Case Report : Intrahepatic bile duct adenoma in a patient with chronic hepatitis B accompanied by elevation of alpha-fetoprotein

( Jem Ma Ahn ),( Yong Han Paik ),( Jun Hee Lee ),( Ju Yeon Cho ),( Won Sohn ),( Geum Youn Gwak ),( Moon Seok Choi ),( Joon Hyeok Lee ),( Kwang Cheol Koh ),( Seung Woon Paik ),( Byung Chul Yoo ) 대한간학회 2015 Clinical and Molecular Hepatology(대한간학회지) Vol.21 No.4

A 51-year-old male patient with chronic hepatitis B was referred to our hospital due to a 1-cm liver nodule on ultrasonography. Alpha-fetoprotein (AFP) was slightly elevated. The nodule showed prolonged enhancement on dynamic liver magnetic resonance imaging and appeared as a hyperintensity on both diffusion-weighted and T2-weighted imaging. The nodule was followed up because it was small and typical findings of hepatocellular carcinoma (HCC) were not observed in the dynamic imaging investigations. However, liver contrast-enhanced ultrasonography performed 1 month later showed enhancement during the arterial phase and definite washout during the delayed phase. Also, AFP had increased to over 200 ng/mL even though AST and ALT were decreased after administering an antiviral agent. He was presumptively diagnosed as HCC and underwent liver segmentectomy. Microscopy findings of the specimen indicated bile duct adenoma. After resection, the follow-up AFP had decreased to within the normal range. This patient represents a case of bile duct adenoma with AFP elevation mimicking HCC on contrast-enhanced ultrasonography. (Clin Mol Hepatol 2015;21:393-397)

Relationship of Liver Stiffness and Controlled Attenuation Parameter Measured by Transient Elastography with Diabetes Mellitus in Patients with Chronic Liver Disease

Jem Ma Ahn,백용한,김소현,이준희,조주연,손원,곽금연,최문석,이준혁,고광철,백승운,유병철 대한의학회 2014 Journal of Korean medical science Vol.29 No.8

High prevalence of diabetes mellitus in patients with liver cirrhosis has been reported inmany studies. The aim of our study was to evaluate the relationship of hepatic fibrosis andsteatosis assessed by transient elastography with diabetes in patients with chronic liverdisease. The study population consisted of 979 chronic liver disease patients. Liver fibrosisand steatosis were assessed by liver stiffness measurement (LSM) and controlledattenuation parameter (CAP) on transient elastography. Diabetes was diagnosed in 165(16.9%) of 979 patients. The prevalence of diabetes had significant difference among theetiologies of chronic liver disease. Higher degrees of liver fibrosis and steatosis, assessed byLSM and CAP score, showed higher prevalence of diabetes (F0/1 [14%], F2/3 [18%], F4[31%], P < 0.001; S0/1 [15%], S2 [17%], S3 [26%], P = 0.021). Multivariate analysisshowed that the independent predictive risk factors for diabetes were hypertension (OR,1.98; P = 0.001), LSM F4 (OR, 1.86; P = 0.010), male gender (OR, 1.60; P = 0.027), andage > 50 yr (OR, 1.52; P = 0.046). The degree of hepatic fibrosis but not steatosis assessedby transient elastography has significant relationship with the prevalence of diabetes inpatients with chronic liver disease.

Recent Trend Changes in Clinical Features, Treatment, and Survival from Korean Patients with Hepatocellular Carcinoma

( Jem Ma Ahn ),( Soon Ho Um ),( Dae Hoe Ku ),( Jung Mi Chang ),( Han Ah Lee ),( Tae Hyung Kim ),( Hyuk Soon Choi ),( Young Kul Jung ),( Eun Sun Kim ),( Bora Keum ),( Ji Hoon Kim ),( Yeon Seok Seo ),( 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: There were limited data regarding recent changes from patients with hepatocellular carcinoma (HCC). Our study aimed to evaluate recent time-trends in etiology, stage, treatment and overall survival in Korean patients with HCC. Methods: We consecutively enrolled 1367 patients who were diagnosed as HCC for the first time in Korea University Anam hospital between 2004.3 and 2015.12. These patients were categorized into four groups based on the date of HCC diagnosis with a 3-year interval as follows: P1, 2004.3 - 2007.2 (n = 321); P2, 2007.3 - 2010.2 (n= 348); P3, 2010.3 - 2013.2 (n = 368); P4, 2013.3 - 2015.12 (n = 330). Results: Over the median 19.0 months of follow-up duration, 68.0% of all patients died. Regarding secular trends from 2004 to 2015, HCC had become diagnosed with better liver function (Child-Pugh stage, P = 0.022). Etiology of HCC were changed; proportion of chronic hepatitis B decreased, while cryptogenic etiology increased (P= 0.004, P = 0.024). The proportion of early stage HCC increased (Barcelona Clinic Liver Cancer staging system, P = 0.001; modified UICC staging system, P = 0.005). More patients tended to receive treatment for HCC other than conservative treatment (P = 0.05); either operation or chemotherapy gradually increased as the first treatment modality, while locoregional therapy decreased (P = 0.012). The 1-, 3-, 5-year overall survival rates also increased from 2004 to 2015 (p < 0.001). Conclusions: Over recent 10 years, HCC had become to be diagnosed at earlier stages with better liver function. In addition, the proportion of chronic hepatitis B in HCC etiology decreased, and operation and chemotherapy were more performed as the first treatment. Thus, the overall survival rates could gradually improve with these changes, which might be derived from advance in treatment as well as improvement of HCC surveillance and wide-spread use of anti-viral therapy.

Acute hepatitis A; Cytotoxic T lymphocyte-associated antigen 4; Programmed death 1

Jem Ma Ahn,Yong Han Paik,Sin Yeong Min,Ju Yeon Cho,Won Sohn,Dong Hyun Sinn,Geum-Youn Gwak,Moon Seok Choi,Joon Hyeok Lee,Kwang Cheol Koh,Seung Woon Paik,Byung Chul Yoo 거트앤리버 소화기연관학회협의회 2016 Gut and Liver Vol.10 No.2

Background/Aims: The aim of this study was to evaluate the relationship between controlled attenuation parameter (CAP) and hepatic steatosis, as assessed by ultrasound (US) in patients with alcoholic liver disease (ALD) or non-alcoholic fatty liver disease (NAFLD). Methods: Patients with either ALD or NAFLD who were diagnosed with fatty liver with US and whose CAP scores were measured, were retrospectively enrolled in this study. The degree of hepatic steatosis assessed by US was categorized into mild (S1), moderate (S2), and severe (S3). Results: A total of 186 patients were included: 106 with NAFLD and 80 with ALD. Regarding hepatic steatosis, the CAP score was significantly correlated with US (ρ=0.580, p<0.001), and there was no significant difference between the NAFLD and ALD groups (ρ=0.569, p<0.001; ρ=0.519, p<0.001; p=0.635). Using CAP, area under receiver operating characteristic curves for ≥S2 and ≥S3 steatosis were excellent (0.789 and 0.843, respectively). For sensitivity ≥90%, CAP cutoffs for the detection of ≥S2 and ≥S3 steastosis were separated with a gap of approximately 35 dB/m in all patients and in each of the NAFLD and ALD groups. Conclusions: The CAP score is well correlated with hepatic steatosis, as assessed by US, in both ALD and NAFLD.

Liver Resection for Hepatocellular Carcinoma as the First Treatment of Modality: Its Survival Outcomes and Poor Survival Predictors

( Jem Ma Ahn ),( Soon Ho Um ),( Dae Hoe Ku ),( Jung Mi Chang ),( Han Ah Lee ),( Tae Hyung Kim ),( Hyuk Soon Choi ),( Yong Dong Yoo ),( Young Kul Jung ),( Eun Sun Kim ),( Bora Keum ),( Ji Hoon Kim ),( 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Liver resection is preferable treatment of option for hepatocellular carcinoma (HCC). Our study aimed to evaluate overall survival rate according to tumor stages and time interval, and find out factors associated with poor survival in the patients with liver resection as the first therapy for HCC. Methods: We enrolled a total of 193 patients who were diagnosed as HCC in Korea university Anam hospital between 2004.3 and 2015.12 and undertook liver resection as the first therapy for HCC. Patients were categorized into each of 5 groups according to Barcelona Clinic Liver Cancer (BCLC) staging system and 2 groups with 6 year time interval (2004.3-2010.2 vs. 2010.3-2015.12). Results: Over the median follow-up of 43.6 months (range, 1.5-15.8), 55 patients died. The 1-, 3-, 5-years overall survival rates were 0.93, 0.79, 0.71, respectively. Each of early BCLC stage and recent operation showed significant better overall survival rates than advanced BCLC stage and remote past operation (P < 0.001, P = 0.03). In univariate Cox regression analysis, various factors associated with liver function [Child-Pugh (CP) scores, Model for End-Stage Liver Disease scores], tumor stage (BCLC stage, modified UICC stage), tumor marker [alpha feto protein (AFP)], pathologic findings (Edmondson-Steiner grades, tumor maximum size, vascular invasion, intrahepatic metastasis, pathologic T stage) were associated with poor survival. Among them, however, CP scores, AFP levels, and pathologically confirmed intrahepatic metastasis were only independent mortality predictors (hazard ratio, 2.46; 95% confidence interval, 1.02-5.88, P = 0.044), (1.0; 1.0-1.0, P = 0.010), (3.57; 1.24 - 10.29, P = 0.019) Conclusions: Liver resection as the first HCC therapy showed good overall survival rates, especially in patients with either early BCLC stage or recent operation. In addition, high CP scores, high AFP levels, and pathologically confirmed intrahepatic metastasis were independent poor survival markers, and thus we should observe the patient with these factors more closely.

LC : The Relationship of Liver Stiffness and CAP Score Measured by Fibroscan with the Prevalence of Diabetes in Patients with Chronic Liver Disease

( Jem Ma Ahn ),( Ju Yeon Cho ),( Won Sohn ),( Geum Youn Gwak ),( Yong Han Paik ),( Moon Seok Choi ),( Joon Hyeok Lee ),( Kwang Cheol Koh ),( Seung Woon Paik ),( Byung Chul Yoo ) 대한간학회 2013 춘·추계 학술대회 (KASL) Vol.2013 No.1

Background: In patients with liver cirrhosis, high prevalence of diabetes has been reported from many studies. The aim of our study was to evaluate the relationship of hepatic fibrosis and steatosis assessed by fibroscan with the diabetes mellitus in patients with chronic liver diseases. Methods: The study population consisted of 567 chronic liver disease patients, all of whom took fibroscan for evaluating the degree of hepatic fibrosis and steatosis. The patients who had high ALT (>2xUNL), total bilirubin (>2 mg/dL), IQR/median (>0.3) were excluded. Diabetes was diagnosed when it was previously diagnosed by doctor or fasting plasma glucose was more than 126 mg/dL or HbA1c was more than 6.5% at least 2 times. Cut-off LSM levels for significant fibrosis (≥F2) and cirrhosis (≥F4) was 8.0 kPa, and 14.0 kPa, respectively. The degree of steatosis was graded by CAP score (mild steatosis (S1): 239- 258 db/m, moderate steatosis (S2): 259-292 db/m, severe steatosis (S3): >292 db/m). 0 셀 (0.0%)은(는) 5보다 작은 기대 빈도를 가지는 셀입니다. 최소 Results: Among 567 patients, 74% were with HBV, 14% with HCV, 7.4% with alcoholic liver disease, and 3.9% with NAFLD. Impaired fasting glucose was observed in 184 of 567 (32%) and diabetes was diagnosed in 84 of 567 (15%). High prevalence of diabetes was observed in alcoholic liver disease (35%), NAFLD (22%), and HCV (17%) compared with HBV (12%) (P<0.001 ). Diabetes was more commonly observed in patients with significant fibrosis (F0/1 (9%), F2/3 (14%), F4 (31%), P<0.001). DM prevalence was higher in patients with moderate to severe steatosis (S0/1 (13%), S2/3 (18%), P<0.001). Regarding life styles, there was significant association of diabetes with older age (>50 years), gender (male), obesity (BMI>25), smoking, hypertension, hyperlipidemia. Conclusions: The patients with chronic liver diseases show high prevalence of diabetes in order of alcoholic liver disease, NAFLD, Hepatitis C, and Hepatitis B. The degree of fibrosis and steatosis assessed by fibroscan has significant relationship with the prevalence of diabetes in patients with chronic liver disease.

Relationship between Controlled Attenuation Parameter and Hepatic Steatosis as Assessed by Ultrasound in Alcoholic or Nonalcoholic Fatty Liver Disease

( Jem Ma Ahn ),( Yong Han Paik ),( Sin Yeong Min ),( Ju Yeon Cho ),( Won Sohn ),( Dong Hyun Sinn ),( Geum Youn Gwak ),( Moon Seok Choi ),( Joon Hyeok Lee ),( Kwang Cheol Koh ),( Seung Woon Paik ),( By 대한소화기학회 2016 Gut and Liver Vol.10 No.2

Background/Aims: The aim of this study was to evaluate the relationship between controlled attenuation parameter (CAP) and hepatic steatosis, as assessed by ultrasound (US) in patients with alcoholic liver disease (ALD) or non-alcoholic fatty liver disease (NAFLD). Methods: Patients with either ALD or NAFLD who were diagnosed with fatty liver with US and whose CAP scores were measured, were retrospectively enrolled in this study. The degree of hepatic steatosis assessed by US was categorized into mild (S1), moderate (S2), and severe (S3). Results: A total of 186 patients were included: 106 with NAFLD and 80 with ALD. Regarding hepatic steatosis, the CAP score was significantly correlated with US (ρ=0.580, p<0.001), and there was no significant difference between the NAFLD and ALD groups (ρ=0.569, p<0.001; ρ=0.519, p<0.001; p=0.635). Using CAP, area under receiver operating characteristic curves for ≥S2 and ≥S3 steatosis were excellent (0.789 and 0.843, respectively). For sensitivity ≥90%, CAP cutoffs for the detection of ≥S2 and ≥S3 steastosis were separated with a gap of approximately 35 dB/m in all patients and in each of the NAFLD and ALD groups. Conclusions: The CAP score is well correlated with hepatic steatosis, as assessed by US, in both ALD and NAFLD. (Gut Liver 2016;10:295-302)

췌장암의 조기 징후로서의 새로 발병한 당뇨병

안젬마 ( Jem Ma Ahn ),이종균 ( Jong Kyun Lee ) 대한소화기학회 2013 대한소화기학회지 Vol.62 No.5

While long-standing diabetes is a risk factor of pancreatic cancer, new-onset diabetes could be a consequence of underlying pancreatic malignancy. About 30% to 50% of pancreatic cancer patients have new-onset diabetes. Because diabetes develops in preclinical or early stages of pancreatic cancer, it could serve as an excellent clue for early detection of pancreatic cancer. Insulin resistance associated with hyperglycemia and hyperinsulinemia by diabetogenic factors secreted from cancer cells have been suggested to be a possible mechanism of pancreatic cancer-induced diabetes. It is difficult to differentiate pancreatic cancer-induced diabetes from the more common type 2 diabetes. Although several clinical features and potential biomarkers have been investigated, optimal strategies and modalities to screen pancreatic cancer among the new-onset diabetes have not yet been fully determined. (Korean J Gastroenterol 2013;62:263-266)

증례 : 순환기 ; 후천성 다발성 관상동맥-심방실누공 1예

안젬마 ( Jem Ma Ahn ),이재민 ( Jae Min Lee ),황영재 ( Young Jae Hwang ),서영호 ( Young Ho Seo ),김용현 ( Yong Hyun Kim ),안정천 ( Jeong Cheon Ahn ),송우혁 ( Woo Hyuk Song ) 대한내과학회 2013 대한내과학회지 Vol.84 No.1

본 증례는 급성 심근경색으로 시행했던 응급 재관류 시술에서 좌전 하행지 관상동맥-좌심실 누공(LAD-LV fistulae)을 발견했고, 10년 후 비전형적인 흉통이 재발하여 시행한 관상동맥 조영술에서 이전 누공(LAD-LV fistulae) 외에 우관상동맥-좌심실 누공(RCA-LV fistulae)을 새롭게 관찰한 예이다. 대다수의 관상동맥 누공은 선천적으로 발생하고 단일혈관에서 기시하며 대개 우심방 또는 우심실로 유입되나, 본 증례의 관상동맥 누공은 후천적으로 발생하였고 다혈관에서 기시하였으며 모두 좌심실로 유입되었다. 이는 매우 희귀한 경우로 문헌고찰과 함께 보고하는 바이다. We report a rare case of acquired multiple coronary-cameral fistulae. A 46-year-old man presented to the cardiology department clinic complaining of recently aggravated exertional chest pain. He had been treated 10 years ago for an acute ST segment elevation myocardial infarction (STEMI) with percutaneous coronary intervention (PCI). During revascularization, diffuse multiple fistulae from the left anterior descending (LAD) artery to the left ventricle (LV) had been observed. The current chest pain was evaluated by elective coronary angiography but no significant stenosis was observed. However, newly developed diffuse fistulae from the distal right coronary artery (RCA) to LV were found during angiography, as well as LAD-LV coronary fistulae. Multiple coronary- cameral fistulae were thought to be causing chest pain. A beta-blocker was prescribed and, after 3 months of follow-up, exertional chest pain had subsided without further complication. (Korean J Med 2013;84:91-95)

Surgery versus Locoregional Treatment in BCLC Stage 0 HCC Patients

( Jung Mi Chang ),( Soon Ho Um ),( Tae Hyung Kim ),( Han Ah Lee ),( Dae Hoe Gu ),( Jem Ma Ahn ),( Yeon Seok Seo ),( Hyung Joon Yim ),( Yoon Tae Jeen ),( Hong Sik Lee ),( Hoon Jai Chun ),( Chang Duck K 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: The aim of this study is to compare the outcome between surgical treatment and locoregional treatment in very early stage hepatocellular carcinoma(BCLC stage 0) patients retrospectively. Methods: The survival rates of hepatocellular carcinoma patients who were newly diagnosed at Korea University Anam Hospital from March 2004 to December 2015 and whose liver function was Child-Pugh grade A and BCLC 0 (n =203) were compared according the treatment methods. In the surgical group (n=54), all patients underwent partial hepatectomy, and in the locoregional treatment group (n=149), patients who underwent TACE, RFA/PEI, and both TACE and RFA/PEI were included. Kaplan-Meier method, log-rank test and univariate multivariate Cox regression analysis were used for statistical analysis. Results: The median age of all patients was 60 years and male accounted for 70.9%. In the univariate analysis, the median survival time of the surgical group was 4345 days(95% CI 1000~7689) and the median survival time of the non-surgical group was 2923 days (95% CI 2395 ~ 3450).The survival time of the surgical group was longer than that of the non-surgical group, but the difference in survival rates between the two groups was not significant (log-rank P = 0.121). The cumulative survival rates of the surgical group in year 1, 3, 5, 7, 9 were 98%, 88.8%, 75.1%, 69.7%, and 69.7%, respectively, and the rates of the non-surgical group were 96.6%, 82.7%, 73.5%, 57.8% and 44.6%, respectively. On the other hand, age, albumin and MELD score were significantly correlated with patient survival (P<0.005) and the surgical group was younger and had higher albumin level and lower MELD score at baseline (P<0.05). The difference in survival rates between the two groups was not significant when these factors were adjusted in multivariate analysis.(P=0.738, HR 1.130, 95% CI 0.552-2.315) Conclusions: In patients with HCC of the very early stage of BCLC, there was no significant difference in survival rates statistically between the surgical and non-surgical groups.