In the elderly, gastrointestinal (GI) disorders, especially those of the large intestine, account for a significant portion of physician visits, inpatient hospitalizations, and health care expenditure in the United States. Not only are large intestinal disorders common, but in the elderly their presentations, complications, and treatment may be different than in the young. This chapter focuses on diagnosis and treatment of a variety of diseases of the large intestine, including diverticular disease, Clostridium difficile-associated diarrhea, microscopic colitis, inflammatory bowel disease, colonic ischemia, colonic obstruction, and lower GI bleeding.
Diagnosis of GI disorders in an elderly patient poses several additional challenges to the physician on top of those present for all patients. First, comorbid illnesses are frequent and often numerous, and some such as dementia and depression may impair adequate communication between patient and caregiver. Second, medications and their side effects may cloud the clinical picture; polypharmacy is common in the elderly. Lastly, symptoms attributable to the large intestine may be manifestations of different diseases in the elderly than they would in the young. The astute geriatrician must take these factors into consideration when treating all patients.
Symptoms of digestive diseases may be misinterpreted or atypical in the aged. For example, constipation may be a symptom of irritable bowel syndrome in a young patient, whereas it might herald an obstructing lesion in an older patient. Rectal bleeding in a young person is most commonly from hemorrhoids or inflammatory bowel disease. In the elderly, diverticulosis or colon cancer more commonly cause rectal bleeding. A complete and thorough history is imperative in patients, especially the elderly. Subtle clues to the diagnosis are sometimes dismissed as physiologic aspects of aging. Physical examination and some laboratory tests including tests of liver function are unaffected by aging, and any abnormality should be evaluated for the presence of a disease state and not dismissed as an age-related change (Table 92-1).
Table 92-1 Influence of Age on Likely Diagnosis of Lower Gastrointestinal Symptoms |Favorite Table|Download (.pdf)
Table 92-1 Influence of Age on Likely Diagnosis of Lower Gastrointestinal Symptoms
Inflammatory bowel disease
Irritable bowel syndrome
Inflammatory bowel disease
Colonoscopy in the elderly is safe and well tolerated. Several studies of indications and outcomes of patients older than 80 years having elective and emergency endoscopic procedures found those tests to be safe; advanced age is not a contraindication to endoscopy. Moreover, the yield for diagnostic testing with colonoscopy in the elderly is relatively high.
Adequate bowel preparation is critical to a successful colonoscopic examination. Bowel cleansing in the elderly should be performed with care. Preparation with standard doses of polyethylene glycol based lavage solutions (PEG-ELS) ...