Gastroenterology
Volume 133, Issue 6 , Page 2075, December 2007

Increased Intra-abdominal Pressure and GERD/Barrett’s Esophagus

Emeritus Professor of Surgery, Virginia Commonwealth University, Richmond, Virginia

Article Outline

 

Dear Sir:

The article, “Abdominal obesity and body mass index as risk factors for Barrett’s esophagus,”1 found that central adiposity, as measured by waist circumference, was a greater predictor of both gastroesophageal reflux disease (GERD) and Barrett’s esophagus than body mass index (BMI). The probable pathophysiology is an increased intra-abdominal pressure (IAP), which may overcome even a normal lower esophageal sphincter (LES). This hypothesis is consistent with data published 10 years ago, where it was noted that both waist circumference and sagittal abdominal diameter correlated directly with IAP (r = 0.68; P < .001), as measured through the urinary bladder; whereas BMI and the waist:hip ratio were only weakly or not, respectively, correlated with IAP.2 Surgical weight loss was associated with a significant decrease in urinary bladder pressure, sagittal abdominal diameter, and obesity comorbidity.3 Several other obesity comorbidities were also postulated to be secondary to an increased IAP, including obesity hypoventilation syndrome, stress overflow urinary incontinence, venous stasis disease, systemic hypertension, and pseudotumor cerebri; both clinical and animal studies supported these hypotheses.4, 5, 6, 7 Severely obese patients were found to have a higher urinary bladder pressure with than those without these comorbidities.1 Several studies have noted a significant decrease in GERD symptoms8, 9, 10 and regression in Barrett’s esophagus11, 12, 13 in severely obese patients after Roux-en-Y gastric bypass (RYGB) surgery. It is thought that these effects are related to both the anatomy of the RYGB, where little acid and no bile can reflux into the esophagus, as well as a progressive decrease in IAP after surgical weight reduction.13 RYGB should be considered preferable to an antireflux procedure for the treatment of severe GERD, with or without Barrett’s esophagus, in the severely obese patient because it addresses both the pathophysiology of GERD and the many other disabling obesity comorbidities. Studies are needed to evaluate the severity of acid reflux with 24-hour esophageal pH monitoring and measurement of LES, urinary bladder pressures, waist circumference and waist:hip ratio.3

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References 

  1. Corley DA, Kubo A, Levin TR, et al. Abdominal obesity and body mass index as risk factors for Barrett’s esophagus. Gastroenterology. 2007;133:34–41
  2. Sugerman HJ, Windsor ACJ. Intra-abdominal pressure, sagittal abdominal diameter and obesity co-morbidity. J Intern Med. 1997;241:71–79
  3. Sugerman H, Windsor A, Bessos M, et al. Effects of surgically induced weight loss on urinary bladder pressure, sagittal abdominal diameter and obesity co-morbidity. Int J Obes Relat Metab Disord. 1998;22:230–235
  4. Bump RC, Sugerman HJ, Fantl JA, et al. Obesity and lower urinary tract function in women: effect of surgically induced weight loss. Am J Obstet Gynecol. 1992;167:392–396
  5. Ridings PC, Bloomfield GL, Blocher CR, et al. Cardiopulmonary effects of raised intra-abdominal pressure before and after volume expansion. J Trauma. 1995;39:1071–1075
  6. Bloomfield GL, Ridings PC, Blocher CR, et al. Increased pleural pressure mediates the effects of elevated intra-abdominal pressure upon the central nervous and cardiovascular systems. Crit Care Med. 1997;25:496–504
  7. Bloomfield GL, Ridings PC, Blocher CR, et al. Chronically increased intra-abdominal pressure produces systemic hypertension in male dogs. Int J Obes Relat Metabol Disord. 2000;24:819–824
  8. Frezza EE, Ikramuddin S, Gourash W, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2002;16:1027–1031
  9. Ortega J, Escudero MD, Mora F, et al. Outcome of esophageal function and 24-hour esophageal pH monitoring after vertical banded gastroplasty and Roux-en-Y gastric bypass. Obes Surg. 2004;14:1086–1094
  10. Nelson LG, Gonzalez R, Haines K, et al. Amelioration of gastroesophageal reflux symptoms following Roux-en-Y gastric bypass for clinically significant obesity. Am Surg. 2005;71:950–953
  11. Cobey F, Oelschlager B. Complete regression of Barrett’s esophagus after Roux-en-Y gastric bypass. Obes Surg. 2005;15:710–712
  12. Csendes A, Burgos AM, Smok G, et al. Effect of gastric bypass on Barrett’s esophagus and intestinal metaplasia of the cardia in patients with morbid obesity. J Gastrointest Surg. 2006;10:259–264
  13. Houghton SG, Romero Y, Sarr MG. Effect of Roux-en-Y gastric bypass in obese patients with Barrett’s esophagus: attempts to eliminate duodenogastric reflux. Surg Obes Relat Dis. 2008;(In press)

PII: S0016-5085(07)01843-4

doi:10.1053/j.gastro.2007.10.017

Refers to article:

  • Abdominal Obesity and Body Mass Index as Risk Factors for Barrett’s Esophagus , 26 April 2007

    Douglas A. Corley, Ai Kubo, Theodore R. Levin, Gladys Block, Laurel Habel, Wei Zhao, Pat Leighton, Charles Quesenberry, Greg J. Rumore, Patricia A. Buffler
    Gastroenterology July 2007 (Vol. 133, Issue 1, Pages 34-41)

Gastroenterology
Volume 133, Issue 6 , Page 2075, December 2007

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