40240 Mauvezin d’Armagnac
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Cholelithiasis is a common complication of obesity and its treatment. Obesity triples the risk of gallstones in women and doubles it in men, in adults and in adolescents. Therapeutic weight loss (medical or surgical) increases the risk of cholelithiasis especially when fast (more than 1.5 kg/week), and in the first 6 months. Stones are usually made of cholesterol. Obesity increases the hepatic secretion of cholesterol, which leads to cholesterol supersaturation of bile. A decreased gallbladder motility and intestinal transit also play an important role. It is unclear whether obesity modifies cholesterol nucleation. Rapid weight loss further increases the saturation of bile (by mobilization of peripheral cholesterol and decreased synthesis of bile acids and phospholipids), increases the nucleation, and decreases gallbladder emptying. The risk of symptoms and complications increases in parallel to that of stone formation, and could be increased with age and the magnitude of weight loss. The morbidity and mortality of biliary acute pancreatitis are increased in obesity. To prevent gallstone formation, restrictive diets should not go below 1,000 kCal/day. Sufficient fat intake should be maintained to stimulate gallbladder contraction. Cholecystectomy before weight loss (including prior to bariatric surgery) is only indicated in cases of symptomatic or complicated stones, because it increases the morbidity and mortality of bariatric surgery when done for asymptomatic gallstones. The administration of ursodeoxycholic acid for 6 months at a dose of 500-600 mg/day significantly reduces the risk of cholelithiasis after dietary weight loss (from a mean of 19% to 3.5%) or bariatric surgery (from 29% to 9%), with a parallel decrease in the risk of symptomatic disease.