Alcohol-induced Liver Cirrhosis Research Articles

Comparative proteomics reveals different protein expression in platelets in patients with alcoholic liver cirrhosis

BackgroundThe role of platelets in disease progression as well as the function of platelets as part of the haemostatic and immunological system in patients with liver cirrhosis is only incompletely understood. This is partly due to difficulties in assessing platelet function. Proteome analyses of platelets have been used to further investigate the role of platelets in other diseases.AimTo assess possible changes in the platelet proteome during different stages of alcohol induced liver cirrhosis compared to healthy donors.Patients and methodsA 45 ml blood sample was drawn from 18 participants aged 18–80 years evenly divided into three groups of healthy donors, patients with less advanced alcohol induced liver cirrhosis (Child-Pugh < 7) and patients with advanced liver cirrhosis (Child-Pugh > 10). The blood was processed to isolate platelets and perform subsequent two-dimensional gel-electrophoresis using a SYPRO™ Ruby dye. After computational analysation significantly in- or decreased protein spots (defined as a two-fold abundance change between different study cohorts and ANOVA < 0.05) were identified via liquid chromatography–mass spectrometry (LCMS) and searching against human protein databases.ResultsThe comparative analysis identified four platelet proteins with progressively decreased protein expression in patients with liver cirrhosis. More specifically Ras-related protein Rab-7a (Rab-7a), Ran-specific binding protein 1 (RANBP1), Rho GDP-dissociation inhibitor 1 (RhoGDI1), and 14–3-3 gamma.ConclusionThere is significant change in protein expression in the platelet proteome throughout the disease progression of alcohol induced liver cirrhosis. The identified proteins are possibly involved in haemostatic and immunoregulatory function of platelets.

Molecular genetics of neuropsychiatric illness: some musings.

Research into the genetic underpinnings of neuropsychiatric illness has occurred at many levels. As more information accumulates, it appears that many approaches may each offer their unique perspective. The search for low penetrance and common variants, that may mediate risk, has necessitated the formation of many international consortia, to pool resources, and achieve the large sample sizes needed to discover these variants. There has been the parallel development of statistical methods to analyse large datasets and present summary statistics which allows data comparison across studies. Even so, the results of studies on well-characterised clinical datasets of modest sizes can be enlightening and provide important clues to understanding these complex disorders. We describe the use of common variants, at multiallelic loci like TOMM40 and APOE to study dementia, weighted genetic risk scores for alcohol-induced liver cirrhosis and whole exome sequencing to identify rare variants in genes like PLA2G6 in familial psychoses and schizophrenia in our Indian population.

Harnessing the potential of probiotics in the treatment of alcoholic liver disorders.

In the current scenario, prolonged consumption of alcohol across the globe is upsurging an appreciable number of patients with the risk of alcohol-associated liver diseases. According to the recent report, the gut-liver axis is crucial in the progression of alcohol-induced liver diseases, including steatosis, steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Despite several factors associated with alcoholic liver diseases, the complexity of the gut microflora and its great interaction with the liver have become a fascinating area for researchers due to the high exposure of the liver to free radicals, bacterial endotoxins, lipopolysaccharides, inflammatory markers, etc. Undoubtedly, alcohol-induced gut microbiota imbalance stimulates dysbiosis, disrupts the intestinal barrier function, and trigger immune as well as inflammatory responses which further aggravate hepatic injury. Since currently available drugs to mitigate liver disorders have significant side effects, hence, probiotics have been widely researched to alleviate alcohol-associated liver diseases and to improve liver health. A broad range of probiotic bacteria like Lactobacillus, Bifidobacteria, Escherichia coli, Sacchromyces, and Lactococcus are used to reduce or halt the progression of alcohol-associated liver diseases. Several underlying mechanisms, including alteration of the gut microbiome, modulation of intestinal barrier function and immune response, reduction in the level of endotoxins, and bacterial translocation, have been implicated through which probiotics can effectively suppress the occurrence of alcohol-induced liver disorders. This review addresses the therapeutic applications of probiotics in the treatment of alcohol-associated liver diseases. Novel insights into the mechanisms by which probiotics prevent alcohol-associated liver diseases have also been elaborated.

A Prospective Study to Identify the Prevalence of Impaired Glucose Tolerance in Patients With Liver Cirrhosis Using Oral Glucose Tolerance Test.

Introduction Diabetes mellitus (DM) is a global health problem that may affect the prognosis of liver cirrhosis by interfering with the various metabolic functions of the body. Hence it is important to know the glycemic status of the patients with liver cirrhosis to anticipate and treat the complications associated with it, which in turn will help in the prognosis. The conventional methods may underestimate impaired glucose tolerance (IGT). Hence, this study was undertaken to identify IGT prevalent among liver cirrhosis patients using an oral glucose tolerance test (OGTT).The aim of our study was to identify the prevalence of IGT in non-diabetic liver cirrhosis patients using OGTT. Materials and methods This was a prospective cross-sectional study done in the Department of General Medicine at Shri BM Patil Medical College and Hospital, Vijayapura. After obtaining institutional ethical committee approval, a sample size of 85 liver cirrhosis patients between the age of 20-80 years who were not known cases of diabetes mellitus were selected from patients attending inpatient and outpatient departments at our hospital. The period of study was from January 2021 to June 2022. Patients were tested with OGTT, and the results were recorded. Results Our study found that IGT was more common in the age group of 40-49 years. All the patients included were males. We found that alcohol-induced liver cirrhosis patients had the maximum of IGT and DM. Our study observed a prevalence of 36.47% of patients with IGT. Our study in addition to IGT, found that DM was more common in 30-39 years, and 24.71% of patients were diagnosed with diabetes mellitus in the 85 patients included in our study. Conclusion We conclude that performing OGTT to find the prevalence of IGT and DM in liver cirrhosis patients will help in diagnosing DM and IGT, aiding in the improvement of the prognosis of the cirrhosis. The glycemic status of the patient may help in deferring the complications associated with poor glucose control. The incidence of potential complications of DM can be reduced by prompt identification and treatment.

Effect of carbon quantum dots derived from extracts of UV-B-exposed Eclipta alba on alcohol-induced liver cirrhosis in Golden Hamster.

The Eclipta alba plant is considered hepatoprotective, owing to its phytoconstituents wedelolactone. In the current study, effect of elevated ultraviolet-B (eUV-B) radiation was investigated on biochemical, phytochemical, and antioxidative enzymatic activities of E. alba (Bhringraj) plant. The UV-B exposure resulted in an increase in oxidative stress, which has caused an imbalance in phytochemical, biochemical constituents, and induced antioxidative enzymatic activities. It was observed that the UV-B exposure promoted wedelolactone yield by 23.64%. Further, the leaf extract of UV-B-exposed plants was used for the synthesis of carbon quantum dots (CQDs) using low cost, one-step hydrothermal technique and its biocompatibility was studied using in vitro MTT (3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide) assay on HepG2 liver cell line. It revealed no toxicity in any treatment groups in comparison to the control. Both CQDs and leaf extract were orally administered to the golden hamster suffering from alcohol-induced liver cirrhosis. In the morphometric study, it was clearly observed that a combination of UV-B-exposed leaf extract and synthesized CQDs delivered the best result with maximum recovery of liver tissues. The present study reveals the positive impact of UV-B exposure on the medicinally important plant, increased yield of wedelolactone, and its enhanced hepatoprotective efficacy for the treatment of damaged liver tissues.

Spontaneous Retroperitoneal Hematoma: A Deadly Complication for Patients Awaiting Liver Transplant.

Patients with end-stage liver disease (ESLD) are at increased risk for hemorrhage and spontaneous retroperitoneal hematoma (sRPH) and also carry a high mortality rate. We sought to review the natural history of sRPH in patients with ESLDat a single center. All patients admitted to a single transplantation intensive care unit (TICU) at Froedtert and the Medical College of Wisconsin Transplant Center between June 2016 and August 2018 were retrospectively reviewed. Six ESLD patients with sRPH were studied. Clinical outcome measures were liver disease severity, sRPH treatment, and patient survival. Six patients were included, four male and two female patients, with a median age of 56.5 years (range 30-67 years). All had alcohol-induced liver cirrhosis. The median Model for End-Stage Liver Disease (MELD) score at the time of sRPH diagnosis was 40 (range 30-43). The most commonly identified source of bleeding was from lumbar arteries. One patient had recurrent bleeding after embolization and underwent repeat embolization. Five patients died. The median time to death from the diagnosis of sRPH was 7.2 days (range 2-12 days). The patient who survived following embolization had the lowest MELD score. Critically ill cirrhotic patients with sRPH have a significant mortality rate. Embolization is successful, albeit seldom. This is the largest retrospective series of sRPH in cirrhotic patients in theliterature.

Management of Pancytopenia in Alcohol-Induced Liver Cirrhosis in Young Women: A Case Study

Management of Pancytopenia in Alcohol-Induced Liver Cirrhosis in Young Women: A Case Study

Study of Clinical Profile and Outcome in Patients of Alcohol Induced Chronic Liver Disease with Hepato Renal Syndrome

Background: Decompensated Chronic liver disease and cirrhosis are frequently complicated with renal dysfunction and this combination, called Hepato-Renal Syndrome (HRS) leads to significant morbidity and mortality. Acute renal dysfunction occurs in 15% to 25% of hospitalized patients with cirrhosis. The annual frequency of Hepato-renal syndrome(HRS) in cirrhotic patients with ascites is roughly 8% and, in some reports, as high as 40%.The observation that morbidity and mortality remain high once the syndrome is established has led to a focus on the prevention and early therapy of renal dysfunction in patients with cirrhosis. Hepato-renal syndrome (HRS) is a serious complication of liver cirrhosis with critically poor prognosis. Rapid diagnosis and management are important, since recent treatment modalities including vasoconstrictor therapy can improve short-term outcome and buy time for liver transplantation, which can result in complete recovery. Recognizing the trait about chronic alcoholism in a patient, counselling by doctor about avoidance of alcohol, &amp; early recognition of progression to CLD by investigations may be helpful in preventing this complication. Aims and Objectives: To study clinical profile, assess the course and severity and outcome of patients admitted with alcohol induced chronic liver disease with hepato-renal syndrome. Methodology: A prospective (observational), hospital based study was carried out in 57 patients who met our inclusion criteria. Results: The study population's most common age group was between 36 and 45 years (33.3%), 46 to 55 years (24.6%), and more than 55 years (22.8%) with the mean age of 43 + 7.8 years amongst study population with a male predominanace (87.7%), Icterus and ascitis (100%) followed by Flapping tremors (98.25%), Oliguria (82.5%), Edema Feet (73.68%), Altered sensorium (66.7%) and Abdominal Distension (59.65%) were the commonest clinical features. History of alcohol intake for more than 10 years (61.4%) followed by less than 10 years (38.6%) and most of them were heavy drinkers (&gt;4 drinks per day) (44.2%) while moderate and light drinkers (2-4 drinks/day and 1-2 drinks/day ) were 32.7% and 23.1% respectively. Previous history of admissions due to similar or related illness was observed in 78.9% of study population. Most of our patients had Type I HRS (75.4%) followed by Type II (24.53%). In our study, death was occurred in all patients with worsened hepatic and renal dysfunction (100%) and the difference was statistically significant. Conclusion: Hepato Renal Syndrome is a major decompensation in advanced alcohol induced liver cirrhosis with a high short-term mortality rate.

A rare drug fever due to everolimus use in a patient with liver transplantation: a case report during the Covid-19 pandemic

Drug-induced fever (DIF) is an uncommon, difficult-to-diagnose complication which is one of the possible causes of fever of unknown origin (FUO). In addition, Covid-19 infection is also a cause of fever in these pandemic days we live. Everolimus (EVR), an inhibitor of the mammalian target of rapamycin (mTOR), is employed as an immunosuppressant in combination with calcineurin inhibitors, following a procedure of organ transplantation, and as a proliferation signal inhibitor coated on a drug-eluting stent and in cancer therapy. EVR has many adverse effects that require follow-up, but fever is not one of the well-known adverse effects thereof. In our literature search, we have found only a single case of fever due to EVR use which had been reported in a patient following a cardiac transplantation in 2004. On the other hand, our case is a patient with a diagnosis of alcohol-induced liver cirrhosis and hepatocellular carcinoma (HCC) who has been subjected to a liver transplantation (LT) has developed fever in the course of our follow-up just after the initiation of EVR treatment at the third month post-transplantation and during the covid-19 pandemic.

Oxidative stress-induced growth inhibitor 1 in alcohol-induced liver cirrhosis.

Human oxidative stress-induced growth inhibitor 1 (OSGIN1) is a protein identified in 2001 which belongs to the OKL38 protein family. The aim of the study was to investigate the levels of this protein depending on the severity of alcohol-induced liver cirrhosis. The study group consisted of 60 patients: 30 patients with cirrhosis in the P-Ch A and B stage and 30 in the P-Ch C stage. The control group consisted of 18 healthy individuals without liver diseases, who did not abuse alcohol. Oxidative stress induced growth inhibitor 1 (OSGIN1), fibroblast growth factor 1 (FGF1) and fibroblast growth factor 21 (FGF21) were determined in blood serum using enzyme-linked immunosorbent assay (ELISA) kits. All absorbance readings were conducted using an Epoch Microplate Spectrophotometer (BioTek Instrumentals, Inc., Winooski, VT, USA). OSGIN1, FGF1 and FGF21 concentrations were determined using Sandwich enzyme immunoassay kits (by Cloud Clone Corp., Katy, TX, USA). Statistica 13.3 (TIBCO Software, Inc.) was used for data analysis. The concentration of OSGIN1 was 0.028 ± 0.017 in the control group which increased with the advancement of liver cirrhosis (stage of Pugh-Child): 0.075 ± 0.098 in the P-Ch A + B group and 0.121 ± 0.134 in the P-Ch C stage. Multiple comparison tests confirmed statistically significant differences in OSGIN1 concentration between the control group and P-Ch C (p <0.02). Significant correlations were noted between OSGIN1 and FGF1 (r = 0.39; p = 0.004) and between OSGIN1 and FGF21 (r = 0.53; p <0.0001). The study revealed that the level of OSGIN1 increased significantly in the P-Ch C stage of liver cirrhosis. It is possible that OSGIN1 may be used for the non-invasive diagnosis of ALD, but its possible diagnostic value is still very uncertain.

Leukocyte cell-derived chemotaxin-2 and fibroblast growth factor 21 in alcohol-induced liver cirrhosis.

BACKGROUNDThe importance of early diagnosis of alcoholic liver disease underscores the need to seek better and especially non-invasive diagnostic procedures. Leukocyte cell-derived chemotaxin-2 (LECT2) has been widely studied to determine its usefulness in monitoring the course of non-alcoholic fatty liver disease but not for alcoholic liver cirrhosis (ALC).AIMTo determine the concentration of LECT2 in the blood serum of patients in relation to progressive stages of ALC, its relation to fibroblast growth factor 1 (FGF-1) and FGF-21, and to examine the possible wider use of LECT2 in diagnosing ALC.METHODSA retrospective case-control study was conducted with 69 ALC cases and 17 controls with no ALC. Subjects were recruited from the region of Lublin (eastern Poland). Liver cirrhosis was diagnosed based on clinical features, history of heavy alcohol consumption, laboratory tests, and abdominal ultrasonography. The degree of ALC was evaluated according to Pugh-Child criteria (the Pugh-Child score). Blood was drawn and, after centrifugation, serum was collected for analysis. LECT2, FGF-1, and FGF-21 were determined using enzyme-linked immunosorbent assay kits.RESULTSThe LECT2 Levels in the control group were 18.99 ± 5.36 ng/mL. In the study groups, they declined with the progression of cirrhosis to 11.06 ± 6.47 ng/mL in one group and to 8.06 ± 5.74 ng/mL in the other (P < 0.0001). Multiple comparison tests confirmed the statistically significant differences in LECT2 Levels between the control group and both test groups (P = 0.006 and P < 0.0001). FGF-21 Levels were 44.27 ± 64.19 pg/mL in the first test group, 45.4 ± 51.69 pg/mL in the second (P = 0.008), and 13.52 ± 7.51 pg/mL in the control group. The difference between the control group and the second test group was statistically significant (P = 0.007).CONCLUSIONWe suggest that LECT2 may be a non-invasive diagnostic factor for alcohol-induced liver cirrhosis. The usefulness of LECT2 for non-invasive monitoring of alcohol-induced liver cirrhosis was indirectly confirmed by the multiple regression model developed on the basis of our statistical analysis.

1033 Endobronchial Sclerotic Neurofibroma: A Case Report of a Very Rare Benign Tumour

Abstract Introduction Endobronchial neurofibromas are exceedingly rare benign lesions most commonly originating at the trachea. Primary pulmonary tumours of neurogenic origin such as peripheral nerve sheath tumours (PNSTs) are extremely rare, accounting for less than 0.2% of all lung tumours. Intrathoracic PNSTs are usually benign and are commonly found in the posterior mediastinum as schwannomas with female preponderance. We present the first reported occurrence of the sclerotic variant of endobronchial neurofibroma and the approach used in its definitive investigation and management. Case Report A 69-year-old Caucasian male with a 66 pack-year smoking history and a background of alcohol induced liver cirrhosis, peripheral vascular disease and dilated cardiomyopathy presented with dyspnoea and fatigue with severe normocytic anaemia. Computed Tomography (CT) chest, abdomen and pelvis revealed an indeterminate nodule at the secondary carina projecting into the bronchus intermedius (BI). Fibreoptic bronchoscopy showed a polypoid lesion with a vascular appearance. Under general anaesthetic, combined fibreoptic and rigid bronchoscopy was used to remove the lesion with rigid forceps. Gross histological appearance showed an 8x6x5mm pedunculated lesion with a 2mm diameter short stalk and histology of a sclerotic neurofibroma with fibroblasts and collagen, positively staining for S100 and LP10. This patient is due for follow up in 6-month with a CT chest to ensure no tumour recurrence. Conclusions Endobronchial neurofibromas appear highly vascular and demand extra caution at bronchoscopic intervention. Prompt, experienced thoracic surgical and intervention pulmonology input should always be sought. Combined approach of fibreoptic and rigid bronchoscopy allows better control of potential bleeding and the airway.

Uncertainty of Liver Cirrhosis Diagnosis and Use of Elastography

A case of severe jaundice in a patient with a long history of alcohol abuse led to a questionable diagnosis of liver cirrhosis. To determine its diagnostic utility in the setting of liver disease, elastography was utilized on our patient to confirm the clinically suspected diagnosis of cirrhosis.A 59-year-old male presented to our emergency department (ED) with two days of progressive jaundice and right upper quadrant (RUQ) pain. The patient admitted to drinking > 500 mL of vodka daily for the last seven years, with his last drink on the morning of admission. Physical exam revealed a man in mild acute distress with severe jaundice and an abdomen diffusely tender to palpation. Two spider angiomas were present on the torso along with caput medusae and mild asterixis. Labs revealed aspartate aminotransferase (AST) 408, alanine aminotransferase (ALT) 69, prothrombin time (PT) 16.3, partial thromboplastin time (PTT) 36, total bilirubin 22.6, and direct bilirubin 19.9 mg/dL. While admitted, total bilirubin rose as high as 31.5 mg/dL. Examination showed a Model for End-Stage Liver Disease (MELD) score of 22 and a Maddrey score of 37. Ultrasound revealed moderate hepatosplenomegaly with no signs of pancreatitis.Based on the patient’s history of alcohol abuse paired with physical exam findings and elevated laboratory markers, we were able to diagnose with a high level of suspicion that this patient was suffering from chronic alcoholic liver disease, exacerbated by an acute episode of alcoholic hepatitis, which led to hepatic encephalopathy. Based on these findings, a diagnosis of liver cirrhosis was suspected; however, this diagnosis required further confirmation. We utilized ultrasound elastography to measure the velocity of shear wave transmission in the liver of our patient. A literature review was conducted on the use of elastography for the diagnosis of liver disease, and a significant correlation between the velocity of shear wave transmission and hepatic histological findings was identified. Elastography revealed a mean velocity of shear wave transmission of 1.77 m/s in our patient. This finding is consistent with a Meta-analysis of Histological Data in Viral Hepatitis (METAVIR) score of F = 4, indicating significant fibrosis and confirming the suspected diagnosis of alcohol-induced liver cirrhosis.As a non-invasive and inexpensive diagnostic tool, elastography demonstrates significant potential for clinical utility in patients with liver disease. Clinicians may benefit from the use of elastography in diagnosis, while patients may receive both therapeutic and prognostic benefits secondary to its use. In similar cases with clinical uncertainty, elastography can reliably identify the presence of fibrous tissue in the liver without tissue biopsy, thus aiding in clinical diagnoses and enabling the use of optimal therapeutic regimens for future patients.

AYURVEDIC MANAGEMENT OF CHRONIC LIVER DISEASE (CLD) –AN ANALYTICAL REVIEW

Liver controls our whole body activities. Liver cirrhosis is a most common medical problem today. One and the chief cause of it is chronic alcoholic consumption. Excessive and prolonged use of alcohol affects every organ of the body. Although liver, heart and kidney are most affected due to heavy consumption, alcohol induced liver cirrhosis is a life threatening condition in maximum cases. More than 50% people of in India rely on Ayurveda and herbal medicine for liver diseases. More than three hundred herbo-mineral preparations are available in Ayurvedic system of medicine for the treatment of jaundice and chronic liver diseases. Ayurveda plays a master role in the fast and safe recovery of damaged liver. Liver cirrhosis can be correlated to Kumbhakamala in Ayurveda w.s.r. etiology, symptoms, complications and line of treatment. Ayurvedic drugs helps in rejuvenating the liver and minimizing the complications of cirrhosis such a liver cancer, fulminant hepatitis and prevents the chronicity of the disease. In the present article, analytical review of liver disorders and its management in Ayurveda has been evaluated.

Transcriptional regulation of alcohol induced liver fibrosis in a translational porcine hepatocellular carcinoma model

Hepatocellular carcinoma (HCC) is the 5th most common and 2nd deadliest cancer worldwide. HCC risk factors include alcohol induced liver cirrhosis, which prompts hepatic inflammation, cell necrosis, and fibrosis deposition. As 25% of HCC cases are associated with alcohol induced liver disease, understanding the effects of the cirrhotic liver microenvironment on HCC tumor biology and therapeutic responses are critical. This study utilized the Oncopig Cancer Model—a transgenic pig model that recapitulates human HCC through induced expression of KRASG12D and TP53R167H driver mutations—to investigate the molecular mechanisms underlying alcohol induced liver disease. Oncopigs (n = 5) underwent fibrosis induction via infusion of ethanol and ethiodized oil (1:3 v/v dosed at 0.75 mL/kg) into the hepatic arterial circulation. Eight-weeks post induction, liver tissue samples from fibrotic and age-matched control (n = 5) Oncopigs were collected for histological evaluation and transcriptional profiling. Increased hepatic inflammation and fibrosis was observed in fibrotic Oncopigs via pathological assessment. Transcriptional profiling (RNA-seq) resulted in the identification of 4387 differentially expressed genes between Oncopig fibrotic and control livers. GO term enrichment analysis identified pathway alterations associated with cirrhosis progression in humans, including cell proliferation, angiogenesis, extracellular matrix deposition, and oxidation-reduction. Key alterations include activation of hepatic stellate cells, increased matrix metalloproteinase production, and altered expression of ABC and SLC transporter genes involved in transport of anticancer drugs.These results demonstrate Oncopig liver fibrosis recapitulates transcriptional hallmarks of human cirrhosis, making the Oncopig an ideal model for studying the effects of the cirrhotic liver microenvironment on HCC tumor biology and therapeutic response.

Alcohol Induced Liver Cirrhosis and its Treatment

The advent of liver diseases globally contributes to a major burden in terms of mortality rate and disease factor. The liver, which is a major complex organ, plays a vital role in the metabolism of the body. The diseases associated with the consumption of alcohol such as cirrhosis and cancer that can be diagnosed through various pathological and cytopathological methods. This review insights how the normally functioning liver cells become vulnerable and lead to the onset of various fatal disorders if left untreated. The alcohol, unlike other drinks, is directly absorbed from the stomach into the bloodstream and is further metabolized by the hepatocytes. The products of alcohol breakdown, such as aldehyde, are toxic to hepatocytes and thus cause liver injury, in cases of chronic alcohol consumption. This injury to the hepatocytes evolves over time and leads to liver cirrhosis. The only cure for severe liver cirrhosis is a transplant of the liver. On the whole, the widespread consumption of alcohol, its making, and effects on the hepatocytes on chronic consumption, which leads to alcoholic liver diseases reviewed.

S3533 Indirect Impacts of COVID on Alcohol-Induced Liver Disease

INTRODUCTION: There is a paucity of COVID-19-negative patients who experienced alcohol-induced liver injury due to the disruption of daily activities and social isolation. CASE DESCRIPTION/METHODS: A 42-year-old male with history of alcohol induced liver cirrhosis (6 months prior MELD-Na 13, Child Pugh A, small esophageal varices and mild portal hypertensive gastropathy) presented to emergency room with 1 week of worsening abdominal pain and distension. For the last 1 month, he increased his alcohol intake to 12 beers a day (prior only 6 beers daily, last drink was 2 days ago); he states this increase was due to loss of employment and living alone. He denied any COVID-19 symptoms and tested negative. On admission, MELD-Na roughly tripled at 32 and Child Pugh now C. Labs were notable for severe hyponatremia (103 mEq/L), AST: ALT ratio ∼3:1 and acute kidney injury, concern for hepatorenal syndrome. He had tense ascites, no asterixis and A&Ox4. His hyponatremia resolved with appropriate therapy, paracentesis was negative for spontaneous bacterial peritonitis, kidney function improved on midodrine, octreotide and albumin. Yet, he developed multifactorial encephalopathy (alcohol withdrawal, ICU delirium and hepatic encephalopathy), not resolved with lactulose and rifaximin, which prolonged his hospitalization. His final days of admission were in MICU for presumed aspiration versus hospital acquired pneumonia, retest for COVID-19 were again negative. His family agreed to comfort care and the patient passed on hospital day 22. DISCUSSION: Our patient demonstrates the significant indirect effects of the COVID-19 pandemic on patients with alcohol induced liver disease. Recent publications predicted that relapses in alcohol abstinence, admissions, and new diagnoses of alcoholic liver disease would increase during quarantine.1-3 Future studies should investigate the increase in alcohol related relapses, admission, and mortality. Our patient is just one of many who, despite not contracting COVID-19, experienced negative health outcomes attributable to the pandemic.

Bizarre bleeps-a case report of propofol-induced urine discoloration following a single dose

Background: Green discoloration of urine following propofol use is a rare yet benign side effect. While rare with propofol infusions, it is even less recognized following single doses of propofol and can cause anxiety for both patients and healthcare professionals. Case Presentation: This paper presents the case of a patient with alcohol-induced liver cirrhosis who transiently produced green urine following a single dose of propofol at the induction of anesthesia. The exact incidence and mechanism are not known; however, it is thought to be due to the extrahepatic pharmacokinetics associated with propofol metabolism and clearance. Due to its rarity, it can propagate anxiety and lead to unnecessary investigations. Conclusion: Propofol is a very commonly used anesthetic drug. The case highlights that the prompt recognition of this rare adverse effect can prevent unnecessary investigations and provide reassurance to the patient and healthcare providers.

Plasma Nogo-A and placental growth factor levels are associated with portal hypertension in patients with liver cirrhosis.

BACKGROUNDClinically significant portal hypertension (CSPH) and severe portal hypertension (SPH) increase the risk for decompensation and life-threatening complications in liver cirrhosis. Pathologic angiogenesis might contribute to the formation of these conditions. Placental growth factor (PlGF) and Nogo-A protein are biomarkers of pathological angiogenesis, but data on their role in liver cirrhosis and portal hypertension is scarce.AIMTo determine plasma levels of PlGF and Nogo-A in patients with liver cirrhosis, CSPH, SPH and potential to predict portal hypertension.METHODSA cohort of 122 patients with hepatitis C virus and/or alcohol-induced liver cirrhosis with characterized hepatic venous pressure gradient (HVPG) were included in the study. Demographic data, medical history, Child-Turcotte-Pugh and Model of End Stage liver disease score, clinical chemistry, liver stiffness values were recorded on the day of the procedure prior HVPG measurement. The degree of portal hypertension was determined by the invasive HVPG measurement. Nogo-A and PlGF plasma levels were evaluated using enzyme linked immunosorbent assay. The control group consisted of 30 healthy age- and sex- matched individuals.RESULTSPeripheral PlGF levels were higher and Nogo-A levels were lower in patients with liver cirrhosis (23.20 vs 9.85; P < 0.0001 and 2.19 vs 3.12; P = 0.004 respectively). There was a positive linear correlation between peripheral levels of PlGF and HVPG (r = 0.338, P = 0.001) and negative linear correlation between the peripheral Nogo-A levels and HVPG (r = -0.267, P = 0.007). PlGF levels were higher in CSPH and SPH (P = 0.006; P < 0.0001) whereas Nogo-A levels were lower (P = 0.01; P < 0.033). Area under the curve for the diagnosis of CSPH for PlGF was 0.68 (P = 0.003) and for Nogo-A - 0.67 (P = 0.01); for SPH 0.714 (P < 0.0001) and 0.65 (P = 0.014) respectively. PlGF levels were higher and Nogo-A levels were lower in patients with esophageal varices (P < 0.05). PlGF cut-off value of 25 pg/mL distinguished patients with CSPH at 55.7% sensitivity and 76.7% specificity; whereas Nogo-A cut-off value of 1.12 ng/mL was highly specific (93.1%) for the diagnosis of CSPH.CONCLUSIONPlasma PlGF levels were higher while Nogo-A levels were lower in patients with liver cirrhosis and portal hypertension. Biomarkers showed moderate predictive value in determining CSPH and SPH.

Unexpected cyst within ascites

A 59-year-old man, with known alcohol-induced liver cirrhosis and diuretic refractory ascites, was seen in General Internal Medicine clinic for a therapeutic paracen­tesis. The tense large volume ascites caused abdominal pain, which had been previously relieved with paracen­tesis on several occasions. In preparation for paracen­tesis, routine POCUS was performed to landmark for the procedure.