만성 B형간염 환자에서 경구용 항바이러스제의 사용은 이들 환자의 예후를 호전시킬 수 있는 가장 현실적이고 적극적인 치료법입니다. 이 강의에서는 특정한 상황에서의 항바이러스제 치료에 대해서 살펴보고자 합니다. 특히 최근 보험급여 변경 및 대규모 연구결과의 발표에 따라 중요한 이슈를 점하게 된 i) 간세포암종이 있는 환자, ii) 면역억제제 또는 항암화학요법 치료 중인 환자, 그리고 iii) 임산부에서의 수직감염을 막기 위한 항바이러스제 투여에 집중하도록 하겠습니다. 더 자세한 내용은 2018년 대한간학회 만성B형간염 진료 가이드라인을 참고해주십시오.

Antiviral therapy of chronic hepatitis B (CHB) is aimed to improve survival by preventing liver damage and development of cirrhosis, decompensation, and hepatocellular carcinoma (HCC). This article will concisely review the antiviral treatment with nucleos(t)ide analogues (NAs) for several specific conditions: i) patients with HCC, ii) patients undergoing immunosuppressive treatment including cytotoxic chemotherapy, and iii) patients who are pregnant or preparing for pregnancy.

Hepatitis E virus (HEV) has been known as a cause of water-borne outbreak of acute non-A non-B hepatitis in developing countries, which affects young people and may produce high mortality in pregnant women. However, in recent decades, HEV genotypes 3 and 4 are known as a cause of sporadic zoonotic infection in older male from swine HEV worldwide. Most acute HEV infection is self-limited. But, in immunosuppressed patient including solid organ transplant recipient, chronic HEV infection may exist and progress to liver cirrhosis or decompensation. Therefore, physicians are required to recognize HEV as a major pathogen for acute and chronic hepatitis of unknown cause and investigate the test relevantly.

Hepatic encephalopathy occurs in more than 10-20% of all cases of cirrhosis and is an important complication that degrades the quality of life. Overt hepatic encephalopathy is readily identifiable since it is apparently accompanied by disorientation or flapping tremor. On the other hand, covert hepatic encephalopathy means that only psychometric or neurophysiological abnormalities appear without signs of clinically obvious cognitive impairment. Covert hepatic encephalopathy includes minimal hepatic encephalopathy and West-Haven Criteria grade I hepatic encephalopathy (Table 1). Covert hepatic encephalopathy is being noticed more often and is regarded as an important disease that needs to be managed appropriately. It is identified up to 38-60% of cirrhosis tested. Recent studies revealed that covert hepatic encephalopathy significantly decrease the quality of life and diminish working ability in patients with compensated liver cirrhosis. Furthermore, it is strongly associated with increased risk of progression to overt hepatic encephalopathy.

Frailty/sarcopenia has attracted growing interest because of its robust association with adverse outcomes in cirrhosis and transplantation. They affect most patients with cirrhosis and are tightly coupled with important disturbances of ammonia metabolism that accelerate muscle injury, disability, and mortality.
Frailty has been incorrectly considered as interchangeable with disability, comorbidity, sarcopenia and malnutrition. Indeed, significant overlap occurs between these other conditions and frailty, and most have been incorporated as a component of various frailty assessment tools. However, frailty remains distinct from and not fully captured by these other associated phenotypes.
Frailty is also not synonymous with sarcopenia. Sarcopenia is a progressive and generalized loss of skeletal muscle mass, strength and function occurring in 40%-70% of patients with cirrhosis. Sarcopenia is thought to represent an earlier phenotype, before progressing to the more established systemic disturbance of frailty. Although muscle strength forms a component of several frailty scores, measures of sarcopenia alone are insufficient to entirely encapsulate frailty.
Frailty and sarcopenia are a growing area of research that is only emerging in hepatology. With the ageing population, the prevalence of frailty and sarcopenia is likely to rise in both the general population as well as patients with cirrhosis. The international hepatology community therefore needs to establish a consensus on a measurement tool to be used in the liver disease population. The ideal tool would achieve a compromise between comprehensively covering the various facets of frailty and sarcopenia, and ease of implementation in a clinic setting. A more sophisticated understanding of the distinct but overlapping phenotypes of frailty, sarcopenia and malnutrition would enhance our ability to assess and manage patients.

Along with endoscopic approaches, interventional procedures have been deeply incorporated in the management of gastric varices over the past three decades. Nowadays transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO) are no longer terms of interventional radiologists and get familiar with from hepatologists to even general physicians who take care of patients with liver cirrhosis.
Recently as an alternative to BRTO, plug-assisted retrograde transvenous obliteration (PARTO) was first introduced in Korea. This time-saving method is getting popular worldwide. In the USA, another variant of BRTO, coil-assisted retrograde transvenous obliteration (CARTO) was invented to overcome shunts in large diameter. TIPS also has variants such as DIPS (direct intrahepatic portocaval shunt) and ultrasound guided percutaneous transhepatic portosystemic shunt creation. When varices have no accessible shunt, percutaneous transhepatic venous obliteration (PTVO) can be considered as a last resort.
This lecture reviews basic concepts of and anatomic requirements for each method to help make a decision on whether these procedures are technically possible or not. Several representative cases are presented to enhance your understanding. From an interventional radiologist point of view, current issues on TIPS, BRTO, and PARTO will be addressed.

Independent of the etiology, the mortality rate due to sepsis increases by fourfold in patients with cirrhosis. Therefore, a high index of suspicion for infection, appropriate diagnosis, and prompt antimicrobial treatment are warranted. The prior definition of sepsis included the presence of systemic inflammatory response syndrome (SIRS), in the setting of documented infection, but this definition lacked specificity in patients with cirrhosis. The most recent definition of sepsis (Sepsis-3) no longer uses SIRS and is based on the presence of signs of organ dysfunction, which can be assessed by the Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) scores. In the recently published Sepsis-3 criteria, the qSOFA score has been proposed as a simplified tool for early detection of sepsis. This score can be applied at bedside prior to any tests and it believed to be suggestive of sepsis when at least two of the following criteria are met: altered consciousness, respiratory rate ≥22/min, and systolic blood pressure ≤100 mm Hg. While the qSOFA score performs well in the general population, its role in cirrhotic patients remains unclear. Not surprisingly, the qSOFA score did not perform well for detection of sepsis in cirrhotic patients, which is likely due to commonly abnormal parameters in this group independent of infection (e.g. hepatic encephalopathy, tachypnea due to ascites and/or systemic hypotension due to hyperdynamic circulation). In this work, we will review the current knowledge of pathogenesis, definition and diagnosis of sepsis in cirrhosis.

알코올 간염은 지속적인 다량의 알코올 섭취에 의해 진행되는 임상적 증후군으로 증상 발생 1개월에 약 40%에 이르는 높은 사망률을 보인다. 치료의 기본은 금주와 영양 공급이며, 질환의 중증도와 예후를 평가하여 적절한 치료를 시작한다. 스테로이드는 1971년 처음 시도된 이후로 20차례 이상의 연구들이 진행되어 왔으며, 최근 보고되었던 steroids or pentoxifylline for alcoholic hepatitis (STOPAH) trial과 메타분석을 통해서 28일 단기 효과를 보이기는 했으나 장기적인 치료 효과를 보이지는 못했다. 그 외에도 알코올 간염을 위한 다른 약물적 치료로서 anti-tumor necrosis factor (TNF) agents, growth factors, propylthiouracil, insulin과 Glucagon 주입 치료, 그리고 antioxidants 등 여러 약제들이 시도되었으나 의미있는 효과를 보이지 못했다. 조기 간이식은 스테로이드 치료에 반응을 보이지 못하는 중증 알코올 간염 환자에서 효과적인 구조 치료의 결과를 보이고 있으며, 최근에는 스테로이드 이외의 새로운 치료로서 장내세균을 이용한 fecal microbiota transplantation, 간세포 재생을 치료 타겟으로 하는 Granulocyte-colony stimulating factor (G-CSF) 등 새로운 연구들이 보고되고 있다.

Given the high, global prevalence of nonalcoholic fatty liver disease (NAFLD), the clinical and economic burden of NAFLD and nonalcoholic steatohepatitis (NASH) can be substantial. It is also a growing contributor to the burden of chronic liver disease requiring liver transplantation. The diagnosis of NASH currently requires liver biopsy but there are no approved therapies for NASH. Moreover, noninvasive techniques for diagnosing NASH and assessing response to treatment are not yet ready for clinical trials, thus liver biopsy continues to be required, although it is suboptimal. Therefore, there is an urgent need to develop better diagnostic strategies for patients with NASH, targeting both those with early-stage disease as well as those with advanced liver fibrosis. Although liver biopsy is the most accurate modality to diagnose and stage the severity of NASH, this method suffers from invasiveness, high cost, potential adverse effects, and interobserver variability. To date, a number of noninvasive modalities and serum biomarkers to diagnose NASH and stage liver fibrosis are being developed. Over the past several decades, remarkable advances have been made in the assessment of NAFLD by noninvasive imaging to quantify liver fat and fibrosis accurately. In this review, we will address the comparative efficacy of various imaging-based elastographic modalities as well as blood-based biomarkers for detection of NASH and advanced fibrosis in patients with NAFLD.