bluuebunny/crossref_metadata_2025_split huggingface dataset:
2428 Direct Intrahepatic Portocaval Shunt (DIPS) as a Therapeutic Option in Acute Variceal Hemorrhage
Authors: Tripathi Alok , Tavri Sidhartha , Cohen Stanley Martin 
Published: October 2019

INTRODUCTION:
Direct Intrahepatic Portocaval Shunt (DIPS) is a modified transjugular intrahepatic portosystemic shunt (TIPS) procedure, in which a stent is placed across the inferior vena cava directly into the portal vein under intravascular ultrasound guidance. DIPS is a recognized salvage therapy for acute variceal hemorrhage, but not commonly utilized. Indications for DIPS include patients with hepatic venous anomalies not amenable to TIPS, distorted post-surgical vascular anatomy of the liver, intrahepatic portal venous thrombus, or a prior failed TIPS.

CASE DESCRIPTION/METHODS:
A 73-year-old male with a history of cirrhosis from alcohol and hepatitis C virus and right lobe hepatocellular carcinoma status-post laparoscopic microwave ablation presented with hematemesis. An EGD revealed a gastric varix (Figure 1), which was deemed too large for treatment with cyanoacrylate glue deposition. A TIPS was attempted but failed due to hepatic venous anomalies. Subsequently, the varix was treated with a balloon-occluded antegrade transvenous obliteration (BATO) and a balloon occluded retrograde transvenous obliteration (BRTO). Figure 2 demonstrates the BATO, which coiled the afferent vessels to the varix (red arrow), and the BRTO, which coiled the efferent gastro-renal shunt of the varix (blue arrow). Two days after the BATO/BRTO, the patient had recurrent melena and anemia. An EGD doppler-guided glue deposition into the gastric varix was attempted but failed. A TIPS was not a viable option as an ultrasonography revealed a new portal vein thrombus extending into the anterior and posterior branches of the right portal vein. Thus, a DIPS was performed. Under intravascular ultrasound guidance, a catheter (red arrows) was advanced from the IVC directly to the left portal vein creating a shunt with stent placement as seen in Figure 3. The pre-procedure portosystemic gradient was 18 mm Hg, and post-procedure portosystemic gradient was 5 mm Hg with a reduction in the gastric varix. The patient is well three-months post-procedure without recurrent melena or anemia.

DISCUSSION:
This case demonstrates the successful utilization of DIPS in a patient where TIPS was not feasible due to hepatic venous anomalies and a portal vein thrombus. Furthermore, DIPS was successful in the treatment of a variceal hemorrhage when other therapies such as cyanoacrylate glue deposition, BATO, and BRTO failed. Therefore, DIPS should be utilized in challenging cases of variceal hemorrhage when performed by an experienced interventional radiologist.
2430 Placental Site Trophoblastic Tumor—Unusual Cause of Nodular Regenerative Hyperplasia and Portal Hypertension: Case Report
Authors: Gebreselassie Agazi , Laurine Jacqueline 
Published: October 2019

INTRODUCTION:
There are various causes of non-cirrhotic portal hypertension which can be classified as pre hepatic, intra hepatic and post hepatic. One of the causes of idiopathic non cirrhotic portal hypertension is nodular regenerative hyperplasia (NRH). There are various disorders which are associated with NRH. We report a case of placental site trophoblastic tumor as a cause of NRH and portal hypertension.

CASE DESCRIPTION/METHODS:
A 36 years old Caucasian female with no known medical illness presented with progressive abdominal swelling of 5 months duration. She had a normal vaginal delivery to a healthy baby one year back. She gained almost 40 pounds since she started to notice abdominal distention. She has no history of alcohol intake or medication use. On physical examination she had markedly distended abdomen, with fluid wave and small umbilical hernia. She had Pitting edema of 3+ in the extremities. Investigations revealed that the platelet count was 114, Sodium 124, ALT 41, AST 46 and albumin 2.6. Otherwise white cell count, hemoglobin, bilirubin, PT and INR values were within normal limit. Viral hepatitis panel and work up for other causes of chronic liver disease were unrevealing. Abdominal ultrasound showed ascites and mild splenomegaly. It also showed a normal liver echotexture, no ductal dilatation and a patent portal vein. Ascitic fluid analysis was suggestive of portal hypertension with SAAG of 2. Transjugular liver biopsy was suggestive of nodular regenerative hyperplasia. Portal pressure was elevated at 11 mmHg. On abdominal CT scan an incidental enlarged heterogeneous uterus with prominent sub endometrial and parametrial vessels was noted. Serum HCG was high (762). Subsequent hysteroscopy and endometrial biopsy revealed trophoblastic maturation suggestive of trophoblastic tumor. PET scan showed that the disease was limited to the uterus. The patient underwent total hysterectomy with bilateral salpingectomy. She was also treated with three cycles of chemotherapy. The patient experienced total resolution of here symptoms. Four months after her surgery the patient continues to be symptom free with resolution of ascites and leg swelling without any medications.

DISCUSSION:
Idiopathic non cirrhotic portal hypertension can be associated with a variety of conditions including hematologic, neoplastic, immunogenic and medication related. To our knowledge, this is the first report of nodular regenerative hyperplasia associated with trophoblastic tumor.
2431 Legionella Pneumonia Masquerading as Acute Hepatitis and Rhabdomyolysis
Authors: Gudipally Sindusha , Bhatt Harsh , Salas Noain Jesus M. , Modi Simple 
Published: October 2019

INTRODUCTION:

Legionella pneumonia commonly presents with myalgia, fatigue, and dyspnea and accounts to about 10-15% of all pneumonia cases. With less than 100 unusual cases of Legionella reported, this is a unique presentation with fulminant hepatic failure, acute kidney failure, and rhabdomyolysis.

CASE DESCRIPTION/METHODS:
52-year-old African-American male with no medical history presented to the emergency room with nausea, diarrhea, and fatigue. He was febrile and tachycardic on presentation. On further evaluation, he reported exposure to a new air-conditioner at work. Chest x-ray (CXR) revealed a right lower lobe pneumonia. Blood work was remarkable for elevated liver enzymes, hyponatremia, acute kidney injury, and elevated creatinine phosphokinase (CPK). His urine drug screen and alcohol level was normal. Liver ultrasound (US) showed fatty infiltration, but no cirrhosis, confirming his social history of being non-alcoholic. Hepatitis (A, B and C), Cytomegalovirus (CMV) IgM and HIV serologies were all negative. Patient was started on fluid resuscitation and antibiotics. Despite a lobar consolidation, Legionella urine antigen returned positive. This confirmed Legionella induced fulminant liver failure and rhabdomyolysis. Patient later developed respiratory symptoms and his repeat Chest x-ray revealed patchy infiltrates in multiple regions, consistent with Legionella. His liver enzymes and CPK trended down, and he was discharged home. He was followed as outpatient with resolution of the fatty infiltration on the Liver US.

DISCUSSION:
Legionella is transmitted through inhalation of aerosols derived from water or soil. It mimics alcoholic hepatitis and is distinguished from other types of hepatitis by having no evidence of cirrhosis. Presentation with gastro-intestinal symptoms, consolidation on imaging, rhabdomyolysis, and acute kidney injury makes Legionella hepatitis most likely etiology. Exact mechanism is still unclear; however, release of endotoxins and bacterial invasion have been reported in many studies. Diagnosis is made with rapid PCR or urine antigen. Levofloxacin or Azithromycin are the preferred antibiotics as these agents are bactericidal, achieve high intracellular concentrations, penetrate lung tissue, and are active against all sub-type species. Treatment usually is for 7-10 days but for immunocompromised patients is 14 days due to risk of re-infection and relapse. Legionella should be high in the differential with the other hepatitis causing diseases like HIV, Hepatitis A, B or C and CMV.
2437 Solitary Fibrous Liver Tumor Diagnosed With EUS-Guided Fine-Needle Biopsy: Case Review
Authors: Nieto Jose , Marriott Denisse , Arévalo Martha 
Published: October 2019

INTRODUCTION:
Attaining SFLT's diagnosis is challenging as there are no specific clinical nor radiological characteristics to follow. Therefore, diagnosis is mainly sought based on histologic features (vascularity, mitosis, necrosis, etc.). We report a case of SFLT in a 73-year-old female diagnosed serendipitously by Endoscopic Ultrasound (EUS) - Fine Needle Biopsy (FNB), histologic, and immunophenotypic findings combined.

CASE DESCRIPTION/METHODS:
A 73-year-old female patient presented with moderate RUQ abdominal pain for 1 month and pristine lab work. Patient denied relevant past medical history. MRI with and without contrast, showed a 12.8 cm × 11.2 cm mass in the anterior segment of the right hepatic lobe and no signs of hepatic steatosis. The diagnosis was made by an EUS-FNB ambulatory procedure performed with a 19-g needle. EUS disclosed a hypoechoic and heterogenous mass and non-alcoholic steatohepatitis (NASH). FNB preliminarily showed a spindle cell lesion. The combined histologic and immunophenotypic findings were: Vimectin and CD34 positive; Smooth Muscle Actin – rare faint positive staining. Prognostication was deferred for the resection of the specimen. Metastasis were to be excluded clinically.

DISCUSSION:
Less than 100 cases of SFLT have been reported worldwide. Classically, it presents itself as benign, predominantly in females around the 5th decade, and with a 2:1 female:male ratio. Clinically, it is mainly asymptomatic, or it can depict constitutional symptoms when malignant. Radiologically, suggestive findings are non-diagnostic; making histopathological features (i.e., spindle shaped cells) critical markers to reach a diagnosis. EUS - FNB yields an advantage over Fine Needle Aspiration (FNA) in diagnosing tissues which require immunohistochemical staining - such as this one - in two ways: FNB renders a core biopsy sample (preserved tissue architecture) and is more affordable; whereas FNA requires bedside rapid onsite evaluation, increasing the overall cost. Surgical resection, adjuvant chemotherapy, and radiotherapy may be required for an effective treatment. In our case study, the patient was a 73-year-old female, which is an uncommonly reported age population. Therefore, despite SFLT's infrequent presentation, this entity should be considered in the differential diagnosis of liver tumors. Lastly, EUS-FNB is a safer and affordable procedure to reach SFLT's definitive diagnosis in comparison to other more invasive/expensive methods (i.e., Percutaneus Liver Biopsy, EUS-FNA respectively).
2440 Acute Hepatitis C in an Elderly Woman With No Risk Factors: A Rare Presentation
Authors: Bhardwaj Gaurav , Boroda Konstantin , Hertan Hilary 
Published: October 2019

INTRODUCTION:
An estimated 4.1 million people of US have been exposed to hepatitis C (HCV), 70% of which were born between 1945 and 1964, known as the “baby boomer” cohort. While a majority of patients with acute HCV go undetected, 15% present as acute hepatitis.

CASE DESCRIPTION/METHODS:
A 77 year old woman presented with right upper quadrant pain, jaundice, loss of appetite and malaise for 2 weeks. She denied recent travel, alcohol or drug use, prior blood transfusions, acetaminophen ingestion and use of herbal supplements. Her exam was remarkable for scleral icterus and RUQ tenderness. Initial laboratory data showed normal chemistry and blood counts. Her liver tests disclosed ALP 128 U/L, AST 1,348 U/L, ALT 1003 U/L, total bilirubin 8.2 mg/dL, direct bilirubin 6.4 mg/dL and INR 1.4 consistent with acute hepatitis. Infectious workup was positive for HCV genotype 1b with a viral load of 27.2 M IU/mL. Ultrasound of the abdomen showed normal liver and biliary tree. Immunological workup was positive for anti-smooth muscle antibody 1:40 titer and elevated IgG at 2,070 mg/dL raising a concern for a concomitant autoimmune hepatitis (AIH). Patient's liver tests continued to climb and she had prolonged abdominal pain, so liver biopsy was performed. It showed moderate lobular lymphoplasmacytic and neutrophilic inflammation with marked hepatocellular injury and areas of hepatocyte loss consistent with active HCV hepatitis (Figures 1 and 2). She was then discharged and immediately started on sofosbuvir-ledipasvir and eventually achieved sustained virologic response.

DISCUSSION:
Acute HCV infection is usually transmitted via needle-stick injury or injection drug use. It is uncommon in elderly patients, however in nursing home residents, it is attributed to parenteral medications, hemodialysis and poor adherence to infection control measures. Our patient was from the community and it is not clear how she was exposed to HCV. Acute HCV hepatitis in elderly patients can be severe, occurring 2 to 26 weeks after exposure. Aminotransferases are often greater than 10 to 20 times normal; bilirubin may be elevated as well. Although HCV is known to induce AIH, the features of acute hepatitis can be mistaken for AIH. A biopsy aids in discerning these two entities with very different treatment strategies. Generally, a waiting period of 12 weeks is instituted to allow for spontaneous viral clearance, but immediate treatment can be initiated in cases of elderly patients with severe presentations.
2441 Hepatotoxicity by Methoxsalen: The Innocuous Culprit
Authors: Aujla Amreet K. , Gill Guneetinder S. , Shah Nihar , Pratt Perry , Hoffman Martin 
Published: October 2019

INTRODUCTION:
Drug-induced liver injury (DILI) is the second most common cause of acute liver failure; 15-20% cases of DILI can be attributed to damage caused by herbal or dietary supplements. Methoxsalen, commonly known as psoralen, is the active ingredient in Bakuchi seeds and is used for treatment of vitiligo and psoriasis. DILI caused by Psoralen is rare, with only three cases reported in literature. This case demonstrates the importance of eliciting a history of herbal supplement use in patients with acute liver failure and the need for regulation of herbal supplements.

CASE DESCRIPTION/METHODS:
A 60-year-old female presented with two-week history of jaundice and right upper quadrant pain (RUQ). She started taking Bakuchi seeds four weeks prior to presentation and would apply it topically and consume it daily. Patient denied history of alcohol use, blood transfusions, or illicit drug use. Physical exam was notable for scleral icterus and jaundice. Labs revealed abnormal liver function tests (LFTs) (Figure 1) with a peak total bilirubin of 19 mg/dL and a MELD-Na on admission of 19. Work up revealed positive anti-smooth muscle antibodies and AFP elevation to 15.9 ng/mL. Pertinent negatives included viral hepatitis serologies, HSV, EBV, factor V activity, and hemochromatosis. A RUQ ultrasound showed no abnormalities. An MRI abdomen was done which revealed mild periportal edema and mildly dilated common bile duct without choledocholithiasis or obvious mass. Given concerns for DILI, patient was started on acetylcysteine. Hospital course was complicated by episodes of confusion; an ammonia level was elevated at 75 umol/l. Patient was started on lactulose. Because patient's LFTs improved with a stabe PT/INR of 12/1.2, she did not meet criteria for a liver transplant. A liver biopsy was performed which revealed submassive necrosis and collapse; hepatitis with plasma cells and eosinophils with significant cholestasis. Given biopsy results consistent with DILI, patient was discharged on oral prednisone and lactulose to follow up with hepatology in one week.

DISCUSSION:
LFT abnormalities were seen in 2% to 12% of subjects taking psoralen; the elevations were mild-moderate in severity, asymptomatic and self-limited in course with recovery of LFT seen in 6 to 8 weeks. However, severe jaundice and death from hepatic failure has been described in patients with preexisting cirrhosis. This case emphasizes the need for increased surveillance to formulate guidelines regarding regulation and use of herbal supplements.
2444 Beyond Weight Loss: Bariatric Surgery as Treatment for NAFLD in the Post-Transplant Patient
Authors: Hashmi Irma , Anjelly David , Zacharias Isabel 
Published: October 2019

INTRODUCTION:
Bariatric surgery, including Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG), has previously demonstrated reversal of abnormal liver histology in non-alcoholic fatty liver disease (NAFLD). However, bariatric surgery following orthotopic liver transplant (OLT) performed for non-alcoholic steatohepatitis (NASH) cirrhosis is less well studied, with only a few retrospective studies cited in the literature. We present the case of bariatric surgery performed in a patient status post OLT with successful reversal of NAFLD.

CASE DESCRIPTION/METHODS:
The patient is a 69-year-old female with past medical history of metabolic syndrome (diabetes, hypertension, dyslipidemia, obesity) and cirrhosis secondary to NASH and alcohol who underwent deceased donor OLT. Eighteen months postoperatively, the patient had gained 20 pounds and required multiple medications to control her blood pressure and diabetes. Subsequent abdominal ultrasound with doppler demonstrated hepatic steatosis, patent transplant vasculature and no ascites. Despite dietary and lifestyle modifications, the patient could not lose weight. She continued to have elevated transaminases (up to aspartate aminotransferase 58, alanine aminotransferase 82) prompting suspicion for recurrent NASH. The patient was ultimately referred for LSG. Her BMI prior to LSG was 37; seven weeks postoperatively it decreased to 32. Her liver function test normalized, and she no longer required Metformin.

DISCUSSION:
NAFLD is the most common chronic liver disorder in developed countries, and NASH cirrhosis is the second most common cause for liver transplant in the United States. Approximately 3-5% of the population in the United States lives with NASH, and this number is expected to rise with the obesity epidemic. Further troubling is NASH and cryptogenic cirrhosis seen in post-OLT patients, with one study citing 39% of those transplanted for NAFLD-related cirrhosis show steatosis on biopsy six months after transplant. Bariatric surgery, both RYGB and LSG, can reverse NAFLD histology, and only recently have retrospective reviews examined bariatric surgery as a successful means of halting and reversing NAFLD in the post-transplant patient. As with the case of our patient, bariatric surgery can provide an effective means of treating NAFLD in the post-OLT patient with metabolic syndrome. More research is currently needed to establish optimal patient selection criteria and long term efficacy in this regard.
2447 A Case of Daptomycin Causing Drug-Induced Liver Injury
Authors: Gurm Hashroop , Bekele Ezana , Arefiev Yevgeniy , Mohanty Smruti R. 
Published: October 2019

INTRODUCTION:
Drug-induced liver injury (DILI) is the most common cause of acute liver failure. DILI is rare and characterized by elevated creatinine kinase (CK) and liver enzymes without associated end-organ damage. We present a rare case of daptomycin associated hepatotoxicity without corresponding elevation in CK.

CASE DESCRIPTION/METHODS:
A 87-year-old man with a history of hypertension, hyperlipidemia, benign prostate hyperplasia, closed fracture of distal lateral malleolus of left ankle, and atrial fibrillation on apixaban presented to the ED from rehab facility with complaints of one day of shortness of breath, cough, diarrhea, and nausea. Patient was a poor historian. He also has had poor oral intake. He was unable to state if he had any prior gastrointestinal problems. No tobacco, alcohol, illicit drug use. On physical examination, patient was noted to have mild purulent drainage on plantar surface of right fifth metatarsal phalangeal joint. A CT scan of foot ruled out osteomyelitis. On admission, labs revealed elevated transaminases with AST 113, likely due to congestive hepatopathy, as per echocardiogram with elevated right ventricular systolic pressure. All other liver enzymes were within normal limits. Blood cultures resulted in Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and he was subsequently started on vancomycin (due to penicillin allergy). After 7 days of vancomycin therapy, he was switched to daptomycin due to the rising creatinine levels. Next 5 days, LFTs trended up dramatically with the initiation of daptomycin. All non-essential medications were discontinued at this time. LFTs peaked at total bilirubin 1.4, AST 432, ALT 535 and alkaline phosphatase (AP) 161. CK was normal. At this time, daptomycin was discontinued. LFTs started a steep downtrend one day after cessation of daptomycin (Figure 1). The rise in creatinine, total bilirubin, and initial CK levels were temporally related to the initiation of vancomycin infusions (Figure 2). Autoimmune work up and hepatitis panel were all negative. An abdominal ultrasound showed hepatomegaly (16.5 cm) with diffuse hypoechoic texture. Liver doppler showed normal flow.

DISCUSSION:
Daptomycin induced hepatotoxicity without evidence of elevated CK levels is rare. The pathophysiology is unclear. There is limited literature on DILI without renal failure or rhabdomyolysis in setting of daptomycin use. We only found one case in literature. The long-term sequela has not been fully studied, thus liver enzymes should be monitored closely.
2448 Late Hepatic Artery Thrombosis Causing Bowel Ischemia
Authors: Garrido Daniel , Halegoua-DeMarzio Dina 
Published: October 2019

INTRODUCTION:
Hepatic artery thrombosis (HAT) is a potentially life-threatening complication following orthotopic liver transplantation (OLT). HAT can be further classified as early-onset HAT (EHAT), occurring <30 days after OLT or late-onset HAT (LHAT), occurring >30 days after OLT. Symptoms include elevated transaminases, fever, abdominal pain, nausea and vomiting. We report a rare case of LHAT in a liver transplant recipient 8 years status post from OLT presenting with atypical symptoms.

CASE DESCRIPTION/METHODS:
A 58-year-old male with a history of hepatitis C virus (HCV) cirrhosis with OLT in 2011, with sustained virologic response (SVR) s/p HCV treatment, presented with severe left-sided abdominal pain and fever. Laboratory data was remarkable for leukocytosis and a mild elevation in transaminases. Due to concern of possible sepsis, he was initially treated on broad-spectrum antibiotics. Subsequent abdominal ultrasound was unable to visualize the hepatic artery, which was confirmed with CT angiogram showing cut off of the transplant hepatic artery 8 mm from its origin as well as a small right lobe infarct. He was started on anticoagulation but three days later he had worsening fever, increasing oxygen requirement, and markedly elevated transaminases. Interventional radiology attempted catheter directed thrombolysis, however this failed. Over the course of the following weeks, his transaminases started to decline, but he continued to have several days of low-grade fevers, secondary to hepatic necrosis.

DISCUSSION:
This case provides an atypical presentation of HAT in a distant status post OLT patient. The etiology of late HAT remains unclear despite multiple reviews of literature. The overall incidence of late HAT is as low as 2.1%, and the likelihood of occurring years later is even lower. In our patient, despite his distant OLT, he presented with a unique presentation of LHAT, masquerading as a sepsis-like picture. This case demonstrates the importance of considering HAT in patients with a distant OLT presenting with abdominal pain. Identifying this could help us stratify these patients for consideration of re-transplantation and appropriate treatment. A recent study demonstrated that conservative management of late HAT patients with only minor complications was deemed safe. In the case of our patient, due the improving nature of his condition, he was ultimately treated conservatively and monitored on an outpatient basis.