In the current aging society, the number of patients with liver cirrhosis demonstrating dementia has been increasing; however, addressing the complex clinical diagnosis of hepatic encephalopathy and/or dementia is challenging. The voxel-based specific regional analysis system for Alzheimer's disease (VSRAD) has been widely used to clinically diagnose dementia. In this study, the VSRAD system revealed that 12 of 32 (37.5%) elderly patients under treatment for hepatic encephalopathy displayed signs of brain atrophy. The presence or absence of brain atrophy in the VSRAD system was found to be closely associated with the degree of independent living for dementia in elderly patients with hepatic encephalopathy. The VSRAD system could play an essential role in understanding the clinical course of patients with hepatic encephalopathy.

A man in his 40s was admitted to our hospital for cerebral hemorrhage with pancytopenia. The bone marrow was slightly hypoplasia without evidence of myeloproliferative neoplasms. Upper gastrointestinal endoscopy detected esophageal and duodenal varices. Abdominal ultrasonography showed a positive portal sandwich sign around the portal vein. Abdominal computed tomography showed no evidence of cirrhosis or portal vein obstruction but showed an enlarged left lobe of the liver and splenomegaly. A portal pressure gradient (16 mmHg) was observed. A hematologic disease was suspected again because pancytopenia worsened after a partial splenic artery embolization. Bone marrow examination revealed de novo acute myeloid leukemia. Although portal hypertension has been reportedly associated with myeloproliferative diseases, such as primary myelofibrosis, it has never been reportedly complicated with de novo acute myeloid leukemia.

A 73-year-old woman arrived at our hospital because of nonalcoholic fatty liver disease cirrhosis. Her abdominal distension worsened, and she was admitted to our department. She did not have a history of trauma or surgery and no evidence of infectious diseases or malignant tumors; thus, chylous ascites was suspected due to liver cirrhosis. After starting an injection therapy, ascites decreased, and she was discharged from the hospital. However, ascites recurred post-discharge. Lypiodol-based lymphangiography did not detect a clear leak site. Administering propranolol improved the ascites. Chylous ascites may be observed in liver cirrhosis. The mechanism of its occurrence is considered related to increased portal pressure. Propranolol seemed to be an effective treatment for chylous ascites due to liver cirrhosis.

A woman in her 50s was referred to our hospital for further examination of liver dysfunction. Liver biopsy revealed interface hepatitis and plasma cell infiltration. Therefore, she was diagnosed with autoimmune hepatitis based on the diagnostic criteria. The treatment was initiated with 40 mg of prednisolone and 900 mg of ursodeoxycholic acid. However, frequent relapse occurred despite the additional administration of azathioprine. The patient eventually became steroid-dependent; therefore, prednisolone could not be reduced to <25 mg. Therefore, azathioprine was changed to mycophenolate mofetil, a second-line treatment according to the US and European guidelines. This treatment led to remission maintenance and steroid-dose reduction.

Some cases are difficult to treat with only drugs recommended by the Japanese guidelines. In such cases, mycophenolate mofetil may be a useful treatment.