A53-43 Delayed Onset Fulminant Liver Failure With Refractory Shock Following Duodenal Switch: A Rare Post-bariatric Surgery Catastrophe

Abstract Introduction Fulminant Live Failure is one of the major complications following bariatric surgeries. Delayed presentations, complex interplay of chronic malnutrition and liver injury in the setting of hemodynamic instability pose a diagnostic and therapeutic challenge. Case report Thirty-three-year-old morbidly obese female with history of biliopancreatic diversion with Duodenal Switch (BPD-DS), chronic malnutrition presented with an unresponsive episode due to hypoglycemia of 56 mg/dl. Her mentation improved with dextrose on arrival. She had frequent hospitalizations due to chronic malnutrition and recurrent emesis. She denied fever, sick contacts, travel, and antibiotic use. Physical exam was remarkable for morbidly obesity, anasarca. She presented in refractory shock requiring vasopressors and antibiotics. Laboratory findings were significant for elevated liver enzymes, INR 4.4, ammonia 87 umol/L (peak 149), lactic acid 10.5 mmol/L, hypoalbuminemia 1.7 g/dL; Tylenol and toxicology screen was normal. Autoimmune serologies, portal venous duplex, blood cultures were unrevealing. Imaging revealed bilateral pleural effusions, large ascites, hepatomegaly, no splenomegaly. Echocardiogram demonstrated hyperdynamic left ventricle with EF 70%, small pericardial effusion. On day 2, she was emergently intubated for acute encephalopathy and hypoxemic respiratory failure; underwent therapeutic paracentesis, studies were negative for infection. She developed severe metabolic acidosis requiring continuous renal replacement therapy; became coagulopathic. Unfortunately, despite aggressive interventions, and appropriate nutritional management in addition to above, she experienced rapid clinical decline and was deemed unsuitable for liver transplantation, leading to demise on day 4. Discussion Among different types of bariatric surgeries, Biliopancreatic Diversion with Duodenal Switch is most commonly associated with fulminant liver failure, albeit rare. Onset ranges from 6-24 months post-operatively, often associated with severe malnutrition, steatohepatitis, and rapid weight loss. Micro-nutrient deficiency (Vitamin A, D, E, K), bacterial overgrowth, compromised intestinal barrier can incite hepatic dysfunction following bariatric surgeries. BPD-DS is a complex procedure, reserved for those with BMI50, it bypasses a significant part of small intestine resulting in malabsorption. Per literature review, about 71% of those with liver dysfunction, developed Acute Liver Failure, either requiring a revision or conversion of bariatric procedure, and some requiring liver transplantation. This case illustrates the importance of recognizing the role of chronic severe malnutrition, the diagnostic and therapeutic challenges when presented with refractory shock, in patients with liver dysfunction following bariatric procedures. This abstract is funded by: None