Bariatric Times

MAR 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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16 The Medical Student Notebook Bariatric Times • March 2017 MEDICAL STUDENT This column is written by medical students and is dedicated to reviewing the science behind obesity and bariatric surgery. Notebook The Bariatric Surgery and Pseudotumor Cerebri by LEITH HATHOUT, BS Bariatric Times. 2017;14(3):16–22. INTRODUCTION Obesity, defined as having a body mass index (BMI) of 30kg/m 2 or more, is an increasingly prevalent disease. In the United States, 34.9 percent of adults and approximately 20 percent of adolescents have obesity. 1,2 Additionally, it is estimated that the prevalence of obesity in adults in the United States will increase to greater than 44 percent by 2030 and the prevalence of obesity worldwide continues to increase as well. 3,4 As is well known, obesity increases risk for several comorbidities, including many common metabolic, cardiovascular, respiratory, musculoskeletal, and gastrointestinal disorders. These comorbidities not only increase the overall disease burden of obesity in patients but also increase the financial burden on the healthcare system. 5 It is well established that weight loss surgery can play a significant role in reducing, or even eliminating comorbidities associated with obesity. As such, the current indications for bariatric surgery rely not only on the calculation of BMI but also on the presence of associated comorbidities, and studies have demonstrated significant rates of improvement or resolution of obesity-related diseases following bariatric surgery. 6–8 Currently, more than 340,000 weight loss surgeries are being performed each year. 9–11 One important, but less frequently highlighted, condition associated with obesity is idiopathic intracranial hypertension (IIH), commonly referred to as pseudotumor cerebri. This article serves as a review of IIH and its association with obesity as well as an overview of the current data for treatment of IIH with bariatric surgery. WHAT IS IIH AND WHO DOES IT AFFECT? IIH is typically diagnosed based on fulfillment of the clinical criteria known as the modified Dandy criteria. This includes having increased intracranial pressure demonstrated on lumbar puncture but normal cerebrospinal fluid (CSF) composition in the setting of signs and symptoms consistent with increased intracranial pressure without other neurologic abnormalities or decreased consciousness, as well as lack of evidence of any other identifiable cause of increased intracranial pressure, such as mass lesions, venous sinus thrombosis, or meningitis on neuroimaging or other means of evaluation. 12,13 In the general population, the annual incidence of IIH has been estimated to be approximately 1–2/100,000 people. 14,15 However, the rates of IIH are considerably higher in patients with obesity, and particularly women of childbearing age with obesity, in whom annual incidence has been estimated to be up to 21/100,000, (i.e., a 10-fold increase in incidence as compared to the general population). 15,16 In one study of 50 consecutively diagnosed IIH patients, it was found that 94 percent had obesity and 92 percent were women. 17 Several other studies have also demonstrated a strong association between development of IIH and obesity, particularly in women. 18,19 Given the strong relationship between obesity and IIH as well as the increasing prevalence of obesity, it should not be surprising that the worldwide incidence of IIH is also increasing. 20 While female gender and obesity are the most significant risk factors for IIH, it should be noted that IIH can also be observed in other patient populations and there may be other associated risk factors as well. For example, IIH can be observed in prepubertal children, and in this patient population it has not been clearly associated with increased BMI. 21–23 Additionally, there are data to suggest that up to five percent of patients with IIH report a family history of IIH. Given that this is higher than the prevalence of IIH in patients with obesity, there may also be unknown genetic factors associated with the development of IIH. 24 CLINICAL PRESENTATION Patients with IIH present with symptoms suggestive of increased intracranial pressure. In the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT), which is the largest prospective cohort study of untreated patients with IIH, it was found that the most common presenting symptoms of IIH include headache, pulsatile tinnitus, retrobulbar pain, transient visual obscurations (monocular vision loss lasting seconds, associated with Daniel B. Jones, MD, MS, FASMBS Professor of Surgery, Harvard Medical School Vice Chair, Beth Israel Deaconess Medical Center Boston, Massachusetts ABSTRACT Obesity increases risk for several comorbidities, including many common metabolic, cardiovascular, respiratory, musculoskeletal, and gastrointestinal disorders.One important, but less frequently highlighted, condition associated with obesity is idiopathic intracranial hypertension, commonly referred to as pseudotumor cerebri. This article serves as a review of idiopathic intracranial hypertension and its association with obesity The author also discusses the current literature on treatment of idiopathic intracranial hypertension with bariatric surgery. KEYWORDS Obesity, bariatric surgery, comorbidity, idiopathic intracranial hypertension, pseudotumor cerebri COLUMN EDITOR FEATURED STUDENT Leith Hathout, BS Medical Student, Harvard Medical School Boston, Massachusetts

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