Background and Objectives Bariatric surgery is a highly effective obesity treatment, yet it may predispose individuals to alcohol-related liver injury. While altered ethanol metabolism following procedures like Roux-en-Y gastric bypass (RYGB) is well described, the long-term hepatic consequences, particularly the risk of portal hypertension in patients who develop alcohol-related hepatitis (AH,) remain poorly defined.

Methods Using the TriNetX US Collaborative Network, we identified adult patients diagnosed with AH or alcohol-related cirrhosis. We compared outcomes between patients with a history of RYGB or sleeve gastrectomy (SG) who subsequently developed AH (Bariatric+AH group) and those with AH and no history of bariatric surgery (AH-only group). Propensity score matching was performed on over 44 demographic, clinical, and laboratory variables. Cox proportional hazards models and Kaplan-Meier survival curves were used to estimate the risk of clinically significant portal hypertension (PH) events, liver transplantation, and all-cause mortality at three-, five-, and seven-year follow-ups.

Results After matching, 772 patients were included in each cohort. At 7 years post-index event, the Bariatric + AH group exhibited a significantly higher risk of PH-related complications compared to the AH-only group (HR 1.519; 95% CI, 1.15–2.005; p = 0.003). No significant differences were observed in liver transplantation (HR 1.412; 95% CI, 0.850–2.346; p = 0.181) or all-cause mortality (HR 1.085; 95% CI, 0.904–1.303; p = 0.381). These findings were consistent across all follow-up intervals.

Conclusion Bariatric surgery is associated with an increased long-term risk of portal hypertension in patients who develop alcohol-related hepatitis despite similar mortality and transplantation rates. These findings underscore the need for targeted postoperative counseling, liver-focused surveillance strategies, and integration of hepatologic risk assessment into metabolic surgery care pathways.

The authors have declared no competing interest.

The author(s) received no specific funding for this work.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

All study procedures adhered to applicable ethical guidelines and regulatory requirements. The analysis was conducted using data obtained solely from the TriNetX Research Network, which aggregates de-identified patient information from participating healthcare institutions. These institutions have secured the necessary permissions, consents, and legal authority to contribute data to TriNetX under Business Associate Agreements, ensuring anonymity and restricting the data's use to research purposes only. This framework guarantees that no individual patients can be identified, either directly or indirectly, thereby maintaining compliance with the Health Insurance Portability and Accountability Act (HIPAA) privacy standards. Based on these safeguards and the retrospective nature of the study, the Thomas Jefferson University Institutional Review Board (IRB) determined that formal informed consent was not required. No identifiable data pertaining to patients or contributing healthcare entities were accessed or disclosed in the conduct of this study.

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All analyses were performed using the TriNetX Research Network platform (TriNetX, Inc., Cambridge, MA, USA), which provides access to de-identified electronic health record data contributed by participating healthcare institutions. Due to data use agreements, the specific datasets generated for this study cannot be downloaded or distributed outside the platform. Researchers who wish to reproduce or expand upon these analyses may obtain access to the same data through an institutional license to the TriNetX Research Network. Information regarding access can be found on the TriNetX website (https://trinetx.com/solutions/real-world-datasets/) and may vary by participating institution. Because analyses are conducted within the secure TriNetX environment using dynamically updated datasets, no static dataset, accession number, or DOI is available.