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Takahashi Y. Nonalcoholic fatty liver disease and adult growth hormone deficiency: An under-recognized association? Best Pract Res Clin Endocrinol Metab 2023; 37:101816. [PMID: 37643935 DOI: 10.1016/j.beem.2023.101816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Growth hormone (GH) plays an essential role not only in promoting growth in children, but also in many important metabolic processes in adults. One of the major metabolic functions of GH is its stimulatory effects on the liver in generating approximately 80% of circulating insulin-like growth factor 1 (IGF-1). Adult growth hormone deficiency (GHD) is an established clinical entity defined as a defect in endogenous GH secretion that is frequently associated with central obesity, loss of muscle mass, decreased bone mass, and impaired quality of life. Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are conditions that are often under-recognized in adults with GHD, and accordingly some studies have shown that GH and IGF-1 levels are decreased in patients with NAFLD. Furthermore, it has been reported that it can progress to end-stage liver cirrhosis in some adults and children with GHD. Due to their underlying mechanisms of action, GH and IGF-1 can act on hepatocytes, macrophages, and hepatic stellate cells to mitigate progression to steatosis and fibrosis. It is, thus, important to recognize NAFLD/NASH as important complications in adult and childhood GHD. Therefore, careful and thorough evaluation of NAFLD/NASH in adults with GHD and the consideration for GH replacement therapy is crucial in these patients, together with management of other metabolic risk factors, such as obesity and dyslipidemia. This review will focus on recent reports on the role of GH and IGF-1 in the liver and its clinical significance in the regulation of hepatic function.
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Affiliation(s)
- Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Japan.
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Ogasawara Y, Kogiso T, Horiuchi K, Taniai M, Tokushige K. Outcomes of fatty liver disease with and without metabolic comorbidities and risk factors for mortality. JGH Open 2023; 7:410-418. [PMID: 37359113 PMCID: PMC10290268 DOI: 10.1002/jgh3.12898] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 06/28/2023]
Abstract
Background and Aim As the clinical course of metabolic-associated fatty liver disease (MAFLD) is unclear, we compared the clinical courses of MAFLD and non-alcoholic FLD (NAFLD). Methods Asian FLD patients (n = 987) from 1991 to 2021 (biopsy-proven in 939) were enrolled. The patients were divided into NAFLD (N-alone, n = 92), both MAFLD and N (M&N, n = 785), and M-alone (n = 90) groups. Clinical features, complications, and survival rates were compared among the three groups. Risk factors of mortality were subjected to Cox regression analysis. Results The N-alone group patients were significantly younger (N alone, M&N, and M alone: 50, 53, and 57 years, respectively), more frequently male (54.3%, 52.6%, and 37.8%), and had a low body mass index (BMI, 23.1, 27.1, and 26.7 kg/m2) and FIB-4 index (1.20, 1.46, and 2.10). Hypopituitarism (5.4%) and hypothyroidism (7.6%) were significantly observed in the N-alone group. Hepatocellular carcinoma (HCC) developed in 0.0%, 4.2%, and 3.5% of the cases, and extrahepatic malignancies in 6.8%, 8.4%, and 4.7% of the cases, respectively, with no significant differences. The cardiovascular event rate was significantly higher in the M-alone group (1, 37, and 11 cases, P < 0.01). Survival rates were similar among the three groups. Risk factors for mortality were age and BMI in the N-alone group; age, HCC, alanine transaminase, and FIB-4 in the M&N group; and FIB-4 in the M-alone group. Conclusion Different risk factors for mortality may exist among the FLD groups.
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Affiliation(s)
- Yuri Ogasawara
- Institute of Gastroenterology, Department of Internal MedicineTokyo Women's Medical UniversityTokyoJapan
| | - Tomomi Kogiso
- Institute of Gastroenterology, Department of Internal MedicineTokyo Women's Medical UniversityTokyoJapan
| | - Kentaro Horiuchi
- Institute of Gastroenterology, Department of Internal MedicineTokyo Women's Medical UniversityTokyoJapan
| | - Makiko Taniai
- Institute of Gastroenterology, Department of Internal MedicineTokyo Women's Medical UniversityTokyoJapan
| | - Katsutoshi Tokushige
- Institute of Gastroenterology, Department of Internal MedicineTokyo Women's Medical UniversityTokyoJapan
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Arefhosseini S, Ebrahimi-Mameghani M, Najafipour F, Tutunchi H. Non-alcoholic fatty liver disease across endocrinopathies: Interaction with sex hormones. Front Endocrinol (Lausanne) 2022; 13:1032361. [PMID: 36419770 PMCID: PMC9676462 DOI: 10.3389/fendo.2022.1032361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) has emerged as the most frequent chronic liver disease globally. NAFLD is strongly associated with metabolic syndrome and it has been recently suggested that to rename NAFLD as metabolic dysfunction-associated fatty liver disease (MAFLD). NAFLD has been studied in different endocrine axes and accumulating body of clinical and experimental studies have suggested that NAFLD is associated with polycystic ovarian syndrome (PCOS), hypopituitarism, growth hormone deficiency (GHD), hypogonadism and other endocrine disorders. In fact, endocrine dysfunction may be considered as the major contributor for the development, progression, and severity of NAFLD. In the present comprehensive review, we discussed the epidemiological and clinical evidence on the epidemiology, pathophysiology, and management of NAFLD in endocrine disorders, with an emphasis on the effects of sex-specific hormones/conditions as well as molecular basis of NAFLD development in these endocrine diseases.
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Affiliation(s)
- Sara Arefhosseini
- Student Research Committee, Department of Biochemistry and Diet Therapy, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrangiz Ebrahimi-Mameghani
- Nutrition Research Center, Department of Biochemistry and Diet Therapy, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farzad Najafipour
- Endocrine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Helda Tutunchi
- Endocrine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Xiao J, Zhu C, Zhang X, Sun L, Gao C, Liang X, He Q, Liu M. Associations among FT 4 level, FT 3/FT 4 ratio, and non-alcoholic fatty liver disease in Chinese patients with hypopituitarism. Endocr J 2022; 69:659-667. [PMID: 35034938 DOI: 10.1507/endocrj.ej21-0536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic metabolic disorder. Thyroid function is associated with NAFLD in different populations; however, little attention has been paid in patients with hypopituitarism. To analyze the association between thyroid function and NAFLD, we included 134 patients with hypopituitarism admitted to the Tianjin Medical University General Hospital between June 2013 and May 2019. Participants were divided into the NAFLD(-) and NAFLD(+) groups based on abdominal ultrasonography findings. We evaluated 68 male and 66 female patients with hypopituitarism. The prevalence of NAFLD was 52.24%. The NAFLD(+) group had a significantly higher free triiodothyronine/free thyroxine (FT3/FT4) ratio than the NAFLD(-) group (p = 0.003). The NAFLD(+) group showed significantly lower levels of FT4 and the growth hormone (GH) than the NAFLD(-) group (p = 0.003 and 0.016, respectively). We observed an association of the FT4 level and FT3/FT4 ratio with NAFLD in the univariate model, which was non-significant after adjustment for metabolic parameters (BMI, HDL-C, triglycerides, serum uric acid, blood pressure, fasting glucose). To better understand the role of each metabolic parameters, we performed additional models for each of those predictors individually after adjustment for age and gender, the association between FT4 level and FT3/FT4 ratio lost significance after adjustment for HDL-C and TG, but not for other predictors. Our findings suggest that thyroid dysfunction may be crucially involved in NAFLD by regulating whole-body metabolism, especially lipid utilization. Therefore, sufficient thyroid hormone replacement therapy for patients with hypopituitarism is recommended from the early stage.
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Affiliation(s)
- Jinfeng Xiao
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Chonggui Zhu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Xinxin Zhang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Longhao Sun
- Department of General surgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Chang Gao
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Xiaoyu Liang
- Department of General surgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Qing He
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Ming Liu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, 300052, China
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Zhang XY, Yuan K, Fang YL, Wang CL. Growth hormone ameliorates hepatopulmonary syndrome and nonalcoholic steatohepatitis secondary to hypopituitarism in a child: A case report. World J Clin Cases 2022; 10:6211-6217. [PMID: 35949851 PMCID: PMC9254213 DOI: 10.12998/wjcc.v10.i18.6211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/25/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Craniopharyngioma is a benign tumor that usually develops in children; however, it is located in the center and close to sensitive structures, such as the pituitary gland and hypothalamus. As the hypothalamus plays a crucial role in the homeostasis of anterior pituitary hormone synthesis, damage to the hypothalamus leads to multiple pituitary hormone deficiencies and non-alcoholic fatty liver disease, including hepatopulmonary syndrome (HPS). HPS has limited treatment and poor prognosis.
CASE SUMMARY A girl aged 13 years and 6 mo underwent surgery for craniopharyngioma 6 years prior. Right craniotomy was performed with total resection via the corpus callosum approach, and the tumor at the base was approximately 3.5 cm × 3.5 cm × 4.0 cm. At 1 year postoperatively, she exhibited abdominal distension and weakness, and the laboratory tests revealed fatty liver disease. Thereafter, she had not visited the outpatient clinic for 2 years. Two years ago, she developed decreased activity endurance, severe cyanosis, chest tightness, wheezing, and intermittent and recurrent low fever after mild physical labor. Hepatobiliary ultrasonography, liver biopsy, and contrast echocardiography of the right heart showed cirrhosis and multiple pituitary hormone deficiencies, indicating HPS. After 1 year of treatment with recombinant human growth hormone, the liver function and oxygenation improved; she did not undergo liver transplantation.
CONCLUSION Craniopharyngioma surgery can easily cause hypopituitarism, which can lead to nonalcoholic steatohepatitis and HPS in children. Early growth hormone therapy is important to improve the prognosis of these diseases.
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Affiliation(s)
- Xiao-Yuan Zhang
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Ke Yuan
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Yan-Lan Fang
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Chun-Lin Wang
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Hwang YA, Lee HW, Ahn SH, Lee EJ, Ku CR, Kim SU. Positive association between nonalcoholic fatty liver disease and growth hormone deficiency in patients with nonfunctioning pituitary adenoma. Front Endocrinol (Lausanne) 2022; 13:1057769. [PMID: 36699040 PMCID: PMC9868829 DOI: 10.3389/fendo.2022.1057769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/01/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Non-alcoholic fatty liver disease (NAFLD) is characterized by growth hormone deficiency (GHd). We investigated the association between NAFLD and GHd in patients with nonfunctioning pituitary adenomas (NFPA). DESIGN AND METHODS We recruited patients with NFPA who underwent transsphenoidal adenectomy between January 2005 and December 2018. Pituitary function was determined by the insulin tolerance test, thyroid hormone assay, and gonadal hormone levels. NAFLD was defined as a hepatic steatosis index greater than 36. RESULTS Among 278 patients (mean age, 44.2 years; 58.6% [n=163] female), 103 (37.0%) had GHd, 139 (50.0%) had hypogonadism, and 75 (27.0%) had NAFLD. The prevalence of NAFLD was significantly higher in patients with GHd than in those without (36.9% vs. 21.1%, p=0.01). Even after adjusting for age, total cholesterol level, gonadal function, and prolactin level, patients with GHd had approximately two-fold higher prevalence of NALFD than those without GHd (adjusted odds ratio [OR]=1.85, 95% confidence interval [CI]=1.05-3.28, p=0.03). Among female patients, the prevalence of NALFD was significantly higher in those with GHd than in those without (adjusted OR=2.39, 95% CI=1.03-5.55, p=0.04); whereas, among male patients, the prevalence of NAFLD was statistically similar between those with and without GHd (p>0.05). In addition, gonadal function did not affect the prevalence of NAFLD in patients with NFPA (29.3% with eugonadism vs. 47.8% with hypogonadism, p=0.14). CONCLUSION Among patients with NFPA, the prevalence of NAFLD was two-fold higher in patients with GHd than that in those without GHd. Thus, screening for NAFLD might be required in NFPA patients with GHd.
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Affiliation(s)
- Yoon-a Hwang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Seoul, Republic of Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Seoul, Republic of Korea
| | - Eun Jig Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea
| | - Cheol Ryong Ku
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea
- *Correspondence: Cheol Ryong Ku, ; Seung Up Kim,
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Seoul, Republic of Korea
- *Correspondence: Cheol Ryong Ku, ; Seung Up Kim,
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Ishay Y, Kolben Y, Kessler A, Ilan Y. Role of circadian rhythm and autonomic nervous system in liver function: a hypothetical basis for improving the management of hepatic encephalopathy. Am J Physiol Gastrointest Liver Physiol 2021; 321:G400-G412. [PMID: 34346773 DOI: 10.1152/ajpgi.00186.2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is a common, incapacitating complication of cirrhosis that affects many patients with cirrhosis. Although several therapies have proven effective in the treatment and prevention of this condition, several patients continue to suffer from covert disease or episodes of relapse. The circadian rhythm has been demonstrated to be pivotal for many body functions, including those of the liver. Here, we explore the impact of circadian rhythm-dependent signaling on the liver and discuss the evidence of its impact on liver pathology and metabolism. We describe the various pathways through which circadian influences are mediated. Finally, we introduce a novel method for improving patient response to drugs aimed at treating HE by utilizing the circadian rhythm. A digital system that introduces a customization-based technique for improving the response to therapies is presented as a hypothetical approach for improving the effectiveness of current medications used for the treatment of recurrent and persistent hepatic encephalopathy.
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Affiliation(s)
- Yuval Ishay
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Yotam Kolben
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Asa Kessler
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Yaron Ilan
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
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Alabsawy E, Serry Y, Kotha S, Berry P, Tritto G. Hepatopulmonary syndrome as the first and only manifestation of cirrhosis in a patient with hypopituitarism. BMJ Case Rep 2021; 14:e244805. [PMID: 34544714 PMCID: PMC8454452 DOI: 10.1136/bcr-2021-244805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/04/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterised by the development of intrapulmonary arteriovenous blood shunts and vascular dilatation with consequent hypoxaemia, usually in the context of end-stage liver disease (ESLD). The estimated incidence of HPS in ESLD has been reported to be 13%-47%. Chronic liver disease has been described in patients with hypothalamic-pituitary dysfunction, mainly in the form of non-alcoholic fatty liver disease due to metabolic syndrome, with occasional progression to cirrhosis. We report a challenging case of a 27-year-old man with a background of hypopituitarism with no known liver disease who presented with progressive dyspnoea and hypoxaemia and was eventually diagnosed with severe HPS.
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Affiliation(s)
- Eman Alabsawy
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yassen Serry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Giovanni Tritto
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Singeap AM, Stanciu C, Huiban L, Muzica CM, Cuciureanu T, Girleanu I, Chiriac S, Zenovia S, Nastasa R, Sfarti C, Cojocariu C, Trifan A. Association between Nonalcoholic Fatty Liver Disease and Endocrinopathies: Clinical Implications. Can J Gastroenterol Hepatol 2021; 2021:6678142. [PMID: 33505943 PMCID: PMC7814954 DOI: 10.1155/2021/6678142] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/31/2020] [Indexed: 02/08/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) has a rising prevalence worldwide. Its potential for evolution towards liver cirrhosis and hepatocellular carcinoma, as well as associations with extrahepatic manifestations, represents a double burden for patients and physicians alike. Recently, there has been increasing evidence of the association between NAFLD and a number of endocrinopathies, such as hypothyroidism, polycystic ovarian syndrome (PCOS), hypopituitarism, growth hormone deficiency (GHD), hypogonadism, and hypercortisolism. Definite correlations are supported by clear evidence so far, but further studies are needed in order to completely clarify the pathogenic mechanisms and, especially, to identify therapeutic implications. In this review, we present the main relationships between NAFLD and endocrinopathies, emphasizing the reciprocal causality, evolutive interconnections, and current clinical scenarios of presentations of which the clinicians should be aware.
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Affiliation(s)
- Ana-Maria Singeap
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Carol Stanciu
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Laura Huiban
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Cristina Maria Muzica
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Tudor Cuciureanu
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Irina Girleanu
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Stefan Chiriac
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Sebastian Zenovia
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Robert Nastasa
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Catalin Sfarti
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Camelia Cojocariu
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Anca Trifan
- 1Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- 2Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
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