Elsevier

Nutrition

Volume 47, March 2018, Pages 110-114
Nutrition

Case report
Fat burner–induced acute liver injury: Case series of four patients

https://doi.org/10.1016/j.nut.2017.10.002Get rights and content

Highlights

  • Dietary supplement–induced acute hepatitis is a diagnosis of exclusion.

  • Liver biopsy is crucial to confirm the diagnosis, especially in cases in which autoimmune hepatitis cannot be ruled out by immunoserology.

  • Over-the-counter weight loss dietary supplements have become popular and widely available. Their consumption should be considered in unexplained acute hepatitis cases, especially in middle-aged female patients with acute hepatocellular injury.

Abstract

Dietary supplements known as "fat burners" are typically marketed with claims of increasing energy expenditure through alterations in fat metabolism. They are marketed as natural products and their use is thus perceived as a safe body weight reduction strategy. We report on five episodes of liver injury in four patients. Liver injury was associated with consumption of different commercially available fat burners: Green tea extract (Camellia sinensis), Garcinia gummi-gutta, green coffee beans, and spirulina (blue-green algae). The patients were admitted to the Department of Gastroenterology and Hepatology at the University Medical Center Ljubljana, in Slovenia, from May 2010 to July 2015. The first patient developed acute liver failure and had to be treated by liver transplantation. Second patient developed acute hepatitis that resolved spontaneously. Another patient required multiple surgical procedures due to severe hemorrhage after liver biopsy. The last patient was treated for two separate episodes of fat burner–induced liver injury after ingesting two different products, in 2010 and 2015. Liver biopsy was performed in all patients and histopathologic examination revealed no other cause of liver injury. Viral, autoimmune, and metabolic liver diseases were excluded, making unsupervised consumption of fat burners the most likely causative agent.

Introduction

Awareness of the health risks and social implications posed by overweight and obesity has generated a demand for solutions that do not require regular exercise and a healthy diet to achieve adequate control of body weight [1]. Fat burners are popular dietary supplements claimed to alter fat metabolism and cause increased energy expenditure [2]. These products are not regulated and their popularity is based on marketing. Their efficacy and safety are questionable. Inherently unrestricted Internet-based advertising and sales have helped increase both demand for them and their availability [3].

The claimed benefits of fat burners include a general increase in performance, weight loss, and improvements in health in general through antiinflammatory and anticancer effects [4]. Green tea extract, green coffee beans, and spirulina are common herbal dietary supplements and often are the main ingredients of fat burners [4]. While tea (based on Camellia sinensis leaves) and coffee are safe and widely consumed beverages worldwide [5], fat burners, which are based on these in combination with noxious herbs, are rendered potentially hepatotoxic only thorough unpredictable secondary processing using undocumented procedures and additives in various combinations. Green tea extract, secondarily processed Camellia sinensis, has been implicated as a cause of acute liver failure [6]. Herbs and dietary supplements are a known cause of liver injury, although this etiology of hepatotoxicity requires diligent history taking, often on multiple occasions and thus remains underrecognized [7].

In this study, we present five cases of acute liver injury in four adult female patients caused by consumption of fat burner products containing green tea extract, green coffee bean, and spirulina (Table 1). One patient required liver transplantation, one patient suffered acute hemorrhage after liver biopsy and was operated on to achieve hemostasis, and two patients suffered from acute hepatitis after ingesting two different fat burner products (Table 2).

Section snippets

Case 1

A female patient, 57 y of age, was admitted to the department with acute hepatitis. She noticed dark-orange urine 4 wk before admission; watery diarrhea, generalized pruritus, nausea, and jaundice appeared 3 wk later. Viral hepatitis and infectious enterocolitis were excluded at the department for infectious diseases just before admission. She had been treated for arterial hypertension and gastroesophageal reflux disease with ramipril 2.5 mg and hydrochlorothiazide 12.5 mg polypill (half of a

Case 2

A 51-y-old woman was hospitalized after visiting the emergency department due to myalgia, sore throat, dry cough, and shaking chills without fever, which were followed by epigastralgia with nausea and vomiting. She denied possible food poisoning, risky sexual behavior, and drug use.

She worked in a metal fabrication company, where zinc, bromine, and bases were used. She did not smoke and rarely consumed alcohol. Clinical examination was unremarkable.

Blood work revealed TBIL of 2.8 mg/dL, AST of

Case 3

A 55-y-old woman was admitted to the department due to chest pain, nausea, vomiting, jaundice, and pruritus. She denied use of both alcohol and medication. Her symptoms developed after she started consuming “green coffee” pills. She took six pills. Her vital signs were all within normal values.

Initial blood work showed TBIL 3.7 mg/dL, AST 221 U/L, ALT 666 U/L, GGT 87 U/L, AP 213 U/L, INR <1, and albumin 4.1 mg/dL. An abdominal ultrasound scan was normal. Endoscopic ultrasound excluded

Case 4

A 57-y-old woman was admitted with jaundice and pruritus. Four days before the visit, she developed epigastric and right-upper quadrant pain with nausea. Mild pain had been intermittently present for almost a year. The pain was commonly exacerbated after a meal or when fasting.

Her medical history was notable for uterus surgery 10 years before admission because of a benign tumor. She had undergone surgery due to ovarian torsion 6 y previously and had been diagnosed with Helicobacter pylori

Discussion

We reported on three patients with spontaneously resolved acute liver injury following consumption of fat burners containing green tea extract and green coffee beans and on one with acute liver failure that required urgent transplantation following consumption of fat burners containing spirulina. All patients were women and in all cases, the main motive for consumption was weight loss.

Contrary to popular belief, products assumed to be natural remedies can be harmful to one's health after being

Conclusion

The present case series confirms previous reports [3] of green tea extract hepatotoxic properties. Dietary supplement–induced liver injury is not uncommon and should be considered outside the presented population of middle-aged female patients taking weight loss pills. The key to diagnosis is a high index of suspicion, diligent history taking, and exclusion of other causes.

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