The intestinal tract (or bowel) ends with the rectum.  The last part of the rectum is a section about 1 1/2 inches long, known as the anal canal.  It ends with the anus—the opening to the outside of the body.  There are several common problems, including hemorrhoids,that can occur in the area from the rectum to the anus.  While almost everyone has heard of hemorrhoids, the other conditions are not so well known.

Anal Fissure

Most people have experienced a tear or fissure at the corner of the mouth that can occur in cold weather or when yawning.  Similarly, an anal fissure is a small tear in the lining of the anus, frequently caused by constipation.  A hard, dry bowel movement results in a break in the tissue.  However, fissures can also occur with severe bouts of diarrhea or inflammation.This results in the anus becoming dry and irritated, causing it to tear.  Injury to the anal area during childbirth and abuse of laxatives may be other causes.

A fissure can be quite painful during and immediately following bowel movements.  This is because the anus and anal canal are ringed with muscles to control the passage of stool and to keep the anus tightly closed at other times.  When those muscles expand, it stretches the fissure open.  There may also be bleeding or itching with an anal fissure.

Diagnosis

A simple visual examination of the anus and surrounding tissue usually reveals the fissure.  It is quite tender when examined by the physician.  Fissures are most often located in the middle posterior (back) section of the anus.

Treatment

More than half of all fissures heal either by themselves or with non-surgical treatment.  Stool softeners can help reduce pain during bowel movements.  Antibiotics may be used for a short time.  Special medicated creams may also be used, especially if the fissure has become ulcerated or infected.  It is important to keep the anus and area between the buttocks clean and dry.  After bathing, the patient should gently pat dry with a soft towel.  Applying talcum powder is frequently recommended.  Sitz baths may help relieve discomfort and promote healing.  A sitz bath is soaking the anal area in plain warm—not hot— water for 15-20 minutes several times a day.  If the fissure is not responding to treatment, the physician re-examines the patient.  There are conditions, such as muscle spasm or scarring that could interfere with the healing process.  Fissures that do not heal can be corrected with surgery.  It is a minor operation that is usually done on an outpatient basis.  The surgeon removes the fissure and any underlying scar tissue.  Cutting a small portion of the anal muscle prevents spasm.  This helps the area to heal and rarely interferes with the control of bowel movements.  Complete healing takes place in a few weeks.  However, the pain often disappears after a few days.

Over 90% of the patients who need surgery for fissures have no further problems.  Patients can help avoid the return of fissures by drinking at least eight glasses of water a day, and maintaining adequate fiber in the diet.  This prevents constipation, which is the cause of most fissures.

Anal Abscess and Fistula

An abscess is a localized pocket of pus caused by infection from bacteria.  It can occur in any part of the body.  When bacteria seep into the underlying tissues in the anal canal, an abscess may develop.  Certain conditions, such as Crohn’s disease (chronic inflammatory bowel disease), can increase the risk of abscess in and around the anal canal.  Patients with conditions that reduce the body’s immunity, such as cancer or AIDS, are also more likely to develop anal abscesses.

An abscess causes tenderness, swelling, and pain.  These symptoms clear when the abscess is drained.  The patient may also complain of fever, chills, and general weakness or fatigue.

A fistula is a tiny channel or tract that develops in the presence of inflammation and infection.  It may or may not be associated with an abscess, but like abscesses, certain illnesses such as Crohn’s disease can cause fistulas to develop.  The channel usually runs from the rectum to an opening in the skin around the anus.  However, sometimes the fistula opening develops elsewhere.  For example, in women with Crohn’s disease or obstetric injuries, the fistula could open into the vagina or bladder.

Since fistulas are infected channels, there is usually some drainage.  Often a draining fistula is not painful, but it can irritate the skin around it.  An abscess and fistula often occur together.  If the opening of the fistula seals over before the fistula is cured, an abscess may develop behind it.

Diagnosis

Diagnosis of an abscess is usually made on examination of the area.  If it is near the anus, there is always pain, and often redness and swelling.  The physician will look for an opening in the skin (a sign that a fistula has developed), and try to determine the depth and direction of the channel or tract of the fistula.  However, signs of fistula and abscess may not be present on the skin’s surface around the anus.  In this case, the physician uses an instrument called an anoscope to see inside the anal canal and lower rectum.

Whenever the physician finds an abscess, and especially a fistula, further tests are needed to be sure Crohn’s disease is not present.  Blood tests, x-rays, and a colonoscopy (a lighted, flexible scope exam of the bowel or colon) are often required.

Treatment for Anal Abscess

An abscess must be surgically opened to promote drainage and relieve pressure.  This is often done in the physician’s office under local anesthesia.  However, patients with a large or deep abscess, or those who have other conditions, such as diabetes, may be admitted to the hospital for the procedure.

Antibiotics cannot take the place of draining an abscess.  Antibiotics are carried by the bloodstream but do not reach the pus within the abscess.  However, they are usually prescribed along with surgical drainage, especially if the patient has other serious diseases, such as diabetes or those associated with reduced immunity.

Treatment for Anal Fistula

Treatment of anal fistula often varies, depending on whether Crohn’s disease is present.  Crohn’s disease is a chronic inflammation of the bowel, including the small and large intestine.  As noted, the physician will often do tests to see if this disease is present.  If it is, then prolonged treatment with a variety of medications, including antibiotics, is usually undertaken.  Often these medications will cure the infection and heal the fistula.

If Crohn’s disease is not present, it still may worthwhile to try a course of antibiotics.  If these do not work, surgery is usually very effective.  The surgeon opens the fistula channel so that healing occurs from the inside out.  Most of the time, fistula surgery is done on an outpatient basis or with a short hospital stay.  Following surgery, there may be mild to moderate discomfort for a few days, but patients usually have a short recovery period.

Summary

Bleeding, pain, or drainage from the anus can occur with several illnesses, so a physician should always be consulted.  Often the diagnosis is anal fissure, abscess, or fistula.  These are problems that are usually easy to diagnose and correct.  A variety of treatments, including surgery, are available to correct these conditions.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Anemia is simply defined as a low red blood cell count.  Red cells are produced inside the bone marrow.  The red cell is what makes the blood red.  Its only purpose is to carry oxygen to the body’s tissues which need it for healthy function.  Inside each red cell is a protein and iron combination that is called hemoglobin.  This can be measured.  A low hemoglobin level in the blood means anemia.  A second way to measure anemia is called the hematocrit.

Hemoglobin  12 to 16 gm% - females
                     14 to 18 gm% - males

Hematocrit  36 to 48 volumes% - females
                   42 to 53 volumes% - males

When these values fall below normal, it is called anemia.  There are not enough red cells in the body.  If you are a little bit below the normal range, it is called a mild anemia.  A bit more and it is moderate anemia.  And with values very below normal, it is severe anemia.

Symptoms

There are usually no symptoms with a mild anemia, unless the person is an athlete who finds his or her performance deteriorating.  A moderate anemia may cause some fatigue, drowsiness or even shortness of breath on exertion.  A severe anemia can cause severe fatigue.  In older patients or those with heart or vascular disease, there may be shortness of breath or chest pain with exertion, or even stroke-like symptoms.  However, if the anemia occurs very slowly, the individual often can tolerate a remarkably low red blood cell count, sometimes with very few symptoms.

Types of Anemia

There are many causes of anemia, so many it is not possible to cover them all.  However, there are certain major categories which are useful to know.

• Blood loss anemia (iron deficiency) - This most often occurs with a slow loss of blood and, with it, the body’s iron.  This usually occurs in the digestive tract and may be from ulcers in the stomach or duodenum, a cancer in the colon, or less commonly, from small broken blood vessels somewhere in the gut.  Females may lose a great deal of blood with excessive menstrual flow leading to iron deficiency anemia.  There are a number of conditions where iron in food is not absorbed through the intestinal tract.  These are called malabsorption problems which means the iron is not absorbed from the intestine.  One such condition is a hereditary disorder called celiac sprue, where the intestine is injured by the gluten protein in wheat.  In children from poor families, the diet may be deficient in iron and cause anemia.  This is called nutritional iron deficiency.

• Large red blood cell anemia (macrocytic anemia) - There are a number of causes where there is anemia, but the remaining red cells are increased in size.  This is called a macrocytic or large red cell anemia.  A deficiency of vitamin B 12, or pernicious anemia, is one example.  A lack of folic acid in the diet and severe liver disease, such as cirrhosis, are other causes of this type of anemia.  Folic acid deficiency is rare since folic acid is now added to so many foods by FDA requirements.

• Bone marrow failure - There are a number of reasons why the bone marrow may fail to produce enough red cells.  One is aplastic anemia, the cause of which is usually not known.  Certain drugs may also cause this problem.

• Red cell destruction (hemolytic anemia) - Certain immune disorders as well as some drugs and diseases may attack the red cells in the blood, destroying them and leading to anemia.

• Chronic kidney disease - There is an important hormone called erythropoietin that is made by the kidney.  It tells the bone marrow to make more red cells when there are not enough.  People with chronic kidney disease, especially when they require kidney dialysis, lack this hormone and therefore become anemic.

• Chronic illnesses and malignancies - Many types of malignancies, leukemias and chronic disorders such as tuberculosis or a combination of several chronic illnesses (lung, kidney, liver) may lead to an anemia.

Testing

As noted, anemia is present when the red cell count is low.  Simply measuring the size of the red blood cell and how much hemoglobin is in the cell will give a clue as to the cause.  The physician will usually need to do certain testing to arrive at a specific cause and so determine the necessary treatment.

• Blood studies - Measuring iron, vitamin B12, folic acid and certain other substances will often provide useful information.

• Imaging - X-rays of the stomach and intestinal tract may be done.  An ultrasound and CAT (CT) exam may also be necessary.

• Endoscopy - These are visual exams of the intestinal tract under sedation using a flexible viewing endoscope.  Ulcers of the stomach and cancers of the colon, both common causes of anemia, can be diagnosed this way.

• Others - There are times when all these tests do not provide an answer and additional tests such as a bone marrow biopsy may be recommended.

Treatment

Since there are so many causes for anemia, no single therapy is right for all.  If there is bleeding from a stomach ulcer, then the ulcer must be healed.  If there is blood loss from colon cancer, then, of course, the cancer needs to be surgically removed.  Likewise, if there is excessive menstrual flow, this must be corrected by medications or surgery.  Vitamin B 12 or folic acid deficiency are easily corrected once diagnosed.  Chronic kidney disease or a failure of the bone marrow to make red cells may not be as easily treated.  If the anemia is severe or causing disabling symptoms, then blood transfusions may be necessary.  However, taking oral iron or receiving a transfusion by themselves are never enough.  The underlying cause must always be sought.

Summary

The meaning of anemia is very simple, not enough red blood cells in the body to carry oxygen to the tissues.  The cause is usually found and corrected, However, there are instances when making the diagnosis may be difficult.  By working with the physician, a satisfactory outcome usually occurs.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The Liver

The liver is the largest organ in the body.  It is found high in the right upper abdomen, behind the ribs.  It is a very complex organ and has many functions.  They include:

• Storing energy in the form of sugar (glucose)

• Storing vitamins, iron, and other minerals

• Making proteins, including blood clotting factors, to keep the body healthy and help it grow

• Processing worn out red blood cells

• Making bile which is needed for food digestion

• Metabolizing or breaking down many medications and alcohol

• Killing germs that enter the body through the intestine

The liver is a resilient organ and has the capacity to regenerate.  However, the liver is also subject to illnesses that can lead to permanent damage.  One example is autoimmune hepatitis, a condition in which the body fights against its own liver.

What is Hepatitis?

When cells in the body are injured by such things as chemicals or infection, the area that is wounded becomes inflamed.  Hepatitis is inflammation of the liver, which in turn causes damage to individual liver cells.  It is most often caused by viral infection.  However, it can also be caused by alcohol, certain drugs, chemicals or poisons, or other diseases.

Hepatitis may be either acute or chronic.  In acute hepatitis, the inflammation develops quickly and lasts only a short period of time.  The patient usually recovers completely, but it can take up to several months.  Occasionally, a person fails to recover fully, and the hepatitis becomes chronic.  Chronic hepatitis can develop over a number of years without the patient ever having acute hepatitis or even feeling sick.  As the liver repairs itself, fibrous tissue develops, much like a scar forms after a cut or injury to the skin heals.  Advanced scarring of the liver is called cirrhosis.  Over time, cirrhosis irreversibly damages the liver, eventually resulting in liver failure.

What is Autoimmune Hepatitis?

The immune system consists of different types of white blood cells that help to fight infections.  Some of these cells produce antibodies.  Antibodies defend the body by destroying bacteria, viruses and other foreign materials.  There are different kinds of antibodies, each fighting against a specific foreign substance.  Thus, the immune system protects the body against outside invasion by germs.  But sometimes, the immune system mistakenly recognizes the body’s own organs as foreign.  It can develop antibodies against these organs.  This can cause various illnesses, such as rheumatoid arthritis and lupus.  These illnesses are called autoimmune disorders because the body is literally fighting against itself.

When the immune system attacks the liver in this way, it is called autoimmune hepatitis.  Autoimmune hepatitis is not caused by a virus or bacteria, so it is not a contagious disease.  Exactly what triggers the immune system against the liver is unknown.  The inflammation is usually chronic, and without treatment it can cause serious injury to the liver.

Symptoms and Diagnosis

Autoimmune hepatitis occurs mainly in adolescent or young adult women (about 70% of the time).  However, there have also been cases of older women and men developing the disease.  Early symptoms are the same as those for most types of hepatitis: fatigue, abdominal discomfort, and aching joints.  These early symptoms are sometimes mild and mistaken for other illnesses, such as the flu.  So, it is wise for people with these symptoms to consult a physician.  When autoimmune hepatitis progresses to severe cirrhosis, there may be jaundice (yellow coloring to the skin and eyes), marked swelling of the abdomen from fluid inside the abdomen, intestinal bleeding, or mental confusion.

The physician often suspects autoimmune hepatitis from the patient’s medical history.  For example, patients with other autoimmune diseases—thyroiditis, ulcerative colitis, diabetes mellitus, vitiligo (a patchy loss of pigment in the skin), Sjogren’s syndrome (a condition causing dry eyes and mouth)—are more likely to have autoimmune hepatitis.  A definite diagnosis of autoimmune hepatitis is obtained with blood testing.  Two antibodies that may develop in the blood are the ANA (antinuclear antibody) and the SMA (smooth muscle antibody).  Also, a certain type of blood protein called gamma globulin is frequently elevated.  A liver biopsy is always needed to determine how much inflammation and scarring has developed.  This exam is performed under local anesthesia.  A slender needle is inserted through the right lower chest to extract a small piece of liver tissue.  The tissue is then examined under a microscope.  This information allows the physician to direct appropriate treatment.

Treatment

The treatment of autoimmune hepatitis is aimed at reducing or suppressing the autoimmune response, and therefore the damage to liver cells.  It is most effective when begun at an early stage of the disease.  In most cases, the initial treatment is with a corticosteroid drug, usually prednisone (trade names: Deltasone, Orasone).  Sometimes a second drug, such as Imuran, may be added.  The medication is taken daily, usually for at least a year.  The physician may attempt to taper and stop treatment if the patient is doing well.  However, a relapse often occurs, and the medication then must be restarted and is often taken indefinitely.  There may be side effects with prednisone, such as swelling of the face, retention of fluid, and weight gain.  Long-term treatment with these drugs may also cause loss of bone.  This can lead to osteoporosis, or even severe damage to joints such as the shoulder and knee.  Therefore, the physician uses the lowest dosage possible to decrease symptoms, improve liver tests, and slow liver damage.

Unfortunately, a few patients do not respond well to treatment, especially if the disease is diagnosed late and cirrhosis is well advanced.  When the patient no longer responds to treatment with medication and liver damage is severe, a liver transplant is considered.

Liver Transplantation

Liver transplantation is now an accepted form of treatment for chronic, severe liver disease.  Advances in surgical techniques and the use of new drugs to suppress rejection have dramatically improved the success rate of transplantation.  The outcome for patients with autoimmune hepatitis is excellent.  Survival rates for this condition at transplant centers are well over 90 percent, with a good quality of life after recovery.

Summary

Autoimmune hepatitis is inflammation of the liver, The inflammation is a result of the immune system developing antibodies against the liver.  It is not a contagious disease, but it is a serious chronic disease that can lead to irreversible cirrhosis, and eventually to liver failure.  However, the outlook for patients with autoimmune hepatitis is generally very favorable.  With early diagnosis, drug treatment to prevent serious liver damage is effective in most patients.  For those few patients who do not respond to other treatment, successful liver transplantation is now a standard form of therapy when liver damage is severe.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Heartburn is a burning sensation felt behind the breastbone and sometimes in the neck and throat. It is caused by stomach acid refluxing up into the esophagus—the muscular tube that connects the throat to the stomach. At the lower end of the esophagus where it enters the stomach, there is a strong muscular ring called the Lower Esophageal Sphincter (LES). The LES should remain tightly closed, except to allow food and liquid to pass into the stomach. Heartburn occurs when the LES opens at the wrong time. Almost everyone has this occasionally, and it is nothing to be concerned about, However, heartburn that is severe or that occurs frequently over a long period of time can be harmful. This is known as Gastroesophageal Reflux Disease (GERD). If GERD is untreated, there is constant acid irritation to the lining of the esophagus, and complications can occur. About 1 in 10 patients with GERD are found to have a condition called Barrett’s esophagus. It can be serious and may lead to cancer of the esophagus.

What is Barrett’s Esophagus

The cells lining the esophagus differ from those lining the stomach or intestines, mainly because they have different functions. They also have a distinctly different appearance, so it is usually easy for a physician to tell them apart when examining the esophagus and stomach. Normally, there is an area at the end of the esophagus that marks the border between the cells of the esophagus and those of the stomach. Barrett’s esophagus is the abnormal growth of intestinal-type cells above this border, into the esophagus.

Since the cells lining the stomach are protected from contact with acid, their growth into the esophagus may actually be a defense mechanism. It may protect the normal tissue in the esophagus against further damage by GERD. This may explain why the symptoms of GERD seem to lessen in some patients with Barrett’s esophagus. Unfortunately, these tissue changes may be a forerunner of cancer of the lower esophagus, known as adenocarcinoma. Cancer of the upper esophagus (squamous cell cancer) is usually related to alcohol and smoking. This type of cancer appears to be decreasing in the population, while the rate of adenocarcinoma is increasing sharply, especially in white males.

In time, the Barrett’s cells may develop abnormal changes known as dysplasia. Over a period of perhaps two to five years, the dysplasia may then progress to low grade, then to high grade dysplasia, and finally to cancer. Fortunately, this happens only in about 1-5% of patients with Barrett’s esophagus.

Cause and Symptoms

For unknown reasons, Barrett’s esophagus is found three times more often in males than in females. In some instances, Barrett’s esophagus appears to be congenital (present at birth). However, current evidence is strong that in most instances, it develops as a result of longstanding GERD.

Patients with Barrett’s usually have symptoms similar to those produced by chronic GERD, such as heartburn and reflux of stomach acid into the mouth. Some Barrett’s patients may also suffer from other complications of GERD, such as esophageal peptic ulcers and stricture—narrowing of the esophagus that comes from scarring. These facts are why it is important for patients with these symptoms to see their physicians regularly.

Diagnosis

Diagnosis of Barrett’s esophagus requires an examination called upper endoscopy or EGD (esophagogastroduodenoscopy). This is done with the patient under sedation. The physician examines the lining of the esophagus and stomach with a thin, lighted, flexible endoscope. Biopsies are performed, taking pieces of tissue to be examined under a microscope for abnormal cells which have the potential of becoming malignant. The changes may be indefinite dysplasia where the pathologist may be uncertain of the changes. In this circumstance, medical treatment is intensified and repeat biopsies are performed in 6-12 months. When dysplasia is definite, some type of definite correction is necessary.

Treatment

Things Patients Can Do

Currently, there are no medications to reverse Barrett’s esophagus. However, it appears that treating the underlying GERD may slow the progress of the disease and prevent complications. Following are some things the patient can do to help reduce acid reflux and strengthen the LES.

• Avoid eating anything within three hours before bedtime.

• Avoid smoking and tobacco products. Nicotine in the blood weakens the LES.

• Reduce consumption of fatty foods, milk, chocolate, mints, caffeine, carbonated drinks, citrus fruits and juices, tomato products, pepper seasoning, and alcohol (especially red wine).

• Eat smaller meals. Avoid tight clothing or bending over after eating.

• Review all medications with the physician. Certain drugs can actually weaken the LES.

• Elevate the head of the bed or mattress 6 to 8 inches. This helps to keep acid in the stomach. Pillows by themselves are not very helpful.

• Lose weight if overweight. This may relieve upward pressure on the stomach and LES.

Medications

A certain category of drugs called proton pump inhibitors are the main tool used to markedly reduce stomach acid. These include Prilosec (omeprazole), Prevacid (lansoprazole) Protonix (pantoprazole), Nexium (esomeprazole) and AcipHex (rabeprazole), taken once or twice a day. Other acid reducing drugs such as Zantac, Pepcid, Axid and Tagamet are also available.

Surgery

Certain patients with GERD may need surgery to strengthen the LES. This type of surgery is called fundoplication. It is now done by laparoscopy. Laparoscopy is minimally invasive surgery, performed with a tiny incision at the naval and a few needle points in the upper abdomen.

Monitoring

A diagnosis of Barrett’s esophagus requires regular monitoring by a physician. While it is thought that controlling GERD reduces the risk of developing cancer, this has not yet been definitely proven. Therefore, the physician must perform regular endoscopy exams and biopsies to look for dysplasia. Just how often these exams are repeated depends on how far the disease has advanced. If cancer is found, surgery to remove the lower esophagus is usually necessary. Physicians often recommend this procedure when high grade dysplasia is present, so as to prevent the cancer that is likely to occur.

The Future

There are presently various newer treatments being studied. These involve the destruction of the abnormal cells in the esophagus without the need for major surgery.

Summary

Barrett’s esophagus is a condition that may develop as a result of chronic GERD. Barrett’s tissue growing in the esophagus appears to be the body’s defense against continued stomach acid irritation. Yet this tissue does not belong in the esophagus, and for some patients, it increases the risk of developing cancer. While treatment does not reverse Barrett’s, the likelihood of developing cancer and complications can probably be reduced with a combination of diet, lifestyle changes, medication, and/or surgery. A regular program of endoscopic examination and biopsy is essential to monitor the Barrett’s tissue. By working closely with a physician, patients can expect good control of both GERD and Barrett’s and an excellent long— term outcome.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Celiac Sprue (CS) is a disease of the lining of the small intestine.  This part of the bowel lies between the stomach and colon or large bowel.  It is about 20 feet long and is where nutrients, calories, vitamins and minerals are absorbed into the blood.  The inside lining of the small bowel has tiny microscopic finger-like projections called villi.  It is through these villi that nutrients are absorbed.

CS is a genetic disorder meaning that it can be passed through the genes from parent to child.  It only occurs when the grain protein called gluten comes in contact with these villi.  Gluten is present in wheat and all wheat products, barley, rye and to a lesser extent in oats.  In celiac sprue, the gluten protein severely damages these delicate villi.  In fact, the damaged villi are actually destroyed so that absorption of nutrients may be severely affected.

CS tends to be most common in people of northern European extraction.  It can occur in infants or those in older ages.  The body’s immune and antibody systems are, in some as yet undefined way, important.  Certain protein antibodies occur in the blood of patients and even their close relatives.  CS is also known as celiac disease, non-tropical sprue and gluten enteropathy or intolerance.

What are the Symptoms?

In children, there may be irritability, diarrhea, nausea, vomiting and failure to thrive or grow.  The same symptoms may occur in adults along with abdominal pain, weight loss, anemia or low red blood cell count, mood changes, joint and muscle pain, fatigue, skin rashes and menstrual irregularity.  Remarkably, some people may have no symptoms at all, Even with the damage to the small bowel, they seem to absorb enough nutrition to remain reasonably healthy.

The Diagnosis

The physician may suspect the disorder by the medical history and abnormal blood tests such as a low red blood cell count.  A more specific blood test for the disease is the endomysial antibody test.  A biopsy of the lining of the small intestine is always needed.  This is done by endoscopy, where, under light sedation, a thin endoscope is passed through the mouth and on into the small bowel where biopsies can be taken.  When damage to the inside lining of the bowel is seen, the diagnosis is usually confirmed.

The Gluten Free Diet

The treatment of CS is with dietary changes called a gluten free diet.

Wheat, rye, barley and perhaps oats are the culprits.  These grains, especially wheat, are part of almost every meal.  They are present in many canned and prepared foods.  The patient must become a label reader to see if wheat in any form has been used.  Further, the patient, and especially the food preparer in the family, must understand the treatment goals.  Instead of wheat flour—potato, rice, soy or even bean flour may be used.  Specialty stores sell gluten free breads, pasta and other gluten-free products.  Meat, fish, poultry, fruits and vegetables do not contain gluten and are good choices.

Patients with CS and their food preparer should see a registered dietitian for several sessions to learn more about this complicated diet.  Another source of information is the internet where there are many support and chat groups as well as professional organizations that provide good information about this disorder.

Eating out can be a challenge as sauces and gravies are often made with wheat based products.  However, once known and understood, the diet can be fairly easy to follow, especially when a patient sees improvement in their condition when these dietary changes are undertaken.

The Response

Most patients have a good response to the elimination of gluten from the diet.  A few are called non-responders and do not respond.  Further testing and medications may then be indicated.

Celiac Sprue and Other Disorders

Since CS is a disorder of the immune system and the genes, it is not surprising to find that it is associated with other diseases that have similar links.  These include:

• dermatitis herpetiformis

• lupus

• diabetes occurring in childhood or requiring insulin

• rheumatoid arthritis and other immune related disorders, often called collagen- vascular diseases

Complications

There are certain complications known to develop with CS.   Usually these can be prevented by staying on a strict gluten free diet.   These include:

• malignancies of the intestines

• osteoporosis

• failure to grow in height or weight

• deficiencies of minerals (iron) and vitamins which, in turn, can lead to convulsions when inadequate folic acid is absorbed

Summary

Celiac Sprue is a disorder which can be difficult to diagnose because of the many different symptoms it may produce.  It can occur at almost any age.  Making the diagnosis is fairly straightforward.  The treatment of avoiding gluten protein in wheat, barley, rye and perhaps oats is the difficult part.  However, once mastered it becomes a fairly easy diet to follow.  Further, the response to dietary treatment is usually so good that patients have no problem staying on this new eating program.

Support Links

Patients with Celiac Sprue can get support and information about their disease through the following contacts.

• Celiac Sprue Association/USA Inc.  (402) 558.0600

Web site: http://www.csaceliacs.org

• Celiac Disease Foundation

(818) 990-2354

Web site: http://www.celiac.org

• Gluten Intolerance Group Of North America

(206) 246-6652

• National Center for Nutrition and Dietetics American Dietetic Association

(800)366-1655

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The liver is a large organ that sits in the right upper abdomen, just under the right lung.  The liver makes proteins, eliminates waste material from the body, produces cholesterol, stores and releases glucose energy and metabolizes many drugs used in medicine.  It also produces bile that flows through bile ducts into the intestine where it helps to digest food.  The liver receives blood from two different sources—the heart and the intestine.  All of this blood flows through the liver and returns to the heart.

What Is Cirrhosis?

Many types of chronic injury to the liver can result in scar tissue.  This scarring distorts the normal structure and regrowth of liver cells.  The flow of blood through the liver from the intestine is blocked and the work done by the liver, such as processing drugs or producing proteins, is hindered.

What Causes Cirrhosis?

Cirrhosis can be caused by many things, some known and others unknown:

• Alcohol—Using alcohol in excess is the most common cause of cirrhosis in the United States.

• Chronic Viral Hepatitis—Hepatitis B and Hepatitis C hepatitis, as well as other viruses can infect and damage the liver over a prolonged time and eventually cause cirrhosis.

• Chronic Bile Duct Blockage—This condition can occur at birth (biliary atresia) or develop later in life (primary biliary cirrhosis).  The cause of the latter remains unknown.  When the bile ducts outside the liver become narrowed and blocked, the condition is called primary sclerosing cholangitis.  This condition is often associated with chronic ulceration of the colon (colitis).

• Abnormal Storage of Copper (Wilson’s Disease) or Iron (Hemochromatosis)— These metals are present in all body cells.  When abnormal amounts of them accumulate in the liver, scarring and cirrhosis may develop.

• Drugs and Toxins—Prolonged exposure to certain chemicals or drugs can scar the liver.

• Autoimmune Hepatitis—This chronic inflammation occurs when the body’s protective antibodies fail to recognize the liver as its own tissue.  The antibodies injure the liver cells as though they were a foreign protein or bacteria.

• Cystic Fibrosis and Alpha 1-antitrypsin Deficiency—These disorders are inherited.

• Non-alcoholic fatty liver disease (NAFLD)—The obesity epidemic in the United States has increased recognition and treatment of this condition.  Many patients with NAFLD often seek attention for abnormal liver tests or changes in the texture of the liver found incidentally on a CAT scan or ultrasound done for other reasons.  Patients with NAFLD often have the metabolic syndrome which consists of a high blood pressure, high cholesterol and lipids, and diabetes.  If left untreated, NAFLD can progress to cirrhosis and eventually require liver transplantation.

What Are the Signs and Symptoms?

Cirrhosis takes years to develop.  During this time, there are usually no symptoms, although fatigue, weakness and decreased appetite may occur and worsen with time.  When cirrhosis is fully developed, a number of signs may be present:

• Fluid Retention in the Legs and Abdomen— The liver produces a protein, called albumin, that holds fluid in blood vessels.  When the blood level of albumin falls, fluid seeps out of the tissues into the legs and abdomen, causing edema (fluid accumulation) and swelling.

• Jaundice—The liver produces bile that normally flows into the intestine.  With advanced cirrhosis, bile can back up into the blood, causing the skin and eyes to turn yellow and the urine to darken.

• Intense Itching—Certain types of cirrhosis, such as chronic bile duct blockage, can produce troublesome itching.

• Gallstones—Cirrhosis causes the abnormal metabolism of bile pigment.  Because of this, gallstones develop twice as often in cirrhosis patients as in those without the disorder.

• Coagulation Defects—The liver makes certain proteins that help clot blood.  When these proteins are deficient, excessive or prolonged bleeding happens.

• Mental Function Change—The liver processes toxins from the intestine.  When these substances escape into the bloodstream, as occurs in severe cases of cirrhosis, a variety of changes in mental function can develop.

• Esophageal Vein Bleeding—In advanced cirrhosis, intestinal blood bypasses the liver and flows up and around the esophagus (the food tube) to the heart.  The veins in the esophagus dilate (widen) and may rupture, causing slow or massive intestinal bleeding.

Diagnosis and Liver Biopsy

The physician can always suspect cirrhosis from the patient’s medical history and physical examination.  In addition, certain blood tests and scans or ultrasound (sonography) can provide helpful information.  To make a definite diagnosis, however, a liver biopsy (tissue sample) is required.  This is performed by anesthetizing the skin of the right-lower chest and inserting a thin, needle into the liver.  A core or specimen of tissue is removed and examined under a microscope.

What Is the Course of Cirrhosis?

When cirrhosis is diagnosed, the patient and physician begin a plan of action designed to preserve the remaining liver cells and correct the complications mentioned above.  By following this plan, many patients can lead long, productive lives.

Prevention

Perhaps 90 percent of cirrhosis is caused by excessive alcohol consumption or hepatitis viruses.  Of course, alcohol can be avoided.  Alcohol consumption should always be limited to no more than 1 or 2 drinks per day.  Hepatitis B now has an effective vaccine against it.  Vaccination against hepatitis B virus is safe and inexpensive.  It should be taken especially by certain high-risk groups: all health care professionals, persons traveling to Third World countries, and other high risk individuals.

Treatment

Often, the only required treatment for cirrhosis is removing the offending cause:

• The alcoholic patient must permanently stop consuming alcohol.

• When iron is being retained in the body, chronic removal of blood by vein eliminates large amounts of iron.

• Cortisone medicine helps treat autoimmune hepatitis and cirrhosis.

• Restricting salt and using fluid pills (diuretics) reduce edema and abdominal swelling.

• Toxins and injurious drugs must be avoided.

• Decreasing dietary protein and using certain laxatives generally can prevent changes in mental function.

• Bleeding veins in the esophagus can be closed with small rubber bands.  Occasionally, surgery is necessary to prevent recurrent massive bleeding.

• Ursodiol (Actigall) and other drugs have been helpful in treating primary biliary cirrhosis and primary sclerosing cholangitis.

• Treating the metabolic syndrome with dietary changes, sustained weight loss, and medications can minimize or even reverse the progression of NAFLD.

Liver Transplant

Liver transplantation has progressed to the stage where it can now be considered as standard treatment for selected patients with advanced cirrhosis.

Summary

Cirrhosis of the liver is a common disorder that has many causes.  With early diagnosis, much can be done to prevent serious complications.  Various treatments are available, depending on the cause of the liver injury and its complications.  Ongoing medical research promises major advances in treating cirrhosis in the future.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Cancer of the colon is a major health problem in the United States.  It ranks as a leading form of cancer, along with lung and breast cancer.  Importantly, colon cancer is also one of the most preventable and curable forms of cancer.  When detected early, more than 90 percent of patients can be cured.

This disease begins in the cells that line the colon.  There now is strong medical evidence that there are abnormal genes for colon polyps and cancer that can be passed from parent to child.  The genes within each cell are the hereditary structures that tell the cell what it should do.  When these controlling genes are absent there is a tendency to grow polyps.  The cells in the polyp eventually become uncontrolled and turn into a cancer.  Colon cancer also can develop with other conditions, such as ulcerative colitis, a chronic inflammation in the colon.

What is a Colon Polyp?

A polyp is a growth that occurs in the colon and other organs.  These growths, or fleshy tumors, are shaped like a mushroom or a dome-like button, and occur on the inside lining of the colon.  They may be as small as a tiny pea or larger than a plum.

Colon polyps start out as benign tumors but in time may become malignant.  The larger the polyp, the more likely it is to contain cancer cells.

Why Do Colon Polyps/Cancer Form?

A great deal is known about why and how polyps form.  In some people heredity and genes are the most important factors.  In others, heredity may be necessary but diet and foods may also be very important.

Risk Factors for Colon Polyps/Cancer.

Heredity and genes

Someone with a family history of colon cancer is at a greater risk for developing colon cancer.  For example, someone who had a parent with colon cancer is at roughly double the average risk.  This risk increases as more family members are affected.

In some families the genetic disorder is so strong that it is the only thing that matters.  Hereditory Familial Adenomatous Polyposis (FAP) and Lynch Syndrome (see below) are two disorders that are clearly linked to genes alone.

Most colon cancers (70-75%) however are sporadic - i.e.  there is no family history.

Nongenetic risk factors

Obesity and Exercise

Obesity appears to increase a person’s risk for colon cancer.  The exact amount of this is unknown.  Diabetics may also be at a higher risk, so we believe there may be a role of insulin resistance contributing to a person’s risk for colon cancer.  Exercise is believed to decrease the risk for colon cancer.

Meat

Red meat may increase the risk of colon cancer.  In all likelihood, this is created by the saturated animal fat.  How the meat is prepared may also impact the risk.  For example, charcoal grilling may increase risk by creating potentially cancer-inducing by-products called heterocyclic aromatic amines.  Non-red meat does not seem to be associated with the same risk.  Finally, processed meats may have an increased risk compared to that of fresh meat.  Nitrate compounds in processed meats may contribute to this risk.

Fruit, Vegetables and Fiber

As much as we would like to think these food groups protect our colon, there is unclear benefit.  The studies are conflicting whether they offer any true benefit in reducing a person’s risk for colon cancer.  Of these, vegetables containing antioxidants (cabbage, brussels sprouts, and broccoli) may be most helpful.  We should not, however, lose sight of the clear overall benefit of a diet rich in these food groups.

Calcium

Calcium may be helpful by binding the bile acids in the colon.  Bile acids may contribute to cancer-forming cells and neutralizing them with calcium may help.  We probably need to take at Least 700-800 mg of calcium a day to achieve this benefit.

Antioxidants

There is insufficient information to draw any conclusions of the benefits of antioxidant therapy and colon cancer.  There is one study to suggest that selenium, contained in brewer’s yeast, may be helpful.

Folate

Folate is a vitamin essential in many body functions, including production of our red cells.  It also helps repair DNA.  Cancer cells form and proliferate when there is uncontrolled replication of DNA.  We know that people who are deficient in folate are at a considerably increased risk for colon cancer.  Some studies have shown that if one takes folate for a long period of time, probably more than ten years, you may reduce the chances of developing colon polyps or colon cancer.   A large recent study, however, questioned this conclusion.

Alcohol

Many studies have confirmed that high alcohol intake will increase a person’s risk for colon polyps and cancer.

Tobacco

There has been a longstanding association of tobacco and colon cancer.  More recently, studies have shown that smoking roughly doubles a person’s risk for colon cancer.  It is estimated that between 7000-9000 deaths a year from colon cancer are attributed to smoking.

Aspirin and Anti-Inflammatory Medication

We have long observed that patients with rheumatoid arthritis who take anti-inflammatory medication, such as Ibuprofen, have a reduced likelihood of getting colon polyps and colon cancer.  These medications are even used in some patients at a very high risk for colon cancer, such as those with familial adenomatous polyposis.  These medications work by inhibiting some of the proteins that are felt to increase polyp formation.  It is not, however, recommended to routinely take these agents solely for the purpose of reducing colon polyp formation as the risk of these is probably greater than the benefit gained.  You should consult with your physician to weigh the overall risks and benefits.

Post-Menopausal Hormonal Therapy Hormonal replacement therapy does appear to reduce the risk of colon cancer by 30-40%.  At the same time, hormonal replacement therapy is a complex issue and you should consult with your physician to weigh the risks and benefits of this therapy in your individual case.

In summary, diets high in fruits, vegetables and calcium and low in saturated fats and meats offer the best protection against colon cancer and many other cancers.

Three Categories of Polyps

Enough is now known about polyps that physicians generally place patients in one of three categories.  In each of these the end result is an adenoma type polyp:

1. The Ordinary Polyp—Most sporadic polyps begin to develop between the ages of 40 and 60.  There may be only one or two present and they may take ten years or more to develop into a cancer.  There is a hereditary link.  Eventually some of these become cancer.

2. Hereditary Familial Polyposis—This is a true hereditary condition in which the entire colon is studded with hundreds, even thousands of polyps.  They begin at a very early age even under ten years old.  Virtually every patient will eventually develop colon cancer.  The only known preventive treatment is surgical removal of the colon.  Fortunately, the condition is not common.

3. Lynch Syndrome (Hereditary Non-Polyposis Colorectal Cancer)—This disorder is more common than familial polyposis but less so than the ordinary polyp.  There is a strong tendency for adenoma type polyps to occur in close blood relatives such as sisters, brothers, aunts, uncles and children.  More polyps are seen and at an early age.  Polyps and even cancer occur at earlier ages, 40’s, 30’s and even in the 20’s.  In some families there is also an increased incidence of breast, ovarian, and other cancers.  So a family history of this type warrants very close surveillance of all direct blood relatives.

Detection

The key to early detection of colon polyps and cancer is the concern and willingness of each person to seek medical attention from a physician.  The physician generally will perform the following:

1. Medical history—The patient’s medical history will identify the presence of risk factors for colon polyps and cancer.

2. Stool exams to detect occult (hidden) blood— Colon cancers and large polyps may shed minute quantities of blood so examination of the stool for occult blood is an important exam.

3. Sigmoidoscopy—This is a visual exam of the rectum and lower colon using a lighted, flexible endoscope.  It allows for the direct detection of colon tumors of the closest third of the colon, but not the entire colon.

4. Colonoscopy—This procedure examines the entire 5-6 foot long colon.  The exam is usually done under sedation, It is considered the gold standard and the most definitive exam since colon polyps can be discovered and removed at the same time.

5. Barium Enema—This x-ray exam is an older exam which at times is still useful.  Barium flows into the colon and x-rays are taken which then can outline the shadows of polyps and cancer.  Polyps cannot be removed by this technique.

6. Virtual Colonoscopy—This test is newer.  Studies indicate that it does not pick up small polyps as well as colonoscopy but will find larger polyps, particularly if they are hidden behind folds.  Furthermore, like barium enema, polyps cannot be removed even when they are found.

Prevention

Since your genes cannot be changed, if there is a family history of colon polyps or cancer, a colonoscopy should be performed to remove the polyps before they become malignant.  Calcium, folic acid, and aspirin may have a protective role.  Ask your physician about these.  While dietary fiber and regular exercise are not clearly protective, they play a real role in promoting long-term good health.

Summary

Cancer of the colon is a serious but readily detected malignancy.  Early detection promises a particularly high chance of survival.  Most colon cancers start as polyps, which can usually be removed through a colonoscopic exam.  Today, there is much that can be done to prevent and cure this cancer.  The essential first step involves action by the patient.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Constipation can be defined as infrequent or hard pellet stools, or difficulty in evacuating stool.  Passing one or more soft, bulky stools every day is a desirable goal.  ‘While troublesome, constipation is not usually a serious disorder.  However, there may be other underlying problems causing constipation and, therefore, testing is often recommended.

What Causes Constipation?

The stomach churns and mixes food so it can be digested.  The near-liquid food then enters the small intestine which extracts calories, minerals and vitamins.  The small intestine ends in the right-lower abdomen where it enters the colon.  The colon, or large bowel, is 5 to 6 feet long.  Its function is to withdraw water from the liquid stool so that by the time it reaches the rectum there is a soft formed stool.  If an excessive amount of water is extracted, the stool can become hard and difficult to expel.

Constipation is often caused by a slow colon that does not contract properly and fails to move the stool to the rectum.  The colon also can become spastic and remain contracted for a prolonged time.  In this case, stool cannot move along.  Too much water is absorbed and hard pellet-like stool develops.  Constipation also can result from a mechanical obstruction, such as tumors or advanced diverticulosis, a disorder which can distort and narrow the lower-left colon.  Other conditions that can produce a sluggish, poorly contracting bowel include: pregnancy, anal fissures and hemorrhoids, certain drugs, thyroid hormone deficiency, the abuse of laxatives, travel, and stress.

Diagnosis

The patient’s medical history is the most important factor in diagnosing constipation.  The physician will perform a physical exam and obtain certain blood tests.  A sigmoidoscopic exam (using a lighted, flexible endoscope) is necessary to rule out a mechanical blockage of the lower bowel, such as a tumor.  This exam allows the physician to view the bowel wall and obtain biopsies (tissue samples) of any suspicious areas.  Colonoscopy may be indicated.  This is the visual exam of the inside of the entire colon using a flexible fiberoptic colonoscope.  The exam is usually performed under mild sedation, A marker test may be done whereby the patient swallows a capsule containing markers.  Some days later an x-ray is taken to analyze the pattern and distribution of markers in the colon.  In some cases, pressure measurements of the rectum and lower colon can provide valuable information.  This exam is called manometry.

Treatment

Because there are many causes of constipation, treatment depends on the physicians findings and diagnosis.  After serious problems are excluded, chronic constipation usually responds to simple measures, such as adding fiber, bran or a bulking agent to the diet.

General guidelines for treating constipation include: eating regularly, drinking plenty of liquids each day, regular walking and performing aerobic exercise.  In particular, patients should respond to the urge to defecate.  Retaining stool at this point will aggravate the condition.

Diet – Foods that are high in roughage, bran, and fiber are essential in correcting and preventing constipation.  In parts of the world where unprocessed grain is used and where large amounts of fiber are consumed, there is little constipation, and passing one or two large, soft stools a day is normal.  The following foods should be eaten daily in adequate amounts:

• Whole grain breads (whole wheat)

• Bran cereals

• Vegetables — Root (potatoes, carrots, turnips), leafy green (lettuce, celery, spinach), or cooked high residue (cabbage)

• Fruit — Cooked or stewed (prunes, applesauce) or fresh fruit (skin and pulp)

Bulking Agents — Fiber is the undigested part of plant food that passes into the colon.  Certain types of fiber can absorb and hold large amounts of water.  This, in turn, results in a larger, bulkier stool which is soft and easier to pass.  Adequate fiber in food or from supplements is recommended daily.  This type of water-retaining fiber generally is easily obtained each day by one of the following:

• Food bran — This is available as wheat, oat or rice bran.  Processing of wheat and other grains removes this valuable fiberous part of the food so these processed products should be avoided.

• Psyllium bran — The psyllium plant is remarkable because its ground seeds can retain so much water.  This product is available as Metamucil, Konsyl, Effersyllium, Per Diem Fiber, or the less expensive generic preparation in drug and health food stores.  Although labeled a laxative, it really is not laxative.

• Methylcellulose — This is another fiber derived from wood which also retains

Laxatives and other medications

There are two main types of laxatives:

stimulants (chemical) and saline (liquid or salt).  They are often used in patients who have constipation that does not respond to more conservative measures described above.  An occasional enema is also used.  In even more severe cases, medications used to stimulate secretion of water in the colon can be prescribed.

Surgery

With certain medical conditions, such as severe diverticulosis, and with extreme constipation in some younger patients, surgery may provide relief.

Suggested Bowel Retraining Program

1. Eat a diet high in roughage, such as bran cereals and leafy vegetables.

2. Drink six (6) ounces of prune or apricot juice each morning.

3. Eat two (2) large servings of stewed fruit each day.

4. Take one (1) heaping tablespoon of a bulking agent twice a day.  Use the NutraSweet® product to avoid excessive calories.

5. Eat a normal breakfast.

6. Set aside 15 minutes after breakfast to sit on the toilet, but do not strain to have a bowel movement.

7. If you do not have a bowel movement by the third day, use an enema and repeat the above steps.

Summary

Constipation usually is a short—term disorder which is easily treated by simple measures.  However, the condition may reflect a serious underlying disorder that can only be detected and treated by the physician.  For chronic constipation, it is important that the patient understands how this occurs.  By the intake of proper foods and fiber supplements, it is usually possible to retrain the colon so that normal regularity occurs.  There are successful medical treatments available for those patients who fail to respond to dietary and lifestyle modification.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Crohn’s disease is a chronic, recurrent inflammatory disease of the intestinal tract.  The two primary sites for Crohn’s disease are the ileum, which is the last portion of the small bowel (ileitis, regional enteritis), and the colon (Crohn’s colitis).  The condition begins as small, microscopic nests of inflammation which persist and smolder.  The lining of the bowel can then become ulcerated and the bowel wall thickened.  Eventually, the bowel may become narrowed or obstructed and surgery would be needed.

What Causes Crohn’s Disease?

There is now evidence of a genetic link as Crohn’s frequently shows up in a family group.  In addition, there is evidence that the normal bacteria that grow in the lower gut may, in some manner, act to promote inflammation.  The body’s immune system, which protects it against many different infections, is known to be a factor.  There are still a number of unknowns about the cause of the disease. Fortunately, a great deal is known about the disease and especially its treatment.

Who Develops Crohn’s Disease?

The condition occurs in both sexes and among all age groups, although it most frequently begins in young people.  Jewish people are at increased risk of developing Crohn’s, while African Americans are at decreased risk, which speaks to the genetic link in this disease.

Symptoms

The symptoms of Crohn’s disease depend on where in the intestinal tract the disorder appears.  When the ileum (ileitis) is involved, recurrent pain may be experienced in the right lower abdomen, At times, the pain mimics acute appendicitis.  When the colon is the site, diarrhea (sometimes bloody) may occur, along with fever and weight loss.  Crohn’s disease often affects the anal area where there may be a draining sinus tract called a fistula.

When the disease is active, fatigue and lethargy appear.  In children and adolescents there may be difficulty gaining or maintaining weight.

Diagnosis

There is no one conclusive diagnostic test for Crohn’s disease.  The patient’s medical history and physical exam are always helpful.  Certain blood and stool tests are performed to arrive at a diagnosis.  X-rays of the small intestine and colon (CT scan or barium studies) can be utilized. In addition, a visual examination (colonoscopy) of the lining of the rectum, colon and small intestine is usually necessary.

The disorder often remains quiet and easily controlled for long periods of time.  Most people treated for Crohn’s disease continue to pursue their goals in life, go to school, marry, have a family, and work with few limitations or inconveniences.  Some problems, outside the bowel, can occur.  Arthritis, eye and skin problems, and—in rare instances—chronic liver conditions may develop.  As noted, the disease can occur around the anal canal.  Open sores called fissures can develop, which are often painful.  A fistula can also form.  This is a tiny channel that burrows from the rectum to the skin around the anus.  In addition, when inflammation persists in the ileum or colon, narrowing and partial obstruction may occur.  Surgery is usually required to treat this problem.  When Crohn’s disease has been present for many years there is an increased risk of cancer.

Treatment

Effective medical and surgical treatment is available for Crohn’s disease.  It is particularly important to maintain good nutrition and health with a balanced diet, adequate exercise, and a positive, upbeat attitude.

Five types of medications are available to treat this disease:

1. Cortisone or Steroids—These powerful drugs provide highly effective results.  A large dose is often used initially to bring the disorder under quick control when the disease is severe.  The drug is then tapered to a low maintenance dose, perhaps taken just every other day.  Hopefully, the drug may eventually be stopped altogether.  This medicine is administered by pill or enema, Prednisone is a common generic name.

2. Anti-inflammation Drugs—sulfasalazine (Azulfidine), Dipentum, Asacol, Rowasa, Lialda and Pentasa belong to a group of drugs called the 5-aminosalicylates. These drugs are often used once the disease is under control.  They are most effective when the disease is present in the colon.  These are available in oral and enema preparations.

3. Immune System Suppressors—These medications suppress the body’s immune system, which appears to be overly active and somehow aggravates the disease.  The names of two of these commonly used medications are azathioprine (trade name: Imuran) and 6 MP (trade name: Purinethol).  These drugs are particularly useful for long-term care. There are other potent immune-suppressing drugs that may be used in difficult cases.

4. Infliximab (trade name: Remicade)—This drug is the first of a group of medications that blocks the body’s inflammation response.  It is given by intravenous infusion over several hours.  These blocking antibody drugs are proving to be very effective in many patients with severe disease.  Other similar agents such as adalimumab (trade name: Humira) are also used.

5. Antibiotics—Since there is frequently a bacterial infection along with Crohn’s disease, antibiotics are often used to treat this problem.  Two that are commonly used are ciprofloxacin (trade name: Cipro) and metronidazole (trade name: Flagyl).

Diet and Emotions

There are no foods known to actually injure the bowel. However, during an acute phase of the disease, bulky foods, milk, and milk products may increase diarrhea and cramping. Generally, the patient is advised to eat a well-balanced diet, with adequate protein and calories. A multivitamin and iron supplement may be recommended by the physician.

Stress, anxiety, and extreme emotions may aggravate symptoms of the disorder, but are not believed to cause it or make it worse. Any chronic disease can produce a serious emotional reaction, which can usually be handled through discussion with the physician.

Surgery

Surgery is commonly needed at some time during the course of Crohn’s disease. It may involve removing a portion of diseased bowel, or simply the draining of an abscess or fistula. In all cases, the guiding principle is to perform the least amount of surgery necessary to correct the problem. Surgery does not cure Crohn’s disease.

Summary

Most people with Crohn’s disease lead active lives with few restrictions. Although there is no known cure for the disorder, it can be managed with present treatments. For a few patients, the course of the disease can be more difficult and complicated, requiring extensive testing and therapy. Surgery sometimes is required. In all cases, follow-up care is essential to treat the disease and prevent or deal with complications that may arise.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Everyone has diarrhea at one time or another and everyone has their own idea of exactly what diarrhea is.  Is it one liquid stool each day? Is it several soft, semiformed stools each day? Or is it frequent, watery stools throughout the day and even the night? Stool is made up mostly of water.  For people in the Western World, the usual amount of water in stool each day is generally no more than 200 ml or 7 oz.  (8 oz.  = 1 cup).  When it is consistently more than this, it is called diarrhea in the medical field.

Causes of Diarrhea

There are many causes of diarrhea.  Fortunately, in most instances, this change in bowel habits is short lived and clears up on its own.  In these cases, it is assumed that it is a virus infection or even “something I ate.” Whenever diarrhea lasts more than two or three weeks, medical advice is generally recommended.  Among the many known causes are:

• Food — Most people have certain foods that may cause diarrhea.  For hot pepper lovers(the chemical in it is called capaiscin), diarrhea often occurs the morning after.  Many people are intolerant of milk and milk products so that even small amounts of the milk sugar lactose can cause diarrhea.  Large amounts of fatty foods cause the same problem in other people.  The obvious solution in all these instances is to avoid the offending agent.

• Chemical Laxatives — Magnesium containing antacids used to treat heartburn can cause diarrhea.  Sorbitol is an artificial sweetener that is used in sugar free gum and prepared foods such as jams and jellies.  Sorbitol can act as a laxative, especially when ingested in large quantities.

• Prescription Drugs — If a change in bowel habit occurs after taking a new drug, the physician should be contacted.  In particular, antibiotics are known to cause diarrhea, at times quite severe.  Diarrhea can develop up to one month after taking antibiotics.

• Infection — There are over 400 different bacteria that normally live quietly and beneficially in the large intestine.  There are also many viruses and other infectious agents that find their way into our bodies.  Some of these can infect the intestinal tract and cause diarrhea.  Fortunately, most of the time these infections come and go on their own.  Some bacterial infections, such as salmonella, are serious and require medical evaluation.  Salmonella commonly comes from contaminated poultry.  There are parasites, such as amoeba and Giardia, that attack the intestines.  Giardia may be found in wild animals and in contaminated streams and well water.  For people infected with the AIDS virus, there are a number of infections that can occur in the intestinal tract.  Close medical follow up is always required in these instances.  Virus infection is probably the most common cause of short term diarrhea and, fortunately, it usually clears up on its own.

• Traveler’s Diarrhea — The cause of traveler’s diarrhea is a toxic bacteria called E.  Coli.  It most often occurs in developing countries where sanitation is not good.  This infection can often be prevented by avoiding fresh, uncooked produce and fruits.  Fruits, such as oranges, that have protective skins are safe.  In particular, tap water in any form and especially ice should be avoided.  Bottled beverages are recommended.  The physician should be contacted prior to travel to these countries to obtain more information on prevention and treatment.

• Diseases — There are certain intestinal disorders that can cause chronic diarrhea.  These include ulcerative and microscopic colitis, Crohn’s disease, and even colon cancer.

These are all serious diseases that require careful medical attention and treatment.  It is a major reason why the cause of chronic diarrhea should always be known.

• Stress and Irritable Bowel Syndrome (IBS)— lBS is a problem that occurs when the intestines, especially the colon do not contract in a smooth, rhythmic manner.  The contractions can be exaggerated in which case diarrhea occurs or they may be sluggish and result in constipation.  Sometimes there is alternating constipation and diarrhea.  Emotional stress often aggravates these symptoms.

Diagnosis

The cause and treatment of diarrhea may be very simple, such as discontinuing magnesium - containing antacids.  Or it may be more difficult.  Testing of blood and stool may be needed.  X-rays and ultrasound may also be necessary.  In some cases, sigmoidoscopy or colonoscopy are required to visually inspect the colon with a lighted, flexible tube.  Testing depends on how severe and prolonged the condition is, and how the physician evaluates a specific case.

Treatment

There are simple things that can be done at the beginning of a diarrheal episode which may help reduce symptoms.  Taking only liquids by mouth and avoiding solid food and milk may be helpful.  Over-the-counter constipating agents, such as Pepto-Bismol, Kaopectate, or Imodium can also be tried.  For explosive or persistent diarrhea, treatment will obviously depend on the cause.  Fortunately, the cause of diarrhea can almost always be found and effective treatment is then usually available.

Summary

Diarrhea is a common problem which is usually not serious.  If it is severe or persistent, a specific diagnosis should be sought.  By working closely with the physician, effective treatment is frequently available.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Eosinophilic Esophagitis is a mouthful of a word. It is a condition that we are seeing more and more frequently. It is a common cause of difficulty swallowing, as well as heartburn that does not respond to conventional therapy.

To understand Eosinophilic Esophagitis, we need to review two different words. We will take the second word, esophagitis, first. The esophagus refers to the food tube that connects our mouth to our stomach. Any time an organ in the body becomes inflamed, we attach an Uitis to it. Esophagitis then is inflammation of the esophagus. There are many things that can cause inflammation of the esophagus such as acid reflux or certain infections.

The second word is eosinophil. To understand eosinophil, we need to look at the cells in our blood. Part of our blood is made up of white cells that circulate through the body and help fight infection. One type of white cell is called the eosinophil. These particular cells are involved in our body’s allergic reactions. For example, eosinphils are believed to be activated in people with asthma.

So, when we put these two words together; eosinophilic esophagitis is an inflammation of the esophagus generated by eosinophils. The eosinophils infiltrate into the wall of the esophagus and can then create certain problems. Eosinophilic Esophagitis has also been referred to as Allergic Esophagitis. This condition is seen throughout the world, It is more often associated with children but is well-described in adults as well. It appears to be more common in males.

Symptoms

Common symptoms of Eosinophilic Esophagitis are difficulty swallowing food, heartburn that doesn’t respond to typical therapy with antacids, or food lodging in the esophagus. Very young children may develop weight loss and difficulty feeding. Rarely, it can also yield chronic abdominal pain. Regardless, the most common symptoms tend to be food that either becomes stuck or gives a sense of getting stuck after it is swallowed. Some people have even had complete impaction of food where a piece of food lodges in the esophagus like a cork in a bottle top.

Cause

We do not fully understand Eosinophilic Esophagitis. We suspect it is an allergic reaction. Some people speculate that the eosinophils are left over from a more acute infection, or that there is some environmental exposure such as pollen. Others believe it is an allergic response to certain foods or food additives. Regardless, it appears to be an allergic reaction. It tends to be more common in families with other environmental allergies or history of other allergic disorders such as asthma.

Diagnosis

The diagnosis is most often made by a history of difficulty swallowing, particularly in a younger person. Endoscopy is usually done to confirm the diagnosis. Endoscopy is a procedure where a small, flexible scope is passed into the mouth and down the esophagus while the person is asleep. There are some features of the esophagus that can be seen at

endoscopy to suggest eosinophilic esophagitis. These include “furrows’, narrow, long, linear channels down the esophagus as well as thin, concentric rings. Small, white plaques, which are dense collections of eosinophils, can also be seen. More importantly is what is seen after biopsies. When a biopsy of the esophagus is taken in someone with Eosinophilic Esophagitis and examined under the microscope, one sees an increase in the number of eosinophils. It is important that the person looking at the biopsy specimen understands the patient’s history and also the location of the biopsy. Other disorders can produce eosinophils of the esophagus, such as reflux disease and inflammatory bowel disease.

Treatment

There is still much to learn about the best treatment for eosinophilic esophagitis. It is important to find an underlying cause if allergy is suspected. Sometimes, a person will have a known food allergy and this food should be avoided until it is clear if the particular food allergy is associated with the symptoms. Common foods associated with Eosinophilic Esophagitis include egg, milk, soy, wheat and corn, Because of these potential associations, often times these foods are eliminated from the diet and slowly reintroduced to determine if there is a correlation between the food and the symptoms. Allergy testing can also be carried out to help guide diet changes. Acid suppression with any number of medications is often a first line approach. It is not always effective but is generally safe and may help some people. When there is a narrowing in the esophagus, sometimes a dilation is performed. Dilation needs to be done particularly carefully as the esophagus can become quite stiff and narrow. Because of this, there is a risk of tearing or perforating the esophagus.

When people do not respond to diet changes or acid suppression, sometimes steroids are used. Fluticasone (Flovent) is an inhaled steroid that is used in asthma, It can be used for patients with Eosinophilic Esophagitis. Instead of inhaling the steroid, however, the steroid is swallowed with a small amount of water. Oral steroids, such as prednisone, have also been found to be effective but the risk and benefits of this approach need to be weighed individually and discussed with your physician.

Summary

There is so much to learn about eosinophilic esophagitis, but it appears to be increasing in incidence and is a common cause for people, young and old, with difficulty swallowing food. The symptoms may be controlled with either acid suppression or identifying a triggering food group. Endoscopy is often used to diagnose the disorder based on the number of eosinophils on biopsy but can also be used to follow a response to treatment. Elimination diets can be effective but referral to an allergist is often helpful to guide the diet changes. Finally, topically applied steroids in the form of swallowed steroid inhalers often control the symptoms.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The esophagus is the food tube that carries food and liquid from the mouth to the stomach.  The stomach churns the food and secretes a strong acid that aids in digestion.  A specialized muscle, known as the lower esophageal sphincter (LES), is located at the end of the esophagus.  This muscle normally contracts firmly, relaxing only to allow food and liquid to pass from the esophagus into the stomach.  This muscle maintains a certain pressure to keep the end of the esophagus closed, preventing stomach acid and digested food from moving back into the esophagus.

However, the LES muscle does not always work perfectly.  It can easily be overcome by a number of factors, the most common being eating a large meal.  Other agents that weaken the LES muscle and allow reflux of stomach juices are:

• Nicotine (cigarettes)

• Fried or fatty foods

• Chocolate

• Coffee

• Citrus fruits and juices

• Peppermints

• Pregnancy

What Is Esophagitis?

When stomach acid and digestive enzymes repeatedly reflux into the esophagus, the tissues become inflamed and ulcerated.  This inflammation is known as esophagitis.  When the inflammation is severe, esophageal ulcers develop.

Does a Hiatus Hernia Cause Esophagitis?

A hiatus hernia exists when part of the stomach protrudes through the diaphragm muscle into the chest.  When the hernia is fixed in this position, stomach acid and food do not drain out of it quickly and the LES pressure is overcome.  This results in tissue damage to the esophagus.  A fixed hiatus hernia, therefore, is an important factor in causing esophagitis.

Are There Other Causes of Esophagitis?

Certain infections, such as a fungus infection (Candida) and viruses, can occur in the esophagus and cause inflammation.  Irradiation and caustic substances, like lye, also can cause esophagitis.  Acid reflux from the stomach, however, is by far the most common cause of the condition.

What Are the Signs and Symptoms?

Heartburn occurs when acid refluxes into the esophagus.  It is experienced as a burning sensation in the lower chest and may be felt up the esophagus.  At times, bitter-tasting liquid may regurgitate up into the mouth.  When esophagitis is severe and ulcers are present, swallowing may cause pain when food reaches this part of the esophagus.  Furthermore, if the lower esophagus narrows due to scarring, food may stick in this area.  This symptom is called dysphagia and is uncomfortable.  Esophagitis also may cause bleeding.  Black stools, anemia (low red-blood cell count), and vomiting of blood are signs of bleeding.

Diagnosis

An endoscopy is often performed during which a flexible, fiberoptic endoscope is passed into the esophagus while the patient is lightly sedated.  The tissues can be visualized and biopsied during this procedure.  This examination is important since cancer of the esophagus can mimic esophagitis.

Treatment

General measures the patient can take to treat esophagitis are:

• Eat smaller and more frequent meals.

• Avoid eating for 2 hours before going to bed.

• Eliminate excessive bending, lifting, abdominal exercises, girdles, and tight belts, all of which increase abdominal pressure and provoke reflux.

• If overweight, lose weight.  Being overweight causes reflux.

• Eliminate or significantly reduce consumption of nicotine (cigarettes), fatty foods, alcohol, coffee, chocolate, and peppermint.

• Elevate the head of the bed 8” to 10” by placing pillows or a wedge under the upper part of the mattress.  In this way, gravity helps keep stomach juices out of the esophagus during sleep.

Other Treatments Include:

Antacids — These can and should be used often.  Generally, antacids should be taken 30 to 60 minutes after eating and at bedtime.  Liquids are preferred to tablets.

Drugs — Medicines are now available that effectively reduce or stop the secretion of stomach acid.  These medicines are usually the most important part of treating esophagitis.

Surgery — Surgery is occasionally required to treat esophagitis, especially if a hiatal hernia is present and when the above steps have been ineffective.  Newer laparoscopic surgery has simplified this procedure.

What Is a Stricture?

The lower esophagus can open to the size of a quarter or wider.  When recurrent inflammation occurs in the esophagus, scarring develops, underlying tissues become fibrous, and the opening narrows.  In advanced cases, this narrowing, or stricture, can be severe.  The opening may be reduced to the size of a pencil or even smaller.  Food and fluid are delayed and only move slowly across the opening into the stomach.  A large piece of food, such as meat, may completely block the esophagus.  As mentioned, cancer can narrow the esophagus in the same way.  Therefore, it is critical that the physician rule out this diagnosis.

Treatment

The physician can use a variety of methods to gently but forcefully open, or dilate, a stricture.  Dilatation is often performed in conjunction with an upper endoscopy exam.  One of the following dilatation methods may be used.  See the section on Esophageal dilation.

Summary

Esophagitis usually can be treated easily with a conservative program of medical care.  When scarring becomes severe, a stricture can occur.  This condition can be treated by simple dilatation.  While complications can occur, they are uncommon.  Most patients obtain complete relief of their swallowing problems.  By working with the physician, the correct program can be developed for each patient.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The liver is the largest organ in the body.  It is found high in the right upper abdomen, behind the ribs.  It is a very complex organ and has many functions.  They include:

• Storing energy in the form of sugar (glucose)

• Storing vitamins, iron, and other minerals

• Making proteins, including blood clotting factors, to keep the body healthy and help it grow

• Processing worn out red blood cells

• Making bile which is needed for food digestion

• Metabolizing or breaking down many medications and alcohol

• Killing germs that enter the body through the intestine

Certain conditions that develop, such as fatty liver and steatohepatitis, may be signs of liver injury that can lead to permanent liver damage.

What is Fatty Liver?

Fatty liver is just what its name suggests: the build-up of fat in the liver cells.  Although this is not a normal condition, fat in the liver usually causes no damage by itself.  However, on some occasions it can be a sign that other more harmful conditions are at work.  Fatty liver may be associated with or may lead to inflammation of the liver.  This can cause scarring and hardening of the liver.  When scarring becomes extensive, it is called cirrhosis, and this is a very serious condition.  Therefore, it is important that a physician thoroughly examine a patient with fat in the liver.

Cause

It would seem logical that eating fatty foods would cause a fatty liver, but this is not the case.  The liver does play an important role in the metabolism or breakdown of fats.  Something goes wrong in this process of metabolism, but it is still not known what does cause fat to build-up in the liver.  It is known that fat accumulates in the liver with a number of conditions.  The most common is obesity.  Fatty liver is also associated with diabetes mellitus, high blood triglycerides, and the heavy use of alcohol.  It may occur with certain illnesses such as tuberculosis and malnutrition, intestinal bypass surgery for obesity, excess vitamin A in the body, or the use of certain drugs such as valproic acid (trade names: Depakene/Depakote) and corticosteroids (cortisone, prednisone).  Sometimes fatty liver occurs as a complication of pregnancy.

Symptoms and Diagnosis

There are usually no symptoms that are noticeable to the patient.  In fact, fatty liver is frequently uncovered during a routine physical examination.  There may be a rise in certain liver enzymes found in the blood, and sometimes the liver is slightly enlarged.  Fatty liver may also be discovered while the physician is evaluating a patient for other illnesses.  For example, an ultrasound exam of the abdomen done for other reasons may show fat in the liver.  To be certain of a diagnosis of fatty liver, the physician may recommend a liver biopsy.  Under local anesthesia, a slender needle is inserted through the right lower chest.  A small piece of liver tissue is taken out with the needle and examined under a microscope.

What is Steatohepatitis?

The term hepatitis means inflammation of and damage to the liver cells.  Steato (pronounced stee-at-toe) refers to fat.  Therefore, steatohepatitis is inflammation of the liver related to fat accumulation.  Heavy alcohol use can lead to fatty liver and inflammation, usually called alcoholic hepatitis.  Steatohepatitis resembles alcoholic hepatitis, but it can and does occur in people who seldom or never drink alcohol, In this instance, it is often called nonalcoholic steatohepatitis or NASH.  Both alcoholic hepatitis and steatohepatitis can lead to serious liver damage and cirrhosis.

Studies have shown that many people who are significantly overweight have developed, or will develop, steatohepatitis.  It can also occur with rapid weight loss.  Steatohepatitis has been connected to estrogen hormones in some women.

In the case of diabetes mellitus, researchers believe steatohepatitis may develop oniy in those patients whose diabetes is not properly controlled.

Treatment

In most instances, treatment of fatty liver and steatohepatitis requires control of the underlying conditions.  This may include reduction of high blood triglycerides, good control of diabetes, or not drinking alcohol.  In some cases, surgical reversal of intestinal bypass for obesity is required.

Since being overweight is by far the most critical factor, weight loss is the key to ridding the liver of fat.  This is especially necessary if damage to the liver is occurring, and early signs of scarring are present on biopsy.  High blood triglycerides and diabetes are also worse with obesity.  So, when steatohepatitis is present with these conditions, people gain even greater benefits from losing weight.  Losing weight can be difficult.  However, it must be done because the alternative may be eventual cirrhosis and the need for a liver transplant.

Currently, studies are underway on certain drugs such as Actigall.  This drug appears to reduce liver damage in cases of steatohepatitis.  At this time, however, it is not certain how helpful these drugs will be.  To repeat the point, losing weight is by far the most important treatment.

Summary

Fatty liver is simply the build-up of fat in the liver.  Fat in the liver usually does not cause liver damage.  However, certain other conditions and diseases can be associated with the development of fatty liver.  Research is ongoing to uncover what processes may take place to trigger fat build-up in the liver.  This condition is usually reversible when the underlying causes are treated or removed.  Patients who follow the advice of their physicians can expect to reverse and control a fatty liver or steatohepatitis.

Liver Transplantation

Liver transplantation is now an accepted form of treatment for chronic, severe liver damage.  Advances in surgical techniques and the use of new drugs to suppress rejection have dramatically improved the success rate.  Steatohepatitis will become a more common reason for a liver transplant.  Survival rates at transplant centers are well over 90% with a good quality of life after recovery.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Everyone comments sometimes on the digestive problem of gas.  When people complain of gas, they usually mean one or more of the following:

• Frequent belching of air from the stomach

• Bloating of the abdomen after eating

• Frequent passing of gas from the rectum

It may be uncomfortable or inconvenient, but only rarely is gas associated with a serious illness.  Gas is usually just the result of certain habits or diet choices.  It occurs in one of two ways: as a result of swallowed air, or it is produced in the intestinal tract.  Reclining after eating, inactivity, and stress may contribute to the problem.  If the physician suspects gas is the result of some other illness, tests will be ordered to diagnose the problem.

Belching

Everyone belches occasionally, especially after eating.  However, some people belch frequently, and it becomes annoying and embarrassing.  Belching is the result of too much air in the stomach.  It gets there by being swallowed with food or liquid.  The stomach releases it by forcing it up the windpipe in a belch.  The more a person swallows, the more air goes into the stomach andthe more belching.  Some people are known as air swallowers.  They gulp large amounts of air when eating or drinking; they may produce larger quantities of saliva that requires frequent swallowing; or they just have a nervous habit of swallowing more often.

Occasionally, it is necessary to treat excessive belching with medicine.  In most cases, however, patients can reduce belching by following simple lifestyle changes to correct the causes.

Hints for Reducing Belching

• Air swallowers should concentrate on trying to reduce the number of times they swallow.

• Avoid pipes, cigarettes, and cigars; chewing gum and hard candy; sipping through straws and bottles with narrow mouths; and dentures that do not fit properly.  They can increase saliva or air swallowing.

• Avoid foods that contain air, such as carbonated beverages or whipped cream.  Fizzy medicines, such as bicarbonate of soda, also add air to the stomach.

• Eat slowly.  Gulping food and beverages adds large amounts of air to the stomach.

• Do not deliberately swallow air to force a belch.

Bloating

For unknown reasons, bloating—that feeling of swelling in the abdomen—occurs most often in females.  For many people, it is simply a sensation of stuffiness.  However, for some it can feel downright painful.  It is not necessarily caused by too much gas.  Usually bloating is a result of poor motility.  Motility refers to the contractions that automatically move food through the digestive tract.  Poor motility slows the movement of food through the stomach and intestinal tract.  Eating fatty foods can also delay stomach emptying, leading to bloating.

Bloating is often a part of irritable bowel syndrome, a condition in which there is disorganized motility and spasm of the bowel.

Sometimes bloating is caused by a disease the upper part of the digestive system.  For this reason, the physician may perform tests, including x-rays and endoscopy.  Endoscopy is a visual examination of the esophagus and stomach with a thin, flexible, lighted tube.

When bloating happens frequently, the physician may prescribe medications to stimulate contractions in the stomach and upper intestine.  Usually however, bloating is not serious.  It may be caused by certain foods or simply by eating too fast.  So a change in eating habits is often all that is needed to control this condition.

Rectal Gas

Excessive flatus (rectal gas) is most often produced by bacteria in the colon (the large intestine).  There are literally hundreds of different bacteria normally present in the colon.  Most are harmless.  In fact, they are even beneficial to digestion.  However, bacteria rely on carbohydrates and sugars for their nutrition.  In the process of breaking down these nutrients, bacteria generate gases such as hydrogen, carbon dioxide, and methane.  Under normal conditions, many of these gases are reabsorbed and do not cause excessive flatus.

Carbohydrates and sugars are normally digested and absorbed in the stomach and small intestine.  Some people have disorders that interfere with the normal digestive process.  For example, lactose is a sugar found in milk.  It requires the enzyme lactase for digestion.  A person with lactase deficiency may not be able to digest lactose properly.  These abnormalities in digestion allow carbohydrates and sugars to pass undigested into the colon, where gas forming bacteria thrive on them.  Some foods, such as legumes, cabbage, or certain types of bran contain carbohydrates that the body cannot digest.  However, bacteria in the colon can use them for food, and as they are digested by the bacteria, gas is produced.

Everyone reacts to foods differently.  For instance, two people can eat the same amount of a carbohydrate.  One forms large amounts of rectal gas; the other forms little.  For those people frequently bothered with excessive gas, a special diet may be recommended to identify and eliminate the offending foods.  The accompanying chart lists those foods that most often contribute to abdominal gas and flatulence.

Gas Elimination Trial Diet

First, check with a physician to rule out any other medical causes for excess gas.  The physician can also give advice on maintaining adequate nutrition.  This trial diet may be conducted in one of two ways:

1.  Eliminate one category of gas producing foods for at least a week.  If there is no lessening of gas, put the foods back in the diet and go on to eliminate another category.  Follow this procedure until reaching a level of gas that is tolerable.

2.  Eliminate all categories from the diet for three or four days.  Then add one food at a time back to the diet, Continue to include this food in the diet for three or four days.  If the selection causes no problems, it may be kept in the diet.  If it does, eliminate it and go on to the next food.

Sometimes the food may not have to be completely eliminated; smaller amounts may be tolerated.  For example, many people complain that adding fiber to the diet causes gas.  Yet, this problem seems to be reduced if the fiber is added gradually over a period of several weeks.  These procedures require time and persistence, but can be very effective in controlling an uncomfortable problem.  Regardless of results, remember that rectal gas is not harmful to the body.

Foods That Contribute to Gas Production

Legumes: Especially dried beans and peas, baked beans, soy beans, lima beans

Milk Products: Milk, ice cream, cheese

Vegetables: Cabbage, radishes, onions, broccoli, Brussels sprouts, cauliflower.  cucumbers, sauerkraut, kohlrabi, asparagus

Root Vegetables: Potatoes, rutabaga, turnips

Fruits: Prunes, apricots, apples, raisins, bananas

Cereals & Breads: cereals, breads, pastries, and all foods containing wheat and ‘heat products.  Check labels

Fatty Foods: Pan-fried or deep-tried foods, fatty meats, rich cream sauces and gravies, pastries, and any high—fat food.  Check labels.

Liquids: carbonated beverages, fizzy medicine

Summary

Gas means different things to different people.  It may refer to belching, abdominal bloating, or rectal gas.  For some it may be simply an embarrassment, while for others it can be quite uncomfortable.  However, it is rarely a serious medical problem.  Working with a physician, a person suffering from gas can usually find simple solutions to significantly reduce the problem.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

GERD

Almost everyone has experienced heartburn.  About 25 million American adults suffer daily from heartburn.  It is that burning sensation felt behind the breastbone and sometimes in the neck and throat.  Heartburn is caused by stomach acid refluxing or splashing up into the esophagus—the muscular tube that connects the throat to the stomach.  Occasional heartburn is nothing to be concerned about.   However, anyone who has heartburn on a regular basis should consult a physician.  Constant exposure to stomach acid can irritate the lining of the esophagus and cause other medical problems.  Serious heartburn is known as gastroesophageal reflux disease or GERD.

What is GERD?

The esophagus carries food and liquid into the stomach.  At the lower end of the esophagus where it enters the stomach, there is a strong muscular ring called the lower esophageal sphincter (LES).  The LES should remain tightly closed, except to allow food and liquid to pass into the stomach.  Reflux occurs when the LES is not working properly.  It may relax for periods of time throughout the day and night, or it may be constantly too weak to function effectively.  This allows the stomach’s acid juices to flow into the esophagus.  How severe the disease becomes depends on how weakened the LES is, and the amount and duration of acid refluxed into the esophagus.

It is also common to find a hiatal hernia complicating GERD.  With a hiatal hernia, the upper part of the stomach actually pushes up into the chest through a weakness in the diaphragm.  The diaphragm is the thin, flat muscle that separates the lungs from the abdomen.  When part of the upper stomach is stuck above the diaphragm, stomach acid is retained there for a longer period and is more likely to reflux into the esophagus.

Symptoms and Causes of GERD

Frequent heartburn is the most common symptom.  However, patients may also experience some of the following: sour or bitter taste • bitter stomach fluid coming into the mouth, especially during sleep • hoarseness • repeatedly feeling a need to clear the throat • difficulty swallowing food or liquid • wheezing or coughing at night • worsening of symptoms after eating, or when bending over or lying down.

Certain diet and lifestyle choices can contribute to the condition.  For example, certain foods increase acid production, and fatty foods increase the time food remains in the stomach.  Chocolate, peppermint, coffee, alcoholic beverages, and especially nicotine in cigarette smoke weaken or relax the LES.  Obesity places added pressure on the upper abdomen, and during pregnancy the LES weakens for unknown reasons.

Complications

Complications occur when GERD is severe or long-standing.  Constant irritation of the esophagus by stomach acid can lead to inflammation, ulcers, and bleeding.  Anemia or low blood count may develop.  Over time, scarring and narrowing of the esophagus can also develop, making it difficult to swallow foods and liquids.  This narrowing is called a stricture.  Some patients develop a condition called Barrett’s esophagus, which is a serious change in the cells lining the esophagus.  Barrett’s esophagus may be a forerunner of esophageal cancer.

Diagnosis of GERD

The diagnosis can usually be suspected by the physician, simply by taking the medical history.  Beyond that, the physician may order an x-ray examination of the esophagus and stomach.  For this x-ray, the patient swallows a liquid containing barium.  This makes it possible to see the reflux and a hiatal hernia on the x-ray.

Endoscopy is the most important test for patients with GERD.  It is done with the patient under sedation.  The physician examines the lining of the esophagus and stomach with a thin, lighted, flexible tube called an endoscope.  This exam is helpful in determining how severe the disease is how much tissue damage there is, and if there are any complications.  Certain conditions, such as narrowing or stricture in the esophagus, can usually be corrected during this procedure.  During an endoscopy, the physician can also look for signs of Barrett’s esophagus, and perform a biopsy to see if precancerous changes have occurred.

There are other tests that are helpful.  A pressure recording of the esophagus is called esophageal manometry.  It measures the pressure in the LES and any abnormal muscle contractions in the main part of the esophagus.  Finally, a 12 to 24 hour recording of the acidity in the esophagus is often helpful.

What is the Treatment?

Treatment is aimed at reducing reflux and damage to the lining of the esophagus.  Initial treatment is with lifestyle changes.  Patients with GERD should follow these recommendations:

• Avoid eating anything within three hours before bedtime.

• Stop smoking.  Nicotine in the blood weakens the LES.

• Avoid fatty foods, milk, chocolate, spearmint, peppermint, caffeine, citrus fruits and juices, tomato products, pepper seasoning, and alcohol — especially red wine.

• Decrease portions of food at mealtime, and avoid tight clothing or bending over after eating.

• Review all medications with the physician.  Certain drugs can weaken the LES, allowing acid irritation of the esophagus.

• Elevate the head of the bed or mattress 6 to 8 inches.  This helps to keep acid in the stomach by gravity when sleeping.  Extra pillows by themselves are not very helpful.

• Lose weight if overweight.  This may relieve upward pressure on the stomach and LES.

Lifestyle changes are often all that is needed to correct mild forms of GERD.  When symptoms are bad or GERD is moderate to severe, the physician will prescribe medications.  These drugs are most frequently used when GERD is severe or does not respond to lifestyle changes.

A number of patients with GERD may need surgery to strengthen the LES.  This procedure is called fundoplication.  Previously this surgery required a major operation, often through the chest.  It is a difficult operation for the patient, with a long recovery.  It is now usually done by laparoscopy.  This is a type of minimally invasive surgery, performed with a tiny incision at the naval and a few needle points in the upper abdomen.  The patient usually returns home 1-2 days after surgery, with few problems.  Surgery, however, should not be considered until all other measures have been tried.  Surgery is often seriously considered for an otherwise healthy patient when the disease is severe, or the patient does not want to face the expense or regimen of long-term treatment with medications.

Summary

GERD is a common problem that requires medical attention when symptoms and tissue damage become troublesome.  Fortunately, there is a great deal that can now be done about GERD.  Lifestyle changes can help, and there are many medications and even surgery to treat and correct GERD.  Working together with the physician, a good medical program can almost always be developed to successfully treat the patient with GERD.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Another way of describing gastroparesis is delayed or abnormal gastric emptying. Gastro means stomach. Paresis means weakness. Gastroparesis is a weak stomach. This condition is common and probably under-diagnosed. It can be the cause of a number of abdominal complaints.

How the Stomach Works

To understand gastroparesis, you first must understand how the stomach functions. The stomach has two parts. The upper portion is called the fundus which is where swallowed food and liquid collect. The lower portion is called the antrum. This is the stomach grinder. It is where food is churned back and forth until it is broken into small fragments and then squirted out into the duodenum, the first part of the small intestine.

It may be a surprise to think of the stomach as being similar to the heart, yet this is really true. Both have an area within them called the pacemaker. This is where an electrical wave originates and then sweeps across the organ. The electrical wave causes the muscles in the heart and stomach to contract. In the stomach, the pacemaker is in the upper outer portion. The wave sweeps down across the antrum causing it to contract, grind up food, and expel small amounts. The normal rate of contraction is about three times a minute, much slower than the heart, but quite adequate for the job.

Gastroparesis

This condition occurs when the rate of the electrical wave slows and the stomach contracts less frequently. Now the food just lays in the stomach relying on acid and digestive enzymes to break down the food and on gravity to empty the stomach. There are a number of causes for this condition:

• Diabetes is the most common known cause. Adrenal and thyroid gland problems can also a cause although these are infrequent

• Scars from ulcers and tumors can block the outlet of the stomach and mimic gastroparesis

• Certain drugs weaken the stomach (Cardizem, Procardia, other calcium blockers, L-dopa, hyoscyamine, Bentyl, Levsin, narcotics)

• Previous stomach surgery, especially for ulcers

• Anorexia and bulemia

• Neurologic or brain disorders such as Parkinson’s disease or brain injuries

• Disorders such as lupus, scleroderma, and poor blood supply to the stomach

• Idiopathic which means the cause is not known. In 40% of instances, this is the case

It should be noted that not all of these disorders affect the pacemaker of the stomach, Some disorders weaken the stomach muscle itself so it can’t respond to the pacemaker. In either case, the result is the same, gastroparesis.

Symptoms

The usual symptoms of gastroparesis are a feeling of fullness after only a few bites of food, bloating—especially after eating, excessive belching, and nausea. At times there will be a vague, nagging ache in the upper abdomen but usually the pain is not sharp or crampy as might occur with ulcers or a gallbladder attack. There may be vomiting or regurgitation. Medications to reduce or eliminate stomach acid usually don’t help much. When gastroparesis is severe, there may be frequent heartburn and regurgitation of stomach juices into the mouth.

Diagnosis

The diagnosis of gastroparesis starts with the medical history where the physician may suspect the diagnosis based on the symptoms. In severe cases, the physical exam and blood tests may show evidence for malnutrition, but usually the exam is normal.

An upper GI barium x-ray measures how liquid barium leaves the stomach. Often this exam is normal.

Upper endoscopy is a visual exam of the stomach using a lighted flexible tube. Mild sedation is usually given for this procedure.

This exam should always be done to be certain there is not a blockage in the stomach.

A gastric or stomach emptying test is presently the best method of making the diagnosis. In this test, a food, such as scrambled eggs, is labeled with a marker which can be seen by a scanner. Following ingestion, the scanner tracks the time it takes for the food to leave the stomach. In general, half the stomach contents should leave within 90 minutes.

A final test, which is not available everywhere, is the electrogastrogram (EGG). This test, like the EKG on the heart, measures the electrical waves that normally sweep over the stomach and precede each contraction.

Treatment

First, if there is an underlying disorder, it needs to be treated effectively. Examples are good blood sugar control in the diabetic patient or thyroid medicine for someone with an underactive thyroid.

Second, there may be a need to address diet and nutrition. When gastroparesis is mild, there are usually few food problems. However, if there is marked delay in stomach emptying, then attention to the diet is necessary. Fats, including vegetable oils, normally cause delay in emptying of the stomach, so foods that are high in fat need to be avoided. High fiber foods such as broccoli and cabbage tend to stay in the stomach, so these foods should be restricted when symptoms are severe. Liquids always leave the stomach faster than solid food so liquid type foods such as low-fat milkshakes should be used. Finally, frequent small feedings, 4-6 times a day, are usually more effective than the normal but larger meals, 2 or 3 times a day. A registered dietitian can be very helpful in providing advice in severe cases.

The third treatment is medications.

Medications

Several medications are now available to stimulate the stomach to contract more normally. These drugs should be taken 20-40 minutes before eating to allow enough time for the drug to get into the blood stream where they can then act on the stomach. They all cause the stomach to contract more often and, hopefully, more vigorously thereby emptying the stomach and reducing symptoms.

Domperidome (Motilin) is effective and available from Canada with little difficulty.

Metoclopramide (Reglan) has a high incidence of side effects including restlessness, fatigue, symptoms of Parkinsonism, agitation and depression. The dose for this older drug is 5-20 mg. This drug is available in generic form.

Bethanechol (Urecholine) and erythromycin, an old antibiotic are occasionally used but generally are not effective or desirable long-term.

There are other newer drugs in the research pipeline that promise to be even more effective than those that are now available.

Summary

Gastroparesis is a fairly frequent medical problem. While causing distressing symptoms in some patients, it rarely causes serious medical problems. The diagnosis is now straightforward. Treatment consists of treating any underlying problem, diet and medications. By working with the physician, most patients are able to reach a satisfactory treatment program.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

This unusual name identifies a specific bacteria that can cause infection of the stomach.  This infection can contribute to the development of diseases, such as dyspepsia (heartbun, bloating and nausea), gastritis (inflammation of the stomach), and ulcers in the stomach and duodenum.  It will be useful to know some things about the upper digestive tract to understand how and where Helicobacter Pylori infection can occur.

When food is swallowed, it passes through the esophagus (the tube that connects the throat to the stomach).  It then enters the larger upper part of the stomach.  A strong acid that helps to break down the food is secreted in the stomach.  The narrower, lower part of the stomach is called the antrum.  The antrum contracts frequently and vigorously, grinding up the food and squirting it into the small intestine.  The duodenum is the first part of the small intestine, just beyond the stomach.  The stomach, including the antrum, is covered by a layer of mucous that protects it from the strong stomach acid.

It is known that alcohol, aspirin, and arthritis drugs such as ibuprofen can disrupt the protective mucous layer.  This allows the strong stomach acid to injure underlying stomach cells.  In some people, corticosteroids, smoking, and stress appear to contribute in some way.  Until the mid 1980s, it was felt that one or more of these factors working together led to the development of gastritis and ulcers.  Since that time, evidence has been mounting that Helicobacter Pylori (H.  Pylori) has a major role in causing these diseases.

The Infection

H. Pylori is a fragile bacteria that has found an ideal home in the protective mucous layer of the stomach.  These bacteria have long threads protruding from them that attach to the underlying stomach cells.  The mucous layer that protects the stomach cells from acid also protects H.  Pylori.  These bacteria do not actually invade the stomach cells as certain other bacteria can.  The infection, however, is very real and it does cause the body to react.  Infection-fighting white blood cells move into the area, and the body even develops H.  Pylori antibodies in the blood.

H. Pylori infection probably occurs when an individual swallows the bacteria in food, fluid, or perhaps from contaminated utensils.  The infection is likely one of the most common worldwide.  The rate of infection increases with age, so it occurs more often in older people.  It also occurs frequently in young people in the developing countries of the world, since the infection tends to be more common where sanitation is poor or living quarters are cramped.  In many cases it does not produce symptoms.  In other words, the infection can occur without the person knowing it.  The infection remains localized to the gastric area, and probably persists unless specific treatment is given.

How is H.  Pylori Infection Diagnosed?

There are currently three ways to diagnose H.  Pylori infection.  During endoscopy (a visual exam of the stomach through a thin, lighted, flexible tube), the physician can remove small bits of tissue through the tube.  The tissue is then tested for the bacteria.  A breath test is now available.  In this test, a substance called urea is given by mouth.  A strong enzyme in the bacteria breaks down the urea into carbon dioxide, which is then exhaled and can be measured.  There is a blood test that measures the protein antibodies against these bacteria that are present in the blood.  This antibody can mean the infection is present, or that it was present in the past and is now cleared.  Finally, there is a stool test that can detect the presence of this bacteria.

Gastritis and Dyspepsia

The symptoms are discomfort, bloating, nausea and perhaps vomiting.  The person may also have symptoms that suggest ulcers—burning or pain in the upper abdomen, usually occurring about an hour or so after meals or even during the night.  The symptoms are often relieved temporarily by antacids, milk, or medications that reduce stomach acidity.  Yet, the physician does not find an ulcer when the patient is tested by x-ray or endoscopy.  When H.  Pylori is found in the stomach, it is tempting to believe that it is the cause of the symptoms, although this connection is not yet clear cut.  The physician will usually prescribe antibiotic therapy to see if clearing the infection relieves symptoms.

Ulcers

Stomach Ulcers: With stomach ulcers, H.  Pylori infection is found in 60 to 80 percent of the cases.  Again, it is still uncertain how the infection acts to cause the ulcer.  It probably weakens the protective mucous layer of the stomach.  This allows acid to seep in and injure the underlying stomach cells.  However, there is still a great deal of research to be done to unravel this relationship.

Duodenal ulcers: In times past, physicians were taught “no acid, no ulcer.” The medical profession felt the single most important factor causing duodenal ulcers to form was strong stomach acid.  Research has now shown that over 90% of all patients who develop duodenal ulcers have H.  Pylori infection in the stomach as well.  Medical studies are under way to determine the relationship between the two and how an infection in the stomach can be related to a duodenal ulcer, Acid is still important; patients without acid in the stomach never get duodenal ulcers.  However, physicians now accept the fact that the infection is directly related to the development of duodenal ulcers.  It is now rather easy to clear duodenal ulcers with the strong acid- reducing medicines available.  But, the ulcers will usually recur unless the H.  Pylori infection is also cleared from the stomach.

Stomach Cancer and Lymphoma

These two types of cancer are now known to be related to H.  Pylori bacteria.  This does not mean that all people with H.  Pylori infection will develop cancer; in fact, very few do.  However, it is likely that if the infection is present for a long time, perhaps from childhood, these cancers may then develop.  This is another reason why it is important to treat H.  Pylori infection.

Treatment

Physicians are treating the acute ulcer with acid-reducing medicines and treating the infection with antibiotics.  Interestingly, one of these antibiotics is a bismuth compound that is available over-the- counter as Pepto-Bismol.  It is also available as a generic drug called bismuth subsalicylate.  The bismuth part of the medicine actually kills the bacteria.  However, do not go to the drugstore and purchase a bottle of Pepto-Bismol, expecting this alone to cure the infection.  H.  Pylori is buried deep in the stomach mucous, so it is difficult to get rid of this infection.  Several antibiotic drugs are always used together to prevent the bacteria from developing resistance to any one of them.  Once treated, a variety of tests are used to confirm that the bacteria has been eradicated.

Summary

H. Pylori is a very common infection of the stomach.  It may be the most common infection in the world.  It is now clear that the infection is directly related to the development of stomach and duodenal ulcers, and it is likely that it may be related to cancers involving the stomach.  There are several diagnostic tests available, and effective treatment can prevent the recurrence of ulcers and perhaps the development of cancer.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The Liver

The liver is the largest organ in the body.  It is found high in the right upper abdomen, behind the ribs.  It is a very complex organ and has many functions.  They include:

• Storing energy in the form of sugar (glucose)

• Storing vitamins, iron, and other minerals

• Making proteins, including blood clotting factors, to keep the body healthy and help it grow

• Processing worn out red blood cells

• Making bile which is needed for food digestion

• Metabolizing or breaking down many medications and alcohol

• Killing germs that enter the body through the intestine

The body absorbs iron from iron-rich foods.  Iron is stored in the liver until it is needed for important body functions.  However, too much stored iron can be harmful, and the body has no effective way to eliminate it once it has been absorbed.  This build-up of iron causes a condition known as hemochromatosis.

What is Hemochromatosis?

Hemochromatosis is commonly known as iron overload disease.  A malfunction in the way iron is absorbed from the intestinal tract causes the body to absorb and store too much iron.  Certain vitamins and minerals are normally stored in the liver, and iron is one of them.  However, too much iron stored in the liver can damage it.  With hemochromatosis, excess iron is also deposited in other organs and tissues, especially the heart and pancreas, causing damage to these organs, too.  This disease occurs more commonly than was originally thought.  It is estimated that hemochromatosis affects about one in every 300- 400 people.  Occasionally, a secondary type of iron overload (called hemosiderosis) occurs in people who take large amounts of iron supplements, or in people who must have repeated blood transfusions, or who have certain other diseases.  However, the body usually returns to normal processing of iron when the excess intake is eliminated.

Cause

Exactly what makes the body absorb and store too much iron is not completely understood.  It is known that hemochromatosis is inherited.  The gene for the disease is a very common one; about one in every 10 people carry it.  However, a person can carry one gene and not get the disease.  It is only when a person gets a hemochromatosis gene from each parent—a double dose—that the disease develops.  Therefore, people who have parents, brothers, or sisters with this disease should be closely monitored by a physician.

Symptoms

The disease can develop at any age, but symptoms usually do not occur until middle age (between the ages of 40 and 60), Women often develop the symptoms at a later age than men, probably because women lose significant amounts of iron through menstruation and pregnancy.  The damage to the liver and other organs comes from long-term storage of excessive iron.

When the liver is badly damaged, scarring or hardening develops.  This is called cirrhosis.  Damage to the liver may also cause jaundice (yellow color to skin and eyes).  Excess iron deposited in the pancreas causes it to stop making insulin, and diabetes mellitus develops.  Hemochromatosis can also cause enlargement of and damage to the heart.  Too much iron can be harmful to the pituitary gland (in the brain), and this may result in a number of hormone problems.  Another common problem is the development of arthritis.  Hemochromatosis can be a perplexing disease, because there are so many symptoms that can vary from patient to patient.

Diagnosis

Early diagnosis is important, because treatment can prevent long-term injury and damage to body organs.  When there is a family history of hemochromatosis, and especially if there are symptoms present, the physician will order certain blood tests.  One of the tests is a measure of iron in the blood.  Another is for blood ferritin, a protein that carries iron.  With hemochromatosis, these tests will be abnormally high.  When the blood tests are repeated and the results are consistently high, the physician usually diagnoses hemochromatosis.  A liver biopsy is then performed to determine how much iron is stored in the liver and if there has been any liver damage.  Liver biopsy is done under local anesthesia.  A slender needle is inserted through the right lower chest to extract a small piece of liver for microscopic analysis.

Treatment

Red blood cells are rich in iron, so their removal will reduce the amount of iron in the body.  Treatment begins with one to two pints of blood being removed each week or so, until stored iron is reduced to normal levels.  It may take several months or longer to accomplish this.  After iron stores are reduced to normal, the patient should continue to have blood drawn periodically.

Complications of hemochromatosis, such as arthritis, hormone deficiency, heart failure, and diabetes, can be treated successfully in most cases.  If these complications have already occurred in the patient, regular treatment with blood withdrawal should still be done.  At this stage, it can prevent further harm and may even improve some of the damage.

How Can the Patient Help?

Alcohol seems to make the problem worse, so people with hemochromatosis should avoid alcohol or have only an occasional drink.  A regular balanced diet is recommended, but patients should avoid large quantities of iron rich foods, such as red meats (especially liver) and iron fortified food products.  Iron supplements should never be taken.  Even small amounts of iron present in some multivitamin preparations can be harmful.

Liver transplantation is now an accepted form of treatment for chronic, severe liver damage.  Advances in surgical techniques and the use of new drugs to suppress rejection have improved the success rate of transplantation.  The outcome is excellent for hemochromatosis patients, and with the slow progression of this disease, it is possible to plan elective transplant surgery.  Survival rates at transplant centers are well over 90 percent with a good quality of life after recovery.

Summary

Hemochromatosis is a common inherited disease that causes the body to absorb and store too much iron.  People with a family history of the disease should be tested early, because symptoms which can signal organ damage usually do not occur until late in the disease.  Hemochromatosis can be controlled, and complications can be avoided or treated.  Those patients who are diagnosed early can look forward to a completely normal and active life.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The Liver

The liver is the largest organ in the body.  It is found high in the right upper abdomen, underneath the ribs.  It is a very complex organ and has many functions.  They include:

• Storing energy in the form of sugar (glucose)

• Storing vitamins, iron, and other minerals

• Making proteins, including blood clotting factors, to keep the body healthy and help it grow

• Processing worn out red blood cells

• Making bile which is needed for food digestion

• Metabolizing or breaking down many medications and alcohol

• Killing germs that enter the body through the intestine

The liver is subject to illnesses, such as hepatitis B, which may lead to serious liver damage.

What is Hepatitis?

When cells in the body are injured by such things as chemicals or infection, the area that is injured becomes inflamed.  Hepatitis is inflammation of the liver, which in turn causes damage to individual liver cells.  It is most often caused by viral infection.  However, it can also be caused by alcohol, certain drugs, chemicals or poisons, or other diseases.

Hepatitis may be either acute or chronic.  In acute hepatitis the inflammation develops quickly, and lasts only a short period of time.  The patient usually recovers completely, but it can take up to several months.  Occasionally, a person fails to recover fully, and the hepatitis becomes chronic.  Chronic hepatitis can develop over a number of years without the patient ever having acute hepatitis or even feeling sick.  As the liver repairs itself, fibrous tissue develops, much like a scar forms after a cut or injury to the skin heals.  Advanced scarring of the liver is called cirrhosis.  Over time, cirrhosis irreversibly damages the liver, eventually ending in liver failure.

What is Hepatitis B?

Hepatitis B is caused by the hepatitis B virus (medically abbreviated as HBV).  Current estimates are that over 250,000 people in the United States contract HBV each year.  It is often spread through sexual contact, accounting for about 50% of the reported cases.  It is also spread through contact with blood or body fluids from a person carrying HBV.  Some groups have a higher risk of becoming infected with HBV.  These include:

• Intravenous drug users

• Health care workers, funeral workers, police

• People in an HBV infected person’s household

• People with multiple heterosexual or, especially, homosexual partners

• Residents of nursing homes

• Hemophiliac and hemodialysis patients

• Prisoners and prison workers

• Travelers to underdeveloped countries

• Certain ethnic groups such as Asians, Hispanics, American Indians, Alaskan Natives, or people from developing countries

In pregnancy, the virus is passed from an infected mother to her child in about 90% of the cases.  This usually occurs during delivery.  HBV is also carried in breast milk.  In about 30% of all cases of hepatitis B, however, it is unknown how the patient contracted the virus.

HBV is much more contagious than the AIDS virus.  For example, it can live outside the body on a dry surface for up to 10 days.  Once a person gets the virus, it may take from one to six months for the infection and symptoms to develop.  One of three things can then happen—most patients develop acute Hepatitis B and recover completely; a small percentage become HBV carriers; and some develop chronic hepatitis B.

Acute Hepatitis B

Many patients with acute hepatitis B have no symptoms, or the symptoms are mild and often mistaken for flu.  Their bodies are able to fight the virus off quickly.  Some, however, can become quite sick while their bodies are fighting off the virus.  The following are symptoms of acute hepatitis B:

• Loss of appetite, nausea, vomiting, fever

• Aching muscles and sometimes joint pain

• Tenderness in the right upper abdomen

• Jaundice (yellowing of skin and eyes)

• Tea-colored urine; putty-like or white stool

Diagnosis of the disease is made by a blood test.  It is called the hepatitis B surface antigen test (HBsAg).  No specific treatment is available or usually necessary for acute hepatitis infection.  The physician may recommend supportive measures to help the patient maintain strength and avoid taxing the liver while the body’s natural defenses are fighting the virus.  Acute hepatitis B patients recover completely within six months and develop antibodies that give them a life-long immunity.

Some patients who become infected, however, do not recover completely.  Up to 10% of adults with Hepatitis B and up to 50% of infected children under five years of age are not able to completely fight off the virus within six months.  This occurs because their bodies are unable to develop antibodies against hepatitis B.  Most of these patients become HBV carriers.

HBV Carriers

HBV carriers recover from the infection completely and feel healthy.  They have no ongoing hepatitis or liver damage.  However, their blood tests show they still have the virus and have not developed hepatitis B antibodies.  Therefore, they can pass on the virus.  This is called an HBV carrier, because carriers do not develop symptoms or feel sick, thousands of people who become carriers of HBV never know it.  There may be as many as one million Americans carrying HBV.

There is no treatment presently available for this situation.  Carriers have a responsibility to practice safe lifestyle habits that will prevent their passing the virus on to others.  This especially includes protected sex.

Chronic Hepatitis B

A smaller percentage of patients who cannot fight off the virus will develop chronic hepatitis B.  Like HBV carriers, chronic hepatitis B patients are also able to pass on HBV.  However, there is a very important difference with chronic hepatitis B.  These patients will also have ongoing hepatitis and liver damage.  A few may have an increased risk for developing cancer of the liver.  Once again, blood tests show that no antibodies have developed.  The physician usually suspects the condition when abnormal enzyme tests are found on routine blood testing.  There are rarely any symptoms in the early stages of chronic hepatitis B.  Additional tests, such as ultrasound, are helpful to determine the condition of the liver.  A liver biopsy is always performed to determine the degree of inflammation and scarring.

Patients with chronic hepatitis B should avoid alcohol because it can cause additional liver damage.  Some medicines and drug combinations may cause liver injury, so patients should review all medications they are taking with their physicians.  Patients should never take over-the-counter drugs without the physician’s approval.  Chronic hepatitis B can now be treated with several medications.  A liver disease specialist is often required to determine if the patient should be placed on the types of therapy.

Liver Transplantation

Liver transplantation is a form of treatment for people with a badly damaged liver.  In those patients with chronic hepatitis B, the new liver usually becomes infected with the virus, but most transplant medical centers are dealing with this effectively.  There are newer drugs for chronic hepatitis B now under investigation.  However, at the present time the best defense against HBV is prevention.

Prevention and Vaccination

There is a safe and effective vaccine to protect or immunize a person against hepatitis B.  The vaccine usually offers protection for about 10 years or more.  However, it is of no use to those already infected with HBV.  Persons who have not been vaccinated and who know they have been exposed to HBV should receive an injection of hepatitis B immune globulin within two weeks of exposure to the virus.  This is called a passive immunization.  It gives immediate short-term protection for 3-6 months.  The Hepatitis B vaccine is active immunization.  Active immunization provides long-term (sometimes lifelong) protection.  Therefore, people who are at risk of coming in contact with the virus, and especially newborn infants and sexually active teenagers, should be immunized.  In the U.S., pediatricians now recommend that all children be actively vaccinated.

There are other precautions people should take to protect themselves against hepatitis B.  Since the virus is most often spread through sexual contact, it is most important to avoid unprotected sex with those who have or are likely to have the infection.  Precautions must be taken to avoid coming in contact with blood or body fluids from an infected individual.  For those living in households with infected patients, surfaces which may hold the virus should be cleaned with one part household bleach to 10 parts water.  Items such as razors, toothbrushes, IV needles or pierced earrings should never be shared.  People should also avoid such practices as tattooing and ear piercing in places where sterile conditions are questionable.  Women who are pregnant should be tested for HBV and follow their physicians’ advice to protect their unborn children.

Summary

Hepatitis B is a serious disease that may result in long-term complications.  While most people recover, some develop chronic hepatitis.  Some people become carriers of HBV without knowing it.  For this reason, it is important to prevent spread of the disease by vaccination and by lifestyle practices that avoid contact with infected blood and body fluids, For acute infections, no therapy is available or usually necessary.  Researchers are continually learning more about hepatitis, and research into new treatments is ongoing.  Chronic hepatitis B patients who are monitored frequently and follow the advice of their physicians have every reason to expect a good quality of life.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The Liver

The liver is the largest organ in the body. It is found high in the right upper abdomen, underneath the ribs. It is a very complex organ and has many functions. They include:

• Storing energy in the form of sugar (glucose)

• Storing vitamins, iron, and other minerals

• Making proteins, including blood clotting factors, to keep the body healthy and help it grow

• Processing worn out red blood cells

• Making bile which is needed for food digestion

• Metabolizing or breaking down many medications and alcohol

• Killing germs that enter the body through the intestine

The liver is subject to illnesses, such as hepatitis B, which may lead to serious liver damage.

What is Hepatitis?

When cells in the body are injured by such things as chemicals or infection, the area that is injured becomes inflamed. Hepatitis is inflammation of the liver, which in turn causes damage to individual liver cells. It is most often caused by viral infection. However, it can also be caused by alcohol, certain drugs, chemicals or poisons, or other diseases.

Hepatitis may be either acute or chronic. In acute hepatitis the inflammation develops quickly, and lasts only a short period of time. The patient usually recovers completely, but it can take up to several months. Occasionally, a person fails to recover fully, and the hepatitis becomes chronic. Chronic hepatitis can develop over a number of years without the patient ever having acute hepatitis or even feeling sick. As the liver repairs itself, fibrous tissue develops, much like a scar forms after a cut or injury to the skin heals. Advanced scarring of the liver is called cirrhosis. Over time, cirrhosis irreversibly damages the liver, eventually ending in liver failure.

What is Hepatitis C?

Hepatitis C is caused by a virus (medically abbreviated as HCV). This type of viral hepatitis is different from the others in an important way. All patients with hepatitis A and most with hepatitis B develop an acute infection, recover completely, and develop antibodies that protect them from ever getting the disease again. Once inside the body, it changes its form to evade discovery and attack by the immune system. Scientists have already identified many forms of HCV, and patients infected with one type are not necessarily safe from other types. Hepatitis C patients do develop antibodies, but they are not curative or protective as in hepatitis A or B. Hepatitis C antibodies may not completely rid the body of the virus. Therefore, most people infected with the HCV virus will develop chronic hepatitis.

Current estimates are that 3.5 million Americans carry the virus that causes hepatitis C, and 150,000 people become infected with HCV each year. This virus is known to be spread through infected blood, blood products, and needles. Prior to the late 1980s, people were most at risk for contracting the disease through blood transfusions. However, a blood test was developed at that time to detect the virus, and the blood supply is now always tested to prevent spread of the disease in this way. Even so, there is a very slight risk for those who must receive blood products on a regular basis, such as hemophiliacs and patients on hemodialysis. Health care workers are also at risk. At this time, the people most at risk for getting hepatitis C are IV drug users who share needles. There are also a larger number of cases among East Asians. In about 40% of all cases of hepatitis C, it is unknown how the patient was infected with the virus. This situation is known as community acquired disease.

Symptoms and Diagnosis

Most patients with hepatitis C do not have symptoms. This is especially true early in the disease. If there are symptoms, they are usually mild and flu-like--—perhaps nausea and fatigue. It can take from 2 to 26 weeks for the disease to develop once the patient is infected with HCV.

Routine blood tests will show an elevation in certain liver enzymes, especially one called the ALT. The physician can then order a specific blood test to determine if the patient has hepatitis C.

Chronic Hepatitis C

Hepatitis C is a cause for concern for two reasons. First, most cases become chronic. Second, patients seldom become acutely ill, so it is possible for them to have the disease for some time before it is diagnosed. Late in the disease, fatigue may become increasingly severe. If cirrhosis has developed, other more serious symptoms may occur. However, the elevation in the blood ALT may not correlate with the degree of liver inflammation. In other words, a high ALT may not necessarily mean there is a serious degree of inflammation. Conversely, a low or normal blood ALT level may be present even though there is chronic liver damage. For this reason, a liver biopsy is almost always required to determine how serious the disease may be. Under. A biopsy can show if cirrhosis is present and how far it has progressed. It is believed that about 20% of the patients with chronic hepatitis C will develop cirrhosis, and a few of those will go on to develop liver cancer. It may take from 10 to 40 years for serious liver damage to occur.

Treatment

Both the patient and physician have a role in treating hepatitis C. It is now known that alcohol use, even in socially accepted amounts, makes the liver disease worse. So while the virus is present in the body, it is best to avoid alcohol altogether. Patients should also discuss the use of over-the-counter medicines with the physician. Some drugs such as acetaminophen (Tylenol) that may not be normally toxic can worsen liver damage in HCV. Of course, a healthy diet is always important. The patient will also want to discuss vaccination against hepatitis viruses A and B. If a person with HCV becomes infected with either of these other viruses, the outcome could be quite severe. The patient should be careful to avoid the possibility of getting these other diseases. This means no IV drugs or unprotected sex with a new partner with unknown sexual activity history.

Hepatitis C can be treated with certain types of medications. A gastroenterologist or hepatologist (a specialist in liver diseases) with experience in treating HCV can help determine if patients with HCV are candidates for medical therapy.

HCV Carriers

Certain people infected with HCV have a positive HCV blood test, but a normal liver enzyme test. These individuals are often called HCV carriers, and they can pass the virus on to others.

Although they appear not to be seriously ill, there is recent evidence that even these people may have chronic hepatitis. Therefore, each should be evaluated by a liver specialist.

Sex and Pregnancy

The risk of transmitting HCV sexually is low compared to hepatitis B and AIDS. In marriages and long-term relationships with monogamous partners, it is often the case that one person is HCV positive and the partner is HCV negative. The current medical recommendation is that in these circumstances, sexual practices need not be changed. However, when people have multiple sex partners or new partners, they should never engage in unprotected sex.

It appears that in pregnancy, HCV is passed on to the fetus less than 5% of the time. It may depend on how high the mother’s blood virus level is during pregnancy. Therefore, hepatitis C infected women should always consult with their physicians before becoming pregnant.

Prevention

There is no vaccine currently available to protect against hepatitis C, as there is with hepatitis A and hepatitis B. People can prevent getting hepatitis C by not sharing anything that is likely to hold and transmit blood—razors, manicure tools, toothbrushes, and especially IV drug needles. Practices such as ear piercing and tattooing should be avoided in places where sterile conditions are questionable. Until all circumstances under which HCV can be transmitted have been thoroughly identified, it should be assumed that every person with hepatitis C can pass the virus on to others. Therefore everyone, especially health care workers, should avoid coming in contact with blood and body fluids from infected individuals.

Liver Transplantation

Liver transplantation is a successful form of therapy for people with a badly damaged liver. Liver transplants have become more common for people with chronic hepatitis C who develop life-threatening liver damage. However, since these patients continue to carry the virus, they will almost always reinfect their new livers. Nevertheless, with continuing treatment for the chronic infection, liver transplantation offers the patients longer life and improved quality of life.

Summary

Hepatitis C is a serious disease that often results in long-term complications. Many patients infected with HCV develop chronic hepatitis C. Some people become carriers of HCV without knowing it. For this reason it is important to prevent spread of the disease by lifestyle practices that avoid contact with infected blood and body fluids. Researchers are continually learning more about hepatitis C, and research into new treatment is ongoing. Chronic hepatitis C patients who are monitored frequently and follow the advice of the physicians have every reason to be hopeful about the future.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Hemorrhoids are one of mankind’s most common and nagging disorders.  By themselves, hemorrhoids are rarely serious, but they can be extremely troublesome.  In some instances, they may mask a more serious disorder, such as colon or rectal cancer.  Therefore, hemorrhoids require the proper diagnosis and treatment by a physician.

Hemorrhoids are dilated (enlarged) veins which occur in and around the anus and rectum.  They may be external (outside the anus) or internal and slip to the outside.  In both of these instances, the hemorrhoids can be felt and seen as lumps or knots, Hemorrhoids also may remain inside the rectum and so cannot be felt or seen.  These are called internal hemorrhoids.

What Causes Hemorrhoids?

A common cause of hemorrhoids is simply the standing position, in which all the blood above the rectum exerts pressure on the rectal and anal areas.  Other conditions which contribute to hemorrhoids are: poor bowel habits, constipation, diarrhea, pregnancy, obesity, and especially frequent straining when having a bowel movement.  However, some patients will have none of these conditions and still develop hemorrhoids.

What Are the Complications?

Hemorrhoids can produce several uncomfortable, but non-serious problems.

• Thrombosis and Pain—A blood clot in the hemorrhoid may cause severe pain and usually demands immediate medical attention.

• Bleeding—Hemorrhoids can ooze fresh red blood, whether located externally or internally.  External hemorrhoids often cause dripping of blood from the anus while sitting on the toilet.  The blood might also be seen as soiling of the underwear.  Internal hemorrhoids that bleed may produce fresh blood in the stool.

• Itching and Irritation—External hemorrhoids can be itchy, especially if the area is moist and irritated.

Do Hemorrhoids Cause Cancer?

Hemorrhoids do not develop into cancer.  However, both hemorrhoids and cancer can cause rectal bleeding.  In fact, many disorders can be the cause of rectal bleeding.  When rectal bleeding occurs in persons over age 30, and especially in those over age 50, it should be considered a serious problem until an exact diagnosis is made.  The physician who directly examines the rectal area can make the specific diagnosis.

Treatment

Treatment of hemorrhoids varies depending on where they are, what problems they are causing, and how serious they are.  Often, time and the normal process of healing clear hemorrhoids with little or no specific treatment.

When hemorrhoids require treatment, the following general measures are recommended:

Conservative Treatment

1. Keep the anal area clean, using a mild soap and gentle dabbing after a bowel movement.  Avoid vigorous rubbing of the area.  2.  Keep the anus and hemorrhoids as dry as possible, using talcum powder and a pad of soft tissue to absorb moisture.

2. Eat a diet high in fiber (bran) and roughage.  Fiber and bran retain water in the stool, producing soft, bulky stools which are easier to pass and reduce the tendency to develop hemorrhoids.  Bulking agents, such as Metamucil, Effersyllium, Konsyl, Citrucel, and Per Diem Fiber, are available in drug stores.  These also come in less expensive generic versions.

3. Avoid straining when having a bowel movement.

4. When thrombosis, pain, and tenderness occur, a 10 to 20 minute hot tub bath two to four times daily brings heat to the area, provides relief from the pain, and promotes healing.  This is called a hot Sitz bath.

5. Ligation

6. A common method of treating internal hemorrhoids is to use a small rubber band to tie off the base of the swollen vein.  The blood circulation stops and the hemorrhoid then falls off.  Repeat treatments are sometimes necessary.

Infrared Photocoagulation

An infrared light source can be used to coagulate internal hemorrhoidal veins.  Often, more than one treatment is necessary.

Band ligation

A new and effective technique involves placing rubber bands around internal hemorrhoids.  This technique is done as an outpatient and is often painless.  To achieve desired benefit, several sessions may be required.

Surgery

Surgery is sometimes recommended in treating hemorrhoids.  It usually is reserved for:

• Acute, painful clot (thrombosis) of hemorrhoids

• Profusely or continuously bleeding hemorrhoids

• Longstanding, irreversible, and large hemorrhoids

• When other treatment is unsuccessful The physician evaluates each patient’s case to determine the appropriate treatment.

To Prevent Hemorrhoids

• Eat plenty of fiber, bran, or roughage, or use a bulking agent to maintain regular, soft bowel movements.

• Do not delay or try to prevent a bowel movement when the urge is present.

• Exercise, especially aerobic, may help produce more regular bowel movements.

• Drink plenty of liquids and eat regularly scheduled meals.

• Keep the area around the anus clean and dry.

Summary

Hemorrhoids are an especially common disorder and often clear up by themselves or with minimal treatment.  Treatment typically is simple and effective, although surgery occasionally is necessary.  Hemorrhoids can mask a more serious disorder and, therefore, must be evaluated and diagnosed properly by a physician.  People with hemorrhoids who work closely with their physician are usually assured a good outcome and relief from this common disorder.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

A hiatal hernia is one of the most misunderstood and maligned conditions in medicine.  People blame this hernia for much more than it ever does.  Patients with a hiatal hernia need to understand what it is and what might occur with it.  Most importantly, they need to know it is unusual for serious problems to develop from this type of hernia.

Anatomy

The diaphragm is a sheet of muscle that separates the lungs from the abdomen.  When a person takes a deep breath, the dome-shaped diaphragm contracts and flattens.  In doing this, the diaphragm pulls air into the lungs.  The left diaphragm contains a small hole through which passes the tube-shaped esophagus that carries food and liquid to the stomach.  Normally this hole, called a hiatus, is small and fits snugly around the esophagus.  The J-shaped stomach sits below the diaphragm.

What Causes a Hiatal Hernia?

In some people, the hiatal or hole in the diaphragm weakens and enlarges.  It is not known why this occurs.  It may be due to heredity, while in others it may be caused by obesity, exercises such as weightlifting, or straining at stool.  Whatever the cause, a portion of the stomach herniates, or moves up, into the chest cavity through this enlarged hole.  A hiatal hernia is now present.  Hiatal hernias are very common, occuring in up to 60 percent of people by age 60.

What Are the Different Types of Hiatal Hernia?

1. Sliding Hiatal Hernia—In this most common type of hiatal hernia, the herniated portion of the stomach slides back and forth, into and out of the chest.  These hernias are normally small and usually problems or even symptoms.

2. Fixed Hiatal Hernia—In this case, the upper part of the stomach is caught up in the chest.  Even with this hernia, there may be few symptoms.  However, the potential for problems in the esophagus is increased.

3. Complicated or Serious Hiatal Hernia— Fortunately, this type of hernia is uncommon.  It includes a variety of patterns of herniation of the stomach, including cases in which the entire stomach moves up in the chest, There is a high likelihood that medical problems will occur with this hernia and that treatment, frequently involving surgery, will be required.  Complicated hernias are uncommon.

Symptoms

In most patients, hiatal hernias cause no symptoms.  This is especially true of sliding hernias.  When symptoms occur, they may only be heartburn and regurgitation, when stomach acid refluxes back into the esophagus.  Some patients with fixed hiatal hernias experience chronic reflux of acid into the esophagus, which may cause injury and bleeding.  Anemia, or low red blood cell count, can result.  Further, chronic inflammation of the lower esophagus may produce scarring and narrowing in this area.  This, in turn, makes swallowing difficult, and food does not pass easily into the stomach.

Does Hiatal Hernia Cause Pain and Indigestion?

It is wrong to always blame a hiatal hernia for pain and indigestion.  Hiatal hernias generally do not cause acute pain.  This symptom may result from other disorders, such as peptic ulcers or even heart disease.  Some patients with coronary heart disease fool themselves into believing their discomfort is due to a hiatal hernia.  If upper- abdominal pain or indigestion occurs, people should not mislead themselves into thinking the cause is a hiatal hernia.  Instead, the patient should seek medical advice.

Diagnosis

Diagnosis of a hiatal hernia is typically made through an upper GI barium x-ray.  A complementary test is gastroscopy, or upper- intestinal endoscopy, in which the physician visually examines the esophagus and stomach using a flexible scope while the patient is lightly sedated.

What Are the Complications?

The complications of hiatal hernia are:

• Chronic heartburn and inflammation of the lower esophagus, called reflux esophagitis

• Anemia due to chronic bleeding from the lower esophagus

• Scarring and narrowing of the lower esophagus causing difficulty in swallowing

• While sleeping, stomach secretions can seep up the esophagus and into the lungs causing chronic cough, wheezing, and even pneumonia

In addition, the complicated hernia can cause serious problems such as difficulty in breathing or severe chest pain, especially in the elderly.

Treatment

Treatment is called for only when the hernia results in symptoms, such as persistent heartburn or difficulty in swallowing.  Acid inflammation and ulceration of the lower esophagus also require treatment.

General guidelines for treating heartburn and esophagitis (inflammation of the esophagus) are:

• Avoid (or use only in moderation) foods and substances that increase reflux of acid into the esophagus, such as:

nicotine (cigarettes)               chocolate               caffeine               fatty foods

peppermint                           caffeine                 alcohol                caffeine               spearmint

• Eat smaller, more frequent meals and do not eat within 2-3 hours of bedtime.

• Avoid bending, stooping, abdominal exercises, tight belts, and girdles all of which increase abdominal pressure and cause reflux.

• If overweight, lose weight.  Obesity also increases abdominal pressure.

• Prescription medications.  Certain drugs, such as intestinal antispasmodics, calcium channel blockers, and some antidepressants weaken the muscle strength of the lower esophagus.

• Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress.  Gravity then helps keep stomach acid out of the esophagus while sleeping.

Other Treatments

Drugs — Some medicines effectively reduce the secretion of stomach acid, while others increase the muscle strength of the lower esophagus, thereby reducing acid reflux.

Surgery — The complicated hiatal hernia requires surgery occasionally on an emergency basis.  Surgery otherwise is reserved for those patients with complications that cannot be handled with medications.  The mere presence of a hiatal hernia is not a reason for surgery.

Summary

A hiatal hernia is an extremely common condition which usually does not cause symptoms problems.  However, when it does, the physician can frequently treat the problem effectively with a well-planned program.  Surgery is infrequently required to treat a hiatal hernia.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

What Is an Irritable Bowel?

Medically, irritable bowel syndrome (IBS) is also known as: spastic colon, spastic colitis, mucous colitis and nervous or functional bowel.  Usually, it is a disorder of the large intestine (colon), although other parts of the intestinal tract—even up to the stomach—can be affected.

The colon, the last five feet of the intestine, serves two functions in the body.  It dehydrates and stores the stool so that, normally, a well-formed soft stool occurs.  Second, rhythmic contractions of the colon quietly propel the stool from the right side over to the rectum, storing it there until it can be evacuated.

When lBS occurs, the colon does not contract normally.  Instead, it seems to contract in a disorganized, at times violent, manner.  The contractions may be terribly exaggerated and sustained, lasting for prolonged periods of time.  One area of the colon may contract with no regard to another.  At other times, there may be little bowel activity at all.  These abnormal contractions result in changing bowel patterns with constipation being most common.

A major symptom of lBS is bloating.  Bloating is a very real phenomenon.  People at times can literally look (and feel) pregnant.  We believe the bloating occurs because of abnormal contractions of bowel with trapping of air.

A final major feature of lBS is abdominal discomfort or pain.  This may move around the abdomen rather than remain localized in one area.  This pain is often relieved with a bowel movement.

These disorganized, exaggerated and painful contractions lead to certain problems.  The pattern of bowel movements is often altered.  Diarrhea may occur, especially after meals, as the entire colon contracts and moves liquid stool quickly into the rectum.  Or, localized areas of the colon may remain contracted for a prolonged time.  When this occurs, which often happens in the section of colon just above the rectum, the stool may be retained for a prolonged period and be squeezed into small pellets.  Excessive water is removed from the stool and it becomes hard.

Also, air may accumulate behind these localized contractions, causing the bowel to swell.  So bloating and abdominal distress may occur.

Some patients see gobs of mucous in the stool and become concerned.  Mucous is a normal secretion of the bowel, although most of the time it cannot be seen.  lBS patients sometimes produce large amounts of mucous, but this is not a serious problem.

The cause of most lBS symptoms—diarrhea, constipation, bloating, and abdominal pain—are due to this abnormal physiology.

Although the symptoms of lBS may be severe, the disorder itself is not a life-threatening one.  There is no actual disease present in the colon.  In fact, an operation performed on the abdomen would reveal a perfectly normal appearing bowel.

Rather, it is a problem of abnormal function.  The condition usually begins in young people, usually below 40 and often in the teens.  The symptoms may wax and wane, being particularly severe at some times and absent at others.  Over the years, the symptoms tend to become less intense.

lBS is extremely common and is present in perhaps half the patients that see a specialist in gastroenterology.  It tends to run in families.  The disorder does not lead to cancer.  Prolonged contractions of the colon, however, may lead to diverticulosis, a disorder in which balloon-like pockets push out from the bowel wall because of excessive, prolonged contractions.

Causes

While our knowledge is still incomplete about the function and malfunction of the large bowel, some facts are well-known.  Certain foods, such as coffee, alcohol, spices, raw fruits, vegetables, and even milk, can cause the colon to malfunction.  In these instances avoidance of these substances is the simplest treatment.

Infections, illnesses, travel, and even changes in the weather somehow can be associated with a flare-up in symptoms.  So can the premenstrual cycle in the female.

By far, the most common factor associated with the symptoms of lBS are the interactions between the brain and the gut.  The bowel has a rich supply of nerves that are in communication with the brain.  Virtually everyone has had, at one time or another, some alteration in bowel function when under intense stress, such as before an important athletic event, school examination, or a family conflict.

People with lBS seem to have an overly sensitive bowel, and perhaps a super abundance of nerve impulses flowing to the gut, so that the ordinary stresses and strains of living somehow result in colon malfunction.

These exaggerated contractions can be demonstrated by placing pressure- sensing devices in the colon.  Even at rest, with no obvious stress, the pressures tend to be higher than normal.  With the routine interactions of daily living, these pressures tend to rise dramatically.  When an emotionally charged situation is discussed, they can reach extreme levels not found in people without lBS.  These symptoms are due to real physiologic changes in the gut—a gut that tends to be inherently overly sensitive, and one that overreacts to the stresses and strains of ordinary living.

Diagnosis

The diagnosis of lBS often can be suspected just by a review of the patient’s medical history.  In the end it is a diagnosis of exclusion; that is, other conditions of the bowel need to be ruled out before a firm diagnosis of lBS can be made.

A number of diseases of the gut, such as inflammation, cancer, and infection, can mimic some or all of the lBS symptoms.  Certain medical tests are helpful in making this diagnosis, including blood, urine and stool exams, x-rays of the intestinal tract and a lighted tube exam of the lower intestine.  This exam is called endoscopy, sigmoidoscopy or colonoscopy.

Additional tests often are required depending on the specific circumstances in each case.  If the proper medical history is obtained and if other diseases are ruled out, a firm diagnosis of lBS then can usually be made.

Treatment

The treatment of lBS is directed to both the gut and the psyche.  The diet requires review, with those foods that aggravate symptoms being avoided.

Current medical thinking about diet has changed a great deal in recent years.  There is good evidence to suggest that, where tolerated, a high roughage and bran diet is helpful.  This diet can result in larger, softer stools which seem to reduce the pressures generated in the colon.

Large amounts of beneficial fiber can be obtained by taking over-the-counter bulking agents such as psyllium mucilloid (Metamucil, Konsyl) or methylcellulose (Citrucel).

As many people have already discovered, the simple act of eating may, at times, activate the colon.  This action is a normal reflex, although in lBS patients it tends to be exaggerated.  It is sometimes helpful to eat smaller, more frequent meals to block this reflex.

There are certain medications that help the colon by relaxing the muscles in the wall of the colon, thereby reducing the bowel pressure.  These drugs are called antispasmodics.  Since stress and anxiety may play a role in these symptoms, it can at times be helpful to use a mild sedative, often in combination with an antispasmodic.  A newer drug called Lotronex (generic: alosetron) is helpful for lBS patients that have diarrhea as a predominant symptom.

Physical exercise, too, is helpful.  During exercise, the bowel typically quiets down.  If exercise is used regularly and if physical fitness or conditioning develops, the bowel may tend to relax even during non-exercise periods.  The invigorating effects of conditioning, of course, extend far beyond the intestine and can be recommended for general health maintenance.

As important as anything else in controlling lBS is learning stress reduction, or at least how to control the body’s response to stress.  It certainly is well-known that the brain can exert controlling effects over many organs in the body, including the intestine.

Summary

Patients with lBS can be assured that nothing serious is wrong with the bowel.  Prevention and treatment may involve a simple change in certain daily habits, reduction of stressful situations, eating better and exercising regularly.

Perhaps the most important aspect of treatment is reassurance.  For most patients, just knowing that there is nothing seriously wrong is the best treatment of all, especially if they can learn to deal with their symptoms on their own.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Lactose intolerance develops when the body has difficulty digesting whole and skim milk and other dairy products.  Lactose is a milk sugar and like most sugars, it is broken down by enzymes in the intestinal tract so it can be absorbed as an energy source.  The enzyme that breaks down lactose is called lactase.  When the intestine does not contain lactase, then lactose intolerance can occur.  It is a troublesome and annoying problem, but it is never a serious one.

Who Has Lactose Intolerance?

As commonly expected, infants and small children have the enzyme lactase so they can digest mothers’ milk.  However, during childhood, lactase begins to disappear in many people.  Some ethnic groups are more likely to develop lactose intolerance.  By adolescence, it is gone in about 75% of African- Americans, Jews, Native Americans, Mexicans, and in 90% of Asians.

What Are The Symptoms?

When undigested lactose reaches the colon (large intestine), it is broken apart by bacteria.  Lactic acid and other acidic chemicals result.  It is these products that create the symptoms of lactose intolerance.  These symptoms include nausea, abdominal cramps and rumbling, bloating, rectal gas (flaws), and diarrhea.  They usually occur 30 minutes to two hours after ingesting lactose-containing foods.  The severity of symptoms usually depends on the amount of lactose ingested and how much of the enzyme, lactase, remains in the intestinal tract.

The Diagnosis

First, the physician reviews the patient’s medical history.  Sometimes that is enough to determine the problem.  However, to make a definitive diagnosis, one of several tests may be needed:

• Lactose Tolerance Test - A test dose of lactose is ingested and blood sugar determinations are made over several hours.  If lactase is present to break down the lactose load, then the blood sugar level rises.  If no lactase is present, the blood sugar level does not change.

• Hydrogen Breath Test - When lactose is broken down by the colon’s bacteria, hydrogen is released, which then passes out through the lungs.  The amount of hydrogen released after a lactose meal can indicate a problem.

• Stool Acidity Test - When lactose breaks down to lactic and other acids in the colon, the resulting acidity can be detected by a simple measurement of stool acidity.

• The Home Do-It-Yourself Test - Since lactose intolerance is not a serious disorder, some people may want to test themselves at home.  First, avoid milk and lactose-containing foods for several days.  Then on a free morning, such as a Saturday, drink two large glasses of skim or low- fat milk (14-16 oz).  If symptoms develop within four hours, the diagnosis of lactose intolerance is fairly certain.

Treatment

Therapy depends on whether a patient is willing to tolerate the symptoms.  If the symptoms are mild, then avoiding large amounts of milk and milk products may be enough.  For those who are very sensitive to small amounts of lactose, there are two options.  First, all foods should be carefully checked for lactose.  Grocery items such as bread, baked goods, cereals, instant potatoes, soups, margarine, lunchmeat, salad dressings, pancakes, biscuits, cookies, and candy can contain hidden lactose.  Even prescription and over-the-counter drugs may contain lactose.  The patient must become a label reader looking for and avoiding “milk” and “lactose”.

The second option is buying milk to which lactase, the enzyme, has been added.  Lactase drops or tablets are also available which can be placed in milk.  A pharmacist or food store manager can provide advice.  There are over-the- counter lactase tablets that can be taken with meals to replace the enzyme the body no longer has.  Finally, a variety of lactose-free products are now available in the specialty section of food stores.

Calcium and Lactose

Milk is a major source of calcium and calcium is necessary for good health and strong bones.  Most people need 1000 mg of calcium a day, except for pregnant and nursing females (1200mg per day) and post-menopausal females (1500 mg per day).  The following list from the National Institutes of Health provides some information on the calcium and lactose contents of food.

For the lactose-intolerant individual, ingesting enough calcium may be difficult.  Calcium supplements are often recommended.  The decision to take calcium supplements should be discussed with the physician.

Calcium and Lactose in Common Foods

Vegetables Calcium Content* Lactose Content**

Broccoli (cooked), 1 cup 94-177 mg 0

Chinese cabbage (bok choy, cooked), 1 cup 158 mg 0

Collard greens (cooked), 1 cup 148-357 mg 0

Kale (cooked), 1 cup 94-179 mg 0

Turnip greens (cooked), 1 cup 194-249 mg 0

Dairy Products

Ice cream/ice milk, 8 oz 176 mg 6-7 g

Milk (whole, low-fat, skim, buttermilk), 8 oz 291-316 mg 12-13 g

Processed cheese, 1 oz 159-2 19 mg 2-3 g

Sour cream, 4 oz 134 mg 4-5 g

Yogurt (plain), 8 oz 274-4 15 mg 12-13 g

Fish/Seafood

Oysters (raw), 1 cup 226 mg 0

Salmon with bones (canned), 3 oz 167 mg 0

Sardines, 3 oz 371 mg 0

Shrimp (canned), 3 oz 98 mg 0

Other

Molasses, 2 tbsp 274 mg 0

Tofu (processed with calcium salts), 3 oz 225 mg 0

* Nutritive Value of Foods.  Values vary with methods of processing and preparation.

**Derived from Lactose Intolerance: A Resource Including Recipes, Food Sensitivity Series, American Dietetic Association, 1985.

Summary

Lactose intolerance is a very common disorder, but it is never a threat to good health.  The diagnosis can readily be made through certain medical or do-it-yourself tests.  Treatments are available for those who enjoy and want to use milk and dairy products.  People who are very sensitive to lactose may have trouble getting enough calcium into the body.  The physician can review all of these questions and make the best recommendations.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

ACUTE PANCREATITIS

The pancreas is called the “quiet, hidden gland” because it is located deep in the abdomen behind the stomach.  About six to eight inches long in the adult, the organ contains thin tubes that come together like the veins of a leaf.  These tubes join to form a single opening into the intestine that is located just beyond the stomach.

The pancreas produces juices and enzymes that flow through these tubes into the intestine, where they mix with food.  The enzymes digest fat, protein, and carbohydrates so they can be absorbed by the intestine.  Pancreatic juices, therefore, play an important role in maintaining good health.  The pancreas also produces insulin, which is picked up by the blood flowing through the organ.  Insulin is important in regulating the amount of sugar or glucose in the blood.

What Are the Diseases of the Pancreas?

A number of problems can occur in the pancreas.  These include:

• Diabetes mellitus

• Acute pancreatitis

• Chronic pancreatitis

• Pancreatic enzyme deficiency

• Pancreas tumor

Diabetes Mellitus

Diabetes is caused by a deficiency of insulin.  Insulin is needed to help glucose, which is a major source of energy, enter the body’s cells.  It is not known why insulin-producing cells in the pancreas die off.  When they cease to function, glucose accumulates in the blood and eventually spills into the urine.  These patients require daily insulin injections.  More importantly, high blood glucose levels, over time, result in significant changes in blood vessels in the eyes, kidneys, heart, legs, and nerves.  Damage to these vital organs represents the major risk for patients with diabetes.

Patients who develop diabetes later in life seem to have sufficient insulin in the pancreas, but for some unknown reason it is not available for the body’s use.  Typically these patients are overweight and weight loss is critical.  In addition, oral medications can be taken that help release insulin from the pancreas.  All diabetics need to maintain normal or near-normal blood glucose levels to prevent or delay the complications of this disease.

Acute Pancreatitis

This condition occurs when the pancreas becomes quickly and severely inflamed.  The major causes are:

• Heavy alcohol ingestion

• Gallstones or gallbladder disease

• Trauma

• Drugs

• High blood fats (triglycerides)

• Heredity

• Unknown factors

Binge alcohol drinking is a common cause of acute pancreatitis.  Gallbladder disease, especially where a gallstone becomes lodged in the main bile duct next to the pancreas, also causes this condition.  Accidents, such as the upper abdomen hitting the steering wheel during a car accident, can cause pancreatitis.  Certain drugs, such as diuretics, can produce the disorder as can extremely high blood fat levels (triglycerides).  Heredity seems to play a role since in some families the condition develops in several members of the family.  Finally, there are the occasional cases that occur for unknown reasons.  In pancreatitis, the digestive enzymes of the pancreas break out into the tissues of the organ rather than staying within the tubes (ducts).  Severe damage to the pancreas then results.

Symptoms, Diagnosis, and Treatment

The main symptoms of pancreatitis are sudden, severe pain in the upper abdomen, frequently accompanied by vomiting and fever.  The abdomen is tender and the patient feels and looks ill.  The diagnosis is made by measuring blood pancreas enzymes which are elevated.  A sound wave test (ultrasound) or abdominal CT exam often shows an enlarged pancreas.  The condition is treated by resting the pancreas while the tissues heal.  This is accomplished through bowel rest, hospitalization, intravenous feeding and pain medications.

When pancreatitis is caused by gallstones, it is necessary to remove the gallbladder.  This is usually done after the acute pancreatitis has resolved.  At times, an ERCP (Endoscopic Retrograde CholangioPancreatography) test is recommended.  This involves passing a flexible tube through the mouth and down to the small intestine.  A small catheter is then inserted into the bile duct to see if any stones are present.  If so, they are then removed with the scope.

Course and Outcome

Most patients with this condition recover well, although a few, especially those who have alcohol- induced pancreatitis, may become severely ill.  When recovered, the patient needs to make lifestyle changes to prevent a recurrence.  For example, avoiding alcohol and drugs, reducing blood triglycerides, or having gallbladder surgery.

Chronic Pancreatitis

This condition occurs mostly in alcoholics or people who repeatedly binge drink alcohol.  The main symptoms are recurrent, dull, or moderate pain without the severe toxic features of acute pancreatitis.  Treatment consists of rest, medication, and certain food restrictions.  Alcohol consumption is absolutely prohibited.  However, in cases where damage is extensive, chronic pancreatitis and pain can occur even when alcohol consumption has stopped.

Diagnosis of this condition is made by measuring blood enzymes and by performing abdominal CT, x-rays, and ultrasound exams.  ERCP is often performed.  During ERCP, an x-ray dye is placed in the pancreas.  The internal anatomy of the pancreas can then be viewed.

Occasionally a problem develops when the patient becomes dependent on narcotic pain medicines.  In some cases, surgery is recommended to provide relief of pain.

Pancreas Enzyme Insufficiency

Digestive enzymes from the pancreas break down protein, fat, and carbohydrates in food.  When there is a deficiency of these enzymes, nutrients are not broken down, resulting in malnutrition and weight loss.  This condition is called malabsorption meaning the intestine is unable to absorb these vital nutrients.

Diarrhea (frequently with fat droplets in the stool) and weight loss are two major symptoms.  This can result from any cause of pancreatitis, including trauma and infection.  Pancreatic enzymes can be taken by mouth to replace those that are no longer made by the pancreas.

Pancreatic Tumors

The pancreas, like most organs, can develop tumors.  Some of these are benign and cause no problems.  However, some benign tumors can secrete hormones which, when present in high levels, have a damaging effect.  For example, insulin can be secreted in excess and result in dangerously low blood sugar levels (hypoglycemia).  Another hormone, gastrin, can stimulate the stomach to secrete its strong hydrochloric acid causing recurrent stomach and peptic ulcers, with many complications.  Fortunately, there is much that can be done about these tumors.

Cancer of the pancreas is a serious malignancy which is difficult to treat.  The disorder occurs in middle- or older-aged people, with the first symptom often being dull pain in the upper abdomen that may radiate into the back.  At times, skin jaundice occurs when the bile duct, which carries yellow bile from the liver and through the pancreas, is blocked.  Surgery is the only effective form of treatment for pancreas cancer.

Summary

The pancreas is vital to good health.  It is subject to a variety of problems, some of which result from the patient’s actions.  There are now effective ways to diagnose pancreatic conditions and, in most cases, good treatment programs can be outlined by the physician.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Peptic ulcer disease (PUD) is a very common ailment, affecting one out of eight persons in the United States.  The causes of PUD have gradually become clear and with this understanding have come new and better ways to treat ulcers and even cure them.

Anatomy and Function of the Stomach

The stomach produces a very strong acid.  This acid digests and breaks down food before it enters the small intestine (duodenum).  The lining of the stomach is covered by a thick protective mucous layer which prevents the acid from injuring the wall of the stomach.

What Causes Peptic Ulcers?

An ulcer is an open sore in the lining of the stomach or intestine, much like mouth or skin ulcers.  Peptic ulcers are eventually caused by acid and pepsin, a digestive stomach enzyme.  These ulcers can occur in the stomach, where they are called gastric ulcers.  Or they can occur in the first portion of the intestine beyond the stomach.  These are called duodenal ulcers.

In the end, it is acid that causes the injury to the bowel wall.  However, a revolutionary and startling discovery is that most peptic ulcers result from a stomach infection caused by the bacteria, Helicobacter pylori.

Helicobacter Pylori (H. Pylori)

This bacteria is the basic cause of most peptic ulcers, excluding those caused by aspirin or arthritis drugs.  The bacteria has a twisted spiral shape (Helico) and infects the mucous layer lining of the stomach.  This is a true infection and produces an inflammation in the stomach wall called gastritis.  The body even develops an antibody in the blood against it.  The bacteria is probably acquired through ingesting contaminated food or drinking glass.  It is only after H.  pylori bacteria injures the protective mucous layer of the stomach that an ulcer develops.

Aspirin and Arthritis Medications

Arthritis medications include ibuprofen (Advil), Feldene, Naprosyn, Voltaren, Indocin, Lodine, and many others.  As with aspirin, they can damage the mucous layer of the stomach, after which the stomach acid causes the final injury.

H. pylori and these above drugs are the two major factors that bring on ulcers.  There also is a small group of patients that produces very large amounts of acid uncontrollably, thereby causing ulcers.  A stomach cancer may look and act like a peptic ulcer.  Finally, some people get ulcers for unknown reasons.

Symptoms

Ulcers cause gnawing, burning pain in the upper abdomen.  These symptoms frequently occur several hours following a meal, after the food leaves the stomach but while acid production is still high.  The burning sensation can occur during the night and be so extreme as to wake the patient.  Instead of pain, some patients experience intense hunger or bloating.  Antacids and milk usually give temporary relief.  Other patients have no pain but have black stools, indicating that the ulcer is bleeding.  Bleeding is a serious complication of ulcers.

Diagnosis

A diagnosis of peptic ulcers can be suspected from the patient’s medical history.  However, the diagnosis should always be confirmed either by an upper intestinal endoscopy, which allows direct examination of the ulcer through a fiberoptic instrument (endoscope), or by a barium x-ray of the stomach, With endoscopy, a biopsy is usually obtained of a gastric ulcer to determine if it is malignant and requires surgery.

Treatment

Therapy of PUD has undergone profound changes.  The first has been the development of drugs which suppresses stomach acid.  These acid-suppresssing drugs have been dramatically effective in relieving symptoms and allowing ulcers to heal.  If an ulcer has been caused by aspirin or an arthritis drug, then no subsequent treatment is usually needed.  Avoiding these latter drugs, should prevent ulcer recurrence.

The second major change in PUD treatment has been the discovery of the H.  pylori infection.  When this infection is cleared by antibiotics, the infection and the ulcer usually do not come back.  So, increasingly, physicians are not just suppressing the ulcer with the acid-reducing drugs listed above, but they are also curing the underlying ulcer problem by getting rid of the bacterial infection.  If not, the ulcers invariably recur.

There are a number of antibiotic programs available now to treat H.  pylori.  The physician will select the best treatment program for the patient.

What Else Can Be Done?

The above factors have altered the approach to ulcers in a dramatic way.  Still, many other factors are still important:

Caffeine and Alcohol - Both of these stimulate the secretion of stomach acid and should be avoided in the acute phase of an ulcer.

Cigarettes - Nicotine will delay the healing of an ulcer, There are many other good reasons to stop cigarette smoking.  Healing an ulcer is one of them.

Antacids - These agents purchased over the counter can be used for relief of peptic ulcer symptoms.  Except for Pepto-Bismol, they do not help heal ulcers.

Stress - In the past, stress and emotion were felt to be a major cause of ulcers, Now it is known that, by itself, stress rarely causes an ulcer although it probably can aggravate the symptoms.

Surgery - Surgery used to be a major form of ulcer treatment.  Now, it is the exceptional patient who needs surgery for an ulcer complication such as perforation, obstruction or uncontrolled hemorrhaging.

In Summary

The new era of peptic ulcer disease is at hand.  With a firm understanding of how ulcers occur, with the potent acid-suppressing drugs now available, and with the knowledge that peptic ulcers caused by H.  pylori can now be cured, the future is indeed bright for patients with ulcers.  The physician now has the tools to deal very effectively with this condition.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

The colon is the large intestine.  It begins where the small intestine ends, near the appendix inside the right lower abdomen.  The colon extends in a wide loop, up the right side of the abdomen to the liver, and across to the left side of the abdomen where it turns down connecting finally to the rectum.

Polyps and Cancer

Polyps are growths that form on the inside lining of the colon.  They are usually shaped like mushrooms or dome-like buttons, and vary in size from a tiny pea to larger than a plum.  While colon polyps start out as benign tumors, certain types of polyps (called an adenoma or adenomatous polyp) may turn into cancer.  The risk is greater as the polyp gets larger.  Adenomatous polyps can be removed before they become cancerous with a procedure called colonoscopy.  Under light sedation, a lighted flexible tube is inserted into the colon, allowing the physician to see the inside of the colon and remove polyps.

Causes and Risks

The complete cause of polyp formation and colon cancer is unknown, but it is known that heredity plays a key role.  Certain genes seem to prevent colon cancer from developing.  Some people may lose these protective genes.  A person whose parents, brothers or sisters have colon cancer or polyps is at significantly greater risk of developing it.  There is also risk, but to a lesser degree, if uncles, aunts or grandparents have had the disease.  Therefore, people with a family history of polyps and colon cancer should be evaluated by their physician and examined regularly.

Prevention

Diet

It only makes sense that a disease that originates in the gut should somehow be related to diet.  While genetic factors are probably the most important, let’s look at the effects of diet.

Vegetables and fruits

The red, yellow, orange and green colored fruits and vegetables such as peppers, oranges, strawberries, and carrots are particularly rich in a complex mixture of substances called antioxidants.  The cruciferous vegetables (cabbage, Brussels sprouts, broccoli) have very high levels of natural cancer fighting chemicals.  Brussels sprouts and broccoli are exceedingly high in these.  There is increasing medical data that people who eat these foods plus generous amounts of unprocessed grains have less colon cancer.  There is no medical evidence that taking antioxidant supplements such as vitamin C and E and betacarotene is helpful.

Meats and saturated fats

Meat contains saturated fat as do many prepared products such as ice cream and especially non-animal foods such as pastries, sauces, etc.  Always read the food labels to see how much saturated fat a food contains.  These fats are broken down by the body’s digestive juices and bile.  Some of these byproducts are known to cause cancer in laboratory animals.  There is some evidence that meat rich diets may increase the risk of breast cancer but this has not been shown in colon cancer.  Nevertheless, a reduced meat and saturated fat diet probably contributes to colon health to some extent.

Fiber

Studies in the 1960’s and 1970’s seemed to relate a fiber rich diet with reduced colon cancer in rural Africans.  However, the hope that it could reduce colon cancer risk has been called into question by a large study of nurses who had little or no change in developing colon cancer or polyps even when eating up to 25 grams of fiber a day.  This is just one study and the positive health benefits of high fiber foods are many, so these foods are still highly recommended.

Calcium

Calcium is one of the most common minerals in the body.  It is necessary for bone strength and for many of the body’s important chemical processes.  For example, it is needed in regulating the growth of cells.  Animal studies have found that a lack of calcium leads to excessive cell growth in the colon.  It is not clear if calcium has a cancer preventive benefit for humans.  Still, since it is important to the body in so many other ways, everyone should get enough calcium in the diet.  Most adults should have 1000 mg per day.  After menopause, females have a greater risk of osteoporosis (loss of calcium causing bones to weaken), and they should have 1500 mg of calcium a day.

A quart of milk a day provides adequate calcium.  Most people do not drink a quart of milk every day, but there are other sources of calcium.  Dairy products (such as cheeses and yogurt), shellfish, seafood and many leafy green vegetables contain calcium.  The calcium from leafy vegetables is not as available for use by the body as calcium in milk.  Some people on low calorie or special diets may not be able to get enough calcium in their diets.  In these cases, the physician can recommend a calcium supplement.  Calcium carbonate is the best and least expensive.

Aspirin

Some, but not all, medical studies show that the incidence of cancer of the colon may be less in those people who take aspirin regularly.  It is known that prostaglandin (a hormone-like substance produced by the body) may promote excessive or abnormal cell growth in the intestine, Aspirin appears to interfere with prostaglandin, which may account for a possible role in preventing colon cancer.

Aspirin can cause stomach ulcers, serious bleeding or hemorrhagic strokes, so it should only be taken with the approval of a physician and under specific conditions.

Other Factors

The large nurse’s study, mentioned before, has shown other factors that appear to be related to colon cancer.

Cigarette Smoking—Long-term smokers had more colon cancer than non-smokers

Leisure Time Activities—Those nurses who were more active in their daily lives had fewer cancers

Estrogen—Those nurses who continued to use estrogen hormones had fewer cancers.

However, it is not recommended that you take estrogen just for this possible reason.

Summary

1. Genes—if there is colon cancer or polyps in your family, have a colonoscopy to detect early cancer or removal of polyps

2. Surveillance—yearly stool exam for hidden blood and sigmoidoscopy (short exam) every 5 years or colonoscopy every 10 years or so, starting at age 50

3. Remove polyps when found, a polyp that is removed cannot become cancer

4. Diet—eat a diet high in yellow, red and orange fruits and vegetables, low in meats and saturated fats and high in fiber

5. Calcium—1,000 to 1,500 mg a day from diet or supplements

6. Aspirin—may be helpful but should be discussed with physician

7. Keep an active lifestyle — walk, exercise

8. Do not smoke cigarettes

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

 

Ulcerative colitis is a chronic, recurring disease of the large bowel.  The large bowel (colon) is the 5 to 6 foot segment of intestine that begins in the right-lower abdomen, extends upward and then across to the left side, and downward to the rectum.  It dehydrates the liquid stool that enters it and stores the formed stool until a bowel movement occurs.

When ulcerative colitis affects the colon, inflammation and ulcers, or sores, form in the lining of the colon, The disease may involve the entire colon (pancolitis), only the rectum (ulcerative proctitis) or, more commonly, somewhere between the two.

Causes

The cause of ulcerative colitis is unknown.  Some experts believe there may be a defect in the immune system in which the body’s antibodies actually injure the colon.  Others speculate that an unidentified microorganism or germ is responsible for the disease.  It is probable that a combination of factors, including heredity, may be involved in the cause.

Who Develops Ulcerative Colitis?

The disorder can occur in both sexes, all races and all age groups.  It is a disease that usually begins in young people.

Symptoms

The disorder typically begins gradually, with crampy abdominal pain and diarrhea that is sometimes bloody.  In more severe cases, diarrhea is very severe and frequent.  Loss of appetite and weight loss occur.  The patient may become weak and very sick.  When the disease is localized to the rectum, the symptoms are rectal urgency and passage of small amounts of bloody stool.  Usually the symptoms tend to come and go, and there may be long periods without any symptoms at all.  Usually, however, they recur.

Diagnosis

Diagnosis of ulcerative colitis can be suspected from the symptoms.  Certain blood and stool tests’ are performed to rule out an infection that can mimic the disorder.  A visual examination of the lining of the rectum and lower colon (sigmoidoscopy) or the entire colon (colonoscopy) is always required.  This exam typically reveals a characteristic pattern.  Small, painless biopsies are taken which show certain features of ulcerative colitis.

Complications

Most patients with this disease respond well to treatment and go about their lives with few interruptions.  However, some attacks may be quite severe, requiring a period of bowel rest, hospitalization and intravenous treatment.  In rare cases, emergency surgery is required.  The disease can affect nutrition causing poor growth during childhood and adolescence.  Liver, skin, eye or joint (arthritis) problems occasionally occur, even before the bowel symptoms develop.  Other problems can include narrowing and partial blocking of the bile ducts which carry bile from the liver to the intestine.  Fortunately, there is much that can be done about all of these complications.

In long-standing ulcerative colitis, the major concern is colon cancer.  The risk of developing colon cancer increases significantly when the disorder begins in childhood, has been present for 8 to 10 years, or when there is a family history of colon cancer.  In these situations, it is particularly important to perform regular and thorough surveillance of the colon, even when there are no symptoms.  Analysis of colon biopsies performed during colonoscopy can often predict if colon cancer will occur.  In these cases, preventive surgery is recommended.

Treatment

There are several types of medical treatments available:

• Steroids, such as Prednisone—These powerful drugs usually provide highly effective results.  A high dose is often used initially to bring the disorder under control.  Then the drug is tapered to low, maintenance doses, even to a dose every other day.

These medications are given by pill, enema or intravenously during an acute attack.  In time, the physician will usually try to discontinue these drugs because of potential long-term, adverse side effects.

• Other Anti-inflammatory Drugs—There are increasing numbers of these drugs available.  They can be given by pill or enema.  The generic and trade names of some of these drugs are sulfasalazine (Azulfidine), olsalazine (Dipentum), mesalamine (Asacol, Pentasa and Rowasa) and balsalazide (Colazal).

• Immune System Suppressors—An overactive immune system is probably important in causing ulcerative colitis.  Certain drugs such as azathioprine (Imuran), 6-MP (Purinethol), cyclosporine (Neoral, Sandimmune), and methotrexate (Rheumatrex) suppress the immune system and at times are effective.  Newer medications such as Remicade and Humira are also used with good results.

Diet and Emotions

There are no foods known to injure the bowel, However, during an acute phase of the disease, bulky foods, milk, and milk products can increase diarrhea and cramping.  Generally, the patient is advised to eat a healthy, well-balanced diet with adequate protein and calories.  A multiple vitamin is often recommended.  Iron may be prescribed if anemia is present.

Stress and anxiety may aggravate symptoms of the disorder, but are not believed to cause it or make it worse.  Any chronic disease can produce serious emotional reaction in the patient.  This can usually be handled through discussion with the physician.  There are excellent support groups available in most communities.  The Crohn’s and Colitis Foundation is one of them (www.ccfa.org).

Surgery

Surgery may be needed at some time during the course of ulcerative colitis that does not respond to medical therapy.  In ulcerative colitis, removing the colon cures the disease.  Depending on the patient’s age, gender and other medical conditions, there are several approaches the surgeon uses to remove the colon and reattach the remaining bowel.

Summary

Most people with Ulcerative Colitis disease lead active lives with few restrictions.  Although there is no known cure for the disorder, it can be managed with present treatments.  For a few patients, the course of the disease can be more difficult and complicated, requiring extensive testing and therapy.  Surgery sometimes is required.  In all cases, follow-up care is essential to treat the disease and prevent or deal with complications that may arise.

 

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider.  It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.