Severe Liver Dysfunction after Donor Lymphocyte Infusion for Relapsed Multiple Myeloma.

Donor lymphocyte infusion (DLI) is performed to augment an anti-tumor immune response or ensure donor stem cells remain engrafted following allogeneic stem cell transplantation but may induce graft-versus-host disease (GVHD) involving skin, intestine, and liver. Although hepatic involvement of GVHD can manifest as mild to severe hepatitis, few reports have mentioned acute severe liver dysfunction with encephalopathy. We experienced a case of acute severe liver dysfunction with semicoma after DLI in a patient with relapsed multiple myeloma following allogeneic stem cell transplantation, in whom chronic viral hepatitis B had been suppressed by antiviral treatment. The patient recovered after high-dose glucocorticoid administration based on an assessment of hepatic GVHD. Clinicians should be aware of the possibility of this catastrophic hepatic complication after DLI in hematologic disorders.

Blood Concentrations of Lead, Cadmium, and Mercury Are Associated With Alcohol-Related Liver Disease.

BACKGROUND: An association between environmental pollutants and alcohol-related liver disease (ALD) has not been determined until now. The objectives of this study were to examine the association of the pollutants with ALD, and whether the pollutants together increased the risk of ALD. METHODS: Data were extracted from the Korea National Health and Nutrition Examination Survey (2010-2013 and 2016-2017; n = 11,993). Blood levels of lead, cadmium, and mercury were measured. ALD was defined by a combination of excessive alcohol consumption and ALD/non-alcoholic fatty liver disease index > 0. The aspartate aminotransferase-to-platelet ratio index and fibrosis (FIB)-4 score were used to evaluate ALD FIB. RESULTS: The odds ratios (ORs) of ALD for the highest versus the lowest quartiles of exposure were for lead, 7.39 (95% confidence interval [CI], 5.51-9.91); cadmium, 1.68 (95% CI, 1.32-2.14); and mercury, 5.03 (95% CI, 3.88-6.53). Adjusting for age, gender, smoking, occupation, education, and personal income attenuated the associations but indicated significant positive trends (all Ptrend < 0.001). A positive additive interaction between cadmium and lead was observed. The relative excess OR due to the interaction was 0.96 (95% CI, 0.41-1.51); synergy index = 2.92 (95% CI, 0.97-8.80). Among 951 subjects with ALD, advanced FIB was associated with lead and cadmium (OR, 3.46, 95% CI, 1.84-6.53; OR, 8.50, 95% CI, 2.54-28.42, respectively), but not with mercury. The effect estimates for lead and cadmium remained significant even after adjustment for daily alcohol intake. CONCLUSION: Blood levels of lead, cadmium, and mercury were significantly associated not only with the risk of ALD but also with ALD FIB. Cadmium and lead have synergistic effects that increase the risk of ALD.

[Epidemiology of Autoimmune Liver Disease].

Autoimmune liver disease is an important immune-mediated pathologic entity involving the liver and intrahepatic bile duct, including autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. Although it is necessary to ascertain its presence in acute or chronic liver disease without common causes, it is not easy to diagnose this disease straightforwardly because of its rarity. Recently, the incidence and prevalence of autoimmune hepatitis and primary biliary cholangitis have increased in several regions. In contrast, there is limited data dealing with the trend of the epidemiology of primary sclerosing cholangitis worldwide. Physicians should consider the epidemiologic characteristics of autoimmune liver disease because early diagnosis and proper treatment might prevent the progression of advanced liver disease. In addition, more sophisticated epidemiologic studies will be needed to elucidate the trend of these rare diseases nationwide.

Response-Guided Therapy With Cefotaxime, Ceftriaxone, or Ciprofloxacin for Spontaneous Bacterial Peritonitis: A Randomized Trial: A Validation Study of 2021 AASLD Practice Guidance for SBP.

INTRODUCTION: For the treatment of spontaneous bacterial peritonitis (SBP), cefotaxime, ceftriaxone, and ciprofloxacin were used as first-line agents. However, considering the increasing rate of antibiotic resistance, it is unclear which of these drugs can be initially recommended. This study aimed to compare the current efficacy of the 3 antibiotics, namely cefotaxime, ceftriaxone, and ciprofloxacin, for the treatment of SBP in patients with cirrhosis with ascites, when guided by therapeutic responses. METHODS: This study was a multicenter, prospective, randomized controlled trial. The inclusion criteria were 16- to 75-year-old patients with liver cirrhosis with ascites, having polymorphonuclear cell count of >250/mm 3 . We performed a follow-up paracentesis at 48 hours to decide continuing or changing the assigned antibiotics and then assessed the resolution rates at 120 and 168 hours of treatment. RESULTS: A total of 261 patients with cirrhosis who developed SBP were enrolled. Most of the patients were diagnosed as those with SBP within 48 hours of admission. The resolution rates at 120 hours, which is the primary endpoint, were 67.8%, 77.0%, and 73.6% in the cefotaxime, ceftriaxone, and ciprofloxacin groups, respectively ( P = 0.388), by intension-to-treat analysis. The 1-month mortality was similar among the groups ( P = 0.770). The model for end-stage liver disease score and the SBP resolution were significant factors for survival. CONCLUSION: The efficacy of empirical antibiotics, such as cefotaxime, ceftriaxone, and ciprofloxacin, against SBP was not significantly different. In addition, these antibiotics administered based on response-guided therapy were still efficacious as initial treatment for SBP, especially in those with community-acquired infections.

Prevalence and risk of colorectal polyps among the Korean population under 50 years.

Colorectal cancer is a common cancer; generally, adults aged ≥ 50 years are screened using stool occult blood tests and colonoscopy. However, colorectal adenoma and cancer have been found in patients under the aged of 50, and studies on characteristics and risk factors in young patients are lacking. We evaluated the prevalence and risk factors of colorectal adenoma and cancer in young adults aged under 50 years. We retrospectively analyzed 570 individuals aged under 50 years who underwent colonoscopy at the Haeundae Paik Hospital, Korea, from January to June 2018. Logistic regression model was used to identify the risk factors for colorectal adenoma and colorectal cancer. The prevalence of colorectal adenoma in group of 19-29 years was 3.2% (1 of 31), 30-39 years was 13.8% (30 of 217) and in the group of 40-49 years was 21.1% (68 of 322) (P = .009). In multivariable analysis, age over 45 years (adjusted odds ratio [OR], 1.941; 95% confidence interval [CI], 1.187-3.172; P = .008) and male sex (adjusted OR, 1.711; 95% CI, 1.044-2.806; P = .033) were independent risk factors for colorectal neoplasia including cancer. The prevalence of colorectal adenoma increases as the age increased in young adults under 50 years of age, especially after the age of 45 years, the risk of colorectal neoplasia increases; hence, early screening should be considered before the age of 50 years.

Subjective Needs and Thoughts for the Treatment of Patients with Inflammatory Bowel Disease: Applying Q Methodology.

Backgrounds/Aims: Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is a chronic inflammatory disorder of the gastrointestinal tract that requires lifetime management. Many studies have attempted to establish questionnaires and/or parameters to assess the quality of care for IBD patients. However, no study to date has investigated patients using the Q-methodology, which is subjective and has been studied systematically, to identify and categorize their opinions and subjective thinking about their disease and treatment. We have therefore aimed here to conduct a preliminary study of the Q-methodology to investigate the subjective thinking of IBD patients in Korea. Methods: Q-methodology, a method of analyzing the subjectivity of questionnaire items, was examined in this study. Inputs from 50 IBD patients were classified into 34 normalized statements using a 9-point scale with a normal distribution. The collected data were analyzed using the QUANL PC program. Results: Using the Q-methodology, IBD patients were classified into type I, II, III, and IV treatment needs: medical staff-dependent, relationship-oriented, information-driven, and social awareness, respectively. Conclusions: The subjective needs of IBD patients and their thoughts about the treatment can be classified into four types. Our findings suggest that we can establish a systematic strategy for personalized care according to patient type.

Real-world Effectiveness and Safety of Direct-acting Antiviral Agents in Patients with Chronic Hepatitis C Genotype 2 Infection: Korean Multicenter Study.

BACKGROUND: The advancement of treatment with direct-acting antiviral (DAA) agents has improved the cure rate of hepatitis C virus (HCV) infection close to 100%. The aim of our study was to assess the real-world effectiveness and safety of DAA regimens for the treatment of patients with chronic HCV genotype 2. METHODS: We retrospectively analyzed the clinical data of patients treated with sofosbuvir plus ribavirin (SOF + RBV) or glecaprevir/pibrentasvir (G/P) for chronic HCV genotype 2 infection at seven university hospitals in the Korean southeast region. RESULTS: SOF + RBV therapy produced an 89% and 98.3% sustained virologic response 12 week (SVR12) after treatment completion in the full analysis set and per-protocol set, respectively, and the corresponding values for G/P therapy were 89.5% and 99.2%, respectively. The difference between the treatments was probably because 6.2% (59/953) of patients in the SOF + RBV group did not complete the treatment and 9.8% (14/143) in the G/P group did not test HCV RNA after treatment completion. Adverse events (A/Es) were reported in 59.7% (569/953) and 25.9% (37/143) of the SOF + RBV and G/P groups, respectively. In the SOF + RBV group, 12 (1.26%) patients discontinued treatment owing to A/Es, whereas no patients discontinued treatment because of A/Es in the G/P group. CONCLUSION: In both treatment groups, SVR was high when treatment was completed. However, there was a high dropout rate in the SOF + RBV group, and the dropout analysis showed that these were patients with liver cirrhosis (LC; 43/285, 15.1%), especially those with decompensated LC (12/32, 37.5%). Therefore, an early initiation of antiviral therapy is recommended for a successful outcome before liver function declines. Furthermore, patients with decompensated LC who are considered candidates for SOF + RBV treatment should be carefully monitored to ensure that their treatment is completed, especially those with low hemoglobin and high alanine transaminase.

Efficacy and Safety of Biphenyl Dimethyl Dicarboxylate and Ursodeoxycholic Acid Combination in Chronic Hepatitis Related to Metabolic Syndrome Components.

Backgrounds/Aims: Steatohepatitis related to metabolic syndrome is a chronic liver disease prevalent in patients not only with non-alcoholic steatohepatitis but also with alcoholic liver disease and chronic viral hepatitis. On the other hand, there is limited data on the effects of hepatotonic agents in these patients. Therefore, this study evaluated the efficacy of a combined hepatotonic agent in this population. Methods: Thirty-three adults with chronic hepatitis and one or more components of metabolic syndrome were assigned randomly to receive biphenyl dimethyl dicarboxylate/ursodeoxycholic acid or a placebo for 24 weeks. The primary outcome was the normalization of ALT (≤40 U/L). The secondary outcomes were the change in controlled attenuation parameter, transient elastography, and Chronic Liver Disease Questionnaire score. Results: The 33 patients were assigned randomly to two groups. Eight (50%) of 16 patients who received the intervention drug showed the normalization of ALT, whereas only one (6%) of 17 patients in the placebo group did so. In contrast, the change in controlled attenuation, transient elastography, and Chronic Liver Disease Questionnaire were similar in the two groups. ALT was changed significantly during the four assessment periods, and this change was affected by the group. The interaction between the group and time was also significant. AST was changed significantly during the same period. This change was not affected by the group. Conclusions: Biphenyl dimethyl dicarboxylate/ursodeoxycholic acid combination reduced ALT in chronic liver disease related to metabolic syndrome. On the other hand, there is no evidence that this leads to improved hepatic steatosis and fibrosis within 6 months.

Prognostic Value of Alpha-Fetoprotein in Patients Who Achieve a Complete Response to Transarterial Chemoembolization for Hepatocellular Carcinoma.

PURPOSE: Alpha-fetoprotein (AFP) is a prognostic marker for hepatocellular carcinoma (HCC). We investigated the prognostic value of AFP levels in patients who achieved complete response (CR) to transarterial chemoembolization (TACE) for HCC. MATERIALS AND METHODS: Between 2005 and 2018, 890 patients with HCC who achieved a CR to TACE were recruited. An AFP responder was defined as a patient who showed elevated levels of AFP (>10 ng/mL) during TACE, but showed normalization or a >50% reduction in AFP levels after achieving a CR. RESULTS: Among the recruited patients, 569 (63.9%) with naïve HCC and 321 (36.1%) with recurrent HCC after complete resection were treated. Before TACE, 305 (34.3%) patients had multiple tumors, 219 (24.6%) had a maximal tumor size >3 cm, and 22 (2.5%) had portal vein tumor thrombosis. The median AFP level after achieving a CR was 6.36 ng/mL. After a CR, 473 (53.1%) patients experienced recurrence, and 417 (46.9%) died [median progression-free survival (PFS) and overall survival (OS) of 16.3 and 62.8 months, respectively]. High AFP levels at CR (>20 ng/mL) were independently associated with a shorter PFS [hazard ratio (HR)=1.403] and OS (HR=1.284), together with tumor multiplicity at TACE (HR=1.518 and 1.666, respectively). AFP non-responders at CR (76.2%, n=359 of 471) showed a shorter PFS (median 10.5 months vs. 15.5 months, HR=1.375) and OS (median 41.4 months vs. 61.8 months, HR=1.424) than AFP responders (all p=0.001). CONCLUSION: High AFP levels and AFP non-responders were independently associated with poor outcomes after TACE. AFP holds clinical implications for detailed risk stratification upon achieving a CR after TACE.

Direct-Acting Antivirals Improve Treatment Outcomes in Patients with Hepatitis C Virus-Related Hepatocellular Carcinoma Treated with Transarterial Chemoembolization: A Nationwide, Multi-center, Retrospective Cohort Study.

BACKGROUND AND AIMS: The influence of direct-acting antivirals (DAAs) on chronic hepatitis C (CHC)-related hepatocellular carcinoma (HCC) remains controversial. We investigated the effect of eradicating CHC using DAAs on treatment outcomes in patients with CHC-related HCC treated with transarterial chemoembolization (TACE). METHODS: This nationwide, multi-center, retrospective study recruited patients with CHC-related HCC treated with TACE as the first-line anti-cancer treatment, and who achieved a sustained virological response (SVR) using DAAs (DAA group) between 2006 and 2017. Patients achieving an SVR following interferon-based treatment (IFN group) and those without treatment (control group) were also recruited for comparison. RESULTS: A total of 425 patients were eligible for the study. Of these, 356 (83.8%), 26 (6.1%), and 43 (10.1%) were allocated to the control, IFN, and DAA groups, respectively. A multivariate analysis showed that liver cirrhosis, segmental portal vein thrombosis, and larger maximal tumor size independently predicted an increased risk of progression (all p < 0.05), whereas, the DAA group (vs. IFN and control groups) independently predicted a reduced risk of progression (hazard ratio (HR) = 0.630, 95% confidence interval 0.411-0.966, p = 0.034). The cumulative incidence rate of HCC progression in the DAA group was significantly lower than that in the IFN and control groups (p = 0.033, log-rank test). In addition, the DAA group (vs. IFN and control groups) was independently associated with a reduced risk of mortality (p = 0.042). CONCLUSIONS: DAA treatment provided significantly prolonged progression-free survival in patients with CHC-related HCC treated with TACE compared to that in patients administered IFN or no treatment.

Current Status of Amebic Liver Abscess in Korea Comparing with Pyogenic Liver Abscess.

Backgrounds/Aims: With the improvement of hygiene, the incidence of amebic liver abscess is decreasing in South Korea. On the other hand, there is little data on the status of amebic liver abscess compared to pyogenic liver abscess. Methods: Patients with an amebic liver abscess, in whom Entamoeba histolytica (E. histolytica) IgG was positive, were identified retrospectively in a university hospital. The clinical, laboratory, and radiological characteristics of amebic liver abscess were compared with those of pyogenic liver abscess in the same period. Results: Between March 2010 and October 2016, 413 patients with a liver abscess were identified. Among them, the serologic test for E. histolytica was performed in 209 patients. Fifteen (7.2%) were classified as an amebic liver abscess, and the remainder were diagnosed with a pyogenic liver abscess. The age, gender, white blood cell, and CRP was comparable between the two groups. Procalcitonin was lower in amebic liver abscess than the pyogenic one. On CT, peripheral rim enhancement was more frequent, but cluster signs were not observed in amebic liver abscess compared to pyogenic liver abscess. None of the patients with amebic liver abscess died. In contrast, the mortality of pyogenic liver abscess was 4.7%. Conclusions: Amebic liver abscess should still be considered as one of the causes of liver abscess in Korea. It is difficult to discriminate an amebic liver abscess from a pyogenic liver abscess only according to the clinical, laboratory, and radiologic findings. Therefore, it is necessary to perform a serologic test for E. histolytica for a precise evaluation of liver abscess in a high-risk group.

Comparison between cap-assisted and ligation-assisted endoscopic mucosal resection for rectal neuroendocrine tumors.

BACKGROUND: Modified endoscopic mucosal resection (EMR) is considered a treatment option for rectal neuroendocrine tumors (NETs) <10 mm in diameter. In this study, we evaluated the clinical outcomes of cap-assisted EMR (EMR-C) and EMR with a ligating device (EMR-L). METHODS: We retrospectively analyzed 158 patients with 162 rectal NETs treated endoscopically at a single Korean tertiary hospital between March 2010 and November 2017. We evaluated the rates of endoscopic en bloc resection, histologic complete resection, and procedural complications according to the treatment method. RESULTS: Among 162 rectal NETs, 42 were treated with EMR-C and 120 with EMR-L. The endoscopic en bloc resection rate was higher in the EMR-L group than in the EMR-C group (100% vs. 92.9%, P=0.003). A trend was observed towards a superior histologic complete resection rate in the EMR-L group, but it was not statistically significant (92.5% vs. 83.3%, P=0.087). There were no significant differences in procedural complications (P=0.870). In a multivariate analysis, a tumor located ≥10 cm from the anal verge was related to histologic incomplete resection (P=0.039). CONCLUSION: EMR-L may be the preferable treatment method, considering both endoscopic en bloc resection rate and histologic complete resection rate.

Pyogenic Liver Abscess or Liver Cyst Infection after Colonoscopic Polypectomy.

A pyogenic liver abscess (PLA) mostly occurs in association with biliary tract disease, but some PLAs have no apparent underlying cause, i.e., they are cryptogenic. The authors experienced three cases of PLA or liver cyst infection after colon polypectomy without other distinct etiologies. These cases suggest that colonoscopic polypectomy can cause a mucosal defect that provides a route for bacteria to invade the portal system or spread intraperitoneally to the liver. Colonoscopic polypectomy should be considered as a procedure that might cause PLA. Moreover, clinicians should be aware of this possibility if a patient complains of fever or abdominal pain after a colonoscopic polypectomy.

The change in prevalence of suspected non-alcoholic fatty liver disease in Korean adolescents from 2001 to 2017.

AIM: Data on trends in the prevalence of suspected non-alcoholic fatty liver disease (NAFLD) in adolescents are scarce, especially in the Asia-Pacific region. The purpose of this study was to determine whether the prevalence of suspected NAFLD changed between 2001-2005 and 2015-2017. METHODS: Data were extracted from the Korea National Health and Nutrition Examination Survey (2001-2005 to 2015-2017, n = 4448). Suspected NAFLD was defined by an elevated alanine aminotransferase (ALT) level of >26 IU/L in boys and >22 IU/L in girls. In addition, the analysis was repeated using the Korean cut-off levels for ALT of 33 IU/L for boys and 25 IU/L for girls. RESULTS: The prevalence of suspected NAFLD increased, with a relative increase of 44% from 7.8% (95% CI 6.6-9.2%) in 2001-2005 to 11.2% (95% CI 9.7-12.9%) in 2015-2017 (p = 0.001). This increase was evident in both boys (10.6 vs 14.7%, p = 0.01) and girls (4.6 vs 7.4%, p = 0.02). Increases were also observed in obesity (7.3 vs 10.6%), central obesity (10.0 vs 12.8%) and ALT level (14.9 vs 16.7 IU/L). The prevalence of suspected NAFLD was approximately 40-45% in obese/central obese adolescents in 2015-2017. Using the Korean cut-off levels, the prevalence of suspected NAFLD has increased, with a relative increase of 55%, from 4.6% (95% CI 3.7-5.7%) in 2001-2005 to 7.2% (95% CI 6.1-8.5%) in 2015-2017 (p = 0.01). CONCLUSIONS: The prevalence of suspected NAFLD continues to increase in Korean adolescents. ABBREVIATIONS: ALT, alanine aminotransferase; BMI, body mass index; KNHANES, Korea National Health and Nutrition Examination Survey; NAFLD, non-alcoholic fatty liver disease.

Efficacy of mosapride citrate with a split dose of polyethylene glycol plus ascorbic acid for bowel preparation in elderly patients: A randomized controlled trial.

BACKGROUND/AIMS: Old age is a risk factor of suboptimal bowel preparation. This study aimed to evaluate the efficacy of mosapride citrate with a split dose of polyethylene glycol (PEG) plus ascorbic acid for bowel preparation in elderly patients (aged ≥65 years) before they underwent a colonoscopy. MATERIALS AND METHODS: This prospective investigator-blinded randomized study was conducted from November 2017 to October 2018. The patients were randomly divided into 2 groups, a mosapride group (mosapride citrate with a split-dose of PEG plus ascorbic acid) or a non-mosapride group (a split-dose of PEG plus ascorbic acid alone). Mosapride citrate 15 mg (Gastin CR) was administered once with each split-dose of the bowel preparation. The bowel preparation quality was assessed using the Boston Bowel Preparation Scale (BBPS). RESULTS: A total of 257 patients were finally included and analyzed in our study. The total BBPS score was significantly higher in the mosapride group than in the non-mosapride group (8.53 vs 8.24, P = .033). The BBPS scores of the right colon and mid-colon were 2.75 vs 2.61 (P = .044) and 2.89 vs 2.79 (P = .030), respectively. The rate of adequate bowel preparation (BBPS ≥ 6) was similar in both groups (98.4% vs 98.5%, P = .968), while the rate of excellent bowel preparation (BBPS = 9) was higher in the mosapride group than in the non-mosapride group (73.8% vs 61.1%, P = .029). The total incidence of adverse events during the administration of the bowel cleansing agent, particularly abdominal fullness, was lower in the mosapride group (11.9% vs 30.5%, P < .001). CONCLUSION: The administration of mosapride citrate with a split-dose of PEG plus ascorbic acid in elderly patients showed an increase in bowel preparation efficacy and reduced adverse events, particularly abdominal fullness, during the administration of a bowel cleansing agent.

Trends in the prevalence of chronic liver disease in the Korean adult population, 1998-2017.

Data on the trends in the prevalence of chronic liver disease (CLD) in Korea are scarce. This study aimed to evaluate whether the CLD prevalence changed between 1998-2001 and 2016-2017. Data were extracted from the Korea National Health and Nutrition Examination Survey (1998-2001 to 2016-2017; n=25,893). Non-alcoholic fatty liver disease (NAFLD) was defined as a hepatic steatosis index >36 in the absence of any other evidence of CLD. The definition of alcoholrelated liver disease (ALD) was excessive alcohol consumption (≥210 g/week for men and ≥140 g/week for women) and an ALD/NAFLD index >0. The prevalence of NAFLD increased from 18.6% (95% confidence interval [CI], 17.8-19.5%) in 1998-2001 to 21.5% (95% CI, 20.6-22.6%) in 2016-2017. During the same time period, increases were observed in the prevalence of obesity (27.0 vs. 35.1%), central obesity (29.4 vs. 36.0%), diabetes (7.5 vs. 10.6%), and excessive drinking (7.3 vs. 10.5%). ALD prevalence also increased from 3.8% (95% CI, 3.4-4.2%) to 7.0% (95% CI, 6.4-7.6%). In contrast, chronic hepatitis B decreased from 5.1% (95% CI, 4.6-5.5%) to 3.4% (95% CI, 3.0-3.8%). The prevalence of chronic hepatitis C was approximately 0.3% in 2016-2017. The prevalence of NAFLD and ALD increase among Korean adults. Our results suggest potential targets for interventions to reduce the future burden of CLD.

Serum Aminotransferase Level in Rhabdomyolysis according to Concurrent Liver Disease.

BACKGROUND/AIMS: The serum aminotransferase level is usually elevated in rhabdomyolysis, and these enzymes originate from the skeletal muscle. On the other hand, there is limited data showing whether the degree of elevation of these enzymes differs according to the concurrent liver disease. METHODS: Patients with rhabdomyolysis were selected when their serum creatinine kinase level was >1,000 U/L. They were categorized as the group with and without concurrent liver disease. The AST and ALT levels in both groups were compared. In addition, the aminotransferase level was compared between those with rhabdomyolysis and those with alcoholic liver disease. RESULTS: Among the 165 patients with rhabdomyolysis, 19 had concurrent liver disease. The median peak AST was higher in the group with concurrent liver disease (332 U/L [interquartile range (IQR), 127-1,604] vs. 219 U/L [IQR, 115-504]). In addition, the median peak ALT was higher in the group with concurrent liver disease (107 U/L [IQR, 74-418] vs. 101 U/L [IQR, 56-218]). On the other hand, there was no significant difference in both enzymes between the two groups. The median peak AST level was significantly higher in those with rhabdomyolysis than in those with alcoholic liver disease (221 U/L [IQR, 118-553] vs. 103 U/L [IQR, 59-206]), but the median peak ALT was not significantly different (102 U/L [IQR, 58-222] vs. 51 U/L [IQR, 26-117]). CONCLUSIONS: Rhabdomyolysis showed an elevated AST-dominant aminotransferase level, which is not different according to concurrent liver disease. Therefore, it is recommended that rhabdomyolysis be considered first in cases of elevated aminotransferase levels in patients with a suspicious skeletal muscle injury.

[Hepatitis E Virus: Epidemiology, Diagnosis, and Management].

The HEV is a known cause of water-borne outbreaks of acute non-A non-B hepatitis in developing countries, which affects young people and may result in high mortality in pregnant women. In recent decades, however, HEV genotypes 3 and 4 have been known as a cause of sporadic zoonotic infections in older males from swine HEV worldwide. Most acute HEV infections are self-limited. On the other hand, in immunosuppressed patients, including solid organ transplant recipients, chronic HEV infections may exist and progress to liver cirrhosis or decompensation. Therefore, physicians need to recognize HEV as a major pathogen for acute and chronic hepatitis of unknown causes and investigate this disease.