Treatment of NAFLD with Adjustable Gastric Band Placement

Abstract

Purpose: Nonalcoholic fatty liver disease is the most common liver disorder in the industrialized world, affecting 20-40% of the general population. Despite its high prevalence, there is no effective treatment other than weight loss. Often these patients have trouble losing weight through conventional methods and over 20% of patients progress to cirrhosis. Laparoscopic adjustable gastric band (AGB) is the least invasive surgical technique for treatment of medically-complicated obesity and the most commonly performed weight loss surgery in Europe. We report a case of a morbidly obese patient with advanced hepatic fibrosis secondary to NAFLD who had reversal of her liver disease after losing weight as a result of AGB placement. This is a 50 year old Hispanic female with a 29 year history of obesity who presented to the ER with right sided abdominal pain, nausea, and vomiting. Physical exam was pertinent for morbid obesity (BMI 38) and right sided abdominal tenderness. Blood work revealed platelets - 131,000, ALT- 148, AST-121 and ALP-167. CT scan of the abdomen showed splenomegaly. Past medical history included diabetes, osteoarthritis, and hyperlipidemia. Patient's morbid obesity was refractory to diets, liposuction, behavior modification, and medications. Patient was discharged two days later for outpatient follow-up of her abnormal liver tests. Complete liver work-up including viral serologies, autoimmune markers, iron studies, ceruloplasmin and antimitochondrial antibody were negative. Liver biopsy revealed chronic portal inflammation, mild to moderate fatty infiltration and stage 3-4 bridging fibrosis. Based on history, blood work, and liver biopsy, she was diagnosed with NAFLD. Subsequently, patient had an AGB placed laparoscopically for treatment of morbid obesity. Following band placement, patient successfully lost weight and this was directly associated with a downward trend in her transaminases. One year after AGB placement patient has lost 32% of her excess body weight with a current BMI of 31. Her transaminases are now within normal limits with AST- 26 and ALT-35. NAFLD is a progressive disease with significant morbidity and mortality due to development of cirrhosis. Routine attempts at losing weight with exercise, behavior modification, dieting, and medications are unsuccessful in these patients. Our case presents AGB placement as a successful intervention for induction of weight loss and prevention of ongoing hepatocellular injury in morbidly obese patients with NAFLD. With the advent of AGB as a minimally invasive weight loss surgery with effective results, we encourage the medical community to consider it as an early intervention for patients with morbid obesity and advanced NAFLD.