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A 61-year-old male patient had four hospital admissions with Escherichia coli sepsis fever and abnormal liver function tests over an 8-year period of time (maximum aspartate aminotransferase 82 IU/L, maximum alkaline phosphatase 231 IU/L and bilirubin normal). On each occasion he was

Ultrasonography is often the initial modality used to evaluate patients found to have abnormal liver function tests (LFTs) in the emergency department. While an assessment for biliary ductal dilatation and obstruction remains one of the main questions to answer, radiologists should also be aware of the ultrasonographic appearance of other conditions that can cause abnormal LFTs. This may be crucial for the management and disposition of patients in the emergency department. This article reviews the ultrasonographic features of diseases that may cause abnormal LFTs.

Objectives: The current study aimed to describe the incidence of abnormal liver function tests (LFTs) in pregnant COVID-19 patients, explore the association between LFTs with current medication, and provide a reference for medical therapy of pregnant patients with COVID-19. Material and methods: This retrospective single tertiary center cohort study included 122 pregnant patients with confirmed COVID-19 admitted and treated from April 1, 2020, to May 31, 2020. We defined abnormal LFTs as the elevation of the following liver enzymes in serum per our hospital’s laboratory reference range standards: AST > 35 U/L, ALT > 35 U/L, and TBIL > 1.2 mg/dL. We evaluated patients for demographic and clinical features, laboratory parameters, medications, and hospital length of stay (LOS). Results: Patients in this cohort had clinical presentations of fever (84.4%), dry cough (78.6%), and shortness of breathing (6.5%). In total, 17 (13.9%) patients had abnormal LFTs during hospitalization. Critically ill patients were three-fold higher in the abnormal LFTs group (11.8%) than in the normal LFTs group (3.8%, p = 0.16). The proportion of patients who used hydroxychloroquine and lopinavir/ritonavir were significantly higher in patients with abnormal LFTs (88.2% and 35.3%, respectively) than those with normal LFTs (62.9% and 15.2%, p = 0.04 and p = 0.04, respectively). The hospital length of stay (LOS) was significantly longer in the abnormal LFTs group (8.2 ± 5.8 days) than in the normal LFT group (6.0 ± 2.8 days, p = 0.02). Conclusions: SARS-CoV-2 may induce liver injury and the LFT abnormality was generally mild in pregnant patients with COVID-19. Abnormal LFTs are associated with prolonged hospital LOS. Drug use was the most crucial risk factor for liver injury during hospitalization. The use of lopinavir/ritonavir and hydroxychloroquine were significantly higher, and the course of treatment of these drugs was significantly longer in pregnant women with abnormal LFTs than the patients with normal LFTs. Therefore, pregnant women with COVID-19 who received antiviral treatment should be closely monitored for evaluating LFTs.

Aloe vera is a medicinal plant widely used for biomedical, pharmaceutical, and cosmetic applications. Oodles studies are going on to evaluate the protective role of Aloe vera while treating it along with different adjuvants compounds/drugs or plants. Therefore, here we aimed to illuminate the combined effect of Aloe vera and Vitamin E against CCl4-induced toxicity. Rats treated with CCl4 displayed reduced body weight, impaired peripheral and cellular (serum/tissues) redox/defense system, abnormal liver function tests, and abnormal histology (liver/Brain); the effect was rescued by the Aloe vera (ethanolic extract) treatment. However, the adjuvant treatment of Vitamin E significantly enhanced the anti-toxic impact of Aloe vera by attenuating free radical production, boosting antioxidants enzyme activities, and improving liver and brain tissues histology. Our findings suggest that Vitamin E enhances the beneficial effects of Aloe vera and could be used as an adjuvant.

Coronavirus disease 2019 (COVID‐19) is an important health problem that has a serious adverse impact on the global economy and healthcare systems. The virus is not only involved in the respiratory system, but also causes other systemic effects as well as several gastrointestinal and liver issues. Evidence has shown direct viral invasion into the gastrointestinal tissue and supporting vascular network, causing various manifestations such as diarrhea, nausea, gastrointestinal bleeding, and abnormal liver function tests. The degree of gastrointestinal injury, especially in terms of liver involvement, is correlated with disease severity. There is no specific treatment for gastrointestinal involvement, and the symptoms can be managed with supportive therapy. Moreover, increased liver decompensation and mortality can be found in COVID‐19‐infected patients with coexisting liver disease. As the virus can be identified in gastrointestinal contents, endoscopic procedures during the pandemic should be carefully selected and proper protection strategies should be encouraged to prevent viral transmission., Patients with coronavirus disease 2019 typically present with fever and respiratory symptoms; however, gastrointestinal symptoms and liver issues have also been reported. Endoscopic procedures during the pandemic should be carefully selected and proper protection strategies should be encouraged to prevent viral transmission.

In patients with treatment-resistant epilepsy (TRE), cannabidiol (CBD) produces variable improvement in seizure control. Patients in the University of Alabama at Birmingham CBD Expanded Access Program (EAP) were enrolled in the genomic study and genotyped using the Affymetrix Drug Metabolizing Enzymes and Transporters plus array. Associations between variants and CBD response (≥50% seizure reduction) and tolerability (diarrhea, sedation, and abnormal liver function) was evaluated under dominant and recessive models. Expression quantitative trait loci (eQTL) influencing potential CBD targets was evaluated in the UK Brain Expression Consortium data set (Braineac), and genetic co-expression examined. Of 169 EAP patients, 112 (54.5% pediatric and 50.0% female) were included in the genetic analyses. Patients with AOX1 rs6729738 CC (aldehyde oxidase; odds ratio (OR) 6.69, 95% confidence interval (CI) 2.19-20.41, P = 0.001) or ABP1 rs12539 (diamine oxidase; OR 3.96, 95% CI 1.62-9.73, P = 0.002) were more likely to respond. Conversely, patients with SLC15A1 rs1339067 TT had lower odds of response (OR 0.06, 95% CI 0.01-0.56, P = 0.001). ABCC5 rs3749442 was associated with lower likelihood of response and abnormal liver function tests, and higher likelihood of sedation. The eQTL revealed that rs1339067 decreased GPR18 expression (endocannabinoid receptor) in white matter (P = 5.6 × 10-3 ), and rs3749442 decreased hippocampal HTR3E expression (serotonin 5-HT3E ; P = 8.5 × 10-5 ). Furthermore, 75% of genes associated with lower likelihood of response were co-expressed. Pharmacogenetic variation is associated with CBD response and influences expression of CBD targets in TRE. Implicated pathways, including cholesterol metabolism and glutathione conjugation, demonstrate potential interactions between CBD and common medications (e.g., statins and acetaminophen) that may require closer monitoring. These results highlight the role of pharmacogenes in fundamental biologic processes and potential genetic underpinnings of treatment-resistance.

Hepatitis A virus immunoglobulin M (HAV-IgM) is often used to diagnose acute hepatitis A virus (HAV) infection serologically. However, false-positive test results can interfere with the diagnosis. A 56-year-old woman was readmitted to the hospital owing to abnormal liver function tests for the last 18 months. She had been diagnosed with acute HAV and was hospitalized in isolation based on a positive HAV-IgM test 18 months ago. Regular follow-up after discharge showed abnormal liver function and an elevated level of antinuclear antibodies and immunoglobulin G. For the last 15 days, the patient had fatigue, decreased appetite, and yellow urine, signaling recrudescence. Liver function tests were also abnormal. Liver biopsy revealed histological changes consistent with typical autoimmune hepatitis. After 2 months of methylprednisolone treatment, liver function returned to normal, and HAV-IgM turned negative. The diagnosis of acute HAV in nonendemic areas requires a comprehensive analysis of epidemic history, clinical characteristics, etiology, etc.

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon condition characterized by abnormal, excessive immune activation resulting in severe cytopenias from an uncontrolled inflammatory response. It can be primary/ familial or secondary/sporadic. Infections, particularly viral infections are a common cause of secondary HLH. HLH due to Human monocytic ehrlichiosis (HME) is very rare, hence we are reporting our cases. Objective: To review cases of Ehrlichia-associated HLH at our institution and perform a literature review regarding this entity. Methods: We reviewed cases of Ehrlichia-associated HLH for the previous two years at our institution (Carilion Clinic). We then performed a review of the published literature on it, using Pubmed. Results: Over the past two years, five cases of Ehrlichia-associated HLH were diagnosed at our hospital. The average age of the patients was 67 years with predominantly males. All the patients were pancytopenic, and a majority had abnormal liver function tests. Diagnosis of ehrlichiosis was made by serum polymerase chain reaction (PCR) assay on blood. Patients had further testing done because of lack of clinical improvement. All patients had significantly elevated ferritin levels. Bone marrow biopsy samples of all patients showed findings of hemophagocytosis. All, but one, patients were treated with doxycycline and a combination of etoposide and dexamethasone. Three patients recovered while two died. On review of medical literature, we found a total of only 36 cases of Ehrlichia-associated HLH, including our five cases. There were 19 adults and 17 children. Both population groups showed varying degrees of pancytopenia. Splenomegaly was relatively uncommon, seen in less than one-third of the patients. Ferritin and triglyceride levels were routinely elevated. Bone marrow biopsy showing hemophagocytosis was the confirmatory test in all patients. A significant number of patients, both adults and children, required a combination of doxycycline and chemotherapy (etoposide and dexamethasone) to achieve clinical cure. Children had a better prognosis than adults, with one child and four adults succumbing to their illness. Conclusions: Ehrlichia-associated HLH is a rare but emerging disease entity. In endemic areas, a high degree of suspicion is required to diagnose ehrlichiosis and HLH resulting from it. Early diagnosis and prompt initiation of treatment for HLH is key to a favorable outcome.

Severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) is a novel coronavirus that causes coronavirus disease 19 (COVID‐19), which has infected millions of people worldwide in only a few months. A minority, but significant number, of infected individuals require hospitalization and intensive care. From the start of this new virus pandemic, it was apparent that obese and/or diabetic individuals had a bad prognosis for COVID‐19 progression, strongly suggesting an association between liver disease and severe COVID‐19. Because chronic liver disease (CLD) is associated with immune dysregulation and inflammation, it is unsurprising that patients with CLD may carry a greater risk of adverse outcomes following SARS‐CoV‐2 infection. Initial COVID‐19 data have also indicated that healthy infected individuals display abnormal liver function tests, suggesting a possible direct implication of SARS‐CoV‐2 in liver damage. Here we show that COVID‐19 affects the liver metabolism and increases the morbidity and mortality of individuals with underlying CLD., Chronic liver disease is associated with COVID‐19 severity and mortalityClinical indicators of liver disease can be prognostic markers of COVID‐19 severityLong‐term liver impact of COVID‐19 must not be neglected and warrants further investigation

Introduction The World Health Organization (WHO) identified a novel coronavirus, originating in Wuhan, China, in December 2019, as a pneumonia causing pathogen. Epidemiological data in Romania show more than 450.000 confirmed patients, with a constant number of approximately 10% admission in intensive care unit. Method A retrospective, observational study was conducted from 1st March to 30th October 2020, comprising 657 patients, confirmed as having COVID-19, and who had been admitted to the intensive care unit of the Mures County Clinical Hospital, Tîrgu Mures, Romania, which had been designated as a support hospital during the pandemic. Patients who presented at admission or developed abnormal liver function tests in the first seven days of admission, were included in the study; patients with pre-existing liver disease, were excluded. Results The mean (SD) age of patients included in the study was 59.41 (14.66) years with a male: female ratio of 1.51:1. Survivor status, defined as patients discharged from the intensive care unit, was significantly associated with parameters such as age, leukocyte count, albumin level, glycaemia level (p Conclusions Liver injury expressed through liver function tests cannot solely constitute a prognostic factor for COVID-19 patients, but its presence in critically ill patients should be further investigated and included in future guideline protocols.

BACKGROUND In December 2019, COVID-19 emerged from China and spread to become a pandemic, killing over 1,350,000 up to November 18, 2020. Some patients with COVID-19 have abnormal liver function tests. We aimed to determine the clinical significance of liver chemistries in patients with COVID-19. METHODS We performed a cross-sectional study of 1044 consecutive patients with confirmed COVID-19 in two referral hospitals in Tehran, Iran, from February to April 2020. All cases were diagnosed by clinical criteria and confirmed by characteristic changes in the spiral chest computed tomography (CT) and nucleic acid testing of the nasopharyngeal samples. We evaluated the association between abnormal liver enzymes or function tests and survival, intensive care unit (ICU) admission and fatty liver changes in CT scans. RESULTS The mean age was 61.01 ± 16.77 years, and 57.68% were male. Of 495 patients with elevated alanine transaminase (ALT) levels, 194 had chest CT scans, in which fatty liver disease was seen in 38.1%. 41 patients (21.13%) had moderate to severe, and 33 (17.01%) had borderline fatty liver disease. Bilirubin, albumin, and partial thromboplastin time (PTT), along with other markers such as HCO3 , C-reactive protein (CRP), triglyceride, and length of admission, were significantly associated with ICU admission and mortality. Prothrombin time (PT), platelet count, and low-density lipoprotein (LDL) levels were also correlated with mortality. Fasting blood sugar (FBS) and pH were important indices in ICU admitted patients. CONCLUSION Liver function tests accurately predict a worse prognosis in patients with COVID-19. However, liver enzymes were only slightly increased in those who died or needed ICU admission and were not related to the fatty liver changes.

Background Abnormal liver function tests (LFT) are common in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vary from 15% to 53%. There are scanty data from India on the prevalence of liver injury in corona virus disease 2019 (COVID-19) patients. Methods We did this retrospective study in a tertiary care hospital, Chennai, India. Patients aged >18 years admitted with COVID-19 from May 1, 2020, to May 31, 2020, were included. We noted the demographic details, symptoms at presentation, history of pre-existing illnesses, and laboratory tests. We also recorded the patient’s clinical course and outcome. Results We took 445 patients for final analysis. Aspartate transaminase (AST) was borderline elevated in 47.5%, mildly elevated in 11.2%, moderately elevated in 2% and severely in 0.7%. Alanine transaminase (ALT) was borderline elevated in 28.7%, mildly elevated in 11.4%, and moderately elevated in 1.3%. Bilirubin and alkaline phosphatase were abnormal in only 19 (4.2%) and 15 (3.3%) patients, respectively. Patients with abnormal LFT were more likely to be symptomatic (90.3% vs. 80.6%, p 0.002). Respiratory symptoms (43.5% vs. 29.7%) and loose stools (11.4% vs. 3.4%) were also more common among them. Patients with abnormal LFT were more likely to have severe disease (25.2% vs. 13.6%, p value 0.003) and mortality (8.8% vs. 0.7%). Conclusion Liver test abnormalities were widespread in patients with COVID-19. Most of the patients had borderline or mild transaminase elevation. Despite only mild changes, patients with abnormal LFT were more likely to be symptomatic and had more severe disease and mortality.

A 72-year-old woman with an elevated body mass index and moderate alcohol intake was seen in the gastroenterology clinic. The patient had a past history of abnormal liver function tests and previous biopsy-proven steatosis with early fibrosis. She was reevaluated, following an initial loss to follow-up, by using US elastography to assess for fibrosis progression. The utility of US elastography in the noninvasive diagnosis and longitudinal monitoring of hepatic fibrosis is discussed. An overview of available technologies, including transient elastography and shear-wave elastography, is provided. ©RSNA, 2021 Online supplemental material is available for this article.

Objective: Approximately 30% of preeclamptic pregnancies exhibit abnormal liver function tests. We assessed liver injury-associated enzyme levels and circulating transforming growth factor beta (TGF-β) levels in an arginine vasopressin (AVP)-induced pregnant Sprague-Dawley rat model.Methods: Pregnant and non-pregnant Sprague-Dawley rats (n=24) received AVP (150 ng/hr) subcutaneously via mini-osmotic pumps for 18 days. Blood pressure was measured, urine samples were collected, and all animals were euthanized via isoflurane. Blood was collected to measure circulating levels of TGF-β1-3 isomers and liver injury enzymes in pregnant AVP (PAVP), pregnant saline (PS), non-pregnant AVP (NAVP), and non-pregnant saline (NS) rats. Results: The PAVP group showed significantly higher systolic and diastolic blood pressure than both saline-treated groups. The weight per pup was significantly lower in the AVP-treated group than in the saline group (p

Background: A large number of patients admitted to the medical intensive care unit (MICU) have abnormal liver function tests (LFT). This includes patients with critical illness with or without preexisting liver disease and patients with acute primary liver injury. There are very few studies which have investigated the spectrum of liver disease, clinical profile and outcome in patients admitted to the MICU. Objective To evaluate the occurrence, etiology, clinical profile, laboratory profile and outcome of hepatic dysfunction in patients admitted to the MICU. To evaluate the utility of model for end-stage liver disease (MELD) score on admission as a predictor of adverse short term outcome in patients with hepatic dysfunction admitted in MICU. Methods: It was a prospective observational study, conducted from December 2017 to December 2018 in a tertiary care hospital. Two hundred and two patients admitted to the MICU with LFTs as per the inclusion criteria were analyzed and their short-term outcome at 7 days was studied in relation to various parameters. Results: LFT abnormalities were present in 202/1126 (17.9%) of the patients admitted to MICU. Critical illness associated liver dysfunction was found in 172 (85.2%) patients, chronic liver disease in 11 (5.4%) patients and acute viral hepatitis in 19 (9.4%) patients. Most common symptom was fever (68.3%) followed by vomiting (48.0%). Among LFT abnormalities, elevated transaminases, raised international normalized ratio and high MELD score on admission correlated with poor short-term outcome. Requirement for inotropes and mechanical ventilation correlated with poor short-term outcome. Mortality did not differ significantly between patients with chronic liver disease, patients with acute viral hepatitis and patients with critical illness associated hepatic dysfunction. Hepatic dysfunction in MICU was associated with poor outcome and a high short-term mortality of 56.4% (114/202). Conclusion: Liver function abnormality is common in patients who are admitted to the MICU and its presence is an indicator of poor short-term outcome. RESUMO Contexto: Um grande número de pacientes internados na unidade de terapia intensiva (UTI) tem testes de função hepática anormais (TFH). Isso inclui pacientes com doença crítica com ou sem doença hepática pré-existente e pacientes com lesão hepática primária aguda. Há poucos estudos que têm investigado o espectro da doença hepática, perfil clínico e desfecho em pacientes admitidos em UTI. Objetivo Avaliar a ocorrência, etiologia, perfil clínico, perfil laboratorial e desfecho de disfunção hepática em pacientes internados na UTI médica. Avaliar a utilidade do modelo para doença hepática em estágio terminal (MELD). Escore na admissão como preditor de desfecho adverso a curto prazo em pacientes com disfunção hepática admitida em UTI. Métodos: Foi realizado um estudo observacional prospectivo, de dezembro de 2017 a dezembro de 2018 em um hospital de atenção terciária. Foram analisados 202 pacientes internados na UTI com TFH conforme os critérios de inclusão e seu desfecho a curto prazo de 7 dias foi estudado em relação a diversos parâmetros. Resultados: Anormalidades dos testes estiveram presentes em 202/1126 (17,9%) dos pacientes internados na UTI. Doença crítica associada à disfunção hepática foi encontrada em 172 (85,2%) pacientes, doença hepática crônica em 11 (5,4%) pacientes e hepatite viral aguda em 19 (9,4%) pacientes. O sintoma mais comum foi a febre (68,3%), seguido de vômito (48,0%) casos. Entre as anormalidades do TFH, transaminases elevadas, INR e escore MELD elevados na admissão correlacionaram-se com desfecho ruim de curto prazo. Exigência de inotrópicos e ventilação mecânica correlacionaram-se com desfecho de curto prazo ruim. A mortalidade não diferiu significativamente entre pacientes com doença hepática crônica, pacientes com hepatite viral aguda e pacientes com doença crítica associada à disfunção hepática. A disfunção hepática em UTI esteve associada a um desfecho ruim e à uma alta mortalidade a curto prazo de 114/202 (56,4%). Conclusão: A anormalidade da função hepática é comum em pacientes que são admitidos nas unidades de tratamento intensivo e sua presença é um indicador de desfecho de curto prazo ruim.

The worldwide outbreak of coronavirus disease 2019 (COVID-19) has challenged the priorities of healthcare system in terms of different clinical management and infection transmission, particularly those related to hepatic-disease comorbidities. Epidemiological data evidenced that COVID-19 patients with altered liver function because of hepatitis infection and cholestasis have an adverse prognosis and experience worse health outcomes. COVID-19-associated liver injury is correlated with various liver diseases following a severe acute respiratory syndrome-coronavirus type 2 (SARS-CoV-2) infection that can progress during the treatment of COVID-19 patients with or without pre-existing liver disease. SARS-CoV-2 can induce liver injury in a number of ways including direct cytopathic effect of the virus on cholangiocytes/hepatocytes, immune-mediated damage, hypoxia, and sepsis. Indeed, immediate cytopathogenic effects of SARS-CoV-2 via its potential target, the angiotensin-converting enzyme-2 receptor, which is highly expressed in hepatocytes and cholangiocytes, renders the liver as an extra-respiratory organ with increased susceptibility to pathological outcomes. But, underlying COVID-19-linked liver disease pathogenesis with abnormal liver function tests (LFTs) is incompletely understood. Hence, we collated COVID-19-associated liver injuries with increased LFTs at the nexus of pre-existing liver diseases and COVID-19, and defining a plausible pathophysiological triad of COVID-19, hepatocellular damage, and liver disease. This review summarizes recent findings of the exacerbating role of COVID-19 in pre-existing liver disease and vice versa as well as international guidelines of clinical care, management, and treatment recommendations for COVID-19 patients with liver disease.

Objectives We aimed to assess the value of liver biopsy in the evaluation of abnormal liver tests. Methods We analyzed consecutive liver biopsy specimens performed for evaluation of unexplained abnormal liver tests from 2014 to 2018. Diagnoses were categorized histologically and clinically. We determined whether histologic examination led to a specific diagnosis and whether prebiopsy laboratory variables predicted the underlying etiology. Results Among the 383 liver biopsy specimens included, chronic hepatitis was the most common histologic (25%) and clinical (17%) diagnosis. Liver biopsy led to a clinical diagnosis in 87% of patients. The most likely clinical diagnoses were autoimmune hepatitis, nonalcoholic fatty liver disease, and drug-induced liver injury (38, 33, and 32 patients, respectively). Using sensitivity, specificity, and positive and negative predictive values, we found that liver tests were not predictive of a specific diagnosis. In patients with no history of liver disease or clinical features of portal hypertension, biopsy specimens revealed histologic cirrhosis in 5% of patients. Conclusions Histopathologic diagnoses were made in 85% of patients undergoing liver biopsy for investigation of unexplained liver tests, leading to a clinical diagnosis in 87% of patients. However, neither liver tests themselves nor their patterns were useful in predicting histologic or clinical diagnoses.

Background Abnormal liver function tests (LFTs) in post-liver transplant (LT) patients pose a challenge in the timing and selection of diagnostic modalities. There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) in diagnosing post-transplant complications. Aim To evaluate the diagnostic performance of ERCP and LB in patients with non-vascular post-LT complications. Methods This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017. Diagnostic operating characteristics including accuracy, sensitivity and specificity for various diagnoses were calculated for ERCP and LB. The R factor (ratio of alkaline phosphatase to alanine aminotransferase) was also calculated for each patient. Results Of the 1284 patients who underwent LT, 91 patients (74.7% males, mean age of 51) were analyzed. Anastomotic strictures (AS, 24.2%), acute cellular rejection (ACR, 11%) and concurrent AS/ACR (14.3%) were the most common diagnoses. ERCP carried an accuracy of 79.1% (95%CI: 69.3-86.9), LB had an accuracy of 93.4% (95%CI: 86.2-97.5), and the combination of the two had an accuracy of 100% (95%CI: 96-100). There was no difference between patients with AS and ACR in mean R factor (AS: 1.9 vs ACR: 1.1, P = 0.24). Adverse events did not differ between the two tests (ERCP: 3.1% vs LB: 1.1%, P = 0.31). Conclusion In patients with abnormal LFTs after LT without vascular complications, the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.

Objectives: The aim of this study was to evaluate the validity of international normalized ratio (INR) in patients with liver diseases or abnormal liver function tests as related to bleeding risk in dental procedures. Materials and Methods: From July 2008 to January 2019, the INR of 187 patients with liver diseases who underwent oral surgical procedures at the Department of Oral and Maxillofacial Surgery Clinic, University of Maryland School of Dentistry was collected and compared with normal value. Patients who were taking anticoagulants were excluded from the data pool. Results: The compiled INR for the 187 patients (M/F = 122/65) with mean age of 47 years (range: 22–77) was 1.126, with a median and mode of 1.1. The standard deviation was 0.17. The range for the INR values was 0.7 (n = 1) to 1.7 (n = 1). Conclusion: In the present study, there was no significant difference between the INR of patients with liver diseases or abnormal liver function tests and normal INR value. This supports the belief that pre-operative INR testing is not a dependable marker to assess bleeding risk in patients with chronic liver diseases who are not taking Vitamin K antagonist anticoagulants.

Introduction: Dengue fever is a major public health problem in tropical and subtropical areas. There are not many studies concerning the complications of dengue fever in pregnancy. We present four serial cases of dengue fever in pregnancy. Case illustration: Three of four cases were delivered by caesarean section; two of them died during post-caesarean care. All cases had the lowest platelet level below 50,000/µL and were given platelet transfusion during and after delivery; they also showed abnormal liver function tests. For foetal outcome, none tested positive for dengue. Discussion: Complication of dengue infection depends on a combination of host and viral virulence. Regardless of prophylactic platelet transfusion, some studies revealed clinical bleeding in patients with dengue infection due to an intricate effect on the haemostatic system. The adverse foetal outcome may contribute because of placental circulation caused by endothelial damage with increased vascular permeability leading to plasma leakage. There is no national guideline for dengue fever in pregnancy. Conclusions: The management of dengue fever in pregnancy at the tertiary hospital is still suboptimal. Dengue fever around peripartum presents a higher risk of morbidity and mortality for the mother and therefore needs a multidiscipline team approach.

Background and study aims Endoscopic ultrasound-guided liver biopsy (EUS-LB) is an accepted technique for tissue acquisition. Traditionally, random LB has been performed with percutaneous (PC-LB) and transjugular (TJ-LB) approaches. The purpose of this study was to compare the safety profile and efficacy of EUS-LB, PC-LB, and TJ-LB. Patients and methods A retrospective analysis was performed at a tertiary academic medical center. Inclusion criteria for analysis were all adult patients who underwent EUS-LB since inception and TJ-LB/PC-LB over a 3-year span (June 2016 to June 2019). The primary outcome assessed was any adverse events. Secondary outcomes included technical success resulting in tissue acquisition and diagnostic adequacy of the sample for histologic analysis. Results A total of 513 patients were included for analysis. There were 135 EUS-LB, 287 PC-LB, and 91 TJ-LB. The most common indication for LB was abnormal liver function tests. For the primary outcome, the rate of adverse events was low with five reported ( Conclusion In comparison with PC-LB and TJ-LB, EUS-LB has comparable safety profile, technical success rate, and diagnostic adequacy. EUS-LB should be considered as an option for random liver biopsy.

SARS-CoV2 is a novel coronavirus responsible for causing COVID-19, first identified in the city of Wuhan, China and officially declared a pandemic by the World Health Organization. SARS-CoV2 expresses high affinity to human ACE2 receptors, including within the gastrointestinal tract. Patients with COVID-19 exhibit a wide spectrum of GI symptoms including anorexia, nausea, vomiting, abdominal pain, and abnormal liver function tests. Pathogenesis behind gastrointestinal symptoms caused by SARS-CoV2 has been postulated to be multifactorial including disruption of the intestinal mechanical barrier integrity, alteration of the gut microbiome and systemic inflammatory response to the virus. SARS-CoV-2 RNA has also been found in stool samples of infected patients for a significantly longer period than in nasopharyngeal samples, though the implication of this finding is unclear at this time. Liver injury in patients with COVID-19 is usually mild, stemming from immune-mediated damage, drug induced hepatotoxicity, or ischemia from sepsis. Patients with pre-existing liver disease may be at a higher risk for hospitalization and mortality. Given the high degree of infectivity of this disease, healthcare providers will need to remain watchful for resurgence of this virus. Strict protocols should be implemented regarding hand hygiene, isolation, personal protective equipment, and appropriate disposal of waste. It is also imperative to identify patients with gastrointestinal symptoms at an early stage as these patients may have a prolonged course between symptom onset and viral clearance.

Introduction Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy specific liver disease characterised by pruritus and abnormal liver function tests and it has been associated with intrauterine fetal distress and stillbirth. We compared two guidelines of the management of ICP: One mandating induction at 38 weeks of gestation (Rigshospitalet and Hvidovre Hospital before 2012) and another separating ICP into a mild and severe form and only women with severe ICP were recommended induction at 38 weeks (Hvidovre Hospital after 2012). Material and methods We performed a historical cohort study at two Copenhagen Hospitals from 2004 to 2015. We included 62,937 women with singleton deliveries at Rigshospitalet and 71,015 at Hvidovre Hospital of which 971 women (1.5%) and 998 women (1.4%) were diagnosed with ICP at Rigshospitalet and Hvidovre Hospital respectively. Data was retrieved from a local medical database. For the analysis of induction and comparison of obstetrical outcomes we only included pregnancies with an ICP diagnosis and excluded women with other medical conditions that could mandate induction. Main outcome measures were induction and cesarean section rates, asphyxia and stillbirth. Results We found no changes in the rate of spontaneous labor, cesarean section and induction over the years at Rigshospitalet (p = 0.17) and Hvidovre Hospital (p = 0.38). For women with intended vaginal delivery we found no change in the final mode of delivery over the years at Rigshospitalet (p = 0.28) and Hvidovre Hospital (p = 0.57). Conclusions The two approaches to the management of mild ICP regarding the timing of induction are comparable. Women with mild ICP and their clinicians should be encouraged to engage in shared decision making when discussing timing of induction.

The aim of our study is to examine the association between age and A1C levels in nondiabetic subjects and develop the age-adjusted A1C levels for screening and diagnosis of prediabetes and diabetes.Participants from National Health and Nutrition Examination Survey (NHANES) -1999-2014 with age over 12 years were examined. Individuals with previous diagnosed diabetes, baseline anemia, established hemoglobinopathies, known liver or chronic kidney disease, and abnormal liver function tests or creatinine levels were excluded. Total 16949 subjects consisting of 8651 female subjects and 8298 male subjects were included in the analyses. Linear regression and multivariate regression analyses were performed to assess the relationship between A1C levels and age. Age adjusted A1C levels were determined.Significant positive correlation between A1C and age was found in both female and male subjects in the fasting plasma glucose (FPG) interval between 4.4-7mmol/L (80-126mg/dL) (P0.0001). There was a linear correlation between A1C levels and age. Linear regression analysis suggested A1C levels rose by 0.009% (about 0.09mmol/mol) in female and by 0.008% (about 0.08mmol/mol) in male per year in subjects without abnormality in glucose homeostasis (p0.0001).Our study concluded that age is a significant independent factor of A1C levels.

Background: There is evidence suggesting that the pregnancy outcome may be affected by some medical conditions, such as liver diseases. Objective: The present study aimed to investigate the prevalence of liver disease and its outcomes in pregnant women referred to antenatal clinic in the hospital. Materials and Methods: In this cross-sectional study, all pregnant women with abnormal liver function test attending antenatal clinic affiliated to Shahid Beheshti University of Medical Sciences were recruited from August 2017 to July 2018. All participants were followed-up until delivery with respect to the maternal and neonatal outcome. Results: Of a total of 7,121 pregnant women recruited in the study, 110 (1.58%) women were detected with a liver disease; of these, 105 women were diagnosed with pregnancy-specific liver diseases, including HELLP syndrome (10.9%), preeclampsia (50.98%), partial HELLP (0.9%), eclampsia (0.9%), acute fatty liver (9.1%), intra-hepatic cholestasis 25 (22.7%), and 5 women the non-pregnancy-specific liver disease, including Liver transplantation (2.7%), and Autoimmune hepatitis (1.8%). Prevalence of the premature birth was 64.5% in pregnancy-specific liver disease, but no premature birth was detected in cases with liver transplantation. We found that neonatal mortality was significantly associated with neonatal prematurity (p = 0.013), IUGR (p < 0.001), placental pathology (p = 0.04), we had no maternal mortality. Conclusion: Liver disease is not uncommon in pregnancy. This study demonstrated that pregnancy is safe in women with liver disease. Key words: Liver diseases, Maternal, Outcome, Neonatal, Pregnancy.

Zusammenfassung. In der hausärztlichen Praxis finden sich im Rahmen der Abklärung unspezifischer Beschwerden oder während einer Gesundheitsvorsorgeuntersuchung bei 25 % aller untersuchten Patienten passager oder chronisch erhöhte Leberwerte. In der gesunden Bevölkerung zeigen sich erhöhte Leberwerte bei rund 2.5 %. Umgekehrt garantieren normale Leberwerte aber nicht immer eine gesunde Leber. Lebererkrankungen sind aber nicht nur häufig, sondern implizieren auch eine erhebliche Mortalität. Ihre Prävalenz nimmt stetig zu, und Lebererkrankungen stellen inzwischen die weltweit fünfthäufigste Todesursache dar. Führend in Prävalenz und verantwortlich für deren Anstieg sind insbesondere nicht-alkoholische Fettleber Erkrankung (NAFLD), alkohol-bedingte Leberschädigung (ARLD) und virale Hepatitiden. Wegen der Vielfalt möglicher Differenzialdiagnosen und dem gleichzeitigen Vorkommen mehrerer Ätiologien stellen sie eine diagnostische Herausforderung mit bedeutender prognostischer Implikation dar. Bei erhöhten Leberwerten sollten initial eine ausführliche Anamnese, sowie eine gründliche klinische Untersuchung durchgeführt werden. Hierdurch lassen sich mögliche Ursachen bereits auf wenige Differenzialdiagnosen eingrenzen. Anschliessend erfolgt je nach Ausmass der Leberwerterhöhung und klinischer Präsentation als Hepatitis oder cholestatischem Krankheitsbild ein Hepatopathiescreening. Die Labordiagnostik und obligate Ultraschalldiagnostik kann durch nicht-invasive Methoden (beispielweise Elastographie, Magnetresonanz-Cholangiopankreatikographie [MRI / MRCP], Computertomographie [CT]) und in ausgewählten Fällen durch invasive Methoden (Leberbiopsie, endoskopische retrograde Cholangiopankreatikographie [ERCP]) ergänzt werden. Im folgenden Artikel stellen wir die Abklärung erhöhter Leberwerte anhand von Algorithmen dar.

Background & Aims Recent data on the coronavirus disease 2019 (COVID-19) outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has begun to shine light on the impact of the disease on the liver. But no studies to date have systematically described liver test abnormalities in patients with COVID-19. We evaluated the clinical characteristics of COVID-19 in patients with abnormal liver test results. Methods Clinical records and laboratory results were obtained from 417 patients with laboratory-confirmed COVID-19 who were admitted to the only referral hospital in Shenzhen, China from January 11 to February 21, 2020 and followed up to March 7, 2020. Information on clinical features of patients with abnormal liver tests were collected for analysis. Results Of 417 patients with COVID-19, 318 (76.3%) had abnormal liver test results and 90 (21.5%) had liver injury during hospitalization. The presence of abnormal liver tests became more pronounced during hospitalization within 2 weeks, with 49 (23.4%), 31 (14.8%), 24 (11.5%) and 51 (24.4%) patients having alanine aminotransferase, aspartate aminotransferase, total bilirubin and gamma-glutamyl transferase levels elevated to more than 3× the upper limit of normal, respectively. Patients with abnormal liver tests of hepatocellular type or mixed type at admission had higher odds of progressing to severe disease (odds ratios [ORs] 2.73; 95% CI 1.19–6.3, and 4.44, 95% CI 1.93–10.23, respectively). The use of lopinavir/ritonavir was also found to lead to increased odds of liver injury (OR from 4.44 to 5.03, both p, Graphical abstract, Highlights • Of 417 patients with COVID-19, 76.3% had abnormal liver tests and 21.5% had liver injury during hospitalization. • Patients with abnormal liver tests had significantly higher odds of developing severe pneumonia. • The use of lopinavir/ritonavir increased the odds of liver injury by 4-fold.

Objective Whether intensive therapy can alleviate subclinical synovitis and reduce flare in rheumatoid arthritis (RA) patients in clinical remission remains unclear. We designed a 1-year open-labelled, randomized controlled clinical trial to elucidate this question. Methods RA patients in clinical remission/low disease activity (defined by DAS28-CRP≤ 3.2), however with subclinical synovitis on ultrasound [power Doppler (PD)≥1 and/or gray scale (GS)≥2] were randomized to receive maintenance or intensive treatment at a ratio of 1:1. The primary outcome was the rate of RA relapse (defined by DAS28-CRP>3.2 and an increase≥0.6). The secondary outcomes were changes of PD and GS scores, and clinical disease activity at each visit from baseline. Results 108 patients with 54 in each group were enrolled. During 1-year follow-up, the relapse rate was significantly higher in maintenance group than in intensive group, regardless of all enrolled patients or those in remission [24.1% (13/54) vs. 9.1% (5/54), p=0.039; 26.2% (11/42) vs. 5.3% (2/38), p=0.026, respectively]. Although GS and PD scores were decreased at 12 months in both groups, the decline was more remarkable in intensive group than in maintenance group. The improvement of clinical disease activity score was only observed in intensive group, not maintenance group. Adverse events were comparable between two groups. Abnormal liver function tests were observed in 24 (22%) patients with 16 from intensive group. Conclusion Intensive therapy can alleviate subclinical synovitis on ultrasound and clinical disease activity, and prevent relapse in RA patients who have achieved clinical remission or low disease activity, with comparable safety profiles to maintenance therapy. Registration number ChiCTR2000029279

BACKGROUND AND AIM Imaging noradrenergic uptake in the liver with norepinephrine analog 123 I-meta-iodobenzylguanidine (mIBG) was explored in normal controls and patients with heart failure (HF). METHODS A total of 961 HF (343 with diabetes mellitus [DM]) and 94 control subjects underwent anterior planar mIBG images including upper abdomen at 15 min (early) and 3 h 50 min (late) post-injection. Decay-corrected liver activity normalized to injected activity and body surface area (counts/pixel [cpp]/MBq/m2 ) was compared in three groups: HF with DM; HF without DM; and controls. Associations with plasma norepinephrine, liver function tests, and level of cardiac innervation were explored. RESULTS In controls, liver mIBG activity decreased over time (early: 2.78 vs late: 2.43 cpp/MBq/m2 , P 520 pg/mL) or ≥ 1 abnormal liver function test had lower early and late liver activity. In subjects with preserved cardiac mIBG uptake, HF subjects had higher and control subjects lower liver activity than comparable subjects with decreased cardiac innervation. CONCLUSIONS In HF subjects, liver mIBG activity increased over time, reversing the normal washout pattern, suggesting a compensatory change in sympathetic nerve function. DM, abnormal liver function tests, and decreased cardiac innervation were associated with decreased liver mIBG uptake in HF.

Aims: Comparing the risk of abnormal liver function tests between severe and non-severe patients with coronavirus disease 2019 (COVID-19) by meta-analysis. Methods: A literature search was conducted using the databases PubMed, Embase, and Cochrane Library. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using fixed- or random-effects models. Publication bias was detected by the Harbord test. Results: We included 8 articles comprising 7,467 COVID-19 patients. When compared between severe and non-severe COVID-19 patients, the pooled ORs of elevated alanine aminotransferase, aspartate aminotransferase, total bilirubin, and lactate dehydrogenase levels were 2.35 (95% CI 1.38-3.98), 3.21 (95% CI 2.59-3.98), 1.87 (95% CI 1.32-2.65), and 4.83 (95% CI 2.90-8.05), respectively. Conclusions: The severity of COVID-19 is associated with liver damage, and can be a risk factor for abnormal liver function tests.

Chronic myeloid leukemia (CML) is a chronic myeloproliferative neoplasm characterized by excess granulocytes at different stages of maturation and the presence of BCR-ABL1 fusion gene or Philadelphia chromosome. Absolute eosinophilia, basophilia, and monocytosis are not uncommon in CML. However, a rare entity called eosinophilic variant of CML (eoCML) can present with eosinophilia without excess neutrophils or basophils. Here, we report a rare and unusual case of eoCML presenting as a liver mass with abnormal liver function tests, which has not been reported in the literature so far.

Background Non-alcoholic fatty liver disease (NAFLD) is the most common type of chronic liver disease in Australia and its recent increase mirrors the obesity and type 2 diabetes epidemics. Currently, many patients who present to primary care with abnormal liver function tests or steatosis on liver ultrasound are referred for assessment in secondary care. Due to the large number of patients with NAFLD, this results in long waits for clinical and fibrosis assessment, placing unnecessary burden on the public hospital system. Methods We will conduct a 1:1 parallel randomised trial to compare two alternative models of care for NAFLD. Participants will be randomised to usual care or the LOCal Assessment and Triage Evaluation (LOCATE) model of care and followed for 1 year. We will recruit patients from the non-neighbouring Sunshine Coast and Metro South Hospital and Health Services (HHSs) in Queensland, Australia. Our primary outcome of interest is time to diagnosis of high-risk NAFLD, based on the number of participants in each arm of the study who receive a diagnosis of clinically significant fibrosis. Two hundred and 34 participants will give us a 95% power to detect a 50% reduction in the primary outcome of time to diagnosis of high-risk disease. We will also conduct an economic evaluation, evaluating the cost-effectiveness of the new model of care. We will also evaluate the implementation of the new model of care. Discussion It is anticipated that the results of this study will provide valuable new information regarding the management of NAFLD in the Australian setting. A relatively simple change to care could result in earlier identification of patients with significant liver disease and lower overall costs for the health system. Results will be directly disseminated to key staff for further distribution to consumers, policy- and decision-makers in the form of evidence briefs, plain language summaries and policy recommendations. Trial registration The trial was registered on 30 January, 2020 and can be found via ANZCTR - number ACTRN12620000158965.

Rhabdomyolysis is a syndrome of skeletal muscle injury with release of cellular constituents such as potassium, phosphate, urate and intracellular proteins such as myoglobin into the circulation, which may cause complications including acute kidney injury, electrolyte disturbance and cardiac instability. Abnormal liver function tests are frequently observed in cases of severe rhabdomyolysis. Typically, there is an increase in serum aminotransferases, namely aspartate aminotransferase and alanine aminotransferase. This raises the question of liver injury and often triggers a pathway of investigation which may lead to a liver biopsy. However, muscle can also be a source of the increased aminotransferase activity. This review discusses the dilemma of finding abnormal liver function tests in the setting of muscle injury and the potential implications of such an association. It delves into some of the clinical and experimental evidence for correlating muscle injury to raised aminotransferases, and discusses pathophysiological mechanisms such as oxidative stress which may cause actual liver injury. Serum aminotransferases lack tissue specificity to allow clinicians to distinguish primary liver injury from muscle injury. This review also explores potential approaches to improve the accuracy of our diagnostic tools, so that excessive or unnecessary liver investigations can be avoided.

Summary Background & Aims Inflammatory bowel diseases (IBD) are associated with various hepatobiliary disorders. There is a strong association for primary sclerosing cholangitis (PSC). Primary biliary cholangitis (PBC), another autoimmune cholestatic liver disease, is not usually associated with IBD. The aim of this study is to report cases of PBC-associated IBD, their clinical features, response to therapy, and long-term outcome. Methods Retrospective analysis of a prospectively collated database identified patients presenting with PBC-associated IBD from 2006 to 2016. PBC has been diagnosed according to accepted criteria, and staged according to Ludwig classification. A magnetic resonance cholangiopancreatography (MRCP) was performed to rule out PSC. Response to ursodeoxycholic acid (UDCA) therapy has been assessed by using the Paris II criteria. Results A total of six patients (five females) with PBC-associated IBD were identified. Median age at IBD diagnosis was 44.7 years (range 22.5–48.8). Three had Crohn's disease and three ulcerative colitis. PBC was diagnosed in all after IBD had been diagnosed. All patients presented with cholestasis, all were positive for anti-mitochondrial antibodies. MRCP was normal in all. Liver biopsy was consistent with PBC (stage I in one, stage II in five). One year after initiation of UDCA, all patients responded to therapy. Conclusion Herein we describe the largest series reported to date of PBC-associated IBD. Although the coexistence of the two conditions is rare, PBC should be considered during the work-up of abnormal liver function tests in patients with IBD.

We are in the middle of coronavirus disease 2019 (COVID-19) pandemic which has affected every aspect of human life all over the world. Although COVID-19 primarily affects the lungs, it is in fact a multisystem disorder causing high mortality and panicking the whole world. Gastrointestinal (GI) manifestations of this disorder usually accompany respiratory manifestations and this combination is indicative of the severity of the disease. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA, which causes COVID-19, enters the body by attaching to angiotensin converting enzyme-2 receptors which are not only present in the respiratory tract but also in the GI tract. Person-to-person droplet transmission is the main mode of spread although there is potential for fecal-oral transmission. Patients with inflammatory bowel disease (IBD) are not at increased risk of developing COVID-19 and they should continue to take their current medications. If they become positive for SARS-CoV-2 RNA or COVID-19, their biologic therapy should be either delayed or on hold temporarily. GI endoscopy units are high-risk areas and GI procedures are high-risk procedures for the transmission of SARS-CoV-2 infection. Only emergency and semi-emergency procedures should be done, and elective procedures should be temporarily on hold until adequate resources are available. Endoscopists should use appropriate personal protective equipment. Mildly abnormal liver function tests (LFTs) are common in COVID-19 patients and are mostly due to systemic inflammatory response, hepatic ischemia or hepatotoxic medications. Close monitoring of liver function and supportive care of COVID-19 patients are recommended.

A phase I, open-label study (NCT02197234) assessed the effects of osimertinib on simvastatin exposure in patients with advanced epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer and disease progression post-EGFR tyrosine kinase inhibitor treatment. Here, we report on a retrospective analysis of two patients (patients 1 and 2) who had liver metastases and high simvastatin exposure prior to osimertinib treatment, which changed following treatment. Patients received single oral doses of simvastatin 40 mg on day (D) 1 and D31, and osimertinib 80 mg once daily on D3-32. At baseline, both patients had abnormal liver function tests (LFTs; Child-Pugh scores of 6 and 8, respectively), significant liver metastasis, and, after a single simvastatin dose, had higher (~ 10-fold) exposure compared with all other patients. Following 31 days of continuous osimertinib treatment, simvastatin exposures (area under the plasma concentration-time curve from zero to infinity (AUC) and maximum plasma concentration (Cmax )) and LFTs, such as alanine transaminase, aspartate aminotransferase, and bilirubin normalized to population mean values. Additionally, ~ 50% and ~ 80% reductions in liver metastases were observed on computed tomography scans in patients 1 and 2, respectively. High simvastatin exposure on D1 likely resulted from impairment of hepatic first pass metabolism due to liver metastases. Reduction in hepatic disease burden due to osimertinib treatment likely resulted in liver function returning to normal levels.

Background Hiatal hernia is defined by the permanent or intermittent prolapse of any abdominal structure into the chest through the diaphragmatic esophageal hiatus. Prolapse of the stomach, intestine, transverse colon, and spleen is relatively common, but herniation of the pancreas is a rare condition. We describe a case of acute pancreatitis and bile duct dilatation secondary to a massive hiatal hernia of pancreatic body and tail. Case presentation An 86-year-old woman with hiatal hernia who complained of epigastric pain and vomiting was admitted to our hospital. Blood tests revealed a hyperamylasemia and abnormal liver function test. Computed tomography revealed prolapse of the massive hiatal hernia, containing the stomach and pancreatic body and tail, with peripancreatic fluid in the posterior mediastinal space as a sequel to pancreatitis. In addition, intrahepatic and extrahepatic bile ducts were seen to be dilated and deformed. After conservative treatment for pancreatitis, an elective operation was performed. There was a strong adhesion between the hernial sac and the right diaphragmatic crus. After the stomach and pancreas were pulled into the abdominal cavity, the hiatal orifice was closed by silk thread sutures (primary repair), and the mesh was fixed in front of the hernial orifice. Toupet fundoplication and intraoperative endoscopy were performed. The patient had an uneventful postoperative course post-procedure. Conclusion A rare massive hiatal hernia, involving the stomach and pancreatic body and tail, can cause acute pancreatitis with bile duct dilatation. The etiology can be flexure of the main pancreatic and extrahepatic bile ducts. Symptomatic herniation is best treated with surgery. Elective surgery is thought to be safer than emergent surgery in patients with serious complications.

Introduction. Hepatic artery pseudoaneurysm is a rare and potentially fatal complication of liver transplantation with a reported incidence of 0.3–2.6% and associated mortality approaching 75%. Clinical presentation typically includes sudden hypotension, gastrointestinal bleed or abnormal liver function tests within two months of transplantation. We report a series of four cases of hepatic artery pseudoaneurysm in adult liver transplant recipients with the goal of identifying factors that may aid in early diagnosis, prior to the development of life threatening complications. Methods. A retrospective chart review at a high volume transplant center revealed 4 cases of hepatic artery pseudoaneurysm among 553 liver transplants (Incidence 0.72%) between March 2013 and March 2017. Results. Two of the four patients died immediately after intervention, one patient survived an additional 151 days prior to death from an unrelated condition and one patient survived at two years follow up. All cases utilized multiple imaging modalities that failed to identify the pseudoaneurysm prior to diagnosis with computed tomography angiography (CTA). Two cases had culture proven preoperative intrabdominal infections, while the remaining two cases manifested a perioperative course highly suspicious for infection (retransplant for hepatic necrosis after hepatic artery thrombosis and infected appearing vessel at reoperation, respectively). Three of the four cases either had a delayed biliary anastomosis or development of a bile leak, leading to contamination of the abdomen with bile. Additionally, three of the four cases demonstrated at least one episode of hypotension with acute anemia at least 5 days prior to diagnosis of the hepatic artery pseudoaneurysm. Conclusions. Recognition of several clinical features may increase the early identification of hepatic artery pseudoaneurysm in liver transplant recipients. These include culture proven intrabdominal infection or high clinical suspicion for infection, complicated surgical course resulting either in delayed performance of biliary anastomosis or a biliary leak, and an episode of hypotension with acute anemia. In combination, the presence of these characteristics can lead the clinician to investigate with appropriate imaging prior to the onset of life threatening complications requiring emergent intervention. This may lead to increased survival in patients with this life threatening complication.

AIM Chronic drug-induced liver injury (DILI) with persistent abnormal liver function tests (LFTs) >6 months after cessation of the insulting drugs could progress to cirrhosis. The aim of the present study was to identify the risk factors of chronic DILI for early recognition and better management. METHODS History of drug intake and results of LFTs were retrospectively retrieved for patients with a discharge diagnosis of DILI for at least 1-year follow up. The risk factors independently associated with chronic DILI were analyzed by multiple logistic regression analyses. RESULTS A total of 33 of the 140 DILI patients had persistent abnormal LFTs >6 months, which were considered as chronic DILI. It was found that the time intervals of alanine aminotransferase and total bilirubin decline from the peak to their half peak (T0.5ALT , T0.5TBIL ) were significantly longer in the chronic DILI group than that in the recovered group (P = 0.001 and P