Biopsy-proven progressive fatty liver disease nine months post mini-gastric bypass surgery: A case study

Highlights • Performance of MGB with a 200 cm bypassed limb in a morbidly obese female. • Presentation of anemia, low albumin, elevated LFT at 8th month despite good intake. • NAFLD activity score progressed from 2/8 to 7/8, leading to revisional surgery. • Rapid course of weight loss after BS and/or long bypassed limb could be responsible. • Bowel length measurement is recommended to avoid a short common intestinal channel.
Introduction Mini-gastric bypass (MGB) is a popular bariatric procedure. Its effect on non-alcoholic fatty liver disease (NAFLD), however, has not yet been comprehensively studied. Presentation of case A 57 year-old non-alcoholic female with a body mass index of 42.8 kg/m2 underwent MGB without any incident. A concurrent liver biopsy showed an NAFLD activity score (NAS) of 2/8 without fibrosis. She presented at postoperative month eight with edema, vague abdominal pain, nausea, and vomiting and was hospitalized. Her BMI had dropped to 25.7 kg/m2. Her blood workup revealed mild anemia, mildly elevated liver enzymes, and hypoalbuminemia (2.5 g/dL). Liver ultrasound revealed grade-2 fatty liver. She received parenteral nutrition and intensive nutrient supplementation. Nevertheless, with regard to unsuccessful supportive measures and rising liver enzymes, revisional surgery −gastrogastrostomy- was performed. Her liver biopsy demonstrated a NAS of 7/8 at the time of revisional surgery. Her postoperative course was uneventful and she was discharged after one week. Discussion Bariatric surgery has shown favorable results regarding improvement of NAFLD in morbid obesity. This beneficial effect has been linked to the amount of weight loss. However, case reports have shown deteriorating liver function and NAFLD even after significant weight loss. They all have in common significant weight loss in a relatively short period of time. There may also be a connection between specific bariatric surgery procedures and this phenomenon. Conclusion Future studies comparing the effect of various bariatric procedures, including MGB, are necessary to help clinicians decide the optimal procedure for patients with this liver condition.