Q. Can drastic weight loss worsen NASH?

Answered by
Dr. Ajeet Kumar Lohana
and medically reviewed by Dr. Sneha Kannan
This is a premium question & answer published on Sep 05, 2020

I was diagnosed with NASH 6 years ago but not given any proper advice except lose weight. A Fibroscan reading of 4.3 (3 years back) and I was not told anything just given the paper readout. Last year, my Fibroscan was 6.6. And I was told “live your life” don’t worry. 2 months back, my Fibroscan was 7.0 with 230 CAP score. Last year, I lost 60 lbs over a nine month period (female, 130 lbs, 5’4’”)on a low carb diet and I’m now being told that I lost weight too fast which has made my liver worst. I now suffer from severe medical anxiety, acid reflux (previously none), abdominal pain, and bouts of neuropathy.. I understand now that NASH is progressive and that I will progress to cirrhosis. My ALT/AST ratio is greater than 1.0

Total Protein 7.0 g/dL 6.0 - 8.2 g/dL Albumin 4.6 g/dL 3.5 - 5.3 g/dL Bilirubin,Total 0.6 mg/dL 0.0 - 1.2 mg/dL Bilirubin,Direct

#

Hello. I welcome you to icliniq.

The diagnosis of NASH means there was presence of inflammation in the liver. Which should be evident on ALT more than 1.5x normal or AST more than 1.5x normal, while excluding other etiologies and in absence of significant active alcohol intake. The Significant alcohol intake is 20 gm / day i.e. two standard drinks per day.

You did not mention your past and current ALT and AST values plus use of alcohol. At moment your weight seem to be in very normal range. And no way that weight loss can worsen one's NASH. The only first recommend therapy for NAASH or NAS (Non alcoholic steosis) is weight loss which you have done nicely.

The Kpa value and CAP value can have falsly high value in case of significant alcohol intake, or presence of other etiology besides NASH. So need to rule out both. If you have past work up for the same kindly share it. regards

Thanks so much for the reply. Sorry all labs didn’t paste. Labs last week Alt -14 AST - 15. They have been in the normal range for the last year. Platelets -270. I was diagnosed with NASH 6 years back. By biopsy. Before weight loss, ALT reached 106. I do not consume alcohol at all, nor sugary drinks. I also do not have a thyroid and must take a synthetic replacement. Nor do I have a gallbladder. Currently having absorption issues which requires close monitoring of thyroid dosage. Acid reflux, GERD, ( Spontaneous gastroesophageal reflux to the level of the GE junction) and IBS has been constant for the last 4 weeks. I’ve taken Rifaximin for possible SIBO Spontaneous gastroesophageal reflux to the level of the GE junction.. But stomach issues returns. I also passes parasite ovas in Jun, but primary care physician refused to order parasite antibiotic. I was also told that IBS signals NASH and Cirrhosis.

Your Value Total Protein 7.0 g/dL 6.0 - 8.2 g/dL Albumin 4.6 g/dL 3.5 - 5.3 g/dL Bilirubin,Total 0.6 mg/dL 0.0 - 1.2 mg/dL Bilirubin,Direct

#

Hello. I welcome you again to icliniq.

Well that solves the problem. You see the weight reduction have caused improvement in the liver function tests. Your ALT and AST are perfectly normal at the moment. Do not be misguided by presence of probably falsely elevated Kpa values and CAP values. You CAP value is still near the upper limit of the normal. A value more than 250 or 300 is a concern for a me. But you do not have this. And with that strategic weight loss I have strong feeling it is not going to get high.

Below are some of the non invasive markers which can predict the presence of significant fibrosis. The significant fibrosis means f3 and f4. F0 to F2 is non significant fibrosis. Remember your BMI is 22 that is normal.

Your NAFLD fibrosis score (NFS) is 3.83. Fib 4 score is 0.52 APRI score is 0.2

These all score have good negative predictive value. Which means if these score does not show fibrosis stage F3 and F4, it is unlikely that you have a significant fibrosis on the liver biopsy. The liver biopsy however is the gold standard. So bottom line is, just do not worry about your NASH any more while you maintaining your weight optimally. For GERD you can simply take Cap Esomprazole 40 mg half hour before breakfast. Not regularly, only when you feel heart burn, sore taste of mouth, or sore throat or feeling of acidity. For SIBO you rightly took rifaximin. I want to know are you on medications for IBS. And what are the predominant symptom? like abdominal pain, gas, or bloating?


The Probable causes:

NAFLD responding to weight reduction therapy

I wish I could feel assured but there are a few markers that concern me. 1-I never had acid reflux before this year—after weight loss. It is so bad that it causes ear fullness, and gastric rhinitis when I eat. 2-My IgG serum (1475) has now climbed to the upper limits. 3- I was on a very low calorie diet, low carb diet, that I believe did me harm because I had hair loss, but it is back now. I also wonder if the weight loss is the cause of neuropathy flares in my feet and hands. I also believe I have gastritis.

It is my understanding that with NASH AST/ALT means nothing and that scarring could still be occurring

As of this morning I am taking Dicyclomine for IBS. I also wonder if the acid reflux is not bile reflux since I don’t have a gall bladder.
#

Hello. You are very valid concerns and let me go through these one by one.

I said in my previous responses that Kpa and CAP values can be falsly high if someone has other disease. Since you have signficant weight loss and with normalization of the ALT AST, it is unlikely that NASH has been in to play at moment causing this rising kpa value. There may be other reason for it, and given your history of weight loss and numbness over feet, frequent reflux, make me believe that there is something running underneath this label of NASH.. so I would suggest you some blood investigation and endoscopy to see inside of your stomach and small bowel.

There are three stages of fatty liver disease Steatosis which is only fat with normal ALT And non progressive and reversible Steatohepatitis which is fat with inflammation, raised ALT , is also reversible but some patient can have progressive disease despite weight loss Cirrhois. Scarring of the liver. In this fat would be replaced by scar tissue, kpa value goes up to 12 and above and it is irreversible thing. So keep in mind you were intially in stage 2. and now have reducrd weight , ALT has normalized, so it is probably reversed. If it were not reversed, then ALT should remain high.

I will.suggest you some tests, kindly get them done, if already done at some point in time, kindly share the reports. Bile reflux is rare phenomenon and often a post surgical complication. The common is acid reflux and should respond to cap.Esomprazole which I have suggested to you. The endoscopy however would help in this regard as well while establishing the reason of your frequent reflux episodes.


Investigations to be done:

complete blood count
crp
esr
ANA, ASMA, AMA, ANTI LKM 1 antibody
ANCA
upload the report of IgG as you mentioned
serum cerluplasmin
serum anti trypsin 1 levels
serum ferritin and transferrin saturation
vitamine B12 and rbc folate
anti ttg Ig A and Anti ttg IgG
serum calcium, mg, pho
bun, creatininr, electrolytes

Probable diagnosis:

Automimmune hepatitis
vitamin deficiency b12 celiac
other metabolic liver disease


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