Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

CHANGES OF THE GASTROINTESTINAL TRACT, ACUTE AND CHRONIC DISORDERS

Erika Pétervári and Márta BalaskóMolecular and Clinical Basics of Gerontology – Lecture 15

Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

TÁMOP-4.1.2-08/1/A-2009-0011

• delicate balance among the organ systems • functional loss in the most vulnerable system,

unrelated to the locus of illness• masked, not typical symptoms (e.g. no pain in

appendicitis)• polymorbidity (interaction with other systems)• altered drug disposition/clearance

Characteristics of geriatric patients

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Interaction with other systems:• ability to raise the cardiac output +

maldistribution of circulation GI motility and/or absorption capacity (hypoxia in the apical part of the villi); postprandial: insufficient rise of GI-perfusion (abdominal angina) or hypoperfusion in other organs (fainting, AMI)

• diabetes, neurologic and vascular changes esophageal motility, gastric atonia, constipation, or even paralytic ileus

• stress (mental and physical limitations and isolation) atypical GI symptoms

Influence of aging on gastrointestinal (GI) disorders

TÁMOP-4.1.2-08/1/A-2009-0011Lifestyle changes in the elderly – more severe complications of GI disorders • decrease in fluid intake;• decrease in protein intake (social and

psychological causes); • caloric malnutrition (weight loss);• insufficient intake of trace elements, vitamins• sedentary lifestyle (lack of exercise, obesity).

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• Upper GI tract disorders- Dysphagia syndromes, disorders of the

esophagus- Disorders of the stomach and the duodenum• Disorders of the lower bowel

- Constipation- Fecal incontinence (pressure ulcers!)- Diverticular disease- Diarrhea (malabsorption, chronic

pancreatitis)- Aging liver• Cancers in the GI tract

(e.g. esophagus, gastric cancer, colorectal carcinoma)• Special emergency situations: GI bleedings

Common GI disorders in the elderly

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• dental, oral disorders (stomatitis, denture), xerostomia + dysphagia (caused by drugs, cerebrovascular or neuromuscular disorders) malnutrition, aspiration

• esophageal carcinoma progressive dysphagia,

weight loss• non-cardiac chest pain: 50% of cases have

esophageal causee.g. gastro-esophageal reflux

nutcracker esophagus (manometric syndrome, high-amplitude peristaltic contractions confined to the distal esophagus)

Dysphagia syndrome, esophageal disorders

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• acid output incidence of duodenal ulcer• intake of NSAIDs incidence of gastric

ulcer• stress + defensive factors gastritis,

stress ulcer• ulcers may lead to serious bleeding,

perforation, penetration• incidence of autoimmune gastric atrophy

with achlorhydria and IF deficiency (pernicious anemia)

Disorders of the stomach and the duodenum

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The most common gastric disorders in elderly

Gastriccarcinoma

GERD

Gastriculcer Atrophic

gastritis

Gastro-paresis

Nutritional causes

• Low dietary fiber • Inadequate fluid and caloric intake

Functional causes

• Immobilization (terminal reservoir syndrome)• Depression• Confusion

Secondary causes(due to

other diseases)

• Neurological disorders(Parkinson’s disease, cerebrovascular accidents, dementia)

• Endocrine disorders(hypothyroidism, hyperparathyroidism, diabetes)

• Colonic obstruction(ischemia, diverticular disease, neoplasms, irradiation)

Drugs • Opiates• Anticholinergics• Cation-containing drugs (Al, Ca, Fe)• Diuretics etc.

Others • Incorrect interpretation of symptoms** Many older people incorrectly believe that their bowel movements are abnormal.

Common causes ofconstipation in the elderly

Common causes offecal incontinence in the elderly Anorectal incontinence(disorders of the anal sphincter and puborectal muscles)• descending perineum

(idiopathic)• trauma• anal surgery• spinal cord injuries• diabetic and other

autonomicneuropathies

Symptomatic incontinence• colorectal disease with

diarrhea

Overflow incontinence• impaired terminal

reservoir capacity (aging, ischemia, cancer, resection)

• fecal impactation

Neurogenic incontinence (sensory-cognitive factors)• dementia• confusion

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Diverticular disease

low-fiber diet

asymptomatic colonic diverticula (sac-like projection of the mucosa and submucosa)

bleedingdiverticulitis (infection of the

diverticula)

peritonitis, paralytic ileus

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• Precipitating factors:- dehydration- hemorrhage- low-output heart failure- polycythemia- diabetes mellitus- digitalis

• The ischemic colitis is rare (many anastomoses), but its mortality rate is high.

Ischemic colitis

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Aging and enteral absorption The small intestine has a large reserve capacity, aging has only subtle influences on the digestive and absorptive processes:• Reduced intestinal blood flow. • Decrease in the absorbing surface (30%),

atrophied villi. • Decreased activity of disaccharidases and

aminopeptidases can lead to osmotic diarrhea (thin, watery), due to the bacterial breakdown of non-digested food.

There is a decrease in the absorption of vitamin D, folic acid, vitamin B12, Ca, Cu, Zn, Fe and cholesterol. Replacement is necessary.

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Major causes:• infections• drug side-effects (long-term and inappropriate

use of antibiotics)• chronic pancreatitis • lactose intoleranceConsequences are more severe(dehydration, hypovolemia, malnutrition)Cave! Alternating diarrhea vs. constipation(colon tumors!)

Diarrhea and malabsorption in the elderly

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Disorders as consequences of malabsorption• osteoporosis (calcium) • sarcopenia (proteins)• infections (vitamins, proteins, trace elements) • pressure ulcers (proteins, fluids)• anemia (Fe, B12)• dementia (B12)• GI tract disorders (fibers, fluids)

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Age-related changes are minimal, significant only in late stage:• drug (alcohol) clearance• cholelithiasis, cholestasis• appearance of abnormal proteins

Aging liver

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CAUSE % Gastric ulcer 29Duodenal ulcer 21Gastritis 17Esophagitis 14Esophageal varices 12

Major causes ofupper GI tract bleeding

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Major causes oflower GI tract bleeding

CAUSE % Diverticulitis 43Vascular ectasia of right colon 20Undetermined 11Radiation proctitis 6Colorectal carcinoma 5Colonic polyps 4Other 11

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Carcinoma

Colitis(infections,

irritable bowel syndrome)

Angio-dysplasia

Ischemic

colitis

Polyps

Hemorrhoids Diverticula

Causes of lower intestinal bleeding