Gastrointestinal Disorders in Athletes

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Gastrointestinal Disorders in Athletes

• Scott W. Pyne M.D.
• United States Naval Academy
• Annapolis, Maryland

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Objectives for GI Disorders

• GI physiology in athletes
• Prevention strategies
• Recognize condition in athletes
• Develop differential diagnosis
• Understand staged evaluation
• Appropriate treatment modalities

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GI Physiology with Exercise

• Vagally-mediated transient lower esophageal
  sphincter relaxation
• Supine or forward posture increases
  intra-abdominal pressure
• Increased exercise intensity yields decreased
  esophageal contractions
• Reduced splanchnic blood flow
• NSAIDs affect multiple layers of protective
  barrier

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Rugby Player with Elevated LFTs

• 45 yo male scrum half
• Runs 20 miles/week
• Won game 3 days ago
• Elevated LFTs on Insurance PE

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History

• Trauma I play rugby, what do you think?
• No previous hx or recent illness
• Married without h/o high risk behavior
• Denies abdominal pain, fever, recent illness
• No medications, supplements or travel history
• EtOH I play rugby, what do you think?

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Physical Exam

• WDWN NAD BP 124/84, P 58, T 98.8
• HEENT benign
• Lungs, Cardiac normal
• Abdomen - BS, soft NT, ND, - HSM, masses or
  peritoneal signs
• Extremities FROM, Motor 5/5, minimally tender
  bruising left quad, left shoulder and right eye

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Lab Results

• Normal CBC, Na, K, BUN, Cr, Glu
• AST, ALT, LDH twice normal range
• CPK 3500
• UA normal
• GGT and GLDH normal

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Final Diagnosis and Discussion

• Post-traumatic muscle enzyme elevation
• Relative rest before retesting in 5-7 days
• GGT ad GLDH more specific for hepatocellular
  injury

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20 yo MIDN with Abdominal Pain

• Nose tackle -2nd team
• 3 days before summer practice
• Sent for evaluation by trainer

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History

• 12 hour onset
• No recent illness or travel
• Epigastic pain
• No diarrhea, fever, chills, nausea, vomiting
• Denies anorexia
• No h/o trauma
• Lifting weights yesterday
• No surgical history
• No EtOH

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Physical Exam

• WD WN NAD BP 136/80, P 68, T 99.8
• Normal HEENT, Lungs, Cardiac
• Abdomen Soft, ND, -HSM or masses TTP RLQ,
  increased with abdominal shake, no rigidity
• Rectal normal tone, no pain

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Lab and Radiology Results

• CBC normal HH and Plt, WBC 15
• Abdominal CT fluid around the appendix

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Final Diagnosis and Discussion

• Acute Appendicitis
• Laparoscopic removal
• Returned to play in 3 weeks

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18 yo Cross Country Runner

• Complaint of abdominal pain while running
• High School soccer player trying new sport in
  college

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History

• Never a long distance runner previously
• One week into season
• Worse if she runs after eating
• Denies trauma, recent illness, F/C/N/D
• Keeps up for the first 1 ½ miles
• Pain resolves with rest
• Menarche at 12yo, 10-12 periods/year
• LMP 2 weeks ago

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Physical Exam

• WD WN NAD BP 98/54, P 52, T 97.4
• Normal HEENT, Lungs, Cardiac
• Abd Benign, NTTP
• Normal healthy athlete

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Final Diagnosis and Discussion

• Side stitch
• Multiple possible etiologies diaphragm, pleura,
  hepatic capsule, gas
• Improves with more conditioning
• Avoid post-meal run
• Stretch

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55 yo runner with substernal pain and burning

• Elite masters runner
• Training for Boston
• Last marathon 2 months ago

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History

• Recent worsening of symptoms
• No illness, F/C/N/V
• Worse with meals and interval workouts
• Associated bloating and belching
• Non-smoker with 40 pack year hx
• Doesnt like doctors
• Unsure of BP or blood sugar
• Motrin 800 mg 4 times per week

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Physical Examination

• WD WN NAD BP 158/96, P 62, T 98.4
• HEENT Normal
• Lungs, Cardiac normal
• Abdomen - BS, Soft NT/ND, - HSM, Masses
• Pulses and extremities normal

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HP
Abnormal physical exam Red Flag Sxs Chronic
untreated sxs Dysphagia Wt. Loss Bleeding
Anemia Odynophagia Vomiting Early Satiety
Atypical Sxs/signs Pulmonary Asthma, Chronic
Cough ENT Dental Erosions, Halitosis
Linguinal sensitivity Chronic pharyngitis
Hoarseness Rhinitis/Sinusitis Cardiac
Atypical Chest Pain
Classic Sxs Heartburn Acid
Regurgitation Nonspecific Sxs Nausea,
Dyspepsia, Bloating, Belching, Indigestion,
Water Brash Normal physical exam
Intermittent or Activity-Related Sxs Only
GI Referral Barium Swallow EGD
Empiric GERD Tx
Consider Empiric Therapy Consider Cardiac
Etiology Assess Cardiac Risk Factors Consider
Stress Testing Consider Subspecialist Referral
Cardiology ENT Pulmonary
Good Response
Esophagitis Strictures Barretts
Trial of Episodic Tx Consider Maintenance Tx
NL Studies Diagnosis unclear Sxs despite
therapy Considering surg.
Breakthrough Sxs or Episodic
GERD
Maintenance Therapy
24 pH monitoring Esophageal manometry
Explore Alternate Diagnosis
Negative
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Lab and Tests

• EKG Normal

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Final Diagnosis and Discussion

• GERD
• Decreased pre-run meals
• H2 receptor blocker
• Cardiologist evaluation was normal

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GERD Numbers

• Wt Liftersgtrunnergtcyclistgtwalkers
• Laparoscopic surgery
• 96 improved, 2 worse, 14 require medication

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Greco Roman Wrestler with Pain

• 26 yo Olympic Wrestler
• 2 week prior to US Trials
• Ranked 6th Nationally

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History

• Mid-epigastric gnawing pain
• Rigorous training, but not concerned about weight
• Sx 2-3h after meals, relief with food and
  antacids
• Naproxen 500 mg BID for 6 months
• 2-3 drinks of EtOH/day

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Physical Exam

• WD WN NAD BP 132/76, P 56, T 98.0
• HEENT, Lungs, Cardiac normal
• Abdomen - BS, Soft ND, TTP epigastric, no HSM,
  masses

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Lab

• CBC, Chem panel normal
• H. Pylori positive

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Final Diagnosis and Discussion

• Test and treat
• Retest no sooner than 4 weeks after therapy
• Multiple regimens
• No need for additional imaging unless red flags,
  worsening sx or not resolving despite treatment

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PUD Numbers

• 11-20 males/8-11 females
• H. pylori
• 40 general population
• gt75 gastric ulcers
• gt90 duodenal ulcers
• Non-selective NSAID 1-4/year
• H. pylori NSAID increased risk x 61

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Cross Country Ski Racer with Diarrhea

• Elite level
• Presents after 50Km race
• Personal best time
• Much worse than previously

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History

• Previous h/o gas, bloating, cramping, diarrhea
• Symptoms developed at 30Km point
• Extreme urgency
• Frank blood in diarrhea
• Healthy with no PMH, PSH
• No EtOH, tob, meds or supplements

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Physical exam

• WD WN NAD BP 114/68, P 52. T 96.8
• HEENT, Lungs, Cardiac normal
• Abdomen BS, soft NT, ND, No HSM or masses
• Rectal Normal tone, no fissure, hemorrhoid,
  masses red blood on glove

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Lab and other tests

• Isolated race site with no lab or radiology
  capability
• Snow storm essentially without transport options
• Normal Tilts

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Final Diagnosis and Discussion

• Post-exertional lower GI bleeding
• Roomed with physician and remained clinically
  stable and decreased frequency over night
• Normal LGI work-up 1 week later

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Lower GI bleeding Numbers

• 20 heme positive after marathon
• 6 frank hematochezia
• 17 with previous episode
• 87 heme positive in ultramarathoners

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Runners Diarrhea Theories

• Increased parasympathetic output may intensify
  peristalsis
• Heightened sympathetic tone may increase gastrin
  and motilin release
• Intestinal fluid and electrolyte shifts
• Ischemic enteropathy (70-80 reduction)
• Normal diarrhea causes

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Runners Diarrhea Numbers

• LGI Sx 37-54 runners
• WomengtMen
• Travelers Diarrhea
• 1/3 American travelers to third world
• 20-59 infection rate

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Brief Comments

• Vomiting
• Irritable Bowel Syndrome
• Trauma Spleen, Liver, Hollow organs
• Abdominal muscle contusion