In 2018, the Intractable Hepato-Biliary Disease Study Group of Japan proposed that patients with cirrhosis and a Child-Pugh score of 5-9 be diagnosed as having ACLF if deterioration of liver function, defined by serum bilirubin level and prothrombin time, develops within 28 days after an acute insult. Disease severity would be classified into four grades depending on the extent of deterioration in organ function. This Study Group has since performed an annual nationwide survey of patients with ACLF who were diagnosed according to the proposed diagnostic criteria as well as those with conditions related to ACLF. Univariate and multivariate analyses revealed that the proposed diagnostic criteria were useful for identifying cirrhotic patients with an unfavorable outcome following an acute insult. Consequently, the Study Group determined that the proposed diagnostic criteria be formally used in both clinical practice and research.

In our hospital, the Infection Control Team (ICT) evaluates patients who test positive for the hepatitis virus during preoperative and preadmission tests (the hepatitis virus round), and adds referral requests to a hepatologist to the electronic medical records of these patients. A review after 1 year of this practice confirmed that number of referrals provided by non-hepatology specialty physicians was low, especially among short-stay inpatients. Therefore, we requested referrals using the nudge method in year 2 of the initial infection control training session. This increased the referral consultation rate for short-term hospitalization from 14.3% (3/21) before ICT referral to 31.6% (6/19) in the 1^st year and 66.7% (8/12) in the 2^nd year (vs. before the start, p<0.01). Thus, the nudge method is effective in promoting voluntary behavior change and can increase rates of referred consultations.

A 20-year-old man was referred to pediatrics for hyperbilirubinemia and mental retardation. Abdominal ultrasonography findings were indicative of a portosystemic shunt, and as a shunt between the left branch of the portal vein and inferior vena cava was confirmed by abdominal computed tomography, he was diagnosed with patency of the venous duct. We decided to perform shunt embolization using IVR, but as the shunt diameter had expanded like a funnel, its embolization was performed using a plug-and -metal coil, which led to an improvement in hepatic reserve and blood ammonia levels postprocedure. Surgical ligation has been typically used in the management of portosystemic shunts, but as it is highly invasive, shunt embolization by IVR has become prevalent in recent years. Here we describe stable embolization using the IVR technique.

Lenvatinib was prescribed to a 71-year-old man with hepatocellular carcinoma (210 mm, largest dimension) and portal vein tumor thrombosis. However, this treatment was discontinued 8 days later due to prolongation of prothrombin time and an increase in AST and LDH levels. Rupture of the hepatocellular carcinoma occurred 4 days after discontinuing Lenvatinib and the patient died. Autopsy findings showed a moderately differentiated hepatocellular carcinoma with diffuse hemorrhagic necrosis. Immunohistochemistry revealed diffuse FGF19 protein expression in the nuclei of tumor cells, whereas some of the nuclei and cytoplasm of the hepatocytes in non-tumorous tissue were only slightly stained. The risk of hepatocellular carcinoma rupture should always be considered even after stopping short-term chemotherapy with Lenvatinib.

A male in his 50s was admitted due to epigastric pain and jaundice. His medical history included an etiology-unknown deep venous thrombus and pulmonary thromboembolism without antiphospholipid antibody positivity approximately 2 years ago. Initial liver tests showed a total bilirubin level of 7.7 mg/dL, AST of 893 IU/L, and ALT of 1217 IU/L, indicating acute hepatitis. Viral, drug-induced, and alcoholic hepatitis were excluded, but autoimmune liver disease was suspected as he tested positive for ANA and AMA-M2 antibodies. A liver biopsy performed on day 5 of admission did not show any remarkable bile duct lesions such as CNSDC, but interface hepatitis, diffuse hepatocytic necrosis, emperipolesis, and rosette formation were seen. Hence, a diagnosis of acute onset AMA-M2 positive autoimmune hepatitis (AIH) was made, and combination therapy with prednisolone and ursodeoxycholic acid was initiated, which led to normalization of liver function tests. A causal relationship between deep thrombotic diseases and AIH is not known, and male case of AMA-M2 positive AIH with acute hepatitis-like onset and a history of deep thrombosis is rare.