Liver Injury and Acute Liver Failure After Bariatric Surgery

Abstract

The obesity epidemic has caused a surge in the use of bariatric surgery. Although surgery-induced weight loss is an effective treatment of nonalcoholic fatty liver disease, it may precipitate severe hepatic complications under certain circumstances. Acute liver injury (ALI) and acute liver failure (ALF) following bariatric surgery have been reported in several case series. Although rare, ALI and ALF tend to emerge several months after bariatric surgery. If so, it can result in prolonged hospitalization, may necessitate liver transplantation, and in some cases prove fatal. However, little is known about the risk factors for developing ALI or ALF after bariatric surgery and the mechanisms of liver damage in this context are poorly defined. This review provides an account of the available data on ALI and ALF caused by bariatric surgery, with emphasis on potential injury mechanisms and the outcomes of liver transplantation for ALF after bariatric surgery.

Acute Liver Injury and Acute Liver Failure following Bariatric Surgery

“…ALI and ALF are uncommon but life-threatening complications of bariatric surgery [ 4 ]. In contrast to other case reports, only 1 out of 3 patients required liver transplantation in this case series.…”

“…Based on the histological images showing an emaciated steatohepatitis, or so called “depleted nonalcoholic steatohepatitis (depleted NASH),” we decided to start treatment with TPN rich in amino acids directly after referral in all 3 cases, in order to “recharge” the hepatocytes. We assume that malabsorption, combined with nonadherence to nutritional supplements, results in protein-energy malnutrition and exhaustion of intrahepatic amino acid stores [ 4 ]. The lack of available resources in our cases, on average, emerged 8 months after bariatric surgery, which is relatively early as compared to the available literature [ 5 ].…”

“…SIBO is a common complication after either a malabsorptive or combined procedure, leading to loss of nutrients due to intestinal barrier alterations and increased intestinal permeability [ 10 ]. Bacterial translocation into the portal venous system may induce hepatocellular damage, followed by liver dysfunction [ 4 ]. Preoperative deficiencies and reduced dietary intake may also contribute to enhanced depletion of liver energy reserves, in addition to inadequate supplement intake.…”

“…Abdominal computed tomography (CT) showed periportal edema and mild ascites, without signs of chronic liver disease. Upon referral, a percutaneous liver biopsy was performed, and total parenteral nutrition (TPN) was started, based on the hypothesis that severe acute liver injury (ALI) might be caused by extensive protein malnutrition and a consequent amino acid shortage [ 4 ]. Autoimmune hepatitis was initially also considered (IgG 15.4 g/L, anti-smooth muscle antibody positive at 1:40), and treatment with prednisone was initiated with a dose of 40 mg daily.…”

“…Weight loss after bariatric surgery generally has a beneficial effect on the hepatic complications of obesity, with improvement of steatosis, inflammation, and fibrosis [ 3 ]. However, a combination of malnutrition, malabsorption, and a compromised intestinal barrier function after surgery occasionally also results in the deterioration of liver function [ 4 , 5 ]. Acute liver failure (ALF) is a rare but life-threatening complication of bariatric surgery.…”