Transcript GI Problems in Athletes Thomas Best MD, PhD

GI Problems in Athletes
Thomas Best MD, PhD
The Ohio State University
February 4, 2011
Sports Medicine
Overview
 Epidemiology/Physiology
 Upper GI Problems
 Runner’s Diarrhea/Ischemic
Colitis
 Practical Recommendations
“Problems cannot be solved with the same level of awareness
that created them.”
Albert Einstein
Sports Medicine
Objectives
 Understand the physiology of exercise and its effects
on the GI tract
 Be familiar with the common GI problems in athletes,
their etiology, work-up and treatment
Sports Medicine
What Is Clinical Outcomes Evidence?
Statistics, probabilities and opinions
 Experimental evidence
– Clinical trials (RCT)
 Observational (epidemiological) evidence
– Cohort studies (prospective and retrospective)
– Case-control studies
– Cross sectional studies
– Case series and reports
– Expert opinion
Sports Medicine
Interpretation of Evidence
Criteria of Judgement
 Consistency of independent investigations
 Strength of association (dose response)
 Specificity of association
 Temporal relationship
 Coherence (biological plausibility)
Sports Medicine
Exercise Effects On The GI Tract
Regular moderate physical activity is associated
with:
 Enhanced gastric emptying
 Improved GI motility
 Less constipation
 Lower risk for liver disease, cholelithiasis,
diverticulosis, colon CA
 Improved control of IBS symptom severity
(Johannesson et al Amer J Gastro Jan 2011)
Exercise MORE effective than
pharmacological treatments in IBS
(Henningsen et al Lancet 2007)
Sports Medicine
GI Symptoms Are Common
Upper
 Heartburn, chest pain, belching, epigastric
pain, nausea and vomiting
 Reported by up to 50% of athletes during
heavy exercise
Lower
 “Runner’s Trots”
Casey, Clin Sport Med 2005 24:525-40
Peters, CSMR 2004, 3:107–111
Sports Medicine
GI Problems Are Common
Prevalence
 Highest during running
 Women > men
 More common in younger athletes
 Less frequent in low impact sports
 Exercise intensity
 Marathoners: 30-80% report GI symptoms
GI bleeding (8 - 85%)
 All sports report
 8% to 22% of marathon runners report gross
fecal blood loss
Jaworski, CSMR 2005, 4:137–143
Casey, Clin Sport Med 2005 24:525-40
Ho, CSMR 2009, 8:85-91
Sports Medicine
GI Problems – Contributing Factors
 Mechanical
 Dietary
 Ingestions: medications, etc
 Emotional
 Infection: viral gastroenteritis, travel, other
 Inflammatory bowel disease: Ulcerative Colitis,
Crohns disease
 Functional
Sports Medicine
Benign  Catastrophic
 May interfere with athletic activities
(requiring significant accommodations)
 May mimic or be an harbinger of other more
ominous pathology
– GERD  CVD
– Multiple etiologies
• Heme + stool
• Abdominal pain and bleeding
 Be attentive, be thorough
Sports Medicine
GI Problems In Athletes –
What Does The Evidence Tell Us
 “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”
Example: use FOBT – non specific
Moses, CSMR 2005, 4:91–95
Sports Medicine
Suffering in Silence
 Poorly understood
– By athletes
– By sports medicine
staff
 Symptoms often ignored
 Commonly:
– Self diagnosed
– Self treated
Sports Medicine
Upper Gut Issues in Athletes
Sports Medicine
Etiology of Upper GI Problems
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Delayed gastric emptying and transit time
LES pressure changes
Gastric distension (empty stomach – 50 to 100ml)
Splanchnic blood flow – training can improve
Increased vibration
Increased levels of gastrin and motilin
High CHO fluids
Malabsorption of water and nutrients – vegetarian diet or highfiber meal prior to exercise
 Psychologic – stress can increase sympathetic discharge and
decrease splanchnic blood flow up to 80%
Sports Medicine
Mechanism
 Slowed motility
– Duration, amplitude and frequency of
esophageal contractions
– Decline with exercise intensity over 90% VO2
max
 Lowered LES pressure
– Increased reflux episodes
– Documented in cyclists >70% VO2 max
Sports Medicine
Delayed Gastric Emptying
 Dehydration can slow gastric emptying up to 40%
 Hypertonic carbohydrate beverages can also slow
gastric emptying (>7% CHO) – Shi X et al. Int J
Sports Med 2004
 Significant delay in gastric emptying above 70%
VO2 max (Baska et al. Dig Dis Sci 1990)
 Delayed gastric emptying can lower LES tone
Sports Medicine
GI Blood Flow And Exercise
 Reduced in excess of 50%
 Estimated hepatic blood flow (EHBF)
– Reduced 12-14% at 30-35% VO2 max
– Reduced 30-45% with 35-60% VO2 max
 Portal vein blood flow in cyclists:
– 20 min at 70% VO2 max : SBF reduced by 57%
– After 1 hr: SBF reduced by 80%
 Predisposes to gut injury
 Increases membrane permeability
 Enhances occult blood loss
 Generates endotoxins that can increase diarrhea
Sports Medicine
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 >4% weight loss
due to dehydration experienced GI symptoms
Sports Medicine
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
Sports Medicine
Upper GI Symptoms
 Dysphagia (solids and/or liquids)
– Oropharyngeal dysphagia
– Esophageal dysphagia
 GERD
 Dyspepsia
 GI bleeding
Sports Medicine
GERD
 60% of athletes
 More frequent with endurance exercise
 Ambulatory pH probe monitoring has shown that
exercise exacerbates reflux
 Sport specific
– Anaerobic sports report most symptoms
– Runners > cyclists
Sports Medicine
Dyspepsia
 Varied complaints including:
Nausea, gnawing/burning epigastric pain,
vomiting, eructation, bloating, indigestion,
generalized abdominal discomfort
 Most common causes include:
– PUD
– GERD
– Gastritis
Sports Medicine
Dyspepsia
Common cause is mucosal damage
 Frequent dehydration
 Repeated stress of racing
 Excessive NSAID use
 Medications
 ETOH
 Caffeine
 Dietary supplements containing amino acids and
creatine
Sports Medicine
GI Bleeding
 Can be upper – 16 runners after a 20km race – UGI;
gastritis 16, esophagitis 6 or lower – Colonoscopy (4) – 1
with multiple erosions splenic flexure (Choi et al. Eur J
Gastroenterol Hepatol 2001)
 Usually transient
Mechanism includes
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Hemorrhagic gastritis, colitis
NSAID induced gastritis
Traumatic hemolysis
Impaired gut absorption
Mechanical trauma
o Lower incidence in cyclists than runners
Sports Medicine
Evaluation
 History: diagnosis in about 80% of cases
– Onset
– Exacerbating factors
– Pain
– Gross blood
 Past medical history
 Family history
 Social history: Tobacco, ETOH, other drugs
 Dietary history: chocolate, caffeine, timing
 Psychosocial history: ? stress
 NSAIDs
Sports Medicine
Evaluation
 Labs: GI bleed
– CBC, CRP, ESR, Ferritin, Iron Panel
 Other labs: H pylori, Celiac sprue
 UGI ?
 EGD
– If hemoptysis, melena, resistant or prolonged
symptoms
 Colonoscopy
– If gross blood
Sports Medicine
Evaluation – Red Flags
 Weight loss
 Progressive dysphagia
 Recurrent vomiting
 GI bleeding
 Family history of CA
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Treatment
 Treat underlying infection
– Dyspepsia: treat H pylori if positive (AGA
guidelines)
 Diet modification
– Avoid ETOH, tobacco, fatty foods, mints,
chocolate, caffeine, citrus fruits
– Timing of pre-exercise meals
 Elevate head of bed
 No food within 4 hours of going to bed
Sports Medicine
Treatment
 PPI are more effective than H2 blockers in treating
PUD and GERD (limited literature in athletes)
 Usual trial of H2 blocker or PPI
– Intermittent symptoms: H2 blocker
– Daily symptoms: PPI
 H2 blockers show varied success in reducing
blood loss
 Maintain hydration
 Avoid NSAIDs
 Optimize fiber
Sports Medicine
Runner’s Diarrhea – A Real Common Problem!
Sports Medicine
Exercise And The Lower 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…”
61% of endurance athletes – lower GI symptoms
Worobetz & Gerrard N Z Med J 1985
Sports Medicine
Exercise And The Lower GI Tract
Common lower GI symptoms:
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Flatulence
Diarrhea (26%)
Hematochezia (6%)
Urgency to defecate (54%)
Women > men
Worobetz & Gerrard N Z Med J 1985
Sports Medicine
Epidemiology - Runner’s Diarrhea
Most commonly affects runners
 “Runner’s Trots”: first coined in 1980 to describe episodes of
bloody diarrhea in 2 marathon runners of incidence: 20% 33%
 50%+ endurance athletes report fecal urgency following
training runs (Green GA Clin Sports Med 1992)
 20% of marathoners have occult blood in stool after races
(Baska RD et al Dig Dis Sci 1990)
 17% - frank hematochezia during training for marathons
 Females > males
Sports Medicine
Etiology of Runner’s Diarrhea
Complete understanding of runner’s diarrhea
etiology remains unclear
 Altered intestinal transit time
 Altered GI blood flow
 Fluid/electrolyte shifts at cellular level
 Mechanical causes
Etiology of Runner’s Diarrhea
Complete understanding of runner’s diarrhea
etiology remains unclear
 Autonomic nervous system stimulation
 Changes in GI hormones gastrin and motilin
 Diet and medications
Altered GI Transit Time
Reduced colonic transit time?
 Cordain et al - transit time reduced from 35 to
24 hours in sedentary individuals who started
exercise program (J Gastro 1991)
 Others have found that oro-cecal transit time is
actually increased in strenuous exercise but
reduced in light exercise
Sports Medicine
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 more than 4%
dehydrated develop lower GI symptoms
(Rehrer NJ et al. Int J Sports Med 1989)
Sports Medicine
Diet And Medications
 Lactose intolerance, celiac disease
 High fiber and high glycemic index diets
 Artificial sweeteners
– Sorbitol and aspartame
– Commonly used in sports drinks
– May lead to osmotic diarrhea - >7% CHO
“dumping syndrome” – osmotic gradient
 Meds: antibiotics, H2 blockers, antacids containing
magnesium
 Laxatives, caffeine
Sports Medicine
Other Etiologic Factors
 Mechanical
– Compression of colon by hypertrophied psoas
muscle
 GI Hormone Changes
– Elevation in gastrin, motilin and VIP occur
during exercise
 Autonomic Nervous System
– Increased parasympathetic tone during
exercise leads to increased transit time due to
smooth muscle contraction
Sports Medicine
Differential Diagnosis
For a Runner with Diarrhea
 Runner’s Diarrhea is a diagnosis of exclusion
 < 40 years of age:
– Infectious
– Inflammatory
– Dietary problems
 > 40 years of age:
As above AND
– Consider malignancy
– Diverticular disease
 Evaluation should be based on age-stratification
Sports Medicine
Evaluation of Runner with Diarrhea
 All patients: careful history
 Timing, characteristics of diarrhea
 Diet and hydration history
 Travel history
 ROS: fever, weight loss, abdominal pain, jaundice
 Past medical history, family history
 Medications
Sports Medicine
Evaluation: Physical Exam
Careful physical examination for all patients:
 Vitals (temperature and weight)
 Abdominal exam: tenderness, masses, bowel
sounds, hepatomegaly
 Rectal exam:
– Sphincter tone
– Occult blood
Sports Medicine
Evaluation: Ancillary Studies
In young (<40 yo) athletes:
– Stool studies: occult blood, culture, O+P
– Consider fecal fat if malabsorption possible
– CBC: anemia, leukocytosis
– Metabolic profile: hypokalemia
– ESR/CRP
– Consider hydrogen breath test, flexible sigmoidoscopy,
HIV testing
Older athletes (>40 yo):
– Comprehensive metabolic profile
– Complete colonoscopy rather than flex sig to evaluate
for cancer or diverticulae
Sports Medicine
Runner’s Diarrhea - Treatment
 Treat any underlying condition
 If no underlying condition is found during
evaluation, consider following strategies
 Dietary changes:
– Avoid sugar alcohols (sorbitol)
– Low-residue, low-fiber diet
– Consider restricting lactose
– Reduce caffeine intake
– Improve hydration
Sports Medicine
Runner’s Diarrhea - 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
 OTC loperamide 30 minutes prior to exercise
Sports Medicine
Runner’s Diarrhea - Treatment
Training and environmental changes (Level 5):
 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
Sports Medicine
Exercise-Associated Intestinal Ischemia
 Abdominal pain and diarrhea, often with bleeding
 Increase in BF in exercising muscles at expense of
visceral BF
 Hypovolemia compounded by hyperthermia,
dehydration, NSAIDs
 Evidence limited to case reports
 Surveys – primarily runners, more common
during/after races than training
 Schwartz A et al Ann Inter Med 1990
9 marathoners - FOBT +, 3 scoped: antral
erosions, splenic flexure erosions, resolved at
second look days later
Sports Medicine
Exercise-Associated Ischemic Colitis
 Moses FM et al. Ann Int Med 1989
 Colon second most common location for exerciseassociated GI bleeding
 9 case reports in the published literature
 Intestinal infarction rarely reported – 65yr old MD
following 50km run (Kam et al Am J Gastro 1994)
 RTP guidelines ?
Sports Medicine
Athletes And Inflammatory Bowel Disease
 Ulcerative colitis and Crohn’s disease
 Cause unknown, likely autoimmune
 Bloody diarrhea (UC), Chrohn’s – fatigue,
diarrhea, abdominal pain
 40% extraintestinal manifestations – pulmonary,
joint (sacroilitis, ankylosing spondylitis,
osteoporosis)
 Vitamin D insufficiency – treat aggressively
 Monitor for side effects of medications –
corticosteroids
Zaharia and Rifat CSMR 2008
Sports Medicine
Summary – Practical Recommendations
 Avoid dehyration and hyperthermia through training
periodization
 Delay 3-4 hours after big meal for exercising at >70%
VO2max
 Small frequent meals of easily digested carbohydrates
during long runs and training sessions
 Limit high-energy, hypertonic drinks (>7% CHO) within
60 mins of exercise
Sports Medicine
Summary – Practical Recommendations
 Limit protein, fat, high fiber foods around run/exercise
time
 Avoid fructose when possible
 Limit caffeine, antibiotics, NSAIDs, sweeteners ‘ol’
 Find a restroom prior to exercise
 Be mindful of red flags and appropriate work-up
Sports Medicine