Liver US Research Articles

Use of a controlled attenuation parameter for the diagnosis of non-alcoholic fatty liver disease

To evaluate the efficacy of vibration-controlled transient elastography (VCTE) with a controlled attenuation parameter (CAP) in a population of patients with non-alcoholic fatty liver disease (NAFLD)and to compare to US and different non-invasive indices. Single center NAFLD patients' database of 2021-2023 years was retrospectively analysed. Data of VCTE evaluation with CAP (FibroScan 530® and FibroScan 630 Expert®) as well as liver US examination results and values of HSI, FLI, BAAT and NAFLD-LFS were extracted. AUROCs for all methods used were constructed and sensitivity and specificity analysis was performed. The data of 1081 patients were available for analysis (385 with steatosis, 274 with NASH, 422 without NAFLD as a control). Ultrasound examination in the diagnosis of liver steatosis compared to VCTE with CAP showed sensitivity and specificity of 94.6 and 63.7%, respectively. Diagnosis of liver steatosis using indices and scales showed sensitivity and specificity of HSI: 97.9 and 60.1% (AUROC 0.90), FLI: 92.5 and 85.3% (AUROC 0.93), BAAT: 76.6 and 73.5% (AUROC 0.82), NAFLD-LFS: 56.7 and 81.8% (AUROC 0.85). The sensitivity of the US of the liver was consistent with previous studies, but the specificity was low. The HSI index had the best indicators of sensitivity and specificity in relation to the diagnosis of liver steatosis. Combination of liver US and HSI can be used in screening of liver steatosis, however, for the complete diagnosis better tools which can simultaneously evaluate liver steatosis and fibrosis should be used.

ODP223 Metabolic efficacy of Very Low Carbohydrate Diet in DKD patients

Abstract Introduction Obesity is strongly linked to the development of diabetic kidney disease. Very low carbohydrate diets (VLCBD) were associated with a reduction in weight but there is little evidence of its effects on diabetic kidney disease (DKD) patients. The aim of the randomized controlled trial study is to determine the metabolic effects of VLCBD in addition to low protein diet (LPD) in DKD patients. Materials and Methods 30 patients with type 2 diabetes aged 40-75 years and a HbA1c 7-10.5% were randomly allocated to receive VLCBD (<20g daily intake) versus standard low protein (0.8g/kg/day) diet. The patients received consultations every two weeks for 12 weeks. Metabolic profiles, glycemic control, inflammatory markers and visceral adipose tissue mass effects of the dietary interventions were compared. Result: The VLCBD group demonstrated significant reductions in weight (-4. 0 IQR 3.9 vs 0.2 IQR4.2 kg, p=<0. 001) and BMI (-1.5 IQR 1.18 vs 0. 074 IQR 1.54, p=<0. 001) in comparison to LPD group. There was reduction in waist circumference within both groups (- 4. 0 IQR 5.25, p= 0. 003 and -2. 0 IQR 3.6, p=0. 009) respectively. Estimated visceral adipose tissue mass and volume were significantly reduce in VLCBD group. There was significant reduction in ALT and GGT in both group. However, there is no significant changes in improvement in liver US in both groups. However, both group also showed significant reduction in HbA1c (-1.3 IQR 1.1% vs -0.7 IQR1.25%, respectively, p=NS). There is significant increment in LDL in VLCBD group which not present in LPD group. The VLCBD group showed a significant reduction in IL-6 levels with a contrasting rise within the LPD group (-1.53 IQR3.35 vs 0.46 IQR 1.95, p= 0. 028). Patients in VLCBD appeared to have improvement in physical activity score in comparison to LPD group. Conclusion After short term intensive VLCBD intervention in DKD patients, improvement were observed in metabolic markers, diabetes status and inflammatory markers with improvement of physical activity score. Presentation: No date and time listed

S3373 Atypical GBS as the Presenting Symptom of Celiac Disease: Recognizing Extra-intestinal Presentations of Celiac Disease

Introduction: Celiac disease (CD) is an immune-mediated enteropathy in response to gluten that occurs in 1% of the population. Classic presenting symptoms include bloating, weight loss, and diarrhea. But, extraintestinal symptoms such as dermatitis herpetiformis, iron deficiency anemia, asymptomatic liver abnormalities, and more rarely, neurologic symptoms can be seen. We present a case of a patient who presented with worsening polyneuropathy and hepatitis leading to a final diagnosis of CD. Case Description/Methods: A 44-year-old male with history of recent left-chest shingles complicated by paralysis of right face and left leg weakness was initially admitted for suspected atypical Guillain Barre Syndrome (GBS) and treated with prednisone and a 5-day course of intravenous immunoglobulin (IVIG). The patient was readmitted a few weeks later with worsening neurologic status. A thorough infectious workup was unremarkable. The patient was also noted to have abnormal liver enzymes on prior admission that initially improved, but were noted to be worse on readmission up to ALP 1103, AST 634 and ALT 689. Given no prior history of liver disease, patient underwent a thorough workup including negative viral hepatitis, normal liver US, abdominopelvic CT showed scattered hypoattenuating lesions in the liver, one measuring up to 2.2 cm. He underwent a liver biopsy which demonstrated acute hepatitis with findings concerning for autoimmune versus drug-induced hepatitis. Autoimmune hepatitis panel was negative, however, he was found to have a tissue transglutaminase IgA >250 U/mL. Finally, he underwent upper endoscopy with biopsies that demonstrated findings consistent with celiac disease. Liver enzymes improved with gluten avoidance, but neurologic impairments persisted. Discussion: Atypical extra-intestinal symptoms at presentation of CD can result in diagnostic delay and permanent neurological disability if not treated. CD has been found in as many as 9% of patients with elevated liver enzymes. It is imperative not only to recognize neurologic presentations of CD but also the spectrum of possible liver impairments. Adherence to a strict gluten-free diet has been shown to improve symptoms of both neuropathy and liver enzyme abnormalities, but must be instituted quickly.

S3201 Zieve's Syndrome: A Case of Hemolytic Anemia in the Setting of Alcoholic Liver Disease

Introduction: Zieve’s syndrome is a rare condition which typically manifests with hemolytic anemia, hyperlipidemia, jaundice in the setting of alcohol-induced liver injury. This is distinct from alcoholic hepatitis which may present simultaneously or develop later. Case Description/Methods: 42-year-old man with a history of alcohol abuse and compensated cirrhosis presented to the emergency department for evaluation of 7 days of fatigue and jaundice in the setting of heavy alcohol use. He was noted to have a normocytic anemia with hemoglobin of 5.6 g/dl, INR of 3.0, total bilirubin of 26.2 mg/dl, AST of 65, and ALT of 23 IU/L. Lipid profile was normal. US liver and Doppler US revealed heterogenous liver with biphasic flow through majority of the veins consistent with portal hypertension. Patient denied recent use of new medications or herbal supplements. Prophylactic antibiotics for suspected gastrointestinal bleeding were started. He underwent EGD which revealed trace esophageal varices and portal hypertensive gastropathy without active bleeding. A peripheral blood smear showed spur cells, but no spherocytes or schistocytes consistent with Zieve's syndrome. Direct and indirect Coombs tests were negative, low haptoglobin levels, and elevated serum LDH. Blood cultures were all negative. In view of evidence of hemolysis and lack of infectious source a diagnosis of Zieve’s syndrome was made and patient treated with supportive care and blood transfusions as needed. Unfortunately, the patient was placed in comfort measures after developing refractory grade IV hepatic encephalopathy and hepato-renal syndrome despite supportive measures. Discussion: Hyperlipidemia in Zieve’s syndrome results from cholestasis and hemolysis induced by alcohol liver injury, but was not present in our case. It is postulated that vitamin E deficiency secondary to alcohol use can result in pyruvate kinase instability which affects RBC metabolism resulting in hemolytic anemia. It is important to recognize that Zieve’s can mimic or present concurrently with alcoholic hepatitis as both conditions present with anemia, jaundice, and alcohol use. An important distinction is the presence of hemolytic anemia in the former. Management is supportive as well as abstinence from alcohol.

Comparison of Quantitative Liver US and MRI in Patients with Liver Disease.

Background Quantitative US techniques can be used to identify changes of liver disease, but data regarding their diagnostic performance and relationship to MRI measures are sparse. Purpose To define associations between quantitative US and MRI measures of the liver in children, adolescents, and young adults with liver disease and to define the predictive ability of quantitative US measures to detect abnormal liver stiffening and steatosis defined with MRI. Materials and Methods In this prospective study, consecutive patients aged 8-21 years and known to have or suspected of having liver disease and body mass index less than 35 kg/m2 underwent 1.5-T MRI and quantitative liver US during the same visit at a pediatric academic medical center between April 2018 and December 2020. Acquired US parameters included shear-wave speed (SWS) and attenuation coefficient, among others. US parameters were compared with liver MR elastography and liver MRI proton density fat fraction (PDFF). Pearson correlation, multiple logistic regression, and receiver operating characteristic curve analyses were performed to assess associations and determine the performance of US relative to that of MRI. Results A total of 44 study participants (mean age, 16 years ± 4 [SD]; age range, 8-21 years; 23 male participants) were evaluated. There was a positive correlation between US SWS and MR elastography stiffness (r = 0.73, P < .001). US attenuation was positively correlated with MRI PDFF (r = 0.45, P = .001). For the prediction of abnormal (>2.8 kPa) liver shear stiffness, SWS (1.56 m/sec [7.3 kPa] cutoff) had an area under the receiver operating characteristic curve (AUC) of 0.95 with 91% sensitivity (95% CI: 71, 99) (20 of 22 participants) and 95% specificity (95% CI: 76, 99) (20 of 21 participants). For the prediction of abnormal (>5%) liver PDFF, US attenuation (0.55 dB/cm/MHz cutoff) had an AUC of 0.75 with a sensitivity of 73% (95% CI: 39, 94) (eight of 11 participants) and a specificity of 73% (95% CI: 55, 86) (24 of 33 participants). Conclusion In children, adolescents, and young adults with known or suspected liver disease, there was moderate to high correlation between US shear-wave speed (SWS) and MR elastography-derived stiffness. US SWS predicted an abnormal liver shear stiffness with high performance. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Khanna and Alazraki in this issue.

An Upgraded Siamese Neural Network for Motion Tracking in Ultrasound Image Sequences.

Deep learning is heavily being borrowed to solve problems in medical imaging applications, and Siamese neural networks are the front runners of motion tracking. In this article, we propose to upgrade one such Siamese architecture-based neural network for robust and accurate landmark tracking in ultrasound images to improve the quality of image-guided radiation therapy. Although several researchers have improved the Siamese architecture-based networks with sophisticated detection modules and by incorporating transfer learning, the inherent assumptions of the constant position model and the missing motion model remain unaddressed limitations. In our proposed model, we overcome these limitations by introducing two modules into the original architecture. We employ a reference template update to resolve the constant position model and a linear Kalman filter (LKF) to address the missing motion model. Moreover, we demonstrate that the proposed architecture provides promising results without transfer learning. The proposed model was submitted to an open challenge organized by MICCAI and was evaluated exhaustively on the Liver US Tracking (CLUST) 2D dataset. Experimental results proved that the proposed model tracked the landmarks with promising accuracy. Furthermore, we also induced synthetic occlusions to perform a qualitative analysis of the proposed approach. The evaluations were performed on the training set of the CLUST 2D dataset. The proposed method outperformed the original Siamese architecture by a significant margin.

237 Massive Subcapsular Intra-hepatic Haematoma Post-laparoscopic Cholecystectomy: A Rare Complication of a Common Procedure

Abstract Abstract Laparoscopic cholecystectomy (LC) is currently considered the gold standard for the management of symptomatic gallbladder stones disease. Specific complications remain challenging, particularly postoperative bleeding, bile leak, and bile duct injury. We report a rare case of a giant intrahepatic subcapsular haematoma (ISH) complicating LC. Case Presentation A 59-year-old female presented with symptomatic biliary colic. Her past medical history was noted for obesity (BMI &amp;gt; 50). She underwent an elective LC with an uncomplicated intraoperative course; however, post-operatively she developed hypovolaemic shock with an acute haemoglobin drop requiring fluid resuscitation and blood transfusion. Emergency CT revealed a massive subcapsular haematoma measuring 21cm×3.1cm× 17cm at the right liver margin without evidence of ongoing bleeding. She was managed conservatively- as per a tertiary hepatobiliary surgery centre’s advice- with meticulous clinical observations, serial monitoring of haemoglobin, and repeat CT to assess for interval progressions. She progressed well with conservative management and did not require surgical or radiological intervention. A follow-up liver US performed eight weeks post-discharge confirmed a complete resolution. Conclusions Giant ISH is an exceedingly rare but life-threatening complication following LC which merits special attention. Our case demonstrates the necessity of close postoperative monitoring of patients undergoing LC and considering the possibility of ISH in those who experience a refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post LC-ISH

S2860 Hepatic Sarcoidosis Diagnosis After COVID-19 Infection

Introduction: Sarcoidosis is a systemic granulomatous disease which may involve the liver in ∼11.5% of cases. Coronavirus disease 2019 (COVID-19) can induce a systemic, pro-inflammatory state but the development of systemic sarcoidosis after COVID-19 has not been described. We present the case of a newly diagnosed systemic sarcoidosis after COVID-19 infection. Case Description/Methods: A 50 year old male patient was evaluated for increased liver enzymes. He had a history of familial hypercholesterolemia, fatty liver disease, and diabetes mellitus. Seven months prior he was admitted to the hospital with shortness of breath, cough, lightheadedness, nausea and was diagnosed with COVID-19. After recovery, he developed pleurisy. CT scan showed mediastinal lymphadenopathy and scattered nodules. PET scan showed uptake concerning for reactive nodes, chronic granulomatous disease or lymphoproliferative disease. Subsequent lymph node aspirate found noncaseating granulomas consistent with sarcoidosis. He was referred to hepatology for abnormal liver enzymes (ALT 104, AST 81, Alkaline Phosphatase 216, Total Bilirubin 1.1). Tests for viral/autoimmune hepatitis, AMA, ANA, hemochromatosis, A1AT and ceruloplasmin were negative. Liver US showed steatosis and no evidence of obstruction. Transient elastography by FibroScan confirmed steatosis, CAP score of 347 and stiffness of 28kPa consistent with cirrhosis or infiltrating disease. Liver biopsy (Figure 1) revealed marked granulomatous inflammation with 10-20% macro/micro-steatosis and stage 2-3 portal fibrosis. AFB stains were negative. Given the marked inflammation and fibrosis, the patient was started on prednisone 40mg daily with 4 week labs showing liver enzyme improvement (ALT 80, AST 31, Alk Phos 149, T Bili 0.6). Prednisone resulted in hyperglycemia requiring insulin, so azathioprine was started as steroid sparing treatment with budesonide added which he tolerated well. Discussion: Multisystem inflammatory syndrome in adults (MIS-A) is a rare complication of COVID-19. This case represents a unique type of MIS-A with hepatic sarcoidosis. The liver may be affected during COVID-19 with liver enzymes elevation reported in 20–30% of those with acute infection. After recovery, persistent elevation in hepatic transaminases and alkaline phosphatase should alert the clinicians to investigate for MIS-A triggered diseases such as sarcoidosis.Figure 1.: Liver biopsy showing granulomatous inflammation (200x).

10K: a large-scale prospective longitudinal study in Israel.

The 10K is a large-scale prospective longitudinal cohort and biobank that was established in Israel. The primary aims of the study include development of prediction models for disease onset and progression and identification of novel molecular markers with a diagnostic, prognostic and therapeutic value. The recruitment was initiated in 2018 and is expected to complete in 2021. Between 28/01/2019 and 13/12/2020, 4,629 from the expected 10,000 participants were recruited (46 %). Follow-up visits are scheduled every year for a total of 25 years. The cohort includes individuals between the ages of 40 and 70 years. Predefined medical conditions were determined as exclusions. Information collected at baseline includes medical history, lifestyle and nutritional habits, vital signs, anthropometrics, blood tests results, Electrocardiography, Ankle-brachial pressure index (ABI), liver US and Dual-energy X-ray absorptiometry (DXA) tests. Molecular profiling includes transcriptome, proteome, gut and oral microbiome, metabolome and immune system profiling. Continuous measurements include glucose levels using a continuous glucose monitoring device for 2 weeks and sleep monitoring by a home sleep apnea test device for 3 nights. Blood and stool samples are collected and stored at - 80°C in a storage facility for future research. Linkage is being established with national disease registries.

S2722 Abernethy Malformation Causing Recurrent Hepatic Encephalopathy

INTRODUCTION: Hepatic encephalopathy (HE) is a spectrum of neuropsychiatric abnormalities in patients with underlying liver dysfunction such as acute liver failure (type A) or cirrhosis (type C). Less commonly, it involves patients with acquired or congenital portosystemic shunt (PSS) in the absence of hepatocellular disease (type B). CASE DESCRIPTION/METHODS: A 70-year-old female with a past medical history of chronic pain, CHF, lymphedema and prior recurrent encephalopathy, presented with altered mental status and seizure-like activity. Vital signs were stable and laboratory studies including CBC, BMP and LFTs were normal except for an ammonia level of 272 umol/L. She denied any prior history of liver disease and was previously informed that the hyperammonemia was secondary to her use of narcotics for chronic pain. CT chest and abdomen was obtained which revealed normal appearing liver, prominent azygos vein and side-to-side porto-azygos shunt (Figures 1 and 2). A liver US indicated normal echotexture with patent vasculature. Liver biopsy showed normal portal triads with mild steatosis and minimal sinusoidal dilatation. She was treated with lactulose until resolution of HE and was eventually discharged. Given the absence of liver disease, the PSS likely represent a congenital malformation that has been perpetuating the HE. DISCUSSION: In the presence of a PSS, underlying liver disease should be excluded to ensure the etiology of the shunt is not a result of portal hypertension. Congenital PSS were first described in 1793 by J. Abernethy and are classified as type 1 which involves an end-to-side porto-caval shunt with absence of the portal vein (PV), and type 2 which consists in a side-to-side shunt with an intact PV. Congenital PSS may also be associated with other abnormalities including biliary atresia, polysplenia, in addition to cardiac, skeletal and renal malformations. HE, which occurs as a complication of the shunt bypassing the hepatic conversion of ammonia to urea, is the most common neurologic complication. In addition, acquired cardiopulmonary complications are also common due to volume overload. Patients with symptomatic congenital PSS should be considered for PSS closure, whether endovascular or surgical. In patients with type 2 shunt, obliteration of the PSS can reverse HE from hyperammonemia and potentially resolve heart failure and hepatopulmonary syndrome but rarely causes regression of pulmonary hypertension. Acute portal hypertension as well as thrombosis have been reported after closure.Figure 1.: Prominent Azygos vein on coronal view.Figure 2.: Side to side portal to azygos vein shunt.

Pyramid graph cut: Integrating intensity and gradient information for grayscale medical image segmentation

Segmentation of grayscale medical images is challenging because of the similarity of pixel intensities and poor gradient strength between adjacent regions. The existing image segmentation approaches based on either intensity or gradient information alone often fail to produce accurate segmentation results. Previous approaches in the literature have approached the problem by embedded or sequential integration of different information types to improve the performance of the image segmentation on specific tasks. However, an effective combination or integration of such information is difficult to implement and not sufficiently generic for closely related tasks. Integration of the two information sources in a single graph structure is a potentially more effective way to solve the problem. In this paper we introduce a novel technique for grayscale medical image segmentation called pyramid graph cut, which combines intensity and gradient sources of information in a pyramid-shaped graph structure using a single source node and multiple sink nodes. The source node, which is the top of the pyramid graph, embeds intensity information into its linked edges. The sink nodes, which are the base of the pyramid graph, embed gradient information into their linked edges. The min-cut uses intensity information and gradient information, depending on which one is more useful or has a higher influence in each cutting location of each iteration. The experimental results demonstrate the effectiveness of the proposed method over intensity-based segmentation alone (i.e. Gaussian mixture model) and gradient-based segmentation alone (i.e. distance regularized level set evolution) on grayscale medical image datasets, including the public 3DIRCADb-01 dataset. The proposed method archives excellent segmentation results on the sample CT of abdominal aortic aneurysm, MRI of liver tumor and US of liver tumor, with dice scores of 90.49±5.23%, 88.86±11.77%, 90.68±2.45%, respectively.

High Prevalence and Gender-Related Differences of Gastrointestinal Manifestations in a Cohort of DM1 Patients: A Perspective, Cross-Sectional Study

Myotonic dystrophy type 1 (DM1, MIM #160900), the most common muscular dystrophy among adults, is a multisystem disorder, which affects, besides the skeletal muscle, several other tissues and/or organs, including the gastrointestinal apparatus, with manifestations that frequently affect the quality of life of DM1 patients. So far, only few, mainly retrospective studies evaluated this specific topic in DM1, so we performed a perspective study, enrolling 61 DM1 patients who underwent an extensive diagnostic protocol, including administration of the Gastrointestinal Symptom Rating Scale (GSRS), a validated patient-reported questionnaire about GI symptoms, laboratory tests, liver US scan, and an intestinal permeability assay, in order to characterize frequency and assess correlations regarding specific gastrointestinal manifestations with demographic or other DM1-related features. Our results in our DM1 cohort confirm the high frequency of various gastrointestinal manifestations, with the most frequent being constipation (45.9%). γGT levels were pathologically increased in 65% of DM1 patients and GPT in 29.82%; liver ultrasound studies showed steatosis in 34.4% of patients. Significantly, 91.22% of DM1 patients showed signs of altered intestinal permeability at the specific assay. We documented a gender-related prevalence and severity of gastrointestinal manifestations in DM1 females compared to DM1 males, while males showed higher serum GPT and γGT levels than females. Correlation studies documented a direct correlation between severity of muscle weakness estimated by MIRS score and γGT and alkaline phosphatase levels, suggesting their potential use as biomarkers of muscle disease severity in DM1.

P1705ARE DIRECT-ACTING ANTI-VIRAL DRUGS ACCUSED OF INCREASED INCIDENCE OF HEPATOCELLULAR CARCINOMA IN ENDEMIC AREA: A PILOT STUDY

Abstract Background and Aims Great progression in treating hepatitis C infection has been made with the new Interferon-free regimens. Reports about developing hepatocellular carcinoma after DAAs have been spotlighted. Kidney transplantation and hemodialysis are considered risk factors for developing malignancies. Here we are evaluating the prevalence of HCC after DAAs treatment in high risk population. Method This cross-sectional study was held in Urology and Nephrology Center, Mansoura University, Egypt including. Total number of 165 patients received DAAs included in this study in 2 phases. The first phase included 50 patients (12 hemodialysis and 38 kidney transplant recipients). All patients completed DAAs course as treatment for hepatitis C infection (HCV) 24 months ago. Alfa feto protein and liver ultrasound (Use of both modalities combined yielded sensitivity (99.2%) and specificity (68.3%)) was used to screening of HCC for all patients. Triphasic CT liver with 86% to 94% sensitivity was done for all hemodialysis patients and KTRs with suspicious lesions or high alfa-feto protein. Results Our patients mean age was 52.32±3.2 years with male predominance. Mean Hemodialysis duration was 48.21±12.3 months and mean kidney transplantation duration was 36.21±6.7 months. Baseline laboratory investigations: ALT: 39.17±16.3 iu/l, Albumin: 3.6±1.32 g/dl, Bilirubin: 0.54±0.21, Hemoglobin: 10.57±1.9 g/dl, AFP: 5.3±2.4 ng/ml. Baseline liver US: normal (49%), enlarged (42%) and cirrhotic (9%) (No focal lesions). Fibro scan: F0 (26%), F1 (31%), F2 (32%) and F3 (11%). None of them experienced hepatic encephalopathy attacks or bleeding varices. All hemodialysis patients received Ombitasvir/Paritaprevir/Ritonavir (OMV/PTV/RTV) regimen (3 months). Only 2 KTRs received OMV/PTV/RTV regimen (3 months), the remaining 36 KTRs received Sofosbuvir/Daclatasvir regimen (6 months). Only 1 case reported relapse within 3 month after completing treatment. The rest achieved 12-week and 24-week SVR successfully. After 2 years from completing treatment, there was significant improvement in ALT levels. Four KTRs passed to graft failure due to accelerated immunologic response (rejection episodes) and 7 KTRs showed rise of serum creatinine (biopsy-proven rejection). Mean AFP rose up to 7.6±2.4 ng/ml with no statistical difference. Three hemodialysis patients and 4 KTRs showed rise in alfa-feto protein above normal values (10ng/dl). Four out of them exceeded 500ng/ml (1 HD and 3 KTRs). Abdominal US revealed: no change (39 patients), enlargement (6 patients) and cirrhosis (5 patients). Suspicious mass was found in 11 patients. Triphasic CT then was done for all hemodialysis patients and 9 KTRs. Regarding hemodialysis, 1 patient was diagnosed as HCC based on increased enhancement by Triphasic CT and alfa-fetoprotein was &amp;gt;500 ng/ml. Regarding KTRs, HCC was diagnosed in 2 patients and liver metastasis secondary to lymphoma was diagnosed in 1 case. The other patients with suspicious lesions (5 patients) showed uniform enhancement by Triphasic CT suggesting benign lesions. So, we have 3 (6%) out of 50 patients has been diagnosed as HCC after DAAs. By retrieval of their data, HCV duration was over 10 years and the liver was cirrhotic or enlarged with cirrhotic changes by ultrasound. Baseline ALT was slightly high without significant improvement after treatment. Also, baseline alfa-feto protein was high. The 3 patients were F2 or F3. Conclusion Hepatocellular carcinoma incidence after Direct-acting anti-virals is related mostly to the poor condition of the patients at baseline not to the drug itself and HCC in such cases could be considered as a part of disease progression not a drug complication.

Contrast-enhanced EUS for evaluation of thickened omentum.

A 68-year-old man presented with upper abdominal pain. He had undergone a Whipple procedure 32 months earlier for pancreatic adenocarcinoma. Clinical examination, liver function tests, serum CA19-9, and US of the abdomen showed normal results. Contrast-enhanced CT revealed thickened omentum. On EUS, thickened omentum was visualized as a sheetlike hypoechoic structure adjacent to the gastric wall (A). Contrast-enhanced harmonic EUS (CH-EUS) by the use of Sonovue (Bracco, Milan, Italy) was done at a low mechanical index of 0.12.

2302 A Case of Hepatitis B Reactivation Resulting in Fulminant Hepatic Failure

INTRODUCTION: Patients with chronic HBV/HIV coinfection are at high risk of HBV chronicity and reactivation. Here we present a case of a patient who presented with acute liver failure secondary to hep B reactivation after adjustment of his HIV medication regimen. CASE DESCRIPTION/METHODS: A 56 year old male with HIV/HBV coinfection with undetectable viral loads was evaluated in the ED for new onset nausea and jaundice. Examination was significant for jaundice in the absence of any encephalopathy or other stigmata of chronic liver disease. Blood tests revealed INR 3, ALK-P 210, ALT 2186, AST 2934 and Bili T/D 25.6/17, platelet count 197K, Cr 1.98, and CD4 count 394. Liver US showed normal hepatic echotexture with patent vasculature. Serologic evaluation showed undetectable HIV viral load, negative Hep C PCR, positive HepBsAg, and highly positive hepatitis B DNA (&gt;1 billion copies). About 5 months prior to this acute presentation, he was switched from (Cobicistat, Elvitegravir, Emtricitabine, and Tenofovir) to another regimen that doesn’t include hepatitis B coverage (Atazanavir, Cobicistat , Rilpivirine, and Abacavir) due to concerns about Tenofovir contributing to his unexplained CKD. He was started on dual therapy with tenofovir and entecavir and was transferred to a nearby liver transplant center. His passed away after a short complicated hospital stay with acute liver failure and colonic pneumatosis. DISCUSSION: Our patient presented with acute fulminant liver failure after a brief period of inadvertent Hep B treatment interruption. Medical treatment was not helpful despite attempts at combination therapy with Tenfovovir and Entecavir (in contrast to Tenofovir monotherapy) despite the scarcity of data in this specific situation. There are case reports that demonstrated clinical improvement especially early treatment in the course; however progression to hepatic failure, liver transplantation, and death has also been widely reported despite therapy. This case serves as a reminder to all medical providers about the complexity of concomitant chronic HBV and HIV coinfection. Any medication regimen change in this patient population needs a multidisciplinary team based approach between HIV specialists and Hepatologists.

995 Lost to Follow-Up: Patients Diagnosed With Hepatitis C Virus During Pregnancy May Not Seek Postpartum Treatment

INTRODUCTION: Patients diagnosed with hepatitis C virus (HCV) during pregnancy represent a unique treatment challenge; direct acting antiviral agents are not currently approved for use during pregnancy. Treatment is delayed until postpartum that may lead to ‘leakage’ of patients ultimately resulting in persistent, untreated infection. We sought to determine the rate of persistent infection in patients diagnosed with HCV during pregnancy in obstetrics (OB) clinics across our health system and determine reasons for non-treatment following pregnancy. METHODS: We queried our health system’s EHR to identify patients with positive HCV antibody and/or RNA who were initially tested during prenatal testing in OB clinics between 2011–2018. We obtained demographic data, liver imaging and fibrosis scores, and determined level of postpartum engagement in health care for HCV treatment. RESULTS: A total of 110 patients were identified who were diagnosed in OB clinic during pregnancy and remained untreated. Ninety-two (84%) patients had follow-up in the first 6 months with any care provider but only 28 (25%) patients presented for follow up in GI clinic. The average time for presentation to GI clinic was 14 weeks after initial diagnosis. Of the patients assessed in GI clinic, 3 patients (11%) were prescribed therapy but did not have evidence of initiating therapy or achieving SVR. There were 12 patients (43%) who were assessed for therapy and required more testing and subsequently lost to follow up. Patients were not offered treatment in 21% (6/28) of cases due to lack of evidence for advanced fibrosis/cirrhosis at time of diagnosis. 25% of patients were evaluated in GI clinic prior to delivery (7/28) but did not present for follow up in the post postpartum period. For the entire cohort, there was no evidence of HIV or HBV co-infection. Only two patients had evidence of steatosis of liver US and no patients had evidence of advanced fibrosis (Fibrosure 0-1; low FIB-4 score). CONCLUSION: Patients diagnosed with HCV during pregnancy are at risk for ‘leakage’ from care in the postpartum period. Our study found a minority of patients presented for follow up in GI clinic for treatment and the vast majority of those patients did not receive treatment. Developing linkage to care programs to retrospectively reengage untreated patients and develop prospective protocols for close monitoring and outreach for future cases may help decrease this gap in care.

3028 Glycogenic Hepatopathy Masquerading as Acute Relapsing Hepatitis: A Diagnostic Pitfall

INTRODUCTION: Glycogenic hepatopathy (GH) is a rare conditioned characterized by elevated liver enzymes, hepatomegaly with or without right upper quadrant pain, typically seen in poorly controlled diabetes type 1, rarely in type II. It is related to glycogen accumulation during periods of high blood glucose, and tends to resolve with improvement of glycemic control. The course of liver enzyme abnormalities is transient. We present a case of glycogenic hepatopathy masquerading as biliary stones. CASE DESCRIPTION/METHODS: A 54 year old female with no known liver, history of HTN, CVA and poorly controlled type 2 diabetes mellitus (T2DM), complicated by multiple episodes of DKA and hyperosmolar hyperglycemic state, presented to the hospital with abdominal pain, nausea, constipation and high liver enzyme abnormalities. This was preceded by an admission 2 months prior with hyperglycemia above 600, ketones, and similar liver enzyme abnormalities. Work up was initiated including liver US, CT scan, MRCP, viral and autoimmune serologies which were normal or negative (Graph 1). Liver biopsy in progress. DISCUSSION: The patient in this case report has risk factors for metabolic syndrome with HTN, BMI of 26, T2DM with poor control, with episodes of hyperglycemia, associated with peaks of liver enzymes that mimic hepatocellular or mixed injury, which resolved slowly with control of hyperglycemia, being completely normal between spikes. This pattern of presentation is typical for GH, a metabolic entity that was linked to poorly controlled diabetes, and is caused by transient accumulation of glycogen within hepatocytes that follows passive influx of glucose into hepatocytes utilizing hepatic glucose transporter-2. Long-term prognosis is unclear and may in recurrent cases progress to fibrosis and cirrhosis, similar to NAFLD. Clinical suspicion for GH is based on correlation between peaks of blood sugar and acute rise in LFTs as well as periods of normalization of LFTs corresponding to resolution of acute hyperglycemia. Recognition of this entity is highly significant, as not only direct the effort to correct the underlying metabolic abnormalities, it also avoids unnecessary and costly work up knowing its transient and self-limited course. Liver biopsy if confirmatory. Glycogenic hepatopathy is an underdiagnosed metabolic hepatopathy in the setting poorly controlled diabetes, completely reversible, and should be considered in patients with T1 or T2DM with risk factors for NAFLD who present with acute and relapsing hepatitis.

Liver stiffness obtained by ElastPQ ultrasound shear wave elastography independently determines mean right atrial pressure.

We aimed to investigate the relationship between right atrial pressure (RAP) and liver stiffness (LS) determined by liver elastography (LE) during cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and conventional pacemaker (PM) implantation in patients without HF. 60 patients with HF who underwent CRT and 60 patients without HF who underwent PM were enrolled. Routine echocardiography and laboratory examinations were performed. Systolic, diastolic, and mean RAP measurements were performed inversely during PM implantation and LS measurement with ElastPQ technique. Systolic, diastolic, and mean RAP, left ventricular (LV) systolic-diastolic, right ventricular (RV) diastolic and left atrial diameters, tricuspid regurgitation pressure gradient, and RV-myocardial performance index (MPI) values were significantly higher in patients with HF (p < 0.05 each-one). LV ejection fraction and tricuspid annular plane systolic excursion values were significantly lower in patients with HF group (p < 0.05 each-one). LS values and inspiratory (Ins) and expiratory inferior vena cava (IVC) diameters were significantly higher in the patients with HF (p < 0.05 each-one). Mean RAP was found to be closely related to LS value, Ins-IVC diameter, RV-MPI, and NT-proBNP levels. LS value and Ins-IVC diameter were found to determine patients with mean RAP > 5mmHg and > 10mmHg. When the cut-off value of LS was taken as 7kPa, it was found that the mean RAP > 10mmHg with 89.6% sensitivity and 87.5% specificity. The non-invasive LS value determined by LE independently determines the mean RAP in patients with and without HF. According to our study results, > 7kPa value for LS determined in liver US may be predictive for increased mean RAP.

A study on the Development of a Korean Metabolic Syndrome Questionnaire

Segmentation of grayscale medical images is challenging because of the similarity of pixel intensities and poor gradient strength between adjacent regions. The existing image segmentation approaches based on either intensity or gradient information alone often fail to produce accurate segmentation results. Previous approaches in the literature have approached the problem by embedded or sequential integration of different information types to improve the performance of the image segmentation on specific tasks. However, an effective combination or integration of such information is difficult to implement and not sufficiently generic for closely related tasks. Integration of the two information sources in a single graph structure is a potentially more effective way to solve the problem. In this paper we introduce a novel technique for grayscale medical image segmentation called pyramid graph cut, which combines intensity and gradient sources of information in a pyramid-shaped graph structure using a single source node and multiple sink nodes. The source node, which is the top of the pyramid graph, embeds intensity information into its linked edges. The sink nodes, which are the base of the pyramid graph, embed gradient information into their linked edges. The min-cut uses intensity information and gradient information, depending on which one is more useful or has a higher influence in each cutting location of each iteration. The experimental results demonstrate the effectiveness of the proposed method over intensity-based segmentation alone (i.e. Gaussian mixture model) and gradient-based segmentation alone (i.e. distance regularized level set evolution) on grayscale medical image datasets, including the public 3DIRCADb-01 dataset. The proposed method archives excellent segmentation results on the sample CT of abdominal aortic aneurysm, MRI of liver tumor and US of liver tumor, with dice scores of 90.49±5.23%, 88.86±11.77%, 90.68±2.45%, respectively.

SUN-282 Sertraline-Induced Dyslipidemia and Liver Toxicity in a 17-Year-Old Adolescent

Background: SSRI’s are very common first line drugs used for treatment of anxiety and depression in adults and children. Different drugs in this group have been reported in adults to be associated with increased weight, cholesterol, triglyceride (TG), insulin level and fasting blood glucose. Sertraline-induced liver toxicity has been described clinically and in vitro. Some studies found Fluoxetine to be the safest SSRI in terms of metabolic syndrome with reduction of weight, cholesterol, TG, fasting blood glucose and hemoglobin A1c. SSRI’s side effects have not been examined thoroughly in the pediatric population. Clinical case: 17 year old Caucasian autistic male teen was referred for initial endocrine evaluation with concern about fatty liver, increased liver enzymes, and increased triglyceride. He was started on Sertraline about 6 months prior to presentation for behavioral issues. He was previously on Aripiprazole and Fluoxetine for few years. Lipid panel showed total cholesterol of 186 mg/dl, TG 245 mg/dl, LDL cholesterol 106 mg/dl, and HDL cholesterol 31 mg/dl. Aspartate Aminotransferase (AST) was 50 U/L and Alanine Aminotransferase (ALT) was 111 U/L. Liver US showed fatty infiltration. Detailed work up for liver disease was negative. He had normal hemoglobin A1c of 5.1%, fasting insulin level of 4 mcIU/ml and TSH of 2.4 mcIU/ml. No major weight change was reported. BMI on presentation was normal at 24.42 kg/m² (78%ile based on CDC 2-20 Years BMI-for-age data). Sertraline-related side effects were suspected giving previous normal lipid panel and liver enzymes prior to starting this medication, and recommendation was made to stop it. He was switched back to Fluoxetine. Labs studies improved quickly within few weeks. Studies after 6 month showed total cholesterol of 141 mg/dl, TG 100 mg/dl, LDL cholesterol 87 mg/dl, HDL cholesterol 34 mg/dl, Aspartate Aminotransferase (AST) 19 U/L and Alanine Aminotransferase (ALT) 21 U/L. Conclusion: SSRIs are increasingly prescribed in the pediatric population, and studies are needed to understand their possible metabolic side effects. This is important giving the increased prevalence of obesity and metabolic syndrome in children and adolescents. Clinicians treating with Sertraline should be aware of its possible metabolic side effects and hepatic toxicity. Laboratory studies should be conducted periodically while taking this medication.