Gastric Bypass Patients at Risk for Alcohol Abuse

Caroline Helwick

May 10, 2011

May 10, 2010 (Chicago, Illinois) — Patients who undergo gastric bypass surgery are at greater risk for alcohol abuse than similar obese patients undergoing restrictive procedures. Bariatric surgery patients, regardless of the type of procedure, are also more likely to be hospitalized for a psychiatric illness than the general population, Swedish investigators reported here at Digestive Disease Week 2011.

Patients who underwent gastric bypass surgery had a 2-fold increased risk for inpatient treatment for alcohol abuse, compared with patients who had a restrictive procedure such as gastric banding, reported Magdalena Plecka Östlund, MD, from the Karolinska Institutet in Stockholm, Sweden.

"Patients undergoing gastric bypass should be carefully counseled on alcohol consumption," she suggested. "In addition, caregivers should be aware of the greater potential for alcohol abuse after surgery so that treatment can be sought if problems arise."

Population-based studies have found that obese people are more likely than the general population to suffer from mood and anxiety disorders, and there are reports that gastric bypass patients are overrepresented in substance abuse treatment programs, she noted. The Swedish study explored these possible associations.

The retrospective cohort study compared 12,277 patients who underwent antiobesity surgery in Sweden between 1980 and 2006 with a matched control cohort of 122,770 people sampled from the general population. The primary surgical procedures were gastric bypass, vertical banded gastroplasty, and gastric banding, which were conducted in almost equal proportions.

The mean patient age at surgery was 40 years; the mean follow-up time was about 9 years.

Compared with the general population, the bariatric population was significantly more likely to be treated for depression (hazard ratio [HR], 1.9), attempted suicide (HR, 2.7), substance abuse (HR, 2.7), and alcoholism (HR 1.7) before surgery, Dr. Östlund reported.

They were not, however, more likely to be hospitalized for psychosis. The lack of association with psychosis was seen with both gastric bypass surgery and restrictive procedures. Other than this disorder, both types of intervention were associated with hospitalization for a psychiatric disorder.

The gastric bypass surgery cohort had higher HRs than the restrictive surgery cohort for substance abuse (HR, 3.8), suicide attempt (HR, 4.1), alcohol abuse (HR, 4.0), and depression (HR, 2.4). For the restrictive surgery cohort, these HRs were, respectively, 1.4, 2.4, 1.2, and 1.8, she said.

Alcoholism Greater After Gastric Bypass

Especially notable was the higher rate of inpatient treatment for alcoholism after gastric bypass surgery, she said. Prior to bariatric surgery, there was no difference in inpatient treatment for alcoholism between patients undergoing gastric bypass and those undergoing a restrictive procedure; however, after surgery, the gastric bypass patients had a 2.3-fold risk of being hospitalized for alcoholism, compared with the restrictive cohort. They also had a 2.5-fold risk of being treated for a substance abuse disorder.

She said the association is most likely due to the altered metabolism of alcohol that occurs after gastric bypass. "A large portion of the stomach is bypassed and the alcohol passes straight to the small intestine and into the blood, where we see increased alcohol concentrations," she said.

Commenting at a press conference, John Morton, MD, director of bariatric surgery at Stanford University Medical Center in Palo Alto, California, elaborated: "We have done studies on alcohol metabolism and it is remarkable to see what a single glass of wine will do. People become legally intoxicated quickly, and there are physiologic reasons for this. You lose first-pass metabolism and the alcohol goes directly into the intestine, which is lined with villi that absorb alcohol extremely well," he explained. "It is important to counsel patients ahead of time. Just warn them that not only should they not eat as much after surgery, they probably should not drink as much either," he said. "It is rare to have these consequences as long as counseling takes place."

Dr. Östlund reminded listeners that bariatric surgery has many health benefits, and the risk for alcoholism should be viewed in the context of these.

She noted that the study's strengths were that it was a nationwide sample, with findings based on comprehensive registry data. "But we had no data on weight development, and different selection criteria may have been applied for the different procedures," she reported.

"Still, we can conclude that the total bariatric surgery cohort had an increased risk for inpatient treatment for the psychiatric disorders we studied," she said.

Vivek N. Prachand, MD, codirector of the Center for the Surgical Treatment of Obesity at the University of Chicago Pritzker School of Medicine, in Illinois, noted that the study might be "comparing apples and oranges" in evaluating the bariatric population with regard to a normal-weight healthy population. Instead, a better comparison would be the bariatric population with a very obese population not undergoing weight-loss surgery, he suggested. "It could be that the differences you found might be seen in a morbidly obese population in general. The differences may not be reflecting the surgery treatment," he suggested.

Dr. Östlund, Dr. Morton, and Dr. Prachand have disclosed no relevant financial relationships.

Digestive Disease Week (DDW) 2011: Abstract 266. Presented May 7, 2011.

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