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Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011 Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011 Erika Pétervári and Márta Balaskó Molecular and Clinical Basics of Gerontology – Lecture 15 CHANGES OF THE GASTROINTESTINAL TRACT, ACUTE AND CHRONIC DISORDERS TÁMOP-4.1.2-08/1/A-2009-0011 Characteristics of geriatric patients • delicate balance among the organ systems • functional loss in the most vulnerable system, unrelated to the locus of illness • masked, not typical symptoms (e.g. no pain in appendicitis) • polymorbidity (interaction with other systems) • altered drug disposition/clearance Influence of aging on gastrointestinal (GI) disorders TÁMOP-4.1.2-08/1/A-2009-0011 Interaction with other systems: • ability to raise the cardiac output + maldistribution of circulation GI motility and/or absorption capacity (hypoxia in the apical part of the villi); postprandial: insufficient rise of GI-perfusion (abdominal angina) or hypoperfusion in other organs (fainting, AMI) • diabetes, neurologic and vascular changes Lifestyle changes in the elderly – more severe complications of GI disorders TÁMOP-4.1.2-08/1/A-2009-0011 • decrease in fluid intake; • decrease in protein intake (social and psychological causes); • caloric malnutrition (weight loss); • insufficient intake of trace elements, vitamins • sedentary lifestyle (lack of exercise, obesity). TÁMOP-4.1.2-08/1/A-2009-0011 Common GI disorders in the elderly • Upper GI tract disorders - Dysphagia syndromes, disorders of the esophagus - Disorders of the stomach and the duodenum • Disorders of the lower bowel - Constipation - Fecal incontinence (pressure ulcers!) - Diverticular disease - Diarrhea (malabsorption, chronic pancreatitis) - Aging liver Dysphagia syndrome, esophageal disorders TÁMOP-4.1.2-08/1/A-2009-0011 • dental, oral disorders (stomatitis, denture), xerostomia + dysphagia (caused by drugs, cerebrovascular or neuromuscular disorders) malnutrition, aspiration • esophageal carcinoma progressive dysphagia, weight loss • non-cardiac chest pain: 50% of cases have esophageal cause e.g. gastro-esophageal reflux TÁMOP-4.1.2-08/1/A-2009-0011 Disorders of the stomach and the duodenum • acid output incidence of duodenal ulcer • intake of NSAIDs incidence of gastric ulcer • stress + defensive factors gastritis, stress ulcer • ulcers may lead to serious bleeding, perforation, penetration • incidence of autoimmune gastric atrophy with achlorhydria and IF deficiency (pernicious anemia) TÁMOP-4.1.2-08/1/A-2009-0011 The most common gastric disorders in elderly GERD Gastric ulcer Gastroparesis Atrophic gastritis Gastric carcinoma Common causes of constipation in the elderly Nutrition al causes Functiona l causes Secondary causes (due to other diseases) Drugs • Low dietary fiber • Inadequate fluid and caloric intake • • • • Immobilization (terminal reservoir syndrome) Depression Confusion Neurological disorders (Parkinson’s disease, cerebrovascular accidents, dementia) • Endocrine disorders (hypothyroidism, hyperparathyroidism, diabetes) • Colonic obstruction (ischemia, diverticular disease, neoplasms, irradiation) • Opiates • Anticholinergics • Cation-containing drugs (Al, Ca, Fe) • Diuretics etc. * Many older people incorrectly believe that their bowel movements Common causes of fecal incontinence in the elderly Anorectal incontinence (disorders of the anal sphincter and puborectal muscles) • descending perineum (idiopathic) • trauma • anal surgery • spinal cord injuries • diabetic and other autonomic neuropathies Symptomatic incontinence • colorectal disease with diarrhea Overflow incontinence • impaired terminal reservoir capacity (aging, ischemia, cancer, resection) • fecal impactation Neurogenic incontinence (sensory- TÁMOP-4.1.2-08/1/A-2009-0011 Diverticular disease low-fiber diet asymptomatic colonic diverticula (sac-like projection of the mucosa and submucosa) bleeding diverticulitis (infection of the diverticula) peritonitis, paralytic ileus TÁMOP-4.1.2-08/1/A-2009-0011 Ischemic colitis • Precipitating factors: - dehydration - hemorrhage - low-output heart failure - polycythemia - diabetes mellitus - digitalis • The ischemic colitis is rare (many anastomoses), but its mortality rate is high. TÁMOP-4.1.2-08/1/A-2009-0011 Aging and enteral absorption The small intestine has a large reserve capacity, aging has only subtle influences on the digestive and absorptive processes: • Reduced intestinal blood flow. • Decrease in the absorbing surface (30%), atrophied villi. • Decreased activity of disaccharidases and aminopeptidases can lead to osmotic diarrhea (thin, watery), due to the bacterial breakdown of non-digested food. There is a decrease in the absorption of TÁMOP-4.1.2-08/1/A-2009-0011 Diarrhea and malabsorption in the elderly Major causes: • infections • drug side-effects (long-term and inappropriate use of antibiotics) • chronic pancreatitis • lactose intolerance Consequences are more severe (dehydration, hypovolemia, malnutrition) Cave! Alternating diarrhea vs. TÁMOP-4.1.2-08/1/A-2009-0011 Disorders as consequences of malabsorption • osteoporosis (calcium) • sarcopenia (proteins) • infections (vitamins, proteins, trace elements) • pressure ulcers (proteins, fluids) • anemia (Fe, B12) • dementia (B12) • GI tract disorders (fibers, fluids) TÁMOP-4.1.2-08/1/A-2009-0011 Aging liver Age-related changes are minimal, significant only in late stage: • drug (alcohol) clearance • cholelithiasis, cholestasis • appearance of abnormal proteins TÁMOP-4.1.2-08/1/A-2009-0011 Major causes of upper GI tract bleeding CAUSE % Gastric ulcer 29 Duodenal ulcer 21 Gastritis 17 Esophagitis 14 Esophageal varices 12 TÁMOP-4.1.2-08/1/A-2009-0011 Major causes of lower GI tract bleeding CAUSE % Diverticulitis Vascular ectasia of right colon Undetermined 43 Radiation proctitis 6 Colorectal carcinoma 5 Colonic polyps 4 Other 20 11 11 TÁMOP-4.1.2-08/1/A-2009-0011 Causes of lower intestinal bleeding Ischemi c colitis Angiodysplasi a Colitis (infections , irritable bowel syndrome) Polyp s Carcinom a Hemorrhoid s Diverticu la