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Q. I don’t see much information about the effects of anorexia nervosa on the liver. Have you seen any new studies? (J.Z., Baltimore)
A. You might be interested in a recent case reported by Dr. Jodi-Anne Wallace at the University of Florida, Gainesville, and a group from Asheville, NC. As reported in the European Journal of Case Reports in Internal Medicine (2023.doi: 10.12890/2023.003675), a 30-year-old woman with a 17-year history of AN was admitted with weight loss, hypocalcemia, and electrolyte abnormalities. Her lab results, especially transaminases, were of particular concern. Her body mass index, or BMI, was 10.29 kg/m2.
On admission, her transaminase levels were much higher than normal. For example, her alkaline phosphatase level (ALP) was 150 units per liter, or U/l (normal range: 35-129 U/l); her aspartate amino transferase (AST) level was 99 U/l (normal range: 0-37 U/l); and her alanine transaminase (ALT) level was 110 U/l (normal range: 0-41 U/l). She refused to have a liver biopsy. She was admitted to a medical service for stabilization before being transferred to an inpatient psychiatric unit.
Her caloric intake was poor during hospitalization, and 9 days after admission her hepatic panel was grossly abnormal. Before nasogastric tube refeeding, her AST levels peaked at 817 U/l, ALT levels at 1066 U/l, and ALP levels at 457 U/l. After a nasogastric feeding tube was inserted, serum levels slowly returned to normal. Her transaminitis was determined to be secondary to severe malnutrition. When she was discharged 45 days after admission, her AST had decreased to 87 U/l, ALT to 151 U/l, and ALP to 158 U/l.
More than 40% of patients admitted with AN have elevated AST or ALT levels, with varying ALP levels (Intern Med. 2008. 47:1447; Intern Med. 1998. 37:32 ). A special subset of patients with BMIs lower than 15 kg/m2 have a higher incidence of transaminitis than those with anorexia and higher BMIs (Singapore Med. 2015.56:488). Some of the causes for elevated transaminase levels in AN patients include hepatic necrosis from ischemic hepatitis, hepatic autophagy, and transaminitis induced by refeeding. This particular case underscored the fact that AN causes silent liver dysfunction, and rarely shows outward physical manifestations. If it is not recognized and if anorexia is not treated, it can lead to severe effects.