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GI Problems in Athletes

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Dysphagia. GERD: MC cause. Less common causes include: Infectious: HSV, Candida, CMV ... Progressive dysphagia. Recurrent vomiting. GI bleeding. Family history ... – PowerPoint PPT presentation

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Title: GI Problems in Athletes


1
GI Problems in Athletes
  • William Dexter, MD, FACSM
  • Maine Medical Center
  • Sports Medicine

2
My thanks to.
  • Mark Snowise, MD
  • Suburban Medical
  • Pittsfield, MA
  • Mike Pleacher, MD
  • Intermountain Healthcare, Ogden UT

3
Overview
  • Upper GI
  • Runners Diarhea
  • Epidemiology
  • Etiology
  • Common issues
  • Evaluation
  • Treatment

4
Evidence Base . . .
  • Lacking . . .
  • majority of published work has studied normal
    subjects under submaximal efforts for relatively
    short durations.
  • incidence of exercise-associated GI bleeding is
    uncertain and studies are inconclusive.
  • Ex use FOBT non specific

Moses, CSMR 2005, 49195
5
GI Problems Common
  • Upper
  • heartburn, chest pain, belching, epigastric pain,
    nausea, and vomiting
  • reported by up to 50 of athletes during heavy
    exercise

Casey, ClinSportMed 2005 24525-40 Peters,
CSMR2004, 3107111
6
GI Problems Common
  • Lower
  • Ex runners trots

7
GI Problems Common
  • Prevalence of GI symptoms
  • Higher during running
  • Women gt men
  • More common in younger athletes
  • Less frequent in low impact sports
  • Exercise intensity
  • Marathoners 30-80 report GI Sx
  • GI Bleeding can be seen (8 - 85)
  • All sports report
  • 8 to 22 of marathon runners report gross fecal
    blood loss

Jaworski, CSMR 2005, 4137143 Casey,
ClinSportMed 2005 24525-40 Peters, CSMR 2004,
3107111
8
GI Problems Common
  • Mechanical
  • Dietary
  • Ingestions meds, etc
  • Poor adaptation
  • Emotional
  • Infection VGE, travel, other
  • Inflammatory UC, Crohns
  • Functional

9
Benign to catastrophic
  • May interfere with athletic activities
  • (requiring significant accommodations)
  • May also be associated with significant disease

10
Benign to catastrophic
  • May mimic or be an harbinger of other more
    ominous pathology
  • GERD CVD
  • Multiple etiologies
  • Heme pos stool
  • Abdominal pain and bleeding
  • Be attentive, be thorough

11
Suffering in Silence
  • Poorly understood
  • By athletes
  • By sports med staff
  • Symptoms often ignored
  • Commonly
  • Self diagnosed
  • Self treated

12
Gastrointestinal Issues in Athletes Upper Gut
13
General
  • Regular moderate physical activity has been
    associated with
  • Enhanced gastric emptying
  • Improved GI motility
  • Lower risk for liver disease, cholelithiasis,
    diverticulosis, colon CA
  • Less constipation

14
Etiology
  • Delayed gastric emptying
  • Transit time
  • LES changes
  • Gastric distension
  • Gastric blood flow
  • Increased vibration
  • Increased levels of hormones
  • Fluid intake
  • Psychologic

15
Mechanism
  • Slowed motility
  • Duration, amplitude and frequency of esophageal
    contractions
  • Decline with exercise intensity over 90 VO2max
  • Lowered LES pressure
  • Increased reflux episodes
  • Documented in cyclists gt 70 VO2max

16
Delayed gastric emptying
  • Dehydration can slow GE up to 40
  • Hypertonic carbohydrate beverages can also slow
    GE
  • Sig delay in gastric emptying above 70 VO2max
  • Delayed gastric emptying can lower LES tone

17
GI blood flow
  • Reduced in excess of 50
  • Estimated hepatic blood flow (EHBF)
  • 12-14 decrease at 30-35 VO2max
  • 30-45 decrease with 35-60 VO2max
  • Portal vein blood flow in cyclists
  • 20 min at 70 VO2max SBF decreased by 57
  • After 1 hr SBF decreased by 80
  • Predisposes to gut injury
  • Increases membrane permeability
  • Enhances occult blood loss
  • Generated endotoxins that can increase diarrhea

18
Fluid intake
  • Gastric emptying is slowed with heavy exercise in
    dehydrated state
  • Exercise releases catecholamines that suppress
    thirst
  • Some athletes cannot tolerate sensation of
    food/fluid in the stomach with exercise
  • 80 of marathon finishers with gt 4 weight loss
    due to dehydration experienced GI symptoms

19
Psychologic
  • Stress can exacerbate GI symptoms
  • Up to 57 of athletes with runners diarrhea
    complained of symptoms prior to race, 32 had
    similar symptoms when emotionally stressed

20
Upper GI Symptoms
  • Dysphagia
  • Oropharyngeal dysphagia
  • Esophageal dysphagia
  • GERD
  • Dyspepsia
  • GI bleeding

21
Dysphagia
  • Oropharyngeal dysphagia (OD)
  • Liquids (v solids)
  • Choking sensation, incomplete swallowing
  • Occurs within a few seconds of swallowing
  • Pain localizes to neck
  • Can also see a change in dietary habits,
    dehydration, regurgitation, weight loss

22
Dysphagia
Oropharyngeal dysphagia
  • Common causes
  • Tonsillitis
  • Pharyngitis
  • Laryngitis
  • Cervical adenitis
  • Thyromegaly
  • Less common causes
  • Ludwigs angina
  • Retropharyngeal abscess
  • Anaphylaxis

23
Dysphagia
  • Esophageal dysphagia
  • Solids and liquids
  • More delayed than OD
  • Pain localized to 6th thoracic dermatome
  • Poorly defined substernal pressure, burning,
    chest pain

24
Dysphagia
  • GERD MC cause
  • Less common causes include
  • Infectious HSV, Candida, CMV
  • Caustic injury
  • Pill esophagitis
  • Aortic aneurysm
  • Mechanical obstruction
  • Motility disorders

25
GERD
  • 60 of athletes
  • More frequent with exercise
  • Ambulatory pH probe monitoring has shown that
    exercise exacerbates reflux
  • Sport specific
  • Anaerobic sports report most symptoms
  • Runners gt cyclists

26
GERD
  • Classic heart burn symptoms
  • Worse with exertion, laying flat at night,
  • Worse after a big meal, fried fatty foods
  • Chest pain
  • Nausea, vomiting, abdominal pain
  • Silent GERD
  • Night time coughing, wheezing

27
Dyspepsia
  • Varied complaints including nausea,
    gnawing/burning epigastric pain, vomiting,
    eructation, bloating, indigestion, generalized
    abdominal discomfort
  • MC causes include
  • PUD
  • GERD
  • Gastritis

28
Dyspepsia
  • Common cause is mucosal damage
  • Frequent dehydration
  • Repeated stress of racing
  • Excessive NSAID use
  • Medications
  • ETOH
  • Caffeine
  • Dietary supplements containing AA and creatine

29
GI bleeding
  • Can be upper or lower
  • Usually transient
  • Well documented in distance runners
  • Endoscopy study
  • N16 runners
  • All had some degree of gastritis,
  • 4 with heme positive stool
  • 2 with lower GI source

30
GI Bleeding
  • Mechanism includes
  • Hemorrhagic colitis
  • NSAID induced gastritis
  • Traumatic hemolysis
  • Impaired gut absorption
  • Mechanical trauma lower incidence in cyclists
    than runners

31
Evaluation
  • History diagnosis in about 80 of cases
  • Onset
  • Exacerbating factors
  • Pain
  • Gross blood
  • PMHx
  • FHx
  • SHx TOB, ETOH, other drugs
  • Dietary history chocolate, caffeine, timing
  • Psychosocial history ? stress
  • NSAIDs

32
Exam
  • General Fever, orthostatic
  • HEENT
  • Looking for any physical signs of obstruction
  • Palpate thyroid
  • CV
  • Lung
  • GI tenderness, mass
  • Stool occult blood cards

33
Evaluation
  • Throat Cx
  • Labs GI bleed
  • CBC, CCP, TSH, Ferritin, Iron Panel
  • Other labs H pylori, Celiac sprue
  • UGI ?
  • EGD if hemoptysis, melena, resistant or
    prolonged Sxs
  • Colonoscopy if gross blood

34
Evaluation
  • Alarm Symptoms
  • Weight loss
  • Progressive dysphagia
  • Recurrent vomiting
  • GI bleeding
  • Family history of CA

35
Treatment
  • Treat underlying infection
  • Dyspepsia treat H pylori if positive (AGA
    guidelines)
  • Diet modification
  • Avoid ETOH, TOB, fatty foods, mints, chocolate,
    caffeine, citrus
  • Timing of pre-exercise meals
  • Elevate head of bed
  • No food w/in 4 hours of going to bed

36
Treatment
  • Literature for PPI vs H2 blockers is limited in
    athletes
  • PPI are more effective than H2 blockers in
    treating PUD and GERD (Up to Date)
  • No difference between PPIs
  • Usual trial of H2 blocker or PPI
  • Intermittent Sx H2 blocker
  • Daily Sxs PPI
  • H2 blockers show varied success in decreasing
    blood loss
  • PPI may decrease GIB

37
Treatment
  • Maintain hydration
  • Avoid NSAIDs
  • Consider iron supplementation
  • Optimize fiber

38
Upper GI Summary
  • Upper GI symptoms are very common
  • Runners mostly affected
  • History will give diagnosis in majority of cases
  • Empiric therapy with H2 blocker or PPI
  • Immediate evaluation with gross blood or abnormal
    exam findings

39
Common Medical ConditionsRunners Diarrhea
40
Exercise and the GI Tract
  • Association between exercise and changes in the
    GI tract has long been appreciated
  • 1794, Dr. John Puch wrote in Treatise on the
    Science of Muscular Action that
  • Exercise helps to throw down wind from the
    bowels and attenuates the contents of the
    stomach. It also serves at once as an evacuant

41
Exercise and the GI Tract
  • Common Lower GI Symptoms
  • Flatulence
  • Diarrhea
  • Hematochezia
  • Urgency to defecate

42
Defining Runners Diarrhea
  • Runners Trots first coined in 1980 to
    describe episodes of bloody diarrhea in 2
    marathon runners
  • Case definition
  • non-bloody or bloody diarrhea
  • lower abdominal cramping
  • frequency and urgency
  • occurs during endurance events

43
Epidemiology of Runners Diarrhea
  • Most commonly affects runners
  • Estimates of incidence 20 - 33
  • 50 endurance athletes report fecal urgency
    following training runs
  • 20 of marathoners have occult blood in stool
    after races,
  • 17 reported frank hematochezia during training
    for marathons
  • Affects more females than males

44
Etiology of Runners Diarrhea
  • Complete understanding of the etiology of
    runners diarrhea remains unclear
  • Altered intestinal transit time
  • Altered GI blood flow
  • Fluid/electrolyte shifts at cellular level
  • Mechanical causes

45
Etiology of Runners Diarrhea
  • Complete understanding of the etiology of
    runners diarrhea remains unclear
  • Autonomic nervous system stimulation
  • Changes in GI hormones
  • Diet and medications

Bob S. training for marathon, exhibiting a. ANS
stimulation b. Signs of change in his GI
hormones c. Medication effects
46
Altered GI Transit Time
  • Decreased colonic transit time?
  • Cordain et al found that transit time decreased
    from 35 to 24 hours in sedentary individuals who
    started exercise program
  • Others have found that oro-cecal transit time is
    actually increased in strenuous exercise but
    decreased in light exercise

47
Altered GI Blood Flow
  • Intense exercise reduces blood flow to the GI
    tract by 80
  • Reduction in colonic blood flow more marked when
    dehydration is present
  • 80 of athletes who are greater than 4
    dehydrated develop lower GI symptoms

48
Diet and Medications
  • Lactose intolerance
  • High fiber diet
  • Artificial sweeteners
  • Sorbitol and aspartame
  • Commonly used in sports drinks
  • May lead to osmotic diarrhea
  • Meds antibiotics, H2 Blockers, Mg-containing
    antacids
  • Laxatives

49
Other Etiologic Factors
  • Mechanical compression of colon by
    hypertrophied psoas muscle
  • GI Hormone Changes elevation in gastrin,
    motilin, and VIP has been demonstrated during
    exercise
  • Autonomic Nervous System increased
    parasympathetic tone during exercise leads to
    increased transit time due to smooth muscle
    contraction

50
Differential Diagnosis for a Runner with Diarrhea
  • Runners Diarrhea is a diagnosis of exclusion
  • lt 40 years of age
  • infectious,
  • inflammatory
  • dietary problems
  • gt 40 years of age
  • As above AND
  • consider malignancy
  • diverticular disease
  • Evaluation is based on age-stratification

51
Evaluation of Runner with Diarrhea
  • All Patients careful history
  • Timing, characteristics of diarrhea
  • Diet and hydration history
  • Travel history
  • ROS fever, wt loss,
  • abd pain, jaundice
  • PMH, FHx
  • Medications

52
Evaluation Physical Exam
  • Careful physical examination for all pts
  • Vitals (temperature and weight)
  • Abdominal exam tenderness, masses, bowel sounds,
    hepatomegaly
  • Rectal exam
  • sphincter tone,
  • occult blood

53
Evaluation Ancillary Studies
  • In young (lt40 yo) athletes
  • Stool studies occult blood, culture, OP
  • Consider fecal fat if malabsorption possible
  • CBC anemia, leukocytosis
  • Metabolic Profile hypokalemia
  • ESR/CRP
  • Consider Hydrogen breath test
  • Consider Flexible Sigmoidoscopy
  • Consider HIV testing

54
Evaluation Ancillary Studies
  • Older athletes (gt40 yo)
  • Same studies as for younger athletes, except
  • Comprehensive metabolic profile
  • Complete Colonoscopy rather than Flex Sig to
    evaluate for cancer or diverticulae

55
Treatment
  • Treat any underlying condition
  • If no underlying condition is found during
    evaluation, consider multi-modal approach to
    treatment
  • Dietary changes
  • Medications
  • Training changes and environmental changes

56
Treatment
  • Dietary Changes
  • Avoid sugar alcohols (sorbitol)
  • Low-residue, low-fiber diet
  • Consider restricting lactose
  • Reduce caffeine intake
  • Improve hydration

57
Treatment
  • Pharmacologic approach
  • Only one study published on pharmacologic
    treatment
  • Lopez compared diosmectate (Al silicate) with
    loperamide diarrhea resolved in 72 vs. 20
  • Anticholinergics (atropine) and opiates
    (loperamide) have been used
  • Most US experts recommend
  • OTC loperamide 30 minutes prior to exercise

58
Treatment
  • Training and Environmental Changes
  • Reduction of intensity and duration of training
    runs often relieves symptoms
  • Consider cross-training
  • Timing of training runs to reduce likelihood of
    dehydration
  • Daily ritual of pre-exercise bowel evacuation is
    mandatory

59
Summary
  • Runners Diarrhea is quite common
  • Multi-factorial etiology
  • Diagnosis of exclusion
  • Very little evidence for treatment approaches
  • Success rate of treatments unknown
  • Given high incidence of this problem, future
    study seems warranted
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