Abnormal liver function is occasionally observed in patients affected by anorexia nervosa. Although numerous studies report a strong relation between malnutrition and liver damage, the pathogenesis remains still unclear. We describe a case of a young girl with severe anorexia nervosa who developed acute liver damage with multiorgan involvement during extremely poor nutritional status. In this patient severe malnutrition constituted a predisposing factor for multiorgan dysfunction. In the absence of other identifiable factors, we hypothesized that a marked increase in liver enzymes and other biochemical abnormalities could be a consequence of a precipitating cause as acute hypoperfusion, suggested by clinical symptoms (marked dehydration, hypotension, bradycardia, hypothermia) and laboratory data. Rapid normalization of liver function tests and other biochemical parameters with rehydration and gradual nutritional support confirmed this hypothesis.