Marie Angèle Robic

Liver stiffness accurately predicts portal hypertension related complications in patients with chronic liver disease: A prospective study

BACKGROUND & AIMS The prognosis of patients with chronic liver disease is to a great extent determined by the presence and degree of portal hypertension (PHT). Hepatic venous pressure gradient (HVPG) has been shown to be an accurate prognostic index in patients with cirrhosis. Transient elastography is a non-invasive procedure that assesses liver fibrosis through the measurement of liver stiffness (LS). In several reports, LS was found to be correlated with HVPG. LS could therefore be useful to identify patients with significant PHT. The aim of the present study was to prospectively assess and to compare the prognostic performances of LS and HVPG in patients with chronic liver disease. METHODS One hundred patients with chronic liver disease underwent LS and HVPG measurements on the same day. Patients were thereafter followed-up for 2 years or until they experienced a complication related to their liver disease. RESULTS Within the two-year follow-up, 41 patients developed, at least, one liver disease related complication. The performances of HVPG and LS for predicting the occurrence of these complications were not significantly different: AUROC 0.815 [0.727-0.903] and 0.837 [0.754-0.920], respectively. When considering only complications related to PHT, both methods were found to be similarly accurate: AUROC 0.830 [0.751-0.910] and 0.845 [0.767-0.823], for HVPG and LS, respectively. When patients were divided in two groups according to a LS value below or above 21.1kPa, actuarial rates of remaining free of any complication at 2 years were 85.4% vs. 29.5%, respectively. When only PHT related complications were considered, these rates were 100% vs. 47.5%, respectively. The performances of LS and HVPG were also similar in the subgroup of 65 patients with cirrhosis. CONCLUSIONS LS proved as effective as HVPG in predicting clinical decompensation and PHT related complications in patients with chronic liver disease. Therefore, LS could be a valuable clinical tool to avoid invasive procedures.

Pre‐transjugular intrahepatic portosystemic shunts (TIPS) prediction of post‐TIPS overt hepatic encephalopathy: The Critical Flicker Frequency is more accurate than psychometric tests

Transjugular intrahepatic portosystemic shunts (TIPS) is a second‐line treatment because of an increased incidence of overt hepatic encephalopathy (OHE). A better selection of patients to decrease this risk is needed and one promising approach could be the detection of minimal hepatic encephalopathy (MHE). The aim of the present prospective study was to determine whether pre‐TIPS minimal hepatic encephalopathy was predictive of post‐TIPS OHE and to compare Psychometric Hepatic Encephalopathy Sum Score (PHES) and the Critical Flicker Frequency (CFF) in this setting. From May 2008 to January 2011, 54 consecutive patients treated with TIPS were included. PHES and CFF were performed 1 to 7 days before and after TIPS at months 1, 3, 6, 9, and 12 or until liver transplantation or death. Before TIPS, MHE was detected by PHES and CFF in 33% and 39% of patients, respectively. After the TIPS procedure, 19 patients (35%) experienced a total of 64 episodes of OHE. OHE developed significantly more often in patients for whom an indication for TIPS had been refractory ascites, with a history of OHE or of renal failure, lower hemoglobin level, or MHE as diagnosed by CFF. Post‐TIPS OHE was more accurately predicted by CFF than by PHES. Absence of MHE at CFF had a good negative predictive value (91%) for the risk of post‐TIPS recurrent OHE, defined as the occurrence of three or more episodes of OHE or of one episode which lasted more than 15 days. The absence of pre‐TIPS history of OHE and a CFF value equal to or greater than 39 Hz had a 100% negative predictive value for post‐TIPS recurrent OHE. Conclusion: Aiming to decrease the rate of post‐TIPS HE, the use of CFF could help selecting patients for TIPS. (Hepatology 2014;59:622–629)

Central obesity is associated with non-cirrhotic portal vein thrombosis

BACKGROUND & AIMS 30-40% of portal vein thrombosis (PVT) remains of unknown origin. An association between metabolic syndrome (MetS) and peripheral vein thrombosis has been reported but not with PVT, to date. The aim of this study was to investigate the association between MetS and PVT. METHODS Between 2003 and 2014, all consecutive patients with non-cirrhotic PVT were prospectively included. Patients characteristics and risks factors were recorded at the time of inclusion. Controls were selected by random in the general population and were matched 1/1 according to age and sex. RESULTS Seventy-nine patients with PVT were included: 40 present with at least one risk factor for PVT (SPVT) and 39 were found to be idiopathic (IPVT). The prevalence of MetS was 25.6% in SPVT group vs. 47.4% in IPVT group and 17.9% in controls from the general population (C-IPVT: p=0.01). The waist circumference and body mass index were higher in the IPVT group than in the SPVT group (105 vs. 93cm, p=0.004 and 29.4 vs. 25.0kg/m(2), p=0.004) and in the C-IPVT group (105 vs. 92cm, p=0.001 and 29.4 vs. 25.8kg/m(2), p=0.003). Overweight was observed in 82.0% of patients in the IPVT group vs. 44% in the SPVT group (p=0.002) and 51% in the C-IPVT group (p=0.01). The mean visceral fat area was higher in IPVT than in SPVT (18,223mm(2)vs. 12,690mm(2), p=0.02). In multivariate analyses, an increase in waist circumference was the strongest parameter associated with idiopathic PVT. CONCLUSION Central obesity is associated with PVT and could become one of the main risk factors for digestive thromboses.

Serum tests, liver stiffness and artificial neural networks for diagnosing cirrhosis and portal hypertension

BACKGROUND The diagnostic performance of biochemical scores and artificial neural network models for portal hypertension and cirrhosis is not well established. AIMS To assess diagnostic accuracy of six serum scores, artificial neural networks and liver stiffness measured by transient elastography, for diagnosing cirrhosis, clinically significant portal hypertension and oesophageal varices. METHODS 202 consecutive compensated patients requiring liver biopsy and hepatic venous pressure gradient measurement were included. Several serum tests (alone and combined into scores) and liver stiffness were measured. Artificial neural networks containing or not liver stiffness as input variable were also created. RESULTS The best non-invasive method for diagnosing cirrhosis, portal hypertension and oesophageal varices was liver stiffness (C-statistics=0.93, 0.94, and 0.90, respectively). Among serum tests/scores the best for diagnosing cirrhosis and portal hypertension and oesophageal varices were, respectively, Fibrosis-4, and Lok score. Artificial neural networks including liver stiffness had high diagnostic performance for cirrhosis, portal hypertension and oesophageal varices (accuracy>80%), but were not statistically superior to liver stiffness alone. CONCLUSIONS Liver stiffness was the best non-invasive method to assess the presence of cirrhosis, portal hypertension and oesophageal varices. The use of artificial neural networks integrating different non-invasive tests did not increase the diagnostic accuracy of liver stiffness alone.

The Periscreen Strip Is Highly Efficient for the Exclusion of Spontaneous Bacterial Peritonitis in Cirrhotic Outpatients

Objectives:We aimed to assess the performance of a new strip (Periscreen) for the rapid diagnosis of spontaneous bacterial peritonitis (SBP).Methods:Ascitic fluid (AF) of cirrhotic patients hospitalized between March 2014 and August 2015 was independently tested by two readers using the new strip, which has four colorimetric graduations (negative, trace, small, and large). SBP was diagnosed on neutrophils in ascites>250/mm3. Ascites not related to portal hypertension were excluded.Results:Overall, 649 patients from 21 French centers were included and 1,402 AF (803 AF samples from 315 outpatients and 599 samples from 334 inpatients) were assessed. Eighty-four AF samples (17 AF in 9 outpatients and 67 AF in 31 inpatients) were diagnosed as SBP. The prevalence of SBP was 6% (2.1% in outpatients vs. 11.2% in inpatients; P<0.001) and 7.2% in patients with symptoms suggestive of SBP (3% in outpatients vs. 11.3% in inpatients; P<0.001). The κ value for inter-reader agreement was 0.81 (95% confidence interval: 0.77–0.84) when using the “trace” threshold. Considering discordant results (n=131) as positive to interpret the diagnostic performance of the strip at the “trace” threshold, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91.7, 57.1, 12.0, and 99.1%, respectively. At this “trace” threshold, sensitivity and NPV were both 100% in outpatients, and 89.5 and 97.9% in inpatients, respectively. At the “small” threshold, sensitivity, specificity, PPV and NPV were 81.0, 85.9, 25.9 and 98.7%, respectively.Conclusions:The Periscreen strip is a rapid and highly efficient tool for excluding SBP in the outpatient setting.

P587 PROGNOSTIC VALUE OF AFP LEVELS IN PATIENTS WITH HEPATOCELLULAR CARCINOMA: PROSPECTIVE EVALUATION OF 715 CONSECUTIVE PATIENTS PRESENTED AT OUR MULTIDISCIPLINARY COMMITTEE FROM 2006 TO 2011

P586 APPEARANCE OF COMBINED HEPATOCELLULAR CHOLANGIOCARCINOMA IN CIRRHOSIS AT CONTRAST ENHANCED IMAGING TECHNIQUES E. Sagrini, M. Iavarone, S. Vavassori, F. Stefanini, M. Maggioni, I. Pettinari, A. Pecorelli, M. Colombo, L. Bolondi, F. Piscaglia. Digestive Disease and Internal Medicine, S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Unit of Gastroenterology 1, UO Anatomia Patologica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy E-mail: elisabetta.sagrini@gmail.com

230 COMPARISON OF SIX SERUM TESTS, LIVER STIFFNESS AND HVPG IN THE PREDICTION OF CLINICAL DECOMPENSATION IN CHRONIC LIVER DISEASES

230 COMPARISON OF SIX SERUM TESTS, LIVER STIFFNESS AND HVPG IN THE PREDICTION OF CLINICAL DECOMPENSATION IN CHRONIC LIVER DISEASES B. Procopet, M.A. Robic, M. Grigorescu, S. Metivier, M. Tantau, J.M. Peron, J.P. Vinel, C. Bureau. Gastroenterology, University of Medicine and Pharmacy “Iuliu Hatieganu”, Gastroenterology, Regional Institute of Gastroenterology and Hepatology “O Fodor”, Cluj-Napoca, Romania; HepatoGastroenterology, Purpan Hospital, CHU Toulouse, INSERM U858 and University of Toulouse, Toulouse, France E-mail: bogdanprocopet@gmail.com