Clinical Assessment: Digestive System

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.


Obesity increases the risk of gallbladder disease, particularly in women. Cholesterol gallstones are most common and are the only type of calculi with a clear relationship to obesity. Potential causes of increased gallstone formation in obesity include changes in bile composition and gallbladder emptying.

Gallstone formation increases significantly during periods of rapid weight loss. Patients who have lost weight rapidly in the past are at increased risk for gallstone disease.

Very low-calorie diets and bariatric surgery both dramatically increase the risk of symptomatic gallstone disease, most likely as a consequence of reduced gallbladder emptying and motility. Some surgeons advocate routine cholecystectomy during bariatric surgery, but this remains controversial as it may increase the chance of surgical complications. In patients with gallstones or sludge, prophylaxis with ursodeoxycholic acid 500 mg twice daily may help to reduce the risk of symptomatic gallstone disease and can be used during periods of rapid weight loss.

Non-alcoholic fatty liver disease (NAFLD) is an increasingly recognized condition that can progress to end-stage liver disease. NAFLD refers to a wide spectrum of liver damage, ranging from simple steatosis (excessive hepatic lipid accumulation) to steatohepatitis, advanced fibrosis and cirrhosis. Simple steatosis may have the best prognosis within the spectrum, but it can progress to steatohepatitis, fibrosis and even cirrhosis. Insulin resistance and oxidative stress play critical roles in the pathogenesis of non-alcoholic fatty liver disease.

Steatosis is found in two-thirds of obese patients and more than 90% of morbidly obese patients. Both the presence and severity of steatosis correlate positively with adiposity. Truncal obesity seems to be an important risk factor even in patients with a normal BMI. Steatohepatitis affects around 20% of obese and almost 50% of morbidly obese populations. Steatohepatitis has been found even in children under the age of 10, and may become more common with the current explosion in childhood obesity rates.

Most patients with non-alcoholic liver disease have no symptoms or signs of liver disease at the time of diagnosis, though some report generalized fatigue or malaise. NAFLD is characterized by hepatomegaly and mild to moderate elevations in serum transaminase levels (specifically ALT with the ALT:AST ratio usually <1). The presence of hypoalbuminemia, prolonged PT and hyperbilirubinemia are much more worrisome and suggest progression toward cirrhosis. Ultrasonography and computer-assisted tomography can detect the fatty infiltration of the liver, but liver biopsy remains the most sensitive and specific means of determining the presence of inflammation and fibrosis, thus providing important prognostic information.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

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