So, we have a case that we want to present to you all, which will be presented by Dr. Marvin Yu. Okay. So, we'll present this case that I think highlights endohepatology applications, and we'll use this as a vehicle to generate discussion moderated by Dr. Marvin Yu. So, this is a case of a 62-year-old woman with a history of obesity, BMI of 38, and recent breast cancer diagnosis, status post chemotherapy, and she is referred to a tertiary center for persistent splenomegaly in possible collateral vessels seen on serial imaging studies, as well as mild thrombocytopenia. Of note, she has no history of alcohol or viral hepatitis. Her liver function tests and synthetic function are normal, and she actually had a transjugular liver biopsy and hepatic venous pressure gradient, HVPG, performed in an outside hospital that were normal. The biopsy showed, for the most part, mild steatosis and absence of significant fibrosis, and the HVPG was 4.5 millimeters of mercury, so absence of portal hypertension. So, let's talk about our next steps. We have this information. It seems like we have a disparate set of data here. We've got thrombocytopenia and collateral vessels on axial imaging, yet we have a liver biopsy that doesn't really help us out very much. Reem, your thoughts on this? So, basically, we know that this patient has obesity. Her BMI is 38. So, off the bat, the IR pressure measurements may not have been accurate in this patient. Also, usually when we get anyone with a liver biopsy, we probably need to look if it was adequate or inadequate. Does it meet the ASLD criteria for the number of cores, the number of sinusoidal tracts and biliary tracts, et cetera? So, first step is probably review everything at our institution, and then maybe repeat. Excellent. I think those are very all-cogent features. I mean, get your biopsy looked at, and as Reem has pointed out elegantly, perhaps another methodology for measuring that portal pressure measurement is necessary. So, because this is an endohepatology session, we proceeded with an endohepatology evaluation. So, the endoscopy revealed, or I should say the endoscopy and the EUS revealed, sorry, was performed with liver biopsy as well as poor systemic pressure gradient measurements. The EGD showed varices, to our surprise, and EUS showed steatosis, but otherwise normal appearing liver, and confirmed the splenomegaly. The portal pressure gradient was reported elevated at 11.0 millimeters of mercury, so portal hypertension was present, almost clinically significant portal hypertension, and the biopsy returned as nodular regenerative hyperplasia, likely chemo-related. So this is a good example where the elevated BMI or even though she doesn't have Nash on the liver biopsy but the fact that she is, or she has obesity, probably gave her a falsely low or normal portal pressure gradient that by IR. Okay. So, to the to the panel. What about coagulopathy and thrombocytopenia when you were, what are your cut offs for approaching these types of things if you, let's say the patient had a platelet count of 45,000 and an INR of 1.6 with it with that keep you up at night. I usually my cut off is 50, and I'm usually pretty like we had a bleed at 49 so that one plate that was really is the cut off, and anything between one point 1.5 to two is fine but the closer it is to 1.5 feel better, Phoenix. I think the liver biopsy to be a little bit more concerning and cut off of INR 1.5, the PPG the needle is very small, and I haven't had any bleeding associated with a 25 gauge platelets at our center we prefer something five and above. Do you commonly Doppler your, your, your biopsy tract Can you talk a little bit about looking at the biopsy tract after taking the biopsy in terms of observation for flow and if you did have flow, what would you do. Yeah, so for PPG usually will turn on the color flow as we're pulling the needle out. And there's been some discussion about putting a little bit of tissue back to clot up the area if you're seeing bleeding. We haven't had much complications in terms of liver biopsy and associated bleeding, but we do turn on the color flow as we're doing the biopsy and pulling the needle back. Thank you. The case continues. I'll stop it here. We've got the diagnosis and Marvin what happened next 12 months later, patient presents hematemesis this time. Sorry. And can we go back please. The endoscopy at a local hospital revealed gastrobaric seal bleeding in to their credit, they perform endoscopic direct sign accurately injection therapy with temporary hemostasis achieved, then was transferred to a tertiary center for further management and after multidisciplinary discussion. It was decided to proceed with us coil injection therapy. So, is Dr. Shira had just previously described that's coil injection, usually one to three coils. followed by injection of an adjunct to secondary adjunct and historically that's been signed accurately glue, but gel foam and Robin have also been described. So, my question is I see a morass of varices, which, which one do you go for. First, how do you, how do you determine how do you do the detective work to say this is should be the right the right one to render therapy to. From a system standpoint, I think this has to be done at a, at a center, ie tertiary center with interventional radiology backup. That's number one. Number two, if there is local expertise for us guided therapies I think this becomes a very viable option supporting this as a as a safe in very effective treatment, probably superior to direct endoscopic injection therapies, which we used to do, and still do. And this is particularly relevant for large cardio fundal varices. So these are the large scary leaders that this refractory to various to typical banding therapy, but with the, the, the advent of us. We have the necessary perspective to proceed with introverse seal needle injection and then delivery of various hemostatic options. Thank you. So, case Apple log. So, us guided combination therapy coil injection therapy followed by by glue was performed, as well as endoscopic variceal banding in the patient was without further bleeding. Thank you. My final slide is not here but I had questions about, I think a couple of them is you've all developed successful end of end of hepatology programs at your institution. So you're kind of sitting at the table the IR people are looking at you the liver transplant people looking at you kind of like I don't know, how did you, how did you develop your, how did you go about developing your program. Why don't you start for us. So I want to say with difficulty but with perseverance, I mean the key thing is to show them that them by them I mean the liver transplant hepatologists who are great colleagues but we're very skeptical with change. And so if you look at the liver biopsy data initially it wasn't as good it was very fragmented, but now with the advent of better us core needles, we're getting much better tissue, we're able to do biopsies in both the right and the left lobe of the liver, and to see, see what we're doing treat what we're doing and do multiple things in one session. And I think the data speaks for itself. And so what we ended up doing is we're doing an ERCP and I'll say okay at the time of ERCP if there's no stricture why don't I just do a liver biopsy at the same time. But then it also takes a great hepatologist so I combined my work with one of the hepatologists who was very interested in portal hypertension I said listen, let's do our first 10 patients together, I'd like you to see what I do, and here's what I did. So he was very impressed by the data we got and started sending me a lot of patients and I think that collaboration from going back and forth with each other is key. Phoenix I have a question for you, train the T word training. So you're an endosynographer you got a reasonable practice and you wanted to kind of get into the endo hepatology realm. Can you talk a little bit about training training in these techniques. We'll start with liver biopsy maybe portal pressure measurements, please. I think the learning curve isn't as great or steep as other us guided techniques. I don't know of a dedicated fellowship but I've been hearing some rumors out there for a dedicated one year for just endo hepatology. In your practice, the more of these you do, I think that you'll be more comfortable. Starting this kind of practice I think I hear we say it's similar to what we had before when we got into the pancreatic area we try to convince our pancreatic surgeons you know this is the way to do it, this is how we going to diagnose it and stage So, you know, we approach the practice and practice building by talking to them you know we're here to compliment your practice, and we're not here to compete with the IR physicians. And I think we provide a very good service for our patients who are going to be there for endoscopy anyway and really think this is the way to diagnose these conditions. Thank you, Marvin, please can I just add up to now the training for these procedures have been very procedure specific, usually offered by industry, which have been excellent, but I think moving forward. ASG is looking to sort of package all these endo hepatology offerings into a more comprehensive training curricula. And so to that end ASG will be working towards an endo hepatology part one, as well as a part two curricula part one will be without us and part two will require us knowledge, probably two day course at the ITT center with didactics and hands on, but look out for those for more formal endo hepatology training. Thanks Marvin and I had one more question to close this session. Marvin Where are we going from, where do you see the future of endo hepatology, I'll start with you. What are the new things that are on the block that we could be talking about next year. So diagnostic endo hepatology I think is Dr. Wynn, Dr. Shirai have mentioned, I'm very excited about the prospects of the US shear wave elastography. So, you know, think about this as fiber scan from the inside out, I think in certain patient populations. The, the accuracy of the US shear wave can really be a great clinical benefit and can address the problem areas for fiber scan, particularly in the, in the obese patient population where NAFLD is endemic so that's what I'm most excited about in the near term. Thanks. And with that, I'm going to close this session I want to thank re Marvin and Phoenix for just a great opportunity here to.

obesity

splenomegaly

endoscopy

varices

endohepatology