1. NASH

2. Morbidly Obese Patient with Normal LFT

3. 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 lb and gains more weight later
His comorbidities make his life very difficult. He is sedentary and smokes daily

4. 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

5. 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

6. 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

7. 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

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

9. Trans-operatory liver biopsy

10. 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

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

12. Second surgery biopsy

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