The World Health Organization 2018 report stated that 2.3 billion persons over 15 years old consume alcohol, and a total of 3.0–3.3 million people died because of uncontrolled or harmful alcohol intake in 2016. Injuries, accidents, liver cirrhosis, and other medical disorders are mainly responsible for alco - hol-related disability and deaths. After emphasizing the importance of alco - hol-related disorders and necessary universal precautions, we focus on alcohol consumption features and alcohol-related cirrhosis and hepatocellular carci - noma in Turkiye. It is estimated that alcohol per se is responsible for 12% of cirrhosis and 10% of hepatocellular carcinoma cases. Additional factors such as hepatitis B virus and hepatitis C virus infections have markedly increased the risk of the development of hepatocellular carcinoma in alcoholic cirrhosis.

Solitary necrotic nodule of the liver (SNNL) is a rare benign lesion with uncertain etiology characterized by a “completely necrotic core” and a hyalinized capsule containing elastin fibers (Journal of Clinical Pathology 36:1181–1183, 1983). We report herein a 26-year-old woman with a previ- ous diagnosis of rheumatoid arthritis, systemic lupus erythematosus, and Sjögren’s syndrome and no history of malignancy who presented with a complaint of diarrhea of 1-year duration. In the abdominal ultrasound, mul- tiple paraaortic, portocaval, and ileal lymphadenopathies (LAPs) have been found with the largest one being 2 cm in size. The biopsy of the iliac LAP showed reactive nodular hyperplasia. An abdominal CT disclosed an inci- dental hypoechoic, heterogenous mass sized 27 × 27 mm close to segment VI of the liver. A trucut biopsy of this lesion was made, and clinicopatho- logic features of the specimen were compatible with a solitary necrotic nod- ule of the liver. Here, we discuss the diagnosis and the clinical course of this rare entity in light of current literature.

Hepatoportal sclerosis (HPS) is an idiopathic non-cirrhotic portal hyper - tension (INCPH) characterized by hypersplenism, portal hypertension, and splenomegaly. Hepatocellular carcinoma (HCC) is the most common form of liver cancer. Non-cirrhotic portal hypertension is an extremely rare cause of HCC. A 36-year-old woman was referred to our hospital with esophageal varices. All serologic tests for etiology were negative. Serum ceruloplasmin and serum Ig A-M-G were normal. In the follow-up, two liver lesions were identified on a triple-phase computer. The lesions had arterial enhancement but no washout in the venous phase. In the magnetic resonance imaging examination, differentiation in favor of HCC was considered at one of the lessions. Radiofrequency ablation therapy was first applied to a patient who had no signs of metastasis. Within 2 months, the patient underwent a living donor liver transplant. In explant pathology, well-differentiated HCC and HPS were considered the cause of non-cirrhotic portal hypertension. The patient has been followed without relapse for 3 years. The development of HCC in INCPH patients is still debatable. Despite the presence of liver cell atypia and pleomorphism in nodular regenerative hyperplasia liver speci- mens, a causal link between HCC and INCPH is yet to be established.

Background and Aim: The study aimed to investigate the effectiveness of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelet values in predicting intrahepatic cholestasis of pregnancy (ICP) in the first trimester, together with the aspartate aminotransferase/platelet ratio index (APRI) score. Materials and Methods: This study consisted of a patient group diagnosed with ICP (n=49) and a control group (n=62). Laboratory tests of both groups were analyzed retrospectively. Results: The first-trimester APRI score and AST and ALT values were found to be statistically significantly higher than those of the control group. The platelet value was found to be statistically significantly lower in the study group, even though it was within the normal reference range. Conclusion: The first-trimester APRI score was found to be effective in predicting ICP. In addition, the first-trimester AST, ALT, and platelet values were found to be effective in predicting ICP diagnosed in the third trimester even though if not as much as the APRI score.

Background and Aim: Early diagnosis and treatment of chronic hepatitis B (CHB) disease are important for the prevention of complications such as cirrhosis and hepatocellular cancer. Liver biopsy is an invasive, complicated, and expensive diagnostic method, which is the gold standard for detecting fibrosis. The aim of this study was to investigate the role of these tests in predicting liver fibrosis and treatment decision. Materials and Methods: A total of 1051 patients diagnosed with CHB between 2010 and 2020 in the Gaziantep University Gastroenterology Department were ret- rospectively evaluated. AAR, API, APRI, FIB-4, KING score, and FIBROQ score were calculated at the time of onset diagnosis. In addition, the Zeugma score, a new formula that is thought to be more sensitive and specific, was determined. Nonin- vasive fibrosis scores were compared according to the biopsy results of the patients Results: In this study, the area values under the curve were 0.648 for the API score, 0.711 for the APRI score, 0.716 for the FIB-4 score, 0.723 for the KING score, 0.595 for the FIBROQ score, and 0.701 for the Zeugma score (p<0.05). No statis- tically significant difference was obtained for the AAR score. The KING, FIB-4, APRI, and Zeugma scores were the best indicators for detecting advanced fibrosis. For KING, FIB-4, APRI, and Zeugma scores, the cutoff value for the prediction of advanced fibrosis were ≥8.67, ≥0.94, ≥16.24, and ≥9.63 with a sensitivity of 50.52%, 56.77%, 59.64%, and 52.34%, specificity of 87.26%, 74.96%, 73.61%, and 78.11%, respectively (p<0.05). In our study, we compared the globulin and GGT parameters with fibrosis, which we used in the Zeugma score formula. Glob- ulin and GGT mean values were significantly higher in the fibrosis group (p<0.05). There was a statistically significant correlation between fibrosis and globulin and GGT values (p<0.05, r=0.230 and p<0.05, r=0.305, respectively). Conclusion: The KING score was found to be the most reliable method for the noninvasive detection of hepatic fibrosis in patients with chronic HBV. The FIB-4, APRI, and Zeugma scores were also shown to be effective in determining liver fibrosis. It was shown that the AAR score was not sufficient for detecting hepatic fibrosis. The Zeugma score, a novel noninvasive test, is a useful and easy tool to evaluate liver fibrosis in patients with chronic HBV and has better accuracy than AAR, API, and FIBROQ.

Background and Aim: Hepatic encephalopathy (HE) is a frequent compli- cation of liver diseases. Systemic inflammation is key for HE pathogenesis. The main goal of the study was to investigate the role of psychometric tests, critical flicker frequency (CFF), and comparative evaluation of inflammato- ry indicators for the diagnosis of covert HE (CHE). Materials and Methods: The study was a prospective, nonrandomized, case–control study with a total of 76 cirrhotic patients and 30 healthy vol- unteers. The West Haven criteria were used to determine the occurrence of CHE in cirrhotic patients. Psychometric tests were applied to healthy and cirrhotic groups. CFF, venous ammonia, serum endotoxin, IL-6, IL-18, tu- mor necrosis factor alpha (TNF-α) levels, and hemogram parameters were evaluated for cirrhotic patients. Results: CFF values and psychometric tests were found to accurately dis- criminate CHE positives from CHE negatives (p<0.05). When the control group was excluded, the digit symbol test and the number connection A test failed, unlike CFF and other psychometric tests. Using CFF, a 45 Hz cutoff value had 74% specificity and 75% sensitivity. Basal albumin levels (p=0.063), lymphocyte-to-monocyte ratio (LMR) (p=0.086), and neutro- phil-to-lymphocyte ratio (p 0.052) were significant, albeit slightly, among CHE groups. Basal albumin levels had 50% sensitivity and 71% specificity when 2.8 g/dL was used as a cutoff value to determine CHE. Conclusion: Both psychometric tests and CFF can be useful in diagnosing CHE. Using cytokine and endotoxin levels seems to be inadequate to diag- nose CHE. Using LMR and albumin levels instead of psychometric tests for diagnosing CHE can be promising.

Background and Aim: Metabolic dysfunction-associated fatty liver disease (MAFLD) is expected to be prevalent among kidney trans - plant recipients (KTRs). In this study, we evaluated the prevalence of MAFLD among KTRs, data that have not been investigated by any clin- ical study to date. Materials and Methods: We included a total of 52 KTRs and 53 age-, sex-, and BMI-matched individuals as the control group through prospective consecutive recruitment. We detected the presence of hepatic steatosis and liver fibrosis using the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) defined by FibroScan. Results: Among the KTRs, 18 (34.6%) had metabolic syndrome. The prevalence of MAFLD among the KTRs and controls was 42.3% and 51.9%, respectively (p=0.375). The CAP and LSM values did not dif- fer significantly between the KTRs and controls (p=0.222 and p=0.119). Among the KTRs, patients with MAFLD had significantly higher age, BMI, waist circumference, LDL, and total cholesterol levels (p<0.001, p=0.011, p=0.033, p=0.022, and p=0.029, respectively). In multivariable analysis, age was the only independent factor for MAFLD among the KTRs (OR: 1.120, 95% confidence interval (CI): 1.039–1.208). Conclusion: MAFLD among KTRs did not show a significantly higher prevalence compared to the normal population. Further clinical studies with larger populations are needed.

Background and Aim: Chronic liver disease (CLD) is a leading cause of morbidity and mortality worldwide with a wide etiological spectrum. Fi- broScan® is used for follow-up of fibrosis and steatosis. This single-cen - ter study aims to review the distribution of indications by referral to Fi - broScan®. Materials and Methods: Demographic characteristics, CLD etiolo - gies, and FibroScan ® parameters of the patients who were referred to our tertiary care center between 2013 and 2021 were retrospectively evaluated. Results: Out of 9345 patients, 4946 (52.93%) were males, and the medi- an age was 48 [18–88] years. Nonalcoholic fatty liver disease (NAFLD) was the most common indication (N=4768, 51.02%), followed by hepa- titis B (N=3194, 34.18%) and hepatitis C (N=707, 7.57%). Adjusting for age, sex, and CLD etiology, the results revealed that patients with old- er age (Odds ratio (OR)=2.908; confidence interval (CI)=2.597–3.256; p<0.001) and patients with hepatitis C (OR=2.582; CI=2.168–3.075; p<0.001), alcoholic liver disease (OR=2.019; CI=1.524–2.674, p<0.001), and autoimmune hepatitis (OR=2.138; CI=1.360–3.660, p<0.001) had increased odds of advanced liver fibrosis compared to NAFLD. Conclusion: NAFLD was the most common indication for referral to FibroScan®.

Background and Aim: Prevention of hepatitis B virus (HBV) reinfection is important for long-term outcomes following liver transplantation (LT). Hepatitis B immunoglobulin (HBIG) is used among recipients who have (i) native HBV disease, (ii) hepatitis B core antibody positivity (HBcAb positivity), or (iii) received HBcAb positive organs. Nucleos(t)ide analogue (NA) monotherapy is emerging for treating patients in this setting. There is no generalized consensus on the ideal dosage of HBIG. The aim of this study was to evaluate the efficacy of low-dose HBIG (1560 international unit [IU]) for post-LT HBV prevention. Materials and Methods: HBcAb positive patients who received either HBcAb positive or hepatitis B core antibody negative (HBcAb negative) organs and HBcAb negative patients who received HBcAb positive organs between January 2016 and December 2020 were reviewed. Pre-LT HBV serologies were collected. HBV-prophylaxis strategy included NA with/ without HBIG. HBV recurrence was defined as HBV deoxyribonucleic acid (DNA) positivity during the 1-year, post-LT follow-up. No HBV surface antibody titers were followed. Results: A total of 103 patients with a median age of 60 years participated in the study. Hepatitis C virus was the most common etiology. Thirty-seven HBcAb negative recipients and 11 HBcAb positive recipients with unde- tectable HBV DNA received HBcAb positive organs and underwent pro- phylaxis with 4 doses of low-dose HBIG and NA. None of the recipients in our cohort had a recurrence of HBV at 1 year. Conclusion: Low-dose HBIG (1560 IU) × 4 days and NA, for HBcAb positive recipients and HBcAb positive donors, appear to be effective in preventing HBV reinfection during the post-LT period. Further trials are needed to confirm this observation.

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Recurrence is still a problem after liver transplant for hepatocellular carcinoma (HCC). We performed an updated systematic review and me ta-analysis of randomized controlled trials comparing tumor recurrence of mammalian target of rapamycin inhibitors (mTORi) versus Calci neurin inhibitor-based immunosuppression after liver transplantation for HCC. A systematic search was conducted in the following databas es: MEDLINE, EMBASE, and Cochrane Central Register of Control Trials databases. The Medical Subject Headings used in the search in cluded: “sirolimus,” “everolimus,” “mTORi,” “HCC,” “mTORi,” “he patic transplantation” “randomized controlled trials,” and “liver trans plantation (LT)”. Seven randomized controlled trials were included for meta-analysis. There were a total of 1,365 patients, with 712 of these patients receiving calcineurin inhibitors (CNIs) while 653 had received mTORi. Our meta-analysis revealed that patients that received mTO Ri-based immunosuppression had superior recurrence-free survival (RFS) at 1 year and 3 years with a hazard ratio of 2.02 and 1.36, re spectively. Meta-analysis also showed that within the first 3 years after LT for HCC, patients receiving CNIs-based immunosuppression have a higher recurrence than those receiving mTORi-based immunosuppres sion. Our meta-analysis revealed that recipients of mTORi-based immu nosuppression had a superior OS at 1 year and 3 years. mTORi-based immunosuppression is associated with decreased early recurrence and improved RFS and overall survival.

This study is written to report a case of 67-year-old female with known au toimmune hepatitis (AIH) who developed balance and walking difficulties. Clinical and imaging investigations were more suggestive of AIH suffering from lymphoproliferative disease. To identify the underlying suspected lym phoproliferative disease, series of brain scans were performed, which showed multiple brain lesions. This is a report on a striking case of multiple contrast enhanced brain lesions discovered in an AIH patient that was resolved upon withdrawal of azathioprine. Many side effects of azathioprine are acknowl edged around the world; however, to the very best of our knowledge, an article on azathioprine inducing suspected malignancy was never reported.

Fingolimod has been used for about ten years to treat multiple recurrent sclerosis. It has been reported that Fingolimod causes an elevation in liver enzymes. In this case report, the clinical and laboratory parameters im proved after discontinuation of the drug. However, there is no publication in the literature regarding acute liver failure and liver transplantation fol lowing Fingolimod treatment. In this article, we presented a 33 – year – old female patient who developed acute liver failure and underwent liver transplantation after Fingolimod treatment for recurrent multiple sclerosis.

Background and Aim: This study investigated the risk of the development of primary biliary cholangitis (PBC) in individuals who were incidentally identified as having positive antimitochondrial antibodies (AMA)-M2. Materials and Methods: We retrospectively reviewed extractable nuclear antibody (ENA) panel test results to identify the incidental AMA-M2- positive patients. Patients who filled the diagnostic criteria for PBC were excluded. AMA-M2-positive patients were further evaluated by physical examination, liver biochemistry, liver ultrasonography, and transient elas tography (TE) and were also closely followed. Results: We included 48 (n=45, 93% female) individuals with a median age of 49 (range: 20–69) years. The median follow-up duration was 27 months (range: 9–42) after the detection of AMA-M2. Thirty-three (69%) patients had concomitant autoimmune/inflammatory disorders. Twenty-eight (58%) individuals showed seropositivity for ANA, and 21 had (43%) positive AMA. Fifteen (31%) patients developed typical PBC according to the international PBC diagnostic criteria during the follow-up, and five of them (18%) had significant fibrosis (≥8.2 kPA) by TE at the time of PBC diagnosis. Conclusion: Two-thirds of the incidental AMA-M2-positive patients devel oped typical features of PBC after a median 27-month follow-up. Our re sults suggest that AMA-M2 patients should be closely followed up to detect the late development of PBC

Background and Aim: In chronic hepatitis B infection, antiviral therapy significantly reduces the incidence of complications. This study aimed to present real-life 12-month effectiveness and safety data for TAF. Materials and Methods: This Pythagoras Retrospective Cohort Study in cluded patients from 14 centers in Turkiye. The study presents 12-month results of 480 patients treated with TAF as initial therapy or after switching from another antiviral drug. Results: The study shows treatment of about 78.1% patients with at least one antiviral agent (90.6% tenofovir disoproxil [TDF]). The rate of unde tectable HBV DNA increased in both treatment-experienced and naive pa tients. In TDF-experienced patients, the rate of alanine transaminase (ALT) normalization increased slightly (1.6%) within 12 months, but the change was not statistically significant (p=0.766). Younger age, low albumin, and high body mass index and cholesterol were identified as risk factors for abnormal ALT after 12 months, but no linear relationship was detected. In TDF-experienced patients, renal and bone function indicators showed sig nificant improvement three months after the transition to TAF and remained stable for 12 months. Conclusion: Real-life data demonstrated effective virological and bio chemical responses with TAF therapy. After switching to TAF treat ment, gains in kidney and bone functions were achieved in the early period.

Background and Aim: Transarterial Chemoembolization (TACE) thera py is currently considered as first option therapy in the intermediate stage HCC. The purpose of our study is to assess the efficacy and prognostic factors related to the DEB- TACE therapy. Materials and Methods: The data from 133 patients with unresecetable HCC who were treated with DEB-TACE and followed between January 2011-March 2018 were retrospectively evaluated. To assess the efficacy of therapy, control imagings were performed at 30th and 90th days after the procedure. Response rates, survival outcomes, and prognostic factors were investigated. Results: According to the Barcelona staging system, 16 patients (13%) were in the early stage, 58 patients (48%) were in the intermediate stage and 48 patients (39%) were in the advanced stage. There were complete response (CR) in 20 patients (17%), partial response (PR) in 36 patients (32%), stable disease (SD) in 24 patients (21%) and progressed disease (PD) in 35 (30%) patients. Median follow-up time was 14 months (range 1-77 months). Median PFS and OS were 4 months and 11 months, re spectively. In multivariate analysis, posttreatment AFP ≥400 ng/ml was found to be an independent prognostic factor on both PFS and OS. Child Pugh classification and tumor size >7 cm were independent prognostic factors on OS. Conclusion: DEB-TACE is effective and a tolerable treatment method for unresectable HCC patients.

Background and Aim: Liver resection (LR) and liver transplantation (LT) are curative treatments for hepatocellular carcinoma (HCC). The main pur pose of this study was to compare the survival of LR and LDLT in patients with HCC within the Milan criteria. Materials and Methods: The results of the LR (n=67) and LDLT (n=391) groups were compared for overall survival (OS) and disease-free survival (DFS). Twenty-six of the HCCs in the LRs met the Milan and Child A cri teria. Also, 200 of the HCC patients in the LDLTs met the Milan criteria, of which 70 also met the Child A criteria. Results: Early mortality was higher in the LDLT group (13.9% vs 1.47%; p=0.003). The 5-year OS was higher in the LDLTs than the LRs, but not statistically significant (84.6% vs 74.2%; p=0.287). However, 5-year DFS was better in the LDLT group (96.8% vs 64.3%; p<0.001). When the LRs (n=26) and the LDLTs (n=70) that met both Milan and Child A criteria were compared, 5-year OS was similar (81.4% vs 74.2%; p=0.512), but DFS was better in the LDLTs (98.6% vs 64.3%; p<0.001). Conclusion: LR can be justified as the first-line treatment for HCC patients who meet Milan and Child A criteria in terms of early mortality and OS

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Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

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