Reversible Subacute Liver Failure Following Revisional Malabsorptive Bariatric Surgery: A Case Report

Bariatric surgery is an effective treatment for obesity and metabolic dysfunction-associated steatotic liver disease (MASLD). Although most patients experience improvement in hepatic steatosis and fibrosis after surgery, severe hepatic decompensation has rarely been reported following malabsorptive procedures. Early recognition of potentially reversible causes of liver failure is essential to prevent progression to irreversible hepatic injury or liver transplantation. We report the case of a 54-year-old woman with obesity-related MASLD who underwent revisional single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) following weight regain after Roux-en-Y gastric bypass. Ten months after surgery, she developed progressive hypoalbuminemia, recurrent hyperammonemia, coagulopathy and worsening porto-systemic encephalopathy culminating in grade IV encephalopathy requiring intensive care admission and invasive mechanical ventilation. Extensive investigation excluded alternative causes of acute hepatic deterioration. Despite six weeks of intensive conservative management, including optimized nutritional rehabilitation with high-protein enteral supplementation, vitamin and micronutrient replacement, correction of electrolyte disturbances, and standard medical therapy for hepatic encephalopathy (lactulose and rifaximin), hepatic synthetic function continued to deteriorate. Following multidisciplinary discussion, surgical reversal of the malabsorptive anatomy was undertaken. Liver biopsy demonstrated advanced chronic liver disease with cholestatic changes, macrovesicular steatosis and severe secondary hepatic siderosis. Neurological improvement was observed within the first postoperative days, with complete resolution of hepatic encephalopathy and normalization of serum ammonia levels by postoperative day five, followed by progressive recovery of hepatic synthetic function. This case highlights persistent malabsorption as a reversible driver of subacute liver failure in patients with limited hepatic reserve following revisional bariatric surgery. Recognition of this rare complication is essential because timely surgical reversal may interrupt ongoing metabolic injury, restore hepatic function and prevent progression to irreversible liver failure or liver transplantation.