EPIDEMIOLOGY OF

GASTROINTESTINAL
PROBLEMS
By:

M. Rum Rahim, MD., MSc.

Suggested Reading:
Lipsky, Martin.S., Gastrointestinal Problems,
Lippincott Williams & Wilkins. Philadelphia, 2000
Yarnell, John., Epidemiology and Prevention: A
System-based Approach., Oxford University Press.,
Oxford New York, 2007

Introduction
This 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

Introduction
The scope of this subject to discuss the
epidemiology of all chronic gastrointestinal 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.

Dyspepsia
Abdominal Pain in Adults
RAP in Children
Jaundice in Adults

DYSPEPSIA
The term dyspepsia covers a variety of
symptoms affecting the upper gastrointestinal 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.

THE ROME I CLASSIFICATION OF

DYSPEPSIA
Pain or discomfort centred in the upper abdomen
Discomfort 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.

Dyspepsia..

Prevalence
A 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 %.

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

Dyspepsia..

Risk Factors
Psychological
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.

Dyspepsia..

Risk Factors
A 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

Dyspepsia..

Time Trends
The 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

Dyspepsia..

Time Trends
Gastro-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.

Helicobacter pylori
H.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.

Abdominal Pain in Adults

DEFINITION
Abdominal 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)

Abdominal Pain in Adults

Possible causes of abdominal pain
in the office setting:
Acute gastroenteritis Cholelitiasis
UTI Diverticulosis
Peptic ulcer disease
Appendicitis
IBS Urolithiasis
Pelvic inflammatory diseaseUlcerative
colitis
GERD
Muscular strain

Abdominal Pain in Adults

RISK FACTORS
Hypertension & 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

Abdominal Pain in Adults

RISK FACTORS
Advancing 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

Abdominal Pain in Adults

RISK FACTORS
Medications have been linked to the
development of gastric & duodenal
ulcers as well as pancreatitis
Hypercalcemia, 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.

Abdominal Pain in Adults

RISK FACTORS
Family 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

Abdominal Pain in Adults

PATIENT EDUCATION
Patient 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.

Abdominal Pain in Adults

PATIENT EDUCATION
Recurrent 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

Recurrent Abdominal Pain (RAP)

in Children
DEFINITION
RAP 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.

Recurrent Abdominal Pain (RAP)

in Children
DEFINITION
It 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.

Recurrent Abdominal Pain (RAP)

in Children
RISK FACTORS
Boys & girls are equally affected up
to age 9 years
9-12 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.

Recurrent Abdominal Pain (RAP)

in Children
RISK FACTORS
G.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.

Recurrent Abdominal Pain (RAP)

in Children
PATIENT EDUCATION
It 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.

Recurrent Abdominal Pain (RAP)

in Children
PATIENT EDUCATION
The 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.

Recurrent Abdominal Pain (RAP)

in Children
PATIENT EDUCATION
Also use active listening to
encouraged the parent & child to
express their fears & concern about

Jaundice in Adults
DEFINITION
Jaundice, 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.

Jaundice in Adults
RISK FACTORS
Many 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.

Jaundice in Adults
RISK FACTORS
It 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.

Jaundice in Adults
Patient Education
Patient 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.

Jaundice in Adults
Patient Education
Patients 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.

EPIDEMIOLOGY &
PREVENTING OF GEH