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Mo1146 Clinical Course of Asymptomatically Dilated Common Bile Duct
AGA Abstracts
Mo1144
duodenal ulcer (3), and periampullary diverticulm (2). 17 cases didn't have explainable findings. There were no change in CBD (37), increase in CBD diameter without obstructing lesion (4), development of gallstone (6) after follow up and 1 developed stricture in distal bile duct area. Dilated CBD with smooth tapering end, normal transaminase or total bilirubin level, past gastrectomy or choecystectomy were related with no change in diameter. Conclusion: Most cases of asymptomatically dilated CBD without obvious obstructing lesion were benign condition and did not change. So, close observation with CT scan could be optimal strategy. From this preliminary results, a comparison between the group with MRCP or ERCP and with only repeated CT scan would be possible in the future.
Efficacy of Diagnosis for Acute Cholecystitis With Contrast Enhanced Ultrasonography: Evaluation for Blood Flow of the Gall Bladder Wall Hiroki Utsunomiya, Atsushi Hiraoka, Miki Kan, Yusuke Imai, Haruka Tatsukawa, Nayu Tazuya, Hiroka Yamago, Yuko Shimizu, Nobukazu Yorimitsu, Satoshi Hidaka, Tetsuya Tanihira, Aki Hasebe, Yasunao Miyamoto, Tomoyuki Ninomiya, Kojiro Michitaka Aim/background: In early phase of acute cholecystitis (AC), ultrasonography (US) or enhanced computed tomography (CECT) sometimes do not show the typical findings. Therefore, its diagnosis is difficult in many patients. We evaluated the efficacy for diagnosis of AC with contrast enhanced US (CEUS). Methods: Subjects were 21 patients who were suspected for AC and 13 controls. B-mode US, CECT, and CEUS were performed in all of them. The symptoms of 21 patients, who were suspected for AC, were any one of upper abdominal pain and/or an attack of fever with elevation of the levels of white blood cell and/or C-reactive protein. B-mode US and CECT were reviewed for distension of GB, GB wall thickness, existence of debris in GB, pericholecystic fluid, subserosal edema, pericholecystic stranding. For diagnosis of AC by B-mode US, more than two findings of the three typical findings (distension of GB, GB wall thickness, existence of debris in GB) were necessary and distension of GB was an indispensable finding. Definitive diagnosis of AC was done by histopathological examination, the result of culture of bile juice from GB, and/or the typical finding of CECT including pericholecystic stranding. CEUS was performed with Perfulbutane (Sonazoid®). Movie video was recorded during the procedure and analysis was done with Receiver Operating Characteristic (ROC), that was focused on the GB wall in arterial phase of CEUS (20-60 seconds after injection of Sonazoid®). The results of analysis for ROC and clinical results were evaluated. Results: Nineteen of 21 patients, who were suspected for AC, were diagnosed as AC. Time intensity curve (TIC) was higher and acceleration time (ACT) was shorter in patients with AC than those without AC (4.50±2.31 vs. 2.34±1.26, P<0.01, and 8.2±2.4 vs. 15.8±7.1 seconds, P<0.01, respectively). These findings indicated the increase of the blood flow and the acceleration of the flow speed, respectively. Cut off values of TIC and ACT for diagnosis in ROC analysis were settled as >1.34, and as <15.8 respectively. With the cut off values of both TIC and ACT, seventeen patients were diagnosed as AC (17/19, 89.5%). Diagnostic value for AC with CEUS using above cut off values was equal to that of CECT (sensitivity and specificity: 89.5% and 100% vs. 73.7% and 100%, respectively). On the other hand, diagnostic value for AC of B-mode was worse (sensitivity and specificity: 21.1% and 100%). In five cases that could not be diagnosed by CECT, CEUS could diagnose them as AC. Conclusion: TIC was high and ACT was shortened in patients with AC. CEUS enabled the accurate diagnosis of AC in majority of patients whose findings of CECT or B-mode US were not typical with AC. CEUS was useful for the diagnosis of AC by analyzing TIC and ACT.
Mo1147 Inhibition of Sphingolipid Pathway Affects Cholesterol Gallstone Formation in Mice by the Modulation of IL-6/STAT3 Pathway Eun-Hye Lim, Jae Seon Kim, Beom Jae Lee, Yoon A Jeong, Jong-Jae Park, Joon Young Lee, Wonho Jung, Sang-ah Lim, Sehe Dong Lee, Young-Tae Bak Background: Previous our study has shown that sphingolipid pathway was associated with cholesterol gallstone formation in mice. Sphingolipid pathways are driven by inflammatory cytokines including IL-6. IL-6-driven Stat3 activation is associated with inflammation and cell proliferation. The aim of out study was whether the modulation of sphingolipid pathway has an impact on IL-6/Stat3 signaling in the inhibition of cholesterol gallstone formation Method: We used the cholesterol gallstone formation model (CB57BL/6J with lithogenic diet for 8 weeks, n=20 each group). Myriocin (serine palmitoyltransferase inhibitor, 0.3 mg/ kg/d, IP) was treated in experimental group and PBS was treated in control group. At the time of euthanization, GB and serum were extracted for the analysis. Gallstone formation was examined by naked eye. Extracted GB was cultured for 24hrs in RPMI medium for the assay for IL-6 by ELISA. Gene expressions of IL-6, SphK1 and S1PR1(S1P receptor 1) were determined using real-time RT-PCR and Western blot for Stat3 was performed. Results: Cholesterol gallstone formation was significantly decreased in myriocin treatment group (11% vs 85%, p<0.05). IL-6 concentrations of both serum and GB were decreased by myriocin (p<0.05). Phosphorylation of Stat3 in GB with gallstone significantly increased. Myriocin downregulated IL-6, SphK1 and S1PR1 gene expressions in GB and inhibited Stat3 activation. Conclusion: SphK/S1PR1 gene expression in GB was associated with cholesterol gallstone formation in mice. Inhibition of sphingolipid pathway affected the formation of cholesterol gallstone by the modulation of IL-6/Stat3 pathway in mice model. Mo1148 Liver Biochemical Tests are Often Normal in Patients With Common Bile Duct Stones Mel Wilcox, Milind A. Phadnis, Jessica Trevino, Shyam Varadarajulu
Mo1145 Regulation of CYP7A1: by Bile Acid or FGF15/19? Quan Shang, Gerald Salen, Guorong Xu
Background Abnormal liver chemistry tests (LFT's) are the hallmark of common bile duct (CBD) stones. However, there has been little study of the frequency and risk factors for normal liver tests in patients with CBD stones. Methods Using a prospective database, over a 10 year, 10 month period, all patients undergoing ERCP were prospectively identified. Patients undergoing ERCP for suspected or radiographically identified CBD stones had LFT's recorded at the time of initial clinical presentation and/or at the time of ERCP. CBD stones were confirmed by endoscopic sphincterotomy and extraction in all patients. Results Over the study period, 4782 patients underwent ERCP in whom 584 patients (67% white, 62% female, mean age 56 years +/- 21.6 years) had the procedure for suspected or radiographically identified CBD stones in whom laboratory results at the time of clinical presentation were available. Ultrasound or computed tomography was abnormal in 43% and 47% of patients, respectively. At the time of clinical presentation, LFT's were abnormal in 532 (51.1%) patients (95% CI - 48% - 54.1%). The most current LFT's prior to ERCP were normal in an additional 47 patients while 379 had abnormal LFTs. For those with abnormal LFT's, the median values were: total bilirubin of 2.7 (0.1 - 38); alkaline phosphatase 200 (range 37 - 1057); AST/ALT 105/139.5 range (3.5/9 - 1114/1152); GGT 249.5 range (4 - 1194). Patients with normal LFT's were more likely older (OR = 1.016; p=0.046) and had a longer duration since cholecystectomy (OR=1.004; p=0.044) as compared to patients with abnormal LFTs. Presence or absence of a solitary or multiple CBD stones, or abnormal ultrasound and computed tomography were not found to significantly associated. Conclusion Normal LFT's in patients presenting with a clinical picture compatible with common bile duct stones is more common than previously recognized. For those with abnormal LFT's, elevation of serum transaminases was the most common abnormal laboratory value.
Aim: It is proposed that CYP7A1 expression is regulated through a gut-liver signaling pathway FGF15/19-FGFR4 which is initiated by activation of FXR in the intestine rather than in the liver. This study evaluates whether the role of intestinal FGF15/19 in the regulation of CYP7A1 has been overstated. Method: New Zealand White rabbits were used (n=6/each group). Study 1 consisted of rabbits fed 0.5% or 2% cholesterol (Ch) and controls. Study 2: controls and rabbits with bile fistula alone (BF) or bile fistula plus 6 hrs of glycodeoxycholic acid perfusion (GDCA) directly into the portal vein to bypass the ileum. Results: In Study 1, portal bile acid concentrations, used to represent the bile acid flux returning to the liver, were increased 76% (p<0.01) in the rabbits fed 2% Ch but unchanged in those fed 0.5% Ch. Ileal FGF19 mRNA increased 100-fold (p<0.001) in rabbits fed either 0.5% or 2% Ch while hepatic CYP7A1 mRNA levels were suppressed only in the 2% Ch (77%, p<0.001) but not the 0.5% Ch group. For the first time, we measured FGF19 protein, the “signal”, in the portal blood which was 4.1±2.8 (control), 4.5±1.8 (0.5%Ch), and 4.7±2.7 pg/ml (2% Ch) respectively with no significant difference. In Study 2, portal bile acid concentrations in the GDCA group increased 3-fold due to the perfusion that bypassed the ileum. Ileal FGF19 mRNA was decreased (p<0.05) in both GDCA and BF groups while hepatic CYP7A1 expression was suppressed 80% (p<0.01) in the GDCA group and unchanged in the BF group. However, portal FGF19 protein concentrations were similar in the control (9.4±3.5pg/ ml), BF (9.4±3.7pg/ml) and GDCA (9.7±3.1pg/ml) groups. Conclusion: In rabbits, the expression of FGF19 in the ileum does not always determine the expression of CYP7A1 in the liver. The signal FGF19 concentration in the portal blood did not reflect the changes in FGF19 expression in the ileum nor correlated with the expression of CYP7A1 in the liver. Our results suggest that in rabbits, portal bile acid flux represents a more consistent signal than FGF19 on the regulation of CYP7A1 expression.
Mo1149 Directional Differentiation of Biliary Tract Disease Allele Risks Across Human Populations Saowanee Ngamruengphong, Tushar Patel
Mo1146 Clinical Course of Asymptomatically Dilated Common Bile Duct Anna Kim, Sung Hee Jung, Hyeon Woong Yang, Yun Jung Lee, Sae Hee Kim, Hyun Cheol Koo, JiWoong Jang, Chan Woong Park, Ho Sup Song, Sang Ok Lee
Background: Primary sclerosing cholangitis (PSC) and Primary biliary cirrhosis (PBC) are the most common chronic cholestatic liver diseases in adults. The geographic prevalence of these conditions varies considerably. Recent genome wide association studies have identified single nucleotide polymorphisms (SNPs) associated with susceptibility to these conditions. Differences in SNP allele frequency between populations can provide evidence that a locus has been subject to selection, with differing selection pressures between the populations. Thus, our aims were to characterize evolutionary trends in the genetic profile of PSC and PBC. Methods: We analyzed the impact of human migration on the genetic risk of these chronic cholestatic disorders, and compared with genetic risk for alcoholic liver disease, or ulcerative colitis (UC). Disease associated SNPs were identified from the NHGRI GWAS database. The frequency of disease associated risk alleles across 53 indigenous populations spanning all continents and obtained from the human genome diversity project was analyzed. A population risk score was derived for these diverse populations based on the relative risk of each SNP and allelic frequency within a population. The data were superimposed on human migration patterns to derive temporal and spatial determinants of the impact of
Introduction: To evaluate dilated common bile duct (CBD), EUS, ERCP, or MRCP are needed. These modalities are expensive and some are invasive. When dilated CBD are found incidentally and abdominal CT scan shows no evidence of obstructing lesion, it is unclear if evaluation is needed or which modality should be chosen. We retrospectively collected cases with asymptomatically dilated CBD and evaluated the clinical course. Method: We retrospectively reviewed CT findings with CBD dilation from 2008 January to 2011 October in our institution. Total of 153 cases with dilated CBD were investigated. 54 cases with obvious obstructing lesions on CT findings or symptoms consistent with cholangitis, and 61 cases followed less than 6 months were excluded. Finally 48 cases were included. Results: Median observation period was 19 months (6-138 months). Mean age of the patients was 66.7 ± 11.7 years. 43/48 cases (89.6%) had normal ALT. All had normal serum bilirubin level. Associated conditions were gastrectomy (11), cholecystectomy (11), gallstone (4),
AGA Abstracts
S-606
Mo1144
duodenal ulcer (3), and periampullary diverticulm (2). 17 cases didn't have explainable findings. There were no change in CBD (37), increase in CBD diameter without obstructing lesion (4), development of gallstone (6) after follow up and 1 developed stricture in distal bile duct area. Dilated CBD with smooth tapering end, normal transaminase or total bilirubin level, past gastrectomy or choecystectomy were related with no change in diameter. Conclusion: Most cases of asymptomatically dilated CBD without obvious obstructing lesion were benign condition and did not change. So, close observation with CT scan could be optimal strategy. From this preliminary results, a comparison between the group with MRCP or ERCP and with only repeated CT scan would be possible in the future.
Efficacy of Diagnosis for Acute Cholecystitis With Contrast Enhanced Ultrasonography: Evaluation for Blood Flow of the Gall Bladder Wall Hiroki Utsunomiya, Atsushi Hiraoka, Miki Kan, Yusuke Imai, Haruka Tatsukawa, Nayu Tazuya, Hiroka Yamago, Yuko Shimizu, Nobukazu Yorimitsu, Satoshi Hidaka, Tetsuya Tanihira, Aki Hasebe, Yasunao Miyamoto, Tomoyuki Ninomiya, Kojiro Michitaka Aim/background: In early phase of acute cholecystitis (AC), ultrasonography (US) or enhanced computed tomography (CECT) sometimes do not show the typical findings. Therefore, its diagnosis is difficult in many patients. We evaluated the efficacy for diagnosis of AC with contrast enhanced US (CEUS). Methods: Subjects were 21 patients who were suspected for AC and 13 controls. B-mode US, CECT, and CEUS were performed in all of them. The symptoms of 21 patients, who were suspected for AC, were any one of upper abdominal pain and/or an attack of fever with elevation of the levels of white blood cell and/or C-reactive protein. B-mode US and CECT were reviewed for distension of GB, GB wall thickness, existence of debris in GB, pericholecystic fluid, subserosal edema, pericholecystic stranding. For diagnosis of AC by B-mode US, more than two findings of the three typical findings (distension of GB, GB wall thickness, existence of debris in GB) were necessary and distension of GB was an indispensable finding. Definitive diagnosis of AC was done by histopathological examination, the result of culture of bile juice from GB, and/or the typical finding of CECT including pericholecystic stranding. CEUS was performed with Perfulbutane (Sonazoid®). Movie video was recorded during the procedure and analysis was done with Receiver Operating Characteristic (ROC), that was focused on the GB wall in arterial phase of CEUS (20-60 seconds after injection of Sonazoid®). The results of analysis for ROC and clinical results were evaluated. Results: Nineteen of 21 patients, who were suspected for AC, were diagnosed as AC. Time intensity curve (TIC) was higher and acceleration time (ACT) was shorter in patients with AC than those without AC (4.50±2.31 vs. 2.34±1.26, P<0.01, and 8.2±2.4 vs. 15.8±7.1 seconds, P<0.01, respectively). These findings indicated the increase of the blood flow and the acceleration of the flow speed, respectively. Cut off values of TIC and ACT for diagnosis in ROC analysis were settled as >1.34, and as <15.8 respectively. With the cut off values of both TIC and ACT, seventeen patients were diagnosed as AC (17/19, 89.5%). Diagnostic value for AC with CEUS using above cut off values was equal to that of CECT (sensitivity and specificity: 89.5% and 100% vs. 73.7% and 100%, respectively). On the other hand, diagnostic value for AC of B-mode was worse (sensitivity and specificity: 21.1% and 100%). In five cases that could not be diagnosed by CECT, CEUS could diagnose them as AC. Conclusion: TIC was high and ACT was shortened in patients with AC. CEUS enabled the accurate diagnosis of AC in majority of patients whose findings of CECT or B-mode US were not typical with AC. CEUS was useful for the diagnosis of AC by analyzing TIC and ACT.
Mo1147 Inhibition of Sphingolipid Pathway Affects Cholesterol Gallstone Formation in Mice by the Modulation of IL-6/STAT3 Pathway Eun-Hye Lim, Jae Seon Kim, Beom Jae Lee, Yoon A Jeong, Jong-Jae Park, Joon Young Lee, Wonho Jung, Sang-ah Lim, Sehe Dong Lee, Young-Tae Bak Background: Previous our study has shown that sphingolipid pathway was associated with cholesterol gallstone formation in mice. Sphingolipid pathways are driven by inflammatory cytokines including IL-6. IL-6-driven Stat3 activation is associated with inflammation and cell proliferation. The aim of out study was whether the modulation of sphingolipid pathway has an impact on IL-6/Stat3 signaling in the inhibition of cholesterol gallstone formation Method: We used the cholesterol gallstone formation model (CB57BL/6J with lithogenic diet for 8 weeks, n=20 each group). Myriocin (serine palmitoyltransferase inhibitor, 0.3 mg/ kg/d, IP) was treated in experimental group and PBS was treated in control group. At the time of euthanization, GB and serum were extracted for the analysis. Gallstone formation was examined by naked eye. Extracted GB was cultured for 24hrs in RPMI medium for the assay for IL-6 by ELISA. Gene expressions of IL-6, SphK1 and S1PR1(S1P receptor 1) were determined using real-time RT-PCR and Western blot for Stat3 was performed. Results: Cholesterol gallstone formation was significantly decreased in myriocin treatment group (11% vs 85%, p<0.05). IL-6 concentrations of both serum and GB were decreased by myriocin (p<0.05). Phosphorylation of Stat3 in GB with gallstone significantly increased. Myriocin downregulated IL-6, SphK1 and S1PR1 gene expressions in GB and inhibited Stat3 activation. Conclusion: SphK/S1PR1 gene expression in GB was associated with cholesterol gallstone formation in mice. Inhibition of sphingolipid pathway affected the formation of cholesterol gallstone by the modulation of IL-6/Stat3 pathway in mice model. Mo1148 Liver Biochemical Tests are Often Normal in Patients With Common Bile Duct Stones Mel Wilcox, Milind A. Phadnis, Jessica Trevino, Shyam Varadarajulu
Mo1145 Regulation of CYP7A1: by Bile Acid or FGF15/19? Quan Shang, Gerald Salen, Guorong Xu
Background Abnormal liver chemistry tests (LFT's) are the hallmark of common bile duct (CBD) stones. However, there has been little study of the frequency and risk factors for normal liver tests in patients with CBD stones. Methods Using a prospective database, over a 10 year, 10 month period, all patients undergoing ERCP were prospectively identified. Patients undergoing ERCP for suspected or radiographically identified CBD stones had LFT's recorded at the time of initial clinical presentation and/or at the time of ERCP. CBD stones were confirmed by endoscopic sphincterotomy and extraction in all patients. Results Over the study period, 4782 patients underwent ERCP in whom 584 patients (67% white, 62% female, mean age 56 years +/- 21.6 years) had the procedure for suspected or radiographically identified CBD stones in whom laboratory results at the time of clinical presentation were available. Ultrasound or computed tomography was abnormal in 43% and 47% of patients, respectively. At the time of clinical presentation, LFT's were abnormal in 532 (51.1%) patients (95% CI - 48% - 54.1%). The most current LFT's prior to ERCP were normal in an additional 47 patients while 379 had abnormal LFTs. For those with abnormal LFT's, the median values were: total bilirubin of 2.7 (0.1 - 38); alkaline phosphatase 200 (range 37 - 1057); AST/ALT 105/139.5 range (3.5/9 - 1114/1152); GGT 249.5 range (4 - 1194). Patients with normal LFT's were more likely older (OR = 1.016; p=0.046) and had a longer duration since cholecystectomy (OR=1.004; p=0.044) as compared to patients with abnormal LFTs. Presence or absence of a solitary or multiple CBD stones, or abnormal ultrasound and computed tomography were not found to significantly associated. Conclusion Normal LFT's in patients presenting with a clinical picture compatible with common bile duct stones is more common than previously recognized. For those with abnormal LFT's, elevation of serum transaminases was the most common abnormal laboratory value.
Aim: It is proposed that CYP7A1 expression is regulated through a gut-liver signaling pathway FGF15/19-FGFR4 which is initiated by activation of FXR in the intestine rather than in the liver. This study evaluates whether the role of intestinal FGF15/19 in the regulation of CYP7A1 has been overstated. Method: New Zealand White rabbits were used (n=6/each group). Study 1 consisted of rabbits fed 0.5% or 2% cholesterol (Ch) and controls. Study 2: controls and rabbits with bile fistula alone (BF) or bile fistula plus 6 hrs of glycodeoxycholic acid perfusion (GDCA) directly into the portal vein to bypass the ileum. Results: In Study 1, portal bile acid concentrations, used to represent the bile acid flux returning to the liver, were increased 76% (p<0.01) in the rabbits fed 2% Ch but unchanged in those fed 0.5% Ch. Ileal FGF19 mRNA increased 100-fold (p<0.001) in rabbits fed either 0.5% or 2% Ch while hepatic CYP7A1 mRNA levels were suppressed only in the 2% Ch (77%, p<0.001) but not the 0.5% Ch group. For the first time, we measured FGF19 protein, the “signal”, in the portal blood which was 4.1±2.8 (control), 4.5±1.8 (0.5%Ch), and 4.7±2.7 pg/ml (2% Ch) respectively with no significant difference. In Study 2, portal bile acid concentrations in the GDCA group increased 3-fold due to the perfusion that bypassed the ileum. Ileal FGF19 mRNA was decreased (p<0.05) in both GDCA and BF groups while hepatic CYP7A1 expression was suppressed 80% (p<0.01) in the GDCA group and unchanged in the BF group. However, portal FGF19 protein concentrations were similar in the control (9.4±3.5pg/ ml), BF (9.4±3.7pg/ml) and GDCA (9.7±3.1pg/ml) groups. Conclusion: In rabbits, the expression of FGF19 in the ileum does not always determine the expression of CYP7A1 in the liver. The signal FGF19 concentration in the portal blood did not reflect the changes in FGF19 expression in the ileum nor correlated with the expression of CYP7A1 in the liver. Our results suggest that in rabbits, portal bile acid flux represents a more consistent signal than FGF19 on the regulation of CYP7A1 expression.
Mo1149 Directional Differentiation of Biliary Tract Disease Allele Risks Across Human Populations Saowanee Ngamruengphong, Tushar Patel
Mo1146 Clinical Course of Asymptomatically Dilated Common Bile Duct Anna Kim, Sung Hee Jung, Hyeon Woong Yang, Yun Jung Lee, Sae Hee Kim, Hyun Cheol Koo, JiWoong Jang, Chan Woong Park, Ho Sup Song, Sang Ok Lee
Background: Primary sclerosing cholangitis (PSC) and Primary biliary cirrhosis (PBC) are the most common chronic cholestatic liver diseases in adults. The geographic prevalence of these conditions varies considerably. Recent genome wide association studies have identified single nucleotide polymorphisms (SNPs) associated with susceptibility to these conditions. Differences in SNP allele frequency between populations can provide evidence that a locus has been subject to selection, with differing selection pressures between the populations. Thus, our aims were to characterize evolutionary trends in the genetic profile of PSC and PBC. Methods: We analyzed the impact of human migration on the genetic risk of these chronic cholestatic disorders, and compared with genetic risk for alcoholic liver disease, or ulcerative colitis (UC). Disease associated SNPs were identified from the NHGRI GWAS database. The frequency of disease associated risk alleles across 53 indigenous populations spanning all continents and obtained from the human genome diversity project was analyzed. A population risk score was derived for these diverse populations based on the relative risk of each SNP and allelic frequency within a population. The data were superimposed on human migration patterns to derive temporal and spatial determinants of the impact of
Introduction: To evaluate dilated common bile duct (CBD), EUS, ERCP, or MRCP are needed. These modalities are expensive and some are invasive. When dilated CBD are found incidentally and abdominal CT scan shows no evidence of obstructing lesion, it is unclear if evaluation is needed or which modality should be chosen. We retrospectively collected cases with asymptomatically dilated CBD and evaluated the clinical course. Method: We retrospectively reviewed CT findings with CBD dilation from 2008 January to 2011 October in our institution. Total of 153 cases with dilated CBD were investigated. 54 cases with obvious obstructing lesions on CT findings or symptoms consistent with cholangitis, and 61 cases followed less than 6 months were excluded. Finally 48 cases were included. Results: Median observation period was 19 months (6-138 months). Mean age of the patients was 66.7 ± 11.7 years. 43/48 cases (89.6%) had normal ALT. All had normal serum bilirubin level. Associated conditions were gastrectomy (11), cholecystectomy (11), gallstone (4),
AGA Abstracts
S-606