Chapter 93: Upper Gastrointestinal Disorders

Learning Objectives

• Identify the presentation of gastroesophageal reflux disease (GERD) in older adults and select the most appropriate therapeutic strategies.

• Employ management strategies that reduce the risk of peptic ulcer disease (PUD) in older adults including: limiting the use of nonsteroidal anti-inflammatory drugs, and eradicating Helicobacter pylori when indicated.

• Recognize the risk factors for upper GI cancers in older adults and initiate evaluation in those at risk, particularly those at risk for Barrett esophagus.

Key Clinical Points

1. GERD is common in older adults with a incidence of 5 per 1000 person years in the United Kingdom and United States. Symptoms are less likely to correlate with the severity of esophageal findings on endoscopy so a trial of proton pump inhibitors (PPIs) should rarely be done without endoscopy for suspected GERD in older adults. PPIs are more effective than H₂-blockers, but prokinetic agents have not been shown to be superior to placebo.

2. Peptic ulcer disease (PUD) increases with age, likely due to H pylori infection, use of mucosa-damaging drugs, and an imbalance between mucosal erosive and protective factors. Despite clear data that treatment of H pylori reduces relapse of peptic ulcer disease, many older adults with PUD go untested for H pylori and only 1/2 to 3/4 of those who test positive are treated. H pylori cure after treatment should be documented with a breath test or stool antigen.

3. Upper GI bleeding (UGIB) occurs in older adults due to the same pathologies as seen in young adults, but may present with exacerbation of underlying disease (eg, cardiac disease) or non-GI symptoms such as syncope.

4. The types of upper GI cancers have changed markedly in recent decades with adenocarcinoma increasing in frequency in the esophagus. Older white men represent a very high risk group due to Barrett esophagus, and those with GERD symptoms or high suspicion of GERD should undergo screening endoscopy. Gastric cancer remains very common in developing nations. The risk of both esophageal and gastric cancer increases with age.

5. PPIs interact with many drugs prescribed in older adults and long-term PPI use has been associated with B₁₂ deficiency, an increased risk of fractures (hip, wrist, or spine), and bacterial diarrhea (including Clostridium difficile), and some studies suggest pneumonia, functional decline, and mortality in frail older adults. Thus, long-term PPI use should be contemplated only in those with clear indications to do so.