A964 AASLD ABSTRACTS

988

A NEW ELECTRONIC TEST FOR THE ASSESSMENT OF HE­PATIC ENCEPHALOPATHY AT HOME.Andreas D. Christ, Allan Novak, Eberhard L. Renner, Michael Fried, PeterBauerfeind, Univ Hosp, Zurich, Switzerland; Div of Gastroenterology,Univ Hosp of Zurich, Zurich, Switzerland.

Background: Assessment of the degree of hepatic encephalopathy is mostreliably done using neuropsychological tests. The standard test is thenumber connection test (NCT), a drawing test that requires the physicalpresence of the patient. We devised and validated an electronic alternative,named Reitan C (RC), that can be applied to patients at home over phoneor internet. Methods: Patients are asked to enter digits on a keypad asquickly and as correctly as possible. Numbers (0-9) are given in randomorder over speakers. The time necessary to enter 25 digits correctly ismeasured; incorrect digits are discarded. Normal values were obtained in109 healthy persons of both sex and equally distributed from 20 to >70years. Reproducibility was tested by administering the test on three occa­sions, two days apart each. RC was validated in 67 hepatology outpatients(table). Results: Normal values: up to 60 years there was no significantdifference in performance (21.07 sec). Performance was slower at age60-70 (25.74 sec, p < 0.001) and ~70 (40.82 sec, p < 0.001). Reproduc­ibility: There was no difference between 3 applications of the test (20.38,19.58 and 19.69 sec, p = n.s.). Validity: NCT and RC are closely correlated(Spearman R 0.69; p < 0.0001), there is no difference in NCT and RCranks (p = n.s.). NCT (p < 0.0005) and RC (p < 0.0001) distinctlyincrease with increasing Child stadium. Summary: RC is a new, reliabletest for encephalopathy and can be administered repeatedly. Advantagesover a standard NCT are: (a) remote test administration possible (e.g.,touch tone phone), (b) no age correction for patients up to 60 years, (c)unbiased by intervention of the physician and (d) less time to administer.This test may prove valuable in clinical studies and in monitoring of criticalpatients at home.

Child NCT (sec.) RC (sec.) N

0 37.5 (29,0-550) 22.8 (21.0-268) 34A 60,5 (45.0-84,0) 29,5 (25,6-41.0) 22B 85.0 (43.0-106,0) 359(26.8-43,8) 6C 170,0 (52,0-300,0) 42.4 (36,1-250,2) 5

GASTROENTEROLOGY Vol. 118, No.4

990

ULTRASOUND ANGIOGRAPHY WITH INTRA VENOUS CON­TRAST AGENT USING WIDEBAND GRAY-SCALE HARMONICIMAGING FOR EVALUATION OF TIPS STENOSIS.Yuko Kono, Robert F. Mattrey, Sean P. Pinnell, Keith McKlendin, SteveRose, Tarek Hassanein, UCSD, San Diego, CA.

Background: Transjuglar intrahepatic portosystemic shunt (TIPS) has be­come a widely accepted treatment for the complication of portal hyperten­sion. Despite its efficacy, the rate of occlusion or stenosis is high and itsdiagnosis is critical for patients management. Duplex sonography has beenused to monitor for TIPS dysfunction with a wide range of accuracy from35 to 90%. The ability to assess shunt patency with duplex sonographyremains controversial. Recent development of ultrasound contrast agentsand a contrast specific imaging technique enabled us "ultrasound angiog­raphy" with intravenous injection with high spatial and temporal resolu­tion. PURPOSE: To evaluate TIPS patency with ultrasound angiography ascompared to duplex ultrasound and x-ray angiography. MATERIALSAND METHODS: Patients with suspected TIPS abnormality either be­cause of clinical deterioration or because of an abnormal duplex ultrasoundthat were scheduled for angiographic evaluation were enrolled in the study.Optison" (Mallinckrodt Inc.• St Louis, MO) was approved by the FDA forechocardiography and used in this study under a physician sponsored IND.Multiple bolus injections of 0.5 to 2ml were given IV. Imaging wasperformed with 3.5MHz transducer of a Siemens Elegra using widebandgray-scale harmonic imaging at 2.5MHz central frequency. The blindedsonographer evaluated the TIPS for filling defects and intimal hyperplasia.The ultrasound images were correlated with the angiogram. RESULTS: 15patients were studied. Total volume of 5.7 ± 2.2 ml of Optison was usedto assess the TIPS stenosis. The stent did not disturb the ultrasound signal.The contrast agent filled the stent completely with bright signal, high­lighted intimal thickening between the enhanced lumen and the TWS wall.Thrombosed TIPS did not enhance. Sensitivity of duplex US to predictsignificant stenosis was 75%. The contrast ultrasound angiograms demon­strated intimal thickening and the site and degree of stenosis comparable tothe x-ray angiography. CONCLUSIONS: Ultrasound angiogram was com­parable to conventional angiography and superior to duplex sonography inassessing patency of TIPS. It demonstrated diffuse as well as focal intimalthickening with high correlation with angiography. The filling of the lumenon gray-scale is superior to Doppler because it is non-angle dependent,allows the depiction of the normal and thickened intima with high resolu­tion, and is free of motion artifacts.

1027

OUTCOME OF ESOPHAGEAL VARICEAL HEMORRHAGE INTHE US.W. R. Kim, P. S. Kamath, Mayo Clin, Rochester, MN.

Aims: (1) To describe the time trend in mortality and health care utilizationassociated with hospitalizations for EVH and (2) To investigate factors thatdetermine the outcome. Methods: We analyzed the Healthcare Cost andUtilization Project (HCUP) data which contains patient-level informationabout hospitalizations from a 20% stratified sample of all acute carehospitals in the US. Records with EVH case were identified using theICD-9 code. Results: Between 1988 and 1996, there was a progressivedecrease in the annual number of hospitalizations for EVH, inflation­adjusted total charges, and in-hospital deaths in the US. The mean lengthof stay (LOS) and charges per hospitalization also decreased. (See Table)During the same period, the utilization of endoscopic therapy for bleedingcontrol increased from 0.1% to 46%. The number of shunt procedures(TIPS or surgery) did not change over time, although the mortality asso­ciated with shunt procedures decreased from 30% to 5%. An age- andgender-adjusted multiple logistic regression analysis indicated that diag­nostic (OR=0.5) and therapeutic (OR=0.7) endoscopy and more recentyear of admission (OR=0.8) were associated with a lower risk of death. Incontrast, the need for a shunt procedure (OR=1.7), non-white race(OR= 1.2-1.8) and non-private insurance (OR= 1.3-1.5) were predictive ofa higher risk of inhospital death. Conclusions: The outcome of inpatientcare for EVH improved significantly during the last decade, which may berelated to wider application of liver transplantation and more effectiveendoscopic management. Minorities and less well insured patients have ahigher mortality.

Aggregate national estimatesYear Number of Charges

Hospitalizations ($million)

Data perhospitalizationMortality Mean Mean

(%) LOS (d) Charges ($)

median (first - third quartile)

989

A META·ANALYSIS OF PROPHYLACTIC VARICEAL LIGA­TION FOR ESOPHAGEAL VARICEAL HEMORRHAGE IN PA­TIENTS WITH CIRRHOSIS.Thomas F. Imperiale, Naga Chalasani, Indiana Univ, Indianapolis, IN.

Despite publication of several trials of prophylactic endoscopic varicealligation (PVL) for esophageal varices (EVs), the extent to which bleeding­related outcomes are affected is unclear. We performed a meta-analysis ofthe randomized controlled trials (RCTs) to determine the extent to whichPVL affected risk of 1" EV bleed (EVB), bleeding-related mortality andoverall mortality as compared with the trials' control groups. We searchedMEDLINE from 1993 to 1999 to identify all publications and used cross­referencing to supplement the search strategy. Both investigators indepen­dently applied inclusion and exclusion criteria, and abstracted clinical,methodological, and quantitative data from each trial. Disagreements wereresolved by consensus. Combinability of the trials was determined from aclinical assessment and by testing for homogeneity. Standard meta-analytictechniques with a random-effects model were used to compute relative risk(RR) with 95% CIs (CIs) and the number needed to treat (NNT) for initialepisode of EV bleed, EV bleed-related mortality & all-cause mortality(ACM). Eight RCTs were found (4 abstracts, 4 papers). Among 601patients in 5 homogeneous trials in which PVL was compared with un­treated controls, the RRs of 1" EV bleed, EV bleed-related mortality andACM were 0.36 (0.26-0.50), 0.16 (0.07-0.34), and 0.55 (0.43-0.71), indi­cating respective risk reductions of 64%, 84% and 45%, and respectiveNNTs of 4.1,6.4, and 5.3. Among 253 subjects from 3 trials in which PVLwas compared with B-blocker controls, the RR of 1st EV bleed was 0.40(0.19-0.86), indicating a risk reduction of 60% and NNT of 10; however,there was no effect on ACM (RR=0.95). This meta-analysis suggests that:I)Compared with untreated controls, PVL has impressive salutary effectson bleed-related outcomes including ACM;2)Compared with B-blockers,PVL significantly reduces risk for 1" EVB, but has no effect on ACM. PVLshould be considered for patients with large EVs who cannot tolerate orhave contraindications to B-blockers. Subsequent research should 1) fur­ther consider comparisons between PVL and B-blockers to determine theeffect on EV-related mortality and 2) measure the cost-effectiveness ofPVL.

88·8990·9192·9394-9596

10,5879,4838,2698,0627,459

215226175162140

13,513.211,611.293

8.7867,97,16,7

21,00624,61622,19520,29518,969