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INTRODUCTION:Endoscopic sleeve gastroplasty (ESG) is a novel procedure that is safe and effective for weight loss that has been shown to have significantly less morbidity than alternative bariatric procedures. We present the first case of Endoscopic ultrasound-guided liver biopsy (EUS-LB) done in the same session as ESG. Both procedures were without complications, and were technically and clinically successful.CASE DESCRIPTION/METHODS:28 year old female with hypertension and morbid obesity presented for elevated liver function tests concerning for NAFLD. In past 20 months patient went from 268 to 293 pounds and failed lifestyle interventions. Medications were Famotidine and Lipitor. Physical Exam was notable for obese female, increased waist circumference, nontender and non distended abdominal exam without rebound or guarding. CBC,BMP,PT/INR were within normal limits. Liver Function: AST 54 U/L, ALT 78U/L, Alkaline Phosphatase 56 U/L, Total Bilirubin 1.0 mg/dL. Ultrasound revealed hepatic steatosis, and FibroScan showed Fibrosis Score F4 consistent with cirrhosis. She did not have physical exam or lab findings consistent with cirrhosis. Patient was planned for ESG for weight loss and given Fibroscan results, same session EUS-LB was performed. EUS-LB was performed first in left lobe with 19 gauge FNB needle with no complications. ESG was performed successfully without complications. Upper GI series the next morning revealed no extravasation, patient tolerated diet and was discharged home. One month later, patient BMI decreased from 51kg/m2à45kg/m2, 298 to 263 lbs. No complaints of abdominal pain, nausea, vomiting and tolerating diet. Pathology from Liver Biopsy showed NAS Score 4/8 consistent with steatohepatitis, Stage 2-3 fibrosis.DISCUSSION:EUS-LB is an effective method for liver biopsy with minimal complications. ESG significantly reduces BMI with low morbidity . With the prevalence of NAFLD and subsequent conversion to NASH and cirrhosis increasing, non-invasive tests are utilized to stage fibrosis in patients with NASH. In cases where there is a discordance between clinical findings and Fibroscan results, liver biopsy can be obtained. This case demonstrates when a liver biopsy is indicated, EUS-LB is a safe and efficient option in a patient undergoing an endoscopy for other reasons. This is also the first reported case of EUS-LB and ESG in the same session. We demonstrate this procedure can be considered simultaneously in patients undergoing ESG to aid in weight loss for fatty liver disease.

INTRODUCTION:Infliximab is an anti-tumor necrosis factor alpha inhibitor commonly used in the treatment of Crohn's disease. It is known to produce mild elevations in liver enzymes, however, severe damage and marked elevations in transaminases related to drug-induced autoimmune hepatitis (AIH) are rare. We present a case of a patient with Crohn's disease who recently began infliximab and presented with severe infliximab-induced autoimmune hepatitis.CASE DESCRIPTION/METHODS:A 37-year-old man with Crohn's ileocolitis, diagnosed at age 28 and recently inducted with infliximab, presented with fatigue, weakness, and epigastric pain. He had previously been on 6-mercaptopurine, adalimumab, and ustekinumab, but had most recently been on azathioprine (AZT) and began infliximab two months prior to presentation. Approximately one month prior to presentation, he developed elevated transaminases with aspartate transaminase (AST) and alanine transaminase (ALT) in the 300s, so AZT was discontinued as this was thought to be the cause. Despite discontinuation of AZT, his liver function tests (LFTs) rose dramatically, prompting hospitalization. Labs on admission revealed a hepatocellular pattern with total bilirubin 7.1, AST 2153, ALT 2931, alkaline phosphatase 156, and international normalized ratio 1.25. Notably, antinuclear antibody was positive 1:1280, smooth muscle antibody was weakly positive, and cytomegalovirus (CMV) IgM was elevated. Hepatobiliary scan and magnetic resonance cholangiopancreatography were consistent with hepatocellular disease. Core liver biopsy revealed active hepatitis with moderate activity (interface moderate), cholestasis, and an infiltrate of eosinophils and plasma cells. CMV staining was negative. Overall, the testing was consistent with drug-induced AIH. Infliximab was stopped and steroids were begun, resulting in normalization of LFTs.DISCUSSION:Infliximab has been implicated in mild cases of hepatotoxicity, and therefore, it is recommended to check LFTs before and after beginning the medication. There are very few reports of severe AIH that have been linked specifically to infliximab, as cases of hepatotoxicity are often secondary to reactivation of viral hepatitis or CMV infections, or related to other biologic therapies. This is a rare case of infliximab-induced AIH, and it is an important consideration in patients with elevated LFTs after starting this drug. Treatment involves cessation of infliximab and treatment with steroids, which usually leads to resolution of the hepatitis.

INTRODUCTION:Mercury (Hg) is a well-known toxic metal that is most commonly found in diet (seafood, rice), and other sources such as dental amalgams and batteries. The pathogenesis for hepatoxicity is theorized to be triggered by oxidative stress. We aim to investigate the association of Mercury with key demographic and clinical factors, as well as NAFLD and Advanced Fibrosis.METHODS:A population of 5,590 non-pregnant individuals age 18-74 were included in this secondary analysis of NHANES 2011-2016. Exclusion criteria: AST/ALT >500 IU/L, alcohol >10 drinks/week (females)/>20 drinks/week (males), transferrin saturation >50%, positive hepatitis B and C serology. NAFLD was defined by Fatty Liver Index score >60. Advanced fibrosis was defined by National Fibrosis Score >0.676. Student's T-test was used for continuous and Rao-Scott Chi-Square test for categorical variables. Comparison across quartiles were done with simple linear regression for continuous, Rao-Scott Chi-Square test for categorical variables. Demographics and patient confounders were adjusted using multivariate logistic regression (SAS 9.4) for odds of NAFLD/Advanced Fibrosis with respect to Mercury quartile.RESULTS:5,590 patients were included, 44% with NAFLD and 56% without NAFLD. Patients with NAFLD vs no NAFLD were more likely to be older (51.1 vs 47.7 years, P < 0.0001), men (55% vs 45%, P < 0.0001), have fewer years of schooling, >high school (60% vs 69%, P < 0.0001), have lower Mercury levels (1.25 vs 1.68, P < 0.0003) and were significantly more likely to have higher BMI, Diabetes incidence, Hypertension, Total Cholesterol. Demographic and clinical characteristics for increased Mercury Levels by Quartile are listed in Table 1. Of note, participants with more Mercury exposure, in quartile 4 vs quartile 1, were older (53.4 vs 45.6 years, P < 0.0001), more educated (>high school 79% vs 53%, P < 0.0001), leaner (BMI 27.4 vs 29.6, P < 0.0001), higher HDL (55.8 vs 50.1), but had similar rates of GGT, ALT, AST, Hypertension, and Diabetes. There was no significant association found for risk of NAFLD or Advanced Fibrosis with Blood Mercury levels in both univariate or multivariate analysis.CONCLUSION:Our results show that Mercury levels are decreased in NAFLD, and are with increased with higher education and lower BMI. Mercury levels did not significantly affect liver enzymes or NAFLD risk factors such as hypertension and diabetes. Further studies are needed to examine Mercury toxicity and liver function.

IntroductionUpper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization.MethodsThis was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay.ResultsA total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03–1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63–2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001).DiscussionOur study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.