Gastroenterology

Gastroenterology

Volume 152, Issue 7, May 2017, Pages 1656-1670
Gastroenterology

Gastrointestinal Implications
Gastrointestinal Complications of Obesity

https://doi.org/10.1053/j.gastro.2016.12.052Get rights and content

Obesity usually is associated with morbidity related to diabetes mellitus and cardiovascular diseases. However, there are many gastrointestinal and hepatic diseases for which obesity is the direct cause (eg, nonalcoholic fatty liver disease) or is a significant risk factor, such as reflux esophagitis and gallstones. When obesity is a risk factor, it may interact with other mechanisms and result in earlier presentation or complicated diseases. There are increased odds ratios or relative risks of several gastrointestinal complications of obesity: gastroesophageal reflux disease, erosive esophagitis, Barrett’s esophagus, esophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Gastroenterologists are uniquely poised to participate in the multidisciplinary management of obesity as physicians caring for people with obesity-related diseases, in addition to their expertise in nutrition and endoscopic interventions.

Section snippets

Esophagus

Many esophageal disorders are associated with obesity.

Stomach

Gastric physiology and its neurohormonal regulation36 are altered in obesity; however, it is unclear whether gastric function abnormalities are the cause or consequence of obesity. Obesity also is associated with symptoms that may arise in the stomach, such as upper abdominal pain, nausea, vomiting, retching, and gastritis.37, 38

Small Intestine

The small intestine is the site of digestion and absorption of most nutrients. In the past, it was thought that the small intestine played a passive role, simply absorbing the excess calories ingested by obese people. Bile acids play a critically important role in the absorption of fats; the role of bile acids in metabolic regulation52 or as potential therapeutic approaches for obesity and metabolic syndrome53 are beyond the scope of this article; however, there is no evidence that bile acid

Constipation

The association between obesity and constipation is controversial, with a higher prevalence of constipation in obese people in a community-based epidemiologic study in the United States3; this was not reproduced in other large cohort studies.59 In children, constipation, but not constipation-predominant irritable bowel syndrome, is more common in obese individuals.86, 87

Diverticular Disease

Obesity is associated with a higher risk of developing diverticulosis,88 as well as an increased number of diverticuli89 and

Dyssynergic Defecation

Female patients have a higher likelihood of experiencing constipation secondary to pelvic floor disorders (83% in 1 large series of 390 female patients)106 and, particularly, constipation associated with descending perineum syndrome,107 which usually is associated with multiparity and is observed almost exclusively in females. In a representative Swedish cohort of 1001 people in the general population, obesity was associated with incomplete rectal evacuation (OR, 1.64; 95% CI, 1.09–2.47),

Liver

The liver is central to nutrient regulation, and frequently is involved in obesity-associated NAFLD. NAFLD has surpassed other chronic liver diseases to become the most prevalent chronic liver disease in the United States and the most frequent cause of increased transaminase levels. It affects approximately 30% of the population; with a worldwide prevalence range of 5%–46%.111, 112, 113 Population-based studies have shown a positive correlation between body mass index and NAFLD, suggesting

Gallbladder

Obesity has been well recognized for its strong association with gallstone diseases.145, 146 Subjects with obesity have a higher incidence of cholelithiasis, cholecystitis, and cholesterolosis when compared with lean controls.147 A meta-analysis showed that the risk for gallbladder disease in men was 1.63 (95% CI, 1.42–1.88) for overweight and 2.51 (95% CI, 2.16–2.91) for obesity; in women, the RR was 1.44 (95% CI, 1.05–1.98) for overweight and 2.32 (95% CI, 1.17–4.57) for obesity.148 Abdominal

Pancreas

Obesity and fat infiltration of the pancreas play a significant role in the endocrine pancreatic dysfunction that leads to the development of type 2 diabetes mellitus (further details are not pertinent for this review).154 Obesity also has been associated with pancreatitis and pancreatic cancer.

Summary

The increased prevalence of gastrointestinal conditions in the general population may be related to the increased prevalence of obesity in Western countries. Thus, it is important to recognize the role of higher BMI and, particularly, increased abdominal adiposity, in the development of gastrointestinal morbidity and, therefore, to measure BMI and waist circumference in patients presenting with gastrointestinal complaints or abnormal liver function.

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    Conflicts of interest The authors disclose no conflicts.

    Funding Supported by National Institutes of Health RO1-DK67071 (M.C.), K08-DK97178 (H.M.), and R03-DK107402 (H.M.).

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