Clinical Features of Drug-induced Liver Injury According to Etiology.

Drug-induced liver injury (DILI) is an increasingly common cause of acute hepatitis. We examined clinical features and types of liver injury of 65 affected patients who underwent liver biopsy according DILI etiology. The major causes of DILI were the use of herbal medications (43.2%), prescribed medications (21.6%), and traditional therapeutic preparations and dietary supplements (35%). DILI from herbal medications, traditional therapeutic preparations, and dietary supplements was associated with higher elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels than was DILI from prescription medications. The types of liver injury based on the R ratio were hepatocellular (67.7%), mixed (10.8%), and cholestatic (21.5%). Herbal medications and traditional therapeutic preparations were more commonly associated with hepatocellular liver injury than were prescription medications (P = 0.002). Herbal medications and traditional therapeutic preparations induce more hepatocellular DILI and increased elevations in AST and ALT than prescribed medications.

Jackhammer esophagus treated by a peroral endoscopic myotomy.

A 49-year-old woman visited our hospital with dysphagia and chest pain. In another hospital, she was diagnosed as reflux esophagitis. Although she had taken proton pump inhibitor and prokinetics drugs for a long time, she was not relieved of any symptoms. On the basis of high resolution manometry and endoscopic ultrasonography findings, Jackhammer esophagus was diagnosed. In this patient, peroral endoscopic myotomy (POEM) was performed for long myotomy of thickened circular muscle. During the procedure, there were no significant complications and she was discharged uneventfully. Symptoms were completely improved during three months after POEM. Here, we report on a case of Jackhammer esophagus treated by POEM.

Long-term outcomes of balloon dilation versus botulinum toxin injection in patients with primary achalasia.

BACKGROUND/AIMS: We compared the long-term outcomes of balloon dilation versus botulinum toxin injection in Korean patients with primary achalasia and identified factors predicting remission. METHODS: We included 73 patients with achalasia newly diagnosed between January 1988 and January 2011. We ultimately enrolled 37 of 55 patients with primary achalasia through telephone interviews, who were observed for over 1 year. Short-term outcomes were evaluated from the medical records based on symptom relief after 1 month of treatment. Long-term outcomes were evaluated in a telephone interview using a questionnaire. RESULTS: Twenty-five patients were administered a botulinum toxin injection and 12 underwent balloon dilation. One month after the botulinum toxin injection, improvements were seen in chest pain (14 [56.0%] to 4 patients [16.0%]), regurgitation (16 [64.0%] to 4 [16.0%]), and dysphagia (25 [100.0%] to 5 [20.0%]). In the balloon dilation group, chest pain (8 [66.7%] to 1 [8.3%]), regurgitation (11 [91.7%] to 1 [8.3%]), and dysphagia (12 [100.0%] to 1 [8.3%]) had improved. A significant difference was observed in the mean remission duration between the botulinum toxin injection and balloon dilation groups (13 months [range, 1 to 70] vs. 29 months [range, 6 to 72], respectively; p = 0.036). Independent factors predicting long-term remission included treatment type (odds ratio [OR], 6.982; p = 0.036) and the difference in the lower esophageal sphincter pressure (OR, 7.198; p = 0.012). CONCLUSIONS: Balloon dilation may be more efficacious than botulinum toxin for providing long-term remission in Korean patients with achalasia. Follow-up manometry may predict the long-term outcome.

Clinically useful diagnostic tool of contrast enhanced ultrasonography for focal liver masses: comparison to computed tomography and magnetic resonance imaging.

BACKGROUND/AIMS: To evaluate the diagnostic value of contrast (SonoVue(®)) enhancement ultrasonography (CEUS) and to compare this method with computed tomography (CT) and magnetic resonance imaging (MRI) in evaluating liver masses. METHODS: CEUS (n=50), CT (n=47), and MRI (n=43) were performed on 50 liver masses in 48 patients for baseline mass haracterization. The most likely impression for each modality and the final diagnosis, based on the combined biopsy results (n=14), angiography findings (n=36), and clinical course, were determined. The diagnostic value of CEUS was compared to those of CT and MRI. RESULTS: The final diagnosis of the masses was hepatocellular carcinoma (n=43), hemangioma (n=3), benign adenoma (n=2), eosinophilic abscess (n=1), and liver metastasis (n=1). The overall diagnostic agreement with the final diagnosis was substantial for CEUS, CT, and MRI, with κ values of 0.621, 0.763, and 0.784, respectively. The sensitivity, specificity, and accuracy were 83.3%, 87.5%, and 84.0%, respectively, for CEUS; 95.0%, 87.5%, and 93.8%, respectively, for CT; and 94.6%, 83.3%, and 93.0%, respectively for MRI. After excluding the lesions with poor acoustic sonographic windows, the sensitivity, specificity, and accuracy for CEUS were 94.6%, 87.5%, and 93.3%, respectively, with a κ value of 0.765. CONCLUSIONS: If an appropriate acoustic window is available, CEUS is comparable to CT and MRI for the diagnosis of liver masses.

Prognostic indicators in primary biliary cirrhosis: significance of revised IAHG (International Autoimmune Hepatitis Group) score.

BACKGROUND/AIMS: Primary biliary cirrhosis (PBC) is a slowly progressing autoimmune disease of the liver that is characterized by portal inflammation and immune-mediated destruction of the intrahepatic bile ducts. Serum total bilirubin is one of the various prognostic factors that have been proposed. A recent study found that PBC with accompanying autoimmune hepatitis (AIH) carries a negative prognosis. This study examined the clinical characteristics of PBC and analyzed the factors that affect its prognosis. METHODS: Patients diagnosed with PBC between January 1998 and December 2010 based on clinical and histopathological findings were compiled and analyzed retrospectively. RESULTS: Among 27 patients, 24 (1 male and 23 females, ages 50.0±9.3 years) were followed up. The follow-up period was 8.6±0.9 years. Of the 24 patients, 9 patients progressed to liver cirrhosis (LC). Comparison between patients who did and did not progress to LC revealed statistically significant differences in the patients' serum total bilirubin (2.7±1.8 vs. 0.8±0.4, P=0.012), the Mayo risk score (5.1±0.7 vs. 3.9±0.6, P=0.001), the revised IAHG (International Autoimmune Hepatitis Group) score (9.2±2.3 vs. 5.4±3.0, P=0.004) and frequency of AIH overlap (5/9 [55.6%] vs. 0/15 [0%], P=0.001) at the time of diagnosis. CONCLUSIONS: We propose that serum total bilirubin, the Mayo risk score, and the revised IAHG score at the time of diagnosis are helpful for predicting PBC prognosis. In particular, since all of the patients with accompanying AIH progressed to LC, the presence of overlap syndrome at the time of diagnosis is helpful for predicting PBC prognosis and providing an adequate treatment.

Relationship between the hepatic venous pressure gradient and first variceal hemorrhage in patients with cirrhosis: a multicenter retrospective study in Korea.

BACKGROUND/AIMS: Variceal hemorrhage is one of the major complications of cirrhosis and is associated with significant mortality and morbidity. The development of gastroesophageal varices and variceal hemorrhage is the most direct consequence of portal hypertension. Correlations between the hepatic venous pressure gradient (HVPG) and first variceal hemorrhage were examined. METHODS: Patients with cirrhosis who underwent HVPG measurement between July 2009 and September 2010 were enrolled (n=535). All patients underwent esophagogastroduodenoscopy to enable the evaluation of gastroesophageal varices. RESULTS: The HVPG for all patients was 16.46±7.05 mmHg (mean±SD), and was significantly higher among those with first variceal hemorrhage than in those without it. The HVPG was significantly correlated with both Child-Turcotte-Pugh (r=0.488, P<0.001) and Model for End-stage Liver Disease (r=0.478, P<0.001) scores. An HVPG value of 11 mmHg was predictive of first variceal hemorrhage with a sensitivity of 92.4% and a specificity of 27.7%. CONCLUSIONS: The HVPG was higher in patients with first variceal hemorrhage than in those without it.