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Peptic Disease in Elderly Patients

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Peptic Disease in Elderly Patients Color profile: _DEFAULT.CCM - Generic CMYK Composite Default screen MINI-REVIEW 100 100 95 95 75 75 25 Peptic disease 25 5 5 0 in elderly patients 0 Neda Khaghan MD, Peter R Holt MD N Khaghan, PR Holt. Peptic disease in elderly patients. Can J L’ulcère gastro-duodénal chez les patients âgés Gastroenterol 2000;14(11):922-928. The increase in life ex- pectancy demands that more attention be given to gastrointesti- RÉSUMÉ : L’augmentation de l’espérance de vie exige qu’une attention nal problems, such as peptic ulcer disease, in elderly people. This plus grande soit portée aux troubles gastro-intestinaux, par exemple l’ul- review summarizes many of the physiological changes that have a cère gastro-duodénal, chez les personnes âgées. Le présent article donne un role in peptic ulcer disease in elderly patients. How Helicobacter résumé d’un bon nombre de changements physiologiques qui jouent un pylori infection modifies the course of peptic disease is also re- rôle dans l’ulcère gastro-duodénal chez les patients âgés. On y traite aussi Helicobacter pylori viewed. The clinical presentation of peptic diseases often differs in de l’incidence des infections à sur l’évolution de la mala- elderly people, and atypical symptoms are common. Accurate di- die. Le tableau clinique diffère souvent chez les personnes âgées, et les agnosis requires aggressive endoscopic evaluation. Treatment re- symptômes atypiques ne sont pas rares. La pose d’un diagnostic précis re- quiert une évaluation endoscopique minutieuse. Il est également parfois gimens using H2 receptor antagonists, proton pump inhibitors and nécessaire de modifier les traitements composés d’antagonistes des récep- regimens to eradicate H pylori may also need to be altered in eld- teurs H ou d’inhibiteurs de la pompe à protons et les traitements visant à erly patients. 2 éradiquer H. pylori chez les patients âgés. Key Words: Elderly people; Helicobacter pylori; Peptic ulcer ecent advances in public health and medical care tech- PATHOPHYSIOLOGY Rnologies have prolonged the average life span through- A wide range of physiological changes are thought to be as- out the world. However, this prolonged life span has been sociated with the process of aging, including changes in the accompanied by a higher incidence of chronic diseases in organs of the gastrointestinal tract. In previous reviews, such elderly people. Gastrointestinal diseases play a significant effects as decreases in motility, and in gastric, pancreatic, role in such chronic illness. As part of this problem, peptic biliary or intestinal secretions, and changes in absorptive ca- ulcer disease has become a major cause of morbidity and pacity have been described. More careful analyses of the mortality in elderly patients. physiological effects of aging that excluded the influence of In 1991, McCarthy (1) estimated that 25% of all admis- disease resulted in a major reconsideration of what can be at- sions to hospitals and 20% of all deaths in the United States tributed to physiological changes as a part of the process of were due to gastrointestinal disease. Of the deaths from gas- aging. trointestinal disease, one-fifth were due to peptic disease of Table 1 summarizes the major issues surrounding peptic the stomach and duodenum. Many authors in the Western diseases in elderly patients. The following are important: the world over the past two decades have clearly shown that the role of Helicobacter pylori infection in altering the control of first diagnosis of peptic ulcer disease and admissions to hospi- gastric acid secretion and in determining the incidence and tal for complications of peptic ulcer disease occur almost en- course of peptic disease in older patients; crucial differences 100 100 tirely in individuals over the age of 65 years (2-4). Thus, in the clinical picture of older patients with peptic disease; 95 peptic ulcer disease is a disease of elderly men and women, the issue of whether the evaluation and the diagnostic ap- 95 and no longer mainly a disease of young men, as was the case proaches that are usually used in younger patients should dif- 75 in the 1940s and 1950s. fer when considering peptic disease in elderly patients; and 75 This mini-review was prepared from a presentation made at the World Congress of Gastroenterology, Vienna, Austria, September 6 to 11, 1998 Gastrointestinal Division, Department of Medicine, St Luke’s/Roosevelt Hospital Center, Columbia University, New York, New York, USA 25 Correspondence and reprints: Dr Peter Holt, Gastroenterology Division, St Luke’s/Roosevelt Hospital Center, Amsterdam Avenue at 114th Street, 25 New York, New York 10025, USA. Telephone 212-523-3680, fax 212-523-3683, e-mail [email protected] 5 Received for publication August 17, 1999. Accepted September 7, 1999 5 0 0 922 Can J Gastroenterol Vol 14 No 11 December 2000 1 G:...khagan2.vp Mon Dec 04 15:41:05 2000 Color profile: _DEFAULT.CCM - Generic CMYK Composite Default screen Aging and peptic disease 100 100 TABLE 1 TABLE 2 95 Major issues concerning elderly patients with peptic disease Physiological changes with age 95 75 Changes in gastric acid and pepsin secretion Aggressive factors 75 Changes related to esophageal or gastric motility Gastric hydrogen ion secretion The role of Helicobacter pylori infection Defense mechanisms 25 Difference in clinical practice Bicarbonate secretion 25 Whether evaluation and diagnostic approaches should differ Mucin production 5 5 Whether treatment should differ Prostaglandin concentration 0 Blood flow 0 Adaptation to injury whether treatment options should be altered because a pa- tient is over the age of 65 years (Table 2). Until recently, it was generally believed that gastric acid studies in rodents (14,15) and in humans (16) have secretion declined with advancing age. For example, Baron suggested that bicarbonate secretion may be lower in older (5) described a decrease in basal secretion and peak acid out- animals and humans than in young animals and humans. put after histamine stimulation with increasing age. This The effect of injury on such bicarbonate secretion has not study, however, used 30 years as the age to divide a small been studied. The secretion of mucopolysaccharides pro- number of young and older subjects. More recent studies vides an important barrier to acid-induced injury of the from the United States and elsewhere reported that basal stomach. There have been relatively few studies of changes and stimulated gastric hydrogen ion secretions did not fall if in mucin secretion as a function of age (17), nor has there patients with atrophic gastritis and H pylori infection were been any systematic evaluation of changes in hydrogen ion excluded (6-8). Most of these studies did not include suffi- transfer through the mucin layer. Furthermore, studies by cient numbers of volunteers older than 65 years of age. A Dial and Lichtenberger (18) indicating the importance of more comprehensive prospective study that included 22 sub- the hydrophobic properties of the gastric mucosa in protect- jects older than 65 years of age found no significant effect of ing gastric epithelial cells have not focused on changes that age on gastric acid secretion after adjusting for the influence might occur during the aging process. of atrophic gastritis and smoking (9). Serum gastrin levels Cryer et al (19,20) evaluated changes in prostaglandin were similar at all age groups but became elevated in the (PG) concentrations in the gastroduodenal mucosa of ani- presence of atrophic gastritis. However, pepsin output was mals and humans, as well as the PG responses of the mucosa significantly depressed in older subjects in this study. A study to injury. These results have been confirmed by others (21). in rats up to 24 months of age demonstrated a reduction in These studies have pointed to lower concentrations of PGE2 basal and gastrin-stimulated acid output, and lower serum and PGFa in the fundus and antrum of the stomach as well as and antral gastrin concentrations in older animals (10). A in the duodenum of elderly subjects (aged 56 to 81 years). recent study in Sprague-Dawley rats between the ages of Furthermore, studies of the effect of stimulants that injure seven and 90 weeks suggested that gastrin receptor mRNA the mucosa upon PG production also suggest that the re- was markedly higher in 65- and 90-week-old rats than in sponse is impaired as a function of age (22). Recent findings younger animals (11). The causes and consequences of these that very small doses of acetylsalicylic acid (ASA) reduce changes are unclear. PG concentrations of the stomach dramatically raise the Further data showing that acid secretion is maintained in question of whether some of the previous results of PG con- old age came from a study using a noninvasive quininium centration may have been due to subjects taking intermit- resin method, which distinguishes acid secretion above and tent salicylates (23). All of these data imply that these below pH 3.5. In this study, basal secretion was found to be individuals have a relatively deficient defense mechanism below 3.5 in nearly 90% of 248 elderly volunteers (12). Sub- associated with PG secretion. jects with consistent hyposecretion usually showed sero- Changes in blood flow have also been demonstrated to logical evidence of atrophic gastritis. In young and elderly occur as a function of age. Arteriosclerotic vascular changes Japanese volunteers, gastric acid secretion was studied both are almost universally present in elderly people, but their im- 100 in the 1970s and in the 1990s, showing greater acid secretion pact on gastrointestinal mucosal blood flow has not been 100 in the young and elderly individuals over these two decades demonstrated to be important. On the other hand, limited 95 in both H pylori-positive and -negative subjects (13).
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