Diarrhoea (In the Elderly)

Dr Philip Bliss

Consultant Gastroenterologist

University Hospital Aintree

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Diarrhoea

• Too frequent passage of too fluid stool

• Passage of a stool which takes the shape of the receptacle into which it is passed

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Diarrhoea – a subjective condition

• Normal stool weight in western diet 200-300g/day

• 95% of population BO x3 per day – x3 per week • Rectal compliance • Faecal incontinence

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Three times a week

Three times a day

No of people

How often do you move your bowels?

95%

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Causes

• Malignancy • Inflammatory Bowel disease • Diverticular disease • Ischaemic colitis • Post surgical diarrhoea • Infectious diarrhoea • Coeliac disease • Overflow diarrhoea • Medication • Pelvic floor problems

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Philip

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Colorectal cancer

• One in twenty people develop bowel cancer

• 80% of all diagnoses in over 60s

• 3rd commonest cancer, second commonest

cancer death

• 90% five year survival in early stage, Dukes A,

disease

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Symptoms

• Change in bowel habit to looser stool

• Rectal bleeding

• Anaemia

• Palpable mass

• Constipation

• Wt loss

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Philip

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Bowel Cancer Screening Programme

• 60-75 yrs

• FOBT test every two years

• 2% positive go on to Colonoscopy

• 50% adenoma rate

• 10% cancer rate – falling with each round of screening

• 12 million test kits sent out

• 11,000 Cancers detected – Majority Dukes A

• On target to reduce cancer deaths by 16%

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Inflammatory Bowel Disease

• Ulcerative colitis

• Crohns disease

• Incidence decreases with age

– 5-10% of patients diagnosed over 60

– Oldest new diagnosis in 91 yr old man

• Patients diagnosed in younger life do grow old

• Treatment no different in elderly

• Risks of surgery can be increased

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What's new in IBD?

• Higher doses of 5 ASA drugs – 4.8g Mesalazine, once daily dosage

• Nutritional therapy for Crohns disease – Polymeric better tolerated than elemental

• Avoidance of steroids in Crohns disease • Lower threshold for thiopurines

– TPMT assay, metabolite monitoring

• Biological therapies – Infliximab, Humira – Step up vs step down approach

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Diverticular disease

• Diverticulosis vs Diverticulitis

• Erratic bowel habit, pain rather than diarrhoea

• Fistulae – Colovesical

– Colovaginal

• CT probably better than Colonoscopy to diagnose

• Diverticular associated colitis – can be confused with Crohns

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Pros Cons Uses

Colonoscopy Mucosal detail

Biopsy polypectomy

Bowel prep, mobile patient,

10% incomplete Perforation, bleeding

Gold standard in fit patient with

diarrhoea/change in bowel habit

CT Colonoscopy

Non – invasive Virtual Colonoscopy Small polyps 5mm

Axial imaging as bonus

Bowel prep, need to lie flat, no biopsy, no therapy

Incomplete colonoscopy Previous difficult or

complicated Colonoscopy

Standard CT Abdo Pelvis

Non – invasive Oral contrast

Large colonic lesions Axial imaging as bonus

Bowel prep, need to lie flat, no biopsy, no therapy

May miss lesions up to 1cm

Iron deficiency anaemia in frail patient

Complicated diverticular disease

Barium Enema Mucosal detail,

Small polyps

Bowel prep Retain air/barium No biopsy/therapy Only image colon

Rarely used Water soluble contrast

enemas for psuedo-obstruction

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Treatment

• Supportive

• Antibiotics for diverticulitis

• 5-ASA for diverticular associated colitis

• Surgery – Avoided if possible

– Symptomatic stricture

– Fistula

– Recurrent paracolic abscess

– ?? Frequent admissions

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Ischaemic colitis

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Ischaemic colitis

• Increasing incidence with age • Arteriopath • Splenic flexure • Self limiting diarrhoea • Quite florid endoscopic appearances contrast

with unimpressive histological features • Conservative management

• Contrast with chronic mesenteric ischaemia

– Abdo pain after food, food avoidance, weight loss

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Post surgery

• Upper GI surgery

– Peptic ulcer disease surgery – “dumping syndrome”

– Cholecystectomy

• Pancreatic

• Colorectal

– R hemicolectomy

– Mesenteric ischaemia “short bowel” syndrome

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Post cholecystectomy diarrhoea

• 10-20% incidence – recall bias

• May have been IBS all along

• Bile acid irritant to colon

• Questran

– Unpalatable, titration difficult

• Loperamide

– Cheap, Effective, portable

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Pancreatic insufficiency

• More likely linked to Chronic pancreatitis than surgery

• Faecal elastase, 24 hour feacal fat collection, light scattering intensity

• Empirical trial of pancreatic enzyme supplements

• Creon

• Nutrizyme – can go down PEG tube easier

• Don’t forget snacks

• Use stools as guide

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Short bowel syndrome

• Fluid restrict – 1.5L day – 750mls double strength dioralyte, 750mls “free” fluid

• Anti-diarrhoeals – Loperamide up to 16mg qds – Codeine phosphate no more than 60mg qds

• High dose PPI – Omeprazole 40mg bd

• Octreotide – Limited use

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Infectious diarrhoea

• Increased in elderly

• Residential care

• Cruise ships

• Impaired immunity

• Polypharmacy – Antibiotics, PPIs

• Consequences more severe – Reluctance to give iv fluids to elderly patients

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Commonest Types of infection

• Viruses – 40% all diarrhoea is viral – Norovirus

• Campylobacter jejuni – commonest bacterial GE

– Painful diarrhoea

– Peaks in early summer

• CDT – Antibiotic avoidance

– Cohort ward

– Immunoglobulin therapy

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“You’re never too old to get Coeliac disease”

• Coeliac disease affects 1% of population

• One third of patients diagnosed over 65 years

• Older age at diagnosis often associated with increased complication rate

• Easy to diagnose – Anti Tissue Transglutaminase antibody

– IgA deficiency

– Duodenal biopsy

• Easy to treat Phil

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Overflow diarrhoea

• More common in elderly age group

• Spurious diarrhoea

• Initial attempts to treat make things worse

• Easy to diagnose

• Once diagnosed, treatment more likely to succeed – Laxatives,

– Enemas, Arachis oil, phosphate

• Controlled use of laxatives to prevent build up

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Medication

• Antibiotics

• Iron

• Proton Pump inhibitors

• Antidiarrhoeals

• Laxatives

• Beta blockers

• Nicorandil

• Artificial sweeteners

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Pelvic floor problems

• Faecal incontinence increases with age – 2% general population

– 10% Elderly

– 50% nursing home residents

• Devastating consequences – Shame, embarrasment, social isolation, early

instutionalisation

– Nutritional consequences

– Skin complications

– Financial $16.3 billion per year

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Causes of feacal incontinence

• Disruption to anal sphincter – Obstetric trauma, perianal surgery

• Puborectalis dysfunction – Prolapse, perineal descent

• Nerve damage – Diabetes, stroke, MS, spinal/head injury

• Poor mobility – Arthritis, stroke

• Impaired cognition – Dementia,

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Various treatment options

• Medical – Loperamide/codeine – Treat underlying IBD/Coeliac etc – Address overflow/impaction

• Surgical – Sacral nerve stimulators – Sphincter repair – Artificial sphincter

• Behavioural – Biofeedback – appliances

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Summary

• Causes of diarrhoea in elderly broadly similar to general population

• Systematic approach to diagnosis usually effective

• Pragmatic approach to investigation

• Always ask about Faecal incontinence

• Symptomatic treatment often appropriate and nearly always successful

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