Sanavannieuwenhove
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Transcript of Sanavannieuwenhove
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Slideshare linkhttp://www.slideshare.net/yvnieuwe/sanavannieuwenhove
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NASH, obesitas en diabetes/metabool syndroom
Y. Van NieuwenhoveDienst gastrointestinale heelkunde
Universitair Ziekenhuis Gent
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Route• Metabool syndroom• Insuline resistentie - diabetes• NAFLD – NAFL – NASH (– cirrose – HCC)• Diagnose en behandeling van NAFLD• Bariatrische heelkunde
– Goede effecten– Maar ook...
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http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf
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Definitie (IDF)
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Definitie (IDF)
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Prof. Lieven Annemans
HLN 11/2013
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Metabool syndrooom
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Glucose metabolisme
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Glucosemetabolisme
Cel
Receptor
Glucose
Insuline
Pancreas
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Insulineresistentie -> DM2
Cel
Receptor
Glucose
Insuline
Pancreas
Vet
ins
glucose
DM2
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Type 2 diabetes is een progressieve ziekte met achteruitgang van de ß-cellen
Func
tie v
an d
e -
celle
n( v
s nor
maa
l vol
gens
HOM
A)
100
80
60
40
20
0-10 -8 -6 -4 -2 0 2 4 6
? Tijdstip van de diagnose
Pancreasfunctie (50% van de normale waarde)
Glucose-intoleranti
e
Verstoordepostprandi
ale glycemie
Verhoogde nuchtere glycemie
Tijd (jaar)12Monnier L. et al., Diabetes Metab 2005; 31: 101-109; Holman R.R., Diabetes Res Clin Pract 199 ; 40 (suppl.1): S21-25; Tkác I., Diab Res Clin Pract 2009: S57-S62
HOMA = homeostasis model assessment
Insulineresistentie
-cel falen
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Diagnose van DM
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Is er een verband?
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Leversteatose
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65% in obese/DM
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Steatosis to steatohepatitisDouble hit
First hit: steatosisSecond hit: oxidative stress - lipid peroxidation –ethanol - drugs
(Berson, Gastroenterology 1998)
Insuline resistance/hyperinsulinemiaFat storage capacity of visceral fat is exceededIncreased level of circulating FFA
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Diagnose• Geen alcohol (<20-30g/d)• Labo
– ALT/AST, GGT, ferritine– Fatty Liver Index, NAFLD Fibrosis Score, Firbrometer
• Beeldvorming– Echografie (1ste keuze), MRI, Fibroscan
• Biopt
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Behandeling• Levensstijlaanpassing
– Zelfs met beperkt gewichtsverlies• Medicatie
– Metformine– Pioglitazone– Voeding laag in verzadigde VZ en KH– Vit E
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Weight loss surgeryGastric bandingGastric bypassSleeve gastrectomyBiliopancreatic diversion
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Only weight loss?
Buchwald (JAMA, 2004)
Pories (Ann Surg, 1995)
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Metabool syndrooomObesitas okhypertension okDyslipidemia okDiabetes okOSAS okLiver ?
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Gastric Bypass• Reductie van maagvolume (15-
30ml)• door overbrugging maag duodenum• Biliopancreatische derivatie
– Alimentaire lis 100-150cm– Biliaire lis (70cm)
• Effect incretines en anorexigenen
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factoren in eetlustregeling
Leptin GO
Insulin
PYYGLP-1OXM
Ghrelin
VagusCCK
Voedsel IntakeEnergy Expenditure
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GLP-1Secreted by L-cells in distal bowel•Potent incretin
– Increases insuline secretion– Decreases glucagon secretion– Increases beta cell mass– Slows gastric emptying and induces satiety
•Half-life only 2 minutes– Degraded by DDP-4
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Is the cure of NAFLD in the operating room?
• (P. Angulo Gastroenterology 2006)
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Long term effect of bariatric surgery
Intervention Steatosis Inflammation FibrosisRYGB (12) Improvement 12/12 Worsening 1/12 Worsening 3/12
LAGB (2) Improvement 2/2 No change ½ Worsening 1/2
BPD(±DS) (2) Improvement 2/2 New onset ½ (11%) Worsening ½ 40%
Rabl et al Sem Liver Dis 2012
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Maar ook...
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Alcohol na bariatrie?
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Ethanolemie na gastric bypass
J Am Coll Surg 2011;212:209–214
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Case• 41 y old woman, BPD 2001
– Extreme weight loss (BMI 46-18kg/m2)– Terminal liver failure– OLT 11/2011– BPD reversal 3/2012
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Belgian Survey on LTX after Bariatric Surgery
Geerts et al,Transpl Proceedings 2010
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Take home• Metabool syndroom
– treft 1 op 4 mensen– gevolg van “Westerse” levensstijl– verkort het leven
• NAFLD – omvat spectrum van leververvetting naar eindstadium levercirrose– Sterke associatie met DM
• Bariatrische heelkunde is een efficiënte behandeling– maar kent ook gevaren