Usefulness of the starry sky liver sign for diagnosing ketotic hypoglycemia in children.

Background: The starry sky liver (SSL) sign, which is characterized by increased visualization of the peripheral intrahepatic vasculature during ultrasound examinations, has been associated with conditions such as acute hepatitis, Burkitt's lymphoma, and prolonged starvation. This study evaluated the utility of the SSL sign for diagnosing ketotic hypoglycemia, which is a condition that presents with vomiting and is characterized by increased ketone levels and hypoglycemia.

Methods: Eighty-two patients who experienced vomiting underwent an ultrasound examination of the liver, and the SSL sign was observed and scored by two pediatricians. Patients were grouped based on blood ketone (≥2.0 mmol/L or <2.0 mmol/L) and glucose (>70 mg/dL or ≤ 70 mg/dL) levels. Ultrasound images were quantitatively analyzed using the SSL index.

Results: A significant association between higher SSL signs, increased ketone levels, and lower glucose levels was observed (p < 0.05). The SSL sign was more frequently observed in patients with high ketone levels or hypoglycemia. A quantitative analysis showed an inverse correlation between the SSL index and ketone levels (R = -0.361) and a positive correlation with glucose levels (R = 0.363). The SSL index indicated good diagnostic accuracy, with areas under the receiver-operating characteristic curves of 0.76 for ketone levels and 0.73 for hypoglycemia.

Conclusion: The SSL sign observed with ultrasound is a useful and noninvasive indicator that can be used to diagnose ketotic hypoglycemia in pediatric patients.