SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 39 SAGES Introduction: Dolutegravir (DLT) is a new antiretroviral agent that targets the HIV integrase. In large trials, DLT was associated with increased alanine transaminase levels. This was not associated with clinical symptoms and did not require dose modification. Herein we present a case of severe drug induced liver injury (DILI) most likely related to DLT. Case Report: A 30-year-old African female was diagnosed with HIV in 2017 and initially commenced on a combination of Tenofovir (TDF), Lamivudine (3TC) and Efavirenz (EFV). She was switched to TDF, 3TC and DLT on February 2021 which achieved viral suppression and immune restoration (CD4 > 1000 cells/µl). In April 2021 she presented with jaundice and pruritus. Blood tests showed AST: 784 U/L, ALT: 697 U/L, total bilirubin: 292mg/dl (conjugated bilirubin 231mg/dl), GGT: 244U/L, ALP: 549U/L and INR: 1.0. DLT containing antiretroviral therapy was only stopped 4 weeks after presentation when the patient was referred for non- improvement. Liver ultrasound and magnetic resonance cholangiogram were normal. Serology for hepatotropic viruses and autoimmune markers were negative. Liver histology showed portal tracts expanded by inflammation comprising mainly lymphocytes with eosinophils, neutrophils and plasma cells. Interface hepatitis was present in a minority of the portal tracts. There was intracellular cholestasis. Overall features were suggestive of a drug induced liver injury with resolving cholestatic hepatitis. Four weeks after withdrawal of DLT, marked improvement in liver enzymes were noted (Total bilirubin: 63mg/dl, AST: 72U/L) and resolution of pruritus. Conclusion: DLT causing severe DILI has been rarely described in the literature. This case serves to highlight DLT as a cause of severe DILI that practitioners need to be aware of especially with increasing use in South Africa. Dolutegravir induced liver injury Factors influencing in-hospital mortality for salvage TIPS in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic haemostasis MMM Ben Hkouma, VG Naidoo Department of Gastroenterology, Nelson Mandela School of Medicine, University of KwaZulu-Natal, Inkosi Albert Luthuli Central Hospital Background: Endoscopic therapy is the first-line treatment of choice for control of acute variceal bleeding (AVB).Transjugular portosystemic shunting (TIPS) provides minimal access stenting in high-risk patients with persistent AVB despite endoscopic intervention. Aim: This study evaluated factors influencing in-hospital mortality after salvage TIPS in cirrhotic patients with continued variceal bleeding despite endoscopic intervention. Methods: Clinical and laboratory data were analyzed in all patients treated with TIPS following failed endoscopic therapy for AVB between January 1991 and December 2020. Factors associated with and predictors of death were determined with bivariate analysis and univariate logistic regression analysis. Results: Thirty-four patients (29 men, 5 women), mean age 52 years (range 31-80) received TIPS for uncontrolled (11) or refractory (23) AVB. Aetiology of portal hypertension was alcohol (24), haemochromatosis (2), hepatitis B+ (2), hepatitis C+ (1), NASH (2), drug-induced (1), Vit A toxicity (1) and sarcoid (1) related cirrhosis. During the index admission TIPS controlled bleeding in 32 patients with recurrence in one. Ten patients died in hospital (mean 4.8, range 1-10 days) of liver failure (4), MOF (3), alcoholic cardiomyopathy (2) and uncontrolled gastric variceal bleeding (1). On bivariate analysis, factors associated with death were Child-Pugh score ≥10 (p=0.006), MELD-Na ≥22 (p<0.001), ≥ 8 units of blood transfused (p<0.001), Sengstaken tube placement (p<0.001), endotracheal intubation (<0.001), inotropic support (p<0.001) and endoscopically uncontrolled bleeding (p<0.001). In an unadjusted univariate logistic regression model the most significant predictors of mortality were need for inotrope support (OR=134, p<0.001), endotracheal intubation (OR=99, p<0.001), endoscopically uncontrolled bleeding (OR=28, p=0.001), grade 3 ascites (OR=20.9, p=0.012) and Child-Pugh grade C (OR=8.8, p=0.011). Conclusion: The most significant predictors of mortality were Child-Pugh grade C, grade 3 ascites, inotrope requirement, endotracheal intubation and endoscopically uncontrolled bleeding. TIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy with 71% in-hospital survival. JEJ Krige 1,2 , M Bernon 1,2 , EG Jonas 1,2 , M Setshedi 3 , SJ Beningfield 4 , UK Kotze 1,2 , S Burmeister 1,2 Surgical Gastroenterology and HPB Unit, University of Cape Town and Groote Schuur Hospital 1 Departments of Surgery, University of Cape Town and Groote Schuur Hospital 2 Devision of Gastroenterology, University of Cape Town and Groote Schuur Hospital 3 Department of Radiology, University of Cape Town and Groote Schuur Hospital 4