Chronic Constipation in the Elderly Patient: Updates in Evaluation and Management.

Chronic constipation (CC) is a common disorder in the elderly population globally and is associated with comorbidities and negative implications on the quality of life. Constipation prevalence varies in different studies, primarily owing to the nonuniformity of the diagnostic criteria. However, 15%-30% of individuals aged >60 years are diagnosed with CC. Primary care physicians are the main healthcare providers that manage constipation in elderly patients in parallel with increased population aging and increased prevalence of constipation. Physical inactivity, polypharmacy, chronic medical conditions, rectal hyposensitivity, and defecatory disorders all play a role in the pathogenesis of CC in elderly patients. Detailed anamnesis, particularly history related to chronic medication use, with digital rectal examination may assist in identifying constipation causes. Additionally, blood tests and colonoscopy may identify organic causes of CC. Physiologic tests (i.e., anorectal manometry, colonic transit time with radiopaque markers, and defecography) can evaluate the physiologic function of the colon, rectum, and anus. However, generally, there are several causes of constipation in older patients, and an individualized approach is recommended. Treatment of chronic idiopathic constipation is empiric, based on the stepwise approach. Lifestyle advice, adjustment of chronic medications, and prescription of laxatives are the first steps of management. Several laxatives are available, and the treatment is evolving in the last decade. Biofeedback is an effective therapy especially for defecatory disorders. This review aimed to summarize the most updated knowledge for primary care physicians in the approach and management of CC in elderly patients.

Ethnic Variations in Inflammatory Bowel Diseases Among Israel's Populations.

BACKGROUND: Crohn's disease and ulcerative colitis are the two major classic presentations of inflammatory bowel diseases (IBD). Studies have shown a wide variation in the incidence and prevalence attributed to different geographic and ethnic populations. OBJECTIVES: To assess the clinical characteristics of IBD among Arabs in Israel and to compare them to characteristics of IBD among Ashkenazi Jews. METHODS: This retrospective, comparative study compared the clinical characteristics of IBD among 150 Arabs from the Holy Family Hospital and the Nazareth Hospital EMMS, both located in Nazareth, Israel, to those of 97 age- and sex-matched Ashkenazi Jewish patients from Shaare Zedek Medical Center, Jerusalem, Israel. RESULTS: The Arab cohort, which included 106 patients (70%) with Crohn's disease and 44 (29%) with ulcerative colitis, was compared to 97 Ashkenazi patients (81% with Crohn's disease and 17% with ulcerative colitis) (P < 0.05). Alcohol consumption was found in both groups, but Arabs smoked more (46% vs. 12%, respectively, P < 0.05). Obstructive phenotype was lower in Arabs (10% vs. 32%, P < 0.05). 5-aminosalicylic acid and anti-tumor necrosis factor alpha were prescribed for the Arab and Ashkenazi groups (89% and 21%, respectively). The need for surgical intervention due to disease severity and/or complications was not significant (22% vs. 24%). CONCLUSIONS: Despite similar reports of NOD2/CARD15 mutations, Crohn's disease is more common than ulcerative colitis within the Arab-Israeli population. Increased smoking rates may explain milder disease severities in Arabs, as reflected by lower obstructive pattern and frequent use of milder therapeutic modalities.

Impact of Chronic Statins Use on the Development of Esophagitis in Patients with Gastroesophageal Reflux Disease.

Background and Aims: We aimed to assess whether chronic statins used (> 6 months) were protective of the development of esophagitis in patients with gastroesophageal reflux disease. In the presence of esophagitis, complications such as strictures, Barrett's esophagus, and adenocarcinoma were the most common. Statins, lipid lowering drugs with a pleiotropic effect, are recently implicated in various pathologies. Nevertheless, the possible impact of statins in esophagitis development has never been assessed. Methods: We performed a retrospective, cross-sectional, single center study that included 4148 gastroesophageal reflux disease patients from 2014 and 2018 at EMMS Nazareth Hospital. We divided the patients into 5 groups. The groups were split into positive control group, which was the nonesophagitis group, and the other 4 groups were A-D (as per Los Angeles classification). Results: Overall, out of the 4148 patients included, 48% were males and 2840 patients were in the control group. In groups A, B, C, and D there were 818, 402, 72, and 16 patients, respectively. Logistic regression analysis revealed that chronic statins usage is protective by preventing development esophagitis (OR 0.463 [95%CI 0.370-0.579], p < 0.0001). NSAIDS use, Hiatus hernia, and H. pylori were promoting factors (OR, 1.362, 1.779, and 1.811; 95% CI, 1.183-1.569, 1.551-2.040, and 1.428-2.298; P<0.0001, P<0.0001, and P<0.0001, respectively). Conclusion: Using chronic statins was protective to the development of esophagitis among GERD patients. Our findings of potential clinical application mandate further randomized controlled trials to better assess the impact of statins on esophagitis.

Bloating and Abdominal Distension: Clinical Approach and Management.

Functional abdominal bloating and distension (FABD) are common gastrointestinal complaints, encountered on a daily basis by gastroenterologists and healthcare providers. Functional abdominal bloating is a subjective sensation that is commonly associated with an objective abdominal distension. FABD may be diagnosed as a single entity (the sole or cardinal complaint) or may overlap with other functional gastrointestinal disorders such as functional constipation, irritable bowel syndrome, and functional dyspepsia. The pathophysiology of FABD is not completely understood. Proposed underlying mechanisms include visceral hypersensitivity, behavioral induced abnormal abdominal wall-phrenic reflexes, the effect of poorly absorbed fermentable carbohydrates, and microbiome alterations. Management includes behavioral therapy, dietary interventions, microbiome modulation, and medical therapy. This review presents the current knowledge on the pathophysiology, evaluation, and management of FABD.

Inadequate identification of fatty liver disease, obesity, and metabolic syndrome by family physicians.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is an emerging condition and is constituted as a vital public health epidemic globally. This study evaluated the process of identification and documentation of NAFLD and metabolic syndrome in correlation with those diagnosed with obesity. METHODS: Participants included 352 patients older than 18 years who were diagnosed with fatty liver disease. We performed a cross-sectional study between August 2016 and September 2017. Categorical variables were extracted and analyzed using SPSS. The body mass index (BMI) was determined by the study staff and compared with the data retrieved from the family physician's database. RESULTS: Patients who presented documented BMI in their past medical history showed to be significantly higher than those without documentation of BMI (29+4.4 vs 25.7+4.6 kg/m2, P<0.01). For instance, 54% of patients with NAFLD were documented in the electronic medical record (EMR) by the family physician, with higher documentation rate among males than females. Moreover, 72% qualified for documentation of metabolic syndrome, but only 5% were documented in their EMR. Patients with significant obesity and obesity-related conditions were more likely to have documentation in their EMR. DISCUSSION: Further analyses supported the conclusion that family physicians inadequately identify BMI in the EMR for overweight, obesity, metabolic syndrome, and fatty liver disease. Additional efforts are necessary to improve knowledge of proper identification of NAFLD and metabolic syndrome.

[ACHALASIA: UPDATES ON DIAGNOSIS AND MANAGEMENT FROM THE LAST DECADE].

INTRODUCTION: Achalasia is a rare idiopathic disease, associated with significant morbidity and negative impact on life quality. The disorder is characterized by impairments in the esophageal motility and loss of the lower esophageal sphincter (LES) relaxation. Achalasia symptoms include dysphagia, regurgitations, chest pain, vomiting and weight loss. Diagnosis of achalasia is based on an appropriate clinical presentation and typical findings on complementary tests. These tests include endoscopy showing a dilated esophageal lumen containing fluid or food, High-resolution manometry (HRM) shows evidence of obstruction at the gastro-esophageal junction and motility failure, and barium swallow shows esophageal dilation and distal narrowing. The recent advent of HRM has permitted more precise diagnosis of achalasia and three subtype designations, based on the pattern of esophageal motility disorders, as per the Chicago Classification. Treatment options include: drugs, endoscopic by means of Botox injection or balloon dilation, and the traditional surgery, laparoscopic Heller myotomy (LHM). The new advent in treatment is the novel per-oral endoscopic myotomy (POEM), a less invasive therapy, approaching the traditional LHM. Since the first POEM procedure performed in 2008, massive amounts of evidence are accumulating regarding the high efficacy and safety profiles of POEM, introducing it as an excellent first line treatment. The current review discusses the diagnosis and management of achalasia, with special highlights on the recent progress of HRM and POEM.