GI Problems in Athletes Thomas Best MD, PhD The Ohio State University February 4, 2011

1. GI Problems in Athletes Thomas Best MD, PhD The Ohio State University February 4, 2011 Sports Medicine

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Suffering in Silence Poorly understood By athletes By sports medicine staff Symptoms often ignored Commonly: Self diagnosed Self treated Sports Medicine

13. Upper Gut Issues in Athletes Sports Medicine

14. 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% Sports Medicine

15. 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

16. 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

17. 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

18. 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

19. 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

20. Upper GI Symptoms Dysphagia (solids and/or liquids) Oropharyngeal dysphagia Esophageal dysphagia GERD Dyspepsia GI bleeding Sports Medicine

21. 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

22. 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

23. 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

24. 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 trauma Lower incidence in cyclists than runners Sports Medicine

25. 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

26. 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

27. Evaluation – Red Flags Weight loss Progressive dysphagia Recurrent vomiting GI bleeding Family history of CA Sports Medicine

28. 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

29. 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

30. Runner’s Diarrhea – A Real Common Problem! Sports Medicine

31. 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

32. 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 Sports Medicine

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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 ? Sports Medicine

49. 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

50. 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