THE AMERICAN JOURNAL OF GASTROENTEROLOGY
1, 2000
© 2000 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
EDITORIALS
Gastrointestinal Problems
in Geriatric Patients:
What’s New About Growing Old?
In the next five issues of the American Journal of Gastro-
enterology, a series entitled “Gastrointestinal Problems in
Geriatric Patients” will be featured. It will include the fol-
lowing articles:
1. An Overview of Special Considerations in the Evaluation
and Management of the Geriatric Patient, by Patricia
Barry, M.D.
2. GERD in the Older Patient: Presentation, Treatment, and
Complications, by Joel Richter M.D., F.A.C.G.
3. Gastrointestinal Bleeding in the Elderly Patient Causes,
The Role of NSAIDs, Endoscopic, and Medical Therapy,
by Christopher Gostout, M.D., F.A.C.G.
4. Functional Bowel Disorders in the Geriatric Patient:
Constipation, Fecal Impaction, and Fecal Incontinence,
by Anthony DeLillo, M.D., and Suzanne Rose, M.D.,
F.A.C.G.
5. Approach to Colon Polyps in the Elderly, by Kenneth
Miller, M.D., and Jerome D. Waye, M.D., F.A.C.G.
The series stems from a symposium that was held at the
ACG Annual Meeting in Boston in October 1998.
One might ask: Why should we view this population
distinctly? Do the elderly have special needs and specific
gastroenterological problems? To answer these questions,
we begin with a formal “need’s assessment,” reviewing the
epidemiological data to determine the importance of the
problem. In her article in this issue, Dr. Barry has done just
that. We learn that the elderly population is growing at a
dramatic rate and that the use of health care services by the
elderly is disproportional. The implications for both quality
of life issues and medical care costs cannot be ignored. Dr.
Barry points out that comorbid conditions exist in the el-
derly population. The physician cannot view the presenta-
tion of a particular symptom in isolation, with the consid-
eration of only a single organ system. A complexity of
processes, medications, and organ systems can interplay in
difficult patterns; a solution to one problem with medica-
tions or surgery can lead to another problem.
What is the impact of age on illnesses involving the
gastrointestinal tract, and what is the effect of gastrointes-
tinal vital processes on aging? Here, it is important to
distinguish two types of problems and processes: those that
may limit the quality of life, and those that may limit the
length of life. The quality of life issues are often the pa-
tients’ main concerns, but in our consideration of length of
life issues, we cannot discount a treatment simply because a
patient is older. On the other hand, we must do a careful
Vol. 95, No.
ISSN 0002-9270/00/$20.00
PII S0002-9270(99)00753-4
risk/benefit analysis to determine whether the treatment of a
certain problem is beneficial, given the patients’ predicted
life spans.
In this series, Dr. Joel Richter will evaluate gastroesoph-
ageal reflux disease, a common complaint of the elderly,
which is often more severe and yet frequently under-diag-
nosed and inadequately treated in this population. This is
largely a quality of life issue, although complications of
peptic stricture can lead to nutritional issues, and Barrett’s
esophagus could be considered a life-limiting problem (1).
Dr. Christopher Gostout’s review of gastrointestinal
bleeding in the elderly evaluates epidemiological data, treat-
ment options, and prophylaxis. Gastrointestinal bleeding
can represent an immediate life-threatening and life-limiting
situation. In contrast to this problem, functional bowel dis-
orders in the geriatric patient, reviewed by my colleague Dr.
Anthony R. DeLillo and myself, reveal significant problems
of morbidity for the elderly population (2). The last in this
series is a review by Dr. Kenneth M. Miller and Dr. Jerome
D. Waye of colon polyps in the elderly. This issue is
particularly complex, as we know that polyps can go on to
develop into carcinomas. The article will describe age as a
risk factor for colonoscopy, and the risks of screening and of
removal of large polyps based on life expectancy (3).
Beyond the multiple medical problems and often complex
psychosocial dynamics, we are faced with yet another chal-
lenge in our interactions with the elderly: we need more time
to integrate the services and to meet the needs of the geri-
atric patient, even as we confront the demands of managed
care and of seeing more patients in less time. Even for those
of us who are focused in our gastroenterological practice
and do not assume a primary care role, we cannot ignore the
complex medical history of present illness, past medical
history, family history, social history, and the review of
systems. The physical examination may take longer because
of decreased mobility. Additionally, these patients are used
to spending time with their doctor, and reasonably hold us
up to the high standards of care that we all strive to follow
and yet, find so difficult to maintain in these challenging
times.
As we consider the gastroenterological illnesses of our
geriatric patients, we must think not only in terms of care
versus cure, risks versus benefits, but we must never forget
the patient’s agenda: s/he is seeking health care from us.
This latter point may be best illustrated by the wisdom of
age as expressed by Doris Lessing: “The great secret that all
old people share is that you really haven’t changed in
seventy or eighty years. Your body changes, but you don’t
change at all. And that, of course, causes great confu-
sion.” (4).
So, what is new about growing old? What clearly is new
and must be addressed by our health care system as a
2 Editorials
community issue, is health promotion, disease prevention,
and management in a population that is growing older and
older. All of this must be considered within the context of
multisystem diseases and complicated social structure in a
population with high expectations of the physician and in
patients who may have complex, integrated health care
needs. What clearly is not so new is that we all aspire to
become a part of this demographic subpopulation—in due
time— because, as Maurice Chevalier so aptly stated, “Old
age isn’t so bad when you consider the alternative.” (5).
Suzanne Rose, M.D., F.A.C.G.
Division of Gastroenterology
Mount Sinai School of Medicine
New York, New York
REFERENCES
1. Van der Burgh A, Dees J, How WCJ, et al. Oesophageal cancer
is an uncommon cause of death in patients with Barrett’s
esophagus. Gut 1996;39:5–10.
2. O’Keefe EA, Talley NJ, Zinmeister AR, et al. Bowel disorders
impair functional status and quality of life in the elderly: A
population-based study. J Gerontol A Biol Sci Med Sci 1995;
50:M184 –9.
3. DiPrima RE, Barkin JS, Blinder M, et al. Age as a risk factor
in colonoscopy: Fact versus fiction. Am J Gastroenterol 1988;
83:123–5.
4. Lessing D. Sunday Times: Books (London, 10 May 1992). The
Columbia Dictionary of Quotations, Columbia University
Press, 1993.
5. Chevalier M. New York Times (9 October 1960). The Colum-
bia Dictionary of Quotations, Columbia University Press, 1993.
Reprint requests and correspondence: Suzanne Rose, M.D.,
F.A.C.G., Mount Sinai School of Medicine, Division of Gastro-
enterology, Office of Student Affairs, Annenberg 516, Box 1257,
One Gustave L. Levy Place, New York, NY 10029.
Received May 10, 1999; accepted Aug. 26, 1999.
Thar’s Gold in
Your Patient’s NG!
Hold the Scalpel, Hold the
Endoscope, Hold the Trochars
As someone concerned about the overuse of diagnostic and
therapeutic ERCP in patients with an initial episode of mild
gallstone pancreatitis, I was intrigued to review the manu-
script by Acosta et al. published in this issue of the Amer-
ican Journal of Gastroenterology (1). Moreover, who can
argue with simple bedside or laboratory tools (presence of
ongoing biliary colic, absence of bile in the gastric aspirate,
and elevated serum bilirubin) to define persistent ampullary
obstruction as opposed to stone passage (or disimpaction),
and the need for urgent as opposed to elective intervention?
As such, the authors prospectively studied 132 consecutive
patients with presumed biliary pancreatitis between 1986
AJG – Vol. 95, No. 1, 2000
and 1996 and concluded that the sudden resolution of biliary
colic, presence of golden bile in an NG aspirate, and rapid
fall in bilirubin was associated with stone disimpaction. In
the 121 patients subjected to intraoperative cholangiography
or ERCP, moreover, the composite of these symptoms and
signs had a sensitivity for ampullary obstruction of 100%, a
specificity of 92%, and a positive predictive value of 61%.
Never mind that open surgery with IOC were the procedures
performed in 112 patients, ERCP and endoscopic sphinc-
terotomy in five patients, and both procedures in the remain-
ing patients who underwent intervention. Never mind that
defining pancreatitis severity within the first 48 h of admis-
sion and quantitating pain are notoriously difficult. Never
mind also that the bulk of these patients had mild disease,
that there was significant overlap in serum bilirubin in
patients with and without impacted calculi, and that 20 of
the patients believed to have disimpacted their stones
(16.5%) and elective operation still had calculi within their
bile duct at time of operative cholangiography. Or that 14 of
the 21 patients operated on urgently (11.5% of those who
underwent surgery) indeed had impacted stones.
Never mind all of this. Are these parameters (absence of
bile in nasogastric [NG] tube, persistent bilirubin elevation,
persistent biliary colic) helpful in deciding who should
undergo urgent surgery or cholangiography? Probably, but
their application and interpretation are more difficult than
the authors would have you believe. Let’s start with pa-
tients’ reluctance, particularly those with mild symptoms, to
accept NG placement. Moreover, although golden bile in the
NG tube may be the gold standard of stone disimpaction, its
presence does not mean the absence of stones within the bile
duct, and subsequent passage or reimpaction has resulted in
exacerbation or recurrence of pancreatitis in a significant
subset of patients operated on electively in some surgical
series (2). Let’s next try to separate the visceral pain of
pancreatitis from the colic of stone impaction—sometimes
difficult, as the two are often superimposed by the time the
patient seeks medical care. Finally, the most objective pa-
rameter, measurement of serum bilirubin every 6 h, can also
be difficult to interpret. Not only is there patient overlap in
bilirubin values, but a subset of patients with significant
pancreatitis can maintain serum hyperbilirubinemia because
of pancreatic head edema compressing the distal biliary tree.
This paper by Acosta et al. (1) is most useful, in my
opinion, because it stresses clinical and biochemical param-
eters available to us all. Hold the urgent MRCPs and EUS
studies, not to mention the ERCPs, which have been proven
useful in patients with severe pancreatitis and those with
concomitant cholangitis but may have dubious value in mild
gallstone pancreatitis (3–5). Save the latter studies for the
sick and do them preoperatively. For those patients who
improve rapidly (mean time for bilirubin to fall was 26 h in
the study by Acosta et al.), send them for (laparoscopic)
cholecystectomy and mandatory IOC. Should a stone be