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GENERAL PRINCIPLES

Gastrointestinal (GI) conditions are commonly seen in older adults and can present in various forms and severity, ranging from mild bouts of constipation to life-threatening episodes of bowel ischemia. Certain conditions have a higher prevalence in older people, such as vascular disease and neoplasia. In addition, older adults often have multiple chronic illnesses and use concomitant medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants, which can both predispose them to GI diseases and complicate their management. Endoscopic procedures can be safely performed in older patients but require careful consideration of their medical multimorbidity, cardiopulmonary status, and overall ability to tolerate procedural sedation.

DYSPHAGIA

ESSENTIALS OF DIAGNOSIS

  • Dysphagia can be oropharyngeal or esophageal.

  • Alarm features such as unintentional weight loss, anemia, and odynophagia should be solicited and warrant endoscopy for evaluation.

  • A modified barium swallow test evaluates oropharyngeal swallow function but does not extend distally to evaluate the entire esophagus, unlike a barium esophagram, which also evaluates the distal esophagus.

  • Successful management of dysphagia requires an interprofessional approach, with medical and endoscopic therapies, as well as behavioral modifications.

General Principles

Dysphagia, or difficulty swallowing, is a common complaint in older adults. Dysphagia can be classified as either oropharyngeal or esophageal. Oropharyngeal dysphagia refers to impaired movement of liquids or solids from the oral cavity to the upper esophagus. Esophageal dysphagia occurs in the esophagus distal to the upper esophageal sphincter. Both types of dysphagia are common, with an estimated 20% of community-dwelling adults experiencing dysphagia of any type over a 1-year period. Various disorders can adversely affect swallow function, particularly in older people, such as neurologic causes (stroke, dementia) and malignancy involving the aerodigestive tract. The aging process itself, associated with decrease in muscle mass and connective tissue elasticity, also predisposes to presbyesophagus, which can impair the swallowing process in older adults.

Clinical Findings

A. Symptoms & Signs

Patients with oropharyngeal dysphagia typically cough, choke, or regurgitate their food during the initiation of a swallow. Those with esophageal dysphagia often feel food getting “caught” or “stuck” in the esophagus and may identify discomfort in the throat or substernal area. Patients may also complain of painful swallowing, known as odynophagia. Dysphagia to solids can often reflect an underlying structural disorder, such as a mechanical obstruction, whereas progressive dysphagia to both solids and liquids is more typical of an underlying motility problem. Alarm features that may indicate underlying serious pathology, such as malignancy, should be solicited and include unintentional weight loss, anemia, and odynophagia.

B. Diagnostic Evaluation

There are a variety of diagnostic tests that evaluate dysphagia, including modified barium swallow, barium esophagram, upper endoscopy, and esophageal manometry.

The modified barium swallow test is useful for evaluation of oropharyngeal dysphagia. This is ...

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