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Non-Alkolik Yağlı Karaciğer Hastalığı Olan ve Olmayan Obez Çocuklarda Hepatik Vasküler Akım Değişikliklerinin Değerlendirilmesi

Yıl 2021, Cilt: 23 Sayı: 3, 607 - 616, 31.12.2021
https://doi.org/10.24938/kutfd.989669

Öz

Amaç: Non-alkolik yağlı karaciğer hastalığı olan ve olmayan obez çocuklarda hepatik vasküler akım değişikliklerini Doppler ultrason ile değerlendirmektir.
Gereç ve Yöntemler: Bu çalışmaya 91 obez ve 30 sağlıklı zayıf (kontrol) çocuk alındı. Obez çocuklar, ultrasondaki hepatik steatoz varlığı ve kan serumu alanin aminotransferaz düzeyinin 30 IU/L'nin üzerinde olması durumuna göre, non-alkolik yağlı karaciğer hastalığı olan ve non-alkolik yağlı karaciğer hastalığı olmayan şeklinde iki gruba ayrıldı. Portal ven çapı, portal ven akım hacmi ve hepatik arter rezistif indeksi Doppler ultrason kullanılarak hesaplandı.
Bulgular: Non-alkolik yağlı karaciğer hastalığında portal ven çapı ve portal ven akım hacmi değerleri kontrol grubuna yakın bulundu. Ancak non-alkolik yağlı karaciğer hastalığı olmayan grupta portal ven çapı ve portal ven akım hacmi değerleri, diğer gruplara göre daha düşüktü (p<0.001). Hepatik arter rezistif indeksi değerleri, non-alkolik yağlı karaciğer hastalığı olmayan grupta non-alkolik yağlı karaciğer hastalığı grubundan istatistiksel olarak anlamlı yüksek bulundu (sırasıyla 0.64±0.1 ve 0.60±0.1) (p=0.03). Buna karşın, non-alkolik yağlı karaciğer hastalığı ve kontrol gruplarında hepatik arter rezistif indeksi değerleri birbirine yakındı. Bulgular, fizyopatolojik çalışmalarda tanımlanmış, non-alkolik yağlı karaciğer hastalığı gelişim sürecinde izlenen, hepatik vasküler değişimlerdeki farklılıklar ile benzerdi.
Sonuç: Obez çocuklarda portal ven çapı, portal ven akım hacmi ve hepatik arter rezistif indeksi değerleri karaciğer yağlanması olup olmamasına göre anlamlı farklılıklar göstermektedir. Bu farklılıklar non-alkolik yağlı karaciğer hastalığındaki hepatik fizyopatolojik değişimler ile uyumludur. Bu nedenle, hepatik vasküler Doppler indeksleri obez çocuklarda non-alkolik yağlı karaciğer hastalığı gelişimi ve ilerlemesinin takibinde kullanılabilecek yeni bir araç olabilir.

Destekleyen Kurum

YOK

Kaynakça

  • 1. Friedman SL, Neuschwander-Tetri BA, Rinella M, Sanyal AJ. Mechanisms of NAFLD development and therapeutic strategies. Nat Med. 2018;24(7):908-22.
  • 2. Akcam M, Boyaci A, Pirgon O, Koroglu M, Dundar BN. Importance of the liver ultrasound scores in pubertal obese children with nonalcoholic fatty liver disease. Clin Imaging. 2013;37(3):504-8.
  • 3. Mosca A, Panera N, Crudele A, Alisi A. Noninvasive diagnostic tools for pediatric NAFLD: where are we now? Expert Rev Gastroenterol Hepatol. 2020:14(11):1035-46.
  • 4. Buzzetti E, Pinzani M, Tsochatzis EA. The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD). Metabolism. 2016;65(8):1038-48.
  • 5. Francque S, Laleman W, Verbeke L, Van Steenkiste C, Casteleyn C, Kwanten W et al. Increased intrahepatic resistance in severe steatosis: endothelial dysfunction, vasoconstrictor overproduction and altered microvascular architecture. Lab Investig. 2012;92(10):1428-39.
  • 6. Francque S, Verrijken A, Mertens I, Hubens G, Van Marck E, Pelckmans P et al. Noncirrhotic human nonalcoholic fatty liver disease induces portal hypertension in relation to the histological degree of steatosis. Eur J Gastroenterol Hepatol. 2010;22(12):1449-57.
  • 7. van der Graaff D, Kwanten WJ, Francque SM. The potential role of vascular alterations and subsequent impaired liver blood flow and hepatic hypoxia in the pathophysiology of non-alcoholic steatohepatitis. Med Hypotheses. 2019;122:188-97.
  • 8. Lautt WW. Regulatory processes interacting to maintain hepatic blood flow constancy: vascular compliance, hepatic arterial buffer response, hepatorenal reflex, liver regeneration, escape from vasoconstriction. Hepatol Res. 2007;37(11):891-903.
  • 9. Balasubramanian P, Boopathy V, Govindasamy E, Venkatesh BP. Assessment of portal venous and hepatic artery haemodynamic variation in non-alcoholic fatty liver disease (NAFLD) patients. J Clin Diagnostic Res. 2016;10(8):TC07.
  • 10. Soresi M, Giannitrapani L, Noto D, Terranova A, Campagna ME, Cefalù AB et al. Effects of steatosis on hepatic hemodynamics in patients with metabolic syndrome. Ultrasound Med Biol. 2015;41(6):1545-52.
  • 11. Hizli S, Koçyigit A, Arslan N, Tuncel SA, Demircioglu F, Cakmakçi H et al. Hepatic artery resistance in children with obesity and fatty liver. Indian J Pediatr. 2010;77(4):407-11.
  • 12. Mohammadi A, Ghasemi-Rad M, Zahedi H, Toldi G, Alinia T. Effect of severity of steatosis as assessed ultrasonographically on hepatic vascular indices in non-alcoholic fatty liver disease. Med Ultrason. 2011;13(3):200-6.
  • 13. Tarzamni MK, Khoshbaten M, Sadrarhami S, Daneshpajouhnejad P, Jalili J, Gholamian M et al. Hepatic artery and portal vein doppler indexes in non-alcoholic fatty liver disease before and after treatment to prevent unnecessary health care costs. Int J Prev Med. 2014;5(4):472-7.
  • 14. Ezaizi Y, Kabbany MN, Selvakumar PKC, Sarmini MT, Singh A, Lopez R et al. Comparison between non-alcoholic fatty liver disease screening guidelines in children and adolescents. JHEP Reports. 2019;1(4):259-64.
  • 15. Suri A, Song E, van Nispen J, Voigt M, Armstrong A, Murali V et al. Advances in the epidemiology, diagnosis, and management of pediatric fatty liver disease. Clin Ther. 2021;43(3):438-54.
  • 16. Tominaga K, Kurata JH, Chen YK, Fujimoto E, Miyagawa S, Abe I et al. Prevalence of fatty liver in Japanese children and relationship to obesity. Dig Dis Sci. 1995;40(9):2002-9.
  • 17. Schwimmer JB, Dunn W, Norman GJ, Pardee PE, Middleton MS, Kerkar N et al. SAFETY study: alanine aminotransferase cutoff values are set too high for reliable detection of pediatric chronic liver disease. Gastroenterology. 2010;138(4):1357-64,1364.e1-2.
  • 18. Fraser A, Longnecker MP, Lawlor DA. Prevalence of elevated alanine aminotransferase among US adolescents and associated factors: NHANES 1999–2004. Gastroenterology. 2007;133(6):1814-20.
  • 19. Ferraioli G, Wong VW-S, Castera L, Berzigotti A, Sporea I, Dietrich CF et al. Liver ultrasound elastography: an update to the world federation for ultrasound in medicine and biology guidelines and recommendations. Ultrasound Med Biol. 2018;44(12):2419-40.
  • 20. Choi SH, Kwon JH, Kim KW, Jang HY, Kim JH, Kwon H et al. Measurement of liver volumes by portal vein flow by Doppler ultrasound in living donor liver transplantation. Clin Transplant. 2017;31(9):e13050.
  • 21. Kim SH, Choi MS, Kim MJ, Kim YH, Cho SH. Role of semi–quantitative dynamic contrast–enhanced MR imaging in characterization and grading of prostate cancer. Eur J Radiol. 2017;94:154-9.
  • 22. Zhang L, Duan YY, Li JM, Yin JK. Hemodynamic features of Doppler ultrasonography in patients with portal hypertension: intraoperative direct measurement of portal pressure in the portal venous system. J Ultrasound Med. 2007;26(12):1689-96.
  • 23. Rocha HLOG, Diniz ALD, Borges VF de A e, Salomão FC. Assessment of portal venous index as a non-invasive method for diagnosing liver fibrosis in patients with chronic hepatitis C. Arq Gastroenterol. 2012;49(1):14-8.
  • 24. Belotta AF, Teixeira CR, Padovani CR, Rahal SC, Mayer MN, Mamprim MJ. Sonographic evaluation of liver hemodynamic indices in overweight and obese dogs. J Vet Intern Med. 2018;32(1):181-7.
  • 25. ML GDRM, Ferreira De Almeida EB V, Machado De Alcântara T, Borges De Araújo L, De Fátima Pinheiro C. Liver hemodynamic patterns in nonalcoholic steatosis: Doppler ultrasonography and histological evaluation. Minerva Gastroenterol Dietol. 2016;62(1):19-29.
  • 26. Singh SP, Barik RK. Noninvasive biomarkers in nonalcoholic fatty liver disease: Are we there yet? J Clin Exp Hepatol. 2020;10(1):88-98.
  • 27. Draijer LG, Feddouli S, Bohte AE, Rijcken THP, Benninga MA, Stoker J, et al. Comparison of diagnostic accuracy of screening tests ALT and ultrasound for pediatric non-alcoholic fatty liver disease. Eur J Pediatr. 2019;178(6):863-70.
  • 28. Tana C, Tana M, Rossi S, Silingardi M, Schiavone C. Hepatic artery resistive index (HARI) and non-alcoholic fatty liver disease (NAFLD) fibrosis score in NAFLD patients: cut-off suggestive of non-alcoholic steatohepatitis (NASH) evolution. J Ultrasound. 2016;9(3):183-9.
  • 29. Lim YS, Kim WR. The global impact of hepatic fibrosis and end-stage liver disease. Clin Liver Dis. 2008;12(4):733-46.
  • 30. Vos MB, Abrams SH, Barlow SE, Caprio S, Daniels SR, Kohli R et al. NASPGHAN clinical practice guideline for the diagnosis and treatment of nonalcoholic fatty liver disease in children: recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr. 2017;64(2):319-34.

EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE

Yıl 2021, Cilt: 23 Sayı: 3, 607 - 616, 31.12.2021
https://doi.org/10.24938/kutfd.989669

Öz

Objective: To evaluate hepatic vascular flow alterations using Doppler ultrasound in obese children with and without non-alcoholic fatty liver disease.
Material and Methods: Ninety-one obese and 30 healthy lean (control) children were enrolled in this study. Obese children were divided into two groups: children with non-alcoholic fatty liver disease and children without non-alcoholic fatty liver disease; according to hepatic fatty changes on ultrasound, and blood serum alanine aminotransferase levels above 30 IU/L. Portal vein diameter, portal blood flow volume and hepatic artery resistive index were calculated using Doppler ultrasound.
Results: Portal vein diameter and portal blood flow volume values in children with non-alcoholic fatty liver disease were found close to the controls. However, the values of portal vein diameter and portal blood flow volume were lower in children without non-alcoholic fatty liver disease group than the other groups (p<0.001). Hepatic artery resistive index was higher in children without non-alcoholic fatty liver disease group than children with non-alcoholic fatty liver disease group (0.64±0.1 and 0.60±0.1, respectively) (p=0.03), whereas hepatic artery resistive index was found to be close in children with non-alcoholic fatty liver disease and controls. These findings were similar to the differences in hepatic vascular changes observed during the development of non-alcoholic fatty liver disease, which were described in physio-pathological studies.
Conclusion: Portal vein diameter, portal blood flow volume and hepatic artery resistive index values in obese children show significant differences according to the presence or absence of fatty liver. These differences are consistent with hepatic physio-pathological changes in non-alcoholic fatty liver disease. Therefore, hepatic vascular Doppler indices may be a new tool that can be used to monitor the development and progression of non-alcoholic fatty liver disease in obese children. 

Kaynakça

  • 1. Friedman SL, Neuschwander-Tetri BA, Rinella M, Sanyal AJ. Mechanisms of NAFLD development and therapeutic strategies. Nat Med. 2018;24(7):908-22.
  • 2. Akcam M, Boyaci A, Pirgon O, Koroglu M, Dundar BN. Importance of the liver ultrasound scores in pubertal obese children with nonalcoholic fatty liver disease. Clin Imaging. 2013;37(3):504-8.
  • 3. Mosca A, Panera N, Crudele A, Alisi A. Noninvasive diagnostic tools for pediatric NAFLD: where are we now? Expert Rev Gastroenterol Hepatol. 2020:14(11):1035-46.
  • 4. Buzzetti E, Pinzani M, Tsochatzis EA. The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD). Metabolism. 2016;65(8):1038-48.
  • 5. Francque S, Laleman W, Verbeke L, Van Steenkiste C, Casteleyn C, Kwanten W et al. Increased intrahepatic resistance in severe steatosis: endothelial dysfunction, vasoconstrictor overproduction and altered microvascular architecture. Lab Investig. 2012;92(10):1428-39.
  • 6. Francque S, Verrijken A, Mertens I, Hubens G, Van Marck E, Pelckmans P et al. Noncirrhotic human nonalcoholic fatty liver disease induces portal hypertension in relation to the histological degree of steatosis. Eur J Gastroenterol Hepatol. 2010;22(12):1449-57.
  • 7. van der Graaff D, Kwanten WJ, Francque SM. The potential role of vascular alterations and subsequent impaired liver blood flow and hepatic hypoxia in the pathophysiology of non-alcoholic steatohepatitis. Med Hypotheses. 2019;122:188-97.
  • 8. Lautt WW. Regulatory processes interacting to maintain hepatic blood flow constancy: vascular compliance, hepatic arterial buffer response, hepatorenal reflex, liver regeneration, escape from vasoconstriction. Hepatol Res. 2007;37(11):891-903.
  • 9. Balasubramanian P, Boopathy V, Govindasamy E, Venkatesh BP. Assessment of portal venous and hepatic artery haemodynamic variation in non-alcoholic fatty liver disease (NAFLD) patients. J Clin Diagnostic Res. 2016;10(8):TC07.
  • 10. Soresi M, Giannitrapani L, Noto D, Terranova A, Campagna ME, Cefalù AB et al. Effects of steatosis on hepatic hemodynamics in patients with metabolic syndrome. Ultrasound Med Biol. 2015;41(6):1545-52.
  • 11. Hizli S, Koçyigit A, Arslan N, Tuncel SA, Demircioglu F, Cakmakçi H et al. Hepatic artery resistance in children with obesity and fatty liver. Indian J Pediatr. 2010;77(4):407-11.
  • 12. Mohammadi A, Ghasemi-Rad M, Zahedi H, Toldi G, Alinia T. Effect of severity of steatosis as assessed ultrasonographically on hepatic vascular indices in non-alcoholic fatty liver disease. Med Ultrason. 2011;13(3):200-6.
  • 13. Tarzamni MK, Khoshbaten M, Sadrarhami S, Daneshpajouhnejad P, Jalili J, Gholamian M et al. Hepatic artery and portal vein doppler indexes in non-alcoholic fatty liver disease before and after treatment to prevent unnecessary health care costs. Int J Prev Med. 2014;5(4):472-7.
  • 14. Ezaizi Y, Kabbany MN, Selvakumar PKC, Sarmini MT, Singh A, Lopez R et al. Comparison between non-alcoholic fatty liver disease screening guidelines in children and adolescents. JHEP Reports. 2019;1(4):259-64.
  • 15. Suri A, Song E, van Nispen J, Voigt M, Armstrong A, Murali V et al. Advances in the epidemiology, diagnosis, and management of pediatric fatty liver disease. Clin Ther. 2021;43(3):438-54.
  • 16. Tominaga K, Kurata JH, Chen YK, Fujimoto E, Miyagawa S, Abe I et al. Prevalence of fatty liver in Japanese children and relationship to obesity. Dig Dis Sci. 1995;40(9):2002-9.
  • 17. Schwimmer JB, Dunn W, Norman GJ, Pardee PE, Middleton MS, Kerkar N et al. SAFETY study: alanine aminotransferase cutoff values are set too high for reliable detection of pediatric chronic liver disease. Gastroenterology. 2010;138(4):1357-64,1364.e1-2.
  • 18. Fraser A, Longnecker MP, Lawlor DA. Prevalence of elevated alanine aminotransferase among US adolescents and associated factors: NHANES 1999–2004. Gastroenterology. 2007;133(6):1814-20.
  • 19. Ferraioli G, Wong VW-S, Castera L, Berzigotti A, Sporea I, Dietrich CF et al. Liver ultrasound elastography: an update to the world federation for ultrasound in medicine and biology guidelines and recommendations. Ultrasound Med Biol. 2018;44(12):2419-40.
  • 20. Choi SH, Kwon JH, Kim KW, Jang HY, Kim JH, Kwon H et al. Measurement of liver volumes by portal vein flow by Doppler ultrasound in living donor liver transplantation. Clin Transplant. 2017;31(9):e13050.
  • 21. Kim SH, Choi MS, Kim MJ, Kim YH, Cho SH. Role of semi–quantitative dynamic contrast–enhanced MR imaging in characterization and grading of prostate cancer. Eur J Radiol. 2017;94:154-9.
  • 22. Zhang L, Duan YY, Li JM, Yin JK. Hemodynamic features of Doppler ultrasonography in patients with portal hypertension: intraoperative direct measurement of portal pressure in the portal venous system. J Ultrasound Med. 2007;26(12):1689-96.
  • 23. Rocha HLOG, Diniz ALD, Borges VF de A e, Salomão FC. Assessment of portal venous index as a non-invasive method for diagnosing liver fibrosis in patients with chronic hepatitis C. Arq Gastroenterol. 2012;49(1):14-8.
  • 24. Belotta AF, Teixeira CR, Padovani CR, Rahal SC, Mayer MN, Mamprim MJ. Sonographic evaluation of liver hemodynamic indices in overweight and obese dogs. J Vet Intern Med. 2018;32(1):181-7.
  • 25. ML GDRM, Ferreira De Almeida EB V, Machado De Alcântara T, Borges De Araújo L, De Fátima Pinheiro C. Liver hemodynamic patterns in nonalcoholic steatosis: Doppler ultrasonography and histological evaluation. Minerva Gastroenterol Dietol. 2016;62(1):19-29.
  • 26. Singh SP, Barik RK. Noninvasive biomarkers in nonalcoholic fatty liver disease: Are we there yet? J Clin Exp Hepatol. 2020;10(1):88-98.
  • 27. Draijer LG, Feddouli S, Bohte AE, Rijcken THP, Benninga MA, Stoker J, et al. Comparison of diagnostic accuracy of screening tests ALT and ultrasound for pediatric non-alcoholic fatty liver disease. Eur J Pediatr. 2019;178(6):863-70.
  • 28. Tana C, Tana M, Rossi S, Silingardi M, Schiavone C. Hepatic artery resistive index (HARI) and non-alcoholic fatty liver disease (NAFLD) fibrosis score in NAFLD patients: cut-off suggestive of non-alcoholic steatohepatitis (NASH) evolution. J Ultrasound. 2016;9(3):183-9.
  • 29. Lim YS, Kim WR. The global impact of hepatic fibrosis and end-stage liver disease. Clin Liver Dis. 2008;12(4):733-46.
  • 30. Vos MB, Abrams SH, Barlow SE, Caprio S, Daniels SR, Kohli R et al. NASPGHAN clinical practice guideline for the diagnosis and treatment of nonalcoholic fatty liver disease in children: recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr. 2017;64(2):319-34.

Ayrıntılar

Birincil Dil İngilizce
Konular Sağlık Kurumları Yönetimi
Bölüm Makaleler
Yazarlar

Hüseyin AYDIN 0000-0003-4704-4759

Ayşe AYDINOĞLU Bu kişi benim 0000-0002-8820-8003

Müge ATAR 0000-0002-9153-8580

Mustafa AKÇAM 0000-0002-4635-7633

Özgür PİRGON 0000-0002-1729-2834

Proje Numarası YOK
Yayımlanma Tarihi 31 Aralık 2021
Gönderilme Tarihi 2 Eylül 2021
Yayımlandığı Sayı Yıl 2021 Cilt: 23 Sayı: 3

Kaynak Göster

APA AYDIN, H., AYDINOĞLU, A., ATAR, M., AKÇAM, M., vd. (2021). EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE. Kırıkkale Üniversitesi Tıp Fakültesi Dergisi, 23(3), 607-616. https://doi.org/10.24938/kutfd.989669
AMA AYDIN H, AYDINOĞLU A, ATAR M, AKÇAM M, PİRGON Ö. EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE. Kırıkkale Üni Tıp Derg. Aralık 2021;23(3):607-616. doi:10.24938/kutfd.989669
Chicago AYDIN, Hüseyin, Ayşe AYDINOĞLU, Müge ATAR, Mustafa AKÇAM, ve Özgür PİRGON. “EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE”. Kırıkkale Üniversitesi Tıp Fakültesi Dergisi 23, sy. 3 (Aralık 2021): 607-16. https://doi.org/10.24938/kutfd.989669.
EndNote AYDIN H, AYDINOĞLU A, ATAR M, AKÇAM M, PİRGON Ö (01 Aralık 2021) EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE. Kırıkkale Üniversitesi Tıp Fakültesi Dergisi 23 3 607–616.
IEEE H. AYDIN, A. AYDINOĞLU, M. ATAR, M. AKÇAM, ve Ö. PİRGON, “EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE”, Kırıkkale Üni Tıp Derg, c. 23, sy. 3, ss. 607–616, 2021, doi: 10.24938/kutfd.989669.
ISNAD AYDIN, Hüseyin vd. “EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE”. Kırıkkale Üniversitesi Tıp Fakültesi Dergisi 23/3 (Aralık 2021), 607-616. https://doi.org/10.24938/kutfd.989669.
JAMA AYDIN H, AYDINOĞLU A, ATAR M, AKÇAM M, PİRGON Ö. EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE. Kırıkkale Üni Tıp Derg. 2021;23:607–616.
MLA AYDIN, Hüseyin vd. “EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE”. Kırıkkale Üniversitesi Tıp Fakültesi Dergisi, c. 23, sy. 3, 2021, ss. 607-16, doi:10.24938/kutfd.989669.
Vancouver AYDIN H, AYDINOĞLU A, ATAR M, AKÇAM M, PİRGON Ö. EVALUATION OF HEPATIC VASCULAR FLOW ALTERATIONS IN OBESE CHILDREN WITH AND WITHOUT NON-ALCOHOLIC FATTY LIVER DISEASE. Kırıkkale Üni Tıp Derg. 2021;23(3):607-16.

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