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About

Gastroenterology deals with the diagnosis and treatment of disorders of the digestive system (esophagus, stomach, intestines, liver and pancreas).

My consultations usually involve taking a detailed history of the patient’s symptoms, a physical examination and designing a plan that may include the prescription of additional tests (some performed in the my office), blood tests and medications. We encourage a discussion about the patient’s possible diagnosis and provide guidance for life style changes that might be favorable. The objective is always to control the symptoms with a minimum of medication. The integration of complementary medicine is also the subject of my attention.

In this website you will find:
 

    • Section Biography: My professional CV

 

    • Section Clinics: Details of the three clinics where I practice.

 

    • Section Procedures: Detailed information about the techniques that I perform in the field of endoscopy and non-invasive tests.

 

    • Section Topics: Articles with updated information on various diseases treated by Gastroenterologists

 

    • Section Publications: A list of the scientific papers I have published.

 

  • Section Links: a list of websites with good quality information and resources for healthy nutrition in the Cascais and Lisbon areas.

Biography

 

  • Born in Lisbon 1951
  • 1970-1974 – University of Lorenzo Marques School of Medicine, Mozambique
  • 1974-1976 – Graduated in Medicine at University of Lisbon School of Medicine, Portugal
  • 1981-1984 – Internal Medicine Residency at the Bronx VA Medical Center – Mount Sinai School of Medicine; New York, USA
  • 1984 – Certifying Examination in Internal Medicine by the American Board of Internal Medicine, USA
  • 1984-1986 – Fellowship in Gastroenterology at Harlem Hospital Center – College of Physicians and Surgeons of Columbia University, New York, USA
  • 1985 – Federal Licensing Examination by the National Board of Medical Examiners USA
  • 1987 – Certifying Examination in Gastroenterology by American Board of Internal Medicine, USA
  • 1987-2003 – Head of the Gastroenterology Division at S. Francisco Xavier Hospital in Lisbon, Portugal
  • 1987-2012 – Private practice in Lisbon

 

Titles

 

  • Board Certified in Gastroenterology by the American Board of Internal Medicine
  • Board Certified in Internal Medicine by the American Board of Internal Medicine
  • Specialist in Gastroenterology by the Ordem dos Medicos Portuguesa
  • Specialist in Internal Medicina by the Ordem dos Medicos Portuguesa
  • Fellow of the American College of Physicians

 

Areas of Special Interest

 

  • Helicobacter pylori
  • Colon cancer prevention
  • Gastro intestinal endoscopy
  • Nutrition

 

Memberships

 

  • American Gastroenterological Association
  • American College of Gastroenterology
  • American Society for Gastrointestinal Endoscopy
  • American College of Physicians
  • Ordem dos Médicos Portuguesa
  • Sociedade Portuguesa de Gastrenterologia
  • Sociedade Portuguesa de Endoscopia Digestiva

Clinics

I personally do not think that the concept of “email consultation” is a very good idea, so in this page you will not find my personal email. My assistants at the various clinics are trained to answer the most frequent questions. Most questions are usually are about procedures. In the Procedures Section you will find detailed information about the techniques I perform.

Lisbon

 

Address
Euromedic Lisboa (CREAR)
Av. João Crisóstomo 30 A,
1050-127 Lisboa
euromedic.pt
Contacts
Tel.: 213 194 130
Fax: 213 194 149

 

 

Cascais

 

Address
Clínica do Rosário.
Avenida Nossa Senhora do Rosário, Nº 1212.
2750-178 Cascais
www.clinicadorosario.org
Contacts
Telefone 214 826 860
Fax 214 826 869
Bookings: São Ferreira and Carla Rodrigues.
clinicarosario@yahoo.com

 

See Clínica do Rosárioin a bigger map

Santarém

 

Address
Euromedic – Imagem Médica
Rua Professor Pinto Correia Lote 6 – Cave
2005-266 Santarém
Contacts
Telefone 243 303 180
Fax 243 303 188
Bookings: Elisabete or Julia.

 

Procedures

In the clinical practice of Gastroenterology we often have to use multiple tests to diagnose and treat different conditions. Below you will find the ones most often performed in my offices. My policy is not to make agreements with insurance companies. This approach gives me the freedom to perform the techniques that I think the patient needs without any constraints. After each procedure a receipt is always issued, to be presented to the patient’s insurance company for reimbursement.

  • Upper Gastrointestinal (GI) Endoscopy

    What is an Upper Gastrointestinal (GI) Endoscopy?

    Upper GI endoscopy is a procedure that uses a lighted, flexible endoscope with
    a video camera at the tip to see inside the upper GI tract. The upper GI tract includes the esophagus, stomach, and duodenum—the first part of the small intestine.
    Upper GI endoscopy is a procedure that uses a lighted, flexible endoscope to see inside the esophagus, stomach, and duodenum.

    Upper GI endoscopy is a procedure that uses
    a lighted, flexible endoscope to see inside
    the esophagus, stomach, and duodenum.

     

    What Problems can Upper GI Endoscopy Detect?

    Upper GI endoscopy can detect:

    • ulcers
    • abnormal growths
    • precancerous conditions
    • bowel obstruction
    • inflammation
    • hiatal hernia

     

    When is Upper GI Endoscopy used?

    Upper GI endoscopy can be used to determine the cause of:

    • abdominal pain
    • nausea
    • vomiting
    • swallowing difficulties
    • gastric reflux
    • unexplained weight loss
    • anemia
    • bleeding in the upper GI tract
    • the presence of Helicobacter pylori (a bacteria that causes gastritis and ulcers)

    Upper GI endoscopy can also be used to remove stuck objects, including food, and to treat conditions such as bleeding ulcers. It can also be used to biopsy tissue in the upper GI tract. During a biopsy, a small piece of tissue is removed for later examination with a microscope.
     

    How to Prepare for Upper GI Endoscopy

    The upper GI tract must be empty before upper GI endoscopy. Generally, no eating or drinking is allowed for 4 to 8 hours before the procedure.
    Patients should tell their doctor about all health conditions they have especially heart and lung problems, diabetes, and allergies and all medications they are taking. Patients may be asked to temporarily stop taking medications that affect blood clotting.
    Medications that may be restricted before and after upper GI endoscopy include:

    • blood thinners
    • diabetes medications

    Driving is not permitted for 12 after upper GI endoscopy to allow sedatives time to completely wear off. Before the appointment, patients should make plans for a ride home.
     

    How is Upper GI Endoscopy performed?

    An intravenous (IV) needle is placed in a vein in the arm and a sedative will be given. Sedatives help patients stay relaxed and comfortable. While patients are sedated, the doctor and medical staff monitor vital signs.
    During the procedure, patients lie on left side on an examination table. An endoscope is carefully fed down the esophagus and into the stomach and duodenum. A small camera mounted on the endoscope transmits a video image to a video monitor, allowing close examination of the stomach lining. Air is pumped through the endoscope to inflate the stomach and duodenum, making them easier to see. Special tools that slide through the endoscope allow the doctor to perform biopsies, stop bleeding, and remove abnormal growths.
     

    Recovery from Upper GI Endoscopy

    During this time, patients may feel bloated or nauseated. They may also have a sore throat, which can stay for a day or two. Patients will likely feel tired and should plan to rest for the remainder of the day. Unless otherwise directed, patients may immediately resume their normal diet and medications.
    Some results from upper GI endoscopy are available immediately after the procedure. The doctor will share the results with the patient and the companion and will give a written report with photos taken during the examination. Biopsy results are usually ready in less than two weeks.
     

    What are the Risks Associated with Upper GI Endoscopy?

    Risks associated with upper GI endoscopy include:

    • abnormal reaction to sedatives
    • bleeding from biopsy
    • accidental puncture of the upper GI tract

    Patients who experience any of the following rare symptoms after upper GI endoscopy should contact the clinic immediately:

    • swallowing difficulties
    • throat, chest, and abdominal pain that worsens
    • vomiting
    • bloody or very dark stool
    • fever

     

    Points to Remember

     

    • Upper gastrointestinal (GI) endoscopy is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract.
    • To prepare for upper GI endoscopy, no eating or drinking is allowed for 4 to 8 hours before the procedure.
    • Patients should tell their doctor about all health conditions they have and all medications they are taking.
    • Driving is not permitted for 12 after upper GI endoscopy to allow the sedative time to wear off. Before the appointment, patients must make plans for a ride home. A companion must be always available as soon as the patient arrives to the clinic.
    • An intravenous (IV) needle is placed in a vein in the arm to give a sedative.
    • During upper GI endoscopy, an endoscope is carefully fed into the upper GI tract and images are transmitted to a video monitor.
    • Special tools that slide through the endoscope allow the doctor to perform biopsies, stop bleeding, and remove abnormal growths.
    • After upper GI endoscopy, patients may feel bloated or nauseated and may also have a sore throat.
    • Unless otherwise directed, patients may immediately resume their normal diet and medications.
    • Possible risks of an upper GI endoscopy include abnormal reaction to sedatives, bleeding from biopsy, and accidental puncture of the upper GI tract.

  • Colonoscopy

    What is a Colonoscopy?

    Colonoscopy is a procedure used to see inside the colon and rectum. Flexible sigmoidoscopy enables the doctor to see only the sigmoid colon, whereas colonoscopy allows the doctor to see the entire colon. Colonoscopy is the preferred screening method for cancers of the colon and rectum. Colonoscopy and sigmoidoscopy can detect inflamed tissue, ulcers, and abnormal growths. The procedure is used to look for early signs of colorectal cancer and can help doctors diagnose unexplained changes in bowel habits, abdominal pain, bleeding from the anus, and weight loss. A flexible instrument with a video camera at the tip called colonoscope is used to see inside the large intestine.
     

    What are the colon and rectum?

    The colon and rectum are the two main parts of the large intestine. Although the colon is only one part of the large intestine, because most of the large intestine consists of colon, the two terms are often used interchangeably. The large intestine is also sometimes called the large bowel.
    The colon and rectum are the two main parts of the large intestine.
    The colon and rectum are the two
    main parts of the large intestine.

     
    Digestive waste enters the colon from the small intestine as a semisolid. As waste moves toward the anus, the colon removes moisture and forms stool. The rectum is about 6 inches long and connects the colon to the anus. Stool leaves the body through the anus. Muscles and nerves in the rectum and anus control bowel movements.
     

    How to Prepare for Colonoscopy

    Detailed instructions how to prepare for colonoscopy are given when you book the examination. The process is called a bowel prep. Generally, all solids must be emptied from the gastrointestinal tract by following a clear liquid diet for 2 days before the procedure. Patients should not drink beverages containing red or purple dye. Acceptable liquids include:

    • fat-free bouillon or broth
    • strained fruit juice
    • water
    • plain coffee
    • plain tea
    • sports drinks, such as Gatorade
    • gelatin

    A laxative is required or the night before colonoscopy. A laxative is medicine that loosens stool and increases bowel movements. Laxatives are usually swallowed in pill form or as a powder dissolved in water. Occasionally enemas may also be required. Patients should inform the doctor of all medical conditions and any medications, vitamins, or supplements taken regularly, including:

    • aspirin
    • blood thinners
    • diabetes medications
    • iron tablets

    Driving is not permitted for 12 hours after colonoscopy to allow the sedative time to wear off. Before the appointment, patients should make plans for a ride home. A companion must be always available as soon as the patient arrives to the clinic.
     

    How is colonoscopy performed?

    An intravenous (IV) needle is placed in a vein in the arm and a sedative will be given. Sedatives help patients stay relaxed and comfortable. Deeper sedation may be required in very occasional cases (an anesthetist will then be present). While patients are sedated, the doctor and medical staff monitor vital signs and attempt to make patients as comfortable as possible.
    During the procedure, patients lie on left side on an examination table.
    The doctor inserts a long, flexible, lighted tube called a colonoscope, or scope, into the anus and slowly guides it through the rectum and into the colon. The scope inflates the large intestine to give the doctor a better view. A small camera mounted on the scope transmits a video image from inside the large intestine to a computer screen, allowing the doctor to carefully examine the intestinal lining. The doctor may ask the patient to move periodically so the scope can be adjusted for better viewing.
    Once the scope has reached the opening to the small intestine, it is slowly withdrawn and the lining of the large intestine is carefully examined again. Bleeding and puncture of the large intestine are possible but uncommon complications of colonoscopy.
     

    Removal of Polyps and Biopsy

    A doctor can remove growths, called polyps, during colonoscopy and later test them in a laboratory for signs of cancer. Polyps are common in adults and are usually harmless. However, most colorectal cancer begins as a polyp, so removing polyps early is an effective way to prevent cancer.
    The doctor can also take samples from abnormal-looking tissues during colonoscopy. The procedure, called a biopsy, allows the doctor to later look at the tissue with a microscope for signs of disease.
    The doctor removes polyps and takes biopsy tissue using tiny tools passed through the scope. If bleeding occurs, the doctor can usually stop it with an electrical probe or special medications passed through the scope. Tissue removal and the treatments to stop bleeding are usually painless.
     

    Recovery

    Colonoscopy usually takes 30 to 60 minutes. Cramping or bloating may occur during the first hour after the procedure. The sedative takes time to completely wear off. Full recovery is usually expected in 12 hours. Discharge instructions should be carefully read and followed.
    Patients who develop any of these rare side effects should contact the clinic immediately:

    • severe abdominal pain
    • fever
    • bloody bowel movements
    • dizziness
    • weakness

    Some results from colonoscopy are available immediately after the procedure. The doctor will share the results with the patient and the companion and will give a written report with photos taken during the examination. Biopsy results are usually ready in less than two weeks
     

    At what age should routine Colonoscopy begin?

    Routine colonoscopy to look for early signs of cancer should begin at age 50 for most people—earlier if there is a family history of colorectal cancer, a personal history of inflammatory bowel disease, or other risk factors. The doctor can advise patients about how often to get a colonoscopy.

    Points to Remember

     

    • Colonoscopy is a procedure used to see inside the colon and rectum.
    • All solids must be emptied from the gastrointestinal tract by following a clear liquid diet for 2 days before colonoscopy.
    • During colonoscopy, a sedative helps keep patients relaxed.
    • A doctor can remove polyps and biopsy abnormal-looking tissues during colonoscopy.
    • Driving is not permitted for 12 hours after colonoscopy to allow the sedative time to wear off.

  • Urease Tests

    What is a Urease Test?

    The urease test is a simple test to determine if you have bacteria (Helicobacter pylori) in your stomach. Helicobacter pylori is the leading cause of gastritis and ulcers.
     

    What are the indications for the Urease Test?

    Due to its low cost and simplicity in our clinic the urease test has become an integral part of the complete examination of the stomach which also includes biopsy in three different areas to assess for the risk of stomach cancer.
     

    How is the Urease Test performed?

    There are several types of urease test. The common feature that they share is that very small pieces of the stomach lining are inserted into a gel or liquid that changes color if Helicobacter is present.
     

    What are the limitations of the Urease Test?

    The test performs poorly is the patient is taking proton pump inhibitors a very potent and very commonly used class of medications. The test also performs poorly if antibiotics have been taken recently.
    For this reason we ask patients to stop taking proton pump inhibitors for at least two weeks.
    If possible we also ask our patients to postpone upper endoscopy for four weeks after taking antibiotics.

  • CUBT

    What is a CUBT?

    CUBT is the acronym for 13C Urea Breath Test
    CUBT is a simple non-invasive test to detect the presence of Helicobacter pylori in your stomach. The most common use for the CUBT is to assess the efficacy of anti Helicobacter pylori treatment without having to undergo upper endoscopy.
    The test is based on the comparison 13C levels in the patient’s breath before and after the ingestion of 100mg of urea labelled with a precise dose of 13C.
    13C is a natural, non-toxic, non radioactive substance that exists in everyday food. Urea is a substance naturally occurring in our body.
     

    Preparation

    CUBT does not demand complicated preparations. Your stomach must however be empty so please don’t eat anything after breakfast or for six hours prior to the test. You can have your regular medications at breakfast time.
     

    What are the limitations?

    There are however some limitations to the CUBT that is important to acknowledge:

    • All solids must be emptied from the gastrointestinal tract by following a clear liquid diet for 2 days before colonoscopy.
    • CUBT can only be performed two months after the anti Helicobacter treatment. Tests performed earlier can be falsely negative.
    • CUBT can also be falsely negative if you have taken any antibiotic during a month prior to the test.
    • CUBT can also be falsely negative if you take any medications with omeprazol, esomeprazol, pantoprazol, lanzoprazol, rabeprazol or bismuth two weeks prior to the test. There are many medications containing these compounds currently on sale in Portugal please check with your doctor.

     

    What will happen?

    A sample of your breath will be taken, you will drink the 13C labelled urea solution (a small amount of an odourless and tasteless liquid). Twenty minutes later a new sample of your breath will be collected.
     

    Afterwards

    You may eat immediately after the test. There is no restriction to your activities. The report will be usually available in less than two weeks.

  • Intestinal Flora Evaluation

    What is an Analysis of the Intestinal Flora?

    It is in the digestive system, especially in the colon, that most of the bacteria that have been evolving with us for millennia reside. In healthy humans, microbial cells in the large intestine (microbiome) are more numerous than human cells in a ratio of ten to one. It is also in the digestive system that about 80% of our immune system is located.
    Until recently, however, this abundant community of microbes associated with humans remained generally poorly studied, leaving their influence on human development, physiology, immunity and nutrition almost entirely unknown. Today it is known that the function and integrity of the microbiome is important for our health.
    The complete fecal examination with parasitology is a noninvasive test that allows to objectively assess the status of bacteria, fungi and parasites that reside in the large intestine. In this test an evaluation of the digestive function is also carried out.  Synthetic and natural medicines that allow correction of the detected imbalances are tested.
     

    What itens are analysed?

    This test comprises many components:

    • Evaluation of beneficial and harmful intestinal flora;
    • Evaluation of the presence of fungi;
    • Evaluation of parasites;
    • Assessment of digestive function (levels of enzymes necessary for the digestion of food and degree of digestion of fats and proteins);
    • Evaluation of food absorption;
    • Inflammation of the bowel wall;
    • Markers of food allergies;
    • Markers of intestinal metabolic activity.

     

    What are the clinical indications for its performance?

    The test has been essentially used in a second line of evaluation when the classic tests do not give us an answer regarding the present symptoms.
     

    Advantages and limitations?

    The main advantage is that essentially with a single test we can evaluate many functions essential for the proper functioning of the digestive system. The fact that the lab work is carried out outside Portugal requires the delivery of the products for analysis on a specific schedule.
     

    Is any preparation needed?

    No special preparation is required. However the instructions have to be read carefully so that the stool collections carried out during two days run with the necessary rigor. Once you are in possession of the kit, I am available to give you a short explanation of the procedures.
     

    Do I need to stop my medication to take the exam?

    It is important not to take antibiotics, antifungal and probiotics for 7 days. Do not take aspirin or anti-inflammatory, mineral oil, pancreatic enzymes, and use suppositories for 3 days prior to collecting feces.
     

    How is the exam performed?

    The exam consists essentially of stool collection on two days.
     

    What happens after the exam?

    The products collected are sent by special courier, the result takes three weeks to return.
     

    What is the cost of examination?

    The price of the test is €370.00
     

    What agreements do you have?

    We have chosen not to have any agreements. After payment of the exam a receipt is always issued. You can then submit it along with your doctor’s request for reimbursement from your insurer.
     

    Do not forget!

    Specimen transportation is booked in advance, and should not be changed. A bit planning is fundamental.

  • Intestinal Permeability Evaluation

    What is an Intestinal permeability Analysis?

    It is a test that evaluates the integrity of the wall of the small intestine. At the same time an analysis of the permeability at the level of the stomach is made. Intolerance to lactose and fructose are also tested.
     

    What is the importance of intestinal permeability?

    It has recently been discovered that many pathologies, especially in the autoimmune field and also the irritable bowel syndrome are linked to an excessive permeability of the small intestinal wall. The increase in intestinal permeability is caused by damage to the lining of the intestines. Usually the intestines only absorb nutrients and small molecules with less than 40 nanometers. When the lining of the intestine is altered or damaged, larger molecules can be absorbed and enter the bloodstream with multiple effects on immunity and metabolism. As the symptoms are not very specific most cases of increased intestinal permeability are not diagnosed.
     

    What are the clinical indications for its performance?

    The test has been essentially used in a second line of evaluation when the classic tests do not give us an answer regarding the present symptoms.
     

    Advantages and limitations?

    The main advantage is that essentially with a single relatively simple and non-invasive test we can detect changes. The procedures are relatively simple (an overnight collection of urine at home) but require a very specific schedule.
    The fact that the lab work is carried out outside Portugal requires the delivery of the products for analysis on a specific schedule.
     

    Is preparation needed?

    No special preparation is required, however the instructions have to be read very carefully. Once I have the kit, I am available to give you a short explanation of the procedures.
     

    Do I need to stop my medications to take the exam?

    It is not possible to get tested if you are taking blood sugar lowering medications.
    It is important not to take aspirin or anti-inflammatories for seven days.
     

    How is the exam performed?

    The examination consists essentially of a collection of urine after ingestion of various types of special sugars.
     

    What happens after the exam?

    The products collected are sent by special courier, the result takes three weeks to return.
     

    What is the cost of examination?

    The price of the test is €120.00
     

    What agreements do you have?

    We have chosen not to have any agreements. After payment of the exam a receipt is always issued. You can then submit it along with your doctor’s request for reimbursement from your insurer.
     

    Do not forget!

    Transportation is booked in advance, and should not be changed. A bit planning is fundamental.

  • Urinary Metabolites Evaluation

    What is an analysis of Urinary Metabolites?

    It is in the digestive system, especially in the colon, that most of the bacteria that have been evolving with us for millennia reside. In healthy humans, microbial cells in the large intestine (microbiome) are more numerous than human cells in a ratio of ten to one.
    Today it is known that the function and integrity of the microbiome is important for our health.
    The study of urinary metabolites aims to measure the products of bacterial and fungi metabolism. It is particularly useful in detecting the presence of imbalances in the composition of the intestinal flora.
     

    Why a urinary test?

    Urine is a practical means to evaluate the bacteria present in the intestine.
    The products resulting from the normal metabolic activity of the bacteria are normally absorbed by the intestinal wall. They pass into the blood and eventually are excreted in the urine.
    The products analyzed in this test specific for microbial metabolism and are not normally produced by human cells. Based on the comparative study of these data it is possible to evaluate the importance of imbalances of the intestinal flora.
     

    What are the clinical indications for its performance?

    The test has been essentially used in a second line of evaluation when the classic tests do not give us an answer regarding the present symptoms.
     

    Advantages and limitations?

    The main advantage is that essentially with a single non-invasive test that is easy to perform, we can evaluate the composition of the microbiome for the proper functioning of the digestive and immune systems. The fact that the lab work is carried out outside Portugal requires the delivery of the products for analysis on a specific schedule.
     

    Is a preparation needed?

    No special preparation is required, however, the instructions must be read carefully so that the urine collection runs with the necessary rigor. Once you are in possession of the kit, I am available to give you a short explanation of the procedures.
     

    Do i need to stop my medication?

    It is important not to eat cranberries, apple, grapes and not to drink wine for 48 hours prior to urine collection. It is also important to moderate the fluid intake the night before urine collection.
     

    How is the exam performed?

    The test consists essentially of urine collection during the night and first urine in the morning.
     

    What happens after the exam?

    A sample of the urine is sent by special courier, the result takes three weeks to return.
     

    What is the cost of examination?

    The price of the test is € 240.00
     

    What agreements do you have?

    We have chosen not to have any agreements. After payment of the exam a receipt is always issued. You can then submit it along with your doctor’s request for reimbursement from your insurer.
     

    Do not forget!

    Transportation is booked in advance, and should not be changed. A bit planning is fundamental.

Topics

These texts are an adaptation of the copyright free material published by the NIH. I hope you find them useful.

  • Celiac Disease

    Celiac disease is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate gluten, a protein in wheat, rye, and barley. Gluten is found mainly in foods but may also be found in everyday products such as medicines, vitamins, and lip balms.

    The small intestine is shaded above.

    The small intestine is shaded above.
     
    When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging or destroying villi—the tiny, fingerlike protrusions lining the small intestine. Villi normally allow nutrients from food to be absorbed through the walls of the small intestine into the bloodstream. Without healthy villi, a person becomes malnourished, no matter how much food one eats.

    Villi on the lining of the small intestine help absorb nutrients.

    Villi on the lining of the small intestine help absorb nutrients.
     
    Celiac disease is both a disease of malabsorption “meaning nutrients are not absorbed properly—and an abnormal immune reaction to gluten. Celiac disease is also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy. Celiac disease is genetic, meaning it runs in families. Sometimes the disease is triggered—or becomes active for the first time—after surgery, pregnancy, childbirth, viral infection, or severe emotional stress.
     

    What are the symptoms of celiac disease?

    Symptoms of celiac disease vary from person to person. Symptoms may occur in the digestive system or in other parts of the body. Digestive symptoms are more common in infants and young children and may include:

    • abdominal bloating and pain
    • chronic diarrhea
    • vomiting
    • constipation
    • pale, foul-smelling, or fatty stool
    • weight loss

    Irritability is another common symptom in children. Malabsorption of nutrients during the years when nutrition is critical to a child’s normal growth and development can result in other problems such as failure to thrive in infants, delayed growth and short stature, delayed puberty, and dental enamel defects of the permanent teeth.
    Adults are less likely to have digestive symptoms and may instead have one or more of the following:

    • unexplained iron-deficiency anemia
    • fatigue
    • bone or joint pain
    • arthritis
    • bone loss or osteoporosis
    • depression or anxiety
    • tingling numbness in the hands and feet
    • seizures
    • missed menstrual periods
    • canker sores inside the mouth
    • canker sores inside the mouth
    • an itchy skin rash called dermatitis herpetiformis

    People with celiac disease may have no symptoms but can still develop complications of the disease over time. Long-term complications include malnutrition—which can lead to anemia, osteoporosis, and miscarriage, among other problems—liver diseases, and cancers of the intestine.
     

    Why are celiac disease symptoms so varied?

    differently. The length of time a person was breastfed, the age a person started eating gluten-containing foods, and the amount of gluten-containing foods one eats are three factors thought to play a role in when and how celiac disease appears. Some studies have shown, for example, that the longer a person was breastfed, the later the symptoms of celiac disease appear.
    Symptoms also vary depending on a person’s age and the degree of damage to the small intestine. Many adults have the disease for a decade or more before they are diagnosed. The longer a person goes undiagnosed and untreated, the greater the chance of developing long-term complications.

    What other health problems do people with celiac disease have?

    People with celiac disease tend to have other diseases in which the immune system attacks the body’s healthy cells and tissues. The connection between celiac disease and these diseases may be genetic. They include:

    • type 1 diabetes
    • autoimmune thyroid disease
    • autoimmune liver disease
    • rheumatoid arthritis
    • Addison’s disease, a condition in which the glands that produce critical hormones are damaged
    • Sjögren’s syndrome, a condition in which the glands that produce tears and saliva are destroyed

     

    How common is celiac disease?

    Celiac disease affects people in all parts of the world. Originally thought to be a rare childhood syndrome, celiac disease is now known to be a common genetic disorder. More than 2 million people in the United States have the disease, or about 1 in 133 people.1 Among people who have a first-degree relative—a parent, sibling, or child—diagnosed with celiac disease, as many as 1 in 22 people may have the disease.
    Celiac disease is also more common among people with other genetic disorders including Down syndrome and Turner syndrome, a condition that affects girls’ development.
     

    How is celiac disease diagnosed?

    Recognizing celiac disease can be difficult because some of its symptoms are similar to those of other diseases. Celiac disease can be confused with irritable bowel syndrome, iron-deficiency anemia caused by menstrual blood loss, inflammatory bowel disease, diverticulitis, intestinal infections, and chronic fatigue syndrome. As a result, celiac disease has long been underdiagnosed or misdiagnosed. As doctors become more aware of the many varied symptoms of the disease and reliable blood tests become more available, diagnosis rates are increasing.
     
    Blood Tests
    People with celiac disease have higher than normal levels of certain autoantibodies—proteins that react against the body’s own cells or tissues—in their blood. To diagnose celiac disease, doctors will test blood for high levels of anti-tissue transglutaminase antibodies (tTGA) or anti-endomysium antibodies (EMA). If test results are negative but celiac disease is still suspected, additional blood tests may be needed.
    Before being tested, one should continue to eat a diet that includes foods with gluten, such as breads and pastas. If a person stops eating foods with gluten before being tested, the results may be negative for celiac disease even if the disease is present.
     
    Intestinal Biopsy
    If blood tests and symptoms suggest celiac disease, a biopsy of the small intestine is performed to confirm the diagnosis. During the biopsy, the doctor removes tiny pieces of tissue from the small intestine to check for damage to the villi. To obtain the tissue sample, the doctor eases a long, thin tube called an endoscope through the patient’s mouth and stomach into the small intestine. The doctor then takes the samples using instruments passed through the endoscope.
     
    Dermatitis Herpetiformis
    Dermatitis herpetiformis (DH) is an intensely itchy, blistering skin rash that affects 15 to 25 percent of people with celiac disease.3 The rash usually occurs on the elbows, knees, and buttocks. Most people with DH have no digestive symptoms of celiac disease.
    DH is diagnosed through blood tests and a skin biopsy. If the antibody tests are positive and the skin biopsy has the typical findings of DH, patients do not need to have an intestinal biopsy. Both the skin disease and the intestinal disease respond to a gluten-free diet and recur if gluten is added back into the diet. The rash symptoms can be controlled with antibiotics such as dapsone. Because dapsone does not treat the intestinal condition, people with DH must maintain a gluten-free diet.
     
    Screening
    Screening for celiac disease means testing for the presence of autoantibodies in the blood in people without symptoms. Americans are not routinely screened for celiac disease. However, because celiac disease is hereditary, family members of a person with the disease may wish to be tested. Four to 12 percent of an affected person’s first-degree relatives will also have the disease.

    How is celiac disease treated?

    The only treatment for celiac disease is a gluten-free diet. Doctors may ask a newly diagnosed person to work with a dietitian on a gluten-free diet plan. A dietitian is a health care professional who specializes in food and nutrition. Someone with celiac disease can learn from a dietitian how to read ingredient lists and identify foods that contain gluten in order to make informed decisions at the grocery store and when eating out.
    For most people, following this diet will stop symptoms, heal existing intestinal damage, and prevent further damage. Improvement begins within days of starting the diet. The small intestine usually heals in 3 to 6 months in children but may take several years in adults. A healed intestine means a person now has villi that can absorb nutrients from food into the bloodstream.
    To stay well, people with celiac disease must avoid gluten for the rest of their lives. Eating even a small amount of gluten can damage the small intestine. The damage will occur in anyone with the disease, including people without noticeable symptoms. Depending on a person’s age at diagnosis, some problems will not improve, such as short stature and dental enamel defects.
    Some people with celiac disease show no improvement on the gluten-free diet. The most common reason for poor response to the diet is that small amounts of gluten are still being consumed. Hidden sources of gluten include additives such as modified food starch, preservatives, and stabilizers made with wheat. And because many corn and rice products are produced in factories that also manufacture wheat products, they can be contaminated with wheat gluten.
    Rarely, the intestinal injury will continue despite a strictly gluten-free diet. People with this condition, known as refractory celiac disease, have severely damaged intestines that cannot heal. Because their intestines are not absorbing enough nutrients, they may need to receive nutrients directly into their bloodstream through a vein, or intravenously. Researchers are evaluating drug treatments for refractory celiac disease.
     
    The Gluten-free Diet
    A gluten-free diet means not eating foods that contain wheat, rye, and barley. The foods and products made from these grains should also be avoided. In other words, a person with celiac disease should not eat most grain, pasta, cereal, and many processed foods.
    Despite these restrictions, people with celiac disease can eat a well-balanced diet with a variety of foods. They can use potato, rice, soy, amaranth, quinoa, buckwheat, or bean flour instead of wheat flour. They can buy gluten-free bread, pasta, and other products from stores that carry organic foods, or order products from special food companies. Gluten-free products are increasingly available from mainstream stores.
    “Plain” meat, fish, rice, fruits, and vegetables do not contain gluten, so people with celiac disease can freely eat these foods. In the past, people with celiac disease were advised not to eat oats. New evidence suggests that most people can safely eat small amounts of oats, as long as the oats are not contaminated with wheat gluten during processing. People with celiac disease should work closely with their health care team when deciding whether to include oats in their diet. Examples of other foods that are safe to eat and those that are not are provided in the table.
    The gluten-free diet requires a completely new approach to eating. Newly diagnosed people and their families may find support groups helpful as they learn to adjust to a new way of life. People with celiac disease must be cautious about what they buy for lunch at school or work, what they purchase at the grocery store, what they eat at restaurants or parties, and what they grab for a snack. Eating out can be a challenge. When in doubt about a menu item, a person with celiac disease should ask the waiter or chef about ingredients and preparation or if a gluten-free menu is available.
    Gluten is also used in some medications. People with celiac disease should ask a pharmacist if prescribed medications contain wheat. Because gluten is sometimes used as an additive in unexpected products—such as lipstick and play dough—reading product labels is important. If the ingredients are not listed on the label, the manufacturer should provide a list upon request. With practice, screening for gluten becomes second nature.
     
    New Food Labeling
    The Food Allergen Labeling and Consumer Protection Act (FALCPA), which took effect on January 1, 2006, requires food labels to clearly identify wheat and other common food allergens in the list of ingredients. FALCPA also requires the U.S. Food and Drug Administration to develop and finalize rules for the use of the term “gluten free” on product labels.
     

    The Gluten-free Diet

    People with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.

    Points to Remember

    • People with celiac disease cannot tolerate gluten, a protein in wheat, rye, and barley.
    • Untreated celiac disease damages the small intestine and interferes with nutrient absorption.
    • Without treatment, people with celiac disease can develop complications such as osteoporosis, anemia, and cancer.
    • A person with celiac disease may or may not have symptoms.
    • Diagnosis involves blood tests and, in most cases, a biopsy of the small intestine.
    • Since celiac disease is hereditary, family members of a person with celiac disease may wish to be tested.
    • Celiac disease is treated by eliminating all gluten from the diet. The gluten-free diet is a lifetime requirement.
    • A dietitian can teach a person with celiac disease about food selection, label reading, and other strategies to help manage the disease.

  • Constipation

    Constipation is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, small in size, and difficult to eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel. Some people think they are constipated if they do not have a bowel movement every day. However, normal stool elimination may be three times a day or three times a week, depending on the person. Constipation is a symptom, not a disease. Almost everyone experiences constipation at some point in their life, and a poor diet typically is the cause. Most constipation is temporary and not serious. Understanding its causes, prevention, and treatment will help most people find relief.

    Lower Digestive System

    Lower Digestive System
     

    Who gets constipated?

    Constipation is one of the most common gastrointestinal complaints in the United States. More than 4 million Americans have frequent constipation, accounting for 2.5 million physician visits a year. Those reporting constipation most often are women and adults ages 65 and older. Pregnant women may have constipation, and it is a common problem following childbirth or surgery.
    Self-treatment of constipation with over-the-counter (OTC) laxatives is by far the most common aid. Around $725 million is spent on laxative products each year in America.

    What causes constipation?

    To understand constipation, it helps to know how the colon, or large intestine, works. As food moves through the colon, the colon absorbs water from the food while it forms waste products, or stool. Muscle contractions in the colon then push the stool toward the rectum. By the time stool reaches the rectum it is solid, because most of the water has been absorbed.
    Constipation occurs when the colon absorbs too much water or if the colon’s muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry. Common causes of constipation are:

    • not enough fiber in the diet
    • lack of physical activity (especially in the elderly)
    • medications
    • milk
    • irritable bowel syndrome
    • changes in life or routine such as pregnancy, aging, and travel
    • abuse of laxatives
    • ignoring the urge to have a bowel movement
    • dehydration
    • specific diseases or conditions, such as stroke (most common)
    • problems with the colon and rectum
    • problems with intestinal function (chronic idiopathic constipation)

     
    Not Enough Fiber in the Diet
    People who eat a high-fiber diet are less likely to become constipated. The most common causes of constipation are a diet low in fiber or a diet high in fats, such as cheese, eggs, and meats.
    Fiber—both soluble and insoluble—is the part of fruits, vegetables, and grains that the body cannot digest. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber passes through the intestines almost unchanged. The bulk and soft texture of fiber help prevent hard, dry stools that are difficult to pass.
    Americans eat an average of 5 to 14 grams of fiber daily,* which is short of the 20 to 35 grams recommended by the American Dietetic Association. Both children and adults often eat too many refined and processed foods from which the natural fiber has been removed.
    A low-fiber diet also plays a key role in constipation among older adults, who may lose interest in eating and choose foods that are quick to make or buy, such as fast foods, or prepared foods, both of which are usually low in fiber. Also, difficulties with chewing or swallowing may cause older people to eat soft foods that are processed and low in fiber.
     
    Not Enough Liquids
    Research shows that although increased fluid intake does not necessarily help relieve constipation, many people report some relief from their constipation if they drink fluids such as water and juice and avoid dehydration. Liquids add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. People who have problems with constipation should try to drink liquids every day. However, liquids that contain caffeine, such as coffee and cola drinks will worsen one’s symptoms by causing dehydration. Alcohol is another beverage that causes dehydration. It is important to drink fluids that hydrate the body, especially when consuming caffeine containing drinks or alcoholic beverages.
     
    Lack of Physical Activity
    A lack of physical activity can lead to constipation, although doctors do not know precisely why. For example, constipation often occurs after an accident or during an illness when one must stay in bed and cannot exercise. Lack of physical activity is thought to be one of the reasons constipation is common in older people.
     
    Medications
    Some medications can cause constipation, including:

    • pain medications (especially narcotics)
    • antacids that contain aluminum and calcium
    • blood pressure medications (calcium channel blockers)
    • antiparkinson drugs
    • antispasmodics
    • antidepressants
    • iron supplements
    • diuretics
    • anticonvulsants

     
    Changes in Life or Routine
    During pregnancy, women may be constipated because of hormonal changes or because the uterus compresses the intestine. Aging may also affect bowel regularity, because a slower metabolism results in less intestinal activity and muscle tone. In addition, people often become constipated when traveling, because their normal diet and daily routine are disrupted.
     
    Abuse of Laxatives
    The common belief that people must have a daily bowel movement has led to self-medicating with OTC laxative products. Although people may feel relief when they use laxatives, typically they must increase the dose over time because the body grows reliant on laxatives in order to have a bowel movement. As a result, laxatives may become habit-forming.
     
    Ignoring the Urge to Have a Bowel Movement
    People who ignore the urge to have a bowel movement may eventually stop feeling the need to have one, which can lead to constipation. Some people delay having a bowel movement because they do not want to use toilets outside the home. Others ignore the urge because of emotional stress or because they are too busy. Children may postpone having a bowel movement because of stressful toilet training or because they do not want to interrupt their play.
     
    Specific Diseases
    Diseases that cause constipation include neurological disorders, metabolic and endocrine disorders, and systemic conditions that affect organ systems. These disorders can slow the movement of stool through the colon, rectum, or anus.
    Conditions that can cause constipation are found below.

    • Neurological disorders
      • multiple sclerosis
      • Parkinson’s disease
      • chronic idiopathic intestinal pseudo-obstruction
      • stroke
      • spinal cord injuries
    • Metabolic and endocrine conditions
      • diabetes
      • uremia
      • hypercalcemia
      • poor glycemic control
      • hypothyroidism
    • Systemic disorders
      • amyloidosis
      • lupus
      • scleroderma

     
    Problems with the Colon and Rectum
    Intestinal obstruction, scar tissue—also called adhesions—diverticulosis, tumors, colorectal stricture, Hirschsprung disease, or cancer can compress, squeeze, or narrow the intestine and rectum and cause constipation.
     
    Problems with Intestinal Function
    The two types of constipation are idiopathic constipation and functional constipation. Irritable bowel syndrome (IBS) with predominant symptoms of constipation is categorized separately.
    Idiopathic—of unknown origin—constipation does not respond to standard treatment.
    Functional constipation means that the bowel is healthy but not working properly. Functional constipation is often the result of poor dietary habits and lifestyle. It occurs in both children and adults and is most common in women. Colonic inertia, delayed transit, and pelvic floor dysfunction are three types of functional constipation. Colonic inertia and delayed transit are caused by a decrease in muscle activity in the colon. These syndromes may affect the entire colon or may be confined to the lower, or sigmoid, colon.
    Pelvic floor dysfunction is caused by a weakness of the muscles in the pelvis surrounding the anus and rectum. However, because this group of muscles is voluntarily controlled to some extent, biofeedback training is somewhat successful in retraining the muscles to function normally and improving the ability to have a bowel movement.
    Functional constipation that stems from problems in the structure of the anus and rectum is known as anorectal dysfunction, or anismus. These abnormalities result in an inability to relax the rectal and anal muscles that allow stool to exit.
    People with IBS having predominantly constipation also have pain and bloating as part of their symptoms.
     

    How is the cause of constipation identified?

    The tests the doctor performs depend on the duration and severity of the constipation, the person’s age, and whether blood in stools, recent changes in bowel habits, or weight loss have occurred. Most people with constipation do not need extensive testing and can be treated with changes in diet and exercise. For example, in young people with mild symptoms, a medical history and physical exam may be all that is needed for diagnosis and treatment.
     
    Medical History
    The doctor may ask a patient to describe his or her constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool, and toilet habits—how often and where one has bowel movements. A record of eating habits, medication, and level of physical activity will also help the doctor determine the cause of constipation.
    The clinical definition of constipation is having any two of the following symptoms for at least 12 weeks—not always consecutive—in the previous 12 months:

    • straining during bowel movements
    • lumpy or hard stool
    • sensation of incomplete evacuation
    • sensation of anorectal blockage/obstruction
    • fewer than three bowel movements per week

     
    Physical Examination
    A physical exam may include a rectal exam with a gloved, lubricated finger to evaluate the tone of the muscle that closes off the anus—also called anal sphincter—and to detect tenderness, obstruction, or blood. In some cases, blood and thyroid tests may be necessary to look for thyroid disease and serum calcium or to rule out inflammatory, metabolic, and other disorders.
    Extensive testing usually is reserved for people with severe symptoms, for those with sudden changes in the number and consistency of bowel movements or blood in the stool, and older adults. Additional tests that may be used to evaluate constipation include:

    • a colorectal transit study
    • anorectal function tests
    • a defecography

    Because of an increased risk of colorectal cancer in older adults, the doctor may use tests to rule out a diagnosis of cancer, including a:

    • barium enema x ray
    • sigmoidoscopy or colonoscopy

     
    Colorectal transit study. This test shows how well food moves through the colon. The patient swallows capsules containing small markers that are visible on an x ray. The movement of the markers through the colon is monitored by abdominal x rays taken several times 3 to 7 days after the capsule is swallowed. The patient eats a high-fiber diet during the course of this test.
     
    Anorectal function tests. These tests diagnose constipation caused by abnormal functioning of the anus or rectum—also called anorectal function.

    • Anorectal manometry evaluates anal sphincter muscle function. For this test, a catheter or air-filled balloon is inserted into the anus and slowly pulled back through the sphincter muscle to measure muscle tone and contractions.
    • Balloon expulsion tests consist of filling a balloon with varying amounts of water after it has been rectally inserted. Then the patient is asked to expel the balloon. The inability to expel a balloon filled with less than 150 mL of water may indicate a decrease in bowel function.

     
    Defecography is an x ray of the anorectal area that evaluates completeness of stool elimination, identifies anorectal abnormalities, and evaluates rectal muscle contractions and relaxation. During the exam, the doctor fills the rectum with a soft paste that is the same consistency as stool. The patient sits on a toilet positioned inside an x-ray machine, then relaxes and squeezes the anus to expel the paste. The doctor studies the x rays for anorectal problems that occurred as the paste was expelled.
     
    Barium enema x ray. This exam involves viewing the rectum, colon, and lower part of the small intestine to locate problems. This part of the digestive tract is known as the bowel. This test may show intestinal obstruction and Hirschsprung disease, which is a lack of nerves within the colon.
    The night before the test, bowel cleansing, also called bowel prep, is necessary to clear the lower digestive tract. The patient drinks a special liquid to flush out the bowel. A clean bowel is important, because even a small amount of stool in the colon can hide details and result in an incomplete exam.
    Because the colon does not show up well on x rays, the doctor fills it with barium, a chalky liquid that makes the area visible. Once the mixture coats the inside of the colon and rectum, x rays are taken that show their shape and condition. The patient may feel some abdominal cramping when the barium fills the colon but usually feels little discomfort after the procedure. Stools may be white in color for a few days after the exam.
     
    Sigmoidoscopy or colonoscopy. An examination of the rectum and lower, or sigmoid, colon is called a sigmoidoscopy. An examination of the rectum and entire colon is called a colonoscopy.
    The person usually has a liquid dinner the night before a colonoscopy or sigmoidoscopy and takes an enema early the next morning. An enema an hour before the test may also be necessary.
    To perform a sigmoidoscopy, the doctor uses a long, flexible tube with a light on the end, called a sigmoidoscope, to view the rectum and lower colon. The patient is lightly sedated before the exam. First, the doctor examines the rectum with a gloved, lubricated finger. Then, the sigmoidoscope is inserted through the anus into the rectum and lower colon. The procedure may cause abdominal pressure and a mild sensation of wanting to move the bowels. The doctor may fill the colon with air to get a better view. The air can cause mild cramping.
    To perform a colonoscopy, the doctor uses a flexible tube with a light on the end, called a colonoscope, to view the entire colon. This tube is longer than a sigmoidoscope. During the exam, the patient lies on his or her side, and the doctor inserts the tube through the anus and rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). The patient may feel gassy and bloated after the procedure.
     

    How is constipation treated?

    Although treatment depends on the cause, severity, and duration of the constipation, in most cases dietary and lifestyle changes will help relieve symptoms and help prevent them from recurring.
     
    Diet
    A diet with enough fiber (20 to 35 grams each day) helps the body form soft, bulky stool. A doctor or dietitian can help plan an appropriate diet. High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, brussels sprouts, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber, such as ice cream, cheese, meat, and processed foods, is also important.
     
    Lifestyle Changes
    Other changes that may help treat and prevent constipation include drinking enough water and other liquids, such as fruit and vegetable juices and clear soups, so as not to become dehydrated, engaging in daily exercise, and reserving enough time to have a bowel movement. In addition, the urge to have a bowel movement should not be ignored.
     
    Laxatives
    Most people who are mildly constipated do not need laxatives. However, for those who have made diet and lifestyle changes and are still constipated, a doctor may recommend laxatives or enemas for a limited time. These treatments can help retrain a chronically sluggish bowel. For children, short-term treatment with laxatives, along with retraining to establish regular bowel habits, helps prevent constipation.
    A doctor should determine when a patient needs a laxative and which form is best. Laxatives taken by mouth are available in liquid, tablet, gum powder, and granule forms. They work in various ways:

    • Bulk-forming laxatives generally are considered the safest, but they can interfere with absorption of some medicines. These laxatives, also known as fiber supplements, are taken with water. They absorb water in the intestine and make the stool softer. These agents must be taken with water or they can cause obstruction. Many people also report no relief after taking bulking agents and suffer from a worsening in bloating and abdominal pain.
    • Stimulants cause rhythmic muscle contractions in the intestines. Studies suggest that phenolphthalein, an ingredient in some stimulant laxatives, might increase a person’s risk for cancer. The Food and Drug Administration has proposed a ban on all over-the-counter products containing phenolphthalein
    • Osmotics cause fluids to flow in a special way through the colon, resulting in bowel distention. This class of drugs is useful for people with idiopathic constipation. People with diabetes should be monitored for electrolyte imbalances.
    • Stool softeners moisten the stool and prevent dehydration. These laxatives are often recommended after childbirth or surgery. These products are suggested for people who should avoid straining in order to pass a bowel movement. The prolonged use of this class of drugs may result in an electrolyte imbalance.
    • Lubricants grease the stool, enabling it to move through the intestine more easily. Mineral oil is the most common example. Lubricants typically stimulate a bowel movement within 8 hours.
    • Saline laxatives act like a sponge to draw water into the colon for easier passage of stool. Saline laxatives are used to treat acute constipation if there is no indication of bowel obstruction. Electrolyte imbalances have been reported with extended use, especially in small children and people with renal deficiency.
    • Chloride channel activators increase intestinal fluid and motility to help stool pass, thereby reducing the symptoms of constipation.

     
    People who are dependent on laxatives need to slowly stop using them. A doctor can assist in this process. For most people, stopping laxatives restores the colon’s natural ability to contract.
     
    Other Treatments
    Treatment for constipation may be directed at a specific cause. For example, the doctor may recommend discontinuing medication or performing surgery to correct an anorectal problem such as rectal prolapse, a condition in which the lower portion of the colon turns inside out.
    People with chronic constipation caused by anorectal dysfunction can use biofeedback to retrain the muscles that control bowel movements. Biofeedback involves using a sensor to monitor muscle activity, which is displayed on a computer screen, allowing for an accurate assessment of body functions. A health care professional uses this information to help the patient learn how to retrain these muscles.
    Surgical removal of the colon may be an option for people with severe symptoms caused by colonic inertia. However, the benefits of this surgery must be weighed against possible complications, which include abdominal pain and diarrhea.
     

    Can constipation be serious?

    Sometimes constipation can lead to complications. These complications include hemorrhoids, caused by straining to have a bowel movement, or anal fissures—tears in the skin around the anus—caused when hard stool stretches the sphincter muscle. As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool. Treatment for hemorrhoids may include warm tub baths, ice packs, and application of a special cream to the affected area. Treatment for anal fissures may include stretching the sphincter muscle or surgically removing the tissue or skin in the affected area.
    Sometimes straining causes a small amount of intestinal lining to push out from the anal opening. This condition, known as rectal prolapse, may lead to secretion of mucus from the anus. Usually eliminating the cause of the prolapse, such as straining or coughing, is the only treatment necessary. Severe or chronic prolapse requires surgery to strengthen and tighten the anal sphincter muscle or to repair the prolapsed lining.
    Constipation may also cause hard stool to pack the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition, called fecal impaction, occurs most often in children and older adults. An impaction can be softened with mineral oil taken by mouth and by an enema. After softening the impaction, the doctor may break up and remove part of the hardened stool by inserting one or two fingers into the anus.
     

    Points to Remember

    • Constipation affects almost everyone at one time or another.
    • Many people think they are constipated when, in fact, their bowel movements are regular.
    • The most common causes of constipation are poor diet and lack of exercise.
    • Other causes of constipation include medications, irritable bowel syndrome, abuse of laxatives, and specific diseases.
    • A medical history and physical exam may be the only diagnostic tests needed before the doctor suggests treatment.
    • In most cases, following these simple tips will help relieve symptoms and prevent recurrence of constipation:
      • Eat a well-balanced, high-fiber diet that includes beans, bran, whole grains, fresh fruits, and vegetables.
      • Drink plenty of liquids.
      • Exercise regularly.
      • Set aside time after breakfast or dinner for undisturbed visits to the toilet.
      • Do not ignore the urge to have a bowel movement.
      • Understand that normal bowel habits vary.
      • Whenever a significant or prolonged change in bowel habits occurs, check with a doctor.

  • Lactose Intolerance

    What is Lactose Intolerance?

    Lactose intolerance is the inability or insufficient ability to digest lactose, a sugar found in milk and milk products. Lactose intolerance is caused by a deficiency of the enzyme lactase, which is produced by the cells lining the small intestine. Lactase breaks down lactose into two simpler forms of sugar called glucose and galactose, which are then absorbed into the bloodstream.

    The digestive tract

    The digestive tract
     
    Not all people with lactase deficiency have digestive symptoms, but those who do may have lactose intolerance. Most people with lactose intolerance can tolerate some amount of lactose in their diet.
    People sometimes confuse lactose intolerance with cow milk allergy. Milk allergy is a reaction by the body’s immune system to one or more milk proteins and can be life threatening when just a small amount of milk or milk product is consumed. Milk allergy most commonly appears in the first year of life, while lactose intolerance occurs more often in adulthood.
     

    What causes Lactose Intolerance?

    The cause of lactose intolerance is best explained by describing how a person develops lactase deficiency.
    Primary lactase deficiency develops over time and begins after about age 2 when the body begins to produce less lactase. Most children who have lactase deficiency do not experience symptoms of lactose intolerance until late adolescence or adulthood.
    Researchers have identified a possible genetic link to primary lactase deficiency. Some people inherit a gene from their parents that makes it likely they will develop primary lactase deficiency. This discovery may be useful in developing future genetic tests to identify people at risk for lactose intolerance.
    Secondary lactase deficiency results from injury to the small intestine that occurs with severe diarrheal illness, celiac disease, Crohn’s disease, or chemotherapy. This type of lactase deficiency can occur at any age but is more common in infancy.
     

    Who is at risk for lactose intolerance?

    Lactose intolerance is a common condition that is more likely to occur in adulthood, with a higher incidence in older adults. Some ethnic and racial populations are more affected than others, including African Americans, Hispanic Americans, American Indians, and Asian Americans. The condition is least common among Americans of northern European descent.
    Infants born prematurely are more likely to have lactase deficiency because an infant’s lactase levels do not increase until the third trimester of pregnancy.
     

    What are the Symptoms of Lactose Intolerance?

    People with lactose intolerance may feel uncomfortable 30 minutes to 2 hours after consuming milk and milk products. Symptoms range from mild to severe, based on the amount of lactose consumed and the amount a person can tolerate.
    Common symptoms include:

    • abdominal pain
    • abdominal bloating
    • gas
    • diarrhea
    • nausea

     

    How is Lactose Intolerance diagnosed?

    Lactose intolerance can be hard to diagnose based on symptoms alone. People may think they suffer from lactose intolerance because they have digestive symptoms; however, other conditions such as irritable bowel syndrome can cause similar symptoms. After taking a medical history and performing a physical examination, the doctor may first recommend eliminating all milk and milk products from the person’s diet for a short time to see if the symptoms resolve. Tests may be necessary to provide more information.
    Two tests are commonly used to measure the digestion of lactose.
     
    Hydrogen Breath Test. The person drinks a lactose-loaded beverage and then the breath is analyzed at regular intervals to measure the amount of hydrogen. Normally, very little hydrogen is detectable in the breath, but undigested lactose produces high levels of hydrogen. Smoking and some foods and medications may affect the accuracy of the results. People should check with their doctor about foods and medications that may interfere with test results.
     
    Stool Acidity Test. The stool acidity test is used for infants and young children to measure the amount of acid in the stool. Undigested lactose creates lactic acid and other fatty acids that can be detected in a stool sample. Glucose may also be present in the stool as a result of undigested lactose.
    Because lactose intolerance is uncommon in infants and children younger than 2, a health professional should take special care in determining the cause of a child’s digestive symptoms.
     

    How is lactose intolerance managed?

    Although the body’s ability to produce lactase cannot be changed, the symptoms of lactose intolerance can be managed with dietary changes. Most people with lactose intolerance can tolerate some amount of lactose in their diet. Gradually introducing small amounts of milk or milk products may help some people adapt to them with fewer symptoms. Often, people can better tolerate milk or milk products by taking them with meals.
    The amount of change needed in the diet depends on how much lactose a person can consume without symptoms. For example, one person may have severe symptoms after drinking a small glass of milk, while another can drink a large glass without symptoms. Others can easily consume yogurt and hard cheeses such as cheddar and Swiss but not milk or other milk products.
    The Dietary Guidelines for Americans 2005 recommend that people with lactose intolerance choose milk products with lower levels of lactose than regular milk, such as yogurt and hard cheese.
    Lactose-free and lactose-reduced milk and milk products, available at most supermarkets, are identical to regular milk except that the lactase enzyme has been added. Lactose-free milk remains fresh for about the same length of time or longer than regular milk if it is ultra-pasteurized. Lactose-free milk may have a slightly sweeter taste than regular milk. Soy milk and other products may be recommended by a health professional.
    People who still experience symptoms after dietary changes can take over-the-counter lactase enzyme drops or tablets. Taking the tablets or a few drops of the liquid enzyme when consuming milk or milk products may make these foods more tolerable for people with lactose intolerance.
    Parents and caregivers of a child with lactose intolerance should follow the nutrition plan recommended by the child’s doctor or dietitian.
     
    Lactose Intolerance and Calcium Intake
    Milk and milk products are a major source of calcium and other nutrients. Calcium is essential for the growth and repair of bones at all ages. A shortage of calcium intake in children and adults may lead to fragile bones that can easily fracture later in life, a condition called osteoporosis.
    The amount of calcium a person needs to maintain good health varies by age. Recommendations are shown in Table 1.

    Table 1. Recommended calcium intake by age group

    Age group Amount of calcium to consume daily, Age group in milligrams (mg)
    0-6 months 210 mg
    7-12 months 270 mg
    1-3 years 500 mg
    4-8 years 800 mg
    19-50 years 1,300 mg
    51-70+ years 1,200 mg

     

    Source: Adapted from Dietary Reference Intakes, 2004, Institute of Medicine, National Academy of Sciences.

    Women who are pregnant or breastfeeding need between 1,000 and 1,300 mg of calcium daily.
    Getting enough calcium is important for people with lactose intolerance when the intake of milk and milk products is limited. Many foods can provide calcium and other nutrients the body needs. Non-milk products that are high in calcium include fish with soft bones such as salmon and sardines and dark green vegetables such as spinach.
    Table 2 lists foods that are good sources of dietary calcium.

    Table 2. Calcium content in common foods

    Non-milk Products Calcium Content
    Rhubarb, frozen, cooked, 1 cup 348 mg
    Sardines, with bone, 3 oz. 325 mg
    Spinach, frozen, cooked, 1 cup 291 mg
    Salmon, canned, with bone, 3 oz. 181 mg
    Soy milk, unfortified, 1 cup 61 mg
    Orange, 1 medium 52 mg
    Broccoli, raw, 1 cup 41 mg
    Pinto beans, cooked, 1/2 cup 40 mg
    Lettuce greens, 1 cup 20 mg
    Tuna, white, canned, 3 oz. 12 mg
    Milk and Milk Products
    Yogurt, with active and live cultures, plain, low-fat, vitamin D-fortified, 1 cup 415 mg
    Milk, reduced fat, vitamin D-fortified, 1 cup 285 mg
    Swiss cheese, 1 oz. 224 mg
    Cottage cheese, 1/2 cup 87 mg
    Ice cream, 1/2 cup 84 mg

     

    Source: Adapted from U.S. Department of Agriculture, Agricultural Research Service. 2008.
    USDA National Nutrient Database for Standard Reference, Release 21.

    Yogurt made with active and live bacterial cultures is a good source of calcium for many people with lactose intolerance. When this type of yogurt enters the intestine, the bacterial cultures convert lactose to lactic acid, so the yogurt may be well-tolerated due to a lower lactose content than yogurt without live cultures. Frozen yogurt does not contain bacterial cultures, so it may not be well-tolerated.
    Calcium is absorbed and used in the body only when enough vitamin D is present. Some people with lactose intolerance may not be getting enough vitamin D. Vitamin D comes from food sources such as eggs, liver, and vitamin D-fortified milk and yogurt. Regular exposure to sunlight also helps the body naturally absorb vitamin D. Talking with a doctor or registered dietitian may be helpful in planning a balanced diet that provides an adequate amount of nutrients—including calcium and vitamin D—and minimizes discomfort. A health professional can determine whether calcium and other dietary supplements are needed.
     

    What other products contain lactose?

    Milk and milk products are often added to processed foods—foods that have been altered to prolong their shelf life. People with lactose intolerance should be aware of the many food products that may contain even small amounts of lactose, such as:

    • bread and other baked goods
    • waffles, pancakes, biscuits, cookies, and mixes to make them
    • processed breakfast foods such as doughnuts, frozen waffles and pancakes, toaster pastries, and sweet rolls
    • processed breakfast cereals
    • instant potatoes, soups, and breakfast drinks
    • potato chips, corn chips, and other processed snacks
    • processed meats, such as bacon, sausage, hot dogs, and lunch meats
    • margarine
    • liquid and powdered milk-based meal replacements
    • protein powders and bars
    • candies
    • non-dairy liquid and powdered coffee creamers
    • non-dairy whipped toppings

     
    Checking the ingredients on food labels is helpful in finding possible sources of lactose in food products. If any of the following words are listed on a food label, the product contains lactose:

    • milk
    • lactose
    • whey
    • curds
    • milk by-products
    • dry milk solids
    • non-fat dry milk powder

     
    Lactose is also used in some prescription medicines, including birth control pills, and over-the-counter medicines like products to treat stomach acid and gas. These medicines most often cause symptoms in people with severe lactose intolerance.

    Points to Remember

     

    • Lactose intolerance is the inability or insufficient ability to digest lactose, a sugar found in milk and milk products.
    • Lactose intolerance is caused by a deficiency of the enzyme lactase, which is produced by the cells lining the small intestine.
    • Not all people with lactase deficiency have digestive symptoms, but those who do may have lactose intolerance.
    • Most people with lactose intolerance can tolerate some amount of lactose in their diet.
    • People with lactose intolerance may feel uncomfortable after consuming milk and milk products. Symptoms can include abdominal pain, abdominal bloating, gas, diarrhea, and nausea.
    • People with lactose intolerance may feel uncomfortable after consuming milk and milk products. Symptoms can include abdominal pain, abdominal bloating, gas, diarrhea, and nausea.
    • Getting enough calcium and vitamin D is a concern for people with lactose intolerance when the intake of milk and milk products is limited. Many foods can provide the calcium and other nutrients the body needs.
    • Talking with a doctor or registered dietitian may be helpful in planning a balanced diet that provides an adequate amount of nutrients—including calcium and vitamin D—and minimizes discomfort. A health professional can determine whether calcium and other dietary supplements are needed.
    • Milk and milk products are often added to processed foods. Checking the ingredients on food labels is helpful in finding possible sources of lactose in food products.

  • Cyclic Vomiting Syndrome (CVS)

    What is Cyclic Vomiting Syndrome (CVS)?

    CVS is characterized by episodes or cycles of severe nausea and vomiting that last for hours, or even days, that alternate with intervals with no symptoms. Although originally thought to be a pediatric disease, CVS occurs in all age groups. Medical researchers believe CVS and migraine headaches are related.
    Each episode of CVS is similar to previous ones, meaning the episodes tend to start at the same time of day, last the same length of time, and occur with the same symptoms and level of intensity. Although CVS can begin at any age, in children it starts most often between the ages of 3 and 7.
    Episodes can be so severe that a person has to stay in bed for days, unable to go to school or work. The exact number of people with CVS is unknown, but medical researchers believe more people may have the disorder than commonly thought. Because other more common diseases and disorders also cause cycles of vomiting, many people with CVS are initially misdiagnosed until other disorders can be ruled out. CVS can be disruptive and frightening not just to people who have it but to family members as well.
     

    The Four Phases of CVS

    CVS has four phases:

    • Symptom-free interval phase. This phase is the period between episodes when no symptoms are present.
    • Prodrome phase. This phase signals that an episode of nausea and vomiting is about to begin. Often marked by nausea—with or without abdominal pain—this phase can last from just a few minutes to several hours. Sometimes, taking medicine early in the phase can stop an episode in progress. However, sometimes there is no warning; a person may simply wake up in the morning and begin vomiting.
    • Vomiting phase. This phase consists of nausea and vomiting; an inability to eat, drink, or take medicines without vomiting; paleness; drowsiness; and exhaustion.
    • Recovery phase. This phase begins when the nausea and vomiting stop. Healthy color, appetite, and energy return.

     

    What triggers CVS?

    Many people can identify a specific condition or event that triggered an episode, such as an infection. Common triggers in children include emotional stress and excitement. Anxiety and panic attacks are more common triggers in adults. Colds, allergies, sinus problems, and the flu can also set off episodes in some people.
    Other reported triggers include eating certain foods such as chocolate or cheese, eating too much, or eating just before going to bed. Hot weather, physical exhaustion, menstruation, and motion sickness can also trigger episodes.
     

    What are the symptoms of CVS?

    A person who experiences the following symptoms for at least 3 months—with first onset at least 6 months prior—may have CVS:

    • vomiting episodes that start with severe vomiting—several times per hour—and last less than 1 week
    • three or more separate episodes of vomiting in the past year
    • absence of nausea or vomiting between episodes

    A person with CVS may experience abdominal pain, diarrhea, fever, dizziness, and sensitivity to light during vomiting episodes. Continued vomiting may cause severe dehydration that can be life threatening. Symptoms of dehydration include thirst, decreased urination, paleness, exhaustion, and listlessness. A person with any symptoms of dehydration should see a health care provider immediately.
     

    How is CVS diagnosed?

    CVS is hard to diagnose because no tests—such as a blood test or x ray—can establish a diagnosis of CVS. A doctor must look at symptoms and medical history to rule out other common diseases or disorders that can cause nausea and vomiting. Making a diagnosis takes time because the doctor also needs to identify a pattern or cycle to the vomiting.
     

    CVS and Migraine

    The relationship between migraine and CVS is still unclear, but medical researchers believe the two are related.

    • Migraine headaches, which cause severe head pain; abdominal migraines, which cause stomach pain; and CVS are all marked by severe symptoms that start and end quickly and are followed by intervals without pain or other symptoms.
    • Many of the situations that trigger CVS also trigger migraines, including stress and excitement.
    • Research has shown that many children with CVS either have a family history of migraine or develop migraines as they grow older.

    Because of the similarities between migraine and CVS, doctors treat some people with severe CVS with drugs that are also used for migraine headaches. The drugs are designed to prevent episodes, reduce frequency, and lessen severity.
     

    How is CVS treated?

    Treatment varies, but people with CVS generally improve after learning to control their symptoms. People with CVS are advised to get plenty of rest and sleep and to take medications that prevent a vomiting episode, stop one in progress, speed up recovery, or relieve associated symptoms.
    Once a vomiting episode begins, treatment usually requires the person to stay in bed and sleep in a dark, quiet room. Severe nausea and vomiting may require hospitalization and intravenous fluids to prevent dehydration. Sedatives may help if the nausea continues.
    Sometimes, during the prodrome phase, it is possible to stop an episode from happening.
    During the recovery phase, drinking water and replacing lost electrolytes are important. Electrolytes are salts the body needs to function and stay healthy. Symptoms during the recovery phase can vary. Some people find their appetite returns to normal immediately, while others need to begin by drinking clear liquids and then move slowly to solid food.
    People whose episodes are frequent and long-lasting may be treated during the symptom-free intervals in an effort to prevent or ease future episodes. Medications that help people with migraine headaches, such as are sometimes used during this phase, but they do not work for everyone. Taking the medicine daily for 1 to 2 months may be necessary before one can tell if it helps.
    The symptom-free interval phase is a good time to eliminate anything known to trigger an episode. For example, if episodes are brought on by stress or excitement, a symptom-free interval phase is the time to find ways to reduce stress and stay calm. If sinus problems or allergies cause episodes, those conditions should be treated.
     

    What are the complications of CVS?

    The severe vomiting that defines CVS is a risk factor for several complications:

    • Dehydration. Vomiting causes the body to lose water quickly. Dehydration can be severe and should be treated immediately.
    • Electrolyte imbalance. Vomiting causes the body to lose important salts it needs to keep working properly.
    • Peptic esophagitis. The esophagus—the tube that connects the mouth to the stomach—becomes injured from stomach acid moving through it while vomiting.
    • Hematemesis. The esophagus becomes irritated and bleeds, so blood mixes with vomit.
    • Mallory-Weiss tear. The lower end of the esophagus may tear open or the stomach may bruise from vomiting or retching.
    • Tooth decay. The acid in vomit can hurt teeth by corroding tooth enamel.

     

    Points to Remember

    • People with CVS have severe nausea and vomiting that come in cycles.
    • CVS occurs in all age groups.
    • Medical researchers believe CVS and migraine headaches are related.
    • CVS has four phases: symptom-free interval phase, prodrome phase, vomiting phase, and recovery phase.
    • Many people can identify a condition or event that triggers an episode of nausea and vomiting. Infections and emotional stress are two common triggers.
    • The main symptoms of CVS are episodes of nausea and vomiting that come and go. Vomiting can lead to severe dehydration that can be life threatening.
    • Symptoms of dehydration include thirst, decreased urination, paleness, exhaustion, and listlessness. A person with any symptoms of dehydration should see a health care provider immediately.
    • The only way a doctor can diagnose CVS is by looking at symptoms and medical history to rule out any other possible causes for the nausea and vomiting. Then the doctor must identify a pattern or cycle to the symptoms.
    • Treatment varies by person, but people with CVS generally improve after learning to control their symptoms. They may also be given medications that prevent a vomiting episode, stop one in progress, speed up recovery, or relieve associated symptoms.
    • Complications include dehydration, which can be severe; electrolyte imbalance; peptic esophagitis; hematemesis; Mallory-Weiss tear; and tooth decay.

  • H Pylori and Peptic Ulcers

    What is a Peptic Ulcer?

    H. pylori bacteria can cause peptic ulcers—sores on the
 lining of the stomach or duodenum.
    H. pylori bacteria can cause peptic ulcers—sores
    on the 
lining of the stomach or duodenum.

     
    A peptic ulcer is a sore on the lining of the stomach or duodenum, the beginning of the small intestine. Less commonly, a peptic ulcer may develop just above the stomach in the esophagus, the tube that connects the mouth to the stomach.
    A peptic ulcer in the stomach is called a gastric ulcer. One that occurs in the duodenum is called a duodenal ulcer. People can have both gastric and duodenal ulcers at the same time. They also can develop peptic ulcers more than once in their lifetime.
    Peptic ulcers are common. Each year in the United States, about half a million people develop a peptic ulcer.

    What causes Peptic Ulcers?

    A bacterium called Helicobacter pylori (H. pylori) is a major cause of peptic ulcers. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, are another common cause. Rarely, cancerous or noncancerous tumors in the stomach, duodenum, or pancreas cause ulcers.
    Peptic ulcers are not caused by stress or eating spicy food, but both can make ulcer symptoms worse. Smoking and drinking alcohol also can worsen ulcers and prevent healing.

    What is H. Pylori?

    H. pylori is a type of bacteria—a germ that may cause infection. H. pylori infection is common, particularly in developing countries, and often begins in childhood. Symptoms usually don’t occur until adulthood, although most people never have any symptoms.
    H. pylori causes more than half of peptic ulcers worldwide.2 The bacterium causes peptic ulcers by damaging the mucous coating that protects the stomach and duodenum. Damage to the mucous coating allows powerful stomach acid to get through to the sensitive lining beneath. Together, the stomach acid and H. pylori irritate the lining of the stomach or duodenum and cause an ulcer.
    Yet, most people infected with H. pylori never develop ulcers. Why the bacterium causes ulcers in some people and not in others is not known. Most likely, development of ulcers depends on characteristics of the infected person; the type, or strain, of H. pylori present; and factors researchers have yet to discover.
     

    How is H. Pylori spread?

    Researchers are not certain how H. pylori is transmitted, although they think it may be spread through contaminated food or water. People may pick up the bacterium from food that has not been washed well or cooked properly or from drinking water that has come from an unclean source.
    Other research is exploring how infection spreads from an infected person to an uninfected person. Studies suggest that having contact with the stool or vomit of an infected person can spread H. pylori infection. And H. pylori has been found in the saliva of some infected people, which means infection could be spread through direct contact with saliva.
     

    What are the Symptoms of a Peptic Ulcer?

    Abdominal discomfort is the most common symptom of both duodenal and gastric ulcers. Felt anywhere between the navel and the breastbone, this discomfort usually:

    • is a dull or burning pain
    • occurs when the stomach is empty—between meals or during the night
    • may be briefly relieved by eating food, in the case of duodenal ulcers, or by taking antacids, in both types of peptic ulcers
    • lasts for minutes to hours
    • comes and goes for several days or weeks

     
    Other symptoms include:

    • weight loss
    • poor appetite
    • bloating
    • burping
    • nausea
    • vomiting

     
    Some people experience only mild symptoms or none at all.
     
    Emergency Symptoms
    A person who has any of the following symptoms should call a doctor right away:

    • sharp, sudden, persistent, and severe stomach pain
    • bloody or black stools
    • bloody vomit or vomit that looks like coffee grounds

     
    These “alarm” symptoms could be signs of a serious problem, such as:

    • bleeding—when acid or the peptic ulcer breaks a blood vessel
    • perforation—when the peptic ulcer burrows completely through the stomach or duodenal wall
    • obstruction—when the peptic ulcer blocks the path of food trying to leave the stomach

     

    How is an H. Pylori-Induced Ulcer Diagnosed?

    Noninvasive Techniques
    If a patient has peptic ulcer symptoms, the doctor first asks about use of over-the-counter and prescription NSAIDs. Patients who are taking an NSAID are asked to stop, reduce the dose, or switch to another medication.
    Then the doctor tests to see if H. pylori is present. Testing is important because H. pylori-induced ulcers are treated differently than ulcers caused by NSAIDs.
    Doctors use one of three simple, noninvasive tests to detect H. pylori in a patient’s blood, breath, or stool. Because the breath test and stool test more accurately detect H. pylori than the blood test, some doctors prefer to use one of these two tests. Each test described below is easily performed, often in an outpatient setting such as a doctor’s office or lab.
     
    Blood test. A blood sample is taken from the patient’s vein and tested for H. pylori antibodies. Antibodies are substances the body produces to fight invading harmful substances—called antigens—such as the H. pylori bacterium. This test does not readily differentiate an active infection from a past infection.
    Urea breath test. The patient swallows a capsule, liquid, or pudding that contains urea “labeled” with a special carbon atom. After a few minutes, the patient breathes into a container, exhaling carbon dioxide. If the carbon atom is found in the exhaled breath, H. pylori is present, as this bacterium contains large amounts of urease, a chemical that breaks urea down into carbon dioxide and ammonia.
    Stool antigen test. The patient provides a stool sample, which is tested for H. pylori antigens.
     
    Invasive Techniques
    If a patient has any alarm symptoms, the doctor orders an endoscopy or upper gastrointestinal (GI) series. Many doctors also recommend these tests for patients who first experience peptic ulcer symptoms around age 50. Often performed as outpatient procedures in a hospital, both procedures are painless and allow the doctor to look inside the patient’s stomach and duodenum.
    For an endoscopy, the patient is lightly sedated. The doctor passes an endoscope—a thin, lighted tube with a tiny camera on the end—into the patient’s mouth and down the throat to the stomach and duodenum. With this tool, the doctor can closely examine the lining of the esophagus, stomach, and duodenum.
    The doctor can use the endoscope to take photos of ulcers or remove a tiny piece of tissue—no bigger than a match head—to view with a microscope. This procedure is called a biopsy. The biopsied tissue is examined to see if H. pylori is present.
    If an ulcer is bleeding, the doctor can use the endoscope to inject medicines that help the blood clot or to guide a heat probe that burns tissue to stop bleeding—a process called cauterization.
    For an upper GI series, the patient drinks a white, chalky liquid called barium. The barium makes the esophagus, stomach, and duodenum and any ulcers show up on an x ray. Sedation is not necessary for this procedure. Due to the low sensitivity of this test it is rarely used nowadays.

  • Digestive System: How it Works

    What is the Digestive System?

    The digestive system
    The digestive system
     
    The digestive system is made up of the digestive tract—a series of hollow organs joined in a long, twisting tube from the mouth to the anus—and other organs that help the body break down and absorb food (see figure).
    Organs that make up the digestive tract are the mouth, esophagus, stomach, small intestine, large intestine—also called the colon—rectum, and anus. Inside these hollow organs is a lining called the mucosa. In the mouth, stomach, and small intestine, the mucosa contains tiny glands that produce juices to help digest food. The digestive tract also contains a layer of smooth muscle that helps break down food and move it along the tract.
    Two “solid” digestive organs, the liver and the pancreas, produce digestive juices that reach the intestine through small tubes called ducts. The gallbladder stores the liver’s digestive juices until they are needed in the intestine. Parts of the nervous and circulatory systems also play major roles in the digestive system.
     

    Why is digestion important?

    When you eat foods—such as bread, meat, and vegetables—they are not in a form that the body can use as nourishment. Food and drink must be changed into smaller molecules of nutrients before they can be absorbed into the blood and carried to cells throughout the body. Digestion is the process by which food and drink are broken down into their smallest parts so the body can use them to build and nourish cells and to provide energy.

    How is food digested?

    Digestion involves mixing food with digestive juices, moving it through the digestive tract, and breaking down large molecules of food into smaller molecules. Digestion begins in the mouth, when you chew and swallow, and is completed in the small intestine.
     
    Movement of Food Through the System
    The large, hollow organs of the digestive tract contain a layer of muscle that enables their walls to move. The movement of organ walls can propel food and liquid through the system and also can mix the contents within each organ. Food moves from one organ to the next through muscle action called peristalsis. Peristalsis looks like an ocean wave traveling through the muscle. The muscle of the organ contracts to create a narrowing and then propels the narrowed portion slowly down the length of the organ. These waves of narrowing push the food and fluid in front of them through each hollow organ.
    The first major muscle movement occurs when food or liquid is swallowed. Although you are able to start swallowing by choice, once the swallow begins, it becomes involuntary and proceeds under the control of the nerves.
    Swallowed food is pushed into the esophagus, which connects the throat above with the stomach below. At the junction of the esophagus and stomach, there is a ringlike muscle, called the lower esophageal sphincter, closing the passage between the two organs. As food approaches the closed sphincter, the sphincter relaxes and allows the food to pass through to the stomach.
    The stomach has three mechanical tasks. First, it stores the swallowed food and liquid. To do this, the muscle of the upper part of the stomach relaxes to accept large volumes of swallowed material. The second job is to mix up the food, liquid, and digestive juice produced by the stomach. The lower part of the stomach mixes these materials by its muscle action. The third task of the stomach is to empty its contents slowly into the small intestine.
    Several factors affect emptying of the stomach, including the kind of food and the degree of muscle action of the emptying stomach and the small intestine. Carbohydrates, for example, spend the least amount of time in the stomach, while protein stays in the stomach longer, and fats the longest. As the food dissolves into the juices from the pancreas, liver, and intestine, the contents of the intestine are mixed and pushed forward to allow further digestion.
    Finally, the digested nutrients are absorbed through the intestinal walls and transported throughout the body. The waste products of this process include undigested parts of the food, known as fiber, and older cells that have been shed from the mucosa. These materials are pushed into the colon, where they remain until the feces are expelled by a bowel movement.
     
    Production of Digestive Juices
    The digestive glands that act first are in the mouth—the salivary glands. Saliva produced by these glands contains an enzyme that begins to digest the starch from food into smaller molecules. An enzyme is a substance that speeds up chemical reactions in the body.
    The next set of digestive glands is in the stomach lining. They produce stomach acid and an enzyme that digests protein. A thick mucus layer coats the mucosa and helps keep the acidic digestive juice from dissolving the tissue of the stomach itself. In most people, the stomach mucosa is able to resist the juice, although food and other tissues of the body cannot.
    After the stomach empties the food and juice mixture into the small intestine, the juices of two other digestive organs mix with the food. One of these organs, the pancreas, produces a juice that contains a wide array of enzymes to break down the carbohydrate, fat, and protein in food. Other enzymes that are active in the process come from glands in the wall of the intestine.
    The second organ, the liver, produces yet another digestive juice—bile. Bile is stored between meals in the gallbladder. At mealtime, it is squeezed out of the gallbladder, through the bile ducts, and into the intestine to mix with the fat in food. The bile acids dissolve fat into the watery contents of the intestine, much like detergents that dissolve grease from a frying pan. After fat is dissolved, it is digested by enzymes from the pancreas and the lining of the intestine.
     
    Absorption and Transport of Nutrients
    Most digested molecules of food, as well as water and minerals, are absorbed through the small intestine. The mucosa of the small intestine contains many folds that are covered with tiny fingerlike projections called villi. In turn, the villi are covered with microscopic projections called microvilli. These structures create a vast surface area through which nutrients can be absorbed. Specialized cells allow absorbed materials to cross the mucosa into the blood, where they are carried off in the bloodstream to other parts of the body for storage or further chemical change. This part of the process varies with different types of nutrients.
     
    Carbohydrates. The Dietary Guidelines for Americans 2005 recommend that 45 to 65 percent of total daily calories be from carbohydrates. Foods rich in carbohydrates include bread, potatoes, dried peas and beans, rice, pasta, fruits, and vegetables. Many of these foods contain both starch and fiber.
    The digestible carbohydrates—starch and sugar—are broken into simpler molecules by enzymes in the saliva, in juice produced by the pancreas, and in the lining of the small intestine. Starch is digested in two steps. First, an enzyme in the saliva and pancreatic juice breaks the starch into molecules called maltose. Then an enzyme in the lining of the small intestine splits the maltose into glucose molecules that can be absorbed into the blood. Glucose is carried through the bloodstream to the liver, where it is stored or used to provide energy for the work of the body.
    Sugars are digested in one step. An enzyme in the lining of the small intestine digests sucrose, also known as table sugar, into glucose and fructose, which are absorbed through the intestine into the blood. Milk contains another type of sugar, lactose, which is changed into absorbable molecules by another enzyme in the intestinal lining.
    Fiber is undigestible and moves through the digestive tract without being broken down by enzymes. Many foods contain both soluble and insoluble fiber. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber, on the other hand, passes essentially unchanged through the intestines.
     
    Protein. Foods such as meat, eggs, and beans consist of giant molecules of protein that must be digested by enzymes before they can be used to build and repair body tissues. An enzyme in the juice of the stomach starts the digestion of swallowed protein. Then in the small intestine, several enzymes from the pancreatic juice and the lining of the intestine complete the breakdown of huge protein molecules into small molecules called amino acids. These small molecules can be absorbed through the small intestine into the blood and then be carried to all parts of the body to build the walls and other parts of cells.
     
    Fats. Fat molecules are a rich source of energy for the body. The first step in digestion of a fat such as butter is to dissolve it into the watery content of the intestine. The bile acids produced by the liver dissolve fat into tiny droplets and allow pancreatic and intestinal enzymes to break the large fat molecules into smaller ones. Some of these small molecules are fatty acids and cholesterol. The bile acids combine with the fatty acids and cholesterol and help these molecules move into the cells of the mucosa. In these cells the small molecules are formed back into large ones, most of which pass into vessels called lymphatics near the intestine. These small vessels carry the reformed fat to the veins of the chest, and the blood carries the fat to storage depots in different parts of the body.
     
    Vitamins. Another vital part of food that is absorbed through the small intestine are vitamins. The two types of vitamins are classified by the fluid in which they can be dissolved: water-soluble vitamins (all the B vitamins and vitamin C) and fat-soluble vitamins (vitamins A, D, E, and K). Fat-soluble vitamins are stored in the liver and fatty tissue of the body, whereas water-soluble vitamins are not easily stored and excess amounts are flushed out in the urine.
    Water and salt. Most of the material absorbed through the small intestine is water in which salt is dissolved. The salt and water come from the food and liquid you swallow and the juices secreted by the many digestive glands.
     

    How is the Digestive Process controlled?

    Hormone Regulators
    The major hormones that control the functions of the digestive system are produced and released by cells in the mucosa of the stomach and small intestine. These hormones are released into the blood of the digestive tract, travel back to the heart and through the arteries, and return to the digestive system where they stimulate digestive juices and cause organ movement.
    The main hormones that control digestion are gastrin, secretin, and cholecystokinin (CCK).
     
    Nerve Regulators
    Two types of nerves help control the action of the digestive system.
    Extrinsic, or outside, nerves come to the digestive organs from the brain or the spinal cord. They release two chemicals, acetylcholine and adrenaline. Acetylcholine causes the muscle layer of the digestive organs to squeeze with more force and increase the “push” of food and juice through the digestive tract. It also causes the stomach and pancreas to produce more digestive juice. Adrenaline has the opposite effect. It relaxes the muscle of the stomach and intestine and decreases the flow of blood to these organs, slowing or stopping digestion.
    The intrinsic, or inside, nerves make up a very dense network embedded in the walls of the esophagus, stomach, small intestine, and colon. The intrinsic nerves are triggered to act when the walls of the hollow organs are stretched by food. They release many different substances that speed up or delay the movement of food and the production of juices by the digestive organs.
    Together, nerves, hormones, the blood, and the organs of the digestive system conduct the complex tasks of digesting and absorbing nutrients from the foods and liquids you consume each day.

  • Heartburn

    What is Gastroesophageal Reflux Disease?

    Gastroesophageal reflux disease (GERD) is a more serious form of gastroesophageal reflux (GER), which is common. GER occurs when the lower esophageal sphincter (LES) opens spontaneously, for varying periods of time, or does not close properly and stomach contents rise up into the esophagus. GER is also called acid reflux or acid regurgitation, because digestive juices—called acids—rise up with the food. The esophagus is the tube that carries food from the mouth to the stomach. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach.
    When acid reflux occurs, food or fluid can be tasted in the back of the mouth. When refluxed stomach acid touches the lining of the esophagus it may cause a burning sensation in the chest or throat called heartburn or acid indigestion. Occasional GER is common and does not necessarily mean one has GERD. Persistent reflux that occurs more than twice a week is considered GERD, and it can eventually lead to more serious health problems. People of all ages can have GERD.
     

    What are the Symptoms of GERD?

    The main symptom of GERD in adults is frequent heartburn, also called acid indigestion—burning-type pain in the lower part of the mid-chest, behind the breast bone, and in the mid-abdomen. Most children under 12 years with GERD, and some adults, have GERD without heartburn. Instead, they may experience a dry cough, asthma symptoms, or trouble swallowing.
     

    What causes GERD?

    The reason some people develop GERD is still unclear. However, research shows that in people with GERD, the LES relaxes while the rest of the esophagus is working. Anatomical abnormalities such as a hiatal hernia may also contribute to GERD. A hiatal hernia occurs when the upper part of the stomach and the LES move above the diaphragm, the muscle wall that separates the stomach from the chest. Normally, the diaphragm helps the LES keep acid from rising up into the esophagus. When a hiatal hernia is present, acid reflux can occur more easily. A hiatal hernia can occur in people of any age and is most often a normal finding in otherwise healthy people over age 50. Most of the time, a hiatal hernia produces no symptoms.
    Other factors that may contribute to GERD include:

    • obesity
    • pregnancy
    • smoking

     
    Common foods that can worsen reflux symptoms include:

    • citrus fruits
    • chocolate
    • drinks with caffeine or alcohol
    • fatty and fried foods
    • garlic and onions
    • mint flavorings
    • spicy foods
    • tomato-based foods, like spaghetti sauce, salsa, chili, and pizza

     

    How is GERD treated?

    See your health care provider if you have had symptoms of GERD and have been using antacids or other over-the-counter reflux medications for more than 2 weeks. Your health care provider may refer you to a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on the severity of your GERD, treatment may involve one or more of the following lifestyle changes, medications, or surgery.
     
    Lifestyle Changes

    • If you smoke, stop.
    • Avoid foods and beverages that worsen symptoms.
    • Lose weight if needed.
    • Eat small, frequent meals.
    • Wear loose-fitting clothes.
    • Avoid lying down for 3 hours after a meal.
    • Raise the head of your bed 6 to 8 inches by securing wood blocks under the bedposts. Just using extra pillows will not help.

     
    Medications
    Your health care provider may recommend over-the-counter antacids or medications that stop acid production or help the muscles that empty your stomach. You can buy many of these medications without a prescription. However, see your health care provider before starting or adding a medication.
     
    Antacids, such as Maalox, Mylanta and Riopan, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts— magnesium, calcium, and aluminum—with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, can have side effects. Magnesium salt can lead to diarrhea, and aluminum salt may cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.
    Calcium carbonate antacids, such as Tums can also be a supplemental source of calcium. They can cause constipation as well.
     
    Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux.
     
    H2 blockers, such as cimetidine and ranitidine, decrease acid production. They are available in prescription strength and over-thecounter strength. These drugs provide short-term relief and are effective for about half of those who have GERD symptoms.
     
    Proton pump inhibitors include omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole, which are available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms and heal the esophageal lining in almost everyone who has GERD.
     
    Prokinetics help strengthen the LES and make the stomach empty faster. This group includes domperidone (Motilium) and metoclopramide (Primperan). Prokinetics can have side effects that limit their usefulness— fatigue, sleepiness, depression, anxiety, and problems with physical movement.
    Because drugs work in different ways, combinations of medications may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, and then the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your health care provider is the best source of information about how to use medications for GERD.
     

    What if GERD Symptoms persist?

    If your symptoms do not improve with lifestyle changes or medications, you may need additional tests.

    • Barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and other structural or anatomical problems of the esophagus. With this test, you drink a solution and then x rays are taken. The test will not detect mild irritation, although strictures—narrowing of the esophagus—and ulcers can be observed.
    • Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor’s office. The doctor after lightly sedating you, will slide a thin, flexible plastic tube with a light and lens on the end called an endoscope down your throat. Acting as a tiny camera, the endoscope allows the doctor to see the surface of the esophagus and search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD.
The doctor also may perform a biopsy. Tiny tweezers, called forceps, are passed through the endoscope and allow the doctor to remove small pieces of tissue from your esophagus. The tissue is then viewed with a microscope to look for damage caused by acid reflux and to rule out other problems if infection or abnormal growths are not found.
    • pH monitoring examination involves the doctor either inserting a small tube into the esophagus or clipping a tiny device to the esophagus that will stay there for 24 to 48 hours. While you go about your normal activities, the device measures when and how much acid comes up into your esophagus. This test can be useful if combined with a carefully completed diary— recording when, what, and amounts the person eats—which allows the doctor to see correlations between symptoms and reflux episodes. The procedure is sometimes helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.

     
    A completely accurate diagnostic test for GERD does not exist, and tests have not consistently shown that acid exposure to the lower esophagus directly correlates with damage to the lining.
     
    Surgery
    Surgery is an option when medicine and lifestyle changes do not help to manage GERD symptoms. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.
    Fundoplication is the standard surgical treatment for GERD. Usually a specific type of this procedure, called Nissen fundoplication, is performed. During the Nissen fundoplication, the upper part of the stomach is wrapped around the LES to strengthen the sphincter, prevent acid reflux, and repair a hiatal hernia.
    The Nissen fundoplication may be performed using a laparoscope, an instrument that is inserted through tiny incisions in the abdomen. The doctor then uses small instruments that hold a camera to look at the abdomen and pelvis. When performed by experienced surgeons, laparoscopic fundoplication is safe and effective in people of all ages, including infants. The procedure is reported to have the same results as the standard fundoplication, and people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.

    What are the long-term complications of GERD?

    Chronic GERD that is untreated can cause serious complications. Inflammation of the esophagus from refluxed stomach acid can damage the lining and cause bleeding or ulcers—also called esophagitis. Scars from tissue damage can lead to strictures— narrowing of the esophagus—that make swallowing difficult. Some people develop Barrett’s esophagus, in which cells in the esophageal lining take on an abnormal shape and color. Over time, the cells can lead to esophageal cancer, which is often fatal. Persons with GERD and its complications should be monitored closely by a physician.
    Studies have shown that GERD may worsen or contribute to asthma, chronic cough, and pulmonary fibrosis.
     

    Points to Remember

    • Frequent heartburn, also called acid indigestion, is the most common symptom of GERD in adults. Anyone experiencing heartburn twice a week or more may have GERD.
    • You can have GERD without having heartburn. Your symptoms could include a dry cough, asthma symptoms, or trouble swallowing.
    • If you have been using antacids for more than 2 weeks, it is time to see your health care provider. Most doctors can treat GERD. Your health care provider may refer you to a gastroenterologist, a doctor who treats diseases of the stomach and intestines.
    • Health care providers usually recommend lifestyle and dietary changes to relieve symptoms of GERD. Many people with GERD also need medication. Surgery may be considered as a treatment option.

  • Irritable Bowel Syndrome

    What is Irritable Bowel Syndrome (IBS)?

    Irritable bowel syndrome is a functional gastrointestinal (GI) disorder, meaning it is a problem caused by changes in how the GI tract works. People with a functional GI disorder have frequent symptoms, but the GI tract does not become damaged. IBS is not a disease; it is a group of symptoms that occur together. The most common symptoms of IBS are abdominal pain or discomfort, often reported as cramping, along with diarrhea, constipation, or both. In the past, IBS was called colitis, mucous colitis, spastic colon, nervous colon, and spastic bowel. The name was changed to reflect the understanding that the disorder has both physical and mental causes and is not a product of a person’s imagination.
    IBS is diagnosed when a person has abdominal pain or discomfort at least three times per month for the last 3 months without other disease or injury that could explain the pain. The pain or discomfort of IBS may occur with a change in stool frequency or consistency or may be relieved by a bowel movement.
    IBS is often classified into four subtypes based on a person’s usual stool consistency. These subtypes are important because they affect the types of treatment that are most likely to improve the person’s symptoms.
     

    What is the GI tract?

    The GI tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus. The movement of muscles in the GI tract, along with the release of hormones and enzymes, allows for the digestion of food. Organs that make up the GI tract are the mouth, esophagus, stomach, small intestine, large intestine—which includes the appendix, cecum, colon, and rectum—and anus. The intestines are sometimes called the bowel. The last part of the GI tract—called the lower GI tract—consists of the large intestine and anus.
    The large intestine absorbs water and any remaining nutrients from partially digested food passed from the small intestine. The large intestine then changes waste from liquid to a solid matter called stool. Stool passes from the colon to the rectum. The rectum is located between the last part of the colon—called the sigmoid colon—and the anus. The rectum stores stool prior to a bowel movement. During a bowel movement, stool moves from the rectum to the anus, the opening through which stool leaves the body.
    The lower GI tract
    The lower GI tract
     

    How common is IBS and who is affected?

    Irritable bowel syndrome is estimated to affect 3 to 20 percent of the population, with most studies ranging from 10 to 15 percent. However, less than one-third of people with the condition see a health care provider for diagnosis. IBS affects about twice as many women as men and is most often found in people younger than 45 years.
     

    What are the Symptoms of IBS?

    The symptoms of IBS include abdominal pain or discomfort and changes in bowel habits. To meet the definition of IBS, the pain or discomfort should be associated with two of the following three symptoms:

    • start with bowel movements that occur more or less often than usual
    • start with stool that appears looser and more watery or harder and more lumpy than usual
    • improve with a bowel movement

     
    Other symptoms of IBS may include:

    • diarrhea—having loose, watery stools three or more times a day and feeling urgency to have a bowel movement
    • constipation—having hard, dry stools; three or fewer bowel movements in a week; or straining to have a bowel movement
    • feeling that a bowel movement is incomplete
    • passing mucus, a clear liquid made by the intestines that coats and protects tissues in the GI tract
    • abdominal bloating

     
    Symptoms may often occur after eating a meal. To meet the definition of IBS, symptoms must occur at least 3 days a month.
     

    What causes IBS?

    The causes of IBS are not well understood. Researchers believe a combination of physical and mental health problems can lead to IBS. The possible causes of IBS include the following:

    • Brain-gut signal problems. Signals between the brain and nerves of the small and large intestines, also called the gut, control how the intestines work. Problems with brain-gut signals may cause IBS symptoms, such as changes in bowel habits and pain or discomfort.
    • GI motor problems. Normal motility, or movement, may not be present in the colon of a person who has IBS. Slow motility can lead to constipation and fast motility can lead to diarrhea. Spasms, or sudden strong muscle contractions that come and go, can cause abdominal pain. Some people with IBS also experience hyperreactivity, which is an excessive increase in contractions of the bowel in response to stress or eating.
    • Hypersensitivity. People with IBS have a lower pain threshold to stretching of the bowel caused by gas or stool compared with people who do not have IBS. The brain may process pain signals from the bowel differently in people with IBS.
    • Mental health problems. Mental health, or psychological, problems such as panic disorder, anxiety, depression, and post-traumatic stress disorder are common in people with IBS. The link between these disorders and development of IBS is unclear. GI disorders, including IBS, are often found in people who have reported past physical or sexual abuse. Researchers believe people who have been abused tend to express psychological stress through physical symptoms.
    • Bacterial gastroenteritis. Some people who have bacterial gastroenteritis—an infection or irritation of the stomach and intestines caused by bacteria—develop IBS. Researchers do not know why gastroenteritis leads to IBS in some people and not others, though psychological problems and abnormalities of the lining of the GI tract may be factors.
    • Small intestinal bacterial overgrowth (SIBO). Normally, few bacteria live in the small intestine. SIBO is an increase in the number of bacteria or a change in the type of bacteria in the small intestine. These bacteria can produce excess gas and may also cause diarrhea and weight loss. Some researchers believe that SIBO may lead to IBS, and some studies have shown antibiotics to be effective in treating IBS. However, the studies were weak and more research is needed to show a link between SIBO and IBS.
    • Body chemicals. People with IBS have altered levels of neurotransmitters, which are chemicals in the body that transmit nerve signals, and GI hormones, though the role these chemicals play in developing IBS is unclear. Younger women with IBS often have more symptoms during their menstrual periods. Post-menopausal women have fewer symptoms compared with women who are still menstruating. These findings suggest that reproductive hormones can worsen IBS problems.
    • Genetics. Whether IBS has a genetic cause, meaning it runs in families, is unclear. Studies have shown that IBS is more common in people with family members who have a history of GI problems. However, the cause could be environmental or the result of heightened awareness of GI symptoms.
    • Food sensitivity. Many people with IBS report that certain foods and beverages can cause symptoms, such as foods rich in carbohydrates, spicy or fatty foods, coffee, and alcohol. However, people with food sensitivity typically do not have clinical signs of food allergy. Researchers have proposed that symptoms may result from poor absorption of sugars or bile acids, which help break down fats and get rid of wastes in the body.

     

    How is IBS diagnosed?

    To diagnose IBS, a health care provider will conduct a physical exam and take a complete medical history. The medical history will include questions about symptoms, family history of GI disorders, recent infections, medications, and stressful events related to the onset of symptoms. For IBS to be diagnosed, the symptoms must have started at least 6 months prior and must have occurred at least 3 days per month for the previous 3 months. Further testing is not usually needed, though the health care provider may do a blood test to screen for other problems. Additional diagnostic tests may be needed based on the results of the screening blood test and for people who also have signs such as:

    • fever
    • rectal bleeding
    • weight loss
    • anemia—too few red blood cells in the body, which prevents the body from getting enough oxygen
    • family history of colon cancer, irritable bowel disease—long-lasting disorders that cause irritation and ulcers, or sores, in the GI tract—or celiac disease—an immune disease in which people cannot tolerate gluten, a protein found in wheat, rye, and barley, because it will damage the lining of their small intestine and prevent absorption of nutrients

     
    Additional diagnostic tests may include a stool test, lower GI series, and flexible sigmoidoscopy or colonoscopy. Colonoscopy may also be recommended for people who are older than 50 to screen for colon cancer.
    Stool tests. A stool test is the analysis of a sample of stool. The health care provider will give the person a container for catching and storing the stool. The sample is returned to the health care provider or a commercial facility and sent to a lab for analysis. The health care provider may also do a rectal exam, sometimes during the physical exam, to check for blood in the stool. Stool tests can show the presence of parasites or blood.
    Lower GI series. A lower GI series is an x-ray exam that is used to look at the large intestine. The test is performed at a hospital or outpatient center by a radiologist—a doctor who specializes in medical imaging. The health care provider may give the person written bowel prep instructions to follow at home. The person may be asked to follow a clear liquid diet for 1 to 3 days before the procedure. A laxative or enema may be used before the test. A laxative is medication that loosens stool and increases bowel movements. An enema involves flushing water or laxative into the anus using a special squirt bottle.
    For the test, the person will lie on a table while the radiologist inserts a flexible tube into the person’s anus. The large intestine is filled with barium, making signs of problems with the large intestine that may be causing the person’s symptoms show up more clearly on x rays.
    For several days, traces of barium in the large intestine cause stools to be white or light colored. Enemas and repeated bowel movements may cause anal soreness. A health care provider will provide specific instructions about eating and drinking after the test.
    Flexible sigmoidoscopy and colonoscopy. The tests are similar, but a colonoscopy is used to view the rectum and entire colon, while a flexible sigmoidoscopy is used to view just the rectum and lower colon. These tests are performed at a hospital or outpatient center by a gastroenterologist—a doctor who specializes in digestive diseases. For both tests, a health care provider will give written bowel prep instructions to follow at home. The person may be asked to follow a clear liquid diet for 1 to 3 days before either test. The night before the test, the person may need to take a laxative. One or more enemas may also be required the night before and about 2 hours before the test.
    In most cases, light anesthesia, and possibly pain medication, helps people relax. For either test, the person will lie on a table while the gastroenterologist inserts a flexible tube into the anus. A small camera on the tube sends a video image of the intestinal lining to a computer screen. The test can show signs of problems in the lower GI tract.
    The gastroenterologist may also perform a biopsy, a procedure that involves taking a piece of intestinal lining for examination with a microscope. You will not feel the biopsy. A pathologist—a doctor who specializes in diagnosing diseases—examines the tissue in a lab.
    Cramping or bloating may occur during the first hour after the test. Driving is not permitted for 24 hours after a colonoscopy to allow the sedative time to wear off. Before the appointment, a person should make plans for a ride home. Full recovery is expected by the next day.

    How is IBS treated?

    Though there is no cure for IBS, the symptoms can be treated with a combination of the following:

    • changes in eating, diet, and nutrition
    • medications
    • probiotics
    • therapies for mental health problems

     
    Eating, Diet, and Nutrition
    Large meals can cause cramping and diarrhea, so eating smaller meals more often, or eating smaller portions, may help IBS symptoms. Eating meals that are low in fat and high in carbohydrates, such as pasta, rice, whole-grain breads and cereals, fruits, and vegetables, may help.
    Certain foods and drinks may cause IBS symptoms in some people, such as

    • foods high in fat
    • milk products
    • drinks with alcohol or caffeine
    • drinks with large amounts of artificial sweeteners, which are substances used in place of sugar
    • foods that may cause gas, such as beans and cabbage

     
    People with IBS may want to limit or avoid these foods. Keeping a food diary is a good way to track which foods cause symptoms so they can be excluded from or reduced in the diet.
    Dietary fiber may lessen constipation in people with IBS, but it may not help with lowering pain. Fiber helps keep stool soft so it moves smoothly through the colon. The Academy of Nutrition and Dietetics recommends consuming 20 to 35 grams of fiber a day for adults. Fiber may cause gas and trigger symptoms in some people with IBS. Increasing fiber intake by 2 to 3 grams per day may help reduce the risk of increased gas and bloating.
     
    Medications
    The health care provider will select medications based on the person’s symptoms.

    • Fiber supplements. Fiber supplements may be recommended to relieve constipation when increasing dietary fiber is ineffective.
    • Laxatives. Constipation can be treated with laxative medications. Laxatives work in different ways, and a health care provider can provide information about which type is best for each person. More information about different types of laxatives can be found in the National Digestive Diseases Information Clearinghouse (NDDIC) fact sheet Constipation.
    • Antidiarrheals. Loperamide has been found to reduce diarrhea in people with IBS, though it does not reduce pain, bloating, or other symptoms.
Loperamide reduces stool frequency and improves stool consistency by slowing the movement of stool through the colon.
    • Antispasmodics. Antispasmodics, such as hyoscine, cimetropium, and pinaverium, help to control colon muscle spasms and reduce abdominal pain.
    • Antidepressants. Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) in low doses can help relieve IBS symptoms including abdominal pain. In theory, TCAs should be better for people with IBS-D and SSRIs should be better for people with IBS-C due to the effect on colon transit, but this has not been confirmed in clinical studies. TCAs work in people with IBS by reducing sensitivity to pain in the GI tract as well as normalizing GI motility and secretion.
    • The antibiotic rifaximin can reduce abdominal bloating by treating SIBO. But scientists are still debating the use of antibiotics to treat IBS, and more research is needed.

     
    Probiotics are live microorganisms, usually bacteria, that are similar to microorganisms normally found in the GI tract. Studies have found that probiotics, specifically Bifidobacteria and certain probiotic combinations, improve symptoms of IBS when taken in large enough amounts. But more research is needed. Probiotics can be found in dietary supplements, such as capsules, tablets, and powders, and in some foods, such as yogurt. A health care provider can give information about the right kind and right amount of probiotics to take to improve IBS symptoms.
     
    Therapies for Mental Health Problems, the following therapies can help improve IBS symptoms due to mental health problems:

    • Talk therapy. Talking with a therapist may reduce stress and improve IBS symptoms. Two types of talk therapy used to treat IBS are cognitive behavioral therapy and psychodynamic, or interpersonal, therapy. Cognitive behavioral therapy focuses on the person’s thoughts and actions. Psychodynamic therapy focuses on how emotions affect IBS symptoms. This type of therapy often involves relaxation and stress management techniques.
    • Hypnotherapy. In hypnotherapy, the therapist uses hypnosis to help the person relax into a trancelike state. This type of therapy may help the person relax the muscles in the colon.
    • Mindfulness training. People practicing this type of meditation are taught to focus their attention on sensations occurring at the moment and to avoid worrying about the meaning of those sensations, also called catastrophizing.

     

    What other conditions are associated with IBS?

    People with IBS often suffer from other GI and non-GI conditions. GI conditions such as gastroesophageal reflux disease (GERD) and dyspepsia are more common in people with IBS than the general population. GERD is a condition in which stomach contents flow back up into the esophagus— the organ that connects the mouth to the stomach—because the muscle between the esophagus and the stomach is weak or relaxes when it should not. Dyspepsia, or indigestion, is upper abdominal discomfort that often occurs after eating. Dyspepsia may be accompanied by fullness, bloating, nausea, or other GI symptoms. More information about these conditions can be found in the NDDIC fact sheets Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD) and Indigestion.
    Non-GI conditions often found in people with IBS include:

    • chronic fatigue syndrome—a disorder that causes extreme fatigue, which is tiredness that lasts a long time and limits a person’s ability to do ordinary daily activities
    • chronic pelvic pain
    • temporomandibular joint disorders— problems or symptoms of the chewing muscles and joints that connect the lower jaw to the skull
    • depression
    • anxiety
    • somatoform disorders—chronic pain or other symptoms with no physical cause that are thought to be due to psychological problems

     

    How does stress affect IBS?

    Stress can stimulate colon spasms in people with IBS. The colon has many nerves that connect it to the brain. These nerves control the normal contractions of the colon and cause abdominal discomfort at stressful times. In people with IBS, the colon can be overly responsive to even slight conflict or stress. Stress makes the mind more aware of the sensations that arise in the colon. IBS symptoms can also increase a person’s stress level. Some options for managing stress include:

    • participating in stress reduction and relaxation therapies such as meditation
    • getting counseling and support
    • taking part in regular exercise such as walking or yoga
    • minimizing stressful life situations as much as possible
    • getting enough sleep

     

    Points to Remember

    • Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder, meaning it is a problem caused by changes in how the GI tract works. People with a functional GI disorder have frequent symptoms, but the GI tract does not become damaged.
    • IBS is not a disease; it is a group of symptoms that occur together.
    • IBS is estimated to affect 3 to 20 percent of the population, with most studies ranging from 10 to 15 percent. However, less than one-third of people with the condition see a health care provider for diagnosis.
    • The symptoms of IBS include abdominal pain or discomfort and changes in bowel habits. Other symptoms of IBS may include:
      • diarrhea
      • constipation
      • feeling that a bowel movement is incomplete
      • passing mucus
      • abdominal bloating
    • The causes of IBS are not well understood. Researchers believe a combination of physical and mental health problems can lead to IBS.
    • To diagnose IBS, a health care provider will conduct a physical exam and take a complete medical history. The medical history will include questions about symptoms, family history of GI disorders, recent infections, medications, and stressful events related to the onset of symptoms.
    • Though there is no cure for IBS, the symptoms can be treated with a combination of the following:
      • changes in eating, diet, and nutrition
      • medications
      • probiotics
      • passing mucus
      • abdominal bloating

  • Polyps

    What are Colon Polyps?

    A colon polyp is a growth on the surface of the colon, also called the large intestine. Sometimes, a person can have more than one colon polyp. Colon polyps can be raised or flat.
    The large intestine is the long, hollow tube at the end of your digestive tract. The large intestine absorbs water from stool and changes it from a liquid to a solid. Stool is the waste that passes through the rectum and anus as a bowel movement.
    Digestive tract with the large intestine highlighted
    Digestive tract with the
    large intestine highlighted

    Are Colon Polyps Cancerous?

    Some colon polyps are benign, which means they are not cancer. But some types of polyps may already be cancer or can become cancer. Flat polyps can be smaller and harder to see and are more likely to be cancer than raised polyps. Polyps can usually be removed during colonoscopy—the test used to check for colon polyps.

    Colon Polyp
    Colon Polyp
     

    Who gets Colon Polyps?

    Anyone can get colon polyps, but certain people are more likely to get them than others. You may have a greater chance of getting polyps if:

    • you’re 50 years of age or older
    • you’ve had polyps before
    • someone in your family has had polyps
    • someone in your family has had cancer of the large intestine, also called colon cancer
    • you’ve had uterine or ovarian cancer before age 50

     
    You may also be more likely to get colon polyps if you:

    • eat a lot of fatty foods
    • smoke
    • drink alcohol
    • don’t exercise
    • weigh too much

     

    What are the Symptoms of Colon Polyps?

    Most people with colon polyps do not have symptoms. Often, people don’t know they have one until the doctor finds it during a regular checkup or while testing for something else.
    But some people do have symptoms, such as:

    • bleeding from the anus. The anus is the opening at the end of the digestive tract where stool leaves the body. You might notice blood on your underwear or on toilet paper after you’ve had a bowel movement.
    • constipation or diarrhea that lasts more than a week.
    • blood in the stool. Blood can make stool look black, or it can show up as red streaks in the stool.

     
    If you have any of these symptoms, see a doctor to find out what the problem is.

    How does the Doctor Test for Colon Polyps?

    The doctor can use one or more tests to check for colon polyps.

    • Barium enema. The doctor puts a liquid called barium into your rectum before taking x rays of your large intestine. Barium makes your intestine look white in the pictures. Polyps are dark, so they’re easy to see.
    • Sigmoidoscopy. With this test, the doctor puts a thin, flexible tube into your rectum. The tube is called a sigmoidoscope, and it has a light in it. The doctor uses the sigmoidoscope to look at the last third of your large intestine.
    • Colonoscopy. The doctor will give you medicine to sedate you during the colonoscopy. This test is like the sigmoidoscopy, but the doctor looks at the entire large intestine with a long, flexible tube with a camera that shows images on a TV screen. The tube has a tool that can remove polyps. The doctor usually removes polyps during colonoscopy.
    • Computerized tomography (CT) scan. With this test, also called virtual colonoscopy, the doctor puts a thin, flexible tube into your rectum. A machine using x rays and computers creates pictures of the large intestine that can be seen on a screen.
The CT scan takes less time than a colonoscopy because polyps are not removed during the test. If the CT scan shows polyps, you will need a colonoscopy so they can be removed.
    • Stool test. The doctor will ask you to bring a stool sample in a special cup. The stool is tested in the laboratory for signs of cancer, such as DNA changes or blood.

     

    Who Should get tested for Colon Polyps?

    Talk with your doctor about getting tested for colon polyps if you’re 50 years of age or older, or earlier if you have symptoms or someone in your family has had polyps or colon cancer.

    How are Colon Polyps treated?

    In most cases, the doctor removes colon polyps during sigmoidoscopy or colonoscopy. The polyps are then tested for cancer.
    If you’ve had colon polyps, the doctor will want you to get tested regularly in the future.

    Polyp removal
    Polyp removal
     

    How can I prevent Colon Polyps?

    Doctors don’t know of one sure way to prevent colon polyps. But you might be able to lower your risk of getting them if you:

    • eat more fruits and vegetables and less fatty food
    • don’t smoke
    • avoid alcohol
    • exercise most days of the week
    • lose weight if you’re overweight

     
    Eating more calcium may also lower your risk of getting polyps. Some foods that are rich in calcium are milk, cheese, yogurt, and broccoli.
    Taking a low dose of aspirin every day might help prevent polyps. Talk with your doctor before starting any medication.

    Points to Remember

     

    • A colon polyp is a growth on the surface of the colon, also called the large intestine.
    • Colon polyps can be raised or flat.
    • Some colon polyps are benign, which means they are not cancer.
    • Some types of polyps may already be cancer or can become cancer. Flat polyps can be smaller and harder to see and are more likely to be cancer than raised polyps.
    • Most people with colon polyps do not have symptoms.
    • Symptoms may include constipation or diarrhea for more than a week or blood on your underwear, on toilet paper, or in your stool.
    • Doctors remove most colon polyps and test them for cancer.
    • Talk with your doctor about getting tested for colon polyps if you’re 50 years of age or older, or earlier if you have symptoms or someone in your family has had polyps or colon cancer.

  • Ulcerative Colitis

    What is Ulcerative colitis?

    Ulcerative colitis is a chronic, or long-lasting, disease that causes inflammation and sores, called ulcers, in the inner lining of the large intestine, which includes the colon and the rectum—the end part of the colon.
    UC is one of the two main forms of chronic inflammatory disease of the gastrointestinal tract, called inflammatory bowel disease (IBD). The other form is called Crohn’s disease.
    Normally, the large intestine absorbs water from stool and changes it from a liquid to a solid. In UC, the inflammation causes loss of the lining of the colon, leading to bleeding, production of pus, diarrhea, and abdominal discomfort.
     

    What causes UC?

    The cause of UC is unknown though theories exist. People with UC have abnormalities of the immune system, but whether these problems are a cause or a result of the disease is still unclear. The immune system protects people from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances. With UC, the body’s immune system is believed to react abnormally to bacteria in the digestive tract. UC sometimes runs in families and research studies have shown that certain gene abnormalities are found more often in people with UC.
    UC is not caused by emotional distress, but the stress of living with UC may contribute to a worsening of symptoms. In addition, while sensitivity to certain foods or food products does not cause UC, it may trigger symptoms in some people.
     

    What are the Symptoms of UC?

    The most common symptoms of UC are abdominal discomfort and blood or pus in diarrhea. Other symptoms include:

    • anemia
    • fatigue
    • fever
    • nausea
    • weight loss
    • loss of appetite
    • rectal bleeding
    • loss of body fluids and nutrients
    • skin lesions
    • growth failure in children

     
    Most people diagnosed with UC have mild to moderate symptoms. About 10 percent have severe symptoms such as frequent fevers, bloody diarrhea, nausea, and severe abdominal cramps. UC can also cause problems such as joint pain, eye irritation, kidney stones, liver disease, and osteoporosis. Scientists do not know why these problems occur, but they think these complications may be the result of inflammation triggered by the immune system. Some of these problems go away when UC is treated.

    Who develops UC?

    While UC can occur in people of any age, it usually develops between the ages of 15 and 30 and less frequently between the ages of 60 and 80. The disease affects men and women equally. People with a family member or first-degree relative with an IBD are at higher risk for developing UC, as are Caucasians and people of Jewish descent.
     

    How is UC diagnosed?

    Ulcerative colitis can be difficult to diagnose because its symptoms are similar to those of other intestinal disorders and to Crohn’s disease. Crohn’s disease differs from UC in that Crohn’s disease causes inflammation deeper within the intestinal wall and can occur in other parts of the digestive system, including the small intestine, mouth, esophagus, and stomach.
    People with suspected UC may be referred to a gastroenterologist, also called a gastroenterological specialist, a doctor who specializes in digestive diseases. A physical exam and medical history are usually the first steps in diagnosing UC, followed by one or more tests and procedures:

    • Blood tests. A blood test involves drawing blood at a health care provider’s office or commercial facility and sending the sample to a lab for analysis. The blood test can show a high white blood cell (WBC) count, which is a sign of inflammation somewhere in the body. Blood tests can also detect anemia, which could be caused by bleeding in the colon or rectum.
    • Stool test. Stool tests can show WBCs, which indicate UC or another IBD. The doctor will give the person a pan and a container for catching and storing the stool. The sample is returned to the health care provider or a commercial facility and sent to a lab for analysis. The sample also allows doctors to detect bleeding or infection in the colon or rectum caused by bacteria, a virus, or parasites.
    • Flexible sigmoidoscopy and colonoscopy. These tests are the most accurate methods for diagnosing UC and ruling out other possible conditions, such as Crohn’s disease, diverticular disease, or cancer. The tests are similar, but colonoscopy is used to look inside the rectum and entire colon, while flexible sigmoidoscopy is used to look inside the rectum and lower colon. For both tests, the doctor will provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for 1 to 3 days before the test. A laxative may be required the night before the test. One or more enemas may be required the night before and about 2 hours before the test.
For both tests, the person lies on a table while the doctor inserts a flexible tube into the anus. A small camera on the tube sends a video image of the intestinal lining to a computer screen. The doctor can see inflammation, bleeding, or ulcers on the colon wall. The doctor may also perform a biopsy by snipping a bit of tissue from the intestinal lining. The person will not feel the biopsy. The doctor will look at the tissue with a microscope to confirm the diagnosis. These tests are performed at a hospital or outpatient center by a gastroenterologist. In most cases, a light sedative, and possibly pain medication, helps people relax. The test can show problems in the rectum or lower colon that may be causing symptoms.
Cramping or bloating may occur during the first hour after the test. Driving is not permitted for 24 hours after the test to allow the sedative time to wear off. Before the appointment, a person should make plans for a ride home. Full recovery is expected by the next day.
    • Computerized tomography (CT) scan and barium enema x ray. A CT scan uses a combination of x rays and computer technology to create three-dimensional (3-D) images. A CT scan may include the injection of a special dye, called contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. The procedure is performed in an outpatient center or hospital by an x-ray technician, and the images are interpreted by a radiologist—a doctor who specializes in medical imaging; anesthesia is not needed. A barium enema x ray involves the injection of contrast medium, called barium, into the colon to make the colon, rectum, and lower part of the small intestine more visible in x-ray images. The procedure is performed in a hospital or outpatient center by an x-ray technician, and the images are interpreted by a radiologist; anesthesia is not needed. These tests can show physical abnormalities and are sometimes used to diagnose UC.

     

    How is UC treated?

    Treatment for UC depends on the severity of the disease and its symptoms. Each person experiences UC differently, so treatment is adjusted for each individual.
     
    Medication Therapy
    While no medication cures UC, many can reduce symptoms. The goals of medication therapy are to induce and maintain remission—periods when the symptoms go away for months or even years—and to improve quality of life. Many people with UC require medication therapy indefinitely, unless they have their colon and rectum surgically removed.
    The type of medication prescribed depends on the severity of the UC.

    • Aminosalicylates, medications that contain 5-aminosalicyclic acid (5-ASA), help control inflammation. Depending on which parts of the colon and rectum are affected by UC, 5-ASAs can be given orally; through a rectal suppository, a small plug of medication inserted in the rectum; or through an enema—liquid medication put into the rectum. Unless the UC symptoms are severe, people are usually first treated with aminosalicylates. These medications are also used when symptoms return after a period of remission.
    • Corticosteroids, such as prednisone, methylprednisone, and hydrocortisone, also reduce inflammation. They are used for people with more severe symptoms and people who do not respond to 5-ASAs. Corticosteroids, also known as steroids, can be given orally, intravenously, or through an enema, a rectal foam, or a suppository, depending on which parts of the colon and rectum are affected by UC. Side effects include weight gain, acne, facial hair, hypertension, diabetes, mood swings, bone mass loss, and an increased risk of infection. Because of harsh side effects, steroids are not recommended for long-term use. Steroids are usually prescribed for short-term use and then stopped once inflammation is under control. The other UC medications are used for long-term symptom management.
    • Immunomodulators, such as azathioprine, 6-mercaptopurine and cyclosporine suppress the immune system. These medications are prescribed for people who do not respond to 5-ASAs. Immunomodulators are given orally, but they are slow-acting and can take 3 to 6 months to take effect. People taking these medications are monitored for complications including nausea, vomiting, fatigue, pancreatitis, hepatitis, a reduced WBC count, and an increased risk of infection. Cyclosporine is only used with severe UC, because one of its frequent side effects is toxicity, which means it can cause harmful effects to the body over time.
    • Infliximab is an anti-tumor necrosis factor (anti-TNF) agent prescribed to treat people who do not respond to the other UC medications or who cannot take 5-ASAs. People taking Infliximab should also take immunomodulators to avoid allergic reactions. Infliximab targets a protein called TNF that causes inflammation in the intestinal tract. The medication is given through intravenous infusion—through a vein—every 6 to 8 weeks at a hospital or outpatient center. Side effects may include toxicity and increased risk of infections, particularly tuberculosis.

     
    Other medications may be prescribed to decrease emotional stress or to relieve pain, reduce diarrhea, or stop infection.
     
    Hospitalization
    Sometimes UC symptoms are severe enough that a person must be hospitalized. For example, a person may have severe bleeding or diarrhea that causes dehydration. In such cases, health care providers will use intravenous fluids to treat diarrhea and loss of blood, fluids, and mineral salts. People with severe symptoms may need a special diet, tube feeding, medications, or surgery.
     
    Surgery
    About 10 to 40 percent of people with UC eventually need a proctocolectomy—surgery to remove the rectum and part or all of the colon.1 Surgery is sometimes recommended if medical treatment fails or if the side effects of corticosteroids or other medications threaten a person’s health. Other times surgery is performed because of massive bleeding, severe illness, colon rupture, or cancer risk. Surgery is performed at a hospital by a surgeon; anesthesia will be used. Most people need to remain in the hospital for 1 to 2 weeks, and full recovery can take 4 to 6 weeks.
    A proctocolectomy is followed by one of the following operations:

      • Ileoanal pouch anastomosis, also called “pouch surgery,” makes it possible for people with UC to have normal bowel movements, because it preserves part of the anus. For this operation, the surgeon preserves the outer muscles of the rectum during the proctocolectomy. The ileum—the lower end of the small intestine—is then pulled through the remaining rectum and joined to the anus, creating a pouch. Waste is stored in the pouch and passes through the anus in the usual manner. Bowel movements may be more frequent and watery than before the procedure. Inflammation of the pouch, called pouchitis, is a possible complication and can lead to symptoms such as increased diarrhea, rectal bleeding, and loss of bowel control. Pouch surgery is the first type of surgery considered for UC because it avoids a long-term ileostomy.

        Ileoanal pouch Anastomosis
        Ileoanal pouch Anastomosis

     

    • Ileostomy is an operation that attaches the ileum to an opening made in the abdomen, called a stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. An ostomy pouch is then attached to the stoma and worn outside the body to collect stool. The pouch needs to be emptied several times a day. An ileostomy performed for UC is usually permanent. A specially trained nurse will teach the person how to clean, care for, and change the ostomy pouch and how to protect the skin around the stoma.

     
    The type of surgery recommended will be based on the severity of the disease and the person’s needs, expectations, and lifestyle. People faced with this decision should get as much information as possible by talking with their doctors; enterostomal therapists, nurses who work with colon surgery patients; other health care professionals; and people who have had colon surgery. Patient advocacy organizations can provide information about support groups and other resources.
     

    Eating, Diet, and Nutrition

    Dietary changes may help reduce UC symptoms. A recommended diet will depend on the person’s symptoms, medications, and reactions to food. General dietary tips that may alleviate symptoms include:

    • eating smaller meals more often
    • avoiding carbonated drinks
    • eating bland foods
    • avoiding high-fiber foods such as corn and nuts

     
    For people with UC who do not absorb enough nutrients, vitamin and nutritional supplements may be recommended.
     

    Is Colon Cancer a concern with UC?

    People with UC have an increased risk of colon cancer when the entire colon is affected for a long period of time. For example, if only the lower colon and rectum are involved, the risk of cancer is no higher than that of a person without UC. But if the entire colon is involved, the risk of cancer is higher than the normal rate.4 The risk of colon cancer also rises after having UC for 8 to 10 years and continues to increase over time. Effective maintenance of remission by treatment of UC may reduce the risk of colon cancer. Surgical removal of the colon eliminates the risk of colon cancer. With UC, precancerous changes—called dysplasia—sometimes occur in the cells lining the colon. People with dysplasia are at increased risk of developing colon cancer. Doctors look for signs of dysplasia when performing a colonoscopy or flexible sigmoidoscopy and when examining tissue removed during these procedures.
    According to the U.S. Preventive Services Task Force guidelines for colon cancer screening, people who have had IBD throughout the colon for at least 8 years and those who have had IBD in only the left side of the colon for 12 to 15 years should have a colonoscopy with biopsies every 1 to 2 years to check for dysplasia. Such screening has not been proven to reduce the risk of colon cancer, but it may help identify cancer early and improve prognosis. These guidelines were produced by an independent expert panel and endorsed by numerous organizations, including the American Cancer Society, the American College of Gastroenterology, the American Society of Colon and Rectal Surgeons, and the Crohn’s & Colitis Foundation of America.
     

    Points to Remember

    • Ulcerative colitis (UC) is a chronic, or long-lasting, disease that causes inflammation and sores, called ulcers, in the inner lining of the colon and rectum.
    • Ulcerative colitis is one of the two main forms of chronic inflammatory disease of the gastrointestinal tract, called inflammatory bowel disease (IBD).
    • The most common symptoms of UC are abdominal discomfort and bloody diarrhea.
    • Flexible sigmoidoscopy and colonoscopy are the most accurate methods for diagnosing UC and ruling out other possible conditions, such as Crohn’s disease, diverticular disease, or cancer.
    • Treatment for UC depends on the severity of the disease and its symptoms. Each person experiences UC differently, so treatment is adjusted for each individual. Treatment may include medication therapy, hospitalization, or surgery to remove the rectum and part or all of the colon.
    • Most people with UC never develop colon cancer, but two factors that increase the risk are the duration of the disease and how much of the colon is affected.

  • Crohn's Disease

    What is Crohn’s Disease?

    Crohn’s disease is a disease that causes inflammation, or swelling, and irritation of any part of the digestive tract—also called the gastrointestinal (GI) tract. The part most commonly affected is the end part of the small intestine, called the ileum.
    The GI tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus. The movement of muscles in the GI tract, along with the release of hormones and enzymes, allows for the digestion of food.

    The GI tract

    The GI tract
     
    In Crohn’s disease, inflammation extends deep into the lining of the affected part of the GI tract. Swelling can cause pain and can make the intestine—also called the bowel—empty frequently, resulting in diarrhea. Chronic—or long-lasting—inflammation may produce scar tissue that builds up inside the intestine to create a stricture. A stricture is a narrowed passageway that can slow the movement of food through the intestine, causing pain or cramps.
    Crohn’s disease is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation and irritation in the intestines. Crohn’s disease can be difficult to diagnose because its symptoms are similar to other intestinal disorders, such as ulcerative colitis and other IBDs, and irritable bowel syndrome. For example, ulcerative colitis and Crohn’s disease both cause abdominal pain and diarrhea.
    Crohn’s disease may also be called ileitis or enteritis.
     

    Who gets Crohn’s Disease?

    Crohn’s disease affects men and women equally and seems to run in some families. People with Crohn’s disease may have a biological relative—most often a brother or sister—with some form of IBD. Crohn’s disease occurs in people of all ages, but it most commonly starts in people between the ages of 13 and 30. Men and women who smoke are more likely than nonsmokers to develop Crohn’s disease. People of Jewish heritage have an increased risk of developing Crohn’s disease.
     

    What causes Crohn’s Disease?

    The cause of Crohn’s disease is unknown, but researchers believe it is the result of an abnormal reaction by the body’s immune system. Normally, the immune system protects people from infection by identifying and destroying bacteria, viruses, or other potentially harmful foreign substances. Researchers believe that in Crohn’s disease the immune system attacks bacteria, foods, and other substances that are actually harmless or beneficial. During this process, white blood cells accumulate in the lining of the intestines, producing chronic inflammation, which leads to ulcers, or sores, and injury to the intestines.
    Researchers have found that high levels of a protein produced by the immune system, called tumor necrosis factor (TNF), are present in people with Crohn’s disease. However, researchers do not know whether increased levels of TNF and abnormal functioning of the immune system are causes or results of Crohn’s disease. Research shows that the inflammation seen in the GI tract of people with Crohn’s disease involves several factors: the genes the person has inherited, the person’s immune system, and the environment.
     

    What are the symptoms of Crohn’s Disease?

    The most common symptoms of Crohn’s disease are abdominal pain, often in the lower right area, and diarrhea. Rectal bleeding, weight loss, and fever may also occur. Bleeding may be serious and persistent, leading to anemia—a condition in which red blood cells are fewer or smaller than normal, which means less oxygen is carried to the body’s cells.
    The range and severity of symptoms varies.
     

    How is Crohn’s Disease diagnosed?

    A doctor will perform a thorough physical exam and schedule a series of tests to diagnose Crohn’s disease.

    • Blood tests can be used to look for anemia caused by bleeding. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation or infection somewhere in the body. Blood is drawn at a health care provider’s office or commercial facility and sent to a lab for analysis.
    • Stool tests are commonly done to rule out other causes of GI diseases, such as infection. Stool tests can also show if there is bleeding in the intestines. The doctor will give the person a container for catching and storing the stool. The sample is returned to the doctor or a commercial facility and sent to a lab for analysis.
      The tests below are usually performed at a hospital or outpatient center by a gastroenterologist, a doctor who specializes in digestive diseases, or a radiologist, a doctor who specializes in medical imaging.
    • Flexible sigmoidoscopy and colonoscopy. These tests are used to help diagnose Crohn’s disease and determine how much of the GI tract is affected. Colonoscopy is the most commonly used test to specifically diagnose Crohn’s disease. Colonoscopy is used to view the ileum, rectum, and the entire colon, while flexible sigmoidoscopy is used to view just the lower colon and rectum. For both tests, a health care provider will provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for 1 to 3 days before the test. A laxative may be required the night before the test. One or more enemas may be required the night before and about 2 hours before the test.
For either test, the person will lie on a table while the doctor inserts a flexible tube into the anus. A small camera on the tube sends a video image of the intestinal lining to a computer screen. The doctor can see inflammation, bleeding, or ulcers on the colon wall. The doctor may also perform a biopsy by snipping a bit of tissue from the intestinal lining. The person will not feel the biopsy. The doctor will look at the tissue with a microscope to confirm the diagnosis. For a colonoscopy, a light sedative—and possibly pain medication—helps people relax.
Cramping or bloating may occur during the first hour after the test. Driving is not permitted for 24 hours after a colonoscopy to allow the sedative time to wear off. Before the appointment, people should make plans for a ride home. Full recovery is expected by the next day.
      The tests below are performed at a hospital or outpatient center by an x-ray technician, and the images are interpreted by a radiologist.
    • Computerized tomography (CT) scan. CT scans use a combination of x rays and computer technology to create three-dimensional (3-D) images. For a CT scan, the person may be given a solution to drink and an injection of a special dye, called contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. CT scans can be used to help diagnose Crohn’s disease. Children may be given a sedative to help them fall asleep for the test.
    • Upper GI series. An upper GI series may be done to look at the small intestine. No eating or drinking is allowed for 8 hours before the procedure, if possible. During the procedure, the person will stand or sit in front of an x-ray machine and drink barium, a chalky liquid. Children may be given a sedative to help them fall asleep for the test. Children who are sedated will lie on a table for the test. Barium coats the small intestine, making signs of Crohn’s disease show up more clearly on x rays. A person may experience bloating and nausea for a short time after the test. For several days afterward, barium liquid in the GI tract causes stools to be white or light colored. A health care provider will provide specific instructions about eating and drinking after the test.
    • Lower GI series. A lower GI series may be done to look at the large intestine. A health care provider may provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for 1 to 3 days before the procedure. A laxative or enema may be used before the test. A laxative is medication that loosens stool and increases bowel movements. An enema involves flushing water, laxative, or sometimes a mild soap solution into the anus using a special squirt bottle. Children may be given a sedative to help them fall asleep for the test. For the test, the person will lie on a table while the doctor inserts a flexible tube into the person’s anus. The large intestine is filled with barium, making signs of Crohn’s disease show up more clearly on x rays.
For several days afterward, traces of barium liquid in the large intestine cause stools to be white or light colored. Enemas and repeated bowel movements may cause anal soreness. A health care provider will provide specific instructions about eating and drinking after the test.

     

    What are the complications of Crohn’s Disease?

    The most common complication of Crohn’s disease is an intestinal blockage caused by thickening of the intestinal wall because of swelling and scar tissue. Crohn’s disease may also cause ulcers that tunnel through the affected area into surrounding tissues. The tunnels, called fistulas, are a common complication—especially in the areas around the anus and rectum—and often become infected. Most fistulas can be treated with medication, but some may require surgery. In addition to fistulas, small tears called fissures may develop in the lining of the mucus membrane of the anus. The health care provider may prescribe a topical cream and may suggest soaking the affected area in warm water.
    Some Crohn’s disease complications occur because the diseased area of intestine does not absorb nutrients effectively, resulting in deficiencies of proteins, calories, and vitamins.
    People with Crohn’s disease often have anemia, which can be caused by the disease itself or by iron deficiency. Anemia may make a person feel tired. Children with Crohn’s disease may fail to grow normally and may have low height for their age.
    People with Crohn’s disease, particularly if they have been treated with steroid medications, may have weakness of their bones called osteoporosis or osteomalacia.
    Some people with Crohn’s disease may have restless legs syndrome—extreme leg discomfort a person feels while sitting or lying down. Some of these problems clear up during treatment for Crohn’s disease, but some must be treated separately.
    Other complications include arthritis, skin problems, inflammation in the eyes or mouth, kidney stones, gallstones, or diseases related to liver function.
     

    What is the treatment for Crohn’s Disease?

    Treatment may include medications, surgery, nutrition supplementation, or a combination of these options. The goals of treatment are to control inflammation, correct nutritional deficiencies, and relieve symptoms such as abdominal pain, diarrhea, and rectal bleeding. Treatment for Crohn’s disease depends on its location, severity, and complications.
    Treatment can help control Crohn’s disease and make recurrences less frequent, but no cure exists. Someone with Crohn’s disease may need long-lasting medical care and regular doctor visits to monitor the condition. Some people have long periods—sometimes years—of remission when they are free of symptoms, and predicting when a remission may occur or when symptoms will return is not possible. This changing pattern of the disease makes it difficult to be certain a treatment has helped.
    Despite possible hospitalizations and the need to take medication for long periods of time, most people with Crohn’s disease have full lives—balancing families, careers, and activities.
     
    Medications
    Anti-inflammation medications. Most people are first treated with medications containing 5-aminosalicylic acid (5-ASA) agents, such as Asacol, Dipentum, or Pentasa. Possible side effects of include nausea, vomiting, heartburn, diarrhea, and headache.
    Cortisone or steroids. These medications, also called corticosteroids, are effective at reducing inflammation. Prednisone and budesonide are generic names of two corticosteroids. During the earliest stages of Crohn’s disease, when symptoms are at their worst, corticosteroids are usually prescribed in a large dose. The dosage is then gradually lowered once symptoms are controlled. Corticosteroids can cause serious side effects, including greater susceptibility to infection and osteoporosis, or weakening of the bones. See the “Nutrition Supplementation” section for more information about preventing and treating osteoporosis.
    Immune system suppressors. Medications that suppress the immune system—called immunosuppressive medications—are also used to treat Crohn’s disease. The most commonly prescribed medications are 6-mercaptopurine and azathioprine. Immunosuppressive medications work by blocking the immune reaction that contributes to inflammation. These medications may cause side effects such as nausea, vomiting, and diarrhea and may lower a person’s resistance to infection. Some people are treated with a combination of corticosteroids and immunosuppressive medications. Some studies suggest that immunosuppressive medications may enhance the effectiveness of corticosteroids.
    Biological therapies. Biological therapies are medications given by an injection in the vein, infliximab, or an injection in the skin, adalimumab. Biological therapies bind to TNF substances to block the body’s inflammation response. The U.S. Food and Drug Administration approved these medications for the treatment of moderate to severe Crohn’s disease that does not respond to standard therapies—mesalamine substances, corticosteroids, immunosuppressive medications—and for the treatment of open, draining fistulas. Some studies suggest that biological therapies may enhance the effectiveness of immunosuppressive medications.
    Antibiotics. Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole.
    Anti-diarrheal medications and fluid replacements. Diarrhea and abdominal cramps are often relieved when the inflammation subsides, but additional medication may be needed. Anti-diarrheal medications include diphenoxylate, loperamide, and codeine. People with diarrhea should drink plenty of fluids to prevent dehydration. If diarrhea does not improve, the person should see the doctor promptly for possible treatment with intravenous fluids.
     
    Surgery
    About two-thirds of people with Crohn’s disease will require surgery at some point in their lives.3 Surgery becomes necessary to relieve symptoms that do not respond to medical therapy or to correct complications such as intestinal blockage, perforation, bleeding, or abscess—a painful, swollen, pus-filled area caused by infection. Surgery to remove part of the intestine can help people with Crohn’s disease, but it does not eliminate the disease. People with Crohn’s disease commonly need more than one operation because inflammation tends to return to the area next to where the diseased intestine was removed.

    • Proctocolectomy. Some people who have Crohn’s disease must have a proctocolectomy, a procedure that is performed by a specialized surgeon. Proctocolectomy is surgery to remove the rectum and part of the colon or the entire colon. People will receive sedation and general anesthesia during surgery. Most people need to remain in the hospital for 1 to 2 weeks, and full recovery can take 4 to 6 weeks.
    • Ileostomy. During proctocolectomy, the surgeon also performs an ileostomy—an operation that attaches the ileum to an opening made in the abdomen called a stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. An ostomy pouch is then attached to the stoma and worn outside the body to collect stool. The pouch needs to be emptied several times a day. A specially trained nurse will teach the person how to clean, care for, and change the ostomy pouch and how to protect the skin around the stoma. The majority of people with an ostomy pouch are able to live normal, active lives.
    • Intestinal resection surgery. Sometimes only the diseased section of intestine is removed and an ileostomy is not needed. Instead, the intestine is cut above and below the diseased area and the ends of the healthy sections are connected in an operation called an intestinal resection. People will receive sedation and general anesthesia during surgery. Most people need to remain in the hospital for several days, and full recovery can take 3 to 4 weeks.

     
    Because Crohn’s disease often recurs after surgery, people considering surgery should carefully weigh its benefits and risks compared with other treatments. People faced with this decision should get information from health care providers who routinely work with GI patients, including those who have had intestinal surgery. Patient advocacy organizations can suggest support groups and other information resources.
     
    Nutrition Supplementation
    The health care provider may recommend nutritional supplements, especially for children whose growth has been slowed. Special high-calorie liquid formulas are sometimes used. A small number of people may receive nutrition intravenously for a brief time through a small tube inserted into an arm vein. This procedure can help people who need extra nutrition temporarily, such as those whose intestines need to rest, or those whose intestines cannot absorb enough nutrition from food.
    The doctor may prescribe calcium, vitamin D, and other medications to prevent or treat osteoporosis for patients taking corticosteroids. People should take vitamin supplements only after talking with their doctor.
     
    Eating, Diet, and Nutrition
    No special diet has been proven effective for preventing or treating Crohn’s disease, but it is important that people who have Crohn’s disease follow a nutritious diet and avoid any foods that seem to worsen symptoms. People with Crohn’s disease often experience a decrease in appetite, which can affect their ability to receive the daily nutrition needed for good health and healing. In addition, Crohn’s disease is associated with diarrhea and poor absorption of necessary nutrients. Foods do not cause Crohn’s disease, but foods such as bulky grains, hot spices, alcohol, and milk products may increase diarrhea and cramping. The health care provider may refer a person with Crohn’s disease to a dietitian for guidance about meal planning.
     

    Can smoking make Crohn’s Disease worse?

    Studies have shown that people with Crohn’s disease who smoke may have more severe symptoms and increased complications of the disease, along with a need for higher doses of steroids and other medications. People with Crohn’s disease who smoke are also more likely to need surgery. Quitting smoking can greatly improve the course of Crohn’s disease and help reduce the risk of complications and flare ups. A health care provider can assist people in finding a smoking cessation specialist.
     

    Can stress make Crohn’s Disease worse?

    No evidence shows that stress causes Crohn’s disease. However, people with Crohn’s disease sometimes feel increased stress in their lives because they live with a chronic illness. Some people with Crohn’s disease report having a flare up when experiencing a stressful event or situation. For people who find there is a connection between stress level and a worsening of symptoms, using relaxation techniques—such as slow breathing—and taking special care to eat well and get enough sleep may help them feel better. The health care provider may suggest a counselor or support group to help decrease stress for people with Crohn’s disease.
     

    Is pregnancy safe for women with Crohn’s Disease?

    Women with Crohn’s disease can become pregnant and have a baby. Even so, women with Crohn’s disease should talk with their health care provider before getting pregnant. Most children born to women with Crohn’s disease are not affected by the condition.
     

    Points to Remember

    • Crohn’s disease is a disease that causes inflammation, or swelling, and irritation of any part of the digestive tract—also called the gastrointestinal (GI) tract.
    • Crohn’s disease affects men and women equally and seems to run in some families.
    • The cause of Crohn’s disease is unknown, but researchers believe it is the result of an abnormal reaction by the immune system.
    • The most common symptoms of Crohn’s disease are abdominal pain and diarrhea.
    • A doctor can diagnose Crohn’s disease by performing a physical exam, blood and stool tests, and imaging tests such as a CT scan, upper GI series, lower GI series, flexible sigmoidoscopy, and colonoscopy.
    • The most common complication of Crohn’s disease is an intestinal blockage caused by thickening of the intestinal wall because of swelling and scar tissue.
    • Doctors treat Crohn’s disease with medications, surgery, nutrition supplementation, or a combination of these options.
    • No special diet has been proven effective for preventing or treating Crohn’s disease, but it is important that people who have Crohn’s disease follow a nutritious diet and avoid any foods that seem to worsen symptoms.
    • Some people with Crohn’s disease report having a flare up when experiencing a stressful event or situation. The health care provider may suggest a counselor or support group to help decrease stress for people with Crohn’s disease.
    • Women with Crohn’s disease can become pregnant and have a baby. Even so, women with Crohn’s disease should talk with their health care provider before getting pregnant

  • Gallstones

    What are gallstones?

    Gallstones are hard particles that develop in the gallbladder. The gallbladder is a small, pear-shaped organ located in the upper right abdomen, the area between the chest and hips, below the liver.

    Gallstones can range in size from a grain of sand to a golf ball. The gallbladder can develop a single large gallstone, hundreds of tiny stones, or both small and large stones. Gallstones can cause sudden pain in the upper right abdomen. This pain, called a gallbladder attack or biliary colic, occurs when gallstones block the ducts of the biliary tract.
     

    What is the biliary tract?

    The biliary tract consists of the gallbladder and the bile ducts. The bile ducts carry bile and other digestive enzymes from the liver and pancreas to the duodenum, the first part of the small intestine.
    The liver produces bile, a fluid that carries toxins and waste products out of the body and helps the body digest fats and the fat-soluble vitamins A, D, E, and K. Bile mostly consists of cholesterol, bile salts, and bilirubin. Bilirubin, a reddish-yellow substance, forms when hemoglobin from red blood cells breaks down. Most bilirubin is excreted through bile.
     

    What causes gallstones?

    Imbalances in the substances that make up bile cause gallstones. Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Scientists do not fully understand why these imbalances occur. Gallstones also may form if the gallbladder does not empty completely or often enough.
    The two types of gallstones are cholesterol and pigment stones:

    • Cholesterol stones, usually yellow-green in color, consist primarily of hardened cholesterol. In the United States, more than 80 percent of gallstones are cholesterol stones.
    • Pigment stones, dark in color, are made of bilirubin.

     

    Who is at risk for gallstones?

    Certain people have a higher risk of developing gallstones than others:

    • Women are more likely to develop gallstones than men. Extra estrogen can increase cholesterol levels in bile and decrease gallbladder contractions, which may cause gallstones to form. Women may have extra estrogen due to pregnancy, hormone replacement therapy, or birth control pills.
    • People over age 40 are more likely to develop gallstones than younger people.
    • People with a family history of gallstones have a higher risk.
    • American Indians have genetic factors that increase the amount of cholesterol in their bile. In fact, American Indians have the highest rate of gallstones in the United States, almost 65 percent of women and 30 percent of men have gallstones.
    • Mexican Americans are at higher risk of developing gallstones.

     
    Other factors that affect a person’s risk of gallstones include

    • Obesity. People who are obese, especially women, have increased risk of developing gallstones. Obesity increases the amount of cholesterol in bile, which can cause stone formation.
    • Rapid weight loss. As the body breaks down fat during prolonged fasting and rapid weight loss, the liver secretes extra cholesterol into bile. Rapid weight loss can also prevent the gallbladder from emptying properly. Low-calorie diets and bariatric surgery, surgery that limits the amount of food a person can eat or digest, lead to rapid weight loss and increased risk of gallstones.
    • Diet. Research suggests diets high in calories and refined carbohydrates and low in fiber increase the risk of gallstones. Refined carbohydrates are grains processed to remove bran and germ, which contain nutrients and fiber. Examples of refined carbohydrates include white bread and white rice.
    • Certain intestinal diseases. Diseases that affect normal absorption of nutrients, such as Crohn’s disease, are associated with gallstones.
    • Metabolic syndrome, diabetes, and insulin resistance. These conditions increase the risk of gallstones. Metabolic syndrome also increases the risk of gallstone complications. Metabolic syndrome is a group of traits and medical conditions linked to being overweight or obese that puts people at risk for heart disease and type 2 diabetes. Pigment stones tend to develop in people who have

     

     
    Other medical conditions associated with gallstones are:

    • cirrhosis, a condition in which the liver slowly deteriorates and malfunctions due to chronic, or long lasting, injury
    • infections in the bile ducts
    • severe hemolytic anemias, conditions in which red blood cells are continuously broken down, such as sickle cell anemia

     

    What are the symptoms and complications of gallstones?

    Many people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called asymptomatic, or silent, gallstones. Silent gallstones do not interfere with the function of the gallbladder, liver, or pancreas.
    If gallstones block the bile ducts, pressure increases in the gallbladder, causing a gallbladder attack. The pain usually lasts from 1 to several hours. Gallbladder attacks often follow heavy meals, and they usually occur in the evening or during the night.
    Gallbladder attacks usually stop when gallstones move and no longer block the bile ducts. However, if any of the bile ducts remain blocked for more than a few hours, complications can occur. Complications include inflammation, or swelling, of the gallbladder and severe damage or infection of the gallbladder, bile ducts, or liver.
    A gallstone that becomes lodged in the common bile duct near the duodenum and blocks the pancreatic duct can cause gallstone pancreatitis, inflammation of the pancreas.
    Left untreated, blockages of the bile ducts or pancreatic duct can be fatal.
     

    When should a person talk with a health care provider about gallstones?

    People who think they have had a gallbladder attack should notify their health care provider. Although these attacks usually resolve as gallstones move, complications can develop if the bile ducts remain blocked.
    People with any of the following symptoms during or after a gallbladder attack should see a health care provider immediately:

    • abdominal pain lasting more than 5 hours
    • nausea and vomiting
    • fever—even a low-grade fever—or chills
    • yellowish color of the skin or whites of the eyes, called jaundice
    • tea-colored urine and light-colored stools

     
    These symptoms may be signs of serious infection or inflammation of the gallbladder, liver, or pancreas.
     

    How are gallstones diagnosed?

    A health care provider will usually order an ultrasound exam to diagnose gallstones. Other imaging tests may also be used.
    Ultrasound exam. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. A specially trained technician performs the procedure in a health care provider’s office, outpatient center, or hospital, and a radiologist, a doctor who specializes in medical imaging, interprets the images. Anesthesia is not needed. If gallstones are present, they will be visible in the image. Ultrasound is the most accurate method to detect gallstones.
     
    Computerized tomography (CT) scan. A CT scan is an x ray that produces pictures of the body. A CT scan may include the injection of a special dye, called contrast medium. CT scans use a combination of x rays and computer technology to create three-dimensional (3-D) images. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. An x-ray technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed. CT scans can show gallstones or complications, such as infection and blockage of the gallbladder or bile ducts. However, CT scans can miss gallstones that are present.
     
    Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed pictures of the body’s internal organs and soft tissues without using x rays. A specially trained technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed, though people with a fear of confined spaces may receive light sedation. An MRI may include the injection of contrast medium. With most MRI machines, the person lies on a table that slides into a tunnel-shaped device that may be open ended or closed at one end; some newer machines allow the person to lie in a more open space. MRIs can show gallstones in the ducts of the biliary system.
     
    Cholescintigraphy. Cholescintigraphy—also called a hydroxyl iminodiacetic acid scan, HIDA scan, or hepatobiliary scan, uses an unharmful radioactive material to produce pictures of the biliary system. In cholescintigraphy, the person lies on an exam table and a health care provider injects a small amount of unharmful radioactive material into a vein in the person’s arm. The health care provider may also inject a substance that causes the gallbladder to contract. A special camera takes pictures of the radioactive material as it moves through the biliary system. A specially trained technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed. Cholescintigraphy is used to diagnose abnormal contractions of the gallbladder or obstruction of the bile ducts.
     
    Endoscopic retrograde cholangiopancreatography (ERCP). ERCP uses an x ray to look into the bile and pancreatic ducts. After lightly sedating the person, the health care provider inserts an endoscope—a small, flexible tube with a light and a camera on the end—through the mouth into the duodenum and bile ducts. The endoscope is connected to a computer and video monitor. The health care provider injects contrast medium through the tube into the bile ducts, which makes the ducts show up on the monitor. The health care provider performs the procedure in an outpatient center or hospital. ERCP helps the health care provider locate the affected bile duct and the gallstone. The stone is captured in a tiny basket attached to the endoscope and removed. This test is more invasive than other tests and is used selectively.
     
    Health care providers also use blood tests to look for signs of infection or inflammation of the bile ducts, gallbladder, pancreas, or liver. A blood test involves drawing blood at a health care provider’s office or commercial facility and sending the sample to a lab for analysis.
    Gallstone symptoms may be similar to those of other conditions, such as appendicitis, ulcers, pancreatitis, and gastroesophageal reflux disease.
    Sometimes, silent gallstones are found when a person does not have any symptoms. For example, a health care provider may notice gallstones when performing ultrasound for a different reason.
     

    How are gallstones treated?

    If gallstones are not causing symptoms, treatment is usually not needed. However, if a person has a gallbladder attack or other symptoms, a health care provider will usually recommend treatment. A person may be referred to a gastroenterologist, a doctor who specializes in digestive diseases, for treatment. If a person has had one gallbladder attack, more episodes will likely follow.
    The usual treatment for gallstones is surgery to remove the gallbladder. If a person cannot undergo surgery, nonsurgical treatments may be used to dissolve cholesterol gallstones. A health care provider may use ERCP to remove stones in people who cannot undergo surgery or to remove stones from the common bile duct in people who are about to have gallbladder removal surgery.
     

    Surgery

    Surgery to remove the gallbladder, called cholecystectomy, is one of the most common operations performed on adults in the United States.
    The gallbladder is not an essential organ, which means a person can live normally without a gallbladder. Once the gallbladder is removed, bile _flows out of the liver through the hepatic and common bile ducts and directly into the duodenum, instead of being stored in the gallbladder.
    Surgeons perform two types of cholecystectomy:

    • Laparoscopic cholecystectomy. In a laparoscopic cholecystectomy, the surgeon makes several tiny incisions in the abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of organs and tissues. While watching the monitor, the surgeon uses instruments to carefully separate the gallbladder from the liver, bile ducts, and other structures. Then the surgeon removes the gallbladder through one of the small incisions. Patients usually receive general anesthesia. 
Most cholecystectomies are performed with laparoscopy. Many laparoscopic cholecystectomies are performed on an outpatient basis, meaning the person is able to go home the same day. Normal physical activity can usually be resumed in about a week.
    • Open cholecystectomy. An open cholecystectomy is performed when the gallbladder is severely inflamed, infected, or scarred from other operations. In most of these cases, open cholecystectomy is planned from the start. However, a surgeon may perform an open cholecystectomy when problems occur during a laparoscopic cholecystectomy. In these cases, the surgeon must switch to open cholecystectomy as a safety measure for the patient. 
To perform an open cholecystectomy, the surgeon creates an incision about 4 to 6 inches long in the abdomen to remove the gallbladder. Patients usually receive general anesthesia. Recovery from open cholecystectomy may require some people to stay in the hospital for up to a week. Normal physical activity can usually be resumed after about a month.

     
    A small number of people have softer and more frequent stools after gallbladder removal because bile flows into the duodenum more often. Changes in bowel habits are usually temporary; however, they should be discussed with a health care provider.
    Though complications from gallbladder surgery are rare, the most common complication is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and possibly dangerous infection. One or more additional operations may be needed to repair the bile ducts. Bile duct injuries occur in less than 1 percent of cholecystectomies.

    Nonsurgical Treatments for Cholesterol Gallstones

    Nonsurgical treatments are used only in special situations, such as when a person with cholesterol stones has a serious medical condition that prevents surgery. Gallstones often recur within 5 years after nonsurgical treatment.
    Two types of nonsurgical treatments can be used to dissolve cholesterol gallstones:

    • Oral dissolution therapy. Ursodiol and chenodiol are medications that contain bile acids that can dissolve gallstones. These medications are most effective in dissolving small cholesterol stones. Months or years of treatment may be needed to dissolve all stones.
    • Shock wave lithotripsy. A machine called a lithotripter is used to crush the gallstone. The lithotripter generates shock waves that pass through the person’s body to break the gallstone into smaller pieces. This procedure is used only rarely and may be used along with ursodiol.

     

    Eating, Diet, and Nutrition

    Factors related to eating, diet, and nutrition that increase the risk of gallstones include

    • obesity
    • rapid weight loss
    • diets high in calories and refined carbohydrates and low in fiber

     
    People can decrease their risk of gallstones by maintaining a healthy weight through proper diet and nutrition.
    Ursodiol can help prevent gallstones in people who rapidly lose weight through low-calorie diets or bariatric surgery. People should talk with their health care provider or dietitian about what diet is right for them.

     

    Points to Remember

    • Gallstones are hard particles that develop in the gallbladder.
    • Imbalances in the substances that make up bile cause gallstones. Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Scientists do not fully understand why these imbalances occur.
    • Women, people over age 40, people with a family history of gallstones, American Indians, and Mexican Americans have a higher risk of developing gallstones.
    • Many people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called asymptomatic, or silent, gallstones.
    • If gallstones block the bile ducts, pressure increases in the gallbladder, causing a gallbladder attack.
    • Gallbladder attacks often follow heavy meals, and they usually occur in the evening or during the night.
    • Gallstone symptoms may be similar to those of other conditions.
    • If gallstones are not causing symptoms, treatment is usually not needed. However, if a person has a gallbladder attack or other symptoms, a health care provider will usually recommend treatment.
    • The usual treatment for gallstones is surgery to remove the gallbladder. If a person cannot undergo surgery, nonsurgical treatments may be used to dissolve cholesterol gallstones. A health care provider may use endoscopic retrograde cholangiopancreatography (ERCP) to remove stones in people who cannot undergo surgery or to remove stones from the common bile duct in people who are about to have gallbladder removal surgery.
    • The gallbladder is not an essential organ, which means a person can live normally without a gallbladder. Once the gallbladder is removed, bile flows out of the liver through the hepatic and common bile ducts and directly into the duodenum, instead of being stored in the gallbladder.

  • Pancreatitis

    What is pancreatitis?

    Pancreatitis is inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum—the first part of the small intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube called the pancreatic duct. Pancreatic enzymes join with bile—a liquid produced in the liver and stored in the gallbladder—to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy.
    Normally, digestive enzymes secreted by the pancreas do not become active until they reach the small intestine. But when the pancreas is inflamed, the enzymes inside it attack and damage the tissues that produce them.
    Pancreatitis can be acute or chronic. Either form is serious and can lead to complications. In severe cases, bleeding, infection, and permanent tissue damage may occur.
     

    What is acute pancreatitis?

    Acute pancreatitis is inflammation of the pancreas that occurs suddenly and usually resolves in a few days with treatment. Acute pancreatitis can be a life-threatening illness with severe complications. Each year, about 210,000 people in the United States are admitted to the hospital with acute pancreatitis. The most common cause of acute pancreatitis is the presence of gallstones, small, pebble-like substances made of hardened bile, that cause inflammation in the pancreas as they pass through the common bile duct. Chronic, heavy alcohol use is also a common cause. Acute pancreatitis can occur within hours or as long as 2 days after consuming alcohol. Other causes of acute pancreatitis include abdominal trauma, medications, infections, tumors, and genetic abnormalities of the pancreas.
     

    Symptoms

    Acute pancreatitis usually begins with gradual or sudden pain in the upper abdomen that sometimes extends through the back. The pain may be mild at first and feel worse after eating. But the pain is often severe and may become constant and last for several days. A person with acute pancreatitis usually looks and feels very ill and needs immediate medical attention. Other symptoms may include

    • a swollen and tender abdomen
    • nausea and vomiting
    • fever
    • a rapid pulse

     
    Severe acute pancreatitis may cause dehydration and low blood pressure. The heart, lungs, or kidneys can fail. If bleeding occurs in the pancreas, shock and even death may follow.
     

    Diagnosis

    While asking about a person’s medical history and conducting a thorough physical examination, the doctor will order a blood test to assist in the diagnosis. During acute pancreatitis, the blood contains at least three times the normal amount of amylase and lipase, digestive enzymes formed in the pancreas. Changes may also occur in other body chemicals such as glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the person’s condition improves, the levels usually return to normal.
    Diagnosing acute pancreatitis is often difficult because of the deep location of the pancreas. The doctor will likely order one or more of the following tests:
     
    Abdominal ultrasound. Sound waves are sent toward the pancreas through a handheld device that a technician glides over the abdomen. The sound waves bounce off the pancreas, gallbladder, liver, and other organs, and their echoes make electrical impulses that create a picture, called a sonogram, on a video monitor. If gallstones are causing inflammation, the sound waves will also bounce off them, showing their location.
     
    Computerized tomography (CT) scan. The CT scan is a noninvasive x ray that produces three-dimensional pictures of parts of the body. The person lies on a table that slides into a donut-shaped machine. The test may show gallstones and the extent of damage to the pancreas.
     
    Endoscopic ultrasound (EUS). After spraying a solution to numb the patient’s throat, the doctor inserts an endoscope, a thin, flexible, lighted tube, down the throat, through the stomach, and into the small intestine. The doctor turns on an ultrasound attachment to the scope that produces sound waves to create visual images of the pancreas and bile ducts.
     
    Magnetic resonance cholangiopancreatography (MRCP). MRCP uses magnetic resonance imaging, a noninvasive test that produces cross-section images of parts of the body. After being lightly sedated, the patient lies in a cylinder-like tube for the test. The technician injects dye into the patient’s veins that helps show the pancreas, gallbladder, and pancreatic and bile ducts.
     

    Treatment

    Treatment for acute pancreatitis requires a few days’ stay in the hospital for intravenous (IV) fluids, antibiotics, and medication to relieve pain. The person cannot eat or drink so the pancreas can rest. If vomiting occurs, a tube may be placed through the nose and into the stomach to remove fluid and air.
    Unless complications arise, acute pancreatitis usually resolves in a few days. In severe cases, the person may require nasogastric feeding, a special liquid given in a long, thin tube inserted through the nose and throat and into the stomach, for several weeks while the pancreas heals.
    Before leaving the hospital, the person will be advised not to smoke, drink alcoholic beverages, or eat fatty meals. In some cases, the cause of the pancreatitis is clear, but in others, more tests are needed after the person is discharged and the pancreas is healed.
     

    Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) for Acute and Chronic Pancreatitis

    ERCP is a specialized technique used to view the pancreas, gallbladder, and bile ducts and treat complications of acute and chronic pancreatitis, gallstones, narrowing or blockage of the pancreatic duct or bile ducts, leaks in the bile ducts, and pseudocysts, accumulations of fluid and tissue debris.
    Soon after a person is admitted to the hospital with suspected narrowing of the pancreatic duct or bile ducts, a physician with specialized training performs ERCP.
    After lightly sedating the patient and giving medication to numb the throat, the doctor inserts an endoscope, a long, flexible, lighted tube with a camera, through the mouth, throat, and stomach into the small intestine. The endoscope is connected to a computer and screen. The doctor guides the endoscope and injects a special dye into the pancreatic or bile ducts that helps the pancreas, gallbladder, and bile ducts appear on the screen while x rays are taken.
    The following procedures can be performed using ERCP:
     
    Sphincterotomy. Using a small wire on the endoscope, the doctor finds the muscle that surrounds the pancreatic duct or bile ducts and makes a tiny cut to enlarge the duct opening. When a pseudocyst is present, the duct is drained.
     
    Gallstone removal. The endoscope is used to remove pancreatic or bile duct stones with a tiny basket. Gallstone removal is sometimes performed along with a sphincterotomy.
     
    Stent placement. Using the endoscope, the doctor places a tiny piece of plastic or metal that looks like a straw in a narrowed pancreatic or bile duct to keep it open.
     
    Balloon dilatation. Some endoscopes have a small balloon that the doctor uses to dilate, or stretch, a narrowed pancreatic or bile duct. A temporary stent may be placed for a few months to keep the duct open.
     
    People who undergo therapeutic ERCP are at slight risk for complications, including severe pancreatitis, infection, bowel perforation, or bleeding. Complications of ERCP are more common in people with acute or recurrent pancreatitis. A patient who experiences fever, trouble swallowing, or increased throat, chest, or abdominal pain after the procedure should notify a doctor immediately.
     

    Complications

    Gallstones that cause acute pancreatitis require surgical removal of the stones and the gallbladder. If the pancreatitis is mild, gallbladder removal, called cholecystectomy, may proceed while the person is in the hospital. If the pancreatitis is severe, gallstones may be removed using therapeutic endoscopic retrograde cholangiopancreatography (ERCP), a specialized technique used to view the pancreas, gallbladder, and bile ducts and treat complications of acute and chronic pancreatitis. Cholecystectomy is delayed for a month or more to allow for full recovery.
    If an infection develops, ERCP or surgery may be needed to drain the infected area, also called an abscess. Exploratory surgery may also be necessary to find the source of any bleeding, to rule out conditions that resemble pancreatitis, or to remove severely damaged pancreatic tissue.
    Pseudocysts—accumulations of fluid and tissue debris—that may develop in the pancreas can be drained using ERCP or EUS. If pseudocysts are left untreated, enzymes and toxins can enter the bloodstream and affect the heart, lungs, kidneys, or other organs.
    Acute pancreatitis sometimes causes kidney failure. People with kidney failure need blood-cleansing treatments called dialysis or a kidney transplant.
    In rare cases, acute pancreatitis can cause breathing problems. Hypoxia, a condition that occurs when body cells and tissues do not get enough oxygen, can develop. Doctors treat hypoxia by giving oxygen to the patient. Some people still experience lung failure, even with oxygen, and require a respirator for a while to help them breathe.
     

    What is chronic pancreatitis?

    Chronic pancreatitis is inflammation of the pancreas that does not heal or improve, it gets worse over time and leads to permanent damage. Chronic pancreatitis, like acute pancreatitis, occurs when digestive enzymes attack the pancreas and nearby tissues, causing episodes of pain. Chronic pancreatitis often develops in people who are between the ages of 30 and 40.
    The most common cause of chronic pancreatitis is many years of heavy alcohol use. The chronic form of pancreatitis can be triggered by one acute attack that damages the pancreatic duct. The damaged duct causes the pancreas to become inflamed. Scar tissue develops and the pancreas is slowly destroyed.
    Other causes of chronic pancreatitis are

    • hereditary disorders of the pancreas
    • cystic fibrosis—the most common inherited disorder leading to chronic pancreatitis
    • hypercalcemia—high levels of calcium in the blood
    • hyperlipidemia or hypertriglyceridemia—high levels of blood fats
    • some medicines
    • certain autoimmune conditions
    • unknown causes

     
    Hereditary pancreatitis can present in a person younger than age 30, but it might not be diagnosed for several years. Episodes of abdominal pain and diarrhea lasting several days come and go over time and can progress to chronic pancreatitis. A diagnosis of hereditary pancreatitis is likely if the person has two or more family members with pancreatitis in more than one generation.
     

    Symptoms

    Most people with chronic pancreatitis experience upper abdominal pain, although some people have no pain at all. The pain may spread to the back, feel worse when eating or drinking, and become constant and disabling. In some cases, abdominal pain goes away as the condition worsens, most likely because the pancreas is no longer making digestive enzymes. Other symptoms include

    • nausea
    • vomiting
    • weight loss
    • diarrhea
    • oily stools

     
    People with chronic pancreatitis often lose weight, even when their appetite and eating habits are normal. The weight loss occurs because the body does not secrete enough pancreatic enzymes to digest food, so nutrients are not absorbed normally. Poor digestion leads to malnutrition due to excretion of fat in the stool.
     

    Diagnosis

    Chronic pancreatitis is often confused with acute pancreatitis because the symptoms are similar. As with acute pancreatitis, the doctor will conduct a thorough medical history and physical examination. Blood tests may help the doctor know if the pancreas is still making enough digestive enzymes, but sometimes these enzymes appear normal even though the person has chronic pancreatitis.
    In more advanced stages of pancreatitis, when malabsorption and diabetes can occur, the doctor may order blood, urine, and stool tests to help diagnose chronic pancreatitis and monitor its progression.
    After ordering x rays of the abdomen, the doctor will conduct one or more of the tests used to diagnose acute pancreatitis, abdominal ultrasound, CT scan, EUS, and MRCP.
     

    Treatment

    Treatment for chronic pancreatitis may require hospitalization for pain management, IV hydration, and nutritional support. Nasogastric feedings may be necessary for several weeks if the person continues to lose weight.
    When a normal diet is resumed, the doctor may prescribe synthetic pancreatic enzymes if the pancreas does not secrete enough of its own. The enzymes should be taken with every meal to help the person digest food and regain some weight. The next step is to plan a nutritious diet that is low in fat and includes small, frequent meals. A dietitian can assist in developing a meal plan. Drinking plenty of fluids and limiting caffeinated beverages is also important.
    People with chronic pancreatitis are strongly advised not to smoke or consume alcoholic beverages, even if the pancreatitis is mild or in the early stages.
     

    Complications

    People with chronic pancreatitis who continue to consume large amounts of alcohol may develop sudden bouts of severe abdominal pain.
    As with acute pancreatitis, ERCP is used to identify and treat complications associated with chronic pancreatitis such as gallstones, pseudocysts, and narrowing or obstruction of the ducts. Chronic pancreatitis also can lead to calcification of the pancreas, which means the pancreatic tissue hardens from deposits of insoluble calcium salts. Surgery may be necessary to remove part of the pancreas.
    In cases involving persistent pain, surgery or other procedures are sometimes recommended to block the nerves in the abdominal area that cause pain.
    When pancreatic tissue is destroyed in chronic pancreatitis and the insulin-producing cells of the pancreas, called beta cells, have been damaged, diabetes may develop. People with a family history of diabetes are more likely to develop the disease. If diabetes occurs, insulin or other medicines are needed to keep blood glucose at normal levels. A health care provider works with the patient to develop a regimen of medication, diet, and frequent blood glucose monitoring.
     

    How common is pancreatitis in children?

    Chronic pancreatitis in children is rare. Trauma to the pancreas and hereditary pancreatitis are two known causes of childhood pancreatitis. Children with cystic fibrosis, a progressive and incurable lung disease, may be at risk of developing pancreatitis. But more often the cause of pancreatitis in children is unknown.

     

    Points to Remember

    • Pancreatitis is inflammation of the pancreas, causing digestive enzymes to become active inside the pancreas and damage pancreatic tissue.
    • Pancreatitis has two forms: acute and chronic.
    • Common causes of pancreatitis are gallstones and heavy alcohol use.
    • Sometimes the cause of pancreatitis cannot be found.
    • Symptoms of acute pancreatitis include abdominal pain, nausea, vomiting, fever, and a rapid pulse.
    • Treatment for acute pancreatitis includes intravenous (IV) fluids, antibiotics, and pain medications. Surgery is sometimes needed to treat complications.
    • Acute pancreatitis can become chronic if pancreatic tissue is permanently destroyed and scarring develops.
    • Symptoms of chronic pancreatitis include abdominal pain, nausea, vomiting, weight loss, diarrhea, and oily stools.
    • Treatment for chronic pancreatitis may involve IV fluids; pain medication; a low-fat, nutritious diet; and enzyme supplements. Surgery may be necessary to remove part of the pancreas.

  • Hemorrhoids

    What are hemorrhoids?

    Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. The rectum is the last part of the large intestine leading to the anus. The anus is the opening at the end of the digestive tract where bowel contents leave the body.
    External hemorrhoids are located under the skin around the anus. Internal hemorrhoids develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse, through the anus. Most prolapsed hemorrhoids shrink back inside the rectum on their own. Severely prolapsed hemorrhoids may protrude permanently and require treatment.
     

    What are the symptoms of hemorrhoids?

    The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement. Internal hemorrhoids that are not prolapsed are usually not painful. Prolapsed hemorrhoids often cause pain, discomfort, and anal itching.
    Blood clots may form in external hemorrhoids. A blood clot in a vein is called a thrombosis. Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus. When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch.
    Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse.
    Hemorrhoids are not dangerous or life threatening. Symptoms usually go away within a few days, and some people with hemorrhoids never have symptoms.
     

    How common are hemorrhoids?

    About 75 percent of people will have hemorrhoids at some point in their lives. Hemorrhoids are most common among adults ages 45 to 65. Hemorrhoids are also common in pregnant women.

    What causes hemorrhoids?

    Swelling in the anal or rectal veins causes hemorrhoids. Several factors may cause this swelling, including

    • chronic constipation or diarrhea
    • straining during bowel movements
    • sitting on the toilet for long periods of time
    • a lack of fiber in the diet

     
    Another cause of hemorrhoids is the weakening of the connective tissue in the rectum and anus that occurs with age.
    Pregnancy can cause hemorrhoids by increasing pressure in the abdomen, which may enlarge the veins in the lower rectum and anus. For most women, hemorrhoids caused by pregnancy disappear after childbirth.

    How are hemorrhoids diagnosed?

    The doctor will examine the anus and rectum to determine whether a person has hemorrhoids. Hemorrhoid symptoms are similar to the symptoms of other anorectal problems, such as fissures, abscesses, warts, and polyps.
    The doctor will perform a physical exam to look for visible hemorrhoids. A digital rectal exam with a gloved, lubricated finger and an anuscope, a hollow, lighted tube, may be performed to view the rectum.
    A thorough evaluation and proper diagnosis by a doctor is important any time a person notices bleeding from the rectum or blood in the stool. Bleeding may be a symptom of other digestive diseases, including colorectal cancer.
    Additional exams may be done to rule out other causes of bleeding, especially in people age 40 or older:
     
    Colonoscopy. A flexible, lighted tube called a colonoscope is inserted through the anus, the rectum, and the upper part of the large intestine, called the colon. The colonoscope transmits images of the inside of the rectum and the entire colon.
     
    Sigmoidoscopy. This procedure is similar to colonoscopy, but it uses a shorter tube called a sigmoidoscope and transmits images of the rectum and the sigmoid colon, the lower portion of the colon that empties into the rectum.
     
    Barium enema x ray. A contrast material called barium is inserted into the colon to make the colon more visible in x ray pictures.
     

    How are hemorrhoids treated?

    At-home Treatments
    Simple diet and lifestyle changes often reduce the swelling of hemorrhoids and relieve hemorrhoid symptoms. Eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on hemorrhoids caused by straining.
    Fiber is a substance found in plants. The human body cannot digest fiber, but fiber helps improve digestion and prevent constipation. Good sources of dietary fiber are fruits, vegetables, and whole grains. On average, Americans eat about 15 grams of fiber each day. The American Dietetic Association recommends 25 grams of fiber per day for women and 38 grams of fiber per day for men.
    Doctors may also suggest taking a bulk stool softener or a fiber supplement such as psyllium or methylcellulose .
    Other changes that may help relieve hemorrhoid symptoms include

    • drinking six to eight 8-ounce glasses of water or other nonalcoholic fluids each day
    • sitting in a tub of warm water for 10 minutes several times a day
    • exercising to prevent constipation
    • not straining during bowel movements

     
    Over-the-counter creams and suppositories may temporarily relieve the pain and itching of hemorrhoids. These treatments should only be used for a short time because long-term use can damage the skin.
     
    Medical Treatment
    If at-home treatments do not relieve symptoms, medical treatments may be needed. Outpatient treatments can be performed in a doctor’s office or a hospital. Outpatient treatments for internal hemorrhoids include the following:

    • Rubber band ligation. The doctor places a special rubber band around the base of the hemorrhoid. The band cuts off circulation, causing the hemorrhoid to shrink. This procedure should be performed only by a doctor.
    • Sclerotherapy. The doctor injects a chemical solution into the blood vessel to shrink the hemorrhoid.
    • Infrared coagulation. The doctor uses heat to shrink the hemorrhoid tissue.

     
    Large external hemorrhoids or internal hemorrhoids that do not respond to other treatments can be surgically removed.

    Points to Remember

    • Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum.
    • Hemorrhoids are not dangerous or life threatening, and symptoms usually go away within a few days.
    • A thorough evaluation and proper diagnosis by a doctor is important any time a person notices bleeding from the rectum or blood in the stool.
    • Simple diet and lifestyle changes often reduce the swelling of hemorrhoids and relieve hemorrhoid symptoms.
    • If at-home treatments do not relieve symptoms, medical treatments may be needed.

  • Diverticular Disease

    What is diverticular disease?

    Diverticular disease is a condition that occurs when a person has problems from small pouches, or sacs, that have formed and pushed outward through weak spots in the colon wall. Each pouch is called a diverticulum. Multiple pouches are called diverticula.
    The colon is part of the large intestine. The large intestine absorbs water from stool and changes it from a liquid to a solid form. Diverticula are most common in the lower part of the colon, called the sigmoid colon.
    The problems that occur with diverticular disease include diverticulitis and diverticular bleeding. Diverticulitis occurs when the diverticula become inflamed, or irritated and swollen, and infected. Diverticular bleeding occurs when a small blood vessel within the wall of a diverticulum bursts.
     

    What is diverticulosis?

    When a person has diverticula that do not cause diverticulitis or diverticular bleeding, the condition is called diverticulosis. Most people with diverticulosis do not have symptoms. Some people with diverticulosis have constipation or diarrhea. People may also have chronic

    • cramping or pain in the lower abdomen—the area between the chest and hips
    • bloating

     
    Diverticular disease is a condition that occurs when a person has problems from small pouches, or sacs, that have formed and pushed outward through weak spots in the colon wall.
    Other conditions, such as irritable bowel syndrome and stomach ulcers, cause similar problems, so these symptoms do not always mean a person has diverticulosis. People with these symptoms should see their health care provider.
     

    What causes diverticulosis and diverticular disease?

    Scientists are not certain what causes diverticulosis and diverticular disease. For more than 50 years, the most widely accepted theory was that a low-fiber diet led to diverticulosis and diverticular disease. Diverticulosis and diverticular disease were first noticed in the United States in the early 1900s, around the time processed foods were introduced into the American diet. Consumption of processed foods greatly reduced Americans’ fiber intake. Diverticulosis and diverticular disease are common in Western and industrialized countries—particularly the United States, England, and Australia—where low-fiber diets are common. The condition is rare in Asia and Africa, where most people eat high-fiber diets. Two large studies also indicate that a low-fiber diet may increase the chance of developing diverticular disease.
    However, a recent study found that a low-fiber diet was not associated with diverticulosis and that a high-fiber diet and more frequent bowel movements may be linked to an increased rather than decreased chance of diverticula.
    Other studies have focused on the role of decreased levels of the neurotransmitter serotonin in causing decreased relaxation and increased spasms of the colon muscle. A neurotransmitter is a chemical that helps brain cells communicate with nerve cells. However, more studies are needed in this area.
    Studies have also found links between diverticular disease and obesity, lack of exercise, smoking, and certain medications including nonsteroidal anti-inflammatory drugs, such as aspirin, and steroids.
    Scientists agree that with diverticulitis, inflammation may begin when bacteria or stool get caught in a diverticulum. In the colon, inflammation also may be caused by a decrease in healthy bacteria and an increase in disease-causing bacteria. This change in the bacteria may permit chronic inflammation to develop in the colon.
     

    What is fiber?

    Fiber is a substance in foods that comes from plants. Fiber helps soften stool so it moves smoothly through the colon and is easier to pass. Soluble fiber dissolves in water and is found in beans, fruit, and oat products. Insoluble fiber does not dissolve in water and is found in whole-grain products and vegetables. Both kinds of fiber help prevent constipation.
    Constipation is a condition in which an adult has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry, and small, making them painful or difficult to pass.
    High-fiber foods also have many benefits in preventing and controlling chronic diseases, such as cardiovascular disease, obesity, diabetes, and cancer.
     

    Who gets diverticulosis and diverticular disease?

    Diverticulosis becomes more common as people age, particularly in people older than age 50.3 Some people with diverticulosis develop diverticulitis, and the number of cases is increasing. Although diverticular disease is generally thought to be a condition found in older adults, it is becoming more common in people younger than age 50, most of whom are male.
     

    What are the symptoms of diverticular disease?

    People with diverticulitis may have many symptoms, the most common of which is pain in the lower left side of the abdomen. The pain is usually severe and comes on suddenly, though it can also be mild and then worsen over several days. The intensity of the pain can fluctuate. Diverticulitis may also cause

    • fevers and chills
    • nausea or vomiting
    • a change in bowel habits—constipation or diarrhea
    • diverticular bleeding

     
    In most cases, people with diverticular bleeding suddenly have a large amount of red or maroon-colored blood in their stool. Diverticular bleeding may also cause weakness, dizziness or light-headedness, abdominal cramping
     

    How are diverticulosis and diverticular disease diagnosed?

    Diverticulosis
    Health care providers often find diverticulosis during a routine x ray or a colonoscopy, a test used to look inside the rectum and entire colon to screen for colon cancer or polyps or to evaluate the source of rectal bleeding.
     
    Diverticular Disease
    Based on symptoms and severity of illness, a person may be evaluated and diagnosed by a primary care physician, an emergency department physician, a surgeon, or a gastroenterologist—a doctor who specializes in digestive diseases.
    The health care provider will ask about the person’s health, symptoms, bowel habits, diet, and medications, and will perform a physical exam, which may include a rectal exam. A rectal exam is performed in the health care provider’s office; anesthesia is not needed. To perform the exam, the health care provider asks the person to bend over a table or lie on one side while holding the knees close to the chest. The health care provider slides a gloved, lubricated finger into the rectum. The exam is used to check for pain, bleeding, or a blockage in the intestine.
    The health care provider may schedule one or more of the following tests:

    • Blood test. A blood test involves drawing a person’s blood at a health care provider’s office, a commercial facility, or a hospital and sending the sample to a lab for analysis. The blood test can show the presence of inflammation or anemia—a condition in which red blood cells are fewer or smaller than normal, which prevents the body’s cells from getting enough oxygen.
    • Computerized tomography (CT) scan. A CT scan of the colon is the most common test used to diagnose diverticular disease. CT scans use a combination of x rays and computer technology to create three-dimensional (3–D) images. For a CT scan, the person may be given a solution to drink and an injection of a special dye, called contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. The procedure is performed in an outpatient center or a hospital by an x-ray technician, and the images are interpreted by a radiologist—a doctor who specializes in medical imaging. Anesthesia is not needed. CT scans can detect diverticulosis and confirm the diagnosis of diverticulitis.
    • Lower gastrointestinal (GI) series. A lower GI series is an x-ray exam that is used to look at the large intestine. The test is performed at a hospital or an outpatient center by an x-ray technician, and the images are interpreted by a radiologist. Anesthesia is not needed. The health care provider may provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for 1 to 3 days before the procedure. A laxative or enema may be used before the test. A laxative is medication that loosens stool and increases bowel movements. An enema involves flushing water or laxative into the rectum using a special squirt bottle. These medications cause diarrhea, so the person should stay close to a bathroom during the bowel prep.
      For the test, the person will lie on a table while the radiologist inserts a flexible tube into the person’s anus. The colon is filled with barium, making signs of diverticular disease show up more clearly on x rays.
      For several days, traces of barium in the large intestine can cause stools to be white or light colored. Enemas and repeated bowel movements may cause anal soreness. A health care provider will provide specific instructions about eating and drinking after the test.
    • Colonoscopy. The test is performed at a hospital or an outpatient center by a gastroenterologist. Before the test, the person’s health care provider will provide written bowel prep instructions to follow at home. The person may need to follow a clear liquid diet for 1 to 3 days before the test. The person may also need to take laxatives and enemas the evening before the test.
      In most cases, light anesthesia, and possibly pain medication, helps people relax for the test. The person will lie on a table while the gastroenterologist inserts a flexible tube into the anus. A small camera on the tube sends a video image of the intestinal lining to a computer screen. The test can show diverticulosis and diverticular disease.
      Cramping or bloating may occur during the first hour after the test. Driving is not permitted for 24 hours after the test to allow the anesthesia time to wear off. Before the appointment, people should make plans for a ride home. Full recovery is expected by the next day, and people should be able to go back to their normal diet.

     

    How are diverticulosis and diverticular disease treated?

    A health care provider may treat the symptoms of diverticulosis with a high-fiber diet or fiber supplements, medications, and possibly probiotics. Treatment for diverticular disease varies, depending on whether a person has diverticulitis or diverticular bleeding.
     
    Diverticulosis
     
    High-fiber diet. Studies have shown that a high-fiber diet can help prevent diverticular disease in people who already have diverticulosis.2 A health care provider may recommend a slow increase in dietary fiber to minimize gas and abdominal discomfort. For more information about fiber-rich foods, see “Eating, Diet, and Nutrition.”
     
    Fiber supplements. A health care provider may recommend taking a fiber product such as methylcellulose (Citrucel) or psyllium (Metamucil) one to three times a day. These products are available as powders, pills, or wafers and provide 0.5 to 3.5 grams of fiber per dose. Fiber products should be taken with at least 8 ounces of water.
     
    Medications. A number of studies suggest the medication mesalazine (Asacol), given either continuously or in cycles, may be effective at reducing abdominal pain and GI symptoms of diverticulosis. Research has also shown that combining mesalazine with the antibiotic rifaximin (Xifaxan) can be significantly more effective than using rifaximin alone to improve a person’s symptoms and maintain periods of remission, which means being free of symptoms.
     
    Probiotics. Although more research is needed, probiotics may help treat the symptoms of diverticulosis, prevent the onset of diverticulitis, and reduce the chance of recurrent symptoms. Probiotics are live bacteria, like those normally found in the GI tract. Probiotics can be found in dietary supplements—in capsules, tablets, and powders—and in some foods, such as yogurt.
    To help ensure coordinated and safe care, people should discuss their use of complementary and alternative medical practices, including their use of dietary supplements and probiotics, with their health care provider. Read more at www.nccam.nih.gov/health/probioticsExternal NIH Link.
    Tips for talking with health care providers are available at www.nccam.nih.gov/timetotalkExternal NIH Link.
     
    Diverticular Bleeding
     
    Diverticular bleeding is rare. Bleeding can be severe; however, it may stop by itself and not require treatment. A person who has bleeding from the rectum—even a small amount—should see a health care provider right away.
    To treat the bleeding, a colonoscopy may be performed to identify the location of and stop the bleeding. A CT scan or angiogram also may be used to identify the site of the bleeding. A traditional angiogram is a special kind of x ray in which a thin, flexible tube called a catheter is threaded through a large artery, often from the groin, to the area of bleeding. Contrast medium is injected through the catheter so the artery shows up more clearly on the x ray. The procedure is performed in a hospital or an outpatient center by an x-ray technician, and the images are interpreted by a radiologist. Anesthesia is not needed, though a sedative may be given to lessen anxiety during the procedure.
    If the bleeding does not stop, abdominal surgery with a colon resection may be necessary. In a colon resection, the surgeon removes the affected part of the colon and joins the remaining ends of the colon together; general anesthesia is used. A blood transfusion may be needed if the person has lost a significant amount of blood.
     
    Diverticulitis
     
    Diverticulitis with mild symptoms and no complications usually requires a person to rest, take oral antibiotics, and be on a liquid diet for a period of time. If symptoms ease after a few days, the health care provider will recommend gradually adding solid foods back into the diet.
    Severe cases of diverticulitis with acute pain and complications will likely require a hospital stay. Most cases of severe diverticulitis are treated with intravenous (IV) antibiotics and a few days without food or drink to help the colon rest. If the period without food or drink is longer, the person may be given parenteral nutrition—a method of providing an IV liquid food mixture through a special tube in the chest. The mixture contains proteins, carbohydrates, fats, vitamins, and minerals.

    What are the complications of diverticulitis and how are they treated?

    Diverticulitis can attack suddenly and cause complications, such as

    • an abscess—a painful, swollen, pus-filled area just outside the colon wall—caused by infection
    • a perforation—a small tear or hole in the diverticula
    • peritonitis—inflammation of tissues inside the abdomen from pus and stool that leak through a perforation
    • a fistula—an abnormal passage, or tunnel, between two organs, or between an organ and the outside of the body
    • intestinal obstruction—partial or total blockage of movement of food or stool through the intestines

     
    These complications need to be treated to prevent them from getting worse and causing serious illness. In some cases, surgery may be needed.
     
    Abscess, perforation, and peritonitis. Antibiotic treatment of diverticulitis usually prevents or treats an abscess. If the abscess is large or does not clear up with antibiotics, it may need to be drained. After giving the person numbing medication, a radiologist inserts a needle through the skin to the abscess and then drains the fluid through a catheter. The procedure is usually guided by an abdominal ultrasound or a CT scan. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure.
    A person with a perforation usually needs surgery to repair the tear or hole. Sometimes, a person needs surgery to remove a small part of the intestine if the perforation cannot be repaired.
    A person with peritonitis may be extremely ill, with nausea, vomiting, fever, and severe abdominal tenderness. This condition requires immediate surgery to clean the abdominal cavity and possibly a colon resection at a later date after a course of antibiotics. A blood transfusion may be needed if the person has lost a significant amount of blood. Without prompt treatment, peritonitis can be fatal.
     
    Fistula. Diverticulitis-related infection may lead to one or more fistulas. Fistulas usually form between the colon and the bladder, small intestine, or skin. The most common type of fistula occurs between the colon and the bladder. Fistulas can be corrected with a colon resection and removal of the fistula.
     
    Intestinal obstruction. Diverticulitis-related inflammation or scarring caused by past inflammation may lead to intestinal obstruction. If the intestine is completely blocked, emergency surgery is necessary, with possible colon resection. Partial blockage is not an emergency, so the surgery or other procedures to correct it can be scheduled.
    When urgent surgery with colon resection is necessary for diverticulitis, two procedures may be needed because it is not safe to rejoin the colon right away. During the colon resection, the surgeon performs a temporary colostomy, creating an opening, or stoma, in the abdomen. The end of the colon is connected to the opening to allow normal eating while healing occurs. Stool is collected in a pouch attached to the stoma on the abdominal wall. In the second surgery, several months later, the surgeon rejoins the ends of the colon and closes the stoma.
     

    Eating, Diet, and Nutrition

    The Dietary Guidelines for Americans, 2010, recommends a dietary fiber intake of 14 grams per 1,000 calories consumed. For instance, for a 2,000-calorie diet, the fiber recommendation is 28 grams per day. The amount of fiber in a food is listed on the food’s nutrition facts label. Some of the best sources of fiber include fruits; vegetables, particularly starchy ones; and whole grains. A health care provider or dietitian can help a person learn how to add more high-fiber foods into the diet.
    Scientists now believe that people with diverticular disease do not need to eliminate certain foods from their diet. In the past, health care providers recommended that people with diverticular disease avoid nuts, popcorn, and sunflower, pumpkin, caraway, and sesame seeds because they thought food particles could enter, block, or irritate the diverticula. However, recent data suggest that these foods are not harmful. The seeds in tomatoes, zucchini, cucumbers, strawberries, and raspberries, as well as poppy seeds, are also fine to eat. Nonetheless, people with diverticular disease may differ in the amounts and types of foods that worsen their symptoms.

    Points to Remember

    • Diverticular disease is a condition that occurs when a person has problems from small pouches, or sacs, that have formed and pushed outward through weak spots in the colon wall. The problems that occur with diverticular disease include diverticulitis and diverticular bleeding.
    • When a person has diverticula that do not cause diverticulitis or diverticular bleeding, the condition is called diverticulosis.
    • Scientists are not certain what causes diverticulosis and diverticular disease.
    • Although diverticular disease is generally thought to be a condition found in older adults, it is becoming more common in people younger than age 50, most of whom are male.
    • Health care providers often find diverticulosis during a routine x ray or a colonoscopy, a test used to look inside the rectum and entire colon to screen for colon cancer or polyps or to evaluate the source of rectal bleeding.
    • To diagnose diverticular disease, a health care provider may schedule one or more of the following tests: blood test; computerized tomography (CT) scan; lower gastrointestinal (GI) series; colonoscopy.
    • A health care provider may treat the symptoms of diverticulosis with a high-fiber diet or fiber supplements, medications, and possibly probiotics.
    • Diverticular bleeding is rare. Bleeding can be severe; however, it may stop by itself and not require treatment. If the bleeding does not stop, abdominal surgery with a colon resection may be necessary.
    • Diverticulitis with mild symptoms and no complications usually requires a person to rest, take oral antibiotics, and be on a liquid diet for a period of time.
    • Diverticulitis can attack suddenly and cause complications, such as an abscess, a perforation, peritonitis, a fistula, or intestinal obstruction. These complications need to be treated to prevent them from getting worse and causing serious illness.

  • Abdominal Adhesions

    What are abdominal adhesions?

    Abdominal adhesions are bands of fibrous tissue that can form between abdominal tissues and organs. Normally, internal tissues and organs have slippery surfaces, preventing them from sticking together as the body moves. However, abdominal adhesions cause tissues and organs in the abdominal cavity to stick together.
     

    What is the abdominal cavity?

    The abdominal cavity is the internal area of the body between the chest and hips that contains the lower part of the esophagus, stomach, small intestine, and large intestine. The esophagus carries food and liquids from the mouth to the stomach, which slowly pumps them into the small and large intestines. Abdominal adhesions can kink, twist, or pull the small and large intestines out of place, causing an intestinal obstruction. Intestinal obstruction, also called a bowel obstruction, results in the partial or complete blockage of movement of food or stool through the intestines.
     

    What causes abdominal adhesions?

    Abdominal surgery is the most frequent cause of abdominal adhesions. Surgery-related causes include

    • cuts involving internal organs
    • handling of internal organs
    • drying out of internal organs and tissues
    • contact of internal tissues with foreign materials, such as gauze, surgical gloves, and stitches
    • blood or blood clots that were not rinsed away during surgery

     
    Abdominal adhesions can also result from inflammation not related to surgery, including

    • appendix rupture
    • radiation treatment
    • gynecological infections
    • abdominal infections

     
    Rarely, abdominal adhesions form without apparent cause.
     

    How common are abdominal adhesions and who is at risk?

    Of patients who undergo abdominal surgery, 93 percent develop abdominal adhesions. Surgery in the lower abdomen and pelvis, including bowel and gynecological operations, carries an even greater chance of abdominal adhesions. Abdominal adhesions can become larger and tighter as time passes, sometimes causing problems years after surgery.
     

    What are the symptoms of abdominal adhesions?

    In most cases, abdominal adhesions do not cause symptoms. When symptoms are present, chronic abdominal pain is the most common.

    What are the complications of abdominal adhesions?

    Abdominal adhesions can cause intestinal obstruction and female infertility—the inability to become pregnant after a year of trying.
    Abdominal adhesions can lead to female infertility by preventing fertilized eggs from reaching the uterus, where fetal development takes place. Women with abdominal adhesions in or around their fallopian tubes have an increased chance of ectopic pregnancy—a fertilized egg growing outside the uterus. Abdominal adhesions inside the uterus may result in repeated miscarriages—a pregnancy failure before 20 weeks.
    Seek Help for Emergency Symptoms
    A complete intestinal obstruction is life threatening and requires immediate medical attention and often surgery. Symptoms of an intestinal obstruction include

    • severe abdominal pain or cramping
    • nausea
    • vomiting
    • bloating
    • loud bowel sounds
    • abdominal swelling
    • the inability to have a bowel movement or pass gas
    • constipation—a condition in which a person has fewer than three bowel movements a week; the bowel movements may be painful

     
    A person with these symptoms should seek medical attention immediately.
     

    How are abdominal adhesions and intestinal obstructions diagnosed?

    Abdominal adhesions cannot be detected by tests or seen through imaging techniques such as x rays or ultrasound. Most abdominal adhesions are found during surgery performed to examine the abdomen. However, abdominal x rays, a lower gastrointestinal (GI) series, and computerized tomography (CT) scans can diagnose intestinal obstructions.
     
    Abdominal x rays use a small amount of radiation to create an image that is recorded on film or a computer. An x ray is performed at a hospital or an outpatient center by an x-ray technician, and the images are interpreted by a radiologist,a doctor who specializes in medical imaging. An x ray does not require anesthesia. The person will lie on a table or stand during the x ray. The x-ray machine is positioned over the abdominal area. The person will hold his or her breath as the picture is taken so that the picture will not be blurry. The person may be asked to change position for additional pictures.
     
    A lower GI series is an x-ray exam that is used to look at the large intestine. The test is performed at a hospital or an outpatient center by an x-ray technician, and the images are interpreted by a radiologist. Anesthesia is not needed. The health care provider may provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for 1 to 3 days before the procedure. A laxative or an enema may be used before the test. A laxative is medication that loosens stool and increases bowel movements. An enema involves flushing water or laxative into the rectum using a special squirt bottle. For the test, the person will lie on a table while the radiologist inserts a flexible tube into the person’s anus. The large intestine is filled with barium, making signs of underlying problems show up more clearly on x rays.
     
    CT scans use a combination of x rays and computer technology to create images. The procedure is performed at a hospital or an outpatient center by an x-ray technician, and the images are interpreted by a radiologist. Anesthesia is not needed. A CT scan may include the injection of a special dye, called contrast medium. The person will lie on a table that slides into a tunnel-shaped device where the x rays are taken.
     

    How are abdominal adhesions and intestinal obstructions treated?

    Abdominal adhesions that do not cause symptoms generally do not require treatment. Surgery is the only way to treat abdominal adhesions that cause pain, intestinal obstruction, or fertility problems. More surgery, however, carries the risk of additional abdominal adhesions. People should speak with their health care provider about the best way to treat their abdominal adhesions.
    Complete intestinal obstructions usually require immediate surgery to clear the blockage. Most partial intestinal obstructions can be managed without surgery.
     

    How can abdominal adhesions be prevented?

    Abdominal adhesions are difficult to prevent; however, certain surgical techniques can minimize abdominal adhesions.
    Laparoscopic surgery decreases the potential for abdominal adhesions because several tiny incisions are made in the lower abdomen instead of one large incision. The surgeon inserts a laparoscope, a thin tube with a tiny video camera attached, into one of the small incisions. The camera sends a magnified image from inside the body to a video monitor. Patients will usually receive general anesthesia during this surgery.
    If laparoscopic surgery is not possible and a large abdominal incision is required, at the end of surgery a special filmlike material can be inserted between organs or between the organs and the abdominal incision. The filmlike material, which looks similar to wax paper and is absorbed by the body in about a week, hydrates organs to help prevent abdominal adhesions.
    Other steps taken during surgery to reduce abdominal adhesions include

    • using starch- and latex-free gloves
    • handling tissues and organs gently
    • shortening surgery time
    • using moistened drapes and swabs
    • occasionally applying saline solution

     

    Eating, Diet, and Nutrition

    Researchers have not found that eating, diet, and nutrition play a role in causing or preventing abdominal adhesions. A person with a partial intestinal obstruction may relieve symptoms with a liquid or low-fiber diet, which is more easily broken down into smaller particles by the digestive system.
     

    Points to Remember

    • Abdominal adhesions are bands of fibrous tissue that can form between abdominal tissues and organs. Abdominal adhesions cause tissues and organs in the abdominal cavity to stick together.
    • Abdominal surgery is the most frequent cause of abdominal adhesions. Of patients who undergo abdominal surgery, 93 percent develop abdominal adhesions.
    • In most cases, abdominal adhesions do not cause symptoms. When symptoms are present, chronic abdominal pain is the most common.
    • A complete intestinal obstruction is life threatening and requires immediate medical attention and often surgery.
    • Abdominal adhesions cannot be detected by tests or seen through imaging techniques such as x rays or ultrasound. However, abdominal x rays, a lower gastrointestinal (GI) series, and computerized tomography (CT) scans can diagnose intestinal obstructions.
    • Surgery is the only way to treat abdominal adhesions that cause pain, intestinal obstruction, or fertility problems.

  • FODMAPs

    What are FODMAPs?

    FODMAPs are short chain carbohydrates part of a normal healthy diet that are poorly absorbed in the small intestine.
    This designation was created in 2005 by Susan Shepherd and Peter Gibson of Monash University in Australia.
    They include short chain polymers of fructose, lactose. stachyose, rafinose, and polyols.
    These are natural substances present in many of the foodstuffs that we commonly eat.
     

    What is the importance of FODMAPs?

    This group of substances can cause GI symptoms such as and gas accumulation bloating and excess flatus.
    On the other hand they inhibit intestinal inflammation, inducing beneficial alterations to intestinal micro-biota and generation of short-chain fatty acids that nourish the colon walls.
    A diet restricted in FODMAPs has been repeatedly shown to alleviate the symptoms of people with severe irritable bowel syndrome.
     

    What are the foodstufs that contain FODMAPs?

    Excess fructose
     

    • Fruits: apples, pears, nashi pears, clingstone peaches, mango, sugar snap peas, watermelon, tinned fruit in natural juice.
    • Honey.
    • Sweeteners: fructose, high-fructose com syrup.
    • Large total fructose dose: concentrated fruit sources: large servings of fruit, dried fruit, fruit juice.

     
    Lactose
     

    • Milk: cow, goat, and sheep.
    • Ice cream (regular and low fat).
    • Yogurt (regular and low fat).
    • Cheeses: soft and fresh (eg, ricotta and cottage).

     
    Fructans and/ or Galactans
     

    • Vegetables: artichokes, asparagus, beetroot, Brussels sprout, broccoli, cabbage, fennel, garlic, leeks, okra, onions, peas, shallots.
    • Cereals: wheat and rye when eaten in large amounts (eg, bread, pasta, couscous, crackers, biscuits).
    • Legumes: chickpeas, lentils, red kidney beans, baked beans.
    • Fruits: watermelon, custard apple, white peaches, rambutan, persimmon.

     
    Polyols
     

    • Mushrooms, snow peas.
    • Sweeteners:sorbitol (420), mannitol (421), xylitol (967), maltitol (965), isomalt (953), and others ending in “ol”.

     

    How can i replace high FODMAP foods im my diet?

    Replace foodstuffs with excess fructose with
     

    • Fruit: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passion fruit, paw paw, raspberry, rockmelon, strawberry, tangelo.
    • Honey substitutes: maple syrup, golden syrup.
    • Sweeteners: sugar (sucrose), glucose, stevia.

     
    Replace foodstuffs with lactose with
     

    • Milk: lactose-free, rice milk.
    • Cheese: “hard” cheeses including brie and camembert.
    • Yogurt: lactose-free.
    • Ice cream substitutes: gelati, sorbet.
    • Butter.

     
    Replace foodstuffs with Fructans and Galactans with
     

    • Vegetables: bamboo shoots, bok choy, carrot, celery, capsicum, choko, choy sum, com, eggplant, green beans, lettuce, chives, parsnip, pumpkin, silverbeet, spring onion (green only), tomato.
    • Onion/garlic substitutes: garlic-infused oil.
    • Cereals: gluten-free and spelt bread/ cereal products.

     
    Replace foodstuffs with Polyolls with
     

    • Fruits: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passion fruit, paw paw, raspberry, rockmelon.
    • Sweeteners: sugar (sucrose), glucose, other artificial sweeteners not ending in “-ol”.

     

    Should i worry about FODMAPs?

    If you do not have symptoms of irritable bowel syndrome (intermittent diarrhea, gas accumulation and colicky pain) you do not have to worry about FODMAPS.
     

      Points to Remember

    • A diet low in FODMAPS its only relevant for people with irritable bowel syndrome.

  • Non Celiac Gluten Sensitivity

    What is gluten sensitivity?

    During the past decade there has been an impressive increase in popularity of the gluten-free diet (GFD), now the most trendy alimentary habit in the United States and other countries. According to recent surveys, as many as 100 million Americans will consume gluten-free products within a year.

    According to traditional medicine approach GFD benefits only individuals with celiac disease (less than 1% of the population).

    However, apart from unfounded trends, a disorder related to ingestion of gluten or gluten-containing cereals, namely non-celiac gluten sensitivity (NCGS), has resurfaced in the medical literature (the first case was described in 1978). There is an ongoing debate on the appropriateness of the GFD for people without celiac disease. Although there is clearly a fad component to the popularity of the GFD, there is also undisputable and increasing evidence for NCGS as a real clinical entity.
     

    What is gluten?

    Gluten is the main storage protein in wheat barley and rye. Wheat is the most widely grown crop worldwide, with more than 25.000 different varieties. Its popularity results from its simplicity of cultivation in different climates, high yield, and good nutritional value. Furthermore, the functional properties of gluten proteins have led to their addition to many foods and cosmetics.
     

    What diseases are associated with gluten?

    Gluten related diseases are activated by the ingestion of gluten containing
    cereals (wheat, barley and rye) by people with a genetic and/or immunologic predisposition.
    The two well defined clinical entities in relation with gluten ingestion are: wheat allergy and celiac disease. Both are mediated by the adaptive immune system
     

    • In wheat allergy the mechanism involves IgE as in all other allergies.
    • Celiac disease, has characteristics of an autoimmune disorder

     
    In addition to celiac disease and wheat allergy, there have been cases of reactions to gluten-containing grains that involved neither allergic nor autoimmune mechanisms. These generally are termed non celiac gluten sensitivity (NCGS) or simply gluten sensitivity. The current evidence points that in NCGS the innate immune system is also involved.
     

    What are the symptoms of NCGS?

    Symptoms of NCGS usually occur within hours or days after ingestion of gluten-containing grains, and disappear rapidly when these grains are eliminated from the diet.
    NCGS most frequently produces a combination of intestinal and extra-intestinal symptoms.
    Irritable Bowel Syndrome-like symptoms, such as abdominal pain, gas, distension, and irregular bowel movements, frequently are reported and therefore make it difficult to distinguish NCGS from IBS induced by other causes.
    The differential diagnosis is facilitated for patients who also experience extra intestinal symptoms, including headache or frank migraine, foggy mind, chronic fatigue, joint and muscle pain, tingling of the extremities, leg or arm numbness. eczema, anemia, depression or for patients who report a reduction in autoimmune symptoms on a GFD.
     

    What is the difference between intolerance and sensitivity?

    • Food intolerance occurs when the body lacks a particular enzyme to digest nutrients, or for other reasons a particular nutrient cannot be digested properly. Symptoms are exclusively GI and mostly secondary to sugar fermentation by the intestinal microbiota, leading to the production of gas, which causes abdominal distention, abdominal pain, and irregular bowel movements. Common examples include lactose intolerance.
    • Food sensitivities are immune mediated reactions to some nutrients involving the GI tract. They can also involve extra intestinal symptoms and frequently do not always occur with the same pattern. Common examples include reactions to nuts fruits and selfish.

     

    How do you make the diagnosis?

    At this moment, apart from a few tests that are used only in research, NCGS is an diagnosis of exclusion based on the following criteria:
     

    • You have to exclude celiac disease and wheat allergy with simple blood tests.
    • The intestinal and/or extra intestinal symptoms resolve once the gluten-containing foodstuffs are eliminated from the diet.

     

    What treatments are available?

    At this moment the treatment consists in avoiding all gluten containing foods.
     

      Points to Remember

    • NCGS is a ill defined but real clinical entity.
    • It can cause symptoms on the GI tract.
    • It can also cause headache, migraine, foggy mind, chronic fatigue, joint and muscle pain, tingling of the extremities, leg or arm numbness. eczema, anemia, depression and autoimmune problems.
    • The diagnosis is not straightforward and necessitates both blood tests and a period of gluten free diet.

Publications

These are the scientific papers I have published. In most of them I am the first author and I designed the research protocol. These clinical research projects were carried out at Harlem Hospital, S. Francisco Xavier Hospital and the clinics in Lisbon and Santarem.
According to the copyright laws I am not the owner of these articles. Therefore I cannot publish the full text in this website. Each article has a link to the publisher that owns the its copyright in case you want to read the full text.

    • Rosario Manuel, Raso Carl, Comer Gail, Clain David. “Transnasal brush cytology for the diagnosis of esophageal candidiasis in acquired immunodeficiency syndrome. Gastrointestinal Endoscopy 1989; 35: 102-3.
      READ THIS PAPER

 

    • Rosario Manuel, Raso, Carl, Comer Gail. “Esophageal tuberculosis”. Digestive Diseases and Sciences 1989; 34: 1281-3.
      READ THIS PAPER

 

    • Rosario Manuel, Costa Nuno F. “Combination of midazolam and flumazenil in upper gastrointestinal endoscopy, a double blind randomized study”. Gastrointestinal Endoscopy 1990; 36: 30-3.
      READ THIS PAPER

 

    • Rosario Manuel, Costa Nuno F. “Flumazenil (Ro-1788), a benzodiazepine inhibitor, in upper gastrointestinal endoscopy”. Gastroenterology 1989; 96: A424.

 

    • Rosario Manuel, Neves Carlos, Ferreira Antonio F. Sales Luis Armando. “Ectopic papila of Vater”. Gastrointestinal Endoscopy 1990; 36: 606-7.
      READ THIS PAPER

 

    • Rosario Manuel, Alves Isabel Madeira, Sales Luis Armando. “Intranasal midazolam for sedation in upper gastrointestinal endoscopy”. European Journal of Gastroenterology and Hepatology 1990; 2: S94.

 

    • Rosario Manuel, Alves Isabel Madeira, Martins Filomena, Dupret Dulce, Sales Luis Armando. “Combination of bismuth subcitrate and furazolidone in eradication therapy for H. pylori” Gastroenterology 1992; 102: A154.

 

    • Rosario Manuel, Alves Isabel Madeira, Sales Luis Armando. “Precut sphincterotomy, how safe how effective?” Gastrointestinal Endoscopy 1993; 39: 256.

 

    • Rosario Manuel, Alves Isabel Madeira, Sales Luis Armando. “Does intranasal flumazenil work?” Gastrointestinal Endoscopy 1993; 39: 269.

 

    • Rosario Manuel, Alves Isabel Madeira, Carneiro António Vaz, Ventura António Madeira, Sales Luis Armando. “Adult duodenal web, endoscopic management”. Endoscopy 1993; 25: 483.
      READ THIS PAPER

 

    • Rosario Manuel, Alves Isabel Madeira, Costa Nuno Felix, Sales-Luis Armando. “Efficacy of intranasal flumazenil a double blind randomized study” CAR Revista 1996; 9: 25-28.

 

    • Rosario Manuel, Machado Caetano Joaquim, Pessanha Maira Ana, Marote Graça, Alves da Silva, Machado Caetano Joaquim António. “Perfil de resistencia aos macrólidos e imidazois do Helicobacter pylori numa amostra da população portuguesa” Acta Médica Portuguesa 1998; 11: 1069.

 

Links

 

There are literally thousands of websites with medical information. However a large part of this information is of dubious quality and full of bias. I selected these websites because they are published by organizations that promote scientific research and provide updated consensual information. In most of these web sites there is a section devoted to the general public, information quality is generally excellent and updated very frequently.

 

 

Other Links

 

I believe that good nutrition is the foundation for a better functioning digestive tract. I think that the organic products are a long-term asset in maintaining good health as well as conserving the environment. I provide here some useful addresses in the Cascais and Lisbon areas.

 

Miosótis
R. Marques de Sá da Bandeira, Nº 16, Lisboa.
T: 213 147 841
http://www.biomiosotis.com

 

Brio – supermercado biológico
Tem várias localizações: Campo de Ourique, Carnaxide, Chiado e Estoril.
http://www.brio.pt

 

Biocoop
Rua Salgueiro Maia, Nº 12
2685-374 Figo Maduro Prior Velho
T: 219 410 479
http://www.biocoop.pt

 

Mercado Biológico do Príncipe Real
Sábados
Praça do Príncipe Real, 1250-184 Lisboa.

 

Instituto Macrobiótico de Portugal
Rua Anchieta, Nº 5, 2º Esq.
1200-023 Lisboa
T: 213 242 290
http://www.e-macrobiotica.com/

 

Sociedade Portuguesa de Naturalogia
Rua do Alecrim, Nº 38, 3º
1200-018 Lisboa
T: 213 463 335
http://www.spn.eco-gaia.net/

 

Restaurante Yin-Yang
R. dos Correeiros, Nº 14, 1100-Lisboa.
T: 213 426 551

 

Restaurante A Espiral
Praça Ilha do Faial, Nº 14, 1000-Lisboa.
http://www.espiral.pt/

 

Restaurante A Colmeia
Rua da Emenda, Nº 110, 1200-170 Lisboa.
T: 213 470 500