Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access
Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc
Journal website

Case Report

Volume 14, Number 2, April 2021, pages 129-137

Severe Protein-Calorie Malnutrition-Associated Hepatic Steatosis in a Woman Who Had Roux-en-Y Gastric Bypass for Morbid Obesity Thirteen Years Ago


Figure 1.
Figure 1. Histology of liver biopsy. Macrovesicular steatosis occupying about 65% biopsy volume (H&E stain, × 100). H&E: hematoxylin and eosin.
Figure 2.
Figure 2. Macrovesicular steatosis, abundant intra-hepatocellular brown pigment, and ceroid material-containing Kupffer cells (H&E stain, × 200). H&E: hematoxylin and eosin.
Figure 3.
Figure 3. Some periportal intra-hepatocellular brown pigment is iron (a) H&E stain, × 400. (b) Prussian blue stain, × 400. H&E: hematoxylin and eosin.
Figure 4.
Figure 4. Centrilobular intra-hepatocellular brown pigment is negative for iron (a) H&E stain, × 400. (b) Prussian blue stain, × 400. H&E: hematoxylin and eosin.


Table 1. Laboratory Results
Laboratory testPatient value (initial presentation)Reference range
INR: international normalized ratio; ALT: alanine transaminase; AST: aspartate transaminase; Ig: immunoglobulin.
Sodium140 mmol/L136 - 145 mmol/L
Potassium4 mmol/L3.3 - 5.1 mmol/L
Chloride109 mmol/L98 - 107 mmol/L
Blood urea nitrogen5 mg/dL6 - 21 mg/dL
Glucose104 mg/dL65 - 99 mg/dL
Total protein3.7 g/dL6.4 - 8.3 g/dL
Albumin< 1.5 g/dL3.5 - 5.2 g/dL
INR1.40.8 - 1.1
AST24 IU/L0 - 37 IU/L
ALT16 IU/L0 - 35 IU/L
Direct bilirubin1.2 mg/dL0 - 0.2 mg/dL
Total bilirubin2.5 mg/dL0 - 1.0 mg/dL
Ammonia136 µmol/L18 - 72 µmol/L
Alkaline phosphatase118 U/L38 - 126 U/L
Hemoglobin7.8 g/dL12 - 16 g/dL
Red blood cell count2.20 × 106/µL4.0 - 5.2 × 106/µL
White blood cell count5.6 × 103/ µL4.0 - 10.0 × 103/µL
Platelet count96 × 103/ µL150 - 450 × 103/µL
Ceruloplasmin< 6 mg/dL18 - 58 mg/dL
Copper28.4 µg/dL80.0 - 155.0 µg/dL
IgG776 mg/dL70 - 433 mg/dL
IgM142 mg/dL45 - 281 mg/dL
Iron45 µg/dL35 - 150 µg/dL
Transferrin< 75 mg/dL200 - 360 mg/dL
Total iron binding capacityUnable to calculate225 - 430 µg/dL
Iron saturationUnable to calculate20-55%
Vitamin B1105 nmol/L70 - 180 nmol/L
Vitamin B12> 1,500 pg/mL180 - 914 pg/mL
Vitamin B6< 5.0 nmol/L20.0 - 125.0 nmol/L
Vitamin E3.7 mg/dL0.0 - 6.0 mg/L
Zinc29.7 µg/dL60.0 - 120.0 µg/dL
25-hydroxy vitamin D2.53 ng/mL20 - 120 ng/mL
Folate (serum)13.1 ng/mL> 5.8 ng/mL


Table 2. Hepatic Complication in Patients Undergoing Roux-en-Y Gastric Bypass in the Literature and Our Case
Case 1Case 2Case 3Case 4Case 5Case 6Our case
BMI: body mass index; HVPG: hepatic venous pressure gradient; RNY-GBP: Roux-en-Y gastric bypass; D: day; N/A: not available.
Age (years)43343734544246
SurgeryGastric bypass surgery, later revised to distal bypassSleeve gastrectomy failed followed by gastric bypass with persistent gastrojejunal ulcerRNY-GBP with an extended Roux limbRNY-GBP with an extended Roux limbRNY-GBP with an extended Roux limbRNY-GBPRNY-GBP with standard Roux limb
Age at surgery (years)44393734543233
Pre-surgery BMI (kg/m2)4742618649N/A38
Total weight loss (%)46%62%27% (48 kg)51% (128 kg)25% (35 kg)N/A63% (57 kg)
Interval (months)30337177120156
At admissionDeveloped hypoglycemiaDid not eat the days before hospitalizationVery limited oral intake, muscle wastingVery limited oral intake, muscle wasting, weakness, fatigue, anasarcaVery limited oral intake, muscle wasting, weakness, jaundicePoor nutritional intake, malodorous stools, wasting, anasarca, weeping blisters and erythemaPoor oral intake, wasting, anasarca, skin wounds
TreatmentLactulose, rifaximin, enteral feedingLactulose, rifaximin, enteral feedingLactulose, nasoenteral feeding, metronidazoleWaiting for liver transplantationLactulose, nasoenteral feeding and metronidazoleN/ALactulose, enteral feeding, and ceftriaxone for urinary tract infection
OutcomeDied of progressive LF and multiorgan failure on D15Died of progressive LF on D2AliveAliveDied of gastric cancerN/ADied of liver failure
Liver biopsyNot performedNot performedMassive steatosis and mild fibrosisSteatosis, steatohepatitis, cirrhosisSevere steatosis, steatohepatitis, and cirrhosisSevere steatosis and inflammation without Mallory hyaline, consistent with steatohepatitisModerate steatosis, mild siderosis, abundant lipofuscin


Table 3. Biochemical Abnormalities in Patients With Hepatic Complications After Roux-en-Y Gastric Bypass
Lab testCase 1Case 2Case 3Case 4Case 5Case 6Our case
INR: international normalized ratio; AST: aspartate transaminase; ALT: alanine transaminase; BUN: blood urea nitrogen; ALP: alkaline phosphatase; N/A: not available.
Total bilirubin (mg/dL)3 × normalNormal1.6 (high)13.3 (high)11.7 (high)7.52.5
Total proteinN/AN/A7.55.8 (low)5.9 (low)N/A3.7
Albumin (g/dL)1.2 (low)1.0 (low)1.6 (low)1.5 (low)2.7 (low)1.9< 1.5
INR> 7 (high)> 7 (high)2.1 (high)1.9 (high)2.0 (high)1.7 (high)1.4 (high)
AST (IU/L)2543 (high)74 (high)137 (high)50 (high)1724
ALT (IU/L)2154 (high)2170 (high)261816
BUN (mg/dL)N/AN/A124 (low)10N/A5 (low)
Platelets (× 103/µL)N/AN/A91 (low)112 (low)136 (low)21 (low)96 (low)
Ammonia (µmol/L)224 (high)86 (high)N/A210 (high)111 (high)N/A136 (high)
Ceruloplasmin (mg/dL)N/AN/AN/AN/AN/A9 (low)< 6 (low)
Vitamin B12HighNormalN/AN/AN/AHighHigh
Vitamin B1NormalNormalN/AN/AN/ANormalN/A
Vitamin B3N/AN/AN/AN/AN/ALowN/A
Vitamin B6LowNormalN/AN/AN/AN/ALow
Vitamin DLowLowN/AN/AN/ALowLow