Crohn's disease after gastric bypass surgery

The impact of bariatric surgery on admissions for gastrointestinal complications and conditions associated with obesity: A nationwide study

BACKGROUND

Obesity worsens various gastrointestinal pathologies. While bariatric surgery ameliorates obesity, it substantially modifies the gastrointestinal system depending on surgery type, with limited data on subsequent impact on obesity-related gastrointestinal admissions.

METHODS

Using the 2012-2014 Nationwide Readmission Database, we included individuals with obesity who received vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), or hernia repair (HR-control surgery). Our main focus was the adjusted odds ratio (aOR) for gastrointestinal inpatient admissions within 6 months following surgery compared to the 6 months preceding it, while controlling for several confounding factors. Gastrointestinal admissions were grouped into postoperative complications or obesity-associated gastrointestinal conditions.

RESULTS

Our cohort included 140,103 adults with RYGB, 132,253 with VSG, and 12,436 HR controls. Postoperative gastrointestinal complications were most common after RYGB, prominently obstruction (aOR = 33.17, 95%CI: 18.01, 61.10), and Clostridium difficile infection (aOR: 12.52, 95%CI: 6.22, 25.19). VSG also saw significantly increased but less frequent similar conditions. Notably, for gastrointestinal conditions associated with obesity, acute pancreatitis risk was higher post-VSG (aOR = 6.26, 95%CI: 4.02, 9.73). Post-RYGB patients were most likely to be admitted for cholelithiasis with cholecystitis (aOR: 4.15, 95% CI: 3.24, 5.31), followed by chronic liver disease (aOR: 3.00, 95% CI: 2.33, 3.87). The risk of noninfectious colitis admissions was threefold higher after RYGB and VSG. No gastrointestinal conditions showed an increase after HR.

CONCLUSION

Despite weight loss, bariatric surgery was associated with an increased risk of hepato-pancreatobiliary and colitis admissions related to obesity in the first six postoperative months, with considerable variations in rates of gastrointestinal conditions by surgery type.

De Novo Inflammatory Bowel Disease Following Bariatric Surgery: a Systematic Review and Meta-analysis

The incidence of both obesity and inflammatory bowel disease (IBD) is rising globally. The influence of bariatric metabolic surgery (BMS) upon IBD development is largely unknown. This systematic review and meta-analysis aimed to evaluate the relationship between BMS and the risk of de novo IBD development following surgery. A systematic literature search and meta-analysis were performed using PubMed and Scopus databases. Inclusion criteria were any study reporting risk of de novo IBD development following BMS relative to an appropriate control cohort. Pooled odds ratios (POR) were calculated. A total of 31 articles were identified by the literature search. Four studies including 149,385 patients met the inclusion criteria and were included in the meta-analysis. Pooled estimation of a meta-analysis of risk ratios studies demonstrated a POR for the development of IBD following BMS of 1.17 (95% CI, 1.06-1.29). This indicates a 17% increase in relative risk of de novo IBD development for those patients receiving BMS compared to those treated by non-surgical methods. Based on the present data, there appears to be an association between BMS and risk of de novo IBD. Compared to the proven benefits of BMS on other aspects of patient health, this potential risk remains proportionally low but may be an important consideration for patients both pre- and post-operatively.

Exploring the Relationship Between Bariatric Surgery and Inflammatory Bowel Disease: A Systematic Review

Background

Obesity affects over 40% of Americans. Bariatric surgery is an increasingly popular and well-studied method to achieve weight loss, improve metabolic homeostasis, and resolve obesity-related comorbid conditions. While the impact of bariatric surgery on weight loss and metabolic health has been extensively studied, there is an increasing body of literature characterizing the impact of bariatric surgery on gastrointestinal health and inflammation. Inflammatory bowel disease (IBD) leads to inflammation in both the small and large intestine, and leads to significant patient morbidity. Similar to obesity, the incidence of IBD is also rising. Patients with IBD and obesity may seek bariatric surgery. The impact of bariatric surgery on IBD is not well understood, but critical to understand for optimal patient care. Herein, we review the currently available literature on the impact of bariatric surgery on IBD including common trends, discrepancies in findings, and remaining knowledge gaps in need of further study.

Methods

A systematic review of the PubMed/MEDLINE database using PRISMA guidelines was performed.

Results

We identified 12 manuscripts discussing de novo IBD after bariatric surgery and 16 studying bariatric surgery in patients with pre-existing IBD. Overall, bariatric surgery appears to be safe in patients with pre-existing IBD but may increase the risk of developing de novo IBD.

Conclusions

Further research into optimal surgical approaches, patient selection, and mechanisms on how bariatric surgery impacts IBD is needed.

The risk of inflammatory bowel disease after bariatric surgery

BACKGROUND

The association between bariatric surgery and new onset of inflammatory bowel disease has so far only been sparsely studied and with conflicting results.

OBJECTIVES

To investigate the association between bariatric surgery and inflammatory bowel disease in a large population-based cohort.

SETTING

Nationwide in Sweden.

METHODS

This population-based retrospective cohort study included Swedish individuals registered in the Scandinavian Obesity Surgery Registry who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy during 2007-2018. Ten control individuals from the general population were matched according to age, sex, and region of residence at time of exposure. The study population was followed until 2019 with regard to the development of inflammatory bowel disease. Cox proportional hazards models were used to compare disease-free survival time between subgroups and control individuals for each outcome.

RESULTS

The final cohort consisted of 64,188 exposed individuals with a total follow-up of 346,860 person-years and 634,530 controls with total follow-up of 3,444,186 person-years. Individuals who underwent Roux-en-Y-gastric bypass had an increased risk of later development of Crohn's disease (hazard ratio [HR] 1.8, 95% CI 1.5-2.2) and unclassified inflammatory bowel disease (HR 2.7, 95% CI 2.0-3.7) but not ulcerative colitis (HR .9, 95% CI .8-1.1) compared with control individuals, whereas individuals who underwent sleeve gastrectomy had an increased risk of ulcerative colitis (HR 1.8, 95% CI 1.1-3.1) but not Crohn's disease (HR .8, 95% CI .3-2.1) and unclassified inflammatory bowel disease (HR 2.5, 95% CI .8-7.8).

CONCLUSIONS

Roux-en-Y gastric bypass was associated with increased risk of Crohn's disease and unclassified inflammatory bowel disease, whereas sleeve gastrectomy was associated with increased risk of ulcerative colitis only.

Bariatric Surgery and Risk of New-onset Inflammatory Bowel Disease: A Nationwide Cohort Study

BACKGROUND AND AIMS

The aim of this study was to examine the risk of new-onset inflammatory bowel disease [IBD] following bariatric surgery.

METHODS

We conducted a nationwide population-based prospective cohort study of the entire Danish population 18 to 60 years of age, alive, and residing in Denmark, from 1996 to 2018. Bariatric surgery was included as a time-dependent variable, and Cox proportional hazards regression models were used to estimate hazard ratios [HRs] of IBD. We used a model adjusting for age, sex, and birth cohort and a multifactor-adjusted model additionally including educational status and number of obesity-related comorbidities.

RESULTS

We followed 3 917 843 individuals of whom 15 347 had a bariatric surgery, for development of new-onset IBD. During 106 420 person-years following bariatric surgery, 100 IBD events occurred [incidence rate 0.940/1000 person-years]. During 55 553 785 person-years without bariatric surgery, 35 294 events of IBD occurred [incidence rate 0.635/1000 person-years]. This corresponded to a multifactor-adjusted hazard ratio [HR] of 1.15 (95% confidence interval[CI], 0.94-1.40) for IBD. Multifactor-adjusted HRs of Crohn's disease [CD] and ulcerative colitis [UC] were 1.85 [95% CI, 1.40-2.44] and 0.81 [95% CI, 0.61-1.08], respectively. Among women, the multifactor-adjusted HR for CD was 2.18 [95% CI, 1.64-2.90]. When limiting the study population to individuals with a diagnosis of overweight/obesity, bariatric surgery remained associated with increased risk of CD, multifactor-adjusted HR 1.59 [95% CI, 1.18-2.13].

CONCLUSIONS

This nationwide cohort study shows that bariatric surgery is associated with increased risk of development of new-onset CD, but not of UC. The underlying mechanisms remain elusive.

TGR5 Protects Against Colitis in Mice, but Vertical Sleeve Gastrectomy Increases Colitis Severity

BACKGROUND AND AIMS

Bariatric surgery, such as vertical sleeve gastrectomy (VSG), is the most effective long-term treatment for obesity. However, there are conflicting reports on the effect of bariatric surgery on inflammatory bowel disease (IBD). Bariatric surgery increases bile acid concentrations, which can decrease inflammation by signaling through the bile acid receptor, TGR5. TGR5 signaling protects against chemically induced colitis in mice. VSG increases circulating bile acid concentrations to increase TGR5 signaling, which contributes to improved metabolic regulation after VSG. Therefore, we investigated the effect of VSG on chemically induced colitis development and the role of TGR5 in this context.

METHODS

VSG or sham surgery was performed in high fat diet-fed male Tgr5^+/+ and Tgr5^-/- littermates. Sham-operated mice were food restricted to match their body weight to VSG-operated mice. Colitis was induced with 2.5% dextran sodium sulfate (DSS) in water post-operatively. Body weight, energy intake, fecal scoring, colon histopathology, colonic markers of inflammation, goblet cell counts, and colonic microRNA-21 levels were assessed.

RESULTS

VSG decreased body weight independently of genotype. Consistent with previous work, genetic ablation of TGR5 increased the severity of DSS-induced colitis. Notably, despite the effect of VSG to decrease body weight and increase TGR5 signaling, VSG increased the severity of DSS-induced colitis. VSG-induced increases in colitis were associated with increased colonic expression of TNF-α, IL-6, MCP-1, and microRNA-21.

CONCLUSIONS

While our data demonstrate that TGR5 protects against colitis, they also demonstrate that VSG potentiates chemically induced colitis in mice. These data suggest that individuals undergoing VSG may be at increased risk for developing colitis; however, further study is needed.

Glucose Metabolism Parameters and Post-Prandial GLP-1 and GLP-2 Release Largely Vary in Several Distinct Situations: a Controlled Comparison Among Individuals with Crohn's Disease and Individuals with Obesity Before and After Bariatric Surgery

BACKGROUND

This study aims to compare the post-prandial curves of glucose, insulin, GLP-1, and GLP-2 among individuals with Crohn's disease (CD), obese individuals before and after bariatric surgery, and healthy controls.

METHODS

This an exploratory cross-sectional study that involved five groups of patients (two groups of individuals with CD-active and inactive), bariatric patients (pre- and post-surgery, who were their own controls), and a distinct separated control group of healthy volunteers. C-reactive protein (CRP) levels and the post-prandial curves of glucose, insulin, GLP-1, and GLP-2 curves were assessed and compared.

RESULTS

The pre-RYGB group presented significantly higher levels of CRP than the post-RYGB (p = 0.001) and the control group (p = 0.001). The inactive CD group presented a higher post-prandial GLP-1 area under the curve (AUC) than the pre-RYGB group (p = 0.009). The post-RYGB group presented significantly higher AUCs of GLP-2 than the pre-RYGB group (p < 0.0001), both inactive and active CD groups (p < 0.0001 in both situations), and the control group (p = 0.002). The pre-RYGB group presented a significantly higher AUC of glucose than the post-RYGB (p = 0.02) and both active and inactive CD groups (p = 0.019 and p = 0.046, respectively). The pre-RYGB group presented a significantly higher AUC of insulin than the control (p = 0.005) and both CD groups (p < 0.0001).

CONCLUSIONS

Obesity is associated with an inflammatory state comparable to the one observed in CD; inflammation may also be enrolled in the blockade of GLP-2. CD individuals present a more incretin-driven pattern of glucose metabolism, as a way to prevent hypoglycemia and compensate the carbohydrate malabsorption and GLP-2 blockade.

Review article: the relationship between obesity, bariatric surgery, and inflammatory bowel disease

BACKGROUND

The convoluted relationship between obesity, bariatric surgery and inflammatory bowel disease (IBD) is of increasing interest.

AIM

To analyse evidence regarding the role of bariatric surgery in the development of de novo IBD and its impact on clinical outcomes and safety in patients with established IBD.

METHODS

A PubMed/Medline search was performed to identify studies reporting the development of IBD after bariatric surgery and the outcomes of IBD patients after bariatric surgery.

RESULTS

Eighty patients were reported to have developed de novo IBD after bariatric surgery (21% ulcerative colitis [UC], 75% Crohn's disease [CD]), mostly females. Roux-en-Y gastric bypass was the most frequent bariatric technique (80%). Symptoms related to IBD occurred within 1 month and 16 years after surgery. Regarding patients with known IBD undergoing bariatric surgery, 60 patients (35 CD, 24 UC, and 1 unclassified colitis) have been reported. Sleeve gastrectomy was the most frequent bariatric procedure, particularly in CD patients. Acute flares after surgery were observed in only four UC patients. In addition, two retrospective population-based studies described perioperative outcomes of bariatric surgery on IBD patients, demonstrating only a significant increase in small bowel obstruction in these patients.

CONCLUSIONS

Bariatric surgery in carefully selected patients with established IBD is technically feasible and probably safe. Development of de novo IBD should be taken into account in individuals with previous bariatric surgery who develop diarrhoea, anaemia or excessive weight loss.

Bariatric surgery is associated with increased risk of new-onset inflammatory bowel disease: case series and national database study

BACKGROUND

Case series suggest a possible association between bariatric surgery and incident IBD.

AIM

The aim of this study was to evaluate the association between bariatric surgery and new-onset IBD.

METHODS

We first conducted a multi-institutional case series of patients with a history of IBD and bariatric surgery. We next conducted a matched case-control study using medical and pharmacy claims from 2008 to 2012 in a US national database from Source Healthcare Analytics LLC. Bariatric surgery was defined by ICD-9 or CPT code. Bariatric surgery was evaluated as recent (code in database timeframe), past (past history V code) or no history. Conditional logistic regression was used to estimate odds ratios (OR) and 95% CI for new-onset IBD, CD and UC.

RESULTS

A total of 15 cases of IBD (10 CD, 4 UC, 1 IBD, type unclassified) with a prior history of bariatric surgery were identified. Most cases were women, had Roux-en-Y surgery years prior to diagnosis and few IBD-related complications. A total of 8980 cases and 43 059 controls were included in our database analysis. Adjusting for confounders, a past history of bariatric surgery was associated with an increased risk of new-onset IBD (OR 1.93, 95% CI 1.34-2.79). However, patients who had recent bariatric surgery did not appear to be at shorter term risk of IBD (OR 0.94, 95% CI 0.58-1.52).

CONCLUSION

New-onset IBD was significantly associated with a past history of bariatric surgery. This potential association needs to be confirmed in future prospective studies.

De-novo Inflammatory Bowel Disease After Bariatric Surgery: A Large Case Series

BACKGROUND

Case reports of inflammatory bowel diseases [IBD] have been reported in patients with a history of bariatric surgery. Our aim was to characterize patients who were diagnosed with IBD after having undergone bariatric surgery.

METHODS

Electronic medical records were reviewed at two institutions to identify patients who developed de-novo Crohn's disease or ulcerative colitis [UC] after bariatric surgery. Data on demographics, type of bariatric surgical procedure, IBD subtype, phenotype and medication usage were obtained. The incidence rate of de-novo IBD after bariatric surgery [per 100000 person-years] and standardized incidence ratio [SIR] were estimated from a prospective bariatric surgery database.

RESULTS

A total of 44 patients with de-novo IBD after bariatric surgery were identified [31 Crohn's disease, 12 UC, one IBD unclassified]. Most patients were female [88.6%], with median age at IBD onset of 44 years [IQR, 37-52] and median time to IBD diagnosis after bariatric surgery of 7 years [IQR, 3-10]. Sixty-eight per cent underwent Roux-en-Y gastric bypass. In the prospective database, the incidence of IBD in patients who underwent bariatric surgery was 26.7 per 100000 person-years [4.5 for UC and 22.3 for Crohn's disease]. The age-adjusted SIR ranged from 3.56 in the 40-49 year age group to 4.73 in the 30-39 year age group.

CONCLUSION

We described a case series of patients developing de-novo IBD after bariatric surgery. There appears to be a numerically higher incidence of Crohn's disease in this population. Confirmation of causality is required in larger patient cohorts.

Diarrhea after bariatric procedures: Diagnosis and therapy

Diarrhea after bariatric procedures, mainly those with malabsorptive elements including Roux-Y Gastric Bypass and Biliopancreatic Diversion, is common and an essential determinant of quality of life and micro- and macronutrient deficiencies. Bariatric surgery is the only sustainably successful method to address morbid obesity and its comorbidities, particularly gaining more and more importance in the specific treatment of diabetic patients. Approximately half a million procedures are annually performed around the world, with numbers expected to rise drastically in the near future. A multitude of factors exert their influence on bowel habits; preoperative comorbidities and procedure-related aspects are intertwined with postoperative nutritional habits. Diagnosis may be challenging owing to the characteristics of post-bariatric surgery anatomy with hindered accessibility of excluded segments of the small bowel and restriction at the gastric level. Conventional testing measures, if available, generally yield low accuracy and are usually not validated in this specific population. Limited trials of empiric treatment are a practical alternative and oftentimes an indispensable part of the diagnostic process. This review provides an overview of causes for chronic post-bariatric surgery diarrhea and details the particularities of its diagnosis and treatment in this specific patient population. Topics of current interest such as the impact of gut microbiota and the influence of bile acids on morbid obesity and especially their role in diarrhea are highlighted in order to provide a better understanding of the specific problems and chances of future treatment in post-bariatric surgery patients.

Bariatric surgery attenuates colitis in an obese murine model

BACKGROUND

Obesity and inflammatory bowel disease (IBD) represent chronic inflammatory conditions. Bariatric surgery improves some obesity-related co-morbidities, but the effects of bariatric surgery on IBD have not been well studied.

OBJECTIVES

To examine if bariatric surgery may attenuate colitis in an obese murine model of IBD and study the mechanisms underlying the postsurgical amelioration of intestinal inflammation.

SETTING

University of California Irvine, Department of Surgery and Microbiology laboratories.

METHODS

Obese mice were assigned to one of 2 bariatric procedures [Duodenojejunal Bypass (DJB n = 6), Sleeve Gastrectomy (SG n = 8)]. Sham-operated mice were (Sham n = 8) were used as a control. After recovering from surgery, IBD was induced by administration of 2% dextran sodium sulfate. Fecal samples were collected before and after IBD induction for microbiome analysis. Pathologic analyses and immunohistochemical staining were performed on colon.

RESULTS

Survival after DJB and SG was higher relative to Sham mice. Histologically, DJB mice had significantly less intestinal inflammation. The observed improvements were not related to a difference in weight among the groups. Farnesoid X receptor staining in the colon was observed quantitatively more in DJB than in SG and sham mice. A statistically significant increase in the number of Lactobacillales was observed in the stool of mice after DJB.

CONCLUSION

These results suggest that bariatric surgery, in particular DJB, reduces the severity of colitis in a chemically-induced IBD murine model. The anticolitis effects of DJB may be associated with Farnesoid X receptor regulation and gut microbiome rearrangements.

Bariatric surgery in morbidly obese patients with inflammatory bowel disease: A systematic review

BACKGROUNDS

With increased prevalence of obesity, the number of inflammatory bowel disease (IBD) patients suffering from morbid obesity has raised. It is not clear yet if bariatric surgery is a safe and effective option in this population.

OBJECTIVES

Our systematic review aims to summarize the available literature on the safety and efficacy of bariatric surgery in morbidly obese patients with IBD.

SETTING

University hospital, Iran.

METHODS

A PubMed/MEDLINE search was performed to identify studies reporting the outcome of morbidly obese IBD patients. Postoperative outcome of IBD patients after bariatric surgery were pooled for early and late complications, change of IBD status, and medication alteration.

RESULTS

A total of 7 studies reported post-bariatric surgery outcomes of 43 morbidly obese IBD patients (31 females, 11 males) with an age ranging from 30 to 64 years and a body mass index from 35.7 to 71 kg/m². Of these, 25 suffered Crohn's disease (CD) (58.2%) and 18 were ulcerative colitis (UC) patients (41.8%). The small bowel was the most common involved gastrointestinal segment in 27.3% of patients. CD patients more commonly underwent sleeve gastrectomy (72%), while UC patients similarly underwent sleeve gastrectomy and Roux-en-Y gastric bypass (44.4%). After a follow-up of 8 to 77 months, IBD patients lost up to 71.4%±5.9% of excess weight and 14.3 kg/m²±5.7 kg/m² of body mass index. There were 9 early (21.4%) and 10 late (23.8%) postoperative complications related to the bariatric procedure. IBD remitted in 20 patients (47.6%), improved in 2 patients (4.8%), but exacerbated in 7 patients (16.7%).

CONCLUSIONS

Although available data on morbidly obese patients with IBD is scarce, bariatric surgery seems to be a safe and effective option for these patients with no added morbidity or mortality. Further studies are necessary to confirm this data.

Does Gastric Surgery (Such as Bariatric Surgery) Impact the Risk of Intestinal Inflammation?

Background

The prevalence of morbid obesity and inflammatory bowel disease (IBD) is on the rise in association with a Western lifestyle. Both conditions are characterized by chronic inflammation. Bariatric surgery (BS) is a recommended and widely used approach to address severe obesity and its related comorbidities. Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG) are the most frequently performed procedures worldwide. Evidence is scarce on outcomes of BS in IBD patients.

Summary

Systemic and adipose-tissue inflammation seems to decrease following BS. Different studies observed decreased serum levels of inflammatory markers (CRP, IL-6, MCP-1, and TNF-α) along with a reduction of insulin resistance both after RYGBP and SG. Several authors documented postbariatric improvement of concomitant chronic inflammatory diseases (rheumatoid arthritis, systemic lupus erythematosus, gout, and psoriasis). There are only few retrospective case series on outcomes of BS in IBD patients. These studies reported safety and feasibility of BS and improvement in IBD status, manifested by prolonged disease remission and decreased use of pharmacotherapy. Weight loss outcomes were excellent and similar to those of non-IBD patients. The preferred surgical approach for morbidly obese IBD patients is SG in order to avoid potential drawbacks of RYGBP, such as malabsorption, intestinal manipulation, and augmentation of technical difficulties for future IBD surgery. Seven cases of newly diagnosed IBD after BS have been reported, which are more likely to result from postoperative intestinal microbial dysbiosis than from directly induced inflammation.

Key Messages

This review summarizes the outcomes of BS in IBD patients. SG is the preferable technique for morbidly obese IBD patients, who have potentially a double benefit from BS: weight loss and IBD remission. Further research is necessary to clarify the common pathophysiology of chronic inflammation in morbid obesity and in IBD. Postbariatric changes in gut microbiota should also be assessed to understand whether they promote IBD development or not.

The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease

BACKGROUND

Bariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients.

METHODS

The prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed.

RESULTS

One male and 9 female morbidly obese IBD patients (8 with Crohn's disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9-67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation.

CONCLUSION

Bariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients.