1. GI Problems in Athletes Thomas Best MD, PhD The Ohio State UniversityFebruary 4, 2011 Sports Medicine

2. Overview  Epidemiology/Physiology  Upper GI Problems  Runner’s Diarrhea/Ischemic Colitis  Practical Recommendations “Problems cannot be solved with the same level of awareness that created them.” Albert Einstein Sports Medicine

3. Objectives  Understand the physiology of exercise and its effects on the GI tract  Be familiar with the common GI problems in athletes, their etiology, work-up and treatment Sports Medicine

4. What Is Clinical Outcomes Evidence? Statistics, probabilities and opinions  Experimental evidence –Clinical trials (RCT)  Observational (epidemiological) evidence –Cohort studies (prospective and retrospective) –Case-control studies –Cross sectional studies –Case series and reports –Expert opinion Sports Medicine

5. Interpretation of Evidence Criteria of Judgement  Consistency of independent investigations  Strength of association (dose response)  Specificity of association  Temporal relationship  Coherence (biological plausibility) Sports Medicine

6. Exercise Effects On The GI Tract Regular moderate physical activity is associated with:  Enhanced gastric emptying  Improved GI motility  Less constipation  Lower risk for liver disease, cholelithiasis, diverticulosis, colon CA  Improved control of IBS symptom severity (Johannesson et al Amer J Gastro Jan 2011) Exercise MORE effective than pharmacological treatments in IBS (Henningsen et al Lancet 2007 ) Sports Medicine

7. GI Symptoms Are Common Upper  Heartburn, chest pain, belching, epigastric pain, nausea and vomiting  Reported by up to 50% of athletes during heavy exercise Lower  “Runner’s Trots” Casey, Clin Sport Med 2005 24:525-40 Peters, CSMR 2004, 3:107–111 Sports Medicine

8. GI Problems Are Common Prevalence  Highest during running  Women > men  More common in younger athletes  Less frequent in low impact sports  Exercise intensity  Marathoners: 30-80% report GI symptoms GI bleeding (8 - 85%)  All sports report  8% to 22% of marathon runners report gross fecal blood loss Jaworski, CSMR 2005, 4:137–143 Casey, Clin Sport Med 2005 24:525-40 Ho, CSMR 2009, 8:85-91 Sports Medicine

9. GI Problems – Contributing Factors  Mechanical  Dietary  Ingestions: medications, etc  Emotional  Infection: viral gastroenteritis, travel, other  Inflammatory bowel disease: Ulcerative Colitis, Crohns disease  Functional Sports Medicine

10. Benign  Catastrophic  May interfere with athletic activities (requiring significant accommodations )  May mimic or be an harbinger of other more ominous pathology –GERD  CVD –Multiple etiologies Heme + stool Abdominal pain and bleeding  Be attentive, be thorough Sports Medicine

11. GI Problems In Athletes – What Does The Evidence Tell Us  “Majority of published work has studied normal subjects under submaximal efforts for relatively short durations”  “Incidence of exercise-associated GI bleeding is uncertain and studies are inconclusive” Example: use FOBT – non specific Moses, CSMR 2005, 4:91–95 Sports Medicine

12. Suffering in Silence  Poorly understood –By athletes –By sports medicine staff  Symptoms often ignored  Commonly: –Self diagnosed –Self treated Sports Medicine

13. Upper Gut Issues in Athletes Sports Medicine

14. Etiology of Upper GI Problems  Delayed gastric emptying and transit time  LES pressure changes  Gastric distension (empty stomach – 50 to 100ml)  Splanchnic blood flow – training can improve  Increased vibration  Increased levels of gastrin and motilin  High CHO fluids  Malabsorption of water and nutrients – vegetarian diet or high- fiber meal prior to exercise  Psychologic – stress can increase sympathetic discharge and decrease splanchnic blood flow up to 80% Sports Medicine

15. Mechanism  Slowed motility –Duration, amplitude and frequency of esophageal contractions –Decline with exercise intensity over 90% VO 2 max  Lowered LES pressure –Increased reflux episodes –Documented in cyclists >70% VO 2 max Sports Medicine

16. Delayed Gastric Emptying  Dehydration can slow gastric emptying up to 40%  Hypertonic carbohydrate beverages can also slow gastric emptying (>7% CHO) – Shi X et al. Int J Sports Med 2004  Significant delay in gastric emptying above 70% VO 2 max (Baska et al. Dig Dis Sci 1990)  Delayed gastric emptying can lower LES tone Sports Medicine

17. GI Blood Flow And Exercise  Reduced in excess of 50%  Estimated hepatic blood flow (EHBF) –Reduced 12-14% at 30-35% VO 2 max –Reduced 30-45% with 35-60% VO 2 max  Portal vein blood flow in cyclists: –20 min at 70% VO 2 max : SBF reduced by 57% –After 1 hr: SBF reduced by 80%  Predisposes to gut injury  Increases membrane permeability  Enhances occult blood loss  Generates endotoxins that can increase diarrhea Sports Medicine

18. Fluid Intake  Gastric emptying is slowed with heavy exercise in dehydrated state  Exercise releases catecholamines that suppress thirst  Some athletes cannot tolerate sensation of food/fluid in the stomach with exercise  80% of marathon finishers with >4% weight loss due to dehydration experienced GI symptoms Sports Medicine

19. Psychologic  Stress can exacerbate GI symptoms  Up to 57% of athletes with runners diarrhea complained of symptoms prior to race, 32% had similar symptoms when emotionally stressed Sports Medicine

20. Upper GI Symptoms  Dysphagia (solids and/or liquids) –Oropharyngeal dysphagia –Esophageal dysphagia  GERD  Dyspepsia  GI bleeding Sports Medicine

21. GERD  60% of athletes  More frequent with endurance exercise  Ambulatory pH probe monitoring has shown that exercise exacerbates reflux  Sport specific –Anaerobic sports report most symptoms –Runners > cyclists Sports Medicine

22. Dyspepsia  Varied complaints including: Nausea, gnawing/burning epigastric pain, vomiting, eructation, bloating, indigestion, generalized abdominal discomfort  Most common causes include: –PUD –GERD –Gastritis Sports Medicine

23. Dyspepsia Common cause is mucosal damage  Frequent dehydration  Repeated stress of racing  Excessive NSAID use  Medications  ETOH  Caffeine  Dietary supplements containing amino acids and creatine Sports Medicine

24. GI Bleeding  Can be upper – 16 runners after a 20km race – UGI; gastritis 16, esophagitis 6 or lower – Colonoscopy (4) – 1 with multiple erosions splenic flexure (Choi et al. Eur J Gastroenterol Hepatol 2001)  Usually transient Mechanism includes –Hemorrhagic gastritis, colitis –NSAID induced gastritis –Traumatic hemolysis –Impaired gut absorption –Mechanical trauma o Lower incidence in cyclists than runners Sports Medicine

25. Evaluation  History: diagnosis in about 80% of cases –Onset –Exacerbating factors –Pain –Gross blood  Past medical history  Family history  Social history: Tobacco, ETOH, other drugs  Dietary history: chocolate, caffeine, timing  Psychosocial history: ? stress  NSAIDs Sports Medicine

26. Evaluation  Labs: GI bleed –CBC, CRP, ESR, Ferritin, Iron Panel  Other labs: H pylori, Celiac sprue  UGI ?  EGD –If hemoptysis, melena, resistant or prolonged symptoms  Colonoscopy –If gross blood Sports Medicine

27. Evaluation – Red Flags  Weight loss  Progressive dysphagia  Recurrent vomiting  GI bleeding  Family history of CA Sports Medicine

28. Treatment  Treat underlying infection –Dyspepsia: treat H pylori if positive (AGA guidelines)  Diet modification –Avoid ETOH, tobacco, fatty foods, mints, chocolate, caffeine, citrus fruits –Timing of pre-exercise meals  Elevate head of bed  No food within 4 hours of going to bed Sports Medicine

29. Treatment  PPI are more effective than H 2 blockers in treating PUD and GERD (limited literature in athletes)  Usual trial of H 2 blocker or PPI –Intermittent symptoms: H 2 blocker –Daily symptoms: PPI  H 2 blockers show varied success in reducing blood loss  Maintain hydration  Avoid NSAIDs  Optimize fiber Sports Medicine

30. Runner’s Diarrhea – A Real Common Problem! Sports Medicine

31. Exercise And The Lower GI Tract Association between exercise and changes in the GI tract has long been appreciated 1794, Dr. John Puch wrote in Treatise on the Science of Muscular Action that: “Exercise helps to throw down wind from the bowels and attenuates the contents of the stomach. It also serves at once as an evacuant…” 61% of endurance athletes – lower GI symptoms Worobetz & Gerrard N Z Med J 1985 Sports Medicine

32. Exercise And The Lower GI Tract Common lower GI symptoms:  Flatulence  Diarrhea (26%)  Hematochezia (6%)  Urgency to defecate (54%)  Women > men Worobetz & Gerrard N Z Med J 1985 Sports Medicine

33. Epidemiology - Runner’s Diarrhea Most commonly affects runners  “Runner’s Trots”: first coined in 1980 to describe episodes of bloody diarrhea in 2 marathon runners of incidence: 20% - 33%  50%+ endurance athletes report fecal urgency following training runs (Green GA Clin Sports Med 1992)  20% of marathoners have occult blood in stool after races (Baska RD et al Dig Dis Sci 1990)  17% - frank hematochezia during training for marathons  Females > males Sports Medicine

34. Etiology of Runner’s Diarrhea Complete understanding of runner’s diarrhea etiology remains unclear  Altered intestinal transit time  Altered GI blood flow  Fluid/electrolyte shifts at cellular level  Mechanical causes

35. Etiology of Runner’s Diarrhea Complete understanding of runner’s diarrhea etiology remains unclear  Autonomic nervous system stimulation  Changes in GI hormones gastrin and motilin  Diet and medications

36. Altered GI Transit Time Reduced colonic transit time?  Cordain et al - transit time reduced from 35 to 24 hours in sedentary individuals who started exercise program (J Gastro 1991)  Others have found that oro-cecal transit time is actually increased in strenuous exercise but reduced in light exercise Sports Medicine

37. Altered GI Blood Flow  Intense exercise reduces blood flow to the GI tract by 80%  Reduction in colonic blood flow more marked when dehydration is present –80% of athletes who are more than 4% dehydrated develop lower GI symptoms (Rehrer NJ et al. Int J Sports Med 1989) Sports Medicine

38. Diet And Medications  Lactose intolerance, celiac disease  High fiber and high glycemic index diets  Artificial sweeteners –Sorbitol and aspartame –Commonly used in sports drinks –May lead to osmotic diarrhea - >7% CHO “dumping syndrome” – osmotic gradient  Meds: antibiotics, H 2 blockers, antacids containing magnesium  Laxatives, caffeine Sports Medicine

39. Other Etiologic Factors  Mechanical –Compression of colon by hypertrophied psoas muscle  GI Hormone Changes –Elevation in gastrin, motilin and VIP occur during exercise  Autonomic Nervous System –Increased parasympathetic tone during exercise leads to increased transit time due to smooth muscle contraction Sports Medicine

40. Differential Diagnosis For a Runner with Diarrhea  Runner’s Diarrhea is a diagnosis of exclusion  < 40 years of age: –Infectious –Inflammatory –Dietary problems  > 40 years of age: As above AND –Consider malignancy –Diverticular disease  Evaluation should be based on age-stratification Sports Medicine

41. Evaluation of Runner with Diarrhea  All patients: careful history  Timing, characteristics of diarrhea  Diet and hydration history  Travel history  ROS: fever, weight loss, abdominal pain, jaundice  Past medical history, family history  Medications Sports Medicine

42. Evaluation: Physical Exam Careful physical examination for all patients:  Vitals (temperature and weight)  Abdominal exam: tenderness, masses, bowel sounds, hepatomegaly  Rectal exam: – Sphincter tone – Occult blood Sports Medicine

43. Evaluation: Ancillary Studies In young (<40 yo) athletes: –Stool studies: occult blood, culture, O+P –Consider fecal fat if malabsorption possible –CBC: anemia, leukocytosis –Metabolic profile: hypokalemia –ESR/CRP –Consider hydrogen breath test, flexible sigmoidoscopy, HIV testing Older athletes (>40 yo): –Comprehensive metabolic profile –Complete colonoscopy rather than flex sig to evaluate for cancer or diverticulae Sports Medicine

44. Runner’s Diarrhea - Treatment  Treat any underlying condition  If no underlying condition is found during evaluation, consider following strategies  Dietary changes: –Avoid sugar alcohols (sorbitol) –Low-residue, low-fiber diet –Consider restricting lactose –Reduce caffeine intake –Improve hydration Sports Medicine

45. Runner’s Diarrhea - Treatment Pharmacologic approach:  Only one study published on pharmacologic treatment –Lopez compared diosmectate (Al silicate) with loperamide –Diarrhea resolved in 72% vs 20%  Anticholinergics (atropine) and opiates (loperamide) have been used  OTC loperamide 30 minutes prior to exercise Sports Medicine

46. Runner’s Diarrhea - Treatment Training and environmental changes (Level 5):  Reduction of intensity and duration of training runs often relieves symptoms  Consider cross-training  Timing of training runs to reduce likelihood of dehydration  Daily ritual of pre-exercise bowel evacuation is mandatory Sports Medicine

47. Exercise-Associated Intestinal Ischemia  Abdominal pain and diarrhea, often with bleeding  Increase in BF in exercising muscles at expense of visceral BF  Hypovolemia compounded by hyperthermia, dehydration, NSAIDs  Evidence limited to case reports  Surveys – primarily runners, more common during/after races than training  Schwartz A et al Ann Inter Med 1990 9 marathoners - FOBT +, 3 scoped: antral erosions, splenic flexure erosions, resolved at second look days later Sports Medicine

48. Exercise-Associated Ischemic Colitis  Moses FM et al. Ann Int Med 1989  Colon second most common location for exercise- associated GI bleeding  9 case reports in the published literature  Intestinal infarction rarely reported – 65yr old MD following 50km run (Kam et al Am J Gastro 1994)  RTP guidelines ? Sports Medicine

49. Athletes And Inflammatory Bowel Disease  Ulcerative colitis and Crohn’s disease  Cause unknown, likely autoimmune  Bloody diarrhea (UC), Chrohn’s – fatigue, diarrhea, abdominal pain  40% extraintestinal manifestations – pulmonary, joint (sacroilitis, ankylosing spondylitis, osteoporosis)  Vitamin D insufficiency – treat aggressively  Monitor for side effects of medications – corticosteroids Zaharia and Rifat CSMR 2008 Sports Medicine

50. Summary – Practical Recommendations  Avoid dehyration and hyperthermia through training periodization  Delay 3-4 hours after big meal for exercising at >70% VO 2 max  Small frequent meals of easily digested carbohydrates during long runs and training sessions  Limit high-energy, hypertonic drinks (>7% CHO) within 60 mins of exercise Sports Medicine

51. Summary – Practical Recommendations  Limit protein, fat, high fiber foods around run/exercise time  Avoid fructose when possible  Limit caffeine, antibiotics, NSAIDs, sweeteners ‘ol’  Find a restroom prior to exercise  Be mindful of red flags and appropriate work-up Sports Medicine