Gastroenterology Clinics of North America
Volume 39, Issue 1, Pages 1-156 (March 2010)
Gastroenterologic Issues in the Obese Patient
Edited by David A. Johnson
Obesity has emerged as a major global health problem with disease prevalence reaching epidemic proportions. In the United States alone, obesity is responsible for more than 300,000 deaths per year. Additionally, the direct and indirect related costs for care of obesity-related disease exceed $100 billion per year. Obesity has a particular relevance to gastroenterologists given the wide spectrum of causally related disease implications specific to this specialty. It is increasingly apparent that obesity has significant implications for gastrointestinal diseases and increased risks of serious consequences, including cancer. Gastroenterologists are increasingly involved in the care of obese and overweight patients. This involvement includes assessing for appropriate screening for neoplasia, as well as conducting evaluations or interventions pre- or postoperatively.
In the first article, Drs Dang Nguyen and Hashem El-Serag define the scope of the obesity problem. Over the last 3 decades, overindulgence and obesity have been transformed from a relatively minor public health issue affecting affluent societies to a current global epidemic with major public health implications. This article puts into perspective the epidemiologic implications, in particular for gastrointestinal-related diseases.
In the next two articles, the focus is on gastrointestinal symptoms in obese patients. The role of gastrointestinal symptoms in overweight and obese individuals has only barely been explored, which is surprising given that the gastrointestinal tract is responsible for the mechanical and chemical breakdown of food for absorption by the body. Dr Guy Eslick puts into perspective the prevalence of particular gastrointestinal symptoms correlated with increased body weight. Dr Amy Foxx-Orenstein follows with an excellent summary of the physiologic explanations for this correlation of increased gastrointestinal symptoms as a function of body habitus.
Gastroesophageal reflux disease is an extremely prevalent disease and there is increasing evidence to support a causal relationship with obesity for both disease prevalence as well as complications. Drs Girish Anand and Phil Katz detail the most recent evidence for mechanistic explanations for causality and highlight the increased severity and complications of gastroesophageal reflux disease in this specific patient population.
While the most studied effect of obesity is on its association with colorectal neoplasia, lesser known effects include a heightened risk of complications of diverticulosis, a heightened risk inadequate bowel preparation, and a poorer, postoperative outcome after colon surgery. Dr Carol Burke provides a comprehensive update on the effects of obesity on colonic diseases and complications. The review highlights the emerging data showing that adverse effects of obesity on the colon promote carcinogenesis and impair wound healing. This has implications for appropriate screening as well as surgical management of the obese patient.
Nonalcoholic fatty liver disease is a very common clinical condition evident as a complication of obesity. The spectrum of liver histologic abnormalities ranges from simple steatosis to steatohepatitis, advanced fibrosis, and cirrhosis. Dr Anna Mae Diehl provides an outstanding overview of the comorbid diseases associated with obesity-related liver disease and then reviews the clinical features, management strategies, and prognosis for this extremely prevalent problem.
The medical management for obesity is a key area of interest. Pharmacologic therapy for obesity is clearly in a state of transition. Historically, there have been few effective agents, and many have been withdrawn because of unacceptable side effects. Given the widespread prevalence of obesity, there is intense interest in a nonsurgical option for treatment. Dr Lee Kaplan details the past, present, and future medications for the medical therapy option. His article focuses on key areas of interest to providers taking care of patients who are on these agents and highlights potential side effects and complications related to these medications.
Gastroenterologists are becoming increasingly involved in both the preoperative and postoperative care of bariatric patients. Accordingly, it is key for gastroenterologists (and those dealing with gastrointestinal-related issues) to understand the full spectrum of assessment and management. This ranges from both the preoperative evaluation for gastrointestinal-related disease to management of a wide array of endoscopic interventions and metabolic complications postoperatively. Dr David Greenwald begins the discussion with the gastrointestinal role in the preoperative assessment of bariatric patients. Drs Mitch Schreiner and Brian Fennerty focus in particular on the standard endoscopic assessment and management both pre- and postoperatively. Drs Tercio Lopes and Mel Wilcox then address the approach to the postoperative bariatric patient with pancreaticobiliary disease and provide insight and technical expertise dealing with the altered anatomy. Dr Tim Koch then provides an excellent overview on the wide array of metabolic complications for the postoperative bariatric patient. His review highlights the macro- and micronutrient potential deficiencies and he provides a comprehensive approach to both the short- and long-term management to treat or potentially avoid these complications.
Bariatric surgery is the most definitive treatment for obesity. As bariatric surgery has gained widespread acceptance, evidence continues to grow that it is the only treatment currently available that demonstrates significant cure rates for such diseases as diabetes, hypertension, and heart failure, as well as the myriad of other comorbid conditions associated with obesity. In 2008, at least 220,000 obesity surgeries were done in the United States, with gastric bypass being the “most popular method.” Drs Mark Fontana and Steve Wohlgemuth review the weight-loss surgery options. The emphasis is on the common operations performed currently, but they also discuss operations no longer performed. Knowledge of the anatomic changes is key to understanding and optimizing management strategies of the short- and long-term postoperative complications. Drs Paul Frank and Peter Crookes provide the surgeon's perspective for the short- and long-term follow up of the postbariatric surgery patient. They emphasize that, although early surgical follow up is concentrated on the perioperative period to ensure healing and care for any surgical complications, the key element of ultimate “surgical success” is the long-term programmatic follow up for these patients. These authors provide recommendations drawing from their extensive experience with the comprehensive program used at their institution.
Recognizably from this edition of Gastroenterology Clinics of North America, obesity is a major risk factor for a range of serious medical conditions, including a wide spectrum of gastrointestinal-related disorders and complications. The complex metabolic activity of adipose tissue results in the production of proinflammatory cytokines and neurohumoral and immune-mediated mechanisms, leading to a host of systemic effects, which include a broad array of gastrointestinal symptoms and diseases.
So where do we go from here? All medical practitioners, including gastroenterologists and bariatric surgeons, must remain aggressive about addressing and treating obesity in their patients. This monograph will, it is hoped, be a key step in advancing the knowledge base of those who care for obese patients. Furthermore, it is the collective intent of the authors that this will also highlight the absolute need for a comprehensive, well-integrated multidisciplinary and lifelong approach to these patients
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