GI Problems in Athletes

Thomas Best MD, PhDThe 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

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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

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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

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Interpretation of Evidence

Criteria of Judgement Consistency of independent investigations Strength of association (dose response) Specificity of association Temporal relationship Coherence (biological plausibility)

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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)

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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 24:525-40Peters, CSMR 2004, 3:107–111

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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 lossJaworski, CSMR 2005, 4:137–143Casey, Clin Sport Med 2005 24:525-40Ho, 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

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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

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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

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Suffering in Silence

Poorly understood– By athletes– By sports medicine

staff

Symptoms often ignored

Commonly:– Self diagnosed– Self treated

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Upper Gut Issues in Athletes

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Etiology of Upper GI Problems

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 high-

fiber meal prior to exercise Psychologic – stress can increase sympathetic discharge and

decrease splanchnic blood flow up to 80%

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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

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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

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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

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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

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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

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Upper GI Symptoms

Dysphagia (solids and/or liquids)– Oropharyngeal dysphagia– Esophageal dysphagia

GERD

Dyspepsia

GI bleeding

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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

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Dyspepsia

Varied complaints including: Nausea, gnawing/burning epigastric pain, vomiting, eructation, bloating, indigestion, generalized abdominal discomfort

Most common causes include:– PUD– GERD– Gastritis

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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

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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

– Hemorrhagic gastritis, colitis

– NSAID induced gastritis

– Traumatic hemolysis

– Impaired gut absorption

– Mechanical traumao Lower incidence in cyclists than runners

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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

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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

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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

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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

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Runner’s Diarrhea – A Real Common Problem!

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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

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Exercise And The Lower GI Tract

Common lower GI symptoms:

Flatulence Diarrhea (26%) Hematochezia (6%) Urgency to defecate (54%) Women > men

Worobetz & Gerrard N Z Med J 1985

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Exercise-Associated Ischemic Colitis

Moses FM et al. Ann Int Med 1989

Colon second most common location for exercise-associated 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 ?

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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 2008Sports 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

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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

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