Gut and Liver, Vol. 6, No. 4, October 2012, pp. 520-523 case report A Case of Nonalcoholic Steatohepatitis and Small Intestinal Bacterial Overgrowth with Peripheral Edema Caused by Intestinal Bypass Surgery and Relieved by Repair Young Kyung Sung, Geum Youn Gwak, Moon Seok Choi, Kwang Chul Koh, Seung Woon Paik, Byung Chul Yoo, and Joon Hyeok Lee Department of Medicine, Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Korea Intestinal bypass surgery, particularly jejuno-ileal bypass surgery, performed for the purpose of weight reduction may cause an unexpected exacerbation of nonalcoholic steato- hepatitis (NASH). Here, we report a case of NASH caused by small intestinal bacterial overgrowth, which developed after jejuno-colic bypass surgery and resolved dramatically after surgical correction. (Gut Liver 2012;6:520-523) Key Words: Nonalcoholic steatohepatitis; Bypass surgery; Small intestinal bacterial overgrowth INTRODUCTION Intestinal bypass surgery, particularly jejuno-ileal bypass, performed for the purpose of weight reduction may cause un- expected exacerbation of nonalcoholic steatohepatitis (NASH). Small intestinal bacterial overgrowth (SIBO) and subsequent stimulation of tumor necrosis factor (TNF) by bacterial endo- toxin has been postulated as one to the etiologic factors, but the exact mechanism remains to be determined. Since morbid obesity is relatively rare in Korea and this type of operation has rarely been performed in the past. Here, we report a case of NASH and SIBO developed after intestinal bypass surgery, which was performed to improve symptoms related to intestinal adhesion, successfully treated by bypass repair. CASE REPORT A 45-year-old man was first seen in the outpatient gastroin- testinal division of this hospital with complaining of diarrhea in 1996. He had diarrhea, bloating, postprandial fullness of 1 year’s duration. The body weight was not changed during 1 year. The other multisystem review was unremarkable. The past medical history revealed intra-abdominal operations in three times. In 1982, the patient has undergone appendecto- my. In 1983, small bowel segmental resection and anastomosis was performed to relieve postoperative small bowel adhesion. In 1995, the recurrent abdominal pain related to small bowel adhesion was relieved by side to side jejuno-colostomy, from mid jejunum to transverse colon (between jejunum below 100 cm from the Treitz ligament and mid-transverse colon) because the greater omentum was densely adherent to about 1/2 to 2/3 of the distal ileum in a very tightly kinked and matted fashion. The amount of his alcohol consumption was less than 40 gm of alcohol each time, once or twice a week. He denied history of diabetes mellitus or any other disease. The family history was unremarkable. Physical examination revealed no significant abnormal find- ing except paramedian abdominal incision scar. His vital signs were normal and his weight and height were 65 kg and 170 cm, respectively. Initial laboratory studies revealed a normal com- plete blood count and chemistry. Quantitative fecal fat test was negative. On the double contrast barium enema study, it was side to enterocolostomy without any passage disturbance or lu- minal narrowing. Symptomatic treatment was initiated with loperamide, fenoverine under a suspicion of bile acid malabsorption or ir- ritable bowel syndrome. In 1998, 2 years after since the first visit and 3 years after bypass surgery, lower extremities pitting edema and weight loss of 4 kg developed. The laboratory tests were as follow: white cell count 5,900/ mm3, hemoglobin 10.5 g/dL, platelet 402,000/mm3, total protein Correspondence to: Joon Hyeok Lee Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Korea Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail: liverjhlee@skku.edu Received on August 12, 2010. Revised on December 22, 2010. Accepted on February 18, 2011. pISSN 1976-2283 eISSN 2005-1212 http://dx.doi.org/10.5009/gnl.2012.6.4.520 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.