Sex & Gender in Acute Care Medicine

1. Sex & Gender in Acute Care Medicine Chapter 10: Gastroenterology

2. Chapter 10: Gastroenterology David J. Desilets

3. Case One • Helen G. is a 47 year-old woman who presented to the ED with right upper quadrant (RUQ) pain, nausea, and vomiting x 3 days • She did not take her temperature but felt febrile for the past day • She denied recent travel or sick contacts and had not eaten outside her home • Medications included hydrochlorothiazide, bupropionHCl, and OTC ibuprofen

4. Case One • Her past medical history included essential hypertension, obesity, depression, glucose intolerance, and low back pain • Review of systems was negative for: • Weight loss, chest pain, cough, dyspnea, rash, itching, dark urine, dysuria, urinary frequency, headache, or dizziness • She was alert and oriented to person, place, time, and situation • She was slightly tachycardic at 100 bpm • Her temperature was 100.6° F

5. Case One • BP 136/87, respiratory rate of 20 • Her exam was remarkable for abdominal tenderness in the epigastrum and RUQ without rebound • Her bowel sounds were normal • WBC: 16,000, lipase 67, AST 121, ALT 256, alkaline phosphatase 186, and total bilirubin was 2.1 with a direct fraction of 1.2

6. Case One • What was this patient’s most likely diagnosis? • What else should have been in the differential? • Does her sex change the way we rank order the differential diagnosis? • What is the next test that should have been ordered?

7. Case Two • Roy G. is Helen’s husband, a 47 year-old man who presented to the ED with RUQ pain, nausea, and vomiting x 3 days • He did not take his temperature but felt febrile for the past day • He denied recent travel or sick contacts and had not eaten outside his home • Medications include hydrochlorothiazide, bupropionHCl, and OTC ibuprofen

8. Case Two • His past medical history included essential hypertension, depression, glucose intolerance, and low back pain • He had had two ED visits in the past for broken ribs after a fall and an episode of idiopathic pancreatitis • He has had an appendectomy in the past • He smokes one pack/day and drinks socially

9. Case Two • Review of systems was negativefor: • Weight loss, chest pain, cough, wheezing, rash, itching, dark urine, dysuria, urinary frequency, headache, or dizziness • He was mildly tachycardic at 100 bpm • He had a temperature of 100.6° F, BP 136/87, respiratory rate of 20 • He was alert and oriented to person, time, and place but seemed confused about the situation

10. Case Two • He was thin and had temporal wasting • He also had abdominal tenderness in the epigastrum and RUQ without rebound and a tender liver palpable 4 finger breadths below the right costal margin • Bowel sounds were active • His lab findings were identical to those described previously

11. Case Two • What is the most likely diagnosis? • What else is in the differential? • Does the fact that Roy is a man change the order of the differential? • What is the next best test?

12. Introduction • These vignettes illustrate how 2 patients of different sexes can present with identical symptoms, vital signs, and labs and yet the differential diagnosis may be different • There were more than 122 million ED visits in the US in 2007; 15 million of these patients had a primary gastrointestinal (GI) diagnosis • The leading diagnoses were abdominal pain, nausea/vomiting, and functional GI disorders

13. Introduction • For each of the 3 leading categories, women far outnumber men in visits to the ED • In fact, for all GI diagnoses, women have more ED visits than men across all age groups except early childhood • A patient’s sex should influence the clinician’s approach in the acute care or ED setting • Although both sexes have the same digestive organs, sex informs most diagnoses

14. Introduction • This chapter provides a sex- and gender-based approach to the patient with GI complaints • We discuss physiological differences and how they influence the differential diagnosis presentations of illness • Women tend to have considerably greater visceral hypersensitivity than men so a recurrent theme of this chapter is that functional disorders predominate among women

15. Normal Physiology - Tongue • Sex differences start with the tongue • More women than men can be classified as “super tasters,” tasting both bitter and sweet foods more intensely • This fundamental difference in physiology, a hypersensitivity to sensory input in women, is reprised throughout the GI tract • For example, women tend to have a lower pain threshold during balloon inflation in the esophagus

16. Normal Physiology - Esophagus • There are only minor differences in esophageal motility between the sexes • Women tend to have longer peristaltic wave duration with swallowing than men, but slower wave velocity

17. Gastroenterology Questions 1. Which of the following is true regarding presentations for abdominal pain by female patients? (A) Women present to the emergency department for abdominal pain more frequently than men. (B) Women have more visceral hypersensitivity than men. (C) Functional abdominal pain disorders predominate in women. (D) More women than men report chronic abdominal pain. (E) All of the above Answer: (E) All of the above Sex differences in gastroenterological conditions between men and women that can result in differences in disease presentation include increased sensitivity to visceral pain, increased rate of presentation for abdominal pain, and increased rate of chronic abdominal pain. References: 1. BertakisKD, Azari R, Helms LJ, Callahan EJ, Robbins JA. Gender differences in the utilization of health care services. Journal of Family Practice 2000;49:147-52. 2. Myer PA, Mannalithara A, Singh G, Pasricha PJ, Ladabaum U. Clinical and economic burden of emergency department visits due to gastrointestinal diseases in the United States. American Journal Gastroenterology 2013;108:1496-1507.

18. Gastroenterology Questions 2. Which of the following are known physiologic sex differences in the gastrointestinal tract? (A) Males have slower esophageal peristalsis than women. (B) Gastric emptying is slower in women. (C) Men have slower small bowel transit than women. (D) Women of child-bearing age have a lower incidence of gallstones than men. (E) Men have a higher rate of chronic constipation than women. Answer: (B) Sex differences in the physiology of the gastrointestinal tract can be found in multiple organs and include the following findings in women: slower esophageal peristalsis, gastric emptying, and small bowel transit; and increased incidence of gallstones and chronic constipation. References: 1. DantasRO, Ferriolli E, Souza MAN. Gender effects on esophageal motility. Brazilian Journal of Medical and Biological Research 1998;31:539-44. 2. DatzFL, Christian PE< Moore J. Gender-related differences in gastric emptying. Journal of Nuclear Medicine 1987;28:1204-7. 3. Bennett EJ, Evans P, Scott AM, Badcock CA, Shuter B et al. Psychological and sex features of delayed gut transit in functional gastrointestinal disorders. Gut 2000;46:83-7. 4. DuaA, Dua A, Desai SS, Kuy S, Sharma R, et al. Gender based differences in management and outcomes of cholecystitis. American Journal of Surgery 2013;206:641-6. 5. McCrea GL, Miaskowski C, Stotts NA, Macera L, Paul SM, et al. Gender differences in self-reported constipation characteristics, symptoms, and bowel and dietary habits among patients attending a specialty clinic for constipation. Gender Medicine 2009;6:259-71.

19. Gastroenterology Questions 3. Which of the following constipation-related complaints are more common in women? (A) Abnormal stool consistency. (B) Accompanying bloating. (C) Anal digitation required to evacuate stool. (D) Increased frequency of accompanying abdominal pain. (E) All of the above. Answer: (E) All of the above Chronic constipation is seen more commonly in women, who also have a higher adjusted odds ratio for all symptoms of constipation than men, including infrequent bowel movements, abnormal stool consistency, associated abdominal pain, bloating, and difficulty with evacuation. Reference: 1. McCrea GL, Miaskowski C, Stotts NA, Macera L, Paul SM, et al. Gender differences in self-reported constipation characteristics, symptoms, and bowel and dietary habits among patients attending a specialty clinic for constipation. Gender Medicine 2009;6:259-71