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

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

• 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

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).

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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

• 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

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

• 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.

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)

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

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

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Carcinoma

Colitis (infections, irritable bowel

syndrome) Angio-

dysplasia

Ischemic colitis

Polyps

Hemorrhoids Diverticula

Causes of lower intestinal bleeding