Constantine A. Soulellis, MD, FRCP(C), GI Fellow, McGill University; Division of Gastroenterology, McGill University Health Centre, Montreal, QC.
Carlo A. Fallone, MD, FRCP(C), AGA(F), Associate Professor, McGill University; Director, GI Services, Royal Victoria Site of the McGill University Health Centre, Montreal, QC.

Peptic ulcer disease (PUD) is a prevalent medical problem among older adults. Several issues unique to older adults impart variability and complexity to PUD, making this entity difficult to diagnose and treat. Age-related gastrointestinal physiological changes, increasing prevalence of Helicobacter pylori, comorbidities, and polypharmacy (especially nonsteroidal anti-inflammatory drug [NSAID] use) are factors that potentiate ulcer formation. Older adults may present with few or none of the usual features of PUD, often delaying diagnosis and therapy. The cornerstones of therapy include cessation of NSAIDs, proton pump inhibition, and eradication of H. pylori if present.
Key words: peptic ulcer, older adults, NSAIDs, Helicobacter pylori.

Clarence K.W. Wong, MD, FRCPC, Gastroenterologist and Clinical Lecturer, Division of Gastroenterology, University of Alberta; Consultant, Cross Cancer Institute, Alberta Cancer Board, Edmonton, AB.

Introduction
Gastrointestinal malignancies collectively account for the greatest number of cancer deaths in Canada.¹ This is particularly evident in the elderly population in which 90% of all new cancers are diagnosed in individuals over the age of 45.² Of these new cancers, one in five are gastrointestinal cancers. As these malignancies are often lethal, improved survival depends on preventive strategies to effectively detect and manage the associated precursor conditions. This paper will review the premalignant conditions associated with three common gastrointestinal cancers. Effective management of conditions leading to esophageal, gastric and colon cancers can greatly reduce the burden of disease among the geriatric population.

Esophageal Cancer
Cancers of the esophagus are lethal, with a death to case ratio of 1.11.¹ Although this estimate is high due to incomplete registration of new cases, it underscores the lack of effective treatment for this disease. Until recently, squamous cell carcinomas were the most common type of esophageal cancer. However, in the last few decades the incidence of esophageal adenocarcinomas has increased exponentially. It is likely that this increase is linked to a rise in incidence of its only known risk factor, Barrett's esophagus.

C.A. Fallone, MD, FRCP(C), Division of Gastroenterology, McGill University Health Centre, Montreal, QC.

Definition of Dyspepsia
Defining dyspepsia is a somewhat confusing endeavour mainly because the definition itself has varied somewhat over the last few decades. Moreover, the distinction between uninvestigated and investigated dyspepsia is not always clear. Clinically, dyspepsia symptoms must be distinguished from the lower gastrointestinal symptoms of irritable bowel syndrome. Furthermore, the term dyspepsia is often used synonymously for upper gastrointestinal symptoms, but because most experts feel that dyspepsia must be distinguished from gastroesophageal reflux disease (GERD), it does not represent all upper gastrointestinal symptoms.

The Rome II definition of dyspepsia is the most recent and widely accepted.¹ Dyspepsia is defined as a pain or discomfort centred in the upper abdomen. This epigastric discomfort can be associated with other gastrointestinal symptoms such as bloating, feeling full, nausea, early satiety and heartburn. It is important to note that burning sensation in the epigastrium is not heartburn. Rather, heartburn refers to a burning sensation that originates from the epigastric region and radiates up towards the neck. Heartburn alone is not considered dyspepsia according to this definition.

Another study has contributed to the growing body of evidence linking Helicobacter pylori, to the development of gastric cancers. Uemura et al., prospectively studied 1,526 Japanese patients who had duodenal ulcers, gastric ulcers, gastric hyperplasia or non-ulcer dyspepsia at the time of study enrollment. Of these, 1,246 had H. pylori infection, and 280 did not.

The researchers found that gastric cancers developed in 2.9% of the H. pylori infected individuals and none of the uninfected patients. Among the H. pylori infected patients, those with severe gastric atrophy, corpuscle-predominant gastritis and intestinal metaplasia, were at significantly higher risk for developing gastric cancer.

Source

1. Uemura, N, Okamoto, S, Yamamoto, S et al. Helicobacter pylori infection and the development of gastric cancer. New England Journal of Medicine. 2001; 345:784-789.