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Background: Acute-on-chronic liver failure encompasses an acute deterioration of liver function in patients with pre-existent cirrhosis. Sometimes the clinical picture of acute-on-chronic liver failure is misleading and may not be secondary to primary liver disease, as described in our case., Case Description: A 65-year-old woman with cirrhosis was transferred to our transplantation centre because of suspected acute-on-chronic liver failure. Given her medical history of breastcancer and suspicious laboratory results, we performed a liver biopsy. This showed diffuse metastases of mammary carcinoma. Earlier CT-scans showed features of cirrhosis without signs of malignancy: a misleading phenomenon called pseudocirrhosis., Conclusion: Diffuse malignant hepatic infiltration can resemble cirrhosis and acute-on-chronic liver failure, both in clinical presentation as in imaging. Liver transplantation is contraindicated in malignant liver failure. To assure a solid indication for transplantation, a liver biopsy has to be considered, even in emergency situations.

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of fatty liver disease. NAFLD is defined as the presence of fatty liver disease observed in imaging or histopathological examinations when there is no secondary cause such as excessive alcohol use or use of certain medications. NAFLD encompasses a whole spectrum, from simple steatosis to steatohepatitis ('non-alcoholic steatohepatitis', NASH), fibrosis and - ultimately - cirrhosis and hepatocellular carcinoma. Several factors play a role in the complex pathogenesis of NAFLD such as genetic predisposition, overweight, insulin resistance, inflammation, bile salts, gut microbiome and nutrition. Patients with NAFLD have an increased risk of developing type 2 diabetes mellitus, cardiovascular disease and malignancies such as hepatocellular carcinoma. To date, no medicines have been authorised for the treatment of NAFLD. The cornerstone of NAFLD treatment is lifestyle adjustment aimed at weight reduction.

A 77-year-old man, treated with risedronic acid to prevent corticosteroid-induced osteoporosis, was admitted to hospital with acute abdominal pain. The patient appeared to have an oesophageal perforation, which was treated with an endoprosthesis. Additional research showed a motility disorder of the oesophagus. Although bisphosphonates are considered a safe medication, the perforation was probably secondary to treatment with an oral bisphosphonate in combination with the motility disorder. Pre-existent gastrointestinal diseases such as motility disorders of the oesophagus occur more frequently among elderly. Therefore it is important to take the increased risk of complications to the gastrointestinal tract into account when prescribing bisphosphonates to these patients.