NASH

Morbidly Obese Patient with Normal LFT

Clinical Presentation Mr. W is a 50 y/o WM with morbid obesity He has failed multiple attempts to keep a lower weight with diets. He loses 20-50 lb and gains more weight later His comorbidities make his life very difficult. He is sedentary and smokes daily

Past History No prior abdominal surgery DM II HTN EtOH occasionally wine 3-4 times a yr Smokes 1ppd (25 pk/yr) Denies illegal drugs No allergies DM II HTN Hyperlipidemia OSA GERD Lumbalgia Knee pain

Physical Exam BP 155/94 HR 92 RR 22 Ht 70 in Wt 453 BMI 65 General: morbidly obese WM, NAD HEENT: anicteric sclerae, MMM Neck: supple, no JVD, no LAD Lungs: CTA B Heart: RRR Abdomen: morbidly obese, no HSM Extremities: 1+ edema LE Neuro: AAO x 3; no asterixis

Evolution After a careful pre-operatory evaluation, he is taken for a gastric bypass surgery His work up included: CBC, CMP, PT, PTT Abdominal ultrasound Echocardiogram Polysomnography

Surgery At the operatory time, cirrhosis is found incidentally The surgeon decides to do a vertical banded gastroplasty instead of the GBP Liver biopsy taken Post operatory uneventful

VERTICAL BANDED GASTROPLASTY Stomach stapling Restrictive surgery Plastic Band Small pouch Normal absorption Failure in 25-50% patients

Trans-operatory liver biopsy

Post Op Mr. W lost 100 lb during the first 6 months His DM, BP, lipids, back pain improved He then started to drink high caloric liquids Gained 60 lbs back GBP was then scheduled

Gastric Bypass Stomach is stapled Roux-en-Y Restrictive and malabsorptive Low incidence of hepatic complications More consistent weight loss

Second surgery biopsy

Evolution Weight became stable at 250 lbs Metabolic syndrome resolved Liver function remained normal Fibrosis decreased in f/u biopsy