TDF-treated patients with chronic hepatitis B have reduced bone mineral density, but the reduction is limited to 1 anatomical site. Age and advanced liver disease are additional contributing factors, underlining the importance of multifactorial fracture risk assessment. FRAX can accurately identify those at greatest risk of osteoporotic fracture.

A 62-year-old woman with type 1 autoimmune hepatitis (AIH) failed to sustain remission when steroids were withdrawn from a regimen of steroids and azathioprine (AZA). Thiopurine metabolites revealed elevated 6-MMP (6-methyl mercaptopurine) and low 6-TGN (6-thioguanine nucleotide) consistent with AZA-induced hepatotoxicity. Introducing the xanthine oxidase inhibitor allopurinol led to rapid normalization of alanine aminotransferase (ALT) and discontinuation of steroids. Repeat liver biopsy revealed steatosis but much reduced interface hepatitis. Thiopurine metabolite levels (Lennard method) revealed a 6-thioguanine (6-TGN-the active moiety) level of 100 pmol/8 Â 10 8 red blood cells (RBC) (normal range 250-450) and a 6-methyl mercaptopurine (6-MMP) level of 5800 pmol/8 Â 10 8 RBC, consistent with hypermethylation and preferential shunting to 6-MMP. Allopurinol 100 mg once daily was added and her AZA dose reduced by 75%. Subsequently, her ALT normalized within 4 weeks (Fig. 1). This combination corrected her metabolite levels (6-TGN 202 pmol/8 Â 10 8 RBC and 6-MMP 196 pmol/8 Â 10 8 RBC). Prednisolone was withdrawn after 3 months; her ALT remains 10-15 IU/L 12 months later. Case Report

Background: Insulinoma is the most common neuroendocrine neoplasm of the pancreas, characterised by hypoglycaemic symptoms. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) and ethanol ablation (EUS-EA) are novel methods for treating insulinoma. We aimed to perform a systematic review to assess the efficacy and safety of EUS-guided ablation techniques for pancreatic insulinomas. Methods: We systematically searched for articles detailing EUS-guided ablations of insulinomas. We performed a qualitative analysis and summarised data on the efficacy and safety of EUS-RFA and EUS-EA techniques. Results: In total, we identified 35 case reports and case series describing 75 patients with insulinomas treatment with EUS-guided ablation. Twenty-seven patients were treated with EUS-RFA, 47 patients with EUS-EA, and 1 patient received EUS-EA and EUS-RFA in the same session. In total, 84 insulinomas were ablated (EUS-RFA: 31, EUS-EA: 53). Most insulinomas were in the head of the pancreas (40%). The clinical success rate for EUS-guided ablation techniques was 98.5%. The median glucose level was 1.95 (Q1-Q3: 1.69–2.13) mmol/L before ablation compared to 6.20 (Q1-Q3: 5.30–7.05) mmol/L after treatment. The median insulin and C-peptide levels before and after RFA/EA were 230 (Q1–Q2: 120–257) pmol/L and 41 (Q1–Q2 35–42) pmol/L; 2077 (Q1–Q2 1644–2459) pmol/L and 819 (Q1–Q2 696–1072) pmol/L, respectively. There were eleven adverse events: seven abdominal pain, two mild acute pancreatitis, one necrotising acute pancreatitis and one local hematoma. All patients recovered, and there were no periprocedural deaths. Conclusions: EUS-guided ablation of insulinoma seems to be a safe and effective treatment and is an alternative to surgical resection in selected cases.

Henoch-Schonlein Purpura (HSP) is the most common systemic vasculitis in childhood and can present in adults. It is a self-limiting disease characterised by a tetrad of manifestations including the mandated typical cutaneous hallmark. We present a classic case of HSP complicated by gastrointestinal haemorrhage associated with hidradenitis suppurativa.

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