Gastric adenocarcinoma (GAC) is the 16th most common cancer in the UK and has a 5-year survival rate of 20.7%. GastroPanel (Biohit Oyj; Helsinki, Finland) is an ELISA kit that measures four plasma biomarkers: Pepsinogen I (PGI), Pepsinogen II (PGII), Gastrin 17 (G17) and Helicobacter pylori IgG antibodies (Hp IgG), for the detection of atrophic gastritis (AG). PGI and PGI/PGII ratio correlates inversely with the severity of chronic atrophic gastritis and have been shown to accurately identify patients at risk of GAC.This clinical validation study assessed the diagnostic accuracy of GastroPanel in detecting AG among consecutive dyspeptic patients referred for gastroscopy at a single UK centre. Two hundred and sixty-eight patients (Females = 151 (56.3%); Median age = 57 (range 39-92 years) underwent gastroscopy and biopsy histology according to the updated Sydney system (USS). Blood (plasma) samples for GastroPanel analysis were collected for the index testing[M1]. GastroPanel results interpretation was performed using GastroSoft (Biohit Oyj, Helsinki, Finland) app. [M1]GP is the index test and gastroscopy is the reference test (gold standard) Overall agreement between GastroPanel and the USS classification was 90% (95%CI=86.7-93.8%), with a weighted kappa (κw) of 0.828 (95%CI=0.781-0.865). In ROC analysis, using moderate/severe atrophic gastritis of the corpus (AGC2+) as the endpoint, AUC=0.840 (95%CI 0.630-1.000) and 0.960 (95%CI 0.907-1.000) for PGI and PGI/PGII ratio, respectively. GastroPanel is a precise triage test, capable of distinguishing patients with functional dyspepsia who can be safely followed up and treated conservatively, from those at high risk of developing GAC for whom diagnostic gastroscopy is mandatory.

active bleeding and/or the need for endoscopic haemostasis. These patients could have an UGI capsule endoscopy in the emergency department as opposed to hospital admission and subsequent wait for an inpatient OGD. This could conse-quently have significant implications on admission rates, LOS and hospital associated morbidity.

Introduction Iron deficiency anaemia (IDA), as a consequence of intestinal bleeding and inflammation, is arguably the most common complication of inflammatory bowel disease (IBD). In controlled trials, oral iron is reportedly as effective as IV iron; however, few studies have included patients with active disease where inflammation through the release of hepcidin may limit the efficacy of oral or dietary iron. Methods To further study the relationship between inflammation and anaemia, we hypothesised that haemoglobin (Hb) levels would rise more in anaemic patients that responded, than in patients who did not respond, to induction anti-TNF therapy. Using electronic case note review, we assessed the prevalence, severity, type and mean change in Hb (ΔHb) of 174 [97 Male] consecutive patients undergoing induction therapy with an anti-TNF agent [Infliximab 139: Adalimumab 35]. Anaemia was defined according to age-sex adjusted WHO criteria. Primary response was assessed at 14 weeks and defined as, at least two of; the absence of symptoms, having withdrawn from steroids, and/or a normal serum C-reactive protein. Non-response was defined as one or none of the above. Results 89% [156/174] patients had Crohn’s disease: the mean [SD] age, age at diagnosis, and disease duration were 34 [17], 24[13], 10 [10] years respectively. Overall 49% [85/174] patients were anaemic at initiation of ant-TNF treatment with a mean [SD] haemoglobin of 10.9 [1.3] g/dl. Only 48% [41/85] had haematinics checked within 3 months of commencing an anti-TNF: 63% [26/41], 31% [13/41] had anaemia of chronic disease and 5% [2/41] were folate deficient. Overall, 37% [31/85] of the anaemic patients were prescribed iron therapy. Considering all anaemic patients, there were no differences in the baseline Hb in patients who responded (11.1 [1.2] g/dl) compared with those who did not respond (10.6 [1.6] g/dl, p = 0.11) to anti-TNF therapy. Regardless of concurrent iron therapy, there was no difference in the mean [SD] change in Hb (ΔHb) between patients that responded to anti-TNF therapy (0.51 [1.2] g/dl) and those who did not (0.47 [1.4] g/dl, p = 0.85). Conclusion Iron deficiency anaemia is common but frequently undertreated in IBD patients receiving anti-TNF therapy. Induction anti-TNF therapy, with or without oral iron therapy, has no effect on haemoglobin levels. In patients with IDA receiving anti-TNF therapies, gastroenterologists should consider IV iron therapy. Disclosure of Interest None Declared.

Introduction NICE guidelines state that unexplained iron deficiency anaemia (IDA) in men and non-menstruating women requires an urgent two week wait (2ww) referral for suspected cancer. These patients require assessment with upper endoscopy and colonoscopy according to BSG guidelines. IDA is defined as a microcytic anaemia with the presence of any of the following serum markers: low ferritin, low transferrin saturation, low iron or raised TIBC. The aim of this audit was to assess how many lower GI 2ww referral patients for IDA actually had IDA. Methods We analysed all consecutive 2ww referrals for suspected lower GI cancer for IDA in our Hospital from May until October 2012. Patients’ demographics, medical history, medications and blood test results (FBC, haematinics, eGFR, CRP, Hb electrophoresis) were collected using the General Practitioner (GP) referral letter and the hospital computer system. IDA was identified as microcytic anaemia with low ferritin; if ferritin was normal but unreliable (concomitant high CRP), we identified IDA as low transferrin saturation with high TIBC. Results A total of 36 patients (mean age 71±11; M:F = 19:17) were referred as 2ww with asymptomatic IDA. IDA was confirmed in 20 patients (55%). 6 patients (17%) did not have iron deficiency (see table): 3 of them had colonoscopy and 2 had CT abdomen (unfit for colonoscopy), none had significant pathology; one was not investigated. 10 patients (28%) had insufficient blood tests to define the cause of the anaemia: ferritin not available (2), normal ferritin with high CRP and no other iron markers available (6), normal ferritin with no inflammatory markers available (2). Conclusion One in six (6/36) patients referred urgently for IDA and suspected lower GI cancer did not have IDA, and the majority were over 80 with multiple co-morbidities. Approximately 1 patient in 4 (10/36) did not have appropriate blood tests performed to assess their anaemia. We recommend GPs perform a full set of haematinics prior to referring patients with IDA and the results should be included in the 2ww referral form. If haematinics are not available at the time of assessment, these should be checked before booking endoscopic investigations. We are amending our referral form accordingly, implementing teaching sessions for GPs and re-auditing in 1 year time. We anticipate a reduction in inappropriate 2ww referrals and subsequent endoscopic requests. Disclosure of Interest None Declared.

Introduction Simulation is increasingly being recognised as an attractive tool to support endoscopic training. Standard training has been associated with certain limitations; longer procedural times, cost, unpredictable pathology and occasionally patient dissatisfaction. Use of endoscopic simulators, has been suggested as alternative training method. Although advocated by national and international endoscopy societies (BSG, ASGE), when and how it should be incorporated into endoscopic training is still debated. A recent Cochrane review, suggested it was of most benefit to novice endoscopists. An endoscopic simulation programme has been established at the Royal Free simulation centre since 2009. Completion of the course is not a formal speciality training programme requirement. Enrolled trainees progress through a staged curriculum with frequent assessment of their endoscopic competencies. How junior trainees use this resource was explored in this study. Methods All trainees that have undertaken endoscopic training at the simulation centre between 2009 and 2012 were invited to complete an anonymous online questionnaire. Subsequently a targeted focus group was conducted; participants included trainees and simulation centre trainers. Results 62 trainees were invited to complete the survey, with a response rate of 48% (30/62). The majority of trainees (93%; 28/30) completed the course during evenings or at weekends. 77% self-funded the course and just 7% obtaining study leave. Trainees enrolled on the course for a median of 2 months. 52% (15/29) were studying for a postgraduate exam while completing this course and 1 in 5 trainees commuted from outside the M25 to attend the course. A third of trainees were undertaking a rotation in Gastroenterology when they enrolled on the course and 82% (22/27) wanted to pursue a career in Gastroenterology. 68% (17/25) reported they were actively applying for Gastroenterology or Surgical registrar training posts in the next 12 months. Frequently sited course outcomes by trainees included; greater familiarity with endoscopic equipment and technique, an opportunity to gain basic endoscopic skill training as a foundation doctor or SHO, improved individual time management skills and was an opportunity for trainees to demonstrate a relevant example of commitment to speciality. Conclusion Trainees completing this course sited a broad range of perceived learning outcomes. In addition to gaining endoscopic skill training, completing the course enabled trainees to develop their interpersonal skills and demonstrate commitment to speciality. This study supports junior doctors undertaking simulated endoscopic training. Disclosure of Interest None Declared

Background The prognosis for patients with hepatocellular cancer (HCC) undergoing transarterial therapy (TACE/TAE) is variable. Methods We carried out Cox regression analysis of prognostic factors using a training dataset of 114 patients treated with TACE/TAE. A simple prognostic score (PS) was developed, validated using an independent dataset of 167 patients and compared with Child–Pugh, CLIP, Okuda, Barcelona Clinic Liver Cancer (BCLC) and MELD. Results Low albumin, high bilirubin or α-fetoprotein (AFP) and large tumour size were associated with a two- to threefold increase in the risk of death. Patients were assigned one point if albumin <36 g/dl, bilirubin >17 μmol/l, AFP >400 ng/ml or size of dominant tumour >7 cm. The Hepatoma arterial-embolisation prognostic (HAP) score was calculated by summing these points. Patients were divided into four risk groups based on their HAP scores; HAP A, B, C and D (scores 0, 1, 2 and >2, respectively). The median survival for the groups A, B, C and D was 27.6, 18.5, 9.0 and 3.6 months, respectively. The HAP score validated well with the independent dataset and performed better than other scoring systems in differentiating high- and low-risk groups. Conclusions The HAP score predicts outcomes in patients with HCC undergoing TACE/TAE and may help guide treatment selection, allow stratification in clinical trials and facilitate meaningful comparisons across reported series.

Introduction NICE guidelines state that unexplained iron deficiency anaemia (IDA) in men and non-menstruating women requires an urgent two week wait (2ww) referral for suspected cancer. These patients require assessment with upper endoscopy and colonoscopy according to BSG guidelines. IDA is defined as a microcytic anaemia with the presence of any of the following serum markers: low ferritin, low transferrin saturation, low iron or raised TIBC. The aim of this audit was to assess how many lower GI 2ww referral patients for IDA actually had IDA. Methods We analysed all consecutive 2ww referrals for suspected lower GI cancer for IDA in our Hospital from May until October 2012. Patients’ demographics, medical history, medications and blood test results (FBC, haematinics, eGFR, CRP, Hb electrophoresis) were collected using the General Practitioner (GP) referral letter and the hospital computer system. IDA was identified as microcytic anaemia with low ferritin; if ferritin was normal but unreliable (concomitant high CRP), we identified IDA as low transferrin saturation with high TIBC. Results A total of 36 patients (mean age 71±11; M:F = 19:17) were referred as 2ww with asymptomatic IDA. IDA was confirmed in 20 patients (55%). 6 patients (17%) did not have iron deficiency (see table): 3 of them had colonoscopy and 2 had CT abdomen (unfit for colonoscopy), none had significant pathology; one was not investigated. 10 patients (28%) had insufficient blood tests to define the cause of the anaemia: ferritin not available (2), normal ferritin with high CRP and no other iron markers available (6), normal ferritin with no inflammatory markers available (2). Abstract PTH-003 Table 1 Age Sex Hb MCV Ferritin CRP eGFR Investigation Result 1 82 F 9.6 89.1 15 < 5 colonoscopy Diverticular disease 2 88 F 9 92 473 < 5 14 CT normal 3 73 M 10.6 81.3 36 < 5 > 90 none 4 86 F 9.5 75.2 22 7 39 CT Diverticular disease 5 67 F 9.3 84.2 62 < 5 46 colonoscopy normal 6 82 F 9.5 81.7 65 < 5 75 colonoscopy Diminutive polyps Conclusion One in six (6/36) patients referred urgently for IDA and suspected lower GI cancer did not have IDA, and the majority were over 80 with multiple co-morbidities. Approximately 1 patient in 4 (10/36) did not have appropriate blood tests performed to assess their anaemia. We recommend GPs perform a full set of haematinics prior to referring patients with IDA and the results should be included in the 2ww referral form. If haematinics are not available at the time of assessment, these should be checked before booking endoscopic investigations. We are amending our referral form accordingly, implementing teaching sessions for GPs and re-auditing in 1 year time. We anticipate a reduction in inappropriate 2ww referrals and subsequent endoscopic requests. Disclosure of Interest None Declared.

Introduction Ileal pouch anal anastomosis (IPAA) is the standard restorative procedure for ulcerative colitis (UC) following colectomy. This operation is, however, associated with distinct rates of failure and complications. We performed a survey to evaluate the quality of life (QoL) after IPAA comparing patients followed up in two different teaching Hospitals in London (L), UK and Bologna (B), Italy. Methods A total of 126 (71L+55B) UC patients received the questionnaire by mail or during clinic. The questionnaire was done according to the IBDQ and it was designed to assess pouch function, disease-specific adjustment, lifestyle aspects and psychological factors. 85 (43L+42B) patients (67%) returned it (M/F= 46/39; age 41±16 years); average pouch duration was 5–7 years. Results There was no significant difference between L and B in terms of age, gender, marital status, pouch duration, bowel frequency (median 3–6 motions per day and 1–2 per night), experience of leakage (30% more than once a week) and need of additional surgery (0.05%). In L there were significantly more patients who had at least one episode of pouchitis (72%) compared to B (33%). L used significantly more alternative remedies (L 11% vs B 0%), antimotility drugs (L 44% vs B 30%), antibiotics (L 65% vs B 29%) and steroids (L 16% vs B 7%). No difference in immunosuppressant (18%) and VSL#3 use (22%). L patients regret having IPAA significantly more frequently (L 13% vs B 0.02%), cope less with the stoma (in L 39% hated it vs 0% in B), suffer more of unpredictability (L 51% vs B 19%), are less capable to hold the stool for more than 1 h (L 62% vs B 88%) and have more worrying thoughts (L 30% vs B 9%). B patients play sport significantly more frequently (B 76% vs L 53%). L and B reported similar QoL, well being, cheerfulness, ability to work, go on holiday and enjoy things they used to do; similar confidence in doing whatever they want and level of concern in finding a toilet. Conclusion Our survey showed that in London patients developed more pouchitis and therefore used more medications. They cope worse with the pouch and regret more having had surgery. Interestingly in Italy patients play more sport, but the overall quality of life was the same. Extent and severity of disease prior to surgery, smoking and association with primary sclerosis cholangitis may play a role in the increase incidence of pouchitis in London, but these data were not available in our anonymous questionnaire. Different biologic behaviour and/or genetic background may contribute in this difference. Competing interests None declared.

Introduction Up to 60% of dyspeptic patients have a normal upper endoscopy. Endoscopy is unable to diagnose myoelectrical disorders which can cause dyspeptic symptoms including epigastric discomfort, early satiety, bloating, nausea and vomiting. Although patients with functional dyspepsia complain of epigastric symptoms, the relation between these symptoms and gastric motility remains controversial. Electrogastrography (EGG) is a simple, non-invasive method for assessing the gastric pacemaker slow wave. Gastric emptying study (GES) is typically the first test in evaluation of gastric motor function using a radiolabelled test meal. The ultrasound of the stomach (USS) is a recent non-invasive and cheap modality to evaluate gastroduodenal motility. We wanted to compare the information given by three different gastric motility tests in patients with endoscopy negative dyspepsia (END). Methods A series of 77 dyspeptic helicobacter pylori negative patients (60 female: 17 male, ages 18–65 years) diagnosed according to the Roman III criteria and a normal upper endoscopy, underwent a standard fasting and postprandial EGG, a technetium labelled mashed potato GES and an ultrasound of the stomach given a soup test meal. The EGG was considered abnormal if <70% of slow wave activity was recorded at 3 cycles/min. Delayed or increased gastric emptying was diagnosed if the T½ for the test meal was outside the normal range for our unit (<15 or >45 min, respectively). The USS was considered normal if the gastric emptying rate was between 45% and 78%. Results Thirty-one (40%) patients had both GES and USS test showing gastroparesis with mainly symptoms of nausea and vomiting (20/31, 64%). Eighty per cent (25/31) of these patients had an abnormal EGG, having as a predominant pattern an abnormal pre and post prandial test (12/31, 38%). Interestingly 17 people (22%) had normal GES and USS, with abnormal EGG in 82% of patients (14/17). Ten of these patients (58%) were experiencing nausea and vomiting as well. Only 2 (2.5%) patients had findings of dumping syndrome on GES and USS. There was more heterogeneity in the results of these tests with patients referring bloating and epigastric discomfort. Conclusion In patients with endoscopy negative dyspepsia, gastroparesis is very common and particularly with symptoms like nausea and vomiting. GES and USS can provide a firm diagnosis and possibly influence treatment strategies. We think these investigations should be incorporated into dyspepsia guidelines at the point where endoscopy is reported as normal. We are currently investigating the role of EGG for the poor correlation with the other tests.

Introduction Oesophageal capsule endoscopy (ESO 2) has been developed to image the oesophageal mucosa and compares with endoscopy (OGD).1 With a battery life of 30 min, the capsule transmits gastric and even duodenal images beyond its designated function. Trituration causes the capsule to tumble back and forth between fundus and antrum, before passing through the pylorus. With its fore and aft cameras providing a 312 degree field of vision, it is likely that ESO could visualise most, if not all the gastric mucosa. The authors9 aim was to compare accuracy of ESO versus OGD for detecting mucosal pathology in patients with uncomplicated dyspepsia and/or heartburn, and patient discomfort. Methods 50 consecutive outpatients, referred with dyspepsia and/or heartburn ingested an ESO 2 PillCam and underwent OGD 4 h later. ESO was reported independently by 2 experienced capsule readers and OGD was performed by an expert endoscopist, blinded to ESO results, and recorded on DVD. At the end of the study, a final report was agreed by 2 gastroenterologists viewing ESO and recorded OGD simultaneously, side by side, with biopsy results. This defined benchmark against which to judge the initial ESO and OGD reports. Each patient completed a questionnaire assessing ESO versus OGD discomfort. Results 50 patients (mean age 56±15; M/F: 17/33) had OGD, 35 without sedation. ESO was ingested by 49 patients (1 unable to swallow the capsule). The duodenum was visualised in 30 of 49 (61%). The final (benchmark) reports identified major pathology in 15 patients (6 Barretts, 1 pyloric channel ulcer, 5 oesophagitis, 6 erosive gastritis and 4 large hiatus hernia) and in 17 minor pathology (13 superficial gastritis, 10 small hiatus hernia and 4 hyperplastic fundal polyps). 17 patients had normal finding. Compared with the benchmark report, sensitivity and specificity of the initial report for major pathology was 93% and 100% for ESO and 87% and 100% for OGD. ESO failed to report 1 oesophagitis and OGD failed to detect 1 pyloric ulcer and 1 Barretts oesophagus. Sensitivity and specificity for minor pathology was 76% and 97% for ESO and 76% and 78% for OGD. ESO had reduced sensitivity for small hiatus hernia and OGD had poor specificity for superficial gastritis. Median patient discomfort (scale 0–10) was 0 for ESO and 4.5 for OGD. Conclusion This pilot study suggests that ESO provides an accurate and well-tolerated method to visualise oesophageal and gastric mucosa, and in 61%, duodenal mucosa. An ESO capsule programmed to broadcast for up to 2 h could offer a minimally invasive method for imaging the oesophagus, stomach and duodenum. Further studies are necessary to fully evaluate the role of capsule OGD in investigating foregut symptoms.

Introduction Fasting gastrin alone is inadequate for diagnosis of gastrinoma because hypergastrinemia occurs in a number of non-gastrinoma conditions, including atrophic gastritis. Confirmation of diagnosis requires more invasive investigations to demonstrate low gastric pH. The density of somatostatin secreting D-cells and gastrin secreting G-cells is dependent on gastric pH. A low gastric pH is associated with a relative increase in D-cell density, resulting in a decrease in G-cell:D-cell ratio. We compared plasma somatostatin levels and the plasma gastrin:somatostatin ratios in patients with achlorhydria secondary to atrophic gastritis and in patients with gastrinoma. We also compared chromogranin A (CgA) levels in the two groups. Methods Plasma gastrin, somatostatin and CgA were measured in 21 patients with gastrinomas and 23 patients with atrophic gastritis referred to the Supra regional Assay and Advisory Service Laboratory at our centre. Results There was no significant difference between plasma gastrin in patients with gastrinomas and atrophic gastritis. Plasma somatostatin was significantly higher in patients with gastrinomas compared to patients with atrophic gastritis (p<0.005). Gastrinoma patients had significantly lower plasma gastrin:somatostatin ratios compared to those with atrophic gastritis (p<0.001). Patients with gastrinomas had significantly higher plasma Cg A compared to patients with atrophic gastritis (p<0.005). No patients with atrophic gastritis had Cg A levels greater than100 pmol/L. The combination of plasma Cg A and plasma gastrin:somatostatin ratio has a predictive power of 76% and an area under ROC curve of 0.87. Conclusion The plasma gastrin:somatostatin ratio and measurement of plasma Cg A may be helpful in planning the diagnostic work-up for patients with raised fasting gastrin levels. Combining these biochemical tests could allow correct identification of gastrinoma patients requiring further assessment and significantly reduce unnecessary investigation of gastric pH in non-gastrinoma patients.

Introduction Ileal pouch anal anastomosis (IPAA) is the standard restorative procedure for ulcerative colitis (UC) following colectomy. This operation is, however, associated with distinct rates of failure and complications. Iron deficiency anaemia (IDA) is common in this group of patients although it is not clear to what degree this is secondary to ongoing inflammation or other mechanisms. The authors therefore performed a systematic audit of the patients after restorative proctocolectomy coming to the Inflammatory Bowel Disease (IBD) Clinic in our department. Methods 74 patients (37 male, 37 female, mean age 47 years) with IPAA were recruited from the Inflammatory Bowel Disease Clinic. Demographic and medical data were collected retrospectively from medical notes. Clinical signs of pouchitis were increased stool frequency, urgency, tenesmus, incontinence, abdominal pain, pelvic discomfort and nocturnal seepage. Results Among 74 patients with IPAA and IBD (66 patients with UC, 4 Crohn9s disease and 4 indeterminate colitis), 24 patients (30%) had anaemia and/or low iron indices. Seven of these 24 patients (30%) had clinical signs of pouchitis, two had β-thalassemia and one celiac disease. A sigmoidoscopy of the pouch was performed in 56 of the patients (75%). Only 23 patients had an oesophageal-gastro-duodenal endoscopy (OGD) but of the remaining 51 patients, 20 had negative antitissue transglutaminases antibody (TTG). The OGDs were all normal, including the duodenal biopsies. The authors performed capsule endoscopy in 11 patients with anaemia: 4 patients had small bowel erosions, 5 patients had erosions at the anastomotic site (4 with active bleeding), 2 had pouchitis, 1 angiodysplasia and 1 was normal. Considering all 75 patients with IPAA, 37 patients developed pouchitis (50%), 5 fistula (7%), 2 had PSC (4%), 2 of whom had OLT. Conclusion In this series of patients who underwent IPAA, nearly one third developed anaemia. In these patients, the most common findings at capsule endoscopy were erosions in the small bowel and at the anastomosis, which though contributory are unlikely to represent the cause of their anaemia. The most frequent complication in this group of anaemic patients was pouchitis. This audit suggests that iron deficiency anaemia is common in patients with IPAA and that further studies are required to investigate the mechanism of iron deficiency in this particular group of patients.

BACKGROUND:Early withdrawal of steroids after liver transplantation has benefits, but rarely is total avoidance of steroids used. We evaluated long-term results of patients with ab initio monotherapy with cyclosporin (CYA) vs. tacrolimus (TAC), in randomized and cohort studies. METHODS:We evaluated long-term outcomes in 66 adults randomized to TAC or CYA and 94 subsequent patients who received TAC. Protocol liver biopsies were performed. Rejection was treated with three 1 g/d methylprednisolone. Further rejection after two courses of methylprednisolone was defined as monotherapy failure. RESULTS:Actuarial five-yr survival was 68% in TAC and 70% CYA. Monotherapy failed in 8% TAC and 13% CYA patients; no rejection in 24% TAC and 19% CYA patients; 42% TAC and 33% CYA patients were not exposed to any steroids. Rejection episodes were less with TAC, compared to CYA: mean 1.8 vs. 2.5, p = 0.042. Chronic rejection occurred in only 4 (11%) CYA patients. During follow-up of median 97 months (range: 0.06-145), there were 16 (44%) deaths in CYA and 48 (39%) in TAC patients (p > 0.05). CONCLUSIONS:TAC monotherapy ab initio is a viable immunosuppressive strategy in liver transplantation and was associated with lower rejection rates and renal complications, compared to CYA.

Introduction HVPG is an established marker of portal hypertension, while transient elastography (TE) has been proposed as a non-invasive marker of portal hypertension/disease progression. Collagen proportionate area (CPA),1 a histological quantitation of liver collagen, was recently shown to be a better correlate with HVPG than Ishak stage. The aim of this study is to evaluate relationships between liver collagen, TE, APRI score, HVPG and Ishak stage. Methods Consecutive HCV transplanted patients had transjugular liver biopsies combined with HVPG, TE and CPA. Linear regression analysis was used to assess correlation: CPA and TE, and CPA, TE and HVPG. ROC curves to assess sensitivities/specificities of each factor. Results 58 HCV transplanted patients: 47 males, mean age 53 years, mean time 50±39 (9–169) months from LT. Median liver stiffness (LSM) 11.3 kPa (3.1–50.3), mean HVPG 5 mm Hg (0–32), mean CPA 7.9% (1–45), mean APRI score 0.06 (0.01–0.7). Correlation between LSM and CPA r2=0.58, (p<0.000), between LSM and HVPG r2=0.16; (p=0.002) and CPA and HVPG r2=0.28(p<0.000). Univariately CPA, Ishak stage, TE (all p<0.0001), APRI score (p=0.04) were associated with HVPG≥6 mm Hg; multivariately CPA was the only independent factor (OR 1.336, 95% CI 1.136 to 1.571, p=0.000). Univariately CPA, Ishak stage, TE and APRI score were also associated with HVPG≥10 mm Hg but multivariately only CPA (OR 1.1, 95% CI 1.02 to 1.2, p=0.020). For HVPG≥6 mm Hg, AUROC for CPA was 0.91(95% CI 0.83 to 0.99). The best cut-off was 8.7% (78% sensitivity and 87% specificity); AUROC for stiffness was 0.83 (95% CI 0.70 to 0.96), cut-off of 10.9 kPa had 78% sensitivity and 87% specificity. For CPA >8%, the AUROC for stiffness was 0.98(95% CI 0.96 to 1.011). A cut-off of 9.6 kpa could predict CPA>8% (93% sensitivity and 99% specificity). For stiffness>11 kPa, AUROC for CPA was 0.96(95% CI 0.89 to 1.018) with a cut-off of 8.4% (87% sensitivity and 99% specificity). Conclusion CPA as a quantitative measure of liver collagen had a better correlation with TE than HVPG. Thus it may represent a better histological index for TE rather than stages which are descriptive categories and not quantitative assessments. CPA was better than Ishak stage or TE in predicting portal hypertension. CPA should be evaluated to subclassify cirrhosis.