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
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 24:525-40Peters, 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 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
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
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
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
– Hemorrhagic gastritis, colitis
– NSAID induced gastritis
– Traumatic hemolysis
– Impaired gut absorption
– Mechanical traumao 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
Sports Medicine
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
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:
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 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
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
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