4.3 g/dL, albumin 1.9 g/dL, globulin 2.4 g/dL, AST 71 U/L, ALT 86 U/L, total bilirubin 0.2 mg/dL, alkaline phosphatase 167 U/ L, cholesterol 100 mg/dL, fasting glucose 97 mg/dL, triglyceride 62 mg/dL, and serum ferritin 5 ng/mL. Prothrombin time was 11.8 seconds with an INR of 0.97 and partial thromboplastin time was 35.5 seconds. Serum immunoglobulin G (IgG), IgA, and IgM levels were in normal range. There was no evidence of cardiac disease or renal disease. Quantitative fecal fat test was positive. Serological markers for hepatitis B and hepatitis C were negative. Antinuclear antibody, anti-smooth muscle antibody, and anti-mitochondrial antibody were all negative and cerulo- plasmin level was within normal limit. Upper gastrointestinal endoscopy was not remarkable. Colo- noscopy revealed multifocal jejunitis. There was no significant passage disturbance or luminal narrowing on small bowel en- teroclysis. Instead of direct culture of jejunal aspirate, hydrogen breath test was performed to identify the presence of SIBO. After intake of 10 g of lactulose in 200 mL water, breath samples were analyzed every 15 minutes for 4 hours. The air was analyzed for hydrogen concentrations with a QuinTron SC MicroLyzer (Quin- Fig. 1. On the computed tomography imaging, the liver was darker than the spleen, suggesting fatty liver. Sung YK, et al: NASH Caused by Bypass Surgery 521 Tron Instrument Company, Milwaukee, WI, USA) with which minimal detectable concentration for hydrogen analysis was 1 part per million (ppm). Double peaks were observed in this test. The Technetium labeled (99mTc) human serum albumin scintig- raphy was performed to detect gastrointestinal protein loss from small or large bowel, but the result was negative. The abdominal computed tomography scan revealed diffuse fatty infiltration of entire liver (Fig. 1) and multifocal mural thickening involving ileal loop and jejunocolostomy site. Percutaneous liver biopsy demonstrated steatohepatitis with mild perisinusoidal and mild pericellular fibrosis (Fig. 2A and B). He was diagnosed as NASH and SIBO caused by a com- plication of intestinal bypass surgery. The 10 days antibiotic treatments using amoxicillin 750 mg/day and clavulanic acid 375 mg/day enterally divided by three time was transiently improved gastrointestinal symptoms, hypoalbuminemia, and pitting edema related with hypoalbuminemia. The albumin level was improved from 2.2 to 3.4 g/dL. But it was not improved the elevated levels of liver enzymes and fatty infiltration on imag- ing. Furthermore, exercise and complete abstinence from alco- hol did not improve the biochemical and radiological features of NASH and the aminotransferase levels was fluctuated from 90 to 210 IU/mL. We continued the medical treatment using intermittent short term antibiotic treatments during about 10 years. Even though the jejuno-colostomy repair is the only curative choice, we con- sidered it would be a very hard with high surgical complication rate as a result of recurrent bowel adhesion. Diarrhea, hypoal- buminemia, and pitting edema related with hypoalbuminemia was still wax and wane with antibiotic treatments. The amino- transferase levels were fluctuated from 50 to 400 IU/mL. He lost weight from 65 to 57 kg during 7 months in late 2006. Con- sidering the risk and benefit of surgery, the jejuno-colostomy repair was performed in July 2007. Intestinal continuity was restored and adhesiolysis was performed. His gastrointestinal symptoms and pitting edema was improved completely and se- rum albumin level was normalized 2 months after intestinal re- constitution. The aminotransferase levels returned to completely normal level with marked improvement in the fatty infiltration Fig. 2. On liver biopsy, the liver parenchyma had moderate fatty change, mild neutrophil infiltration suggesting steatohepatitis (A, H&E stain, ×100), and mild perisinusoidal and pericellular fibrosis (B, Masson trichrome stain, ×100).