Anorexia nervosa is an eating disorder predominantly affecting young women and characterized by an intense fear of gaining weight and becoming fat. Liver injury with mild elevation of hepatic enzymes is a frequent complication, and steatosis of the liver is thought to be the major underlying pathology. However, acute hepatic failure with transaminase levels over 1000 u/L is a very rare complication, and the precise mechanism of the liver injury is still unclear. We report a case of a 35-year-old woman with a history of anorexia nervosa who developed acute liver damage with deep coma in relation to profound hypoglycemia. The treatment was hydration, correction of electrolyte and fluid imbalance, and gradual nutritional support to prevent refeeding syndrome. Our patient's consciousness was significantly improved with the recovery of liver function and normalization of transaminase levels. Although the mechanism of pathogenesis is largely unknown, we discuss the two principal hypotheses: starvation-induced autophagy and acute hypoperfusion.

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A 28-year old man presented to the emergency department with vomiting and epigastric pain radiating to the right shoulder.

We treated a patient suffering from severe anorexia nervosa [body mass index (BMI), 10.5 kg/m²] complicated with hepatic insufficiency. The treatment consisted of rehydration and the correction of her malnutrition, using adapted protocols to avoid the development of the refeeding syndrome. In view of her successful progress she was discharged from the hospital on day 50. Although we do not perform a hepatic biopsy, the mechanism seems to be related to autophagy more than hypoperfusion because of the extremely low BMI. This observation also highlights the need of following a multidisciplinary approach in these difficult cases (BMI < 13 kg/m²), involving intensive care unit doctors, gastroenterologists, endocrinologists and psychiatrists.