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EPIDEMIOLOGY OF GASTROINTESTINAL PROBLEMSBy:M. Rum Rahim, MD.,
MSc.
Suggested Reading:Lipsky, Martin.S., Gastrointestinal Problems,
Lippincott Williams & Wilkins. Philadelphia, 2000Yarnell,
John., Epidemiology and Prevention: A System-based Approach.,
Oxford University Press., Oxford New York, 2007
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IntroductionThis lecture, the epidemiology of dyspepsia, which
is one of the commonest GEH problems presenting in primary care,
the diseases associated with Helicobacter pylori infection, &
the epidemiology of IBD, cirrhosis of the liver, & abdominal
pain in adult
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IntroductionThe scope of this subject to discuss the
epidemiology of all chronic gastro-intestinal disease. Instead,
several important topics have been chosen, which include dyspepsia,
because of the substantial health cost associated with this group
of symptoms & Helicobacter pylori. This is the most common
bacterial infection known to man, & its association with
diseases has only recently become known through epidemiological
& clinical studies.
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DyspepsiaAbdominal Pain in AdultsRAP in ChildrenJaundice in
Adults
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DYSPEPSIAThe term dyspepsia covers a variety of symptoms
affecting the upper gastro-intestinal tract, which include
epigastric pain or discomfort, heartburn, acid regurgitation,
excessive burning or bleching, a feeling of slow digestion, early
satiety, nausea, and bloating. Standardization of the definition of
dyspepsia has proven very difficult, & although consensus
definition of dyspepsia are available, for example the Rome I
criteria, they have not been widely used in epidemiological
studies.
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THE ROME I CLASSIFICATION OF DYSPEPSIAPain or discomfort centred
in the upper abdomenDiscomfort may be characterized by
post-prandial fullness early satiery nausea, retching, vomiting,
upper abdominal bloating. Patients with symptoms of heartburn &
acid regurgitation are considered to be distinct from patients with
dyspepsia.
Westbrook, J.L. et al, (2000) The Impact of Dyspepsia Definition
on Prevalence Estimates. Scandinavian Journal of Gastroenterology,
3:227-33.
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Dyspepsia..PrevalenceA recent systematic review of
population-based studies of dyspepsia in developed countries showed
substantial variation in the reported prevalence of dyspeptic
symptoms, ranging from 8 % to 54 %.
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Dyspepsia..Risk Factors are approximately 50% more likely to
report dyspeptic symptoms than , & dyspepsia prevalence
increases slightly with age until 65 years.Smokers are more likely
to have dyspeptic symptoms, especially heartburn &
regurgitation, but alcohol consumption in moderate amounts does not
appear to be a RF
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Dyspepsia..Risk FactorsPsychological factors play an important
role both in reporting dyspeptic symptoms & seeking medical
attention for these symptoms.Obese people are approximately 3 X
more likely to suffer from heartburn & regurgitation but being
overweigth is less clearly related to other dyspeptic symptoms.
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Dyspepsia..Risk FactorsA recent meta-analysis of randomized
controlled trials has confirmed that users of NSAIDs are 3 X more
likely to experience dyspepsia than non users. This risk is limited
to the use of high doses of any NSAIDs or to any dose of
indomethacin, meclofenamate, & piroxicam.
NSAIDs : Non-Steroidal Anti Inflammatory Drugs
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Dyspepsia..Time TrendsThe interpretation of trends in dyspepsia
is difficult for reason related to the problems of definition,
& because of paucity of population based studies before the
1980s. It is clear though, that dyspeptic symptoms have been very
common for many years in people living in developed countries.
Indeed, Milk of Magnesia was invented as a treatment for dyspepsia
by Sir James Murray in Belfast in 1812
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Dyspepsia..Time TrendsGastro-oesophageal reflux is a RF for GERD
has been increasingly diagnosed in recent decades. Greater use of
endoscopy has contributed to the trend in diagnosis of reflux
oesophagitis, & data not available to confirm whether this
reflects an increase in heartburn and regurgitation in the general
population.
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Helicobacter pyloriH.pylori is a gram(-) spiral bacterium that
infects human gastric mucosa.Approximately 50% of the worlds
population are infected by H.pylori, making it the commonest
chronic infection worldwide.However, infection rates vary
substantially according to geographic region, age, & birth
cohort.
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Abdominal Pain in AdultsDEFINITIONAbdominal pain is a common
problem with a variety of presenting symptoms & potential
causes.
Diagnostic possibilities range from the chronic & benign
(e.g., IBS) to the acute & life threatening (e.g., ruptured
aortic aneurysm)
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Abdominal Pain in AdultsPossible causes of abdominal pain in the
office setting:Acute
gastroenteritisCholelitiasisUTIDiverticulosisPeptic ulcer
diseaseAppendicitisIBSUrolithiasisPelvic inflammatory
diseaseUlcerative colitisGERDMuscular strain
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Abdominal Pain in AdultsRISK FACTORSHypertension & known
vascular disease are RF for vascular causes of abdominal pain as
well as referred pain from myocardial infarction. In addition,
atrial fibrillation is a RF for mesenteric artery emboli.Alcohol
use, cigarette smoking, and caffeine use all predispose to the
development of GERD. Alcohol use can cause gastritis &
pancreatitis. Cigarette smoking has been linked to peptic ulcer
disease.
GERD: Gastro Esophageal Reflux Disease
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Abdominal Pain in AdultsRISK FACTORSAdvancing age is a RF for
development of vascular disease, cholecystitis, &
diverticulitis.Hyperlipidemia is a RF for vascular disease &
pancreatitis. Triglyceride values greater than 700 mg/dl place the
patient at increased risk for pancreatitis, & often the values
in patients with pancreatitis are greater than 1000 mg/dl.Obesity
or a change in weight can predispose to gallstone formation
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Abdominal Pain in AdultsRISK FACTORSMedications have been linked
to the development of gastric & duodenal ulcers as well as
pancreatitisHypercalcemia, such as occurs with hyperthyroidism, can
cause pancreatitis.Abdominal surgery can lead to the formation of
adhesion & resultant bowel obstruction. In addition, past
history can signify recurrence of disease, such as
diverticulitis.
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Abdominal Pain in AdultsRISK FACTORSFamily history can play a
significant role for patient who develop gallstone, kidney stones,
colon cancer, IBS; it may play a role in peptic ulcer disease.In
women, abdominal pain may have a gynecologic cause (e.g., ovarian
torsion, endometriosis, ectopic pregnancy, & pelvic
inflammatory disease). A history of sexually transmitted disease
& prior episodes of pelvic inflammatory disease. Women are also
at a greater risk of developing cholecystitis
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Abdominal Pain in AdultsPATIENT EDUCATIONPatient with
pancreatitis should be counseled regarding the potential causes of
pancreatitis. If alcohol is a trigger or potential causative
factor, then provide information regarding abstinence &
resources for substance abuse counseling & support. Patient
with acute or chronic pancreatitis who are diabetic will need
education regarding their diabetes, including information about a
low-fat, diabetic diet, glucose menitoring, & insulin or oral
hypoglycemic therapy.
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Abdominal Pain in AdultsPATIENT EDUCATIONRecurrent symptoms of
abdominal pain or fever should be reported by patients with
diverticulitis or appendicitis, as they may signify abscess
formation or recurrent diverticular disease. Instruction to
increase dietary fiber may be helpful for patient with diverticular
disease
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Recurrent Abdominal Pain (RAP) in ChildrenDEFINITIONRAP occurs
in 10% to 15% of children aged 4-16 years. It is defined as
episodic pain that occurs for longer than 3 months & affects
normal activity. The pain is real but may be isolated &
paroxysmal, accompanied by dyspepsia, or associated with an altered
bowel pattern.
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Recurrent Abdominal Pain (RAP) in ChildrenDEFINITIONIt is often
caused by a functional bowel disorder. The child may refuse to go
to school or be sent home from school because of persisting pain.
Children aged less than 4 years who have chronic abdominal pain
require a more detailed evaluation to exclude organic causes.
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Recurrent Abdominal Pain (RAP) in ChildrenRISK FACTORSBoys &
girls are equally affected up to age 9 years9-12 years 1.5 times
more likely to have RAP.Lactase deficiency is most common in Asian,
African-American, & Hispanic children.Crohns disease &
ulcerative colitis >> in whites, especially those of Jewish
descent.
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Recurrent Abdominal Pain (RAP) in ChildrenRISK FACTORSG.lamblia
infection occurs in travellers who drink contaminated water from
mountain streams, but can also occur in institusional settings such
as day-care centers.C.difficile enterocolitis has occurred as a
result of exposure to almost all antibiotics.
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Recurrent Abdominal Pain (RAP) in ChildrenPATIENT EDUCATIONIt is
important to reassure the child & parents that major
life-threatening illnesses have been excluded by the examination.
However, it must be emphasized that the pain that the child is
experiencing is real & not just in his/her head. Explain that
the reason for the pain is not completely understood, but may be
caused by the child being more sensitive to normal GI sensations or
to increased GI activity.
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Recurrent Abdominal Pain (RAP) in ChildrenPATIENT EDUCATIONThe
child should be encouraged to resume normal activity. Parent can
comfort & reassure the child, but should avoid actions that
reward pain behavior, such as keeping the child home from school.
This message should also be conveyed to others involved in the care
of the child, including school authorities.
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Recurrent Abdominal Pain (RAP) in ChildrenPATIENT EDUCATIONAlso
use active listening to encouraged the parent & child to
express their fears & concern about
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Jaundice in AdultsDEFINITIONJaundice, also referred to as
icterus, is a syndrome characterized by hyperbilirubinemia &
deposition of bile pigment in the skin, mucous membrane, &
sclera that results in a yellowish appearance.
Usually bilirubin level need to be greater than 2.5 to 3.0 mg/dl
for jaundice to be visible.
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Jaundice in AdultsRISK FACTORSMany RF exist to various disorders
causing jaundice. RF for viral hepatitis include multiple sexual
partners, IV drug use, travel to endemic area, & prior blood
transfusions.Family history may be an important RF in developing
alcohol dependency & its associated liver disease.
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Jaundice in AdultsRISK FACTORSIt is also a factor in familial
disorders such as Gilberts syndrome or
hemachromatosis.Dubin-Johnson syndrome & Rotors syndrome are
both inherited in an autosomal recessive fashion & there may be
a family history of one of these disorders.Patients on multiple
medications are also at risk for developing jaundice.
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Jaundice in AdultsPatient EducationPatient with jaundice should
be advised of their condition. Those with benign hereditary
conditions need to be assured that their condition is neither
serious nor contagious. However, they should be aware that other
family members are at risk for having the syndrome.
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Jaundice in AdultsPatient EducationPatients with underlying
liver disease should avoid alcohol or medications that an adversely
affect their liver function.They should be immunized againts viral
hepatitis to avoid concomitant illness that may worsen their
condition.
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EPIDEMIOLOGY & PREVENTING OF GEH
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