Background and Aims The association between obstructive sleep apnea (OSA) and abnormal liver enzymes has been reported in multiple studies. The existing literature regarding the relationship between OSA and nonalcoholic steatohepatitis (NASH) is conflicting. Thus we aimed to determine the relationship between OSA and NASH from a large database. Methods A cross-sectional study was performed using the 2012 Nationwide Inpatient Sample. We identified adult patients (18–90 year) who had a diagnosis of OSA using the International Classification of Diseases ICD-9 codes. The control group was comprised of adult individuals with no discharge records of OSA. NASH diagnosis was also identified using the ICD-9 codes. The association between OSA and NASH was calculated using univariable and multivariable logistic regression. Results 30,712,524 hospitalizations were included. The OSA group included 1,490,150 patients versus 29,222,374 in the control non-OSA group. The OSA group average age was 61.8±0.07 years (44.2% females) compared to 57.0±0.11 years (60.1% females) in the non-OSA group. NASH prevalence was significantly higher in the OSA group compared to the non-OSA group [2% (95% CI: 1.9, 2.1) versus 0.65% (0.63, 0.66), p<0.001]. After adjusting for obesity, diabetes, hypertension, dyslipidemia, the metabolic syndrome and Charlson comorbidity index, OSA patients were 3 times more likely to have NASH [adjusted OR:3.1 (95% CI: 3.0 – 3.3), p<0.001]. Conclusions Patients with OSA are three times more likely to have NASH compared to patients without OSA after controlling for other confounders. These data indicate that OSA should be considered as an independent risk factor for developing NASH.

Purpose: Needs, risks, and outcomes of patients admitted to a post liver transplant intensive care unit (POLTICU) differ in important ways from those admitted to pretransplant intensive care units (ICUs). The aim of this study was to create the optimal model to risk stratify POLTICU patients. Methods: Consecutive patients who underwent first deceased donor liver transplantation (LT) at a large United States center between 2008 and 2014 were followed from admission to LT and to discharge or death. Receiver–operating characteristic analysis was performed to assess the value of various scores in predicting in-hospital mortality. A predictive model was developed using logistic regression analysis. Results: A total of 697 patients underwent LT, and 3.2% died without leaving the hospital. A model for in-hospital mortality was derived from variables available within 24 hours of admission to the POLTICU. Key variables best predicting survival were white blood cell count, 24-hour urine output, and serum glucose. A model using these variables performed with an area under the curve (AUC) of 0.88, compared to the Acute Physiology and Chronic Health Evaluation III and Model for End-Stage Liver Disease, which performed with AUCs of 0.74 and 0.60, respectively. Conclusion: An improved model, the early mortality after LT (EMALT) score, performs better than conventional models in predicting in-hospital mortality after LT.

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BACKGROUND Critically ill patients with cirrhosis, particularly those with acute decompensation, have higher mortality rates in the intensive care unit (ICU) than patients without chronic liver disease. Prognostication of short-term mortality is important in order to identify patients at highest risk of death. None of the currently available prognostic models have been widely accepted for use in cirrhotic patients in the ICU, perhaps due to complexity of calculation, or lack of universal variables readily available for these patients. We believe a survival model meeting these requirements can be developed, to guide therapeutic decision-making and contribute to cost-effective healthcare resource utilization. AIM To identify markers that best identify likelihood of survival and to determine the performance of existing survival models. METHODS Consecutive cirrhotic patients admitted to a United States quaternary care center ICU between 2008-2014 were included and comprised the training cohort. Demographic data and clinical laboratory test collected on admission to ICU were analyzed. Area under the curve receiver operator characteristics (AUROC) analysis was performed to assess the value of various scores in predicting in-hospital mortality. A new predictive model, the LIV-4 score, was developed using logistic regression analysis and validated in a cohort of patients admitted to the same institution between 2015-2017. RESULTS Of 436 patients, 119 (27.3%) died in the hospital. In multivariate analysis, a combination of the natural logarithm of the bilirubin, prothrombin time, white blood cell count, and mean arterial pressure was found to most accurately predict in-hospital mortality. Derived from the regression coefficients of the independent variables, a novel model to predict inpatient mortality was developed (the LIV-4 score) and performed with an AUROC of 0.86, compared to the Model for End-Stage Liver Disease, Chronic Liver Failure-Sequential Organ Failure Assessment, and Royal Free Hospital Score, which performed with AUROCs of 0.81, 0.80, and 0.77, respectively. Patients in the internal validation cohort were substantially sicker, as evidenced by higher Model for End-Stage Liver Disease, Model for End-Stage Liver Disease-Sodium, Acute Physiology and Chronic Health Evaluation III, SOFA and LIV-4 scores. Despite these differences, the LIV-4 score remained significantly higher in subjects who expired during the hospital stay and exhibited good prognostic values in the validation cohort with an AUROC of 0.80. CONCLUSION LIV-4, a validated model for predicting mortality in cirrhotic patients on admission to the ICU, performs better than alternative liver and ICU-specific survival scores.

A 56-year-old man presented with recurrent gastrointestinal obstruction. Computed tomography showed fluid-filled, distended stomach, small intestine, and large intestine. Extensive workup including esophagogastroduodenoscopy, colonoscopy, magnetic resonance enterography, push enteroscopy, and video capsule enteroscopy showed no mechanical obstruction. Endoscopic ultrasound-guided biopsy of peripancreatic nodes detected on 18 F-fluorodeoxyglucose positron emission tomography revealed a duodenal neuroendocrine tumor. The lesion showed intense uptake on gallium-68 DOTATOC positron emission tomographycomputed tomography scan. The patient underwent surgical resection of the tumor with resolution of bowel obstruction events. He had elevated pancreatic polypeptide levels, which are known to delay gastric emptying and could explain his symptoms.Previous computed tomography (CT) scans of the abdomen showed variable distension of the stomach, or fluid-filled small intestine with concern for transition point at the ileum, or distended large intestine. He had formerly undergone 2 esophagogastroduodenoscopies, which did not reveal gastric outlet obstruction. His current CT abdomen showed a fluid-filled stomach and duodenum, suggestive of gastric outlet obstruction (Figure 1). Magnetic resonance enterography (MRE) did not show obstruction, but demonstrated a 2.1 3 2.3-cm right mesenteric nodule with similar enhancement as the spleen, raising the possibility of ectopic splenic tissue, and a 0.7-cm nodule posterior to the uncinate process.Push enteroscopy revealed esophagitis and severe aphthous ulcerations in the small intestine, but no obstruction. Colonoscopy did not reveal any obstructive pathology. Video capsule enterography revealed erythematous mucosa with villous blunting and nonobstructive luminal narrowing in the duodenum through which the capsule passed easily.An 18 F-fluorodeoxyglucose positron emission tomography ( 18 FDG PET)/CT scan was performed to further evaluate the mesenteric lesion seen on MRE. It showed multiple mild to moderately FDG avid cervical lymph nodes (LN), the largest a 4-cm left supraclavicular LN. It redemonstrated the soft-tissue lesion anterior to the duodenum with mild to moderate FDG uptake and multiple