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22 Cards in this Set
- Front
- Back
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GI System- Upper Gastrointestinal Issues of the Geriatric Patient by Knepp
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GI System- Upper Gastrointestinal Issues of the Geriatric Patient by Knepp
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Physiology that does not change:
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•Esophageal function persist until very advanced age.
•Incidence of reflux is stable but the duration of each reflux episode is longer. •Gastric emptying of solids remains stable although liquid emptying is prolonged. •Small bowel transit times remain stable. |
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What's often the last thing that stops working for a patient?
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swallowing.
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Declining absorption-secretion functions:
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Gastric prostagladin synthesis
Bicarbonate secretion Nonparietal fluid secretion Jejunal lactase activity Vitamin D absorption Zinc absorption Calcium absorption |
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Stable absorption – secretion functions.
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Intrinsic factor secretion
Duodenal glucose transport Protein digestion and assimilation Fat absorption Thiamine (B1) absorption Cyanocobalamin (B12) absorption Ascorbic Acid (C) absorption Iron absorption (if not hypochlorhydric) |
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Key Point #1
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Most changes of the function and structure of the upper gastrointestinal tract in elderly patients presenting with clinical symptoms, are the result of pathological changes secondary to disease processes, rather than being the direct result of aging alone!
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UGI System includes...
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-Oral cavity (teeth, mucosa, tongue, salivary glands)
-Pharynx (oral, laryngeal) -Upper Esophageal Sphincter (UES) -Esophagus and LES -stomach -small intestine |
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Deglutition, oropharyngeal stage..which cranial nerves are involved?
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-Begins with contraction of tongue and striated muscles.
-Food bolus is propelled into the oropharnyx which triggers the involuntary swallow reflex. -The cerebellum controls the motor output of the motor nuclei of CN V, VII and XII. -The sequence lasts about one second -The soft palate elevates to close the nasopharynx. -The suprahyoid muscles pull the larynx up and forward. -The epiglottis covers the trachea. -Striated pharyngeal and upper esophageal muscles move the food past the cricopharyngeus muscle (UES) into the proximal esophagus. This lasts about one second and involves the motor and sensory tracts of CN IX and X. |
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Deglutition, esophageal stage... what initiates the involuntary/ voluntary swallow reflex?
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-As food enters the esophagus, involuntary smooth muscles force the bolus through the mid and distal esophagus.
-The medulla controls the involuntary swallow reflex. -Voluntary swallows may be initiated by the cerebral cortex. -The lower esophageal sphincter (LES) relaxes at the initiation of the swallow and stays relaxed until the food passes into the stomach (8 to 20 seconds). |
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Key Point #2.. what's the NUMBER ONE problem with impaired swallowing?!
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-The number one problem with an impaired swallowing process is aspiration!
-Involuntary aspiration in an elderly, immune compromised patient will lead to aspiration pneumonia. -Unrecognized and inadequately treated, pneumonia will lead to death! -any kind of cerebral infarction can affect the swallowing process (many CNs involved in deglutition) When related to the UGI system, the elderly patient’s presenting complaint will often be: Weight loss, Fatigue, Difficulty swallowing -think OLDCAARTS |
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Dysphagia
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-The sensation of impaired passage of food or liquids from the pharnyx to the stomach.
-Odynophagia is used to describe painful swallowing. -*Dysphagia is not attributable to normal aging! -Dysphagia is an alarm signal that deserves immediate evaluation! -*Most common esophageal complaint of the elderly. -Pyrosis is used to describe heartburn. |
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Oropharyngeal dysphagia
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Can also be called transfer dysphagia and results from disease affecting the pharnyx, the upper esophageal sphincter or the upper esophagus.
DDx: *neurological (stroke, dementia, parkinson's) iatrogenic (medicaions) infectious (mucositis like herpes or candida) dentition aka no teeth (edentulous) metabolic (endocrine things) myopathic structural (Zenker's diverticulum) |
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Esophageal dysphagia
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Arises within the body of the esophagus, the lower esophageal sphincter or the cardia of the stomach.
DDx from mechanical lesions: -intrinsic (caustic esophagitis, esophageal strictures, malignancy, pill esophagitis, post surgery, post radiation, reflux disease) -extrinsic (enlarged aorta, mediastinal mass, post surgery) -hiatal hernia DDx from motility disorders: -achalasia (loss of dilation in LES) -diffuse esoph. spasm |
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What are some important history elements in making diagnosis?
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-Alcohol abuse, smoking, weight loss -consider malignancy.
-dry mouth, eyes - saliva productions -nerve dysfunction/muscle weakness clues -halitosis, food regurg, cough-> diverticulum (such as Zenker's) -pain ->inflammatory process -fatigue-> MG |
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Videofluoroscopy
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Patient swallows a barium bolus.
Fluoroscopy video recordings are made as the barium passes through the oral, pharynx and esophagus. Study can identify the following: -Inability or excessive delay in initiation of pharyngeal swallowing. -Aspiration of ingestate. -Nasopharyngeal regurgitation. -Residue of ingestate within the pharyngeal cavity after swallowing. |
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Barium Swallow
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Patient ingests barium bolus.
X-rays are take as the barium passes through the esophagus and into the stomach. Serial small bowel follow-up x-rays can be taken. Good for identifying achalasia (bird beak) and some mechanical and motility disorders. |
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Nasopharyngeal Laryngoscopy
Manometry Endoscopy |
Allows direct visualization of oropharynx, hypopharynx, larynx and proximal esophagus.
Permits direct biopsy of masses. Can be performed at bedside. Good for evaluating sphincter function. Can identify muscle dysfunction. Can identify peristalsis dysfunction related to nerve dysfunction. Permits direct visualization of esophagus, stomach and duodenum. Allows biopsies to be taken. Balloons can be introduced to dilate strictures. |
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Most common voluntary phase problem is due to? and what is the most likely cause of that?
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neurological, stroke.
dx with brain imaging. if the problem is oropharyngeal, you really gotta worry about stroke. |
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Treatment-Esophageal Dysphagia
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-Peptic stricture (complication of GERD), medical management, therapeutic endoscopy.
-Esophageal webs and rings, dietary changes and endoscopy. -Carcinoma requires surgical excision, chemotherapy and/or radiation therapy. -Achalasia requires diagnosis by barium x-ray. Care must be taken not to cause perforation with endoscopy. |
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Esophagitis/Pill Esophagitis
treatment |
-Remove offending agent.
-Mechanical soft diet with high liquid content. -Reduce possibilities of Gastric Reflux including medication therapy. -Consider oral liquid sulcralfate suspension. -Hold alendronate until asymptomatic. -Reinstruct in correct method of taking alendronate. -Consider repeat endoscopy in a few weeks to confirm healing and reevaluate for carcinoma. |
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Treatment-Oropharyngeal Dysphagia
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Tumors require resection, chemotherapy or radiation therapy.
Neurological injuries require rehabilitation, swallow therapy. Esophageal webs and strictures usually benefit from therapeutic endoscopy. Surgery is required for Zenker’s diverticulum. |
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stroke patient treatment
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For stroke patients, immediate evaluation is required before starting oral intake.
IV fluids and nasogastric feedings may be needed. Speech therapy evaluation and swallowing exercises may allow return to oral intake. If not, long-term decisions on placement of permanent gastric or jejunal feeding tubes will need to be made. Always be aggressive with acute symptom onset. |
