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Loss of Appetite
Loss of Bowel Control
Peptic Ulcer Disease
Colon and Rectal Cancers
Hemorrhoids and Other Rectal Problems
The digestive system consists of one continuous tube from the mouth to the rectum (see Figure 35). Its basic role is to digest and absorb food so that it can be converted into energy. On the whole, the digestive system shows fewer age-related changes in function than most of the other organ systems. The lining cells of the gut maintain an extraordinary capacity to reproduce themselves and to absorb nutrients efficiently.
Older people experience the same bowel and digestive symptoms and conditions that younger people do. The effects of stress often lead to gastrointestinal symptoms. Constipation and diverticular disease are associated with aging, but generally digestive problems do not begin in old age. However, gastrointestinal malignancies occur more commonly in elderly people, and any change in bowel or digestive function warrants further evaluation.
Abdominal pain is a challenging condition to evaluate because it can be a sign of a serious illness or a relatively minor problem. Abdominal pain with bleeding or that becomes progressively worse can be a medical or surgical emergency.
Any of the structures in the lower chest, abdomen, or pelvis can cause abdominal pain. The location of the pain may not always indicate the location of the problem (see Figure 36). For example, stomach problems may cause pain in the middle of the upper abdomen; gallbladder and liver problems cause discomfort in the upper right side of the abdomen; the appendix in the lower right side. The nature of the discomfort can help identify the cause. Pain from the bowel or gallbladder tends to be sharp and intermittent like a gas pain. Pain caused by other structures tends to be more constant. Relatively common causes of progressive pain include a gallbladder attack; severe infection involving the gallbladder or liver; obstruction of the bowel; a twisting of the bowel, called volvulus; an infection within the abdominal cavity due to a hole (perforation) in the large intestine. Inadequate circulation of blood in the bowel or gastrointestinal tract can produce severe pain.
Severe abdominal pain can also be caused by a variety of problems not involving the digestive system, for example, heart attack, shingles, kidney infection, and an expanding (or tearing) abdominal aortic aneurysm. These conditions are discussed elsewhere.
Older people with abdominal pain and bleeding, fever, or any change in function require urgent medical attention. Although there is a mortality rate of 15 to 50 percent for emergency surgery in such cases, the survival rate is not related to age itself but rather to the associated medical problems and the timeliness of surgical intervention.
The treatment of abdominal pain depends upon its cause. Fortunately, minor problems are more common than major ones.
The loss of appetite is caused by medical or psychiatric diseases. Underlying illnesses such as infections, liver and kidney disease, or cancer can affect appetite. Various medications such as digitalis preparations may also have an impact on appetite. Depression can be another contributing factor and is discussed in detail on page 192. The reason for this association is not entirely clear, but some studies have shown that depressed people have elevated levels of corticotropin releasing factor (CRF) in their spinal fluid. As CRF is a potent inhibitor of food intake in animals, this small protein may play a role in the development of loss of appetite in depression. Although they are rare, classic cases of anorexia nervosa and distorted body image have been reported in elderly people. This suggests that in some cases weight loss may be caused by pathologic attitudes toward eating.
Physicians generally evaluate loss of appetite by clinical interview, a physical examination, and specific laboratory tests. A report of weight loss is the most important information to be obtained from the interview. Other important clues are weakness, changes in smell or taste, abdominal pain, nausea, vomiting, diarrhea, constipation, difficulty swallowing, problems chewing food or in using dentures, changes in mental function, and the presence of other significant diseases. In the nursing home, diseases or conditions that affect appetite include hip fracture, pressure ulcers, depression, dementing illness, and cancer. Other important items to know about include all medications taken (both prescription and over-the-counter drugs) and any alcohol use.
The objective of general treatment is to maintain body weight, and it should begin while the underlying cause is still being investigated. It is important to be able to identify foods with high nutritional value and, if necessary, to be taught to improve shopping and food preparation techniques, and to be encouraged to make snacks of fruits and vegetables. (See Chapter 23 for more on nutrition.) The specific treatment depends upon the underlying condition.
Normal swallowing involves a complex coordination of muscles in the mouth, throat, and esophagus. A disturbance in this delicate coordination may result in decreased food intake. Difficulty in swallowing must always be thoroughly evaluated because it is never normal and may represent a treatable condition. Swallowing difficulty is the most common symptom of cancer of the esophagus.
Swallowing difficulty is usually caused by either a problem in the upper third of the esophagus or in the lower two-thirds. Problems in the upper part of the esophagus make it difficult to initiate swallowing, so that people with this condition complain of food sticking in the back of the throat, but usually not of pain on swallowing. Regurgitation of food through the nose or aspiration of food into the lungs may occur. The disorders that often cause the difficulty--myasthenia gravis (a condition where the facial muscles fatigue excessively), hypothyroidism, or Parkinson's disease--usually affect the muscles in the upper esophagus. Sometimes a person who has abnormal relaxation of the upper part of the esophagus will have difficulty swallowing. This disorder is sometimes caused by a Zenker's diverticulum (named for the 19th-century German pathologist Friedrich Albert Zenker, who first described it). A Zenker's diverticulum occurs when the lining of the upper esophagus is squeezed through a portion of the outer esophageal wall, creating a little pouch that can fill with food (see Figure 37). Tumors of the throat and upper esophagus also cause swallowing problems. Certain strokes can produce damage to the brain's swallowing center or affect the nerves that control swallowing. The weakness of the tongue and facial muscles can be so severe that the person is unable to move food to the back of the throat.
People with swallowing difficulties in the lower esophagus complain either of food getting stuck in their throat or pain on swallowing. Progressive difficulty in swallowing only solid foods suggests that something is obstructing or narrowing the passage. Difficulty in swallowing both solids and liquids suggests a problem in coordinating the swallowing reflex. Intermittent symptoms without any progression suggest the presence of a constricting muscular ring, called a Schatzki's ring. When heartburn is present, long-standing irritation of the esophagus with severe narrowing may be responsible, but cancer in the esophagus may cause similar symptoms.
People who have problems with coordinated swallowing in the lower esophagus often have pain on swallowing or chest pain. Sometimes the esophagus can spasm due to simultaneous contractions. Occasionally people have a disorder where the opening between the lower esophagus and the stomach fails to relax properly (a condition called achalasia). People with this condition generally do not have pain but have swallowing difficulty that is relieved by regurgitation.
Evaluation of Swallowing Difficulties. Special x-ray studies create a moving picture of a person swallowing to determine if any abnormalities in the upper esophagus are present. If muscle disease is not seen, a careful examination of the ear, nose, throat, and esophagus is usually necessary.
Treatment of Swallowing Problems. Specific treatment is available for only a few of these neuromuscular disorders, such as myasthenia gravis and Parkinson's disease. Sometimes people with neuromuscular disorders benefit from rehabilitation and additional, supplemental nutrition. Surgery may repair a Zenker's diverticulum.
When a person with swallowing problems has difficulty in the lower esophagus, the physician will examine the esophagus carefully to check for signs of a malignant tumor or other signs of inflammation. Treatment will depend upon the underlying cause of the swallowing abnormality.
Heartburn occurs in people of all ages. It is more common in older people, but precise rates are hard to determine because people with the condition have many different complaints. Heartburn can produce discomfort that ranges from a mild burning in the chest to very severe chest pain. Coughing and wheezing can occur at night as a result of reflux of stomach contents into the lungs. Sometimes people complain only of hoarseness.
Heartburn is caused by excessive exposure of the lining of the esophagus to stomach contents, the major irritants being hydrochloric acid and an enzyme called pepsin. Normally stomach acid does not regurgitate into the esophagus because a one-way valve keeps stomach liquids from traveling toward the mouth. When the valve does not close as tightly as it should, heartburn results.
Sometimes heartburn is caused by pills that severely irritate the lining of the esophagus if they do not pass completely into the stomach. Pills likely to do this include potassium, tetracycline, or quinidine. Contributing factors include not drinking enough water when swallowing these medications, taking these medications while lying flat, or having a condition within the esophagus that prevents its emptying easily into the stomach.
Treating heartburn involves modifications in lifestyle, such as eating smaller meals, eating more than three hours before lying flat, avoiding tight-fitting clothing, and avoiding certain foods and drugs that relax the valve in the lower part of the esophagus. These include alcohol, coffee, tomato sauce, chocolate, and some medicines. People with the condition should elevate the head of their bed six to eight inches with bricks or blocks. Generally sleeping on two or three pillows is not helpful because of the changes of positions that occur during sleep. If these nondrug treatments fail or if the person is found to have an ulcer, then medication therapy is necessary.
Although heartburn usually disappears with lifestyle changes and antacids or other medications, it can sometimes lead to significant bleeding in the esophagus or stomach. In this case, as in all circumstances involving active bleeding, the person needs prompt medical attention.
Constipation is difficulty in forming or passing a bowel movement or a feeling of incomplete evacuation associated with a reduced number of bowel movements.
As people age, the muscle tone of the rectum relaxes, which can disrupt the normal emptying of the colon and rectum. This in turn increases the likelihood of constipation. Constipation is usually painless and is related to the slowing down of the bowel, with most of the slowing occurring in the large intestine. Complications of constipation include the sense of not feeling right, intestinal blockage, a massively dilated bowel, and loss of bowel and bladder control. A new onset of constipation in an older person raises the possibility of obstruction of the colon from such conditions as a large amount of hard stool--called a fecal impaction--polyps or other benign tumors, and cancer.
Prolonged constipation over many years can lead to a condition called megacolon, a massively dilated colon that contracts very poorly. This megacolon can be seriously worsened by various medications, including those used for Parkinson's disease, iron supplements, and those that block the neurotransmitter acetylcholine (this blockade slows down bowel contraction). Older people who have developed megacolon are at increased risk for having the colon twist around itself, causing severe obstruction, a condition called volvulus.
The physician's evaluation of constipation includes examination of the abdomen and rectum and often includes lower endoscopy. The lower endoscopy is an inspection of the lining of the rectum and large intestine using a flexible tube called an endoscope. Occasionally an X ray of the lower bowel (a barium enema) is obtained.
The treatment of constipation in older people begins with stopping any medications that slow down the bowel such as narcotics. The diet should be changed to increase the amount of dietary fiber intake to between 6 and 15 grams per day. Bran is the most effective source of fiber; somewhat less effective but useful sources include apples, cabbage, lettuce, and raw vegetables. Additional ways to prevent constipation include regularly scheduled mealtimes, drinking plenty of liquids to ensure adequate hydration, and regular physical activity. Stool softeners are commonly prescribed, and some people respond to lubricating the rectum with a glycerine suppository. The regular use of stimulanttype laxatives such as castor oil, cascara, or phenolphthalein is strongly discouraged for people who are otherwise physically active because these stimulants can damage the delicate nerve supply to the intestines and end up worsening the condition in the long run. Stimulant or saline laxatives, however, may be required to manage constipation in those people who have severely limited mobility or who have specific diseases that affect the intestines, such as Parkinson's disease.
One treatment for fecal impaction involves increasing the size and fluid nature of the stool with bulk-forming agents (such as Metamucil) or poorly absorbed sugars (such as lactulose), intermittent suppositories, or large-volume enemas.
Diarrhea is the body's way of rapidly getting rid of bacteria or toxins in the digestive system. It is usually defined as the passage of loose stools with a greater than normal water content, but some people equate the urgent desire to pass a bowel movement with diarrhea. Diarrhea can cause disabling loss of bowel control in elderly people.
A list of causes of diarrhea is shown in Table 32. Overflow around a fecal impaction is found in almost 20 percent of people with diarrhea. Infections that produce diarrhea include those caused by bacteria such as Campylobacter, Salmonella, and Shigella. Druginduced diarrhea is also common. Any medication should be considered a potential cause. In fact, infections and drugs (antibiotics) cause about one-third of the cases of diarrhea. Antibioticcaused diarrhea is particularly common in elderly people. Up to one-third of people in a chronic care facility (nursing home) may have Clostridium difficile, a disease-producing bacterium that may be found in the stools of people with diarrhea who have been on antibiotics. Factors in the diet also need to be looked for, especially diarrhea caused by milk and dairy products. This can occur because of intolerance to lactose, a sugar found in milk. Underlying illnesses such as thyroid disease and diabetes mellitus must be considered when seeking the cause of diarrhea.
The initial evaluation by a physician usually includes an interview and physical examination and examination of the stool to look for signs of inflammation. Stool samples are often sent to the laboratory to look for bacteria, toxins, and parasites. If these tests do not reveal the cause, a lower endoscopy is performed. This is an examination using a special tube to examine the lining of the rectum and large intestine.
Severe diarrhea can be prominent in people with long-standing diabetes, especially if the diabetes affects the nervous system. This type of diarrhea is generally worse at night and is characterized by watery, brown stools.
An important complication of diarrhea is dehydration. Fluid intake needs to be maintained, usually with clear liquids. It is a good idea to avoid milk for a few days because it can temporarily worsen diarrhea. Diarrhea lasting more than a week should receive medical evaluation. Severe diarrhea or the presence of any bloody stools warrants immediate medical attention. Specific treatments for diarrhea are available depending on the underlying cause.
Table 32. Causes of Diarrhea in Older People
Older people complain of passing excess gas, but it is hard to determine the extent of the problem since the complaint is so common in other age groups; no one knows if an increase in gas production occurs with aging.
The two main causes of intestinal gas are swallowed air and gas production by bacteria in the bowel. Some people swallow large amounts of air, which they eventually return to the environment. These people can often be trained to avoid air swallowing. Sugars that are not absorbed in the small intestine can be chemically broken down by bacteria in the colon with significant gas production (hydrogen, carbon dioxide, and methane) as a result. Some older people have difficulty absorbing the milk sugar lactose, which can cause diarrhea, abdominal bloating, and gas.
Dietary modification, the use of yogurt, and low-lactose milk can be helpful. Effective dietary strategies include eliminating beans, cabbage, legumes, raisins, and nonabsorbable sugars (such as some artificial sweeteners). A product called Beeno is available to break down the nonabsorbable sugars in these foods that stimulate gas production. It appears to be safe, although it can cause mild elevations in the blood sugar. Unfortunately, there is no accepted treatment for foul-smelling gas.
Bleeding in the gastrointestinal tract is a significant cause of disability and mortality in elderly people. Bleeding can occur spontaneously or it may be related to disease in other organ systems.
Important causes of gastrointestinal bleeding in the esophagus, stomach, and small intestine include peptic ulcers, an irritated esophagus or stomach, and cancer. These gastrointestinal bleedings stop on their own in about 80 percent of people.
Hemorrhoids, diverticulosis, various tumors, and small abnormalities in the blood vessels lining the colon constitute the important causes of bleeding in the colon and rectum. In most circumstances, this lower gastrointestinal bleeding stops on its own.
Diverticula, tiny pouches that form in the intestinal lining, increase in number in the colon with age and are present in more than half of people over the age of 70 (see Figure 40 on page 371). Active bleeding occurs in only about 5 percent of people with diverticula. Generally when diverticula bleed, the person does not usually feel pain but notices bright red rectal blood. The bleeding usually stops by itself in 80 percent of people. About one-fourth of older people who have had bleeding diverticula will have another bleeding episode. Diverticular disease is common in older people, but it is not always the source of lower gastrointestinal bleeding. Other causes must be looked for in every person. It should never be assumed that significant bleeding from the lower tract is automatically due to hemorrhoids or diverticula, and a thorough evaluation by a physician is always warranted. Diverticulitis and hemorrhoids are discussed in more detail later in this chapter.
Delays in discovering the source of bleeding can result in a greater risk of mortality. As a result, it is crucial to have the physician identify the bleeding source rapidly in order to initiate prompt treatment.
The physician will want to know if the person has a history of peptic ulcer disease, liver disease, previous bleeding episodes, surgery in the abdomen, alcohol use, or uses NSAIDs or other drugs. Bleeding from the stomach or upper intestine usually produces dark tar-colored bowel movements. The patient may vomit blood, which may be bright red or look like coffee grounds. Bright, red blood passed from the rectum suggests that the bleeding is occurring in the colon or rectum. A recent history of severe abdominal pain suggests that something in the abdomen has been perforated or that there is poor blood flow to the intestines. For bleeding in the upper gastrointestinal tract, it is important for a gastroenterologist to look at the esophagus and stomach by means of a procedure called an upper gastrointestinal endoscopy in order to identify the bleeding site. Appropriate treatment can then begin immediately for those people with actively bleeding lesions who do not stop bleeding promptly. If this procedure does not identify the bleeding site, additional studies may be necessary. If lower gastrointestinal tract bleeding continues, the physician can perform special tests (sigmoidoscopy, special X rays) to identify the bleeding site and to determine the rate of bleeding.
Chronic or occult (invisible to the naked eye) blood loss through the intestines sometimes occurs in older people. People may see small amounts of blood in the stool, have a positive laboratory test for blood in a stool sample, or have unexplained iron-deficiency anemia. Iron-deficiency anemia without a known reason or the discovery of any blood in the stool requires prompt evaluation. This evaluation is necessary to detect and remove early gastrointestinal tumors and to diagnose and treat any underlying conditions. A test of a stool sample for blood will detect active blood loss from any site in the gastrointestinal tract. More commonly the source is located in the colon. As in more rapid bleeding in the intestines, the site responsible for the bleeding should be identified and treated.
Treatment for gastrointestinal bleeding depends upon the source of the bleeding. Fortunately, most bleeding stops on its own. Active bleeding must be treated as a medical emergency. Surgery is the definitive treatment for persistent bleeding.
The medical term for loss of bowel control is fecal incontinence. The term is applied to an inability either to hold or to pass fecal matter through voluntary muscle action. Its prevalence in the community is not known, but various studies have reported it to range from 17 to 66 percent in the hospital setting. Between 10 and 15 percent of people in long-term care facilities may have the problem.
Loss of bowel control can have devastating consequences, significantly increasing the burden on caregivers and frequently resulting in institutionalization. It is a source of discomfort for the person with an intact mental function. It often occurs with urinary problems, including loss of bladder control.
The anal canal is approximately two inches long and its junction with the large intestine is maintained at a right angle (90 degrees) by a muscle that forms a powerful sling that helps support the pelvic structures (see Figure 38). The weight of the abdominal organs pushes down on the large intestine and closes the opening at the point of the right angle. This flap valve helps to prevent any leakage of stool into the anus, and any increases in abdominal pressure tend to make the valve more effective.
The normal anal muscles and lining perform two functions that are essential for bowel control. The first is the ability to discriminate between solid, liquid, or gas in the rectal area. The second is the ability to postpone a bowel movement to a convenient time and place. The nerve endings that line the anal canal normally enable people to tell gas from solid or liquid, but such exquisite anal sensation appears to diminish with age. The muscles forming the bowel control mechanism are influenced by the nervous system. In the resting state, the muscles maintain closure of the anal cavity by keeping maximally contracted.
An increase in abdominal pressure is followed by relaxation of the muscles that form the sling. This relaxation straightens the right angle and allows the anal canal to distend and open. The contents of the bowel can then pass out through the anus.
Table 33. Causes of Loss of Bowel Control
The causes of loss of bowel control are shown in Table 33. When hard stool collects and remains in the bowel for a long time, it creates a fecal impaction. This is the most common cause of loss of bowel control in elderly people. It is often associated with reduced mobility and commonly occurs in people who are hospitalized or in nursing homes. Physical inactivity is also an important factor. People with fecal impaction frequently have a history of constipation and of taking laxatives. They may also have diseases that slow the nervous system, such as Parkinson's disease, or take medications that reduce bowel contractions. In these people, the time that it takes for the stool to reach the rectum is usually prolonged (for normal people it may take three days for material to pass from the mouth to the rectum). This reduced bowel activity can progress to constipation, and eventually to impaction with a large mass of stool in the rectum. Other factors include a lack of fiber in the diet and changes in the gastrointestinal hormones that stimulate bowel motility. Most impactions can be easily found by the physician or nurse by inserting a finger into the rectum and feeling the unpassed stool in the rectal vault.
Damage to the nerves around the rectum, with resultant changes in the muscles, has been noted in people who have loss of bowel control. Such nerve loss can be caused by compression and stretching of the nerves due to prolonged straining. Nerve damage has also been shown in people who have decades of excessive laxative use. In addition, prolonged laxative use can produce a brown staining in the lining of the colon that is visible on examination. Local nerve damage can impair the efficiency of the flap-valve bowel control mechanism.
In older people, loss of bowel control due to neurological problems in the brain or spinal cord is more common than that due to damage to nerves around the rectum. Pinched nerves in the back, tumors, and abnormalities in the spinal cord can disrupt normal bowel contractions, cause loss of sensation, and produce incomplete bowel emptying. People with strokes or Alzheimer's disease sometimes have a loss of bowel control. People with these conditions may pass a formed stool following a cup of coffee or a meal. The bowel control mechanism can also be impaired by surgery or, in women, by trauma after labor and delivery; both of these can produce a loss of muscle tone and a disruption of the flap-valve mechanism.
Diarrhea overwhelms the normal bowel control mechanism. Diarrhea is caused by medications, bowel infections, and inflammation of the bowel. It is especially important to check for infectious causes if people have been treated with antibiotics, because organisms resistant to usual antibiotics may be causing the diarrhea. (Diarrhea is addressed more completely earlier in this chapter.)
Psychological and behavioral problems can also be responsible for loss of bowel control. They may be the signal of dementing illness or depression. Loss of bowel control may occur, for example, when a severely depressed person is unable to reach the toilet in time or when a demented person is unwilling to do so.
The primary goals of the clinical evaluation are to identify the cause of the loss of bowel control and the effect on a person's ability to function (see Table 34).
Table 34. Important Factors in the Evaluation of Loss of Bowel Control
The presence of other symptoms such as urgency, pain, bleeding, or abdominal cramps suggests problems in the anal area. Any obstetric history or record of previous surgery can also provide important clues. Bleeding indicates the need for prompt evaluation to look for infection, inflammation, or cancer.
The presence of any neurologic disease is especially relevant. Stroke, for example, can limit the person's access to the toilet, and Alzheimer's disease or other dementing illness can cause a number of difficulties. All medications should be reviewed. The amount of fluid and fiber intake and the timing and size of meals are also important. A person should be aware of constipating foods, such as foods with high fat content and refined breads. It is also important to understand the person's means of toileting, including access to a toilet and any difficulties in making use of toilet facilities. It is also helpful to consider the ease with which they can remove garments and the degree of privacy available.
The basic components of the physician's examination usually include determination of neurologic function and a careful examination of the abdomen and rectum. X rays and other special tests are sometimes ordered.
Loss of bowel control caused by fecal impaction is treated by addressing all conditions that increase difficulty in passing a bowel movement. If possible, all constipating medicines should be stopped and a thorough emptying of the bowel should be undertaken. Enemas are often administered until there is no return of stool, indicating that the bowel is clean. For hard stool, oil-retention enemas using olive oil are recommended.
To prevent recurrence, a maintenance program of exercise and diet is needed that includes increased exercise, increased water intake, and increased dietary fiber. The person should be encouraged to walk; people who are bedridden should be encouraged to perform simple exercises in bed to stimulate large bowel function. Daily intake of at least two quarts of liquid is desirable. Fiber in the diet needs to be increased to between 20 and 40 grams per day. Dietary fiber is important because it increases the stool bulk, speeds up the bowel motility, increases bowel contractions, and improves muscle tone. One nursing home documented that by adding bran cereal every morning, the need for laxatives in the facility was totally eliminated. A person must receive plenty of fluids with the fiber to prevent recurrence of constipation.
People with neurologic causes of loss of their bowel control experience frequent soiling with formed stools; their examination may be normal. The goal of treatment for these people is to have the bowel movement occur at predictable times to reduce both soiling and caregiver burden. This goal is usually accomplished by having bowel movements scheduled at the same time every day using simple behavioral therapies. A glycerin suppository is given to provide local stimulation of the anal sphincter and thereby enable the person to have a planned bowel movement. Usually the best time for this is just after the person wakes up or shortly after eating to utilize the normal bowel reflexes.
Bowel control can be maintained in people who have had damage to the pelvic muscles by avoiding constipation. Biofeedback therapy by an experienced professional can be helpful for most people who cannot otherwise achieve good bowel control. Successful conditioning using biofeedback consists of the person being able to tell when the rectum is full and learning how and when to contract the sphincter.
The treatment of diarrhea, which can overcome the continence mechanism of people at any age, is directed at the underlying problem. A common cause of poor bowel control when diarrhea is involved is inadequate access to toilet facilities. Obviously, the treatment of this problem should focus on providing adequate facilities and improving the person's mobility. People with mobility problems who cannot get to the bathroom on time can often benefit from a bedside commode. Clothing with elastic waistbands or Velcro fasteners may be used to simplify undressing. By using these approaches, bowel control can be achieved in up to 60 percent of people with the problem.
There is limited experience with surgical treatments for poor bowel control in older people. Individuals who are candidates for this type of surgery often have a history of previous pelvic or abdominal surgery, pelvic injury, or obstetrical trauma such as forceps delivery or significant muscle tears. Even after surgery, a majority of people will continue to have urgency, and three-quarters still experience some involuntary leakage.
Peptic ulcer disease refers to erosions and craters in the lining of the stomach and duodenum, the first part of the small intestine. The incidence of peptic ulcer disease and the complications of ulcers is rising in elderly people.
Ulcers generally occur when the normal defense mechanisms of the lining of the stomach and intestines become defective and no longer provide protection from stomach acid. Three important predisposing factors for peptic ulceration are infection with a bacterium called Helicobacter pylori, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and cigarette smoking. H. pylori is found in the stomachs of more than 95 percent of people with ulcers in the duodenum area, just beyond where the stomach joins the small intestine, and in two-thirds of those with ulcers in the stomach, called gastric ulcers. H. pylori is also present in about 60 percent of people who are older than age 60. The treatment for this particular bacterium requires three drugs, metronidazole, tetracycline, and bismuth subsalicylate--the best regimen is still being established.
NSAIDs are clearly implicated in the development of gastric ulcers but not duodenal ulcers. NSAIDs include aspirin, ibuprofen, indomethacin, naproxen, and several others. Ulcers caused by these drugs occur more frequently in older people because they use these drugs more than younger persons do. NSAID use increases the death rate due to complications of peptic ulcer disease. Among people using NSAIDs, 2 to 4 percent will develop a significant ulcer within a given year. In people who are older than age 65, the use of NSAIDs causes about one-fourth of all cases of upper intestinal hemorrhaging (which has a mortality rate of at least 10 percent). A history of peptic ulcer, cigarette smoking, and alcohol-related disease increases the risk for a NSAID-related ulcer complication. Age, however, is not a risk factor.
Older people with peptic ulcer disease may experience a variety of discomforts. Up to one-third of elderly persons with peptic ulcer disease experience no abdominal pain and have no symptoms until a complication such as bleeding, perforation, or obstruction develops. Some people have the classic complaints (more common in younger people with peptic ulcer disease) of a hunger pain or burning in the upper part of the abdomen that is relieved by antacids or food. More often elderly people have vague abdominal discomfort, poor appetite, vomiting, or weight loss. Sometimes the appearance of blood in the stool is the first indication of an ulcer. A bloody stool often appears black and tarry and is usually foul smelling.
People who suspect they have a peptic ulcer need prompt evaluation. Usually a physician will use an instrument called an endoscope to inspect the inside of the gastrointestinal tract. This enables the physician to look at the lining of the esophagus, stomach, and small intestine for ulcers or signs of irritation and bleeding. The physician may also use the endoscope to treat any bleeding sites, and biopsy any suspicious-looking areas to check for cancer or infection. In people with significant pain in the upper abdomen, the chance of finding evidence of illness through an endoscopic procedure is about 60 percent for those who are 65 and older. (In contrast, endoscopy reveals evidence of disease in only 30 percent of people ages 40 through 65 who complain of stomach pain.) An alternate but less precise procedure is a barium x-ray, which will show most gastric and many duodenal ulcers.
The treatment of peptic ulcer disease includes antacids, drugs to coat the surface of the ulcer, and drugs that decrease stomach acid production called histamine receptor antagonists. As a result of drug therapy, 80 to 90 percent of duodenal ulcers heal in 8 weeks. A similar percentage of gastric ulcers heal at 12 weeks. If after 12 weeks of treatment gastric ulcers are still present, the ulcer margins are usually biopsied to check for malignancy. The rate of healing is related to the size of the ulcer not to the age of the person; very large ulcers tend to heal slowly. Ulcers in the stomach and duodenum that are not associated with NSAID use tend to recur in about four months on average. Because of this, the need for maintenance therapy and the length of treatment remains controversial. Treatment of H. pylori bacteria may significantly reduce the rate of ulcer recurrence.
People who develop an ulcer while they are receiving NSAID therapy are best treated by stopping the NSAIDs; the ulcers then heal rapidly.
Stones are found in the gallbladders of about 20 percent of people who are 60 years and older, and the prevalence of gallstone disease increases with age. The gallbladder concentrates and stores the bile that is made in the liver. When the bile gets too concentrated, it crystallizes to form a stone.
Problems begin when stones move from the gallbladder and create severe pain (see Figure 39). The pain of a gallbladder attack is usually felt in the right upper part of the abdomen just below the ribs. The discomfort can be either sharp and crampy or steady and consistent. The person may feel nauseated and vomit, with fever and chills. If a gallstone obstructs the opening of the bile duct into the intestine, the person will develop intense fever, chills, and jaundice (a yellow discoloration of the skin and eyes).
Gallbladder inflammation without gallstones is also encountered in elderly people. The reason for this appears to be poor blood flow to the gallbladder. This condition tends to smolder, causing very minimal symptoms or signs of gallbladder problems. A physician may suspect and discover this condition before it causes the gallbladder to perforate or becomes a site for blood poisoning (septicemia).
Any new abdominal symptoms in an older person should warrant a very careful evaluation by a physician. Generally, the evaluation of someone suspected of having a gallbladder attack includes blood tests to check the function of the liver and an ultrasound, a noninvasive procedure using sound waves, which can detect gallstones, an enlarged gallbladder, bile duct enlargement, or, possibly, a localized abscess.
The management of gallstones that do not cause symptoms (usually discovered by coincidence) is usually conservative because most people will not develop complications (people with diabetes mellitus are an important exception). In persons 60 years and older, removal of the gallbladder is the most commonly performed intraabdominal operation. In part, this is because the rate of septicemia, perforation, gangrene, and deaths associated with sudden gallbladder infection increases with advancing age.
Treatment options for gallstones that cause symptoms have expanded. Surgery remains the standard treatment, and new surgical techniques reduce the amount of discomfort after the operation. Some nonsurgical options include trying to dissolve the gallstones and trying to remove the stones by passing a tube into the stomach and through the small intestine to the site where the bile drains from the liver.
Diverticula are small outpouchings in the muscular wall of the large bowel that become more common with age (see Figure 40). Diverticulitis is the inflammation of one or more diverticula, and is often initiated by a small piece of hard stool becoming stuck in the "neck" of the diverticulum. Diverticulitis occurs in up to one-quarter of those people who have diverticulosis.
Older people with diverticulitis may have either very few symptoms or may feel a painful spasm in the lower abdomen, severe abdominal pain, or show signs of blood poisoning. Diverticulitis may lead to small perforations in the bowel wall, causing complications such as abscess formation, inflammation of the lining of the abdomen called peritonitis, or blood poisoning. Diverticulitis can produce many symptoms depending upon its severity. Other conditions with symptoms similar to diverticulitis include colon cancer, fecal impaction, poor circulation to the bowel, appendicitis, and urinary tract infection.
Because of the potential severity of these other conditions, prompt medical attention is necessary.
Medical treatment for diverticulitis consists of intravenous fluids and antibiotics. Surgery may be necessary for recurrent episodes, large abscesses, obstruction of the bowel, or other conditions.
Appendicitis is often not considered when an older person becomes ill. However, in people who have not had their appendixes removed, appendicitis remains a risk throughout life. Approximately 5 percent of all cases of appendicitis occur in people who are 60 years or older, but it is more important to note that the majority of appendicitis-related deaths occur in the older age group. This increased mortality is due in part to difficulty in identifying the condition, which in turn leads to complications such as perforation and gangrene of the appendix. The high mortality is also increased by the presence of other diseases and postoperative complications.
Since the older person may not exhibit the usual signs and symptoms of appendicitis, the condition must be considered in any older person who has not had an appendectomy and who has unexplained abdominal pain of recent onset or who exhibits signs of infection such as fever or chills. These symptoms should receive prompt, immediate medical evaluation.
The treatment for appendicitis is surgery to remove the inflamed appendix (see Figure 36 on page 350).
Colon and rectal cancers are the second most common cancers in the United States, and their incidence increases with age.
Colon cancer seems to occur more commonly in people who eat diets that are low in fiber and high in refined sugar and animal fat. Other factors that increase the risk of colon cancer are having polyps in the colon, having a close relative with colon cancer, having breast cancer or other malignancy involving the female organs, having inflammatory bowel disease such as ulcerative colitis, and longstanding infection with parasites.
Polyps in the colon are thought to be precancerous and can usually be removed with an endoscope. If the polyps have cancer cells in their stalk or if many polyps are found, then surgical removal is recommended.
Early colon cancer does not produce symptoms, so the tumor must be discovered either by testing the stool for blood (which usually is not visible to the naked eye) or by inspection of the lining of the colon using a flexible tube called an endoscope.
The symptoms of colon cancer depend upon where the cancer is in the colon. Rectal cancers often produce pain when passing a bowel movement, a sense that the rectum has not emptied completely, or rectal bleeding. Cancers in the colon above the rectum (on the left side of the body) tend to cause abdominal cramps and bleeding. Cancers even farther up the colon, near the appendix, can grow into large masses that can sometimes be felt. People with these cancers may experience fatigue, weakness, and loss of energy due to subtle blood loss and iron-deficiency anemia.
Colon cancer can be identified through endoscopy or X rays (barium enema). A biopsy of the area can be used to confirm the presence of colon cancer.
Treatment of a tumor of the colon is surgical removal. This involves leaving margins that are free of any sign of cancer. Usually, this involves the placement of a temporary colostomy--a surgical creation of an opening of the colon on the outside of the body, usually on the surface of the abdomen. The bowel contents empty into a plastic pouch that surrounds the opening. A colostomy is considered temporary if it can be reconstructed at a later time to restore normal elimination of stool through the rectum.
An abdominal operation may be required to treat primary rectal cancer; this is more likely to be needed in tumors that involve the middle or upper part of the rectum. Other surgical procedures that can be considered are lasers and freezing. Laser surgery may also offer some improvement in symptoms for people who are not candidates for very extensive procedures.
The outlook for people with either primary colon or primary rectal cancer is related to the extent of the disease. When the disease has spread to local or regional lymph nodes, chemotherapy may prolong survival for the afflicted person.
Hemorrhoids are swellings of rectal tissue that are caused by dilated veins often produced from straining to pass a bowel movement. The complications of hemorrhoids, which are common in older people, include bleeding, enlargement, and pain.
Prolapsed hemorrhoids appear as reddish masses protruding from the opening of the rectum (see Figure 41). They may spontaneously go back into the rectum or they may need to be pushed back in place by the finger. Although pain is not a frequent symptom, hemorrhoids that have clotted, called thrombotic hemorrhoids, can cause severe pain around the rectum.
Tears along the anal lining, called fissures, usually cause pain while passing a bowel movement. Fissures can be treated with sitz baths, stool softeners, and pain-relieving ointments. However, tissues that do not heal may require surgical treatment. People who have abscesses around the rectal area often have pain that increases when trying to pass a bowel movement. Abscesses usually require surgical drainage.
Hemorrhoids and fissures can be detected through a rectal examination as well as through an examination of the lining of the rectum. This procedure is performed with a tube that is called a proctoscope.
The treatment of hemorrhoids begins with the use of dietary fiber, stool softeners to reduce straining, pain-relieving ointments, and sitz baths. This may be all the treatment that is necessary for the early stages of hemorrhoids with either no prolapse or prolapse occurring with bowel movements that spontaneously resolves. However, if the hemorrhoids do not respond, more aggressive medical therapy is indicated. The goal of more aggressive treatments is to produce inflammation and scarring, which causes the hemorrhoids to adhere to the underlying muscle tissues. Surgery is often necessary for clotted hemorrhoids.