Gluten-free diet in obese patients with celiac disease: an enemy of the bariatric surgeon?

Post-bariatric Surgery Outcomes and Complications in Patients with Celiac Disease: a Matched Case-Control Study

PURPOSE

The shift towards an obese phenotype in celiac disease (CD) patients increases risk of morbidity and mortality. Bariatric surgery (BS) is the gold standard treatment for obesity. Few studies have explored the role of BS in patients with CD. This study aimed to assess the effectiveness and safety of BS in this population.

MATERIAL AND METHODS

This is a retrospective matched case-control (1:5) study of adult patients with confirmed CD who underwent BS at our institution from 1998 to 2018. Demographics, operative data, post-operative outcomes, complications, and nutritional parameters were collected.

RESULTS

Seventy-eight patients (mostly Caucasian females) were included. Thirteen had confirmed CD and were compared with 65 controls. The most common type of BS was the RYGB. The percent of total body weight loss (%TWL) was similar for both groups at 6, 12, 18, 24, and 36 months, with the highest weight loss being at 12 months: %TWL 28.4 (20.2-38.4) for CD, n=13; vs. 29.1 (19.6-39.3) for non-CD, n=49; p=0.8. Obesity-associated co-morbidities greatly and comparably improved in both groups. Patients with CD had no complications after BS. Post-BS malodorous and oily stools were more common among patients with CD (23.1% vs. 4.6%, p=0.03). Micronutrient deficiencies were common and comparable among both groups with iron and vitamin D being the most common deficiencies. Gluten-free diet (GFD) non-adherence post-operatively was associated with a higher incidence of post-BS abdominal pain (60.0% vs. 0.0%, p=0.012).

CONCLUSIONS

BS is safe and effective in patients with CD. Close monitoring is necessary to ensure compliance with GFD and vitamin supplementation.

KEY POINTS

• Bariatric surgery leads to significant weight loss in celiac disease (CD) patients. • Mid- and long-term weight loss does not differ between patients with and without CD. • Obesity-associated co-morbidities significantly improve after surgery in CD patients. • The incidence of post-surgical complications is not higher in CD patients.

Celiac Disease and Obesity: Is Bariatric Surgery an Option?

Celiac disease is an immune-mediated enteropathy associated with malabsorptive syndrome and fat-soluble vitamin deficiencies. Celiac disease affects 1% of individuals but is largely underdiagnosed, as its multifaceted clinical presentations create challenging diagnostic scenarios. With the rise of the obesity epidemic, doctors are increasingly seeing celiac disease patients with overweight or obesity, which raises the question of bariatric surgery. However, few studies so far have investigated bariatric surgery in this patient population. Here, we provide a comprehensive review of the literature on celiac disease, its nutritional consequences and complications, and we discuss the possible impact of bariatric surgery on weight loss, nutritional deficiencies, response to gluten-free diet, and long-term post-operative complications. We also review the effect of bariatric surgery on the incidence of celiac disease.

Implications of Celiac Disease Among Patients Undergoing Gastric Bypass

INTRODUCTION

Bariatric surgery is generally safe and effective, but co-existing malabsorptive processes may increase the risk of complications or nutritional deficiencies. Bariatric surgery has not been well studied in the setting of pre-existing celiac disease.

MATERIALS AND METHODS

Patients who underwent Roux-en-Y gastric bypass (RYGB) from January 2002 to December 2015 were retrospectively reviewed for either diagnosis of or serum testing for celiac disease. Identified patients were re-reviewed for adherence to American Gastroenterological Association (AGA) diagnostic criteria. Patient demographics, operative data, and post-operative weight loss and nutritional parameters were collected.

RESULTS

Of the > 12,000 patients who underwent bariatric surgery during this study period, there were 342 patients that had abnormal serology or pathology results. Expert review confirmed three patients (0.8%) with celiac disease diagnosed before RYGB procedure. All were female, with an average age of 33 years and a mean BMI of 44.07 kg/m². At the time of surgery, two of the three patients were following a gluten-free diet. At 6 months follow-up, mean % excess weight loss was 76.5%. The patients following a gluten-free diet preoperatively continued post-operatively. No patients were anemic nor had vitamin B12 or iron deficiencies at 12-month follow-up. Two patients had vitamin D insufficiencies and responded to daily oral supplementation.

CONCLUSION

Though many bariatric patients may carry a presumptive diagnosis of celiac disease, a small percentage of these meet AGA diagnostic criteria. RYGB appears safe in this population with comparable weight loss in non-celiac counterparts. Increased attention to vitamin D levels may be warranted post-operatively.

Impact of bariatric surgery on outcomes of patients with celiac disease: a nationwide inpatient sample analysis, 2004-2014

Background

While patients with celiac disease have increasingly developed an atypical pattern of weight gain and obesity, the role of bariatric surgery remains unclear. The primary aim of this study was to evaluate the effect of bariatric surgery on clinical outcomes among hospitalized patients with celiac disease.

Methods

The United States Nationwide Inpatient Sample database was queried for discharges with co-diagnoses of morbid obesity and celiac disease between 2004 and 2014. The primary outcome was in-hospital mortality. Secondary outcomes included renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, strictures, micronutrient deficiency, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior bariatric surgery compared to those without bariatric surgery.

Results

Among 1499 patients with a discharge diagnosis of celiac disease and morbid obesity, 126 patients (8.4%) underwent bariatric surgery. Despite an increase in morbid obesity over the study period, the proportion of morbidly obese patients with celiac disease who had bariatric surgery declined by 18.5% (P_trend<0.05). On multivariable analysis, bariatric surgery did not influence mortality (P=0.98), but was associated with a lower risk of renal failure, pneumonia, sepsis, urinary tract infection and respiratory failure (all P<0.05). Bariatric surgery increased the risk of vitamin D deficiency (IRR 3.5; 95% confidence interval [CI] 1.6-7.7; P=0.002) and post-operative strictures (IRR 3.3; 95%CI 1.5-7.5; P=0.004).

Conclusion

Despite the underutilization of bariatric surgery in morbidly obese celiac disease patients, the procedure is safe and appears to significantly reduce morbidity.

Problems in bariatric patient care - challenges for dieticians

Obesity management options include a low-calorie diet, behavioral therapy, regular physical activity and pharmacological therapy. However, treatment failure is frequently encountered, most of these methods are ineffective, and a positive outcome is rarely maintained in the long term. In morbidly obese patients, bariatric surgery is considered the most effective treatment for obesity as well as the accompanying diseases. Bariatric surgery promotes much greater weight loss than conservative treatment, regardless of the applied surgical technique. Bariatric surgery patients should receive professional perioperative (preoperative, intraoperative and postoperative) care from a multidisciplinary team of specialists, including a bariatric surgeon, a general practitioner, a dietitian and a health psychologist. Patients require postoperative nutritional counseling to be able to stabilize their weight and maintain long-term weight loss after surgery. Patients are guided by bariatric dietitians through the process of adopting new eating habits and behavior, learning how to make healthy food choices.

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.

Clinical onset of celiac disease after duodenal switch: a case report

To our knowledge, this is the first reported case of clinical onset of celiac disease (CD) following duodenal switch surgery. A 61-year-old obese woman developed severe diarrhea soon after bariatric surgery (BS), which was unresponsive to standard medical treatment. After the most common diarrhea etiologies in the immediate postoperative period have been excluded, serological tests were performed. Final diagnosis was determined by anti-tissue transglutaminase antibody positivity. In light of this case report, we propose that CD should be ruled out in any patient presenting with typical or atypical symptoms after BS, regardless of the latency of onset.