Changes of the gastrointestinal tract, acute and chronic disorders

1. Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

2. Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011 Erika Pétervári and Márta Balaskó Molecular and Clinical Basics of Gerontology – Lecture 15 Changes of the gastrointestinal tract, acute and chronic disorders

3. Characteristics of geriatric patients • 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

4. Influence of aging on gastrointestinal (GI) disorders 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

5. 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).

6. Common GI disorders in the elderly • 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(pressureulcers!) • 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

7. Dysphagia syndrome, esophageal disorders • 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 haveesophageal cause • e.g. gastro-esophageal refluxnutcracker esophagus (manometric syndrome, high-amplitude peristaltic contractions confined to the distal esophagus)

8. Disorders of the stomach and the duodenum •  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)

9. The most common gastric disorders in elderly GERD Gastric ulcer Atrophic gastritis Gastro- paresis Gastric carcinoma

10. Common causes ofconstipation in the elderly *Many older people incorrectly believe that their bowel movements are abnormal.

11. Common causes offecal 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

12. Diverticular disease low-fiberdiet asymptomatic colonic diverticula (sac-like projection of the mucosa and submucosa) bleeding diverticulitis (infection of the diverticula) peritonitis, paralytic ileus

13. Ischemic colitis • Precipitating factors: • dehydration • hemorrhage • low-output heart failure • polycythemia • diabetes mellitus • digitalis • The ischemiccolitis is rare (manyanastomoses), but itsmortality rate is high.

14. Aging and enteralabsorption • The smallintestine has a largereservecapacity, aging has onlysubtleinfluencesonthedigestive and absorptiveprocesses: • 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.

15. Diarrhea and malabsorption in the elderly Major causes: • infections • drugside-effects (long-term and inappropriateuse of antibiotics) • chronic pancreatitis • lactose intolerance Consequences are more severe(dehydration, hypovolemia, malnutrition) Cave! Alternating diarrhea vs. constipation(colon tumors!)

16. Disordersas consequences of malabsorption • osteoporosis (calcium) • sarcopenia (proteins) • infections (vitamins, proteins,traceelements) • pressureulcers (proteins, fluids) • anemia (Fe, B12) • dementia (B12) • GI tractdisorders (fibers, fluids)

17. Aging liver • Age-relatedchangesareminimal, significantonlyinlatestage: •  drug (alcohol) clearance • cholelithiasis, cholestasis • appearance of abnormal proteins

18. Major causes ofupper GI tract bleeding

19. Major causes oflower GI tract bleeding

20. Causes of lower intestinal bleeding Ischemic colitis Colitis(infections, irritablebowelsyndrome) Angio-dysplasia Polyps Carcinoma Diverticula Hemorrhoids