Acute liver damage and anorexia nervosa: A case report

Abstract

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.

Gastrointestinal complications associated with anorexia nervosa: A systematic review

“…Several studies reported elevations in alanine transaminase (ALT) greater than aspartate transaminase (AST) and others have shown the reverse . Similarly a number of studies noted elevated alkaline phosphatase (ALP) and bilirubin while others have not. Several studies noted the patients developed severe hypoglycemia, all of which then required transfer to the ICU at some point during their treatment, suggesting that significant hypoglycemia may be a marker for imminent severe liver failure.…”

“…104,113,120 In the vast majority of patients with AN and elevated transaminases, the only treatment necessary is gradual refeeding and hydration, which leads to complete normalization of liver enzymes over time. 100,101,105,106,110,113,114 The time course to peak transaminase levels during refeeding appears to be 2 to 5 days after which transaminase level then start to recede and normalize between Day 20 and Day 40 of the refeeding process. 99,106,110 Published studies have not presented a consistent pattern with regards to the elevation of liver enzymes.…”

“…99,106,110 Published studies have not presented a consistent pattern with regards to the elevation of liver enzymes. Several studies reported elevations in alanine transaminase (ALT) greater than aspartate transaminase (AST) 101 97,102,111,114 all of which then required transfer to the ICU at some point during their treatment, suggesting that significant hypoglycemia may be a marker for imminent severe liver failure. This pattern may differ from what is most often observed clinically, and it should be noted that most studies did not consistently report on all liver function parameters, making it difficult to draw meaningful conclusions.…”

“…Hypotheses regarding the mechanism of liver damage during the course of AN include autophagy based on the presence of autophagomes identified on liver biopsy, 106,114,116 acute hypoperfusion, 101,109,116 or possibly oxidative stress secondary to iron deposits in the liver. 121 Three studies have described fatal outcomes during treatment in patients initially presenting with elevated transaminases.…”

“Fixing a heart”: the game of electrolytes in anorexia nervosa

“…The treatment is hydration, correction of electrolytes and fluid imbalance, and gradual nutritional support to prevent refeeding syndrome [8]. The patient exhibits elevated serum transaminases, elevated alkaline phosphatase, and prolonged prothrombin time, which collectively are suggestive of acute liver failure.…”