Lynda Greenslade

Single portal pressure measurement predicts survival in cirrhotic patients with recent bleeding

Background Height of portal pressure correlates with severity of alcoholic cirrhosis. Portal pressure indices are not however used routinely as predictors of survival. Aims To examine the clinical value of a single portal pressure measurement in predicting outcome in cirrhotic patients who have bled. Methods A series of 105 cirrhotic patients who consecutively underwent hepatic venous pressure measurement were investigated. The main cause of cirrhosis was alcoholic (64.8%) and prior to admission all patients had bled from varices. Results During the follow up period (median 566 days, range 10–2555), 33 patients died, and 54 developed variceal haemorrhage. Applying Cox regression analysis, hepatic venous pressure gradient, bilirubin, prothrombin time, ascites, and previous long term endoscopic treatment were the only statistically independent predictors of survival, irrespective of cirrhotic aetiology. The predictive value of the pressure gradient was much higher if the measurement was taken within the first or the second week from the bleeding and there was no association after 15 days. A hepatic venous pressure gradient of at least 16 mm Hg appeared to identify patients with a greatly increased risk of dying. Conclusions Indirectly measured portal pressure is an independent predictor of survival in patients with both alcoholic and non-alcoholic cirrhosis. In patients with a previous variceal bleeding episode this predictive value seems to be better if the measurement is taken within the first two weeks from the bleeding episode. A greater use of this technique is recommended for the prognostic assessment and management of patients with chronic liver disease.

Clinical vs haemodynamic response to drugs in portal hypertension

BACKGROUND/AIMS The combination of non-selective beta-blockers and nitrates is an effective therapy for the prevention of rebleeding from oesophageal varices. However, a significant number of patients fail to respond and have further haemorrhage. It has been suggested that measurement of the hepatic venous pressure gradient response to long-term drug therapy may allow early selection of non-responders. We aimed to test this hypothesis in 63 patients with cirrhosis and variceal bleeding treated with propranolol+/-isosorbide mononitrate. METHODS Hepatic venous pressure gradient was measured before and during treatment. Response was defined as a reduction of 20% or more in hepatic venous pressure gradient, or a fall in hepatic venous pressure gradient to 12 mmHg or less. RESULTS Forty-four patients were evaluable: 28 responders and 16 non-responders. Hepatic venous pressure gradient fell significantly in the responder group (17.5+/-0.5 mmHg vs 12.2+/-0.5 mmHg; p<0.01) but not in the non-responders (18.0+/-1.0 vs 17.9+/-1.2 mmHg; p=n.s.). Overall, there was no difference in rebleeding rates between the two groups: responders 43%, non-responders 25%. However, rebleeding was uncommon in compliant patients with alcoholic cirrhosis, in whom the hepatic venous pressure gradient fell to less than 12 mmHg (9%). CONCLUSIONS In this study a fall in hepatic venous pressure gradient of 20% was not a reliable predictor of clinical response. A threshold value of 12 mmHg was useful, but applied to relatively few patients.

Endoscopic detection of ischaemia with a new probe indicates low oxygenation of gastric epithelium in portal hypertensive gastropathy.

Changes in mucosal blood flow may be important in the pathogenesis of many conditions. Study of mucosal blood perfusion is difficult, and available methods have significant technical limitations. This study describes the development of an instrument for endoscopy, which indicates blood flow indirectly, by measuring the quantity of tissue oxygen that can diffuse from the mucosa to a luminal surface electrode. The instrument was used through an endoscope in patients with portal hypertension (n = 14), scleroderma (n = 3), disease controls (n = 7), and normal controls (n = 11). In portal hypertension readings were one quarter that in normal controls in both antrum (geometric mean (SEM) 35 (1.1)), nanoamps v 137 (1.1), and upper corpus 34 (1.1) v 125 (1.1)). Scleroderma patients showed greatly reduced oxygen readings in both antrum (18 (1.2)) and corpus (24 (1.2)), an expected but hitherto undiscovered result. These differences are highly significant (p = 0.0001), and the findings suggest that tissue hypoxia may contribute to mucosal changes in portal hypertensive gastropathy and in scleroderma.

Palliative care for cirrhosis: a UK survey of health professionals' perceptions, current practice and future needs

Objective To determine the knowledge and practice patterns of a UK cohort of relevant healthcare professionals (HCPs) about delivering palliative care in cirrhosis, and to inform priorities for future research. Design An on-line questionnaire survey with closed and open responses. Setting HCPs identified from the mailing list of special interest groups in hepatology and gastroenterology (liver), general practice and specialist palliative care (SPC) across the UK. Results Of the 6181 potential contacts identified, 517 HCPs responded. Most believed a role exists for SPC in caring for people with cirrhosis, but many SPC HCPs felt ill prepared to provide good care to those facing death. Further training was needed in managing liver-related symptoms, symptom control and end of life issues. All HCP groups wished to increase community provision of palliative care support, but many general practitioners felt unable to manage advanced cirrhosis in the community. There were differences in the optimal trigger for SPC referral with liver HCPs less likely to refer at symptom deterioration. Prognostication, symptom management and service configuration were key areas identified for future research. Conclusions All who responded acknowledged the role of SPC in caring for those dying with cirrhosis and need for further training to improve confidence and enable joint working between SPC, general practice and liver teams. Low response rates make it difficult to generalise these findings, which require further validation.

Advanced chronic liver disease in the last year of life: a mixed methods study to understand how care in a specialist liver unit could be improved

Objective To identify the limitations in palliative care provision in the last year of life for people with liver cirrhosis and potential barriers to and enablers of palliative care. Design Mixed methods, including a retrospective case note review, qualitative focus groups and individual interviews. Setting A tertiary referral liver centre in the south of England (UK). Participants Purposively selected case notes of 30 people with cirrhosis who attended the tertiary referral liver centre and died during an 18-month period; a purposive sample of 22 liver health professionals who participated in either focus groups or individual interviews. Primary and secondary outcomes Data collected from case notes included hospital admissions, documented discussions of prognosis and palliative care provision. Qualitative methods explored management of people with cirrhosis, and barriers to and enablers of palliative care. Results Participants had high rates of hospital admissions and symptom burden. Clinicians rarely discussed prognosis or future care preferences; they lacked the skills and confidence to initiate discussions. Palliative care provision occurred late because clinicians were reluctant to refer due to their perception that reduced liver function is reversible, poor understanding of the potential of a palliative approach; palliative care was perceived negatively by patients and families. Conclusions People dying with cirrhosis have unpredictable trajectories, but share a common pathway of frequent admissions and worsening symptoms as death approaches. The use of clinical tools to identify the point of irreversible deterioration and joint working between liver services and palliative care may improve care for people with cirrhosis.

Why do we offer palliative care so late to patients with liver disease

Patients with advanced liver disease carry a high symptom burden and short life expectancy, but receive limited supportive and palliative care1. Providing planned day care for large volume paracentesis reduced costs, inpatient bed days and probability of dying in hospital after an unplanned admission1. These recent findings illustrate how care to people with advanced liver disease can be improved with the burden on acute service alleviated by the adoption of day-case models across the UK. This point is timely as palliative care provision for this group is poor, often occurring near to the patients’ death2. Why is this? It is recognised that prognosis or future care needs are often not discussed with liver patients until the very late stages of the disease. Clinicians report that they lack the expertise and confidence to initiate these discussions and a limited understanding about what palliative care can offer, and believe that patients have negative expectations of palliative care referral2. Conversations regarding palliation often introduces family members into the patient and clinician relationship, and family members may be resistant to the idea of palliative care2. Furthermore, many clinicians find it difficult to identify the point of ‘deterioration’ due to the fluctuating disease trajectory of advanced cirrhosis.

PWE-084 Relationship between indices of frailty/disability with disease severity and nutritional status in patients with cirrhosis

Introduction Disease severity and nutritional status are important determinants of outcome in patients with cirrhosis. Health-related quality of life, mental health, disability and frailty all affect outcome. However it is unclear if these measures of functional decline provide information additional to that provided by conventional outcome measures. This study aimed to determine whether indices of functional decline correlate with nutritional status and disease severity. Methods Eighty-six consecutive patients (mean [range] age 54.6 [24–81] yr: 59 men; mean MELD 12.7 [6–37]) attending the hepatology service at the Royal Free Hospital, London were included. All underwent the following assessment in a single sitting: disease severity: MELD; nutritional status: The Royal Free Hospital-Nutritional Prioritising Tool (RFH-NPT); quality of life: Chronic Liver Disease Questionnaire (CLDQ) and Euro Quol-5 Dimension Tool (EQ-5D); mental health: Beck Anxiety/Depression Indices (BAI; BDI); disability: Activities (ADL) and Independent Activities of Daily Living (IADL); frailty: Clinical Frailty Scale (CFS), Short Physical Performance Battery (SPPB) and Fried Frailty Criteria (FFC) plus two composite measures, the Bristol Prognostic Index and Karnofsky Age MELD Model (KAM). Results There was a significant degree of cross correlation between the tools used to assess functional decline (|R| between 0.05–0.58). There were significant correlations between indices of functional decline and nutritional status with the exception of the disability indices (table 1). However, only the Bristol and KAM tools, which contain a measure of disease severity, correlated with MELD. Conclusion In patients with cirrhosis indices of functional decline correlate with nutritional status but not with disease severity. These indices likely provide information of value in determining outcome not captured using conventional outcome measures. Information on their predicative validity would help determine their clinical utility.Abstract PWE-084 Table 1 Functional decline, disease severity and nutritional status Tool MELD RFH-NPT r (p value) CLDQ 0.04 (0.74) −0.33 (0.00)* EQ-5D-5L −0.07 (0.55) −0.36 (0.00)* BAI 0.03 (0.78) 0.31 (0.01)* BDI 0.13 (0.26) 0.38 (0.00)* ADL −0.14 (0.22) −0.15 (0.16) IADL −0.11 (0.30) −0.19 (0.08) CFS 0.07 (0.52) 0.41 (0.00)* SPPB −0.2 (0.09) −0.38 (0.00)* FFC 0.04 (0.7) 0.47 (0.00)* Hand Grip 0.01 (0.96) −0.21 (0.06)* Bristola 0.28 (0.01)* 0.32 (0.00)* KAMa 0.34 (0.00)* 0.37 (0.00)* *p<0.05aincludes disease severity.

What support do people with cirrhosis need from liver healthcare professionals in a liver transplant centre

Background and aims The incidence of liver disease is increasing in the UK; it is now the 3rd commonest cause of death in those aged under 65. People with cirrhosis often have complex physical problems that require regular comprehensive management. Limited evidence exists on the ways that people with cirrhosis cope with the disease. We aimed to explore their experience to ascertain whether current levels of healthcare support were sufficient. Methods Ten people with cirrhosis were recruited from hepatology clinics in one liver transplant centre. In semi-structured qualitative interviews, we explored their understanding of their disease and prognosis; healthcare services received; specific problems encountered; concerns for the future. Interviews were audio-taped and transcribed verbatim. Data were analysed using a Framework approach. Results Our sample was 50% male: 5 were on the liver transplant list. Everyone said that the healthcare they received from the hospital was good; staff continuity and relationships with clinicians were seen as important. However, people lacked understanding of their diagnosis, health status and symptoms and wanted more management advice and psychological support. Contacting a member of the clinical team was difficult if problems developed at home, leading to A+E attendance. Limited discussions were held about disease progression and future care if treatment failed. Conclusions Symptom burden in people with cirrhosis is high and needs are complex. Active communication from professionals about current disease status and likely progression may enable better understanding and encourage involvement in plans for their future care. References Poonja Z, Brisebois A, van Zanten SV, et al. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management. Clin Gastroenterol Hepatol 2014;12(4):692–698 Kimbell B, Boyd K, Kendall M, Iredale J, Murray SA. Managing uncertainty in advanced liver disease: a qualitative, multi-perspective, serial interview study. BMJ Open 2015;e009241. doi:10.1136/bmjopen-2015-009241

PTH-125 A national survey of palliative care in end stage liver disease in the UK

Introduction Liver disease is the third largest cause of premature death in the United Kingdom (UK) and currently accounts for 2% of deaths in England, but there is little strategy to improve care for those dying from it, as well as a lack of research in this area. Understanding of the views of health care professionals (HCP) on how care can be improved for patients dying from cirrhosis is poor. Aim To conduct a national survey of primary, secondary and tertiary care providers to explore current attitudes and practices, to identify future training needs, ideas for service improvement and research priorities. Method An online questionnaire survey was emailed to a maximum of 6,181 HCPs working in hepatology and gastroenterology (liver), general practice (GP) and specialist palliative care (SPC) across the UK. Results 517 HCP responded: 195 from liver, 46 from GPs and 273 from SPC (response rates 4%, 23% and 10% respectively; overall response rate 8%). Nearly all liver and SPC professionals felt that SPC had a role in the care of patients with cirrhosis. Liver professionals tended to refer to SPC whilst patients were in hospital but overall numbers were low, with only 14% (22/161) and 6% (9/61) of liver professionals referring more than 20 patients/year from in-patient and out-patient care respectively. Patients with cirrhosis only made up a median 1% of the SPC workload. All HCPs wanted further training in: managing liver-related symptoms (SPC), symptom control and end of life issues (liver and GP). Open responses were received from 221 participants. Two main research priorities were identified by all three health professional groups: better symptom control (in particular how best to manage recurrent ascites, opioid pharmacology in liver disease and optimal management of pruritus and encephalopathy), and prognostication. Conclusion Although all HCPs recognised the important role of SPC in caring for dying patients with cirrhosis, they all needed further training and uptake of skills to improve their confidence. We recommend a focus on improved understanding of the needs of patients with cirrhosis and their families, identification of better ways in communicating with patients at risk of death, smoother links across care boundaries, and enhanced training for all staff groups. Disclosure of interest None Declared.

PTH-133 Understanding the care pathway of patients with cirrhosis in the last year of life

Introduction Liver disease is a growing global public health problem and the 5thlargest cause of death in the UK. Health policy for this patient group primarily centres on prevention, paying minimal attention to improving end of life care for those affected. Aims To follow patients with cirrhosis in the last year of life, plotting healthcare use and identifying barriers to good end of life care. Method Retrospective review of purposively selected case notes (30 cirrhotic patients) referred to a tertiary London liver unit. Pathways of care were modelled, by combining clinical data and service utilisation information extracted from medical notes, and qualitative focus groups/interviews with 14 liver health professionals, about barriers to good end of life care. Results During the last 12 months of life medical crises often precipitated unplanned emergency admissions to hospital. Patients experienced high symptom burden and were repeatedly treated intensively to aid recovery. Although clinicians recognised that limited treatments and services exist to address patients’ problems, many continued to treat patients actively. Opportunities to initiate palliative care were documented but not always acted upon. Discussions were rarely held with patients about their future wishes; care planning conversations occurred late in the patient trajectory and were more likely to occur with the patient’s family. Specialist palliative care referral occurred within the last few days of life. Conclusion Clinicians have difficulties identifying when to initiate end of life care for patients with cirrhosis, when prognosis is uncertain and active treatment may afford a degree of short term recovery. Earlier integration of palliative care would facilitate care planning discussions and better inform patients and families of the choices available, in the knowledge they may be entering the dying phase. Disclosure of interest None Declared.