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Acute pancreatitis (AP) severity is determined by associated organ failure (OF). However, enzymatic erosion of peripancreatic vessels can lead to life-threatening hemoperitoneum in clinically non-severe AP without OF. We herein report a case of unexpected hemoperitoneum which developed in a patient with clinically resolving AP without OF. A 36-year-old woman with alcohol use disorder presented with resolving epigastric pain and sustained abdominal distension of 2 weeks’ duration. Ranson’s score on admission was 1 and Computed tomography (CT) revealed non-necrotic AP with peripancreatic fluid collection. She showed sudden hypotension with an abrupt decrease in serum hemoglobin within 24 hours after admission. She was suspected to have an acute hemoperitoneum associated with venous bleeding from AP based on repeated CT. Venous bleeding from the splenic branch was ligated during surgery. The possibility of bleeding at the pancreatic bed should be considered even if the pancreatitis is not severe.

Background: Until now, various types of combined therapy with nucleotide analogs and pegylated interferon (Peg-INF) in patients with hepatitis B patients have been tried. However, studies regarding the benefits of de novo combination, late-add on, and sequential treatment are very limited. The objective of the current study was to identify the efficacy of sequential treatment of Peg-INF after short-term antiviral treatment. Methods: Between June 2010 and June 2015, hepatitis B e antigen (HBeAg)-positive patients (n = 162) received Peg-IFN for 48 weeks (mono-treatment group, n = 81) and entecavir (ETV) for 12 weeks with a 48-week course of Peg-IFN starting at week 5 of ETV therapy (sequential treatment group, n = 81). The primary endpoint was HBeAg seroconversion at the end of follow-up period after the 24-week treatment. The primary endpoint was analyzed using Chi-square test, Fisher's exact test, and regression analysis. Results: HBeAg seroconversion rate (18.2% vs. 18.2%, t = 0.03, P = 1.000) and seroclearance rate (19.7% vs. 19.7%, t = 0.03, P = 1.000) were same in both mono-treatment and sequential treatment groups. The rate of alanine aminotransferase (ALT) normalization (45.5% vs. 54.5%, t = 1.12, P = 0.296) and serum hepatitis B virus (HBV)-DNA

Liver stiffness measurement (LSM) by transient elastography is a non-invasive method to assess liver fibrosis. Decline in LSM value has been reported after antiviral treatment (AVT) using nucleos(t)ide analogues (NUCs) in chronic hepatitis B (CHB) patients, however, factors associated with changes in LSM during AVT remains unclear.A total of 76 CHB patients who received AVT with NUCs and had serial LSM (median duration: 16 months, range: 12 to 35 months) during AVT were analyzed. Complete virological response (CVR) was defined when hepatitis B virus DNA level was undetectable by real-time PCR assay (50 copies/mL).LSM value had significantly decreased after AVT with NUCs [median (quartile): 6.5 (4.7-9.2) to 5.3 (3.9-6.7), P0.001]. The median change of LSM value/year was -0.8 (range: -9.5∼4.9). The annual change of LSM value was associated with baseline total bilirubin levels, HBeAg status and achievement of CVR during follow-up in univariable analysis, and achievement of CVR during follow-up was an only independent factor associated with the annual change of LSM value [beta coefficients (95% confidence interval)=-0.29 (-2.81∼-0.26), P=0.02]. The annual LSM change was significantly different between those who achieved and did not achieve CVR (median change: -1.08/year vs. 0.26/year, P0.01), and more patients with CVR had decrease in LSM value (89% (47/53) vs. 35% (8/23), P0.01).A significant decrease in LSM value was observed in CHB patients after AVT with NUCs. Achievement of CVR was significant factor associated with change in LSM value. Achieving CVR might be a key to decrease LSM value during AVT with NUCs.

Background/Aims: A diagnosis of hepatorenal syndrome (HRS) is based on a differential evaluation of acute kidney injury (AKI), which may aggravate the clinical course. This study assessed the clinical significance of the urinary neutrophil gelatinase- associated lipocalin (u-NGAL) levels in a differential diagnosis of AKI in patients with liver cirrhosis (LC). Methods: Patients with LC who developed AKI were enrolled prospectively. Clinically, patients with AKI were classified into prerenal azotemia (PRA), HRS, and acute tubular necrosis (ATN) groups. Results: Fifty-five patients (male, 74.5%) with LC who exhibited AKI upon admission were enrolled; 28, 9, and 18 patients were included in the PRA, HRS, and ATN groups, respectively. The baseline model for end-stage liver disease (MELD) scores was similar in the subgroups. The median event creatinine level, measured at the time of the AKI diagnosis, was similar in the HRS and ATN subgroups. On the other hand, the median event u-NGAL level differed significantly between the three subgroups (PRA, HRS, and ATN: 37 vs. 134 vs. 2,625 ng/mL, p=0.003). In particular, the median u-NGAL level of the HRS group was clearly different from those of the PRA (p

†Background/Aims: It is unclear whether the risk factors associated with complicated diverticulitis in Asian and Western countries are the same. We evaluated the risk factors associated with severe diverticulitis (SD) in Korea and compared the clinical characteristics of diverticulitis according to location. Methods: A retrospective review of 190 patients hospitalized with acute diverticulitis from January 2005 to June 2010 was conducted. SD was defined as one of the following: perforation, abscess, obstruction, sepsis, or peritonitis that required an urgent operation. Results: Twenty-four patients (12.6%) were diagnosed with SD. SD was significantly associated with older age, a fever over 38 o C, changes in bowel habits and a high visceral adipose tissue (VAT)/total adipose tissue (TAT) ratio. Multivariate analysis showed that the risk factors for developing SD were an age of 40 years or more (odds ratio [OR], 3.2; p=0.032), male gender (OR, 4.0; p=0.021) and left-sided diverticulitis (OR, 6.2; p=0.017). Right-sided diverticulitis (n=175, 92.1%) was signifi cantly associated with younger ages, fewer changes in bowel habits, fewer comorbidities and non-SD. Conclusions: This study suggests that the risk factors for developing SD in Korea, where right-sided diverticulitis is predominant, are the male gender, an age of more than 40 years old, and left-sided diverticulitis. Given that there are different risk factors for developing SD in Western countries, different strategies for the treatment of diverticulitis in the Korean population seem to be needed. (Gut Liver 2012;6:78-85)

Here, we report a case of corrosive injury-induced pharyngeal stricture in a 69-year-old female, which was successfully treated with endoscopic adhesiolysis using an electrosurgical knife. The patient had ingested sodium hydroxide in an attempted suicide, and immediate endoscopy revealed corrosive injuries of the pharynx, esophagus, and stomach. When a liquid diet was permitted, she complained of nasal regurgitation of food. Follow-up endoscopy revealed several adhesive bands and a web-like scar that did not allow passage of the endoscope into the hypopharyngeal area. For treatment of the hypopharyngeal stricture, the otolaryngologist attempted to perform an excision of the fibrous bands around the esophageal inlet using microscissors passed through an esophagoscope, but this procedure was not effective. We then dissected the mucosal adhesion and incised the adhesive bands using an electrosurgical knife. After this procedure, nasal regurgitation of food no longer occurred. To our knowledge, this case is the first report of endoscopic adhesiolysis with an electrosurgical knife in a patient with a corrosive injury-induced pharyngeal stricture.

Despite the limitations of screening or early diagnosis of colorectal cancers (CRC), carcinoembryonic antigen (CEA) is frequently measured in practice and during health promotion programs. The aim of this study was to evaluate the role of colonoscopy in healthy individuals with elevated CEA levels. From January 2003 to November 2008, 117,731 healthy persons underwent an opportunistic screening program in two health promotion centers; 1,497 subjects (1.3%) showed an elevated CEA level (>5 ng/ml). Among them, 174 patients were recruited to undergo a colonoscopy to determine if colorectal malignancies were present. A total of 372 age- and sex-matched persons were selected as controls from among the healthy subjects who had a normal level of CEA and had received surveillance colonoscopy. The primary outcome was the incidences of CRC in elevated CEA and normal CEA groups. The secondary outcome was the predictive factors of CRC in the elevated CEA group. The incidence of CRC was higher in the group with higher CEA-levels than in the group with normal CEA levels (4.6 vs. 1.3%; P = 0.031). In the CEA-elevated group, patients with CRCs were diagnosed at more advanced stages than were those in the CEA-normal group. The incidence of colorectal polyps was not different between the two groups. In the CEA-elevated group, anemia was an independent predictive factor of CRCs by multivariate analysis (P = 0.002). Anemia itself is not a predictive factor of CRC in the entire population, but is an independent predictive factor of CRC in healthy individuals with an elevated level of CEA. Therefore, colonoscopy should be recommended for healthy subjects with an elevated level of CEA accompanied with anemia in the absence of other adenocarcinomas to evaluate the presence of colorectal malignancy.

AIM: To analyze whether prompt and appropriate empirical antibiotic (AEA) use is associated with mortality in cirrhotic patients with bacteremia. METHODS: A total of 102 episodes of bacteremia in 72 patients with cirrhosis were analyzed. AEA was defined as a using or starting an antibiotic appropriate to the isolated pathogen at the time of bacteremia. The primary endpoint was 30-d mortality. RESULTS: The mortality rate at 30 d was 30.4% (31/102 episodes). Use of AEA was associated with better survival at 30 d (76.5% vs 46.9%, P = 0.05), and inappropriate empirical antibiotic (IEA) use was an independent factor associated with increased mortality (OR = 3.24; 95%CI: 1.50-7.00; P = 0.003, adjusted for age, sex, Child-Pugh Class, gastrointestinal bleeding, presence of septic shock). IEA use was more frequent when the isolated pathogen was a multiresistant pathogen, and when infection was healthcare-related or hospital-acquired. CONCLUSION: AEA use was associated with increased survival of cirrhotic patients who developed bacteremia. Strategies for AEA use, tailored according to the local epidemiological patterns, are needed to improve survival of cirrhotic patients with bacteremia.

Objective: Pre-operative endoscopic clipping for determining the resection line in patients with early gastric cancer (EGC) has been used safely, and its efficacy has been demonstrated. However, the optimal timing of endoscopic clipping for determining the resection line in EGC patients undergoing laparoscopy-assisted distal gastrectomy (LADG) has not been investigated. Methods: A retrospective analysis of 92 patients with EGC who underwent gastric resection after endoscopic clipping at OOO Hospital, Korea was performed. We analyzed the clinical and endoscopic features of patients, number of clips, time from clipping to surgery, and number of patients showing detachment of clips from the gastric wall before surgery. Patients were categorized into the following 2 groups: group A included patients whose clips were applied within 1 day before surgery and group B included patients whose clips were applied more than 1 day before surgery. Results: Of the 92 patients, 56 were in group A and 36 were in group B. In 11 patients (12.0%, 5 in group A and 6 in group B, P=0.329), the clips were detached from the gastric wall before surgery. The mean time from clipping to surgery did not differ significantly between the detached and non-detached groups (11 patients, mean 4.6 ± 4.6 days vs. 81 patients, mean 3.0 ± 4.0 days, P = 0.227). Conclusion: The timing of endoscopic clipping for the localization of tumors in EGC patients undergoing gastrectomy is not important for determining the resection line.

Hepatic peribiliary cysts (HPCs) are characterized by cystic dilatations of the peribiliary glands located throughout the branches of the biliary systems. Specifically, they are mainly located along the hepatic hilum and major portal tracts. The natural history and prognosis of HPCs are uncertain. In fact, almost all HPCs have been discovered incidentally during radiological examination or autopsy, and they are considered to be clinically harmless. Recently, several cases of HPCs associated with obstructive jaundice or liver failure were reported in patients with pre-existing liver disease in several studies. However, until now there have been no reports of such a case in Korea. Herein, we report a case of HPCs that show a disease course with a poor prognosis. These HPCs developed in a 47-year-old man with progressive alcoholic liver cirrhosis.

Oral 5-aminosalicylic acid (5-ASA) has been known as a first-choice drug for ulcerative colitis. However, hypersensitivity reactions, including pancreatitis, hepatitis, and skin rash, have been reported with 5-ASA. Topical formulations of 5-ASA like suppositories have been rarely reported to induce adverse reactions because of their limited absorption rate. We recently experienced a case of acute pancreatitis caused by 5-ASA suppositories in a patient with ulcerative colitis. A 26-year-old male was admitted with abdominal pain and diagnosed as ulcerative colitis. Acute pancreatitis occurred soon after 24 hours of treatment with oral mesalazine. Drug-induced pancreatitis was suspected and administration of mesalazine was discontinued. Then 5-ASA suppositories were started instead of oral mesalazine. Twenty-four hours after taking 5-ASA suppositories, he experienced severe abdominal pain, fever, and elevation of amylase levels. The suppositories were immediately stopped and symptoms resolved over next 48 hours. Herein, we suggest that, in patients treated with 5-ASA suppositories who complain of severe abdominal pain, drug-induced pancreatitis should be suspected.

Intussusception is primarily a disease of children, and is relatively rare in adults. Unlike childhood intussusception, adult intussusception has an identifiable leading lesion such as malignant or benign neoplasm. However, intussusception caused by hemangioma is very rare. There were few cases of small bowel intussusception caused by hemangioma in adults, but those reports were presented with abdominal pain. This report describes a 65-year-old female who suffered from small bowel intussusception caused by hemangioma presenting with intestinal bleeding. Upper gastrointestinal endoscopy and colonoscopy were performed, but bleeding focus was not found. Abdominal computed tomography showed the target sign of small bowel with a leading point of mass. This mass turned out to be a hemangioma after the small bowel resection. Therefore, small bowel intussusception by hemangioma should be also considered as a bleeding focus when an adult patient presented intestinal bleeding without bleeding focus in the stomach and colon. Herein we report a case of small bowel intussusception caused by hemangioma presenting with intestinal bleeding.

3 33-year-old man was admitted to our department because of fever, myalgia, nausea, and vomiting. His liver function test revealed elevation f the hepatic enzyme and hyperbilirubinemia, ie, AST 213 IU, ALT 1105 IU, nd total bilirubin 7.5 mg/dL. Hepatitis A serologic test, ie, HAV IgM, was ositive, and serologic tests for hepatitis B and C were negative. While his liver unction test results were improving, he was discharged with the diagnosis of ecovery state of acute hepatitis A. Five days later, he was readmitted with constipation, urinary retention, and eakness in the low extremities. He also complained of hypersthenia of trunk nd legs. A physical examination revealed grade I of motor weakness in both ow extremities, with bilateral positive Babinski’s sign, deep tendon reflex grade II), and ankle clonus. Lab testing on admission included AST 49 IU, LT 185 IU, total bilirubin 12.3 mg/dL, alkaline phosphatase 142 IU, gammalutanyl transpeptidase 116 U, lactate dehydrogenase 460 U/L, and prothromin time international normalized ratio 1.0. Foley catheter was inserted because of urinary retention on day 2. In view of he ongoing weakness of low extremities, brain computed tomography scan nd a lumbar puncture were performed. Brain computed tomography scan as normal. Cerebrospinal fluid analysis showed red blood cell count 23/mm3, hite blood cell count 20/mm3, 61 mg/dL of glucose, and 65 mg/dL of rotein. The Levin tube was inserted for gaseous distention of abdomen caused by ngoing ileus on day 4. Spine magnetic resonance imaging was performed and howed diffuse increased signal intensity near whole thoracolumbar spinal ord except mid-thoracic level and suggestive of myelitis (Figure A). The atient was diagnosed with acute transverse myelitis after acute hepatitis A. he treatment was started with Ig (400 mg/kg) infusion. Follow-up hepatitis antibody test revealed positive HAV IgM and IgG, but neurologic disorder of he patient was not improved. Steroid therapy (methylprednisolone, 1 mg/kg) was started on day 8 after 5 ays of Ig infusion when HAV IgM titer was slightly decreased. Bedside hysical therapy was also offered. The patient showed decreased abdominal iscomfort, and the abdominal x-ray showed improvement of ileus. Therefore, A

Background Distinguishing those patients with fulminant hepatic failure (FHF) and who require transplantation from those FHF patients who will survive with receiving only intensive medical care remains problematic, and this distinction is important because of the chronic shortage of donor livers. Methods To assess the applicability of two prognostic scoring systems, referred to as the London and Clichy criteria, we compared using both systems, at the time of admission, for 43 FHF patients (15 M/28 F; age: 3716 yrs). Acetaminophen (ACM) was the etiology for 16 patients, while the remaining 27 had other etiologies. All the patients received intensive care, and 18 (8 ACM/10 non-ACM) had investigational BAL support. Results For the ACM toxicity, neither the London nor the Clichy criteria exhibited acceptable sensitivity (71 vs 86%, respectively), specificity (78 vs 56%, respectively), a positive predictive value (71 vs 60%, respectively), a negative predictive value (78 vs 83%, respectively) or predictive accuracy (75 vs 69%, respectively) to predict patient survival without transplantation. In contrast, applying the London and Clichy criteria to the FHF patients with non-ACM etiologies showed a sensitivity of 96 vs 80%, respectively, a specificity of 100 vs 100%, respectively, a positive predictive value of 100 vs 100%,, respectively a negative predictive value of 67 vs 29%, respectively and a predictive accuracy of 96% vs 82%, respectively. Conclusions Overall, the London criteria more accurately predicted the need for transplantation, and neither the London criteria nor the Clichy prognostic criteria accurately predicted the outcome of those patients who suffered with FHF due to ACM. BAL support may have contributed to the survival of the patients with ACM toxicity and who didn't undergo transplantation, and this survival exceeded the predictions of both prognostic systems. Additional multicenter studies should be conducted to refine these prognostic scoring systems, and this will help physicians rapidly identify those FHF patients who can survive without undergoing liver transplantation.

The liver plays important roles in the homeostasis of glucose metabolism since it acts as a major target organ for insulin and a site for gluconeogenesis and glycogen storage. Diabetes mellitus (DM) commonly develops in patients with liver cirrhosis as the result of hepatocyte dysfunction and/or inadequate mass. To assess differences between DM due to liver cirrhosis (hepatogenous DM) and the other type 2 DM, we compared the patterns of hyperglycemia and hyperinsulinemia in hepatogenous DM with those observed in type 2 DM.18 diabetic patients with liver cirrhosis (caused by alcohol, n=8; HBV, n=5; HCV, n=2; others, n=3) were matched with 18 type 2 diabetic patients without liver cirrhosis for age and gender. None of the patients or controls had been treated with insulin or beta-blockers. The level of glycosylated hemoglobin (HbA1C), fasting plasma glucose (FPG), postprandial plasma glucose (PP2h), fasting plasma C-peptide and insulin were measured.The ratio of PP2h/FPG (2.27 vs. 1.69), fasting insulin (23.2: 11.6 microIU/mL) and HOMA-IR index (8.38 vs. 3.52) were significantly higher in hepatogenous DM than the other type 2 DM (P0.05). PP2h, fasting C-peptide and ratio of fasting insulin/C-peptide tend to be higher in hepatogenous DM than those of controls, but which were not statistically significant.The ratio of PP2h/FPG and fasting plasma insulin differentiated hepatogenous DM from the other type 2 DM. Insulin resistance in liver cirrhosis was higher than the other type 2 DM, and impaired hepatic insulin degradation might be an important mechanism of hyperinsulinemia in liver cirrhosis.

Data from previous studies on gastric acid secretion and the prevalence of H. pylori in liver cirrhosis patients remain poorly defined. H. pylori is a potential source of NH3, but the possible role of H. pylori in hepatic encephalopathy is not clear. The purpose of this study was to compare gastric acid secretion, the impact of H. pylori infection, and the production of NH3 between cirrhotic patients and healthy, matched controls.Twenty-nine patients with liver cirrhosis (HBV, n=12; Alcohol, n=12; HCV, n=5) were matched with 33 healthy persons for age and sex. None of the patients or controls were being treated with antacids, H2-receptor blockers or proton pump inhibitors. The pH and NH3 concentration was measured in gastric juice obtained by endoscopy. H. pylori infection was diagnosed using the rapid urease test. The level of NH3 in venous blood was also measured.The average gastric pH was significantly higher in cirrhosis patients compared to controls (3.91 vs. 2.99, P0.05). In addition, the prevalence of hypochlorhydria (defined as pH4) was significantly greater in cirrhosis patients (45 vs. 21%, P0.05). In contrast, the prevalence of H. pylori infection (62% vs. 58%) and gastric NH3 concentrations (3.4 vs. 3.3 mM/L) were similar between both groups. However, venous NH3 levels were significantly higher in cirrhotics than in controls (63.1 vs. 25.2 microM/L, P0.05). The patients with H. pylori infection had significantly higher gastric NH3 concentration (3.8 vs. 1.6 mM/L) and gastric pH (3.87 vs. 2.76, P0.05) than those without infection, but no significant difference in venous NH3 levels were detected (39.6 vs. 48.1 microM/L). In patients with cirrhosis, the presence of H. pylori infection was not correlated with either gastric or blood NH3 levels.The gastric pH of liver cirrhosis patients is higher than that of controls and a larger proportion of cirrhotic patients have hypochlorhydria. The prevalence of H. pylori in liver cirrhosis patients was similar to that in controls and no correlation was found between gastric and blood NH3 levels. Thus, H. pylori infection does not seem to play a major role in generation of elevated NH3 associated with hepatic encephalopathy.

Pure red cell aplasia (PRCA) and autoimmune hemolytic anemia (AIHA) have rarely been reported as an extrahepatic manifestation of acute hepatitis A (AHA). We report herein a case of AHA complicated by both PRCA and AIHA. A 49-year-old female with a diagnosis of AHA presented with severe anemia (hemoglobin level, 6.9 g/dL) during her clinical course. A diagnostic workup revealed AIHA and PRCA as the cause of the anemia. The patient was treated with an initial transfusion and corticosteroid therapy. Her anemia and liver function test were completely recovered by 9 months after the initial presentation. We review the clinical features and therapeutic strategies for this rare case of extrahepatic manifestation of AHA.

cooler and 5/36 patients (14%) found the insertion uncomfortable. No complications occurred during or after the use of the anal cooler. No differences were found between patients who had improvement with the anal cooler and patients who had not. The 14/50 patients (28%) who did not use the anal cooler, had a lower post-banding pain score compared to patients who used the anal cooler (1.4 vs 6.4; P

Lymphocytic ascites with low serum-ascites albumin gradient (SAAG) are observed mainly in tuberculous peritonitis, peritoneal carcinomatosis, and pancreatic disease. However, pelvic inflammatory disease (PID) induced generalized peritonitis causing diffuse ascites has been rarely described. We report a 26-year old female patient, who was diagnosed as generalized peritonitis with diffuse ascites due to Chlamydia trachomatis infection. Gynecologic examination did not show the clue of PID and in the analysis of ascites, low SAAG, predominant lymphocyte count and high level of adenosine deaminase were noted. Although the best impression was tuberculous peritonitis on the base of these findings, the laparoscopic finding was consistent with PID and the PCR for C. trachomatis infection in cervical swab was positive. This case suggests that C. trachomatis peritonitis should be considered as a rare cause of low SAAG and lymphocytic ascites in sexually active women and should be intensively evaluated including laparoscopic examination.

Hyperplastic polyps (HPs) are the most common cause of all benign epithelial gastric polyps, constituting 30 to 93%. Although gastric HPs are usually considered as benign lesions compared with adenoma, neoplastic transformation has been known to occur rarely. We aimed to identify the clinical factors of gastric HPs predicting for neoplastic transformation.Between January 2002 to August 2010, a total of 274 gastric HPs, which had been removed by endoscopic polypectomy or surgical resection from 210 patients, were analyzed retrospectively.Neoplastic transformation was found in 15 cases (5.5%) of 274 HPs including 10 cases of low grade dysplasia (3.7%), 2 cases of high grade dysplasia (0.7%) and 3 cases of adenocarcinoma (1.1%). Neoplastic transformations were significantly associated with1 cm in size (n=10 [66.7%] vs. n=91 [35.1%], p=0.024), with pedunculated shape (n=9 [60.0%] vs. n=62 [23.9%], p=0.002), with previous history of gastrectomy (n=3 [20.0%] vs. n=3 [1.2%], p=0.002) and with synchronous neoplastic lesions occurring elsewhere in the gastric mucosa (n=5 [33.3%] vs. n=31 [12.0%], p=0.021). However, no significant difference was found between HPs with and without neoplastic transformation in terms of age, sex, number of polyps detected per patient, location, macroscopic appearance such as erosion, hyperemia.Neoplastic transformation of gastric HPs had significant relationships with ž1 cm in size, pedunculated shape, postgastectomy state, and synchronous neoplastic lesion. Therefore, endoscopic polypectomy should be considered in these HPs to avoid the risk of missing HPs with neoplastic potential.

Spontaneous regression of hepatocellular carcinoma (HCC) is extremely rare. We report a case of 67-year-old man having HBV-associated HCC with multiple lung metastases which regressed spontaneously. The patient had single liver mass and received surgical resection. The mass was confirmed as HCC histopathologically. Nine years after surgical resection, a 3.3 cm sized recurred HCC was detected on the resection margin in CT scan. Transarterial chemoembolization (TACE) was performed 3 times, and lung metastases developed thereafter. The patient received 2 more sessions of TACE, however, metastatic lung nodules were in progress very rapidly. We decided to stop TACE and followed the patient regularly without any anti-cancer treatment. Nine months after development of lung metastasis, the size and number of metastatic lung nodules decreased and were not detected anymore after 14 months. Serum alpha-fetoprotein levels also decreased to normal range and no viable tumor was noted in the liver. The patient is still alive 12 years after the first diagnosis of HCC and 16 months after lung metastasis developed.

Hemophagocytic syndrome (HPS) is a rare but serious condition that is histopathologically characterized by activation of macrophage or histiocytes with hemophagocytosis in bone marrow and reticuloendothelial systems. Clinically it presents with high fever, hepatosplenomegaly, pancytopenia, liver dysfunction, and hyperferritinemia. Hepatitis A virus is a very rare cause of secondary HPS. We report a case of a 22-year-old woman infected by hepatitis A virus who was consequently complicated with HPS. She presented typical clinical features of acute hepatitis A, and showed clinical and biochemical improvements. However, HPS developed as a complication of acute hepatitis A and the patient died of intraperitoneal bleeding caused by hepatic decompensation and disseminated intravascular coagulation.

Wegener's granulomatosis is an uncommon disease that is characterized by granulomatous necrotizing vasculitis affecting small vessels. It typically targets the upper and lower respiratory tract and the kidney, but gastrointestinal involvement is rare. A 41-year-old man who has been already diagnosed with Wegener's granulomatosis by nasal cavity biopsy was admitted with bloody diarrhea and high fever. He had discontinued taking the immunosuppressive medication. His colonoscopic finding revealed colitis and ulcer lesions which biopsies show vasculitis and ill-defined granuloma. Therefore he was treated with systemic steroid and improved dramatically.