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Gastrointestinal Disease -

Gastro-Oesophageal Reflux Disease and Hiatal Hernia:

  1. Raised intra-abdominal pressure caused by the increased volume of fat inside the abdomen, raises the pressure in the abdomen and pushes the upper part of the stomach into the thorax (chest), with resultant distortion and impaired function of the lower oesophageal sphincter, a muscular ring which normally allows food into the stomach but prevents stomach contents from flowing back up into the oesophagus.
  2. Stomach acid refluxes into the oesophagus and burns the lower oesophagus. This causes the symptom “heartburn”, which is due to inflammation and ulceration of the lower oesophagus.
  3. Chronic reflux can lead to a pre-malignant condition called Barrett’s metaplasia (abnormal cells in the oesophagus), which can progress to dysplasia (physically noticeable changes in the oesophagus) and, ultimately to adenocarcinoma (cancer) of the oesophagus.
  4. A Roux-en-Y gastric bypass will cure the problem of acid reflux, because a) there will be very little acid produced by the small gastric pouch and b) after significant weight loss, the intra-abdominal pressure will decrease.


Fatty Liver:

  1. Fatty liver is usually associated with a) obesity, b) type 2 diabetes and/or c) excessive alcohol intake.
  2. The first stage is called steatosis where there is infiltration of fat into the liver cells. This can progress to steatohepatitis, where the presence of fat results in inflammation that damages the liver cells. From here the condition can progress to fibrosis in the liver and eventually to cirrhosis, an end-stage disorder of the liver that ultimately causes liver failure.

Bariatric surgery will ameliorate the condition by greatly reducing obesity and, in a significant proportion of patients, curing the type 2 diabetes and improving the blood lipid levels.

Mattar SG et al published in Annals of Surgery (2005;242: 610–620) their analysis of liver biopsies before and after surgical weight loss and showed that surgical weight loss results in significant improvement of liver morphology in severely obese patients. They concluded that these beneficial changes may be associated with a significant reduction in the prevalence of the metabolic syndrome.


Gallstones:

  1. Gallstones occur most commonly in obese females. They also form more commonly in people who lose weight rapidly. Thus, obese women who diet intermittently and repeatedly are particularly prone to developing gallstone disease.
  2. Once gallstones have formed they can cause gallstone colic when the gallbladder contracts and tries to push the stones through the narrow cystic duct that connects the gallbladder to the main bile duct. This can cause attacks of very severe upper abdominal pain that may last from a few minutes to several hours. Typically the pain radiates round to the back at the lower tip of the shoulder blade (scapula).
  3. Some people with gallstones have less dramatic, but more chronic pain, associated with chronic cholecystitis where there is low-grade inflammation in the gallbladder.
  4. If the chronically inflamed gallbladder becomes infected acute cholecystitis results. When this happens the patient has pain, nausea and fever and needs to be admitted to hospital for antibiotics and urgent surgical removal of the gallbladder (cholecystectomy).
  5. If gallstones pass through the cystic duct into the main bile duct, they may obstruct the bile duct, causing obstructive jaundice or they may obstruct the pancreatic duct causing acute pancreatitis. If an obstructed bile duct becomes contaminated by bacteria, the stagnant bile becomes infected and cholangitis results. This is a very serious, life-threatening condition if appropriate intervention is not implemented very urgently.
  6. Bariatric surgery does not directly improve gallstone disease and by virtue of the fact that it causes rapid weight loss, it may predispose to the formation of gallstones in the medium term. If a patient has gallstones at the time of undergoing bariatric surgery, it is often advised that the gallbladder be removed at the same time.

Acute Pancreatitis:

  1. This is a serious disease that results from inappropriate activation of pancreatic enzymes within the pancreas itself (normally they are only activated in the intestine), resulting in autodigestion (self-digestion) of the pancreas and, resulting from this, severe inflammation.
  2. Clinically, acute attacks of pancreatitis are classified as a) mild (85%), requiring only short hospitalization for bowel rest with intravenous fluids and pain-killers, or b) severe (15%) in which where multi-organ failure occurs, requiring prolonged admission to an intensive care unit. There is a 20-30% risk of death in severe pancreatitis.
  3. There are many causes of acute pancreatitis, but the most common by far are: a) passage of a gallstone and b) excessive alcohol intake, typically in the form of binge drinking.
  4. Obese people, as mentioned above, have a high incidence of gallstone disease and by virtue of this are at increased risk of acute pancreatitis. Another important cause of acute pancreatitis is elevated blood levels of a form of fat called triglycerides, which is common in type 2 diabetics. Obviously, obese people who binge drink have numerous risk factors for acute pancreatitis.
  5. Importantly, obese people are much more likely to develop severe acute pancreatitis.
  6. Many drugs have been implicated as causes of acute pancreatitis. Orlistat, a lipase inhibitor used to treat obesity is one drug on this list.

Cancers:

  1. Obese people are generally regarded as being at higher risk of developing cancers of three of the most common cancers of the gastrointestinal tract, viz. colon, pancreas and stomach.
  2. It has been shown that in men, a 5kg/m2 increase in BMI was strongly associated with oesophageal adenocarcinoma (RR 1•52, p<0•0001) and colon cancers (RR 1•24, p<0•0001). In women, there are strong associations between a 5kg/m2 increase in BMI and adenocarcinoma of gallbladder (1•59, p=0.04) and oesophagus (1 • 51, p<0•0001). There were also weaker positive associations (RR < 1•20) between increased BMI and rectal cancer in men and pancreatic and colon cancers in women.

Diverticular Disease:

  1. This is a degenerative disease of the colon (large intestine) in which the mucosa (inner layer) of the colon herniates through the muscular layers. The resulting small pockets of herniated mucosa are prone to being filled with inspissated (thickened, condensed) faeces, getting infected and causing severe illness. Delay in appropriate treatment can result in abscess formation around the affected segment of colon or even frank perforation (in which the contents of the infected colon leak into the abdominal cavity.) This has very serious consequences.
  2. Diverticular disease, gallstone disease and hiatal hernia are commonly associated (Saint’s triad) and much more common in obese people.

 

Pelvic Floor Disorders including rectal prolapse and faecal incontinence:

  1. Varma MG et al published in the journal Diseases of Colon and Rectum (in June 2006; 49(6):841-851) the results of their study of risk factors for faecal incontinence in females aged over 40. Obesity was one of 5 factors found on multivariate analysis to be associated with an increased prevalence, of faecal incontinence, with obesity accounting for a 20% increase in prevalence.
  2. In another study published by Danforth KN et al in American Journal of Obstetrics and Gynaecology in February 2006, women with a BMI over 30 had 3.1 times the incidence of severe urinary incontinence compared to women with a BMI of 22-24.
  3. Subak LL et al (Journal of Urology August 28 2006) showed in a prospective randomized trial that women who lost a mean of 16kg had a 60% reduction in urinary incontinence episodes. They concluded that a 5-10% loss of weight had a similar effect to other non-surgical treatments for urinary incontinence.
  4. Brown JS et al in Diabetes Care (2006 February; 29(2): 385-390) showed that changes in weight accounted for most of the protective effects of an intensive lifestyle intervention study in diabetic women with stress incontinence.


For more information on pelvic floor disorders, go to www.pfdu.co.za