Gastroenterology

Gastroenterology

Volume 124, Issue 3, March 2003, Pages 795-841
Gastroenterology

American Gastroenterological Association
AGA technical review on osteoporosis in gastrointestinal diseases,☆☆,

https://doi.org/10.1053/gast.2003.50106Get rights and content

Abstract

Osteoporosis is increasingly recognized as a source of significant disability, an awareness that has prompted clinicians to actively pursue the diagnosis among high-risk patients. Fractures have an obvious associated morbidity, negative impact on quality of life, and both direct and indirect costs. Hip fractures have long been associated with an increased mortality rate, but only recently has excessive mortality also been shown to accompany non–hip fractures and low bone mass.1, 2, 3 The excessive mortality associated with fractures is largely confined to elderly males and postmenopausal females. Many patients with gastrointestinal (GI) disorders at risk for osteoporosis are young, and these data may not apply to them. Much of the available clinical information regarding osteoporosis screening, outcomes, and therapeutic interventions is derived from the postmenopausal osteoporosis literature. It is recognized, however, that osteoporosis may accompany many other medical conditions, occurring as a sequela to disease or even to its treatment.

GASTROENTEROLOGY 2003;124:795-841

Section snippets

Methods

We conducted a systematic literature review and critically appraised the studies found using published methods.5 We graded evidence using guidelines adapted from the Practice Guidelines Committee of the American Association of the Study of Liver Diseases,6 as summarized in Table 1.

. Quality of evidence on which a recommendation is based

GradeDefinition
AHomogeneous evidence from multiple well-designed randomized (therapeutic) or cohort (descriptive) controlled trials, each involving a number of

Biology of bone metabolism

Bone is a dynamic tissue comprising cellular, organic, and inorganic components with a complex internal structure. Bone is constantly remodeled throughout life as the result of the opposing activities of 2 major cellular elements, osteoblasts and osteoclasts.

Bone tissue reacts to stress and injury through a well-orchestrated sequence for removing old bone and building new tissue. Bone remodeling is carried out by the basic multicellular unit, which consists of both osteoclasts and osteoblasts.7

General

Education on the importance of lifestyle changes (e.g., regular exercise, smoking cessation) and vitamin D and calcium supplementation should be given. Vitamin D deficiency should be identified and treated aggressively to maintain serum levels of 25-OHD within the normal range. For individuals found to be at high risk for osteoporotic fractures, therapy with an approved agent should be considered. Major abnormalities in BMD, calcium level, vitamin D metabolism, or PTH level warrant referral to

Conclusions

Bone disease has become a well-recognized problem in patients with GI disorders. The rising prevalence of IBD and more frequent diagnosis of asymptomatic celiac disease (aided by serological testing) will increase the number of patients with potential bone disease in all gastroenterology practices. The widespread accessibility to DXA testing has led to more gastroenterology patients with diagnoses of osteopenia and osteoporosis. There is a clear need to better define the implications of a DXA

Acknowledgements

The Clinical Practice Committee acknowledges the following individuals whose critiques of this review paper provided valuable guidance to the authors: Francis A. Farraye, M.D., M.Sc., Eileen Hay, M.D., Sunanda Kane, M.D., and Hillary Steinhart, M.D.

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    Dr. Charles Bernstein is supported in part by a Research Scientist Award from the Crohn's and Colitis Foundation of Canada and an Investigator Award from the Canadian Institutes of Health Research. The authors would like to thank Jacqueline Cantin for her assistance with this manuscript.

    ☆☆

    Address requests for reprints to: Chair, Clinical Practice Committee, American Gastroenterological National Office, c/o Membership Department, 4930 Del Ray Avenue, Bethesda, Maryland 20814. fax: (301) 654-5920.

    This literature review and the recommendations therein were prepared for the American Gastroenterological Association (AGA) Clinical Practice Committee. The paper was approved by the Committee on September 21, 2002 and by the AGA Governing Board on November 1, 2002.

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