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Some gastrointestinal disorders may present as atypical chest pain. This is chest pain not related to the heart. This usually is associated with gastroesophageal reflux (reflux of stomach acids) and esophageal spasm. In addition, chest pain can be caused when food or liquid gets stuck in the esophagus. Food may get stuck for many different reasons, the most common being stricture or narrowing in the bottom of the esophagus.
There are various ways of making the diagnosis of either reflux or strictures. Either an Upper GI Series cna be done or, more likely, an Upper Endoscopy to directly view the Esophagus.
Heartburn (Gastroesophageal Reflux Disease)
Gastroesophageal reflux disease (GERD) is a digestive disorder that affects the lower esophageal sphincter (LES) the muscle connecting the esophagus with the stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called hiatal hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery. This fact sheet provides information on GERD: its causes, symptoms, treatment, and long-term complications.
1) What Is Gastroesophageal Reflux?
Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus.
In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately allowing the stomach's contents to flow up into the esophagus.
The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.
2) What Is the Role of Hiatal Hernia?
Some doctors believe a hiatal hernia may weaken the LES and cause reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the stomach from the chest. Recent studies show that the opening in the diaphragm acts as an additional sphincter around the lower end of the esophagus. Studies also show that hiatal hernia results in retention of acid and other contents above this opening. These substances can reflux easily into the esophagus.
Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.
Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, i.e., paraesophageal hernia) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.
3) What Other Factors Contribute to GERD?
Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholic beverages, may weaken the LES causing reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also cause GERD.
4) What Does Heartburn Feel Like?
Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.
The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.
Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.
5) How Common Is Heartburn?
More than 60 million American adults experience Gerd and heartburn at least once a month, and about 25 million adults suffer daily from heartburn. Twenty-five percent of pregnant women experience daily heartburn, and more than 50 percent have occasional distress. Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing and other respiratory problems, or failure to thrive.
6) What Is the Treatment for GERD?
Doctors recommend lifestyle and dietary changes for most people with GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.
Avoiding foods and beverages that can weaken the LES is recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided.
Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.
Cigarette smoking weakens the LES. Therefore, stopping smoking is important to reduce GERD symptoms.
Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus.
Antacids taken regularly can neutralize acid in the esophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent such as alginic acid helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occuring.
Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 3 weeks, a doctor should be consulted.
For chronic reflux and heartburn, the doctor may prescribe medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. Currently, four H2 blockers are available: cimetidine, famotidine, nizatidine, and ranitidine. Another type of drug, the proton pump (or acid pump) inhibitor omeprazole inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. The acid pump inhibitor lansoprazole is currently under investigation as a new treatment for GERD.
Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs include cisapride, bethanechol, and metoclopramide.
Tips To Control Heartburn
Avoid foods and beverages that affect LES pressure or irritate the esophagus lining, including fried and fatty foods, peppermint, chocolate, alcohol, coffee, citrus fruit and juices, and tomato products.
Lose weight if overweight.
Elevate the head of the bed 6 inches.
Avoid lying down 2 to 3 hours after eating.
Take an antacid.
7) What If Symptoms Persist?
People with severe, chronic esophageal reflux or with symptoms not relieved by the treatment described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn.
An upper GI series may be performed during the early phase of testing. This test is a special x-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to rule out other diagnoses, such as peptic ulcers.
Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful.
The Bernstein test (dripping a mild acid through a tube placed in the mid-esophagus) is often performed as part of a complete evaluation. This test attempts to confirm that the symptoms result from acid in the esophagus. Esophageal manometric studies-pressure measurements of the esophagus-occasionally help identify critically low pressure in the LES or abnormalities in esophageal muscle contraction.
For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.
8) Does GERD Require Surgery?
A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. Fundoplication is a surgical procedure that increases pressure in the lower esophagus. However, surgery should not be considered until all other measures have been tried.
9) What Are the Complications of Long-Term GERD?
Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett's esophagus, which is severe damage to the skin-like lining of the esophagus. Doctors believe this condition may be a precursor to esophageal cancer.
Although GERD can limit daily activities and productivity, it is rarely life-threatening. With an understanding of the causes and proper treatment most people will find relief.
As gastroenterologists, we treat many types of liver disease. Most commonly we see Hepatitis related to viral infections or medications and cirrhosis related to alcoholism. Other less common disorders include Primary Biliary Cirrhosis, Fatty Liver Syndrome, Hemochromatosis and Sclerosing Cholangitis.
Please Visit Our Liver Disease Pages listed below:
Jaundice is a symptom of liver disease and manifests as yellow discoloration of the skin and sclera (whites of the eyes). Usually when one is jaundiced the urine is very dark in color and the stool very light.
Jaundice can be caused by a number of things such as liver inflammation (hepatitis) of many causes (medication, viruses, alcohol, etc.) blockage of the tube leading out of the liver (Bile Duct) or blood disorders.
Jaundice is often temporary and if not, is very often treated either with medication or surgery.
The gallbladder is a small pear-shaped organ located beneath the liver on the right side of the abdomen. The gallbladder's primary functions are to store and concentrate bile and secrete bile into the small intestine at the proper time to help digest food.
The gallbladder is connected to the liver and the small intestine by a series of ducts, or tube-shaped structures, that carry bile. Collectively, the gallbladder and these ducts are called the biliary system.
Bile is a yellow-brown fluid produced by the liver. In addition to water, bile contains cholesterol, lipids (fats), bile salts (natural detergents that break up fat), and bilirubin (the bile pigment that gives bile and stools their color). The liver can produce as much as three cups of bile in 1 day, and at any one time, the gallbladder can store up to a cup of concentrated bile.
As food passes from the stomach into the small intestine, the gallbladder contracts and sends its stored bile into the small intestine through the common bile duct. Once in the small intestine, bile helps digest fats in foods. Under normal circumstances, most bile is recirculated in the digestive tract by being absorbed in the intestine and returning to the liver in the bloodstream.
1) What Are Gallstones?
Gallstones are pieces of solid material that form in the gallbladder. Gallstones form when substances in the bile, primarily cholesterol and bile pigments, form hard, crystal-like particles.
Cholesterol stones are usually white or yellow in color and account for about 80 percent of gallstones. They are made primarily of cholesterol.
Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They account for the other 20 percent of gallstones. Risk factors for pigment stones include cirrhosis, biliary tract infections, and hereditary blood cell disorders, such as sickle cell anemia.
Gallstones vary in size and may be as small as a grain of sand or as large as a golf ball. The gallbladder may develop a single, often large, stone or many smaller ones, even several thousand.
2) What Causes Gallstones?
Progress has been made in understanding the process of gallstone formation. Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, body weight, gallbladder motility (movement), and perhaps diet.
Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors seem to be important in causing gallstones. The first is how often and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone formation. The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones.
Other factors also seem to play a role in causing gallstones but how is not clear. Obesity has been shown to be a major risk factor for gallstones. A large clinical study showed that being even moderately overweight increases one's risk for developing gallstones. This is probably true because obesity tends to cause excess cholesterol in bile, low bile salts, and decreased gallbladder emptying. Very low calorie, rapid weight-loss diets, and prolonged fasting, seem to also cause gallstone formation.
In addition, increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the use of birth control pills, may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation.
No clear relationship has been proven between diet and gallstone formation. However, low-fiber, high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation.
3) Who Is at Risk for Gallstones?
This year, more than 1 million people in the United States will learn they have gallstones. They will join the estimated 20 million Americans--roughly 10 percent of the population--who already have gallstones.
Women between 20 and 60 years of age. They are twice as likely to develop gallstones than men.
Men and women over age 60.
Pregnant women or women who have used birth control pills or estrogen replacement therapy.
Native Americans. They have the highest prevalence of gallstones in the United States. A majority of Native American men have gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women have gallstones by age 30.
Mexican-American men and women of all ages.
Men and women who are overweight.
People who go on "crash" diets or who lose a lot of weight quickly.
4) What Are the Symptoms of Gallstones?
Most people with gallstones do not have symptoms. They have what are called silent stones. Studies show that most people with silent stones remain symptom free for years and require no treatment. Silent stones usually are detected during a routine medical checkup or examination for another illness.
5) What Problems Can Occur?
A gallstone attack usually is marked by a steady, severe pain in the upper abdomen. Attacks may last only 20 or 30 minutes but more often they last for one to several hours. A gallstone attack may also cause pain in the back between the shoulder blades or in the right shoulder and may cause nausea or vomiting. Attacks may be separated by weeks, months, or even years. Once a true attack occurs, subsequent attacks are much more likely.
Sometimes gallstones may make their way out of the gallbladder and into the cystic duct, the channel through which bile travels from the gallbladder to the small intestine. If stones become lodged in the cystic duct and block the flow of bile, they can cause cholecystitis, an inflammation of the gallbladder. Blockage of the cystic duct is a common complication caused by gallstones.
A less common but more serious problem occurs if the gallstones become lodged in the bile ducts between the liver and the intestine. This condition can block bile flow from the gallbladder and liver, causing pain and jaundice. Gallstones may also interfere with the flow of digestive fluids secreted from the pancreas into the small intestine, leading to pancreatitis, an inflammation of the pancreas.
Prolonged blockage of any of these ducts can cause severe damage to the gallbladder, liver, or pancreas, which can be fatal. Warning signs include fever, jaundice, and persistent pain.
6) How Are Gallstones Diagnosed?
Many times gallstones are detected during an abdominal x-ray, computerized axial tomography (CT) scan, or abdominal ultrasound that has been taken for an unrelated problem or complaint.
When actually looking for gallstones, the most common diagnostic tool is ultrasound. An ultrasound examination, also known as ultrasonography, uses sound waves. Pulses of sound waves are sent into the abdomen to create an image of the gallbladder. If stones are present, the sound waves will bounce off the stones, revealing their location.
Ultrasound has several advantages. It is a noninvasive technique, which means nothing is injected into or penetrates the body. Ultrasound is painless, has no known side effects, and does not involve radiation.
7) How Are Gallstones Treated?
Despite the development of nonsurgical techniques, gallbladder surgery, or cholecystectomy, is the most common method for treating gallstones. Each year more than 500,000 Americans have gallbladder surgery. Surgery options include the standard procedure, called open cholecystectomy, and a less invasive procedure, called laparoscopic cholecystectomy.
The standard cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 5-to 8-inch incision. Patients may remain in the hospital about a week and may require several additional weeks to recover at home.
Laparoscopic cholecystectomy is a new alternative procedure for gallbladder removal. Some 15,000 surgeons have received training in the technique since its introduction in the United States in 1988. Currently about 80 percent of cholecystectomies are performed using laparoscopes.
Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through separate small incisions. The gallbladder is identified and carefully separated from the liver and other structures. Finally, the cystic duct is cut and the gallbladder removed through one of the small incisions. This type of surgery requires meticulous surgical skill.
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection. Recovery is usually only a night in the hospital and several days recuperation at home.
The most common complication with the new procedure is injury to the common bile duct, which connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed nonsurgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. At this time it is unclear whether these complications are more common following laparoscopic cholecystectomy than following standard cholecystectomy.
Complications such as abdominal adhesions and other problems that obscure vision are discovered during about 5 percent of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder.
Many surgeons believe that laparoscopic cholecystectomy soon will totally replace open cholecystectomy for routine gallbladder removals. Open cholecystectomy will probably remain the recommended approach for complicated cases.
A Consensus Development Conference panel, convened by the National Institutes of Health in September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel noted, however, that laparoscopic cholecystectomy should be performed only by experienced surgeons and only on patients who have symptoms of gallstones.
In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly influenced by the training, experience, skill, and judgment of the surgeon performing the procedure. Therefore, the panel recommended that strict guidelines be developed for training and granting credentials in laparoscopic surgery, determining competence, and monitoring quality. According to the panel, efforts should continue toward developing a noninvasive approach to gallstone treatment that will not only eliminate existing stones, but also prevent their formation or recurrence.
8) What Are the Alternatives to Gallbladder Surgery?
In addition to surgery, nonsurgical approaches have been pursued but are used only in special situations and only for gallstones that are predominantly cholesterol.
Oral dissolution therapy with ursodiol (Actigallr) and chenodiol (Chenixr) works best for small, cholesterol gallstones. These medicines are made from the acid naturally found in bile. They most often are used in individuals who cannot tolerate surgery. Treatment may be required for months to years before gallstones are dissolved.
Mild diarrhea is a side effect of both drugs; chenodiol may also temporarily elevate the liver enzyme transaminase and mildly elevate blood cholesterol levels.
Two therapies, contact dissolution with methyltert butyl ether instillation through a catheter placed into the gallbladder and extracorporeal shock-wave lithotripsy (ESWL), are still experimental.
Each of these alternatives to gallbladder surgery leaves the gallbladder intact; so stone recurrence, which happens in about one-half the cases, is a major drawback.
Colitis refers to inflammation of the large intestine. Also this is used to refer to inflammation of the small intestine. Although the proper term would be ileitis when speaking of the ileum which is the end of the small intestine, colitis may be due to infections like Salmonella, diseases like ulcerative colitis or Crohn's disease.
Stress-related colitis, also called the irritable bowel syndrome does not truly cause inflammation of the colon, but it does cause the same symptoms.
Diarrhea is an increase in the frequency of the number of bowel movements in a 24-hour period. People interpret diarrhea differently but the strict defnition as stated: " Diarrhea may be caused by many different disorders ranging from food poisoning, infections, food allergies, malabsorption (not absorbing food properly), medications (prescription and non-prescription) and colitis ". Any persistent diarrhea should come to one's attention and should be addressed by a physician.
Intestinal bleeding is a serious symptom of gastrointestinal disease. It can present as vomiting blood related to a bleeding ulcer, black and tarry stool related to a bleeding ulcer, or bright red blood from the rectum related to an ulcer, colitis or hemorrhoids. Bleeding can also be microscopic so that it cannot be seen, but can be detected through chemical analysis.
if someone is anemic or notices bloodless stool bleeding from the intestinal tract may be present. The most accurate way of determining where and what is believed is by doing an upper endoscopy or colonoscopy depending upon where the doctor thinks the bleeding is coming from. In addition, there are many feet of small intestine in between the stomach and the colon. This area can be examined either by an upper GI series in which the barium, which is what the patient drinks, is followed through the small intestinal tract. Alternatively there is a newer examination where the patient swallows a capsule and wears a vast that has a receiver on it. The capsule transmits an image every one half second to the receiver. We then get a six or seven hours video of the capsule passing through the intestines. We review this and often can identify what's bleeding. As well, there is a tiny endoscope that can be passed to the small intestines. This is a fairly specialized procedure and often one has to go to university center to have this done.
Abdominal pain is the symptom for which we frequently see patients. Many different diseases can lead to various types of abdominal pain. When trying to differentiate the various causes for these types of pains, the physician will want to know several characteristics and qualities about the pain. These questions might include:
1) Does food precipitate the pain?
2) Is the pain relieved by food?
3) Does the pain occur during the night?
4) Does the pain come in waves or is it present constantly?
In addition, the nature of the pain is also quite important in delineating its cause. Cramping pain is quite different than a sharp, steady, boring pain. Some of the conditions that can be associated with significant abdominal pain include:
1) Peptic Ulcer Disease.
2) Gallbladder Disease.
3) Kidney Stones.
Usually, colon cancers and polyps do not cause abdominal pain. If someone experiences significant abdominal pain it is best to consult a physician immediately since serious disorders may be associated with this. For more information on each of the diagnoses discussed above, please refer back to our home page.
1) What Is an Ulcer?
During normal digestion, food moves from the mouth down the esophagus into the stomach. The stomach produces hydrochloric acid and an enzyme called pepsin to digest the food. From the stomach, food passes into the upper part of the small intestine, called the duodenum, where digestion and nutrient absorption continue.
An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where acid and pepsin are present. Ulcers in the stomach are called gastric or stomach ulcers. Those in the duodenum are called duodenal ulcers. In general, ulcers in the stomach and duodenum are referred to as peptic ulcers. Ulcers rarely occur in the esophagus or in the first portion of the duodenum, the duodenal bulb.
2) Who Has Ulcers?
About 20 million Americans develop at least one ulcer during their lifetime. Each year:
Ulcers affect about 4 million people.
More than 40,000 people have surgery because of persistent symptoms or problems from ulcers.
About 6,000 people die of ulcer-related complications.
Ulcers can develop at any age, but they are rare among teenagers and even more uncommon in children. Duodenal ulcers occur for the first time usually between the ages of 30 and 50. Stomach ulcers are more likely to develop in people over age 60. Duodenal ulcers occur more frequently in men than women; stomach ulcers develop more often in women than men.
3) What Causes Ulcers?
For almost a century, doctors believed lifestyle factors such as stress and diet caused ulcers. Later, researchers discovered that an imbalance between digestive fluids (hydrochloric acid and pepsin) and the stomach's ability to defend itself against these powerful substances resulted in ulcers. Today, research shows that most ulcers develop as a result of infection with bacteria called Helicobacter pylori (H. pylori). While all three of these factors--lifestyle, acid and pepsin, and H. pylori--play a role in ulcer development, H. pylori is now considered the primary cause.
While scientific evidence refutes the old belief that stress and diet cause ulcers, several lifestyle factors continue to be suspected of playing a role. These factors include cigarettes, foods and beverages containing caffeine, alcohol, and physical stress.
Smoking--Studies show that cigarette smoking increases one's chances of getting an ulcer. Smoking slows the healing of existing ulcers and also contributes to ulcer recurrence.
Caffeine--Coffee, tea, colas, and foods that contain caffeine seem to stimulate acid secretion in the stomach, aggravating the pain of an existing ulcer. However, the amount of acid secretion that occurs after drinking decaffeinated coffee is the same as that produced after drinking regular coffee. Thus, the stimulation of stomach acid cannot be attributed solely to caffeine.
Alcohol--Research has not found a link between alcohol consumption and peptic ulcers. However, ulcers are more common in people who have cirrhosis of the liver, a disease often linked to heavy alcohol consumption.
Stress--Although emotional stress is no longer thought to be a cause of ulcers, people with ulcers often report that emotional stress increases ulcer pain. Physical stress, however, increases the risk of developing ulcers particularly in the stomach. For example, people with injuries such as severe burns and people undergoing major surgery often require rigorous treatment to prevent ulcers and ulcer complications.
Acid and pepsin--Researchers believe that the stomach's inability to defend itself against the powerful digestive fluids, acid and pepsin, contributes to ulcer formation. The stomach defends itself from these fluids in several ways. One way is by producing mucus--a lubricant-like coating that shields stomach tissues. Another way is by producing a chemical called bicarbonate. This chemical neutralizes and breaks down digestive fluids into substances less harmful to stomach tissue. Finally, blood circulation to the stomach lining, cell renewal, and cell repair also help protect the stomach. Nonsteroidal anti-inflammatory drugs (NSAIDs) make the stomach vulnerable to the harmful effects of acid and pepsin. NSAIDs such as aspirin, ibuprofen, and naproxen sodium are present in many non-prescription medications used to treat fever, headaches, and minor aches and pains. These, as well as prescription NSAIDs used to treat a variety of arthritic conditions, interfere with the stomach's ability to produce mucus and bicarbonate and affect blood flow to the stomach and cell repair. They can all cause the stomach's defense mechanisms to fail, resulting in an increased chance of developing stomach ulcers. In most cases, these ulcers disappear once the person stops taking NSAIDs.
H.pylori is a spiral-shaped bacterium found in the stomach. Research shows that the bacteria (along with acid secretion) damage stomach and duodenal tissue, causing inflammation and ulcers. Scientists believe this damage occurs because of H.pylori's shape and characteristics.
H.pylori survives in the stomach because it produces the enzyme urease. Urease generates substances that neutralize the stomach's acid--enabling the bacteria to survive. Because of their shape and the way they move, the bacteria can penetrate the stomach's protective mucous lining. Here, they can produce substances that weaken the stomach's protective mucus and make the stomach cells more susceptible to the damaging effects of acid and pepsin.
The bacteria can also attach to stomach cells further weakening the stomach's defensive mechanisms and producing local inflammation. For reasons not completely understood, H.pylori can also stimulate the stomach to produce more acid.
Excess stomach acid and other irritating factors can cause inflammation of the upper end of the duodenum, the duodenal bulb. In some people, over long periods of time, this inflammation results in production of stomach-like cells called duodenal gastric metaplasia. H.pylori then attacks these cells causing further tissue damage and inflammation, which may result in an ulcer.
Within weeks of infection with H.pylori, most people develop gastritis--an inflammation of the stomach lining. However, most people will never have symptoms or problems related to the infection. Scientists do not yet know what is different in those people who develop H.pylori-related symptoms or ulcers. Perhaps, hereditary or environmental factors yet to be discovered cause some individuals to develop problems. Alternatively, symptoms and ulcers may result from infection with more virulent strains of bacteria. These unanswered questions are the subject of intensive scientific research.
Studies show that H.pylori infection in the United States varies with age, ethnic group, and socioeconomic class. The bacteria are more common in older adults, African Americans, Hispanics, and lower socio- economic groups. The organism appears to spread through the fecal-oral route (when infected stool comes into contact with hands, food, or water). Most individuals seem to be infected during childhood, and their infection lasts a lifetime.
The History of Helicobacter pylori
In 1982, Australian researchers Barry Marshall and Robin Warren discovered spiral-shaped bacteria in the stomach, later named Helicobacter pylori (H.pylori). After closely studying H.pylori's effect on the stomach, they proposed that the bacteria were the underlying cause of gastritis and peptic ulcers.
Marshall and Warren came to this conclusion because in their studies all patients with duodenal ulcers and 80 percent of patients with stomach ulcers had the bacteria. The 20 percent of patients with stomach ulcers who did not have H.pylori were those who had taken NSAIDs such as aspirin and ibuprofen, which are a common cause of stomach ulcers.
Although their findings seem conclusive, Marshall and Warren's theory was hotly debated and remained in dispute. The debate continued even after Marshall and a colleague performed an experiment in which they infected themselves with H.pylori and developed gastritis.
Evidence linking H.pylori to ulcers mounted over the next 10 years as numerous studies from around the world confirmed its presence in most people with ulcers. Moreover, researchers from the United States and Europe proved that using antibiotics to eliminate H.pylori healed ulcers and prevented recurrence in about 90 percent of cases.
To further investigate these findings, the National Institutes of Health (NIH) established a panel to closely review the link between H.pylori and peptic ulcer disease. At the February 1994 Consensus Development Conference, the panel concluded that H.pylori plays a significant role in the development of ulcers and that antibiotics with other medicines can cure peptic ulcer disease.
4) What Are the Symptoms of Ulcers?
The most common ulcer symptom is a gnawing or burning pain in the abdomen between the breastbone and the navel. The pain often occurs between meals and in the early hours of the morning. It may last from a few minutes to a few hours and may be relieved by eating or by taking antacids. Less common ulcer symptoms include nausea, vomiting, and loss of appetite and weight. Bleeding from ulcers may occur in the stomach and duodenum. Sometimes people are unaware that they have a bleeding ulcer, because blood loss is slow and blood may not be obvious in the stool. These people may feel tired and weak. If the bleeding is heavy, blood will appear in vomit or stool. Stool containing blood appears tarry or black.
5) How Are Ulcers Diagnosed?
The NIH Consensus Panel emphasized the importance of adequately diagnosing ulcer disease and H.pylori before starting treatment. If the person has an NSAID-induced ulcer, treatment is quite different from the treatment for a person with an H.pylori-related ulcer. Also, a person's pain may be the result of nonulcer dyspepsia (persistent pain or discomfort in the upper abdomen including burning, nausea, and bloating), and not at all related to ulcer disease. Currently, doctors have a number of options available for diagnosing ulcers, such as performing endoscopic and x-ray examinations, and for testing for H.pylori.
Locating and monitoring ulcers
Doctors may perform an upper GI series to diagnose ulcers. An upper GI series involves taking an x-ray of the esophagus, stomach, and duodenum to locate an ulcer. To make the ulcer visible on the x-ray image, the patient swallows a chalky liquid called barium.
An alternative diagnostic test is called an endoscopy. During this test, the patient is lightly sedated and the doctor inserts a small flexible instrument with a camera on the end through the mouth into the esophagus, stomach, and duodenum. With this procedure, the entire upper GI tract can be viewed. Ulcers or other conditions can be diagnosed and photographed, and tissue can be taken for biopsy, if necessary.
Once an ulcer is diagnosed and treatment begins, the doctor will usually monitor clinical progress. In the case of a stomach ulcer, the doctor may wish to document healing with repeat x-rays or endoscopy. Continued monitoring of a stomach ulcer is important because of the small chance that the ulcer may be cancerous.
Testing for H.pylori
Confirming the presence of H.pylori is important once the doctor has diagnosed an ulcer because elimination of the bacteria is likely to cure ulcer disease. Blood, breath, and stomach tissue tests may be performed to detect the presence of H.pylori. While some of the tests for H.pylori are not approved by the U.S. Food and Drug Administration (FDA), research shows these tests are highly accurate in detecting the bacteria. However, blood tests on occasion give false positive results, and the other tests may give false negative results in people who have recently taken antibiotics, omeprazole (Prilosec), or bismuth (Pepto-Bismol).
Blood tests--Blood tests such as the enzyme-linked immunosorbent assay (ELISA) and quick office-based tests identify and measure H.pylori antibodies. The body produces antibodies against H.pylori in an attempt to fight the bacteria. The advantages of blood tests are their low cost and availability to doctors. The disadvantage is the possibility of false positive results in patients previously treated for ulcers since the levels of H.pylori antibodies fall slowly. Several blood tests have FDA approval.
Breath tests--Breath tests measure carbon dioxide in exhaled breath. Patients are given a substance called urea with carbon to drink. Bacteria break down this urea and the carbon is absorbed into the blood stream and lungs and exhaled in the breath. By collecting the breath, doctors can measure this carbon and determine whether H.pylori is present or absent. Urea breath tests are at least 90 percent accurate for diagnosing the bacteria and are particularly suitable to follow-up treatment to see if bacteria have been eradicated. These tests are awaiting FDA approval.
Tissue tests--If the doctor performs an endoscopy to diagnose an ulcer, tissue samples of the stomach can be obtained. The doctor may then perform one of several tests on the tissue. A rapid urease test detects the bacteria's enzyme urease. Histology involves visualizing the bacteria under the microscope. Culture involves specially processing the tissue and watching it for growth of H.pylori organisms.
6) How Are Ulcers Treated?
In the past, doctors advised people with ulcers to avoid spicy, fatty, or acidic foods. However, a bland diet is now known to be ineffective for treating or avoiding ulcers. No particular diet is helpful for most ulcer patients. People who find that certain foods cause irritation should discuss this problem with their doctor. Smoking has been shown to delay ulcer healing and has been linked to ulcer recurrence; therefore, persons with ulcers should not smoke.
Doctors treat stomach and duodenal ulcers with several types of medicines including H2-blockers, acid pump inhibitors, and mucosal protective agents. When treating H.pylori, these medications are used in combination with antibiotics.
H2-blockers--Currently, most doctors treat ulcers with acid-suppressing drugs known as H2-blockers. These drugs reduce the amount of acid the stomach produces by blocking histamine, a powerful stimulant of acid secretion.
H2-blockers reduce pain significantly after several weeks. For the first few days of treatment, doctors often recommend taking an antacid to relieve pain.
Initially, treatment with H2-blockers lasts 6 to 8 weeks. However, because ulcers recur in 50 to 80 percent of cases, many people must continue maintenance therapy for years. This may no longer be the case if H.pylori infection is treated. Most ulcers do not recur following successful eradication. Nizatidine (Axid) is approved for treatment of duodenal ulcers but is not yet approved for treatment of stomach ulcers. H2-blockers that are approved to treat both stomach and duodenal ulcers are:
Acid pump inhibitors--Like H2-blockers, acid pump inhibitors modify the stomach's production of acid. However, acid pump inhibitors more completely block stomach acid production by stopping the stomach's acid pump - the final step of acid secretion. The FDA has approved use of omeprazole for short-term treatment of ulcer disease. Similar drugs, including lansoprazole, are currently being studied.
Mucosal protective medications--Mucosal protective medications protect the stomach's mucous lining from acid. Unlike H2-blockers and acid pump inhibitors, protective agents do not inhibit the release of acid. These medications shield the stomach's mucous lining from the damage of acid. Two commonly prescribed protective agents are: Sucralfate (Carafate) and Misoprostol (Cytotec). Sucralfate adheres to the ulcer, providing a protective barrier that allows the ulcer to heal and inhibits further damage by stomach acid. Sucralfate is approved for short-term treatment of duodenal ulcers and for maintenance treatment. Misoprostol (Cytotec) is a synthetic prostaglandin, a substance naturally produced by the body, protects the stomach lining by increasing mucus and bicarbonate production and by enhancing blood flow to the stomach. It is approved only for the prevention of NSAID-induced ulcers.
Two common non-prescription protective medications are: Antacids and Antibiotics. Antacids can offer temporary relief from ulcer pain by neutralizing stomach acid. They may also have a mucosal protective role. Many brands of antacids are available without prescription. Bismuth subsalicylate has both a protective effect and an antibacterial effect against H.pylori. The discovery of the link between ulcers and H.pylori has resulted in a new treatment option. Now, in addition to treatment aimed at decreasing the production of stomach acid, doctors may prescribe antibiotics for patients with H.pylori. This treatment is a dramatic medical advance because eliminating H.pylori means the ulcer may now heal and most likely will not come back. The most effective therapy, according to the NIH Panel, is a 2-week, triple therapy. This regimen eradicates the bacteria and reduces the risk of ulcer recurrence in 90 percent of people with duodenal ulcers. People with stomach ulcers that are not associated with NSAIDs also benefit from bacterial eradication. While triple therapy is effective, it is sometimes difficult to follow because the patient must take three different medications four times each day for 2 weeks.
Typical 2-week, triple therapy Metronidazole 4 times a day Tetracycline (or amoxicillin) 4 times a day Bismuth subsalicylate 4 times a day Typical 2-week, dual therapy Amoxicillin 2 to 4 times a day, or clarithromycin 3 times a day Omeprazole 2 times a day
In addition, the treatment commonly causes side effects such as yeast infection in women, stomach upset, nausea, vomiting, bad taste, loose or dark bowel movements, and dizziness. The 2-week, triple therapy combines two antibiotics, tetracycline (e.g., Achromycin or Sumycin) and metronidazole (e.g., Flagyl) with bismuth subsalicylate (Pepto-Bismol). Some doctors may add an acid-suppressing drug to relieve ulcer pain and promote ulcer healing. In some cases, doctors may substitute amoxicillin (e.g., Amoxil or Trimox) for tetracycline or if they expect bacterial resistance to metronidazole, other antibiotics such as clarithromycin (Biaxin). As an alternative to triple therapy, several 2-week, dual therapies are about 80 percent effective. Dual therapy is simpler for patients to follow and causes fewer side effects. A dual therapy might include an antibiotic, such as amoxicillin or clarithromycin, with omeprazole, a drug that stops the production of acid. Again, an accurate diagnosis is important. Accurate diagnosis and appropriate treatment prevent people without ulcers from needless exposure to the side effects of antibiotics and should lessen the risk of bacteria developing resistance to antibiotics.
Although all of the above antibiotics are sold in the United States, the FDA has not yet approved the use of antibiotics for treatment of H.pylori or ulcers. Doctors may choose to prescribe antibiotics to their ulcer patients as "off label" prescriptions as they do for many conditions.
When Is Surgery Needed? In most cases, anti-ulcer medicines heal ulcers quickly and effectively. Eradication of H.pylori prevents most ulcers from recurring. However, people who do not respond to medication or who develop complications may require surgery. While surgery is usually successful in healing ulcers and preventing their recurrence and future complications, problems can sometimes result. At present, standard open surgery is performed to treat ulcers. In the future, surgeons may use laparoscopic methods. A laparoscope is a long tube-like instrument with a camera that allows the surgeon to operate through small incisions while watching a video monitor. The common types of surgery for ulcers--vagotomy, pyloroplasty, and antrectomy are described below:
Vagotomy: A vagotomy involves cutting the vagus nerve, a nerve that transmits messages from the brain to the stomach. Interrupting the messages sent through the vagus nerve reduces acid secretion. However, the surgery may also interfere with stomach emptying. The newest variation of the surgery involves cutting only parts of the nerve that control the acid-secreting cells of the stomach, thereby avoiding the parts that influence stomach emptying.
Antrectomy: Another surgical procedure is the antrectomy. This operation removes the lower part of the stomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. Sometimes a surgeon may also remove an adjacent part of the stomach that secretes pepsin and acid. A vagotomy is usually done in conjunction with an antrectomy.
Pyloroplasty: Pyloroplasty is another surgical procedure that may be performed along with a vagotomy. Pyloroplasty enlarges the opening into the duodenum and small intestine (pylorus), enabling contents to pass more freely from the stomach.
What Are the Complications of Ulcers? People with ulcers may experience serious complications if they do not get treatment. The most common problems include bleeding, perforation of the organ walls, and narrowing and obstruction of digestive tract passages.
Bleeding: As an ulcer eats into the muscles of the stomach or duodenal wall, blood vessels may also be damaged, which causes bleeding. If the affected blood vessels are small, the blood may slowly seep into the digestive tract. Over a long period of time, a person may become anemic and feel weak, dizzy, or tired. If a damaged blood vessel is large, bleeding is dangerous and requires prompt medical attention. Symptoms include feeling weak and dizzy when standing, vomiting blood, or fainting. The stool may become a tarry black color from the blood. Most bleeding ulcers can be treated endoscopically - the ulcer is located and the blood vessel is cauterized with a heating device or injected with material to stop bleeding. If endoscopic treatment is unsuccessful, surgery may be required.
Perforation: Sometimes an ulcer causes a hole in the wall of the stomach or duodenum. Bacteria and partially digested food can spill through the opening into the sterile abdominal cavity (peritoneum). This causes peritonitis, an inflammation of the abdominal cavity and wall. A perforated ulcer that can cause sudden, sharp, severe pain usually requires immediate hospitalization and surgery.
Narrowing and obstruction: Ulcers located at the end of the stomach where the duodenum is attached, can cause swelling and scarring, which can narrow or close the intestinal opening. This obstruction can prevent food from leaving the stomach and entering the small intestine. As a result, a person may vomit the contents of the stomach. Endoscopic balloon dilation, a procedure that uses a balloon to force open a narrow passage, may be performed. If the dilation does not relieve the problem, then surgery may be necessary.
Points to Remember: An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where the digestive fluids acid and pepsin are present. Recent research shows that most ulcers develop as a result of infection with bacteria called Helicobacter pylori (H.pylori). The bacteria produce substances that weaken the stomach's protective mucus and make the stomach more susceptible to damaging effects of acid and pepsin. H.pylori can also cause the stomach to produce more acid. Although acid and pepsin and lifestyle factors such as stress and smoking cigarettes play a role in ulcer formation, H.pylori is now considered the primary cause. Nonsteroidal anti-inflammatory drugs such as aspirin make the stomach vulnerable to the harmful effects of acid and pepsin, leading to an increased chance of stomach ulcers. Ulcers do not always cause symptoms. When they do, the most common symptom is a gnawing or burning pain in the abdomen between the breastbone and navel. Some people have nausea, vomiting, and loss of appetite and weight. Bleeding from an ulcer may occur in the stomach and duodenum. Symptoms may include weakness and stool that appears tarry or black. However, sometimes people are not aware they have a bleeding ulcer because blood may not be obvious in the stool. Ulcers are diagnosed with x-ray or endoscopy. The presence of H.pylori may be diagnosed with a blood test, breath test, or tissue test. Once an ulcer is diagnosed and treatment begins, the doctor will usually monitor progress. Doctors treat ulcers with several types of medicines aimed at reducing acid production, including H2-blockers, acid pump inhibitors, and mucosal protective drugs. When treating H.pylori, these medications are used in combination with antibiotics. According to an NIH panel, the most effective treatment for H.pylori is a 2-week, triple therapy of metronidazole, tetracycline or amoxicillin, and bismuth subsalicylate. Surgery may be necessary if an ulcer recurs or fails to heal or if complications such as bleeding, perforation, or obstruction develop.
Conclusion: Although ulcers may cause discomfort, rarely are they life threatening. With an understanding of the causes and proper treatment, most people find relief. Eradication of H.pylori infection is a major medical advance that can permanently cure most peptic ulcer diseases.
Inflammatory bowel disease (IBD) is a group of chronic disorders that cause inflammation or ulceration in the small and large intestines. Most often IBD is classified as ulcerative colitis or Crohn's disease but may be referred to as colitis, enteritis, ileitis, and proctitis.
Ulcerative colitis causes ulceration and inflammation of the inner lining of the colon and rectum, while Crohn's disease is an inflammation that extends into the deeper layers of the intestinal wall. Crohn's disease also may affect other parts of the digestive tract, including the mouth, esophagus, stomach, and small intestine.
Ulcerative colitis and Crohn's disease cause similar symptoms that often resemble other conditions, such as irritable bowel syndrome (spastic colitis). The correct diagnosis may take some time.
In ulcerative colitis, the inner lining of the large intestine (colon or bowel) and rectum becomes inflamed. The inflammation usually begins in the rectum and lower (sigmoid) intestine and spreads upward to the entire colon. Ulcerative colitis rarely affects the small intestine except for the lower section, the ileum. The inflammation causes the colon to empty frequently, resulting in diarrhea. As cells on the surface of the lining of the colon die and slough off, ulcers (tiny open sores) form, causing pus, mucus, and bleeding. An estimated 250,000 Americans have ulcerative colitis. It occurs most often in young people ages 15 to 40, although children and older people sometimes develop the disease. Ulcerative colitis affects males and females equally and appears to run in some families.
1) What Are the Symptoms of Ulcerative Colitis?
The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may suffer fatigue, weight loss, loss of appetite, rectal bleeding, and loss of body fluids and nutrients. Severe bleeding can lead to anemia. Sometimes patients also have skin lesions, joint pain, inflammation of the eyes, or liver disorders. No one knows for sure why problems outside the bowel are linked with colitis. Scientists think these complications may occur when the immune system triggers inflammation in other parts of the body. These disorders are usually mild and go away when the colitis is treated.
2) What Causes Ulcerative Colitis?
The cause of ulcerative colitis is not known, and currently there is no cure, except through surgical removal of the colon. Many theories about what causes ulcerative colitis exist, but none has been proven. The current leading theory suggests that some agent, possibly a virus or an atypical bacterium, interacts with the body's immune system to trigger an inflammatory reaction in the intestinal wall.
Although much scientific evidence shows that people with ulcerative colitis have abnormalities of the immune system, doctors do not know whether these abnormalities are a cause or result of the disease. Doctors believe, however, that there is little proof that ulcerative colitis is caused by emotional distress or sensitivity to certain foods or food products or is the result of an unhappy childhood.
3) How Is Ulcerative Colitis Diagnosed?
If you have symptoms that suggest ulcerative colitis, the doctor will look inside your rectum and colon through a flexible tube (endoscope) inserted through the anus. During the exam, the doctor may take a sample of tissue (biopsy) from the lining of the colon to view under the microscope. You also may receive a barium enema x-ray of the colon to determine the nature and extent of disease. This procedure involves putting a chalky solution (barium) into the colon. The barium shows up white on x-ray film, revealing growths and other abnormalities in the colon.
The doctor will give you a thorough physical exam, including blood tests to see if you are anemic (as a result of blood loss), or if your white blood cell count is elevated (a sign of inflammation). Examination of a stool sample can tell the doctor if an infection, such as by amoebae or bacteria, is causing the symptoms.
If you have ulcerative colitis, you may need medical care for some time. Your doctor also will want to see you regularly to check on the condition.
4) What Is the Treatment?
While no special diet for ulcerative colitis is given, patients may be able to control mild symptoms simply by avoiding foods that seem to upset their intestine. In some cases, the doctor may advise avoiding highly seasoned foods or milk sugar (lactose) for a while. When treatment is necessary, it must be tailored for each case, since what may help one patient may not help another. The patient also should be given needed emotional and psychological support.
Patients with either mild or severe colitis are usually treated with the drug sulfasalazine. This drug can be used for as long as needed, and it can be used along with other drugs. Side effects such as nausea, vomiting, weight loss, heartburn, diarrhea, and headache occur in a small percentage of cases. Patients who do not do well on sulfasalazine often do very well on related drugs known as 5-ASA agents.
In some cases, patients with severe disease, or those who cannot take sulfasalazine-type drugs, are given adrenal steroids (drugs that help control inflammation and affect the immune system) such as prednisone or hydrocortisone. All of these drugs can be used in oral, enema, or suppository forms. Other drugs may be given to relax the patient or to relieve pain, diarrhea, or infection.
Patients with ulcerative colitis occasionally have symptoms severe enough to require hospitalization. In these cases, the doctor will try to correct malnutrition and to stop diarrhea and loss of blood, fluids, and mineral salts. To accomplish this, the patient may need a special diet, feeding through a vein, medications or surgery.
The risk of colon cancer is greater than normal in patients with widespread ulcerative colitis. The risk may be as high as 32 times the normal rate in patients whose entire colon is involved, especially if the colitis exists for many years. However, if only the rectum and lower colon are involved, the risk of cancer is not higher than normal.
Sometimes precancerous changes occur in the cells lining the colon. These changes in the cells are called "dysplasia." If the doctor finds evidence of dysplasia through endoscopic exam and biopsy, it means the patient is more likely to develop cancer. Patients with dysplasia, or whose colitis affects the entire colon, should receive regular followup exams, which may involve colonoscopy (examination of the entire colon using a flexible endoscope) and biopsies.
About 20 to 25 percent of ulcerative colitis patients eventually require surgery for removal of the colon because of massive bleeding, chronic debilitating illness, perforation of the colon, or risk of cancer. Sometimes the doctor will recommend removing the colon when medical treatment fails or the side effects of steroids or other drugs threaten the patient's health.
Patients have several surgical options, each of which has advantages and disadvantages. The surgeon and patient must decide on the best individual option.
The most common surgery is the proctocolectomy, the removal of the entire colon and rectum, with ileostomy, creation of a small opening in the abdominal wall where the tip of the lower small intestine, the ileum, is brought to the skin's surface to allow drainage of waste. The opening (stoma) is about the size of a quarter and is usually located in the right lower corner of the abdomen in the area of the beltline. A pouch is worn over the opening to collect waste and the patient empties the pouch periodically.
The proctocolectomy with continent ileostomy is an alternative to the standard ileostomy. In this operation, the surgeon creates a pouch out of the ileum inside the wall of the lower abdomen. The patient is able to empty the pouch by inserting a tube through a small leak-proof opening in his or her side. Creation of this natural valve eliminates the need for an external appliance. However, the patient must wear an external pouch for the first few months after the operation.
Sometimes an operation that avoids the use of a pouch can be performed. In the ileoanal anastomosis ("pullthrough operation"), the diseased portion of the colon is removed and the outer muscles of the rectum are preserved. The surgeon attaches the ileum inside the rectum, forming a pouch, or reservoir, that holds the waste. This allows the patient to pass stool through the anus in a normal manner, although the bowel movements may be more frequent and watery than usual.
The decision about which surgery to have is made according to each patient's needs, expectations, and lifestyle. If you are ever faced with this decision, remember that getting as much information as possible is important. Talk to your doctor, to nurses who work with patients who have had colon surgery (enterostomal therapists), and to other patients. In addition, read pamphlets and books, such as those available from the Crohn's & Colitis Foundation of America, before you decide.
Most people with ulcerative colitis will never need to have surgery. If surgery ever does become necessary, you may find comfort in knowing that after the surgery, the colitis is cured and most people go on to live normal, active lives.
Inflammatory bowel disease (IBD) is a group of chronic disorders that cause inflammation or ulceration in the small and large intestines. Most often IBD is classified as ulcerative colitis or Crohn's disease but may be referred to as colitis, enteritis, ileitis, and proctitis.
Ulcerative colitis causes ulceration and inflammation of the inner lining of the colon and rectum, while Crohn's disease is an inflammation that extends into the deeper layers of the intestinal wall.
Ulcerative colitis and Crohn's disease cause similar symptoms that often resemble other conditions such as irritable bowel syndrome (spastic colitis). The correct diagnosis may take some time.
Crohn's disease usually involves the small intestine, most often the lower part (the ileum). In some cases, both the small and large intestine (colon or bowel) are affected. In other cases, only the colon is involved. Sometimes, inflammation also may affect the mouth, esophagus, stomach, duodenum, appendix, or anus. Crohn's disease is a chronic condition and may recur at various times over a lifetime. Some people have long periods of remission, sometimes for years, when they are free of symptoms. There is no way to predict when a remission may occur or when symptoms will return.
1) What Are the Symptoms?
The most common symptoms of Crohn's disease are abdominal pain, often in the lower right area, and diarrhea. There also may be rectal bleeding, weight loss, and fever. Bleeding may be serious and persistent, leading to anemia (low red blood cell count). Children may suffer delayed development and stunted growth.
2) What Causes Crohn's Disease and Who Gets It?
There are many theories about what causes Crohn's disease, but none has been proven. One theory is that some agent, perhaps a virus or a bacterium, affects the body's immune system to trigger an inflammatory reaction in the intestinal wall. Although there is a lot of evidence that patients with this disease have abnormalities of the immune system, doctors do not know whether the immune problems are a cause or a result of the disease. Doctors believe, however, that there is little proof that Crohn's disease is caused by emotional distress or by an unhappy childhood.
Crohn's disease affects males and females equally and appears to run in some families. About 20 percent of people with Crohn's disease have a blood relative with some form of inflammatory bowel disease, most often a brother or sister and sometimes a parent or child.
3) How Does Crohn's Disease Affect Children?
Women with Crohn's disease who are considering having children can be comforted to know that the vast majority of such pregnancies will result in normal children. Research has shown that the course of pregnancy and delivery is usually not impaired in women with Crohn's disease. Even so, it is a good idea for women with Crohn's disease to discuss the matter with their doctors before pregnancy. Children who do get the disease are sometimes more severely affected than adults, with slowed growth and delayed sexual development in some cases.
4) How Is Crohn's Disease Diagnosed?
If you have experienced chronic abdominal pain, diarrhea, fever, weight loss, and anemia, the doctor will examine you for signs of Crohn's disease. The doctor will take a history and give you a thorough physical exam. This exam will include blood tests to find out if you are anemic as a result of blood loss, or if there is an increased number of white blood cells, suggesting an inflammatory process in your body. Examination of a stool sample can tell the doctor if there is blood loss, or if an infection by a parasite or bacteria is causing the symptoms.
The doctor may look inside your rectum and colon through a flexible tube (endoscope) that is inserted through the anus. During the exam, the doctor may take a sample of tissue (biopsy) from the lining of the colon to look at under the microscope.
Later, you also may receive x-ray examinations of the digestive tract to determine the nature and extent of disease. These exams may include an upper gastrointestinal (GI) series, a small intestinal study, and a barium enema intestinal x-ray. These procedures are done by putting the barium, a chalky solution, into the upper or lower intestines. The barium shows up white on x-ray film, revealing inflammation or ulceration and other abnormalities in the intestine.
If you have Crohn's disease, you may need medical care for a long time. Your doctor also will want to test you regularly to check on your condition.
5) What Is the Treatment?
Several drugs are helpful in controlling Crohn's disease, but at this time there is no cure. The usual goals of therapy are to correct nutritional deficiencies; to control inflammation; and to relieve abdominal pain, diarrhea, and rectal bleeding.
Abdominal cramps and diarrhea may be helped by drugs. The drug sulfasalazine often lessens the inflammation, especially in the colon. This drug can be used for as long as needed, and it can be used along with other drugs. Side effects such as nausea, vomiting, weight loss, heartburn, diarrhea, and headache occur in a small percentage of cases. Patients who do not do well on sulfasalazine often do very well on related drugs known as mesalamine or 5-ASA agents. More serious cases may require steroid drugs, antibiotics, or drugs that affect the body's immune system such as azathioprine or 6-mercaptopurine (6-MP).
6) Can Diet Control Crohn's Disease?
No special diet has been proven effective for preventing or treating this disease. Some people find their symptoms are made worse by milk, alcohol, hot spices, or fiber. But there are no hard and fast rules for most people. Follow a good nutritious diet and try to avoid any foods that seem to make your symptoms worse. Large doses of vitamins are useless and may even cause harmful side effects.
Your doctor may recommend nutritional supplements, especially for children with growth retardation. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need periods of feeding by vein. This can help patients who temporarily need extra nutrition, those whose bowels need to rest, or those whose bowels cannot absorb enough nourishment from food taken by mouth.
7) What Are the Complications of Crohn's Disease?
The most common complication is blockage (obstruction) of the intestine. Blockage occurs because the disease tends to thicken the bowel wall with swelling and fibrous scar tissue, narrowing the passage. Crohn's disease also may cause deep ulcer tracts that burrow all the way through the bowel wall into surrounding tissues, into adjacent segments of intestine, into other nearby organs such as the urinary bladder or vagina, or into the skin. These tunnels are called fistulas. They are a common complication and often are associated with pockets of infection or abcesses (infected areas of pus). The areas around the anus and rectum often are involved. Sometimes fistulas can be treated with medicine, but in many cases they must be treated surgically.
Crohn's disease also can lead to complications that affect other parts of the body. These systemic complications include various forms of arthritis, skin problems, inflammation in the eyes or mouth, kidney stones, gallstones, or other diseases of the liver and biliary system. Some of these problems respond to the same treatment as the bowel symptoms, but others must be treated separately.
8) Is Surgery Often Necessary?
Crohn's disease can be helped by surgery, but it cannot be cured by surgery. The inflammation tends to return in areas of the intestine next to the area that has been removed. Many Crohn's disease patients require surgery, either to relieve chronic symptoms of active disease that does not respond to medical therapy or to correct complications such as intestinal blockage, perforation, abscess, or bleeding. Drainage of abscesses or resection (removal of a section of bowel) due to blockage are common surgical procedures.
Sometimes the diseased section of bowel is removed. In this operation, the bowel is cut above and below the diseased area and reconnected. Infrequently some people must have their colons removed (colectomy) and an ileostomy created.
In an ileostomy, a small opening is made in the front of the abdominal wall, and the tip of the lower small intestine (ileum) is brought to the skin's surface. This opening, called a stoma, is about the size of a quarter or a 50-cent piece. It usually is located in the right lower corner of the abdomen in the area of the beltline. A bag is worn over the opening to collect waste, and the patient empties the bag periodically. The majority of patients go on to live normal, active lives with an ostomy.
The fact that Crohn's disease often recurs after surgery makes it very important for the patient and doctor to consider carefully the benefits and risks of surgery compared with other treatments. Remember, most people with this disease continue to lead useful and productive lives. Between periods of disease activity, patients may feel quite well and be free of symptoms. Even though there may be long-term needs for medicine and even periods of hospitalization, most patients are able to hold productive jobs, marry, raise families, and function successfully at home and in society.
There is a whole constellation of symptoms which fall into the realm of the Irritable Bowel Syndrome or nervous stomach. This frequently has been called Spastic Colitis. This is not a disease but rather a group of symptoms which may be attributed to stress, tension and anxiety. The symptoms may be diarrhea, diarrhea alternating with constipation, constipation, mucus in the stools and abdominal pain. Often the diagnosis is made after a reasonable medical evaluation is performed to rule out other causes of the symptoms. There will soon be an explosion of medications that allow us to treat nervous stomach or irritable syndrome much more effectively.
It's now very clear that Irritable Bowel Syndrome has several different manifestations. It can be constipation predominant, diarrhea predominate, or alternating diarrhea and constipation. Currently there are medications that target these different types of Irritable Bowel Syndrome.
Now there seems to be evidence that there may be some genetic component to your will bowel syndrome. Much research is being done and should dramatically change the way we treat it over the next several years.
Hemochromatosis is the #1 genetic killer in the U.S., affecting nearly two million Americans, yet most victims are unaware that they have it. Hemochromatosis is also very common in Europe and Western Africa. If left undetected and untreated, hemochromatosis is fatal in most cases.
Hemochromatosis is an inherited disorder of the small intestine that causes a person to absorb too much iron from his food. Over time, iron builds to toxic levels and destroys many organs. Symptoms of toxic iron excess can differ greatly from person to person. Symptoms might include fatigue or depression, arthritis, impotence and infertility, diabetes, heart disease, and liver disease or liver cancer. Fortunately, early detection and treatment will prevent iron excess and its toxic effects.
Although hemochromatosis is widespread, the blood test for it, called a "fasting Percent TIBC Saturation" (percent TIBC SAT), is rarely included in general screenings. A 1994 study in the Archives Of Internal Medicine showed the cost effectiveness of the test "over a wide range" of conditions and recommended adding the test to routine blood screens. The test costs $40-$60 in most areas and is covered by many insurance plans.
The Hemochromatosis Foundation is a nonprofit organization that has worked for nearly twenty years to improve the lives of people with hemochromatosis. For more information about the disease, screening events in your area, or how you can help in finding the cure for hemochromatosis, contact your local chapter, or write to:
PO Box 8569
Albany, NY 12208
1) What is Lactose Intolerance?
Lactose intolerance is the inability to digest significant amounts of lactose, the predominant sugar of milk. This inability results from a shortage of the enzyme lactase, which is normally produced by the cells that line the small intestine. Lactase breaks down milk sugar into simpler forms that can then be absorbed into the bloodstream. When there is not enough lactase to digest the amount of lactose consumed, the results, although not usually dangerous, may be very distressing. While not all persons deficient in lactase have symptoms, those who do are considered to be lactose intolerant.
Common symptoms include nausea, cramps, bloating, gas, and diarrhea, which begin about 30 minutes to 2 hours after eating or drinking foods containing lactose. The severity of symptoms varies depending on the amount of lactose each individual can tolerate.
Some causes of lactose intolerance are well known. For instance, certain digestive diseases and injuries to the small intestine can reduce the amount of enzymes produced. In rare cases, children are born without the ability to produce lactase. For most people, though, lactase deficiency is a condition that develops naturally over time. After about the age of 2 years, the body begins to produce less lactase. However, many people may not experience symptoms until they are much older.
Between 30 and 50 million Americans are lactose intolerant. Certain ethnic and racial populations are more widely affected than others. As many as 75 percent of all African-Americans and Native Americans and 90 percent of Asian-Americans are lactose intolerant. The condition is least common among persons of northern European descent.
2) How Is Lactose Intolerance Diagnosed?
The most common tests used to measure the absorption of lactose in the digestive system are the lactose tolerance test, the hydrogen breath test, and the stool acidity test. These tests are performed on an outpatient basis at a hospital, clinic, or doctor's office.
The lactose tolerance test begins with the individual fasting (not eating) before the test and then drinking a liquid that contains lactose. Several blood samples are taken over a 2-hour period to measure the person's blood glucose (blood sugar) level, which indicates how well the body is able to digest lactose.
Normally, when lactose reaches the digestive system, the lactase enzyme breaks down lactase into glucose and galactose. The liver then changes the galactose into glucose, which enters the bloodstream and raises the person's blood glucose level. If lactose is incompletely broken down the blood glucose level does not rise, and a diagnosis of lactose intolerance is confirmed.
The hydrogen breath test measures the amount of hydrogen in the breath. Normally, very little hydrogen is detectable in the breath. However, undigested lactose in the colon is fermented by bacteria, and various gases, including hydrogen, are produced. The hydrogen is absorbed from the intestines, carried through the bloodstream to the lungs, and exhaled. In the test, the patient drinks a lactose-loaded beverage, and the breath is analyzed at regular intervals. Raised levels of hydrogen in the breath indicate improper digestion of lactose. Certain foods, medications, and cigarettes can affect the test's accuracy and should be avoided before taking the test. This test is available for children and adults.
The lactose tolerance and hydrogen breath tests are not given to infants and very young children who are suspected of having lactose intolerance. A large lactose load may be dangerous for very young individuals because they are more prone to dehydration that can result from diarrhea caused by the lactose. If a baby or young child is experiencing symptoms of lactose intolerance, many pediatricians simply recommend changing from cow's milk to soy formula and waiting for symptoms to abate.
If necessary, a stool acidity test, which measures the amount of acid in the stool, may be given to infants and young children. Undigested lactose fermented by bacteria in the colon creates lactic acid and other short-chain fatty acids that can be detected in a stool sample. In addition, glucose may be present in the sample as a result of unabsorbed lactose in the colon.
3) How Is Lactose Intolerance Treated?
Fortunately, lactose intolerance is relatively easy to treat. No treatment exists to improve the body's ability to produce lactase, but symptoms can be controlled through diet.
Young children with lactase deficiency should not eat any foods containing lactose. Most older children and adults need not avoid lactose completely, but individuals differ in the amounts of lactose they can handle. For example, one person may suffer symptoms after drinking a small glass of milk, while another can drink one glass but not two. Others may be able to manage ice cream and aged cheeses, such as cheddar and Swiss but not other dairy products. Dietary control of lactose intolerance depends on each person's learning through trial and error how much lactose he or she can handle.
For those who react to very small amounts of lactose or have trouble limiting their intake of foods that contain lactose, lactase enzymes are available without a prescription. One form is a liquid for use with milk. A few drops are added to a quart of milk, and after 24 hours in the refrigerator, the lactose content is reduced by 70 percent. The process works faster if the milk is heated first, and adding a double amount of lactase liquid produces milk that is 90 percent lactose free. A more recent development is a chewable lactase enzyme tablet that helps people digest solid foods that contain lactose. Three to six tablets are taken just before a meal or snack.
Lactose-reduced milk and other products are available at many supermarkets. The milk contains all of the nutrients found in regular milk and remains fresh for about the same length of time or longer if it is super-pasteurized.
4) How Is Nutrition Balanced?
Milk and other dairy products are a major source of nutrients in the American diet. The most important of these nutrients is calcium. Calcium is essential for the growth and repair of bones throughout life. In the middle and later years, a shortage of calcium may lead to thin, fragile bones that break easily (a condition called osteoporosis). A concern, then, for both children and adults with lactose intolerance, is getting enough calcium in a diet that includes little or no milk.
The recommended dietary allowance (RDA) for calcium, revised in 1989 by the Food and Nutrition Board of the National Academy of Sciences, varies by age group. Infants up to 5 months need 400 mg per day, and from 5 months to 1 year, 600 mg. Children 1 to 10 years need 800 mg and 11- to 24-year-olds need 1,200 mg. Pregnant and nursing women also need 1,200 mg per day, and people age 25 and older need 800 mg per day. However, the results of a 1984 conference at the National Institutes of Health (NIH) suggest that women who have not yet reached menopause and older women who are taking the hormone estrogen after menopause should consume about 1,000 mg of calcium daily (roughly the amount in a quart of milk).
In planning meals, making sure that each day's diet includes enough calcium is important, even if the diet does not contain dairy products. Many nondairy foods are high in calcium. Green vegetables, such as broccoli and kale, and fish with soft, edible bones, such as salmon and sardines, are excellent sources of calcium.
Recent research shows that yogurt with active cultures may be a good source of calcium for many people with lactose intolerance, even though it is fairly high in lactose. Evidence shows that the bacterial cultures used in making yogurt produce some of the lactase enzyme required for proper digestion.
Clearly, many foods can provide the calcium and other nutrients the body needs, even when intake of milk and dairy products is limited. However, factors other than calcium and lactose content should be kept in mind when planning a diet. Even though some vegetables are high in calcium (Swiss chard, spinach, and rhubarb, for instance), the body cannot use their calcium content. They contain substances called oxalates, which stop calcium absorption. Calcium is absorbed and used only when there is enough vitamin D in the body. A balanced diet should provide an adequate supply of vitamin D. Sources of vitamin D include eggs and liver. However, sunlight helps the body naturally absorb or synthesize vitamin D, and with enough exposure to the sun, food sources may not be necessary.
Some people with lactose intolerance may think they are not getting enough calcium and vitamin D in their diet. Consultation with a doctor or dietitian may be helpful in deciding whether any dietary supplements are needed. Taking vitamins or minerals of the wrong kind or in the wrong amounts can be harmful. A dietitian can help in planning meals that will provide the most nutrients with the least chance of causing discomfort.
5) What Is Hidden Lactose?
Although milk and foods made from milk are the only natural sources, lactose is often added to prepared foods. People with very low tolerance for lactose should know about the many food products that may contain lactose, even in small amounts. Food products that may contain lactose include:
Bread and other baked goods
Processed breakfast cereals.
Instant potatoes, soups, and breakfast drinks.
Lunch meats (other than kosher)
Candies and other snacks.
Mixes for pancakes, biscuits, and cookies.
Some products labeled nondairy, such as powdered coffee creamer and whipped toppings, may also include ingredients that are derived from milk and therefore contain lactose.
Smart shoppers learn to read food labels with care, looking not only for milk and lactose among the contents but also for such words as whey, curds, milk by-products, dry milk solids, and nonfat dry milk powder. If any of these are listed on a label, the item contains lactose.
In addition, lactose is used as the base for more than 20 percent of prescription drugs and about 6 percent of over-the-counter medicines. Many types of birth control pills, for example, contain lactose, as do some tablets for stomach acid and gas. However, these products typically affect only people with severe lactose intolerance.
Even though lactose intolerance is widespread, it need not pose a serious threat to good health. People who have trouble digesting lactose can learn which dairy products and other foods they can eat without discomfort and which ones they should avoid. Many will be able to enjoy milk, ice cream, and other such products if they take them in small amounts or eat other food at the same time. Others can use lactase liquid or tablets to help digest the lactose. Even older women at risk for osteoporosis and growing children who must avoid milk and foods made with milk can meet most of their special dietary needs by eating greens, fish, and other calcium-rich foods that are free of lactose. A carefully chosen diet (with calcium supplements if the doctor or dietitian recommends them) is the key to reducing symptoms and protecting future health.
Hepatitis refers to inflammation of the liver. Most commonly we think of viral hepatitis caused by several different viruses - A, B, C, Delta and Infectious Mononucleosis. Medications may also cause hepatitis.
Hepatitis simply refers to inflammation of the liver. Anytime the liver is irritated or inflamed for whatever reason, not just viruses, we call that hepatitis. Causes include hepatitis viruses such as hepatitis a, hepatitis B, hepatitis C and in fact now there are others, mononucleosis, Epstein-Barr virus, and many other viruses.
In addition, hepatitis may be caused by medications, probably the most dramatic one is Tylenol. In fact that's why Tylenol intake should be limited although we all think of it as a drug with no side effects. There are many other medications that can cause hepatitis including cholesterol-lowering drugs, some heart medications, some antibiotics, and in fact the list is very long.
Currently becoming one of the most common causes of liver transplantation is something called Nonalcoholic Steatohepatitis. This is a condition in which one who does not drink alcohol has a disease whereby the liver appears, on biopsy, exactly like the person was drinking very heavily. There is another condition called Hepatic Steatosis. This is disease in which the liver has a large amount of fat within it yet appears to be a very benign condition that does not need specific treatment.
There are many other conditions that can cause hepatitis including Lyme disease, CMV infections, autoimmune diseases, and less common diseases confined to the liver. Obviously if you are ever told that your liver tests are high you should see your physician.
1) What Are Hemorrhoids?
Hemorrhoids are swollen but normally present blood vessels in and around the anus and lower rectum that stretch under pressure, similar to varicose veins in the legs.
The increased pressure and swelling may result from straining to move the bowel. Other contributing factors include pregnancy, heredity, aging, and chronic constipation or diarrhea.
Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external).
2) What Are the Symptoms of Hemorrhoids?
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as hemorrhoids.
Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days.
Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid.
Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid.
In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.
3) How Common Are Hemorrhoids?
Hemorrhoids are very common in men and women. About half of the population have hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.
4) How Are Hemorrhoids Diagnosed?
A thorough evaluation and proper diagnosis by the doctor is important if bleeding from the rectum or blood in the stool lasts more than a couple of days. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.
The doctor will examine the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.
Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.
To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.
5) What Is the Treatment?
Medical treatment of hemorrhoids initially is aimed at relieving symptoms. Measures to reduce symptoms include:
Warm tub or sitz baths several times a day in plain, warm water for about 10 minutes.
Ice packs to help reduce swelling.
Application of a hemorroidal cream or suppository to the affected area for a limited time.
Prevention of the recurrence of hemorrhoids is aimed at changing conditions associated with the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of fluid (not alcohol) result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.
Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel).
In some cases, hemorrhoids must be treated surgically. These methods are used to shrink and destroy the hemorrhoidal tissue and are performed under anesthesia. The doctor will preform the surgery during an office or hospital visit.
A number of surgical methods may be used to remove or reduce the size of internal hemorrhoids. These techniques include:
Rubber band ligation - A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.
Sclerotherapy - A chemical solution is injected around the blood vessel to shrink the hemorrhoid.
Techniques used to treat both internal and external hemorrhoids include:
Electrical or laser heat (laser coagulation) or infrared light (infrared photo coagulation) - Both techniques use special devices to burn hemorrhoidal tissue.
Hemorrhoidectomy - Occasionally, extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy. This is the best method for permanent removal of hemorrhoids.
6) How Are Hemorrhoids Prevented ?
The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass. In addition, a person should not sit on the toilet for a long period of time.
Constipation is the infrequent and difficult passage of stool. The frequency of bowel movements among healthy people varies greatly, ranging from three movements a day to three a week. As a rule, if more than 3 days pass without a bowel movement, the intestinal contents may harden, and a person may have difficulty or even pain during elimination. Stool may harden and be painful to pass even after shorter intervals between bowel movements.
1) What Are Some Common Misconceptions About Constipation?
Many false beliefs exist concerning proper bowel habits. One of these is that a bowel movement every day is necessary. Another common fallacy is that wastes stored in the body are absorbed and are dangerous to health or shorten the life span. These misconceptions have led to a marked overuse and abuse of laxatives. Every year, Americans spend $725 million on laxatives. Many are not needed and some are harmful.
2) What Are Some of the Causes of Constipation?
Constipation is a symptom, not a disease. Like a fever, constipation can be caused by many different conditions. Most people have experienced an occasional brief bout of constipation that has corrected itself with diet and time. The following is a list of some of the most common causes of constipation:
A main cause of constipation may be a diet high in animal fats (meats, dairy products, eggs) and refined sugar (rich desserts and other sweets), but low in fiber (vegetables, fruits, whole grains). Some studies have suggested that high-fiber diets result in larger stools, more frequent bowel movements, and therefore less constipation.
This is very common and results from misconceptions about what is normal and what is not. If recognized early enough, this type of constipation can be cured by informing the sufferer that the frequency of his or her bowel movements is normal.
Irritable Bowel Syndrome (IBS).
Also known as spastic colon, IBS is one of the most common causes of constipation in the United States. Some people develop spasms of the colon that delay the speed with which the contents of the intestine move through the digestive tract, leading to constipation.
Poor Bowel Habits.
A person can initiate a cycle of constipation by ignoring the urge to have a bowel movement. Some people do this to avoid using public toilets, others because they are too busy. After a period of time a person may stop feeling the urge. This leads to progressive constipation.
People who habitually take laxatives become dependent upon them and may require increasing dosages until, finally, the intestine becomes insensitive and fails to work properly.
People often experience constipation when traveling long distances, which may relate to changes in lifestyle, schedule, diet and drinking water.
Certain hormonal disturbances, such as an underactive thyroid gland, can produce constipation.
Pregnancy is another common cause of constipation. The reason may be partly mechanical in that the pressure of the heavy womb compresses the intestine, and may be partly due to hormonal changes during pregnancy.
Fissures and Hemorrhoids.
Painful conditions of the anus can produce a spasm of the anal sphincter muscle, which can delay a bowel movement.
Many diseases that affect the body tissues, such as scleroderma or lupus, and certain neurological or muscular diseases, such as multiple sclerosis, Parkinson's disease and stroke can be responsible for constipation.
Loss of Body Salts.
The loss of body salts through the kidneys or through vomiting or diarrhea is another cause of constipation.
Scarring, inflammation around diverticula, tumors and cancer can produce mechanical compression of the intestine and result in constipation.
Injuries to the spinal cord and tumors pressing on the spinal cord can produce constipation by affecting the nerves that lead to the intestine.
Many medications can cause constipation. These include pain medications (especially narcotics), antacids that contain aluminum, antispasmodic drugs, antidepressant drugs, tranquilizers, iron supplements, and anti-convulsants for epilepsy.
4) What Causes Constipation in Older Adults?
Older adults are five times more likely than younger adults to report problems with constipation. Poor diet, insufficient intake of fluids, lack of exercise, the use of certain drugs to treat other conditions, and poor bowel habits can result in constipation. Experts agree, however, that too often older people become overly concerned with having a bowel movement and that constipation is frequently an imaginary ailment.
Diet and dietary habits can play a role in developing constipation. Lack of interest in eating, a problem common to many single or widowed older people, may lead to heavy use of convenience foods, which tend to be low in fiber. In addition, loss of teeth may force older people to choose soft, processed foods, which also tend to be low in fiber.
Older people sometimes cut back on fluids, especially if they are not eating regular or balanced meals. Water and other fluids add bulk to stools, making bowel movements softer and easier to pass.
Prolonged bedrest, for example, after an accident or during an illness, and lack of exercise may contribute to constipation. Also, drugs prescribed for other conditions, such as antidepressants, antacids containing aluminium or calcium, antihistamines, diuretics, and antiparkinsonism drugs, can produce constipation in some people.
The preoccupation with bowel movements sometimes leads older people to depend heavily on laxatives, which can be habit forming. The bowel begins to rely on laxatives to bring on bowel movements, and over time, the natural mechanisms fail to work without the help of drugs. Habitual use of enemas also can lead to a loss of normal function.
5) What Diagnostic Tests Can Help Determine the Causes of Constipation?
Constipation may be caused by abnormalities or obstructions of the digestive system in some people. A doctor can perform tests to determine if constipation is the symptom of an underlying disorder.
In addition to routine blood, urine, and stool tests, a sigmoidoscopy may help detect problems in the rectum and lower colon. In this procedure, which can be done in the doctor's office, the doctor inserts a flexible, lighted instrument through the anus to examine the rectum and lower intestine. The doctor may perform a colonoscopy to inspect the entire colon. In colonoscopy, an instrument similar to the sigmoidoscope, but longer and able to follow the twists and turns of the entire large intestine, is used. A barium enema x-ray will provide similar information. If bleeding is present, a double-contrast barium enema is preferred. Other highly specialized techniques are available for measuring pressures and movements within the colon and its sphincter muscles, but these are used only in unusual cases.
6) Is Constipation Serious?
Although it may be extremely bothersome, constipation itself usually is not serious. However, it may signal and be the only noticeable symptom of a serious underlying disorder such as cancer. Constipation can lead to complications, such as hemorrhoids caused by extreme straining or fissures caused by the hard stool stretching the sphincters. Bleeding can occur for either of these reasons and appears as bright red streaks on the surface of the stool. Fissures may be quite painful and can aggravate the constipation that originally caused them. Fecal impactions tend to occur in very young children and in older adults and may be accompanied by a loss of control of stool, with liquid stool flowing around the hard impaction.
Occasionally, straining causes a small amount of intestinal lining to push out from the rectal opening. This condition is known as rectal prolapse and may lead to secretion of mucus that may stain underpants. In children, mucus may be a feature of cystic fibrosis.
7) When Is Medical Attention Needed?
The doctor should be notified when symptoms are severe, last longer than 3 weeks, or are disabling; or when any of the complications listed above occur. The doctor should be informed whenever a significant and prolonged change of usual bowel habits occurs.
8) What Is the Treatment for Constipation?
The first step in treating constipation is to understand that normal frequency varies widely, from three bowel movements a day to three a week. Each person must determine what is normal to avoid becoming dependent on laxatives.
For most people, dietary and lifestyle improvements can lessen the chances of constipation. A well-balanced diet that includes fiber-rich foods, such as unprocessed bran, whole-grain breads, and fresh fruits and vegetables, is recommended. Drinking plenty of fluids and exercising regularly will help to stimulate intestinal activity. Special exercises may be necessary to tone up abdominal muscles after pregnancy or whenever abdominal muscles are lax.
Bowel habits also are important. Sufficient time should be set aside to allow for undisturbed visits to the bathroom. In addition, the urge to have a bowel movement should not be ignored.
If an underlying disorder is causing constipation, treatment will be directed toward the specific cause. For example, if an underactive thyroid is causing constipation, the doctor may prescribe thyroid hormone replacement therapy.
In most cases, laxatives should be the last resort and taken only under a doctor's supervision. A doctor is best qualified to determine when a laxative is needed and which type is best. There are various types of oral laxatives, and they work in different ways. Above all, it is necessary to recognize that a successful treatment program requires persistent effort and time. Constipation does not occur overnight, and it is not reasonable to expect that constipation can be relieved overnight.
Bulk-forming laxatives are generally considered the safest laxative form but can interfere with the absorption of some drugs. These laxatives, which should be taken with 8 ounces of water, absorb water in the intestine and make the stool softer. Bulk laxatives include psyllium (Metamucil), methylcellulose(Citrucel), calcium polycarbophil (FiberCon), and bran (in food and supplements).
Stimulants cause rhythmic muscular contractions in the small or large intestine. These agents can lead to dependency and can damage the bowel with prolonged daily use. These products include phenolphthalein (Correctol, Ex-Lax), bisacodyl (Dulcolax), castor oil (Purge, Neoloid), and senna (Senokot, Fletcher's Castoria).
Stool softeners, or wetting agents, provide moisture to the stool and prevent excessive dehydration. These laxatives often are recommended after childbirth or surgery. Products include those with docusate (Colace, Dialose, and Surfak).
Osmotics are salts or carbohydrates that cause water to remain in the intestine for easier movement of stool. Laxatives in this group include milk of magnesia, citrate of magnesia, lactulose, and Epsom salts.
The frequency of bowel movements among healthy people varies from three movements a day to three a week. Individuals must determine what is normal. As a rule, constipation should be suspected if more than 3 days pass between bowel movements or if there is difficulty or pain when passing a hardened stool. Most people experience occasional short bouts of constipation, but if a laxative is necessary for longer than 3 weeks, check with a doctor.
Doctors agree that prevention is the best approach to constipation. While there is no way to ensure never experiencing constipation, the following guidelines should help:
Know what is normal and do not rely unnecessarily on laxatives.
Eat a well-balanced diet that includes unprocessed bran, whole wheat grains, fresh fruits and vegetables.
Drink plenty of fluids.
Set aside time after breakfast or dinner for undisturbed visits to the toilet.
Don't ignore the urge to defecate.
Whenever there is a significant or prolonged change in bowel habits, check with a doctor.
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