7Gastro-oesophageal reflux disease and obesity: Pathogenesis and response to treatment
Introduction
Although the association may not be causal, there has been a clear increase in the prevalence of obesity and gastro-esophageal reflux disease (GERD) over the last 20 years or so, in Western countries but also in Asia and other countries [1]. The United States lead the way with close to 70% of adults either overweight or obese in some areas [2]. In Europe, the trends may not be as ominous, as shown by the OBEPI national survey performed in France by the pharmaceutical company Roche: 47% of French adults were overweight or obese in 2012. However, obesity almost doubled from 8.5% in 1997 to 15% in 2012.
GERD is one of many diseases clearly linked to obesity. We will review this evidence, and look at the mechanisms that may explain this link. We will also discuss the impact of weight loss on GERD symptoms and complications, and explore the specificities of GERD and obesity in the context of bariatric surgery.
Section snippets
Epidemiology of obesity and GERD
The strong positive association between obesity and GERD symptoms has been convincingly demonstrated in population–based studies over the past ten years [3], [4], [5]. For example, the data from the Nurses' Health Study described a dose-dependent relationship between increasing BMI and frequent (at least once a week) reflux symptoms [5]. The odds ratio for frequent GERD symptoms were above two for obese women (Body mass index, BMI >30 kg m−2) as compared to normal weight individuals. This study
Pathogenesis of GERD in obese patients: general factors
The link between BMI and GERD symptoms, esophageal acid exposure and GERD complications is therefore quite clear. Recent studies have proposed that abdominal rather than global obesity might be the real culprit. A large study of more than 80,000 subjects showed that abdominal diameter (a surrogate measure of visceral fat) rather than BMI was associated with frequent GER symptoms [15]. Based on measurement of abdominal fat by CT scan, two studies found a significant association between erosive
Pathogenesis of GERD in obese patients: digestive factors
Increased fat consumption is frequent in obese patients, and this eating behaviour may induce by itself GER symptoms and erosive oesophagitis, while high fibre intake reduces the risk of GER symptoms [24]. Fox et al showed, by recording esophageal pH variations during four days with a wireless capsule that a high-fat diet increased the frequency of GER symptoms, compared to a low-fat diet, and this effect was independent of the caloric content of the meal [25]. It has been shown in classical
Weight loss and GERD: medical aspects
The main objective when confronted to an obese patient with GERD is to treat the obesity first, as weight loss will improves quality of life, and also decreased all the comorbidities associated with obesity such as cardiovascular diseases, diabetes, etc. Once again, the Nurses' Health Study clearly demonstrated that weight loss is beneficial for GERD symptoms [5]: a weight loss amounting to a decrease of BMI of 3.5 kg m−2 over a period of 14 years decreased the risk of frequent GER symptoms by
Obesity and GERD: surgical aspects
The issue of GERD with or without HH in the event of bariatric surgery has been discussed ever since bariatric procedures have become technically similar to the oeso-gastric procedures performed in general surgery, i.e. after jejuno-ileal bypass has been discarded in the early sixties. Does GERD cause malfunction of a given surgical intervention, and does a given intervention elicit GERD, improve or worsen it? Debates have been strong, and are still going on, since proponents of various
What are the results of bariatric surgery in terms of GERD improvement?
As a powerful weight-loss tool, bariatric surgery aims at the relief of GERD symptoms. De Groot et al have presented a review of the literature on the effects of bariatric surgery, diet and lifestyle interventions, and weight loss on GERD [39]. With regard to conservative management, four of seven studies reported an improvement of GERD. For Roux-en-Y gastric bypass (RYGB), a positive effect on GERD was found in all studies, although this was mainly evaluated by questionnaires. In contrast, for
Should HH repair be associated with bariatric surgery?
It occurs to many surgeons that weight loss achieved through bariatric procedures may be insufficient to cure GERD when present at the time of the surgery. This question remains largely unanswered, yet HH repair is commonly done concomitantly with laparoscopic RYGB, LSG and LAGB to decrease GERD. In order to find evidence about the additional surgical risk these combined procedures engender, al-Haddad et al reviewed the United States Nationwide Inpatient Sample 2004–2009 to compare mortality
Vertical banded gastroplasty
We must consider this operation although it belongs more or less to history, having been discarded for some years and no longer recommended worldwide. GERD has been pointed out has a possible complication of the technique, as well as pouch issues and esophageal dysmotility, but to a lesser extent than with LAGB [49]. The creation of a rather small gastric pouch with a narrow outlet of 4–5 cm diameter had similar consequences as LAGB, although its volume and shape were different. Likewise, food
Can we draw lessons from GERD endoscopic treatment if we move to minimally invasive bariatric techniques?
Endoscopic therapy for GERD has been a leading research procedure for more than 15 years, and has been deemed to possibly replace anti-reflux surgery and HH repair. This ability is now questioned in comparison to proton pump inhibitors (PPI) treatment and laparoscopic surgery. Various techniques have been described that reinforce the EGJ. Two of them should probably be discarded for obesity treatment: radio-frequency (Stretta) and non-circular injection of polymers. Two of them have potential
Conflict of interest statement
None.
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