GI Disease in the Older Patient

GASTROENTEROLOGYGASTROENTEROLOGYCURRENT HOT TOPICSCURRENT HOT TOPICS

Aging and GI Disorders

Karen E. Hall, MD, PhDAssociate ProfessorDepartment of Internal MedicineDivision of Geriatric MedicineUniversity of Michigan/VAMCAnn Arbor, MI

Karen E. Hall, MD, PhDAssociate ProfessorDepartment of Internal MedicineDivision of Geriatric MedicineUniversity of Michigan/VAMCAnn Arbor, MI

AGS 2007AGS 2007

CURRENT HOT TOPICSCURRENT HOT TOPICS

The “Age Wave” The “Age Wave”

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Increase in the Number of Persons Aged 65+ Years in the United StatesIncrease in the Number of Persons Aged 65+ Years in the United States

Number (millions)

Percent of population

3 (4%)

5 (5%)

9 (7%)

17(9%)

26(11%)

31(13%)

35(12%)

40(13%)

55(17%)

72(20%)

4 (4%)

7 (5%)

12(8%)

20 (10%)

He W, et al. US Census Bureau. Current Population Reports, P23-209. 65+ in the United States: 2005. US Government Printing Office. Washington DC, 2005.



Population Aged ≥ 65 by Race in 2003, 2030, and 2050Population Aged ≥ 65 by Race in 2003, 2030, and 2050



83

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White

AfricanAmerican

Asian Other orcombination

races*

Hispanic

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Percent total population aged ≥65

Percent total population aged ≥65

*Includes American Indian and Alaska Native alone, Native Hawaiian and Other Pacific Islander alone, and all other who reported 2 or more races

*Includes American Indian and Alaska Native alone, Native Hawaiian and Other Pacific Islander alone, and all other who reported 2 or more races


EpidemiologyEpidemiology

• Over 35 million people aged >65 years in the United States

– 12% of the 2003 US population were older than 65 • 18.3 million aged 65-74• 12.9 million aged 75-84• 4.7 million aged ≥ 85

• 35% to 40% (45-50 million) of geriatric patients will have at least one GI symptom in any year

– Common problems in this age group include constipation, fecal incontinence, diarrhea, reflux disease, and swallowing disorders

• Over 35 million people aged >65 years in the United States

– 12% of the 2003 US population were older than 65 • 18.3 million aged 65-74• 12.9 million aged 75-84• 4.7 million aged ≥ 85

• 35% to 40% (45-50 million) of geriatric patients will have at least one GI symptom in any year

– Common problems in this age group include constipation, fecal incontinence, diarrhea, reflux disease, and swallowing disorders


Hall KE, et al. Gastroenterology. 2005;129:1305-1338.




CostsCosts

• $300 million to treat GI disease in older patients today• Individuals aged 65 years or older account for 60% of

all medical expenditures

• $300 million to treat GI disease in older patients today• Individuals aged 65 years or older account for 60% of

all medical expenditures

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Hall KE, et al. Gastroenterology. 2005;129:1305-1338.


The Geriatric Patient ProfileThe Geriatric Patient Profile

• Increasing age = increased heterogeneity in functional status, cognition, and co-morbidities

• Future cohorts likely to be more interested in the maintenance of independent living

• Older patients are at high risk of iatrogenic complications

– Especially true when the patient is seeing multiple specialists who may be prescribing treatments without coordination of care

• Specialists need to be aware of the potential for complications if interventions of other medical providers are not considered

• Increasing age = increased heterogeneity in functional status, cognition, and co-morbidities

• Future cohorts likely to be more interested in the maintenance of independent living

• Older patients are at high risk of iatrogenic complications

– Especially true when the patient is seeing multiple specialists who may be prescribing treatments without coordination of care

• Specialists need to be aware of the potential for complications if interventions of other medical providers are not considered



Age-related Changes in the Gastrointestinal TractAge-related Changes in the Gastrointestinal Tract

MotilityMotility

ImmunityImmunity

Drug metabolism

Drug metabolism

VisceralsensitivityVisceral

sensitivity

• Areas identified as important to aging are:

– Pathophysiology of swallowing disorders

– Esophageal reflux

– Dysmotility symptoms

– GI immunobiology

– Cellular mechanisms of neoplasia in the GI tract

– Decreased visceral sensitivity

• Areas identified as important to aging are:

– Pathophysiology of swallowing disorders

– Esophageal reflux

– Dysmotility symptoms

– GI immunobiology

– Cellular mechanisms of neoplasia in the GI tract

– Decreased visceral sensitivity

Hormoneresponsiveness

Hormoneresponsiveness

Lithogenicbile

Lithogenicbile

Pancreasstructure

and function

Pancreasstructure

and function

Liver sensitivityto stress

Liver sensitivityto stress

ColonicfunctionColonicfunction

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Robins J, et al. GI Motility Online. 2006

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Robins J, et al. GI Motility Online. 2006


Cellular Mechanisms of AgingCellular Mechanisms of Aging

• Most people experience a rapid change in physiologic function between the ages of 60-75 years that results in impaired function represented by:

– Cellular aging• Acquisition of genetic errors• Oxidant damage• Alterations in pathways in growth and repair

– Immunobiology of aging• Decreased ability to generate immune response to new stimulus• Loss of immunocompetent B cells• Immunosuppressive/cytotoxic T cells increased in animal models

– Neurodegenerative disease• Dementia rises steeply after age 65• Visceral autonomic function impaired• Pain sensitivity decreased

• Most people experience a rapid change in physiologic function between the ages of 60-75 years that results in impaired function represented by:

– Cellular aging• Acquisition of genetic errors• Oxidant damage• Alterations in pathways in growth and repair

– Immunobiology of aging• Decreased ability to generate immune response to new stimulus• Loss of immunocompetent B cells• Immunosuppressive/cytotoxic T cells increased in animal models

– Neurodegenerative disease• Dementia rises steeply after age 65• Visceral autonomic function impaired• Pain sensitivity decreased



Decreased Autonomic SensitivityDecreased Autonomic Sensitivity

• “Painless GERD”• “No Peritonitits”

• “Painless GERD”• “No Peritonitits”


CT scan for Acute AbdomenCT scan for Acute Abdomen


Effect of Aging on SwallowingEffect of Aging on Swallowing

• Oro-pharyngeal dyskinesia – normal aging– Slow Transit past pharynx and upper esophageal sphincter

(UES)• Aspiration• Zenker’s Diverticulum

– Decreased lower esophageal sphincter (LES) pressure • Gastroesophageal reflux (GERD)

– Esophagitis– Bleeding

– Secondary Esophageal Dysmotility• Poor clearance (“tertiary contractions”)• Spasm• Presbyesophagus (long tortuous esophagus)

• Oro-pharyngeal dyskinesia – normal aging– Slow Transit past pharynx and upper esophageal sphincter

(UES)• Aspiration• Zenker’s Diverticulum

– Decreased lower esophageal sphincter (LES) pressure • Gastroesophageal reflux (GERD)

– Esophagitis– Bleeding

– Secondary Esophageal Dysmotility• Poor clearance (“tertiary contractions”)• Spasm• Presbyesophagus (long tortuous esophagus)



Esophageal AgingEsophageal Aging

• Dysphagia, regurgitation, nausea are common• Heartburn not so common• Atypical chest pain

• “Presbyesophagus”: (age-related changes in esophageal function)

– Decreased contractile amplitude– Polyphasic waves– Incomplete relaxation of the lower esophageal sphincter (LES)– Esophageal dilation

• GERD – Impaired clearance of acid– Longer duration of reflux episodes– Atypical symptom presentation

• Dysphagia, regurgitation, nausea are common• Heartburn not so common• Atypical chest pain

• “Presbyesophagus”: (age-related changes in esophageal function)

– Decreased contractile amplitude– Polyphasic waves– Incomplete relaxation of the lower esophageal sphincter (LES)– Esophageal dilation

• GERD – Impaired clearance of acid– Longer duration of reflux episodes– Atypical symptom presentation



Effect of Disease on SwallowingEffect of Disease on Swallowing

• Oro-pharyngeal dyskinesia– Neurodegenerative disease

• Stroke• Dementia• Parkinson’s Disease• Others

– Tumor • Head and neck (extrinsic to gut)• Esophageal• Paraneoplastic (lung)• Brain and spinal cord

– Benign “Stricture”• Peptic• Achalasia

• Oro-pharyngeal dyskinesia– Neurodegenerative disease

• Stroke• Dementia• Parkinson’s Disease• Others

– Tumor • Head and neck (extrinsic to gut)• Esophageal• Paraneoplastic (lung)• Brain and spinal cord

– Benign “Stricture”• Peptic• Achalasia



Peptic Esophageal StricturePeptic Esophageal Stricture



AchalasiaAchalasia

• Impaired relaxation of the LES– Loss of inhibitory myenteric neurons

• Idiopathic• Paraneoplastic• Chagas Disease (parasitic infection)

– Tumor can present in same way• Get endoscopy• LES is distensible• Tumor or peptic stricture is fixed

– Balloon dilation • Botulinum toxin injection• Myotomy

• Impaired relaxation of the LES– Loss of inhibitory myenteric neurons

• Idiopathic• Paraneoplastic• Chagas Disease (parasitic infection)

– Tumor can present in same way• Get endoscopy• LES is distensible• Tumor or peptic stricture is fixed

– Balloon dilation • Botulinum toxin injection• Myotomy


GERD and Barrett’s EsophagusGERD and Barrett’s Esophagus

• Barrett’s Esophagus– Unclear if acid exposure is the cause– Intestinal metaplasia– Endoscopic monitoring

• How often? 1-3 years• Multiple biopsies• Dysplasia can regress or progress• Proton pump inhibitor (PPI) treatment• Not clear if beneficial

– High grade dysplasia or cancer• Esophagectomy• Endoscopic mucosal stripping or laser ablation• ?DNA testing – experimental

• Barrett’s Esophagus– Unclear if acid exposure is the cause– Intestinal metaplasia– Endoscopic monitoring

• How often? 1-3 years• Multiple biopsies• Dysplasia can regress or progress• Proton pump inhibitor (PPI) treatment• Not clear if beneficial

– High grade dysplasia or cancer• Esophagectomy• Endoscopic mucosal stripping or laser ablation• ?DNA testing – experimental



Nutrition Nutrition

• Geriatric patients, especially aged >85 years are at risk for decreased food intake due to several factors:

– Mobility impairment– Ability to obtain food– Loss of taste, may be due to decreased olfaction– Poor dentition– Decreased appetite– “Anorexia of aging”, may be related to neuroendocrine changes– Depression

• Geriatric patients, especially aged >85 years are at risk for decreased food intake due to several factors:

– Mobility impairment– Ability to obtain food– Loss of taste, may be due to decreased olfaction– Poor dentition– Decreased appetite– “Anorexia of aging”, may be related to neuroendocrine changes– Depression



Weight LossWeight Loss

• Assess amount of food eaten• Screen for depression and dementia• Get labs

– CBC, basic renal, hepatic, TSH level, folate, B12, iron

• Trial of increased calories with prompting by caregivers

• If patient will not eat consider further tests– CT or referral

• Consider treatment of depression• Abdominal pain may be symptom of depression

• Assess amount of food eaten• Screen for depression and dementia• Get labs

– CBC, basic renal, hepatic, TSH level, folate, B12, iron

• Trial of increased calories with prompting by caregivers

• If patient will not eat consider further tests– CT or referral

• Consider treatment of depression• Abdominal pain may be symptom of depression

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:288-295.

Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11.




Depression Affects the Elderly Depression Affects the Elderly

• Affects 1% of the general population– Most common psychiatric disorder

• Affects 3%-12% of community-dwelling elderly patients

– More common (>26%) in nursing home residents

• May be associated with GI symptoms• Social withdrawal, and somatic symptoms such as

nausea, abdominal pain, and weight loss add to the burden of GI disease

• Affects 1% of the general population– Most common psychiatric disorder

• Affects 3%-12% of community-dwelling elderly patients

– More common (>26%) in nursing home residents

• May be associated with GI symptoms• Social withdrawal, and somatic symptoms such as

nausea, abdominal pain, and weight loss add to the burden of GI disease






Aging and the StomachAging and the Stomach

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Cullen DJE, et al. Gut. 1997;41:459-462.

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Cullen DJE, et al. Gut. 1997;41:459-462.

DecreasedDecreased IncreasedIncreased

•Clearance of liquids from stomach

•Perception of gastric distention

•Cytoprotective factors

•Mucosal blood flow and impaired sensory neuron function in animal models

•Contact time with NSAID’s or other noxious agents in delayed emptying

•Tendency for gastric mucosal injury in delayed emptying

•Prevalence of H. pylori associated with increased risk of bleeding peptic ulcer, pernicious anemia, gastric cancer and lymphoma


Gastritis Gastritis

• Very common• NSAIDs• Other meds (iron, bisphosphonates)

• Very common• NSAIDs• Other meds (iron, bisphosphonates)



Gastroparesis Gastroparesis

• Diabetes• Medications (anticholinergic)• Obstructive (benign or malignant)

• Endoscopy• UGI series• Gastric emptying study (abnormal if >3 hours)• Prokinetics

– Metoclopramide– Erythromycin (motilin analog)– (Domperidone in Canada)– (Cisapride)

• Diabetes• Medications (anticholinergic)• Obstructive (benign or malignant)

• Endoscopy• UGI series• Gastric emptying study (abnormal if >3 hours)• Prokinetics

– Metoclopramide– Erythromycin (motilin analog)– (Domperidone in Canada)– (Cisapride)


Gastrointestinal Bleeding is Common in the ElderlyGastrointestinal Bleeding is Common in the Elderly

• 30% GI bleeding in the lower tract

– Terminal ileum– Colon– Rectum

• 70% GI bleeding in the upper tract

– Esophagus– Stomach– Small bowel



Gastrointestinal Bleeding in the ElderlyGastrointestinal Bleeding in the Elderly

• Upper tract– 50% bleeding is due to NSAID use– 50% bleeding is due to ulceration or

erosions (peptic or esophageal)

• Females are at higher risk than males

• Continued bleeding or rebleeding are the highest predictors of mortality and morbidity in older patients

• Upper tract– 50% bleeding is due to NSAID use– 50% bleeding is due to ulceration or

erosions (peptic or esophageal)

• Females are at higher risk than males

• Continued bleeding or rebleeding are the highest predictors of mortality and morbidity in older patients

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Image courtesy of David C. Metz, MD.



Gastrointestinal Bleeding in the ElderlyGastrointestinal Bleeding in the Elderly

• Visible vessel – laser or bicap coagulation

• Esophageal varicies – usually Grade II-IV

• Gastric varicies• Rarely small bowel or biliary

• Visible vessel – laser or bicap coagulation

• Esophageal varicies – usually Grade II-IV

• Gastric varicies• Rarely small bowel or biliary




Celiac Disease – Malabsorbtion and AnemiaCeliac Disease – Malabsorbtion and Anemia

• IgA and/or IgG antibodies to:– Anti-tissue transglutamidase– Anti-endomysial– Anti-gliadin

• Small bowel mucosal atrophy• Weight loss and malabsorbtion – diarrhea• Anemia• Vitamin deficiencies (fat soluble and B vitamins)• May present for first time in geriatric patients• Get serology, imaging (UGI + SBFT), duodenal biopsy• If diet-resistant: oral steroid and workup for small

bowel lymphoma

• IgA and/or IgG antibodies to:– Anti-tissue transglutamidase– Anti-endomysial– Anti-gliadin

• Small bowel mucosal atrophy• Weight loss and malabsorbtion – diarrhea• Anemia• Vitamin deficiencies (fat soluble and B vitamins)• May present for first time in geriatric patients• Get serology, imaging (UGI + SBFT), duodenal biopsy• If diet-resistant: oral steroid and workup for small

bowel lymphoma


Colonic Bleeding in the ElderlyColonic Bleeding in the Elderly

• Angiodysplasia in the colon• Colitis (medications, ischemic,

inflammatory)

• Angiodysplasia in the colon• Colitis (medications, ischemic,

inflammatory)


Colorectal Cancer in the ElderlyColorectal Cancer in the Elderly

• An estimated 106,680 cases of colon and 41,930 cases of rectal cancer are expected to occur in 2006

• 90% of all cases occur in individuals older than aged 50 years

• An estimated 106,680 cases of colon and 41,930 cases of rectal cancer are expected to occur in 2006

• 90% of all cases occur in individuals older than aged 50 years

ACS Cancer Facts and Figures 2006.Burt RW. Gastroenterology. 2000;119:837-853.

Image courtesy of Subhas Banerjee, MD.

ACS Cancer Facts and Figures 2006.Burt RW. Gastroenterology. 2000;119:837-853.

Image courtesy of Subhas Banerjee, MD.


Colorectal Cancer in the ElderlyColorectal Cancer in the Elderly

• In a study of 1244 participants divided into three age groups who underwent screening colonoscopy, increasing age was associated with an increased prevalence of neoplasia

• In a study of 1244 participants divided into three age groups who underwent screening colonoscopy, increasing age was associated with an increased prevalence of neoplasia

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Age group (years)Age group (years)Lin OS, et al. JAMA. 2006;295:2357-2365.Lin OS, et al. JAMA. 2006;295:2357-2365.

n = 1034 n = 147 n = 63


Colonic PolypsColonic Polyps

• Most colon cancer (>90%) originates in adenomatous polyp

• >60% are right sided (cecal and transverse) polyps - colonoscopy

• 1-5% of low risk patients undergoing colonoscopy have a carcinoma-in-situ (CIS)

• 8% of patients over 85 have CIS

• 60% of 85+ patients have Dukes A tumors (no extension out of the polyp)

• Virtual colonoscopy not sensitive or specific enough (no insurance reimbursement !)

• No “age cutoff” – “less than 5 year life expectancy”

• Most colon cancer (>90%) originates in adenomatous polyp

• >60% are right sided (cecal and transverse) polyps - colonoscopy

• 1-5% of low risk patients undergoing colonoscopy have a carcinoma-in-situ (CIS)

• 8% of patients over 85 have CIS

• 60% of 85+ patients have Dukes A tumors (no extension out of the polyp)

• Virtual colonoscopy not sensitive or specific enough (no insurance reimbursement !)

• No “age cutoff” – “less than 5 year life expectancy”

ACS Cancer Facts and Figures 2006.Burt RW. Gastroenterology. 2000;119:837-853.MD.

ACS Cancer Facts and Figures 2006.Burt RW. Gastroenterology. 2000;119:837-853.MD.


Aging-Associated Changes in Colonic MotilityAging-Associated Changes in Colonic Motility

• Common disorders observed in the elderly that are correlated with colonic motility are:

– Constipation – Diverticular disease – Diarrhea– Fecal incontinence

• There are age-associated reductions in myenteric neurons, calcium influx, and compliance in connective tissue

• No clear effect of age on colonic transit, as many constipated older patients appear to have normal transit times

• Common disorders observed in the elderly that are correlated with colonic motility are:

– Constipation – Diverticular disease – Diarrhea– Fecal incontinence

• There are age-associated reductions in myenteric neurons, calcium influx, and compliance in connective tissue

• No clear effect of age on colonic transit, as many constipated older patients appear to have normal transit times

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23:1379-1391.

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23:1379-1391.


Coronary heart diseaseCoronary heart disease

Asthma Asthma

DiabetesDiabetes

MigrainesMigraines

HypertensionHypertension

ConstipationConstipation

Prevalence in millionsPrevalence in millions00 2020 4040 6060 8080

Prevalence of Selected Diseases in US AdultsPrevalence of Selected Diseases in US Adults

*Prevalence in North Americans*Prevalence in North AmericansLethbridge-Çejku M, et al. Vital Health Stat 10. 2005;1.Higgins PDR, et al. Am J Gastroenterol. 2004;99:750. Lethbridge-Çejku M, et al. Vital Health Stat 10. 2005;1.Higgins PDR, et al. Am J Gastroenterol. 2004;99:750.

1414

1616

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4949

63*63*

Prevalence of Constipation Compared to Other Common DiseasesPrevalence of Constipation Compared to Other Common Diseases


Constipation in the ElderlyConstipation in the Elderly

• Constipation is the most common chronic digestive complaint in the United States

• Age– The incidence increases after the age of 65– Prevalence 30% - 40% among people aged > 65 years

• Gender– 2-3x more common in females– Impaired evacuation a significant factor in elderly women

• Of community-residing elderly patients, 30% report that they suffer from constipation at least monthly

• Constipation is the most common chronic digestive complaint in the United States

• Age– The incidence increases after the age of 65– Prevalence 30% - 40% among people aged > 65 years

• Gender– 2-3x more common in females– Impaired evacuation a significant factor in elderly women

• Of community-residing elderly patients, 30% report that they suffer from constipation at least monthly

Talley NJ, et al. Am J Gastroenterol. 1996;91:19.Johanson JF, et al. J Clin Gastroenterol. 1989;11:525.Pekmezaris R, et al. J Am Med Dir Assoc. 2002;3:224.Higgins PDR, et al. Am J Gastroenterol. 2004;99:750.

Muller-Lissner S. Best Pract Res Clin Gastroenterol. 2002;16:115-133.

Talley NJ, et al. Am J Gastroenterol. 1996;91:19.Johanson JF, et al. J Clin Gastroenterol. 1989;11:525.Pekmezaris R, et al. J Am Med Dir Assoc. 2002;3:224.Higgins PDR, et al. Am J Gastroenterol. 2004;99:750.

Muller-Lissner S. Best Pract Res Clin Gastroenterol. 2002;16:115-133.


Geriatric Risk Factors for ConstipationGeriatric Risk Factors for Constipation

• Immobility (bed-bound)• Pain

– Musculoskeletal in spine, pelvis, hips– Abdominal– Severe generalized pain– Opiate use

• Deconditioning• Muscle weakness• Neurodegenerative disease• Thyroid disease

• Immobility (bed-bound)• Pain

– Musculoskeletal in spine, pelvis, hips– Abdominal– Severe generalized pain– Opiate use

• Deconditioning• Muscle weakness• Neurodegenerative disease• Thyroid disease

Higgins PDR, et al. Am J Gastroenterol. 2004;99:750. Muller-Lissner S. Best Practice Res Clin Gastroenterol. 2002;16:115-33.

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.De Lillo AR, et al. Am J Gastroenterol. 2000;95:901.

Higgins PDR, et al. Am J Gastroenterol. 2004;99:750. Muller-Lissner S. Best Practice Res Clin Gastroenterol. 2002;16:115-33.

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.De Lillo AR, et al. Am J Gastroenterol. 2000;95:901.


Atypical Presentation of Constipation in the ElderlyAtypical Presentation of Constipation in the Elderly

• Anorexia• Nausea• Behavioral changes• Abdominal

discomfort/distension• Fecal impaction• Overflow incontinence -

“diarrhea”

• Get an abdominal xray– if stool proximal to descending

colon – not “normal”

• Anorexia• Nausea• Behavioral changes• Abdominal

discomfort/distension• Fecal impaction• Overflow incontinence -

“diarrhea”

• Get an abdominal xray– if stool proximal to descending

colon – not “normal”

De Lillo AR, et al. Am J Gastroenterol.2000;95:901.Leonard R, et al. Arch Intern Med. 2006. Jun 26;166(12):1295-1300.

De Lillo AR, et al. Am J Gastroenterol.2000;95:901.Leonard R, et al. Arch Intern Med. 2006. Jun 26;166(12):1295-1300.


Patient and Physician Descriptions of ConstipationPatient and Physician Descriptions of Constipation

• Patient description– “I haven’t had a bowel movement today”– “My stools are hard and lumpy”– “It’s hard to have a bowel movement”

• Physician description– Infrequent bowel movements – Difficulty during defecation (straining)– Sensation of incomplete bowel evacuation– Abnormal stool form– Smaller bowel movements

• Patient description– “I haven’t had a bowel movement today”– “My stools are hard and lumpy”– “It’s hard to have a bowel movement”

• Physician description– Infrequent bowel movements – Difficulty during defecation (straining)– Sensation of incomplete bowel evacuation– Abnormal stool form– Smaller bowel movements

Herz MJ, et al. Fam Pract. 1996;13:156.Herz MJ, et al. Fam Pract. 1996;13:156.


Bristol Stool ChartBristol Stool Chart

• Types 1-7• More than 25% of the time• Correlates with colonic transit

– type 1 slow; type 7 fast

• Types 1-7• More than 25% of the time• Correlates with colonic transit

– type 1 slow; type 7 fast

Lewis SJ, Heaton KW. Scan J Gastroenterol 2007; 32:920 Lewis SJ, Heaton KW. Scan J Gastroenterol 2007; 32:920


ConstipationConstipation

• No evidence that fiber or hydration alone is effective in patients >70 years without dehydration

• Only RTC evidence for psyllium, osmotic agents (PEG solution) and newer drugs (tegaserod, lubiprostone)

• Tegaserod recently withdrawn (April 2007) due to cardiac events (0.11% vs 0.03% placebo)

• Consider stimulant laxative (senna, bisacodyl, milk of magnesia, lubiprostone)

• No evidence of myenteric damage with above agents• Osmotic agents (lactulose, sorbital, PEG) also

effective but may cause bloating or vomiting

• No evidence that fiber or hydration alone is effective in patients >70 years without dehydration

• Only RTC evidence for psyllium, osmotic agents (PEG solution) and newer drugs (tegaserod, lubiprostone)

• Tegaserod recently withdrawn (April 2007) due to cardiac events (0.11% vs 0.03% placebo)

• Consider stimulant laxative (senna, bisacodyl, milk of magnesia, lubiprostone)

• No evidence of myenteric damage with above agents• Osmotic agents (lactulose, sorbital, PEG) also

effective but may cause bloating or vomiting


Enema v.s. Oral agentsEnema v.s. Oral agents

• “Get patient moving from below before given meds from above”

• If no BM in 1-2 days use suppository

• Use tap water or milk and molasses (1 liter: 0.5 cups) enemas for severely constipated

• Mineral oil enema may work but some cases of oil absorption and pneumonia

• Avoid soapsuds enemas (ischemic colitis)

• “Get patient moving from below before given meds from above”

• If no BM in 1-2 days use suppository

• Use tap water or milk and molasses (1 liter: 0.5 cups) enemas for severely constipated

• Mineral oil enema may work but some cases of oil absorption and pneumonia

• Avoid soapsuds enemas (ischemic colitis)


Diverticular DiseaseDiverticular Disease

• An abnormality in the aging colon involving decreased tensile strength of the muscle wall

• By aged 50 years one third of Americans will have diverticulosis coli; by aged 80 years, two-thirds will be affected

– Incidence less than 5% <40 years– Incidence greater than 60% by aged 85 years– Mean age at presentation is aged 60 years

• The majority of those affected are asymptomatic

• An abnormality in the aging colon involving decreased tensile strength of the muscle wall

• By aged 50 years one third of Americans will have diverticulosis coli; by aged 80 years, two-thirds will be affected

– Incidence less than 5% <40 years– Incidence greater than 60% by aged 85 years– Mean age at presentation is aged 60 years

• The majority of those affected are asymptomatic

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Cooperman A. Diverticulitis. eMedicine Web Site. Available at: www.emedicine.com/MED/topic578.htm. Accessed 11/3/2006.

Image courtesy of Jennifer Christie, MD.

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Cooperman A. Diverticulitis. eMedicine Web Site. Available at: www.emedicine.com/MED/topic578.htm. Accessed 11/3/2006.

Image courtesy of Jennifer Christie, MD.


Diverticular Disease (Cont.)Diverticular Disease (Cont.)

• Other factors of diverticular disease:– Slow colonic transit– Increased frequency of segmenting contractions resulting in

increased water resorption and hard feces

• National Demographic and Health Survey (NDHS) 1996 to 2002 for diverticulitis

– Hospital admissions increased by 14% to 261,180– Office visits increased by 14% to 1,493,865– Emergency department visits increased by 47% from 87,512

161,364

• Significant morbidity and mortality from abcess and perforation (delay in diagnosis)

• Other factors of diverticular disease:– Slow colonic transit– Increased frequency of segmenting contractions resulting in

increased water resorption and hard feces

• National Demographic and Health Survey (NDHS) 1996 to 2002 for diverticulitis

– Hospital admissions increased by 14% to 261,180– Office visits increased by 14% to 1,493,865– Emergency department visits increased by 47% from 87,512

161,364

• Significant morbidity and mortality from abcess and perforation (delay in diagnosis)



Diarrhea Diarrhea

• Definition: – Loose stools of more than 200g/day in at least three bowel

movements per day– Patient’s description usually focuses on loose stools

• Approximately 85% of all mortality associated with diarrhea involves the elderly

– 73 million consultations for acute diarrhea in the United States each year

• Between 1997 and 2000– Office visits for chronic diarrhea increased by 115% from

991,886 2,132,272– ?Medications vs Exposure – food, institutions

• Definition: – Loose stools of more than 200g/day in at least three bowel

movements per day– Patient’s description usually focuses on loose stools

• Approximately 85% of all mortality associated with diarrhea involves the elderly

– 73 million consultations for acute diarrhea in the United States each year

• Between 1997 and 2000– Office visits for chronic diarrhea increased by 115% from

991,886 2,132,272– ?Medications vs Exposure – food, institutions

Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36.Hall KE, et al. Gastroenterology. 2005;129:1305-1338.



Causes of Diarrhea in the ElderlyCauses of Diarrhea in the Elderly

Common CausesCommon Causes

Infections

Drug-induced diarrhea

Malabsorption

Fecal impaction

Colonic carcinoma

Small bowel bacterial overgrowth

Diabetic diarrhea




Causes of Diarrhea in the ElderlyCauses of Diarrhea in the Elderly

Less Common CausesLess Common Causes

Celiac disease

Inflammatory bowel disease

Thryotoxicosis

Scleroderma with systemic manifestations

Whipple’s disease

Amyloidosis with small bowel involvement

Pancreatic insufficiency (screen for ETOH)

Small bowel tumors




Fecal IncontinenceFecal Incontinence

• Fecal incontinence is uncommon in the general population (2.2%) but has a significantly higher prevalence (10%) in the older population

• Fecal incontinence is uncommon in the general population (2.2%) but has a significantly higher prevalence (10%) in the older population


Fecal incontinence can result from:

Fecal impaction and subsequent

flow

Internal anal sphincter

incompetence

Decreased rectal or anal

sensation

Structural impairments in the pelvic floor

Anorectal damage from surgery or

irradiation


Fecal IncontinenceFecal Incontinence

• Risk factors identified are: – Advancing age– Diabetes mellitus– Urinary incontinence– Stroke– Physical limitations– Female gender– Peri-anal injury or surgery– Hypertension– Poor general health– Bowel –related factors (incomplete defecation, constipation,

straining, fecal urgency)

• Risk factors identified are: – Advancing age– Diabetes mellitus– Urinary incontinence– Stroke– Physical limitations– Female gender– Peri-anal injury or surgery– Hypertension– Poor general health– Bowel –related factors (incomplete defecation, constipation,

straining, fecal urgency)

Goode PS, et al. J Am Geriatr Soc. 2005;53:629-635.Goode PS, et al. J Am Geriatr Soc. 2005;53:629-635.


Implications for Elderly Suffering from Diarrhea and/or Fecal IncontinenceImplications for Elderly Suffering from Diarrhea and/or Fecal Incontinence

• Both can become a chronic problem resulting in social isolation and decreased activity out of the home

• It is important to obtain a good history to determine if fecal incontinence is due to diarrhea, urgency, obstruction, or rectal dysfunction

• Refer to specialist center for multifactorial assessment and treatment (biofeedback, surgery)

• Both can become a chronic problem resulting in social isolation and decreased activity out of the home

• It is important to obtain a good history to determine if fecal incontinence is due to diarrhea, urgency, obstruction, or rectal dysfunction

• Refer to specialist center for multifactorial assessment and treatment (biofeedback, surgery)

Hall KE, et al. Gastroenterology. 2005;129:1305-1338 Akhtar AJ, et al. J Amer Med Dir. Assoc. 2005;6:54-60.Hall KE, et al. Gastroenterology. 2005;129:1305-1338

Akhtar AJ, et al. J Amer Med Dir. Assoc. 2005;6:54-60.


Hepato-biliary Function with AgingHepato-biliary Function with Aging

• Dynamic assessments of liver function decrease with aging

• Compared to younger adults, in healthy subjects there is a decrease by 30% - 40% decrease in

– Liver size– Blood flow– Perfusion

• Nonalcoholic steatohepatitis (NASH) is a common complication of obesity and diabetes mellitus

– Diabetes affects 12% of the US population; >70% of affected individuals are in the geriatric age range

– NASH may progress to cirrhosis in up to ~25% of patients– NASH increases the risk of hepatic side effects of drugs

• Dynamic assessments of liver function decrease with aging

• Compared to younger adults, in healthy subjects there is a decrease by 30% - 40% decrease in

– Liver size– Blood flow– Perfusion

• Nonalcoholic steatohepatitis (NASH) is a common complication of obesity and diabetes mellitus

– Diabetes affects 12% of the US population; >70% of affected individuals are in the geriatric age range

– NASH may progress to cirrhosis in up to ~25% of patients– NASH increases the risk of hepatic side effects of drugs

Hall KE, et al. Gastroenterology. 2005;129:1305-1338.Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905.



Hepato-biliary FunctionHepato-biliary Function

• Liver “function” tests – actually dysfunction tests– Enzymes, bilirubin level

• Liver Function tests– Albumin– PT/INR– Bilirubin conjugation

• Hepatic Ultrasound with Portal vein Doppler– Check for cirrhosis, portal hypertension– May add CT if undiagnostic

• Refer to specialist if enzymes >100, hepatic alkaline phosphatase persistently elevated, or liver function impaired

• Mild AST or ALT elevation without dysfunction is NOT a contraindication to use of statins

• Liver “function” tests – actually dysfunction tests– Enzymes, bilirubin level

• Liver Function tests– Albumin– PT/INR– Bilirubin conjugation

• Hepatic Ultrasound with Portal vein Doppler– Check for cirrhosis, portal hypertension– May add CT if undiagnostic

• Refer to specialist if enzymes >100, hepatic alkaline phosphatase persistently elevated, or liver function impaired

• Mild AST or ALT elevation without dysfunction is NOT a contraindication to use of statins




Gallbladder Function with AgingGallbladder Function with Aging

• Bile becomes increasingly lithogenic with aging– Precipitation of supersaturated bile and concomitant

crystallization of cholesterol or calcium bilirubinate• In subjects older than 35 years, fasting and

postprandial gallbladder volumes increased– In older individuals there was less complete gallbladder

emptying following a meal• Aging women may be more susceptible to impaired

gallbladder contractility • Compared to young patients, cholecystitis and

cholangitis in older patients has increased morbidity and mortality

• Hepatic ultrasound and HIDA scan, consider referral for ERCP

• Bile becomes increasingly lithogenic with aging– Precipitation of supersaturated bile and concomitant

crystallization of cholesterol or calcium bilirubinate• In subjects older than 35 years, fasting and

postprandial gallbladder volumes increased– In older individuals there was less complete gallbladder

emptying following a meal• Aging women may be more susceptible to impaired

gallbladder contractility • Compared to young patients, cholecystitis and

cholangitis in older patients has increased morbidity and mortality

• Hepatic ultrasound and HIDA scan, consider referral for ERCP



Pancreatic Function with AgingPancreatic Function with Aging

• Exocrine and endocrine pancreatic function in non-diabetic patients is preserved with aging

• Incidence of pancreatic cancer is increasing in patients aged > 65 years

– Older patients have significantly worse surgical outcomes– Median survival is 11 months vs. 25 months in patients < 65 yrs

• Approximately half of acute pancreatitis cases are patients >60 years

– Gallstones are most common etiology (60%)– 40%: surgery, drugs, trauma, infection, alcohol– Mortality in elderly is 20%; twice that of general population

• Exocrine and endocrine pancreatic function in non-diabetic patients is preserved with aging

• Incidence of pancreatic cancer is increasing in patients aged > 65 years

– Older patients have significantly worse surgical outcomes– Median survival is 11 months vs. 25 months in patients < 65 yrs

• Approximately half of acute pancreatitis cases are patients >60 years

– Gallstones are most common etiology (60%)– 40%: surgery, drugs, trauma, infection, alcohol– Mortality in elderly is 20%; twice that of general population



SummarySummary

• The age wave will continue to increase in the next 25 years resulting in a substantial boom of the 65+ geriatric population

• Many physiological and psychological changes occur with age

• There are significant changes in gastrointestinal function that occur in geriatric-aged patients

• Aging increases the risk of several disorders: – Dysphagia, GI bleeding, colorectal cancer, constipation,

diverticular disease, diarrhea, fecal incontinence , pancreatic cancer, and hepatobiliary disorders

• The age wave will continue to increase in the next 25 years resulting in a substantial boom of the 65+ geriatric population

• Many physiological and psychological changes occur with age

• There are significant changes in gastrointestinal function that occur in geriatric-aged patients

• Aging increases the risk of several disorders: – Dysphagia, GI bleeding, colorectal cancer, constipation,

diverticular disease, diarrhea, fecal incontinence , pancreatic cancer, and hepatobiliary disorders






HandoutsHandouts

• Sitemaker.umich.edu/khallinfo

– AGS 2007

• Sitemaker.umich.edu/khallinfo

– AGS 2007

Documents

GI Disease in the Older Patient