Ji Hee Han

Rationale: Colonic variceal bleeding is a rare but potentially life-threatening manifestation of portal hypertension. Bevacizumab therapy is associated with an increased risk of variceal bleeding, but bleeding from ectopic varices is less well recognized. Patient concerns: A 66-year-old man with alcohol-related cirrhosis and advanced hepatocellular carcinoma developed hematochezia on the day following the initiation of atezolizumab plus bevacizumab therapy. Diagnoses: Acute ascending colonic variceal bleeding in the setting of portal hypertension and portal vein thrombosis. Interventions: Coil-assisted retrograde transvenous obliteration (CARTO) was performed via the right common femoral vein. The portocolonic shunt was embolized using detachable coils and gelfoam slurry. Outcomes: Hematochezia ceased immediately after the procedure, and the patient remained hemodynamically stable without further transfusion. Follow-up computed tomography confirmed successful embolization of the variceal complex without residual shunt. Lessons: CARTO may be an effective treatment option for colonic variceal bleeding, particularly in patients with portal vein thrombosis or complex portosystemic shunts. Clinicians should remain aware of the potential for bleeding from ectopic varices in patients receiving bevacizumab-based therapy.

Rationale: Colonic intussusception is a rare cause of intestinal obstruction in adults, and is frequently associated with an underlying malignancy. Mucinous adenocarcinoma (MAC) is an uncommon histological subtype of colorectal cancer, characterized by abundant extracellular mucin and unfavorable biological behaviors. However, its presentation as a lead point for an intussusception is rare. Here we describe a rare case of MAC causing colonic intussusception. Patient concerns: We describe the case of a 75-year-old woman with multiple comorbidities who presented with hematochezia, abdominal distension, intermittent colicky pain, and progressive weight loss. Diagnoses: Colonoscopy revealed a large intraluminal mass in the ascending colon, while contrast-enhanced computed tomography revealed ileocecal intussusception with ischemic features. Interventions: Emergency right hemicolectomy was performed. Histopathology confirmed a moderately differentiated MAC without lymph node metastasis. Molecular analysis revealed a p.Gly13Asp KRAS (KRAS proto-oncogene, GTPase; protein change: glycine to aspartate substitution at codon 13) mutation with microsatellite stability. Outcomes: The patient’s prolonged immobility due to dementia and prior hip fracture surgery likely contributed to chronic bowel hypomotility, potentially exacerbating symptoms. Lessons: This case presents an unusual occurrence of MAC causing adult colonic intussusception, highlighting how tumor biology may synergize with host-related factors such as immobility to accelerate clinical deterioration. Early recognition using endoscopy and computed tomography and timely surgical resection is essential to optimize outcomes.

Background/Objectives: No current guideline specifies the timing of catheter removal after percutaneous transhepatic biliary drainage (PTBD). This study aimed to evaluate the clinical outcomes of early PTBD catheter removal after resolution of biliary obstruction in patients with acute cholangitis. Methods: This retrospective, single-center cohort study included 357 patients with acute cholangitis who underwent PTBD. Patients were divided into an early removal group (7–10 days, n = 199) and a late removal group (>10 days, n = 158) according to the timing of PTBD catheter removal. Clinical outcomes after catheter removal were compared between the two groups. Results: There was no significant difference between the two groups in the complication rate after PTBD catheter removal (2.5%; 95% CI, 1.1–5.7% in the early group vs. 1.9%; 95% CI, 0.6–5.4% in the late group; p > 0.999). In the early group, the most common complication was biloma (n = 3, 1.5%), followed by bile peritonitis (n = 1, 0.5%) and hemobilia (n = 1, 0.5%). In the late removal group, biloma, bile peritonitis, and hemobilia each occurred in one patient (0.6%). The total length of hospital stay was significantly shorter in the early group than in the late group (12 days [IQR, 10–15] vs. 17 days [IQR, 14–24]; p < 0.001). In exploratory multivariable analysis, early removal was associated with a 5.36-day shorter adjusted conditional median hospital stay than late removal (95% CI, 3.63–7.08; p < 0.001). Conclusions: Early PTBD catheter removal 7–10 days after placement appears to be feasible and was associated with a low rate of post-removal complications in appropriately selected patients with acute cholangitis, provided that predefined removal criteria are met.

Background: The Baveno VII consensus recently introduced the term “recompensated cirrhosis,” but its prognostic relevance in alcohol-related cirrhosis remains unclear. This study aims to analyze the frequency and associated factors of recompensation in patients with alcohol-related cirrhosis following the first decompensation and evaluate the prognosis based on recompensation status. Methods: This prospective cohort study was conducted at a tertiary care hospital in South Korea between 2017 and 2022. We enrolled 184 consecutive patients with alcohol-related cirrhosis presenting with a first decompensating event. According to the Baveno VII criteria, recompensation was defined as alcohol abstinence, improvement in liver function, and resolution of ascites/encephalopathy (off diuretics/lactulose) and absence of recurrent variceal bleeding (for at least 12 months). Patients were followed for outcomes including further decompensation, liver transplantation, or death. Results: Of the 184 patients, 45 (24.5%) achieved abstinence-induced recompensation while 38 (20.6%) died during the index hospitalization. In the multivariable Fine-Gray competing risk regression analysis, a lower baseline Child-Pugh score (sHR = 0.77, 95% CI = 0.61–0.98, P = 0.032) and lower MELD score (sHR = 0.93, 95% CI = 0.88–0.99, P = 0.023) were independent factors associated with recompensation. Among the 146 survivors, 51 (34.9%) died, 10 (6.8%) underwent liver transplantation, and 95 (65.1%) experienced further decompensation. Time-dependent multivariable Cox regression analysis showed that recompensation decreased the risk of death or liver transplantation by 96% (HR = 0.04, 95% CI = 0.01–0.30, P = 0.002) and the risk of further decompensation by 75% (HR = 0.25, 95% CI = 0.13–0.48, P < 0.001). Conclusions: Approximately one-fourth of the patients with alcohol-related cirrhosis achieved recompensation after first decompensation, which was strongly associated with reduced mortality and lower risk of further decompensation.

Background: Hypoxic hepatitis contributes to the development and progression of multiple organ failure (MOF). We evaluated whether MOF is associated with 30-day mortality in patients with hypoxic hepatitis. Methods: This retrospective study included 1011 patients diagnosed with hypoxic hepatitis at two centers in South Korea between 2010 and 2021. Organ failure was defined as a sequential organ failure assessment score ≥ 3 for each individual organ system. Results: Circulatory failure was the most common organ failure (n = 521), followed by respiratory (n = 380), cerebral (n = 307), renal (n = 236), coagulation (n = 182), and hepatic failure (n = 73). The proportions of patients without organ failure, with single organ failure, and with MOF were 28.7%, 22.3%, and 49.1%, respectively, with corresponding 30-day mortality rates of 17.9%, 29.3%, and 70.0%. In the multivariate Cox regression model, the presence of MOF grade 1 (two organ failures), grade 2 (three organ failures), and grade 3 (≥four organ failures) increased the risk of 30-day mortality by approximately threefold, fourfold, and fivefold, respectively, compared to patients without MOF. Conclusions: MOF is frequently observed in patients with hypoxic hepatitis and is a strong independent predictor of short-term mortality.

Cases of foreign body ingestion are encountered relatively often in clinical settings; however, serious complications are rare. In such cases, mediastinal abscess due to esophageal perforation can become a life-threatening complication. We encountered two cases of severe complications due to an esophageal fish bone foreign body. The first case was a 40-year-old male with an intramural esophageal abscess due to a fish bone after eating fish five days before visiting the hospital. The patient underwent surgical treatment, but the esophageal abscess did not improve; so, the abscess was drained through endoscopic mucosal dissection, and the abscess improved. In the second case, a 64-year-old male, who had eaten fish three days before visiting the hospital, had esophageal perforation by a fish bone, and abscess formation in the mediastinum and the lesser sac in the abdominal cavity were observed. Although surgical treatment was performed, the intra-abdominal abscess formation was not controlled; so, percutaneous drainage (PCD) was inserted, and the abscess improved. Both patients were discharged without any complications. Here, we report two cases that were improved through surgical treatments and additional treatments such as endoscopic dissection and PCD.

Background: Markedly elevated aminotransferase levels are commonly encountered among hospitalized patients. However, data regarding the trajectory of enzyme elevation and disease-specific prognosis are limited. Methods: This study included 3237 patients with at least one episode of aspartate aminotransferase or alanine aminotransferase level being higher than 400 U/L between January 2010 and December 2019 at 2 centers. Patients were classified into 5 groups comprising 13 diseases according to etiology. Factors associated with 30-day mortality were evaluated using a logistic regression analysis. Results: The most common disease leading to markedly elevated aminotransferase level was ischemic hepatitis (33.7%), followed by pancreatobiliary disease (19.9%), DILI (12.0%), malignancy (10.8%), and viral hepatitis (7.0%). The 30-day all-cause mortality rate was 21.6%. The mortality rate for patients from the pancreatobiliary, hepatocellular, extrahepatic, malignancy, and ischemic hepatitis groups was 1.7%, 3.2%, 13.8%, 39.9%, and 44.2%, respectively. Age, etiology, and peak aminotransferase levels were independently associated with 30-day mortality. Conclusions: In patients with markedly elevated liver enzymes, the etiology and peak AST level are significantly associated with mortality.

There have been no reports on mortality in patients with markedly elevated aspartate aminotransferase (AST) levels from non-hepatic causes to date. This study aimed to determine the etiologies of markedly elevated AST levels > 400 U/L due to non-hepatic causes and to investigate the factors associated with mortality in these cases. This retrospective study included 430 patients with AST levels > 400 U/L unrelated to liver disease at two centers between January 2010 and December 2021. Patients were classified into three groups according to etiology: skeletal muscle damage, cardiac muscle damage, and hematologic disorder. Binary logistic regression analysis was performed to evaluate the factors associated with 30-day mortality. The most common etiology for markedly elevated AST levels was skeletal muscle damage (54.2%), followed by cardiac muscle damage (39.1%) and hematologic disorder (6.7%). The 30-day mortality rates for the skeletal muscle damage, cardiac muscle damage, and hematologic disorder groups were 14.2%, 19.5%, and 65.5%, respectively. The magnitude of the peak AST level significantly correlated with 30-day mortality, with rates of 12.8%, 26.7%, and 50.0% for peak AST levels < 1000 U/L, <3000 U/L, and ≥3000 U/L, respectively. In the multivariate analysis, cardiac muscle damage (odds ratio [OR] = 2.76, 95% confidence interval [CI] = 1.31–5.80), hematologic disorder (OR = 9.47, 95% CI = 2.95–30.39), peak AST < 3000 U/L (OR = 2.94, 95% CI = 1.36–6.35), and peak AST ≥ 3000 U/L (OR = 9.61, 95% CI = 3.54–26.08) were associated with increased 30-day mortality. Our study revealed three etiologies of markedly elevated AST unrelated to liver disease and showed that etiology and peak AST level significantly affected the survival rate.