studies

HEPATOLOGY, VOLUME 62, NUMBER 1 (SUPPL) AASLD ABSTRACTS 931A
1477
Perceptions of the ‘cirrhotic coagulopathy’ influence low
yield testing for cerebral hemorrhage in patients with
cirrhosis and hepatic encephalopathy: an international,
multi-specialty survey
Elliot B. Tapper 1 , Laura Mazer 2 ; 1 Gastroenterology, Beth Israel
Deaconess Medical Center, Boston, MA; 2 Surgery, Beth Israel Deaconess
Medical Center, Boston, MA
Patients with cirrhosis and hepatic encephalopathy (HE) are
often evaluated for intracranial hemorrhage (ICH) even in the
absence of focal neurologic findings or trauma due to perceptions
of a tendency toward bleeding - the so-called ‘cirrhotic
coagulopathy.’. There is limited data on the prevalence and
clinical impact of such perceptions. Methods: We conducted
a prospective survey of physicians in internal medicine (IM),
emergency medicine (EM), general surgery (GS) and gastroenterology
(GI) at 35 centers in 5 countries. All respondents
were presented with a standard HE patient presentation (somnolence,
no focal neurologic findings, no evidence of a fall/
trauma). Subjects rated their likelihood to order computed
tomography (CT) of the head to exclude ICH on a 7 point
scale from -3 to +3.They were asked to re-rate their likelihood
after seeing the patient’s labs (including INR 2.4 and platelet
count 59) and again after seeing the results of a study
demonstrating the low yield of CT for this presentation (CGH
2015;13(1):165). Results: 1033 physicians responded, 86%
from the US. The proportions of IM, ED, GS and GI were 55%,
29%, 7% and 9%. The proportion of attendings, fellows and
residents were 42%, 7% and 49%. The baseline tendency to
order a CT was lowest among GI attendings, median -2 interquartile
range (IQR) (-2 – 0.75) and highest among EM physicians,
2 IQR (1-3). At baseline 56.0% of respondents were
likely to order a head CT. All groups (by specialty, level of
training and familiarity with cirrhosis) were significantly more
likely (p < 0.001 for all and to 0.03 for attending GI) to order
a head CT after seeing the labs. Of the subjects unlikely to
order a head CT at baseline, 114 (25.4%) would order after
the labs. All groups were less likely to order head CTs after
seeing the research data (mean difference -1.51 95% CI (-1.61
- -1.41), p < 0.0001). Of the 651 likely to order a head CT
after the labs, 313 (48.1%) were dissuaded by the published
yield data. 61.2% of IM physicians interested in head CTs
were most likely to report disinterest after exposure to the data
compared to 31.3% of EM physicians, p = 0.0002. Conclusions:
Misperceptions regarding the coagulopathy of cirrhosis
are highly prevalent and affect clinical decision-making, but
are amenable to education.
Disclosures:
The following authors have nothing to disclose: Elliot B. Tapper, Laura Mazer
1478
Prospective Multicenter Observational Study of Overt
Hepatic Encephalopathy (OHE): Nomenclature and Disease
Burden
Charles S. Landis 1 , Marwan Ghabril 2 , Vinod K. Rustgi 3 , Adrian
M. Di Bisceglie 4 , Benedict Maliakkal 5 , Don C. Rockey 6 , John M.
Vierling 7 , Richard Rowell 8 , Michael Santoro 8 , Aimee Enriquez 8 ,
Marzena Jurek 8 , Masoud Mokhtarani 8 , Dion F. Coakley 8 , Bruce F.
Scharschmidt 8 ; 1 University of Washington, Seattle, WA; 2 Indiana
University, Indianapolis, IN; 3 University of Pittsburgh, Pittsburgh,
PA; 4 St Louis University, St Louis, MO; 5 University of Rochester,
Rochester, NY; 6 Medical University of South Carolina, Charleston,
SC; 7 Baylor College of Medicine, Houston, TX; 8 Horizon Therapeutics
(formerly Hyperion Therapeutics, Inc.), Brisbane, CA
Overview: OHE, a complication of advanced liver disease, is
devastating to patients and families, burdensome to society,
and challenging with respect to both diagnosis and nomenclature,
evidenced by recent ISHEN and AASLD/EASL guidelines.
However, there is little prospectively collected data regarding
either the presenting manifestations of OHE or its associated
economic burden, as reflected, for example, by frequency of
recurrence and hospitalizations. Study Design: Surveys pertaining
to OHE were sent to over 200 centers in 23 countries;
176 centers (67% university and 29% public), which followed
a median of ~40 patients with OHE responded. A subset of
centers, which followed a median of ~100 OHE patients was
invited to participate in an observational study. To be eligible
for enrollment, patients were required to have a clinical diagnosis
of cirrhosis and at least 1 episode of OHE within 30
days prior to consent (qualifying OHE). Once enrolled, patients
were followed to capture OHE recurrence (on-study OHE). Clinical
manifestations of both qualifying and on-study OHE episodes
as recorded in the patients’ charts were noted. Results:
269 patients with a qualifying OHE event were enrolled at 31
sites in North America and Europe; data from 260 patients
who were followed for up to 8 months (mean=73 days) were
available for this interim analysis (median age=61; median
time since OHE diagnosis=1.1 years, 61% male, 87% Caucasian).
The most frequently documented clinical manifestations
of both qualifying and on-study OHE episodes included confusion
(73%), change in mental status (56%), disorientation
(46%), lethargy (44%) and asterixis (44%). West Haven grade
was recorded in only 27% of all OHE episodes. Fifty seven
patients had 101 on-study OHE episodes. The median time
for occurrence of 2 nd , 3 rd and 4 th OHE episodes was 28, 19
and 11 days, respectively. Of 87 and 47 patients followed for
at least 3 or 4 months, 32% and 34% experienced a mean
(SD) of 0.7 (1.5) or 0.9 (1.8) on-study OHE episodes, respectively.
57% of qualifying and 84% of on-study OHE episodes
occurred while patients were on rifaximin; 65% of qualifying
and 91% of on-study OHE episodes were associated with
hospitalization. Conclusions: Among patients enrolled in this
multi-center and multi-national observational study, clinical disorientation,
level of consciousness and asterixis were the most
commonly documented manifestations of OHE, whereas West
Haven was infrequently recorded. Despite the availability of
rifaximin, OHE, as reflected by frequent recurrence and hospitalizations,
continues to represent a major unmet clinical need
and societal burden.
Disclosures:
Charles S. Landis - Grant/Research Support: Gilead, Abbvie, BMS
Marwan Ghabril - Grant/Research Support: Salix
Vinod K. Rustgi - Advisory Committees or Review Panels: Abbvie, BMS, Merck;
Grant/Research Support: Gilead
Adrian M. Di Bisceglie - Advisory Committees or Review Panels: Gilead, AbbVie,
Novartis, Bayer, BTG; Grant/Research Support: Gilead, AbbVie