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From the basics with the relationship between ER stress in the liver and in the gut and the progression of CLD or different mechanism of liver regeneration (associated with glucose metabolism and novel tools for the study of liver regeneration: organoids), to clinical human trials where exercise and statins were evaluated. In addition, the use of novel technologies like -omics was also covered at this meeting.</p>" ] ] ] "autores" => array:2 [ 0 => array:2 [ "autoresLista" => "Carlos Sanz-Garcia, Yulia A. Nevzorova, Eduardo Martínez-Naves, Francisco Javier Cubero" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Carlos" "apellidos" => "Sanz-Garcia" ] 1 => array:2 [ "nombre" => "Yulia A." 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"apellidos" => "Macías-Rodriguez" ] 6 => array:2 [ "nombre" => "Astrid" "apellidos" => "Ruiz-Margain" ] 7 => array:2 [ "nombre" => "David" "apellidos" => "Kershenobich-Stalnikowitz" ] 8 => array:2 [ "nombre" => "Nestor R." "apellidos" => "Vargas" ] 9 => array:2 [ "nombre" => "Alberto E." "apellidos" => "Muñoz" ] 10 => array:2 [ "nombre" => "Helder I." "apellidos" => "Nakaya" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570522001613?idApp=UINPBA00004N" "url" => "/02105705/0000004600000004/v2_202304070008/S0210570522001613/v2_202304070008/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0210570522002126" "issn" => "02105705" "doi" => "10.1016/j.gastrohep.2022.08.008" "estado" => "S300" "fechaPublicacion" => "2023-04-01" "aid" => "1980" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Gastroenterol Hepatol. 2023;46:319-20" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Billiary casts in post-COVID-19 cholangiopathy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "319" "paginaFinal" => "320" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cilindros biliares en la colangiopatía post-COVID-19" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 616 "Ancho" => 1005 "Tamanyo" => 148238 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left – endoscopic retrograde cholangiopancreatography (ERCP) with removal of a biliary cast. Right – cast with the format of extra-hepatic biliary tree.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jonathan Soldera, Raul Angelo Balbinot, Silvana Sartori Balbinot" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jonathan" "apellidos" => "Soldera" ] 1 => array:2 [ "nombre" => "Raul Angelo" "apellidos" => "Balbinot" ] 2 => array:2 [ "nombre" => "Silvana Sartori" "apellidos" => "Balbinot" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570522002126?idApp=UINPBA00004N" "url" => "/02105705/0000004600000004/v2_202304070008/S0210570522002126/v2_202304070008/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Cullen's sign associated with variceal bleeding" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor,</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "320" "paginaFinal" => "321" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria Manuela Estevinho, João Carlos Silva, Teresa Freitas, Rolando Pinho" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Maria Manuela" "apellidos" => "Estevinho" "email" => array:1 [ 0 => "mmestevinho@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "João Carlos" "apellidos" => "Silva" ] 2 => array:2 [ "nombre" => "Teresa" "apellidos" => "Freitas" ] 3 => array:2 [ "nombre" => "Rolando" "apellidos" => "Pinho" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Gastroenterology, Vila Nova de Gaia Espinho Hospital Centre, Vila Nova de Gaia, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Signo de Cullen asociado a hemorragia por várices esofágicas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2424 "Ancho" => 3175 "Tamanyo" => 1227486 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inspection of the abdomen (A1) and endoscopic views of the esophagus (large esophageal varices [A2], white nipple sign [A3], band ligation [A4]).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The authors describe the case of a 78-year-old patient who presented with melena for 48<span class="elsevierStyleHsp" style=""></span>h. No abdominal pain or other symptoms were recalled. The patient had obesity (body mass index of 33<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), arterial hypertension, type 2 diabetes mellitus and stage 3 chronic kidney disease; there were no smoking or drinking habits. The patient had been extensively studied 4 years earlier due to thrombocytopenia and splenomegaly, whose etiology remained undefined. Indeed, advanced liver fibrosis had been excluded (liver parameters were sustainedly normal, no radiological signs of cirrhosis neither endoscopic signs of portal hypertension (PH) were found, mean transient elastography-measured liver stiffness was 9.2<span class="elsevierStyleHsp" style=""></span>kPa [interquartile range 0.4]); two bone marrow biopsies were under the normality. The patient was under anti-hypertensive and oral hypoglycemic drugs, daily ferrous sulphate, and erythropoietin every two weeks. At admission, the physical examination was normal, except for periumbilical ecchymosis with onset in the prior 24<span class="elsevierStyleHsp" style=""></span>h (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A1). Laboratory tests showed normocytic and normochromic anemia (hemoglobin 9.7<span class="elsevierStyleHsp" style=""></span>g/dL), leukocytosis (27.2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL), thrombocytopenia (100<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL) and a mildly deranged coagulation (international normalized ratio 1.4). The liver panel and C-reactive protein were normal. Considering the suspicion of upper gastrointestinal bleeding, an esophagogastroscopy was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A2–4). Large esophageal varices with a «white nipple sign» were identified and promptly banded. To exclude the presence of any concomitant illness that could associate with the Cullen's sign and justify the presence of leukocytosis (even more considering that the patient had chronic leukopenia), an abdominopelvic computed tomography scan with contrast was performed. It revealed a cirrhotic liver, identified esophagogastric and retroperitoneal varices and signs of splenorenal shunt; the pancreas and the remaining organs were normal, and no active bleeding was detected. The patient remained asymptomatic and hemodynamically stable, presented no additional blood losses and leukocytosis remitted.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The bruising surrounding the umbilicus corresponds to the Cullen's sign. This sign was first described more than 100 years ago, in the setting of a ruptured ectopic pregnancy. Since then, it has been reported to occur in several clinical scenarios, including pancreatitis (the most common, appearing in 3.0–5.0% of the acute pancreatitis cases), splenic injury, perforated duodenal ulcer, acute pyelonephritis, as a manifestation of intraabdominal metastasis, among others.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> The common ground is that all these may course with retroperitoneal bleeding, being hypothesized that blood then spreads to the periumbilical fatty tissue through the round ligament of liver which forms part of the free edge of the falciform ligament.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> This is the second report of Cullen's sign associated with PH,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and the first in a patient with acute variceal bleeding and without a prior diagnosis of cirrhosis. This case highlights the large interindividual heterogeneity of metabolic-associated fatty liver disease (MAFLD), and the importance of developing tools to identify the «rapid progressors», as up to one fifth of the patients without significant fibrosis may develop F3/F4 fibrosis over 5 years,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> with undeniable increase in morbidity and mortality. In addition, it must be acknowledged that, in MAFLD, PH may be present even in the absence of fibrosis, and that PH-related complications may occur with lower portal pressure gradients, when compared to other etiologies.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0015" class="elsevierStylePara elsevierViewall">All authors were involved in patients’ management and approved the final version of the manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study did not receive funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2424 "Ancho" => 3175 "Tamanyo" => 1227486 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inspection of the abdomen (A1) and endoscopic views of the esophagus (large esophageal varices [A2], white nipple sign [A3], band ligation [A4]).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute pyelonephritis with Cullen's sign masquerading as pancreatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Singh" 1 => "A. Mittal" 2 => "V.K. Panwar" 3 => "R. Ghorai" 4 => "A. Upadhyay" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7759/cureus.23222" "Revista" => array:5 [ "tituloSerie" => "Cureus" "fecha" => "2022" "volumen" => "14" "paginaInicial" => "e23222" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35449670" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cullen's sign: not always acute pancreatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.O. Ximenes" 1 => "J.P. Vieira Costa" 2 => "E. Pereira" 3 => "K.T. 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Tellez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cgh.2021.10.023" "Revista" => array:6 [ "tituloSerie" => "Clin Gastroenterol Hepatol" "fecha" => "2022" "volumen" => "20" "paginaInicial" => "2276" "paginaFinal" => "2286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34688952" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105705/0000004600000004/v2_202304070008/S0210570522002515/v2_202304070008/en/main.assets" "Apartado" => array:4 [ "identificador" => "9010" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Director" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105705/0000004600000004/v2_202304070008/S0210570522002515/v2_202304070008/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570522002515?idApp=UINPBA00004N" ]
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Letter to the Editor
Cullen's sign associated with variceal bleeding
Signo de Cullen asociado a hemorragia por várices esofágicas
Maria Manuela Estevinho
, João Carlos Silva, Teresa Freitas, Rolando Pinho
Autor para correspondencia
Department of Gastroenterology, Vila Nova de Gaia Espinho Hospital Centre, Vila Nova de Gaia, Portugal