Gastrointestinal Diseases

Disclaimer: While every attempt is made to ensure that drug dosages provided within the text of this journal and the website are accurate, readers are urged to check drug package inserts before prescribing. Views and opinions in this publication and the website are not necessarily endorsed by or reflective of those of the publisher.

Supporting Research and Public Education in Digestive Disorders

Gary A. Levy, MD, FRCP, President, Canadian Digestive Health Foundation; Director, Multi Organ Transplant Program, Toronto General Hospital, University of Toronto, Toronto, ON.

The Burden of Digestive Disorders in Canada
Many are aware of the devastating impact that diseases such as cancer and heart disease have on Canadians. However, few might realize that digestive diseases constitute an even greater health and economic burden, and seriously impair quality of life.

Despite the staggering statistics (see sidebar), funding for education and research from provincial and federal agencies lags far behind the prevalence and burden of disease. As an example, from 1988-1998, successful government gastroenterology grants decreased from 76 to 53. The total dollar value for digestive disease research also decreased from $6 million to $4.4 million over the same period.

Introducing the Canadian Digestive Health Foundation
In 1991, the Canadian Digestive Health Foundation (CDHF; then the Canadian Digestive Disease Foundation) was formed by a small group of Canadian gastroenterologists interested in enhancing the profile of gastroenterology in Canada and generating a stable source of funds for research and education. In 1994, the Foundation became a charitable organization. Between 1995 and 2000, one to two grants in gastrointestinal research were awarded annually, funding seven young investigators who have since become key members of the Canadian GI research community. However, it was only in the last few years that the organization began to grow towards its full potential.

In 2001, renewed support allowed the Foundation to establish a National Office. The Canadian Association of Gastroenterology (CAG), a professional society of physicians, other health care professionals and basic scientists, fully endorsed the Foundation as its fundraising foundation. Strong ties with the Canadian Institutes of Health Research (CIHR) offered new research funding opportunities. With this revitalization, the organization became the Canadian Digestive Health Foundation and redefined its mandate.

In 2001/2002, the Foundation made great strides in the arenas of research and public education. A detailed listing of all CDHF-sponsored research can be found on the CDHF website.

Public Education and the CDHF
Last year the CDHF launched its website (www.cdhf.ca) as the primary means of providing education for patients and the public regarding digestive diseases. Among other resources, the site contains a growing library of information on various gastrointestinal problems, prepared by key Canadian medical experts specializing in the area. While contacts from patients have confirmed the usefulness of this information, patients clearly desire a forum to interact with medical specialists regarding their particular situation. To meet this need, the CDHF is pleased to introduce a new program coming in January 2003 called Ask a Specialist.

This program allows you and your patients to ask a Canadian gastrointestinal specialist a question about a particular digestive disorder or health issue, via e-mail, and receive an answer within seven days. Please join us for the first installment in the series, Ask a Specialist About Dyspepsia, beginning January 1, 2003 at www.cdhf.ca.

Dr. Richard Lee, MD, CCFP(EM), FRCPC
Undergraduate Program Director
Emergency Medicine,
University of Alberta

Introduction
Approximately 13% of our population is comprised of persons who are aged 65 years or older. This age group represents the fastest growing segment of our population and it is expected that by the year 2030, it will amount to 20% of the total population. On average, the older person tends to visit the emergency department (ED) more frequently, stays longer, is more likely to be admitted, and also consumes more health care resources than does the younger person. Up to 10% of these elderly patients will present with their chief complaint being abdominal pain. Results from one survey found that 78% of emergency physicians believe that abdominal pain is more difficult to manage in the elderly when compared to a younger age group, and 86% found it more time consuming to treat elderly patients.¹

Fifty to sixty-three percent of elderly patients required admission--versus 10% in the younger age group--and 22.1-42% required surgery--versus 16% in the younger group.^1-3 The ability of the physician to correctly diagnose abdominal pain decreases dramatically as the age of the patient increases. Concurrently, there is a subsequent rise in the morbidity and mortality in this age group.

Elana S. Lavine, BSc

Irritable bowel syndrome (IBS) is a very common gastrointestinal disorder typically characterized by abdominal pain, bloating, and constipation and/or diarrhea. There is no known organic disease process in the gastrointestinal tract, and no pathology is observed when the colons of patients with IBS are examined via endoscopy. IBS can, therefore, be categorized as a functional illness. However, certain differences have been observed experimentally between the colons of IBS patients and normal controls (see pathophysiology). The onset of novel IBS-like symptoms in the elderly patient merits a thorough investigation. Successful management may require both symptomatic treatment and emotional support from a physician.

Epidemiology
IBS is considered a syndrome of the young and middle-aged; in the elderly, it may be a reluctant diagnosis.¹ Fifty percent of patients experience an onset of symptoms before age 35, and another 40% between the ages of 35 to 50.2 One recent study followed a cohort of 2,956 newly-diagnosed IBS patients, ranging in age from 20-79, and noted that only 12% were above 60 years of age.³ One national study conducted in the UK indicated that prevalence rates dropped between 78% and 92% from middle to old age.⁴ The question has been raised as to whether such statistics reflect a true decline in incidence with age, or an underreporting.

Sheldon Singh, BSc

Constipation is a very common complaint. In the United States, it accounts for over 2.5 million physician visits annually. The occurrence is highest among individuals 65 years and older.¹ Constipation has been shown to diminish the quality of life and well-being of individuals. It may also lead to complications such as fecal impaction, fecal incontinence, dilatation and even perforation of the colon.

Defining Constipation
Constipation is not easily defined. Since more than ninety-five percent of the population have between three bowel movements a day and three bowel movements a week, constipation has historically been defined as the passage of fewer than three bowel movements a week. However, most would agree that the effort needed to pass stool and the consistency of the stool are more important; difficulty passing stool, even if one passes stool daily, may constitute constipation. Thus, constipation may be defined as persistent symptoms of difficult, infrequent, or seemingly incomplete evacuation.

Leora Horn, MSc

Inflammatory bowel disease (IBD) is the general term used to describe idiopathic chronic disorders that cause inflammation or ulceration of the gastrointestinal system. Canada is believed to have one of the highest incidences of IBD in the world with an estimated one hundred thousand people suffering from the disease (Crohn's and Colitis Foundation of Canada). The majority of IBD cases are characterized by periods of remission and exacerbation of symptoms often requiring long-term drug therapy, hospitalization, and recurrent surgery. IBD may develop at any age in the geriatric population, but the peak incidence falls between ages 60 and 80. IBD is a chronic disease; people who develop IBD when they are young will carry the disease into old age. Within the elderly population, two-thirds of IBD patients develop the disease in their sixties, a quarter of patients develop IBD in their seventies, and one tenth of patients develop IBD in their eighties.

IBD is classified as either ulcerative colitis (UC) or Crohn's disease. UC is three times more likely than Crohn's disease to occur in the elderly, with twelve percent of UC patients developing the disease when they are over sixty years of age. Approximately four percent of people with Crohn's disease develop symptoms when they are over sixty with incidence among women being higher than among men.¹

Related Terms: Gastrointestinal Diseases, colitis, Crohn’s disease, IBS, inflammatory bowel disease

Nariman Malik, BSc

Diverticular disease of the colon had been a rare clinical entity before the twentieth century. Currently, diverticulosis is the most common condition affecting the intestine.¹ The incidence of diverticular disease increases with age from approximately 9% in those younger than 50 to 50% in those over the age of 70.² Diverticular disease is almost exclusively seen in populations that consume low fibre diets such as those common in Western society. Interestingly, these conditions are less common in vegetarians than in non-vegetarians. There is no associated risk with smoking, caffeine, or alcohol use.³

A diverticulum is defined as a sac-like protrusion of the colonic wall. Colonic diverticuli are formed by the herniation of the mucosa and submucosa through the muscularis mucosa. They tend to develop at points where the vasa recta penetrates the circular muscle layer.

Diverticular disease is a spectrum of diseases that encompass three clinical multi-faceted conditions: diverticulosis, diverticulitis, and diverticular bleeding. Each condition has a unique set of presenting symptoms and an individualized course of management (see Table 1).

Barry Goldlist, MD, FRCPC, FACP

There is more and more evidence accumulating in recent years that demonstrates the critical importance of nutrition in the elderly. The negative consequences of being overweight have long been known. Much of the modern 'pandemic' of type II diabetes mellitus is secondary to this. As well, hypertension and hyperlipoproteinemias are related to obesity. Recent evidence has confirmed the long suspected relationship between arthritis of the knee and excess weight. Despite this, the average weight of North Americans continues to rise. My personal belief is that this does not simply reflect a lack of personal self-discipline, but rather a societal structure that constrains physical activity in day-to-day existence. Irregular trips to the gym are no substitute for walking each day, even if only to the bus stop. Our cities in North America, with their sprawling suburbs, seem designed specifically to discourage walking and encourage driving. A rethinking of how we design our living spaces might help in controlling the occurence of obesity.

We understand even less about the causes of under-nutrition in old age. Is it a consequence of disease and decline, or is it a factor that causes functional decline? Certainly the causes of weight loss in old age are almost always multifactorial. The various factors range from poor dentition, loss of ability to smell, the effects of drugs, to specific disease processes, such as cancer. Eating is also an intensely social process, and isolated seniors are particularly at risk for under-nutrition. Regardless of whether under-nutrition is the 'chicken or the egg', once an elderly person becomes ill, careful attention to nutritional issues is often the key to ultimate functional recovery. Thus, in any geriatric service, the clinical dietitian is a key member of the team. For any physician following elderly patients in their own practice, the easiest way to detect problems at an early stage is to carefully record the patient's weight at regular intervals. This is particularly important in nursing homes, where weights should be recorded on a monthly basis. In the USA, intense research interest has been focused on this issue, particularly on the fact that protein loss seems to predominate in some patients. The resulting loss of muscle mass has been called 'sarcopenia', and is clearly a factor in functional decline.

It is ironic, that as a geriatrician, even though I have seen wonderful therapeutic advances in care of the elderly, the best strategy for maintaining quality of life in old age, continues to consist of regular exercise and good eating habits.

Alexandra Nevin, BSc

Gastroesophageal Reflux Disease (GERD) is the pathological manifestation of a normal physiological process, and is associated with a range of clinical symptoms and complications of varying severity. In normal individuals, gastric acid reflux into the esophagus occurs without any accompanying signs or symptoms of mucosal damage. The majority of these events are the result of transient lower esophageal sphincter relaxation (TLESR).^1,2 Normally, TLESR is not accompanied by inadequate innate esophageal protective mechanisms which characterize the development of GERD. The wide spectrum of presenting symptoms makes definitive and accurate diagnosis and management of GERD a clinical challenge. This is especially true for physicians who treat the elderly and have to contend with the increased absolute incidence of GERD, the number of concurrent medical conditions, changing physiology of the aging esophagus, and the prevalence of atypical symptoms and complications.

The incidence and natural history of GERD
In the United States, 44% of the adult population surveyed reported experiencing heart burn, the most frequently noted symptom of GERD sufferers, at least once every month.^3,4 The absolute incidence of GERD has been shown to increase with age, with an initial dramatic rise in incidence after 40 years of age, and significant increases at age 60 and then again at age 70.

Normal Function is Retained Despite Age-related Changes

J. Sedmihradsky, BSc, MA

Introduction
Although failing gastrointestinal function may have been previously associated with advancing age, this is not currently the case. In recent years, clinical studies have changed perceptions about how the gastrointestinal tract ages, demonstrating that in general, normal gastrointestinal function is retained in healthy elderly individuals. This article will discuss the age-related changes that can occur in the gastrointestinal system of the elderly.

Overall, the gastrointestinal tract does not undergo major changes with the aging process. Consequently, the recommended dietary intake of nutrients for the elderly remains quite similar to that of younger adults.

Subscribe to Gastrointestinal Diseases

The Canadian Digestive Health Foundation

The Emergency Management of Abdominal Pain in the Elderly

Irritable Bowel Syndrome is Not Just a Psychosomatic Illness--It Warrants Medical Investigation and Treatment

Constipation: There May be a Number of Underlying Causes

Inflammatory Bowel Disease (Crohn’s and Colitis) is Harder to Diagnose in Older Patients

Diverticulitis, Diverticulosis and Diverticular Bleeding--Managing these Afflictions of the Colon

Good Nutrition is Often Key to Functional Recovery

Recognizing the Unique Presentations of GERD Complications

Good Prospects for the Aging Gastrointestinal System