Starvation hepatitis and refeeding-induced hepatitis: mechanism, diagnosis, and treatment

Abstract

Anorexia nervosa (AN) is one of the most common psychiatric disorders among young adults and is associated with a substantial risk of death from suicide and medical complications. Transaminase elevations are common in patients with AN at the time of hospital admission and have been associated with longer lengths of hospital stay. Multiple types of hepatitis may occur in these patients, including two types that occur only in patients with AN: starvation hepatitis and refeeding-induced hepatitis. Starvation hepatitis is characterized by severe transaminase elevation in patients in the advanced phase of protein-energy deprivation and is associated with complications of severe starvation, such as hypoglycaemia, hypothermia, and hypotension. Refeeding-induced hepatitis is characterized by a milder increase in transaminases that occurs in the early refeeding phase and is associated with hypophosphatemia, hypokalemia, and hypomagnesaemia. Among the most common forms of hepatitis, drug-induced liver injury is particularly relevant in this patient cohort, given the frequent use and abuse of methamphetamines, laxatives, antidepressants, and antipsychotics. In this review, we provided an overview of the different forms of anorexic-associated hepatitis, a diagnostic approach that can help the clinician to correctly frame the problem, and indications on their management and treatment.

Keywords: anorexia nervosa; fatty liver; hepatitis; refeeding syndrome; starvation; transaminases.

Figure 1.

Proposed diagnostic flow chart of malnourished patients with AN and liver damage. ANA = anti-nuclear antibodies, SMA = anti-smooth muscle antibodies, LKM = anti-liver–kidney microsome antibodies, BMI = body mass index, DILI = drug-induced liver injury, HAV = hepatitis A virus, HBV = hepatitis B virus, HCV = hepatitis C virus, HEV = hepatitis E virus, M = magnesium, P = phosphorus, K = kalium.