Background/Aims: Low-level viremia (LLV) after nucleos(t)ide analog treatment was presented as a possible cause of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). However, detailed information on patients’ adherence in the real world was lacking. This study aimed to evaluate the effects of LLV on HCC development, mortality, and cirrhotic complications among patients according to their adherence to entecavir (ETV) treatment.Methods: We performed a retrospective observational analysis of data from 894 consecutive adult patients with treatment-naïve CHB undergoing ETV treatment. LLV was defined according to either persistent or intermittent episodes of <2,000 IU/mL detectable hepatitis B virus DNA during the follow-up period. Good adherence to medication was defined as a cumulative adherence ≥90% per study period.Results: Without considering adherence in the entire cohort (n=894), multivariate analysis of the HCC incidence showed that LLV was an independent prognostic factor in addition to other traditional risk factors in the entire cohort (<i>P</i>=0.031). Good adherence group comprised 617 patients (69.0%). No significant difference was found between maintained virologic response and LLV groups in terms of the incidence of liver-related death or transplantation, HCC, and hepatic decompensation in good adherence group, according to multivariate analyses.Conclusions: In patients with treatment-naïve CHB and good adherence to ETV treatment in the real world, LLV during treatment is not a predictive factor for HCC and cirrhotic complications. It may be unnecessary to adjust their antiviral agent for patients with good adherence who experience LLV during ETV treatment.

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Background/Aims: Tenofovir alafenamide (TAF) has a less favorable effect on lipids compared to TDF (Tenofovir disoproxil fumarate) in clinical trials. However, data regarding these outcomes in patients with chronic hepatitis B (CHB) are scarce.Methods: This study is to evaluate the effects of TAF on the lipids of 237 CHB patients, compared with TDF, inactive CHB, and non-HBV infected control groups, using propensity score-matching (PSM).

Background This study was conducted to determine which type and dose of sedative drugs should be given to cirrhotic patients with compensation or decompensation during esophagogastroduodenoscopy (EGD) to prevent hepatic encephalopathy (HE) after sedation. Methods We reviewed the medical records of cirrhotic patients consecutively admitted to the hospital and conducted a number connection test (NCT) before and 2 h after EGD with moderate sedation. Sedation was performed using either propofol alone, midazolam alone, or combined propofol + midazolam. Results Sixty-seven patients were admitted for a screening EGD. The NCT before and after sedation were not significantly different in the propofol alone (pre-NCT = 47.3 ± 19.71 seconds vs. post-NCT = 49.4 ± 21.79 seconds, P = 0.6389). In the midazolam alone (pre-NCT = 50.3 ± 20.56 vs. post-NCT = 63.7 ± 33.17, P = 0.0021) and in the combined propofol + midazolam (pre-NCT = 47.4 ± 20.99 vs. post-NCT = 60.0 ± 30.79, P = 0.0002), NCT were significantly delayed. The propofol alone group received 52.3 ± 16.31 mg (0.82 ± 0.29 mg/kg). In 45 (67.2%) decompensated patients, only the propofol alone was not significantly different between pre-NCT (49.2 ± 22.92) and post-NCT (52.3 ± 24.90) ( P = 0.4548). Serum sodium level was significantly correlated with delta-NCT (r = 0.3594, P = 0.0028). Conclusion Propofol alone could be the best sedation strategy for cirrhotic patients with compensation or decompensation without aggravation of covert or overt HE. Hyponatremia could be a risk factor for developing or worsening HE after EGD with sedation.

Tenofovir disoproxil fumarate (TDF) is thought to cause varying degrees of hypophosphatemia in patients with chronic hepatitis B (CHB). Therefore, we investigated factors that cause hypophosphatemia in patients treated with TDF and methods to increase serum phosphorus concentrations in clinical practice.We completed a retrospective review of patients with CHB treated with TDF initially at

Aims This study aimed to evaluate the clinical usefulness of the aminotransferase to platelet ratio index (APRI), fibrosis‐4 (FIB‐4), and modified FIB‐4 (mFIB‐4) indices in predicting hepatocellular carcinoma (HCC) in patients receiving entecavir (ETV) treatment. Methods Among 1955 patients treated with ETV, a total of 857 treatment‐naive chronic hepatitis B patients (424 with liver cirrhosis [LC], 433 without cirrhosis) treated with ETV for more than 1 year were analyzed. Results Of the 857 patients, 85 (9.9%) patients (77 in the LC group and 8 in the non‐LC group) developed HCC during the follow‐up period. The median observation period was 6.9 years. Multivariate regression analysis of HCC incidence revealed that the initial mFIB‐4 index (hazard ratio [HR] 1.058; 95% confidence interval [CI], 1.007–1.112; p = 0.027) and improvement in the FIB‐4 index after 1 year of ETV treatment (HR 0.531; 95% CI, 0.339–0.831; p = 0.006) were independent prognostic factors in the entire cohort. In the LC group, the improvement of the FIB‐4 index following ETV treatment (HR 0.491; 95% CI, 0.280–0.861; p = 0.013) was negatively correlated with incidence of HCC. However, the area under the receiver operating characteristic curve of specific cut‐off values of the FIB‐4 index at baseline and 1 year after ETV treatment were 0.572 (95% CI, 0.504–0.640) and 0.615 (95% CI, 0.546–0.684), respectively. In the non‐LC group, none of the invasive fibrosis indices could predict HCC incidence. Conclusions The specific cut‐off value of the FIB‐4 index was not suitable for predicting HCC. However, the improvement in the FIB‐4 index after 1 year of ETV therapy could be a predictor of HCC development in cirrhotic patients.

Background: Effective treatment of Graves’ disease during pregnancy is important because uncontrolled hyperthyroidism is associated with increased fetal and maternal morbidity and mortality. While there have been case reports of patients with Graves’ disease who failed to achieve euthyroid state during pregnancy, anesthesiologists rarely encounter patients with uncontrolled hyperthyroidism undergoing urgent Cesarean section.Case: A 31-year-old pregnant patient had uncontrolled hyperthyroidism due to Graves’ disease despite medical treatment. Her signs and symptoms suggested fetal distress and aggravation of the disease, leading to hospitalization. After a failed induction for vaginal delivery, an urgent Cesarean section was performed under spinal anesthesia via an interlaminar approach using 9 mg of 0.5% heavy bupivacaine and 20 μg of fentanyl. It resulted in successful delivery, with no perioperative complications for the mother and neonate. Conclusions: This case demonstrates that spinal anesthesia may provide clinical stability to patients with uncontrolled hyperthyroidism undergoing urgent Cesarean section.

Background/Aims: Minor disorders of peristalsis are esophageal motility disorders categorized by the Chicago Classification (CC), version 3.0, which was announced in 2014. This study evaluated the efficacy of anti-reflux therapy in patients with minor peristaltic disorders. Methods: Patients with minor peristaltic disorders in accordance with CC v3.0 were included. We reviewed the medical records of patients with esophageal high-resolution manometry findings, and investigated the demographic and clinical information as well as the medical therapy. Thereafter, the response to treatment was assessed after at least 4 weeks of treatment. Results: A total of 24 patients were identified as having minor disorders of peristalsis from January 2010 to December 2015. The mean follow-up period was 497 days, and there were 17 patients (70.8%) patients with ineffective esophageal motility. In terms of anti-reflux therapy, proton pump inhibitors (PPIs) with prokinetic agents and PPIs alone were prescribed in 19 patients (79.2%) and 5 patients (20.8%), respectively. When the rate of response to the treatment was assessed, the responders rate (complete+sat-isfactory [≥50%] responses) was 54.2% and the non-responders rate (partial [<50%]+refractory responses) was 45.8%. Patients in the responder group were younger than those in the non-responder group (p=0.020). Among them, 13 patients underwent 24-hour multichannel intraluminal impedance-pH, and 10 patients (76.9%) were pathologic gastroesophageal reflux. Conclusions: The majority of esophageal minor peristaltic disorders were accompanied by gastroesophageal reflux, and therefore, they might respond to acid inhibitor. Further well-designed, prospective studies are necessary to confirm the effect of anti-reflux therapy in these patients. (Korean J Gastroenterol 2017;69:212-219)