Abdominal MRI Research Articles

Cardiac Manifestations in Patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD): A Single-Center Study.

Key Points Cardiovascular disease—a key driver of morbidity in CKD—is common in patients with autosomal dominant polycystic kidney disease (ADPKD).Pathologic echocardiography findings, including valvular defects, aortic root dilation, and hypertrophy, are found in most patients with ADPKD.These findings correlate with parameters indicating disease progression in ADPKD. Echocardiography should be offered to all patients with ADPKD. Background ADPKD is the most common monogenetic kidney disease and results in kidney failure in >75% of affected individuals. As a systemic disorder, ADPKD is associated with a variety of extrarenal manifestations, including cardiac manifestations, that affect the majority of patients. We characterized the cardiac involvement in patients with ADPKD from the German AD(H)PKD registry and compared them with kidney donor candidates as controls. Methods In this single-center cohort study, we evaluated 141 patients with ADPKD (44.17±11.23 years) from the German AD(H)PKD registry and 60 kidney donor candidates (55.08±10.21 years). All patients underwent clinical examination, abdominal MRI, and transthoracic echocardiography. Results Of the patients with ADPKD, 65% showed hypertrophy of the left ventricle (as defined by an end-diastolic interventricular septal wall thickness [IVSd] >10 mm) compared with 55% in control patients. Mitral regurgitation was the most common finding among 54% of patients with ADPKD who exhibited valvular dysfunction, albeit mild in most patients. Interestingly, left ventricular ejection fraction (LV-EF) differed significantly between both groups, with higher values in patients with ADPKD (64%±6% versus 60%±6%), whereas other parameters, including IVSd, left ventricular end-diastolic diameter (LVEDD), tricuspid annular plane systolic excursion (TAPSE), and pressure gradients across the aortic and tricuspid valve were similar between groups. Correlations of echocardiographic parameters with markers of disease progression revealed statistically significant associations for aortic root diameter (P=0.01), the pressure gradient across the aortic valve (AV dPmax; P=0.0003), and IVSd (P=0.0001), indicating rapid kidney disease progression may also be associated with cardiac findings. Conclusion Cardiovascular abnormalities are prevalent in patients with ADPKD. Considering the importance of cardiovascular disease for outcomes in CKD, early management and possibly prevention are important goals of any treatment scheme. Consequently, echocardiography should be offered to all patients with ADPKD in routine management.

S1979 De Novo Association Between Gastrin and CEA in Colorectal Cancer

Introduction: Colorectal cancer (CRC) is the third leading cause of mortality in the United States. CEA and CA-19 remain the 2 most common prognostic markers for cancer surveillance. However, gastrin, a peptide hormone, may have some diagnostic benefits as well. Our case report uniquely demonstrates a positive and parallel correlation between gastrin and CEA levels in a patient diagnosed with Stage 3A colon adenocarcinoma status post sigmoidectomy and 5-FU therapy. Case Description/Methods: We present an 84-year-old female with a past medical history of Stage 3A colon adenocarcinoma status post sigmoidectomy and 5-FU therapy, Hashimoto's thyroiditis, hypertension and paroxysmal atrial fibrillation on Eliquis who reported chronic diarrhea ongoing for the past 7 years that she noticed worsening after the sigmoidectomy. Additionally, she reported no family history of any gastrointestinal malignancies. Initial CEA was 4.2, Hg was stable at 12.5 and no other lab abnormalities were noted (Figure). Surveillance CT colonography, abdominal MRI and Dotatate scan demonstrated no evidence of any neuroendocrine tumor or mass. An extensive workup was unable to delineate any infectious or inflammatory etiology. 5-HIAA and paraneoplastic testing were negative. EGD revealed mucosal hyperplasia with concern for atrophic gastritis and a stomach pH of 8. With no history of PPI consumption and an initial gastrin level of 2242 pg/mL, Zollinger Ellinson syndrome was also subsequently excluded. Colonoscopy was unremarkable with no evidence of microscopic colitis or inflammatory bowel disease. Given initial elevation of serum gastrin, serial gastrin levels were obtained and were found to be closely correlated to the patient's elevated CEA levels. Discussion: Our case report reveals that the gastrin and CEA lab values positively correlate with each other in a patient with underlying colon adenocarcinoma. Further studies to examine the significance and potential use of gastrin as a marker for diagnosing or determining prognosis in colorectal cancer is imperative.Figure 1.: Serial Gastrin and CEA levels.

S1932 Acute Pancreatitis After Liver Biopsy: Clots or Stones?

Introduction: Percutaneous liver biopsy is a frequently utilized tool in the diagnosis of many liver diseases including metastatic liver lesions. Bleeding complications occur in 1% of cases and hemobilia is rare. Hemobilia causing acute pancreatitis after percutaneous liver biopsy is extremely rare with approximately 20 reported cases in literature. Symptoms include right upper quadrant pain, nausea, jaundice, hematemesis, hematochezia or melena. We present an interesting case of a woman who developed acute pancreatitis secondary to hemobilia after liver biopsy. Case Description/Methods: A 60-year-old female with recurrent high-grade serious peritoneal cancer and recent metastases to liver was admitted for acute pancreatitis. Patient presented with nausea and right upper quadrant pain that started after percutaneous liver biopsy one day prior. Labs notable for Hgb 10.4, lipase > 3000, amylase 3349, total bilirubin 3.6, direct 3.3, AST 631, ALT 482, alkaline phosphatase 240. CT A/P showed diffuse swelling of pancreas with fluid and mesenteric fat stranding suspicious for acute pancreatitis. Given liver enzyme elevation with mixed hepatocellular and cholestasis pattern, abdominal MRI was obtained to evaluate any biliary obstruction. MRI showed mildly prominent CBD at 0.8 cm with debris in distal CBD, cystic duct, and gallbladder indicative of hemorrhagic products. No hematoma noted in the liver parenchyma. Patient underwent ERCP with sphincterotomy and clots were cleared from the duct with balloon sweep (Figure). Discussion: Hemobilia, described as upper GI bleeding within the biliary tree has a reported incidence of less than 0.059% after percutaneous liver biopsy. It can occur within a few hours or several days later, with an average interval of five days. Although rare, hemobilia can lead to acute pancreatitis in a mechanism similar to gallstone pancreatitis. Excessive bleeding and increased clot formation cause obstruction in the biliary tree and impedes drainage from the ampulla which in turn triggers pancreatitis. Diagnosis can be made by ultrasound, angiography, ERCP, or MRCP. Treatment depends on the extent of bleeding and includes conservative management to advanced interventions-hepatic angiography with arterial embolization, ERCP with sphincterotomy or stent placement. Thus, our case highlights importance of recognizing hemobilia as an etiology for acute pancreatitis after percutaneous liver biopsy.Figure 1.: Removal of blood clots from bile duct by balloon sweep via ERCP

S2935 Autoimmune Hepatitis After COVID-19 Vaccine: An Unusual Complication

Introduction: Vaccination against SARS-Cov2 has represented a major milestone in our ability to ameliorate the COVID-19 pandemic. The vaccines are generally safe and effective, but some adverse events have been reported, including recent reports of autoimmune-like hepatitis. This case report presents a rare diagnosis of autoimmune hepatitis after administration of an mRNA COVID-19 vaccine. Case Description/Methods: An 18-year-old man with no medical history presented after receiving the Pfizer COVID-19 vaccine in April 2021, and second dose in May 20221. In June of 2021, about two weeks after the second dose, the patient was found with AST 120 u/L, ALT 181 u/L, Platelets 90. See Table 1 for further lab values. Per family, prior liver chemistries were normal. Initial serological workup was completed, including viral hepatitis (Hepatitis A, B, C, E), CMV IgG and IgM, EBV IgG and IgM, ceruloplasmin, alpha-1-antitrypsin, iron studies, all of which were unremarkable. Patient was also found to have ANA titer 1:640, positive anti-smooth-muscle antibody of 1:640, IgG level of 1,845, and positive antibody to soluble liver antigen of 2.321. Abdominal MRI was completed with findings of splenomegaly 20 cm, radiographic evidence of advanced hepatic fibrosis Patient underwent a liver biopsy with foci of interface and lobular hepatitis, areas of bridging necrosis, and scarring and focal nodularity concerning for transition to cirrhosis. Given these findings and it's timing close to administration of COVID-19 vaccine, the patient was diagnosed with autoimmune hepatitis associated with the vaccine. Patient was started on steroids in November 2021, and later, azathioprine, with improvement of liver enzymes. Discussion: Autoimmune hepatitis is a rare complication of COVID-19 vaccines, reported in few case reports in the literature. The pathophysiology remains unclear but is hypothesized to be related to molecular mimicry. The mRNA vaccines developed against COVID-19 leads to the production of the spike protein, and its antibodies. Antibodies to the spike protein have high affinity toward other human tissue proteins, which can lead to autoimmune tissue injury. In most reports, patients improved after treatment with steroids, though two have been reported to have passed away of liver failure. No liver transplants have yet been reported. Given the serious implications of this disease and the number of vaccines against COVID-19 given world-wide, further research is needed to better understand this entity and its pathophysiology. Table 1. - Lab Values 6/6/2021 11/15/2021 12/2/2021 1/12/2022 2/11/2022 4/18/2022 5/30/2022 AST U/L 120 323 31 35 48 37 50 ALT U/L 181 519 87 58 74 44 48 ALK P U/L 265 292 165 101 109 116 124 PLATELET COUNT 90 86 93 82 96 111 98

S3272 A Potential New Use for Tocilizumab: A Case of Refractory Checkpoint Inhibitor Hepatitis

Introduction: Immune checkpoint inhibitors (CPI) are becoming increasingly common treatment options for several types of cancers. While their use in cancer treatment is very promising, these medications are not without side effects. Specifically, these drugs are commonly associated with hepatic adverse events, including auto-immune hepatitis (AIH). In fact, in one study, AIH was found in approximately 5% of people treated with a CPI. While we know that CPI hepatitis is a potential outcome of treatment with CPIs, we have yet to establish the best treatment options for this adverse event. Based on expert opinion, the recommended course of treatment involves high dose steroids and immunomodulators if needed. There is not, however, much literature on management of CPI hepatitis that is refractory to the typical treatments, though use of tocilizumab has shown some success previously in treatment of immune-related adverse events secondary to CPIs . Case Description/Methods: A 35 y.o. female with recurrent right renal cell carcinoma, status-post resection with nephrectomy, on palliative treatment with nivolumab/ipilimumab, presented to the hospital for further evaluation of elevated liver function tests (LFT) and an abdominal MRI concerning for hepatitis. At time of admission, she was on her 3rd week of steroids, started with concern for drug-induced autoimmune hepatitis due to her checkpoint inhibitor (CPI) treatment. At admission, she was started on IV steroids and mycophenolic acid. LFTs and bilirubin continued to rise despite several days of this treatment and she was given a dose of rituximab. Liver biopsy was obtained which was consistent with CPI induced hepatitis. LFTs and bilirubin continued to rise and tocilizumab was given. 4 days after that treatment, AST and ALT were nearly half their pretreatment values and bilirubin began downtrending. At this point, the patient was stable enough for discharge with very close follow up (Figure). Discussion: Studies from 2019 reveal that 43.68% of all people with cancer in the United States are eligible for CPI therapy. This number translates to 7.9 million patients who are potentially eligible for CPI therapy. With the incidence of severe CPI hepatitis suspected to be up to 20% of all people taking CPIs, this equates to 1.58 million people of whom could be affected. More studies need to be done to address treatment for refractory auto-immune CPI hepatitis, and to better understand the underlying pathogenesis in this rapidly growing population.Figure 1.: Liver biopsy with significant lobular hepatitis, loss of zone 3 hepatocytes, acidophil bodies, and Kupffer cell hyperplasia consistant with checkpoint inhibitor auto-immune hepatitis.

S1767 Metastatic Solid Pseudopapillary Neoplasm of the Pancreas, Rare Presentation of an Uncommon Tumor

Introduction: Solid pseudopapillary neoplasms (SPN) make up less than 3% of all diagnosed pancreatic neoplasms. Abdominal CT or MRI are the imaging modalities most utilized, and biopsy is necessary to confirm the diagnosis. Resection of the mass is standard of care and the prognosis is quite good, with 5-year survival rates of over 95%. Both recurrence and metastasis of the tumor are exceedingly rare, occurring in only 1-4% of patients. Case Description/Methods: A 26-year-old female presented with several years of abdominal pain. CT scan revealed a 10cm mass in the neck and body of the pancreas and patient underwent a hybrid resection including subtotal pancreatectomy, splenectomy, and cholecystectomy. Pathology showed a neoplasm extending to the inked margins with positive beta-catenin and CD10 nuclear staining with no evidence of metastasis. At the age of 32, the patient presented again with abdominal pain. A CT and PET scan showed numerous LUQ, perirenal, pancreatic, and periadrenal soft tissue densities. Laparoscopic resection of a 3.5x3 cm soft tissue mass near the remnant pancreas was performed, showing fibrous stroma with angulated islands of epithelioid cells with cystic degeneration and positive staining for vimentin, CD56, and beta-catenin. Resection of multiple abdominal soft tissue tumors, in bulk measuring more than 10 cm, as well as complete omentectomy, left adrenalectomy, bilateral salpingo-oophorectomy, appendectomy, and hyperthermic intraperitoneal chemotherapy with cisplatin was performed. Pathology showed multiple metastatic tumors all consistent with SPN. The appendix, left adrenal gland, bilateral ovaries, and all lymph nodes were negative for any tumor. Two years later, MRI revealed 3.0 x 2.1 cm hyperintense lesion in the caudate lobe of the liver. EUS with biopsy was performed, revealing clusters of uniform, bland cells with ovoid nuclei and associated fibrillary stroma circumscribing vessels with a background of hemorrhagic debris (Figure). Immunohistochemistry showed cells positive for vimentin, LEF1, and beta-catenin, again consistent with SPN. Discussion: This is one of the few cases of multiple instances of both recurrence and metastasis of SPN documented in the literature. This case report shows that serial imaging studies and close follow-up are needed even years after resection and that, although rare, recurrence and metastasis can occur more than one time after the initial diagnosis.Figure 1.: Biopsy of the caudate liver lesion showing clusters of uniform, bland cells with ovoid nuclei and associated fibrillary stroma and hemorrhagic debris, consistent with SPN.

S1348 Patterns of GI Specialty Referral for Primary Care Patients With Nonalcoholic Fatty Liver Disease

Introduction: Early specialist intervention for patients with significant fibrosis from nonalcoholic fatty liver disease (NAFLD) is important in preventing related morbidity and mortality. For patients with evidence of hepatic steatosis, we aim to determine what proportion received gastroenterology (GI) referral, the reason for referral, and the severity of fibrosis between groups. Methods: This retrospective study of electronic health record data from 2012-2018 included patients with (i) radiographic reports of liver steatosis (abdominal ultrasound, CT, or MRI) and (ii) no competing, non-NAFLD chronic liver disease diagnoses. Referral to GI any time after imaging was the primary outcome. Chart review was conducted to determine if a patient was referred and the reason for the referral. Fibrosis-4 Index (FIB-4) scores were calculated and categorized by advanced fibrosis risk. Statistical analysis was performed with Student t-tests and Chi-square tests using SAS. Results: The cohort included 652 patients with a mean age of 55 (SD ± 14) years. Of included patients, 64% were female and 36% identified as Black. One in four patients received a formal diagnosis of NAFLD. FIB-4 scores were high-risk for advanced fibrosis in 12% of patients, indeterminate-risk for 31% of patients, and low-risk for 57% of patients. Overall, 46% of patients received a GI referral, with 32% of these referrals being for colonoscopy. A larger portion of referred patients (33%) received a diagnosis of NAFLD during the study period compared to those not referred (19%, p< 0.001). Of patients referred for non-colonoscopy reasons, only 15% of referral orders mentioned steatosis. When fatty liver disease was mentioned at referral, a larger proportion of patients received a formal NAFLD diagnosis compared to all other non-colonoscopy referrals (80% vs. 26%, p< 0.001). There was no difference in the proportion of high-risk FIB-4 scores between patients with and without a GI referral (p=0.95). Conclusion: Appropriate GI referral for NAFLD management remains a concern, even so NAFLD is predicted to be the leading indication for liver transplantation within the next 10 years. Our data suggests hepatic steatosis is infrequently recognized as a notable finding on abdominal imaging and did not prompt excessive GI referral. Use of FIB-4 scoring has been shown to reduce unnecessary referral and improve detection of advanced fibrosis, though FIB-4 scoring did not influence referral likelihood in this cohort.

S3186 The Imaging Negative Hepatic Lesions: A Rare Case of Infiltrative Hepatocellular Carcinoma

Introduction: Hepatocellular Carcinoma (HCC) is the 6th most common cancer and the 4th leading cause of cancer-related death worldwide. The infiltrative subtype is the most difficult to diagnose with imaging because of its inherently ill-defined micronodules involving a segment or entire hepatic parenchyma without a distinguishable mass. Prognosis is poor and estimated at a 5-year survival rate of < 20%. Diagnosis of HCC requires a sensitive imaging test. In situations where imaging is not able to identify a mass, EUS-FNA has been shown to have a higher detection rate. Case Description/Methods: A 61-year-old female with a past medical history of HCV cirrhosis with sustained virology response (SVR), presented with abdominal pain and worsening lower extremity edema. Remarkable examination findings include a distended abdomen and bilateral pitting lower extremity edema. Significant work up showed platelet of 109k/cmm (150-440), AST of 159 unit/l (15-37), total bilirubin of 1.2mg/dl (0.2-1.0), AFP of >20,000ng/ml (0.5-8.0), peritoneal fluid cytology was negative. A right upper quadrant ultrasound, CT, and MRI showed no hepatic mass, Fig CD. With markedly elevated AFP and a high suspicion for HCC, the patient had EGD-EUS guided fine-needle aspiration showing multiple infiltrative hepatic lesions, Fig E. The biopsy report showed malignant cells positive for AFP with cells reactive for glypican-3 and negative for Hep-Par1 (Fig A), supporting the diagnosis of HCC. The patient was referred to oncology and a month later, she died. Discussion: SVR is associated with decreased risk of HCC, however, with a cirrhotic liver, patients still have an absolute risk of developing HCC. Initial diagnosis of HCC can be obtained non-invasively using abdominal ultrasound, CT, MRI, and EUS-FNA. Abdominal ultrasound is the best imaging modality recommended for HCC surveillance because it is readily available. However, its sensitivity for detecting early HCC is about 47%. AFP cut-off level of > 20ng/ml has a sensitivity of about 60% with low specificity. A level of > 400ng/ml is diagnostic for HCC with a specificity of almost 100%. Incremental changes in AFP are associated with an increased mortality rate. The median survival rate of infiltrative HCC with AFP of > 400 is estimated to be about 5 months. EUS is superior to CT in detecting small hepatic lesions, with a sensitivity of 100% compared to 71% of CT. We recommend that EUS be considered an integral modality while investigating the diagnosis of infiltrative HCC.Figure 1.: Fig A showing Hepatocellular carcinoma, 200x. Glypican-3 immunostain shows strong, diffuse staining in HCC (A). Background non-neoplastic liver is negative (B). Fig C is the cirrhotic liver with no identifiable mass. Fig D shows fluid around the liver and spleen. Fig E is the EUS showing multiple infiltrative hepatic lesions.

S2964 COVID-19 Vaccination May Increase the Risk of Autoimmune Hepatitis in Patients With Underlying Autoimmune Disease

Introduction: It is established that COVID-19 viral infection is associated with many autoimmune processes, especially in predisposed patients, such as autoimmune hepatitis AIH [1,2]. Molecular mimicry is one of the suggested mechanisms behind such phenomena. mRNA COVID-19 vaccination can plays the same role as the infection does. Case Description/Methods: 55 year old Hispanic male with ulcerative colitis on home sulfasalazine who presented to the ED with complaints of a vague, non-cramping, and dull RUQ abdominal pain for 3 weeks duration. Negative ROS. The patient’s social history is unremarkable. No recent travel, occupational exposures, herbal supplements use, or acetaminophen use. He received 2 doses of Pfizer COVID -19 vaccines , last dose was around 21 days before admission. VS were normal, physical examination was remarkable for jaundice and mild RUQ tenderness. laboratory tests were remarkable for: Liver Function Tests: AST/ALT 1621/1476 units per liter (U/L) , T. bilirubin 6.0 milligrams per deciliter (mg/dL), D.bilirubin 4.5 (mg/dL), Alkaline phosphatase 167 (U/L) , GGT: 339 , ESR: 99 mm, CRP: 3.40 (mg/dL). Abdominal ultrasound and MRI were unremarkable. EUS showed a diffuse abnormal echotexture in the visualized portion of the liver. No significant ductal pathology. The patient was treated with azathioprine and prednisone 60 mg daily with slow tapering and with continuation of his home dose sulfasalazine (Figure). Discussion: Few case reports were reported over billions of doses of vaccine administration. The increasing number of case reports associating autoimmune processes with COVID-19 related infection and mRNA vaccines might allow for more data analysis to determine risk factors that predispose patients for AIH. It is likely that patients with pre-existing autoimmune diseases are more vulnerable to develop autoimmunity after exposure to spike-protein based COVID-19 vaccines. If more data confirms causality of COVID-19 vaccine induced AIH, this will help providers to identify patient at high risk to develop AIH as a side effect, and also may encourage scientists to find out other types of vaccines that has low/no chance of molecular mimicry.Figure 1.: Liver biopsy - histopathology.

S2789 A Rare Triad of Ulcerative Colitis, Large Vessel Vasculitis and Celiac Disease

Introduction: Inflammatory bowel disease (IBD) has been associated with large-vessel vasculitis (LVV), with the diagnosis of IBD preceding that of LVV by years. We present for the first time in known literature a triad of concurrent ulcerative colitis (UC), aortitis and celiac disease. Case Description/Methods: A 58 year old Hispanic man with a history of hypertension and gout presented with two weeks of intractable temporomandibular headaches, and two months of non-bloody diarrhea and weight loss. Physical exam was unremarkable. Labs showed hemoglobin 6.9 g/dL, erythrocyte sedimentation rate 120 mm/hr, C-reactive protein 281 mg/dL and IgA tissue transglutaminase antibody 23 U/mL. ANA, C3, C4, proteinase-3 and myeloperoxidase antibodies were within normal limits. Colonoscopy showed pancolitis from rectum to ascending colon. The terminal ileum was normal. Abdominal MRI found aortic wall hyperintensity from the renal arteries to common iliac bifurcation. CT angiogram showed wall thickening of the left carotid artery, aortic arch, descending thoracic and abdominal aorta, consistent with vasculitis. Patient was given stress dose steroids with improvement in headache and normalization of ESR and CRP. Temporal artery biopsy was unremarkable. Four months after hospitalization, repeat colonoscopy with duodenal biopsies for celiac disease revealed mild increase in intraepithelial lymphocytes with preserved villous architecture. He was started on a gluten free diet and adalimumab in combination with methotrexate for UC and LVV. Discussion: About 10 case reports of patients with both UC and either Takayasu (TAK) or giant cell arteritis (GCA) have been described, with UC typically diagnosed 15-45 years before the vasculitis. Vasculitis in the GI tract can mimic IBD, making colonoscopy and biopsy crucial for diagnosis. HLA haplotypes A24, B52, and DR2 are associated with both UC and aortitis and Interleukin-9, observed in temporal arteritis lesions, may be implicated in the pathogenesis of UC. Shared chromosomal variants between patients with UC and celiac disease may explain why IBD risk is up to 9-fold higher in patients with celiac disease. Our patient may have presented with isolated aortitis or an early form of GCA. Methotrexate is used to treat LVV and is combined with an anti-TNF agent to treat UC, as in our case. This is the first known report of co-occurring UC, celiac disease and aortitis; however, whether the three inflammatory conditions are mechanistically related warrants further research.

S3101 When a Cyst Isn't Just a Cyst: A Rare Case of a Hydatid Liver Cyst Caused by Echinococcus in the United States

Introduction: Echinococcus Granulosus is a parasite that causes hydatid disease. It is endemic to many countries but is rarely seen in the US, particularly in the Northeast. We present a case of a 22-year-old American male with a hydatid liver cyst due to an Echinococcus infection. Case Description/Methods: 22-year-old obese male presented to a local hospital for RUQ abdominal pain that radiated throughout his abdomen. He denied recent diet changes, travel or sick contacts.On presentation the patient had leukocytosis, transaminitis, hyperbilirubinemia and an elevated alkaline phosphatase. CT abdomen showed mild splenomegaly and a new 8.6cm diameter heterogeneous low density poorly enhancing mass in the right hepatic lobe. RUQ US revealed a heterogeneous irregularly marginated hypoechoic 9.6 × 9.5 × 5.7 cm soft tissue liver mass. Abdominal MRI showed a 9.3 × 7.3 cm complex, cystic and multilobulated lesion with thick walls and internal septations in the right hepatic lobe. He was transferred to our hospital for GI evaluation, where an US guided aspiration of the collection was recommended. 5 ccs of purulent aspirate were drained, sent for culture and a hepatic drain was placed. There was no evidence of malignancy in the aspirate. He then shared that over a year before his presentation, he served 9 months in Afghanistan with the US military. An infectious workup then showed serum positive for echinococcus antibody. Treatment was started with daily oral albendazole for Cystic Echinococcus (CE). Eight and half weeks later his pain had resolved and interval improvement with decreased abscess size was seen on CT (Figure 1). Discussion: CE is common in South America, the Middle East, Africa and Asia. Most cases of CE in the US are found in immigrants from endemic countries. Local transmission has been reported in California, Alaska and the southwest US. Our case of an American male with CE highlights the importance of understanding the lifecycle of CE as there is often many years between ingestion of eggs and symptom onset. It also demonstrates the importance of obtaining enzyme-linked immunosorbent assay test for Echinococcus, which is 90% sensitive, prior to considering surgery for a cystic liver lesion. Rupture of hydatid cysts occurs spontaneously or during surgery and can cause multifocal dissemination leading to fever, urticaria, eosinophilia or anaphylaxis. If physicians are familiar with pathology endemic to different countries, patients will be more likely to receive timely, appropriate care.Figure 1.: A. CT abdomen completed at time of presentation demonstrating heterogenous low density and poorly enhancing mass. B. MRI abdomen completed at time of presentation showing complex cystic and multilobulated lesion with thick walls and thick internal septations. C. CT abdomen eight and half weeks after initiation of Albendazole.

S2943 Budd-Chiari Syndrome Diagnosis Achieved With High Clinical Suspicion Raised by EUS-Guided Portal Pressures and Liver Biopsy

Introduction: Budd Chiari syndrome (BCS) is a rare syndrome due to hepatic venous obstruction in the absence of cardiac cause, mostly secondary to thrombosis. As high as 80%of patients present with ascites. The diagnosis should be suspected in patient with acute or chronic liver disease without identified cause. Venous obstruction can be seen on Doppler ultrasound, CT, or MRI of the hepatic veins and inferior vena cava. In some cases, hepatic venogram is needed for its diagnostic and therapeutic advantages. We report a 50-year-old woman with BCS who underwent successful wire recanalization, angioplasty and thrombolysis of the right hepatic vein. Case Description/Methods: 50-year-old woman with no significant past medical history presented with abdominal distension and bilateral lower extremity swelling of two weeks duration. On exam, abdomen was distended with positive signs of fluid collection with +3 bilateral lower extremity edema. Labs revealed total bilirubin 3.3 direct bilirubin 1.4, ALP 477, ALT 38, AST 96, PT 14.4, INR 1.35. Ultrasound showed Heterogeneous appearance of liver and large volume ascites. Doppler study showed normal hepatic and portal venous flow. Abdominal MRI showed hepatic steatosis and caudate lobe hypertrophy. Large volume paracentesis was done with analysis showing SAAG of 3.1, WBC 364, Neutrophils 8. EGD revealed large esophageal varices. Viral hepatitis panel, ceruloplasmin, alpha-1antitripsin, ASMA, AMA antibodies were negative. EUS guided liver biopsy and portal pressure measurement was done showing venous pressure gradient of 13 consistent with portal hypertension. Liver biopsy showed grade 2 fibrosis and zone 3 congestion. Hepatic venogram showed chronically occluded right hepatic vein on which successful wire recanalization was done. Pt was worked up for hypercoagulable state and was found to have JAK 2 mutation and Protein C deficiency. Apixaban, Beta blocker and diuretics were started. Patient showed significant improvement with ascites and MELD score. Discussion: First line investigation for diagnosis of BCS is doppler ultrasound. Doppler US and MRI venography didn’t reveal the hepatic venous thrombosis in our patient. However, high index of suspicion, finding of elevated IVC pressure on EUS, and caudate lobe hypertrophy found on imaging as well as congestion liver biopsy findings led us to further investigate with hepatic venogram which confirmed the diagnosis and provided therapeutic advantages. Table 1. - Prothrombotic risk factors for BCS ACG Clinical Guideline A. Acquired thrombophilia B. Inherited thrombophilia C. Systemic factors D. Hormonal factors Myeloproliferative disorderPolycythemia veraEssential thrombocytosisIdiopathic myelofibrosisJAK 2 mutationPNH Hyperhomocysteinemia Factor V LeidenProthrombin gene G20210A mutationMTHFR C677T mutationThalassemiaPC deficiencyProtein C deficiencyAntithrombin deficiency SarcoidosisVasculitisBehcet’s diseaseConnective tissue diseaseInflammatory bowel diseases OCP usePregnancy Disorders of the Hepatic and Mesenteric Circulation Simonetto, Douglas A.; Singal, Ashwani K.; Garcia-Tsao, Guadalupe; Caldwell, Stephen H.; Ahn, Joseph; Kamath, Patrick S. Official journal of the American College of Gastroenterology | ACG115(1):18-40, January 2020. doi: 10.14309/ajg.0000000000000486

Accelerated T2-weighted MRI of the liver at 3T using a single-shot technique with deep learning-based image reconstruction: impact on the image quality and lesion detection.

Fat-suppressed T2-weighted imaging (T2-FS) requires a long scan time and can be wrought with motion artifacts, urging the development of a shorter and more motion robust sequence. We compare the image quality of a single-shot T2-weighted MRI prototype with deep-learning-based image reconstruction (DL HASTE-FS) with a standard T2-FS sequence for 3T liver MRI. 41 consecutive patients with 3T abdominal MRI examinations including standard T2-FS and DL HASTE-FS, between 5/6/2020 and 11/23/2020, comprised the study cohort. Three radiologists independently reviewed images using a 5-point Likert scale for artifact and image quality measures, while also assessing for liver lesions. DL HASTE-FS acquisition time was 54.93 ± 16.69, significantly (p < .001) shorter than standard T2-FS (114.00 ± 32.98s). DL HASTE-FS received significantly higher scores for sharpness of liver margin (4.3 vs 3.3; p < .001), hepatic vessel margin (4.2 vs 3.3; p < .001), pancreatic duct margin (4.0 vs 1.9; p < .001); in-plane (4.0 vs 3.2; p < .001) and through-plane (3.9 vs 3.4; p < .001) motion artifacts; other ghosting artifacts (4.3 vs 2.9; p < .001); and overall image quality (4.0 vs 2.9; p < .001), in addition to receiving a higher score for homogeneity of fat suppression (3.7 vs 3.4; p = .04) and liver-fat contrast (p = .03). For liver lesions, DL HASTE-FS received significantly higher scores for sharpness of lesion margin (4.4 vs 3.7; p = .03). Novel single-shot T2-weighted MRI with deep-learning-based image reconstruction demonstrated superior image quality compared with the standard T2-FS sequence for 3T liver MRI, while being acquired in less than half the time.

Free-breathing 3D CEST MRI of human liver at 3.0T.

To develop a novel 3D abdominal CEST MRI technique at 3 T using MR multitasking, which enables entire-liver coverage with free-breathing acquisition. k-Space data were continuously acquired with repetitive steady-state CEST (ss-CEST) modules. The stack-of-stars acquisition pattern was used for k-space sampling. MR multitasking was used to reconstruct motion-resolved 3D CEST images of 53 frequency offsets with entire-liver coverage and 2.0 × 2.0 × 6.0 mm3 spatial resolution. The total scan time was 9min. The sensitivity of amide proton transfer (APT)-CEST (magnetization transfer asymmetry [MTRasym ] at 3.5ppm) and glycogen CEST (glycoCEST) (mean MTRasym around 1.0ppm) signals generated with the proposed method were tested with fasting experiments. Both APT-CEST and glycoCEST signals showed high sensitivity between post-fasting and post-meal acquisitions. APT-CEST and glycoCEST MTRasym signals from post-mean scans were significantly increased (APT-CEST: -0.019 ± 0.017 in post-fasting scans, 0.014 ± 0.021 in post-meal scans, p < 0.01; glycoCEST: 0.003 ± 0.009 in post-fasting scans, 0.027 ± 0.021 in post-meal scans, p < 0.01). The proposed 3D abdominal steady-state CEST method using MR multitasking can generate CEST images of the entire liver during free breathing.

Pancreatic Cystic Lesions on MRI: What Is The Likelihood of a Present or Future Diagnosis of Pancreatic Carcinoma?

Pancreatic cystic lesions (PCLs) are followed for years due to older and likely biased works demonstrating a strong association with pancreatic carcinoma; more recent data are needed clarifying this relationship. To determine the association between PCLs on MRI and a synchronous or future diagnosis of pancreatic carcinoma. Single-center retrospective cohort. A total of 192 patients (111 female, 58%) with median age 66 years (range 26-87 years) with PCLs on abdominal MRI from 2011 to 2016. 1.5 T and 3T, including T2 WI, T1 WI, diffusion weighted imaging and contrast-enhanced T1 WI. Each PCL was reviewed independently by 2 of 10 fellowship-trained abdominal radiologists. Fukuoka guideline worrisome features and high-risk stigmata were evaluated. Follow-up imaging and clinical notes were reviewed within a system that captures pancreatic carcinoma for the region, for a median follow-up of 67months (interquartile range: 43-88months). Pancreatic carcinoma prevalence and incidence rate for future carcinoma with 95% confidence intervals (95% CI). Fisher exact test, logistic regression with odds ratios (OR) and the Wilcoxon rank-sum test were used to assess PCL morphologic features with the Kolmogorov-Smirnov test used to assess for normality. P < 0.05 defined statistical significance. The prevalence of pancreatic carcinoma on initial MRI showing a PCL was 2.4% (95% CI: 0.9%, 5.2%). Thickened/enhancing cyst wall was associated with pancreatic carcinoma, OR 52 (95% CI: 4.5, 1203). Of 189 patients with a PCL but without pancreatic carcinoma at the time of initial MRI, one developed high-grade dysplasia and none developed invasive carcinoma for an incidence rate of 0.97 (95% CI: 0.02, 5.43) and 0 (95% CI: 0, 3.59) cases per 1000 person-years, respectively. A low percentage of patients with a PCL on MRI had a pancreatic carcinoma at the time of initial evaluation and none developed carcinoma over a median 67months of follow-up. 3 TECHNICAL EFFICACY: 5.

Severe neonatal hyperbilirubinemia secondary to combined RhC hemolytic disease, congenital hypothyroidism and large adrenal hematoma: a case report

BackgroundABO blood group incompatibility, neonatal sepsis, G-6-PD deficiency, thyroid dysfunction, and hereditary spherocytosis are all probable causes of neonatal hyperbilirubinemia. However, the etiology of some hyperbilirubinemia is extremely complicated, which may be caused by multiple factors, resulting in severe jaundice. We report a case of severe jaundice due to three causes, showing the significance for the investigation of the etiology of neonatal hyperbilirubinemia.Case presentationAt 96 h of life, a full-term and vaginal delivery male infant with yellowish discoloration of body was transferred to our hospital. When he entered neonatal intensive care unit on the fourth day after birth, he developed jaundice and the transcutaneous bilirubin was 28 mg/dl. Total bilirubin was 540.2 μmol/L, while the indirect bilirubin was 516.7 μmol/L. Both parents and the baby’s blood types were O Rh(D +), and direct coomb’s test was negative. But mother’s indirect coomb’s test was positive. Investigating for minor blood group revealed that the father’s blood type of Rh was CCDee, the mather’s was ccDEE, and CcDEe for the baby. After intensive phototherapy and double volume exchange transfusion, the total bilirubin remained at 303 μmol/L. At day 10, the bilirubin level was 303.5 μmol/L, intensive phototherapy was continued, and intravenous immunoglobulin was used again. The test for thyroid hormones at day 10, the TSH was 13.334mIU/L. And the screening for congenital hypothyroidism showed the TSH was 33mIU/L. Because of the palpable abdominal mass, ultrasound and MRI was done, showed a huge mass in the right adrenal gland. Brainstem auditory evoked potential was performed at day 7, which indicated hearing impairment (65db for left ear and 70db for the right). Euthyrox and intermittent phototherapy were given as following treatment. The jaundice did not subside until the 12th day.ConclusionEven if their parents' ABO blood group and Rh (d) are consistent, a Coomb test is required for newborns with hyperbilirubinemia since they may have minor blood group incompatibilities. When bilirubin rises rapidly or the clinical treatment effect is inadequate, additional causes should be aggressively screened. Adrenal ultrasound should be performed on newborns with palpable abdominal mass, anemia and jaundice to determine whether there is adrenal hemorrhage.

Clinical Study of Anti-PD-1 Immunotherapy Combined with Gemcitabine Chemotherapy in Multiline Treatment of Advanced Pancreatic Cancer.

Objective This study aimed to investigate the efficacy and safety of anti-PD-1 immunotherapy combined with gemcitabine chemotherapy in multiline treatment of advanced pancreatic cancer. Methods A retrospective analysis was performed on the clinical data of 32 patients with advanced pancreatic cancer treated with sintilimab regimen from January 2019 to December 2021 in our hospital. All patients were followed up until death or April 2022, in the form of outpatient, in-hospital review, or telephone follow-up. Follow-up content included routine blood, liver and kidney functions, tumor markers, plain or enhanced abdominal CT, and abdominal MRI examinations. Clinical efficacy was evaluated according to mRECIST criteria, and the severity of adverse effects was evaluated according to American Institute for Cancer Research (AICR) Standard Term for Adverse Events, Version 5.0. Results During treatment, the dosage of sintilimab was halved in 2 patients due to adverse reactions. All patients were treated with sintilimab for 1~10 times, with an average of 6 ± 4 times. The total response rate (ORR) and disease control rate (DCR) were 6.25% and 12.50% and 25.00% and 37.50%, respectively, after 1 and 3 months of treatment. The mean follow-up time of 32 patients was 1-12 months, and the median follow-up time was 4 ± 3 months. By the end point of follow-up, a total of 25 patients died, and the median progression-free survival (PFS) was 3.8 (95% CI (1.85-5.63)) months. The median overall survival (OS) was 5.1 months (95% CI (3.63~7.68). After treatment, the levels of tumor markers CA125, CEA and CA199 were partly decreased compared with those before treatment (all P < 0.001). After treatment, the blood routine indexes d-dimer, CRP (C-reactive protein), NLR (neutral granulocyte to lymphocyte ratio), and MLR (monocyte to lymphocyte ratio) decreased compared with those before treatment. In 32 patients with advanced pancreatic cancer, the adverse reactions with an incidence more than 10% included fatigue, rash, hypothyroidism, hyperuricemia, and renal insufficiency. Only 2 patients showed grade 3 fatigue symptom, and all the others showed no adverse reactions of grades 3~5. In this study, all patients' adverse reactions were relieved after symptomatic treatment. Conclusion Gemcitabine chemotherapy in multiline treatment of advanced pancreatic cancer with sintilimab can achieve certain clinical benefits without serious adverse reactions.

Prospective motion correction in kidney MRI using FID navigators.

Abdominal MRI scans may require breath-holding to prevent image quality degradation, which can be challenging for patients, especially children. In this study, we evaluate whether FID navigators can be used to measure and correct for motion prospectively, in real-time. FID navigators were inserted into a 3D radial sequence with stack-of-stars sampling. MRI experiments were conducted on 6 healthy volunteers. A calibration scan was first acquired to create a linear motion model that estimates the kidney displacement due to respiration from the FID navigator signal. This model was then applied to predict and prospectively correct for motion in real time during deep and continuous deep breathing scans. Resultant images acquired with the proposed technique were compared with those acquired without motion correction. Dice scores were calculated between inhale/exhale motion states. Furthermore, images acquired using the proposed technique were compared with images from extra-dimensional golden-angle radial sparse parallel, a retrospective motion state binning technique. Images reconstructed for each motion state show that the kidneys' position could be accurately tracked and corrected with the proposed method. The mean of Dice scores computed between the motion states were improved from 0.93 to 0.96 using the proposed technique. Depiction of the kidneys was improved in the combined images of all motion states. Comparing results of the proposed technique and extra-dimensional golden-angle radial sparse parallel, high-quality images can be reconstructed from a fraction of spokes using the proposed method. The proposed technique reduces blurriness and motion artifacts in kidney imaging by prospectively correcting their position both in-plane and through-slice.

Transabdominal self-expandable metal stent placement as a rescue therapy for drainage of walled-off necrosis.

Video 1CT scan of a walled-off necrosis in the right pararenal space extended to the iliac area.

Self-supervised learning for automated anatomical tracking in medical image data with minimal human labeling effort

Background and Objective: Tracking of anatomical structures in time-resolved medical image data plays an important role for various tasks such as volume change estimation or treatment planning. State-of-the-art deep learning techniques for automated tracking, while providing accurate results, require large amounts of human-labeled training data making their wide-spread use time- and resource-intensive. Our contribution in this work is the implementation and adaption of a self-supervised learning (SSL) framework that addresses this bottleneck of training data generation. Methods: To this end we adapted and implemented an SSL framework that allows for automated anatomical tracking without the necessity for human-labeled training data. We evaluated this method by comparison to conventional- and deep learning optical flow (OF)-based tracking methods. We applied all methods on three different time-resolved medical image datasets (abdominal MRI, cardiac MRI, and echocardiography) and assessed their accuracy regarding tracking of pre-defined anatomical structures within and across individuals. Results: We found that SSL-based tracking as well as OF-based methods provide accurate results for simple, rigid and smooth motion patterns. However, regarding more complex motion, e.g. non-rigid or discontinuous motion patterns in the cardiac region, and for cross-subject anatomical matching, SSL-based tracking showed markedly superior performance. Conclusion: We conclude that automated tracking of anatomical structures on time-resolved medical image data with minimal human labeling effort is feasible using SSL and can provide superior results compared to conventional and deep learning OF-based methods.