Esophageal disorders in the elderly

Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia.

METHODS

We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively.

RESULTS

The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux.

CONCLUSION

PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.

Videofluoroscopy and oropharyngeal manometry for evaluation of swallowing in elderly patients

Presbyphagia represents the physiological aging evolution of the swallowing function. It is related to the natural changes of the anatomical structures involved in the swallowing process. These age-related modifications can be asymptomatic in the early stages of life, but in the late stages, they could lead to dysphagia, aspiration pneumonia, dehydration, or malnutrition, reducing the quality of life. Videofluoromanometry (VFM) is the combined study of videofluoroscopy (VFS) and oropharyngeal manometry that allows simultaneous identification of functional and morphological features of the presbyphagia, also in asymptomatic otherwise healthy elderly adults. This study retrospectively evaluated the effectiveness of the VFM and the role of a multidisciplinary team of specialists in the analysis of a large cohort of old patients with presbyphagia, with the objective of achieving early diagnosis of the disease and the best therapy to delay the development of complications such as aspiration pneumonia, malnutrition, and dehydration.

The ageing gastrointestinal tract

PURPOSE OF REVIEW

This article reviews the impact of ageing on the gastrointestinal tract, including effects on the absorption of nutrients and drugs and the gastrointestinal tract defence system against ingested pathogens.

RECENT FINDINGS

Recent publications support earlier observations of an age-related selective decline in gut function including changes in taste, oesophageal sphincter motility, gastric emptying, and neurons of the myenteric plexus related to gut transit which may impact the nutritional status. Ageing is also associated with structural and functional mucosal defence defects, diminished abilities to generate protective immunity, and increased incidence of inflammation and oxidative stress. A number of gastrointestinal disorders occur more frequently in the elderly population.

SUMMARY

Alterations in gut function with ageing have particular implications for oesophageal, gastric, and colonic motility. Older individuals are particularly susceptible to malnutrition, postprandial hypotension, dysphagia, constipation, and faecal incontinence. Decrease in the number of nerve cells of the myenteric plexus that impact digestive absorption and the surface area of the small intestine because of degeneration of villi may lead to blunted absorption of nutrients. Impairment of the intestinal immune system as a result of ageing, including the mucosal layer of the gastrointestinal tract, appears to be a significant contributor to the age-related increase in the incidence and severity of infections.

Effect of aging on hypopharyngeal safe volume and the aerodigestive reflexes protecting the airways

OBJECTIVES/HYPOTHESIS

Studies on young volunteers have shown that aerodigestive reflexes are triggered before the maximum volume of fluid that can safely collect in the hypopharynx before spilling into the larynx is exceeded (hypopharyngeal safe volume [HPSV]). The objective of this study was to determine the influence of aging on HPSV and pharyngo-glottal closure reflex (PGCR), pharyngo-UES contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS).

STUDY DESIGN

Comparison between two groups of different age ranges.

METHODS

Ten young (25 ± 3 standard deviation [SD] years) and 10 elderly (77 ± 3 SD years) subjects were studied. PGCR, PUCR, and RPS were elicited by perfusing water into the pharynx rapidly and slowly. HPSV was determined by abolishing RPS with pharyngeal anesthesia.

RESULTS

Frequency-elicitation of PGCR and PUCR were significantly lower in the elderly compared to the young during slow water perfusion (47% vs. 97% and 40% vs. 90%, respectively, P < .001). RPS was absent in five of the 30 (17%) slow injections in the elderly group. In these elderly subjects, HPSV was exceeded and laryngeal penetration of the water was seen. The threshold volume to elicit PGCR, PUCR, and RPS was significantly lower than the HPSV during rapid injections. Except for RPS, these volumes were also significantly lower than HPSV during slow injections.

CONCLUSIONS

PGCR, PUCR, and RPS reflexes are triggered at a threshold volume significantly lower than the HPSV in both young and elderly subjects. Lower frequency-elicitation of PGCR, PUCR, and RPS in the elderly can predispose them to the risks of aspiration.

Identification of impaired oesophageal bolus transit and clearance by secondary peristalsis in patients with non-obstructive dysphagia

Impaired secondary peristalsis has been shown in non-obstructive dysphagia (NOD). The relationship between such changes and alterations in bolus transport has not been studied. The aim of this study was to evaluate the integrity and characteristics of oesophageal bolus transit by secondary peristalsis in NOD patients with multichannel intraluminal impedance (MII). Eleven healthy volunteers and 10 consecutive patients underwent combined MII recording and manometry. Secondary peristalsis was stimulated by mid-oesophageal injections of saline. Values for bolus presence time at each of the recording sites and bolus transit time were calculated. Bolus transit was considered to be complete when impedance defined complete bolus clearance at all recording sites. Secondary peristaltic responses were triggered significantly less frequently in patients with NOD than in controls (P < 0.001). The proportion of secondary peristalsis demonstrating complete bolus transit was lower in NOD patients than in controls (P < 0.001). Oesophageal bolus transit time by secondary peristalsis was longer in NOD patients than in controls (P = 0.005), as was bolus presence time at each of the recording sites (P < 0.05). When compared with controls, NOD patients demonstrated a higher proportion of incomplete bolus transit in response to normal secondary peristalsis (P < 0.001). Abnormal bolus transit occurred more often associated with ineffective and synchronous responses than normal responses in both groups studied (P < 0.001). Multichannel intraluminal impedance identifies functional defects of oesophageal bolus clearance by secondary peristalsis in NOD patients and such defects are characterized by a longer oesophageal dwell and a prolonged clearance time.

Esophagitis in frail elderly people

INTRODUCTION

We studied the clinical course of elderly patients acutely hospitalized for various diseases, assessing any differences between patients with and without esophagitis.

STUDY

A case-control study on the presence of esophagitis was conducted on the clinical records of all in-patients undergoing gastroduodenoscopy at Padova Geriatric Hospital from 1997 to 2001. Data were examined on 338 sex-matched patients: 169 with a diagnosis of esophagitis and 169 with a negative endoscopy.

RESULTS

Admissions for acute respiratory disorders [odds ratios (OR) 2.68; 95% confidence interval (CI) 0.89-8.01], a remote diagnosis of esophagitis (OR 11.34; 95%CI 2.68-48.07), obesity (OR 3.36; 95%CI 0.91-12.48), and being bedridden (OR 6.84; 95%CI 3.27-14.29) were found to be independent risk factors for the presence of esophagitis. The symptoms prompting the endoscopic diagnoses included: gastrointestinal bleeding (OR 7.61; 95%CI 2.76-21.0), heartburn (OR 4.58; 95%CI 1.86-11.28), and cough (OR 3.59; 95%CI 1.34-9.62). Steroids (OR 2.68; 95%CI 1.11-6.44) and calcium antagonists (OR 1.50; 95%CI 0.79-2.87) were associated with esophagitis as risk factors, whereas proton pump inhibitors (OR 0.46; 95%CI 0.25-0.87), nitrates (OR 0.14; 95%CI 0.02-0.78), and sucralfate in males (OR 0.09; 95%CI 0.01-0.92) were associated as protective factors. Patients with esophagitis were discharged with an endocrinologic/metabolic-type diagnosis. Deaths were significantly higher among patients with esophagitis (25 vs. 9); more severe esophagitis was characterized by a higher Charlson comorbidity index and a greater presence of anorexia and nausea.

CONCLUSIONS

These findings seem to substantiate the theory that esophagitis is a characteristic which exacerbates frailty in hospitalized elderly people and its identification may be helpful in these patients.

Ageing and the gut

The current concepts on diagnosis, clinical features, and management of common gastrointestinal conditions in the elderly population, taking into account physiological aspects of ageing, are evaluated. Gastrointestinal (GI) disorders are discussed with an emphasis on oesophageal problems, Helicobacter pylori infection, malabsorption, diverticular disease, and cancer. GI problems are acquiring greater importance in hospitals and in the community and their incidence is increasing. Newer treatments have less impact on patients' wellbeing and meticulously planned investigation and treatment is needed. Careful selection of patients and application of modern techniques has improved survival and outcomes, with comparable results to those in younger age groups.

Age-related neurodegenerative changes and how they affect the gut

The enteric nervous system (ENS) is the division of the autonomic nervous system that regulates gastrointestinal (GI) function. Although large numbers of enteric neurons may be lost with age, the GI tract remains surprisingly functional. Exceptions to this generality include swallowing disorders and reduced colonic motility in the elderly. Evidence of age-related neurodegenerative changes in structure and function of the ENS is briefly reviewed in this Perspective.

Aging, the gastrointestinal tract, and risk of acid-related disease

It is estimated that by 2020, >16% of people in the United States will be > or =65 years of age and that nearly 20 million will be >85 years of age. Aging imparts a variety of physiologic changes in the oropharynx, esophagus, and stomach that increase the risk for esophageal and gastrointestinal disorders. Older individuals also tend to have a higher prevalence of comorbid factors, such as Helicobacter pylori infection, smoking, presence of other diseases, or use of medications (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs]) that increase their risk for acid-related disorders. Given these physiologic and comorbidity factors, the elderly are at higher risk for gastroesophageal reflux disease (GERD), pill-induced esophagitis, peptic ulcer disease, and complications related to the use of NSAIDs. Unfortunately, in the elderly patient with these disorders--even those with severe disease or complications--symptom presentation may be subtle or atypical, resulting in a delayed diagnosis. Endoscopy remains the "gold standard" for the identification of mucosal disease and should be performed in all patients with "new-onset" or persistent symptoms who are >45 years of age, as well as in individuals of any age who present with alarm symptoms, such as weight loss, vomiting, anemia, dysphagia, or evidence of gastrointestinal bleeding. In general, the treatment of older individuals with peptic ulcer or GERD and its complications is similar to that of younger individuals. Proton pump inhibitors are the mainstay of therapy for symptom relief, healing of erosive esophagitis, resolution of peptic ulceration, reduction of the risk for NSAID-induced mucosal damage, and prevention of disease recurrence.

Heartburn severity underestimates erosive esophagitis severity in elderly patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Gastroesophageal reflux disease is common in adults of all ages, but its complications are more frequent in elderly patients. Although heartburn is the most common symptom of reflux disease, it is unclear whether the severity of heartburn reliably indicates the severity of erosive esophagitis. We therefore assessed the relationship between age, severe heartburn symptoms, and severe erosive esophagitis.

METHODS

This post hoc analysis of baseline data on the severity of both heartburn and erosive esophagitis pooled data from 5 prospective, randomized, controlled clinical trials that assessed the effect of proton pump inhibitors on healing of erosive esophagitis and symptom resolution. The clinical trials were conducted in 683 private and academic offices and hospital-based gastroenterology practices and involved 11,945 patients aged 18 years and older with gastroesophageal reflux disease and erosive esophagitis.

RESULTS

A progressive increase in the prevalence of severe erosive esophagitis was observed with each decade of age, ranging from 12% in patients aged <21 years to 37% in patients aged >70 years. Among patients with severe esophagitis, severe heartburn was less frequent in the older age groups: ranging from 82% of patients aged <21 years to 34% of those aged >70 years. Each of these associations was statistically significant (P < 0.001).

CONCLUSIONS

Although the prevalence of severe erosive esophagitis increases with age, the severity of heartburn is an unreliable indicator of the severity of erosive disease. More aggressive investigation and treatment may be necessary for elderly patients, regardless of the reported severity of heartburn.

Lung infections and aging

Respiratory tract infections are the leading cause of death due to infectious disease in the elderly. Many factors, especially waning immune responses and the onset of age-associated organ dysfunction, likely account for an increase in susceptibility to respiratory tract infection in the elderly, and morbidity and mortality rates are substantially greater for the elderly when outcomes are compared to that of younger individuals. The presence of underlying disease states such as chronic obstructive pulmonary disease (COPD) or other organ system disease further increases the likelihood of developing severe pneumonia in the elderly population, and the frail elderly, particularly when institutionalized in chronic care facilities, are at high risk for developing severe and recurrent pneumonia. This article will discuss various factors associated with advanced age that predispose the elderly to respiratory infections and summarize current approaches to treatment and prevention.

Medical management of nocturnal symptoms of gastro-oesophageal reflux disease in the elderly

Elderly patients with nocturnal symptoms of gastro-oesophageal reflux disease (GORD) usually experience a more aggressive and complicated disease course compared with younger patients, resulting in impaired quality of life. The severity of disease and possible complications should be evaluated with upper endoscopy once the diagnosis is suspected. Elderly patients with nocturnal symptoms of GORD and evidence of endoscopic complications (oesophagitis, Barrett's oesophagus, etc.) and those with severe endoscopically negative reflux disease (ENRD) should be treated with proton pump inhibitors. Histamine H(2) receptor antagonists are suitable for mild-to-moderate ENRD. Antacids and lifestyle modifications may be incorporated into the management as adjuncts to more potent and durable therapeutic agents. Effective treatment of nocturnal GORD symptoms in the elderly will result in relief of symptoms, healing of oesophagitis and improved quality of life, and should be maintained indefinitely to prevent relapses of the disease.

Dysphagia: evaluation and treatment

The evaluation of dysphagia begins with a careful history, which usually points to the underlying cause in up to 80% of cases. The goals of the history are to distinguish oropharyngeal causes from esophageal causes of dysphagia and to distinguish mechanical from motor disorders of the esophagus in those patients with esophageal dysphagia. Evaluation typically begins with a videofluoroscopic examination in patients with oropharyngeal dysphagia and begins with a routine barium swallow or upper GI endoscopy in patients with esophageal dysphagia. Esophageal manometry may be an adjunct to the evaluation of patients with esophageal dysphagia, particularly to confirm specific motor disorders, such as achalasia. The management of functional causes of dysphagia is supportive and empiric given the lack of well-controlled treatment studies in this heterogenous group of patients.

Gastrointestinal diseases in the elderly

PURPOSE OF REVIEW

The subject of gastrointestinal disorders in the elderly is timely and important because of the demographic reality that soon over 20% of our population will be older than 65 years of age, utilizing perhaps 50% of our total healthcare costs. The purpose of this review is to draw attention to some areas of clinical information that point in the direction of better clinical care for the elderly. Medicine is finally advancing from the era when most symptoms in older patients were ascribed to the aging process itself. Indeed, within gastroenterology there are few changes that occur inevitably as part of aging.

RECENT FINDINGS

Progress has been made in several areas of gastrointestinal pathophysiology. These include: the pathophysiology of swallowing and evacuation disorders and the beginning of the application of techniques derived from physiological studies to improve function; recognizing the importance of reflux esophagitis and its complications and improving treatment; understanding the importance of disorders of malabsorption and their impact upon nutrition in the elderly; major issues in the diagnosis and management of inflammatory bowel disease in this age group; and approaches to the prevention and treatment of gastrointestinal cancer, particularly colorectal cancer.

SUMMARY

As we pay more attention to these areas and encourage clinical research we expect to improve the treatment of older patients with these diseases and to reduce the burden of morbidity in this population.

Aging and neural control of the GI tract: IV. Clinical and physiological aspects of gastrointestinal motility and aging

The gastrointestinal motility changes that occur as a function of age are reviewed herein. Careful attention must be given in any review of aging phenomena to exclude, or at least be cognizant of, the many comorbid conditions that can alter physiological functioning in older adults. The dramatic increase in life expectancy over the past 10-15 years demands that clinicians be aware of the various physiological and clinically relevant changes that occur with age. Gastrointestinal motility changes associated with age are relatively subtle, and in many instances only conflicting data exist. As the older adult population increases, and as the control of disease is improved, much more work needs to be done to understand the true effects of aging on gastrointestinal functioning.

Aging and neural control of the GI tract. II. Neural control of the aging gut: can an old dog learn new tricks?

There has been a dramatic increase in funding available for aging research, primarily due to the fact that answers to questions on aging are likely to have a major impact on the well-being and healthy aging of the world's population for decades to come. The incidence of certain gastrointestinal problems, such as dysphagia and constipation, increases dramatically with age. Changes in gastrointestinal neuromuscular function with aging have been demonstrated in both human and animal models of aging. This article focuses on recent advances in our knowledge of the effects of aging on gastrointestinal function, treatment options, and future opportunities for research.