Effect of cimetidine on marathon-associated gastrointestinal symptoms and bleeding

A Role for Subtraction Scintigraphy in the Evaluation of Lower Gastrointestinal Bleeding in the Athlete

While lower gastrointestinal haemorrhage (LGIH) in the athlete tends to be self-limiting in the majority of athletes, recurrent symptoms occur in some athletes. It is important to identify the smaller percentage of athletes in whom risks and recurrence are greater because both their general health and athletic performance might benefit from more rigorous clinical evaluation. Technetium-99m red blood cell ((99m)Tc RBC) scintigraphy is a technique for detection and localisation of LGIH and offers a number of significant advantages over other imaging modalities in the evaluation of LGIH. Nonetheless, there are a number of limitations recognised in (99m)Tc RBC scintigraphic evaluation of LGIH. Subtraction scintigraphy in (99m)Tc RBC evaluation of gastrointestinal haemorrhage may offer a tool to overcome limitations of conventional scintigraphy. In essence, subtracting a nominal 'mask' or reference image from all subsequent images provides a mechanism to view only the information contributed by accumulated bleeding, removing potential sources of both false-positive and false-negative findings. While the limitations of procedures available for the evaluation of LGIH are generally prohibitive of effective application in the obscure bleeding associated with athletic performance, adopting subtraction methods in conjunction with conventional (99m)Tc RBC scintigraphy may offer a valuable tool in identification and localisation of bleeding sites. The general health and athletic performance may be enhanced in some athletes when the underlying cause of bleeding can be more appropriately managed.

Ischemic colitis in marathon runners: a case-based review

In the United States over 450,000 participants finished a marathon in 2002. Some of them will present to an Emergency Department (ED) with a variety of gastrointestinal complaints. The diagnosis of ischemic colitis should be considered in patients who present with bloody diarrhea. We describe three patients who presented to our ED with abdominal pain and bloody diarrhea after a marathon. Gastrointestinal complaints with emphasis on mesenteric ischemia and ischemic colitis are discussed.

Medical problems of marathon runners

Several organ systems can be affected by marathon running. Acute musculoskeletal injuries are common, but running does not result in increased rates of musculoskeletal disability. Gastrointestinal complaints are also common among runners; some of these complaints are explained by the decreased mesenteric blood flow during exercise. Although cardiac events are rare, they can be devastating. Symptomatic hyponatremia is another serious but mostly preventable problem.

Proton pump inhibition prevents gastrointestinal bleeding in ultramarathon runners: a randomised, double blinded, placebo controlled study

BACKGROUND

Ultra-endurance running is emerging as a popular sport in Western industrialised countries. Gastrointestinal bleeding has been reported to be an adverse effect in these runners.

OBJECTIVE

To see if the oral administration of a proton pump inhibitor would reduce the incidence of gastrointestinal bleeding in an ultramarathon.

METHODS

In a randomised, double blinded, placebo controlled study, a prophylactic regimen of three days of an oral proton pump inhibitor (pantoprazole 20 mg) was tested in healthy athletes participating in the Spartathlon ultramarathon. The incidence of gastrointestinal bleeding was assessed by a stool guaiac test.

RESULTS

Results were obtained for 70 healthy volunteers. The data for 20 of 35 runners in the intervention group and 17 of 35 runners in the placebo group were entered into the final analysis. At the end of the ultramarathon, two subjects in the intervention group and 12 in the placebo group had positive stool guaiac tests (risk difference 0.86; 95% confidence interval 0.45 to 0.96; p = 0.001).

CONCLUSION

A short prophylactic regimen of oral proton pump inhibition can successfully decrease the incidence of gastrointestinal bleeding in participants in an ultramarathon.

Exercise-associated intestinal ischemia

Ischemic bowel disease exhibits a complex spectrum of clinical presentations and in the athlete the disease may be superimposed on dehydration, hyperthermia, and exhaustion. Physicians caring for athletes should be aware of the manifestations of ischemic bowel disease and the optimum methods of diagnosis and treatment. Abdominal pain and diarrhea are typical initial symptoms of ischemia and these symptoms generally limit further damage. However, symptoms may be overridden in cases of extreme athletic competition or other significant endurance events such as combat. Athletes and coaches should be aware of the danger of ischemic bowel disease. Patients or athletes with recurrent symptoms of abdominal pain and diarrhea during exercise may be at increased risk for ischemic damage. However, no underlying anatomic abnormalities have been noted. Ischemic hemorrhagic gastritis is generally reversible and may be controlled with effective acid blockade. Ischemic colitis generally presents with pain, diarrhea, and bleeding. It is usually mild but may require volume and transfusion support, rarely progressing to need for resection or stricture. Severe presentations with intestinal infarction are rare but potentially life threatening. The athlete is usually able to ultimately resume his or her activities without restriction.

Training Room Management of Medical Conditions: Sports Gastroenterology

Gastrointestinal (GI) illnesses are common in athletes. Various causes include adverse physiologic adaptations of the gut during exercise; excess ingestion of carbohydrate drinks, alcohol, and anti-inflammatory medications; emotional stressors; exposure to pathogens in closed environments and during travel; trauma; and abdominal wall pressure overload. Unfortunately, evidence-based management of GI illnesses in athletes is limited because most studies have compared various GI illnesses between different sports, rather than comparing athletes to nonathletes. This article reviews the evidence that is available specifically relating to etiology, pathophysiology, clinical presentation, relevant differential diagnoses, acute management, and recommendations for specialist consultation of various GI illnesses in the training-room setting.

Iron supplementation in athletes--first do no harm

Although it generally does not improve performance, iron is often used by elite athletes. The physiologic changes induced by exercise can mimic iron deficiency and decrease hemoglobin and ferritin concentrations. Determination of serum transferrin receptor concentrations may identify true iron deficiency, which occurs particularly in young athletes. In contrast, increased iron stores in the body are a frequent finding in elite athletes who have used long-term iron supplementation. Elite runners have increased intestinal blood loss, but this usually can be compensated by enhanced absorption of dietary iron. The combination of exercise-induced hemolysis with enhanced intestinal blood loss in various endurance sports leads to severe abnormalities of routine tests, and extreme physical activity may be responsible for positive fecal occult blood determinations. Indiscriminate iron supplementation carries the risk of inducing hemochromatosis in individuals homozygous for the widespread C282Y allele of the HFE gene. This polymorphism is common and can be found in about 1% of individuals of Northern European descent; moreover, iron supplementation can modify the presentation of important underlying diseases such as celiac disease or colon carcinoma. In conclusion, iron supplements should be prescribed for athletes with iron-deficiency anemia and carefully monitored if given for prophylaxis; unless a therapeutic response occurs, investigations to establish the cause of iron deficiency should be initiated.

Efficacy of omeprazole for the prevention of exercise-induced gastritis in racing Alaskan sled dogs

Exercise-induced gastritis and gastric ulcers are common in humans and horses, and recently have been described in racing sled dogs. The cause of exercise-induced gastric disease is not completely understood in any species, but pharmacologic suppression of acid secretion is an effective treatment in humans and horses. Thus, we tested the hypothesis that omeprazole, a proton-pump inhibitor shown to reduce gastric acid secretion in dogs, would reduce the severity of exercise-induced gastric disease. Three teams of 16 dogs each competing in the 2002 Iditarod Sled Dog Race were recruited for participation. Within each team, dogs were randomly assigned to either treatment (20 mg omeprazole PO q24h) or placebo. Treatments were administered until either completion of the race or withdrawal of an individual dog from competition. Gastric endoscopy was performed in all dogs 24 hours after completion or withdrawal, and the gastric mucosa was scored by using a subjective severity score (0 = normal, 3 = numerous bleeding ulcers). Treatment with omeprazole significantly reduced mean gastricseverity score compared to placebo (omeprazole: 0.65 +/- 0.17, placebo: 1.09 +/- 0.18; P = .028), but also was associated with increased frequency of diarrhea during the race (omeprazole 54%, placebo 21%; P = .017). Examination of our data suggests that omeprazole may be an effective treatment for exercise-induced gastric disease in racing sled dogs. However, further investigation regarding the cause and clinical relevance of diarrhea associated with omeprazole treatment must be conducted before omeprazole can be recommended for routine prophylactic treatment in these athletes.

The role of gastrointestinal endoscopy in long-distance runners with gastrointestinal symptoms

BACKGROUND

Exercise-related gastrointestinal symptoms are not uncommon among athletes. The occurrence of gastrointestinal bleeding has been reported, especially in long-distance runners. We studied gastrointestinal mucosal damage, using gastrointestinal endoscopy, in competitive long-distance runners. Gastrointestinal blood loss and anaemia before and after running were also assessed.

METHODS

Sixteen competitive long-distance runners (all men; age range 16-19 years) participated in the study. All runners completed a symptom questionnaire prior to a 20 km race. Stool occult blood and haematological studies (haemoglobin, haematocrit, serum iron, total iron-binding capacity [TIBC] and ferritin) were performed before and immediately after the race. Gastrointestinal endoscopy was performed to assess macroscopic changes. Colonoscopy was also performed on the patients who had positive stool occult blood before or after the race.

RESULTS

Gastrointestinal symptoms were frequently experienced by the runners. Gastritis (n = 16), oesophagitis (n = 6) and gastric ulcer (n = 1) were found at gastroscopy. Colonoscopy was performed on four patients who had positive stool occult blood. One had multiple erosions at the splenic flexure and one had a rectal polyp. Five runners had anaemia, and all of these had at least one endoscopic lesion (three gastritis, two oesophagitis and one multiple erosion at the splenic flexure). There were significant changes in the following haematological parameters after the race: iron (decreased, P = 0.02), ferritin (decreased, P = 0.001) and TIBC (increased, P = 0.00005).

CONCLUSIONS

Gastrointestinal symptoms and gastrointestinal mucosal damage are prevalent among long-distance runners. Prior to treatment, gastrointestinal endoscopy should be considered in long-distance runners with gastrointestinal symptoms and/or anaemia.

Aetiology of running-related gastrointestinal dysfunction. How far is the finishing line?

30 to 65% of long distance runners experience gastrointestinal (GI) symptoms related to exercise. Several hypotheses have been postulated; however, the aetiology and pathophysiology are far from clear. The mechanical effect of running on the viscera must be involved in the development of GI symptoms in this sport. Reduction of splanchnic blood flow due to visceral vasoconstriction is another widely supported theory; nevertheless, it does not explain many of the clinical findings. Examination of the GI tract during exercise is a difficult task, and measurements of both orocaecal and whole-gut transit time have shown equivocal results. GI hormones, and especially prostaglandins, may be of crucial importance for the production of symptoms. Intestinal absorption, secretion and permeability may also be altered during exercise, provoking intestinal dysfunction. Factors such as stress, diet, dehydration, infections and other factors need to be analysed in order to present a global view of the hypotheses regarding the aetiology of this common and often overlooked problem.

Monoclonal antibodies for exercise-induced fecal blood detection--comparison with Hemofec

The purpose of this investigation was to determine the incidence of fecal occult blood in marathoners using an immunochemical technique (OC-Hemodia). Five stool specimens (2 pre- and 3 postrace) were collected from 24 male runners (mean age 41.4 +/- 9.3 yrs) and analysed for fecal occult blood using the OC-Hemodia test. The results were also compared with a qualitative test (Hemofec) in 12 subjects who were randomly selected from the overall group of 24 runners. With the immunochemical technique, the results evidenced the presence of fecal occult blood in 8 subjects in the first postrace stool specimens. Four of these 8 subjects also tested positive in the second postrace sample, whereas in the third postrace sample only one of them tested positive. With the qualitative test, fecal blood was demonstrated in 10 runners in the first postrace sample. Eight of them tested positive in the second sample, whereas only 5 tested positive in the third sample. The immunochemical technique is recommended for fecal occult blood detection in marathoners.