Gastrointestinal Diseases and Disorders Karen E. Hall, M.D., Ph.D. GRECC, Ann Arbor VA Health System University of Michigan Health System Contributors to GI chapter: George Triadafilopoulos, MD Annette Medina-Walpole, MD William J. Hall, MD

Purpose

Handouts

Question 1: Effect of aging on GI function

Answer: 3

Small bowel “resistant” to aging

Proximal and distal GI tract at greatest risk for dysfunction with aging

Age and Swallowing

Reflux risk increases with age LES pressure decreases with age: Gastroesophageal reflux disease (GERD)

Achalasia Subset of patients have pathologic increase in LES pressure: Female: Male 4:1 Age years Progressive dysphagia to liquids and solids

Achalasia LES: “Bird’s beak” LES normally closed at rest Relaxation impaired: inhibitory NO and VIP neurons absent or dysfunctional

Achalasia Treatment Forcible balloon distension Rupture, mediastinitis, sepsis Botulinum toxin injection Relief x weeks-months ?Frail - high risk for balloon Laparoscopic LES myotomy ?similar risk/benefit as balloon

Splanchnic blood flow decreases with age Upper GI tract and proximal small bowel protected due to rich anastomotic supply Decreased blood flow to liver: Impaired metabolism: drugs, bilirubin “Watershed” areas at risk for ischemia (colon)

Diverticular disease: ?Western Aging Circular muscle: fewer fibers; larger spaces between fibers Colonic collagen increases in thickness with aging: Prolongation of muscle contraction Intraluminal pressure increases Mucosa/submucosa protrudes through wall = diverticulum

Aging sets the stage for clinical impairment Physiologic effects of aging + Superimposed disease Effects of medications = Clinical impairment in areas already at risk due to normal aging

Question 2: Dysphagia

Answer: 1

Gastroesophageal reflux disease (GERD)

GERD in older patients

Barrett’s Esophagus Mucosa: Squamous to intestinal Pre-malignant: Dysplastic foci require biopsy for detection High grade dysplasia (HGD) has significant risk of progression to adenocarcinoma

Barrett’s Esophagus Earlier studies: 7-10% risk of adenocarcinoma per year? Up to : 1. Screening EGD for patients with GERD history 2.+Barrett’s: biopsy HGD: surgical referral 3.Low-Moderate Grade Dysplasia: high dose PPI 4.Follow-up EGD every ? 6 months – 1 year?

Should we treat Barrett’s Esophagus? Recent RCTs of proton pump inhibitor treatment: No significant effect on: Rate of progression of low- moderate dysplasia to HGD Rate of esophageal adenocarcinoma Screening EDG: esophageal cancer in 3%

Should we treat Barrett’s Esophagus? Why didn’t PPI treatment work? ? Not long enough (6 mo – 2 years) ? Genetic mutation already present ? Acid exposure not the only cause ? Biopsy error

Should we treat Barrett’s Esophagus? Current recommendations: 1. Screening EGD for patients with GERD history 2. +Barrett’s: biopsy +for HGD: surgical referral 3.M-LGD: ?PPI + Follow-up EGD ?timing Watch for future developments

Back to Question 2

Question 3

Answer: 4. Swallowing evaluation

Aspiration pneumonia

Feeding Tube?

Feeding tubes in Dementia

Question 4: “The Bottom End”

Question 4

Answer: 4. Enema

Constipation

Question 5

Answer: 5. Surgical Evaluation

Acute Abdomen in the Older Patient

Appendicitis in the Older Patient

Finally - Back to Question 5

For Additional Information: GRS Syllabus