The liver is the second largest organ in the body. This organ helps process nutrients in food and beverages and purifies harmful substances from the blood. Fatty liver is also known as hepatic steatosis, which occurs when fat accumulates in the liver. It is normal to have a small amount of fat in the liver, but too much of it can become a health problem. When fatty liver develops in a person who consumes a lot of alcohol, it is called alcoholic fatty liver disease (AFLD). In people who do not drink a lot of alcohol, it is called non-alcoholic fatty liver disease (NAFLD). NAFLD usually does not cause any harm in the early stages, but if it gets worse it can lead to serious liver damage, including cirrhosis. Having high levels of fat in the liver is associated with an increased risk of serious health problems such as diabetes, high blood pressure and kidney disease. Also, if you have diabetes, NAFLD increases your chances of having heart problems.
Stages of nonalcoholic fatty liver disease (NAFLD) develop in 4 main stages:
- Simple fatty liver (steatosis) – The accumulation of fat in liver cells that is somewhat harmless and may only be detected during tests performed for other reasons.
- Non-alcoholic steatohepatitis (NASH) – a more serious form of NAFLD, where the liver is inflamed. It is estimated to affect up to 5% of the British population.
- Fibrosis – where persistent inflammation causes scar tissue around the liver and adjacent blood vessels, but the liver is still able to function normally.
- Cirrhosis – The most severe stage that occurs after years of inflammation, where the liver shrinks and ulcers and bumps form. This damage is permanent and can lead to liver failure (where your liver stops completely) and liver cancer.
It seems that hepatic fibrosis is more likely to occur in 1/3 of NAFLD patients within 4 years of no treatment.
You are at risk for NAFLD if:
- Obese or overweight – especially if you have a lot of fat on your waist (“apple-shaped” body shape)
- Type 2 diabetes
- High blood pressure
- High cholesterol
- Metabolic syndrome (a combination of diabetes, high blood pressure and obesity)
- Age over 50 years
- Cigarettes
NAFLD is strongly associated with obesity, and the prevalence of both diseases is increasing significantly. Another issue is the concern about effective treatment options for patients with NAFLD. No medication has been approved for the treatment of NAFLD. The current recommended treatment is weight loss, which can reduce liver fat, inflammation, and fibrosis or ulcers. While current guidelines in the management of obesity recommend diet and exercise as the first line of treatment, it is now well established that weight loss resulting from lifestyle modification is transient and most patients have recurrences. New studies show that bariatric surgery can be an effective treatment for NAFLD. A study comparing three methods of bariatric surgery, including gastric sleeve, gastric bypass and gastric banding, showed that gastric bypass may be the best surgical option for these patients.
Steatosis
Numerous studies have shown improvement in steatosis after obesity surgery. A statistically significant reduction in steatosis after obesity surgery has been shown based on liver biopsy specimens.
Non-alcoholic steatohepatitis (NASH)
Studies have shown that NASH patients undergoing obesity surgery have reported significant improvements in steatosis and hepatocyte balloons with NASH removal at 1 and 5 years postoperatively. In a study, complete NASH elimination was observed in 82% of patients undergoing bariatric surgery. In addition to improving histology, bariatric surgery also improved the functional capacity of the liver.
Hepatic fibrosis
Studies have shown that liver fibrosis may not change or may improves after bariatric surgery. 95% of patients with fibrosis, at the time of surgery, did not have a fibrosis score greater than 1, indicating less disease progression after surgery. In a study of obese patients (BMI> 50) undergoing gastric bypass surgery, it was found that although fibrosis did not change and hepatic expression of profyrogenic cytokines decreased after surgery, but this was essential and important due to reduced fibrogenesis (fibrosis production). Adipose tissue has now been shown to be a source of proinflammatory cytokines. Most of the weight loss after obesity surgery is in adipose tissue, which leads to a decrease in the production of these factors and thus a decrease in fibrosis. Reduction of fat cells also improves insulin resistance, which is an important mechanism due to the association between the insulin resistance and oxidative stress and the development of fibrosis. Therefore, it seems that obesity surgery can be performed safely in patients with fibrosis.
Compensated liver cirrhosis
Cirrhosis is detected in only 1 to 3% of bariatric surgery patients, and data on cirrhosis are still limited. However, this is becoming more and more important because it has now been suggested by some that in patients with compensated cirrhosis, obesity surgery is well tolerated and may be really helpful. However, due to the lack of data at this stage of the disease, we cannot strongly recommend obesity surgery to treat the disease at this stage.
Non-compensatory liver cirrhosis
Limited studies have been published on irreversible cirrhosis patients undergoing bariatric surgery. However, as we know, cirrhosis involves many surgical challenges, including extensive bleeding, coagulation problems, decreased hepatic blood flow leading to liver dysfunction, and decreased drug metabolism. Obese patients often have multiple comorbid conditions, including type 2 diabetes, high blood pressure, dyslipidemia, and obstructive sleep apnea that when they are combined with irreversible cirrhosis, increase the risk of surgery greatly for these people.
Why may liver enzymes rise after surgery?
Surgery and anesthesia are stressful events, so there is a possibility of elevated liver enzymes and bilirubin after surgery. Slight increases in serum aminotransferase, alkaline phosphatase, or bilirubin levels are possible after surgery, whether under general or spinal anesthesia.
Can Obesity Surgery Increases Liver Enzymes?
Bariatric surgery (BS) can improve the unfavorable metabolic status and pathological condition of liver cells in nonalcoholic fatty liver disease (NAFLD). However, abnormal levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were observed in the early stages after BS.
How long does it take for liver enzymes to return to normal?
About one-third of people with high liver enzymes will have normal liver enzyme levels after two to four weeks. If your liver enzymes are high, your doctor may order more blood tests or imaging tests such as ultrasound, CT scan or MRI. You may also be referred to a liver specialist. After bariatric surgery, lifestyle changes, a healthy and balanced diet, increased physical activity, avoidance of alcohol, and periodic checkups are critical to achieving the best results from surgery and effective treatment of the disease.