Best Practice & Research Clinical Gastroenterology RSS feed: Current Issue. In practical paperback format, each 200 page topic-based issue of Best Practice & Research Clinical Gastroenterology will provide a comprehensive review of current clinical practice and thinking within the specialty of gastroenterology. All chapters are commissioned and written by an international team of practising clinicians with the Guest Editors for each issue drawn from a pool of renowned experts and opinion leaders. Reference is made to: • the latest original research • Cochrane Reviews • audits and confidential enquiries • national and international conferences • national and international guidelines • personal communications All chapters take the form of practical, evidence-based reviews that seek to address key clinical issues of diagnosis, treatment and patient management. Each issue follows a problem-orientated approach that focuses on the key questions to be addressed, clearly defining what is known and not known. Management will be described in practical terms so that it can be applied to the individual patient. Boxed and bulleted Learning Objectives and Practice Points are features within each chapter and will highlight the core and essential knowledge that will help the physician to provide the best care to their patients. The series' objective is to provide a continuous update for the busy clinician and researcher. 2009 topics Vol 23:1 February - Emerging Diseases of the Gastrointestinal Tract Ernst J. Kuipers (The Netherlands) 2008 topics Vol 22:3 June - Eosinophils in Healthy Gut and Gastrointestinal Diseases S. C. Bischoff (Germany) and A. Straumann (Switzerland) Vol 22:4 April - Advances in diagnostic assessment of the oesophageal mucosa J Dent (Australia), P Sharma (USA), G N Tytgat (The Netherlands) Vol 22: 5 October - Gastrointestinal Endoscopy G N Tytgat (The Netherlands) Vol 22: 6 December - Recent Developments in Hepatitis B & C S. W. Schalm and H. L. A. Janssen (The Netherlands) 2007 topics, volume 21, issues 1-6 Vol 21:1 February - Complications of cirrhosis D Lebrec (France) Vol 21:2 April - Helicobacter Pylori A Axon (UK) Vol 21:3 June - The difficult patient in gastroenterology J Tack (Belgium) and J Scholmerich (Germany) Vol 21:4 August - Severe gastrointestinal motor disorders G E Boeckxstaens (The Netherlands) Vol 21:5 October - Pregnancy-related gastroenterological and hepatological diseases and complications F Shanahan (Ireland) Vol 21:6 December - The multidisciplinary management of gastrointestinal cancer E. van Gutsem (Belgium) 2006 topics, volume 20, issues 1-6 Vol 20:1 February - Advances in imaging of the GI tract G Bianchi Porro (Italy) Vol 20:2 April - Pancreatic cancer J Neoptolemos UK) Vol 20:3 June - Novel developments in GI nutrition L Mathus-Vliegen (The Netherlands)and A Thomson (UK) Vol 20:4 August - Gastric cancer K McColl (UK) Vol 20:5 October - Oesophageal cancer J van Lanschot and G Tytgat (The Netherlands) Vol 20:6 December - Gallstone disease K van Erpecum and P Portincasa (The Netherlands) http://www.bpgastro.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Best Practice & Research Clinical Gastroenterology1521-6918236December 2009 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.bpgastro.com/article/PIIS1521691809001437/abstract?rss=yesAims & Scope/ Editorial Board10.1016/S1521-6918(09)00143-7Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9iiiiiihttp://www.bpgastro.com/article/PIIS1521691809001358/abstract?rss=yesWith the increase in the aging population, the study and care of gastrointestinal disorders in the elderly have become priority topics for both clinicians and researchers. In the last years the medical literature has provided several studies on the changes that occur in gastrointestinal physiology as a function of advanced age, as well as on clinical features of gastrointestinal diseases associated with aging.PrefaceAlberto Pilotto10.1016/j.bpg.2009.10.007Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9791792http://www.bpgastro.com/article/PIIS152169180900136X/abstract?rss=yesPopulation aging is a global phenomenon. It is estimated that there were 600 million people in the world aged 60 and over in 2000 and that there will be 1.2 billion by 2025. People aged 65 and over comprise 16% of the population of Europe. About half of the world's elderly population live in the developing world.Many of the gastrointestinal disorders seen in specialist practise show age-specific incidence and prevalence rates that increase substantially with increasing age. In this review, hospitalization rates for gastroenterological disorders in England are presented by age to demonstrate gradients with age. Some of the disorders, such as colorectal cancer, appendicitis, diverticular disease and inflammatory bowel disease, became common in developed countries in association with economic development and changes in lifestyle. As the developing world becomes more urbanised and westernised, disorders that are now rare in the developing world will probably become much more common.Demography of aging and the epidemiology of gastrointestinal disorders in the elderlyMichael J. Goldacre10.1016/j.bpg.2009.10.008Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9793804http://www.bpgastro.com/article/PIIS1521691809001334/abstract?rss=yesDuring ageing, histological and physiological modifications occur in the stomach leading to a confirmed state of gastric frailty defined by a decreased capacity of tissue repairing after mucosa gastric aggression. The process of intrinsic gastric ageing may play a role in inducing abnormalities of gastric epithelial proliferation against injury but, most of the time, pathophysiological modifications observed in older people are the consequences of chronic insults, such as chronic Helicobacter pylori infection, polymedication, especially Proton-pump inhibitors(PPI) and Non-steroidal Anti-inflammatory Drugs(NSAID), and co morbidities. One of the major clinical consequences of the gastric frailty is the higher vulnerability to the occurrence of peptic ulcer disease during ageing.In this review recent data on gastric changes during ageing, focussing especially on histological modifications and motility disorders are summarized.Is stomach spontaneously ageing? Pathophysiology of the ageing stomachNathalie Salles10.1016/j.bpg.2009.09.002Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9805819http://www.bpgastro.com/article/PIIS1521691809001280/abstract?rss=yesEven though endoscopy is performed in patients of all ages, currently there is little literature on this topic in elderly patients. As a result of population demographics the use of endoscopy is expected to rise in this section of the population. Elderly patients represent a special group of patients, as they usually have a higher incidence of co-morbid diseases and may be more susceptible to endoscopic interventions. Due to the decreased physiologic reserve and associated diseases, complications in elderly patients can be more severe than in adult or young subjects. Moreover, ethical considerations play a special role in elderly frail patients with a potential poor prognosis. Thus, the endoscopist needs to pay special attention when considering or performing endoscopy in elderly patients.The aim of this article is to review the role of endoscopy in elderly patients, paying special emphasis on indications, special precautions and specific interventions.Gastrointestinal endoscopy in the elderly: Current issuesKlaus Mönkemüller, Lucia C. Fry, Peter Malfertheiner, Walter Schuckardt10.1016/j.bpg.2009.10.002Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9821827http://www.bpgastro.com/article/PIIS1521691809001279/abstract?rss=yesThe Comprehensive Geriatric Assessment (CGA) is a multidimensional, usually interdisciplinary, diagnostic process intended to determine an elderly person's medical, psychosocial, and functional capacity and problems with the objective of developing an overall plan for treatment and short- and long-term follow-up. The potential usefulness of the CGA in evaluating treatment and follow-up of older patients with gastroenterological disorders is unknown. In the paper we reported the efficacy of a Multidimensional-Prognostic Index (MPI), calculated from information collected by a standardized CGA, in predicting mortality risk in older patients hospitalized with upper gastrointestinal bleeding and liver cirrhosis. Patients underwent a CGA that included six standardized scales, i.e. Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Short-Portable Mental Status Questionnaire (SPMSQ), Mini-Nutritional Assessment (MNA), Exton-Smith Score (ESS) and Comorbity Index Rating Scale (CIRS), as well as information on medication history and cohabitation, for a total of 63 items. The MPI was calculated from the integrated total scores and expressed as MPI 1=low risk, MPI 2=moderate risk and MPI 3=severe risk of mortality. Higher MPI values were significantly associated with higher short- and long-term mortality in older patients with both upper gastrointestinal bleeding and liver cirrhosis. A close agreement was found between the estimated mortality by MPI and the observed mortality. Moreover, MPI seems to have a greater discriminatory power than organ-specific prognostic indices such as Rockall and Blatchford scores (in upper gastrointestinal bleeding patients) and Child-Plugh score (in liver cirrhosis patients). All these findings support the concept that a multidimensional approach may be appropriate for the evaluation of older patients with gastroenterological disorders, like it has been reported for patients with other pathological conditions.The Comprehensive Geriatric Assessment and the multidimensional approach. A new look at the older patient with gastroenterological disordersAlberto Pilotto, Filomena Addante, Grazia D'Onofrio, Daniele Sancarlo, Luigi Ferrucci10.1016/j.bpg.2009.10.001Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9829837http://www.bpgastro.com/article/PIIS1521691809001310/abstract?rss=yesDiseases of the upper gastrointestinal tract such as gastroesophageal reflux disease (GERD), peptic ulcer and gastric cancer become more common and more severe with advancing age. Older individuals also tend to have a higher prevalence of co-morbid factors, such as Helicobacter pylori infection, presence of other diseases, or use of medications (e.g., nonsteroidal anti-inflammatory drugs, bisphosphonates) that increase their risk for acid-related disorders. Unfortunately, in the elderly patient with these disorders symptom presentation may be slight or atypical, resulting in a delayed diagnosis.In general, the treatment of older individuals with peptic ulcer or GERD and its complications is similar to that of younger individuals. Proton pump inhibitors are the basis of therapy for symptom relief, healing of erosive esophagitis and peptic ulceration, reduction of the risk for NSAID induced mucosal damage, and prevention of disease relapses.The strongest prevalence of H.pylori infection in the elderly, as well as the role of H.pylori in the occurrence of gastric lesions, in particular ulcer diseases, gastric precancerous lesions and gastric cancer, make the diagnosis and the eradication of H.pylori in this population of the utmost importance. Strategies to improve the management of upper gastrointestinal diseases in older people will reduce mortality and improve quality of life.Acid-related disorders in the elderlyMarilisa Franceschi, Francesco Di Mario, Gioacchino Leandro, Stefania Maggi, Alberto Pilotto10.1016/j.bpg.2009.10.004Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9839848http://www.bpgastro.com/article/PIIS1521691809001346/abstract?rss=yesDrug use increases with age and the elderly is at increased risk of adverse drug reactions. Gastrointestinal adverse effects are one of the most often reported. Serious event are mostly caused by NSAIDs and/or aspirin which are the most widely prescribed medications in the world. NSAIDs and/or aspirin use are associated with complications from both the upper and the lower gastrointestinal tract. The risk of these complications depends on presence of risk factors, and age is the most frequent and relevant one. At-risk patients should be on prevention strategies including the use of the lowest effective dose, co-therapy with a gastroprotective agents or use of a COX-2 selective agent. Treatment of Helicobacter pylori infection is beneficial in patients starting therapy with these agents, especially in the presence of ulcer history. The best strategy to prevent lower GI complications has yet to be defined.Drug-related damage of the ageing gastrointestinal tractCarlos Sostres, Carla Gargallo, Angel Lanas10.1016/j.bpg.2009.10.006Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9849860http://www.bpgastro.com/article/PIIS1521691809001371/abstract?rss=yesAbstract: The topic of gastroenterology (GI) in the elderly has been extensively reviewed. It takes special skill, patience and insight to interview the elderly, as well as to appreciate their altered physiology and interpretation of their presenting symptoms and signs, often against an extreme background of complex medical problems. The maldigestion and malabsorption coupled with altered motility contributes to the development of malnutriton. There generally a decrease of function of the GI tract, but there may be loss of adaptability in response to changes in diet or nutritional stress. Pathological alterations which might lead to minor overall intestinal functional variations in the young because of a normal process of adaptation, may lead to much more serious events in the elderly.Small intestinal disorders in the elderlyAlan B.R. Thomson10.1016/j.bpg.2009.10.009Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9861874http://www.bpgastro.com/article/PIIS1521691809001292/abstract?rss=yesThe prevalence of constipation increases with age. However, constipation is not a physiological consequence of normal ageing. Indeed, the aetiology of constipation in older people is often multifactorial with co-morbid diseases, impaired mobility, reduced dietary fibre intake and prescription medications contributing significantly to constipation in many instances. A detailed clinical history and physical examination including digital rectal examination is usually sufficient to uncover the causes of constipation in older people; more specialized tests of anorectal physiology and colonic transit are rarely required. The scientific evidence base from which to develop specific treatment recommendations for constipation in older people is, for the most part, slim. Constipation can be complicated by faecal impaction and incontinence, particularly in frail older people with reduced mobility and cognitive impairment; preventative strategies are important in those at risk.Constipation in old agePaul Gallagher, Denis O'Mahony10.1016/j.bpg.2009.09.001Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9875887http://www.bpgastro.com/article/PIIS1521691809001383/abstract?rss=yesColorectal cancer is one of the commonest tumours in the Westernized world affecting mainly the elderly. This neoplasm in older individuals occurs more often in the right colon and grows more rapidly than in the young, often shows a mucinous histology and mismatch repair gene changes. Effective screening permits discovery of colorectal cancer at an early highly treatable stage and allows for detection and removal of premalignant colorectal adenomas. Screening methods that focus on cancer detection use fecal assays for the presence of blood or altered DNA, those for detection of adenomas (and early cancer) use endoscopic or computerised radiologic techniques. Broad use of screening methods has lowered colorectal cancer development by about 50%. In addition, prevention of the earliest stage of colon carcinogenesis has been shown to be effective in small prospective studies and epidemiologic surveys but have not been employed in the general population.Since 1996 the chemotherapeutic armamentarium for metastatic colorectal cancer has grown beyond 5-fluorouracil to include an oral 5-fluorouracil prodrug, capecitabine as well as irinotecan and oxaliplatin. Three targeted monoclonal antibodies (Moabs), bevacizumab (an anti-vascular endothelial growth factor Moab) and cetuximab/panitumumab, both anti-epidermal growth factor receptor inhibitors, have also earned regulatory approval. Most stage IV patients are treated with all of these drugs over 2 or 3 sequential lines of palliative chemotherapy and attain median survivals approaching 24 months. Lastly, adjuvant oxaliplatin plus 5-fluorouracil for high risk resected stage II and stage III colon cancer patient has led to substantial improvement in cure rates. With appropriate care of age associated comorbidities these treatment modalities are feasible and effective in the geriatric population.Colon cancer and the elderly: From screening to treatment in management of GI disease in the elderlyPeter R. Holt, Peter Kozuch, Seetal Mewar10.1016/j.bpg.2009.10.010Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9889907http://www.bpgastro.com/article/PIIS1521691809001322/abstract?rss=yesAbstract: Although there are no specific age-related liver diseases, it is increasingly recognized that the percentage and the actual number of elderly will increase substantially over the next twenty years.Moreover, the developments of new emerging conditions (e.g. non-alcoholic steatohepatitis) and novel therapeutic approaches have provoked increasing enthusiasm among hepatologists. Some liver diseases are particularly frequent in the elderly, e.g. chronic hepatitis C and hepatocellular carcinoma. The clinical course and management of liver disease in the elderly may differ in several aspects from those of younger adults. The problem of whether to offer antiviral treatment to a wide range of patients with chronic hepatitis C has arisen over the last eight to ten years, since the reduction in the risk of hepatocellular carcinoma was analyzed. Selected patients aged 65 and older have a chance of treatment with pegylated interferon plus ribavirin, despite a higher likelihood of side effects. The diagnosis of autoimmune hepatitis should be suspected in a patient over 65 years of age in case of ‘acute’ presentation with 10-fold increase in transaminases, jaundice and hyper-gammaglobulinemia, to avoid any delay in starting immunosuppressive therapy. The age of an end stage liver disease will increase over the next years, thus we will expects an increasing number of decompensated liver disease and hepatocellular carcinomas.Liver disorders in the elderlyAnnarosa Floreani10.1016/j.bpg.2009.10.005Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9909917http://www.bpgastro.com/article/PIIS1521691809001309/abstract?rss=yesAbstract: Hepato-pancreatico-biliary (HPB) surgery encompasses major hepatic resection and pancreatic surgery, both procedures of high complexity with a potentially high complication rate. The establishment of centres of excellence with a high patient volume has lowered the complication and increased the resection rate. Besides this, increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Because elderly patients have more co-morbidities and decreased life expectancy, the benefit of these procedures must be critically evaluated in such patients. Analysis of the literature on this subject demonstrated that pancreatico-duodenectomy can be performed safely in selected elderly patients (80 years of age or older), with morbidity and mortality rates approaching those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumour or gallbladder carcinoma. Nevertheless, those elderly patients who will benefit from surgery must be critically selected.Surgical aspects in management of hepato-pancreatico-biliary tumours in the elderlyPierluigi di Sebastiano, Leonardina Festa, Markus W. Büchler, Fabio F. di Mola10.1016/j.bpg.2009.10.003Best Practice & Research Clinical Gastroenterology 23, 6 (2009)2009-12-01Best Practice & Research Clinical Gastroenterology2009-12-01236S1521-6918(09)X0008-9919923