Sports Medicine: Just the Facts

CHAPTER 35 • GASTROENTEROLOGY 205

35 GASTROENTEROLOGY

David L Brown, MD

Chris G Pappas, MD

INTRODUCTION AND EPIDEMIOLOGY

• From a gastrointestinal(GI) perspective, long dis-
  tance runners have been the most scrutinized group,
  but recent studies have looked at the GI symptoms of
  long distance walkers, cyclists, triathletes, and
  weight lifters. Upper and lower GI tract symptoms
  occur with equal prevalence in cyclists. Lower GI
  symptoms predominate nearly two to one over upper
  GI symptoms in endurance runners. Whether run-
  ning or riding, these same patterns also hold true in
  triathletes (Peters, 1999a). In low-intensity long-dis-
  tance walking, the overall occurrence of GI symp-
  toms is much lower than in other sports studied. The
  most common symptoms are flatulence and nausea
  each of which occurs in only 5% of walkers (Peters,
  1999 b).


• Symptomatic gastroesophageal reflux is extremely
  common in athletes. Cyclists have the lowest
  esophageal acid exposure, followed closely by run-
  ners. Weight lifters have the highest rates of reflux.
  All groups have increased reflux when exercising
  postprandially. Cyclists have a modest increase in
  reflux after eating, while weight lifters nearly
  double and runners triple their reflux (Collings et al,
  2003).


• Peptic ulcer disease(PUD) is associated with the pri-
  mary risk factors of Helicobacter pylori infection and
  nonsteroidal anti-inflammatory drugs(NSAID) use.

H. pyloriis associated with 65–95% of gastric ulcers

and 75% of duodenal ulcers. The estimated risk of a

clinically significant NSAID-induced event, including

bleeding and perforation, is 1 to 4% per year for non-

selective NSAID. Either of these factors alone

increases ulcer risk twentyfold. When both risk fac-

tors are present, an individual is 61 times more likely

to develop ulcer disease (Tytgat et al, 1985).

•The primary lower GI condition of athletes is

runner’s diarrhea, affecting up to 26% of marathon

runners (Keefe et al, 1984). Runner’s diarrhea is not

typically associated with bleeding; however, studies

in marathon runners showed that 20% of runners

completing a marathon had occult blood in their

stools, another 6% had bloody diarrhea, and 17% had

frank hematochezia while in training (McCabe et al,

1986).

UPPER GI DISEASES

GASTROESOPHAGEAL REFLUX DISEASE

• The most common presenting complaints for gastroe-
  sophageal reflux disease(GERD) are heartburn and
  acid regurgitation. The classic presentation is retroster-
  nal burning, exacerbated by meals, intense workouts,
  and recumbency with resolution on antacids. Atypical
  symptoms include nausea, excessive salivation (water
  brash), bloating, and belching (Richter, 1996).
  Extraintestinal complaints include sore throat, exer-
  tional dyspnea, cough, or wheezing (Table 35-1).
  •GERD pathophysiology involves retrograde movement
  of gastric acid and the proteolytic enzyme pepsin,
  which causes irritation of the esophageal epithelium.
  Reflux alone is insufficient to explain why individuals
  become symptomatic because affected patients have

TABLE 35-1 GERD Symptom Patterns

CLASSIC SYMPTOMS ATYPICAL SYMPTOMS/SIGNS RED FLAG SYMPTOMS

Pulmonary

Asthma

Chronic cough

ENT

Dental erosions

Halitosis

Lingual sensitivity

Chronic pharyngitis

Hoarseness

Rhinitis/Sinusitis

Globus

Cardiac

Atypical chest pain

Chronic untreated symptoms

Dysphagia

Weight loss

Hemetemesis

Melena

Odynophagia

Vomiting

Early satiety

Heartburn
Acid regurgitation
Nonspecific Symptoms

Nausea

Dyspepsia

Bloating

Belching

Indigestion

Hypersalivation/water brash