Aggressive non-alcoholic steatohepatitis following rapid weight loss and/or malnutrition

Abstract

While non-alcoholic steatohepatitis is a slowly progressive disease, patients may rarely present in acute liver failure. We describe six patients who developed severe hepatic dysfunction following rapid weight loss or malnutrition. Rapid weight loss (18 to 91 kg) occurred after Roux-en-Y gastric bypass in four patients and starvation-like dieting or hypoalbuminemia was noted in two patients. Four patients either died or received an urgent liver transplant. Pathologic findings were characterized by advanced alcoholic steatohepatitis-like features, including extensive/circumferential centrizonal pericellular fibrosis, central scar with perivenular sclerosis/veno-occlusion with superimposed hepatocellular dropout, abundant/prominent hepatocellular balloons, and numerous Mallory–Denk bodies, but there was no history of excess alcohol consumption. This study characterizes clinicopathologic features of aggressive non-alcoholic steatohepatitis following rapid weight loss or malnutrition, which should be included in the differential diagnosis with alcohol when a patient is considered for liver transplantation. The mechanism of liver injury in aggressive steatohepatitis is unknown, but rapid fat mobilization in obese patients may potentially cause oxidative stress to the liver and further study is needed to determine if there is a genetic predisposition to this form of injury and if antioxidants may protect the liver during rapid weight loss/malnutrition.

Oxidative Stress and First-Line Antituberculosis Drug-Induced Hepatotoxicity

“…In malnutrition, oxidative stress is heightened, and impoverished nutritional status is conspicuously associated with immune dysfunction (42,43). Hepatic steatosis has also been found in the malnourished animals and humans, with a likely link to oxidative stress and mitochondrial dysfunction (44,45). It is conceivable that malnutrition would especially merit attention in the elderly population with tuberculosis.…”

Complete resolution of postbariatric surgery associated hepatic steatosis after nutrition support

“…Nevertheless, some liver complications have been reported after BS. Jejunoileal bypass was abandoned due to a high incidence of progressive hepatic disease leading to liver failure and cirrhosis [3,4]. Endotoxin from the bacterial overgrowth in blind loop with increased permeability are suggested as the pathogenesis of liver failure in jejunoileal bypass ( Fig.…”

“…2A) [4][5][6]. Recently, several cases of NAFLD and even liver failure after bariatric surgery have been reported [3]. Increasing lipolysis and the influx of free fatty acid from adipose tissue to liver has been suggested as a possible mechanism of hepatic injury (Fig.…”

“…Increasing lipolysis and the influx of free fatty acid from adipose tissue to liver has been suggested as a possible mechanism of hepatic injury (Fig. 2B) [3].…”

“…Bariatric surgery (BS) has been known to have favorable effects on preexisting nonalcoholic fatty liver disease (NAFLD) with weight loss [1,2]. Contradictorily, several cases of liver injuries with rapid weight loss or malnutrition after bariatric surgery have been reported [3]. The pathophysiology of liver injuries due to BS remains poorly understood.…”