Liver abnormalities in severely obese subjects: Effect of drastic weight loss after gastroplasty

Abstract

OBJECTIVE: To examine the factors associated with liver steatosis in severely obese subjects and to test the potential reversibility of fatty liver after weight loss. DESIGN: Retrospective clinical study. SUBJECT: 528 obese patients before bariatric surgery and 69 obese subjects of the initial cohort evaluated before and 27 AE 15 months after gastroplasty. MEASUREMENTS: Fatty deposition (scored as mild, moderate or severe) and in¯ammatory changes were evaluated in liver biopsies; clinical (body mass index (BMI), age, gender, duration of obesity) and biological (glucose, triglycerides, liver enzymes) parameters were related to histological ®ndings. RESULTS: 74% of the 528 biopsies showed fatty change, estimated as mild in 41% of cases, moderate in 32% and severe in 27%. The prevalence of steatosis was signi®cantly higher in men than in women (91% vs 70%, P 0.001) and in patients with impaired glucose tolerance or type 2 diabetes compared with nondiabetics (89% vs 69% P 0.001). The severity of the steatosis was associated with BMI (P 0.002) but not with the duration of obesity or the age of the patient. When compared with patients without fatty change, those with liver steatosis had signi®cantly higher fasting plasma glucose (5.5 mmol/l vs 5.1 mmol/l, P 0.007) and triglycerides (1.8 mmol/l vs 1.3 mmol/l, P 0.002). Mean serum liver enzyme activities (alkaline phosphatase, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl-transpeptidase (gGT) were signi®cantly (P`0.001) increased in patients with fatty change but remained within laboratory reference values. In the 69 patients who have been evaluated after a marked weight reduction (732 AE 19 kg), 45% of the biopsies were considered as normal (vs 13% before, P`0.001) while pure fatty change was still observed in 38% of the patients (vs 83% before, P 0.001). However, the severity of the steatosis was signi®cantly (P`0.001) reduced (mild: 62% vs 21%; moderate: 23% vs 37%; severe: 15% vs 42%). In addition, a signi®cant increase of hepatitis was observed in 26% of the biopsies (vs 14% before, P`0.05). CONCLUSIONS: Liver steatosis in obese subjects is associated with men, diabetic status, BMI, higher fasting glucose and hypertriglyceridaemia. Postgastroplasty weight loss reduces liver steatosis, but seems to increase the incidence of in¯ammatory lobular hepatitis.

Obesity and liver disease

“…59 In a large personal series of 528 severely obese subjects (BMI 42.6 + 6.8 kg/m 2 ), 74% of the biopsies showed fatty deposition, estimated as mild in 41% of cases, moderate in 32% and severe in 27%. 60 The severity of steatosis was positively associated with BMI (P = 0.002), but not with the known duration of obesity. 55 Ten percent of these patients had signs of steatohepatitis, inflammatory changes being scored as mild in 86%, moderate in 12% and severe in 2% of cases.…”

“…60 When compared with patients without fatty liver deposition, those with liver steatosis had significantly higher fasting plasma glucose, insulin, triglycerides and ALT levels. The severity of the steatosis was positively correlated not only with BMI (P = 0.002), but also with fasting plasma glucose, insulin and triglycerides concentrations and serum liver enzyme levels (Figure 1).…”

“…In the above personal series of 528 severely obese subjects, the prevalence of steatosis was higher in patients with impaired glucose tolerance or type 2 diabetes compared to non-diabetic subjects (89 versus 69%, P < 0.001). 60 In 48 consecutive NAFLD patients, type 2 diabetes was found in 44% of the subjects, 29% had impaired glucose tolerance, and 17% were hyperinsulinaemic. 64 According to several studies, no clear correlation seems to exist between the degree of glucose control or the duration of the disease and the fatty liver infiltration (reviewed in refs 19 and 55).…”

Bariatric surgery for pediatric extreme obesity: now or later?

“…116 Consistent with a larger burden of obesity-related comorbidities in extremely obese adults, liver disease in such patients is more prevalent and advanced. [121][122][123][124][125][126] Therefore, to define the spectrum and determinants of NAFLD in extremely obese adolescents, we correlated liver histology with clinical features and compared findings to reported adult Bariatric surgery for pediatric extreme obesity TH Inge et al data. 127 In our cross-sectional study of 41 adolescent subjects undergoing gastric bypass, 83% had NAFLD.…”

“…Several studies in adults have reported improvement in NAFLD and NASH after surgery, though some studies have highlighted a transient increase in inflammation after surgery. 34,121 Two recent studies of outcome of NASH after bariatric surgery in adults have demonstrated significant decreases in steatosis, but variable or no changes in inflammation and fibrosis. 128,129 Although both of these recent studies in adults suggest a clear beneficial effect of gastric bypass surgery on NAFLD and NASH, the persistence of fibrosis and inflammation in a subset of patients indicate the need for longer-term followup.…”