1. Gastrointestinal System 2 Problem BaseD Learning Module Geriatric Cases
Janice A. Knebl, DO, MBA
Reynolds Geriatrics Education and Training in Texas Project Director
Dallas Southwest Osteopathic Physicians Endowed Chair in Clinical Geriatrics
Chief, Division of Geriatrics
UNTHSC/TCOM

2. Mr. Tex Oilman
A 80-year-old man has difficulty swallowing solids and liquids. At times he regurgitates undigested food. His dysphagia has progressed slowly over 8 months and he has lost 20 pounds.
The patient reports no pain.
Barium radiograph demonstrates a narrowed distal esophageal segment 4.1 cm long and no dilated esophageal segment proximal to the narrowed portion.
Esophageal manometry demonstrates failure of the lower esophageal sphincter to relax with swallowing, and aperistalsis of the esophageal body.

3. Mr. Tex Oilman
Based on his history and findings which of the following is the most likely diagnosis?
A. Zenker’s Diverticulum
B. Diffuse Esophageal Spasm
C. Presbyesophagus
D. Achalasia
Answer D: Achalasia is not frequent in elderly, but has a 2nd prevalence peak in old age. Symptoms are a long history, with insidious onset of intermittent dysphagia to liquids and solids, regurgitation of undigested foods or aspiration. Dx: CXR widened mediastinum, Barium swallow with bird beak narrowing, Manometry is key diagnostic test: nonperistaltic contractions (aperistalsis of the esophageal body), elevated esophageal pressure, poor relaxation of LES and very high pressure in LES, Endoscopy. Pathology exam reveals a defect in the myenteric plexus.

4. Geriatric Case
Which of the following diagnostic procedure(s) should be performed first?
(A) Esophagoscopy
(B) Endoscopic ultrasonography
(C) Computed tomography
(D) Chest magnetic resonance imaging
(E) Laparotomy

5. Mrs Tea Toatler
83 year old retired choir director presents to your office with symptoms of some chest and epigastric pain, and hoarseness that has increased over the past few months. Her weight has been stable and she has not experienced any nausea or vomiting.
She has a PMHx of HBP, hyperlipidemia, osteoporosis and was recently diagnosed with Parkinson’s Disease. Medications consist of HCTZ 12.5mg daily, Simvastatin 40mg daily, Alendronate 70mg once weekly and Carbidopa/Levadopa 25/100 QID.
Physical Exam is WNL except for a resting tremor and mild cogwheeling of upper extremities.
Laboratory WNL

6. Mrs Tea Toatler
What additional information might you ask Mrs. T during her clinic visit?
What makes the symptoms better? What makes the symptoms worse ? When do the symptoms occur? Relationship to eating ? To sleeping? Describe the symptoms. How long has she been on the various medications ? Does she drink alcohol?

7. Mrs Tea Toatler
Which of the following would be the most likely diagnosis given her history and physical examination ?
A. Peptic Ulcer Disease
B. Atypical Angina Pectoris
C. Gastroesophageal Reflux Disease
D. Zenker’s Diverticulum
Answer: C. GERD.Clinical presentation of GERD in elderly has a significantly lower prevalence of typical symptoms ie, heartburn, acid regurgitaion and epigastric pain. Atypical symptoms also are relatively rare in elderly. In contrast, the prevalence of nonspecific symptoms ie vomiting, anorexia, weight loss and anemia significantly increased with age.

8. Mrs Tea Toatler
Which of the following medications that she is taking may have caused a reduction in the LES pressure?
A. HCTZ
B. Simvastatin
C. Alenodrate
D. Carbidopa/Levadopa
Answer: D. Carbidopa/Levadopa can cause reduction in LES pressure as can anticholinergics, tricyclic antidepressants, benzodiazepines, calcium channel blockers, nitroderivates and theophylline. The medications that have a direct effect on the esophageal mucosa are ASA, NSAIDs , Potassium salts, Ferrous sulfate, Corticosteroids and Alendronate.

9. Gastroesophageal Reflux Disease (GERD)
Which of the following is the most common cause of GERD in older adults ?
A. Increased LES pressure and length
B. Sliding Hiatal Hernia
C. Poor esophageal peristalsis and delayed
clearance
D. No change in salivary secretions
Pathophysiological Changes in Esophageal Functions that occur with aging: Impaired motility of the esophagus, reduced LES pressure and length, Normal gastric acid secretion, delayed gastric emptying transit time, reduced salivary secretions, decreased tissue resistance as a result of impaired epithelial cell regeneration and duodenogastroesophpagela reflux of bile salts.

10. Mrs Tea Toatler
What would you recommend to this patient regarding her symptoms?
Trial of treatment. If no imrprovement or in some cases to proceed with endoscopy because the level of symptoms and what is found at endoscopy does not always correlate.

11. Ms. Gypsy Rose Lee
An 88 year old retired stripper presents to the office with complaints of difficulty swallowing. She feels that food is getting “stuck” at times but she denies significant pain. She is able to drink liquids without difficulty. She has had minimal weight loss. This symptom has been getting gradually worse over the past 4 months.
Her PMH consists of HBP, thoracic aortic aneurysm, hyperlipidemia, PVD, osteoporosis and anemia
Medications: Alendronate 70mg weekly, ASA 81mg daily, amlodipine 5mg daily, simvastatin 80mg daily, cilostazol 100mg BID and FeSO4 325mg BID. 11

12. Ms. Gypsy Rose Lee
PE:
Vitals: BP 130/50, P 70BPM, Afebrile, RR 16 unlabored
Gen- conversant, in NAD, in good spirits, cognitively intact
Neck - carotids with a Corrigan pulse
Heart – Grade 2/6 holosystolic murmur LSB to apex;
Grade 3 / 4 diastolic murmur RSB
Lungs – clear
Abd – benign
Extremities – decreased peripheral pulses
Corrigan pulse – Rapidly rising and falling pulse to palpation 12

13. Ms. Gypsy Rose Lee
Which of the following is the most likely cause of her dysphagia?
A. Peptic stricture
B. Achalasia
C. Dysphagia Aortica
D. Diffuse Esophageal Spasm
E. Esophageal Carcinoma
Answer: C In the elderly severe ASCVD or a large aneurysm of the thoracic aorta can reesult in impingement on the esophagus and produce dysphagia (dysphagia aortica). When symptoms are intractable, surgical intervention should be considered. Symptoms usually develop in childhood, but may develop in adults. Enlargement of the left atrium may cause dysphagia in patients with mitral valve disease. This is due to extrinsic compression by the enlarged atrium, resulting in partial luminal obstruction at the mid to lower third portion of the esophagus. 13

14. Mr. I. M. Happy
He is a 68 year old healthy and happy retired gastroenterologist who comes to the office for a physical examination. Ten years ago he had four adenomatous polyps removed; follow-up colonoscopy 5 years ago was negative.
Which of the following is the most appropriate colon cancer screening recommendation for him?
A. Immunohistochemical fecal occult blood testing
B. No further screening
C. Colonoscopy
D. Flexible sigmoidoscopy plus occult blood testing
E. Virtual Colonoscopy
Answer: C Colonoscopy is the most appropriate screening test for a healthy older person with a risk factor for colon cancer, such as an adenomatous polyp, who has a life expectancy of 10 years or longer. Patients with a family history of colorectal cancer, with more than two adenomas, with adenomas 1 cm or larger or with adenomas with high-grade dysplasia or villous architecture should be screened more intensively. As this patient has a life expectancy of more than 10 yrs, repeat endoscopy is the preferred screening test. A frequency of every 5 years in this patient with previous polyps is appropriate.
In patients without risk factors, appropriate screening for colon cancer can by annual fecal occult blood testing, flexible sigmoidoscopy every 5 years, annual fecal occult blood testing with flexible sigmoidoscopy every 5 years, double-contrast BE every 5 years or colonoscopy every 10 yrs. There is insufficient evidence to recommend one of these approaches over another and the choice must be individualized. There is insufficient evidence to recommend colon cancer screening with CT colonography (virtual colonoscopy) immunohistochemical fecal occult blood testing, stool test for detection of altered human DNA or video endoscopy.

15. Mr. I. B. Fine
He is a 78 year old man who presents to the ED following the abrupt onset of rectal bleeding.
He has PMH of CAD, CHF, CKD, GERD and DJD.
Medications: metoprolol, celecoxib furosemide, potassium chloride, simvastatin and lansoprazole.
The bleeding stops spontaneously.
Diagnostic colonoscopy, performed after oral cleansing with polyethylene glycol and electrolyte solution, demonstrates residual blood in the ascending colon, scattered diverticula in the sigmoid colon and multiple 5-mm, flat cherry red lesions in the cecum

16. Mr. I. B. Fine
What is the most likely cause for bleeding in this patient?
A. Angiodysplasia
B. Ulcerative colitis
C. Aortoenteric fistula
D. Upper gastrointestinal lesion
E. Colon carcinoma
Answer: A Incidence of lower GI bleeding increases more than 200 fold between ages 20 and 80. Angiodysplasia, also called arteriovenous malformation or vascular ectasia, is the source of lower GI bleeding in up to 20% of older patients and occurs with equal frequency in men and women. Two thirds of cases are found in persons older than age 70. More than half are located in the cecum and proximal ascending colon, but they may occur throughout the GI trct, usually are multiple and are 5-10 mm wide. They are dilated, thin walled vessels in the mucosa and submucosa that are lined by endothelium or by smooth muscle. In more than 90% of cases, bleeding stops spontaneously. Typically diagnosis is by direct visualization by colonoscopy, but mesenteric angiography is more sensitive than colonoscopy and can detect angiodysplasia deep in the submucosa that may not be visible grossly.
Diverticular disease is the cause in up to 37% of older patients with brisk rectal bleeding. The prevalence of divwerticualr disease is age dependent, increasing to 30% by age 60 and 65% by age 85. Diverticula occur at weak points in the bowel wall, usualy in the sigmoid colon, where blood vessels penetrate the circular muscle of the bowel. Diverticular bleeding is usually painless and serf-limited, and it rarely coexists with acute diverticulitis. Diverticular bleeding and angiodysplasia are responsible for almost 60% of cases of lower GI bleeding in older adults. Other sources of bleeding include colorectal neoplasms, an upper GI source, colitis (from ischemia, inflammation, infection, or radiation) , solitary rectal ulcers and hemorrhoids. Aortoenteric fistula is a less common cause.
Approx 10% of cases of major lowere intestinal bleeding and 20% of cases of minor bleeding in elderly persons are caused by benign or malignant neoplasm. In 15% of older adults, the source of lower GI bleeding is in the upper GI tract. Upper intestinal endoscopy may be necessary to reveal the source of bleeding.
An infectious cause should be excluded in an older paitent with acute bloody diarrhea. Salmonella organisms and Escherichia coli O157:H7 serotypes are common in elderly patients. CD induced diarrhea rarey causes bleeding.
NSAIDs have been implicated as a cause of nonspecific colitis, exacerbation of idiopathic inflammatory bowel disease, and diverticular bleeding.

17. Constipation in Older Adults
Tracy Truelove is an active 85 year old retired nurse who comes to your office for a routine office visit. As a new complaint, she mentions that she is having some discomfort with her hemorrhoids and thinks it may be worsened by her infrequent BMs. She frequently will miss a daily BM but mentions that when she was younger she would have a movement every day. She also states that her stools are harder than they used to be during every bowel movement. Her medical history includes HBP, Urinary incontinence, GERD and iron deficiency anemia. Surgical history reveals only a deviated nasal septum repair. 17

18. Constipation in Older Adults
1. Does she meet the ROME III criteria for constipation ?
ROME III Criteria: must include two or more of the following: Straining during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, sensations of incomplete evacuation for at least 25% of defecations, sensation of anorectal obstruction/blockage for at least 25% of defecations and manual maneuvers to facilitate at least 25% of defecations, fewer than three defecations per week.

19. Constipation in Older Adults
2. Could her medical problems be contributing to her complaints?
Her medical history includes HBP, Urinary incontinence, GERD and iron deficiency anemia. 19

20. Constipation in Older Adults
3. What questions would you ask her next ?
Ask her other symptoms mentioned on the ROME III cirteria. Ask her what she is taking. Aske her about physical activity level. Ask her about fluid intake and fiber. 20

21. Constipation in Older Adults
Which medication class is generally NOT implicated in constipation ?
A. Calcium channel blockers
B. Opioids
C. Iron preparations
D. Proton pump inhibitors
E. Antidepressants
Topic
Slide 21

22. Ms. Daisy Diarrhea
An 86 yr old nursing facility resident is transferred to the hospital for the treatment of pneumonia where she received a 7 day course of ceftriaxone and azithromycin. She returns to the nursing home after a 3 day hospitalization. Five days after being back at the nursing facility she experiences watery diarrhea, cramping lower abdominal pain and tenderness, low-grade fever and leukocytosis on recent lab testing.

23. Ms. Daisy Diarrhea
Which of the following would be the most appropriate next step in diagnosing her condition?
A. Stool for fecal leukocytes
B. Abdominal CT scan
C. Stool culture
D. Stool immunoassay for CDT
E. Blood cultures X 2
Answer D: CD causes approx 25% of all cases of antibiotic associated diarrhea. All antibiotics have been associated with DC diarrhea, most commonly clindamycin, ampicillin, amoxicillin and the cephalosporins. Clinical presentation varies from asymptomatic colonization to mild diarrhea to severe debilitating disease with high fever, severe abdominal pain, paralytic ileus, colonic dilatation and rarely perforation. In patients with CD diarrhea, symptoms usually begin soon after colonization. The incubation period for disease after colonization is lidely to be less than 1 week, with a medican time to onset of approximately 2 days. Colonization may occur during antibiotic txment or during the weeks after a course of antibiotics. Commercial immunoassays for CD infection have reasonable sensitivity (70-90%) and specificity (99%) and are most commonly performed for diagnosis. Stool and blood cultures would not reveal the CD infections.
As CD diarrhea is the most likely cause of this patients diarrhea, given the clinical course and presentation, the other choices are not appropriate as the next steps in diagnsosis. A stool culture is unlikely to reveal a pathogen in this case. Abdominal imaging tests may show only nonspecific findings.

24. Mr. FR Almanac
78 year old retired rancher presented to the Emergency Department with vertigo, nausea and vomiting, hoarseness, dysphagia and facial numbness 20 hours after the onset of symptoms. He is diagnosed with a completed stroke.
Which of the following artery(ies) were most likely involved?
A. Middle cerebral artery
B. Anterior cerebral and choroidal artery
C. Vertebral and posteroinferior cerebellar artery
D. Postcommunal posterior cerebral artery
Answer:C
Middle cerebral artery produces a complete hemiplegia equally involving the face, arm, hand, leg and foot. Eye deviation toward the ischemic hemisphere occurs when either hemisphere is affected. Aphasia or neglect. Anterior cerebral artery involvement could cause foot and leg weakness and incontinence occasionally and possibly abulia, gait apraxia and forced grasping. Ant choroidal artery supplies post limb of internal capsule and its posterolateral white matter. Contralateral hemiparesis, hemianesthesia and hemianopia. Postcommunal posterior cerebral artery includes branches to the medial inferior temporal lobe, giving rise to memory loss and delirium and to homonymous visual field defects. Could also get Balint syndrome where there is an inablility to recognize faces or pictures.
Vertebral and posteroinferior cerebellar artery infarcts affects infarction in the lateral medulla. Symptoms and signs vary, but the most frequent include vertigo, nausea and vomiting, hoarseness, dysphagia, ipsilateral facial numbness associated with impaired sensation of pain and heat over the ipsilateral face and contralateral arm and leg, ipsilateral Horner syndrome and ipsilateral limb ataxia.

25. Mr. FR Almanac
He was admitted to the hospital because of the stroke and associated symptoms.
You have determined him to be at increased nutritional risk because he has dysphagia as a result of the stroke. What would be your first step in considering nutritional intervention?
A. Order a video swallow study
B. Start enteral feedings via NG tube
C. Thicken all of the liquids to honey-like consistency
D. Start the patient on liquid nutritional supplements
E. Order a general diet as tolerated
Answer A.

26. Mrs. Minnie Mouse
An 85 year old retired dietician presents to your office with complaints of decreased appetite and weight loss over the past 3 months. When considering weight loss in older adults, which of the following is NOT responsible for reduced calorie intake?
A. Social factor such as decreased income, social isolation and
depression
B. Medications that can suppress appetite or impair
absorption
C. An increase in smell and taste sensations
D. Increased functional problems that make it difficult to prepare
food
E. Improperly fitting dentures
Answer: C There is a decrease in smell and taste sensations that can affect nutrition in older adults.

27. References
1. Geriatric Medicine: An Evidence-Based Approach. 4th Edition. Cassel, Leipzig, Cohen, Larson, Meier Primary Care Geriatrics: A Case Based Approach 5th Edition. Ham, Sloane, Warshaw, Bernard, Flaherty AGS Teaching Slides/ Geriatric Syndromes 4. Geriatrics Review Syllabus 6th Edition Geriatric Medicine and Gerontology, 6th Edition. Hazzard et al., Troutman’s DSA’s and Cecil references..