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Hepatology
Lower survival and higher rates of cirrhosis in patients with ROUX-EN-Y gastric bypass hospitalised with alcohol-associated hepatitis
  1. Chimaobi Anugwom1,2,
  2. Mary Thomson1,
  3. Rebecca L Freese3,
  4. John R Lake1,
  5. Nicholas Lim1
  1. 1Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
  2. 2Digestive Care, HealthPartners, Bloomington, Minnesota, USA
  3. 3Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota, USA
  1. Correspondence to Dr Chimaobi Anugwom; anugw001{at}umn.edu

Abstract

Objective The incidence of alcohol-associated liver disease (ALD) is increasing, and weight loss surgery is more common due to the obesity epidemic. Roux-en-Y gastric bypass (RYGB) is associated with alcohol use disorder and ALD; however, its impact on outcomes in patients hospitalised for alcohol-associated hepatitis (AH) is unclear.

Design We performed a single-centre, retrospective study of patients with AH from June 2011 to December 2019. Primary exposure was the presence of RYGB. The primary outcome was inpatient mortality. Secondary outcomes included overall mortality, readmissions and cirrhosis progression.

Results 2634 patients with AH met the inclusion criteria; 153 patients had RYGB. Median age of the entire cohort was 47.3 years; median Model for End Stage Liver Disease - Sodium (MELD-Na) was 15.1 in the study group versus 10.9 in the control group. There was no difference in inpatient mortality between the two groups. On logistic regression, increased age, elevated body mass index, MELD-Na >20 and haemodialysis were all associated with higher inpatient mortality. RYGB status was associated with increased 30-day readmission (20.3% vs 11.7%, p<0.01), development of cirrhosis (37.5% vs 20.9%, p<0.01) and overall mortality (31.4% vs 24%, p=0.03).

Conclusions Patients with RYGB have higher rates of readmissions, cirrhosis and overall mortality after discharge from hospital for AH. Allocation of additional resources on discharge may improve clinical outcomes and reduce healthcare expenditure in this unique patient population.

  • CIRRHOSIS
  • ALCOHOLIC LIVER DISEASE
  • GASTRIC SURGERY

Data availability statement

No data are available.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgast-2022-001083

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • The incidences of alcohol use disorder (AUD) and alcohol-associated liver disease (ALD) are increasing in the USA, while the obesity epidemic has resulted in a rise in weight loss surgery (WLS). Although there is an association between AUD and WLS, the impact of WLS on ALD, specifically alcohol-associated hepatitis (AH), is unknown.

    WHAT THIS STUDY ADDS

    • Patients with a history of roux-en-y gastric bypass (RYGB) surgery who are hospitalised with AH have higher overall mortality, higher readmission rates and cirrhosis following discharge from hospital.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Patients with RYGB who are hospitalised with AH may need additional resources to prevent readmissions, reduce mortality and for early detection of advanced liver disease after discharge from hospital.

    Introduction

    The prevalence of alcohol-associated liver disease (ALD) is increasing, notably in women and patients with low socioeconomic status, and ALD is now the leading indication for liver transplantation in the USA.1–3 Alcohol-associated hepatitis (AH) is defined by the American Association for the Study of Liver Diseases (AASLD) as a clinicopathologic syndrome of jaundice (onset within 8 weeks), associated with elevated liver enzymes (hepatocellular pattern with AST/ALT> 1.5; AST and ALT <400 IU/L) occurring in an individual with ongoing/recent alcohol use.4 AH represents a major cause of morbidity, mortality and healthcare utilisation, particularly within the first year of diagnosis.5 The incidence of AH increased by 30% over an 8-year period in 2013 and is expected to increase further due to the spike of ALD observed in the context of the recent COVID-19 global pandemic.6 7

    The obesity epidemic is a public health crisis in the USA, directly impacting the incidence of diabetes mellitus (DM), coronary artery disease (CAD) and cerebrovascular disease.8 Weight loss surgery (WLS) is the most effective intervention for the management of obesity by inducing rapid, durable weight loss and has also been shown to improve long-term survival.9 10 Roux-en-Y gastric bypass (RYGB) surgery—division of the stomach into a small pouch with formation of an anastomosis to the jejunum—was the standard of care in WLS until 2013 with the advent of the sleeve gastrectomy.11 12 RYGB results in significant loss of body weight, improvement of hepatic steatosis and can treat hypertension and type 2 DM.13–15 However, long-term studies have shown that RYGB is also associated with gastrointestinal ulcers, dumping syndrome and chronic nutritional deficiencies, which can result in high rates of hospitalisations and the need for repeat surgery.16–18

    WLS is associated with alcohol use disorder (AUD) and ALD.19–21 Prospective studies show that patients with WLS have an increased risk for the development of AUD, particularly patients with RYGB.22 23 Furthermore, patients with a history of RYGB are at increased risk of mortality from alcohol and drug use.24 While the relationship between AUD and WLS is well established, the impact of RYGB surgery on clinical outcomes specifically in patients with AH remains largely unknown. In patients hospitalised for AH, two database studies have shown that the presence of RYGB results in a higher risk of 30-day hospital readmission.25 26

    We aimed to evaluate the impact of RYGB on mortality, hospital readmissions and diagnosis of cirrhosis following an initial hospitalisation for AH. Due to the increased risk of mortality related to AUD and long-term complications associated with RYGB, we hypothesised that patients with a history of RYGB admitted to hospital for AH would have lower inpatient and overall survival, more frequent readmissions and higher instances of cirrhosis following discharge from hospital.

    Methods

    Study population and patient characteristics

    By interrogating the electronic health record (EHR) at the University of Minnesota Medical Center from June 2011 to December 2019, we identified all patients who carried the discharge diagnosis of AH without a history of cirrhosis. We included all patients above the age of 18 and excluded those with incomplete records. We defined AH using AASLD guidelines, which further categorises AH as ‘possible AH’ (clinically diagnosed with potential confounding factors), ‘probable AH’ (clinically diagnosed without potential confounding factors) and ‘definite AH’ (clinically diagnosed and biopsy proven evidence of AH).4 A large sample of patient records were carefully reviewed to ensure that the diagnosis of AH was accurate. Patients with AH and a history of RYGB (study group) were compared with those diagnosed with AH without a history of RYGB (control group). Baseline characteristics as well as clinical features, hospital course and follow-up were extracted from the EHR. Patients were excluded from analysis if they did not meet criteria for probable or definite AH, if they were below 18 years of age, if they ever had a diagnosis code consistent with cirrhosis prior to admission or if medical records pertaining to comorbidities, laboratory investigations and outcomes were missing or incomplete.

    Outcomes

    The primary outcome of our study was inpatient mortality after admission for AH. Secondary outcomes included overall mortality, 30-day readmissions and diagnosis of cirrhosis after discharge.

    Statistical analysis

    Patient demographic and clinical characteristics were summarised using median (range) for continuous and count (percentage, %) for categorical variables, overall and by RYGB status. C-square tests were used to evaluate associations on categorical variables by group. The association of RYGB on the differences in time to inpatient mortality was assessed using Kaplan-Meier curves, where participants without the event were censored at the date of data collection, 28 June 2021. Time to overall mortality and progression to cirrhosis were also assessed using Kaplan-Meier curves, again with censoring on 28 June 2021. The impact of RYGB on the differences in inpatient mortality was assessed using logistic regression models, adjusted for demographic characteristics that may strongly affect clinical course such as age, sex, race, body mass index (BMI), CAD, DM, and peripheral artery disease. Finally, all p values are two sided and considered at 0.05 for statistical significance. Analyses were conducted in R (R Core Team (2021), V.4.0.4).

    Results

    Patient characteristics

    2634 patients had an International Classification of Diseases (ICD) -9 or -10 code for AH over the study period. A total of 153 (5.8%) patients were in the RYGB group, in which 127 (83%) patients were women compared with 883 (35.6%) patients in the control group. The median age was 47.5 years in both groups and the majority of patients were white (85.2% in the RYGB group and 89% of controls). The median BMI (31.3 kg/m2 vs 25.7 kg/m2) was higher in the RYGB group compared with controls. Obstructive sleep apnoea (8.5% vs 2.9%) and hypertension (49% vs 44.3%) were more common in the RYGB group, while the presence of DM (1.3% vs 1.3%) and CAD (0.7% vs 0.8%) were similar between the groups (table 1).

    View this table:
    Table 1

    Patient characteristics

    Regarding severity of liver disease, complications such as ascites (65.3% vs 63.3%) and hepatic encephalopathy (13.1% vs 8%) were higher in the RYGB group. The median MELD-Na (Model for End Stage Liver Disease - Sodium) at presentation was higher in the RYGB group (15.1 vs 10.9); in addition, more patients in the RYGB group had a MELD-Na score >20 (32.1% vs 19.9%, χ2 test p=0.03). Renal replacement therapy was more common in 7.2% of patients in the RYGB group compared with 4.4% patients in the control group. Endotracheal intubation (2.6% vs 6.7%) and steroid therapy (6.5% vs 7.5%) were more common in the control group (table 1).

    Primary outcome

    The inpatient mortality rate was similar between the RYGB group and the control group (2.6% vs 2.7%, respectively). The Kaplan-Meier estimates of inpatient survival were also similar between the two groups (log-rank p=0.82) (figure 1A). After controlling for confounders, the presence of RYGB did not affect the risk of inpatient mortality (OR 0.53, 95% CI 0.13 to 1.73, p=0.33). Increased age at admission (OR 1.05, 95% CI 1.03 to 1.08, p=0.00), increased BMI (OR 1.05, 95% CI 1.01 to 1.09, p=0.02), MELD-Na >20 (OR 5.88, 95% CI 2.82 to 12.61, p=0.00) and need for haemodialysis (OR 14.86, 95% CI 7.61 to 29.91, p=0.00) were all associated with increased inpatient mortality (table 2). In patients with MELD-Na >20, the Kaplan-Meier estimates of inpatient survival did not differ between the RYGB and control groups (log-rank p=0.97) (figure 1B).

    Figure 1
    Figure 1

    A: Kaplan-Meier Estimates of Inpatient Mortality Following Admission for AH. B: Kaplan-Meier Estimates of Inpatient Mortality Following Admission for AH in Patients with MELD-Na>20. AH, alcohol-associated hepatitis; RYGB Roux-en-Y gastric bypass.

    View this table:
    Table 2

    Odds of inpatient mortality in all patients using a multivariate logistic regression model

    Secondary outcomes

    Overall mortality

    The median follow-up time from date of admission to death was 3.3 years in the RYGB group and 3.6 years in the control group. In the RYGB group, 31.4% patients died, compared with 24% in the control group. The Kaplan-Meier estimates of overall survival were 86.3%, 83.4% and 67.2% at 1, 2 and 5 years in the RYGB group, respectively, and 88.4%, 84.3% and 74.8% at 1, 2 and 5 years in the control group, respectively (log-rank p=0.03) (figure 2A). In patients with MELD-Na >20, the Kaplan-Meier estimates of overall survival were 74.3%, 67.8% and 41.6% at 1, 2 and 5 years in the RYGB group, respectively, and 57.7%, 52.6% and 42.1% at 1, 2 and 5 years in the control group, respectively (log-rank p=0.51) (figure 2B).

    Figure 2
    Figure 2

    A: Kaplan-Meier Estimates of Overall Mortality Following Admission for AH. B: Kaplan-Meier Estimates of Overall Mortality Following Admission for AH in Patients with MELD-Na>20. RYGB, Roux-en-Y gastric bypass.

    30-day readmissions

    The instances of 30-day readmissions were higher in the RYGB group compared with the control group (20.3% vs 11.7%, χ2 test p<0.01). Among these patients readmitted within the first 30 days, the number of rehospitalisations was similar between both groups (table 3).

    View this table:
    Table 3

    Rates of 30-day readmissions

    Development of cirrhosis

    Cirrhosis was diagnosed in 57 (37.5%) patients in the RYGB group following discharge from hospital compared with 518 (20.9%) patients in the control group. The median time to diagnosis of cirrhosis was 2.4 (0, 10.0) years in the RYGB group compared with 3.7 (0, 10.1) years in the control group. The Kaplan-Meier estimates for diagnosis of cirrhosis were 28.9%, 34.7% and 38.9% at 1, 2 and 5 years in the RYGB group, respectively, and 15.1%, 17.6% and 21.5% at 1, 2 and 5 years in the control group, respectively (log-rank p<0.01) (figure 3).

    Figure 3
    Figure 3

    Kaplan-Meier Estimates of Development of Cirrhosis After Discharge from Hospital with AH. RYGB, Roux-en-Y gastric bypass.

    Discussion

    Increases in the diagnosis of AUD and the obesity epidemic have resulted in rising rates of both ALD and WLS in the USA, making it important to understand the complex relationship between these two entities. In this single-centre study, a history of RYGB surgery was not associated with an increase in inpatient mortality in patients hospitalised with AH; however, RYGB was associated with 30-day readmissions, higher overall mortality and higher rates of cirrhosis after discharge from hospital.

    Although we did not observe a significant difference in inpatient mortality between the two groups, RYGB was associated with lower overall survival compared with controls particularly beyond 3 years after discharge from hospital. Despite a history of WLS, patients with a history of RYGB had a higher BMI, which influenced inpatient mortality on multivariate analysis in our study. Obesity is associated with several comorbidities, for example, type II DM, cardiovascular disease and obstructive sleep apnea, which negatively affect patient survival.27–29 Furthermore, protein-calorie malnutrition, a frequent complication of WLS, is associated with worse clinical outcomes in patients with AH.30–32 Longer term follow-up may be needed for patients with RYGB who recover from AH to address the associated comorbidities, which may contribute to higher rates of mortality after discharge from hospital.

    Two recent studies using data from the National Readmissions Database showed that bariatric surgery was associated with higher rate of readmissions in patients with AH: our results show a similar increase in the risk of readmissions for patients with AH who specifically had a history of RYGB.25 26 Increased readmission rates have contributed greatly to healthcare spending on patients with AH at a time when healthcare costs continue to rise exponentially in the USA.5 25 Patients with a history of RYGB who require admission to hospital for AH may require closer follow-up on discharge to prevent readmissions. In patients with cirrhosis, one study has shown that early follow-up visits after admission can reduce readmissions and lower short-term mortality.33

    Our study is the first to examine the relationship between RYGB and the development of cirrhosis in patients with AH. We found that patients with RYGB and AH had higher rates of cirrhosis after discharge from hospital when compared with controls. First-pass alcohol metabolism by gastric alcohol dehydrogenase is significantly reduced in patients with RYGB, while faster gastric emptying results in uncontrolled exposure to and absorption of alcohol through the small bowel.34 35 As a result, patients with RYGB who ingest alcohol may have higher peak blood alcohol concentrations compared with patients with normal stomach anatomy, which may be more directly toxic to the liver and accelerate the development of cirrhosis.36 Patients with RYGB may also have concurrent non-alcoholic fatty liver disease hastening the development of cirrhosis after discharge.37 38 In patients with RYGB, early liver biopsy should be considered after biochemical recovery of AH to identify cirrhosis and determine the need for screening for oesophageal varices and hepatocellular carcinoma. Non-invasive strategies, such as transient/shear wave elastography or magnetic resonance elastography, may also be considered although data on their accuracy in patients with a history of RYGB are currently limited.39–42

    In the USA, active AUD is a contraindication to WLS. The American Society for Metabolic and Bariatric Surgery recommends that all patients being considered for WLS are screened for AUD and counselled about the risk of development of AUD after surgery. Patients with AUD may be considered for WLS after undergoing treatment and a period of prolonged abstinence.43 Our data suggest that reinforcement of preoperative education, ongoing education regarding the risks of alcohol and screening for AUD are important to prevent morbidity and mortality from ALD, AH and potentially cirrhosis in patients with RYGB. Individuals at high risk for AUD may benefit from referral for additional mitigation strategies such as psychoeducation and counselling.44

    The results from our study should be interpreted with certain limitations. First, the retrospective study design has its inherent flaws, although the granularity of our data is improved compared with large database studies. Second, as a tertiary referral centre, our results may not be generalisable to patients presenting to community hospitals. Third, readmission data may be underestimated as patients discharged from tertiary referral centres may represent to their local hospitals without requiring referral back to the tertiary centre. Fourth, we used ICD codes to identify patients with AH and cirrhosis; however, each diagnosis of AH was validated with manual chart review and a recent study showed that using ICD diagnosis codes for cirrhosis has a high specificity and a high positive predictive value.45–47 Finally, details about alcohol use prior to WLS and after hospitalisation for AH were incomplete, an important factor in the development of cirrhosis after discharge.

    In conclusion, RYGB did not affect inpatient mortality in patients hospitalised with AH but impacted overall survival, readmissions and rates of cirrhosis after discharge compared with similar patients without RYGB. Providers should recognise these risks and additional resources may be necessary to improve clinical outcomes in this unique population. Further study is needed to develop interventions to reduce readmissions for RYGB patients admitted to hospital with AH and to better understand the impact of alcohol use on liver function in these patients.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    References

    1. ↵
      1. Mellinger JL,
      2. Shedden K,
      3. Winder GS, et al
      . The high burden of alcoholic cirrhosis in privately insured persons in the United States. Hepatology 2018;68:872–82. doi:10.1002/hep.29887
      OpenUrl
    2. ↵
      1. Grant BF,
      2. Chou SP,
      3. Saha TD, et al
      . Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001-2002 to 2012-2013: results from the National epidemiologic survey on alcohol and related conditions. JAMA Psychiatry 2017;74:911–23. doi:10.1001/jamapsychiatry.2017.2161
      OpenUrl
    3. ↵
      1. Kwong AJ,
      2. Kim WR,
      3. Lake JR, et al
      . OPTN/SRTR 2019 annual data report: liver. Am J Transplant 2021;21 Suppl 2:208–315. doi:10.1111/ajt.16494
      OpenUrl
    4. ↵
      1. Crabb DW,
      2. Im GY,
      3. Szabo G, et al
      . Diagnosis and treatment of alcohol-associated liver diseases: 2019 practice guidance from the American association for the study of liver diseases. Hepatology 2020;71:306–33. doi:10.1002/hep.30866
      OpenUrlCrossRefPubMed
    5. ↵
      1. Thompson JA,
      2. Martinson N,
      3. Martinson M
      . Mortality and costs associated with alcoholic hepatitis: a claims analysis of a commercially insured population. Alcohol 2018;71:57–63. doi:10.1016/j.alcohol.2018.02.003
      OpenUrl
    6. ↵
      1. Chen CM
      . Alcohol use and alcohol use disorders in the united states: main findings from the 2012–2013 national epidemiologic survey on alcohol and related conditions-III (NESARC-III). U.S. alcohol epidemiologic data reference manual, volume 10, april 2016, NIH publication no. 16-AA-8020. Bethesda, MD National Institute on Alcohol Abuse and Alcoholism; 2016.
    7. ↵
      1. Cholankeril G,
      2. Goli K,
      3. Rana A, et al
      . Impact of COVID-19 pandemic on liver transplantation and alcohol-associated liver disease in the USA. Hepatology 2021;74:3316–29. doi:10.1002/hep.32067
      OpenUrl
    8. ↵
      1. Mitchell NS,
      2. Catenacci VA,
      3. Wyatt HR, et al
      . Obesity: overview of an epidemic. Psychiatr Clin North Am 2011;34:717–32. doi:10.1016/j.psc.2011.08.005
      OpenUrlCrossRefPubMed
    9. ↵
      1. Arterburn DE,
      2. Olsen MK,
      3. Smith VA, et al
      . Association between bariatric surgery and long-term survival. JAMA 2015;313:62–70. doi:10.1001/jama.2014.16968
      OpenUrlCrossRefPubMed
    10. ↵
      1. Courcoulas AP,
      2. King WC,
      3. Belle SH, et al
      . Seven-year weight trajectories and health outcomes in the longitudinal assessment of bariatric surgery (labs) study. JAMA Surg 2018;153:427–34. doi:10.1001/jamasurg.2017.5025
      OpenUrl
    11. ↵
      1. Kootte AM,
      2. Lensen LM,
      3. van Es LA, et al
      . Controlled cyclosporine conversion at three months after renal transplantation. Long-term results. Transplantation 1988;46:677–80. doi:10.1097/00007890-198811000-00010
      OpenUrlPubMed
    12. ↵
      1. Koh CY,
      2. Inaba CS,
      3. Sujatha-Bhaskar S, et al
      . Laparoscopic adjustable gastric band explantation and implantation at academic centers. J Am Coll Surg 2017;225:532–7. doi:10.1016/j.jamcollsurg.2017.06.015
      OpenUrl
    13. ↵
      1. Simonson DC,
      2. Halperin F,
      3. Foster K, et al
      . Clinical and patient-centered outcomes in obese patients with type 2 diabetes 3 years after randomization to Roux-en-Y gastric bypass surgery versus intensive lifestyle management: the SLIMM-T2D study. Diabetes Care 2018;41:670–9. doi:10.2337/dc17-0487
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Schiavon CA,
      2. Ikeoka D,
      3. Santucci EV, et al
      . Effects of bariatric surgery versus medical therapy on the 24-hour ambulatory blood pressure and the prevalence of resistant hypertension. Hypertension 2019;73:571–7. doi:10.1161/HYPERTENSIONAHA.118.12290
      OpenUrl
    15. ↵
      1. Fakhry TK,
      2. Mhaskar R,
      3. Schwitalla T, et al
      . Bariatric surgery improves nonalcoholic fatty liver disease: a contemporary systematic review and meta-analysis. Surg Obes Relat Dis 2019;15:502–11. doi:10.1016/j.soard.2018.12.002
      OpenUrl
    16. ↵
      1. van Olst N,
      2. van Rijswijk AS,
      3. Mikdad S, et al
      . Long-term emergency department visits and readmissions after laparoscopic roux-en-Y gastric bypass: a systematic review. Obes Surg 2021;31:2380–90. doi:10.1007/s11695-021-05286-0
      OpenUrl
    17. ↵
      1. Obeid NR,
      2. Malick W,
      3. Concors SJ, et al
      . Long-term outcomes after roux-en-Y gastric bypass: 10- to 13-year data. Surg Obes Relat Dis 2016;12:11–20. doi:10.1016/j.soard.2015.04.011
      OpenUrl
    18. ↵
      1. Auge M,
      2. Menahem B,
      3. Savey V, et al
      . Long-term complications after gastric bypass and sleeve gastrectomy: what information to give to patients and practitioners, and why? J Visc Surg 2022;159:298–308. doi:10.1016/j.jviscsurg.2022.02.004
      OpenUrl
    19. ↵
      1. Suzuki J,
      2. Haimovici F,
      3. Chang G
      . Alcohol use disorders after bariatric surgery. Obes Surg 2012;22:201–7. doi:10.1007/s11695-010-0346-1
      OpenUrlCrossRefPubMed
    20. ↵
      1. Ostlund MP,
      2. Backman O,
      3. Marsk R, et al
      . Increased admission for alcohol dependence after gastric bypass surgery compared with restrictive bariatric surgery. JAMA Surg 2013;148:374–7. doi:10.1001/jamasurg.2013.700
      OpenUrl
    21. ↵
      1. Mellinger JL,
      2. Shedden K,
      3. Winder GS, et al
      . Bariatric surgery and the risk of alcohol-related cirrhosis and alcohol misuse. Liver Int 2021;41:1012–9. doi:10.1111/liv.14805
      OpenUrl
    22. ↵
      1. King WC,
      2. Chen J-Y,
      3. Courcoulas AP, et al
      . Alcohol and other substance use after bariatric surgery: prospective evidence from a U.S. multicenter cohort study. Surg Obes Relat Dis 2017;13:1392–402. doi:10.1016/j.soard.2017.03.021
      OpenUrlCrossRefPubMed
    23. ↵
      1. Svensson P-A,
      2. Anveden Å,
      3. Romeo S, et al
      . Alcohol consumption and alcohol problems after bariatric surgery in the Swedish obese subjects study. Obesity (Silver Spring) 2013;21:2444–51. doi:10.1002/oby.20397
      OpenUrlCrossRefPubMed
    24. ↵
      1. White GE,
      2. Courcoulas AP,
      3. King WC
      . Drug- and alcohol-related mortality risk after bariatric surgery: evidence from a 7-year prospective multicenter cohort study. Surg Obes Relat Dis 2019;15:1160–9. doi:10.1016/j.soard.2019.04.007
      OpenUrl
    25. ↵
      1. Adejumo AC,
      2. Cholankeril G,
      3. Iqbal U, et al
      . Readmission rates and associated outcomes for alcoholic hepatitis: a nationwide cohort study. Dig Dis Sci 2020;65:990–1002. doi:10.1007/s10620-019-05759-4
      OpenUrlPubMed
    26. ↵
      1. Garg SK,
      2. Sarvepalli S,
      3. Singh D, et al
      . Incidence and risk factors associated with 30-day readmission for alcoholic hepatitis. J Clin Gastroenterol 2019;53:759–64. doi:10.1097/MCG.0000000000001202
      OpenUrl
    27. ↵
      1. Pi-Sunyer X
      . The medical risks of obesity. Postgrad Med 2009;121:21–33. doi:10.3810/pgm.2009.11.2074
      OpenUrlCrossRefPubMed
    28. ↵
      1. Pantalone KM,
      2. Hobbs TM,
      3. Chagin KM, et al
      . Prevalence and recognition of obesity and its associated comorbidities: cross-sectional analysis of electronic health record data from a large US integrated health system. BMJ Open 2017;7:e017583. doi:10.1136/bmjopen-2017-017583
    29. ↵
      1. Afshin A,
      2. Forouzanfar MH,
      3. Reitsma MB, et al
      . Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 2017;377:13–27. doi:10.1056/NEJMoa1614362
      OpenUrlCrossRefPubMed
    30. ↵
      1. Faintuch J,
      2. Matsuda M,
      3. Cruz MELF, et al
      . Severe protein-calorie malnutrition after bariatric procedures. Obes Surg 2004;14:175–81. doi:10.1381/096089204322857528
      OpenUrlCrossRefPubMedWeb of Science
    31. ↵
      1. Mendenhall CL,
      2. Tosch T,
      3. Weesner RE, et al
      . VA Cooperative study on alcoholic hepatitis. II: prognostic significance of protein-calorie malnutrition. Am J Clin Nutr 1986;43:213–8. doi:10.1093/ajcn/43.2.213
      OpenUrlAbstract/FREE Full Text
    32. ↵
      1. Fialla AD,
      2. Israelsen M,
      3. Hamberg O, et al
      . Nutritional therapy in cirrhosis or alcoholic hepatitis: a systematic review and meta-analysis. Liver Int 2015;35:2072–8. doi:10.1111/liv.12798
      OpenUrl
    33. ↵
      1. Morales BP,
      2. Planas R,
      3. Bartoli R, et al
      . Hepacontrol. A program that reduces early readmissions, mortality at 60 days, and healthcare costs in decompensated cirrhosis. Dig Liver Dis 2018;50:76–83. doi:10.1016/j.dld.2017.08.024
      OpenUrl
    34. ↵
      1. Jones AW,
      2. Jönsson KA,
      3. Neri A
      . Peak blood-ethanol concentration and the time of its occurrence after rapid drinking on an empty stomach. J Forensic Sci 1991;36:376–85.
      OpenUrlPubMed
    35. ↵
      1. Sharma R,
      2. Gentry RT,
      3. Lim RT, et al
      . First-pass metabolism of alcohol. Absence of diurnal variation and its inhibition by cimetidine after evening meal. Dig Dis Sci 1995;40:2091–7. doi:10.1007/BF02208989
      OpenUrlPubMed
    36. ↵
      1. Woodard GA,
      2. Downey J,
      3. Hernandez-Boussard T, et al
      . Impaired alcohol metabolism after gastric bypass surgery: a case-crossover trial. J Am Coll Surg 2011;212:209–14. doi:10.1016/j.jamcollsurg.2010.09.020
      OpenUrlCrossRefPubMed
    37. ↵
      1. Beymer C,
      2. Kowdley KV,
      3. Larson A, et al
      . Prevalence and predictors of asymptomatic liver disease in patients undergoing gastric bypass surgery. Arch Surg 2003;138:1240–4. doi:10.1001/archsurg.138.11.1240
      OpenUrlCrossRefPubMedWeb of Science
    38. ↵
      1. Ekstedt M,
      2. Franzén LE,
      3. Holmqvist M, et al
      . Alcohol consumption is associated with progression of hepatic fibrosis in non-alcoholic fatty liver disease. Scand J Gastroenterol 2009;44:366–74. doi:10.1080/00365520802555991
      OpenUrlCrossRefPubMed
    39. ↵
      1. Husain A,
      2. Chiwhane A,
      3. Kirnake V
      . Non-invasive assessment of liver fibrosis in alcoholic liver disease. Clin Exp Hepatol 2020;6:125–30. doi:10.5114/ceh.2020.95739
      OpenUrl
    40. ↵
      1. Oeda S,
      2. Tanaka K,
      3. Oshima A, et al
      . Diagnostic accuracy of fibroscan and factors affecting measurements. Diagnostics (Basel) 2020;10:11. doi:10.3390/diagnostics10110940
      OpenUrl
    41. ↵
      1. Thiele M,
      2. Detlefsen S,
      3. Sevelsted Møller L, et al
      . Transient and 2-dimensional shear-wave elastography provide comparable assessment of alcoholic liver fibrosis and cirrhosis. Gastroenterology 2016;150:123–33. doi:10.1053/j.gastro.2015.09.040
      OpenUrlCrossRefPubMed
    42. ↵
      1. Pereira PF,
      2. Von Diemen V,
      3. Trindade EN, et al
      . Are noninvasive methods comparable to liver biopsy in postoperative patients after Roux-en-Y gastric bypass? Obes Surg 2020;30:2566–71. doi:10.1007/s11695-020-04513-4
      OpenUrl
    43. ↵
      1. Parikh M,
      2. Johnson JM,
      3. Ballem N, et al
      . ASMBS position statement on alcohol use before and after bariatric surgery. Surg Obes Relat Dis 2016;12:225–30. doi:10.1016/j.soard.2015.10.085
      OpenUrl
    44. ↵
      1. Heinberg LJ,
      2. Ashton K,
      3. Coughlin J
      . Alcohol and bariatric surgery: review and suggested recommendations for assessment and management. Surg Obes Relat Dis 2012;8:357–63. doi:10.1016/j.soard.2012.01.016
      OpenUrlPubMed
    45. ↵
      1. Ramrakhiani NS,
      2. Le MH,
      3. Yeo YH, et al
      . Validity of international classification of diseases, tenth revision, codes for cirrhosis. Dig Dis 2021;39:243–6. doi:10.1159/000510981
      OpenUrl
    46. ↵
      1. Dahiya M,
      2. Eboreime E,
      3. Hyde A, et al
      . International classification of diseases codes are useful in identifying cirrhosis in administrative databases. Dig Dis Sci 2022;67:2107–22. doi:10.1007/s10620-021-07076-1
      OpenUrl
    47. ↵
      1. Pang JXQ,
      2. Ross E,
      3. Borman MA, et al
      . Validation of coding algorithms for the identification of patients hospitalized for alcoholic hepatitis using administrative data. BMC Gastroenterol 2015;15:116. doi:10.1186/s12876-015-0348-5
      OpenUrl

    Footnotes

    • Contributors CA: conceptualisation: supporting; data curation: lead; investigation: equal; writing—original draft: lead); MT: conceptualisation: supporting; data curation: supporting; investigation: equal; writing—review and editing: equal; RLF: formal analysis: lead; methodology: lead; writing—review and editing: supporting; JRL: conceptualisation: equal; supervision: lead; writing—review and editing: equal; NL: conceptualisation: lead; investigation: lead; supervision: equal; writing.

      Guarantor: NL

    • Funding This study was funded by National Center for Advancing Translational Sciences (UL1TR002494).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.