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Figure 1: Relationship between post TIPS portosystemic gradient (mm Hg) and clinical response in cirrhotic patients with refractory hepatic hydrothorax. Mo1017 Comparison of Efficacy of Rifaximin and Non-Absorbable Disaccharides in Management of Hepatic Encephalopathy: A Meta-Analysis Sandhya Shukla, Shahid Mehboob, Sushovan Guha Introduction: Hepatic Encephalopathy (HE) is a serious complication of chronic liver disease characterized by complex neuropsychiatric abnormalities that range from mild confusion to coma. Although there have been different treatment options for HE, lactulose (a non- absorbable disaccharide, NADS) has been most commonly used and remains the mainstay of therapy. Rifaximin is a non-absorbable antibiotic and was recently approved by FDA for prevention of recurrent HE. Several small trials in the past have compared the effectiveness of rifaximin and NADS in management of HE. The results of these trials have been conflicting and limited due to small number of subjects involved. Aim: We therefore conducted a meta- analysis of Randomized controlled trials (RCT) to evaluate the efficacy of rifaximin in comparison to NADS. Methods: Two reviewers searched MEDLINE, EMBASE, CINAHL and the Cochrane Database using search terms “hepatic encephalopathy”, “rifaximin, “lactulose”, “lactitol”, “non-absorbable disaccharides”, “cirrhosis”. Inclusion criteria were:1) Studies invol- ving patients with HE 2) study be a RCT 3) comparison of rifaximin with NADS (either lactulose or lactitol). The review was done per guidelines of PRISMA statement and methodo- logical quality evaluated using Jadad scoring system. The results were pooled and relative risk ratio and 95% confidence interval (95% CI) derived using fixed effect estimates using STATA 10. Results: Five studies with a total of 259 patients met the pre-specified inclusion criteria. Of these 134 were randomized to rifaximin while 125 to NADS. In comparison to NADS, use of rifaximin was associated with significant reduction in risk of no improvement of HE (RR 0.57, 95% CI 0.35 - 0.94, p = 0.028). There was no significant heterogeneity amongst studies with Chi square statistic = 3.9, p = 0.41, I squared statistic = 0.0%. Discussion: Rifaximin is more beneficial in comparison to NADS in management of HE. Although Lactulose is used as the first line agent, frequent side effects such as bloating, flatulence, diarrhea limit tolerability. Rifaximin is not absorbed systemically and thus better tolerated. Further research should explore the optimum treatment duration for HE and cost- analysis with use of rifaximin. Rifaximin versus NADS for hepatic encephalopathy Mo1018 Excessive Reduction in Hvpg is Predictive of Mortality After Transjugular Intrahepatic Portosystemic Shunt (TIPS) Stacy Banerjee, Gabriel Lang, Thuong VanHa, Andrew Aronsohn, Helen S. Te, Nancy Reau, Donald M. Jensen Introduction: While transjugular intrahepatic portosystemic shunt (TIPS) is associated with improvement in variceal bleeding, refractory ascites, and hepatorenal syndrome, several questions remain regarding its impact on mortality. We explored procedural and peri- procedural factors that might be associated with mortality following TIPS. Methods: A retrospective review of 80 patients who underwent successful initial TIPS between January 2004 and December 2009 was performed. Characteristics of those who survived past the first 90 days were compared with those of the 25 individuals who died. Univariate and multivariate analyses of potential predictors of mortality was performed with Chi-squared S-955 AASLD Abstracts analyses. Results: The mean age of patients undergoing TIPS was 56.7 years. 61% of patients were male. 32.9% of patients died and none were transplanted within 90 days of TIPS. Factors studied include: sex, age, race, cause of cirrhosis, Child Pugh score, MELD score, heart rate, systolic blood pressure, serum sodium, hepatic venous portosystemic gradient (HVPG) before and after TIPS, and relative and absolute reduction in HVPG. The results are included in the table below. In multivariate analysis, two variables retained independent predictive value: relative reduction in HVPG 60% and post-TIPS AST: pre-TIPS AST ratio 2. Conclusion: A post-TIPS AST: pre-TIPS AST ratio greater than 2 and relative reduction in HVPG greater than 60% are predictive of 90-day mortality following TIPS, regardless of indication for shunt. Univariate Analysis for 90-day Mortality Mo1019 NASH Patients With Ascites Frequently Have Normal Serum Albumin, but a Higher Mortality When Low Albumin Occurs Achuthan Sourianarayanane, Robert O'Shea, David S. Barnes, Arthur J. McCullough Background and Aim: Portal hypertension, oncotic pressure and sodium retention are causal factors in the development of ascites, which usually develops pari passu with detoriating liver function. However, a small group of patients develop ascites despite normal serum albumin. Starling principle would predict that such patients would have higher portal pressure to offset the oncotic pressure. To investigate this principle, we studied the relation- ship between the hepatic venous wedge pressure gradient (HVWP) and serum albumin in ascites patients with cirrhosis of different etiologies. Methods: Medical records (from 2005 through 2009) of all patients undergoing transjugular liver procedures were reviewed. Patients without ascites, wedge pressure measurements, or defined hepatic pathology were excluded. Patient's demographics, disease etiology and biochemistry were obtained and related to disease severity (Model for End-Stage Liver Disease [MELD] and Child Pugh Turcotte [CPT] scores), ascites and clinical outcomes. Results: Of 227 patients reviewed, 138 met the above criteria. 74 were male (53.63%); mean age was 54.9 ± 10.5 years. Patients with normal (3.5 gm/dl) and low serum albumin (<3.5 gm/dl) were compared. There were no statistical differences in terms of age, gender, and HVWP gradient. Normal serum albumin was more frequent in patients with non alcoholic steato-hepatitis (NASH) (34.15% p=0.009) compared to hepatitis C virus (HCV) (8.33%) or alcoholic cirrhosis (9.43%) (Table 1). The HVWP gradient was lower in patients with NASH (14.95) compared to those with cirrhosis from alcohol (18.17, p =0.0108) or HCV (17.25, p=0.1377) There was no difference in mortality among diagnostic groups, however low serum albumin was associated with increased mortality compared to normal albumin (58.93% vs 23.08% p=0.001) and in the NASH sub group (Table 2). A similar association was also seen when patients were categorized by pathology (i.e., in centrivenular pattern vs. perivenular pattern of onset of fibrosis). Conclusion: In our study there was no significant increase in HVWP gradient in patients with normal serum albumin compared to patients with low serum albumin. However, NASH patients and patients with a central venular pattern of cirrhosis have higher frequency of normal serum albumin despite developing ascites. They also have lower HVWP gradients and no difference in urine sodium excretion compared to other groups. In these patients mechanisms other than portal pressure, serum albumin and sodium retention - must play a significant role in development of ascites, which may also play a part in the increased mortality rate seen when complicated by low albumin. These issues should be further studied. Table 1: Demographics Table 2: Mortality among groups AASLD Abstracts

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Figure 1: Relationship between post TIPS portosystemic gradient (mm Hg) and clinicalresponse in cirrhotic patients with refractory hepatic hydrothorax.

Mo1017

Comparison of Efficacy of Rifaximin and Non-Absorbable Disaccharides inManagement of Hepatic Encephalopathy: A Meta-AnalysisSandhya Shukla, Shahid Mehboob, Sushovan Guha

Introduction: Hepatic Encephalopathy (HE) is a serious complication of chronic liver diseasecharacterized by complex neuropsychiatric abnormalities that range from mild confusion tocoma. Although there have been different treatment options for HE, lactulose (a non-absorbable disaccharide, NADS) has been most commonly used and remains the mainstayof therapy. Rifaximin is a non-absorbable antibiotic and was recently approved by FDA forprevention of recurrent HE. Several small trials in the past have compared the effectivenessof rifaximin and NADS in management of HE. The results of these trials have been conflictingand limited due to small number of subjects involved. Aim: We therefore conducted a meta-analysis of Randomized controlled trials (RCT) to evaluate the efficacy of rifaximin incomparison to NADS. Methods: Two reviewers searched MEDLINE, EMBASE, CINAHL andthe Cochrane Database using search terms “hepatic encephalopathy”, “rifaximin, “lactulose”,“lactitol”, “non-absorbable disaccharides”, “cirrhosis”. Inclusion criteria were:1) Studies invol-ving patients with HE 2) study be a RCT 3) comparison of rifaximin with NADS (eitherlactulose or lactitol). The review was done per guidelines of PRISMA statement and methodo-logical quality evaluated using Jadad scoring system. The results were pooled and relativerisk ratio and 95% confidence interval (95% CI) derived using fixed effect estimates usingSTATA 10. Results: Five studies with a total of 259 patients met the pre-specified inclusioncriteria. Of these 134 were randomized to rifaximin while 125 to NADS. In comparison toNADS, use of rifaximin was associated with significant reduction in risk of no improvementof HE (RR 0.57, 95% CI 0.35 - 0.94, p = 0.028). There was no significant heterogeneityamongst studies with Chi square statistic = 3.9, p = 0.41, I squared statistic = 0.0%.Discussion: Rifaximin is more beneficial in comparison to NADS in management of HE.Although Lactulose is used as the first line agent, frequent side effects such as bloating,flatulence, diarrhea limit tolerability. Rifaximin is not absorbed systemically and thus bettertolerated. Further research should explore the optimum treatment duration for HE and cost-analysis with use of rifaximin.

Rifaximin versus NADS for hepatic encephalopathy

Mo1018

Excessive Reduction in Hvpg is Predictive of Mortality After TransjugularIntrahepatic Portosystemic Shunt (TIPS)Stacy Banerjee, Gabriel Lang, Thuong VanHa, Andrew Aronsohn, Helen S. Te, NancyReau, Donald M. Jensen

Introduction: While transjugular intrahepatic portosystemic shunt (TIPS) is associated withimprovement in variceal bleeding, refractory ascites, and hepatorenal syndrome, severalquestions remain regarding its impact on mortality. We explored procedural and peri-procedural factors that might be associated with mortality following TIPS. Methods: Aretrospective review of 80 patients who underwent successful initial TIPS between January2004 and December 2009 was performed. Characteristics of those who survived past thefirst 90 days were compared with those of the 25 individuals who died. Univariate andmultivariate analyses of potential predictors of mortality was performed with Chi-squared

S-955 AASLD Abstracts

analyses. Results: The mean age of patients undergoing TIPS was 56.7 years. 61% of patientswere male. 32.9% of patients died and none were transplanted within 90 days of TIPS.Factors studied include: sex, age, race, cause of cirrhosis, Child Pugh score, MELD score,heart rate, systolic blood pressure, serum sodium, hepatic venous portosystemic gradient(HVPG) before and after TIPS, and relative and absolute reduction in HVPG. The resultsare included in the table below. In multivariate analysis, two variables retained independentpredictive value: relative reduction in HVPG ≥ 60% and post-TIPS AST: pre-TIPS AST ratio≥ 2. Conclusion: A post-TIPS AST: pre-TIPS AST ratio greater than 2 and relative reductionin HVPG greater than 60% are predictive of 90-day mortality following TIPS, regardless ofindication for shunt.Univariate Analysis for 90-day Mortality

Mo1019

NASH Patients With Ascites Frequently Have Normal Serum Albumin, but aHigher Mortality When Low Albumin OccursAchuthan Sourianarayanane, Robert O'Shea, David S. Barnes, Arthur J. McCullough

Background and Aim: Portal hypertension, oncotic pressure and sodium retention are causalfactors in the development of ascites, which usually develops pari passu with detoriatingliver function. However, a small group of patients develop ascites despite normal serumalbumin. Starling principle would predict that such patients would have higher portalpressure to offset the oncotic pressure. To investigate this principle, we studied the relation-ship between the hepatic venous wedge pressure gradient (HVWP) and serum albumin inascites patients with cirrhosis of different etiologies. Methods: Medical records (from 2005through 2009) of all patients undergoing transjugular liver procedures were reviewed.Patients without ascites, wedge pressure measurements, or defined hepatic pathology wereexcluded. Patient's demographics, disease etiology and biochemistry were obtained andrelated to disease severity (Model for End-Stage Liver Disease [MELD] and Child PughTurcotte [CPT] scores), ascites and clinical outcomes. Results: Of 227 patients reviewed,138 met the above criteria. 74 were male (53.63%); mean age was 54.9 ± 10.5 years. Patientswith normal (≥ 3.5 gm/dl) and low serum albumin (<3.5 gm/dl) were compared. Therewere no statistical differences in terms of age, gender, and HVWP gradient. Normal serumalbumin was more frequent in patients with non alcoholic steato-hepatitis (NASH) (34.15%p=0.009) compared to hepatitis C virus (HCV) (8.33%) or alcoholic cirrhosis (9.43%) (Table1). The HVWP gradient was lower in patients with NASH (14.95) compared to those withcirrhosis from alcohol (18.17, p =0.0108) or HCV (17.25, p=0.1377) There was no differencein mortality among diagnostic groups, however low serum albumin was associated withincreased mortality compared to normal albumin (58.93% vs 23.08% p=0.001) and in theNASH sub group (Table 2). A similar association was also seen when patients were categorizedby pathology (i.e., in centrivenular pattern vs. perivenular pattern of onset of fibrosis).Conclusion: In our study there was no significant increase in HVWP gradient in patientswith normal serum albumin compared to patients with low serum albumin. However, NASHpatients and patients with a central venular pattern of cirrhosis have higher frequency ofnormal serum albumin despite developing ascites. They also have lower HVWP gradientsand no difference in urine sodium excretion compared to other groups. In these patientsmechanisms other than portal pressure, serum albumin and sodium retention - must playa significant role in development of ascites, which may also play a part in the increasedmortality rate seen when complicated by low albumin. These issues should be further studied.Table 1: Demographics

Table 2: Mortality among groups

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