001). Furthermore, they had increased prevalence of ACLF as per CANONIC study criteria (73.2% vs 34.7%; P < 0.001), increased duration of hospitalisation (5days vs 4days,IQR; P < 0.001) and decreased survival both at 28days (57.9% vs 80.6%; P < 0.001) and 90days (36% vs 55.6%; P = 0.005). Kaplan–Meier survival curves showed significant differencesin survival between patients with and without AKI both at 28 days (log rank P value < 0.001) and 90 days (log rank P value < 0.001) (Figure 1).

CONCLUSION:

In our institution, over three fourth of alcoholic liver disease patients had severe AH and three fourth of them had AKI at admission. Patients with AH and AKI had increased proportion of ACLF, longer hospital stay, and decreased survival both at day 28 and 90.
1102 Direct Oral Anticoagulants May Be Used in the Treatment of Portal Vein Thrombosis in Patients With Cirrhosis: A Systematic Review and Comparative Meta-Analysis
Authors: Mohan Babu P. , Khan Shahab R. , Aravamudan Veeraraghavan Meyyur , Trakroo Sushrut , Garg Rajat , Ponnada Suresh , Asokkumar Ravishankar , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Well-defined guidelines for the treatment of portal vein thrombosis (PVT) in patients with cirrhosis do not exist due to lack in robust data. Treatment options include low molecular weight heparin (LMWH), vitamin K antagonists (VKAs), and the newer direct anticoagulants (DOACs). Anticoagulation safety has been an issue in patients with cirrhosis, and the best choice of anticoagulation is unknown.

METHODS:

We conducted a comprehensive search of multiple databases and conference proceedings (through November 2018) to identify studies that reported on the use of LMWH, VKAs, and DOACs in the treatment of PVT in patients with cirrhosis. Goals were to evaluate the pooled rate of treatment success and bleeding with LMWH, VKAs, and DOACs, and indirectly compare the outcomes.

RESULTS:

From a total of 744 patients (17 studies), 648 were treated with some form of anticoagulation and 96 were control. 155, 315, and 70 patients were treated with LMWH, VKAs, and DOACs respectively. Baseline characteristics were comparable among the groups. Age ranged from 41 to 71 years with a predominantly male population. 144 patients were Childs A, 182 Childs B, and 121 Childs C. Pooled rate of treatment responders with anticoagulation was 66.7% (95% CI 58.3-74.1, I2 = 72.7) and with control was 26% (95% CI 14.2-42.7, I2 = 36.7). The difference was statistically significant, P = 0.001. Pooled rate of bleeding was similar between these two groups (7.8%, 95% CI 4.5-13.3 and 15.4%, 95% CI 4.3-42.7, P = 0.33). Pooled rates of treatment success and bleeding events were comparable between LMWH, VKAs, and DOACs (Table 1). On meta-regression analysis, Child-Pugh classification did not seem to affect the treatment success and/ or the bleeding outcomes. The calculated 2-sided P-value of intercept was 0.39, Childs A was 0.15, Childs B was 0.11, and Childs C was 0.15.

CONCLUSION:

Our study demonstrates that anticoagulation is effective and safe in the treatment of PVT in patients with cirrhosis. Bleeding is not increased in treatment group compared to control group. Due to their similar and comparable outcomes, DOACs may be offered as a first line treatment based on patient preferences. Limitations of our study were the comparatively small sample size of patients on DOACs, heterogeneity, and indirect comparison. Well-conducted studies are warranted to ascertain the role of DOACs in the treatment of PVT in patients with cirrhosis.
1103 Can Non-invasive Markers of Liver Histology for Non-Alcoholic Fatty Liver Disease (NAFLD) Help Predict Cardiovascular Risk by Application of the Framingham Scoring System?
Authors: Malik Fahad , Kim Marina , Heldon Alec , Vaze Reema , Golpanian Daniel , Mohanty Smruti R.
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in developed countries with a prevalence of 25%-30%. Independent of cardiovascular and metabolic risk factors, NAFLD is associated with the progression of coronary atherosclerosis. The Framingham risk score (FRS) is useful in identifying patients at higher 10-year coronary heart disease risk. We aim to creative a simple, safe, cost-effective and non-invasive method for diagnosing NAFLD and assigning a cardiovascular risk.

METHODS:

In this retrospective analysis, 1038 adult patients who underwent a liver biopsy between the years of 2009 – 2016 were examined. NAFLD was diagnosed on the basis of histology after the exclusion of alcohol, viral, metabolic and autoimmune liver disease by chart review. Clinical and laboratory data was collected from the time of the liver biopsy. The NAFLD Activity Score was used to histologically classify our patients into different degrees of steatohepatitis. From the initial 1038 patients, 276 patients were identified to have steatosis on histology (< 5% steatosis excluded). We calculated the FRS score based on a standard score sheet that is gender specific and includes the following variables: age, blood pressure, total cholesterol, HDL-cholesterol, smoking history and history of diabetes. To conform to the FRS, we included only patients between 30-74 years old. Non-invasive scores for liver fibrosis such as AST platelet ratio index, BARD, Fibrosis-4 index, and NAFLD fibrosis score were calculated for the remaining 50 patients and compared to the liver histology graded by the NAFLD Activity Score and to the FRS.

RESULTS:

Regression of our variables showed a positive association between AST platelet ratio index with the FRS, 2.71 (P = 0.0162), and a negative association between the BARD score and FRS 1.38 (P = 0.0189). The remaining non-invasive scores (FIB-4, NFS) did not show a statistically significant association with the FRS. Finally, the NAS score did not show a statistically significant association with the FRS score.

CONCLUSION:

The APRI score can accurately predict the degree of liver fibrosis in a patient with NAFLD and the FRS can readily be calculated in NAFLD patients that may be at highest risk of CHD outcomes and could benefit from an intervention. Our study was limited due to a small sample size, which may attribute to the lack of statistical significant association between FIB4, NFS, and the NAS to the FRS and the 10 year risk of coronary heart disease.
1109 Ethnic and Geographic Variations for NAFLD-Related Hospitalizations
Authors: Tawadros Augustine , Bhurwal Abhishek , Rustgi Vinod K. , Pioppo Lauren , Reja Debashis
Published: October 2019

INTRODUCTION:

Non-Alcoholic fatty liver disease (NAFLD) is increasingly being recognized as an epidemic in the United States. We analyzed geographic patterns of hospitalized patients with NAFLD. Multiple factors are involved in NAFLD/NASH including genetic factors such as has been shown with GWAS studies identifying the PNPLA3 polymorphism which is increased in the Hispanic population.

METHODS:

This was a retrospective cohort study using the 2016 Nationwide Inpatient Sample (NIS) utilizing International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10 CM). All patients greater than 18 years of age with principal or secondary discharge diagnoses of NAFLD were included in the cohort. Comparisons were made between four geographic regions (northeast, south, Midwest and east) and between ethnicities (Caucasian, African American, Hispanics). Outcomes included incidence of NAFLD-related admissions, in-hospital mortality, length of stay (LOS) and total hospitalization charges. Proportions were compared using fisher’s exact test and continuous variables using student t-test. Multivariable and Poisson regressions were performed for length of stay and hospitalization charges. All statistics were performed utilizing STATA software.

RESULTS:

A total of 109,634 discharges had principal or secondary diagnoses of NAFLD for the year 2016. Of these, 19,815 (18%) were in the Northeast, 18,340 (16.7%) in the Midwest, 46,214 (42.15%) were noted in the South, whereas 25,264 (23%) were identified in the East as shown in Table 1. 62% were Caucasians, 10% were African Americans, while 18% were Hispanics. Table 2 shows ethnic differences. The Hispanic population was significantly younger with an increased predominance in males and was disproportionately present in all four regions. Diabetes Mellitus was more significantly associated with NAFLD in the South and African-Americans. The length of stay was significantly shorter in the East (3.03 days vs 3.53 days in Northeast, P < 0.001. These findings persisted after adjustment for confounders.

CONCLUSION:

Our study does show differences in hospitalization related to NAFLD during the year 2016 in terms of cost and length of stay. NAFLD-related hospitalizations were more common in the South. Further studies are needed to elucidate the reasons for the predominance of NAFLD in the South and the Hispanic population.
1110 The Use of Four-Factor Prothrombin Complex Concentrate versus Fresh Frozen Plasma in Patients With Cirrhosis
Authors: Mandel Julie , Ahmad Samrah , Lee Susan , Bernstein David
Published: October 2019

INTRODUCTION:

Cirrhotic patients (pts) are at increased risk for bleeding due to alterations in hemostasis. Fresh frozen plasma (FFP) is the most common agent used for reversal of coagulopathy. However, four-factor prothrombin complex concentrate (4F-PCC) usage has increased as it has a lower infusion volume and shorter administration time. The objective of this study was to evaluate the efficacy of 4F-PCC compared to FFP in correcting INR for treatment and prophylaxis of bleeding in pts with cirrhosis undergoing urgent procedures.

METHODS:

A retrospective chart review of cirrhotic pts who received at least one dose of 4F-PCC or FFP during the defined study period of January 2016 through March 2019 was performed. Pts were identified in the Allscripts EMR. Cirrhosis was identified by the presence of one or more of seven pre-determined diagnostic codes. Pts were excluded if they received both agents within 24 hours or had no documented INRs. Data collected included: age, sex, race, etiology of liver disease, baseline anticoagulant and antiplatelet use, reversal agent administered, baseline and subsequent INR values,, thromboembolic events, mortality, and length of stay (LOS). All data was recorded confidentially and de-identified. The primary outcome was time to INR reversal, defined as an INR of less than 1.5 ULN. Secondary outcomes included thromboembolic event occurrence, all-cause mortality and hospital length of stay. Appropriate statistical analysis was performed.

RESULTS:

39 pts were included in the study with 43 reversal agents administered, 29 FFP and 14 4F-PCC. There was no statistical difference in baseline characteristics between groups. A majority of pts had Child’s C cirrhosis. Reversal of INR was observed in 4 FFP pts (14%), and 8 4F-PCC pts (57%). The median time to reversal in the 4F-PCC group was 267.5 minutes (P = 0.035). The reduction in INR from baseline to nadir was 0.5 units (20.5%) in the FFP group and 1.2 units (44%) in the 4F-PCC group (P < 0.001). There was no observed thromboembolic events and mortality rates did not differ between groups (44% vs 30%, P = 0.70). Mean hospital (LOS) was 20.7 days in the FFP group and 12.8 days in the 4F-PCC group (P = 0.67).

CONCLUSION:

4F-PCC was associated with significantly 1) improved time to INR reversal, 2)improved extent of INR correction and 3)decreased hospital LOS compared to FFP. Cirrhotic pts with an abnormal INR who present with bleeding may benefit from the administration of 4F-PCC prior to procedural intervention.
1112 Hepatitis C Virus Infection in Young Adults - A Re-Emerging Problem
Authors: Nagaraj Savitha V. , Lin Kyawzaw , Etienne Denzil , Reddy Madhavi
Published: October 2019

INTRODUCTION:

Hepatitis C virus (HCV) infection is a major cause of life-threatening liver diseases worldwide. People born between 1945-1965 have been known to have high incidence of HCV. In recent years, increased rate of HCV infection is noted in the younger populations. This has been attributed to injection drug use, opioid addiction and perinatal transmission. It is paramount to understand the pattern of HCV transmission, disease severity and treatment rates in the young adults which can enable us to provide timely intervention and prevent detrimental liver complications.

METHODS:

Retrospective observational study including patients between 18 to 40 years who tested positive for HCV antibody between 2016-2017. Descriptive and statistical analyses were performed to evaluate prevalence of HCV, treatment rates and disease severity. Liver disease severity was calculated using Model of End Stage Liver Disease (MELD) and Child-Pugh Turcot (CTP) scores.

RESULTS:

A total of 507 patients who tested positive for HCV antibodies between 2016-2017 was evaluated. Of these, 83 (n = 83) patients between 18 to 40 years were included in this study. Prevalence of HCV was noted to be 16.4%. Majority of the population were African American (66%). An almost equal number of males and females (53% and 47%) were present. The incidence of smoking, alcohol use and IV drug use were 12%, 25% and 19% respectively. Majority had CTP score of 5-6 (87%) and rest had CTP score 7-9 (13%). Majority also had MELD < 9 (60%) followed by MELD 10-19 (23%) and MELD 20-29 (17%). The MELD and CTP scores were lower compared to patients >40 years of age with HCV. A small population had decompensated cirrhotic features of hepatic encephalopathy and ascites (7% and 2% respectively). A very low number of them Hepatitis B surface Ab positive (1%) and majority had not received treatment for HCV infection (90%).

CONCLUSION:

In this study we noted a high number of young adults between 18-40years of age infected with HCV, majority were HCV treatment naïve and had less advanced liver disease with low rates of liver cirrhosis, hepatic encephalopathy and low MELD and CTP scores. IVDU was low in our population in contrary to other data. Very low HBV vaccination rate was noted, indicating the high risk for HBV infection in this population. In conclusion, HCV in young adults is a growing problem and it is pivotal to increase awareness and study the disease and transmission patterns to adequately manage this issue and prevent liver complications.
1118 Transplantation of Human Adipose Tissue Derived-SVF Enhance Liver Function in Fibrotic Liver Through High Hepatogenic and Anti-Fibrotic Capabilities
Authors: Choi Ja Sung , Kim Sung-Whan
Published: October 2019

INTRODUCTION:

Although human adipose tissue-derived stromal vascular fraction (SVF) has been considered a promising source of stem cells, its characteristics relevant to treatment of a damaged liver have not been fully elucidated. In the present study, we sought to characterize the hepatogenic and anti-fibrogenic property of human SVF and determine the therapeutic utility of SVF in the liver cirrhosis model.

METHODS:

We performed microarray, quantitative (q)-PCR experiments, and in vivo therapeutic assays using a liver cirrhotic mouse model.

RESULTS:

q-PCR results revealed that the well-known hepatogenic or anti-inflammatory factors hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF)-A, Interleukin (IL)-10 and microRNA(miR)-146 were more highly upregulated in SVF than in human adipose-derived mesenchymal stem cells (ASCs). The SVF culture medium (CM) inhibited the activation of hepatic stellate cells in vitro. Injection of SVF significantly suppressed TAA-induced liver fibrosis and repaired liver function by inhibition of infiltrating inflammatory cells and induction of capillary/hepatocyte regeneration in vivo.

CONCLUSION:

Our data indicate that SVF has a high therapeutic potential for treating fibrotic liver diseases through their hepatogenic and anti-fibrogenic properties. Therefore, SVF might be a novel therapeutic alternative for the treatment of liver cirrhosis in clinical settings.
1125 Body Fatness over the Life Course and the Risk of High-Risk Serrated Polyps and Advanced Conventional Adenomas
Authors: Lo Chun-Han , He Xiaosheng , Hang Dong , Wu Kana , Onigo Shuji , Chan Andrew , Giovannucci Edward , Song Mingyang
Published: October 2019

INTRODUCTION:

Obesity is an established risk factor for colorectal cancer. Serrated polyp (SP) and conventional adenoma (CA) represent two distinct groups of colorectal premalignancy. In contrast to the well-documented effect of adulthood obesity, the influence of early-life body fatness on the risk of developing SPs and CAs remains unclear.

METHODS:

This prospective study within the Nurses’ Health Study (1990-2012), the Nurses’ Health Study 2 (1991-2013), and the Health Professional Follow-up Study (1990-2010) collected detailed information on body fatness at different ages and the diagnosis of SPs and CAs. We individually examined the risk of high-risk SPs (≥10 mm or proximal SPs) and advanced CAs (≥10 mm or advanced histology) in relation to body fatness in early childhood (age 5), late childhood (age 10), early adulthood (age 18 for women and 21 for men), middle adulthood (baseline) and weight change from early adulthood to middle adulthood. Multivariable-adjusted logistic regression for clustered data was used to calculate the odds ratios (OR) and 95% confidence intervals (CI).

RESULTS:

Among 29221 men and 132546 women in the three cohorts who had undergone at least one lower bowel endoscopy during 18-20 years of follow-up, we documented 3119 cases of high-risk SP and 3299 cases of advanced CA. The ORs of high-risk SPs and advanced CAs ranged from 1.12 (95% CI, 1.02-1.23) to 1.25 (95% CI, 1.10-1.42) in women who were obese in early and late childhood. The associations were attenuated after adjusting for adulthood BMI. Body fatness in middle adulthood showed a strong positive relationship with the risk of both types of CRC precursor lesion in men and women. Weight change from early adulthood to middle adulthood was associated with greater risk of high-risk SPs in women (OR comparing weight gain ≥20.0 kg to gain or loss < 2.0 kg, 1.39; 95% CI, 1.22-1.58) and men (OR, 1.40; 95% CI, 1.01-1.29), and advanced CAs in both women (OR, 1.14; 95% CI, 1.07-1.82) and men (OR, 1.21; 95% CI, 1.03-1.42). The associations were stronger for high-risk SPs than for advanced CAs in women (P
heterogeneity = 0.01 for adulthood BMI, 0.004 for weight change).

CONCLUSION:

Weight gain during early adulthood and attained adiposity are associated with increased risk of high-risk SPs and advanced CAs in both men and women. There is heterogeneity in the associations among different types of colorectal precursor lesions in women but not in men. Body fatness in childhood is also associated with an increased risk in women.
1130 Bariatric Surgery Is Associated With a Recent Temporal Increase in Colorectal Cancer Resections, Most Pronounced in Adults <50 Years of Age: A 2006-2013 National Analysis
Authors: Hussan Hisham , Patel Arsheya , Porter Kyle , Lieberman David , Ahnen Dennis
Published: October 2019

INTRODUCTION:

The incidence rates of early-age onset colorectal cancer (CRC) are rapidly rising in the United States. In parallel, evolving evidence suggests an unexpected increase in long-term risk of CRC after bariatric surgery (BRS). BRS utilization expanded in the past three decades, however limited knowledge exists regarding the impact of BRS on age-stratified trends of obesity-related gastrointestinal cancers (OGCs) including that of CRC.

METHODS:

We queried the 2006-2013 National Inpatient Sample (NIS), the largest publicly available all-payer data repository, to identify patients who underwent resections for OGCs. We investigated patients with morbid obesity (body mass index ≥ 40 kg/m2) and those with prior BRS. In a separate analysis, we also looked at non-BRS/non-obese individuals. We divided OGCs into two groups: CRC and non-CRC OGCs (esophageal, gastric, liver, gallbladder and pancreatic cancers combined). Joinpoint regression analysis was used to calculate the average annual percent change (AAPC) in patients undergoing cancers resections across age groups (age < 50 and ≥ 50 years old).

RESULTS:

We identified 28,041 patients with morbid obesity and 2,238 patients with a prior BRS who had resections for OGCs in 2006-2013. BRS patients were younger, with more females and fewer comorbidities (Table 1). The yearly number of morbidly obese and BRS patients who underwent CRC resections concurrently increased across all age groups (Figures 1 and 2). When stratified by age, the steepest rise in CRC was observed in BRS patients <50 years of age (AAPC +18.7%, P < 0.001). Conversely, non-CRC OGCs did not go up after BRS, while number of morbidly obese patients undergoing non-CRC OGCs increased in patients ≥50 years of age (AAPC +18.1%, P = 0.004). Finally, in a supplementary analysis, the number of non-BRS/non-obese patients with CRC resections, decreased in 2006-2013 [AAPC -3.3 (P = 0.002) and -3.4 (P < 0.001) for patients < and ≥50 respectively].

CONCLUSION:

Our results identify a recent paradoxical increase in CRC resections after bariatric surgery, most pronounced for early-age onset CRC. Other obesity-related gastrointestinal cancers did not increase after bariatric surgery, suggesting a low probability of referral bias leading to our findings. Further research is warranted to elaborate on these trends and provide biological context.
1132 Establishment and Validation of a New Protocol and Normative Values for the Evaluation of Gastric Emptying and Gastric Accommodation in Bariatric Surgery Patients
Authors: Wang Xiao Jing , Vargas Eric J. , Breen-Lyles Margaret , Nord Sara Linker , Burton Duane , Camilleri Michael
Published: October 2019

INTRODUCTION:

Increasing rates of obesity have led to increased numbers of bariatric surgeries performed world-wide. However, some patients do not achieve significant weight loss or develop weight regain following these procedures. Other than estimating the size of the gastric remnant at endoscopy or transaxial imaging, there are limited approaches to quantitate the function of the post-surgical stomach in order to evaluate the disparate weight patterns, or to develop strategy for future treatments, e.g., pharmacotherapy or endoscopic intervention. We hypothesize that altered gastric function in the pre- and post-surgical periods may offer an explanation. Studies performed thus far are difficult to interpret due to heterogeneity in approaches to diagnostic evaluation. The aims of this project were: to assess the feasibility of a new protocol for simultaneous evaluation of gastric accommodation and gastric emptying in the post-bariatric state; and to report normative values in healthy volunteers.

METHODS:

Methods: We utilized single photon emission computed tomography (SPECT) and gamma scintigraphy to concurrently study postprandial gastric accommodation responses and gastric emptying rates of a limited size meal designed for subsequent use in post-bariatric patients. The standard meal consisted of 1 egg and 1 extra egg yolk scrambled with 111Indium-activated charcoal (∼130kcal, 9.5g fat) and 120mL 2% milk (130kcal, 4.4g fat). Gastric accommodation was measured using 99mTechnetium-SPECT. SPECT imaging was obtained concomitant with gastric emptying of the 111In-labeled meal. Anterior and posterior scans of the abdomen were obtained for estimating gastric emptying parameters every 15 minute until 90 minutes, and then in 30-minute intervals until 240 minutes or complete emptying.

RESULTS:

Data on 28/30 healthy volunteers (35.7% men; 67% Caucasian) with completed studies to date are shown in the Table 1 (data presented as mean ± standard deviation). Gastric emptying proportion at 1, 2, and 4 hours, T1/2, and gastric volumes including accommodation are graphically depicted in Figures 1 and 2, respectively.

CONCLUSION:

Discussion: This study has demonstrated feasibility of simultaneous measurement of gastric emptying and accommodation and provides normal values; this sets the stage for future baseline and post-operative scans on patients undergoing sleeve gastrectomy.
1133 Bariatric Surgery Is Associated With Post-Operative Constipation
Authors: Lin Elissa , Persily Jesse , Arbit David , Sidhu Sharnendra , Popov Violeta , Saunders John , Parikh Manish , Ren-Fielding Christine
Published: October 2019

INTRODUCTION:

Bariatric surgery has become a common therapeutic approach to obesity. However, bariatric procedures may affect bowel habits due to changes in dietary intake as well as altered anatomy. To date, few studies have evaluated the impact of bariatric surgery on post-operative constipation. The aim of this study is to determine if patients experience a greater rate of constipation after bariatric surgery compared to non-bariatric controls.

METHODS:

A retrospective chart review at New York Langone Hospital (NYU) was performed on 160 bariatric surgery patients who had surgery in the year 2012 and 160 control patients with BMI < 30 kg/m2 seen in primary care in 2012. Reports of constipation were recorded up until November 2018. Exclusion criteria included those with inflammatory bowel disease or hereditary colorectal cancer syndromes prior to age 50. The primary outcome was diagnosis of post-operative constipation. Secondary outcomes included rates of constipation according to surgical procedure. Presence of constipation was recorded if listed on the problem list or if medications for constipation were prescribed. Logistic regression and chi-squared testing was used to assess differences in groups.

RESULTS:

Table 1 shows patient characteristics of the study population. The average age of bariatric surgery patients was 64.1 years compared to 69.8 in the control group. Overall, 20% of bariatric patients were diagnosed with constipation compared to 15% of controls (P = 0.239). Constipation rates post-bariatric surgery were 17.9% in lap band, 20.6% in sleeve gastrectomy, and 7.1% in gastric bypass patients (P = 0.256). A logistic regression controlling for age, sex, and Charlson co-morbidity index was performed between controls and post-surgery subjects. This revealed no significant difference in rates of constipation between the two groups (OR 1.158, 95% CI 0.790 – 1.696 P-value = 0.45). There was, however, a significant difference in constipation rates between the bariatric group pre-surgery (13.8%) and post-surgery (17.5%) (P = < 0.001) (Table 2).

CONCLUSION:

Bariatric surgery patients experience significantly higher rates of constipation after surgery compared to prior to surgery, but similar rates to controls without obesity. Constipation impairs quality of life and is associated with significant health care costs. Further studies investigating the mechanisms underlying this increase in constipation after bariatric surgery and effective measures to treat it are warranted.
1134 Bariatric Surgery Type Impacts the Risk for Gastrointestinal, Liver, and Pancreatic Diseases Admissions Within 1 Year From Surgery
Authors: Patel Arsheya , Dayyeh Barham Abu , Balasubramanian Gokulakrishnan , Hinton Alice , Krishna Somashekar , Hussan Hisham
Published: October 2019

INTRODUCTION:

Bariatric surgery (BRS) is an effective weight loss method that should, in theory, improve many gastrointestinal, liver, and pancreatic (GILP) diseases seen with obesity. At the same time, there is an increased morbidity related to BRS’s gastrointestinal alterations. Thus, we examined the short-term impact of BRS type on admission rates of various GILP diseases.

METHODS:

We queried the 2012-2014 Nationwide Readmission Database to identify obese patients who underwent vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), or, as a control, hernia repair surgery (HR). Our primary aim was to compare rates of GILP diseases within 6 months post- and 6 months pre-surgery in the VSG, RYGB, and HR cohorts. In a time to event analysis we evaluated readmission rates up to 11 months post-BRS.

RESULTS:

We identified a total of 140,103 patients in the VSG cohort, 132,253 patients in the RYGB cohort, and 12,436 patients in the HR cohort. HR patients were slightly older with a higher percentage of Medicare insurance carriers in contrast to VSG and RYGB (Table 1). RYGB was associated with a 33-fold increased risk of intestinal obstructions compared to pre-RYGB (P < 0.001). Other notably increased GILP diseases after RYGB from highest to lowest risk (Table 2): C. difficile infection [adjusted odds ratio (aOR): 12.52, P < 0.001], GI hemorrhage (aOR: 10.95, P < 0.001), biliary disease (aOR: 4.15, P < 0.001) and functional/motility disorders (aOR: 3.57, P < 0.001). In contrast, post- versus pre-VSG patients were most frequently admitted for acute pancreatitis (aOR: 6.26, P < 0.001), followed by C. difficile infection (aOR: 4.86, P < 0.001), biliary disease (aOR: 3.14, P < 0.001), noninfectious gastroenteritis (aOR: 3.05, P < 0.001) and functional/motility disorders (aOR: 2.74, P < 0.001). No increase in admissions was observed in the control HR cohort for any of these diseases. In our time to event analysis, the probability of being admitted was most notable for intestinal obstructions within 30 days after RYGB while functional disorders predominate afterwards (Figure 1). Similarly, patients were more frequently admitted for functional disorders following VSG.

CONCLUSION:

The type of BRS has a differential impact on GILP admissions after surgery. There may be a limited impact of weight loss on functional disorders that seem to dominate irrespective of BRS type. This data can help better inform patients on the choice of surgery to pursue, however more data are warranted.