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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 H pylori when indicated.
Ascertain the mechanisms that ensure proper use of proton pump inhibitors (PPI) in preventing PUD and UGIB with appropriate discontinuation of PPI therapy when not needed, making use of good clinical practice guidelines including multidimensional approach and noninvasive gastric function tests.
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Key Clinical Points
GERD is common in older adults with an incidence of 5 per 1000 person years in the United Kingdom and United States. Symptoms may not 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.
The prevalence of PUD increases with age, likely due to H pylori infection, use of mucosa-damaging drugs, and an imbalance between mucosal erosive and protective factors. Treatment of H pylori reduces PUD relapse, but many older adults go untested and untreated. H pylori eradication after treatment should be documented with a breath test or stool antigen.
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.
PPIs interact with many drugs prescribed for older adults, and long-term PPI use has been associated with multiple adverse outcomes, especially in frail older adults. Thus, long-term PPI use should be avoided unless there are clear indications, and deprescription should be enacted whenever possible.
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Upper gastrointestinal disorders (UGIDs) are highly prevalent in the aging population and may influence greatly nutrition, general well-being, and quality of life of older people. This chapter discusses the pathophysiology, clinical features, diagnostic approaches, and treatments of UGIDs, focusing on gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD) including considerations on Helicobacter pylori infection and its eradication, and upper gastrointestinal bleeding (UGIB). Particular attention is given to pharmacology of UGIDs, both as a causal mechanism, as in the use of nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination with anticoagulants/antiplatelet agents, but also in the treatment of acid-related disorders. Special attention is given to situations when deprescription of widely used antisecretory drugs, mainly proton pump inhibitors, is warranted. UGIDs may present insidiously in older adults, who often have nonspecific symptoms, independently of whether esophageal and/or gastroduodenal lesions are demonstrated on instrumental diagnostic evaluations. Since UGIDs often require an interdisciplinary approach including endoscopists, radiologists, gastroenterologists, and surgeons, scenarios when referral to a specialist is recommended are also described.
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GASTROESOPHAGEAL REFLUX DISEASE
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