C, Genton B. Immunogenicity and safety of a virosomal hepatitis a vaccine in the elderly. Journal of Travel Medicine. 2006; 13;78–83.
10 10. Thomas DL. Global elimination of chronic hepatitis. NEJM. 2019; 380: 2041–2050.
11 11. Yartel AK, Rein DB, Brown KA, et al. Hepatitis C virus testing for case identification in persons born during 1945‐1965: Results from three randomized trials. Hepatology. 2018; 67:524–533.
12 12. Chung RT, Ghana MG, Kim Ay, et al. Hepatitis C guidance 2018 update: AASLD‐ADSA recommendations for testing managing, and treating hepatitis c virus infection. Clin Infect Dis. 201; 67:1477–1492.
13 13. Udompap P, Kim D, Kim WR. Current and future burden of chronic nonmalignant liver disease. Clin Gastroenterol Hepatol. 2015; 13(12):2031–2041.
14 14. Puri P, Sanyal AJ. Nonalcholic fatty liver disease: Definitions, risk factors and work up. Critical Liver Disease. 2012; 1:99–10.
15 15. Diehl A, Day C. Cause, pathogenesis and treatment of nonalcholic steatohepatitis. NEJM 2017; 377:2063–2072.
16 16. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease — meta‐analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016; 64:73–84.
17 17. Hemaez R, Lazo M, Beonekamp E, et al. Diagnostic accuracy and reliability of ultrasonography for detection of fatty liver: a meta‐analysis. Hepatology. 2011; 54:1082–1090.
18 18. Cotreau MM, von Moltke LL, Greenblatt DJ. The influence of age and sex on the clearance of cytochrome P450 3A substrates. Clin Pharmacokinet. 2005; 44(1):33–60.
19 19. Hoofnagle JH, Bjornsson ES. Drug‐induced liver injury – types and phenotypes. NEJM. 2019 July 18:264–269.
20 20. Mirand AL, Welte JW. Alcohol consumption among the elderly in a general population. Erie County. New York. Am J Public Health. 1996; 86(7):978–984.
21 21. Caputo F. Vignoli T, Addolorato G, Zoli G, Bernadi M. Alcohol use disorders in the elderly: a brief overview from epidemiology to treatment options. Exp Gerontol. 2012; 47(6):411–416.
22 22. Bellentani S, Saccoccia G, Costa G, et al. Drinking habits as cofactors of risk for alcohol induced liver damage. The Dionysos Study Group. Gut. 1997; 41(6):845–50.
23 23. Wong T, Dang K, ladhani S, et al. Prevalence of alcoholic fatty liver disease among adults in the United States 2001–2016. JAMA. 2019; 321(17);1723–1725.
24 24. Tapper EB, Parikh ND. Mortality due to cirrhosis and liver cancer in the United States, 1999–2016: observational study. BMJ. 2018; 362:k2817.
25 25. Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M SO. Primary biliary cholangitis: 2018 practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2019; 69(1):394. Epub 2018 Nov 6.
26 26. Bacon BR, Adams PC, Kowdley KV, et al. Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Disease. Hepatology. 2011; 54:328–43.
27 27. Fitzsimons EJ, Cullis JO, Thomas DW, et al. Diagnosis and therapy of genetic hemochromatosis (review and 2017 update). Br J Haematol. 2018; 181:293–303.
28 28. Al‐Chalabi T, Boccato S, Portman BC, et al. Autoimmune hepatitis (AIH) in the elderly: a systematic retrospective analysis of a large group of consecutive patients with definite AIH followed at a tertiary referral centre. J Hepatol. 2006; 45(4):575–83.
29 29. Rizvi S, Gawrieh S. Autoimmune hepatitis in the elderly: diagnosis and pharmacologic management. Drugs & Aging. 2018; 35:589–602.
30 30. Karlsen TH, Folseraas T, Thorburn D, Vesterhus M. Primary sclerosing chlangitis – a comprehensive review. Hepatology. 2017; 67:1298–1323.
31 31. Borie F, Tretarre B, Bouvier AM, et al. Primitive liver cancers: epidemiology and geographical study in France. J Gastrenterolo Hepatology. 2009; 21:984–989.
32 32. Regev A, Schiff ER. Liver disease in the elderly. Gastroenterology Clinics of North America. 2001; 30(2):547–61.
33 33. Siegel JH, Kasmin FE. Biliary tract disease in the elderly: management and outcomes.GUT 1997; 41;433–435.
34 34. Bates T, Hamm M, Lowe D, Lawson C, Padle N. Longitudinal study of gallstone prevalence at necropsy. Gut. 1992; 33: 103–7.
35 35. Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology. 1999; 117Z:632–636.
36 36. Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emergency Medicine Clinics of North America. 2003; 21:937–969).
37 37. Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994; 142(22):2573–2578.
38 38. Attili AF, De Santis A, Capri R, et al. The natural history of gallstones: the GREPCO experience. Hepatology. 1995; 21(3):655–662.
39 39. Irojah B, Bell T, Grim R, et al. Are they too old for surgery? Safety of cholecystectomy in superelderly patients. Perm J. 2017; 21:16–013.
40 40. Galeazzi M, Mazzola P, Valcarcel B, et al. Endoscopic retrograde cholangiopancreatography in the elderly: results of a retrospective study and a geriatricians’ point of view. BMC gastroenterology. 2018; 18:38.
41 41. Aduen JF, Suray B, Dickson RC, et al. Outcomes after liver transplant in patients aged 70 years or older compared with those younger than 60 years. Mayo Clinic Proceedings. 2009; 84:973–978.
CHAPTER 19 Faecal incontinence
William Gibson
Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
Introduction
Faecal incontinence (FI),* the involuntary loss of liquid or solid stool,1 is a common but under‐reported problem in older adults. Accurate estimates of the prevalence of FI are challenging due to under‐reporting,2 and prevalence estimates for FI in older adults are highly variable, from 2.2–25% in the general population, to 9–30% in community‐dwelling older adults, and up to 50% in institutionalized older people.3,4 Faecal incontinence is a highly stigmatizing symptom5 and is associated with shame and embarrassment6 and social isolation,7 and it has been reported to increase institutionalization8 and mortality.9
The physiology of defecation
Much like urination, defecation is a learned skill under conscious control and should only occur at the time and place of one’s choosing. The control of defecation and, therefore, the maintenance of faecal continence rely on many interconnected systems, including the alimentary canal, anus, pelvic floor, and peripheral and central nervous systems. Fundamentally, faecal continence is maintained as long as the pressure in the rectum is lower than the pressure generated by the anus.
Anatomy of the lower alimentary canal
The rectum forms the final part of the alimentary tract. It is a tubular structure 12–15 cm in length, extending the sigmoid colon to the anal canal, which extends around 4 cm from the anal verge to the anorectal ring. The rectum follows the shape of the sacrum and, unlike the rest of the colon, lacks teniae coli, as these fuse in the sigmoid and are continuous in the rectum, forming a longitudinal muscle layer that surrounds the rectum along its length. The anal canal is separated by a dentate line into an upper mucosal lining and lower cutaneous segment. The area above the dentate line is supplied by the sympathetic and parasympathetic systems, whereas below the dentate line, the somatic nervous system