S152 Abstracts
less than 18 years of age or pregnant were excluded in addition to those who (P=0.004) longer length of stay (4.65 vs. 3.9 days) especially so in pre-operative
received only oral amiodarone, or received IV amiodarone one week prior to
hospital admission. Descriptive statistics will be used to analyze baseline char-
acteristics and study outcomes. Data will be presented in percentages, mean
and median values.
Results: A total of 1510 patients received intravenous amiodarone from July
2005 to July 2011. Seventy-eight patients, approximately 5.16% had elevated
liver enzymes [median:range; AST 253:82-12005; ALT 189:37-10006] after the
administration of IV amiodarone. Of the 78 patients with transaminitis, 10
developed fulminate hepatic failure (AST or ALT >1000) with 90% all-cause
mortality. Most patients developed a transient transaminitis that lasted three
days on average that resolved with cessation of the medication.
Conclusion: Although transaminitis is common with oral amiodarone, only
5.16% developed transaminitis while receiving intravenous amiodarone. Since
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the transaminitis resolved after cessation of the medication, it is more of a tran-
sient hepatic injury. The incidence of fulminate hepatic failure was rare but
with an all cause mortality of 90%.
358
Do Patients with Acute Cholecystitis with Elevated Liver Function Tests
and a Normal Cholangiogram Have Different Outcomes than Those with
Normal Liver Function Tests?
Venkata Gourineni, MD, MRCP, Zana Nikolla, MD, Jona Golbin, MD, George
Abdelsayed, MD, Yaw Amoateng-Adjepong, MD, Andrew Bedford, MD.
Bridgeport Hospital, Bridgeport, CT.
Purpose: Current guidelines suggest that, in the setting of acute cholecysti-
tis, early cholecystectomy may be performed within 24-72 hours of diagnosis.
When elevated liver function tests (LFTs) are present, a cholangiogram is fre-
quently obtained to rule out choledocholithiasis.This inevitably delays surgery.
We hypothesized that patients with elevated LFTs and a normal cholangiogram
might represent a group with more severe acute cholecystitis and, hence, antic-
ipated different outcomes including the duration of hospitalization compared
to group of patients with normal LFTs.
Methods: We collected information on several clinical variables including the
duration of hospitalization from case records of patients who underwent cho-
lecystectomy after acute cholecystitis between January 2005 and January 2010.
We divided them into two groups - Group 1 with normal LFTs and Group 2
with elevated LFTs. Of 207 patients identified, 107 had normal LFTs and 100
had abnormal LFTs.
Results: We found no statistical difference between the two groups in terms
of clinical variables including age,sex, white cell count on presentation
(P=0.759), evidence of systemic inflammatory response syndrome
(P=0.507), sepsis (P=0.68), need for conversion of laparoscopic approach to
open cholecystectomy (P=0.62), post-operative complications (P=1.0) and
post-operative length of stay. Group 2 patients had statistically significant
[359] Figure. Hemoglobin levels during treatment.
The American Journal of GASTROENTEROLOGY
period (1.5 vs. 1.2 days). On further analysis of group 2, we found that patients
who had a cholangiogram (ERCP/MRCP/EUS) pre-operatively (N=15) had
longer total length of stay (6 vs. 4.4 days) and pre-operative length of stay
(3.2 vs. 1.2) in the hospital compared to group who did not have cholangio-
gram (N=85) performed. This difference is statistically significant (P = 0.000).
Patients who had cholangiogram had an average of 3.3 investigations (US/CT/
HIDA/ERCP/MRCP/EUS) per patient, compared to 1.45 investigations in the
group that did not have cholangiogram performed.
Conclusion: In the setting of acute cholecystitis, the principle difference
between patients with elevated LFTs with a normal cholangiogram and nor-
mal LFTs was the duration of hospitalization. This prolonged hospitalization is
due to number of investigations they underwent to rule out common bile duct
stones, given no other reason for delaying cholecystectomy. Therefore, elevated
liver function tests in patients with acute cholecystitis may not represent clini-
cal severity but may have a tendency to delay surgery. Effective utilization of
investigations and expediting cholangiography, if felt to be indicated, could
significantly reduce the length of stay in patients with acute cholecystitis.
359
Development and Natural History of Anemia in Hepatitis C Patients
Treated with Protease Inhibitors
Gurshawn Singh, MD, Emad Sedki, MD, Brigette Bevly, PA, Ibrahim
Hanouneh, MD, Rocio Lopez, MS, Nizar Zein, MD, Naim Alkhouri, MD.
Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH.
Purpose: Protease inhibitors, telaprevir and boceprevir, have revolutionized
the treatment for hepatitis C virus (HCV) genotype 1 infection. Phase III trials
have shown that triple therapy with either medication can cause additional
drops in hemoglobin levels when compared to treatment with peg-interferon
and ribavirin alone. In this study, we investigated the development and natural
history of anemia in patients who are treated with telaprevir or boceprevir in
real life settings outside of clinical trials.
Methods: 61 patients were followed from initiation of treatment with telapre-
vir (45) or boceprevir (16) through 16 weeks of treatment. All patients had
baseline blood work done before treatment and weekly hemoglobin levels.
Anemia grade was defined using National Cancer Institute guidelines: Grade
0 (normal), Grade 1: 10 g/dL to normal limits, Grade 2: 8.0-10.0 g/dL, Grade
3: 6.5-7.9 g/dL, and Grade 4: <6.5 g/dL. Patients with symptomatic anemia or
medically significant drops in hemoglobin levels (grades 2-4) were treated by
dose reductions of ribavirin, red blood cell transfusions, epoetin alfa injec-
tions, or taken off treatment based on the clinician’s judgment. Univariable and
multivariable logistic regression analyses were performed.
Results: Study population had a mean age of 51.3 years, 59% were male, and
31% Caucasian; 40% were treatment naïve, and 29% were cirrhotics. The
mean baseline hemoglobin was 14.8±1.3 g/dL. Incidence of grade 2-4 ane-
mia (hemoglobin < 10g/dL) in patients treated with protease inhibitors was
VOLUME 107 | SUPPLEMENT 1 | OCTOBER 2012 www.amjgastro.com
 Abstracts S153

50.8% (31/61). Grade 3 & 4 anemia developed in 8% of patients. Lowest mean

hemoglobin was 10.3±1.9 g/dL vs. 10.3±1.8 g/dL for telaprevir and bocepre- [360] Table 2. CKD-EPI
vir, respectively (p<0.87). Hemoglobin nadir was reached between treatment eGFR-CKD-EPI Iothalamate group
weeks 8-10 (Figure). Anemia required ribavirin dose reduction in 58.6%, epo- Frequency < 15 15-29 30-59 60-89 > 90 Total
etin alfa in 27.3%, and blood transfusion in 18.5%. Treatment was not stopped
in any patient due to anemia. There was no significant difference between tela- < 15 8 0 0 0 0 8
previr and boceprevir in terms of the incidence or severity of anemia, the need 15-29 8 60 28 0 0 96
for dose reduction, use of epoetin alfa, or blood transfusions. 30-59 0 25 206 38 1 270
Conclusion: Using protease inhibitors to treat patients with hepatitis C does
60-89 0 1 60 98 31 190
results in clinically significant anemia that requires frequent monitoring and
modification of therapy. There was no significant difference in incidence or > 90 0 0 0 13 9 22
severity of anemia between telaprevir and boceprevir. CKD_EPI eGFR=141 × min(Scr/κ,1)α × max(Scr/κ,1)-1.209 × 0.993Age × 1.018 [if female] × 1.159 [if black]
Weighted Kappa Statistics=0.60.

360
Cystatin-C Based Equation More Accurate Than CKD-EPI in Estimating
Glomerular Filtration Rate in Liver Transplant Recipients 361
ACG/AstraZeneca Fellow Award Changes in Patients’ Knowledge and Perception of Hepatitis C Infection in
Presidential Poster the United States: Data from the National Health and Nutrition Examina-
Alina Allen, MD, Andrew Rule, MD, Nelson Leung, MD, Chun Fan, N/A, Terry tion Survey (NHANES)
Therneau, PhD, W. Ray Kim, MD. Gastroenterology and Hepatology, Mayo Siddesh Besur, MD, FACP, Jyothsna Talluri, MD, Vamsi Korrapati, MD, Siva
Clinic, Rochester, MN. Talluri, MD, FACP. Internal Medicine, McLaren Flint, Flint, MI.
Purpose: Chronic kidney disease (CKD) is a common yet serious complica- Purpose: Chronic hepatitis C infection affects liver and is a significant cause of
tion in long term liver transplant (LTx) recipients. Although assessment of morbidity and mortality in the United States. There has been a gradual decline
renal function, namely glomerular filtration rate (GFR) is an essential element in hepatitis C infection but this decline is not similar in all age groups. This
in the diagnosis and management of these patients, currently available meth- disparity may be due to lack of awareness of their infection or access to treat-
ods are suboptimal. In our previous work, we developed an equation based on ment.
cystatin C (‘MOLTO eGFR-C’) to estimate GFR in LTx recipients, which was Methods: We conducted a secondary analysis of the survey data of patients
superior to MDRD equation. Recent studies show that GFR is more accurately who tested positive for hepatitis C infection and interviewed during NHANES
estimated by CKD-EPI equation when compared to MDRD. In this work, (2001-2001) and NHANES (2007-2008). We included all adult patients (18
compare accuracy of ‘MOLTO eGFR-C’ to CKD-EPI equation. years or older) who tested positive for hepatitis C antibody and were inter-
Methods: GFR was measured in LTx recipients by iothalamate clearance after viewed as a part of hepatitis C follow-up survey.
a mean of 47.15 months after LTx (range: 0.46-264.13 months). A total of 600 Results: A total of 87 and 88 patients were found to have hepatitis C dur-
iothalamate results were obtained in 414 recipients. Of those, 586 were selected ing the years 2001-2002 and 2007-2008, respectively. The number of patients
to minimize redundancy while ensuring optimal coverage in the range that who previously are aware of hepatitis C was higher in 2007-2008 compared to
is clinically relevant (<90 ml/min). Concurrent laboratory data and demo- 2001-2002 (94% vs. 71%, respectively) (P<0.001). Patients’ understanding
graphic information were extracted from a prospective database. Banked of hepatitis C transmission has decreased with a higher number of patients
serum samples within a day of the GFR measurement were retrieved and believing that hepatitis C could be transmitted from shaking hands (16%
cystatin-C was assayed. (2007-2008) vs. 7% (2001-2002); a lower number of patients understood that
Results: The following variables were considered in modeling GFR: age, sex, injecting drugs transmitted hepatitis C (75% (2007-2008) vs.83% (2001-2002)
creatinine, BUN, albumin, hemoglobin and cystatin-C. A linear regression (P<0.005). There was overall improvement in number of patients who had
model incorporating these variables had overall accuracy (‘MOLTO eGFR- received liver biopsy (68% (2007-2008) vs. 19% (2001-2002) (P<.005).
C’ formula shown in table, R2=0.83) that was superior to that of CKD-EPI Conclusion: There is a reduction in the knowledge of hepatitis C transmission
(R2=0.75). The latter model was also superior to a generic cystatin-C-contain- from 2001-2001 to 2007-2008.
ing GFR estimating equation (eGFR-cys, R2=0.82). The tables compare how
well the MOLTO eGFR-C and CKD-EPI classify patients into appropriate
CKD stages.
Conclusion: The previously developed cystatin-C equation accurately esti-
362
mates GFR and may perform better than CKD-EPI in transplant recipients. Probiotics in Minimal Hepatic Encephalopathy: A Meta-Analysis
Further validation studies, particularly including race differences, will be
Manasi Agrawal, MBBS, Peter Homel, PhD, Nison Badalov, MD, Ira Mayer,
conducted. MD, FACG, Rabin Rahmani, MD. Maimonides Medical Center, Brooklyn, NY.
Purpose: Minimal hepatic encephalopathy (MHE) is characterized by abnor-
mal neurophysiological testing and absence of clinical symptoms. Attention
Table 1. MOLTO-eGFR-Cys
span and reaction time are reduced, with impaired quality of life and reduced
MOLTO-eGFR-Cys Iothalamate group survival. Elevated ammonia is implicated in the pathophysiology; treatment
Frequency < 15 15-29 30-59 60-89 > 90 Total options are directed at lowering it. Probiotics are live microorganisms, benefi-
cial to the host in therapeutic doses. They prevent the proliferation of patho-
< 15 9 1 0 0 0 10
genic bacteria in the GI tract and hence decrease ammonia production. Several
15-29 7 66 28 0 0 101 studies have been conducted to identify its role in the management of MHE
30-59 0 17 211 34 2 264 with variable results. We herein perform a meta-analysis of these studies.
60-89 0 0 32 91 22 145
Methods: We performed a search on Pubmed and Medview to identify ran-
domized controlled trials (RCT) on probiotics in MHE in the last 20 years.
> 90 0 0 0 9 12 21
To be eligible, studies had to include at least two randomized groups with a
MOLTO eGFR-C=8.53*Cys -0.64 *MOLTO LTx 0.54 Where MOLTO LTx=60.34 × SerumCr-1.05 *BUN-0.08 pre post comparison of mean ± standard deviation of serum ammonia levels.
*Albumin0.05 *Hgb0.48 *age-0.27 *1.3 (if male) Weighted Kappa Statistics=0.68.
Five studies comparing probiotics vs placebo/no treatment and three studies

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