Bariatric surgery for non-alcoholic steatohepatitis in obese patients
ABSTRACT Nonalcoholic fatty liver disease (NAFLD) is increasingly recognised as a condition associated with overweight or obesity that may progress to end-stage liver disease. NAFLD histology resembles alcohol-induced liver injury, but occurs in patients with no history of alcohol abuse. NAFLD has a broad spectrum of clinical and histological manifestations, ranging from simple fatty liver to hepatic steatosis with inflammation, advanced fibrosis, and cirrhosis. The inflammatory stage is known as non-alcoholic steatohepatitis (NASH). Recent reports indicate that weight loss induced by bariatric procedures could be beneficial for NASH treatment.
To assess the benefits and harms of bariatric surgery for NASH in obese patients.
We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to October 2009.
All randomised clinical trials evaluating any bariatric procedure versus no intervention, placebo (sham procedure), or other interventions in patients with NASH regardless of publication status, number of patients randomised, language, or blinding. Quasi-randomised clinical studies were to be considered for the review if no randomised clinical trials were identified. If included, their bias towards positive findings was to be considered.
We extracted data in duplicate, and we planned to analyse the data by intention-to-treat.
We could not find any randomised clinical trials or quasi-randomised clinical studies that fulfilled the inclusion criteria. Our search resulted in twenty-one prospective or retrospective cohort studies, in which improvement on steatosis or inflammation scores was reported. However, four studies also described some deterioration in the degree of fibrosis.
The lack of randomised clinical trials and quasi-randomised clinical studies precludes us to assess the benefits and harms of bariatric surgery as a therapeutic approach for patients with NASH. Limitations of all other studies with inferior design did not allow us to draw any unbiased conclusion on bariatric surgery for treatment of NASH.
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ABSTRACT: A 25-year-old female nurse was referred to our diabetes outpatient clinic with poorly controlled type 2 diabetes, obesity and elevated liver function tests (LFTs). Following a liver biopsy she was diagnosed with non-alcoholic steatohepatitis (NASH) and liver fibrosis. Treatment with subcutaneous injections of the glucagon-like peptide-1 receptor (GLP-1R) agonist liraglutide was initiated. After 46 weeks of treatment the patient had lost 16 kg, glycemic control was excellent and LFTs had normalized. Repeat liver biopsy and ultrasound showed reduction in hepatic fat content and inflammatory cells. The biopsy no longer fulfilled the criteria for NASH. The liver biopsies did not express hepatic GLP-1Rs using quantitative polymerase chain reaction. Our case suggests that liraglutide may benefit patients with NASH.Case Reports in Gastroenterology 09/2014; 8(3):398-403. DOI:10.1159/000369968
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ABSTRACT: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly common cause of chronic liver disease worldwide. The diagnosis of NASH is challenging as most affected patients are symptom-free and the role of routine screening is not clearly established. Most patients with severe obesity who undergo bariatric surgery have NAFLD, which is associated insulin resistance, type 2 diabetes mellitus (T2DM), hypertension, and obesity-related dyslipidemia. The effective treatment for NAFLD is weight reduction through lifestyle modifications, antiobesity medication, or bariatric surgery. Among these treatments, bariatric surgery is the most reliable method for achieving substantial, sustained weight loss. This procedure is safe when performed by a skilled surgeon, and the benefits include reduced weight, improved quality of life, decreased obesity-related comorbidities, and increased life expectancy. Further research is urgently needed to determine the best use of bariatric surgery with NAFLD patients at high risk of developing liver cirrhosis and its role in modulating complications of NAFLD, such as T2DM and cardiovascular disease. The current evidence suggests that bariatric surgery for patients with severe obesity decreases the grade of steatosis, hepatic inflammation, and fibrosis. However, further long-term studies are required to confirm the true effects before recommending bariatric surgery as a potential treatment for NASH.Frontiers in Endocrinology 10/2014; 5:164. DOI:10.3389/fendo.2014.00164
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ABSTRACT: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver enzymes and chronic liver disease in the US with expected rise in incidence paralleling the epidemic of obesity. A subset of patients with NAFLD have the progressive form of NAFLD that is termed non-alcoholic steatohepatitis (NASH), which is characterized by specific features on liver histology including hepatocellular ballooning degeneration, lobular inflammation, and zone-3 steatosis with or without peri-sinusoidal fibrosis. Non-alcoholic steatohepatitis can progress to cirrhosis and result in liver-related death. Insulin resistance is commonly seen in patients with NASH and often co-exists with other features of the metabolic syndrome including hypertension, hyperlipidemia, and obesity. Although weight loss through lifestyle modifications including dietary changes and increased physical exercise remains the backbone of management of NASH, it has proved challenging for patients to achieve and maintain weight loss goals. Thus, it is often necessary to couple lifestyle changes with another pharmacologic treatment for NASH. Insulin sensitizers including the biguanides (metformin), thiazolidinediones (pioglitazone and rosiglitazone), and glucagon-like peptide-1 receptor agonists (exenatide) are large groups of medications that have been studied for the treatment of NASH. Other agents with anti-inflammatory, anti-apoptotic, or anti-fibrotic properties which have been studied in NASH include vitamin E, pentoxifylline, betaine, and ursodeoxycholic acid. This review will provide a detailed summary on the clinical data behind the full spectrum of treatments that exist for NASH and suggest management recommendations.06/2012; 2(2):156-173. DOI:10.1016/S0973-6883(12)60104-2