The document discusses GI and liver problems commonly seen in elderly patients and how management may differ. Physiologic declines with aging can impact the GI tract indirectly by increasing other medical issues. Common GI problems include swallowing difficulties, constipation, weight loss, and anemia. Liver disease progression may be faster in elderly due to reduced regenerative ability and increased susceptibility to injury from medications. Careful evaluation and treatment of underlying conditions is important when managing GI and liver issues in elderly patients.

1. Title
Speaker
GI/Liver problems in elderly
patients - How should we
manage them differently?
Speaker: Dr Loh Poh Yen
Gastroenterologist

2. Physiology in elderly
• Aging causes physiologic declines in the body
systems including immunologic, neurologic, and
metabolic systems

4. • Aging appears to have less direct effect on most GI
functions
• Mostly due to other contributing factors
• multiple comorbidities
• Medications
• Effects of medications eg opiods, NSAIDs, antiplatelets
• Increased SE due to reduced excretory function, eg
renal disease or chronic liver disease

5. Common GI issues in the elderly
• Swallowing difficulty/ dysphagia
• Constipation
• Weight loss
• Anemia
• Drug induced liver injury

6. Swallowing difficulty/dysphagia

7. Swallowing difficulty/dysphagia
• 35% to 68% of people aged 65 years and older have
some degree of swallowing dysfunction
• healthy elderly patients exhibited significant changes in
esophageal peristalsis and delayed esophageal emptying
when compared to younger age groups
• may be explained by loss of intrinsic enteric neurons
E. Ferriolli European Journal of Gastroenterology & Hepatology 1996

10. Types of dysphagia
• Oropharyngeal dysphagia
• Esophageal dysphagia

11. Oropharyngeal dysphagia
• Difficulty initiating swallowing due to desynchronization of
swallowing response which coordinates the tongue, pharynx, and
upper esophageal sphincter (UES).
• Medical conditions eg dementia, stroke, and Parkinson's disease
• symptoms
• food sticking in the throat
• coughing during swallowing
• nasal regurgitation
• aspiration

12. Esophageal dysphagia
• symptoms
• food or liquid sticking in the chest
• reflux symptoms
• Causes
• mechanical obstruction (stricture, tumor)
• compression from surrounding tissues (vascular compression or
mediastinal masses)
• neuromuscular causes (achalasia, scleroderma, diffuse esophageal
spasm)
• inflammatory and infectious causes (eosinophilic esophagitis,
candidiasis)

13. complications of dysphagia
• aspiration pneumonia
• Malnutrition
• dehydration

14. Investigations
• OGD
• Videofluoroscopic swallow study
(VFSS)
• High resolution esophageal
manometry (HRM)

15. Treatment of dysphagia
• Thorough chewing, good dental health, properly fitting
dentures, eating slowly, and sitting upright while
eating
• speech therapist rehabilitation

16. • Treatment of underlying cause eg
balloon dilation for achalasia
• NG tube feeding
• percutaneous endoscopic
gastrostomy (PEG)

17. Pill esophagitis
• Symptoms:
• retrosternal chest pain (71.8%)
• odynophagia (38.5%)
• OGD findings: ulceration (80%) ,
kissing ulcers (42%)

18. Pill esophagitis
• decrease in esophageal motility
• increases medication contact with esophageal
mucosa
• harmful effects of medication cause inflammation of
the esophagus

20. • Contributing factors
• Polypharmacy
• taking medication with insufficient amounts of water
• Cardiomegaly
20

21. Prevention of pill esophagitis
• Generous amount of water
• avoid lying down for at least 30 minutes after
administration

22. Constipation

23. Constipation
• 35% of patients above the age of 65 years have constipation
• Rome IV criteria (functional constipation), any two of the
following features
• straining
• lumpy hard stools
• sensation of incomplete evacuation
• use of digital maneuvers
• sensation of anorectal obstruction or blockage with 25 percent of
bowel movements
• decrease in stool frequency (less than three bowel movements per
week)

24. • Colonic transit in the elderly does not seem to differ from
earlier years
• Contributing causes:
• decreased mobility
• dietary changes and inadequate water intake
• cognitive impairment
• comorbid medical problems eg diabetes, stroke, hypothyroidism,
and Parkinson
• polypharmacy eg opioid, anticholinergic, iron
• Organic causes

26. stool impaction
• Symptoms:
• Constipation
• abdominal pain
• diarrhea, fecal incontinence
• urinary symptoms
• can lead to stercoral ulceration
and colonic perforation
• Risk factors: reduced rectal
sensation, limited mobility,
weakness, and dementia

27. Types of constipation
• Normal transit constipation
• Slow transit constipation
• Anorectal dysfunction
(inefficient coordination between
pelvic musculature and evacuation
mechanism)

28. Investigations
• Colonic transit study
• Anorectal manometry
• Colonoscopy (recent onset of
constipation, warning symptoms
such as gastrointestinal bleeding)

29. Constipation Treatments
• Check the medication side effects
• Stay active
• Eat more fiber and drink more water
• Medications
• stool softeners and osmotic laxatives
• Stimulant laxatives (short-term therapy)
• colonic secretagogues eg lubiprostone (chloride channel stimulation)
• 5HT4 receptor agonist eg prucalopride
• Suppositories and enemas
• Bio feedback for anorectal dysfunction

30. Weight loss

31. weight loss
• Protein-energy malnutrition
• 15% of community-dwelling elderly people
• 5%–85% of institutionalized older patients
• Associated with increased mortality, hospital lengths
of stay, and costs associated with malnutrition

33. • The major problem comes from reduced oral intake
of food
• The enzymes secretion and absorptive function of
the small intestine in older adults is not significantly
different in comparison to younger counterparts

34. Inadequate calorie intake
• changes in ingestion eg dental problems, dry mouth,
changes in taste and smell
• Cognitive impairment
• Socioeconomic factor
• Type of diet

35. 35

36. SIBO
• prevalence of SIBO in elderly
• 15.6% compared to 5.9% in younger age groups
• slower motility of small intestine
• Medications, polypharmacy
• Comorbidities eg diabetes, chronic atrophic gastritis
• structural lesions eg adhesions, strictures, diverticula,
bypass
A. Parlesak Journal of the American Geriatrics Society 2003

37. SIBO
• associated with chronic diarrhea, malabsorption,
weight loss, and secondary nutritional deficiencies
• More commonly causes vague and subtle symptoms,
such as bloating and nonspecific abdominal
discomfort

38. Investigations
• Direct culture of small bowel contents
• presence of greater than 100,000 colony-forming units
• hydrogen breath testing

40. Anemia

42. Age related causes of GI bleeding
in elderly
• Medications eg NSAIDs, antiplatelets, anticoagulants
• diverticular bleed (prevalence of diverticular disease
70% at age 80)
• Angiodysplasia
• Mesenteric ischemia
• ischemic colitis
• Cancer – can be prevented by CRC screening

43. Liver disease in the elderly

44. Liver changes in the elderly

45. LFT
• Not much changes
• serum aminotransferase maintains the normal level
• serum bilirubin is gradually reduced

46. • No liver disease is specific to old age
• More susceptible to liver injury by causes of liver disease
• cellular responses to injury
• increased oxidative stress
• increased inflammatory response
• accelerated cellular senescence
• decreased regenerative ability

47. • NAFLD
• elderly > 65 years reported higher NASH prevalence rate
than their younger counterparts (72 vs 56 %) and also
displayed a higher fibrosis rate
Noureddin M Hepatology. 2013
• Hepatitis C
• time of infection at older age has been associated with
more rapid fibrotic progression and hepatocarcinogenesis
Poynard T J Hepatol. 2001

48. Drug metabolism
• drug metabolism is reduced by up to 30% after 70
years of age
• Reduced first pass metabolism
• Reduced cytochrome P450 activity
• increase susceptibility to drug-induced liver injury
(DILI)
• More cholestatic type of liver injury in elderly
• > 65 years (46%) vs < 65 years (31.6%)

49. • Avoid polypharmacy
• Elderly patients > 75 years with DILI were taking
significantly more concomitant drugs at the time of liver
injury
Onji M Hepatol Res 2009

50. Summary
• aging has little direct clinical effect on most
gastrointestinal functions due to large functional
reserve capacity of GI tract
• Identify and treat underlying comorbidities and
check medication side effects
• Look for liver disease in the elderly due to the
faster progression of liver damage

51. THANK YOU
Email:
gutcarecme@gmail.com