The Gastrointestinal Tract in the Elderly Jürgen Bauer, M.D. Friedrich-Alexander-Universität Erlangen-Nürnberg The Esophagus Is there something like a presbyesophagus ? Esophageal motility in the elderly I Upper esophageal sphincter Strength of pharyngeal muscle groups increased Delay in relaxation of UES Increasing flow resistance Potential relevance in selected patients II Tubular esophagus Reduction of peristaltic pressure in high age Increased frequency of tertiary contractions No clinical relevance III Lower esophageal sphincter Small/ no change in function No clinical relevance Rao SSC et al, Am J Gatroenterol, 2003 Esophageal sensory function in the elderly • Elevated sensory threshold – Ballon distention Lasch H et al, Am J Physiol 1997 Rao SSC et al, Am J Gatroenterol, 2003 – Bernstein test /Acid perfusion test Grades A et al, Am J Gastroenterol 1997 • Hypothesis Nerval dysfunction – Intramural – Central Clinical relevance Diagnostic delay – advanced stages of disease Is there something like a presbyesophagus ? There are some minor changes in esophageal motility with age but they are in most cases not clinically relevant. But Age induced changes in sensitivity may have a clinically relevant impact on the severity of some esophageal diseases. Dysphagia in the elderly Dysphagia • Prevalence Short-term care hospitals 12 – 13 % Nursing homes 40 – 60 % Dysphagia - Symptoms • I Oropharyngeal Dysphagia Inability to initiate the act of swallowing „transfer problem“ nasal regurgitation, choking, dysarthria, coughing, nasal speech, aspiration • II Esophageal Dysphagia Sensation of difficult passage of solids or liquids from pharynx to stomach „transport problem“ functional / organic dysphagia odynophagia, weight loss, anemia Oropharyngeal Dysphagia • Causes – Cerebrovascular accidents – Parkinson`s disease – Polymyositis / Dermatomyositis – Myotonic Dystrophy / oculopharyngeal dystrophy – Myasthenia gravis – Drugs – Hypothyroidism / Hyperthyroidism – Local obstructive lesions – Zenker`s diverticulum / cricopharyngeal dysfunction Esophageal Dysphagia • Causes – GERD and its complications – Schatzki-ring – Webs – Carcinoma – Medication-induced injury – Dysphagia aortica – Mediastinal adenopathy – Motility disorders – Scleroderma Esophageal Dysphagia • Diagnostic work-up of dysphagia – History • Comorbidity • Medication – Examination by the ENT specialist – Endoscopy – Videofluoroscopy – Conventional X-ray of the esophagus – Manometry – Endosonography Medication-induced injury of the esophagus Medication-induced Esophageal Injury • Symptomatology acute dysphagia stricture formation odynophagia perforation heartburn • Location mid-esophagus at the aortic arch just above the gastroesophageal junction Medication-induced Esophageal Injury • Predisposing factors ingestion of tablets with only small amounts of liquid taking pills just before bedtime multi-drug regimes structural esophageal abnormalities - stenosis motility disorders • Common responsible drugs doxycycline slow release potassium chloride quinidine iron sulfate biphosphonates aspirin NSAIDs Medication-induced Esophageal Injury • Diagnosis Endoscopy (Barium-swallow) (CT-Scan) • Treatment taking medication while standing/sitting drinking enough water with the medication avoiding medication at bedtime prefering liquid preparations discontinuation of offending medication acid suppression Achalasia in the elderly Achalasia • Primary motor disorder characterized by abnormal relaxation of the lower esophageal sphincter and aperistalsis of the tubular part • Onset usually between age 20 and 40 but a third above age 60 ! • Symptomatology – Dysphagia for solids and liquids – Regurgitation – Chest pain (less common in the elderly) – Weight loss Achalasia • Diagnosis Endoscopy Barium esophagogram Manometry Endoscopic ultrasound Secondary achalasia has to be excluded especially in the elderly Achalasia • Treatment Pneumatic dilatation symptomatic relief in 74 – 90 % of patients better long-term symptom relief in elderly patients Surgical myotomy-Modified Heller`s approach laparoscopic approach possible clinical response rate 83 – 100 % Side effect: GERD in 10 % Achalasia • Botulinum toxin Option for high risk dilatation/surgical patients Endoscopic injection in the lower esophageal sphincter better symptomatic response in elderly patients 82 vs. 43 % • Medication Nitrates, calcium channel blockers Application sublingually before meals Risks: headaches, lightheadedness, pedal edema Side effects worse in the elderly ! Gastroesophageal reflux disease in the elderly Epidemiology of GERD • Contradictory data concerning the prevalence of GERD in elderly patients • GERD in about 20 % of elderly outpatients Risk factors for more severe forms of GERD – Male sex – Older age – White ethnicity Age and sex-specific prevalence rates for heartburn or acid regurgitation Locke GR III et al, Gastroenterology 1997; 112: 1448 - 56 Men any, ; weekly, Women any, ; weekly, Pathophysiology of GERD Esophageal Clearance ↓ Diminished salivary secretion Inedaquate relaxation of the LES Hiatal hernia Basal pressure of the LES Increase of acid/ pepsinogen production Disturbed antrum motility Duodenal reflux Gastric emptying delayed Esophageal motility in relation to acid exposure and age in elderly GERD patients Achem AC et al, Am J Gastroenterol 2003, 98: 35 - 39 Acid Age Normal Ineffective Nontransmitted Simultan. exposure (yr) < 5% ≤ 40 86.2 1.0 11.4 1.4 ≥ 65 79.9 3.1 12.1 5.0 >10 % ≤ 40 95.0 0.0 5.0 0.0 ≥ 65 62.6 3.4 21.7 12.6 Higher prevalence of esophageal dysmotility in patients with more frequent acid reflux in the elderly Pathophysiologic causes for GERD in the elderly • Problems with maintaining an upright position after meals • Increasing prevalence of hiatus hernia with age • Use of drugs with direct damaging effects on esophageal mucosa aspirin, NSAIDS, potassium salts, ferrous sulfate, alendronate • Use of drugs with indirect effects propagating GERD – reducing LES pressure theophylline, nitroderivatives, calcium channel blockers, benzodiazepines, dopaminergics, tricyclic antidepressants, anticholinergics – slowing esophageal transit Pilotto et al, GERD in the elderly, 2003 Pathophysiology of GERD in the elderly I Esophageal tubular dysmotility Reduced salivary secretion Prolonged duration of reflux episodes II Diminished sensibility for acid-induced mucosal damage Less severe symptoms Clinical symptoms of GERD in the elderly • „Classic“ GERD symptoms less frequent – Heartburn – Acid regurgitation (< 25 %) • Growing relevance of atypical GERD symptoms – Vomiting – Dysphagia – Respiratory symptoms – Upper gastrointestinal bleeding – Anemia Percentage of specific disorders in 228 patients with GERD according to age in decades Collen MJ et al, Am J Gastroenterol 1995; 90: 11053 – 1057 Prevalence of symptoms in esophagitis according to age Franceschi M et al, Gut 2001; 49 (suppl 3), A 2335 80 70 60 50 16 - 49 y. 40 50 - 69 y. 70 - 84 y. 30 > 84 y. 20 10 0 heartburn pain regurgitation dysphagia vomiting Clinical symptoms of GERD in the elderly • Increasing frequency of severe esophagitis and of complications of GERD with age – Ulcerations – Strictures – Barrett • Correlation between subjective symptoms and severity of esophagitis less strong than in younger patients Diagnosis of GERD in the elderly • Clinical evaluation • Endoscopy ! • 24 hour pH metry • (Esophageal Manometry) • (Impedance analysis ?) Endoscopy • It should be undertaken in all elderly patients with typical and atypical symptoms suggestive of GERD regardless of the severity or duration of complaints ! the presence Diagnosing the severity and the complications of GERD Therapy of gastroesophageal reflux disease in the elderly Lifestyle and dietary modifications • Elevating the head of the bed during night • Weight loss • Avoiding tight-fittig garments, smoking and late meals • Chewing gum for 1 h after meals • Decreasing intake of citrus juices, tomato products, coffee, alcohol, mint and chocolate Clinical effectiveness in patients with clinical relevant disease doubtful ! Prokinetics in GERD • Substances: – Domperidon – Metoclopramid – (Cisaprid) • No randomized clinical studies in the elderly published • Side effects for metoclopramid in up to one third esp. extrapyramidal disturbances • GERD-therapy with prokinetics is not evidence based Therapy of reflux esophagitis Complete healing of esophagitis % grade II - IV PPI 83,6 H2RA Sucralfat 51,9 Plazebo 39,2 28,2 20 40 60 80 Chiba et al, Gastroenterology 1997 Drug interactions between PPIs and other drugs Klotz U. Clin Pharmacokinet 2000; 38: 243 - 270 Drug Mechanism OME LAN PAN RAB Digoxin Absorption AUC ? NO AUC Theophyllin CP4501A2 ( CL) ( CL) NO NO Warfarin CP450C19 ↓ CL NO NO NO Carbamaz. CP4503A4 ↓ CL ? NO ? Diazepam CP4502C19 ↓ CL NO NO NO Phenytoin CP4502C9 ↓ CL NO NO NO Ketoconazole Absorption ↓ AUC ? ? ↓ AUC Metoprolol CP4502D6 No ? NO ? Alcohol ADH + CP450 No ? NO ? Oral contracep. CP4503A ? NO NO ? Antipyrine Liver function ↓ CL ( CL) NO ? Cyclosporin CP4503A4 NO ? NO ? Nifedipine CP4503A4 ↓ CL ? NO ? Natural course of GERD after cessation of treatment Patienten in remission (%) 100 Patients with esophagitis (n=123) 80 Patients with NERD (n=145) 60 40 25% 20 10% 1 2 3 4 5 6 Months without treatment Carlsson et al 1998 Short- and long-term therapy for reflux esophagitis in the elderly Pilotto A et al, Aliment Pharmacol Ther 2003; 17: 1399 - 1406 % 90 80 70 60 50 40 healing rates 30 20 10 0 8 weeks 6 months 12 months 12 months 40 mg 20 mg 20 mg Placebo PAN PAN PAN n=164 n=133 n=49 n=56 Long-term therapy for GERD • Risk factors for relapse – Presence of typical symptoms – Presence of hiatal hernia – High grade of severity of esophagitis • Step down of acid suppression as far as possible in patients with no or less severe esophagitis • In some patients even on demand therapy is successful Long-term therapy for GERD • Hp eradication recommended in the „younger old“ • No modification of carbohydrate or protein digestion nor iron or calcium absorption • But especially in frail elderly patients with poor diet monitoring of vit B12 advised Surgical therapy for GERD • Indications – Medical treatment failures – Side effects of medical therapy – Aspiration / large hiatal hernias • Surgery in specialized centres is safe for the elderly • Further studies comparing medical and surgical therapies in the elderly needed Stretta ® Radiofrequencytherapy Endoscopic therapy is still experimental ! The Stomach / Duodenum Physiology of acid secretion in age • Decline in gastric acid secretion related to the presence of mucosal atrophy • Development of atrophic gastritis not strictly age-related, but a consequence of longstanding Hp-infection No significant change of basal or stimulated gastric acid output with aging in healthy humans Helicobacter pylori in the elderly Increasing prevalence of Helicobacter pylori infection with age H. pylori positive [%] 60 n = 496 50 40 30 20 10 0 <31 31 - 40 41 - 50 51 - 60 >70 Age groups [years] G. Holtmann, Eur J Gastroenterol Hepatol; 13, Suppl. 1: S5 - S11 (2001) H. pylori in the elderly • Prevalence – 40 – 60 % in the asymptomatic elderly – >70 % in elderly patients with gastroduodenal disease • Frequency of diagnosis and therapy US: only 40 -56 % with peptic ulcer disease screened Hood HMet al. Arch Intern Med 1999 only 50 -73 % with positive test treated with antibiotics Ofmann JJ et al. Am J Gastroenterol 2000 Peptic ulcer disease and H. pylori in the elderly Incidence of gastric ulcers Incidence of duodenal ulcers Incidence of severe complications US-patients with peptic ulcer disease 1995 – 1997 26 % Hp-positive 82 % recent use of NSAIDs Brock J et al. JAMA 2001 In the future even higher impact of drug regimens – NSAIDs, low-dose aspirin, warfarin, phenprocoumon NSAIDs and Helicobacter pylori • Hp-eradication before starting NSAID-therapy reduced clinical ulcer end points in high-risk patients Chan FK et al, Lancet 2002 • For Hp-positive patients on chronic NSAIDs-therapy benefit of eradication not established Hp testing and eradication advisable – In patients with a history of uncompliacted or complicated peptic ulcers before start of NSAID- therapy – In high risk patients before start of NSAID-therapy H. pylori and functional dyspepsia • Positive results in 2 studies in patients with elderly patients Problems: High numbers of NTT patients (15/20) Follow-up only 2 months ! Pilotto A J Gastroenterol Hepatol 1999 Catalano F Dig Dis sci 1999 • Data for long-term results missing Indication for eradication in functional dyspepsia still open for debate H. pylori and chronic atrophic gastritis • Increasing incidence of chronic atrophic gastritis with age a function of chronic H. pylori infection • Successful eradication of H. pylori improves the mucosa status • Results independent from the age of the patient H. pylori in nursing homes • Seropravalence in elderly patients living in nursing homes longer than 5 years: 86 % Pilotto et al, Age Aging, 1996 • Seroprevalence higher for people staying in nursing homes longer than 15 months: 84 vs. 63 %, p < 0.05 Regev et al, Helicobacter, 1999 • Higher prevalence among employees in institutions for the intellectually disabled Bohmer CJ et al, Am J Gasrtoenterol, 1997 Diagnosing H. pylori infection in the elderly • Endoscopy is warranted for all elderly patients with abdominal complaints • Key points: – H. pylori may be found only in the fundus or corpus in elderly patients on antisecretory therapy – Chronic atrophic gastritis may make the diagnosis of H.pylori infection more difficult • Consequences: – Perform gastric biopsies from the antrum and the body of the stomach – Perform a second test if urease-test or histology negative Posttreatment evaluation • Evaluation at least one month after completion of therapy • If repeated endoscopy is not necessary – 13C-urea breath test – Stool antigen test • If repeated endoscopy is necessary – gastric ulcer, complicated duodenal ulcer, MALT lymphoma, severe gastritis – histology and urease test via endoscopic biopsy Cumulative data on H. pylori eradication in the elderly Pilotti A, Malfertheiner P, Aging and the Gastrointestinaltract, 2003 Number ITT PP Dropouts Side of patients eradication eradication effects PPI + C 37 43,2 47,0 8,1 8,1 PPI + 83 59,0 61,2 3,6 3,6 A1/A2 PPI + C + 296 88,2 90,9 3,0 3,4 M/T PPI + A1 + 253 84,2 89,1 5,5 7,1 C PPI + A1 + 154 79,8 83,7 4,5 7,1 M M = metronidazole, T = tinidazole, A1 = amoxycillin 1g twice daily, A2 = amoxicillin 500 mg three times a day Resistency rate in Germany in relation to number of eradication treatments Not treated once treated > once treated N=296 N=29 N=28 Personal communication M. Kist, 2004 Treatment of H. pylori in the elderly • 1-week, PPI-based triple therapies are very effective in the elderly • Low doses of both PPIs and clarithromycin are sufficient to obtain excellent cure rates • Concomitant diseases and concomitant treatments do not influence the efficiacy of eradication therapy • Low compliance and antibiotic resistance are the main factors related to treatment failure NSAIDs and Ulcer Disease Characteristics of NSAIDs induced peptic ulcer disease • Gastric ulcer > duodenal ulcer • Frequently asymptomatic • Hospital admissions more frequent than in non-NSAID-users • High risk for complications/hospital admission during the first 30 days of NSAIDs-therapy Risk factors for NSAID induced gastro- intestinal toxicity • Prior history of an adverse event (ulcer, hemorrhage) Risk increases four to fivefold • Age > 60 Risk increases five to sixfold • High (more than twice normal) dosage of a NSAID Risk increases 10-fold • Concurrent use of glucocorticoids Risk increases four to fivefold • Concurrent use of anticoagulants Risk increases 10- to 15-fold Recommendations for therapy of gastro- duodenal NSAID ulcers A Stop of NSAID/aspirin therapy, if possible Start of traditional ulcer therapy with H2RA or PPI For patients with large ulcers PPI preferred Hp – Eradication, if positive Recommendations for therapy of gastro- duodenal NSAID ulcers B NSAID/aspirin therapy must be continued Therapy with PPI for 4 – 8 weeks mandatory Hp eradication, if positive Maintenance therapy with PPI necessary while on NSAID/aspirin therapy Alternatively switch to COX-2 inhibitor/ clopidogrel, if possible and indicated ? Incidence of gastroduodenal ulcers at the end of treatment with valdecoxib or naproxen in elderly subjects 12 10 8 Gastric 6 Duodenal 4 Gastroduodenal 2 0 Placebo Valdecoxib 40mg Naproxen 500mg b.i.d. b.i.d. n=61 n=60 n=60 Goldstein JL et al, Aliment Pharmacol Ther, 2003 Recommendations for prevention of gastro-duodenal NSAID ulcers I Consider therapy with a COX-2 inhibitor/clopidogrel, if feasible Attention: Advantage of COX-2 inhibitor offset, if used together with low dose aspirin Gastroenterology, 2004 Consider serious spectrum of side effects in some of the COX-II-inhibitors Recommendations for prevention of gastro- duodenal NSAID ulcers II For high risk patients on therapy with traditional NSAIDs: - Use lowest effective possible dose - Misoprostol (4 x 200 μgr) or PPI - Monitor patients while on NSAIDs: anemia, iron deficiency, severe dyspepsia, overt GI bleeding Ulcer recurrence and ulcer bleeding with different prophylactic regimes 30 25 20 Diclofenac + 15 Omeprazol Celecoxib 10 5 0 Peptic Ulcer Bleeding ulcer Chan FK et al. Gastroenterology, 2004 Upper gastrointestinal bleeding in the elderly • Most common: peptic ulcer • Predictors of higher morbidity and mortality: – Age > 80 – Continuous bleeding – Rebleeding • Predictors of endoscopic failure: – Ulcer size > 2 cm – Torrential bleeding – Post. bulb ulcer with visibel vessel – Refractory/ recurrrent bleeding with shock – Resusitative envent/ > 4 units of erythrocytes Gastric cancer in the elderly Gastric cancer in the elderly - Epidemiology • Prevalence strongly related to age • Median age around 72 years • ¼ > 80 years of age • 5 year survival rate < 10 % • 90 % adenocarcinoma – 5 % lymphomas • Proximal cancers more common in Caucasians and strongly rising in incidence Gastric cancer in the elderly Early carcinomas in > 80 % asymptomatic Symptoms in most cases associated with an advanced stage of disease Late presentation particular common in the elderly Essential principle for adequate staging: Invasive staging only in fit and potentially resectable patients Classification of early gastric carcinoma Local endoscopic therapy in selected cases - EMR, laser, photodynamic therapy Surgical therapy of gastric cancer Curative resection Palliative resection R0-resection D1/D2 – lymphadenomectomy Improved survival Improved quality of life Mortality of surgical therapy for gastric cancer in the elderly Age, years Number of patients Mortality rate % (%) < 70 109 (41,3) 12,8 70 - 79 111 (42,0) 17,1 > 80 44 ( 16,7) 18,2 McKinlay A et al, Aging and the Gatrointestinal Tract, Karger 2003 Mortality of surgery for gastric cancer in the elderly and ASA status Age, years Mortality % Mortality % ASA I / II ASA III / IV < 70 10,5 20,8 70 – 79 10,6 25,6 80 15,8 45,5 McKinlay A et al, Aging and the Gatrointestinal Tract, Karger 2003 Chemotherapy for gastric cancer • Palliative chemotherapy Indicated for symptomatic patients Improvement of quality of life, survival benefit unclear Remissionsrate 30 – 50 % Let`s have a short break ! Liver disease in the elderly The Liver and Aging • Liver size diminishes • Liver blood flow declines • Histologically – Reduction in the volume of lobules and hepatocytes – Changes in the mitochondrial volume, the ER and in pigment disposition • Slightly reduced bile acid synthesis + increase in cholesterol synthesis and secretion • Growth factors in regeneration Hepatitis in the elderly • Acute HAV-hepatitis more severe, frequently cholestatic and potentially lethal in the elderly • Because of improved sanitation serious HAV-hepatitis now found more in adult and geriatric patients • Subclinical and oligosymptomatic acute HBV-hepatitis common • Chronic hepatitis B in the elderly usually less active with slow progression Hepatitis C Virus - HCV • Most important hepatitis virus in the elderly • Great regional differences Italy: > 65 years prevalence 4,1 – 33,1 % • In most cases longstandig chronic infection • New infections in the elderly rare • Genotype 1b more frequent than in younger populations • Old age associated with more severe histopathological damage and cirrhosis Autoimmune hepatitis in the elderly • 17 – 56% of all patients with autoimmune hepatitis (AIH) > 65 years at presentation • Typical sign of AIH: acute icteric hepatitis • Prognosis after diagnosis and therapy excellent The pancreas in the elderly • The pancreas in the elderly functions well under unstressed conditions. • Exocrine insufficiency under excessive ingestion of high fat meals. • No proof of diminished capacity of carbohydrate digestion in the elderly. • Pancreatic insufficiency in the elderly mostly a consequence of disease. The Large Bowel Inflammatory bowel diesease in the elderly • Second peak of incidence of Crohn`s disease after age 65 (15 % of all patients) Gastroenterol Clin North Am 2001;30:409-426 • Incidence of ulcerative colitis 4,5/100 000/y for people > 65 years Gastroenterol Clin Biol 2002;26:157-161 • Medical therapy for the elderly identical to therapy in younger age groups Drugs Aging 2002;19:355-363 Colorectal Carcinoma in the Elderly Colorectal carcinoma - Epidemiology • Second most common cause of death for both sexes • Most common cause of death for women > 75 years Greenlee RT et al. Cancer J Clin 2001 • Decrease of overall CRC-associated mortality at an annual rate of 1,7 % since 1990 Sial SH, Catalano MF, Gastroenterol Clin North Am 2001 Colorectal carcinoma - Epidemiology • Average age at diagnosis for men 67 years, for women 70 years • > 70 % of patients older than 65 years • > 40 % of patients older than 75 years • In most therapy studies for CRC the eldlerly are underrepresented Localisation of CRC in the elderly • Older patients more likely to have right-sided colonic cancer • 40 % of CRC and of colonic polyps in the elderly found proximal to the splenic flexure • Typical symptom of the elderly with CRC: asymptomatic iron deficiency anemia • With suspicion of CRC colonoscopy is mandatory ! Localisation of CRC Screening options for CRC • OBT yearly • OBT yearly + sigmoideoscopy every 5 years • Colonoscopy every 10 years • Double contrast radiology of the colon • (Virtual colonoscopy) Occult blood testing • No valuable data > 70 years • Success of OBT yearly from 50 years on (calculated) – 75 years: 68 % risk reduction with regard to mortality – 80 years: 83 % risk reduction with regard to mortality Rich JS et al. Eff Clin Pract 2000 3:78-84 • Problems in the elderly – Compliance – Visus – False-positive results found more often CRC screening and colonoscopy • 2/3 of patients with proximal colonic carcinoma show no neoplastic lesion distal to the splenic flexure. • Screening colonoscopy recommended every 10 years. • Upper limit for screening colonoscopy 80 years in the fit elderly. • Often the individual situation of the elderly has to be taken into account. Surgical therapy for CRC • Initial treatment of choice • Operative procedures identical for the elderly • Contradictory data concerning the operative risk for the elderly • Postoperative mortality: 70 – 79 years 3,7 % 80 – 89 years 9,8 % > 90 years 12,9 % Damhuis RAM, Int J Colorectal Dis, 1996 Surgical therapy for CRC • Age not a significant independant risk factor for postoperative mortality but overall medical status essential. • Good results for elective resection after medical stabilization. • Steep increase in mortality after emergency operations. Wolters U et al. Anticancer Res. 1997 Chemotherapy in CRC • No negative effect of age on remission and survival in metaanalysis • Slightly increased risk for hematologic toxicity and hand food syndrome • Prognostic factors – Overall medical condition – Number of leucocytes – Number of involved organs – Alkaline phosphatase Stratification of the elderly with CRC • Instruments Mini mental status examination ADL IADL • 3 categories 1. Standard full-dose therapy or combination therapy possible 2. (Mono)Therapy possible, reduced starting dose advisable 3. Supportive therapy Chemotherapy in CRC • Chemtherapeutic options in CRC – 5 – FU + folic acid infusional regimen – Oral fluoropyridine (Capecitabine®) – Oxaliplatin - combination with 5-FU/FA or Capecitabine® – Irinotecan - mono- oder combination therapy with 5-FU/FA • New therapeutics – Modifiers of EGF-function – Bevacizumab (in combination with IFL) – Cetuximab (monotherapy) Take home messages I • Because of reduced sensitivity esophageal diseases in the elderly tend to be diagnosed in advanced stages. • Achalasia in the elderly can be treated safely by pneumatic dilatation, but botulinum toxin is a valuable option in high risk patients. • GERD in the elderly shows less typical, but more atypical symptoms and a higher prevalence of severe esophagitis and complications. Take home messages II • Long term therapy of GERD in the vast majority of all cases necessary. • Hp still relevant in peptic ulcer disease, but its importance will be declining in the next decades. • With respect to new data on side effects and the high incidence of bleeding complications when combined with aspirin the indication for cox-II- inhibitors in the elderly has to be questioned. Take home message III • In any case of prevention or diagnosis of CRC high colonoscopy is still the diagnostic procedure of choice. • The success of gastrointestinal surgery in the elderly is not matter of age, but depends on the overall medical condition of the patient and adequate preparation. • Chemotherapy for CRC with standard and newer drug regimens can be undertaken safely in the elderly.
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