Gastroenterology

Contents

Preface xiii

Seymour Katz

Gastrointestinal Drug Interactions Affecting the Elderly 1

Mandeep Singh, Shawn Chaudhary, Sadra Azizi, and Jesse Green

With the burgeoning elderly population in the United States, drug interac-tions are an increasing concern because of altered drug metabolism asso-ciated with age and polypharmacy. This article describes interactionsbetween drugs used in common gastrointestinal diseases, including acidpeptic disease, diarrhea, constipation, endoscopic procedural sedation,and inflammatory bowel disease, and those used to treat 5 common geri-atric primary care diseases: hypertension, diabetes, hyperlipidemia, arthri-tis, and psychiatric illnesses.

Vaccinations in Older Adults with Gastrointestinal Diseases 17

Henry A. Horton, Hayoon Kim, and Gil Y. Melmed

Vaccines play a key role in the prevention of illness in the elderly, are costeffective, and generally safe. Hepatitis C, cirrhosis, autoimmune hepatitis,and inflammatory bowel disease aremore prevalent than ever among olderadults. Along with an age-related decline in immune system function(immunosenescence), these diseases make elderly individuals more sus-ceptible to infections and more likely to experience a poor outcome rela-tive to their younger counterparts. Vaccinations also appear to be lesseffective in the elderly, warranting research into different vaccination strat-egies such as booster vaccines, higher doses of vaccine, and measure-ment of antibody titers to guide vaccination.

Reflux and Acid Peptic Diseases in the Elderly 29

Amir Soumekh, Felice H. Schnoll-Sussman, and Philip O. Katz

Gastroesophageal reflux disease (GERD) is a common disorder amongelderly patients seeking medical care. Diagnosis and management ofGERD in the older patient is a unique challenge for both the primary careprovider and the gastroenterologist. Such patients may have atypicalsymptoms, more severe disease, and a higher rate of complications suchas erosive esophagitis, Barrett esophagus, and esophageal cancer. More-over, the elderly may be more sensitive to the morbidity andmortality of theavailable treatments for GERD. A careful and vigilant approach to the diag-nosis,monitoring, and treatment of reflux disease in the elderly iswarranted.

Dysphagia in the Elderly 43

Abraham Khan, Richard Carmona, and Morris Traube

Dysphagia, or difficulty swallowing, is a common problem in the elderly.Based on the initial clinical history and physical examination, the dyspha-gia is assessed as either primarily oropharyngeal or esophageal in origin.

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Most oropharyngeal dysphagia are of neurologic origin, and managementis coordinated with a clinical swallow specialist in conjunction with an ear,nose, and throat (ENT) physician if warning signs imply malignancy.Several structural and functional esophageal disorders can cause dyspha-gia. If a patient has likely esophageal dysphagia, a video barium esopha-gram is a good initial test, and referral to a gastroenterologist is generallywarranted leading to appropriate treatment.

Microscopic Colitis 55

Darrell S. Pardi

Microscopic colitis is a frequent cause of chronic watery diarrhea, espe-cially in older persons. Common associated symptoms include abdominalpain, arthralgias, and weight loss. The incidence of microscopic colitis hadbeen increasing, although more recent studies have shown a stabilizationof incidence rates. The diagnosis is based on characteristic histologic find-ings in a patient with diarrhea. Microscopic colitis can occur at any age,including in children, but it is primarily seen in the elderly. Several treat-ment options exist to treat the symptoms of microscopic colitis, althoughonly budesonide has been well studied in randomized clinical trials.

Medical Management of Inflammatory Bowel Disease in the Elderly: BalancingSafety and Efficacy 67

Christina Y. Ha

The medical management of inflammatory bowel disease (IBD) in the olderpatient extends beyond luminal disease activity. Factors such as comor-bidity, functional status, polypharmacy, and age-related changes in phys-ical reserve and drug metabolism may affect therapeutic decision making.The older patient with IBD is more susceptible to disease-related compli-cations and also to adverse events with therapy, particularly immunosup-pression. Appropriate medication selection along with multidisciplinarycare, factoring not only disease activity but also these age-related risk fac-tors, may improve therapeutic outcomes and decrease adverse events totherapy.

Clostridium difficile Infection in the Elderly 79

Jonathan M. Keller and Christina M. Surawicz

Clostridium difficile–associated illness is an increasingly prevalent andmorbid condition. The elderly population is at a disproportionate risk ofdeveloping symptomatic disease and associated complications, includingprogression to severe or fulminant disease, and development of recurrentinfections. This article analyzes the factors that influence C difficile diseasepropensity and severity, with particular attention directed toward featuresrelevant to the rapidly aging population.

Anorectal Physiology and Pathophysiology in the Elderly 95

Siegfried W.B. Yu and Satish S.C. Rao

Anorectal medical disorders facing the elderly include fecal incontinence,fecal impaction with overflow fecal incontinence, chronic constipation,

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dyssynergic defecation, hemorrhoids, anal fissure, and pelvic floor disor-ders. This article discusses the latest advances in age-related changesin morphology and function of anal sphincter, changes in cellular andmolecular biology, alterations in neurotransmitters and reflexes, and theirimpact on functional changes of the anorectum in the elderly. Thesebiophysiologic changes have implications for the pathophysiology of ano-rectal disorders. A clear understanding and working knowledge of thefunctional anatomy and pathophysiology will enable appropriate diagnosisand treatment of these disorders.

Constipation: Understanding Mechanisms and Management 107

Vanessa C. Costilla and Amy E. Foxx-Orenstein

Constipation is a frequently diagnosed gastrointestinal disorder. Symp-toms of constipation are common, with the greatest prevalence in theelderly. Evaluation of constipation begins with a detailed medical historyand a focused anorectal examination. Diagnostic testing for constipationis not routinely recommended in the initial evaluation in the absence ofalarm signs. Key self-management strategies include increased exercise,a high-fiber diet, and toilet training. High-fiber diets can worsen symptomsin some patients who have chronic constipation. Biofeedback is an effec-tive treatment option for patients who have constipation caused by outletobstruction defecation. A variety of medications are available to remedyconstipation.

Colorectal Cancer and the Elderly 117

Lukejohn W. Day and Fernando Velayos

Colorectal cancer and precancerous adenomas disproportionately affectthe elderly, necessitating the need for screening and surveillance in thisgroup. However, screening and surveillance decisions in the elderly canbe challenging. Special considerations such as comorbid medical condi-tions, functional status, and cognitive ability play a role in one’s decisionsregarding the utility of screening and surveillance as well as the successand safety of various screening modalities. This article explores the evi-dence for screening and surveillance in the elderly, and addresses keychallenges unique to this population.

Endoscopy in the Elderly: Risks, Benefits, and Yield of Common EndoscopicProcedures 133

Farid Razavi, Seth Gross, and Seymour Katz

There has been limited research examining the risks, benefits, and use ofcommon endoscopic procedures in the elderly. Furthermore, gastroenter-ology training programs do not routinely incorporate elderly concernswhen dealing with common gastrointestinal issues. There exists a broadarray of endoscopic procedures with varying inherent risks that must beweighed with each elderly patient in mind. This article discusses the ben-efits and drawbacks of the most common procedures and indications forendoscopy including upper endoscopy, colonoscopy, endoscopic retro-grade cholangiopancreatography, endoscopic ultrasound, percutaneousendoscopic gastrostomy, and deep enteroscopy.

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Hepatitis B and C 149

Anupama T. Duddempudi and David E. Bernstein

Hepatitis B and hepatitis C are common predisposing factors leading tocirrhosis and liver cancer. Therapies for hepatitis B suppress viral replica-tion and improve morbidity and mortality. Treatment and evaluation ofhepatitis B should be similar in all age groups. This article discussesspecial topics related to hepatitis B and the elderly. Hepatitis C is a treat-able disease whose treatment can lead to viral eradication. This articlediscusses key points regarding hepatitis C diagnosis and treatment inthe context of new advances in disease staging and treatment, with spe-cial attention on hepatitis C infection in the elderly.

Index 169