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  • Geriatric Gastroenterology

  • C.S. Pitchumoni T.S. DharmarajanEditors

    Geriatric Gastroenterology

  • EditorsC.S. Pitchumoni, MD, MPH, FRCP(C), MACP

    MACG, AGAFClinical Professor of MedicineRobert Wood Johnson School of MedicineDrexel University School of MedicineAdjunct Professor of MedicineNew York Medical College, Valhalla, NY

    Chief, Gastroenterology, Hepatology and Nutrition

    Saint Peters University Hospital New Brunswick, NJ, USA

    T.S. Dharmarajan, MD, FACP, AGSFProfessor of MedicineAssociate DeanNew York Medical College, Valhalla, NYVice Chairman, Department of MedicineClinical Director, Division of GeriatricsProgram Director, Geriatric Medicine

    Fellowship ProgramMontefiore Medical Center (North Division)Bronx, New York, USA

    Please note that additional material for this book can be downloaded from

    ISBN 978-1-4419-1622-8 ISBN 978-1-4419-1623-5 (eBook)DOI 10.1007/978-1-4419-1623-5Springer New York Heidelberg Dordrecht London

    Library of Congress Control Number: 2012938546

    Springer Science+Business Media, LLC 2012This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publishers location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law.The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

    Printed on acid-free paper

    Springer is part of Springer Science+Business Media (

  • Dedicated to my parents,My wife, PremaAnd children Sheila, Shoba and Suresh For love, encouragement and understanding!

    CSPDedicated to my mother,My wife, Lekshmi,And, Kumar and Kavita,With love and gratitude,


  • vii

    The de fi nition of old age is not a clear one; most societies use arbitrary language to de fi ne the older adult. One hundred years ago, old age was de fi ned as any age after fi fty. Later, criteria such as pension schemes evolved to de fi ne the older adult, and ages 60 to 65 are numbers still accepted today. The term geriatrics means related to the aged and geriatric medicine deals with medical problems of old age. Aging is associated with a gradual decline in physiologic processes, along with susceptibility to disease. The needs of the old differ from those of the young. Geriatric patients often present atypically. Both evaluation and care differ. Decision-making is in fl uenced not only by the disease process itself, but also by life expectancy, quality of life issues and patient choices. This book deals with both the physiologic and pathologic changes in the gastrointestinal system as the aging process advances, and with the evaluation and care appropriate to the older age group.

    The gastroenterology and geriatric medicine disciplines are fortunate to have two experi-enced editors in Dr. Pitchumoni and Dr. Dharmarajan: they have conceived this book and have brought it to fruition. They are distinguished educators and clinicians who have achieved national and international respect in the fi elds of gastroenterology, internal medicine and geri-atrics. As authors and editors, they have been collaborating for over three decades. Having co-authored a series of articles in geriatric gastroenterology in peer-reviewed journals, they have now taken a step further in the design and execution of this work. The diverse back-grounds of the two editors bring strength and breadth to this ambitious text.

    Both editors have spent the majority of their professional careers in academic gastroenterol-ogy and geriatric medicine respectively. They have published extensively and have served on the editorial boards of prestigious journals. Dr. Pitchumoni, a recognized master teacher, is a Master of both the American College of Physicians and the American College of Gastroenterology. He has advanced degrees and board certi fi cation in the fi elds of internal medicine, gastroenterology, clinical nutrition and public health. Although he considers this author to be his mentor, I have certainly reaped equal bene fi t from our personal and profes-sional relationship over the years.

    Dr. Dharmarajan, a dedicated geriatrician, developed one of the largest known acute care hospital geriatric programs and associated geriatric medicine fellowships. He also serves as Associate Dean of his af fi liated medical school. In 1998, he published Launching a Geriatric Unit in Health Progress . The two continued their academic alliance in 2002 with the publica-tion Geriatric Medicine Programs in India: Has the Time Arrived? in the Journal of Association of Physicians India . The present book joins several other textbooks previously edited by this fi ne team of scholars.

    This is not just another gastroenterology textbook. The design is unique in providing con-temporary information in the fi eld of gastroenterology pertinent to the older adult.

    Although not the fi rst book in geriatric gastroenterology, this fi rst edition is conceptually bold and novel. The text is a state of the art, comprehensive and practical approach to the clini-cal practice of internal medicine, geriatrics and gastroenterology. The references are updated


  • viii Foreword

    and current clinical practice guidelines are appropriately presented. The book impresses me as one meant for the practicing physician as well as the resident in training and the fellow in geriatric medicine or gastroenterology. Key points at the end of every chapter summarize the highlights. Every chapter is amply supplemented with easy- to-understand tables and fi gures. Two chapters are devoted to radiologic images of gastrointestinal disorders in the aged. A chapter dealing with gastrointestinal pathology is rich in photographs of virtually every common gastrointestinal disorder in the elderly. The book as a whole is liberally illustrated with high quality images and clear captions.

    The editors have done an excellent job in their plan and execution of the contents. Seventy-two chapters are presented in fourteen sections. Introductory chapters present the perspectives of the editors as geriatrician and gastroenterologist. These are followed by a chapter on future trends in health care, and enable clinicians become knowledgeable on management of gastro-intestinal disorders in the aged population, a view supported by the American College of Gastroenterology. Chapters follow on the basic sciences and principles of gastroenterology in the context of the older adult and the aging process. Subsequent chapters deal with the impor-tant topics of pharmacology and drug interactions. The next few focus on geriatric nutrition, with topics ranging from healthy diet to enteral feeding to ethical issues in end-of-life care. The chapters which follow deal with luminal disorders, malignancies of the gastrointestinal tract, the liver, gallbladder and pancreas, palliative care, systemic disorders, and psychiatric disease. Each chapter focuses on evaluation, differential diagnosis and management of gastro-intestinal problems relevant to the older adult.

    Over eighty authors have contributed to the writing of this book. Many are of national and international repute, and ably supported by junior faculty members. In addition to their role as editors, Dr. Pitchumoni and Dr. Dharmarajan have also contributed a signi fi cant share of book chapters.

    In summary, this fi rst edition of Geriatric Gastroenterology is a major attempt to be all-inclusive in the fi eld of gastroenterology pertinent to the geriatric patient. The information therein is contemporary and basic to the practice of medicine. It is a privilege and honor to write this Foreword. The Editors are world-renowned educators and scholars who have designed and delivered a masterful textbook for clinicians of internal medicine, geriatrics and gastroenterology. They are to be congratulated for this effort.

    Clinical Professor of Medicine Martin H. Floch, M.D. Yale University School of Medicine

  • ix

    Over the past several decades, trends in global aging have focused attention on the manner in which we care for older adults. How can we be best prepared to meet the demands of medical illness in our aging population? Many of the medical societies have increasingly promoted the blending