B Vijayan

Familial collagenous colitis involving a 6-year old child

Collagenous colitis is a recognised cause of persistent, non-bloody, watery diarrhoea. There are few cases of collagenous colitis reported in children or occurring within families. To our knowledge, no familial cases under 14 years of age have been reported previously; we describe a case of familial collagenous colitis affecting a 6-year old girl and her mother. The relevant published literature is reviewed and management is discussed. Colonic mucosal biopsies should be considered in both adults and children presenting with persistent watery diarrhoea even in the absence of any macroscopic abnormality at colonoscopy.

OC-004 Development and validation of a prognostic scoring system for lower gastrointestinal bleeding

Introduction Lower gastrointestinal bleeding (LGIB) is a common and heterogeneous condition, in which there is a paucity of data concerning predictors of adverse outcomes. This study aimed to identify independent risk factors for adverse outcomes in LGIB and derive prognostic scoring systems to stratify patients by risk on admission. Method The Aberdeen bleeding unit opened in 1991 and has recorded demographics, presenting features, haemodynamic status and outcomes on all admissions in a comprehensive database. Analysis was performed on admissions due to LGIB over the period 1991 to 2005. Independent risk factors for re-bleeding, requirement for surgical intervention, and mortality at 30 days were elucidated by means of univariate and multivariate binary logistic regression analyses. Risk factors were then modelled into simple numerical prognostic scoring systems which underwent preliminary validation using the period 2015–2016 to determine their predictive performance. Threshold analysis with a score <1 was performed to assess suitability of the score for determining early discharge. Results The derivation cohort consisted of 2385 patients admitted with LGIB over a 15 year period. Re-bleeding was experienced in 322 (13.5%), 135 (5.7%) required surgery and 129 (5.6%) died within 30 days of admission. Multivariate analysis revealed that rebleeding was associated with inpatient status at the time of initial bleed (OR 1.8), age 60–79 (OR 1.5), age >80 (OR 2.1), syncope (OR 2.3), underlying malignancy (OR 2.1), hypotension (OR 2.3) and haemoglobin <10 g/dL (OR 5.0). 30 day mortality was associated with inpatient status at the time of initial bleed (OR 3.3), age 60–79 (OR 3.3), age >80 (OR 6.0), underlying liver disease (OR 7.2), hypotension (OR 2.9) and tachycardia (OR 2.1). Modelling provided a 30 day rebleeding risk score (0–7) and mortality risk score (0–7) with area under ROC curves 0.742 and 0.802 respectively. A score of 0 reflected a re-bleeding risk of 1.1% (95% CI 0.4–2.7) and 30 day mortality of 0.0% (95% CI 0.0–0.1), whereas a score of 6 reflected a re-bleeding risk and 30 day mortality risk of 50% in both scoring systems. In the validation cohort (n=121, median age 68 years, 60 males), application of the scoring systems gave 30 day rebleeding and mortality rates that were not significantly different from those predicted. A score of 0 gave a 30 rebleeding risk of 0.0% (95% CI 0.0–9.8) and 30 day mortality risk of 0.0% (95% CI 0.0%–10.7%). Conclusion LGIB rebleeding and mortality can be reliably predicted using these scoring systems. Patients scoring 0 may be eligible for safe early discharge and outpatient management. Further external validation and confirmation is required. Disclosure of Interest None Declared

PWE-040 Natural History of Cirrhosis in A Cohort of Patients Undergoing Structured Surveillance for Hepatocellular Carcinoma: Results from The Aberdeen Surveillance Cohort

Introduction Cirrhosis is the end-stage of chronic liver disease due to a variety of different aetiologies with the natural history of this condition characterised by a variable asymptomatic phase of compensation followed by a rapid ‘decompensated’ phase marked by ascites, jaundice, variceal bleeding, encephalopathy and development of hepatocellular carcinoma (HCC). The cornerstone of management for cirrhotic subjects includes 6 monthly surveillance to detect development of HCC. Aberdeen Royal Infirmary is one of the few centres in the UK to have a structured HCC screening program where patients are followed up in a nurse led clinic. The aim of this study was to determine rates of decompensation and development of HCC in a cohort of cirrhotic patients undergoing structured surveillance. Methods The electronic records of 231 patients who were initiated on surveillance between the years 2010–2015 were reviewed. Only patients who attended the clinic on at least 2 occasions were included. Those with a prior history of HCC or had an HCC discovered at their first ultrasound were excluded. Primary end-points studied were the time to develop ascites, variceal haemorrhage, hepatic encephalopathy, jaundice, HCC and mortality. Data analyses were conducted using SPSS version 23. Statistical methods used include Cox regression and Kaplan Meier survival analyses. Results The 231 patients included in the study were mostly male (61.5%) with alcohol being the predominant aetiological factor (33.3%). The mean age at entry into the cohort was 58.1± 11.2 years, with a mean MELD of 8.6±2.9 and UKELD of 48.2± 3.1. The median follow-up duration was 26 months (range 6–60) giving a total cohort follow up of 522 patient years. Most patients had compensated and Childs-Pugh A cirrhosis at the time of entry (62.8% and 60.2% respectively). Of the 145 patients with compensated cirrhosis at entry, 26 (19.9%) developed jaundice or other signs of decompensation during follow up. Mean time to first decompensation episode was 49 (95% CI; 45–52) months, giving a rate of 8.7 /100 patient years. During follow-up, 7 patients developed HCC giving a detection rate of 1.36/100 patient-years. Mean age at detection of HCC was 71.6 ± 7.3 years. Mortality rate in the entire cohort was 3.6/100 patient years. Conclusion The results from our surveillance cohort outline the natural history of a large group of cirrhotic patients systematically followed up in a structured nurse-led clinic. The rates of decompensation and HCC highlight the importance of pursuing the strategy of active surveillance. Disclosure of Interest None Declared

Fracture risk calculation tool enhances dual-energy X-ray absorptiometry scan referral pathway in cirrhosis patients.

Objectives Liver cirrhosis is associated with osteoporosis leading to an increased risk of fractures. We aimed to establish whether a risk stratification strategy using a fracture risk calculation tool (FRAX) to determine which patients should receive a dual-energy X-ray absorptiometry (DXA) scan is effective in reducing scan rates without compromising sensitivity for detecting osteoporosis. Methods A retrospective analysis of 252 patients with liver cirrhosis attending hepatoma surveillance clinics. Receiver operating characteristic analysis was performed to assess sensitivity and specificity at 10-year fracture risk thresholds of 5, 10 and 15%. Results DXA scans were performed among 252 patients. Mean age was 61.6±10.2 years, of which 53.2% were male. Cirrhosis aetiology was largely a result of alcohol excess (n=33.3%), chronic hepatitis C virus infection (n=20.2%) and nonalcoholic fatty liver disease (n=15.9%). The majority of patients were in good prognostic groups (87.4% Child–Pugh A, 11.3% Child–Pugh B, 1.3% Child–Pugh C). Osteoporosis was present in 19.0% of those who underwent DXA scanning. The optimum 10-year fracture risk threshold was found to be 10% using the FRAX tool. This retained a high sensitivity of 95.8%, specificity 64.7%, and negative predictive value 98.5%. Introduction of a 10% FRAX threshold would result in a reduction of the DXA scanning rate to 46.8% of the current rate. Conclusion A risk stratification strategy for DXA scanning using a fracture risk assessment tool (FRAX) and a 10-year fracture risk threshold of 10% leads to a significant reduction in scan rates without compromising osteoporosis detection rates.

PWE-129 Decompensated alcohol related liver disease – how well are we serving our patients?

Introduction Scotland has one of the highest alcohol consumption in the world resulting in significant burden on the NHS. 36206 admissions in Scottish Hospital in 2013 were related to alcohol and 1:6 had Alcohol Related Liver Disease (ARLD).1SIGN guidelines along with BSG, BASL and RCP joint position paper on ARLD recommend that all patients with alcohol related physical disorder should be seen by specialist alcohol services.2,3In Aberdeen Royal Infirmary all patients with decompensated ARLD are managed in the Digestive Disorders Unit. Method We prospectively collected data on all patients admitted to our unit between 01/05/14 and 31/12/14. Demographics, presenting symptoms, treatment, progress, complications and outcomes were analysed with descriptive statistics. Results 94 patients with ARLD were admitted (30 first presentation) on 155 occasions. Male to Female ratio was 5:2, mean age of 55 ± 11 years. The mean length of stay was 15.7 ± 13 days, median 8 days. The primary reason for admission was control of ascites (33%), jaundice (19%), encephalopathy (13%) and upper GI bleeding (13%). 83%(78/94) had ongoing alcohol dependency. 23% (7/30) of new patients died during their first admission. 58/94(62%) patients had Ascites, 19/94(20%) had SBP. We performed 86 large volume paracenteses and 51 gastroscopies. Encephalopathy was present in 57(37%) and HRS in 37(24%) of the 155 admissions. Dieticians reviewed 28/30(93%) new and 71/94(76%) of all patients with 38/94(32%) requiring NG feeding. We referred 36/78(45%) dependent patients to Integrated Alcohol Service, 17 accepted.5 were seen in 2 to 7 months post discharge.1 patient was seen in less than 3 weeks from referral.2 people referred to the drop in clinic didn’t attend. Conclusion ARLD is the single most common cause of unscheduled admissions to our service. Despite nutritional support and judicious use of antibiotics, Human Albumin Solution and vasopressors, there continues to be a significant readmission rate and mortality in this group. During the study period there was no inpatient Alcohol Liaison Service which may be relevant. A minority of those referred to the Integrated Alcohol Service were seen. Numerous reasons account for failure to attend out-patient alcohol services but it is clear that a more robust system to tackle long-term alcohol dependency and recidivism is required. A structured outpatient follow up clinic and alcohol services in the future will help improve the outcomes for these patients. Disclosure of interest None Declared. References Alcohol-related Hospital Statistics Scotland. 2012/13 -25Feb14 SIGN guidelines N74. 2003 Moriarty, KJ. Alcohol related disease: meeting the challenge of improved quality of care and better use of resources;2010. Joint Position Paper by BSG/BASL/AHA

OC-011 Is Coffee Ground Vomiting Important? Findings From A Large Bleeding Unit Database With Outcomes At 30 Days

Introduction Upper gastrointestinal bleeding (UGIB) is a common reason for admission and “coffee ground vomiting” (CGV) has classically been considered a sign but clinical experience hasn’t always borne this out. There is a paucity of data concerning endoscopic findings and outcomes in patients presenting with CGV. The aim of this study was to analyse endoscopic yield and outcomes at 30 days in patients presenting with CGV alone compared to those with haematemesis or melaena. Methods The Aberdeen bleeding unit opened in 1991 and has recorded demographics, presenting symptoms, endoscopic diagnosis and outcomes on all admissions. Endoscopic diagnostic groups were varices, gastric ulcers (GU) or duodenal ulcers (DU), cancer, trivial (e.g. Mallory-Weiss tear (MWT)), no source found, no bleed and colonic. Analysis was performed over the period 1991 to 2005 and three groups identified; CGV alone (group A), haematemesis (group B) and melaena (group C). Endoscopic diagnosis, rebleeding and mortality rate were calculated and using group A as reference, odds ratios calculated (shown in brackets). Results 6105 patients were admitted over the study period with suspected UGIB (A, n = 1708 (923 males), B, n = 1663 (968 males) and C, n = 2734 (1640 males)). Trivial, no source found and no bleed diagnoses were found in 1390 (75%) group A, 1291 (50%) group B and 1130 (40%) group C. Group B was younger than groups A and C (mean age 50.4 vs. 64.6 and 64.8 respectively, p < 0.001) therefore groups were stratified into <50 or ≥ 50. In < 50, group B had significantly more varices (OR 2.3) and MWT (OR 2.8) whereas group C had significantly more GU (OR 2.6), DU (OR 9.9) and colonic bleeds (OR 6.9). Only 4 cases had upper GI cancer all presented with melaena. 30 day mortality (<50) for groups A, B and C was 2.7%, 1.6% and 1.9% but rebleeding was significantly higher in group C (OR 3.5). In ≥ 50, group B had significantly more varices (OR 6.9), GU (OR 1.8), gastric cancer (OR 2.4), oesophageal cancer (OR 3.2) and MWT (OR 3.1) whereas group C had significantly more varices (OR 2.9), GU (OR 2.5), DU (OR 3.7), gastric cancer (OR 2.0), and colonic bleeds (OR 6.1). 30 day mortality (≥50) for groups A, B and C was 11.8%, 12.5% and 11.1% but rebleeding was significantly higher in groups B and C (OR 5.3 and OR 5.0 respectively). Conclusion Presenting with CGV is associated with the same mortality as haematemesis or malaena but has significantly lower endoscopic yield and rebleeding suggesting a non-gastrointestinal cause. CGV should not be synonymous with UGIB and needs to be considered for investigations other than endoscopy. Disclosure of Interest None Declared.

PWE-149 Minimal Hepatic Encephalopathy Is A Significant Complication In Cirrhotic Patients Admitted To Hospital

Introduction Minimal hepatic encephalopathy (MHE) is a subtle cognitive impairment in patients with cirrhosis or porto-systemic shunts in the absence of abnormalities in standard neurological examination. The diagnosis of MHE has always taken a back seat in the evaluation of patients with cirrhosis primarily due to the fact that it is time consuming and not well validated. However, the prognostic importance of MHE cannot be understated as it has been found to affect motor skills like driving and timely treatment does improve quality of life and progression to overt encephalopathy (OHE). Objective To estimate the prevalence of minimal hepatic encephalopathy in a sequential population of cirrhotic patients admitted in the gastroenterology ward at Aberdeen Royal Infirmary. Methods 26 patients with a diagnosis of cirrhosis admitted over a 3 week period were included in the study. All patients with overt encephalopathy and sepsis were excluded from the study. The psychometric hepatic encephalopathy score (PHES) was used to assess the patients at the bedside. This comprises of a standardised battery of five paper–pencil psychometric tests: number connexion test A, number connexion test B, the digit symbol test, the line tracing test (time and errors) and the serial dotting test. Minimal hepatic encephalopathy can be diagnosed when the psychometric hepatic encephalopathy score is less than -5. This score can be easily obtained by inputting data in an online tool (http://www.redeh.org/phesapp/datosE.html). Results The mean age of the selected cirrhotic patients was 59 ± 2.8 years and 74.1% were male. The commonest aetiology of cirrhosis was alcohol related liver disease (62.9%). 33.3% of patients were Child’s A, 44.4% were Child’s B and 22.3% were Child’s C. The mean MELD score was 16.5 ± 9.2. The median PHES score was 1 (Range -10 to 2). Of the 26 patients evaluated, 7 patients were diagnosed to have MHE (25.9%). The prevalence varied with the Child’s stage, 11.1% in Child’s A, 25% in Child’s B and 60% of Child’s C patients. All patients diagnosed with MHE were commenced on Lactulose. Conclusion Hospitalised patients with cirrhosis have a significant prevalence of MHE which is proportional to the stage of the liver disease. Prompt identification and treatment of this cohort will help in preventing them from progressing to overt encephalopathy. Disclosure of Interest None Declared.

PTH-084 Nutritional Impact Of Anti-viral Therapy Of Genotype 1 Hepatitis C Patients

Introduction Hepatitis C Virus (HCV) is a leading cause of chronic hepatitis and liver cirrhosis, with an estimated 170 million patients infected worldwide. The, UKmost common genotype of HCV is Genotype 1. For many years, the ‘Standard of Care’ has been prolonged therapy with the combination of Polyethylene glycol interferon-α and Ribavirin for one year. The recent approval of drugs such as Telaprevir and Boceprevir has restructured treatment for genotype 1 HCV infection, both for previously treated or treatment-naïve patients. Specific dietary intake is warranted for adequate absorption of the protease inhibitors and this has led to a structured dietary advice being given to patients. We wanted to compare the nutritional impact of antiviral therapy in two groups of patients who underwent either dual or triple therapy. Methods Treatment of hepatitis C patients at Aberdeen Royal Infirmary is undertaken by Hepatology specialist nurses who review these patients at designated time intervals. At each of these clinic visits the MUST score (Malnutrition Universal Screening Tool) is recorded in addition to the weight and BMI of the patient. Any patient who has a MUST score of 2 is referred for specialist dietetic input, which is also available at the clinic. At 4 weekly intervals, the HAD score for anxiety and depression is also recorded for all patients. Results A total of 73 patients with Genotype 1 underwent therapy in the year 2012–2013, including 25 patients with dual therapy of PEG-IFN and Ribavirin and 48 patients on triple therapy of PEG-IFN, Ribavirin and Telaprevir. There was no statistical difference in the initial weight, BMI and MUST scores of these two groups of patients. The mean weight fell from 89.6 ± 17.9 kg to 83.7 ± 15.6 kg by the end of treatment in the dual therapy group with a parallel fall in BMI from 30.7 ± 5.4 to 28.8 ± 4.6 kg/m2. However, in the triple therapy group, the mean weight increased from 82.2 ± 30.5 kg to 82.7 ± 26.0 kg and a stable BMI from 26.4 ± 9.5 to 26.2 ± 8.3 kg/m2. Dietary referral and intervention was needed in 7/25 patients on dual therapy (28%) as opposed to 7/48 patients on triple therapy (14.6%) (p = 0.23) Conclusion Weight reduction is a significant problem in patients undergoing dual therapy for hepatitis C as opposed to those undergoing triple therapy. Referral to the dietician was needed in a larger proportion of cases undergoing standard of care though it did not reach statistical significance. Dietary advice given with respect to protease inhibitors may have had a significant effect in combating the ill effects of the standard treatment of patients with Genotype 1 HCV infection. This specific advice should be extrapolated to all patients undergoing anti-viral treatment. Disclosure of Interest None Declared.

PTH-077 Geographical Mapping Of Hepatitis C Infection In North East Scotland Using A Geographical Information System (gis)

Introduction Chronic HCV infection affects around 37,500 people in Scotland. A Geographical Information System (GIS) allows exploratory data analysis (EDA), mapping and visualisation of geographical data. GIS can be used to illustrate the geographical patterns and distribution of HCV infection to aid on the planning services for treatment of these patients Methods Data was extracted from the NHS Grampian Hepatitis C database between the years 2002 to 2013 and input to the ESRI ArcGIS software. For confidentiality, each case was mapped utilising the first half of their postcodes. The Scottish Index of Multiple Deprivation was used to calculate the average deprivation score for each postcode sector. Exploratory data and statistical analysis were undertaken using Spearman’s rank correlation coefficient. Results A total of 2114 patients with hepatitis C were identified from the local NHS Grampian Hepatitis C database. The overall prevalence of hepatitis C in the Grampian region was 523 cases per 100,000 population. The highest rate of hepatitis C was from AB11 in Aberdeen city, with 1440/100,000 individuals. The area with the lowest occurrence was AB38 in rural Aberdeen with 21/100,000 individuals. The higher prevalence areas corresponded to Aberdeen city and the towns of Peterhead and Fraserburgh. Outreach centres for treatment of hepatitis C were adequately stationed in high prevalence areas. The most deprived post code, AB16 in Aberdeen city, had a rate of 940/100,000 populations. There was no statistical significance between the diagnosis of hepatitis C infection and deprivation scores of the post codes studied. There was a significant correlation between the percentage of untreated patients and average deprivation score with a correlation coefficient of -0.333 (p < 0.05). Conclusion In this study GIS is useful to explore, visualise and present the data in a spatial context, highlighting areas with high prevalence and where individuals are being treated and where they are not. The Outreach centres were shown to be appropriately located. The higher prevalence in urban regions mirrors risk factors like drug usage in these areas. A statistically significant correlation, albeit not very high, was shown between the percentage of untreated patients and levels of deprivation. This may mean that more emphasis needs be placed on assisting those individuals who live in the most deprived areas to gain access to the treatment programmes which are available. Aberdeen Royal Infirmary is the only referral hospital for the treatment of hepatitis C and it is likely that the study underestimates the true prevalence of the infection due to a referral bias Disclosure of Interest None Declared.

PTU-035 Development and Initial Validation of Prognostic Scoring Systems for lower Gastrointestinal Bleeding

Introduction Lower gastrointestinal bleeding (LGIB) is a common and heterogeneous condition, in which there is a paucity of data concerning predictors of adverse outcomes. This study aimed to identify independent risk factors for adverse outcomes in LGIB, and derive prognostic scoring systems to stratify patients by risk on admission. Methods The Aberdeen bleeding unit opened in 1991 and has recorded demographics, presenting features, haemodynamic status and outcomes on all admissions in a comprehensive database. Analysis was performed on admissions due to LGIB over the period 1991 to 2005. Independent risk factors for re-bleeding, requirement for surgical intervention, and mortality at 30 days were elucidated by means of univariate and multivariate binary logistic regression analyses. Risk factors were then modelled into simple numerical prognostic scoring systems which underwent preliminary validation tests in order to determine their predictive performance using receiver operating curve analysis. Results Over the study period, 2385 patients were admitted with LGIB. Re-bleeding was experienced in 322 (13.5%), 135 (5.7%) required surgery and 129 (5.6%) died within 30 days of admission. Multivariate analysis revealed that re-bleeding was associated with inpatient status at the time of initial bleed (OR 1.8; 95% CIs 1.3–2.5), age 60–79 (OR 1.5; 95% CIs 1.0–2.3), age > 80 (OR 2.1; 95% CIs 1.3–3.2), syncope (OR 2.3; 95% CIs 1.5–3.6), underlying malignancy (OR 2.1; 95% CIs 1.0–4.3), hypotension (OR 2.3; 95% CIs 1.4–3.6) and haemoglobin < 10g/dL (OR 5.0; 95% CIs 2.8–8.9). 30 day mortality was associated with inpatient status at the time of initial bleed (OR 3.3; 95% CIs 2.0–5.4), age 60–79 (OR 3.3; 95% CIs 1.5–7.1), age > 80 (OR 6.0; 95% CIs 2.6–13.7), underlying liver disease (OR 7.2; 95% CIs 2.9–17.7), hypotension (OR 2.9; 95% CIs 1.5–5.3), and tachycardia (OR 2.1; 95% CIs 1.3–3.6). No independent risk factors were identified for the requirement of surgery. Separate prognostic scoring systems (0–7) were created for re-bleeding and mortality outcomes, with area under ROC curves 0.742 and 0.802 respectively. A score of 0 reflected a re-bleeding risk of 1.1% and 30 day mortality of 0.0%, whereas a score of 6 reflected a re-bleeding risk and 30 day mortality risk of 50% in both scoring systems. No patients scored the highest risk grade of 7 in either model. Conclusion These scoring systems can be used to calculate re-bleeding risk and 30 day mortality in patients with LGIB. Further external validation and confirmation is required. Disclosure of Interest None Declared