Sita Chokhavatia

Fecal Incontinence in the Elderly: FAQ

Fecal incontinence (FI) is a common gastrointestinal (GI) complaint in patients aged 65 years and older. This evidence-based review article discusses the epidemiology, pathophysiology, evaluation, and management of FI in the geriatric population. We emphasize aging-related changes leading to and impacting evaluation and treatment of this symptom while incorporating the core geriatric principles of functional status and management aligned with patient preference and goals of care.

Constipation in Elderly Patients with Noncancer Pain: Focus on Opioid-Induced Constipation

Constipation is a common and often debilitating condition in the elderly, which may be caused by underlying disease conditions, structural abnormalities in the bowel, and a variety of medications such as anticholinergics, antidepressants, and opiates. In this review, we focus on opioid-induced constipation (OIC), which is often underrecognized and undertreated in the elderly. When opioid therapy is initiated, healthcare providers are encouraged to evaluate risk factors for the development of constipation as part of a thorough patient history. To this end, the patient assessment should include the use of validated instruments, such as the Bristol Stool Scale and Bowel Function Index, to confirm the diagnosis and provide a basis for evaluating treatment outcomes. Healthcare providers should use a stepwise approach to the treatment of OIC in the elderly. Conventional laxatives are a first-line option and considered well tolerated with short-term use as needed; however, evidence is lacking to support their effectiveness in OIC. Moreover, because of the risk of adverse events and other considerations, such as chewing difficulties and swallowing disorders, conventional oral laxatives may be inappropriate for the treatment of OIC in the elderly. Thus, the availability of new pharmacologic agents such as the peripherally acting µ-opioid receptor antagonists methylnaltrexone and naloxegol, which target the underlying causes of OIC, and the secretagogue lubiprostone may provide more effective treatment options for elderly patients with OIC.

Management of Inflammatory Bowel Disease in the Elderly

Opinion StatementA substantial and growing proportion of patients with inflammatory bowel disease (IBD) are elderly, and these patients require tailored treatment strategies. However, significant challenges exist in the management of this population due to the paucity of data. Establishing the initial diagnosis and assessing the etiology of future symptoms and flares can be challenging as several other prevalent diseases can masquerade as IBD, such as ischemic colitis, diverticular disease, and infectious colitis. Important pharmacologic considerations include reduced glomerular filtration rate and drug-drug interactions in the elderly. No drug therapy is absolutely contraindicated in this population; however, special risk and benefit assessments should be made. Older patients are more susceptible to side effects of steroids such as delirium, fractures, and cataracts. Budesonide can be an appropriate alternative for mild to moderate ulcerative colitis (UC) or Crohn’s disease (CD) as it has limited systemic absorption. Pill size and quantity, nephrotoxicity, and difficulty of administration of rectal preparations should be considered with 5-aminosalicylic (5-ASA) therapy. Biologics are very effective, but modestly increase the risk of infection in a susceptible group. Based on their mechanisms, integrin receptor antagonists (e.g., vedolizumab) may reduce these risks. Use of antibiotics for anorectal or fistulizing CD or pouchitis in UC increases the risk of Clostridium difficile infection. Pre-existing comorbidities, functional status, and nutrition are important indicators of surgical outcomes. Morbidity and mortality are increased among IBD patients undergoing surgery, often due to postoperative complications or sepsis. Elderly adults with IBD, particularly UC, have very high rates of venous thromboembolism (VTE). Colonoscopy appears safe, but the optimal surveillance interval has not been well defined. Should the octogenarian, nonagenarian, and centurion undergo colonoscopy? The length of surveillance should likely account for the individual’s overall life expectancy. Specific health maintenance should emphasize administering non-live vaccines to patients on thiopurines or biologics and regular skin exams for those on thiopurines. Smoking cessation is crucial to overall health and response to medical therapy, even among UC patients. This article will review management of IBD in the elderly.

Review of gastroesophageal reflux disease (GERD) in the diabetic patient.

This article reviews the known pathophysiological mechanisms of comorbid gastroesophageal reflux disease (GERD) in the diabetic patient, discusses therapeutic options in care, and provides an approach to its evaluation and management. We searched for review articles published in the past 10 years through a PubMed search using the filters diabetes mellitus, GERD, pathophysiology, and management. The search only yielded a handful of articles, so we independently included relevant studies from these review articles along with related citations as suggested by PubMed. We found diabetic patients are more prone to developing GERD and may present with atypical manifestations. A number of mechanisms have been proposed to elucidate the connection between these two diseases. Studies involving treatment options for comorbid disease suggest conflicting drug–drug interactions. Currently, there are no published guidelines specifically for the evaluation and management of GERD in the diabetic patient. Although there are several proposed mechanisms for the higher prevalence of GERD in the diabetic patient, this complex interrelationship requires further research. Understanding the pathophysiology will help direct diagnostic evaluation. In our review, we propose a management algorithm for GERD in the diabetic patient.

Targeting Small Bowel Receptors to Treat Constipation and Diarrhea

BackgroundThe options for the treatment of diarrhea and constipation are evolving as emerging therapies target small bowel receptors. The goal of this review is to discuss small bowel receptors involved in intestinal absorption, secretion, and motility. The review highlights therapies already approved or currently being studied for the modulation of these receptors.MethodsThe articles cited in this review focus on the molecular level of pathways involved in diarrhea and constipation, and highlight the respective pharmacotherapies.ResultsThe majority of the studies in the current literature investigate the effects of both the small and large intestine receptors on diarrhea and constipation. There are fewer studies that isolate the effects of these receptors solely on the small bowel, and focusing more on the receptors found distinctly in the small intestine may be an area of interest for future studies as this can inspire more targeted therapies.

Investigator-Initiated Trials (IITs)—A Primer for Physician Researchers for Conducting IITs

Nonclinical (including in vitro , preclinical, and other) and clinical are the two major categories of investigational studies in drug development. Clinical trials may be sponsored by pharmaceutical, biotech, or medical device companies (industry-sponsored trials); by government, academic, or

Esophageal Pathology: A Brief Guide and Atlas

This article contains a brief atlas for esophageal dysphagia, with an emphasis on endoscopic evaluation. Dysphagia refers to an abnormality with food propulsion, and it may be caused by oropharyngeal or esophageal disorders. Radiological modalities, endoscopy, and manometry play an important role in both the diagnosis and management of esophageal disorders.

Sodium polystyrene induced colonic perforation unmasked after flexible sigmoidoscopy

77 years old female with CAD, CVA, and polycystic kidney disease was admitted for 2 weeks of abdominal pain and 20 lb weight loss with anorexia over 6 months. Three weeks prior to this admission, she was given stool softeners for constipation. Subsequently, she had diarrhea and developed sharp left lower quadrant abdominal pain radiating to her back; associated with nausea and bilious vomiting. She also had 1 week of fevers up to 100°F which dissipated upon admission. Physical exam revealed normoactive bowel sounds and left lower quadrant tenderness without rebound or guarding. Lab data: hemoglobin 9.0 gm/dl, white count 9.2 k/cu mm, BUN 52 mg/dl and creatinine 2.6 mg/dl, bicarbonate 14 mmol/liter and lactate 0.5 mmol/liter. A CT scan of the abdomen revealed large tumor involving the sigmoid colon, sigmoid diverticula, polycystic kidneys, and small pericardial effusion. Empiric antibiotics (levofloxacin and metronidazole) were given. During hospitalization, she developed K+ 5.1 mg/dl for which she received a dose of oral sodium polystyrene (SPS). Flexible-sigmoidoscopy up to 35 cm from the anal verge revealed multiple diverticula and edematous and erythematous folds from 15 cm to 20 cm (biopsy showed acute colitis with focal non-necrotizing granulomas). Immediately post-sigmoidoscopy, she developed distended, tympanic abdomen and became tachycardic. An abdominal x-ray revealed free air and she underwent emergency exploratory laparotomy. The left colon was rock hard and the right colon was dusky with gross fecal soilage from cecal perforation. A right hemicolectomy was performed along with an abdominal wash out. Pathological examination revealed acute ischemic perforation of cecum with SPS crystals noted within the feces and in the perforation tract. She continued to deteriorate and expired one week later.