Parenchymal Liver Disease Research Articles

Parvovirus-Induced Adult Onset Stills Disease Presenting With Elevated Liver Transaminases

Adult-onset Still's disease (AOSD) is an inflammatory disorder affecting multiple systems characterized by polyarthritis, rash, fever, and an elevated erythrocyte sedimentation rate. Macrophage activating syndrome is a severe complication of AOSD leading to pancytopenia, hypofibrinogenemia, elevated triglycerides, lactate dehydrogenase, soluble IL-2 receptor alpha chain (CD25), and ferritin. AOSD is a very rare cause of markedly elevated liver chemistries. A 50-year-old female with a past medical history of asthma developed sore throat, diffuse joint aches, muscle weakness, and a fever of 104° F. She was evaluated at an outside facility and noted to have positive Parvovirus IgM/IgG. She was started on Prednisone 30 mg and with a taper, she experienced a reticular erythematous rash, arthralgias involving the wrist and ankle, myalgias, and cyclic fevers with a temperature max of 100.8° F. She had an aspartate aminotransferase (AST) of 853, alanine transaminase (ALT) of 866, and total bilirubin of 1.5 from prior normal baseline. Complete evaluation for viral hepatitis and hereditary liver disease was negative. Ultrasound with doppler showed parenchymal liver disease with patent vascular flow. Within 48 hours, her AST increased to 2,452, ALT 2,213, and total bilirubin of 3.3. Ferritin was elevated >30,000 ng/mL. Transjugular liver biopsy showed hepatic parenchyma with acidophil bodies, Kupffer aggregates, and preserved architecture with patchy collections of acute and chronic inflammatory cells. No bridging necrosis or iron deposition was appreciated. She was treated with high dose Methylprednisolone 250 mg IV daily with downtrend in transaminases. As steroids were tapered, AST rose from 71 to 198 and ALT from 390 to 900. Percutaneous liver biopsy showed mildly increased inflammation and confluent necrosis. She was discharged on anakinra 100 mg, a recombinant interleukin 1 receptor antagonist, and prednisolone 60 mg twice daily with continued improvement in transaminases to AST of 59 and ALT of 380. The patient developed AOSD likely induced by parvovirus which was complicated by MAS and transaminase elevation >5 upper limit of normal. The pathogenesis of liver involvement of AOSD is unknown but it is presumed that sustained macrophage activation with cytokine production play a role. This is evidenced in this case as transaminases decreased with steroid dosing and increased with the initial taper.

Endoscopic Ultrasonography (EUS)-Guided Liver Biopsy for the Diagnosis of Liver Parenchymal Diseases: A Systematic Review and Meta-Analysis

Introduction: Endoscopic ultrasonography (EUS)-guided liver biopsy is a novel technique to obtain adequate liver sample for diagnosis of liver parenchymal diseases. There are studies that evaluated the feasibility and safety and EUS-guided liver biopsy, however factors that influence specimen quality is yet to be determined. Methods: We performed a detailed search of PubMed, MEDLINE and Web of ScienceTMdatabases to identify studies in which results of EUS-guided liver parenchymal biopsies were reported published up to March 2018. A random-effects model was used to estimate pooled values (mean ± SE) for total specimen length (TSL) and complete portal tracts (CPT). Subgroup analyses were applied to find out the procedural factors associated with better specimen quality using Cochrane's Q test. Results: Ten studies with a total of 451 patients included in the meta-analysis. Overall pooled mean TSL and CPT were 33.2 ± 5.6 and 11.9 ± 1.9, respectively. In subgroup analysis, fine-needle biopsy (FNB) proved to better in terms of TSL and CPT than EUS-guided tru-cut biopsies (TSL; 46.8 ± 5.9 vs 13.6 ± 6.9 mm, p<0.001; CPT; 15.5 ± 2.1 vs 2.67 ± 3.24, p<0.001). FNB with slow-pull or suction technique provided a similar TSL (TSL; 64.3 ± 22.3 vs 52.4 ± 10.9 mm, p=0.63), however slow-pull technique was better in terms of CPT (34.5 ± 6.9 vs 17.1 ± 3.2, p=0.02). Standard versus core-type needle had comparable results in terms of TSL and CPT. Conclusion: EUS-guided parenchymal liver biopsy is a good alternative to other methods of liver sampling. Using FNB needles with a slow-pull technique can provide better results.961_A Figure 1. Overall Pooled Analysis for Total Specimen Length (TSL)961_B Figure 2. Overall Pooled Analysis for Complete Portal Tracts (CPT)

A Multi-Center Retrospective Study of 420 EUS-Guided Fine Needle Core Liver Biopsy with a Modified 1-Pass 1-Actuation Wet Suction Technique Comparing Two Types of EUS Core Needles

Introduction: Endoscopic Ultrasound guided (EUS) Fine Needle Core Biopsy (FNCB) has proven to be safe and effective technique for diagnosis and staging of liver parenchymal disease. We evaluated the diagnostic yield, specimen adequacy in EUS-guided parenchymal biopsies and documented adverse events. We compared two types of EUS 19 G core needles. Methods: This is a multi-center, retrospective study of 420 patients with unexplained abnormal liver function tests who were referred for EUS evaluation of elevated liver enzymes to evaluate for biliary obstruction and pancreatic pathology. EUS-guided liver biopsy (EUS-LB) was performed at the same session after biliary obstruction was excluded. We compared EUS-LB in 210 patients using a Franseen needle to 210 patients using a Fork-tip needle, using a modified 1-pass 1-actuation wet suction technique in patients referred for abnormal liver function tests. We compared intact specimen length (ISL), total specimen length (TSL), complete portal triads (CPT) and adverse events (AE). Comparison between means used a 2-sample Z test and Levene's test found equal variance between all compared means except for mean TSL of patients with a fibrosis score of 0-2. Results: 420 consecutive patients underwent EUS-LB and data were retrospectively evaluated. Median patient age was 52 yrs(range 7-84) and 185(44%) were male. The fork tip needle had an average ISL of 2.7 cm, TSL of 6 cm, and mean 19.5 CPT(range 7-73). Abdominal pain occurred in 35 patients(17%) immediately post-procedure, which resolved in all patients except two after intravenous administration of a low-dose narcotic. Subcapsular hematomas occurred in 1(0.5%) patients. The Franseen needle had an average ISL of 3.1 cm, TSL of 6.5 cm, and mean of 24 CPT(range 8-49). Abdominal pain occurred in 4 patients(2%) immediately post-procedure, which resolved in all patients after intravenous administration of a low-dose narcotic. Subcapsular hematoma occurred in 1(0.5%) and bile leak in 1(0.4%) patients. Conclusion: This is a multi-center comparative study of 2 19G second generation EUS needles of different designs, in patient undergoing EUS-LB. The average CPT and ISL were significantly higher in the Franseen needle compared to fork-tip needle. Both needles using a modified 1-pass 1-actuation wet suction technique met 100% AASLD specimen adequacy (>11 CPT or TSL >2.5cm). AE were comparable between both needles.752_A Figure 1. Gross Specimen752_B Figure 2. Comparison between needle type based on fibrosis score752_C Figure 3. Comparison between Franseen and Fork-tip needles

Composite serum liver Fibrosis/Cirrhosis scores may be associated with parenchymal liver disease in patients with chronic intestinal failure

Composite serum liver Fibrosis/Cirrhosis scores may be associated with parenchymal liver disease in patients with chronic intestinal failure

A prospective pilot comparison of wet and dry heparinized suction for EUS-guided liver biopsy (with videos)

As EUS-guided liver biopsy sampling (EUS-LB) becomes more widely used, further studies have investigated ways to improve tissue yields. Use of a heparin-primed needle may lead to less clotting of blood within the needle, improve tissue recovery, and decrease fragmentation. The purpose of this study was to prospectively evaluate wet suction using a heparin-primed needle for EUS-LB. This was a prospective crossover study evaluating wet suction for EUS-LB in parenchymal liver disease. The primary outcome was specimen adequacy, defined by an aggregate specimen length≥15mm and≥5 complete portal tracts (CPTs). Secondary outcomes included number of CPTs, length of the longest piece, aggregate specimen length, and number of small (≤4mm), medium (5-8mm), and large (≥9mm) fragments. Adverse events were tracked at 7 and 30 days. One hundred twenty biopsy specimens were collected from 40 participants (3 specimens per patient). Specimen adequacy occurred in 39 wet heparin (98%), 37 dry heparin (93%), and 30 dry needle biopsy samples (80%; 95% confidence interval [CI], .14-.18; P= .01). There was no difference between dry needle techniques. Length of the longest piece was 8.9mm for wet heparin and 5.8mm for dry techniques (95% CI, .33-1.53; P=.003). Aggregate specimen length was 49.2mm for wet heparin and 23.9mm for dry heparin (95% CI, -46.34 to 44.94; P= .003). Mean CPT count was 7.0 for wet heparin versus 4.0 for dry (95% CI, .74-6.26; P= .01). There were more medium (2.0 vs 1.0; 95% CI, .06-1.24; P= .03) and large (1.0 versus 0.0; 95% CI, .33-1.53; P= .003) fragments with wet suction with no difference in small fragments between groups. The use of wet suction EUS-LB demonstrated improved tissue adequacy compared with dry needle techniques. (Clinical trial registration number: NCT03103997.).

Reference values of liver volume in Caucasian population and factors influencing liver size

PurposeTo investigate factors influencing liver size and to determine reference values of liver volume (LV) for healthy subjects. Methods2773 volunteers underwent magnetic resonance imaging (MRI) of the liver in the setting of the population based Study of Health in Pomerania. Based on measurement of maximum diameters in three orientations, LVs were calculated and correlated with demographic factors such as age, gender, and body mass index. In addition, LVs of healthy volunteers and participants with parenchymal liver diseases such as fatty liver disease, iron overload, fibrosis/cirrhosis were compared. Adjusted reference values of liver volumes were defined for the group of healthy participants. ResultsIn general, mean LV (mean ± standard deviation) was 1505 ± 385 cm3. Age, gender and body mass index correlated significantly with the liver volume (p ≤ 0.001). Parenchymal liver diseases significantly influence LV (with: 1624 ± 420 cm3, n = 1525 and without parenchymal liver diseases: 1360 ± 273 cm3; n = 1.248, p ≤ 0.001). Compared to LV of participants without liver diseases, LV was increased in volunteers with hepatic steatosis (1717 ± 419 cm3; n = 1111), liver iron overload (1558 ± 367 cm3; n = 553; p ≤ 0.001) as well as in participants with fibrosis/cirrhosis (1494 ± 459 cm3; n = 383). ConclusionsLV is influenced by age, body mass index and parenchymal liver diseases. Reference values were established to aid in the diagnosis of parenchymal liver diseases.

Su1391 COMPARISON OF THE DIAGNOSTIC YEILD AND SAFETY OF 1ST GENERATION EUS CORE BIOPSY NEEDLES WITH FINE NEEDLE ASPIRATION AND NEXT GENERATION EUS CORE BIOPSY NEEDLES- A SYSTEMATIC REVIEW

EUS-guided liver biopsy for the diagnosis of parenchymal liver diseases is being considered as an alternative to percutaneous method of liver biopsy. Several studies have evaluated the diagnostic yield from EUSLB with varying results. Different needle types have been used in the studies published to date. It is unknown if the discrepancy in the diagnostic yield is due to the various needle designs. We performed this meta-analysis to evaluate the diagnostic yield from different needle designs of similar gauge (19G only). We searched several electronic databases for all the studies evaluating the diagnostic yield of EUSLB for parenchymal liver diseases using 19G EUS-fine needle aspiration (FNA) or fine needle biopsy (FNB) needle (Procore and Shark Core needles). Studies were excluded if EUS FNA or FNB needle other than 19G was used, animal or ex-vivo models, biopsy for focal liver lesions, small case-series (<10). Measured outcomes included number of complete portal triads (CPT) which were pooled as weighted means. These were analyzed using random effects model. Heterogeneity was explored with meta-regression based on total specimen length (TSL). Weighted mean difference (WMD) were calculated to compare all three needles. A total of 9 studies with 394 patients (FNA needle (Boston-Scientific, Natick, Mass) in 78 patients, Procore needle (Cook Medical Inc, Winston-Salem, NC) in 127 patients and Shark Core needle (Medtronic, Sunnyvale, CA) in 189 patients, were included in this systematic review and meta-analysis. Weighted pooled mean with 95% confidence interval (CI) for Procore needle was 6.38 (3.92, 8.83), Cochran Q test P < 0.001, I2= 90%. Meta-regression analysis was conducted to explore heterogeneity. TSL was found to be a significant predictor of heterogeneity (intercept -0.05; TSL coefficient 0.36; P < 0.001) and R2 was 0.95. Therefore, longer specimen length resulted in higher number of complete portal tracts and completely explained heterogeneity across studies. Weighted pooled mean for Shark Core needle and FNA needle were 27.71 (8.27, 47.15), Cochran Q test P<0.001, I2=92% and 13.77 (4.18, 22.78), Cochran Q test P < 0.001, I2 =90%, respectively. Due to paucity of number of studies, meta-regression was not conducted for these analyses. WMD comparing Shark Core and Procore needles was 21.33 (-2.32, 44.99) (P=0.06). For the comparison between FNA and Procore needles WMD was 7.41 (-0.26, 15.10), (P=0.06). Finally, WMD for comparison of Shark Core with FNA was 13.91 (-16.92, 44.75) (P=0.37). Both Shark Core needle and FNA needle showed a trend towards obtaining higher complete portal tracts as compared to Procore needles. Further prospective studies comparing these needles are required at this time to identify optimal needle for EUS guided liver biopsy.Fig A: Forest plot showing complete portal tracts obtained by Shark Core needleFig. B: Forest plot showing complete portal tracts obtained by FNA needleView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Increased intermediate monocyte fraction in peripheral blood is associated with nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) currently represents the most common hepatic disease worldwide and is closely linked to cardiovascular disease, obesity and diabetes mellitus. This study aimed to investigate NAFLD and its influence on different monocyte subpopulations to determine the presence of significant associations. A total of 3monocyte subpopulations were investigated, i.e. classical (CD14++CD16-), intermediate (CD14++CD16+) and non-classical (CD14+CD16++). Of the participants 261 were included in this study (n = 53 with NAFLD, n = 208 controls). Ultrasonography was used to diagnose NAFLD and exclude other morphologic causes of liver diseases and other tests (including medical history inquiries and detection of hepatitis virus) were performed to exclude other causes of parenchymal liver disease. Classical inflammatory and metabolic-related NAFLD biomarkers were also determined. In contrast to the healthy control group, the intermediate monocyte fraction was increased in NAFLD patients (p = 0.032), while the classical monocyte fraction was decreased (p = 0.025). Intermediate monocyte fraction, body mass index (BMI) and tumor necrosis factor alpha (TNF-α) were independent risk factors for NAFLD. Classical, non-classical and intermediate monocytes fraction were strongly associated with age, triglyceride, and waist circumference. This study suggests that the intermediate monocyte fraction in peripheral blood is likely related to the aggravation of NAFLD.

Endoscopic Ultrasound for the Hepatologist: A Comprehensive Review.

In the last few years, the diagnostic and therapeutic utilization of endoscopic ultrasound (EUS) for a variety of liver conditions has exponentially grown. We performed a thorough search for all available studies on the performance of diagnostic and therapeutic EUS in the field of hepatology. This article reviews the indication of EUS in the evaluation and treatment of portal hypertension, portal vein pressure measurement, focal liver lesions, and parenchymal liver diseases, and presents all the clinical evidences available so far in this regard. All the review data suggest that EUS is becoming an increasingly important tool in the armamentarium of the hepatologists for the management of certain liver-related conditions. Implementation in the education of the hepatologists of means to become more familiar with both diagnostic and therapeutic capabilities of EUS is warranted.

Ayurvedic Approach for Management of Liver Parenchymal Disease: A Case Study

Diseases of liver, biliary tract and pancreas are grouped under Grahani and Udar Roga. These triode has been narrated as places of Agni i.e., digestion, metabolism and assimilation. Agni refers to digestion and metabolism mechanism of human body and normal physiology of Agni is essential for maintenance of healthy status. Its vitiation leads to different ailments especially disorders of GIT. Liver parenchymal diseases were considered as Udar Roga. Alcohol has been identified as the major cause of liver parenchymal disease, but the ancient Ayurveda scholar Acharya Charaka identified different causes like drinking cold beverages/cold water after heavy food, eating unwholesome food in indigestion, diseases of other visceral organs, and piles, etc. Present management options for liver parenchymal disease is limited, liver transplant is costly management and has limitation of getting donor and bears risk. Ayurveda with its holistic approach of management offers management options with low risk, and better general wellbeing control of symptoms with oral medicaments or simple OPD based procedures. Author has treated liver parenchymal disease and remarkable improvement in symptoms and general wellbeing has been observed. Marked improvement was observed in cases chronic liver parenchymal disease, pancreatic calculus, hydatid cysts with only Ayurveda medicaments (mostly herbal treatment). The clinical success stories would be dealt in details in full paper.

EUS anatomy of the liver segments

Clinical applications of EUS for the liver have been recently increasing. They include the screening and diagnosis of liver parenchymal disease and malignant tumors as well as EUS-guided interventions such as hepaticogastrostomy, tumor ablation therapy, and portal pressure gradient measurement. Although the segmental localization of the targeted tumor, bile duct, and vessel in the liver is important to complete these procedures, little information is available regarding hepatic segmental anatomy on EUS. The liver can be visualized with EUS by transgastric and transduodenal scanning, and the EUS determination of segmental location can be achieved using various anatomical landmarks. Identification of the right posterior segments is, however, technically difficult because they are located far from the stomach and duodenum. In the present review, we describe the normal anatomy of liver segments using linear EUS.

Hypothermic perfusion with retrograde outflow during right hepatectomy is safe and feasible

In situ hypothermic perfusion during liver resection performed under vascular inflow occlusion decreases hepatic ischemia-reperfusion injury, but technical limitations have restricted its widespread use. In situ hypothermic perfusion with retrograde outflow circumvents these impediments and thus could extend the applicability of in situ hypothermic perfusion. The safety and feasibility of in situ hypothermic perfusion with retrograde outflow were analyzed in selected patients undergoing right (extended) hepatectomy and compared to intermittent vascular inflow occlusion, the gold standard method, in this randomized pilot study. Patients were first screened for parenchymal liver disease (exclusion criteria: steatosis ≥30%, cirrhosis, or cholestasis). Study participants were randomized intraoperatively to undergo in situ hypothermic perfusion with retrograde outflow (n=9) or intermittent vascular inflow occlusion (n=9). The target liver core temperature during in situ hypothermic perfusion with retrograde outflow was 28°C. The primary end point was ischemia-reperfusion injury (expressed by peak postoperative transaminase levels). Secondary outcomes included functional liver regeneration (assessed by hepatobiliary scintigraphy) and clinical outcomes. Peak transaminase levels, total bilirubin, and the international normalized ratio were similar between both groups, although a trend toward more rapid normalization of bilirubin levels was noted for the in situ hypothermic perfusion with retrograde outflow group. Functional liver regeneration as evaluated by hepatobiliary scintigraphy was improved on postoperative day 3 fafter in situ hypothermic perfusion with retrograde outflow but not after intermittent vascular inflow occlusion. Furthermore, in situ hypothermic perfusion with retrograde outflow (requiring continuous ischemia) was comparable to intermittent vascular inflow occlusion for all clinical outcomes, including postoperative complications and hospital stay. The use of in situ hypothermic perfusion with retrograde outflow appears to be safe and feasible in selected patients with healthy liver parenchyma and may benefit early functional liver regeneration. Future applications of in situ hypothermic perfusion with retrograde outflow include patients with damaged liver parenchyma who would require major hepatic resection with a prolonged vascular inflow occlusion duration.

A case with gastric purpura induced acute gastrointestinal hemorrhage

A 72 years old male, with medical histories of hypertension and gout with herb use, was admitted because of tarry stool passage for one day. On admission, the vital signs were relatively stable. Physical exam didn't show significant findings. Blood tests revealed leukocytosis (WBC: 20810/ul), thrombocytopenia (platelet: 2000/ul), coagulopathy (activated partial thromboplastin time: 55.1 second), abnormal liver and renal function (AST: 390U/L, ALT: 155U/L, Cre: 1.8 mg/dl). Abdominal ultrasound revealed parenchymal liver disease without splenomegaly. Esophagogastroduodenoscopy (EGD) disclosed multiple rosette-like hyperemic patches, some with exposed vessels, at the antrum (Fig. 1). Hemoclipping was applied for hemostasis. Biopsy showed no evidence of Helicobacter pylori infection. Esophagogastroduodenoscopy (EGD) in our elderly patient. (A) Multiple gastric purpura presented as rosette-like hyperemic patches at the antrum. (B) Exposed vessel on the lesions. Blood transfusion was performed for severe thrombocytopenia correction. Medication (herb) was suspected to be the possible cause of thrombocytopenia after work-up and discussing with an experienced hematologist. After improvement of thrombocytopenia, liver and renal function, he was discharged few days later. There was no more episode of gastrointestinal hemorrhage. Follow-up EGD one month later showed dramatic improvement of previous gastric purpura (Fig. 2). Follow-up EGD one month later. (A) Shallow ulcer with previous hemoclip at the antrum. (B) Gastric purpura resolved completely. Gastric purpura was initially described in 1997 with the feature of subepithelial hemorrhage [1]. It was a rarely cause of gastric bleeding with only few cases [1–3]. The cause of gastric purpura was attributed to severe thrombocytopenia, probably due to immune-mediated [2]. In our patient, EGD showed multiple rosette-like hyperemic patches in the stomach. This unique picture was the typical feature of subepithelial hemorrhage. Spontaneous resolution after correction of thrombocytopenia seemed to be an evidence of thrombocytopenia induced gastric purpura. Interestingly, there were no purpura-like lesions seen in the esophagus or the duodenum from literatures. The actual reason needed to be further clarified. In summary, severe thrombocytopenia may lead to spontaneous subepithelial hemorrhage with manifestation as purpura in stomach and resulted in gastrointestinal bleeding. Fortunately it was expected to resolve after thrombocytopenia correction. All authors declare no conflicts of interest.

Hilar Cholangiocarcinoma: Resection or Transplantation?

This is a review of the current status of surgical resection and liver transplantation in the treatment of hilar cholangiocarcinoma (CCA). For patients with hilar CCA and underlying parenchymal disease, specifically those with primary sclerosing cholangitis, liver transplantation is generally favored as there is risk of hepatic insufficiency and multicentric disease with extended resection. For de novo patients with no underlying liver disease, the decision between resection and transplantation proves to be more difficult. Results have shown that when margin- and node-negative resections are achieved, survival outcomes between patients undergoing resection and liver transplantation are comparable, though at baseline the patients selected for transplant were unresectable and, thus, had no other curative option and potentially more advanced disease than those selected for resection. Difficulty lies, however, in accurately predicting which patients are resectable as commitment to surgical resection precludes liver transplantation and vice versa. Recent work has focused on improving surgical resection outcomes as liver transplantation continues to be limited by the extreme organ shortage. Hilar lesions previously considered unresectable as a result of vascular involvement are now being resected using en bloc surgical techniques with vascular reconstruction. Additionally, the application of portal vein embolization to CCA has allowed for safer extended hepatic resections in a select group of patients. At present, surgical resection and liver transplantation remain as the only potentially curative treatment options for perihilar CCA. The presence of underlying parenchymal liver disease, ability to obtain margin- and node-negative resection, and overall candidacy for transplantation should guide decision making.

Hereditary hemorrhagic telangiectasia, liver disease and elevated serum testosterone (Osler\u2013Weber\u2013Rendu syndrome): a case report

BackgroundA Sri Lankan girl with hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu syndrome) is described.Case presentationShe presented with recurrent spontaneous epistaxis, pulmonary arterio venous malformation and oral telangiectasia. A diagnosis of Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu syndrome) was made based on the presence of three Curacao criteria (out of four). Evaluations of her jaundice revealed chronic parenchymal liver disease with multiple nodules in the liver with early portal hypertension. She had a muscular build, with elevated serum testosterone but low serum dehydroepiandrosterone sulphate levels. This could be attributed to impaired sulfation of dehydroepiandrosterone due to portocaval shunting of blood, leading to hyperandrogenemia.ConclusionsHyperandorogenemia due impaired sulfation of dehydroepiandrosterone as a result of portocaval shunting is seen in Hereditary haemorrhagic telangiectasia.

Endoscopic ultrasonography - emerging applications in hepatology.

The inspection of the liver is a valuable part of the upper endoscopic ultrasonography (EUS) studies, regardless of the primary indication for the examination. The detailed images of the liver segments provided by EUS allows the use of this technique in the study of parenchymal liver disease and even in the diagnosis and classification of focal liver lesions. EUS has also emerged as an important tool in understanding the complex collateral circulation in patients with portal hypertension and their clinical and prognostic value. Recently, EUS-guided portal vein catheterization has been performed for direct portal pressure measurement as an alternative method to evaluate portal hemodynamics. In this review, the authors summarize the available evidence regarding the application of EUS to patients with liver diseases and how we can apply it in our current clinical practice.

A rare case of acquired hepatocerebral degeneration in cirrhosis

Hepatic encephalopathy is the most common neurologic complication of cirrhosis of the liver, while acquired hepatocerebral degeneration (AHD) is an underestimated neurologic manifestation. It is characterized by parkinsonism, ataxia, and neuropsychiatric symptoms. It is an underdiagnosed cause of psychomotor retardation in patients with chronic parenchymal liver disease with portosystemic shunting. Manganese deposition in the basal ganglia has been proposed as a mechanism for AHD. Here, we report a case of AHD in a patient with chronic parenchymal liver disease who responded to dopamine agonist.

Increased renal parenchymal retention of 99mTc-MDP (hot kidneys) in two patients of Hepatocellular Cancer: one with and other without osseous metastases

Background: Hepatocellular cancer (HCC) is the fifth-leading cancer in men worldwide. Here we present two HCC patients who showed high diffuse renal parenchymal retention of 99mTc MDP on bone scan. Cases presentation: Bone scan with 99mTc MDP was performed on two known HCC patients, which showed skeletal metastases in one and absent in the other case. Their kidneys showed high renal parenchymal retention of tracer with kidneys looking much HOT than adjacent bones. The differential diagnosis of hot kidneys include nephrocalcinosis, hypercalcemia, hyperparathyroidism, chemotherapy, sickle cell disease, acute renal injury, recent radiotherapy and aluminum breakthrough of 99Mo-99mTc generator. Our patients did not fit in any of these. Hot kidneys in patient with liver cirrhosis have been reported due to hepatorenal syndrome. Although chronic liver parenchymal disease was present in the background of HCC, but our patients were not having hepatorenal syndrome (normal renal function tests). Quality control of generator and MDP vials used showed absence of any aluminum breakthrough and labeling efficiency was greater than 95% respectively. So, the exact cause of hot kidneys in these cases cannot be ascertained and some altered metabolism in liver and hemodynamic changes in body due to HCC might be the cause. Conclusion: High diffuse renal parenchymal retention of 99mTc MDP might be seen on bone scan in HCC cases. Its clinical significance is unknown and needs further research to find out its exact mechanism and cause.

Recurrent Upper Gastrointestinal Bleeding in 56-Year-Old Woman With Liver Cirrhosis Associated With Schistosomiasis: A Case Report

Schistosomiasis, an infection caused by blood flukes remains an important health problem in many countries. Despite the availability of treatment, it is endemic in tropical countries like the Philippines. The incidence is also rising in non-endemic countries due to immigrant populations and tourists. This disease infects over 200 million people worldwide and translates in approximately 25 million disability-adjusted life years lost. Untreated infection causes pathologic changes in the hepatic parenchyma leading to portal hypertension and liver cirrhosis. A significant complication of decompensated cirrhosis is the development of bleeding from esophagogastric varices. A 56-year-old Filipino female from Agusan del Sur, Philippines, a highly endemic area for schistosomiasis presented with recurrent hematemesis. She was a non-alcoholic beverage drinker and had no co-morbidities. She was negative for viral hepatitis screening. Ultrasound of the abdomen showed liver parenchymal disease with a characteristic lace-like pattern. Rectal biopsy was positive for schistosomes. Upper gastrointestinal endoscopy revealed Grade III esophageal varices. She was treated with praziquantel and rubber band ligation was attempted. However the recurrence of bleeding necessitated devascularization with splenectomy (Modified Sugiura Procedure). We highlight the importance of knowledge and education regarding schistosomiasis - its distribution, clinical presentation, and diagnosis. This disease is widely endemic in tropical countries despite worldwide efforts to control it. Untreated schistosomiasis could lead to liver cirrhosis, an irreversible disease that can cause life-threatening hematemesis from esophageal varices.

An Unusual Case of Acute Hepatitis in a Pregnant Woman

Viruses, such as Epstein-Barr virus (EBV) may affect the liver, with hepatic injury that can range from mild and transient elevations in aminotransferases to acute and even fulminant hepatitis. Since EBV is a rare causative agent of hepatitis, the demographics, clinical features and outcome are not completely understood. A 22 year old female with no past medical history presented to the Emergency Room due to jaundice since seven days prior to evaluation. Skin discoloration was preceded by a prodrome of fatigue, general malaise, headaches, retro-orbital pain, nausea, vomiting, anorexia and myalgia. Patient denied sick contacts, or recent travel and immunizations were up to date. She had no history of smoking or alcohol, and no family history of liver disease. Physical exam showed lymphadenopathy and icteric sclera. Laboratories showed an AST of 946 U/L, ALT of 957 U/L, AlkPhos of 339 U/L, GGT of 212 U/L, total bilirubin level of 4.56 mg/dL with direct bilirubin at 3.23 mg/dL. Quantitative beta-hcg was positive at 3,039 mIU/ml; and last menstrual period and vaginal sonogram confirmed intrauterine pregnancy at 5 WGA. Findings were suggestive of acute hepatitis in pregnancy. Patient was admitted for further workup and supportive measures. Abdominal ultrasound with Doppler examination revealed no evidence of parenchymal liver disease or biliary obstruction or vascular thrombosis. HIV, RPR, ANA, ASMA, AMA and serum and urine toxicology were negative. Patient was also tested serologically for acute and chronic viral hepatitis including hepatitis A, B, C, E, EBV and Cytomegalovirus (CMV); showing evidence of past Hepatitis A infection, immunity to Hepatitis B, and positive for Epstein Barr Viral Capsid IgM Antibody. After several days of conservative therapy, liver enzymes and physical examination showed improvement and patient was discharged home. This case illustrates the clinical presentation of EBV hepatitis in a pregnant woman, causing self-limiting hepatitis. Since the clinical presentation may be indistinguishable between the various forms of viral hepatitis, a high index of suspicion is required in the adequate clinical setting, to allow for prompt recognition, treatment and avoid long term complications.