Case Report
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Mar 27, 2018; 10(3): 396-399
Published online Mar 27, 2018. doi: 10.4254/wjh.v10.i3.396
Liver failure caused by prolonged state of malnutrition following bariatric surgery
Willem J Lammers, Antonie JP van Tilburg, Jan A Apers, Janneke Wiebolt
Willem J Lammers, Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam 3015 CE, the Netherlands
Antonie JP van Tilburg, Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam 3045 PM, the Netherlands
Jan A Apers, Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam 3045 PM, the Netherlands
Janneke Wiebolt, Department of Internal Medicine, Franciscus Gasthuis and Vlietland, Rotterdam 3045 PM, the Netherlands
Author contributions: Lammers WJ contributed to drafting of the manuscript; all authors contributed to acquisition of data, interpretation of data and critical revision of the manuscript for important intellectual content.
Informed consent statement: Patients were not required to give informed consent to this study, because the case report was written after the patients received agreed to and necessary treatments. All patient data were handled as anonymous.
Conflict-of-interest statement: All authors certify that they have no affiliations with or involvements in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Willem J Lammers, MD, PhD, Academic Fellow, Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam’s-Gravendijkwal 230, Rotterdam 3015 CE, the Netherlands.
Telephone: +31-63-3343636 Fax: +31-10-7035172
Received: December 12, 2017
Peer-review started: December 13, 2017
First decision: January 15, 2018
Revised: January 22, 2018
Accepted: February 7, 2018
Article in press: February 7, 2018
Published online: March 27, 2018

Bariatric surgery is an effective tool in the treatment of patients with morbid obesity. In these case reports we describe 2 patients who developed liver failure after currently-practiced types of bariatric surgery, caused by a prolonged state of malnutrition provoked by psychiatric problems. Despite intensive guidance of a psychologist and dieticians after surgery, our patients deteriorated psychologically, resulting in a prolonged state of severe malnutrition and anorexia. Finally, a state of starvation was reached, passing a critical level of the liver capacity. Patients who present with signs of severe protein malnutrition after bariatric surgery should be closely monitored and checked for nutritional status. Specific attention should be given to patients who develop psychiatric problems post-bariatric surgery. If refeeding does not result in clinical improvement, reversal surgery should be considered in a timely manner.

Keywords: Protein deficiency, Hyperbilirubinemia, Hyperammonemia, Liver failure, Urea cycle

Core tip: Monitoring of patients after bariatric surgery is important. When psychiatric problems appear, you should be alert and treat your patients proactively. Unfortunately, these case reports show that psychiatric deterioration can lead to severe malnutrition and anorexia, although rarely resulting in liver insufficiency and failure.