During the aging process , the digestive system , like any other in the body , undergoes modifications derived both from its own use due to the passage of time, as well as from diseases and surgical mutilations accumulated during life or from environmental conditions and risk factors to that the individual has been exposed (environment).
Description
As the losses derived from the aging process affect the whole organism to a greater or lesser extent , the possibilities of simultaneous claudication of other organs or systems will also be higher, for this reason the diagnosis in an elderly man with digestive manifestations requires a exhaustive evaluation that allows to lay the foundations for a correct therapeutic action.
Digestive conditions
The physiological modifications typical of aging that bring with them disorders of the ingestion , digestion and absorption of food frequently cause the following digestive disorders.
Gustatory dysfunction
The chemoreceptor cells for mouthfeel are surrounded by a network of nerve fibers and are arranged in papillae, distributed by the buccal cavity , especially in the dorsum .
Among the most frequent causes of taste dysfunction can be cited:
a) The processes that condition an alteration of saliva (in the period of senescence there is a decrease in salivary secretion and the stimulating functions of the taste, lubrication , digestive, bactericidal , among others, receptors are inhibited ).
b) Direct damage to papillary receptors originates from taste alterations (it can occur in elderly patients in malnutrition states and determined by socioeconomic factors that limit the variety and quality of digested food ).
Functional Dyspepsia
Clinical condition characterized by the occurrence of symptoms attributable to the most proximal segments of the gastrointestinal tract , in patients who do not present evidence of organic disease of the digestive tract , after appropriate endoscopic , ultrasonographic , biochemical , hematological and microbiological examinations .
Its causal agent is mainly due to the following mechanisms:
- Gastrointestinal motility abnormalities (with age, in the digestive system there is a slowdown in gastrointestinal motility and decreased secretion and gastric emptying rate).
- Increased visceral sensitivity to stimuli from the digestive tract lumen (the decline in the relationship between organs and systems causes, during aging, a consequent decrease in splanchnic flow in order not to affect other risk areas).
- Anomalies in the psycho- emotional sphere (in senile age, psychic decline restricts human contacts, which means apathy, depression and anorexia )
Intestinal Malabsorption
It is characterized by inadequate absorption of nutrients from the intestine until their incorporation into the bloodstream or lymph . It is considered that there is malabsorption when there are certain alterations in the interior of the intestine, in its wall or in lymphatic transport.
Clinical manifestations : diarrhea , steatorrhea , notable weight loss, anemia and malnutrition , derived from the disorder in the absorption of various nutrients, such as fats, proteins , carbohydrates , vitamins and minerals . Basically, malabsorption is the consequence of the alteration of the following functions or, at least, one of them.
a) Intraluminal digestion : intestinal absorption is altered in the elderly, without reaching malabsorption with steatorrhea, which seems to be related to ischemia of the small intestine, since steatorrhea is more frequent in the elderly who have suffered cerebral stroke or myocardial infarction.
b) Terminal digestion : The intestinal mucosa wall has a brush border where the hydrolysis of carbohydrates occurs. Destruction of this can lead to malabsorption problems. With aging, the level of enzymatic secretion necessary for proper digestive function decreases.
c) Transepithelial transport or absorptive phase : Aging brings with it a thinning and reduction of the absorptive surface in the small intestine, with the consequent decrease in the absorption of water, iron, vitamin D and calcium. Gluten (celiac disease) or lactose intolerance can sometimes be observed.
d) Lymphatic transport : Circulatory disorders typical of aging affect lymphatic circulation to some extent .
Metabolic Alterations of the Liver
The liver is the main organ responsible for the biotransformation of drugs , it synthesizes proteins that transport drugs in the blood , maintains the osmotic pressure of the extracellular fluid and synthesizes other active molecules , such as various coagulation factors .
The aging of this causes the following changes :
- Decreased organ size as well as blood flow with redistribution of regional blood flow
- Reduction in the activity of liver microsomal enzymes and their metabolic functions ( bromosulfthalein clearance , microsomal oxidation , demethylation, and superoxide dismutase activity ).
- Decreased protein synthesis, with reduction of plasma albumin and vitamin k .
Fecal incontinence
The fecal continence results from the existence of a number of barriers to control the evacuation of feces. These barriers are reversible and, when they disappear, they allow defecation . Fecal continence includes the following mechanisms: arrival of fecal content to the rectum, rectal distention and accommodation, internal anal sphincter response , rectal and pelvic sensation , as well as skeletal muscle response . Stool is usually retained in the sigmoid colon and presents to the rectum only intermittently. Rectal accommodation to strain depends on the intrinsic nervous system and its own smooth muscles.
The internal anal sphincter is primarily responsible for maintaining the resting position in the anal canal ; its hypotonia has been related to the appearance of fecal incontinence in certain groups of patients, such as diabetics, after anal dilations, in senescence and in some individuals with neurogenic or idiopathic incontinence .
Intestinal and Colonic Diverticulosis
The intestinal diverticulosis and colonic is rare before age 40 and increases with age, from 5% in the fifth decade of life , up to 50% in the ninth. About 80% of those who suffer from it are asymptomatic; This is diagnosed by means of a colon exploration ( radiographic or endoscopic), when trying to know the cause of the abdominal discomfort.
The main symptom is continuous or intermittent abdominal pain , usually mild and located mainly in the left iliac fossa. It is usually relieved by passing gas or passing gas, or both, and worsens after ingestion of food . Sometimes diverticular disease of the colon evolves with severe pain that lasts from a few hours to several days and is clinically difficult to differentiate from acute diverticulitis . Patients may also have a variation in the rhythm of bowel movements ( constipation or diarrhea or both), abdominal distension , rectal urgency , and discharge of mucus with the stool.
The colonic location of the diverticula is the most frequent in the entire digestive tract , since they appear in the area between the mesenteric longitudinal muscle tape and the two antimesenteric tapeworms, together with the small arteriolar vessels, which explains the pathogenesis of the hemorrhage diverticular , without diverticulitis . It is estimated that 95% of colon diverticula are located in the sigmoid. Over the years, the diverticula increase in number and size, but they rarely spread to other areas of the colon.
There are two forms of diverticulosis: those associated with a spastic colon and thickening of the muscle layers, and those without colon spasticity or muscle thickening. On physical examination, the left colon is often palpated as an elongated, elastic, and painful mass ( colic chord ).
Constipation
This is a symptom caused by numerous diseases and other circumstances, characterized by its pathogenic and pathophysiological complexity. The elderly are the most affected by constipation, with a prevalence of 23% and 42% in men and women over 60 years of age, respectively.
The diagnostic evaluation in these patients must exclude, by means of pertinent examinations, local organic causes (especially colorectal cancer) or systemic causes capable of altering the stool rhythm ; It is also necessary to review the hygienic-dietetic conditions, the ingestion of drugs, as well as the family and social health conditions.
Once the possible causes of constipation have been ruled out , the pathophysiological conditions of colonic transport and rectal evacuation will be analyzed, which can be divided into two large groups, according to imaging techniques:
- Due to alterations in the colonic progression of the fecal content (transit constipation).
- Due to disorders in rectal evacuation (distal constipation or functional obstruction of the outflow tract). The latter includes constipation in the elderly, whose main clinical manifestation is constipation accompanied by impaction due to fecalomas and false incontinence due to overflow.
In these patients, the bowel habit is characterized by infrequent stools, heavy stools, frequent impaction, and involuntary leakage due to overflow. There are multiple pathogenic pathways that motivate this situation:
- Inadequate diet (low amount of fiber and water).
- Mental state ( depression , dementia , among others).
- Administration of a large number of drugs ( antacids , antidepressants , [[ calcium channel blockers ).
- Frequent suffering from digestive and extra- digestive diseases that can impair defecation habits.
- Immobility in many patients.
- Difficulty in accessing the laundries in some homes.
- Neglect by relatives or institutions.
The greatest complication of constipation in these cases is fecal impaction, almost always accompanied by incontinence, which can cause intestinal obstruction.
Treatment of fecal impaction is performed by digital extraction, if possible, or by repeated cleansing enemas with saline solutions; In some patients, it may be necessary to administer polyethylene glycol solutions orally or by nasogastric tube to wash the colon.
After achieving disimpaction and the disappearance of the fecaloma , a diet rich in vegetable residues and even supplemented with fiber, abundant ingestion of fluids, and general hygiene measures ( physical exercise , defecation with a fixed schedule, among others) should be indicated. The administration of laxatives (of the lactulose type) may be necessary, as well as cleansing enemas every 5-6 weeks, especially in the elderly with recurrent fecal impaction.
The digestive disorders are very common in the elderly, so diagnosis requires a thorough evaluation to lay the groundwork for successful therapeutic action. Based on this, decisions must be individualized as much as possible, and always bear in mind the physiological changes typical of aging that bring about the appearance of disorders of food ingestion , digestion and absorption.