1. Gastrointestinal Diseases and Disorders Karen E. Hall, M.D., Ph.D. GRECC, Ann Arbor VA Health System University of Michigan Health System Contributors to GI chapter: George Triadafilopoulos, MD Annette Medina-Walpole, MD William J. Hall, MD

2. Purpose

3. Handouts

4. Question 1: Effect of aging on GI function

5. Answer: 3

6. Small bowel “resistant” to aging

7. Proximal and distal GI tract at greatest risk for dysfunction with aging

8. Age and Swallowing

9. Reflux risk increases with age LES pressure decreases with age: Gastroesophageal reflux disease (GERD)

10. Achalasia Subset of patients have pathologic increase in LES pressure: Female: Male 4:1 Age 75-85 years Progressive dysphagia to liquids and solids

11. Achalasia LES: “Bird’s beak” LES normally closed at rest Relaxation impaired: inhibitory NO and VIP neurons absent or dysfunctional

12. Achalasia Treatment Forcible balloon distension Rupture, mediastinitis, sepsis Botulinum toxin injection Relief x weeks-months ?Frail - high risk for balloon Laparoscopic LES myotomy ?similar risk/benefit as balloon

13. Splanchnic blood flow decreases with age Upper GI tract and proximal small bowel protected due to rich anastomotic supply Decreased blood flow to liver: Impaired metabolism: drugs, bilirubin “Watershed” areas at risk for ischemia (colon)

14. Diverticular disease: ?Western Aging Circular muscle: fewer fibers; larger spaces between fibers Colonic collagen increases in thickness with aging: Prolongation of muscle contraction Intraluminal pressure increases Mucosa/submucosa protrudes through wall = diverticulum

15. Aging sets the stage for clinical impairment Physiologic effects of aging + Superimposed disease Effects of medications = Clinical impairment in areas already at risk due to normal aging

16. Question 2: Dysphagia

17. Answer: 1

18. Gastroesophageal reflux disease (GERD)

19. GERD in older patients

20. Barrett’s Esophagus Mucosa: Squamous to intestinal Pre-malignant: Dysplastic foci require biopsy for detection High grade dysplasia (HGD) has significant risk of progression to adenocarcinoma

21. Barrett’s Esophagus Earlier studies: 7-10% risk of adenocarcinoma per year? Up to 1998-99: 1. Screening EGD for patients with GERD history 2.+Barrett’s: biopsy HGD: surgical referral 3.Low-Moderate Grade Dysplasia: high dose PPI 4.Follow-up EGD every ? 6 months – 1 year?

22. Should we treat Barrett’s Esophagus? Recent RCTs of proton pump inhibitor treatment: No significant effect on: Rate of progression of low- moderate dysplasia to HGD Rate of esophageal adenocarcinoma Screening EDG: esophageal cancer in 3%

23. Should we treat Barrett’s Esophagus? Why didn’t PPI treatment work? ? Not long enough (6 mo – 2 years) ? Genetic mutation already present ? Acid exposure not the only cause ? Biopsy error

24. Should we treat Barrett’s Esophagus? Current recommendations: 1. Screening EGD for patients with GERD history 2. +Barrett’s: biopsy +for HGD: surgical referral 3.M-LGD: ?PPI + Follow-up EGD ?timing Watch for future developments

25. Back to Question 2

26. Question 3

27. Answer: 4. Swallowing evaluation

28. Aspiration pneumonia

30. Feeding Tube?

31. Feeding tubes in Dementia

32. Question 4: “The Bottom End”

33. Question 4

34. Answer: 4. Enema

35. Constipation

38. Question 5

40. Answer: 5. Surgical Evaluation

41. Acute Abdomen in the Older Patient

43. Appendicitis in the Older Patient

44. Finally - Back to Question 5

45. For Additional Information: GRS Syllabus