35: Gastrointestinal & Abdominal Complaints

According to data from the U.S. Census Bureau in 2005, 45–50 million people older than age 65 years had at least 1 gastrointestinal (GI) complaint that impacted their daily life and that could result in a medical visit. GI symptoms are common in older adults and range from mild self-limited episodes of constipation or acid reflux to life-threatening episodes of infectious colitis or bowel ischemia. In addition to the increased prevalence of diseases such as diverticulitis and colon cancer in older patients, other common comorbidities, such as pain requiring nonsteroidal antiinflammatory drug use or atrial fibrillation requiring use of anticoagulants, increase the risk of GI complications such as ulceration or bleeding. Patients may present with unusual or subtle symptoms of serious GI disease caused by alterations in physiology with aging. An example of this is seen in older patients presenting with a GI perforation or colitis who do not have guarding or significant abdominal tenderness as a result of the decrease in visceral sensitivity that accompanies aging. Changes in the neuromuscular control of the colon with aging appear to predispose to constipation, thus explaining the increased prevalence of constipation and impaction developing with bed rest or use of constipating medications.

General Principles in Older Adults

Gastroesophageal reflux disease (GERD) is one of the more common GI disorders affecting older adults. Population studies indicate that more than 20% of adults older than age 65 years have heartburn at least weekly. This may actually underestimate the true prevalence of GERD because of the finding that, although symptoms appear to decrease in intensity with age, the severity of reflux and the risk of complications increases. Once symptoms develop, more than 50% of patients will have persistent symptoms and may require ongoing medical therapy.

Clinical Findings

Symptoms & Signs

GERD can be readily diagnosed if the patient complains of typical symptoms of pyrosis (substernal burning with radiation to the mouth and throat) and sour regurgitation, and if these symptoms improve with treatment. Pathophysiologic changes with aging outlined above may decrease symptoms of GERD, such that patients may present with atypical symptoms, such as a chronic cough, difficult-to-control asthma, laryngitis, or recurrent chest pain rather than heartburn.

Lab Findings

Patients with esophagitis may present with anemia and low iron levels. Esophagitis is a more common cause of anemia than has previously been recognized, and older patients presenting with anemia of unknown cause should have an esophagogastroduodenoscopy (EGD) exam to check for esophagitis and other upper GI tract sources of bleeding.

Diagnostic Studies

Upper endoscopy (EGD) should be performed in all patients with new-onset GERD who are older than 50 years of age, have persistent symptoms of reflux despite medical therapy, have a history of acid reflux longer than 5 years, and possibly have complications from acid reflux. EGD is safe to perform, even in the very old, frail patient. Patients thought to have atypical or extraintestinal manifestations of GERD should undergo ambulatory evaluation with a 24-hour pH probe after a negative work-up, including EGD and other tests for malignancy. Esophageal manometry is not routinely of benefit in the evaluation of older patients with GERD, unless antireflux surgery is being considered.

Differential Diagnosis

In older patients with heartburn and dysphagia, malignancy in the esophagus and/or stomach must be considered and excluded as a cause. Patients presenting with chest pain or cough often must undergo evaluation to exclude acute coronary syndrome, aortic dissection, or pulmonary disease. Patients with hoarseness and cough may require evaluation to exclude oropharyngeal causes of dysphagia, such as stroke or malignancy.

Complications

Complications that have been associated with GERD include esophagitis and esophageal ulceration, bleeding, strictures, Barrett esophagus, and esophageal adenocarcinoma, all of which are increased in patients older than 65 years of age. Risk factors shown in population studies for increased complications include age, male sex, white race, and presence of a hiatal hernia.

Treatment

Treatment of GERD in older adults is essentially the same as that in younger patients. Although the “step-up” approach of lifestyle changes followed by acid-reducing drugs recommended in Table 35–1 may work, immediate initiation of a proton pump inhibitor (PPI) with lifestyle modifications usually results in fewer office visits, a reduction in procedures, improved patient satisfaction, and reduced overall costs. Cimetidine is generally not recommended in older patients because of potential drug interactions and a higher incidence of adverse side effects compared with other histamine-2 receptor antagonists.

Persistent symptoms, or incomplete resolution of symptoms with treatment warrant evaluation with upper endoscopy. Although effective, chronic PPI use is associated with an increased relative risk of osteoporosis of 1.97 with long-term use of PPIs (>7 years). There have been reports of other concerns, such as decreased efficacy of clopidogrel anticoagulation for prophylaxis against coronary stent occlusion when clopidogrel is used in conjunction with PPIs (Table 35–2). For this reason, it is recommended to reevaluate the need for PPIs in patients who have been taking them for longer than 6 months.

Antireflux surgery should be reserved for patients with severe refractory GERD with complications. Results from high-volume centers indicate that mortality and morbidity are not increased in older adults. However, as in younger patients undergoing reflux surgery, although there is an immediate decrease in patients with symptoms postsurgery to 10% to 15%, 60% of patients are taking acid-suppressive medications 5–15 years later. Endoscopic therapies for GERD such as the Enteryx and Stretta procedures have been withdrawn because of significant complications.

General Principles in Older Adults

Dysphagia, or difficulty swallowing, is a common complaint in older adults. Dysphagia is classified as oropharyngeal (transfer) or esophageal (transit). Oropharyngeal dysphagia refers to impaired movement of liquids or solids from the oral cavity to the upper esophagus. Several changes with aging affect the ability to chew and swallow food, including painful or diseased teeth, xerostomia, poorly fitting dentures, and mandibular destruction. Transfer of food into the pharynx slows with aging, resulting in discoordination between the pharynx and delayed relaxation of the upper esophageal sphincter (UES). The result can be penetration of food into the area above the vocal cords, and possibly aspiration into the trachea. Studies of normal healthy adults older than age 85 years demonstrate that approximately 10% have silent aspiration documented on barium cinefluoroscopy. Causes include neuromuscular disorders affecting the tongue, soft palate, oropharynx, and UES, such as cerebrovascular disease, Parkinson disease, multiple sclerosis, Alzheimer disease, and upper motor neuron diseases. Other causes include muscular disorders such as myasthenia gravis, polymyositis, and amyloidosis. Finally, patients with a history of surgery or radiation to the oral cavity or neck are at risk for transfer dysphagia. Dysphagia occurring in the esophagus distal to the UES is transit dysphagia, and is even more common than transfer dysphagia. In a review of patients presenting with dysphagia in a primary care setting, the most common diagnoses were esophageal reflux (44%), benign strictures (36%), esophageal motility disorder (11%), neoplasm (6%), infectious esophagitis (2%), and achalasia (1%).

Clinical Findings

Symptoms & Signs

Patients with oropharyngeal dysphagia typically cough, gag, choke, or aspirate their food during the initiation of a swallow. Patients may also complain of odynophagia, or painful swallowing (Table 35–3). Those with transit dysphagia often complain of solid foods or liquids “sticking,” “catching,” or “hanging up” in their esophagus, and may point to their substernal area as the problem location. Using a series of questions and the algorithm outlined in Figure 35–1, the cause of esophageal (transit) dysphagia can be identified in nearly 90% of cases. Dysphagia to solids usually reflects an underlying mechanical obstruction, whereas dysphagia to both liquids and solids starting simultaneously usually reflects an underlying neuromuscular disorder. Patients with odynophagia may have underlying infection (such as candidal esophagitis) or obstruction. Globus (a persistent sensation of fullness in the throat that usually improves with eating) is a benign condition that may respond to passive esophageal dilation. History of smoking or heavy alcohol use is associated with increased risk of squamous cell esophageal cancer. The physician should look for evidence of anemia and unintentional weight loss as a result of an inability to eat, either of which could indicate a serious disorder such as malignancy. The nature of the dysphagia (solids or both solids and liquids) and the temporal nature of the swallowing disorder (intermittent or progressive in nature) are helpful in determining the likely cause. Finally, associated symptoms of chest pain or acid reflux should be elicited, as GERD is a risk for peptic strictures and development of Barrett esophagus and subsequent adenocarcinoma.

Diagnostic Studies

In older adults, a barium esophagogram is often ordered as the initial test to evaluate dysphagia, but an EGD should be performed to check for malignancy and take biopsies. During EGD, the esophagus can be dilated if a stricture or mass is present. Patients with oropharyngeal symptoms of transit dysphagia should be evaluated by a speech language pathologist who can coordinate a swallowing study (modified barium swallow or videofluoroscopy) using thin, thick, and solid food materials. If upper endoscopy is normal and complaints of dysphagia persist, then esophageal manometry should be performed. This is a safe and readily performed procedure that can accurately identify neuromuscular disorders that cause dysphagia.

Treatment

Treatment is directed toward the underlying disorder in addition to ensuring adequate nutrition and preventing aspiration. Patients with transfer dysphagia are taught which consistency of foods can be safely swallowed, proper swallowing techniques, and how to modify their posture to improve their swallowing. Medical therapy is not effective. Patients with transit dysphagia caused by increased contractility (achalasia and lower esophageal sphincter [LES] spasm) may benefit from LES dilation, botulinum toxin injection, or drugs that decrease smooth muscle contractions (anticholinergics, calcium antagonists, nitrates). Laparoscopic Heller myotomy has been performed in older patients with achalasia with reasonable safety and efficacy. If aspiration occurs or the nutritional status of the patient suffers, a feeding jejunostomy or gastrostomy should be considered if the patient has adequate ability to participate in the decision to use one. Use of feeding tubes in patients with dementia is controversial (see Chapter 68, “Defining Adequate Nutrition for Older Adults”).

General Principles in Older Adults

Disorders of esophageal motility occur in older adults, and may be caused by underlying disease or by changes associated with aging.

Clinical Findings

Signs & Symptoms

Presenting symptoms are usually dysphagia, chest pain, or other symptoms of persistent acid reflux disease. Common motility disorders that can occur in older adults include diffuse esophageal spasm, nutcracker esophagus, hypertensive LES, and ineffective esophageal motility. These conditions are diagnosed by esophageal manometry.

Achalasia is the most well-recognized motility disorder of the esophagus. Its prevalence increases with age; 7–12 in 100,000 older patients are affected. Treatment options include pneumatic dilatation, botulinum toxin injection of the LES, and surgery. Medical therapy (eg, nitrates, calcium channel blockers) is rarely effective; although these can be helpful in treatment of other motility disorders that cause dysphagia (see “Dysphagia” above). Pneumatic dilation produces significant relief of symptoms in many patients, but is associated with a 3% to 10% risk of perforation. For many older patients, initial treatment of achalasia can be approached using botulinum toxin injection. It is safe and effective and provides symptom relief in the majority of patients for up to 12 months. A second injection is often required; however, it is usually effective. Side effects are uncommon and include transient chest or abdominal pain, rash, or low-grade fever. Surgery should be reserved for patients who fail balloon dilation or botulinum toxin injection, and should be approached cautiously as the complication rate is higher.

General Principles in Older Adults

Peptic ulcer disease (PUD) refers to both gastric ulcers (GUs) and duodenal ulcers (DUs). Approximately 5 million cases of PUD will occur this year in the United States, and the demographics are shifting toward an older age of presentation. This may be a result of increased use of NSAIDs, H. pylori infection, and longer life span. Older adults are more likely to suffer complications of PUD, including hospitalization, need for blood transfusions, emergency surgery, and death. The 2 most common causes of PUD are NSAIDs and H. pylori.

Clinical Findings

Symptoms & Signs

Patients may have hematemesis or coffee-ground emesis. Older patients are less likely to have epigastric pain with PUD than younger patients, with as many as 50% of patients without significant pain from either a GU or a DU. Because older patients may have little or no symptoms of significant ulceration, complications such as perforation are also more common in this age group. Chronic ulceration may present with symptoms of gastric outlet obstruction such as early satiety, nausea, and vomiting, as well as anemia.

Diagnostic Studies

In patients suspected of having PUD, a complete blood cell count (CBC), prothrombin time, blood urea nitrogen (BUN), and creatinine should be obtained and stool checked for occult blood. Patients should be asked about a history of PUD; their use of aspirin, NSAIDs, and warfarin; and previous diagnostic studies (upper GI series, testing for H. pylori). Upper endoscopy should be performed in older patients suspected of having PUD to identify the lesion, perform a biopsy in the stomach for H. pylori, rule out a malignancy, and initiate endoscopic therapy for a bleeding ulcer, if necessary.

Complications

Hemorrhage and perforation are the most common complications of PUD and have been reported to occur in approximately 50% of patients older than 70 years. Morbidity and mortality of GI bleeding is higher in patients older than 70 years.

Treatment

If an ulcer is found, therapy should be initiated with a PPI for at least 8 weeks to ensure healing. NSAIDs and aspirin should be stopped. Testing of biopsies for H. pylori urease production should be performed, and if the patient is found to be H. pylori-positive, double or triple antibiotic therapy should be started. In the case of a GU, healing should be documented 8–12 weeks later with follow-up EGD to make sure that the ulcer is not malignant. Patients with a prior history of PUD who require chronic NSAID or aspirin use should be treated concurrently with a PPI or misoprostol if they must have NSAIDs or acetylsalicylic acid (ASA). Both agents are effective in reducing the risk of PUD in chronic NSAID users, although, as a group, the PPIs are generally better tolerated than misoprostol. Patients with serious complications, such as hemorrhage or perforation, should avoid NSAIDs and ASA, as risk of recurrent bleeding is high, even with prophylaxis with PPIs or misoprostol.

General Principles in Older Adults

Dyspepsia is defined as chronic or recurrent pain or discomfort in the upper abdomen, which is thought to arise in the upper GI tract. It is exceedingly common in clinical practice, affecting an estimated 20% to 30% of older adults.

Clinical Findings

Symptoms & Signs

Patients may complain of upper abdominal pain, nausea, bloating, early satiety, or reflux symptoms. Dyspepsia traditionally has been classified as ulcer-like, reflux-like, or dysmotility-like; however, this classification has not been satisfactorily shown to improve either the evaluation or the treatment of patients with dyspepsia, suggesting that the symptoms are very nonspecific. However, it is important to distinguish patients with organic problems, such as an ulcer, from those with functional or nonulcer dyspepsia, because the treatment is dramatically different.

Evaluation of dyspepsia begins with a thorough history and physical examination to determine whether the pain or discomfort arises in the GI tract or elsewhere (heart, lungs, musculoskeletal system). Patients should be asked about unintentional weight loss, odynophagia, dysphagia, prior PUD, pancreatitis, biliary tract disease, bleeding, prior trauma, a family history of GI tract cancer, and evidence of blood loss or jaundice. H. pylori infection is a risk factor for PUD, and accounts for a significant number of cases of dyspepsia. Worldwide, more than 50% of patients older than age 60 years have H. pylori infection, although most are asymptomatic. Noninvasive tests for H. pylori include urease breath testing and stool antigen. These are more sensitive and specific than serum antibody for H. pylori. Patients undergoing endoscopy for dyspepsia should be tested for H. pylori with a rapid urease test of biopsy specimens, and, if positive, treated with a 14-day course of triple therapy (PPI + clarithromycin + amoxicillin).

Diagnostic Studies

Laboratory tests, including a CBC, erythrocyte sedimentation rate (ESR), liver function tests (LFTs), electrolytes, amylase, and lipase, should be performed. Older patients should be evaluated by upper endoscopy to rule out an ulcer or cancer. Initial testing with upper endoscopy has been shown to improve quality of life and lead to a reduction in dyspeptic symptoms. If endoscopy is normal and symptoms persist, a right upper quadrant (RUQ) ultrasonogram should be performed to check for evidence of cholecystitis (gallbladder wall thickening and fluid around the gallbladder). If this is normal and complaints persist, a solid-phase gastric emptying scan should be performed. In an older patient with persistent symptoms, concerns about occult malignancy should prompt a CT scan of the abdomen with both oral and intravenous contrast.

Treatment

If the abdominal pain is caused by a specific disease, then treatment will be guided by the diagnosis. However, patients with persistent dyspeptic symptoms and a normal evaluation are categorized as having nonulcer dyspepsia. Treating this group of patients can be quite challenging. Few data support the routine use of antacids, antimuscarinic agents, or sucralfate. Routine treatment with histamine-2 receptor antagonists has shown a slight benefit, but better results have been obtained with the use of once- or twice-daily PPIs. It is important to consider depression with somatization as a potential underlying cause, as recent studies have shown a correlation with chronic abdominal pain and depression. Older patients may have somatic manifestations of depression, such as chest pain, abdominal pain, nausea, and early satiety. There are no controlled, published studies to date on the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of dyspepsia; however, if the patient has other symptoms and signs of depression, use of SSRIs should be considered. Antidepressants that have been used to treat chronic pain include tricyclic antidepressants, fluoxetine, paroxetine, venlafaxine, and duloxetine. Anticonvulsants, such as gabapentin, carbamazepine, and lamotrigine, may provide safer pain relief in older patients who are not depressed.

General Principles in Older Adults

Patients with diarrhea most often complain of frequent stools (>3/day) or loose stools. However, other patients use the term diarrhea to describe fecal incontinence or fecal urgency. The etiology of acute diarrhea (lasting <2 weeks) in older adults is similar to that of younger adults, with a few exceptions. Most cases of acute diarrhea are related to viral or bacterial infections, but it can also be caused by medications, medication interactions, or dietary supplements. Clostridium difficile colitis is more prevalent in older adults because of more frequent hospitalizations, increased antibiotic use, and increased numbers of patients in institutional settings. C. difficile colonization in long-term care facilities has been estimated to be at least 50% in the United States. Chronic diarrhea, lasting longer than 2 weeks, may result from fecal impaction, medications, irritable bowel syndrome, IBD, obstruction from colon cancer, malabsorption, small bowel bacterial overgrowth, thyrotoxicosis, or lymphoma.

Small bowel bacterial overgrowth occurs when small bowel transit is slowed, or when the normal flora of the colon is altered with antibiotic treatment. The phenomenon causes premature fermentation of sugars by bacteria in the small bowel, leading to production of methane and/or hydrogen, which causes bloating and flatulence.

Lactase deficiency is common worldwide and is present in most individuals to some degree as they age, although it is less common in northern Europeans, North American Indians, and certain groups in Africa. Symptoms of bloating, abdominal distention, and loose stools usually begin in early adulthood, often worsening with age. Patients are usually aware that they are lactose intolerant; however, lactose intolerance can develop acutely after an episode of diarrhea because of other causes. This usually resolves, but may take several weeks or months in some patients. Celiac disease is an increasingly recognized cause of diarrhea and bloating in older adults. Whether this is occurring de novo in later life, or reflects chronic gluten intolerance is not clear. Uncommon causes of diarrhea include Whipple disease, jejunal diverticulosis, bowel ischemia, amyloidosis, lymphoma, and scleroderma with bacterial overgrowth.

Clinical Findings

Symptoms & Signs

A complete history and physical examination, including a rectal examination, may provide information on cause and direct further evaluation. Medication history may reveal a causative agent for the diarrhea, and recent antibiotic use or hospitalization should trigger a work-up for C. difficile. A history of recent weight loss raises the concern for malignancy, IBD, microcytic colitis, malabsorption, or thyrotoxicosis. Fluid status should be assessed in all older patients with diarrhea because they are particularly susceptible to dehydration. Characteristic signs of bloating and gas may indicate small bowel overgrowth, or even underlying celiac disease.

Diagnostic Studies

Stool cultures should be obtained to exclude infection in patients with acute diarrhea. Routine stool cultures usually give a specific diagnosis in only 20% to 30% of cases, likely because most diarrheas are caused by viruses such as rotavirus and Norwalk agent. C. difficile toxin assay (toxin A and possibly toxin B) should be obtained if there is a history of recent antibiotic use. For chronic diarrhea, qualitative or quantitative stool fat should be checked to detect steatorrhea, and a thyroid-stimulating hormone (TSH) should be performed. In patients with C. difficile who fail sequential therapy with metronidazole first and then oral vancomycin, third line antibiotics such as rifaxamin or fidaxomin can be used. Colonoscopy is appropriate in patients with a history of weight loss, bloody diarrhea, and diarrhea lasting >4 weeks. If the colonoscopy appears grossly normal, biopsies should be obtained to rule out microscopic colitis, which has a much higher prevalence in older adults. The mucosa may look normal, however biopsies demonstrate white cell infiltrates in the submucosa. Colonoscopy has a risk of causing perforation in patients with acute diarrhea caused by colitis, and should be used cautiously in patients with acute IBD or severe colitis. X-rays and CT scan of the abdomen may demonstrate bowel wall thickening with severe enteritis or colitis, and are also useful if complications such as perforation or abscess formation are suspected. In patients who are suspected to have small bowel bacterial overgrowth, a positive breath hydrogen/methane test will confirm early fermentation of ingested sugars in the small bowel. Serum antibodies to tissue transglutaminase (tTG), gliadin, and endomysial antigens are often positive in patients with celiac disease, with immunoglobulin (Ig) A tTG being the most sensitive and specific. The diagnosis is made on demonstration of villous damage and atrophy in small bowel biopsies performed during upper endoscopy.

Treatment

Treatment of diarrhea is based on the underlying cause. In those with no evidence of acute infection and no blood in the stool, loperamide (≤8/day) is generally effective in treating symptoms. Bismuth subsalicylate, which has bactericidal action, can also be used. C. difficile is usually treated with metronidazole, and vancomycin is used for moderate-severe colitis or very ill patients. Older patients have a response to metronidazole that is less than that of younger patients (85% vs. 95%), and relapse of C. difficile diarrhea is more common in the older patient. Antidiarrhea agents should be avoided in C. difficile colitis because of the risk of precipitating ileus and megacolon. Care must be exercised in older adults with commonly used antimotility products, such as Lomotil, which contain atropine. In microscopic colitis, treatment is generally aimed at slowing colonic transit with the use of loperamide. Other alternatives include bismuth subsalicylate, prednisone, cholestyramine, or the 5-ASA products. Deodorized tincture of opium often improves symptoms in patients who fail to respond to other treatments. If small bowel overgrowth is present, then treatment with bismuth-containing medications may be helpful in mild cases. For severe small bowel overgrowth, treatment with 14–21 days of antibiotics to eradicate the bacteria is needed. A variety of antibiotics have been shown to be effective, including ciprofloxacin, neomycin, and rifaximin. If the underlying cause of slow intestinal transit is not addressed, or is not treatable, then overgrowth is likely to recur. Elimination of gluten is the treatment for celiac disease, and has become easier with the increase in gluten-free foods. Medication review is often helpful in patients with refractory celiac disease, as medications have been shown to be an unsuspected source of gluten. Web-based patient support groups are often a valuable resource for this kind of information.

General Principles in Older Adults

Diverticular disease has a higher incidence in industrialized nations and increases with age, such that >60% of those older than 70 years and nearly 80% of those older than 80 years have diverticular outpouchings of the colonic mucosa and submucosa. They are thought to develop because of increased colonic luminal pressures, particularly with constipation and straining. Diverticula are most commonly found on the left side of the colon; they are less common on the right side of the colon and are rarely, if ever, found in the cecum or rectum. The majority of patients who have diverticula are asymptomatic. They are commonly found during a barium enema, colonoscopy, or CT scan performed for some other reason. Approximately 15% to 20% of older adults who have diverticulosis will have a complication, among them diverticular bleeding or inflammation of a diverticulum (diverticulitis).

Diverticular Bleeding

Diverticular bleeding is characterized by the sudden onset of painless hematochezia, sometimes in large volume. Although most diverticula are present on the left side of the colon, 70% of diverticular bleeding occurs on the right side. If an episode occurs and the patient is thermodynamically stable, colonoscopy can be scheduled urgently as an outpatient. Eighty percent of diverticular bleeding episodes stop spontaneously without requiring treatment. Patients should be hospitalized if bleeding persists, if they are hemodynamically unstable, or if blood loss compromises other organ systems. Older patients are at higher risk for poor outcomes with bleeding, and the threshold for hospitalization should be lower than in younger patients.

Clinical Findings

Diagnostic Studies

Evaluation of lower GI diverticular bleeding usually involves colonoscopy to exclude sources of bleeding such as arteriovenous malformations (AVMs), ischemia, IBD, and cancer. Diverticular bleeding is often a diagnosis of exclusion in a patient with diverticula, significant bleeding and no other source found. If bleeding persists, a red blood cell scan or angiography should be performed, if necessary for intervention to control bleeding. In refractory cases, surgical resection of the bleeding area may be required.

In uncomplicated diverticulitis, patients have lower abdominal pain (usually on the left), fever, and an elevated white blood cell count. On physical examination, the patient does not appear hemodynamically unstable, and there are no palpable abdominal masses or peritoneal signs. An abdominal radiograph should be performed to look for pneumoperitoneum. If there is no evidence of perforation or sepsis, treatment can be initiated in the outpatient setting with clear liquids for 2–3 days and oral antibiotics that should cover both anaerobes and Gram-negative organisms. Metronidazole and a fluoroquinolone or third-generation cephalosporin for 2 weeks is generally well tolerated and very effective. The patient should call the office in 24 hours and be seen 48–72 hours after the initial evaluation. If no improvement occurs, the patient should be hospitalized and a CT scan of the abdomen performed.

Diverticulitis becomes complicated if an abscess, stricture, or fistula develops. In addition to presenting with tachycardia or hypotension, older patients may present with lethargy or confusion. Abdominal examination may reveal a mass in the left lower quadrant, with or without peritonitis, or evidence of a draining fistula to the bladder, uterus, or skin. Patients with complicated diverticulitis require hospitalization. Patients should be given nothing by mouth and provided intravenous fluids. Blood cultures and an abdominal CT scan should be performed. Intravenous antibiotics should be initiated rapidly to cover both Gram-negative organisms and anaerobes. If no improvement is seen within 48–72 hours, an abdominal CT scan should be repeated, and consultation with surgery and interventional radiology should be pursued in case drainage or resection is required.

Patients with an episode of diverticulitis have approximately a 35% chance of a second episode occurring within the next 5 years. Patients with >2 episodes of diverticulitis in the same segment of colon should be referred to a surgeon for consideration of segmental resection.

General Principles in Older Adults

Although the majority of patients with IBD are younger than age 65 years, approximately 10% to 15% of all newly diagnosed cases of Crohn disease and ulcerative colitis occur in patients older than age 65 years. Symptoms of Crohn disease are similar to those in a younger population, although older patients with Crohn disease may have fewer complaints of abdominal pain or cramps possibly because of reduced sensory thresholds or the concurrent use of multiple medications.

Clinical Findings

Symptoms & Signs

Patients typically have a history of nonbloody diarrhea, unintentional weight loss, and fatigue. Evidence of anemia may be present (pallor, shortness of breath, reduced exercise tolerance). Extraintestinal manifestations of Crohn disease, including joint effusions, oral ulcers, painful nodular lesions on the extremities (erythema nodosum), uveitis, and back pain secondary to sacroiliitis, commonly occur. Although Crohn disease may develop anywhere from the mouth to the anus, it is less likely in older patients than in younger patients to involve large portions of the GI tract. The correct diagnosis is often delayed in older patients because symptoms of Crohn disease may mimic other diseases, including infectious diarrhea, ischemic colitis, lactose intolerance, medication-induced diarrhea, diverticulitis, celiac disease, microscopic colitis, and bacterial overgrowth.

Ulcerative colitis (UC) usually presents with tenesmus and frequent bloody bowel movements. Extraintestinal manifestations of UC are similar to those of Crohn disease and also include dermatologic manifestations, such as pyoderma gangrenosum (round or oval lesions on the shins and forearms). Older patients with UC are more likely than younger patients to have limited left-sided disease or proctitis. The first attack of UC in an older patient is generally more severe and more likely to require steroids than that in a younger patient. Of older patients with UC, approximately 15% will eventually require surgery.

Diagnostic Studies

The diagnosis of either UC or Crohn is made based on a thoughtful physical examination and history supplemented by appropriate laboratory studies and colonoscopy. Patients will require endoscopy for definitive diagnosis; however, this should be undertaken with caution in patients with severe colitis because of the risk of perforation. Limited examination with sigmoidoscopy using minimal insufflation may be adequate for diagnosis. Patients should be followed by a gastroenterologist with expertise in treating IBD.

General Principles in Older Adults

Chronic fecal incontinence is the continuous or recurrent uncontrolled passage of fecal material for at least 1 month. Acute and chronic fecal incontinence occur commonly in older patients with comorbid conditions and are often a socially embarrassing and incapacitating problem. Despite its adverse effects on patients, fecal incontinence is underreported by older patients to physicians. The prevalence of fecal incontinence increases with age. Among community-residing people, the prevalence of fecal incontinence in older women is as high as 15%, and in older men 10%. The prevalence is nearly 50% in patients in long-term care. Fecal incontinence is now the second leading cause of nursing home placement in the United States. Up to 7% of the older population has incontinence of solid or liquid stool at least once each week. Fecal incontinence is closely associated with urinary incontinence and constipation (ie, the passage of infrequent, hard, or difficult-to-pass stools). Because overflow fecal incontinence with liquid stool is a common manifestation of constipation, the latter should always be considered in the work-up of fecal incontinence.

Pathogenesis

Fecal incontinence is often a result of fecal impaction caused by constipation; it also can be caused by dysfunction of the internal or external anorectal sphincters. Factors that contribute to the risk of fecal incontinence include disordered muscle integrity, decreased rectal sensation or compliance, declining mental function, and loss of physical mobility. Rectal trauma, pudendal nerve injury, autonomic neuropathies, rectal prolapse, hyperosmolar diets, and fecal impaction are common physiologic factors contributing to incontinence. Aging is associated with neuronal loss and changes in neuromuscular function that may predispose patients to constipation and difficulty with anorectal control. Fecal incontinence can be classified as “passive,” “urgency,” or “fecal leakage.” Patients with passive incontinence complain of leakage of small quantities of liquid or solid stool without awareness. Loss of external sphincter tone and leakage of liquid stool past an obstructing cancer or fecal impaction are common causes. Patients with urgency incontinence have frequent urgency to defecate, followed by passage of small quantities of liquid stool with or without mucus or blood. Urgency incontinence usually implies a loss of rectal compliance, which occurs with inflammatory, infectious, or radiation-induced colitis or stercoral rectal ulcers. Medications, especially opioids and anticholinergic agents, are common causes of constipation, impaction, and incontinence. Acute fecal incontinence may be seen in diarrheal states, and intermittent incontinence is often seen in patients with dementia, delirium, pelvic floor denervation, or excessive laxative use.

Clinical Findings

Symptoms & Signs

The evaluation of fecal incontinence includes a careful review of the patient’s cognitive status, a history of the circumstances of the incontinence episodes, abdominal and neurologic examination, and a rectal examination. Abdominal tenderness, bloating, or distention may indicate a fecal impaction. A careful rectal examination begins with visual inspection for skin irritation, the presence of fecal matter, rectal prolapse, or prolapsing hemorrhoids. The digital examination allows determination of internal and external anal sphincter tone. The rectal examination may occasionally detect structural defects (eg, rectal mass) that might contribute to overflow incontinence. The presence of hard stool in the rectal vault may suggest a fecal impaction; however, a negative rectal examination does not rule out a proximal fecal impaction. With high impactions, x-ray or CT scan of the abdomen may confirm feces. Mental status examination identifies the patient with dementia or delirium who may have lost self-toileting capacity. The absence of anal sphincter tone or anal wink may suggest denervation of the pudendal nerve (S2–4), resulting from a local or spinal cord lesion.

Diagnostic Studies

An abdominal plain film is helpful when fecal impaction is suspected. Acute onset of passive incontinence should prompt examination and spinal imaging to rule out cord compression. In select patients, but rarely in physically frail or bed-bound patients, a rigorous structural and functional evaluation of the anal sphincter with anorectal manometry, anal ultrasonography, defecography, pudendal nerve latency studies, or pelvic magnetic resonance imaging suggests a precise diagnosis^. Other investigations performed by a gastroenterologist that may be helpful include flexible sigmoidoscopy or colonoscopy to look for a mechanical cause of incontinence such as a colonic mass or fistula. Anorectal manometry can objectively measure the resting pressure of the anal canal (predominantly from the internal anal sphincter), tone and contractile pressures of the external anal sphincter, and sensation within the anorectal area. Pudendal nerve testing may be required in some patients.

Treatment

The treatment of fecal impaction includes disimpaction, bowel cleansing, modification of risk factors, and an effective maintenance regimen. Disimpaction should start with manual removal of stool and/or enemas, before administering a polyethylene glycol solution. Amounts of 1 to 2 L may be needed for initial treatment. Avoid magnesium citrate solutions and Fleet Phospho-Soda enemas in patients with underlying cardiac or renal disease, and do not use phosphate-containing oral solutions, as these have been linked to development of phosphate nephropathy. Prevention of recurrent impaction involves risk factor modification including mobilization, good hydration and nutrition, and minimizing use of constipating medications. Scheduled toileting after breakfast may decrease risk of impaction and fecal accidents in demented patients. Add fiber supplements when bowel function has been regularized to regulate bowel habits and prevent constipation. Regular use of a stimulant laxative such as senna or Dulcolax, or use of hyperosmolar solutions such as polyethylene glycol or lactulose, may prevent severe constipation or impaction in high-risk patients. Some high-risk patients require maintenance bowel cleansing with osmotic agents on a weekly basis. The role of diet in the prevention of impaction is unclear. Intermittent use of glycerin or bisacodyl suppositories is warranted if patients have infrequent episodes of constipation. The role of other agents, such as lubiprostone or probiotics, is not clear; however, these could be used as an alternative in patients who are unable to take other laxatives.

If a fissure is contributing to constipation and fecal impaction, conservative therapy with sitz baths, stool softeners, and fiber products usually leads to healing of an acute anal fissure over 1–2 weeks. Topical nitroglycerin, calcium channel blockers, or botulinum toxin injection can be used to treat nonhealing or chronic fissures. Surgical therapy, using lateral internal sphincterotomy, may be necessary in some patients; however, fecal incontinence may develop in 3% to 30% of patients.

General Principles in Older Adults

The colon is more commonly affected by ischemia than the small bowel, because of the high prevalence of silent occlusion of the inferior mesenteric artery (IMA) in older patients (up to 10% of autopsies of persons older than age 80 years). The causes of colonic ischemia (CI) include acute and chronic mesenteric ischemia as a result of IMA thrombus or embolus, congestive heart failure (CHF), cardiac arrhythmias, shock, vasculitis, hematologic disorders, infections, medications (NSAIDs, digitalis, vasopressin, pseudoephedrine, sumatriptan, cocaine, amphetamines, gold), constipation, surgery, and trauma. Abdominal aortic aneurysm repair is a well-known risk for acute CI, with up to 3% of elective repairs and 14% of emergent repair developing CI, usually as a result of superior mesenteric artery (SMA) occlusion. The usual site of ischemic damage is the splenic flexure in the so-called watershed area of the colon primarily supplied by the IMA. Most cases of chronic CI do not have a definitive cause because of the insidious nature of the slow occlusion. The extent of injury can range from mild reversible colopathy to gangrene or fulminant colitis.

Clinical Findings

Symptoms & Signs

Patients with acute CI usually present with crampy lower left quadrant pain and loose, bloody stools. Blood loss significant enough to lead to hemodynamic instability is atypical of CI and suggests other diagnoses. Physical examination often reveals abdominal tenderness of variable severity over the location of the affected portion of bowel. Peritoneal signs may be transiently present in reversible CI; the persistence of these signs for several hours suggests transmural infarction and mandates surgical exploration. Strictures, chronic colitis, gangrene resulting in perforation, and intraabdominal sepsis are complications of CI. Chronic CI may present with diarrhea, left-sided abdominal cramps, and gas or bloating as a result of dysmotility caused by the mismatch of blood supply to demand. Endoscopy may show mild inflammation in the left colon near the splenic flexure, but the mucosa can appear relatively normal if the ischemia is slowly developing. Many patients are asymptomatic and found to have IMA occlusion with extensive collateral blood supply to the affected colon.

Diagnostic Studies

Stool cultures should be obtained to exclude infectious colitis. The patient with suspected CI who does not have peritoneal signs should undergo a careful nonprepared colonoscopy within 48 hours of symptom onset. Patients with peritoneal signs should undergo urgent surgical exploration. CT scans are normal in up to 66% of patients with established CI, but may show colonic thickening, mucosal edema or pericolonic fluid and/or stranding suggestive of inflammation. Angiography using Doppler ultrasound may indicate a SMA occlusion; however, more invasive procedures, such as magnetic resonance angiogram or interventional angiography, often are required. The latter allows treatment with thrombolytics or angioplasty if required.

Treatment

The patient with CI who does not have peritoneal signs should be treated with fluids, bowel rest, and broad-spectrum antibiotics. Underlying CHF or cardiac arrhythmias should be treated and vasoconstricting medications withdrawn. The patients should be monitored closely for fever, leukocytosis, or peritoneal signs. The persistence of peritoneal signs should prompt surgical exploration. Recurrence of CI occurs in only 3% to 10% of patients. Congenital or acquired thrombophilic states may account for a significant percentage of ambulatory patients presenting with CI, and should be tested.

General Principles in Older Adults

Obtaining a complete and accurate history may be difficult in older adults with abdominal pain because of cognitive impairment or sensory deficits that limit communication. At the same time, ability to mount a febrile response and the sensation of pain are limited in older patients in part because of age-related decreases in sensory function and increased use of medications, such as steroids and NSAIDs. Similarly, laboratory values may be spuriously normal in older patients despite the presence of considerable underlying disease. To prevent these factors from delaying diagnosis and treatment in older patients, the physician must use great skill in the medical interview, physical examination, and diagnostic testing.

Clinical Findings

Signs & Symptoms

The history should assess the chronology, character, location, and severity of the pain along with precipitating and alleviating factors. Chronology includes the onset, progression, and duration of pain. Pain of abrupt onset with rapid progression suggests a more aggressive cause. Characterization of the pain may help in diagnosis. Pain may be described as aching (appendicitis, diverticulitis, pelvic inflammatory disease), burning (GERD, perforated peptic ulcer), cramping (small bowel obstruction, biliary colic), boring (pancreatitis), excruciating (acute mesenteric ischemia), or tearing (ruptured abdominal aortic aneurysm). However, older patients may have limited pain or atypical presentations.

Location of the pain can also offer diagnostic clues. Epigastric pain and upper abdominal pain suggest a gastric, hepatobiliary, or pancreatic process. Gastric cancer can present with insidious epigastric pain or dyspepsia, and should be considered in the differential diagnosis of persistent abdominal pain. Liver disease can cause abdominal pain, usually in the RUQ, and in the case of parenchymal diseases such as viral hepatitis or nonalcoholic steatohepatitis (NASH), is a result of stretching of the liver capsule. Biliary disease, particularly gallstone obstruction, should be considered in sudden onset of RUQ pain and nausea. Acute and chronic pancreatitis can occur in older patients, and gallstones should always be looked for as a cause. Unfortunately, pancreatic cancer is also more prevalent in the geriatric age group, and may present with pain and jaundice late in the course of the disease. Midabdominal pain may represent an ileocecal process, whereas hypogastric pain suggests involvement of the colon or genitourinary structures. Shifting location of the pain may represent appendicitis or the development of peritonitis after visceral rupture. Subdiaphragmatic irritation is often referred to the shoulder. Because cardiac disease presents atypically in older adults, any complaints of upper abdominal discomfort by patients with appropriate risk factors should raise the suspicion of coronary disease.

Severe pain in the absence of commensurate physical findings should raise the suspicion of acute mesenteric ischemia. Postprandial pain suggests GUs, mesenteric ischemia, pancreatitis, cholecystitis, or biliary colic. Patients with DUs may report relief of pain with food.

A thorough medication history should be obtained. The use of NSAIDs, steroids, and anticoagulants should be noted. The possibility of drug-induced pancreatitis or hepatotoxicity should be considered.

Absence of fever in older patients should not diminish the suspicion for infection because older patients frequently do not mount an appropriate febrile response to infectious agents. The abdomen should be examined for distension, ecchymoses, abnormal masses, enlarged organs, hernias, and abnormal peristalsis. Hyperperistalsis suggests obstruction or enteritis, whereas hypoperistalsis supports the diagnosis of peritonitis. An abdominal bruit, although neither sensitive nor specific, supports the diagnosis of mesenteric ischemia. The absence of rebound tenderness in older adults should not exclude the possibility of peritonitis. Rectal and genital/pelvic examinations are an essential component of the evaluation.

Diagnostic Tests

A urinalysis and CBC with differential should be ordered with the caveat that older patients may have significant underlying infection with normal white blood cell counts. Serum chemistry analysis provides information regarding fluid status. Amylase, lipase, and a liver chemistry profile are appropriate in the setting of upper abdominal pain, and an abdominal ultrasound should be obtained to check for liver abnormalities, and biliary obstruction caused by stones or neoplasm. Diagnostic tests should be ordered based on the findings of the history, physical examination, and laboratory evaluation. A set of supine and upright plain abdominal films is useful in identifying obstruction, radiopaque gallstones, or a calcified pancreas. An upright chest x-ray film should be obtained to check for air under the diaphragm. Suspected hepatobiliary or pancreatic disease should be investigated by ultrasonography or CT scan. CT scanning is useful in demonstrating appendicitis, diverticulitis, bowel obstruction, retroperitoneal hemorrhage, and mesenteric lymph node enlargement, as well as hepatobiliary, pancreatic disease and cancer. Carcinoembryonic antigen (CEA) levels may be elevated in patients with GI cancer, although this is not sensitive enough to use as a screening test. Endoscopy should be performed, and biopsies of the stomach and colon taken to check for MALT (mucosal-associated lymphoid tissue) lymphoma and H. pylori infection. Patients suspected of having acute mesenteric ischemia should have prompt selective mesenteric angiography.