Non-cirrhotic Patient Research Articles

Protocolo diagnóstico y terapéutico de la trombosis portal

Portal vein thrombosis (PVT) is occlusion of the vein by thrombotic material with or without extension to other segments of the splanchnic venous system (splenic and mesenteric vein). Portal vein occlusion due to a thrombus occurs most frequently in patients with cirrhosis. It is most often diagnosed as an incidental finding on routine imaging tests. However, non-cirrhotic DVT, despite being a rare disease with a prevalence between 0.7–3.7 per 100,000 individuals, is the second most frequent cause of portal hypertension. The clinical manifestations depend on the duration (acute or chronic) of the event. PVT is diagnosed via Doppler ultrasound and the extent and presence of associated factors is confirmed via contrast-enhanced CT/MRI. It is essential for the therapeutic approach to differentiate whether there is an underlying cirrhosis or if it has occurred in a non-cirrhotic patient. In both cases, anticoagulation is the indicated treatment. However, the duration of anticoagulation depends on other factors, including the extent, temporality, and the existence or not of associated untreatable prothrombotic disease. In addition, alternative treatments are available in the case of anticoagulation failure, including transjugular intrahepatic postosystemic shunting.

Transjugular intrahepatic portosystemic shunt-induced hemolysis in a non-cirrhotic patient: a case report

BackgroundIn the 1990s, transjugular intrahepatic portosystemic shunts (TIPS) were performed using bare metal stents, and stent-induced hemolysis was a complication noted in 10% of patients. This was due to the mechanical stress created by turbulent flow from the uncovered interstices. Polytetrafluoroethylene (PTFE) stents came into regular use in the early 2000s becoming the standard equipment for TIPS placements, which are predominately covered. Due to this, stent-induced hemolysis has become a rare phenomenon.Case presentationWe describe a case of TIPS-induced hemolysis in a 53-years-old Caucasian female patient without cirrhosis. The patient had a history of heterozygous factor 5 Leiden mutation and abnormal lupus anticoagulant profile with development of a portal vein thrombus. She had undergone previous TIPS placement complicated by a TIPS thrombosis 3 years after initial placement requiring venoplasty and extension of the stent. Within one month, the patient developed hemolytic anemia with extensive evaluation that did not yield an alternative cause. Due to temporal association and clinical symptoms, the hemolytic anemia was attributed to the recent TIPS revision.ConclusionThis particular case of TIPS-induced hemolysis in a patient who does not have cirrhosis has not been previously described in the literature. Our case highlights that TIPS-induced hemolysis should be considered in anyone who could have potential underlying red blood cell dysfunction, not just those with cirrhosis. Further, the case demonstrates an important point that mild hemolysis (i.e., not requiring blood transfusion) can likely be managed conservatively, without stent removal.

Portal Vein Recanalization–Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) with superior mesenteric vein access and balloon-assisted shunt placement

BackgroundTo report the technique and outcome of ultrasound-guided percutaneous access to the superior mesenteric vein (SMV) for balloon-assisted portal vein recanalization–transjugular intrahepatic portosystemic shunt (PVR-TIPS) in a patient with chronic portal venous and splenic vein occlusion.Case presentationA 51-year-old, non-cirrhotic patient with severe portal hypertension was admitted for PVR-TIPS. Neither splenic nor hepatic access was feasible due to chronic portal and splenic vein occlusion. Percutaneous ultrasound-guided direct puncture of the SMV was performed to obtain access for balloon-assisted PVR-TIPS. The transmesenteric approach in combination with a balloon puncture technique for PVR-TIPS was successful, and no immediate complications were observed post-procedure. The subsequent follow-up exams showed patent TIPS and SMV without signs of intraabdominal hemorrhage.ConclusionPercutaneous ultrasound-guided superior mesenteric vein access for balloon-assisted PVR-TIPS is a feasible option in cases where hepatic or splenic access is not.

Antibody response and safety of inactivated SARS-CoV-2 vaccines in chronic hepatitis B patients with and without cirrhosis.

The immune response and safety of inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines among patients with chronic hepatitis B (CHB), especially those with cirrhosis, are not clear. Therefore, this study was conducted to evaluate the efficacy and safety of inactivated SARS-CoV-2 vaccines among CHB patients with and without cirrhosis. A total of 643 CHB patients who received two doses of inactivated SARS-CoV-2 vaccines (BBIBP-CorV and CoronaVac) were enrolled. Serum samples were collected and tested for SARS-CoV-2 S-receptor-binding domain (S-RBD) immunoglobulin G (IgG) at enrollment. Data on adverse events (AEs) within 7days after the second dose were obtained using a questionnaire. A total of 416 non-cirrhotic and 227 cirrhotic patients were included in the analysis. Cirrhotic patients had lower antibody titers than non-cirrhotic patients after adjusting for age, sex, and time interval (2.45 vs. 2.60ng/ml, p=0.034). Furthermore, the study revealed that cirrhotic patients demonstrated a slower rate of seropositivity increase, with the highest rate being recorded at week4 and reaching 94.7%. On the other hand, among non-cirrhotic patients, the seropositivity rate peak was observed at week2 and reached 96.0%. In addition, cirrhotic patients displayed a more rapid decline in the seropositivity rate, dropping to 54.5% after ≥16weeks, while non-cirrhotic patients exhibited a decrease to 67.2% after the same time period. The overall incidence of AEs was low (18.4%), and all AEs were mild and self-limiting. In addition, 16.0% of participants had mild liver function abnormalities, and half of them returned to normality within the next 6months without additional therapy. The participants who experienced liver function abnormalities showed a higher seropositivity rate and antibody titer than those who did not (91.6% vs. 79.5%, p=0.005; 2.73 vs. 2.41ng/ml, p<0.001). Cirrhotic CHB patients had lower antibody titers to inactivated SARS-CoV-2 vaccines than non-cirrhotic patients. The vaccines were generally well tolerated in both non-cirrhotic and cirrhotic CHB patient groups. Patients with abnormal liver function may have a better antibody response than those without.

Safety and Efficacy of Endoscopic Retrograde Cholangio-Pancreatography in Patients of Liver Cirrhosis: A Case-Control Study.

Background With the improvement in noninvasive diagnostic imaging modalities, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has evolved into a primarily therapeutic procedure. Besides being efficacious and one of the most commonly done procedures, ERCP is also associated with a high risk of complications. However, there is a lack of studies analyzing the safety and success of ERCP in patients with liver cirrhosis. We retrospectively evaluated the outcome of ERCP in patients with cirrhosis of the liver compared to non-cirrhotic patients using the database from our institute. Methods Patients with liver cirrhosis who underwent ERCP from January 2010 to March 2020 were analyzed. This was a matched case-control study in which one cirrhotic patient undergoing ERCP was age and gender-matched randomly to one non-cirrhotic patient. We compared adverse events and the success rate of ERCP between cirrhotic patients and non-cirrhotic patients. The primary outcome of the study was analyzing the prevalence of procedure-related adverse events and their independent risk factors in patients of cirrhosis compared to the non-cirrhotic population. Results Two hundred patients were analyzed in both groups. Choledocholithiasis was the most common reason for ERCP in both groups. Mean Child-Turcotte-Pugh (CTP) score and Model for End-stage Liver Disease (MELD) score in the cirrhosis group were 9.16 ±1.78 and 19.09 ±7.06 respectively. Patients in the cirrhosis group had a significantly higher frequency of complications compared to the controls: 41 (20.5 %) versus 15 (7.5%), p < 0.01. Bleeding was the most common adverse event in both groups: 19 (9.5%) vs 6(3%). High International Normalised Ratio (INR), low platelets, and cholangitis at presentation were independently predictive of post-ERCP complications. Despite a similar technical success rate, the clinical success rate was lower in the cirrhotic than in the noncirrhotic group (83.9% versus 97.9%, p=0.006). Conclusion The prevalence of complications following ERCP was nearly three-fold higher in patients with cirrhosis than in non-cirrhotic patients. These events were related primarily to cholangitis, coagulopathy, and the advanced status of chronic liver disease.

Cirrhotic and non-cirrhotic huge hepatocellular carcinoma (≥ 10cm): a comparative study of surgical management and follow-up treatment in a single institution.

Liver resection (LR) of huge hepatocellular carcinoma (HCC) has increasingly been regarded as a viable option of enhanced efficacy for patients, but most studies have focused on comparing various tumor sizes and the outcomes of surgery. The study aim was to evaluate the clinicopathologic characteristics and surgical outcomes of huge HCC with and without cirrhosis that underwent LR, and to delineate the treatment for recurrence. Sixty-three patients with huge HCC who underwent hepatectomy from 2010 to 2019 were enrolled and reviewed. Clinicopathological findings, surgical outcomes of the entire cohort, and differences between the cirrhotic and non-cirrhotic groups were analyzed. Forty patients (60.3%) had huge HCC with cirrhosis. Clinicopathological findings were not different between the two groups, except tumor size ≥ 15cm (40% in cirrhosis vs 17.4% in non-cirrhosis, p = 0.024) and major portal vein tumor thrombus were detected only in the cirrhosis group (11 patients, p = 0.006). Extended LR was performed in 13 cirrhotic patients (32.5%) and in 1 non-cirrhotic patient (4.4%) (p = 0.010). Operative data, postoperative complications including postoperative liver failure, and pattern of recurrence were not different between the two groups. For the entire cohort, mortality rate was 1.5%. The 1-, 3-, and 5-year overall survival rates (OS) were 81%, 54%, and 39%. Multivariate analysis showed resection margin ≥ 0.1cm was a good prognostic factor for OS (HR 0.247 (p = 0.017)). For tumor recurrence, local ablative treatment for liver recurrence and resection for lung recurrence provided good long-term outcomes. Although huge HCC with cirrhosis has been a more unfavorable tumor, LR still provided long-term survival with acceptable risk morbidity and mortality.

After A Year of Follow Up Non-Cirrhotic Portal Hypertension Patient with Partial Spleen Embolization (PSE) Management

Non-cirrhotic portal hypertension (NCPH) is a heterogeneous group of liver disorders leading to portal hypertension. There are multiple approaches to managing portal hypertension' clinical complications to treat/prevent spontaneous hemorrhage by mitigating thrombocytopenia. Portal hypertension complications have been traditionally managed with serial endoscopic variceal ligation (EVL) or with invasive open surgical procedures such as orthotopic liver transplantation (OLT) or portosystemic shunting, splenectomy.6–9 There are several risks associated with splenectomies, such as hemorrhagic complications or intraoperative blood loss.5,6,14 Partial Spleen Embolization (PSE) ‎may overcome the limitations of splenectomy and provide patients with an alternative treatment. An eighteen-year-old male has a splenomegaly history since he was 12 years old and has recurring hematemesis and melena. After performing abdominal computed tomography, laboratory studies, and several endoscopies, the results indicated secondary hypersplenism due to non-cirrhotic portal hypertension. The patient had 13 endoscopies and 2 EVL in 5 years. Despite adequate treatment, the patients developed recurrent variceal bleeding and no improvement in blood function. The patient underwent PSE at Integrated Cardiovascular Center in Dr. Cipto Mangunkusumo, General Hospital, Jakarta, Indonesia. It was performed through the femoral access with a PVA (polyvinyl alcohol) embolus. The procedure went successful, and there was no major complication with the patient. Twenty days after the patient had an abdominal CT scan, it showed no abscess, and the spleen volume was reduced by 20%. Long-term results over a year after the procedure are presented. PSE is a safe, effective, semi-invasive alternative to splenectomy in non-cirrhotic portal hypertension because it preserves functional spleen mass and avoids postprocedure accelerated liver disease or encephalopathy.

High Grade Dysplastic Nodule in a Non-Cirrhotic Liver in the Young

Patients with high grade dysplastic nodule (HGDN) have an increased risk for development of hepatocellular carcinoma. Hepatocellular carcinoma (HCC) in a young patient with no cirrhosis or fibrosis is a relatively rare condition. HCC develops in patients in the setting of liver cirrhosis with established risk factors related to various etiologies including hepatitis virus infection, high alcohol intake or metabolic diseases. This was a case of a 29-year-old male with a 7-month history of intermittent right upper quadrant pain with CT scan findings of caudate lobe mass with malignant features. The patient underwent extended left hepatectomy with caudate lobectomy. Patient was discharged on fifth postoperative day, and was advised for follow-up surveillance on an outpatient basis. Liver cirrhosis is the main risk factor for developing HGDN, although rare cases of HGDN in a non-cirrhotic young patient should not be disregarded. Even though, it difficult to differentiate HGDN from early HCC based on radiologic imaging and histopathological criteria. Early diagnosis accompanied with proper surgical intervention such as anatomic resection and regular surveillance should be considered in the course and management of these patients, despite its rarity

Sofosbuvir-Based Therapies Achieved Satisfactory Virological Response in Chinese Individuals with Genotypes 3 and 6 Infections: A Real-World Experience.

BackgroundPrevious studies have shown that sofosbuvir-based regimens yield high sustained virological response rates in patients with hepatitis C virus (HCV) infection except for genotype 3b complicated with cirrhosis. This real-world study aims to explore the efficacy and safety of sofosbuvir-based regimens in Chinese patients with genotypes 3 and 6 infections, especially the impact of ribavirin coadministration on sustained virological response in cirrhotic patients with genotype 3b infection.MethodsThis is a retrospective cohort study that included 101 patients initiated on sofosbuvir-based regimens. The main endpoint of treatment was sustained virological response at posttreatment week 12 (SVR12).ResultsOverall, the SVR12 rates were 95.0% (96/101); specifically, the rates were 100% in sofosbuvir, 88.2% in sofosbuvir+ribavirin, 100% in sofosbuvir+daclatasvir, 100% in sofosbuvir+daclatasvir+ribavirin, 95.0% in sofosbuvir/velpatasvir, and 97.1% in sofosbuvir/velpatasvir+ribavirin (p=0.534). The SVR12 rates were comparable in patients infected with genotypes 3 and 6 (93.2% versus 97.6%, p=0.339). The SVR12 rate was 93.9% in cirrhotic patients (31/33). Among those infected with genotype 3, the SVR12 rate was 91.7% (22/24); the rate was 95.0% in those with ribavirin coadministration regimens, which was numerically higher than the 75.0% in those without ribavirin. However, no statistical difference was found (p=0.312). In total, five patients failed to achieve SVR12, including 3 patients with genotype 3b infection treated with ribavirin coadministration regimens (one of them was cirrhotic), 1 cirrhotic patient with genotype 3k infection, and 1 noncirrhotic patient with genotype 6a infection. No severe adverse event occurred.ConclusionReal-world data show that sofosbuvir-based regimens are highly effective and safe for patients with HCV genotypes 3 and 6 infections.

A case report of giant hepatic hemangioma spontaneous regression in adult, non-cirrhotic patient and literature review

A case report of giant hepatic hemangioma spontaneous regression in adult, non-cirrhotic patient and literature review

Variceal Bleed and Portal Hypertensive Gastropathy in a Noncirrhotic Patient with Isolated Splenomegaly

Portal hypertension caused by cirrhosis is the most common etiology of esophageal varices. However, abnormalities of the splenoportal axis in the absence of liver disease may also cause portal hypertension resulting in varices. We report a rare case of esophageal variceal bleed in a noncirrhotic patient with isolated splenomegaly secondary to chronic granulocyte colony stimulating factor (G-CSF) therapy. The patient is a 26-year-old male with Cohen syndrome who required long-term G-CSF treatment for chronic neutropenia. He presented with large volume hematemesis and pancytopenia in the setting of known splenomegaly with no evidence of cirrhosis. An urgent EGD revealed active variceal bleeding and portal hypertensive gastropathy. The patient was appropriately resuscitated and underwent a successful transjugular intrahepatic portosystemic shunt and CT-guided coil placement for the bleeding varices. We are the first to report variceal bleed as a complication of long-term G-CSF use, a life-threatening consequence that requires urgent intervention.

S2294 Severe Inflammation Leading to Colonic Varices

INTRODUCTION: Colonic varices are a rare finding during endoscopy, especially in an individual without known liver disease. Based on limited case reports, the estimated incidence of colonic varices is 0.07%, irrespective of the etiology[1]. Common causes of colonic varices include portal hypertension from underlying liver disease, non-cirrhotic portal hypertension, most commonly from pre-sinusoidal disease in the form of splenic vein thrombosis, arteriovenous malformation, and idiopathic colonic varices[1, 2]. We present a case of colonic varices in a non-cirrhotic patient leading to an unexpected diagnosis. CASE DESCRIPTION/METHODS: A 23 year-old male was referred for iron deficiency anemia noted on a routine health visit. Initial labs demonstrated a hemoglobin of 12.4 g/dL and a ferritin level below 15 ng/mL. He was referred to the gastroenterology clinic where he reported a prior diagnosis of iron deficiency anemia 10 years ago without endoscopic investigation and treated with iron supplements, but otherwise was in his usual state of health. He denied change in his bowel movements, but endorsed scant, intermittent blood in his stools with wiping. He underwent EGD which was normal and a colonoscopy which was notable for large submucosal varices at the splenic flexure and in the proximal descending colon, multiple erythematous polyps ranging in size from 5-15 mm from the descending colon to the rectum, and erythematous, ulcerated, and friable mucosa from the descending colon to the rectum. CT angiography was performed which showed marked pelvic and lower abdominal lipomatosis with mass effect on the small bowel and abdominal vasculature. The patient was diagnosed with severe left sided ulcerative colitis with mesenteric adipose tissue hypertrophy resulting in colonic varices. He was lost to follow-up prior to initiation of biologic therapy. DISCUSSION: Mesenteric adipose tissue hypertrophy is a known complication of severe Crohn’s disease[3, 4]. Mechanistically, transmural inflammation in Crohn’s disease allows bacterial translocation into the mesenteric adipose tissue, which elaborates a cascade of adipocytokines resulting in inflammatory cell recruitment and adipose tissue hypertrophy, which serves as an additional barrier to systemic bacterial infection[3-5]. This case is unique in that it demonstrates mesenteric adipose tissue hypertrophy in long-standing, untreated UC that created a mass effect, resulting in colonic varices.Figure 1.: Coronal view - mesenteric adipose tissue hypertrophy resulting in visceral organ displacement and colonic varices.Figure 2.: Coronoal view - mesenteric adipose tissue hypertrophy resulting in visceral organ displacement.Figure 3.: Cross-sectional view - colonic varices in the transverse colon.

Efficacy of dacaltasvir and sofosbuvir combination therapy in chronic HCV population in private clinic set up.

All- oral antiviral therapy for chronic hepatitis C is standard of care in 2018. Daclatasvir and Sofosbuvir combination therapy was approved in 2015 by EASL. Generics are also available since 2016. Objectives: We evaluated efficacy of Daclatasvir and Sofosbuvir based therapy in cirrhotic and non-cirrhotic patients. Study Design: Retrospective Observational Study. Setting: Athar Medical Center Muslim Town, Sargodha Road, Faisalabad. Period: One Year Dec 2017 to Dec 2018. Material &amp; Methods: 151 patients were treated with Daclatasvir 60 mg daily and Sofosbuvir 400 mg daily combination therapy. Decompensated Cirrhotic patients were treated for 6 months along with ribavirin according to weight of patient. Treatment experienced patients were treated along with ribavirin. Naïve non-cirrhotic patients were treated for three months or 12 weeks. Primary end point was negative SVR 24 weeks after completing therapy. Results: Over all 151 patients were treated. 85 (56.29%) patients were male. 30(19.86%) patients were cirrhotics and remaining were non-cirrhotics. SVR was obtained in 149 patients. Treatment failure was seen in one cirrhotic and one non-cirrhotic patient. Conclusion: Daclatasvir and Sofosbuvir combination is highly effective in chronic hepatitis C patients in our population of Faisalabad division.

Efficacy of Combination Sofosbuvir, Pegylated-Interferon, and Ribavirin for Treatment of Hepatitis C Virus Genotype 1 Infection in Indonesia

Background: The presence of direct-acting antiviral (DAA) has improved the treatment of HCV infection and making it more preferable than Pegylated-interferon (PegIFN) and Ribavirin (RBV) based treatment. However, treatment with all DAA combination regimen is limited and expensive in low health care affordability country including Indonesia. The appearance of generic sofosbuvir (SOF) facilitate the utilization of SOF plus PegINF with or withour RBV combination. Therefore, in this study we assessed the efficacy of SOF+RBV and SOF+RBV+PegINF combination for treatment of chronic hepatitis C infections patient with genotype 1 in Indonesia.Method: We performed retrospective study comprising 128 patients in Cipto Mangunkusumo Hospital with chronic hepatitis C, genotype 1, infection. 36 patients was treated with PegINF+SOF+RBV and 92 patients was treated with SOF+RBV with the duration of therapy was 12 and 24 weeks in both arms. The primary endpoint was sustained virologic response after treatment completion (SVR12).Results: In the end of treatment, 99.2% patients achieved undetected HCV RNA in 12 weeks and 24 weeks duration of therapy (100% in PegINF+SOF+RBV group and 98.9% in SOF+RBV group). The SVR12 of PegINF+SOF+RBV reach 100% meanwhile The SVR12 of SOF+RBV reach 88%. No different in SVR12 between cirrhotic and non-cirrhotic patient in PegINF+SOF+RBV group while in SOF+RBV group, the SVR12 was lower in cirrhotic patients (82.9%) compared to non-cirrhotic patients (92.2%). In multivariate analysis, HIV co-infection is associated with lower SVR12 in SOF+RBV group.Conclusion: 12 weeks and 24 weeks of PegINF+SOF+RBV and SOF+RBV is effective in the treatment of genotype 1 chronic hepatitis C infection.

SAT-660 Rare Case of Portal Vein Thrombosis Secondary to Acute Pyelonephritis in Type 1 Diabetic Patient

Background: Portal vein thrombosis (PVT) refers to venous thrombosis that develops within the extrahepatic portal venous system and can extend to the branches of the intrahepatic portal vein or up to splenic veins and superior mesenteric. A few cases have been reported about portal vein thrombosis in non-cirrhotic patient. Asymptomatic or non-specific symptom of portal vein thrombosis may lead to misdiagnosed or delay the diagnosis until the complications develop. We report a case of Portal vein thrombosis in type one diabetes associated with acute pyelonephritis. Case report: 18 years old female with type one diabetes on insulin pump present with epigastric abdominal pain for three days associated with nausea and vomiting of three days duration. On examination; conscious alert oriented young female looks in pain, vital sign were stable temperature 37oC, heart rate 89 beat per minute, blood pressure 103/72 mmHg, respiratory rate 20 per minute, oxygen saturation 100% and random blood sugar (RBS) 179 mg/dl. Abdominal examination revealed soft and lax abdomen with tenderness in the epigastric area and right renal angle. No sign of rigidity or rebound tenderness. Bowel sound was present. No sign of ascites, splenomegaly or hepatomegaly. Investigations showed; WBC: 10.2, neutrophil 65%, urine analysis WBCs 30-50 per high field microscopy, RBC 5-10, PH 7, negative nitrate and culture did not show any growth. ESR was 48 and CRP was 4.2. Thrombophilic screen was done and all within normal. Computed tomography (CT) reveled reduced enhancement of right kidney likely indicating acute pyelonephritis and portal vein edema with complete occlusion of left branch of portal vein. Local factors and prothrombotic disorders were ruled out. The patient was managed with ciprofloxacin, enoxaparin and warfarin. The patient was symptomatic free and discharge home with a therapeutic range INR. Conclusion: Portal vein thrombosis is uncommon condition in absence of liver diseases. Few case report liking between sepsis and portal vein thrombosis. Sepsis can create a predisposed environment for hypercoagulability.

A72 VARICEAL BLEED &amp; PORTAL HYPERTENSIVE GASTROPATHY IN A NON-CIRRHOTIC PATIENT WITH ISOLATED SPLENOMEGALY

Abstract Background Portal hypertension caused by cirrhosis is the most common etiology of esophageal varices. However, abnormalities of the spleno-portal axis in the absence of liver disease may also cause portal hypertension resulting in varices. We report a rare case of esophageal variceal bleed in a non-cirrhotic patient with isolated splenomegaly secondary to chronic G-CSF therapy. Aims This report outlines the case of a patient with Cohen Syndrome (CS) who presented with an upper gastrointestinal (GI) bleed in the setting of previously documented splenomegaly and portal hypertension. We expand on the clinical investigations, diagnosis, treatment plan and hospital course of this patient. Methods Case report, review of literature. Results A 26-year old male with previously diagnosed CS presented with large volume hematemesis and pancytopenia. CS is a rare autosomal recessive disorder. In our patient this manifested with congenital neutropenia, microcephaly, retinal dystrophy and global developmental delay. He required long term G-CSF therapy to manage chronic neutropenia and subsequently developed splenomegaly, a known side effect. The most recent MRI identified stable splenomegaly with a craniocaudal length of 23 cm, normal liver size and no radiographic evidence of cirrhosis. The imaging was also significant for gastroesophageal and splenorenal varices but no ascites or recanalization of the umbilical vein. A recent liver biopsy had shown mild pericellular fibrosis with no active liver disease or cirrhosis. In the past, the patient had declined EGD, therapeutic splenectomy or assessment of hepatic venous pressure gradient through invasive venography. His liver enzymes, bilirubin and albumin had always been within normal limits. The patient had no history of GI bleeding. Previous investigations for hematologic malignancies or myelodysplastic syndrome had been negative. Upon admission, an urgent EGD revealed active variceal bleeding in the esophagus and portal gastropathy. Given the extent of his congenital orofacial abnormalities a variceal band ligator could not be passed for appropriate intervention. The patient was transferred to the Intensive Care Unit and managed with intravenous proton pump inhibitor, octreotide, as well as transfusions of packed red blood cells, platelets and fresh frozen plasma. Within the next 48 hours, the patient underwent successful transjugular intrahepatic portosystemic shunt and CT-guided coil placements for the bleeding varices. Conclusions This is a rare case of variceal bleed in a non-cirrhotic patient with portal hypertension from iatrogenic splenomegaly. While there are previous reports of spontaneous splenic rupture secondary to G-CSF therapy we are the first to report variceal bleed as a complication. This is a life-threatening consequence that requires urgent intervention and intensive care. Funding Agencies None

What are the Particularities of Pancreatic Surgery in the Cirrhotic Patient?

The objective of this work was to review the entire literature on pancreatic surgery in order to best define the surgical indications and the specifics of their management. The bibliographic research was done on Pubmed over the period from January 1995 to June 2015, using French and English as the languages of publication. The two main indications discussed here are the management of cancer and chronic pancreatitis. Surgery in the cirrhotic patient exposes the patient to a higher risk of complications than in the non-cirrhotic patient. Child-Pugh and MELD scores should be used to assess risk and guide operative decision. Child-Pugh classes B and a MELD score value greater than 15 are associated with higher morbidity and mortality. However, if suitable selection is made of cirrhotic patients who are candidates for pancreatic surgery, long-term survival seems to be equivalent to the non-cirrhotic group. No risk factors for long-term survival have been reported. In conclusion, cirrhotic patients, candidates for pancreatic surgery must be correctly selected, cirrhosis exposes to a higher risk of postoperative morbidity and mortality.

Portosystemic Encephalopathy in a Noncirrhotic Patient Treated by Vascular Plug Embolization of Mesoiliac Shunt

Mesoiliac shunts in the absence of liver cirrhosis are rarely reported as a cause of hyperammonemia with encephalopathy. Here, we report the case of a 65-year-old female patient with no history of liver disease, who developed significant confusion. Workup showed hyperammonemia and encephalopathy due to spontaneous mesoiliac shunt with no imaging signs of portal hypertension. Liver biopsy showed no evidence of cirrhosis. The shunt was occluded using a vascular plug, resulting in complete resolution of symptoms with no recurrence at 8-year follow-up.

2501 A Rare Case of Sofosbuvir/Velpatasvir/Voxilaprevir Failure in a Patient With Hepatitis C Virus Infection and Previously Undiagnosed Hepatocellular Carcinoma

INTRODUCTION: The advent of direct acting antiviral (DAA) agents has revolutionized the treatment for chronic hepatitis C virus (HCV) infection with greater than 95% success rate. In 2017, a combination of sofosbuvir, velpatasvir, and voxilaprevir (sof-vel-vox) was approved after clinical trials demonstrated a 97-100% sustained virological response (SVR) rate in patients who had failed a previous NS5A inhibitor regimen. We present a rare case of treatment failure with sof-vel-vox in a non-cirrhotic patient with previously undiagnosed hepatocellular carcinoma (HCC). CASE DESCRIPTION/METHODS: The patient is a 68-year-old African-American male with a history of HCV-G1b infection who had previously failed treatment with a 12-week regimen of sofosbuvir/ledipasvir. He was subsequently retreated with 12 weeks of sof-vel-vox. He had an end of treatment response but had a viral relapse at 3 months post-treatment. He denied hepatitis exposure in the interim and repeat genotyping was G1b. He was compliant with his medications. He was referred to Hepatology for salvage treatment options. Prior labs and images did not show evidence of cirrhosis and he did not have a history of hepatic decompensations. Combined HIV Ab/Ag and Hepatitis B Core Ab were negative. A Fibrosure test revealed F3 fibrosis but unfortunately, he did not undergo HCC surveillance. At our initial evaluation a contrast MRI was ordered and revealed a 4.6 cm right lobe enhancing lesion with delayed washout consistent with HCC. Resection was not possible due to the location of the lesion, so he underwent locoregional therapy and is currently listed for liver transplantation with MELD exception. DISCUSSION: Treatment failure with sof-vel-vox is a rare event. Underlying HCC is known to be associated with lower SVR rates in patients treated with DAAs. Some have surmised a protection from eradication due to immunologic changes in cancer patients. We hypothesize that the presence of HCC was the most likely factor for this treatment failure. With sof-vel-vox as the last available option in the treatment paradigm, failure of this regimen in previous NS5A treated patients leads to a situation where there is not an available proven treatment regimen for salvage therapy. As such, we suggest that patients being considered for sof-vel-vox have “up to date” advanced imaging of the liver even in the absence of documented cirrhosis. If treatment failure does occur, one should consider the possibility of an underlying diagnosis of HCC.

Performance of Hong Kong Liver Cancer staging system in patients of hepatocellular carcinoma treated with surgical resection: An Indian validation study.

Hong Kong Liver Cancer staging (HKLCS) system lacks external validation. We conducted a study to validate the prognostic and clinical utility of HKLCS system in the patients with hepatocellular carcinoma (HCC) of heterogeneous etiologies treated with hepatic resection with curative intent at Tata Memorial Centre, Mumbai, India. A total of 144 patients underwent resection for HCC. Our patient cohort was comparable to the original developmental cohort in median age and gender distribution but differed in etiology, liver function status, and tumor venous invasion. On Kaplan-Meier survival curve analysis for overall and disease-free survival, we could achieve statistically significant separation of curves in both Barcelona Clinic Liver Cancer staging (BCLCS) and HKLCS staging systems (P < .000). Interstage discrimination between early and intermediate stages for survival was higher in HKLCS system (P value of .039 vs .091). The area under the receiver operating characteristic curve for the survival of BCLCS and HKLCS systems for the entire patient population was 0.66 and 0.60, respectively, which was not statistically significant (P = .31). The HKLCS system offered higher interstage discrimination power in the patients with HCC treated with resection and may be equally applicable to nonalcoholic steatosis-related chronic liver disease and noncirrhotic patient population.