KNES 495 - Final

Digestive disorders statistics

• Make up 1/3 of the doctor visits among patients older than 65

• 35% to 40% of geriatric patients will have at least
  one GI symptom in any year

  • Constipation, fecal incontinence,

  • Diarrhea, irritable bowel syndrome (IBS),

  • Reflux disease and swallowing disorders

Digestive changes as you age

• ↓ taste buds

• ↓ pancreatic enzymes

• ↓ GI absorption

• ↓ GI motility

  • constipation

• ↓ Sphincter activity

  • Heart burn

• ↓ GI blood flow

• ↓ Gastric acid secretion

• ↓ Absorption of iron, calcium, & folic acid.

Common signs and symptoms of digestive disorders

• Perforations

  • cause peritonitis and septicemia

• Alteration in motility

  • Diarrhea (15% of 65+ Canadians)

  • Nausea / Vomiting

  • Constipation (25% of those 65+)

Bleeding and digestive disorders

Hematemesis (esophagus or stomach)
• Blood in vomit
Hematochezia
• Blood in feces (bright red)
Melena (stomach or top part of intestines)
• Blood in feces (dark, tarry)

Gastrointestinal Bleeding in the Elderly

• Bleeding is common in patients over 65
  

• 75% of the bleeding is in the upper tract

  • 50% is due to NSAID use

  • 50% is due to ulcers or erosions (peptic or esophageal)

• Females are at higher risk than males

Digestive disorders diagnostic tests

• X-ray

• GI series

  • Barium swallow and enema

• Occult blood

  • Blood in feces

• Endoscopic exam

  • Esophagogastroduodenoscopy (EGD

  • colonoscopy

Oral Health and Aging

• 30% of Canadians over the age of 65 are missing teeth (endentulous)

• Osteoporosis of mandible and maxilla bones

  • Sunken jaw

  • tooth loss

Aging of teeth

• Bad breath

• Yellowish brown discoloration

• Recession of pulp from crown

• Narrowing of root canal

• Pulp calcification

  • Teeth fracture easily

• Odontoblasts secrete less dentin

  • Roots become brittle

• Teeth shorten due to wear

  • Discolouration

• Gum recession and infection (peridontitis)

  • Gum bleeding

Periodontal disease

• 1 in 5 Canadians have periodontal disease

  • 7 out of 10 will experience gum disease in their lifetime

  • More severe in Men

• Gum recession and inflammation causes the loosening and loss of teeth

Periodontal disease: Canadian statistics

• 5% of Canadians have no teeth

  • 21% of population over the age of 65

• 1 in 5 Canadians over the age of 60 have full dentures

  • More than half have bridges

Dysphagia

Difficulty swallowing may be associated with

• Difficulty with chewing (choking risk)

• Nerve dysfuncton - Stroke or Parkinson’s disease or ALS

• Failure of lower esophageal sphincter to relax

• Reduced peristaltic contractions in esophagus

• Reduced saliva production

Deglutination - Swallowing

Food to the back of the throat

• Tongue rises pushes posterior

• Soft palate and hyoid elevates / Epiglottis closes

• Peristaltic contraction of the esophagus

  • 8-20 seconds for food movement

Dysphagia symptoms, causes and treatments

• Symptoms

  • Pain on swallowing

  • Coughing, gagging

  • Food “getting stuck”

  • Weight loss? Change in voice?

• Causes

  • Poor muscle or nerve function

  • Abnormal growths

  • Chronic inflammation (eg. Smoking)

  • Narrowing of esophagus

• Treatments

  • Surgery, stents, dilations

  • Lifestyle changes (Eat slowly, chew well, sit straight, exercise)

Dysphagia Stages

• Stages 1 and 2 – difficulty eating dry foods

• Stages 3 and 4 – semi-solid and liquids only

• Stages 5 and 6 – unable to swallow fluid

Gastro-Esophageal-Reflux Disease (GERD) symptoms

• Reflux of gastric acid into the esophagus

• Seen in 35% of individuals 50-79 yrs old

• Symptoms

  • Chest pain / burning

  • Burping

  • Bad breath

  • Tooth decay

  • Coughing

  • Excess saliva

Gastro-Esophageal-Reflux Disease (GERD) causes and treatment

• Causes

  • Decreased emptying of stomach

    - Slower digestion with aging

  • increased gastric pressure (over-eating)

  • Decreased low esophageal sphincter pressure

  • Increased gastric secretion

• Treatment

  • H2 receptor blockers

    - suppress gastric secretion

Esophagitis

• Long-term reflux

  • bleeding, ulceration, and scarring

• Treatment:

  • Avoid large meals

  • Avoid spicy foods

  • loose clothing

  • gum

  • Surgery if severe

Hiatal Hearnia

• Wider diaphragmatic opening with aging

• Part of stomach moves into chest

• Symptoms

  • Heartburn (↑ with age)

  • Or asymptomatic

• Treat

  • Avoid large food intake / spicy food

  • Surgery may be required

Aging and the stomach

Diabetics

• Gastric emptying slows by up to 50%

Peptic (Gastric) Ulcer

Hole caused by inflammation and necrosis

• Caused in part by pepsin, low mucous (with aging)

• Helicobacter pylori

• NSAIDs

• stomach and duodenum

Peptic (Gastric) Ulcer symptoms and risk factors

• Symptoms

  • Pain

  • Bleeding (hematemesis or melena)

• Risk Factors

  • Smoking / alcohol

  • Use of NSAIDS

  • Low fibre / poor diet

  • Spicy food

  • Stress

Classes of Bleeding Ulcers and Treatment

• Classes of Bleeding Ulcers

  • Active bleeding

  • Non-bleeding visible vessel

  • Clotted / Dot

  • Clean base

• Treatment:

• Reduction of contributory factors

• Antacids

• Surgery in severe cases

Functional Dyspepsia

• Chronic disorder of the upper digestive tract

  • Poor sensation and peristalsis

• Affects 30-45% of Canadians over 65

Functional Dyspepsia symptoms and causes

• Symptoms

  • Nausea, vomiting

  • Belching

  • Bloating

  • Indigestion / heartburn

• Causes

  • Slow emptying of stomach / Altered intestinal motility

  • Changing acid and enzyme levels

  • Gallstones / Ulcers / Cancer / GERD

  • Chronic inflammation

Functional Dyspepsia

• Reduce individual food triggers

  • milk, alcohol, caffeine, fatty foods, mint, tomatoes, citrus fruits, and some spices

• Medications

  • H2RA’s – block histamine
    ⬧ Eg. Zantac and Pepcid

  • PPI’s – block acid secretion
    ⬧ Nexium, Prevacid, LoSec

  • Medications that increase gut motility

• Lifestyle changes

  • Exercise regularly / No smoking, alcohol

Absorption in the Small Intestine with aging

• Absorption decreases with aging

  • Reduced enzymes and carriers

• Malabsorption syndrome

  • SI can’t absorb nutrients

    - fats and minerals

    - Diarrhea, foul feces

  • Causes

    - Disease of intestinal wall

    - Blocked exocrine ducts

  • Diet therapy

    - Treat malnutrition

Diseases of the Small Intestine

Regional enteritis

• Crohn’s disease

• inflammatory bowel disease (IBD)

  • Often SI

• Exacerbation / remission

Regional enteritis symptoms and treatment

• Symptoms:

  • Anorexia

  • Flatulence

  • pain

  • Diarrhea and constipation

• Supportive treatment:

  • Low-residue diet

  • Medications

  • surgery

Diseases of the Colon: Intestinal obstruction

Blockage in intestine or bowel

• tumours, hernias, adhesions

• volvulus, intussusception

• paralytic obstruction

Intestinal obstruction: Symptoms and Treatment

• Symptoms:

  • abdominal pain

  • distention

  • Nausea and vomiting

• Treatment:

  • Nasogastric suctioning

  • Surgery

Ulcerative Colitis Symptoms

• Chronic inflammation of colon

• Symptoms:

  • Lower abdominal pain

  • Blood in stools

  • Anemia

  • Diarrhea

Ulcerative Colitis Treatment

• Dietary limitations

• Stress reduction

• Mild sedatives

• Anti-inflammatories

• Surgery

Irritable bowel syndrome Symptoms

• aka spastic colon

• Inflammation of bowel with chronic lesions

• Symptoms:

  • Abdominal pain

  • Altered motility

  • Diarrhea or constipation

Irritable bowel syndrome Causes and Treatment

• Causes:

  • Spicy foods and seasonings

  • Caffeine

  • Alcohol

  • Stress

  • age

• Treatment:

  • Avoidance causative factors

Hemorrhoids Causes

• Varicose veins in rectum

  • Inflamed veins with prolonged stresses

  • Internal or external

• Causes:

  • Pressure in anal area

  • Constipation

  • Age

Hemorrhoids aging effects and symptoms

• Aging effects

  • less motility - constipation

  • blood flow to anal region (and lower body) slow

  • Blood is more likely to pool in the veins

• Symptoms

  • Pain

  • Itching

  • Bleeding

Hemorrhoids prevention and treatment

• Prevention:

  • Good bowel habits – fluids, fibre

  • Exercise

  • Avoid laxatives

• Treatment:

  • Medications / creams

  • Warm sitz baths

  • Manual reduction

  • Cryosurgery

  • hemorrhoidectomy

Colorectal Cancer and Aging

90% of all cases occur in individuals aged > 50 years

Colorectal Cancer: warning signs, prevention and treatment

• Warning Signs

  • Nocturnal Bowel movements

  • Weight loss

  • Diarrhea / constipation

  • Rectal bleeding

• Preventative

  • Colonscopy

  • Fibre / diet / Exercise

• Treatment

  • Surgery / chemotherapy if needed

Diverticular Diseases

• Common with aging

  • 5% of population younger than 40

  • 50% of those aged 60 years and older

  • 65% of those over 85 years of age

• Diverticula

  • pouch-like projections

• Two conditions

  • Diverticulosis

  • Diverticulitis

Diverticular Diseases: risk factors and potential causes

• Risk factors

  • Lack of fibre in diet

    - weak areas form pouches

  • Lack of exercise / obesity

  • Smoking / Alcohol

• Potential causes:

  • Constipation

  • Pressure from moving dry, hard bowel movements

  • Genetics

Diverticulosis

• Diverticula usually measure 0.5-1cm

  • Can exceed 2 cm

  • Some as large as 10 cm

• Most people have no pain or symptoms – some will have

  • Diarrhea

  • Constipation

  • Flatulence

  • Heartburn

• Inflammation of the diverticula

  • Infection and bleeding

  • Due to material caught in diverticula

• 10-25 % of diverticulosis patients become inflamed

Diverticulosis symptoms and treatment

• Symptoms

  • Tenderness / cramps

  • Abdominal pain

  • Infection / Fever

  • Nausea, vomiting

  • Blood in the stool

• Treatment

  • Low fibre diet in flare-ups

  • Hospital – IV feeding (to rest the bowel)

  • Anti-spasmodics

  • Pain meds

  • Surgery if perforated (Antibiotics)

  • Colostomy

Controlling Diverticular Disease

Diverticulosis

• High fibre diet

  • Adds bulk and softens stools

  • Fruits, vegetables, whole grains and beans
    ⬧ Limit seeds (eg. popcorn)

  • High volumes of water

• Diverticulitis

  • Low fibre (residue) diet initially

    - Gradually increase fibre (Doctor’s supervision)

  • Low fat diet

Exercise and Diverticular Disease

• Important for colon health

  • Exercise increase gut movement

• 30 minutes most days of the week

  • Divide into 5 to 10 minute sessions

• Moderate intensity

  • Brisk walking, swimming, dancing, yard work, housework

Constipation Causes

Transit time too slow in colon
Causes:

• Diet is too low in fibre and fluid

• Insufficient physical activity,

• Irritable bowel syndrome,

• Diabetes, stroke, hypothyroidism

• Parkinson’s disease (low motility)

• Gut biome imbalance

• medication side effect

  • opiates, anti-depressants, calcium channel blockers, iron

Constipation Treatment

• 25% over age 65

• Treatment

  • Adequate fluid and fibre

  • Increase exercise

  • Prunes / fruit

  • Laxatives

  • Stool softeners

• Risk of hemorrhoids and chronic bowel inflammation

Diarrhea Causes

• Loose stools at least 3 times a day

• 15% of people over 65

  • 85% of aged digestive mortality involve diarrhea

• Causes

  • Malabsorption

  • Medication side effects

  • Cancer

  • Infections

  • Diabetes

  • Celiac Disease / IBS

Diarrhea Treatment

Need transit through large intestine to slow down
Treatment

• Bulk formers – fibre or psyllium

  • Eg. Metamucil (soak up water)

• Meds to slow down motility

  • Immodium, Anti-spasmodics

• Diet / Exercise

  • BRAT plan
    ⬧ Bananas, rice, yogurt, oats

Fecal Incontinence

• In ~10% of people over 70

• Causes

  • Weak pelvic floor

  • Weak sphincters

  • Neural changes

• Risk Factors

  • Age, female

  • Stroke, diabetes

  • Urinary incontinence, bowel changes

Diseases that affect integrative function

Comprehensive Diseases

• Affect more than one body system

• Heart Failure

• Diabetes

• Liver Failure

• Kidney Failure

• Pancreas failure

Functions of the Liver

• Makes bile from cholesterol

• Makes plasma proteins (albumin)

  • to pull water out of tissues

• Makes Clotting factors

• Stores Nutrients (Fe, Mg, Cu, Zn)

• Helps remove and recycle old RBCs

• Stores/Metabolizes Vitamins

• Makes glycogen

• Angiotensinogen

• Biotransformation

Effects of Aging on the Liver stats

• Liver starts to show changes after the age of 35

  • Intensifies after age 60

  • Female > Male

• 30-50% decrease in liver size

• 30% decrease in blood flow to liver

  • Normal flow is ~1.5 L/min

• 10-20% decrease in perfusion

Effects of Aging on the Liver

• Decreased number of hepatoctyes

• Decreased Bile formation

• Bile becomes lithogenic

  • More cholesterol within the bile

  • More likely to form gall stones

• Increased fat in liver

• Increased collagen

• Increased lipofuscin (“age” pigments)

• Decreased liver enzyme activity

  • Decreased Biotransformation

• Drug clearance slowed (by up to 50%)

  • Made worse by alcohol, smoking, diet

• More susceptible to drug-induced injury

• Hepatitis and Cirrhosis more severe with age

Common signs and Symptoms of liver failure

• Liver disease

  • Jaundice

• Gallbladder disease

  • Pain

Diagnostic Tests for liver failure

• Liver function tests

  • bilirubin, albumin, and enzymes

• Ultrasound, x-rays, CAT scan

• Biopsy

Liver Diseases: hepatitis causes

• Inflammation of liver

• Causes:

  • Chemical actions of drugs

  • Toxic substances

  • Chronic alcoholism

  • Group of viruses

Liver Diseases: hepatitis symptoms

• Jaundice and liver enlargement

• Myalgia and abdominal pain

• Clay or light-colored stools

• Dark-colored urine

• Malaise

• Anorexia

• Fever

Hepatitis treatment and prevention

• Treatment:

  • Rest

  • Good nutrition

  • Anti-virals

  • transplant

• Prevention:

  • Good hygiene

  • vaccination

  • Special care when handling needles and body fluids

Cirrhosis

• Chronic, irreversible, degenerative

  • Alcohol, toxins. disease

• Loss of normal liver cells

  • No organization

  • Scar tissue

Cirrhosis Symptoms and Treatment

• Symptoms

  • Nausea

  • Weight loss / Weakness

  • Inflammation then degeneration
    ⬧ Hobnailed (nodular)

  • Ascites
    ⬧ High abdominal venous pr.
    ⬧ Organs swell
    ⬧ bleeding

• Treat

  • transplant

Gallstones

• consist of cholesterol, bilirubin, and calcium

• Can block ducts

  • If small – gravel

Five Fs for risk of gall bladder diseases

1. Female

2. Fair complexion

3. Fat

4. Fertile

5. Forty or older

Cholecystitis

• Inflammation of gallbladder

• Eg. blockage

• Symptoms:

  • RUQ pain

  • Nausea and vomiting after eating

• Treatment:

  • Surgical excision

Liver Failure

• Irreversible damage

• Usually Chronic and gradual

  • Some acute failure

    - Can be < 48 hours

• Difficult to detect until end-stage

Causes of Chronic Liver failure

• Hepatitis (B and C are most common)

• Long-term alcohol and drug consumption

• Aging

• Cirrhosis

• Hemochromatosis

  • Excess iron absorption

• Malnutrition

• Liver cancer

Causes of Acute Liver Failure

• Tylenol overdose

• Hepatitis

• Ingestion of poisonous wild mushrooms

• Reactions to some prescription and herbal meds

Progression of liver failure

• Fatty liver

• Liver fibrosis

• Cirrhosis

Fatty Liver

Aka Hepatic steatosis

• Build up of fats in the liver

  • Alcohol

  • Obesity, diabetes, hyperlipidemia

• May be asymptomatic

  • Most common symptom is fatigue

• May be reversible with diet control and exercise

• NAFLD (non-alcoholic fatty liver disease vs AFLD - alcoholic

Liver Fibrosis

• High inflammation

  • Oxidative stress

  • Mitochondrial dysfunction

  • apoptosis

• Formation of fibroids

• Progression from fatty liver disease or from hepatitis B or C

Cirrhosis

• Extensive fibrotic scarring and inflammation

• Death of cells

• Loss of function

  • Irreversible degeneration

• Needs Transplant

• NAFLD – fatty liver

• NASH –non-alcoholic steatic hepatitis

NAFLD vs. AFLD fatty liver

• NAFLD (non-alcoholic fatty liver disease)

  • better recovery

• AFLD - alcoholic

  • much harder to pull fats out

Early Symptoms of liver failure

• nausea

• vomiting

• loss of appetite

• diarrhea

• fatigue

Later Symptoms of liver failure

• Jaundice

• Bleeding easily

• Ascites (swollen abdomen)

• hepatic encephalopathy

• Myalgia

Digestive system with liver failure

Decreased bile

• Decreased fat digestion

• diarrhea

• Decreased essential fatty acids

• Decreased fat soluble vitamin

  • Eg. Vitamin K – clotting

• Large intestine problems due to higher fat content

Poor storage of vitamins, nutrients, and minerals

• Malnutrition

• Affects enzyme activity and metabolism

Cardiovascular system with liver failure

• ↓ Angiotensinogen

  • Inability to control blood pressure

• Sepsis / inflammation may occur

  • ↓blood pressure

• ↓ blood proteins

  • Affects water balance

• High portal pressure in liver

  • Edema

• Atherosclerosis

  • Less fat processing

• ↓ blood proteins

  • Poor transport of hormones and vitamins

  • edema

• ↓ formation of clot factors

• ↓ vitamin K

  • Bleeding issues

Immune system with liver failure

• ↑ toxins

  • weakens immune response

• Sepsis

Lymph system with liver failure

lymph vessels cannot drain the fluid caused by sepsis.

Nervous system with liver failure

• Less ammonia converted to urea

• ↑ ammonia

  • Hepatic encephalopathy

  • Cerebellar shrinkage

  • Less cerebral function

Endocrine system with liver failure

• ↓ somatomedins

  • ↓ cell growth and repair

• ↓ angiotensinogen/angiotensin

• ↓ thrombopoietin

  • So ↓ megakaryocytes

    - ↓ platelets

Renal system with liver failure

• fails to filter excess amino acids

• Can’t process them into urea

• Build-up of toxins (not biotransformed)

• Leads to Kidney failure

Respiratory system with liver failure

Metabolic acidosis may occur

• Result of retained amines

• high levels of NH4+

  • lead to brain swelling and decreased blood flow to the brain

• Body may Hyperventilate to compensate

• May result in respiratory Alkalosis

Treatments for liver failure

• Anti-virals (for Hep C)

• In advanced stages

  • liver transplant

  • preventing progression

Alcohol stats

• Globally

  • Alcohol-related deaths account for 5.1% of all deaths

• In the US

  • Alcohol-related deaths account for more than 10% of all deaths

  • Large increase in the last 10 years

• Primary cause of Liver failure and Fatty
  Liver disease

Alcohol Processing

• Absorbed in the stomach and small intestine

• Bio-transformed by the liver

  • Acetaldehyde is the more toxic version

  • Acetate can then be excreted by the kidney

• Higher Dehydrogenase Activity

  • Higher NADH

  • Triggers formation of fatty acids

    - Steatosis

    - Results in Alcoholic Fatty Liver disease

• Liver toxicity

  • Impaired function

  • spirals

Alcoholic Liver Disease (ALD)

• Alcohol-induced hepatitis

  • Excess biotransformation / inflammation

• Alcohol intake to induce ALD

  • Males > 4 drinks/day or 14 drinks /week

  • Females > 3 drinks / day or 7 drinks / week

  • now dropped to like ½

• Moderate

  • Males > 2 drinks / day

  • Females > 1 drink / day

• 1 standard drink – 14 g alcohol

  • 1 beer or 1 glass of wine or 1 shot

Alcohol effects on the liver

• Fatty liver

  • Fat deposits in hepatocytes

• Alcoholic hepatitis

  • jaundice

• Cirrhosis

• Liver cancer

Alcohol Effect on Thiamin

B1 vitamin

• Needed to activate steps in the metabolic pathways

  • E.g. Activates Pyruvate Dehydrogenase
    ⬧ Needed for aerobic respiraton

• Alcohol processing will divert Thiamin away from the metabolic pathways and into the acetaldehyde pathways

  • Thiamin deficiency

Effects of Chronic Alcohol Abuse

Increased risk for:

• Liver disease

• Cardiovascular disease

• Cancer

• Pancreatitis

• Type II Diabetes

• Neurological disorders

• Korsakoff’s syndrome (memory disorder – thiamin deficiency)

• Death

Alcohol medical problems with the digestive system

• oral cavity cancer

• esophageal cancer

• esophageal varices

  • Changes in Liver - portal pressures
    ⬧ Causes GI bleeding

• Pancreatitis

• All made worse when combined with smoking!!!!!

Alcohol medical problems with the cardiovascular system

• Atrial fibrillation

• Hypertension

• Strokes

• Cardiomyopathy

• Heart failure

Alcohol medical problems with the kidney

• Must secrete acetate

  • Can lead to kidney failure

  • Kidney inflammation
    ⬧ Blocked ducts

• ADH inhibited

  • High excretion of water - Dehydration

• Can lead to acid-base imbalance

Alcohol medical problems with the nervous system

• acute intoxication with loss of consciousness

• Withdrawal

• Seizures

• subdural haemorrhage

• peripheral neuropathy

• Wernicke-Korsakoff syndrome

  • Low thiamin

• cerebellar degeneration

• Balance problems

Fetal Alcohol syndrome

No alcohol intake is safe during pregnancy

• Reduced brain size

• Low body weight

• Poor coordination

• Small head size

• Hyperactive behavior

• Attention deficit

• Poor memory

Alcohol – Endocrine Effects

Suppresses the CNS

• decreased hormone release from Pituitary and Hypothalamus

• Results in

  • Decreased thyroid hormone (decreased metabolism)

  • Decreased cortisol

  • Decreased growth hormone and cell repair

  • Poor water balance (ADH effects)

  • Possible reproductive effects long-term (FSH/ LH)
    ⬧ Testosterone / estrogen effects
    ⬧ Secondary sex characteristics

Alcohol - Blood Effects

Alcohol causes a thinning of the blood
Vasodilates the arterioles

• Face becomes flushed

• Can affect thermoregulation (lose heat faster)

Alcohol – Metabolic effects

Decreased ATP production

• Thiamin deficiency

  • Due to alcohol biotransformation

• Results in poor glucose metabolism

  • Lack of TPP

  • Slows pyruvate dehydrogenase – less ATP

• can cause permanent metabolic dysfunction

Alcohol – Respiratory Effects

• Breathing is suppressed at the medulla

  • Decreased blood oxygen

    - Affects cell function

• Reduced breathing – CO2 levels rise

  • Respiratory acidosis

• If vomit is aspirated – risk of aspiration pneumonia or respiratory infections

Alcohol – Skin Effects

• With ADH inhibited – body (and skin) becomes dehydrated

  • More wrinkles

• Also causes skin inflammation and rashes

  • Acetaldehyde effect