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Unlabelled: Liver transplantation is the treatment of choice for end stage liver disease and fulminant hepatic failure. Outcome of the procedure may be dependent on multiple factors including patient selection, donor selection, and centre experience., Aim: To determine whether the outcome for liver transplantation has improved over the time for the Irish National Liver Transplant Unit since its initial set up in 1993., Methods: All patients who underwent liver transplantation between Jan 1993 to Oct 2004 were included. Patients were sub-divided into three sequential cohorts of 90 patients each. Survival outcomes were compared between the groups., Results: 270 patients (male = 137) underwent 323 liver transplants (median age 49 yrs, range 16-68 yrs). Indications included primary biliary cirrhosis (14.1%), alcohol related liver disease (6.2%), fulminant hepatic failure (14.2%), primary sclerosing cholangitis (10.1%), chronic active hepatitis (9.5%), viral hepatitis (9.5%) and cryptogenic cirrhosis (7.1%). Most procedures (85.8%) were elective. Re-transplantation rates within the first 3 months of primary procedure were 9%, 5%, and 5% for the three chronological groups. Overall calculated 3-month, 1-year and 3 year survival rates for group 1 were 87%, 82% and 77%. For the groups 2 and 3 the figures were 86%, 81%, 77% and 89%, 89%, and 81% respectively. One- and 3-year survival rates were significantly better for group 3 compared to group 1 (p < 0.05)., Conclusions: Survival outcome has improved significantly over the past 12 years and is likely attributed to increasing experience of the transplant centre.

Hepatitis C infection commonly complicates injecting drug use. The outcome of end stage liver disease for this cohort in Ireland has not been estimated. (1) to estimate the prevalence of persistent hepatitis C viraemia and distribution of genotypes in a drug using cohort. (2) To measure the frequency of poor prognostic co-factors. (3) To extrapolate the burden of hepatitis C related disease nationally for this route of infection. A cross section survey of attendees at an East Coast Area drug treatment clinic. Of 94 patients studied (63 male), 70 were hepatitis C antibody positive and 39 were PCR positive. 26 had genotype 1 and 11 had genotype 2 or 3. Most displayed factors associated with a poor prognosis: 72% male, 83% problem drinkers and 87% abnormal liver blood tests. Using published data, we extrapolate over 1,214 cases of cirrhosis via this route of infection nationally, leading to approximately 35, 60 and 50 cases of hepatocellular carcinoma, hepatic decompensation and liver related death respectively per annum. A high prevalence of hepatitis C infection in injecting drug users, compounded by a high frequency of poor prognostic co-factors, means a significant burden of disease can be expected from this group.

Malnutrition is common in patients awaiting liver transplantation and may contribute to operative and post-operative mortality, although this is controversial. We assessed the pre-operative nutritional status of 87 patients and the impact this had on mortality and morbidity following liver transplantation for chronic liver disease. Thirty six per cent of patients had more than 10% loss of body weight prior to transplantation. Nutritional depletion, considered present if triceps skin fold thickness or mid-arm muscle circumference were < 5th percentile, was present in 17% and 15% of the total group respectively. Patients whose pre-operative body weights were < 90% of their ideal body weight (IBW) had a longer hospital stay (p = 0.001) and required longer post-operative ventilatory support (p = 0.033). This group also required significantly more treatment with intravenous antibiotics (p = 0.001) suggesting an increased incidence of infective complications. Patients who were obese pre-operatively (body mass index > 30Kg/m2) also required a longer period in high dependency (p = 0.0003). No individual nutritional variable correlated with mortality. In the Irish population undergoing liver transplantation, we found a relatively low prevalence of malnutrition in comparison with other studies. Both under- nutrition and obesity significantly affected morbidity and length of hospital stay post-transplant, although no individual nutritional variable predicted survival post transplant.

Despite advances in treatment, severe alcoholic hepatitis is still associated with a high mortality rate of 30% to 40%. Nutritional support and steroids in selected patients are believed to improve prognosis. In controlled trials steroids have been beneficial in patients with a discriminant function (DF) value >32 or spontaneous hepatic encephalopathy. The aim of this study was to investigate current practice and outcomes in the treatment of acute alcoholic hepatitis. We retrospectively studied patients admitted to our unit with acute alcoholic hepatitis over a 4 year period. Forty-three patients with acute alcoholic hepatitis were admitted between 1994 and 1997. Overall mortality was 26% (11/43). Only 5 patients were treated with steroids of whom 1 died (mortality 20%). Liver biopsy was available in 19/43 of whom 12/19 (63%) had underlying cirrhosis in addition to alcoholic hepatitis. Mortality was higher in patients with a discriminant function of greater than 32 but not significantly so (32%: 8/25 vs 17%: 3/18 p = 0.31). A discriminant function of greater than 32 and contra-indications to steroid use was the best predictor of mortality (60% 6/10 P = 0.0096) compared to patients not fulfilling these criteria In this study overall mortality was comparable with published reports. Of interest was the relatively low liver biopsy rate and the fact that steroids were used in only a minority of eligible patients. We found that mortality was concentrated in a subgroup of patients with a discriminant function value >32 and contra-indications to steroids. These criteria appear to identify a high-risk subgroup of patients. If confirmed, experimental treatments need to be targeted at this group to improve the overall prognosis of acute alcoholic hepatitis.

The causes of ulcerative colitis and Crohn's disease are unknown. Current research is focused on genetic factors but environmental factors may also be important. Exposure to infections in early life is believed to reduce the incidence of bronchial asthma. We hypothesised that exposure to enteric bacteria and infections in early life may also reduce the incidence of idiopathic inflammatory bowel disease. Chronic inflammatory bowel disease may be a by-product of our over-clean environment. Social groups with poorer living standards might be expected to have a lower prevalence of this condition. The "traveller" or itinerant community in Ireland is one such group. We therefore attempted to estimate the prevalence of inflammatory bowel disease in the traveller population. Twenty five of 30 gastroenterologists or surgeons in Ireland responded to requests for information. None could recall ever seeing a "traveller" with idiopathic inflammatory bowel disease. While genetic factors cannot be excluded, a low prevalence of idiopathic inflammatory bowel disease would support the environmental hypothesis.

Transjugular liver biopsy is advocated as the technique of choice for use in those with contraindications to standard transabdominal biopsy. This technique was introduced to our unit in 1995. We audited our experience in performing transjugular liver biopsies over a three year period. Eighty-eight biopsies were performed in seventy-eight patients. We identified no major procedure related complications, despite the presence of coagulopathy and thrombocytopenia in 85% and 47% of cases respectively. Biopsy provided histological diagnosis in 97.7% of cases. Availability of the technique allowed us to perform liver biopsy safely and quickly in patients with both acute and chronic liver problems in whom standard techniques were contraindicated. We conclude that transjugular liver biopsy is a safe and effective technique, invaluable in the investigation and management of patients in a liver diseases referral unit.

Despite an effective antidote, paracetamol overdose is a frequent cause of fulminant hepatic failure in Ireland and the United Kingdom. Most treatment failures are due to late presentation but some may be related to delayed treatment in hospital. The aim of this study was to investigate delays in treatment in patients presenting to two large Dublin accident and emergency departments. One hundred and seventy seven admissions were recorded over a two year period. The average patient presented 6-8 hours after the overdose and waited another 1.5 to 2 hours for treatment to commence. Treatment was delayed more than 2 hours after presentation in 24/110 (22%) and more than 4 hours in 10/110 (10%). The majority had no adverse sequelae but four patients required ventilation, one haemofiltration and one died. The patient who died presented 35 hours after overdose. This study suggests that delays in treatment of paracetamol overdose are common. Delays of this magnitude may be clinically important in the small minority of patients with significant liver injury. It is possible that oral administration of n-acetylcysteine may reduce delays in treatment.