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Tan R, Abasszade JH, Dhillon H, Kuan CC, Worland T, Tabatabai S. Severe Hepatitis Complicating Olmesartan Enteropathy: A Case Report. Case Rep Gastroenterol 2024; 18:238-243. [PMID: 38665145 PMCID: PMC11045212 DOI: 10.1159/000538552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 03/24/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction Olmesartan, an angiotensin II receptor antagonist, is associated with an uncommon complication of enteropathy that presents insidiously, usually months to years after initial commencement of anti-hypertensive therapy which can be dose-dependent. It has a variable spectrum of clinical presentation but commonly presents as a moderate to severe malabsorptive process with potential severe complications related to poor end-organ perfusion. Lymphocytic gastritis and microscopic colitis are often noted in patients presenting with olmesartan-induced enteropathy; however, hepatic involvement has been less frequently observed. Case Presentation We illustrate a case of a 43-year-old female presenting with 2 weeks of profuse non-bloody diarrhea in the context of olmesartan enteropathy which was complicated by an acute severe ischemic and enteropathic hepatopathy. Conclusion Our case prompts clinicians to maintain a high index of suspicion in cases presenting with a seronegative enteropathy and concurrent acute liver injury while on olmesartan therapy. Cessation of olmesartan therapy resulted in prompt resolution of diarrheal symptoms and normalization of the acute transaminitis on subsequent three-week follow-up.
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Affiliation(s)
- Ruyi Tan
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, VIC, Australia
| | | | - Hardesh Dhillon
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, VIC, Australia
| | - Chih Chien Kuan
- Department of Anatomical Pathology, Monash Health, Melbourne, VIC, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, VIC, Australia
| | - Shireen Tabatabai
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, VIC, Australia
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2
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Liu MN, Au M, Bishara M, Worland T, Con D, Chew S, McNiece A, Gronbaek H, Sluka P, Nicoll AJ. Serum interleukin-4 is elevated in clinical drug-induced liver injury. Scand J Gastroenterol 2023; 58:1499-1504. [PMID: 37464727 DOI: 10.1080/00365521.2023.2237154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Drug-induced liver injury (DILI) remains a challenging diagnosis due to an absence of specific biomarkers. DILI due to volatile anaesthetics (VA-DILI) is characterised by trifluoroacetyl and CYP2E1 antibodies, but may not be seen for weeks after injury. Interleukin-4 (IL-4) may be involved in the production of these antibodies and may serve as a clinically useful early biomarker of VA-DILI. AIM To prospectively compare serum IL-4 levels between patients who develop VA-DILI and controls following exposure to the volatile anaesthetic. METHODS A nested case-control study of patients exposed to VA during surgery was conducted. Thirteen DILI cases were identified from the original cohort, and 26 controls were matched according to age, sex and VA agent. Serum samples were collected before and 48-96 h after VA exposure, and analysed for IL-4 using quantitative enzyme-linked immunosorbent assay techniques. RESULTS There was a statistically significant difference in serum IL-4 in post-VA samples between DILI cases and controls (control: 0.030 pg/mL, IQR: 0.030 - 0.030 pg/mL vs DILI: 0.044 pg/mL, IQR: 0.030 - 0.061 pg/mL; p = 0.039). A greater proportion of DILI cases had post-VA IL-4 levels above the assay lower limit of detection compared to controls (control: 23% vs DILI: 69%; p = 0.013). CONCLUSION IL-4 is a potential biomarker of DILI. Clinical diagnosis and understanding of DILI disease mechanisms may be improved by further investigation of novel biomarkers, and this IL-4 signal in serum is important as proof of concept for prospective study designs.
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Affiliation(s)
- M N Liu
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - M Au
- Department of Gastroenterology, Eastern Health, Box Hill, VIC, Australia
| | - M Bishara
- Department of Gastroenterology, Eastern Health, Box Hill, VIC, Australia
| | - T Worland
- Department of Gastroenterology, Eastern Health, Box Hill, VIC, Australia
| | - D Con
- Department of Gastroenterology, Eastern Health, Box Hill, VIC, Australia
| | - S Chew
- Department of Anaesthetics, Eastern Health, Box Hill, VIC, Australia
| | - A McNiece
- Department of Anaesthetics, Eastern Health, Box Hill, VIC, Australia
| | - H Gronbaek
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
| | - P Sluka
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - A J Nicoll
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
- Department of Gastroenterology, Eastern Health, Box Hill, VIC, Australia
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3
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Apostolov R, Wong D, Low E, Vaz K, Spurio J, Worland T, Liu D, Chan RK, Gow P, Grossmann M, Sinclair M. Testosterone is lower in men with non-alcoholic fatty liver disease and alcohol-related cirrhosis and is associated with adverse clinical outcomes. Scand J Gastroenterol 2023; 58:1328-1334. [PMID: 37282344 DOI: 10.1080/00365521.2023.2220857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/16/2023] [Accepted: 05/29/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND/AIMS Low serum testosterone is common in cirrhotic men, but the impact of disease aetiology remains uncertain. This study compares serum total testosterone (TT) levels by disease aetiology and assesses its prognostic value. METHODS Single-centre retrospective study of cirrhotic men who had TT levels measured between 2002 and 2020. A cut-off of 12 nmol/L was used to define low TT and 230 pmol/L for calculated free testosterone (cFT). Linear and logistic regression used to adjust for variables known to affect testosterone levels and assess for an association between levels and outcomes. RESULTS Of 766 cirrhotic men, 33.3% had alcohol-related liver disease (ALD) and 11.9% had non-alcoholic fatty liver disease (NAFLD). The median age was 56 years (interquartile range (IQR) 50-61), and the model for end-stage liver disease (MELD) score 14 (IQR 9-20). TT levels were low in 53.3% of patients, (median 11.0 nmol/L; IQR 3.7-19.8) and cFT low in 79.6% (median 122 pmol/L; IQR 48.6-212). Median TT was lower in men with ALD (7.6 nmol/L; IQR 2.1-16.2) and NAFLD (9.8 nmol/L; IQR 2.75-15.6) compared to other aetiologies (11.0 nmol/L; IQR 3.73-19.8) (p < 0.001 for all), which remained true after adjustment for age and MELD score. TT was inversely associated with 12-month mortality or transplant (381 events, p = 0.02) and liver decompensation (345 events, p = 0.004). CONCLUSIONS Low serum testosterone is common in cirrhotic men and is associated with adverse clinical outcomes. TT levels are significantly lower in ALD and NAFLD compared to other disease aetiologies. Further large-scale studies are required to assess the potential benefits of testosterone therapy.
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Affiliation(s)
- Ross Apostolov
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Darren Wong
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Low
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Karl Vaz
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Jessica Spurio
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Thomas Worland
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Dorothy Liu
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | | | - Paul Gow
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - Marie Sinclair
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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4
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Ngu NL, Saxby E, Worland T, Anderson P, Stothers L, Figredo A, Hunter J, Elford A, Ha P, Hartley I, Roberts A, Seah D, Tambakis G, Liew D, Rogers B, Sievert W, Bell S, Le S. A home-based, multidisciplinary liver optimisation programme for the first 28 days after an admission for acute-on-chronic liver failure (LivR well): a study protocol for a randomised controlled trial. Trials 2022; 23:744. [PMID: 36064596 PMCID: PMC9444080 DOI: 10.1186/s13063-022-06679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 08/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. Methods We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry. Discussion This study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897. Registered on 13 December 2021. WHO Trial Registration Data Set. See Appendix 1 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06679-x.
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Affiliation(s)
- Natalie Ly Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia. .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.
| | - Edward Saxby
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Patricia Anderson
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Lisa Stothers
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Anita Figredo
- Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Jo Hunter
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Alexander Elford
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Andrew Roberts
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Dean Seah
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - George Tambakis
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Danny Liew
- Adelaide Medical School, The University of Adelaide, Corner of North Terrace & George St, Adelaide, South Australia, 5000, Australia
| | - Benjamin Rogers
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.,Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - William Sievert
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Suong Le
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
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5
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Worland T, O'Neill P, Rusli F. Resolution of metastatic hepatocellular carcinoma with sour cherry intake. Clin Res Hepatol Gastroenterol 2021; 45:101663. [PMID: 33667729 DOI: 10.1016/j.clinre.2021.101663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Thomas Worland
- Department of Gastroenterology, Monash Health, 246 Clayton road, Clayton, Melbourne, Australia.
| | - Paul O'Neill
- Department of Gastroenterology, Monash Health, 246 Clayton road, Clayton, Melbourne, Australia
| | - Ferry Rusli
- Department of Gastroenterology, Monash Health, 246 Clayton road, Clayton, Melbourne, Australia
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6
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Worland T, Bloom A, Robertson M. An Unusual Case of Small Bowel Obstruction. Gastroenterology 2021; 160:e12-e13. [PMID: 33039463 DOI: 10.1053/j.gastro.2020.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/29/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Thomas Worland
- Monash Health, Department of Gastroenterology, Melbourne, Australia.
| | - Ashley Bloom
- Monash Health, Department of Gastroenterology, Melbourne, Australia
| | - Marcus Robertson
- Monash Health, Department of Gastroenterology, Melbourne, Australia
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7
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Worland T, Chin KL, Rodrigues B, Nicoll A. A retrospective case-controlled cohort study of inpatient drug induced liver injury: the RIDDLE study. Transl Gastroenterol Hepatol 2020; 5:33. [PMID: 32632384 DOI: 10.21037/tgh.2019.10.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022] Open
Abstract
Background Identification of risk factors for drug-induced liver injury (DILI) has been hindered by the unpredictable incidence and idiosyncratic nature of DILI. The aim of this study was to identify characteristic host risk factors for DILI. Methods A retrospective cohort study was performed examining all patients admitted with a diagnosis of DILI over a 5.5-year period. Cases were compared to a control group non-exposed to DILI using propensity score-derived inverse probability weights. Patients with DILI due to alcohol or paracetamol were excluded from analysis. Results Seventy-two cases of DILI admitted to hospital were identified. Antimicrobials caused 56.9% of cases, with amoxicillin-clavulanate the single most common agent, responsible for 13.9% of cases. DILI cohort median age (50.2±36 years) was significantly younger than controls (65.0±38 years) (P<0.001). Pre-existing chronic liver disease (OR, 3.44; 95% CI, 1.38-8.59; P=0.008), length of stay (P<0.001) and in-hospital death (P=0.009) were more likely to be associated with DILI cases. There was no correlation with sex (OR male, 0.92; 95% CI, 0.50-1.67; P=0.78), presence of comorbid autoimmune disease (OR, 1.44; 95% CI, 0.68-3.05; P=0.35), past drug allergies (OR, 1.71; 95% CI, 0.92-3.16; P=0.09), or atopy (OR, 0.87; 95% CI, 0.42-1.82; P=0.72). Conclusions Younger age and presence of chronic liver disease were associated with an admission with DILI; however, it remains difficult to predict the population at risk of DILI on clinical grounds and putative risk factors such as female gender, and history of other drug allergies and autoimmunity, were not demonstrated in this study.
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Affiliation(s)
- Thomas Worland
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
| | - Ken Lee Chin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Beverley Rodrigues
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
| | - Amanda Nicoll
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia.,Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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8
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Worland T, Apostolov R, Asadi K, Leung C. Hepatitis B virus activity is not associated with degree of liver steatosis in patients with hepatitis B-related chronic liver disease. Liver Int 2020; 40:1500-1502. [PMID: 31883410 DOI: 10.1111/liv.14344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS The recently published manuscript by Zhu and colleagues "Hepatitis B virus infection and risk of non-alcoholic fatty liver disease: A population-based cohort study" found no correlation between presence of chronic HBV and presence of common risk factors for non-alcoholic fatty liver disease on primary analysis. A limitation to this study, like most population based research, is the absence of liver histology, which is considered gold standard for assessment of non-alcoholic fatty liver disease. METHODS Our group studied the association between hepatitis B viral activity and non-alcoholic fatty liver disease activity as measured by grade of steatohepatitis/fibrosis on liver biopsy by analysing consecutive liver histology samples from patients with chronic hepatitis B at a single quaternary liver transplant centre. RESULTS Linear regression modelling for active viral hepatitis on histological examination against degree of steatohepatitis showed no correlation (r2 = .018, all P> .1). Linear regression of degree of steatohepatitis vs hepatitis B viral load also showed no correlation. CONCLUSIONS Our work is concordant with the manuscript from Zhu et al; we found no significant correlation between hepatitis B viral activity and degree of steatohepatitis.
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Affiliation(s)
- Thomas Worland
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Vic., Australia
| | - Ross Apostolov
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Vic., Australia
| | - Khashayar Asadi
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Vic., Australia
| | - Christopher Leung
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Vic., Australia
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9
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Bohra A, Worland T, Hui S, Terbah R, Farrell A, Robertson M. Prognostic significance of hepatic encephalopathy in patients with cirrhosis treated with current standards of care. World J Gastroenterol 2020; 26:2221-2231. [PMID: 32476788 PMCID: PMC7235207 DOI: 10.3748/wjg.v26.i18.2221] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/27/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a reversible neuropsychiatric complication of liver cirrhosis and occurs in up to 50% of cirrhotic patients. Studies examining the prognostic significance of HE are limited despite the high prevalence in cirrhosis.
AIM To define the clinical outcomes of patients after an episode of HE treated with current standards-of-care.
METHODS All patients hospitalised with HE requiring Rifaximin to 3 tertiary centres over 46-mo (2012–2016) were identified via pharmacy dispensing records. Patients with hepatocellular carcinoma and those prescribed Rifaximin prior to admission were excluded. Medical records were reviewed to determine baseline characteristics and survival. The Kaplan-Meier method was used to calculate survival probability. Univariate survival analysis was performed with variables reaching statistical significance included in a multivariate analysis. The primary outcome was 12-mo mortality following commencement of Rifaximin.
RESULTS 188 patients were included. Median age was 57 years (IQR 50-65), 71% were male and median model for end stage liver disease and Child Pugh scores were 25 (IQR 18-31) and 11 (IQR 9-12) respectively. The most common causes of cirrhosis were alcohol (62%), hepatitis C (31%) and non-alcoholic fatty liver disease (20%). A precipitating cause for HE was found in 92% patients with infection (43%), GI bleeding (16%), medication non-compliance (15%) and electrolyte imbalance (14%) the most common. During a mean follow up period of 12 ± 13 mo 107 (57%) patients died and 32 (17%) received orthotopic liver transplantation. The most common causes of death were decompensated chronic liver disease (57%) and sepsis (19%). The probability of survival was 44% and 35% at 12- and 24-mo respectively. At multivariate analysis a model for end stage liver disease > 15 and international normalised ratio reached statistical significance in predicting mortality.
CONCLUSION Despite advances made in the management of HE patients continue to have poor survival. Thus, in all patients presenting with HE the appropriateness of orthotopic liver transplantation should be considered.
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Affiliation(s)
- Anuj Bohra
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
| | - Thomas Worland
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
- Department of Gastroenterology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Samuel Hui
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
| | - Ryma Terbah
- Department of Gastroenterology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Ann Farrell
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
| | - Marcus Robertson
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
- Department of Gastroenterology, Austin Health, Heidelberg 3084, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton 3168, Victoria, Australia
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10
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Worland T, Chin KL, van Langenberg D, Garg M, Nicoll A. Retrospective study of idiosyncratic drug-induced liver injury from infliximab in an inflammatory bowel disease cohort: the IDLE study. Ann Gastroenterol 2020; 33:162-169. [PMID: 32127737 PMCID: PMC7049241 DOI: 10.20524/aog.2020.0453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 11/24/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infliximab therapy may be associated with drug-induced liver injury (DILI), often resembling a drug-induced autoimmune hepatitis. However, the prevalence of DILI in patients receiving infliximab is unclear. Abnormal liver biochemistry is common in patients with inflammatory bowel disease (IBD) and definitive diagnosis may be difficult. The aim of this study was to describe the patterns of abnormal liver biochemistry in an IBD cohort. Methods In a retrospective cohort study of adult patients with IBD treated with infliximab through a single institution we used the Roussel Uclaf Causality Assessment Method (RUCAM) to evaluate liver biochemistry and possible DILI. All cases of abnormal liver biochemistry were ascribed a presumptive diagnosis from the electronic medical record. Results Fifty-seven of the 175 patients (149 Crohn's disease, 26 ulcerative colitis) had abnormal liver biochemistry. Of the 57 cases, one had highly probable, and 10 possible DILI due to infliximab. There were no significant differences regarding demographics, concomitant therapy/disease, indication for infliximab or outcomes between patients with normal and abnormal liver biochemistry, except for higher baseline alanine transaminase and alkaline phosphatase in the abnormal biochemistry group (P<0.001). Multivariate logistic regression showed male sex (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.22-5.09; P=0.01) and background liver disease (OR 15.09, 95%CI 4.09-55.69; P<0.001) to be associated with the abnormal liver biochemistry group. Conclusions Abnormal liver biochemistry is common in IBD patients on infliximab. Patients who are male, or have abnormal pre-therapy liver biochemistry or background liver disease, are more likely to develop worsening liver biochemistry during infliximab therapy. RUCAM scoring may help identify true cases of DILI.
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Affiliation(s)
- Thomas Worland
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll)
| | - Ken Lee Chin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University (Ken Lee Chin)
| | - Daniel van Langenberg
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll).,Eastern Health Clinical School, Monash University, Eastern Health Clinical School (Daniel van Langenberg, Mayur Garg, Amanda Nicoll), Australia
| | - Mayur Garg
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll).,Eastern Health Clinical School, Monash University, Eastern Health Clinical School (Daniel van Langenberg, Mayur Garg, Amanda Nicoll), Australia
| | - Amanda Nicoll
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll).,Eastern Health Clinical School, Monash University, Eastern Health Clinical School (Daniel van Langenberg, Mayur Garg, Amanda Nicoll), Australia
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Worland T, Cronin O, Harrison B, Alexander L, Ding N, Ting A, Dimopoulos S, Sykes R, Alexander S. Clinical and financial impacts of introducing an endoscopic mucosal resection service for treatment of patients with large colonic polyps into a regional tertiary hospital. Endosc Int Open 2019; 7:E1386-E1392. [PMID: 31673609 PMCID: PMC6805202 DOI: 10.1055/a-0970-8828] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005 - 2008) and 9 years after its introduction (2009 - 2017). Results From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50 % male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56 % reduction in the number of patients referred for surgery (32 surgical procedures, 47 % male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60 % male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7 % vs 54.7 %, P < 0.0001), and shorter average LoS (1 vs 9 days, P < 0.0001). A cost saving of AUD $ 19 543.5 was seen per lesion removed with EMR compared to SR. Conclusions The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.
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Affiliation(s)
| | | | | | | | - Nik Ding
- St Vincent’s Hospital, Melbourne, Australia,University of Melbourne, Melbourne, Australia
| | - Alvin Ting
- University Hospital Geelong, Geelong, Australia,Deakin University, Geelong, Australia
| | | | | | - Sina Alexander
- University Hospital Geelong, Geelong, Australia,Deakin University, Geelong, Australia,Corresponding author Dr. Sina Alexander Department of GastroenterologyBarwon HealthUniversity Hospital GeelongRyrie St.GeelongAustralia 3220
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Plant LD, Taylor DM, Worland T, Puri A, Ugoni A, Patel SK, Johnson DF, Burrell LM. Development of Acute Decompensated Heart Failure Among Hospital Inpatients: Incidence, Causes and Outcomes. Heart Lung Circ 2017. [PMID: 29519692 DOI: 10.1016/j.hlc.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND We aimed to investigate the incidence, precipitants, and outcomes of acute decompensated heart failure (ADHF) that develops during the inpatient stay. METHODS We undertook a case-control study in the medical, oncology, surgical, and orthopaedic wards of a tertiary referral hospital (February-May, 2016). Patients aged ≥18 years who developed ADHF during their inpatient stay were enrolled as cases. One control patient was matched to each case by age, gender, presenting complaint/surgery performed and co-morbidities. Multivariate regression was employed to determine variables associated with ADHF. RESULTS The incidence of ADHF was 1.0% of patients. Eighty cases were well-matched to 80 controls (p>0.05). ADHF precipitants comprised infection (30%), inappropriate intravenous (IV) fluid and medication management (23.8% and 8.8%, respectively), tachyarrhythmia (12.5%), ischaemic heart disease (8.8%), renal failure (1.3%), and other/unclear causes (15%). Three variables were associated with ADHF: not having English as the preferred language (OR 3.5, 95%CI 1.2-9.8), a history of ischaemic heart disease (OR 3.3, 95%CI 1.2-9.1), and the administration of >2000ml of IV fluid on the day before the ADHF (OR 8.3, 95%CI 1.5-48.0). The day before the ADHF, cases were administered significantly more IV fluids than controls (median 2,757.5 versus 975ml, p=0.001). Medication errors mostly related to failure to restart regular diuretics. Cases had significantly greater length of stay (median 15 versus 6 days, p<0.001) and mortality (12.5% versus 1.3%, p=0.01). CONCLUSIONS New onset ADHF is common and a substantial proportion of cases are iatrogenic. Cases experience significantly increased length of hospital stay, morbidity, and mortality.
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Affiliation(s)
- Luke D Plant
- Department of Emergency Medicine, Austin Hospital, Melbourne, Vic, Australia
| | - David McDonald Taylor
- Department of Emergency Medicine, Austin Hospital, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia.
| | - Thomas Worland
- Department of Medicine, Austin Hospital, Melbourne, Vic, Australia
| | - Arvind Puri
- Department of Medicine, Austin Hospital, Melbourne, Vic, Australia
| | - Antony Ugoni
- Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Sheila K Patel
- Department of Medicine, University of Melbourne, Melbourne, Vic, Australia; Department of Medicine, Austin Hospital, Melbourne, Vic, Australia
| | - Douglas F Johnson
- Department of Medicine, University of Melbourne, Melbourne, Vic, Australia; Department of Medicine, Austin Hospital, Melbourne, Vic, Australia; Department of Infectious Diseases, Austin Hospital, Melbourne, Vic, Australia
| | - Louise M Burrell
- Department of Medicine, University of Melbourne, Melbourne, Vic, Australia; Department of Medicine, Austin Hospital, Melbourne, Vic, Australia
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