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Although at some point in our lives most of us finally accept that we are not going to live forever, few enjoy the process of getting old, particularly when it involves loss of function. However, improved living standards and the continuing progress in the quality and availability of healthcare, particularly in westernised countries, is resulting in populations being skewed towards the elderly. In these communities, provision for the aged will become one of the major challenges for the next century.
The editors of more than 100 international medical journals decided last year to sponsor a world wide movement to bring healthcare problems of the elderly to the fore in October 1997. Gut decided to join the initiative by dedicating part of this issue to aging with focused leading articles and original papers on gastrointestinal and liver topics as they relate to the elderly. We took two approaches to procure material for this theme issue. We commissioned five short leading articles on topics we considered important in the aging gut and liver and collected original articles that were relevant to the theme that had been submitted and peer-reviewed by our usual process. Jan Tack and Gaston Vantrappen (p 422) review oesophageal problems in the elderly; they under-play the concept of “presby-oesophagus” while acknowledging the importance of dysphagia and gastro-oesophageal reflux disease. Makau Lee and Mark Feldman (p 425) stress again the importance of non-steroidal anti-inflammatory drugs in the aging stomach and consider the effects that the aging process has on epithelial integrity and mucosal defence mechanisms. Both of these reviews show beautifully how earlier prejudice and ignorance concerning gut physiology and function in old age are being replaced by well conducted studies in humans and animals. Such knowledge is beginning to allow us to understand the interactions between a lifetime exposure to environmental agents (medications, tobacco, alcohol), together with chronic disease (heart failure, chronic obstructive airways disease, non-insulin dependent diabetes mellitus, for example) and the gut and hepatobiliary system. Gwyn Seymour (p 427) considers ethical and practical issues with respect to gastrointestinal surgery in old age. The need for careful preoperative assessment and immediate postoperative care is stressed, although wider issues of equality of access to treatment and quality of care are also discussed. Although these issues are, of course, not confined to gastroenterology, our specialty provides a paradigm for medical care and treatment of old people in general. Oliver James (p 430) focuses our attention on the decline in parenchymal liver function with age and describes the specific problems of hepatitis A, B and C infections in elderly patients. The success of liver transplantation in this age group is emphasised, being related, at least in part, to the decline in immune function in the aging population. Finally, Jerome Siegel and Franklin Kasmin (p 433) review the management of biliary tract diseases in the elderly, stressing the safety and efficacy of timely endoscopic interventions and minimally invasive surgery. It is helpful to have this thoughtful and authoritative contribution reflecting their own widely admired practice in the management of biliary disease in old age. In many instances age is not a major factor in making management decisions in gastrointestinal and liver disorders but these reviews draw our attention to aspects of the care of elderly patients with digestive disorders that may require special attention.
In addition to these reviews, we include five original articles on gastrointestinal topics that have special relevance for the elderly. Cullen et al (p 459) explore possible interactions betweenHelicobacter pylori and non-steroidal anti-inflammatory drugs in peptic ulcer bleeding in the elderly and Kinoshita et al(p 452) report on chronological changes in gastric acid secretion in Japan (commented on by Adrian Lee (p 575)). Christieet al (p 513) propose that the age for screening uncomplicated dyspepsia could be increased to 55 years of age. Aimone-Gastin et al (p 475) describe the use of a physiologically relevant test for B12 absorption in the elderly, and Deans et al (p 545) stress again the relative safety of endoscopic sphincterotomy in patients over 65 years of age.
For most gastroenterologists and hepatologists, age is rarely a dominant factor in producing a management strategy. However, as these contributions clearly state, there are age related issues about which we need to be informed and which will undoubtedly increase as gastroenterology and hepatology move through the next millennium.