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WLS May Lead to Acetaminophen-Induced Acute Liver Failure

November 26, 2012

Want another reason to avoid weight loss surgery (WLS) at all costs? An article in MedPage Today, “Obesity Tx Linked to Liver Failure Risk,” is one more in a long list of complications from WLS that just may be worse than the “disease” of being fat that the medical establishment thinks needs to be “cured”.

In a retrospective analysis of 101 liver failure patients, 54 had disease induced by acetaminophen overdose, and of those 16.7% had previous bariatric surgery, according to Edward Holt, MD, of California Pacific Medical Center in San Francisco.

Fifty-four patients had liver disease induced by acetaminophen overdose, and nine of those fifty-four had had WLS. This is important, since most WLS done today causes patients to be unable to absorb a variety of nutrients, and affects how they metabolize medications. Most pain medications don’t work in the same dosages that work for people with un-mutilated digestive systems.

Meaning, if you’ve had WLS, you may have to take double or triple the amount of pain medication to get half to one quarter of the pain relief you used to get.

In contrast, among the 47 patients with liver disease with other causes, there were none who had previously had bariatric surgery, Holt reported at the annual meeting of the American Association for the Study of Liver Diseases (AASLD).

That right there is some scary shit, y’all. And that’s not even the scariest thing about this whole mess.

The association appeared to be independent of other factors linked to acetaminophen-induced acute liver failure, including depression, alcohol abuse, the use of combination analgesics, and the intention to commit suicide.

Holt cautioned that the study is retrospective, but suggests a prevalence of bariatric surgery among patients with acetaminophen-induced acute liver failure that is “strikingly higher” than the 0.66% prevalence in the general population.

He said the findings are sufficiently alarming that larger multi-center studies are needed, as well as research into the mechanisms that might underlie the phenomenon.

Gee, Dr Holt, ya think? 9 out of 54 vs. less than 1 out of 100 is “strikingly higher”? Understatement much?

Bariatric surgery has a number of important consequences, Holt noted, including changes in how the body processes some drugs, such as alcohol, an increased risk of suicide, and nutritional changes.

No shit, Sherlock, what was your first clue? Any time you take a functioning digestive system and cut it apart and piece it back together again, minus bits and pieces here and there, you’re going to change how it processes everything that passes through it. Maybe the medical community should have thought about that before they started fucking around with peoples’ insides?

To see if bariatric surgery plays a role in acetaminophen-induced acute liver failure they studied a cohort of 101 patients whose liver disease was prospectively identified between 2009 and 2011.

Of those, nine patients had undergone bariatric surgery, on average 5.9 years before the liver failure — eight with a Roux-en-Y procedure and one with a duodenal switch.

Acetaminophen-induced acute liver failure was determined either by the presence of the drug in the system or by medical history, in the absence of other possible causes, Holt reported.

So, 9% of the patients in the cohort had had WLS, on average less than six years before their liver failure (because their livers were fine before the WLS, otherwise they wouldn’t have qualified for WLS in the first place).

There was no difference between the acetaminophen and non-acetaminophen groups in age, but there were more women and Caucasians in the drug-induced disease group and more deaths and transplants among the others.

As well as containing all those with bariatric surgery, the acetaminophen group had significantly more depression, alcohol abuse, and combinations of analgesics, Holt said.

On the other hand, when the nine bariatric surgery patients were compared with the remaining 92, there were no significant differences in age, sex, ethnicity, depression, alcohol abuse, combination analgesic use, transplants, or death, he noted.

I don’t know why the acetaminophen group as a whole had more depression, alcohol abuse, and combinations of analgesics, but I can certainly understand why the WLS group would have more of every one of those conditions. Dealing with the complications of WLS can be depressing, especially if/when the lost weight starts to come back. If one was a drinker before WLS, zie may find out that the alcohol hits them faster and harder than it ever did before — abusing alcohol is a coping mechanism, not a good one, but one all the same. And those combinations of analgesics are probably because WLS patients are hunting for something, anything, to help them deal with whatever pain they may be having.

If the finding is validated, the 1.6 million people in the U.S. who have undergone bariatric surgery are at increased risk of acetaminophen-induced acute liver failure, which would require changes in management, including additional warnings about the painkiller.

The only way to validate this finding is by having every WLS patient have a liver function test. Well, those who haven’t already died from liver failure or had to have a liver transplant because their liver failed. And I’m sure any patients who’ve had transplants or are on the list for a transplant have been told that they need to be careful with acetaminophen in order to avoid a repeat of what they’re going through now (and if they haven’t been warned, then their doctors are remiss).

The rate of bariatric surgery is likely to increase owing to the “growing epidemic of obesity,” commented AASLD president Guadalupe Garcia-Tsao, MD, of Yale University School of Medicine, who discussed the study with reporters.

If the finding is replicated, she said, “there will be important implications in the practical management of patients who have bariatric surgery.”

What “growing epidemic of obesity” is Dr Garcia-Tsao talking about? I think she needs to pull her head out of her hyperbolic ass and join the real world here. There is no “growing obesity epidemic,” that leveled off in 1999 for women and children and in 2004 for men. What is “growing” is the panic and the determination to eradicate fat people, to make everyone fit this “cookie-cutter” ideal that has never existed, doesn’t exist today, and will never exist because we’re not all meant to fit into one dog-damned mold.

The longer WLS exists, the more complications they find with it, and those complications are sometimes worse than just being fat. Doctors and researchers need to quit concentrating on that number on the scale, and start concentrating on health instead. They need to listen to their patients, believe their patients, and help their patients. Panicking over an “obesity epidemic” that doesn’t exist isn’t doing any of that.

Definition: Epidemic:1:a widespread outbreak of an infectious disease; many people are infected at the same time; 2:(especially of medicine) of disease or anything resembling a disease; attacking or affecting many individuals in a community or a population simultaneously.

Medical community, I hate to tell you this, but no matter how much you want to classify “obesity” as an epidemic, it just doesn’t fit the definition. Well, maybe the last part affecting many individuals in a community or a population simultaneously. But even that’s a stretch because not everyone who’s fat got fat all at the same exact instant in time.

And being fat certainly isn’t infectious — no one catch “obesity.” I can’t sneeze on you and voila! you’re suddenly fat. I can’t exchange bodily fluids with you and make you fat. I can’t sit next to you and make you fat. And it certainly isn’t something that just happens overnight either. You don’t go to bed one night and wake up in the morning and OMFG, I’m fat! (Unless someone plays with the BMI and decides to lower the categories at which being fat is determined, of course. But that’s never happened, amirite? /sarcasm).

13 Comments leave one →
  1. Kala permalink
    November 26, 2012 12:34 pm

    ” the acetaminophen group had significantly more depression, alcohol abuse, and combinations of analgesics”

    I think the acetaminophen group would be likely to be more depressed because they’re taking the drug for a reason, and pain problems are correlated with depression.

  2. Kala permalink
    November 26, 2012 12:47 pm

    I will apologize if this offends you, but the whole obesity isn’t infectious so it’s not an epidemic thing is a fallacy.

    Your quoted definition is not the real definition of epidemic used in clinical and health practice. An epidemic is a definite increase of some kind of condition, it need not be infectious or a disease. You could easily have an epidemic of a birth defect, which is neither infectious nor a disease. An infant or fetus can not infect anyone else with its defect, and its defect is not a disease.

    Now, I think there’s an issue when scientists use the word epidemic to the general public. In fact, when it comes to infectious disease, they often don’t use the accurate word, epidemic or sometimes pandemic, because it freaks people out. The particular use of the word epidemic when reaching out to the public has an ideological purpose because of the disjoint relationship between the science understanding of a term and the general public understanding of the term, and the public advocacy people know what they’re doing. However, the term is scientifically accurate.

    • November 26, 2012 1:21 pm

      I cannot remember who told me this or the context, but it was one of the interviews I’ve done and I was told that the scientific definition of epidemic is, essentially “more than we’d expect in a given population.” It may have been Katherine Flegal, now that I’m thinking about it. Anyway, the point was that by this very fast and loose definition, the rise in rates was unexpected, and hence fit this definition. But how long does a plateau have to last before what is expected is now the new norm? And is it really all that unexpected given the socioeconomic issues that are obviously swirling around this issue?

      I think the acetaminophen connection is interesting, and if there are other overdose issues that are going unreported with respect to WLS.


      • Kala permalink
        November 26, 2012 2:22 pm

        It’s not a fast and loose definition, especially since “fast and loose” implies some kind of recklessness. There’s nothing reckless in the scientific definition of the thing, what irks you and seemingly just about all FA, is that epidemic is a negative word in everyday speech, and you don’t want to see it applied to you. That’s fine, but that’s a matter of rhetoric and not a matter of scientific definitions.

        An epidemic could last a day, or maybe even a generation, depending on what you’re looking at and how you look at it. Back to my birth defect example. Let’s say that there’s some treatment or environmental exposure that a woman could undertake for some reason, and it permanently altered her ovaries in such a way that certain defects could be expected in her children for the rest of her reproductive years. (This generally isn’t the case, many defects seem to happen because of exposures during the generation of fetal organs, but bear with me) Take a generation of such women, and you could see an epidemic of a specific birth defect that lasts decades, until such exposed women age out of reproduction. You wouldn’t simply say that such a situation was a new normal, even if it went on for many years. Removing the exposure or the effect of exposure would shift the population back towards its previous state. I think a lot of people feel the same way about increased prevalence of obesity.

        • November 26, 2012 9:13 pm

          So, what’s your ultimate point? I’m not asking to be snide, I genuinely am curious. I understand and accept that “epidemic” is a scientifically accurate word in this context, but what does it have to do with WLS? It doesn’t change the fact that acetominophen will likely lead to complications.

          • Kala permalink
            November 26, 2012 10:28 pm

            I mention it, because this is not a simply opinion piece, it’s an attempt to discuss a piece of research. Also because it’s a FA go-to truism, to show why the science establishment is the opposition, and this is at least the 10th time I’ve seen it. Additionally, it wasn’t just a one off, she devoted about a 1/4 of her writing this to the point. It distracts and detracts from a better point about the paper.

        • November 27, 2012 10:24 am

          I’m just paraphrasing what Flegal said, which is that there isn’t a quantifiable definition of “epidemic,” as it’s impossible to quantify something when you don’t know what you’ll be quantifying in advance. I understand what you’re saying, but when you look at the distribution curves on obesity, you know that it doesn’t look nearly as significant a shift as when you do the state-by-state analysis using cut-off points.

          But I think that my problem is the focus on obesity as the epidemic rather than, say, insulin resistance. Obesity without insulin resistance is benign, and obesity with insulin resistance is more about IR than weight, in terms of health. The whole point of labeling fat as an epidemic is to amp up the public health campaign against it. So, I’m against the idea that obesity is an epidemic because it really does not help anything except to incite panic and fear among the population that the fatties are overfatting the world.


  3. November 26, 2012 6:42 pm

    This is a really great piece; thanks for writing it and sharing it. The more people who know how dangerous WLS is the fewer will do it (I hope!)

  4. Fab@54 permalink
    November 26, 2012 6:42 pm

    Not sure I see the point in arguing about the word epidemic, but this is from a medical dictionary:

    ep·i·dem·ic (p-dmk) also ep·i·dem·i·cal (–kl) adj.

    1. Spreading rapidly and extensively by infection and affecting many individuals in an area or a population at the same time: an epidemic outbreak of influenza.

    2. Widely prevalent: epidemic discontent.

    1. An outbreak of a contagious disease that spreads rapidly and widely.
    2. A rapid spread, growth, or development: an unemployment epidemic.

  5. vesta44 permalink
    November 27, 2012 10:15 am

    The rate of bariatric surgery is likely to increase owing to the “growing epidemic of obesity,” commented AASLD president Guadalupe Garcia-Tsao, MD, of Yale University School of Medicine, who discussed the study with reporters.

    Emphasis mine in the above quote – this is why I spent part of this post on the definition of epidemic. It doesn’t matter what the article is about, when it comes to fat people and eradicating fat, it usually always comes down to the growing epidemic of obesity. The article can be about complications of WLS, correlations of disease to obesity, how diets fail, yada yada yada, but every damned time, there’s that clarion call to end the “growing epidemic of obesity”. And how many people, in the general population, will stop to think of the medical definition of “epidemic”? Nope, they see “epidemic” and they think flu or black plague and “OMFG, the fat people are taking over the world, we have to do something about it soonest!” Panic ensues, the call to enact policies, no matter how ill-thought out they are, goes out, and fat people suffer because of it. We’re blamed and shamed, told we have no right to exist, and the list of atrocities goes on and on and on.
    This post isn’t only for those of us who know what “epidemic” means, medically, it’s also for those who are just starting on the road to accepting that fat people exist and have a right to exist, have a right to respect and dignity, have the right to love themselves right now, just as they are. The definition I used for “epidemic” came from a medical page when I googled the word – I’m sorry I didn’t look up every definition that google gave me and throw that in too – as this was a medical post, I thought a medical definition was all that was necessary. I see I was wrong.

    • November 27, 2012 10:26 am

      This is exactly right. The connotation of “epidemic” is that it’s something that spreads uncontrollably, and as if that wasn’t already implied by the terminology, Garcia-Tsao falsely stokes those fires.


  6. CarolynS permalink
    November 27, 2012 4:41 pm

    There really is no quantitative way to decide if something is an “epidemic” or not. Obesity though is pretty much endemic not epidemic. Flegal wrote a wholoe article about this in the International Journal of Obesity some years ago. The word “epidemic” is mostly a scare word and the Dictinary of Epidemiology points out that it tends to be sensationalist and perhaps should be avoided because of that.

    • November 27, 2012 5:14 pm

      Aaaaaaaaaaaaaaaaaah! You are a wonderful, wonderful person CarolynS!!! This is what Flegal told me in the interview I did with her, but I did not have the wherewithal to go back and listen to the interview. Thank you so much for sharing. Now I’ll have to dig up that study. And reading the definition of endemic, that seems to encapsulate it much better. Thank you again. And welcome to Fierce Fatties!


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