Background and Aims: The large global population of patients with metabolic dysfunction-associated steatotic liver disease (MASLD) has recently been shown to have an association with chronic kidney disease (CKD) due to a host of proposed mechanisms, one of which being lipoprotein dysmetabolism. Furthermore, metabolic comorbidities have been concurrently prevalent in MASLD and CKD independently. This study aimed at analyzing risk and predictive traits among an obese population for both MASLD and CKD. Methods: A retrospective chart review of 546 obese patients with a diagnosis of either MASLD or metabolic dysfunction-associated steatohepatitis between January 2020 and June 2021 was performed. Markers of liver and kidney function in addition to demographic data and renoprotective medications were recorded. Both univariable and multivariable linear regression analyses were performed to understand possible associations between MASLD markers, renal function, and markers of metabolic derangements. Results: Univariate analysis revealed that increased age (P < .001), elevated alanine aminotransferase (defined as alanine aminotransferase >= 30 IU/L, P = .01), low albumin (P = .011), and increasing fibrosis-4 (FIB-4) (P = .005) were statistically associated with a reduced renal function. A reduction in glomerular filtration was associated with an increase in FIB-4 (effect size [beta] of a one-unit increase in glomerular filtration on FIB-4 = -0.013, P < .001) in univariate linear regression. In multivariate linear regression, type 2 diabetes (T2D) was independently associated with increased liver fibrosis (effect size of T2D on FIB-4 = 0.387925, P < .02). Conclusion: Our study shows that in a patient population with obesity and a diagnosis of MASLD, advanced fibrosis is independently associated with reduced renal function.

BACKGROUND AND AIMS: We aimed to test the performance of the Fibroscan-aspartate aminotransferase (FAST) score, a noninvasive test, to identify nonalcoholic steatohepatitis (NASH) and significant fi brosis (NASH + >= F2) in a cohort of patients with a histological diagnosis of NASH, using a cutoff of >= 0.35 as a rule in factor. We also compared performance to liver stiffness measurement (LSM) >= 8 kPa and the fi brosis-4 index (FIB-4) >= 1.3 and attempted to identify risk factors to develop a model for improving diagnostic accuracy. METHODS: Patients with histologically confirmed NASH were identified from 2020-2021. Demographic information, laboratory data, and LSM were collected. The FAST score and FIB-4 were calculated. Univariate and backward entry multivariate logistic regression analyses were performed to identify risk factors in addition to the FAST score >= 0.35 that are associated with an accurate histological diagnosis of NASH + >= F2. Discrimination and overall accuracy were assessed using area under receiver operating characteristic curves. RESULTS: Using a rule in cutoff of >= 0.35, the FAST score performed with a sensitivity, specifi city, negative predictive value, and positive predictive value of 96.4%, 36.8%, 77.7%, and 81.8%, respectively. Age (P = .05) and FAST >= 0.35 (P = .001) correctly identified histologically confirmed NASH + >= F2. The FAST + age model outperformed FAST >= 0.35 (0.70, confidence interval [CI]: 0.55-0.84), LSM >= 8 kPa (0.72, CI: 0.59-0.85), and FIB-4 >= 1.3 (0.73, CI: 0.59-0.87) with a c-statistic of 0.78 (CI: 0.64-0.92). CONCLUSION: A FAST score with a rule cutoff of >= 0.35 performed well (c-statistic: 0.70) and was superior to LSM and FIB-4 when age was incorporated into the model (0.78) in detecting NASH + >= F2 fi brosis in the real world.

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Introduction: Portal vein thrombosis (PVT) is an infrequent complication of bariatric surgery observed in approximately 1% of the general population and in 4.4%-15% of patients with cirrhosis. Local risk factors for PVT include portal venous system injury, while systemic risk factors encompass genetic coagulopathies associated with thrombotic disease. Here, we present a case of PVT development following bariatric surgery in a non-cirrhotic patient. Case Description/Methods: A 48-year-old woman with a history of prior cigarette use and class III obesity presented to the emergency department (ED) one month after laparoscopic sleeve gastrectomy with epigastric pain. Preoperatively she was found to have a Caprini risk score of 3-4 with a venous thromboembolism risk of 3.0%. Computed tomography (CT) scan revealed a superior mesenteric vein and portal vein thrombosis. Confirmation with magnetic resonance imaging (MRI) of the abdomen showed portomesenteric vein thrombus involving the portal venous system, superior mesenteric vein, and splenic vein. She was discharged on rivaroxaban which she completed for 4 months before self-discontinuation. The patient returned to the ED 9 months later with similar epigastric pain and CT scan showed cavernous transformation of the portal vein thrombus and collateralization in the superior mesenteric vein. Coagulopathy workup was negative. The patient was advised to receive further anticoagulation with rivaroxaban, but is currently with stable disease without anticoagulation. Discussion: PVT is a rare yet significant complication that can arise following bariatric surgery. Among surgical approaches, laparoscopic sleeve gastrectomy has been identified as the procedure most associated with thrombotic complications. In this case, the patient presented approximately 1 month after the surgery, a period known to be particularly vulnerable (2-4 weeks) to thrombotic events in bariatric patients. Independent risk factors for PVT development include liver disease, a history of thromboembolism, and serious operative complications. Although the patient did not possess a history of thromboembolism or liver disease, undergoing sleeve gastrectomy did place them at an elevated risk of PVT. Employing scoring systems like the Caprini Score, as utilized in this case, provides a reliable foundation for assessing the risk. Furthermore, considering the potential impact of the surgical approach in heightening the risk of PVT enables a more comprehensive management strategy for bariatric surgery patients.

Introduction: Pancreatic pleural fistula (PPF) is a rare complication of acute and chronic pancreatitis, characterized by leakage of pancreatic secretions into the thorax, resulting in pleural effusions. While the incidence of pancreatitis-related pleural effusion is low, estimated at 3%-7%, PPF is even rarer, with an estimated incidence of 1%. It is atypical for PPF to be diagnosed in patients without a documented history of pancreatitis. This report describes a case of a middle-aged man who presented with dyspnea and was found to have large bilateral effusions secondary to PPF, despite having no recent episode of pancreatitis. Case Description/Methods: A 48-year-old man with a past medical history of treated hepatitis C infection and remote alcohol use disorder presented with a 1-month history of dyspnea, dry cough, and chest discomfort. Chest x-ray revealed bilateral pleural effusions with nearly complete opacification of the left lung fields. Computed tomography (CT) angiography showed a 1.4 x 1.1 cm rim-enhancing fluid collection arising from the pancreatic tail, ascending upward and posteriorly. A diagnostic and therapeutic thoracentesis provided significant relief of symptoms after removal of 2 liters of dark serosanguinous fluid, which was exudative with a high amylase level of 1703 U/L. Magnetic resonance cholangiopancreatography (MRCP) was obtained to identify a unifying diagnosis. It revealed a fluid-filled tract extending from the tail of the pancreas to the left pleural space, concerning for a PPF. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with successful stent placement after a stenosis of 10mm in length was observed in the proximal pancreatic duct with upstream duct dilation (Figure 1). Discussion: PPF typically presents with a recent history of pancreatitis and may cause cough and dyspnea due to pleural effusions (Table 1). However, in this case, the patient had no documented history or symptoms of pancreatitis, making the diagnosis of PPF challenging. It is important to consider PPF in patients with even a history of alcohol use disorder presenting with dyspnea and pleural effusions. Prompt treatment with ERCP or surgery is necessary, as recurrence of pleural effusions can be prevented with success rates of over 90%.Figure 1.: MRCP demonstrating a fluid-filled tract (blue and yellow arrows). Table 1. - Literature review revealed 9 patients with PPF including our case where pleural effusion was the presenting symptom, published in English between 2012 and 2023 Year Age Sex Presenting symptoms Bilateral/unilateral Hx of known pancreatitis Diagnostic tool of PPF Treatment 1 2020 47 F Dry cough/ abdominal pain Bilateral Chronic CT pancreatectomy 2 2017 44 M Dyspnea Right-sided Recurrent acute MRCP ERCP 3 2012 45 M Chest pain/cough/dyspnea Left-sided Chronic + recurrent acute CT Roux-en-Y jejuno-pseudocystostomy 4 2020 43 M Dyspnea/epigastric pain Bilateral Chronic + recurrent acute CT ERCP 5 2020 57 M Dyspnea/ dry cough Left-sided Recurrent acute CT ERCP 6 2020 47 M Exertional dyspnea Right-sided Chronic ERCP ERCP 7 2022 58 F Dyspnea Right-sided Chronic MRCP N/A 8 2023 81 M Dyspnea Left-sided Acute on chronic CT ERCP 9 (our case) 2022 48 M Dry cough/dyspnea Bilateral NONE MRCP ERCP

Introduction: Primary appendiceal cancers are considered rare gastrointestinal malignancies, with an estimated incidence of approximately 1.2 per 1,000,000 individuals. These malignancies are commonly discovered incidentally within surgical specimens during appendectomy procedures performed for appendicitis. Alternatively, appendiceal cancers can be detected through imaging studies or during colonoscopy examinations. Recent research indicates an increasing incidence of appendiceal cancer over the past few decades, highlighting the need for further understanding of its clinical presentation and treatment. Here, we present a rare case of appendiceal malignancy occurring subsequent to persistent appendix obstruction. Case Description/Methods: A 73-year-old woman presented to the emergency room (ER) in September 2022 with right lower quadrant pain which was diagnosed as acute appendicitis on Computed tomography (CT) scan of abdomen and pelvis. Her pain improved with symptomatic treatment, but recurred shortly after discharge from the ER. A subsequent colonoscopy in January 2023 revealed diverticulosis of the colon and an irregular appendix with abnormal mucosa in the colon. Pathology findings revealed showed mildly reactive colitis. A repeat CT scan revealed a mildly dilated appendix with wall thickening. In March 2023, a laparoscopic ileocecectomy showed a 4.5 cm moderately differentiated mucinous adenocarcinoma of the appendix. The tumor had also invaded the visceral peritoneum and involved lymph nodes. The patient initiated follow-up care with oncology and was started on a 3-month regimen of adjuvant capecitabine. Discussion: Appendiceal cancer is a rare gastrointestinal malignancy often identified incidentally during pathological examination. It can mimic recurrent or complicated appendicitis, leading to diagnostic challenges. Surgical intervention remains the cornerstone of treatment, although chemotherapy regimens have emerged as a viable option for advanced disease. In the present case, which involved peritoneal invasion, the administration of adjuvant capecitabine aligns with the growing trend of improved outcomes observed in patients with appendiceal malignancies (see Figure 1).Figure 1.: CT abdomen/pelvis.

Liver disease in pregnancy often requires diagnostic and therapeutic considerations that are unique to pregnancy. Liver disease in pregnancy is commonly thought of as either liver disease unique to pregnancy, chronic liver disease, or liver disease coincidental to pregnancy. This review summarizes the approach to evaluation of liver disease in pregnancy.