Manifestation of Novel Social Challenges of the European Union

in the Teaching Material of

Medical Biotechnology Master’s Programmes

at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

CHANGES OF THE

GASTROINTESTINAL

TRACT, ACUTE AND

CHRONIC DISORDERS

Erika Pétervári and Márta Balaskó

Molecular and Clinical Basics of Gerontology – Lecture 15

Manifestation of Novel Social Challenges of the European Union

in the Teaching Material of

Medical Biotechnology Master’s Programmes

at the University of Pécs and at the University of Debrecen Identification 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

TÁMOP-4.1.2-08/1/A-2009-0011

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

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Lifestyle 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).

TÁMOP-4.1.2-08/1/A-2009-0011

• 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

TÁMOP-4.1.2-08/1/A-2009-0011

• 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 cause

e.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

TÁMOP-4.1.2-08/1/A-2009-0011

The most common gastric disorders

in elderly

Gastric

carcinoma

GERD

Gastric

ulcer 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 of

constipation in the elderly

Common causes of

fecal 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

autonomic

neuropathies

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)

bleeding diverticulitis (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.

TÁMOP-4.1.2-08/1/A-2009-0011

Major causes:

• infections

• drug side-effects (long-term and inappropriate use

of antibiotics)

• chronic pancreatitis

• lactose intolerance

Consequences 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)

TÁMOP-4.1.2-08/1/A-2009-0011

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 29

Duodenal ulcer 21

Gastritis 17

Esophagitis 14

Esophageal varices 12

Major causes of

upper GI tract bleeding

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Major causes of

lower GI tract bleeding

CAUSE %

Diverticulitis 43

Vascular ectasia of right colon 20

Undetermined 11

Radiation proctitis 6

Colorectal carcinoma 5

Colonic polyps 4

Other 11

TÁMOP-4.1.2-08/1/A-2009-0011

Carcinoma

Colitis

(infections,

irritable bowel

syndrome)

Angio-

dysplasia

Ischemic

colitis

Polyps

Hemorrhoids Diverticula

Causes of lower intestinal bleeding