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The Gastrointestinal Tract in the Elderly

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The Gastrointestinal Tract in the Elderly Powered By Docstoc
					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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