Liver and serum adiponectin levels in non-alcoholic fatty liver disease.

OBJECTIVE: Adiponectin is an adipokine that has anti-steatotic, anti-inflammatory and anti-fibrotic effects. The impact of these different activities impact on the development and progression of non-alcoholic fatty liver disease (NAFLD) is not well understood. The aim of this study was to evaluate both liver and serum adiponectin levels in patients with and without NAFLD and determine any clinical correlations. METHODS: Liver tissue and serum samples were collected from patients undergoing liver biopsy between April 2014 and July 2020, and categorized based on histopathological diagnosis into hepatic steatosis (HS), non-alcoholic steatohepatitis (NASH), and hepatitis control (HC). A Luminex xMAP assay was performed on both liver and serum samples to measure adiponectin levels. Statistical analysis compared liver adiponectin (LA) and serum adiponectin (SA) levels between groups. RESULTS: A total of 48 participants were included in the analysis. The mean LA level was lowest in the HS group, followed by the NASH group and the HC group (P = 0.036). The mean SA level was 3.61 µg/mL for the NAFLD group and was significantly lower than that in the HC (7.51 µg/mL; P = 0.001). CONCLUSION: Adiponectin levels are lower in NAFLD compared to HC in both serum and liver tissue. LA levels in patients with HS were significantly lower than in both the NASH and HC groups, suggesting that adiponectin is related to inflammation in the liver and probably reflects its role in the pathogenesis of NAFLD.

Outcomes of Bariatric Surgery in Chronic Liver Disease: a National Inpatient Sample Analysis.

INTRODUCTION: Obesity is a challenging condition to treat in patients with chronic liver disease (CLD). The safety and efficacy of bariatric surgery (BS) in patients with CLD is not well established. The aim of this study is to evaluate outcomes of BS in patients with CLD. METHODS: Data from the National Inpatient Sample for 2012-2015, accounting for over 7 million discharges, were analyzed. All patients undergoing BS were identified using ICD-9/CPT codes. Patients were then stratified based on the presence of CLD using ICD-9 codes. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges (THC). Secondary outcomes, including infection, bleeding, improper wound healing, and surgical revision, were identified using ICD-9 codes. RESULTS: A total of 302,306 patients underwent BS, of which 20,095 (6.6%) were diagnosed with CLD. CLD patients had greater inpatient mortality, with adjusted odds ratio of 1.47 (95% CI 1.24-1.73). CLD patients also had greater THC but shorter LOS. CLD patients had significantly less surgical revision, improper wound healing, and postoperative infection. There was no difference in bleeding complications between groups. CONCLUSION: Inpatient mortality following BS in CLD patients is low; however, there was an increased risk compared with the non-CLD population. Postoperative complications were no different or even less frequent in CLD patients compared with the general population. BS should not be discounted as a treatment option for obesity in patients with CLD.

Secondary Gastrointestinal Melanoma of Unknown Origin: A Case Report of a Rare Entity.

Metastatic oculocutaneous melanoma is a malignant process most commonly identified in the lungs, bone, gastrointestinal tract (most frequently the liver), and brain. In most cases, the primary oculocutaneous lesion responsible for the metastases is identified. However, in very rare cases, patients present with metastatic lesions with an occult primary site, termed melanoma of unknown primary (MUP), secondary to the partial or complete regression of the primary lesion. We describe the case of an 89-year-old male whose initial diagnosis of achalasia was later identified to be MUP in the cardia of the stomach with protrusion into the esophagus.

Nonalcoholic fatty liver disease does not predict worse perioperative outcomes in bariatric surgery.

Nonalcoholic fatty liver disease (NAFLD) occurs in 84-95% of obese individuals. Bariatric surgery (BS) is an effective treatment of obesity, with a potential sustained weight loss of 21-45%. The safety and efficacy of BS among NAFLD patients is not well established. The aim of this study was to determine outcomes for patients with NAFLD undergoing BS compared to patients without. METHODS: All adults undergoing BS were identified from the National Inpatient Sample 2012-2015 and stratified based on the presence of NAFLD using ICD-9/CPT codes. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges (THC). Secondary outcomes included infection, bleeding, improper wound healing and surgical revision. RESULTS: 302,306 patients underwent BS, of which 15,607 had NAFLD and 286,699 did not (non-NAFLD). NAFLD patients had 35% lower inpatient mortality and shorter LOS, but slightly greater THC. NAFLD patients had smaller risk of improper wound healing and post-operative infection. There was no difference in bleeding, or incidence of surgical revision between groups. CONCLUSION: NAFLD patients had lower mortality and complication rates following BS. A significant postsurgical weight loss should attenuate liver inflammation and fibrosis, and therefore has the potential to stop or even reverse progression of liver disease.

Metastatic cholangiocarcinoma in a patient with undiagnosed Wilson disease.

Cholangiocarcinoma (CC) is the second most common primary hepatic malignancy. Although the frequency of malignancy is generally increased in chronic liver disease, CC rarely presents in Wilson disease (WD). The incidence of hepatic malignancy in WD is only 1.2%, with CC accounting for 0.5%. A 66 year old male with history of hypertension, diabetes, and compensated cryptogenic cirrhosis presented with acute onset dyspnea and pleuritic chest pain. He was incidentally found to have a sizeable mass in the right hepatic lobe. Ultimately, a liver biopsy revealed dense demoplasia and increased mucin production, consistent with diagnosis of CC. Biopsy also demonstrated increased copper deposition consistent with WD, explaining the patient's underlying cirrhosis. Unlike other forms of chronic liver disease where incidence of liver cancer is increased, the lower rate of malignancy seen in WD may be explained by a protective effect of copper in WD. Copper acts to both directly stabilize DNA and inhibit angiogenesis. In this case, it is possible that the degree of copper deposition in his liver was mild, causing cirrhosis and the chronic liver inflammation that caused his CC. However, it may not have been sufficient to "protect" against development of CC.

SPINK-1 Polymorphism as a Pancreatitis Risk Factor.

Pancreatitis in both acute and chronic variants is a common health concern in the US as well as globally. While the most common etiologies for disease remain gallstone impaction in the common bile duct and alcohol abuse, recent studies have shown that genetics may play a significant role as well. Unfortunately, this correlation is not clearly defined and at present, we lack the ability to identify which patients with known pancreatic genetic polymorphisms will develop pancreatitis. We describe the case of a middle-aged male who presented with recurrent pancreatitis in the setting of the serine peptidase inhibitor, Kazal type 1 (SPINK-1) genetic polymorphism. Additionally, we discuss the mechanism behind SPINK-1 polymorphisms in the development of pancreatitis as well as the role of genetic screening for the polymorphism in the general population.

Chronic Liver Disease Patients have Worse Outcomes and Increased Postoperative Complications After Orthopedic Fractures.

INTRODUCTION: Cirrhotic patients are at a higher risk for sustaining orthopedic fractures with a reported prevalence of 5% to 20%. Cirrhosis also affects wound healing and bleeding risk, and hence, impacts the postoperative outcomes after fracture repair. However, there is limited data available on the postoperative risk factors and clinical outcomes of fractures in patients with chronic liver disease (CLD). METHODS: Data from the National Inpatient Sample for the years 2012 to 2015 were analyzed. Patients were identified using ICD-9 codes for any fracture. ICD-9 codes for CLD were used to categorize patients into CLD and non-CLD groups. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges. Secondary outcomes included complications such as postoperative infection, prosthetic failure, bleeding, and improper wound healing. RESULTS: A total of 931,193 patient encounters for orthopedic fractures were identified and divided into 17,388 with CLD and 913,806 without CLD (non-CLD). The inpatient mortality in patients with CLD was almost twice that of non-CLD patients (odds ratio, 1.95; 95% confidence interval, 1.8-2.1). Patients with CLD also had a longer mean LOS at 7.4±8.6 days versus 5.6±7.2 days (P<0.001) and higher total hospital charges at $76,198±99,494 versus $64,294±95,673 (P<0.001). CLD patients also had higher rates of infections, improper wound healing, and bleeding. DISCUSSION: In this large retrospective study, CLD patients with fractures had significantly higher mortality, LOS and hospital charges. These findings correlate with the higher rates of infection, bleeding, and poorer wound healing in this population. Increased clinician awareness of these risks is a key to improving the care of CLD patients.

Hepatic Angiosarcoma: A Challenging Diagnosis.

Hepatic angiosarcoma (HA) accounts for 2% of primary liver tumors. Though rare, it is exceptionally deadly. The initial presentation of HA is nonspecific and no tumor markers have been associated with it. In general, liver function is maintained until later stages of the disease, often leading to diagnosis once the disease is already advanced or metastatic. In this report, we present the case of a 54-year-old male whose vague symptoms and non-diagnostic liver biopsy delayed the diagnosis of a rapidly progressing HA.

HBV-HCV Coinfection: Viral Interactions, Management, and Viral Reactivation.

Hepatitis B virus (HBV) and hepatitis C virus (HCV) coinfection is a complex clinical entity that has an estimated worldwide prevalence of 1-15%. Most clinical studies have shown that progression of disease is faster in HBV-HCV coinfected patients compared to those with monoinfection. Hepatocellular carcinoma development appears to have higher rate in coinfections. Viral replication in coinfected cells is characterized by a dominance of HCV over HBV replication. There are no established guidelines for treatment of HBV-HCV coinfection. Studies on interferon-based therapies and direct-acting antivirals have shown varying levels of efficacy. Clinical reports have indicated that treatment of HCV without suppression of HBV increases the risk for HBV reactivation. In this review, we appraise studies on both direct-acting antivirals and interferon-based therapies to evaluate the efficacy and rates of reactivation with each regimen. Screening for and prevention of coinfection are important to prevent serious HBV reactivations.

Differentiating Cystic Liver Lesions: A Review of Imaging Modalities, Diagnosis and Management.

Hepatic cysts (HCs) are frequently discovered incidentally on abdominal imaging. The prevalence of HCs has been reported as high as 15-18% in the United States. Although most cysts are benign, some are malignant or premalignant. It is important to diagnose cystic lesions in order to properly manage them. Imaging with conventional ultrasound, computed tomography, magnetic resonance imaging, or contrast-enhanced ultrasound can be used to further characterize and diagnose HCs. Ultrasound is typically the first-line imaging modality, whereas more advanced imaging can help narrow down the specific lesion. Contrast-enhanced ultrasound is a newer modality, recently approved in the United States, which offers non-invasive evaluation in real-time. The first step in diagnosis is stratifying risk by differentiating simple and complex cysts. There are several features that can help identify HCs, including septae, mural consistency, calcifications, and quality of cystic fluid. Simple cysts are mainly congenital cysts, but also occur in polycystic liver disease. Complex cysts include mucinous neoplasms, echinococcal cysts, hemorrhagic cysts, cystic hepatocellular carcinoma and other rare lesions. Treatment is indicated in symptomatic cysts or those suspicious for malignant or premalignant features. Treatment modalities include fenestration, aspiration sclerotherapy, or surgical resection.

Acute Esophageal Necrosis: A Case Series.

Acute esophageal necrosis (AEN) is a particularly rare syndrome with an incidence of only 0.1-0.28%, whose appearance is notable for proximal extensions of black, necrotic appearing mucosa extending proximally in the esophagus and abruptly interrupted at the gastroesophageal junction. In this case series, we explore the cases of two males: one middle-aged and one elderly, who after presenting with emesis, were found to have acute esophageal necrosis on esophagogastroduodenoscopy.

Mechanisms and Prevention of Vertical Transmission in Chronic Viral Hepatitis.

Vertical transmission (VT) is the primary route of transmission of viral hepatitis in children. The rate of VT ranges from 1-28% with hepatitis B virus (HBV) and 3-15% with hepatitis C virus (HCV). VT for both viruses can occur during the intrauterine or peripartum period. VT of HBV primarily occurs by intrauterine transmission (IUT). Hepatitis B surface antigen is unable to cross the placenta and, therefore, relies on processes like transplacental leakage, placental infection, cellular transmission by peripheral blood mononuclear cells, and germline transmission. HCV can also infect the fetus by IUT. Both viruses also have the potential for transmission during delivery, when there is increase chance of maternal-fetal blood exposure. HBV and HCV share some common risk factors for VT, including maternal viral load, human immunodeficiency virus co-infection and neonatal sex. Prevention of VT differs greatly between HBV and HCV. There are several alternatives for prevention of HBV VT, including antiviral medications during the third trimester of pregnancy and HBV vaccine, as well as hepatitis B immunoglobulin administration to infants post-partum. In contrast, there are no preventative interventions available for HCV. Despite these differences, the key to prevention with both viruses is screening women prior to and during pregnancy.

The Evolving Nature of Hepatic Abscess: A Review.

Hepatic abscess (HA) remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed the portal system. However, over the years, the etiologies and risks factors for HA have continued to evolve. Prompt recognition is important for instituting effective management and obtaining good outcomes.