Digestive Health Center

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Appendicitis is inflammation of the appendix, a small portion of the large intestine that hangs down from the lower right side. Although the appendix does not seem to serve any purpose, it can still become diseased. If untreated, an inflamed appendix can burst, causing infection and even death. About 1 in 500 people has appendicitis each year.

Appendicitis may occur after a viral infection in the digestive tract or when the tube connecting the large intestine and appendix is blocked by trapped stool. The inflammation can cause infection, a blood clot, or rupture of the appendix. Because of the risk of rupture, appendicitis is considered an emergency. Anyone with symptoms needs to see a doctor immediately. Symptoms include:

  • Pain in the right side of the abdomen. The pain usually begins near the navel and moves down and to the right. The pain becomes worse when moving, taking deep breaths, coughing, sneezing, and being touched in the area
  • Nausea
  • Vomiting
  • Constipation
  • Diarrhea
  • Inability to pass gas
  • Low fever that begins after other symptoms
  • Abdominal swelling

Not everyone has all symptoms. It is important that people with symptoms of appendicitis not take laxatives or enemas to relieve constipation because these medicines could cause the appendix to burst. People also should not take pain medicine because it can mask symptoms that the doctor needs to know about.

The doctor bases an appendicitis diagnosis on symptoms, a physical exam, blood tests to check for signs of infection such as a high white blood cell count, and urine tests to rule out a urinary tract infection. Some doctors use ultrasound to see whether the appendix looks inflamed. Treatment is surgery to remove the appendix, called appendectomy. Doctors are beginning to use laparoscopic surgery for appendectomy. This technique involves making several tiny cuts in the abdomen and inserting a miniature camera and surgical instruments. The surgeon then removes the appendix with the instruments, so there is no need to make a large incision in the abdomen. People can live a normal life without their appendix -- no changes in diet, exercise, or other lifestyle factors are necessary.

Barrett's esophagus is a condition that develops in some people who have chronic gastroesophageal reflux disease (GERD) or inflammation of the esophagus (esophagitis). In Barrett's esophagus, the normal cells that line the esophagus, called squamous cells, turn into a type of cell not usually found in humans, called specialized columnar cells. Damage to the lining of the esophagus -- for example, by acid reflux from GERD -- causes these abnormal changes.

People who have had regular or daily heartburn for more than 5 years may be at risk for Barrett's esophagus and should discuss the possibility with their doctor. Symptoms include; waking during the night because of heartburn pain, vomiting, blood in vomit or stool, and difficulty swallowing. Some people do not have symptoms.

Diagnosis involves an endoscopy to look at the lining of the esophagus and a biopsy to examine a sample of tissue. To do an endoscopy, the doctor gently guides a long, thin tube called an endoscope through the mouth and into the esophagus. The scope contains instruments that allow the doctor to see the lining of the esophagus and to remove a small tissue sample, called a biopsy. The biopsy will be examined in a lab to see whether the normal squamous cells have been replaced with columnar cells.

Once the cells in the lining of the esophagus have turned into columnar cells, they will not revert back to normal. In other words, at this time, there is no cure for Barrett's esophagus. The goal of treatment is to prevent further damage by stopping any acid reflux from the stomach. Medications that are helpful include H2 receptor antagonists (or H2 blockers) and proton pump inhibitors, which reduce the amount of acid produced by the stomach. Examples of H2 blockers are cimetidine, ranitidine, and famotidine; the drugs omeprazole and lansoprazole are proton pump inhibitors. If these medications do not work, surgery to remove damaged tissue or a section of the esophagus itself may be necessary.

Sometimes the damaged lining of the esophagus becomes thick and hardened, causing strictures, or narrowing of the esophagus. Strictures can interfere with eating and drinking by preventing food and liquid from reaching the stomach. Strictures are treated by dilation, in which an instrument gently stretches the strictures and expands the opening in the esophagus.

About 5 to 10 percent of people with Barrett's develop cancer of the esophagus. Because of the cancer risk, people with Barrett's esophagus are screened for esophageal cancer regularly by endoscopy.

Bleeding in the digestive tract is a symptom of digestive problems rather than a disease itself. Bleeding can occur as the result of a number of different conditions, many of which are not life threatening. Most causes of bleeding are related to conditions that can be cured or controlled, such as hemorrhoids. The cause of bleeding may not be serious, but locating the source of bleeding is important.

The digestive or gastrointestinal (GI) tract includes the esophagus, stomach, small intestine, large intestine or colon, rectum, and anus. Bleeding can come from one or more of these areas, that is, from a small area such as an ulcer on the lining of the stomach or from a large surface such as an inflammation of the colon. Bleeding can sometimes occur without the person noticing it. This type of bleeding is called occult or hidden. Fortunately, simple tests can detect occult blood in the stool.

What Causes Bleeding in the Digestive Tract?Stomach acid can cause inflammation that may lead to bleeding at the lower end of the esophagus. This condition is called esophagitis or inflammation of the esophagus. Sometimes a muscle between the esophagus and stomach fails to close properly and allows the return of food and stomach juices into the esophagus, which can lead to esophagitis. In addition, enlarged veins (varices) at the lower end of the esophagus may rupture and bleed massively. Cirrhosis of the liver is the most common cause of esophageal varices. Esophageal bleeding can be caused by Mallory-Weiss syndrome, a tear in the lining of the esophagus. Mallory-Weiss syndrome usually results from prolonged vomiting but may also be caused by increased pressure in the abdomen from coughing, hiatal hernia, or childbirth.

The stomach is a frequent site of bleeding. Alcohol, aspirin, aspirin-containing medicines, and various other medicines (particularly those used for arthritis) can cause stomach ulcers or inflammation (gastritis). The stomach is often the site of ulcer disease. Acute or chronic ulcers may enlarge and erode through a blood vessel, causing bleeding. Also, patients suffering from burns, shock, head injuries, or cancer, or those who have undergone extensive surgery may develop stress ulcers. Bleeding can occur from benign tumors or cancer of the stomach, although these disorders usually do not cause massive bleeding.

The most common source of bleeding from the upper digestive tract is ulcers in the duodenum (the upper small intestine). Researchers now believe that these ulcers are caused by excess stomach acid and infection with Helicobacter pylori bacteria.

In the lower digestive tract, the large intestine and rectum are frequent sites of bleeding. Hemorrhoids are probably the most common cause of visible blood in the digestive tract, especially blood that appears bright red. Hemorrhoids are enlarged veins in the anal area that can rupture and produce bright red blood, which can show up in the toilet or on toilet paper. If red blood is seen, however, it is essential to exclude other causes of bleeding since the anal area may also be the site of cuts (fissures), inflammation, or tumors.

Benign growths or polyps of the colon are very common and are thought to be forerunners of cancer. These growths can cause either bright red blood or occult bleeding. Colorectal cancer is the second most frequent of all cancers in the United States and usually causes bleeding at some time.

Inflammation from various causes can produce extensive bleeding from the colon. Different intestinal infections can cause inflammation and bloody diarrhea. Ulcerative colitis can produce inflammation and extensive surface bleeding from tiny ulcerations. Crohn's disease of the large intestine can also produce spotty bleeding.

Diverticular disease caused by diverticula -- outpouchings of the colon wall -- can result in massive bleeding. Finally, as one gets older, abnormalities may develop in the blood vessels of the large intestine, which may result in recurrent bleeding.

What Are the Common Causes of Bleeding in the Digestive Tract?

Esophagus

    Inflammation (esophagitis)    Enlarged veins (varices)    Mallory-Weiss syndrome

Stomach

    Ulcers    Inflammation (gastritis)

Small Intestine

    Duodenal ulcer

Large Intestine and Rectum

    Hemorrhoids    Inflammation (ulcerative colitis)    Colorectal polyps    Colorectal cancer    Diverticular disease

How Is Bleeding in the Digestive Tract Recognized?The signs of bleeding in the digestive tract depend upon the site and severity of bleeding. If blood is coming from the rectum or the lower colon, bright red blood will coat or mix with the stool. The stool may be mixed with darker blood if the bleeding is higher up in the colon or at the far end of the small intestine. When there is bleeding in the esophagus, stomach, or duodenum, the stool is usually black or tarry. Vomited material may be bright red or have a coffee grounds appearance when one is bleeding from those sites. If bleeding is occult, the patient might not notice any changes in stool color.

If sudden massive bleeding occurs, a person may feel weak, dizzy, faint, short of breath, or have crampy abdominal pain or diarrhea. Shock may occur, with a rapid pulse, drop in blood pressure, and difficulty in producing urine. The patient may become very pale. If bleeding is slow and occurs over a long period of time, a gradual onset of fatigue, lethargy, shortness of breath, and pallor from the anemia will result. Anemia is a condition in which the blood's iron-rich substance, hemoglobin, is diminished.

How Is Bleeding in the Digestive Tract Diagnosed?The site of the bleeding must be located. A complete history and physical examination are essential. Symptoms such as changes in bowel habits, stool color (to black or red) and consistency, and the presence of pain or tenderness may tell the doctor which area of the GI tract is affected. Because the intake of iron or foods such as beets can give the stool the same appearance as bleeding from the digestive tract, a doctor must test the stool for blood before offering a diagnosis. A blood count will indicate whether the patient is anemic and also will give an idea of the extent of the bleeding and how chronic it may be.

EndoscopyEndoscopy is a common diagnostic technique that allows direct viewing of the bleeding site. Because the endoscope can detect lesions and confirm the presence or absence of bleeding, doctors often choose this method to diagnose patients with acute bleeding. In many cases, the doctor can use the endoscope to treat the cause of bleeding as well.

The endoscope is a flexible instrument that can be inserted through the mouth or rectum. The instrument allows the doctor to see into the esophagus, stomach, duodenum (esophago-duodenoscopy), colon (colonoscopy), and rectum (sigmoidoscopy); to collect small samples of tissue (biopsies); to take photographs; and to stop the bleeding.

Small bowel endoscopy, or enteroscopy, is a new procedure using a long endoscope. This endoscope may be introduced during surgery to localize a source of bleeding in the small intestine.

Other ProceduresSeveral other methods are available to locate the source of bleeding. Barium x-rays, in general, are less accurate than endoscopy in locating bleeding sites. Some drawbacks of barium x-rays are that they may interfere with other diagnostic techniques if used for detecting acute bleeding; they expose the patient to x-rays; and they do not offer the capabilities of biopsy or treatment.

Angiography is a technique that uses dye to highlight blood vessels. This procedure is most useful in situations when the patient is acutely bleeding such that dye leaks out of the blood vessel and identifies the site of bleeding. In selected situations, angiography allows injection of medicine into arteries that may stop the bleeding.

Radionuclide scanning is a noninvasive screening technique used for locating sites of acute bleeding, especially in the lower GI tract. This technique involves injection of small amounts of radioactive material. Then, a special camera produces pictures of organs, allowing the doctor to detect a bleeding site.

In addition, barium x-rays, angiography, and radionuclide scans can be used to locate sources of chronic occult bleeding. These techniques are especially useful when the small intestine is suspected as the site of bleeding since the small intestine may not be seen easily with endoscopy.

How Is Bleeding in the Digestive Tract Treated?The use of endoscopy has grown and now allows doctors not only to see bleeding sites but to directly apply therapy as well. A variety of endoscopic therapies are useful to the patient for treating GI tract bleeding.

Active bleeding from the upper GI tract can often be controlled by injecting chemicals directly into a bleeding site with a needle introduced through the endoscope. A physician can also cauterize, or heat treat, a bleeding site and surrounding tissue with a heater probe or electrocoagulation device passed through the endoscope. Laser therapy, although effective, is no longer used regularly by many physicians because it is expensive and cumbersome.

Once bleeding is controlled, medicines are often prescribed to prevent recurrence of bleeding. Medical treatment of ulcers to ensure healing and maintenance therapy to prevent ulcer recurrence can also lessen the chance of recurrent bleeding. Studies are now under way to see if elimination of Helicobacter pylori affects the recurrence of ulcer bleeding.

Removal of polyps with an endoscope can control bleeding from colon polyps. Removal of hemorrhoids by banding or various heat or electrical devices is effective in patients who suffer hemorrhoidal bleeding on a recurrent basis. Endoscopic injection or cautery can be used to treat bleeding sites throughout the lower intestinal tract.

Endoscopic techniques do not always control bleeding. Sometimes angiography may be used. However, surgery is often needed to control active, severe, or recurrent bleeding when endoscopy is not successful.

How Do You Recognize Blood in the Stool and Vomit?

    Bright red blood coating the stool    Dark blood mixed with the stool    Black or tarry stool    Bright red blood in vomit    Coffee-grounds appearance of vomit

What Are the Symptoms of Acute Bleeding?

    Weakness    Shortness of breath    Dizziness    Crampy abdominal pain    Faintness    Diarrhea

What Are the Symptoms of Chronic Bleeding?

    Fatigue    Shortness of breath    Lethargy    Pallor

What Is Celiac Disease?Celiac disease is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate a protein called gluten, which is found in wheat, rye, barley, and possibly oats. When people with celiac disease eat foods containing gluten, their immune system responds by damaging the small intestine. Specifically, tiny finger-like protrusions, called villi, on the lining of the small intestine are lost. Nutrients from food are absorbed into the bloodstream through these villi. Without villi, a person becomes malnourished -- regardless of the quantity of food eaten.

Because the body's own immune system causes the damage, celiac disease is considered an autoimmune disorder. However, it is also classified as a disease of malabsorption because nutrients are not absorbed. Celiac disease is also known as celiac sprue, non-tropical sprue, and gluten-sensitive enteropathy.

Celiac disease is a genetic disease, meaning that it runs in families. Sometimes the disease is triggered -- or becomes active for the first time -- after surgery, pregnancy, childbirth, viral infection, or severe emotional stress. What Are the Symptoms?Celiac disease affects people differently. Some people develop symptoms as children, others as adults. One factor thought to play a role in when and how celiac appears is whether and how long a person was breast-fed -- the longer one was breast-fed, the later symptoms of celiac disease appear, and the more atypical the symptoms. Other factors include the age at which one began eating foods containing gluten and how much gluten is eaten.

Symptoms may or may not occur in the digestive system. For example, one person might have diarrhea and abdominal pain, while another person has irritability or depression. In fact, irritability is one of the most common symptoms in children.

Symptoms of celiac disease may include one or more of the following:

  • Recurring abdominal bloating and pain
  • Chronic diarrhea
  • Weight loss
  • Pale, foul-smelling stool
  • Unexplained anemia (low count of red blood cells)
  • Gas
  • Bone pain
  • Behavior changes
  • Muscle cramps
  • Fatigue
  • Delayed growth
  • Failure to thrive in infants
  • Pain in the joints
  • Seizures
  • Tingling numbness in the legs (from nerve damage)
  • Pale sores inside the mouth, called aphthus ulcers
  • Painful skin rash, called dermatitis herpetiformis
  • Tooth discoloration or loss of enamel
  • Missed menstrual periods (often because of excessive weight loss)

Anemia, delayed growth, and weight loss are signs of malnutrition -- not getting enough nutrients. Malnutrition is a serious problem for anyone, but particularly for children because they need adequate nutrition to develop properly.

Some people with celiac disease may not have symptoms. The undamaged part of their small intestine is able to absorb enough nutrients to prevent symptoms. However, people without symptoms are still at risk for the complications of celiac disease. See Complications.

How Is Celiac Disease Diagnosed?Diagnosing celiac disease can be difficult because some of its symptoms are similar to those of other diseases, including irritable bowel syndrome, Crohn's disease, ulcerative colitis, diverticulosis, intestinal infections, chronic fatigue syndrome, and depression.

Recently, researchers discovered that people with celiac disease have higher than normal levels of certain antibodies in their blood. Antibodies are produced by the immune system in response to substances that the body perceives to be threatening. To diagnose celiac disease, physicians test blood to measure levels of antibodies to gluten. These antibodies are antigliadin, anti-endomysium, and antireticulin.

If the tests and symptoms suggest celiac disease, the physician may remove a tiny piece of tissue from the small intestine to check for damage to the villi. This is done in a procedure called a biopsy: the physician eases a long, thin tube called an endoscope through the mouth and stomach into the small intestine, and then takes a sample of tissue using instruments passed through the endoscope. Biopsy of the small intestine is the best way to diagnose celiac disease.

ScreeningScreening for celiac disease involves testing asymptomatic people for the antibodies to gluten. Americans are not routinely screened for celiac disease. However, because celiac disease is hereditary, family members -- particularly first-degree relatives -- of people who have been diagnosed may need to be tested for the disease. About 10 percent of an affected person's first-degree relatives (parents, siblings, or children) will also have the disease. The longer a person goes undiagnosed and untreated, the greater the chance of developing malnutrition and other complications.

What Is the Treatment?The only treatment for celiac disease is to follow a gluten-free diet -- that is, to avoid all foods that contain gluten. For most people, following this diet will stop symptoms, heal existing intestinal damage, and prevent further damage. Improvements begin within days of starting the diet, and the small intestine is usually completely healed -- meaning the villi are intact and working -- in 3 to 6 months. (It may take up to 2 years for older adults.)

The gluten-free diet is a lifetime requirement. Eating any gluten, no matter how small an amount, can damage the intestine. This is true for anyone with the disease, including people who do not have noticeable symptoms. Depending on a person's age at diagnosis, some problems, such as delayed growth and tooth discoloration, may not improve.

A small percentage of people with celiac disease do not improve on the gluten-free diet. These people often have severely damaged intestines that cannot heal even after they eliminate gluten from their diets. Because their intestines are not absorbing enough nutrients, they may need to receive intravenous nutrition supplements. Drug treatments are being evaluated for unresponsive celiac disease. These patients may need to be evaluated for complications of the disease.

If a person responds to the gluten-free diet, the physician will know for certain that the diagnosis of celiac disease is correct.

The Gluten-Free DietA gluten-free diet means avoiding all foods that contain wheat (including spelt, triticale, and kamut), rye, barley, and possibly oats -- in other words, most grain, pasta, cereal, and many processed foods. Despite these restrictions, people with celiac disease can eat a well-balanced diet with a variety of foods, including bread and pasta. For example, instead of wheat flour, people can use potato, rice, soy, or bean flour. Or, they can buy gluten-free bread, pasta, and other products from special food companies.

Whether people with celiac disease should avoid oats is controversial because some people have been able to eat oats without having a reaction. Scientists are doing studies to find out whether people with celiac disease can tolerate oats. Until the studies are complete, people with celiac disease should follow their physician or dietitian's advice about eating oats.

Plain meat, fish, rice, fruits, and vegetables do not contain gluten, so people with celiac disease can eat as much of these foods as they like. Examples of foods that are safe to eat and those that are not are provided below.

The gluten-free diet is complicated. It requires a completely new approach to eating that affects a person's entire life. People with celiac disease have to be extremely careful about what they buy for lunch at school or work, eat at cocktail parties, or grab from the refrigerator for a midnight snack. Eating out can be a challenge as the person with celiac disease learns to scrutinize the menu for foods with gluten and question the waiter or chef about possible hidden sources of gluten. However, with practice, screening for gluten becomes second nature and people learn to recognize which foods are safe and which are off limits.

A dietitian, a health care professional who specializes in food and nutrition, can help people learn about their new diet. Also, support groups are particularly helpful for newly diagnosed people and their families as they learn to adjust to a new way of life.The Gluten Free Diet: Some Examples

Following are examples of foods that are allowed and those that should be avoided when eating gluten-free. Please note that this is not a complete list. People are encouraged to discuss gluten-free food choices with a physician or dietitian who specializes in celiac disease. Also, it is important to read all food ingredient lists carefully to make sure that the food does not contain gluten.

FOOD GROUP

ALLOWED

NOT ALLOWED

Beverages

image001

 

 

Coffee, tea, carbonated drinks, wine made in U.S., rum, some root beer

Ovaltine, malted milk, ale, beer, gin, whiskey, flavored coffee, herbal tea with malted barley

Milk

image002

 

 

Fresh, dry, evaporated, or condensed milk; cream; sour cream; whipping cream; yogurt

Malted milk, some commercial chocolate milk, some nondairy creamers

Meat, Fish, Poultry

image003

 

 

Fresh meats, fish, other seafood, and poultry; fish in canned oil, brine, or water; some hot dogs and lunch meats

Prepared meat containing wheat, rye, oats, or barley; tuna canned in vegetable broth

Cheese

image004

 

 

All aged cheese, such as cheddar, Swiss, edam, parmesan; cottage cheese; cream cheese; pasteurized processed cheese; cheese spreads

Any cheese product containing oat gum, some veined cheeses (bleu, stilton, roquefort, gorgonzola)

Potato or Other Starch

image005

 

 

White and sweet potatoes, yams, hominy, rice, wild rice, gluten-free noodles, some oriental rice and bean thread noodles

Regular noodles, spaghetti, macaroni, most packaged rice mixes, seminola, spinach noodles, frozen potato products with wheat flour added

Cereals

Coffee

 

 

Hot cereals made from cornmeal, Cream of Rice, hominy, rice; Puffed Rice, Kellogg's Corn Pops, cereals made without malt

All cereals containing wheat, rye, oats, or barley; bran; graham; wheat germ; durum; kaska; bulgar; buckwheat; millet; triticale; amaranth; spelt; teff; quinoa; kamut

Breads

Coffee

 

 

Specially prepared breads using only allowed flours

All breads containing wheat, rye, oat, or barley flours and grains listed above

Flours and Thickening Agents

Coffee

 

 

Arrowroot starch, corn bran, corn flour, corn germ, cornmeal, corn starch, potato flour, potato starch flour, rice bran, rice flour, rice polish, rice starch, soy flour, tapioca starch, bean and lentil flours, nut flours

Amaranth, wheat germ, bran, wheat starch; all flours containing wheat, rye, oats, or barley; buckwheat; spelt; quinoa; teff; kamut; millet

Vegetables

Coffee

 

 

All plain, fresh, frozen, or canned vegetables; dried peas and beans; lentils; some commercially prepared vegetables

Creamed vegetables, vegetables canned in sauce, some canned baked beans, commercially prepared vegetables and salads

Fruits

Coffee

 

 

All fresh, frozen, canned, or dried fruits; all fruit juices; some canned pie fillings

Thickened or prepared fruits; some pie fillings; raisins and dried dates that have been dusted with flour

Fats

Coffee

 

 

Butter, margarine, vegetable oil, nuts, peanut butter, hydrogenated vegetable oils, some salad dressings, mayonnaise, nonstick cooking sprays

Some commercial salad dressings, wheat germ oil, nondairy cream substitutes, most commercial gravies and sauces

Soups

Coffee

Homemade broth and soups made with allowed ingredients, some commercially canned soups, specialty dry soup mixes

Most canned soups and soup mixes, bouillon and bouillon cubes with hydrolyzed vegetable protein

Desserts

image013

 

Cakes, quick breads, pastries, and puddings made with allowed ingredients; cornstarch, tapioca, and rice puddings; some pudding mixes; custard; ice cream with few, simple ingredients; sorbet; meringues; mousse; sherbets; frozen yogurt Commercial cakes, cookies; pies made with wheat, rye, oats, or barley; millet, amaranth, buckwheat, spelt, teff, quinoa, kamut; prepared mixes; puddings; ice cream cones; Jell-O instant pudding; cream fillings; products made with brown rice syrup

Sweets

image014

 

Jelly, jam, honey, brown and white sugar, molasses, most syrups, some candy, chocolate, pure cocoa, coconut, marshmallows Commercial candies dusted with wheat flour, butterscotch chips; flavored syrups; sweets containing malt/malt flavorings; some brown rice syrup; some corn syrup

Miscellaneous

image015

 

Salt, pepper, herbs, herb extracts, food coloring, cloves, allspice, ginger, nutmeg, cinnamon, chili powder, tomato puree and paste, olives, active dry yeast, bicarbonate of soda, baking powder, cream of tartar, dry mustard, some condiments, apple cider, rice or wine vinegar Curry powder, dry seasonings mixes, gravy extracts, meat sauces, catsup, mustard, horseradish, chip dips, most soy sauce, some distilled white vinegar, instant dry baking yeast, some cinnamon, condiments made with wheat-derived distilled vinegar, communion wafers/bread, some alcohol-based flavoring extracts

Source: Food and Nutrition Services, The University of Iowa Hospitals and Clinics. (1996). Gluten Restricted, Gliadin Free Diet. Iowa City, Iowa: The University of Iowa Hospitals and Clinics.

What Are the Complications of Celiac Disease?Damage to the small intestine and the resulting problems with nutrient absorption put a person with celiac disease at risk for several diseases and health problems.

  • Lymphoma and adenocarcinoma are types of cancer that can develop in the intestine.
  • Osteoporosis is a condition in which the bones become weak, brittle, and prone to breaking. Poor calcium absorption is a contributing factor to osteoporosis.
  • Miscarriage and congenital malformation of the baby, such as neural tube defects, are risks for untreated pregnant women with celiac disease because of malabsorption of nutrients.
  • Short stature results when childhood celiac disease prevents nutrient absorption during the years when nutrition is critical to a child's normal growth and development. Children who are diagnosed and treated before their growth stops may have a catch-up period.
  • Seizures, or convulsions, result from inadequate absorption of folic acid. Lack of folic acid causes calcium deposits, called calcifications, to form in the brain, which in turn cause seizures.

How Common Is Celiac Disease?Celiac disease is the most common genetic disease in Europe. In Italy about 1 in 250 people and in Ireland about 1 in 300 people have celiac disease. It is rarely diagnosed in African, Chinese, and Japanese people.

An estimated 1 in 4,700 Americans have been diagnosed with celiac disease. Some researchers question how celiac disease could be so uncommon in the United States since it is hereditary and many Americans descend from European ethnic groups in whom the disease is common. A recent study in which random blood samples from the Red Cross were tested for celiac disease suggests that as many as 1 in every 250 Americans may have it. Celiac disease could be underdiagnosed in the United States for a number of reasons:

  • Celiac symptoms can be attributed to other problems.
  • Many doctors are not knowledgeable about the disease.
  • Only a handful of US laboratories are experienced and skilled in testing for celiac disease.

More research is needed to find out the true prevalence of celiac disease among Americans. Diseases Linked to Celiac DiseasePeople with celiac disease tend to have other autoimmune diseases as well, including

  • Dermatitis herpetiformis
  • Thyroid disease
  • Systemic lupus erythematosus
  • Type 1 diabetes
  • Liver disease
  • Collagen vascular disease
  • Rheumatoid arthritis
  • Sjogren's syndrome

The connection between celiac and these diseases may be genetic.

Dermatitis HerpetiformisDermatitis herpetiformis (DH) is a severe itchy, blistering skin disease caused by gluten intolerance. DH is related to celiac disease since both are autoimmune disorders caused by gluten intolerance, but they are separate diseases. The rash usually occurs on the elbows, knees, and buttocks.

Although people with DH do not usually have digestive symptoms, they often have the same intestinal damage as people with celiac disease.

DH is diagnosed by a skin biopsy, which involves removing a tiny piece of skin near the rash and testing it for the IgA antibody. DH is treated with a gluten-free diet and medication to control the rash, such as dapsone or sulfapyridine. Drug treatment may last several years.

Points to Remember

  • People with celiac disease cannot tolerate gluten, a protein in wheat, rye, barley, and possibly oats.
  • Celiac disease damages the small intestine and interferes with nutrient absorption.
  • Treatment is important because people with celiac disease could develop complications like cancer, osteoporosis, anemia, and seizures.
  • A person with celiac disease may or may not have symptoms.
  • Diagnosis involves blood tests and biopsy.
  • Because celiac disease is hereditary, family members of a person with celiac disease may need to be tested.
  • Celiac disease is treated by eliminating all gluten from the diet. The gluten-free diet is a lifetime requirement.

The liver, the largest organ in the body, is essential in keeping the body functioning properly. It removes or neutralizes poisons from the blood, produces immune agents to control infection, and removes germs and bacteria from the blood. It makes proteins that regulate blood clotting and produces bile to help absorb fats and fat-soluble vitamins. You cannot live without a functioning liver.

In cirrhosis of the liver, scar tissue replaces normal, healthy tissue, blocking the flow of blood through the organ and preventing it from working as it should. Cirrhosis is the eighth leading cause of death by disease, killing about 25,000 people each year. Also, the cost of cirrhosis in terms of human suffering, hospital costs, and lost productivity is high.

CausesCirrhosis has many causes. In the United States, chronic alcoholism and hepatitis C are the most common causes.

Alcoholic Liver DiseaseTo many people, cirrhosis of the liver is synonymous with chronic alcoholism, but in fact, alcoholism is only one of the causes. Alcoholic cirrhosis usually develops after more than a decade of heavy drinking. The amount of alcohol that can injure the liver varies greatly from person to person. In women, as few as two to three drinks per day have been linked with cirrhosis and in men, as few as three to four drinks per day. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, and carbohydrates.

Chronic Hepatitis CThe hepatitis C virus ranks with alcohol as the major cause of chronic liver disease and cirrhosis in the United States. Infection with this virus causes inflammation of and low grade damage to the liver that over several decades can lead to cirrhosis.

Chronic Hepatitis B and DThe hepatitis B virus is probably the most common cause of cirrhosis worldwide, but in the United States and Western world it is less common. Hepatitis B, like hepatitis C, causes liver inflammation and injury that over several decades can lead to cirrhosis. The hepatitis D virus is another virus that infects the liver, but only in people who already have hepatitis B.

Autoimmune HepatitisThis type of hepatitis is caused by a problem with the immune system.

Inherited DiseasesAlpha-1 antitrypsin deficiency, hemochromatosis, Wilson's disease, galactosemia, and glycogen storage diseases are among the inherited diseases that interfere with the way the liver produces, processes, and stores enzymes, proteins, metals, and other substances the body needs to function properly.

Nonalcoholic Steatohepatitis (NASH)In NASH, fat builds up in the liver and eventually causes scar tissue. This type of hepatitis appears to be associated with diabetes, protein malnutrition, obesity, coronary artery disease, and corticosteroid treatment.

Blocked Bile DuctsWhen the ducts that carry bile out of the liver are blocked, bile backs up and damages liver tissue. In babies, blocked bile ducts are most commonly caused by biliary atresia, a disease in which the bile ducts are absent or injured. In adults, the most common cause is primary biliary cirrhosis, a disease in which the ducts become inflamed, blocked, and scarred. Secondary biliary cirrhosis can happen after gallbladder surgery, if the ducts are inadvertently tied off or injured.

Drugs, Toxins, and InfectionsSevere reactions to prescription drugs, prolonged exposure to environmental toxins, the parasitic infection schistosomiasis, and repeated bouts of heart failure with liver congestion can each lead to cirrhosis.

SymptomsMany people with cirrhosis have no symptoms in the early stages of the disease. However, as scar tissue replaces healthy cells, liver function starts to fail and a person may experience the following symptoms:

  • Exhaustion
  • Fatigue
  • Loss of appetite
  • Nausea
  • Weakness
  • Weight loss

As the disease progresses, complications may develop. In some people, these may be the first signs of the disease.

  • Complications of Cirrhosis - Loss of liver function affects the body in many ways. Following are common problems, or complications, caused by cirrhosis.
  • Edema and Ascites - When the liver loses its ability to make the protein albumin, water accumulates in the leg (edema) and abdomen (ascites).
  • Bruising and Bleeding - When the liver slows or stops production of the proteins needed for blood clotting, a person will bruise or bleed easily.
  • Jaundice - Jaundice is a yellowing of the skin and eyes that occurs when the diseased liver does not absorb enough bilirubin.
  • Itching - Bile products deposited in the skin may cause intense itching.
  • Gallstones - If cirrhosis prevents bile from reaching the gallbladder, a person may develop gallstones.
  • Toxins in the Blood or Brain - A damaged liver cannot remove toxins from the blood, causing them to accumulate in the blood and eventually the brain. There, toxins can dull mental functioning and cause personality changes, coma, and even death. Signs of the buildup of toxins in the brain include neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleep habits.
  • Sensitivity to Medication - Cirrhosis slows the liver's ability to filter medications from the blood. Because the liver does not remove drugs from the blood at the usual rate, they act longer than expected and build up in the body. This causes a person to be more sensitive to medications and their side effects.
  • Portal Hypertension - Normally, blood from the intestines and spleen is carried to the liver through the portal vein. But cirrhosis slows the normal flow of blood through the portal vein, which increases the pressure inside it. This condition is called portal hypertension.
  • Varices - When blood flow through the portal vein slows, blood from the intestines and spleen backs up into blood vessels in the stomach and esophagus. These blood vessels may become enlarged because they are not meant to carry this much blood. The enlarged blood vessels, called varices, have thin walls and carry high pressure, and thus are more likely to burst. If they do burst, the result is a serious bleeding problem in the upper stomach or esophagus that requires immediate medical attention.
  • Problems in Other Organs - Cirrhosis can cause immune system dysfunction, leading to infection. Ascites (fluid) in the abdomen may become infected with bacteria normally present in the intestines, and cirrhosis can also lead to kidney dysfunction and failure.

 DiagnosisThe doctor may diagnose cirrhosis on the basis of symptoms, laboratory tests, the patient's medical history, and a physical examination. For example, during a physical examination, the doctor may notice that the liver feels harder or larger than usual and order blood tests that can show whether liver disease is present.

If looking at the liver is necessary to check for signs of disease, the doctor might order a computerized axial tomography (CAT) scan, ultrasound, or a scan of the liver using a radioisotope (a harmless radioactive substance that highlights the liver). Or the doctor might look at the liver using a laparoscope, an instrument inserted through the abdomen that relays pictures back to a computer screen.

A liver biopsy will confirm the diagnosis. For a biopsy, the doctor uses a needle to take a small sample of tissue from the liver, then examines it for scarring or other signs of disease. TreatmentLiver damage from cirrhosis cannot be reversed, but treatment can stop or delay further progression and reduce complications. Treatment depends on the cause of cirrhosis and any complications a person is experiencing. For example, cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis and corticosteroids for autoimmune hepatitis. Cirrhosis caused by Wilson's disease, in which copper builds up in organs, is treated with medications to remove the copper. These are just a few examples -- treatment for cirrhosis resulting from other diseases will depend on the underlying cause. In all cases, regardless of the cause, following a healthy diet and avoiding alcohol are essential because the body needs all the nutrients it can get, and alcohol will only lead to more liver damage.

Treatment will also include remedies for complications. For example, for ascites and edema, the doctor may recommend a low-sodium diet or the use of diuretics, which are drugs that remove fluid from the body. Antibiotics will be prescribed for infections, and various medications can help with itching. Protein causes toxins to form in the digestive tract, so eating less protein will help decrease the buildup of toxins in the blood and brain. The doctor may also prescribe laxatives to help absorb the toxins and remove them from the intestines.

For portal hypertension, the doctor may prescribe blood pressure medication such as a beta-blocker. If varices bleed, the doctor may either inject them with a clotting agent or perform a rubber-band ligation, which uses a special device to compress the varices and stop the bleeding.

When complications cannot be controlled or when the liver becomes so damaged from scarring that it completely stops functioning, a liver transplant is necessary. In liver transplantation surgery, a diseased liver is removed and replaced with a healthy one from an organ donor. About 80 to 90 percent of people survive liver transplantation. Survival rates have improved over the past several years because of drugs such as cyclosporine and tacrolimus, which suppress the immune system and keep it from attacking and damaging the new liver.

Constipation is passage of small amounts of hard, dry bowel movements, usually fewer than three times a week. People who are constipated may find it difficult and painful to have a bowel movement. Other symptoms of constipation include feeling bloated, uncomfortable, and sluggish.

Many people think they are constipated when, in fact, their bowel movements are regular. For example, some people believe they are constipated, or irregular, if they do not have a bowel movement every day. However, there is no right number of daily or weekly bowel movements. Normal may be three times a day or three times a week depending on the person. In addition, some people naturally have firmer stools than others.

At one time or another almost everyone gets constipated. Poor diet and lack of exercise are usually the causes. In most cases, constipation is temporary and not serious. Understanding causes, prevention, and treatment will help most people find relief.

Who Gets Constipated?According to the 1991 National Health Interview Survey, about 4 1/2 million people in the United States say they are constipated most or all of the time. Those reporting constipation most often are women, children, and adults age 65 and over. Pregnant women also complain of constipation, and it is a common problem following childbirth or surgery.

Constipation is the most common gastrointestinal complaint in the United States, resulting in about 2 million annual visits to the doctor. However, most people treat themselves without seeking medical help, as is evident from the $725 million Americans spend on laxatives each year.

What Causes Constipation?To understand constipation, it helps to know how the colon (large intestine) works. As food moves through it, the colon absorbs water while forming waste products, or stool. Muscle contractions in the colon push the stool toward the rectum. By the time stool reaches the rectum, it is solid because most of the water has been absorbed.

The hard and dry stools of constipation occur when the colon absorbs too much water. This happens because the colon's muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly.

Common Causes of Constipation

  • Not enough fiber in diet
  • Not enough liquids
  • Lack of exercise
  • Medications
  • Irritable bowel syndrome
  • Changes in life or routine such as pregnancy, older age, and travel
  • Abuse of laxatives
  • Ignoring the urge to have a bowel movement
  • Specific diseases such as multiple sclerosis and lupus
  • Problems with the colon and rectum
  • Problems with intestinal function (Chronic idiopathic constipation).

DietThe most common cause of constipation is a diet low in fiber found in vegetables, fruits, and whole grains and high in fats found in cheese, eggs, and meats. People who eat plenty of high-fiber foods are less likely to become constipated.

Fiber -- soluble and insoluble -- is the part of fruits, vegetables, and grains that the body cannot digest. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber passes almost unchanged through the intestines. The bulk and soft texture of fiber help prevent hard, dry stools that are difficult to pass.

On average, Americans eat about 5 to 20 grams of fiber daily, short of the 20 to 35 grams recommended by the American Dietetic Association. Both children and adults eat too many refined and processed foods in which the natural fiber is removed.

A low-fiber diet also plays a key role in constipation among older adults. They often lack interest in eating and may choose fast foods low in fiber. In addition, loss of teeth may force older people to eat soft foods that are processed and low in fiber.

Not Enough LiquidsLiquids like water and juice add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. People who have problems with constipation should drink enough of these liquids every day, about eight 8-ounce glasses. Other liquids, like coffee and soft drinks, that contain caffeine seem to have a dehydrating effect.

Lack of ExerciseLack of exercise can lead to constipation, although doctors do not know precisely why. For example, constipation often occurs after an accident or during an illness when one must stay in bed and cannot exercise.Medications

Pain medications (especially narcotics), antacids that contain aluminum, antispasmodics, antidepressants, iron supplements, diuretics, and anticonvulsants for epilepsy can slow passage of bowel movements.

Irritable Bowel Syndrome (IBS)Some people with IBS, also known as spastic colon, have spasms in the colon that affect bowel movements. Constipation and diarrhea often alternate, and abdominal cramping, gassiness, and bloating are other common complaints. Although IBS can produce lifelong symptoms, it is not a life-threatening condition. It often worsens with stress, but there is no specific cause or anything unusual that the doctor can see in the colon.

Changes in Life or RoutineDuring pregnancy, women may be constipated because of hormonal changes or because the heavy uterus compresses the intestine. Aging may also affect bowel regularity because a slower metabolism results in less intestinal activity and muscle tone. In addition, people often become constipated when traveling because their normal diet and daily routines are disrupted.

Abuse of LaxativesMyths about constipation have led to a serious abuse of laxatives. This is common among older adults who are preoccupied with having a daily bowel movement.

Laxatives usually are not necessary and can be habit-forming. The colon begins to rely on laxatives to bring on bowel movements. Over time, laxatives can damage nerve cells in the colon and interfere with the colon's natural ability to contract. For the same reason, regular use of enemas can also lead to a loss of normal bowel function.

Ignoring the Urge to Have a Bowel MovementPeople who ignore the urge to have a bowel movement may eventually stop feeling the urge, which can lead to constipation. Some people delay having a bowel movement because they do not want to use toilets outside the home. Others ignore the urge because of emotional stress or because they are too busy. Children may postpone having a bowel movement because of stressful toilet training or because they do not want to interrupt their play.

Specific DiseasesDiseases that cause constipation include neurological disorders, metabolic and endocrine disorders, and systemic conditions that affect organ systems. These disorders can slow the movement of stool through the colon, rectum, or anus.

Diseases That Cause ConstipationNeurological disorders that may cause constipation include:

    Multiple sclerosis    Parkinson's disease    Chronic idiopathic intestinal pseudo-obstruction    Stroke    Spinal cord injuries

Metabolic and endocrine conditions include:

    Diabetes    Underactive or overactive thyroid gland    Uremia.

Systemic disorders include:

    Amyloidosis    Lupus    Scleroderma

 Problems with the Colon and RectumIntestinal obstruction, scar tissue (adhesions), diverticulosis, tumors, colorectal stricture, Hirschsprung's disease, or cancer can compress, squeeze, or narrow the intestine and rectum and cause constipation.

Problems with Intestinal Function (Chronic Idiopathic Constipation)Also known as functional constipation, chronic idiopathic (of unknown origin) constipation is rare. However, some people are chronically constipated and do not respond to standard treatment. This chronic constipation may be related to multiple problems with hormonal control or with nerves and muscles in the colon, rectum, or anus. Functional constipation occurs in both children and adults and is most common in women.

Colonic inertia and delayed transit are two types of functional constipation caused by decreased muscle activity in the colon. These syndromes may affect the entire colon or may be confined to the left or lower (sigmoid) colon.

Functional constipation that stems from abnormalities in the structure of the anus and rectum is known as anorectal dysfunction, or anismus. These abnormalities result in an inability to relax the rectal and anal muscles that allow stool to exit. What Diagnostic Tests Are Used?Most people do not need extensive testing and can be treated with changes in diet and exercise. For example, in young people with mild symptoms, a medical history and physical examination may be all the doctor needs to suggest successful treatment. The tests the doctor performs depends on the duration and severity of the constipation, the person's age, and whether there is blood in stools, recent changes in bowel movements, or weight loss.Medical History

The doctor may ask a patient to describe his or her constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool, and toilet habits (how often and where one has bowel movements). Recording eating habits, medication, and level of physical activity or exercise also helps the doctor determine the cause of constipation.Physical Examination

A physical exam may include a digital rectal exam with a gloved, lubricated finger to evaluate the tone of the muscle that closes off the anus (anal sphincter) and to detect tenderness, obstruction, or blood. In some cases, blood and thyroid tests may be necessary.

Extensive testing usually is reserved for people with severe symptoms, for those with sudden changes in number and consistency of bowel movements or blood in the stool, and for older adults. Because of an increased risk of colorectal cancer in older adults, the doctor may use these tests to evaluate constipation and rule out a diagnosis of cancer:

    Barium enema x-ray    Sigmoidoscopy or colonoscopy    Colorectal transit study    Anorectal function tests

Barium Enema X-rayA barium enema x-ray involves viewing the rectum, colon, and lower part of the small intestine to locate any problems. This test may show intestinal obstruction and Hirschsprung's disease, a lack of nerves within the colon.

The night before the test, bowel cleansing, also called bowel prep, is necessary to clear the lower digestive tract. The patient drinks 8 ounces of a special liquid every 15 minutes for about 4 hours. This liquid flushes out the bowel. A clean bowel is important, because even a small amount of stool in the colon can hide details and result in an inaccurate exam.

Because the colon does not show up well on an x-ray, the doctor fills the organs with a barium enema, a chalky liquid to make the area visible. Once the mixture coats the organs, x-rays are taken that reveal their shape and condition. The patient may feel some abdominal cramping when the barium fills the colon, but usually feels little discomfort after the procedure. Stools may be a whitish color for a few days after the exam.Sigmoidoscopy or Colonoscopy

An examination of the rectum and lower colon (sigmoid) is called a sigmoidoscopy. An examination of the rectum and entire colon is called a colonoscopy.

The night before a sigmoidoscopy, the patient usually has a liquid dinner and takes an enema at bedtime. A light breakfast and a cleansing enema an hour before the test may also be necessary.

To perform a sigmoidoscopy, the doctor uses a long, flexible tube with a light on the end called a sigmoidoscope to view the rectum and lower colon. First, the doctor examines the rectum with a gloved, lubricated finger. Then, the sigmoidoscope is inserted through the anus into the rectum and lower colon. The procedure may cause a mild sensation of wanting to move the bowels and abdominal pressure. Sometimes the doctor fills the organs with air to get a better view. The air may cause mild cramping.

To perform a colonoscopy, the doctor uses a flexible tube with a light on the end called a colonoscope to view the entire colon. This tube is longer than a sigmoidoscope. The same bowel cleansing used for the barium x-ray is needed to clear the bowel of waste. The patient is sedated before the exam. During the exam, the patient lies on his or her side and the doctor inserts the tube through the anus and rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). The patient may feel gassy and bloated after the procedure.Colorectal Transit Study

This test, reserved for those with chronic constipation, shows how well food moves through the colon. The patient swallows capsules containing small markers, which are visible on x-ray. The movement of the markers through the colon is monitored with abdominal x-rays taken several times 3 to 7 days after the capsule is swallowed. The patient follows a high-fiber diet during the course of this test.Anorectal Function Tests

These tests diagnose constipation caused by abnormal functioning of the anus or rectum (anorectal function). Anorectal manometry evaluates anal sphincter muscle function. A catheter or air-filled balloon inserted into the anus is slowly pulled back through the sphincter muscle to measure muscle tone and contractions.

Defecography is an x-ray of the anorectal area that evaluates completeness of stool elimination, identifies anorectal abnormalities, and evaluates rectal muscle contractions and relaxation. During the exam, the doctor fills the rectum with a soft paste that is the same consistency as stool. The patient sits on a toilet positioned inside an x-ray machine and then relaxes and squeezes the anus and expels the solution. The doctor studies the x-rays for anorectal problems that occurred while the patient emptied the paste. How Is Constipation Treated?Although treatment depends on the cause, severity, and duration, in most cases dietary and lifestyle changes will help relieve symptoms and help prevent constipation.

DietA diet with enough fiber (20 to 35 grams each day) helps form soft, bulky stool. A doctor or dietitian can help plan an appropriate diet. High-fiber foods include beans; whole grains and bran cereals; fresh fruits; and vegetables such as asparagus, Brussels sprouts, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber such as ice cream, cheese, meat, and processed foods is also important.

Lifestyle ChangesOther changes that can help treat and prevent constipation include drinking enough water and other liquids such as fruit and vegetable juices and clear soup, engaging in daily exercise, and reserving enough time to have a bowel movement. In addition, the urge to have a bowel movement should not be ignored.Laxatives

Most people who are mildly constipated do not need laxatives. However, for those who have made lifestyle changes and are still constipated, doctors may recommend laxatives or enemas for a limited time. These treatments can help retrain a chronically sluggish bowel. For children, short-term treatment with laxatives, along with retraining to establish regular bowel habits, also helps prevent constipation.

A doctor should determine when a patient needs a laxative and which form is best. Laxatives taken by mouth are available in liquid, tablet, gum, powder, and granule forms. They work in various ways:

  • Bulk-forming laxatives generally are considered the safest but can interfere with absorption of some medicines. These laxatives, also known as fiber supplements, are taken with water. They absorb water in the intestine and make the stool softer. Brand names include Metamucil, Citrucel, and Serutan
  • Stimulants cause rhythmic muscle contractions in the intestines. Brand names include Correctol, Dulcolax, Purge, Feen-A-Mint, and Senokot. Studies suggest that phenolphthalein, an ingredient in some stimulant laxatives, might increase a person's risk for cancer. The Food and Drug Administration has proposed a ban on all over-the-counter products containing phenolphthalein. Most laxative makers have replaced or plan to replace phenolphthalein with a safer ingredient.
  • Stool softeners provide moisture to the stool and prevent dehydration. These laxatives are often recommended after childbirth or surgery. Products include Colace, Dialose, and Surfak.
  • Lubricants grease the stool enabling it to move through the intestine more easily. Mineral oil is the most common lubricant.
  • Saline laxatives act like a sponge to draw water into the colon for easier passage of stool. Laxatives in this group include Milk of Magnesia, Citrate of Magnesia, and Haley's M-O

People who are dependent on laxatives need to slowly stop using the medications. A doctor can assist in this process. In most people, this restores the colon's natural ability to contract.

Other TreatmentTreatment may be directed at a specific cause. For example, the doctor may recommend discontinuing medication or performing surgery to correct an anorectal problem such as rectal prolapse.

People with chronic constipation caused by anorectal dysfunction can use biofeedback to retrain the muscles that control release of bowel movements. Biofeedback involves using a sensor to monitor muscle activity that at the same time can be displayed on a computer screen allowing for an accurate assessment of body functions. A health care professional uses this information to help the patient learn how to use these muscles.

Surgical removal of the colon may be an option for people with severe symptoms caused by colonic inertia. However, the benefits of this surgery must be weighed against possible complications, which include abdominal pain and diarrhea.

Can Constipation Be Serious?Sometimes constipation can lead to complications. These complications include hemorrhoids caused by straining to have a bowel movement or anal fissures (tears in the skin around the anus) caused when hard stool stretches the sphincter muscle. As a result, rectal bleeding may occur that appears as bright red streaks on the surface of the stool. Treatment for hemorrhoids may include warm tub baths, ice packs, and application of a cream to the affected area. Treatment for anal fissure may include stretching the sphincter muscle or surgical removal of tissue or skin in the affected area.

Sometimes straining causes a small amount of intestinal lining to push out from the anal opening. This condition is known as rectal prolapse and may lead to secretion of mucus from the anus. Usually, eliminating the cause of the prolapse such as straining or coughing is the only treatment necessary. Severe or chronic prolapse requires surgery to strengthen and tighten the anal sphincter muscle or to repair the prolapsed lining.

Constipation may also cause hard stool to pack the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition, called fecal impaction, occurs most often in children and older adults. An impaction can be softened with mineral oil taken by mouth and an enema. After softening the impaction, the doctor may break up and remove part of the hardened stool by inserting one or two fingers in the anus.

Points to Remember

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

Constipation means that bowel movements are hard and dry, difficult or painful to pass, and less frequent than usual. It is a common problem for children, but it is usually temporary and no cause for parents to be concerned.

When a child does not eat enough fiber, drink enough liquids, or get enough exercise, constipation is more likely to occur. It also happens when children ignore the urge to have a bowel movement, which they often do out of either embarrassment to use a public bathroom, fear or lack of confidence in the absence of a parent, or unwillingness to take a break from play. Sometimes constipation is caused by medicines or a disease.

Symptoms of constipation include:

  • No bowel movement for several days or daily bowel movements that are hard and dry
  • Cramping abdominal pain
  • Nausea
  • Vomiting
  • Weight loss
  • Liquid or solid, clay-like stool in the child's underwear -- a sign that stool is backed up in the rectum

Constipation can make a bowel movement painful, so the child may try to prevent having one. Clenching buttocks, rocking up and down on toes, and turning red in the face are signs of trying to hold in a bowel movement.

Treatment depends on the child's age and the severity of the problem. Often eating more fiber (fruits, vegetables, whole-grain cereal), drinking more liquids, and getting more exercise will solve the problem. Sometimes a child may need an enema to remove the stool or a laxative to soften it or prevent a future episode. However, laxatives can be dangerous to children and should be given only with a doctor's approval.

Although constipation is usually harmless, it can be a sign or cause of a more serious problem. A child should see a doctor if

  • Episodes of constipation last longer than 3 weeks
  • The child is unable to participate in normal activities
  • Small, painful tears appear in the skin around the anus
  • A small amount of the intestinal lining is pushed out of the anus (hemorrhoids)
  • Normal pushing is not enough to expel stool
  • Liquid or soft stool leaks out of the anus

 

Crohn's disease causes inflammation in the small intestine. Crohn's disease usually occurs in the lower part of the small intestine, called the ileum, but it can affect any part of the digestive tract, from the mouth to the anus. The inflammation extends deep into the lining of the affected organ. The inflammation can cause pain and can make the intestines empty frequently, resulting in diarrhea.

Crohn's disease is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the intestines. Crohn's disease can be difficult to diagnose because its symptoms are similar to other intestinal disorders such as irritable bowel syndrome and to another type of IBD called ulcerative colitis. Ulcerative colitis causes inflammation and ulcers in the top layer of the lining of the large intestines or colon.

Crohn's disease affects men and women equally and seems to run in some families. About 20 percent of people with Crohn's disease have a blood relative with some form of IBD, most often a brother or sister and sometimes a parent or child.

Crohn's disease may also be called ileitis or enteritis.

What Causes Crohn's Disease?Theories about what causes Crohn's disease abound, but none has been proven. The most popular theory is that the body's immune system reacts to a virus or a bacterium by causing ongoing inflammation in the intestine.

People with Crohn's disease tend to have abnormalities of the immune system, but doctors do not know whether these abnormalities are a cause or result of the disease. Crohn's disease is not caused by emotional distress.

What Are the Symptoms?The most common symptoms of Crohn's disease are abdominal pain, often in the lower right area, and diarrhea. Rectal bleeding, weight loss, and fever may also occur. Bleeding may be serious and persistent, leading to anemia. Children with Crohn's disease may suffer delayed development and stunted growth.

How Is Crohn's Disease Diagnosed?A thorough physical exam and a series of tests may be required to diagnose Crohn's disease.

Blood tests may be done to check for anemia, which could indicate bleeding in the intestines. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. By testing a stool sample, the doctor can tell if there is bleeding or infection in the intestines.

The doctor may do an upper gastrointestinal (GI) series to look at the small intestine. For this test, the patient drinks barium, a chalky solution that coats the lining of the small intestine, before x-rays are taken. The barium shows up white on x-ray film, revealing inflammation or other abnormalities in the intestine.

The doctor may also do a colonoscopy. For this test, the doctor inserts an endoscope -- a long, flexible, lighted tube linked to a computer and TV monitor -- into the anus to see the inside of the large intestine. The doctor will be able to see any inflammation or bleeding. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the intestine to view with a microscope.

If these tests show Crohn's disease, more x-rays of both the upper and lower digestive tract may be necessary to see how much is affected by the disease.

What Are the Complications of Crohn's Disease?The most common complication is blockage of the intestine. Blockage occurs because the disease tends to thicken the intestinal wall with swelling and scar tissue, narrowing the passage. Crohn's disease may also cause sores, or ulcers, that tunnel through the affected area into surrounding tissues such as the bladder, vagina, or skin. The areas around the anus and rectum are often involved. The tunnels, called fistulas, are a common complication and often become infected. Sometimes fistulas can be treated with medicine, but in some cases they may require surgery.

Nutritional complications are common in Crohn's disease. Deficiencies of proteins, calories, and vitamins are well documented in Crohn's disease. These deficiencies may be caused by inadequate dietary intake, intestinal loss of protein, or poor absorption (malabsorption).

Other complications associated with Crohn's disease include arthritis, skin problems, inflammation in the eyes or mouth, kidney stones, gallstones, or other diseases of the liver and biliary system. Some of these problems resolve during treatment for disease in the digestive system, but some must be treated separately.

What Is the Treatment for Crohn's Disease?Treatment for Crohn's disease depends on the location and severity of disease, complications, and response to previous treatment. The goals of treatment are to control inflammation, correct nutritional deficiencies, and relieve symptoms like abdominal pain, diarrhea, and rectal bleeding. Treatment may include drugs, nutrition supplements, surgery, or a combination of these options. At this time, treatment can help control the disease, but there is no cure.

Some people have long periods of remission, sometimes years, when they are free of symptoms. However, the disease usually recurs at various times over a person's lifetime. This changing pattern of the disease means one cannot always tell when a treatment has helped. Predicting when a remission may occur or when symptoms will return is not possible.

Someone with Crohn's disease may need medical care for a long time, with regular doctor visits to monitor the condition.

Drug TherapyMost people are first treated with drugs containing mesalamine, a substance that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Patients who do not benefit from it or who cannot tolerate it may be put on other mesalamine-containing drugs, generally known as 5-ASA agents, such as Asacol, Dipentum, or Pentasa. Possible side effects of mesalamine preparations include nausea, vomiting, heartburn, diarrhea, and headache.

Some patients take corticosteroids to control inflammation. These drugs are the most effective for active Crohn's disease, but they can cause serious side effects, including greater susceptibility to infection.

Drugs that suppress the immune system are also used to treat Crohn's disease. Most commonly prescribed are 6-mercaptopurine and a related drug, azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. These drugs may cause side effects like nausea, vomiting, and diarrhea and may lower a person's resistance to infection. When patients are treated with a combination of corticosteroids and immunosuppressive drugs, the dose of corticosteriods can eventually be lowered. Some studies suggest that immunosuppressive drugs may enhance the effectiveness of corticosteroids.

The U.S. Food and Drug Administration has approved the drug infliximab (brand name, Remicade) for the treatment of moderate to severe Crohn's disease that does not respond to standard therapies (mesalamine substances, corticosteroids, immunosuppressive agents) and for the treatment of open, draining fistulas. Infliximab, the first treatment approved specifically for Crohn's disease, is an anti-tumor necrosis factor (TNF) substance. TNF is a protein produced by the immune system that may cause the inflammation associated with Crohn's disease. Anti-TNF removes TNF from the bloodstream before it reaches the intestines, thereby preventing inflammation. Investigators will continue to study patients taking infliximab to determine its long-term safety and efficacy.

Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or prior surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, ciproflaxacin or metronidazole.

Diarrhea and crampy abdominal pain are often relieved when the inflammation subsides, but additional medication may also be necessary. Several antidiarrheal agents could be used, including diphenoxylate, loperamide, and codeine. Patients who are dehydrated because of diarrhea will be treated with fluids and electrolytes.

Nutrition SupplementationThe doctor may recommend nutritional supplements, especially for children whose growth has been slowed. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need periods of feeding by vein. This can help patients who need extra nutrition temporarily, those whose intestines need to rest, or those whose intestines cannot absorb enough nutrition from food.

SurgerySurgery to remove part of the intestine can help Crohn's disease but cannot cure it. The inflammation tends to return next to the area of intestine that has been removed. Many Crohn's disease patients require surgery, either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine.

Some people who have Crohn's disease in the large intestine need to have their entire colon removed in an operation called colectomy. A small opening is made in the front of the abdominal wall, and the tip of the ileum is brought to the skin's surface. This opening, called a stoma, is where waste exits the body. The stoma is about the size of a quarter and is usually located in the right lower part of the abdomen near the belt line. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. The majority of colectomy patients go on to live normal, active lives.

Sometimes only the diseased section of intestine is removed and no stoma is needed. In this operation, the intestine is cut above and below the diseased area and reconnected.

Because Crohn's disease often recurs after surgery, people considering it should carefully weigh its benefits and risks compared with other treatments. Surgery may not be appropriate for everyone. People faced with this decision should get as much information as possible from doctors, nurses who work with colon surgery patients (enterostomal therapists), and other patients. Patient advocacy organizations can suggest support groups and other information resources.

People with Crohn's disease may feel well and be free of symptoms for substantial spans of time when their disease is not active. Despite the need to take medication for long periods of time and occasional hospitalizations, most people with Crohn's disease are able to hold jobs, raise families, and function successfully at home and in society.

Research - Researchers continue to look for more effective treatments. Examples of investigational treatments include

Anti-TNF - Research has shown that cells affected by Crohn's disease contain a cytokine, a protein produced by the immune system, called tumor necrosis factor (TNF). TNF may be responsible for the inflammation of Crohn's disease. Anti-TNF is a substance that finds TNF in the bloodstream, binds to it, and removes it before it can reach the intestines and cause inflammation. In studies, anti-TNF seems particularly helpful in closing fistulas.

Interleukin 10 - Interleukin 10 (IL-10) is a cytokine that suppresses inflammation. Researchers are now studying the effectiveness of synthetic IL-10 in treating Crohn's disease.

Antibiotics - Antibiotics are now used to treat the bacterial infections that often accompany Crohn's disease, but some research suggests that they might also be useful as a primary treatment for active Crohn's disease.

Budesonide- Researchers recently identified a new corticosteroid called budesonide that appears to be as effective as other corticosteroids but causes fewer side effects.

Methotrexate and cyclosporine - These are immunosuppressive drugs that may be useful in treating Crohn's disease. One potential benefit of methotrexate and cyclosporine is that they appear to work faster than traditional immunosuppressive drugs.

Zinc

Free radicals -- molecules produced during fat metabolism, stress, and infection, among other things -- may contribute to inflammation in Crohn's disease. Free radicals sometimes cause cell damage when they interact with other molecules in the body. The mineral zinc removes free radicals from the bloodstream. Studies are under way to determine whether zinc supplementation might reduce inflammation.

Can Diet Control Crohn's Disease?

No special diet has been proven effective for preventing or treating this disease. Some people find their symptoms are made worse by milk, alcohol, hot spices, or fiber. People are encouraged to follow a nutritious diet and avoid any foods that seem to worsen symptoms. But there are no consistent rules.

People should take vitamin supplements only on their doctor's advice.

Is Pregnancy Safe for Women with Crohn's Disease?Research has shown that the course of pregnancy and delivery is usually not impaired in women with Crohn's disease. Even so, women with Crohn's disease should discuss the matter with their doctors before pregnancy. Most children born to women with Crohn's disease are unaffected. Children who do get the disease are sometimes more severely affected than adults, with slowed growth and delayed sexual development in some cases.

Crohn's & Colitis Foundation of America

What is Diarrhea?Diarrhea -- loose, watery stools occurring more than three times in one day -- is a common problem that usually lasts a day or two and goes away on its own without any special treatment. However, prolonged diarrhea can be a sign of other problems.

Diarrhea can cause dehydration, which means the body lacks enough fluid to function properly. Dehydration is particularly dangerous in children and the elderly, and it must be treated promptly to avoid serious health problems. Dehydration is discussed below.

People of all ages can get diarrhea. The average adult has a bout of diarrhea about four times a year.

What Causes Diarrhea?Diarrhea may be caused by a temporary problem, like an infection, or a chronic problem, like an intestinal disease. A few of the more common causes of diarrhea are

  • Bacterial infections. Several types of bacteria, consumed through contaminated food or water, can cause diarrhea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli.
  • Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, and viral hepatitis.
  • Food intolerances. Some people are unable to digest a component of food, such as lactose, the sugar found in milk.
  • Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.
  • Reaction to medicines, such as antibiotics, blood pressure medications, and antacids containing magnesium.
  • Intestinal diseases, like inflammatory bowel disease or celiac disease.
  • Functional bowel disorders, such as irritable bowel syndrome, in which the intestines do not work normally.

Some people develop diarrhea after stomach surgery or removal of the gallbladder. The reason may be a change in how quickly food moves through the digestive system after stomach surgery or an increase in bile in the colon that can occur after gallbladder surgery.

In many cases, the cause of diarrhea cannot be found. As long as diarrhea goes away on its own, an extensive search for the cause is not usually necessary.

People who visit foreign countries are at risk for traveler's diarrhea, which is caused by eating food or drinking water contaminated with bacteria, viruses, or, sometimes, parasites. Traveler's diarrhea is a particular problem for people visiting developing countries. Visitors to the United States, Canada, most European countries, Japan, Australia, and New Zealand do not face much risk for traveler's diarrhea.

What Are the Symptoms?Diarrhea may be accompanied by cramping abdominal pain, bloating, nausea, or an urgent need to use the bathroom. Depending on the cause, a person may have a fever or bloody stools.

Diarrhea can be either acute or chronic. The acute form, which lasts less than 3 weeks, is usually related to a bacterial, viral, or parasitic infection. Chronic diarrhea lasts more than 3 weeks and is usually related to functional disorders like irritable bowel syndrome or diseases like celiac disease or inflammatory bowel disease.

Diarrhea in ChildrenChildren can have acute (short-term) or chronic (long-term) forms of diarrhea. Causes include bacteria, viruses, parasites, medications, functional disorders, and food sensitivities. Infection with the rotavirus is the most common cause of acute childhood diarrhea. Rotavirus diarrhea usually resolves in 5 to 8 days.

Medications to treat diarrhea in adults can be dangerous to children and should be given only under a doctor's guidance.

Diarrhea can be dangerous in newborns and infants. In small children, severe diarrhea lasting just a day or two can lead to dehydration. Because a child can die from dehydration within a few days, the main treatment for diarrhea in children is rehydration. Rehydration is discussed below.

Take your child to the doctor if any of the following symptoms appear:

  • Stools containing blood or pus, or black stools
  • Temperature above 101.4 degrees Fahrenheit
  • No improvement after 24 hours
  • Signs of dehydration (see below)

 What is Dehydration?General signs of dehydration include

  • Thirst
  • Less frequent urination
  • Dry skin
  • Fatigue
  • Lightheadedness

Signs of dehydration in children include

  • Dry mouth and tongue
  • No tears when crying
  • No wet diapers for 3 hours or more
  • Sunken abdomen, eyes, or cheeks
  • High fever
  • Listlessness or irritability
  • Skin that does not flatten when pinched and released

If you suspect that you or your child is dehydrated, call the doctor immediately. Severe dehydration may require hospitalization When Should a Doctor Be Consulted?Although usually not harmful, diarrhea can become dangerous or signal a more serious problem. You should see the doctor if

  • You have diarrhea for more than 3 days
  • You have severe pain in the abdomen or rectum
  • You have a fever of 102 degrees Fahrenheit or higher
  • You see blood in your stool or have black, tarry stools
  • You have signs of dehydration

If your child has diarrhea, do not hesitate to call the doctor for advice. Diarrhea can be dangerous in children if too much fluid is lost and not replaced quickly.

What Tests Might the Doctor Do?Diagnostic tests to find the cause of diarrhea include the following:

  • Medical history and physical examination. The doctor will need to know about your eating habits and medication use and will examine you for signs of illness.
  • Stool culture. Lab technicians analyze a sample of stool to check for bacteria, parasites, or other signs of disease or infection.
  • Blood tests. Blood tests can be helpful in ruling out certain diseases.
  • Fasting tests. To find out if a food intolerance or allergy is causing the diarrhea, the doctor may ask you to avoid lactose (found in milk products), carbohydrates, wheat, or other foods to see whether the diarrhea responds to a change in diet.
  • Sigmoidoscopy. For this test, the doctor uses a special instrument to look at the inside of the rectum and lower part of the colon.
  • Colonoscopy. This test is similar to sigmoidoscopy, but the doctor looks at the entire colon.

 What Is the Treatment?In most cases, replacing lost fluid to prevent dehydration is the only treatment necessary. (See "Preventing Dehydration" below.) Medicines that stop diarrhea may be helpful in some cases, but they are not recommended for people whose diarrhea is from a bacterial infection or parasite --stopping the diarrhea traps the organism in the intestines, prolonging the problem. Instead, doctors usually prescribe antibiotics. Viral causes are either treated with medication or left to run their course, depending on the severity and type of the virus

Preventing DehydrationDehydration occurs when the body has lost too much fluid and electrolytes (the salts potassium and sodium). The fluid and electrolytes lost during diarrhea need to be replaced promptly -- the body cannot function properly without them. Dehydration is particularly dangerous for children, who can die from it within a matter of days.

Although water is extremely important in preventing dehydration, it does not contain electrolytes. To maintain electrolyte levels, you should also have chicken or beef broth, which contains sodium, and fruit and cola drinks, which contain potassium.

For children, doctors often recommend a special rehydration solution that contains the nutrients they need. You can buy this solution in the grocery store without a prescription. Examples include Pedialyte, Ceralyte, and Infalyte.

Tips About FoodUntil diarrhea subsides, try to avoid milk products and foods that are greasy, high-fiber, or very sweet. These foods tend to aggravate diarrhea.

As you improve, you can add soft, bland foods to your diet, including bananas, plain rice, boiled potatoes, toast, crackers, cooked carrots, and baked chicken without the skin or fat. For children, the pediatrician may recommend what is called the BRAT diet: bananas, rice, applesauce, and toast.

Preventing Traveler's DiarrheaTraveler's diarrhea happens when you consume food or water contaminated with bacteria, viruses, or parasites. You can take the following precautions to prevent traveler's diarrhea when you go abroad:

  • Do not drink any tap water, not even when brushing your teeth.
  • Do not drink unpasteurized milk or dairy products.
  • Do not use ice made from tap water.
  • Avoid all raw fruits and vegetables (including lettuce and fruit salad) unless they can be peeled and you peel them yourself.
  • Do not eat raw or rare meat and fish.
  • Do not eat meat or shellfish that is not hot when served to you.
  • Do not eat food from street vendors.

You can safely drink bottled water (if you are the one to break the seal), carbonated soft drinks, and hot drinks like coffee or tea.

Depending on where you are going and how long you are staying, your doctor may recommend that you take antibiotics before leaving to protect you from possible infection. Points To Remember

  • Diarrhea is a common problem that usually resolves on its own.
  • Diarrhea is dangerous if a person becomes dehydrated.
  • Causes include viral, bacterial, or parasitic infections; food intolerance; reactions to medicine; intestinal diseases; and functional bowel disorders.
  • Treatment involves replacing lost fluids and electrolytes. Depending on the cause of the problem, a person might also need medication to stop the diarrhea or treat an infection. Children may need an oral rehydration solution to replace lost fluids and electrolytes.
  • Call the doctor if a person with diarrhea has severe pain in the abdomen or rectum, a fever of 102 degrees Fahrenheit or higher, blood in the stool, signs of dehydration, or diarrhea for more than 3 days.

Most people have in their colons small pouches that bulge outward through weak spots, like an inner tube that pokes through weak places in a tire. Each pouch is called a diverticulum. Pouches are diverticula. The condition of having diverticula is called diverticulosis. About half of all Americans age 60 to 80, and almost everyone over age 80, have diverticulosis.

When the pouches become infected or inflamed, the condition is called diverticulitis. This happens in 10 to 25 percent of people with diverticulosis. Diverticulosis and diverticulitis are also called diverticular disease.

What Causes Diverticular Disease?Doctors believe a low-fiber diet is the main cause of diverticular disease. The disease was first noticed in the United States in the early 1900's. At about the same time, processed foods were introduced to the American diet. Many processed foods contain refined, low-fiber flour. Unlike whole-wheat flour, refined flour has no wheat bran.

Diverticular disease is common in developed or industrialized countries -- particularly the United States, England, and Australia -- where low-fiber diets are common. The disease is rare in countries of Asia and Africa, where people eat high-fiber vegetable diets.

Fiber is the part of fruits, vegetables, and grains that the body cannot digest. Some fiber dissolves easily in water (soluble fiber). It takes on a soft, jelly-like texture in the intestines. Some fiber passes almost unchanged through the intestines (insoluble fiber). Both kinds of fiber help make stools soft and easy to pass. Fiber also prevents constipation.

Constipation makes the muscles strain to move stool that is too hard. It is the main cause of increased pressure in the colon. The excess pressure causes the weak spots in the colon to bulge out and become diverticula.

Diverticulitis occurs when diverticula become infected or inflamed. Doctors are not certain what causes the infection. It may begin when stool or bacteria are caught in the diverticula. An attack of diverticulitis can develop suddenly and without warning. What Are the Symptoms?DiverticulosisMost people with diverticulosis do not have any discomfort or symptoms. However, symptoms may include mild cramps, bloating, and constipation. Other diseases such as irritable bowel syndrome (IBS) and stomach ulcers cause similar problems, so these symptoms do not always mean a person has diverticulosis. You should visit your doctor if you have these troubling symptoms.

DiverticulitisThe most common symptom of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications. You should contact your doctor if you feel you could have diverticulitis.

Are There Complications?Diverticulitis can lead to complications such as infections, perforations or tears, blockages, or bleeding. These complications always require treatment to prevent them from progressing and causing serious illness.

BleedingBleeding from diverticula is a rare complication. When diverticula bleed, blood may appear in the toilet or in your stool. Bleeding can be severe, but it may stop by itself and not require treatment. Doctors believe bleeding diverticula are caused by a small blood vessel in a diverticulum that weakens and finally bursts. If you have bleeding from the rectum, you should see your doctor. If the bleeding does not stop, surgery may be necessary.Abscess, Perforation, and Peritonitis

The infection causing diverticulitis often clears up after a few days of treatment with antibiotics. If the condition gets worse, an abscess may form in the colon.

An abscess is an infected area with pus that may cause swelling and destroy tissue. Sometimes, the infected diverticula may develop small holes, called perforations. These perforations allow pus to leak out of the colon into the abdominal area. If the abscess is small and remains in the colon, it may clear up after treatment with antibiotics. If the abscess does not clear up with antibiotics, the doctor may need to drain it.

To drain the abscess, the doctor uses a needle and a small tube called a catheter. The doctor inserts the needle through the skin and drains the fluid through the catheter. This procedure is called "percutaneous catheter drainage." Sometimes surgery is needed to clean the abscess and, if necessary, remove part of the colon.

A large abscess can become a serious problem if the infection leaks out and contaminates areas outside the colon. Infection that spreads into the abdominal cavity is called peritonitis. Peritonitis requires immediate surgery to clean the abdominal cavity and remove the damaged part of the colon. Without surgery, peritonitis can be fatal.

FistulaA fistula is an abnormal connection of tissue between two organs or between an organ and the skin. When damaged tissues come into contact with each other during infection, they sometimes stick together. If they heal that way, a fistula may form. When diverticulitis-related infection spreads outside the colon, the colon's tissue may stick to nearby tissues. The most common organs involved are the urinary bladder, small intestine, and skin.

The most common type of fistula occurs between the bladder and the colon. It affects men more than women. This type of fistula can result in a severe, long-lasting infection of the urinary tract. The problem can be corrected with surgery to remove the fistula and the affected part of the colon.Intestinal Obstruction

The scarring caused by infection may cause partial or total blockage of the colon. When this happens, the colon is unable to move bowel contents normally. When the obstruction totally blocks the intestine, emergency surgery is necessary. Partial blockage is not an emergency, so the surgery to correct it can be planned.

How Does the Doctor Diagnose Diverticular Disease?To diagnose diverticular disease, the doctor asks about medical history, does a physical exam, and may perform one or more diagnostic tests. Because most people do not have symptoms, diverticulosis is often found through tests ordered for another ailment.Medical History and Physical Exam

When taking a medical history, the doctor may ask about bowel habits, symptoms, pain, diet, and medications. The physical exam usually involves a digital rectal exam. To perform this test, the doctor inserts a gloved, lubricated finger into the rectum to detect tenderness, blockage, or blood. The doctor may check stool for signs of bleeding and test blood for signs of infection. The doctor may also order x-rays or other tests.

What Is the Treatment for Diverticular Disease?A high-fiber diet and, occasionally, mild pain medications will help relieve symptoms in most cases. Sometimes an attack of diverticulitis is serious enough to require a hospital stay and possibly surgery.

DiverticulosisIncreasing the amount of fiber in the diet may reduce symptoms of diverticulosis and prevent complications such as diverticulitis. Fiber keeps stool soft and lowers pressure inside the colon so that bowel contents can move through easily. The American Dietetic Association recommends 20 to 35 grams of fiber each day. Table 1 shows the amount of fiber in several foods that you can easily add to your diet.

The doctor may also recommend drinking a fiber product such as Citrucel or Metamucil once a day. These products are mixed with water and provide about 4 to 6 grams of fiber for an 8-ounce glass.

Many doctors recommend avoiding foods with small seeds such as tomatoes or strawberries because they believed that particles could lodge in the diverticula and cause inflammation. However, this is now a controversial point and no evidence supports this recommendation.

If cramps, bloating, and constipation are problems, the doctor may prescribe a short course of pain medication. However, many medications affect emptying of the colon, an undesirable side effect for people with diverticulosis.

Table 1. Amount of Fiber in Some Foods

Fruits

raspberries

1 cup

=

6 grams of fiber

apple

1

=

3 grams

tangerine

1

=

2 grams

peach

1

=

1 gram

Vegetables

acorn squash

3/4 cup

=

4 grams

brussel sprouts

1/2 cup

=

3 grams

cabbage

1/2 cup

=

2 grams

carrot

1

=

2 grams

potato, peeled

1

=

2 grams

tomato

1

=

2 grams

asparagus

1/2 cup

=

1 gram

broccoli

1/2 cup

=

1 gram

cauliflower

1/2 cup

=

1 gram

romaine lettuce

1 cup

=

1 gram

spinach

1/2 cup

=

1 gram

zucchini

1 cup

=

1 gram

Starchy Vegetables

black-eyed peas

1/2 cup

=

4 grams

lima beans

1/2 cup

=

4 grams

kidney beans

1/2 cup

=

3 grams

Grains

brown rice

1 cup

=

3 grams

oatmeal

2/3 cup

=

3 grams

whole-wheat cereal

1 cup

=

3 grams

whole-wheat bread

1 slice

=

2 grams

white rice

1 cup

=

1 gram

Source: JAT Pennington. Sixteenth Edition of Bowes and Church's Food Values of Portions Commonly Used. J.B. Lippincott Publishing Co., Philadelphia, PA. 1994.

DiverticulitisTreatment for diverticulitis focuses on clearing up the infection and inflammation, resting the colon, and preventing or minimizing complications. An attack of diverticulitis without complications may respond to antibiotics within a few days if treated early.

To help the colon rest, the doctor may recommend bed rest and a liquid diet, along with a pain reliever or a drug such as propantheline (Pro-Banthine) to control muscle spasms in the colon.

An acute attack with severe pain or severe infection may require a hospital stay. Most acute cases of diverticulitis are treated with antibiotics and a liquid diet. The antibiotics are given by injection into a vein. In some cases, however, surgery may be necessary.

When Is Surgery Necessary?If attacks are severe or frequent, the doctor may advise surgery. The surgeon opens the abdomen and removes the affected part of the colon. The remaining sections of the colon are rejoined. This type of surgery, called colon resection, aims to keep attacks from coming back and to prevent complications. The doctor may also recommend surgery for complications of a fistula or intestinal obstruction.

If antibiotics do not correct the attack, emergency surgery may be required. Other reasons for emergency surgery include a large abscess, perforation, peritonitis, or continued bleeding.

Emergency surgery usually involves two operations. The first surgery will clear the infected abdominal cavity and remove part of the colon. Because of infection and sometimes obstruction, it is not safe to rejoin the colon during the first operation. The surgeon creates a temporary hole, or stoma, in the abdomen during the first operation. The end of the colon is connected to the hole, a procedure called a colostomy, to allow normal eating and bowel movement. The stool goes into a bag attached to the opening in the abdomen. In the second operation, the surgeon rejoins the ends of the colon.

Points to Remember

  • Diverticulosis occurs when small pouches, called diverticula, bulge outward through weak spots in the colon (large intestine).
  • The pouches form when pressure inside the colon builds, usually because of constipation.
  • The main cause of diverticulosis is a low-fiber diet because it increases constipation and pressure inside the colon.
  • Most people with diverticulosis never have any discomfort or symptoms.
  • Diverticulitis occurs when the pouches get infected or inflamed and cause pain and tenderness around the left side of the lower abdomen.
  • For most people with diverticulosis, eating a high-fiber diet is the only treatment needed.
  • You can increase your fiber intake by eating these foods: whole grain breads, cereals, and other products; fruit such as berries, apples, and peaches; and vegetables such as broccoli, cabbage, spinach, carrots, asparagus, and squash; and beans.

What Are Gallstones?Gallstones form when liquid stored in the gallbladder hardens into pieces of stone-like material. The liquid, called bile, is used to help the body digest fats. Bile is made in the liver, then stored in the gallbladder until the body needs to digest fat. At that time, the gallbladder contracts and pushes the bile into a tube called the bile duct that carries it to the small intestine, where it helps with digestion.

Bile contains water, cholesterol, fats, bile salts, and bilirubin. Bile salts break up fat, and bilirubin gives bile and stool a brownish color. If the liquid bile contains too much cholesterol, bile salts, or bilirubin, it can harden into stones.

The two types of gallstones are cholesterol stones and pigment stones. Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Pigment stones are small, dark stones made of bilirubin. Gallstones can be as small as a grain of sand or as large as a golf ball. The gallbladder can develop just one large stone, hundreds of tiny stones, or almost any combination.

Gallstones can block the normal flow of bile if they lodge in any of the ducts that carry bile from the liver to the small intestine. That includes the hepatic ducts, which carry bile out of the liver; the cystic duct, which takes bile to and from the gallbladder; and the common bile duct, which takes bile from the cystic and hepatic ducts to the small intestine. Bile trapped in these ducts can cause inflammation in the gallbladder, the ducts, or, rarely, the liver. Other ducts open into the common bile duct, including the pancreatic duct, which carries digestive enzymes out of the pancreas. If a gallstone blocks the opening to that duct, digestive enzymes can become trapped in the pancreas and cause an extremely painful inflammation of the pancreas called pancreatitis.

If any of these ducts remain blocked for a significant period of time, severe possibly fatal damage can occur, affecting the gallbladder, liver, or pancreas. Warning signs of a serious problem are fever, jaundice, and persistent pain. What Causes Gallstones?Cholesterol StonesScientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason.

Pigment StonesThe cause of pigment stones is uncertain. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anemia.

Other FactorsIt is believed that the mere presence of gallstones may cause more gallstones to develop. However, other factors that contribute to gallstones have been identified, especially for cholesterol stones.

  • Obesity. Obesity is a major risk factor for gallstones, especially in women. A large clinical study showed that being even moderately overweight increases one's risk for developing gallstones. The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying.
  • Estrogen. Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.
  • Ethnicity. Native Americans have a genetic predisposition to secrete high levels of cholesterol in bile. In fact, they have the highest rates of gallstones in the United States. A majority of Native American men have gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women have gallstones by age 30. Mexican-American men and women of all ages also have high rates of gallstones.
  • Gender. Women between 20 and 60 years of age are twice as likely to develop gallstones as men.
  • Age. People over age 60 are more likely to develop gallstones than younger people.
  • Cholesterol-lowering drugs. Drugs that lower cholesterol levels in blood actually increase the amount of cholesterol secreted in bile. This in turn can increase the risk of gallstones.
  • Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids increase the risk of gallstones.
  • Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.
  • Fasting. Fasting decreases gallbladder movement, causing the bile to become overconcentrated with cholesterol, which can lead to gallstones.

 

Who Is at Risk for Gallstones?

  •     Women.
  •     People over age 60.
  •     Native Americans.
  •     Mexican-Americans.
  •     Overweight men and women.
  •     People who fast or lose a lot of weight quickly.
  •     Pregnant women, women on hormone therapy, and women who use birth control pills.

 

What are the Symptoms?Symptoms of gallstones are often called a gallstone "attack" because they occur suddenly. A typical attack can cause

  • Steady, severe pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours.
  • Pain in the back between the shoulder blades
  • Pain under the right shoulder
  • Nausea or vomiting

Gallstone attacks often follow fatty meals, and they may occur during the night. Other gallstone symptoms include:

  • Abdominal bloating
  • Recurring intolerance of fatty foods
  • Colic
  • Belching
  • Gas
  • Indigestion

People who also have the following symptoms should see a doctor right away:

  • Sweating
  • Chills
  • Low-grade fever
  • Yellowish color of the skin or whites of the eyes
  • Clay-colored stools

Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called "silent stones." They do not interfere in gallbladder, liver, or pancreas function and do not need treatment. How Are Gallstones Diagnosed?Many gallstones, especially silent stones, are discovered by accident during tests for other problems. But when gallstones are suspected to be the cause of symptoms, the doctor is likely to do an ultrasound exam. Ultrasound uses sound waves to create images of organs. Sound waves are sent toward the gallbladder through a handheld device that a technician glides over the abdomen. The sound waves bounce off the gallbladder, liver, and other organs, and their echoes make electrical impulses that create a picture of the organ on a video monitor. If stones are present, the sound waves will bounce off them, too, showing their location.

Other tests used in diagnosis include:

  • Cholecystogram or cholescintigraphy. The patient is injected with a special iodine dye, and x-rays are taken of the gallbladder over a period of time. (Some people swallow iodine pills the night before the x-ray.) The test shows the movement of the gallbladder and any obstruction of the cystic duct.
  • Endoscopic retrograde cholangiopancreatography (ERCP). The patient swallows an endoscope, a long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts.
  • Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

Gallstone symptoms are similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

What is the Treatment?SurgerySurgery to remove the gallbladder is the most common way to treat symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.) Each year more than 500,000 Americans have gallbladder surgery. The surgery is called cholecystectomy.

The standard surgery is called laparoscopic cholecystectomy. For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions.

Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. Recovery usually involves only one night in the hospital, followed by several days of restricted activity at home.

If the surgeon discovers any obstacles to the laparoscopic procedure, such as infection or scarring from other operations, the operating team may have to switch to open surgery. In some cases the obstacles are known before surgery, and an open surgery is planned. It is called "open" surgery because the surgeon has to make a 5- to 8-inch incision in the abdomen to remove the gallbladder. This is a major surgery and may require about a 2- to 7-day stay in the hospital and several more weeks at home to recover. Open surgery is required in about 5 percent of gallbladder operations.

The most common complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes be treated non-surgically. Major injury, however, is more serious and requires additional surgery.

If gallstones are in the bile ducts, ERCP may be used to remove them before or during the gallbladder surgery. Once the endoscope is in the small intestine, the doctor locates the affected bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope. This two-step procedure is called ERCP with endoscopic sphincterotomy.

Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the bile ducts weeks, months, or even years after the surgery. The two-step ERCP procedure is usually successful in removing the stone.

Non-surgical TreatmentNon-surgical approaches are used only in special situations such as when a patient's condition prevents using an anesthetic and only for cholesterol stones. Stones recur after non-surgical treatment about half the time.

  • Oral dissolution therapy. Drugs made from bile acid are used to dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix), work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs cause mild diarrhea, and chenodiol may temporarily raise levels of blood cholesterol and the liver enzyme transaminase.
  • Contact dissolution therapy. This experimental procedure involves injecting a drug directly into the gallbladder to dissolve stones. The drug methyl tert butyl can dissolve some stones in 1 to 3 days, but it must be used very carefully because it is a flammable anesthetic that can be toxic. The procedure is being tested in patients with symptomatic, non-calcified cholesterol stones.
  • Extracorporeal shockwave lithotripsy (ESWL). This treatment uses shock waves to break up stones into tiny pieces that can pass through the bile ducts without causing blockages. Attacks of biliary colic (intense pain) are common after treatment, and ESWL's success rate is not very high. Remaining stones can sometimes be dissolved with medication.

Don't People Need Their Gallbladders?Fortunately, the gallbladder is an organ that people can live without. Losing it won't even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder. However, because the bile isn't stored in the gallbladder, it flows into the small intestine more frequently, causing diarrhea in some people. Also, some studies suggest that removing the gallbladder may cause higher blood cholesterol levels, so occasional cholesterol tests may be necessary.

Points To Remember

  • Gallstones form when substances in the bile harden.
  • Gallstones are common among women, Native Americans, Mexican-Americans, and people who are overweight.
  • Gallstone attacks often occur after eating a fatty meal.
  • Symptoms can mimic those of other problems, including heart attack, so accurate diagnosis is important.
  • Gallstones can cause serious problems if they become trapped in the bile ducts.
  • Laparoscopic surgery to remove the gallbladder is the most common treatment.

Everyone has gas and eliminates it by burping or passing it through the rectum.However, many people think they have too much gas when they really have normal amounts. Most people produce about 1 to 3 pints a day and pass gas about 14 times a day.

Gas is made primarily of odorless vapors -- carbon dioxide, oxygen, nitrogen, hydrogen, and sometimes methane. The unpleasant odor of flatulence comes from bacteria in the large intestine that release small amounts of gases that contain sulfur.

Although having gas is common, it can be uncomfortable and embarrassing. Understanding causes, ways to reduce symptoms, and treatment will help most people find relief.

What Causes Gas?Gas in the digestive tract (that is, the esophagus, stomach, small intestine, and large intestine) comes from two sources:

Swallowed airAir swallowing (aerophagia) is a common cause of gas in the stomach. Everyone swallows small amounts of air when eating and drinking. However, eating or drinking rapidly, chewing gum, smoking, or wearing loose dentures can cause some people to take in more air.

Burping, or belching, is the way most swallowed air -- which contains nitrogen, oxygen, and carbon dioxide -- leaves the stomach. The remaining gas moves into the small intestine where it is partially absorbed. A small amount travels into the large intestine for release through the rectum. (The stomach also releases carbon dioxide when stomach acid and bicarbonate mix, but most of this gas is absorbed into the bloodstream and does not enter the large intestine.)

Breakdown of undigested foodsThe body does not digest and absorb some carbohydrates (the sugar, starches, and fiber found in many foods) in the small intestine because of a shortage or absence of certain enzymes.

This undigested food then passes from the small intestine into the large intestine, where harmless and normal bacteria break down the food, producing hydrogen, carbon dioxide, and, in about one-third of all people, methane. Eventually these gases exit through the rectum.

People who make methane do not necessarily pass more gas or have unique symptoms. A person who produces methane will have stools that consistently float in water. Research has not shown why some people produce methane and others do not.

Foods that produce gas in one person may not cause gas in another. Some common bacteria in the large intestine can destroy the hydrogen that other bacteria produce. The balance of the two types of bacteria may explain why some people have more gas than others.

Which Foods Cause Gas?Most foods that contain carbohydrates can cause gas. By contrast, fats and proteins cause little gas.

SugarsThe sugars that cause gas are: raffinose, lactose, fructose, and sorbitol.

  • Raffinose - Beans contain large amounts of this complex sugar. Smaller amounts are found in cabbage, brussels sprouts, broccoli, asparagus, other vegetables, and whole grains.
  • Lactose - the natural sugar in milk. It is also found in milk products, such as cheese and ice cream, and processed foods, such as bread, cereal, and salad dressing. Many people, particularly those of African, Native American, or Asian background, have low levels of the enzyme lactase needed to digest lactose. Also, as people age, their enzyme levels decrease. As a result, over time people may experience increasing amounts of gas after eating food containing lactose.
  • Fructose -  naturally present in onions, artichokes, pears, and wheat. It is also used as a sweetener in some soft drinks and fruit drinks.
  • Sorbitol -  Sorbitol is a sugar found naturally in fruits, including apples, pears, peaches, and prunes. It is also used as an artificial sweetener in many dietetic foods and sugarfree candies and gums.

StarchesMost starches, including potatoes, corn, noodles, and wheat, produce gas as they are broken down in the large intestine. Rice is the only starch that does not cause gas.

FiberMany foods contain soluble and insoluble fiber. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Found in oat bran, beans, peas, and most fruits, soluble fiber is not broken down until it reaches the large intestine where digestion causes gas.

Insoluble fiber, on the other hand, passes essentially unchanged through the intestines and produces little gas. Wheat bran and some vegetables contain this kind of fiber.

What Are Some Symptoms and Problems of Gas?The most common symptoms of gas are belching, flatulence, abdominal bloating, and abdominal pain. However, not everyone experiences these symptoms. The determining factors probably are how much gas the body produces, how many fatty acids the body absorbs, and a person's sensitivity to gas in the large intestine. Chronic symptoms caused by too much gas or by a serious disease are rare.

BelchingAn occasional belch during or after meals is normal and releases gas when the stomach is full of food. However, people who belch frequently may be swallowing too much air and releasing it before the air enters the stomach.

Sometimes a person with chronic belching may have an upper GI disorder, such as peptic ulcer disease, gastroesophageal reflux disease (GERD), or gastritis.

Believing that swallowing air and releasing it will relieve the discomfort of these disorders, this person may unintentionally develop a habitual cycle of belching and discomfort. Frequently, the pain continues or worsens, leading the person to believe he or she has a serious disorder.

Two rare chronic gas syndromes are associated with belching: Meganblase syndrome and gas-bloat syndrome. The Meganblase syndrome, which causes chronic belching, is characterized by severe air swallowing and an enlarged bubble of gas in the stomach following heavy meals. The resulting fullness and shortness of breath may mimic a heart attack.

Gas-bloat syndrome may occur after surgery to correct GERD. The surgery creates a one-way valve between the esophagus and stomach that allows food and gas to enter the stomach but often prevents normal belching and the ability to vomit.

FlatulenceAnother common complaint is passage of too much gas through the rectum (flatulence). However, most people do not realize that passing gas 14 to 23 times a day is normal. Although rare, too much gas may be the result of severe carbohydrate malabsorption or overactive bacteria in the colon.

Abdominal bloatingMany people believe that too much gas causes abdominal bloating. However, people who complain of bloating from gas often have normal amounts and distribution of gas. They actually may be unusually aware of gas in the digestive tract.

Doctors believe that bloating is usually the result of an intestinal motility disorder, such as IBS. Motility disorders are characterized by abnormal movements and contractions of intestinal muscles. These disorders may give a false sensation of bloating because of increased sensitivity to gas.

Splenic-flexure syndrome is a chronic disorder that seems to be caused by trapped gas at bends (flexures) in the colon. Symptoms include bloating, muscle spasms, and upper abdominal discomfort. Splenic-flexure syndrome often accompanies IBS.

Any disease that causes intestinal obstruction, such as Crohn's disease or colon cancer, may also cause abdominal bloating. In addition, people who have had many operations, adhesions (scar tissue), or internal hernias may experience bloating or pain. Finally, eating a lot of fatty food can delay stomach emptying and cause bloating and discomfort, but not necessarily too much gas.

Abdominal pain and discomfortSome people have pain when gas is present in the intestine. When gas collects on the left side of the colon, the pain can be confused with heart disease. When it collects on the right side of the colon, the pain may feel like the pain associated with gallstones or appendicitis.

What Diagnostic Tests Are Used? Because gas symptoms may be caused by a serious disorder, those causes should be ruled out. The doctor usually begins with a review of dietary habits and symptoms. The doctor may ask the patient to keep a diary of foods and beverages consumed for a specific time period.

If lactase deficiency is the suspected cause of gas, the doctor may suggest avoiding milk products for a period of time. A blood or breath test may be used to diagnose lactose intolerance.

In addition, to determine if someone produces too much gas in the colon or is unusually sensitive to the passage of normal gas volumes, the doctor may ask patients to count the number of times they pass gas during the day and include this information in a diary.

Careful review of diet and the amount of gas passed may help relate specific foods to symptoms and determine the severity of the problem.

If a patient complains of bloating, the doctor may examine the abdomen for the sound of fluid movement to rule out ascites (build up of fluid in the abdomen) and for signs of inflammation to rule out diseases of the colon.

The possibility of colon cancer is usually considered in people 50 years of age and older and in those with a family history of colorectal cancer, particularly if they have never had a colon examination (sigmoidoscopy or colonoscopy). These tests may also be appropriate for someone with unexplained weight loss, diarrhea, or blood not visible in the stool.

For those with chronic belching, the doctor will look for signs or causes of excessive air swallowing. If needed, an upper GI series (x-ray to view the esophagus, stomach, and upper small intestine) may be performed to rule out disease.

How Is Gas Treated?The most common ways to reduce the discomfort of gas are changing diet, taking medicines, and reducing the amount of air swallowed.

DietDoctors may tell people to eat fewer foods that cause gas. However, for some people this may mean cutting out healthy foods, such as fruits and vegetables, whole grains, and milk products.

Doctors may also suggest limiting high-fat foods to reduce bloating and discomfort. This helps the stomach empty faster, allowing gases to move into the small intestine.

Unfortunately, the amount of gas caused by certain foods varies from person to person. Effective dietary changes depend on learning through trial and error how much of the offending foods one can handle.

Non-prescription medicinesMany non-prescription, over-the-counter medicines are available to help reduce symptoms, including antacids with simethicone and activated charcoal. Digestive enzymes, such as lactase supplements, actually help digest carbohydrates and may allow people to eat foods that normally cause gas.

Antacids, such as Mylanta II, Maalox II and Di-Gel, contain simethicone, a foaming agent that joins gas bubbles in the stomach so that gas is more easily belched away. However, these medicines have no effect on intestinal gas. The recommended dose is 2 to 4 tablespoons of the simethicone preparation taken 1/2 to 2 hours after meals.

Activated charcoal tablets (Charcocaps) may provide relief from gas in the colon. Studies have shown that when taken before and after a meal, intestinal gas is greatly reduced. The usual dose is 2 to 4 tablets taken just before eating and 1 hour after meals.

The enzyme lactase, which aids with lactose digestion, is available in liquid and tablet form without a prescription (Lactaid, Lactrase, and Dairy Ease). Adding a few drops of liquid lactase to milk before drinking it or chewing lactase tablets just before eating helps digest foods that contain lactose. Also, lactose-reduced milk and other products are available at many grocery stores (Lactaid and Dairy Ease).

Beano, a newer over-the-counter digestive aid, contains the sugar-digesting enzyme that the body lacks to digest the sugar in beans and many vegetables. The enzyme comes in liquid form. Three to 10 drops are added per serving just before eating to break down the gas-producing sugars. Beano has no effect on gas caused by lactose or fiber.

Prescription medicinesDoctors may prescribe medicines to help reduce symptoms, especially for people with a motility disorder, such as IBS. Promotility or prokinetic drugs, such as metoclopramide (Reglan), may move gas through the digestive tract quickly.

For those who have chronic belching, doctors may suggest ways to reduce the amount of air swallowed. Recommendations are to avoid chewing gum and to avoid eating hard candy. Eating at a slow pace and checking with a dentist to make sure dentures fit properly should also help.

ConclusionAlthough gas may be uncomfortable and embarrassing, it is not life-threatening. Understanding causes, ways to reduce symptoms, and treatment will help most people find some relief. Points to Remember

1. Everyone has gas in the digestive tract.

2. People often believe normal passage of gas to be excessive.

3. Gas comes from two main sources: swallowed air and normal breakdown of certain foods by harmless bacteria naturally present in the large intestine.

4. Many foods with carbohydrates can cause gas. Fats and proteins cause little gas.

5. Foods that may cause gas include:

    Beans    Vegetables, such as broccoli, cabbage, Brussels sprouts, onions, artichokes, and asparagus    Fruits, such as pears, apples, and peaches    Whole grains, such as whole wheat and bran    Soft drinks and fruit drinks    Milk and milk products, such as cheese and ice cream, and packaged foods prepared with lactose, such as bread, cereal, and salad dressing    Foods containing sorbitol, such as dietetic foods and sugarfree candies and gums.

6. The most common symptoms of gas are belching, flatulence, bloating, and abdominal pain. However, some of these symptoms are often caused by an intestinal motility disorder, such as irritable bowel syndrome, rather than too much gas.

7. The most common ways to reduce the discomfort of gas are changing diet, taking non-prescription or prescription medicines, and reducing the amount of air swallowed.

8. Digestive enzymes, such as lactase supplements, actually help digest carbohydrates and may allow people to eat foods that normally cause gas.

 

Why Do I Have Gas?Everyone has gas. Burping or passing gas through the rectum is normal. Because it is embarrassing to burp or pass gas, many people believe they pass gas too often or have too much gas. They do not realize that passing gas 14 to 23 times a day is normal. An occasional burp during or after meals is normal, too. It is rare for a person to have too much gas.

Most of the time gas is odorless. The odor comes from sulfur made by bacteria in the large intestine. Sometimes gas causes bloating and pain. Not everyone has these symptoms. It probably depends on how much gas the body makes and how sensitive a person is to gas in the large intestine.

What Can I Do About Gas?Changing what you eat and drink can help prevent or relieve gas. If you feel like you have too much gas, you might want to try these things before going to the doctor.

1. Cut down on foods that cause gas. The amount of gas caused by certain foods varies from person to person. The only way to know your own limits is through trial and error.

2. These are some foods that cause gas:

    Beans.    Vegetables such as broccoli, cabbage, brussels sprouts, onions, artichokes, and asparagus.    Fruits such as pears, apples, and peaches.    Whole grains such as whole wheat and bran.    Soft drinks and fruit drinks.    Milk and milk products, such as cheese and ice cream.    Packaged foods that have lactose in them, such as bread, cereal, and salad dressing.    Dietetic foods and sugarfree candies and gums.

3. Reduce the amount of air you swallow.

Here are some ways to avoid swallowing air:

  • Eat slower and chew more. This will cut down on the amount of air you swallow when you eat.
  • Avoid chewing gum and eating hard candy.
  • If you smoke, try to cut down or quit.
  • If you have false teeth, see your dentist to make sure they fit right.
  • Keep a diary. Write down the foods (and the amounts) that seem to cause you the most problems. Also keep track of the number of times you pass gas. You may be surprised to find that it is within the 14 to 23 times a day that is considered normal. If you are troubled by gas, you may want to see your doctor. Take your diary with you to help you answer the doctor's questions about eating habits and symptoms.

4. Drink plenty of water, non-"fizzy" liquids, and clear soup. Try not to drink liquids that cause gas, like soda and beer. If you do drink these liquids, pour them into a glass first to let some of the "fizz" out.

Remember

  • Everyone has gas in the digestive tract.
  • People often think they pass too much gas when they don't.
  • Passing gas 14 to 23 times a day is normal.
  • Two ways to reduce the amount of gas you have are the following:
  • Cut down on the foods that cause gas.
  • Reduce the amount of air you swallow.

Gastroesophageal reflux disease (GERD) is a digestive disorder that affects the lower esophageal sphincter (LES) -- the muscle connecting the esophagus with the stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called hiatal hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery. This fact sheet provides information on GERD-its causes, symptoms, treatment, and long-term complications.

What Is Gastro- esophageal Reflux? Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus.

In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately allowing the stomach's contents to flow up into the esophagus.

Gastroesophageal Reflux Disease

Figure 1 shows the location of the LES between the esophagus and the stomach.

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.

What Is the Role of Hiatal Hernia?Some doctors believe a hiatal hernia may weaken the LES and cause reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the stomach from the chest. Recent studies show that the opening in the diaphragm acts as an additional sphincter around the lower end of the esophagus. Studies also show that hiatal hernia results in retention of acid and other contents above this opening. These substances can reflux easily into the esophagus.

Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, i.e., paraesophageal hernia) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

What Other Factors Contribute to GERD?Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholic beverages, may weaken the LES causing reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also cause GERD.

What Does Heartburn Feel Like? Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.

The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.

Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.

How Common Is Heartburn?More than 60 million American adults experience GERD and heartburn at least once a month, and about 25 million adults suffer daily from heartburn. Twenty-five percent of pregnant women experience daily heartburn, and more than 50 percent have occasional distress. Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing and other respiratory problems, or failure to thrive.

What Is the Treatment for GERD?Doctors recommend lifestyle and dietary changes for most people with GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.

Avoiding foods and beverages that can weaken the LES is recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided.

Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.

Cigarette smoking weakens the LES. Therefore, stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus.

Antacids taken regularly can neutralize acid in the esophagus and stomach and stop heartburn. Many people find that non-prescription antacids provide temporary or partial relief. An antacid combined with a foaming agent such as alginic acid helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occurring.

Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 3 weeks, a doctor should be consulted.

For chronic reflux and heartburn, the doctor may prescribe medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. Currently, four H2 blockers are available: cimetidine, famotidine, nizatidine, and ranitidine. Another type of drug, the proton pump (or acid pump) inhibitor omeprazole inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. The acid pump inhibitor lansoprazole is currently under investigation as a new treatment for GERD.

Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs include bethanechol and metoclopramide.

Tips To Control Heartburn

  • Avoid foods and beverages that affect LES pressure or irritate the esophagus lining, including fried and fatty foods, peppermint, chocolate, alcohol, coffee, citrus fruit and juices, and tomato products.
  • Lose weight if overweight
  • Stop smoking
  • Elevate the head of the bed 6 inches
  • Avoid lying down 2 to 3 hours after eating
  • Take an antacid

What If Symptoms Persist?People with severe, chronic esophageal reflux or with symptoms not relieved by the treatment described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn.

An upper GI series may be performed during the early phase of testing. This test is a special x-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to rule out other diagnoses, such as peptic ulcers.

Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful.

The Bernstein test (dripping a mild acid through a tube placed in the mid-esophagus) is often performed as part of a complete evaluation. This test attempts to confirm that the symptoms result from acid in the esophagus. Esophageal manometric studies -- pressure measurements of the esophagus -- occasionally help identify critically low pressure in the LES or abnormalities in esophageal muscle contraction.

For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.

Does GERD Require Surgery?A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. Fundoplication is a surgical procedure that increases pressure in the lower esophagus. However, surgery should not be considered until all other measures have been tried.

What Are the Complications of Long-term GERD?Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett's esophagus, which is severe damage to the skin-like lining of the esophagus. Doctors believe this condition may be a precursor to esophageal cancer.

ConclusionAlthough GERD can limit daily activities and productivity, it is rarely life-threatening. With an understanding of the causes and proper treatment most people will find relief.

What Is Gastroparesis?Gastroparesis is a disorder in which the stomach takes too long to empty its contents. Gastroparesis is most often a complication of type 1 diabetes. At least 20 percent of people with type 1 diabetes develop gastroparesis. It also occurs in people with type 2 diabetes, although less often.

Gastroparesis happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.

Diabetes can damage the vagus nerve if blood glucose (sugar) levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

SymptomsSymptoms of gastroparesis are

  • Nausea
  • Vomiting
  • An early feeling of fullness when eating
  • Weight loss
  • Abdominal bloating
  • Abdominal discomfort

These symptoms may be mild or severe, depending on the person.

Complications of GastroparesisIf food lingers too long in the stomach, it can cause problems like bacterial overgrowth from the fermentation of food. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.

Gastroparesis can make diabetes worse by adding to the difficulty of controlling blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Since gastroparesis makes stomach emptying unpredictable, a person's blood glucose levels can be erratic and difficult to control.

Major Causes of Gastroparesis

  • Diabetes
  • Postviral syndromes
  • Anorexia nervosa
  • Surgery on the stomach or vagus nerve
  • Medications, particularly anticholinergics and narcotics (drugs that slow contractions in the intestine)
  • Gastroesophageal reflux disease (rarely)
  • Smooth muscle disorders such as amyloidosis and scleroderma
  • Nervous system diseases, including abdominal migraine and Parkinson's disease
  • Metabolic disorders, including hypothyroidism

DiagnosisThe diagnosis of gastroparesis is confirmed through one or more of the following tests:

  • Radioisotope gastric-emptying scan: You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours.
  • Barium x-ray: After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x-ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the x-ray shows food in the stomach, gastroparesis is likely. If the x-ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.
  • Gastric manometry: This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.
  • Blood tests: The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.
  • Upper endoscopy: After giving you a sedative, the doctor passes a long, thin, tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.
  • Ultrasound. To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

TreatmentThe primary treatment goal for gastroparesis related to diabetes is to regain control of blood glucose levels. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

It is important to note that in most cases treatment does not cure gastroparesis -- it is usually a chronic condition. Treatment helps you manage the condition so that you can be as healthy and comfortable as possible.

If you have gastroparesis as a result of diabetes, your food is being absorbed more slowly and at unpredictable times. To control blood glucose, you may need to

    Take insulin more often.    Take your insulin after you eat instead of before.    Check your blood glucose levels frequently after you eat, administering insulin whenever necessary.

Some doctors recommend taking two injections of intermediate insulin every day and as many injections of a fast-acting insulin as needed according to blood glucose monitoring. The newest insulin, lispro insulin (Humalog), is a quick-acting insulin that might be advantageous for people with gastroparesis. It starts working within 5 to 15 minutes after injection and peaks after 1 to 2 hours, lowering blood glucose levels after a meal about twice as fast as the slower-acting regular insulin. Your doctor will give you specific instructions based on your particular needs.

MedicationSeveral drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

  • Metoclopramide (Reglan). This drug stimulates stomach muscle contractions to help empty food. It also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug are fatigue, sleepiness, and sometimes depression, anxiety, and problems with physical movement.
  • Erythromycin. This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects are nausea, vomiting, and abdominal cramps.
  • Domperidone. The Food and Drug Administration is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis. It is a promotility agent like cisapride and metoclopramide. Domperidone also helps with nausea.
  • Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. Antibiotics will clear up a bacterial infection. If you have a bezoar, the doctor may use an endoscope to inject medication that will dissolve it. Also, medication may be prescribed to lower the production of stomach acid.

Meal and food changesChanging your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis is corrected. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

The doctor may also recommend that you avoid fatty and high-fiber foods. Fat naturally slows digestion -- a problem you do not need if you have gastroparesis -- and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding tubeIf other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem -- the stomach --and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

Parenteral nutritionParenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use. This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult spell of gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.

Points to Remember

  • Gastroparesis is a common complication of type 1 diabetes.
  • Gastroparesis is the result of damage to the vagus nerve, which controls the movement of food through the digestive system. Instead of the food moving through the digestive tract normally, it is retained in the stomach.
  • The vagus nerve becomes damaged after years of poor blood glucose control, resulting in gastroparesis. In turn, gastroparesis contributes to poor blood glucose control.
  • Symptoms of gastroparesis include early fullness, nausea, vomiting, and weight loss.
  • Gastroparesis is diagnosed through tests such as x-rays, manometry, and scanning.
  • Treatments include changes in when and what you eat, changes in insulin type and timing of injections, oral medications, a jejunostomy, or parenteral nutrition.

What Is a Peptic Ulcer?A peptic ulcer is a sore on the lining of the stomach or duodenum, which is the beginning of the small intestine. Peptic ulcers are common: one in every 10 Americans develops an ulcer at some time in his or her life. The main cause of peptic ulcer is bacterial infection, but some ulcers are caused by use of non-steroidal anti-inflammatory agents (NSAIDs), like aspirin and ibuprofen. In a few cases, cancerous tumors in the stomach or pancreas can cause ulcers. Peptic ulcers are not caused by spicy food or stress, although alcohol & tobacco use increase risk of Peptic Ulcer.

What Is H. pylori?Helicobacter pylori (H. pylori) is a type of bacteria. Researchers recently discovered that H. pylori causes almost all peptic ulcers, accounting for 80 percent of stomach ulcers and more than 90 percent of duodenal ulcers.

H. pylori infection is common in the United States: about 20 percent of people under 40 and half of people over 60 are infected with it. Most infected people, however, do not develop ulcers. Why H. pylori doesn't cause ulcers in every infected person is unknown. Most likely, infection depends on characteristics of the infected person, the type of H. pylori, and other factors yet to be discovered.

Researchers are not certain how people become infected with H. pylori, but they think it may be through food, water or person to person contact.

Researchers have found H. pylori in some infected people's saliva, so the bacteria may also spread through mouth-to-mouth contact such as kissing.

How Does H. pylori Cause a Peptic Ulcer?H. pylori weakens the protective mucous coating of the stomach and duodenum, which allows acid to get through to the sensitive lining beneath. Both the acid and the bacteria irritate the lining and cause a sore, or ulcer.

H. pylori is able to survive in stomach acid because it secretes enzymes that neutralize the acid. This mechanism allows H. pylori to make its way to the "safe" area -- the protective mucous lining. Once there, the bacterium's spiral shape helps it burrow through the mucous lining.

What Are the Symptoms of an Ulcer?Pain is the most common symptom. The pain usually

  • Is a dull, gnawing ache.
  • Comes and goes for several days or weeks.
  • Occurs 2 to 3 hours after a meal.
  • Occurs in the middle of the night (when the stomach is empty).
  • Is relieved by food.

Other symptoms include:

  • Weight loss.
  • Poor appetite.
  • Bloating.
  • Burping.
  • Nausea.
  • Vomiting.

Some people experience only very mild symptoms, or none at all.

Emergency SymptomsIf you have any of these symptoms, call your doctor right away:

    Sharp, sudden, persistent stomach pain.    Bloody or black stools.    Bloody vomit or vomit that looks like coffee grounds.

They could be signs of a serious problem, such as

    Perforation -- when the ulcer burrows through the stomach or duodenal wall.    Bleeding -- when acid or the ulcer breaks a blood vessel.    Obstruction -- when the ulcer blocks the path of food trying to leave the stomach.

How Is an H. pylori-related Ulcer Diagnosed?Diagnosing an UlcerTo see if symptoms are caused by an ulcer, the doctor may do an upper gastrointestinal (GI) series or an endoscopy. An upper GI series is an x-ray of the esophagus, stomach, and duodenum. The patient drinks a chalky liquid called barium to make these organs and any ulcers show up more clearly on the x-ray.

An endoscopy is an exam with an endoscope, a thin, lighted tube with a tiny camera on the end. The patient is sedated, and the doctor carefully eases the endoscope through the patient's mouth and down the throat to the stomach and duodenum. This allows the doctor to see the lining of the esophagus, stomach, and duodenum. The doctor can use the endoscope to take photos of ulcers or remove a tiny piece of tissue to view under a microscope.

Diagnosing H. pyloriIf an ulcer is found, the doctor will test the patient for H. pylori. This test is important because treatment for an ulcer caused by H. pylori is different from that for an ulcer caused by NSAIDs (aspirin or ibuprofen).

H. pylori is diagnosed through blood, breath, and tissue tests. Blood tests are most common. They detect antibodies to H. pylori bacteria.

Breath tests are mainly used after treatment to see if treatment worked, but they can be used in diagnosis, too. The test is called a urea breath test.

In the doctor's office, the patient drinks a solution of urea that contains a special carbon atom. If H. pylori is present, it breaks down the urea, releasing the carbon. The blood carries the carbon to the lungs, where the patient exhales it. The breath test is 96 percent to 98 percent accurate.

Tissue tests are usually done using tissue removed with the endoscope. There are three types:

  1. The rapid urease test detects the enzyme urease, which is produced by H. pylori.
  2. A histology test allows the doctor to find and examine the actual bacteria.
  3. A culture test involves allowing H. pylori to grow in the tissue sample.

    How Are H. pylori Peptic Ulcers Treated?Antibiotics that are used to kill the H. pylori bacteria and which are proven to be effective include metronidazole, tretracyclene, clarithromycin, and amoxicillan. The antibiotics are given in combination with medications to block stomach acid that include cimetidine, ranitidine, famotidine, and nizatidine, omeprazole, and lansoprazole.

The H2-blockers cimetidine, ranitidine, famotidine, and nizatidine work by blocking histamine, which stimulates acid secretion. These help reduce ulcer pain after a few weeks. The proton pump inhibitors omeprazole, lansoprazole suppress acid production by halting the mechanism that pumps the acid into the stomach. H2-blockers and proton pump inhibitors have been prescribed alone for years as treatments for ulcers. But used alone, these drugs do not eradicate H. pylori, and therefore do not cure H. pylori-related ulcers. Bismuth subsalicylate, a component of Pepto-Bismol, is used to protect the stomach lining from acid. It also kills H. pylori. Treatment usually involves a combination of antibiotics, acid suppressors, and stomach protectors.

At this time, the most proven effective treatment is a 2-week course of treatment called triple therapy. It involves taking two antibiotics to kill the bacteria and either an acid suppressor or stomach lining shield. Two-week triple therapy reduces ulcer symptoms, kills the bacteria, and prevents ulcer recurrence in more than 90 percent of patients.

Unfortunately, patients may find triple therapy complicated because it involves taking as many as 20 pills a day. Also, the antibiotics used in triple therapy may cause mild side effects such as nausea, vomiting, diarrhea, dark stools, metallic taste in the mouth, dizziness, headache, and yeast infections in women. (Most side effects can be treated with medication withdrawal.) Nevertheless, recent studies show that 2 weeks of triple therapy is ideal.

Early results of studies in other countries suggest that 1 week of triple therapy may be as effective as the 2-week therapy, with fewer side effects.

Another option is 2 weeks of dual therapy. Dual therapy involves two drugs: one antibiotic and one acid suppressor. It is not as effective as triple therapy.

Two weeks of quadruple therapy, which uses two antibiotics, an acid suppressor, and a stomach lining shield, looks promising in research studies. It is also called bismuth triple therapy.

After TreatmentTo be sure that treatment has killed all H. pylori, the doctor may do a follow-up endoscopy or breath test 6 to 12 months after treatment to check for the bacterium. This is not commonly done as the antibiotic therapy is so effective.

Can H. pylori Infection Be Prevented?No one knows for sure how H. pylori spreads, so prevention is difficult. Researchers are trying to develop a vaccine to prevent infection.

Why Don't All Doctors Automatically Check for H. pylori?Changing medical belief and practice takes time. For nearly 100 years, scientists and doctors thought that ulcers were caused by stress, spicy food, and alcohol. Treatment involved bed rest and a bland diet. Later, researchers added stomach acid to the list of causes and began treating ulcers with antacids.

Since H. pylori was discovered in 1982, studies conducted around the world have shown that using antibiotics to destroy H. pylori cured peptic ulcers. The National Institutes of Health released a consensus statement in 1994 confirming that H. pylori causes peptic ulcers. Despite the evidence, however, the medical community continues to debate H. pylori's role in peptic ulcers. If you have a peptic ulcer and have not been tested for H. pylori infection, talk to your doctor.

Points To Remember

  • A peptic ulcer is a sore in the lining of the stomach or duodenum.
  • Most peptic ulcers are caused by the H. pylori bacterium. None are caused by spicy food or stress.
  • H. pylori may be transmitted from person to person through contaminated food and water.
  • Always wash your hands after using the bathroom and before eating.
  • Antibiotics are the most effective treatment for H. pylori peptic ulcers.

What Is Hemochromatosis?Hemochromatosis is a disorder in which the body absorbs too much iron from food. Normally, any iron that the body doesn't need is excreted. But in hemochromatosis, the excess iron is stored throughout the body, including in the pancreas, liver, and skin. The iron deposits damage these organs and tissues.

Is Hemochromatosis Hereditary?Hemochromatosis is a hereditary disease and is sometimes called hereditary hemochromatosis, or HHC. Symptoms include fatigue, abdominal pain, jaundice (yellowing of skin and eyes), and a change in skin color to bronze or gray. Over time, hemochromatosis can cause liver disease, liver failure, liver cancer, heart disease, and diabetes.

How Is Hemochromatosis Diagnosed?Hemochromatosis is diagnosed through blood tests that measure iron levels. Sometimes a liver biopsy is done to check for the amount of iron in the liver and for liver damage.

Is Hemochromatosis Treatable?Hemochromatosis is a treatable condition, but if untreated, it could lead to early death. Hemochromatosis is treated by drawing blood to remove excess iron from the body and keep it from building up in organs. For the first 18 months, blood is drawn once or twice a week. After that, blood is drawn once every 2 to 6 months for the rest of the person's life.

What Are Hemorrhoids?Hemorrhoids are swollen but normally present blood vessels in and around the anus and lower rectum that stretch or dilate under pressure, similar to varicose veins in the legs.

The increased pressure and swelling may result from straining to move the bowel. Other contributing factors include pregnancy, heredity, aging, and chronic constipation, diarrhea or heavy physical activity.

Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external)

What Are the Symptoms of Hemorrhoids?Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as hemorrhoids.

Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days.

Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid.

Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms in the hemorrhoid. This condition is known as a thrombosed external hemorrhoid.

In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.

How Common Are Hemorrhoids?Hemorrhoids are very common in men and women. About half of the population have hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.

How Are Hemorrhoids Diagnosed?A thorough evaluation and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.

The doctor will examine the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.

Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.

To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.

What Is the Treatment?Medical treatment of hemorrhoids initially is aimed at relieving symptoms. Measures to reduce symptoms include:

  • Warm tub or sitz baths several times a day in plain, warm water for about 10 minutes.
  • Ice packs to help reduce swelling.
  • Application of a hemorroidal cream or suppository to the affected area for a limited time.

Prevention of the recurrence of hemorrhoids is aimed at changing conditions associated with the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of fluid (not alcohol) result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.

Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel). In some cases, hemorrhoids must be treated surgically. These methods are used to shrink and destroy the hemorrhoidal tissue and are performed under anesthesia. The doctor will perform the surgery during an office or hospital visit.

A number of surgical methods may be used to remove or reduce the size of internal hemorrhoids. These techniques include:

  • Rubber band ligation-A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.
  • Sclerotherapy-A chemical solution is injected around the blood vessel to shrink the hemorrhoid.
  • Techniques used to treat both internal and external hemorrhoids include:
  • Electrical or laser heat or infrared light -Both techniques use special devices to burn hemorrhoidal tissue.
  • Hemorrhoidectomy-Occasionally, extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy. This is the best method for permanent removal of hemorrhoids.

How Are Hemorrhoids Prevented?The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass.

What Is Hepatitis A?Hepatitis A is a liver disease. Hepatitis (HEP-ah-TY-tis) is inflammation of the liver. It makes your liver swell and stops it from working right.

You need a healthy liver. The liver does many things to keep you alive. The liver fights infections and stops bleeding. It removes drugs and other poisons from your blood. The liver also stores energy for when you need it.

What Causes Hepatitis A?Hepatitis A is caused by a virus. A virus is a germ that causes sickness. (For example, the flu is caused by a virus.) People can pass viruses to each other. The virus that causes hepatitis A is called the hepatitis A virus.

How Could I Get Hepatitis A?Hepatitis A spreads by touching stool from a bowel movement. You could get hepatitis A by

  • Touching an infected person's stool (for example, when changing an infected baby's diaper), and then eating or drinking with your hands.
  • Eating food made by someone who touched infected stool.
  • Drinking water made dirty by infected stool (this is a problem in developing countries).
  • Having anal sex with an infected person. You might be able to get hepatitis A by kissing an infected person. Wash your hands after touching stool and before fixing or eating food.

Who Can Get Hepatitis A?Anyone can get hepatitis. Children in day care could get hepatitis A. But some people are more likely to than others:

  • People who live with someone who has hepatitis A.
  • Children who go to daycare.
  • People who work in a daycare center.
  • Men who have sex with men.
  • People who travel to other countries.

What Are the Symptoms?Hepatitis A can make you feel like you have the flu. You might

  • Feel tired.
  • Feel sick to your stomach.
  • Have a fever.
  • Not want to eat.
  • Have stomach pain.
  • Have diarrhea.

Some people have

  • Dark yellow urine.
  • Light-colored stools.
  • Yellowish eyes and skin.

Some people don't have any symptoms. If you have symptoms, or think you might have hepatitis A, go to a doctor. The doctor will test your blood.

How Is Hepatitis A Treated?Most people who have hepatitis get well on their own after a few weeks. Bed rest and medicine will help you.

You may need to rest in bed for several days or weeks, and you won't be able to drink alcohol until you are well. The doctor may give you medicine for your symptoms.

How Can I Protect Myself?You can get the hepatitis A vaccine. Vaccines protect you from getting hepatitis A. A vaccine is a drug that you take when you are healthy that keeps you from getting sick. Vaccines teach your body to attack certain viruses, like the hepatitis A virus.

The hepatitis A vaccine is given through a shot. Children can get the vaccine after they turn 2 years old. Children aged 2 to 18 will need three shots. The shots are spread out over a year. Adults get two shots over 6 to 12 months. You need all of the shots to be protected. If you miss a shot, call your doctor or clinic right away to set up a new appointment.

You can protect yourself and others from hepatitis A in these ways, too:

  • Always wash your hands after using the toilet and before fixing food or eating.
  • Wear gloves if you have to touch other people's stool. Wash your hands afterwards.
  • Drink bottled water when you are in another country. (And don't use ice cubes or wash fruits and vegetables in tap water.)

What Is Hepatitis B?Hepatitis B is a liver disease. Hepatitis (HEP-ah-TY-tis) is inflammation of the liver. It makes your liver swell and stops it from working right. You need a healthy liver. The liver does many things to keep you alive. The liver fights infections and stops bleeding. It removes drugs and other poisons from your blood. The liver also stores energy for when you need it.

What Causes Hepatitis B?Hepatitis B is caused by a virus. A virus is a germ that causes sickness. (For example, the flu is caused by a virus.) People can pass viruses to each other. The virus that causes hepatitis B is called the hepatitis B virus.

How Could I Get Hepatitis B?Hepatitis B spreads by contact with an infected person's blood, semen, or other body fluid.

You could get hepatitis B by

  •     Having sex with an infected person without using a condom.
  •     Sharing drug needles.
  •     Getting a tattoo or body piercing with dirty tools that were used on someone else.
  •     Getting pricked with a needle that has infected blood on it (health care workers can get hepatitis B this way).
  •     Sharing a toothbrush or razor with an infected person.
  •     An infected woman can give hepatitis B to her baby at birth or through her breast milk.

You can NOT get hepatitis B by

  •     Shaking hands with an infected person.
  •     Hugging an infected person.
  •     Sitting next to an infected person.

What Are the Symptoms?Hepatitis B can make you feel like you have the flu. You might

  •     Feel tired.
  •     Feel sick to your stomach.
  •     Have a fever.
  •     Not want to eat.
  •     Have stomach pain.
  •     Have diarrhea.

Some people have

  •     Dark yellow urine.
  •     Light-colored stools.
  •     Yellowish eyes and skin.

Some people don't have any symptoms. If you have symptoms, or think you might have hepatitis B, go to a doctor.

What Are the Tests for Hepatitis B?To check for hepatitis B, the doctor will test your blood. These tests show if you have hepatitis B and how serious it is. The doctor may also do a liver biopsy. Biopsy (BYE-op-see) is a simple test. The doctor removes a tiny piece of your liver through a needle. The doctor checks the piece of liver for signs of hepatitis B and liver damage.

How Is Hepatitis B Treated?Treatment for hepatitis B may involve shots. Hepatitis B is treated through medicine.

A drug called interferon (in-ter-FEAR-on). It is given through shots. Most people are treated for 4-6 months.

A drug called Lamivadine. It is taken in pill form. Most people are treated for 4-6 months.

Surgery. Over time, hepatitis B may cause your liver to stop working. If that happens, you will need a new liver. The surgery is called a liver transplant. It involves taking out the old, damaged liver and putting in a new, healthy one from a donor.

How Can I Protect Myself?You can get the hepatitis B vaccine. A vaccine is a drug that you take when you are healthy that keeps you from getting sick. Vaccines protect you from getting hepatitis B. Vaccines teach your body to attack certain viruses, like the hepatitis B virus. The hepatitis B vaccine is given through three shots. All babies should get the vaccine. Infants get the first shot within 12 hours after birth. They get the second shot at age 1 to 2 months and the third shot between ages 6 to 18 months.

Older children and adults can get the vaccine, too. They get three shots over 6 months. Children who have not had the vaccine should get it. You need all of the shots to be protected. If you miss a shot, call your doctor or clinic right away to set up a new appointment. You can also protect yourself and others from hepatitis B if you

  •     Use a condom when you have sex.
  •     People who touch blood at work should wear gloves to protect themselves from hepatitis B. [Health care provider]
  •     Don't share drug needles.
  •     Wear gloves if you have to touch anyone's blood.
  •     Don't use an infected person's toothbrush, razor, or anything else that could have blood on it.
  •     Also, if you get a tattoo or body piercing, make sure it is done with clean tools.

Hepatitis A Vaccination

Routine vaccination

  • Children living in areas with high prevalence of hepatitis A and periodic outbreaks.

High-risk populations

  • Travelers to developing countries, including Hepatitis A. (Mexico)
  • Men who have sex with men
  • Users of illegal drugs
  • People who work with hepatitis A virus in research settings
  • People who work with infected non-human primates
  • Recipients of clotting factor concentrates
  • People with chronic liver disease (because of risk of fulminant hepatitis A)

HAVRIX*

Age # of Doses Schedule Dose
Children age 2 to 18 yrs. 2 0 and 6 to 12 months 720 ELISA units (0.5 ml)
Adults 3 0, 1, and 6 to 12 months 360 EL.U. (0.5 ml)
2 0 and 6 to 12 months 1440 EL.U. (1.0 ml)

VAQTA*

Age # of Doses Schedule Dose
Children age 2 to 17 yrs. 2 0 and 6 to 18 months 25 units (0.5 ml)
Adults > 17YRS 2 0 and 6 to months 50 U. (1.0 ml)

*Inactivated vaccine. Manufactured by Merck and Company, Inc.

Postexposure prophylaxis Immune globulin is more than 85 percent effective in preventing hepatitis A when given within 2 weeks of exposure to the hepatitis A virus. The dose is 0.02 ml/kg injected into the deltoid or gluteal muscle in adults or the anterolateral thigh muscle in children under 2 years. Concurrent vaccination may also be appropriate in people 2 years and older.

Hepatitis B Vaccination

Routine vaccination

  • All infants, children, and adolescents.
  • Unvaccinated children under 11 years who are Pacific Islanders or who live with first-generation immigrants from high or intermediate HBV rate countries.

High-risk populations

  • People with multiple sex partners and those who have been recently diagnosed with a sexually transmitted diseases
  • Sex partners and household contacts of HBV carriers
  • Men who have sex with men
  • Adoptees from countries with endemic hepatitis B
  • Injection drug users
  • Travelers to countries with high HBV rates (staying longer than 6 months)
  • People with occupational exposure to blood or body fluids
  • Clients and staff in institutions for the developmentally disabled
  • Patients with chronic renal failure
  • Patients receiving clotting factor concentrates
  • Inmates of long-term corrections facilities

 

Age # of Doses Schedule Dose
Infants HBsAg-negative mother 3 0 to 2, 1 to 4 and 6 to 18 months 2.5 micrograms 10ug (0.5 ml)
HBsAg-positive mother 3 HBIG and vaccination within 12 hours of birth, then vaccine at 1 to 2 and 6 months 5.0 ug (0.5 ml) 10ug (0.5 ml)
Children (1 to 10 yrs) 3 0, 1, to 2, and 4 to 6 months 2.5ug (0.5 ml) 10ug (0.5 ml)
Adolescents (11 to 19 yrs) 3 0, 1, to 2, and 4 to 6 months 2.5ug (0.5 ml) 10ug 90.5 ml)
Adults (20 yrs •) 3 0, 1, to 2, and 4 to 6 months 10ug (1.0 ml) 20ug (1.0 ml)
Immunocompromised adults

3

4

0, 1, and 6 months

0, 1, 2, and 6 months

40ug (1.0 ml)

40ug (2.0 ml)

40ug (2.0 ml)

Postexposure prophylaxis Prophylactic treatment for exposure to hepatitis B virus involves either hepatitis B immune globulin (HBIG), hepatitis B vaccine, or a combination of both. The HBIG dose equals 0.06 ml/kg. Efficacy ranges from 70 to 95 percent for different types of exposure.

Exposure Treatment
Perinatal 1 dose of HBIG given with the first hepatitis B vaccine dose.
Percutaneous or permucosal HBIG and vaccination.
Sexual HBIG with or without vaccination for exposure to acute hepatitis B; vaccination alone for chronic exposure.
Household contact HBIG with or without vaccination for acute hepatitis B (infants under age 12 months receive both); vaccination alone for chronic.

What Is Hepatitis C?Hepatitis C is a liver disease. Hepatitis (HEP-ah-TY-tis) is inflammation of the liver. It makes your liver swell and stops it from working right. You need a healthy liver. The liver does many things to keep you alive. The liver fights infections and stops bleeding. It removes drugs and other poisons from your blood. The liver also stores energy for when you need it.

What Causes Hepatitis C?Hepatitis C is caused by a virus. A virus is a germ that causes sickness. (For example, the flu is caused by a virus.) People can pass viruses to each other. The virus that causes hepatitis C is called the hepatitis C virus.

How Could I Get Hepatitis C?Hepatitis C spreads by contact with an infected person's blood. You could get hepatitis C by:

  •     Sharing drug needles.
  •     Getting pricked with a needle that has infected blood on it (hospital workers can get hepatitis C this way).
  •     Being born to a mother with hepatitis C.

In rare cases, you could get hepatitis C by:

  •     Getting a tattoo or body piercing with unsterilized, dirty tools.
  •     Having sex with an infected person, especially if you or your partner has other sexually transmitted diseases.

You can NOT get hepatitis C by:

  •     Shaking hands with an infected person.
  •     Hugging an infected person.
  •     Kissing an infected person.
  •     Sitting next to an infected person.   

Could I Get Hepatitis C from a Blood Transfusion?Before 1992, doctors could not check blood for hepatitis C, and some people received infected blood. If you had a blood transfusion or organ transplant before 1992, ask a doctor to test you for hepatitis C.

What Are the Symptoms?Many people with hepatitis C don't have symptoms. However, some people with hepatitis C feel like they have the flu. So, you might:

  •     Feel tired.
  •     Feel sick to your stomach.
  •     Have a fever.
  •     Not want to eat.
  •     Have stomach pain.
  •     Have diarrhea.

Some people have:

  •     Dark yellow urine.
  •     Light-colored stools.
  •     Yellowish eyes and skin.

If you have symptoms, or think you might have hepatitis C, go to a doctor.

What Are the Tests for Hepatitis C?Your doctor will take some blood to check for hepatitis C. These tests show if you have hepatitis C and how serious it is. The doctor may also do a liver biopsy. Biopsy (BYE-op-see) is a simple test. The doctor removes a tiny piece of your liver through a needle. The doctor checks the piece of liver for signs of hepatitis C and liver damage.

How Is Hepatitis C Treated?Hepatitis C is treated with shots of a drug called interferon alone or in combination with the drug ribavirin. You may need surgery if you have hepatitis C for many years. Over time, hepatitis C can cause your liver to stop working. If that happens, you will need a new liver. The surgery is called a liver transplant. It involves taking out the old, damaged liver and putting in a new, healthy one from a donor.

How Can I Protect Myself?You can protect yourself and others from hepatitis C:

  •     Don't share drug needles with anyone. If you inject drugs, use your own needles.
  •     Wear gloves if you have to touch anyone's blood.
  •     Don't use an infected person's toothbrush, razor, or anything else that could have blood on it.
  •     If you get a tattoo or body piercing, make sure it is done with clean tools.
  •     If you have several sex partners, you should use a condom during sex.
  •     If you have hepatitis C, don't give your blood or plasma. The person who receives it could become infected with the virus.

The hepatitis C virus (HCV) is one of the most important causes of chronic liver disease in the United States. It accounts for about 20 percent of acute viral hepatitis, 60 to 70 percent of chronic hepatitis, and 30 percent of cirrhosis, end-stage liver disease, and liver cancer. Almost 4 million Americans, or 1.8 percent of the U.S. population, have antibody to HCV (anti-HCV), indicating ongoing or previous infection with the virus. Hepatitis C causes an estimated 8,000 to 10,000 deaths annually in the United States. A distinct and major characteristic of hepatitis C is its tendency to cause chronic liver disease. At least 75 percent of patients with acute hepatitis C ultimately develop chronic infection, and most of these patients have accompanying chronic liver disease.

Chronic hepatitis C varies greatly in its course and outcome. At one end of the spectrum are patients who have no signs or symptoms of liver disease and completely normal levels of serum liver enzymes. Liver biopsy usually shows some degree of chronic hepatitis, but the degree of injury is usually mild, and the overall prognosis may be good. At the other end of the spectrum are patients with severe hepatitis C who have symptoms, HCV RNA in serum, and elevated serum liver enzymes, and who ultimately develop cirrhosis and end-stage liver disease. In the middle of the spectrum are many patients who have few or no symptoms, mild to moderate elevations in liver enzymes, and an uncertain prognosis. Researchers estimate that at least 20 percent of patients with chronic hepatitis C develop cirrhosis, a process that takes 10 to 20 years. After 20 to 40 years, a smaller percentage of patients with chronic disease develop liver cancer.

Chronic hepatitis C can cause cirrhosis, liver failure, and liver cancer. About 20 percent of patients develop cirrhosis within 10 to 20 years of the onset of infection. Liver failure from chronic hepatitis C is one of the most common reasons for liver transplants in the United States. Hepatitis C might be the most common cause of primary liver cancer in the developed world. In Italy, Spain, and Japan, at least half of liver cancers could be related to HCV. Men, alcoholics, patients with cirrhosis, people over age 40, and those infected for 20 to 40 years are more likely to develop HCV-related liver cancer.

Risk Factors and TransmissionHCV is spread primarily by contact with blood and blood products. Blood transfusions and the use of shared, unsterilized, or poorly sterilized needles and syringes have been the main causes of the spread of HCV in the United States. With the introduction in 1991 of routine blood screening for HCV antibody and improvements in the test in mid-1992, transfusion-related hepatitis C has virtually disappeared. At present, injection drug use is the most common risk factor for contracting the disease. However, many patients acquire hepatitis C without any known exposure to blood or to drug use.

The major high-risk groups for hepatitis C are:

  • People who had blood transfusions before June 1992, when sensitive tests for anti-HCV were introduced for blood screening.
  • People who have frequent exposure to blood products. These include patients with hemophilia, solid-organ transplants, chronic renal failure, or cancer requiring chemotherapy.
  • Health care workers who suffer needle-stick accidents.
  • Injection drug users, including those who used drugs briefly many years ago.
  • Infants born to HCV-infected mothers.

Other groups who appear to be at slightly increased risk for hepatitis C are:

  • People with high-risk sexual behavior, multiple partners, and sexually transmitted diseases.
  • People who use cocaine, particularly with intranasal administration, using shared equipment.
  • People who have tattoos.

Maternal-Infant TransmissionMaternal-infant transmission is not common. In most studies, only 5 percent of infants born to infected women become infected. The disease in newborns is usually mild and free of symptoms. The risk of maternal-infant spread rises with the amount of virus in the mother's blood. Breast-feeding has not been linked to HCV's spread.

Sexual TransmissionSexual transmission of hepatitis C between monogamous partners appears to be uncommon. Whether hepatitis C is spread by sexual contact has not been conclusively proven, and studies have been contradictory. Surveys of spouses and monogamous sexual partners of patients with hepatitis C show that less than 5 percent are infected with HCV, and many of these have other risk factors for this infection. For this reason, changes in sexual practices are not recommended for monogamous patients. Testing sexual partners for anti-HCV can help with patient counseling. People with multiple sex partners should be advised to follow safe sex practices, which should protect against hepatitis C as well as hepatitis B and HIV.

Sporadic TransmissionSporadic transmission, when the source of infection is unknown, occurs in about 10 percent of acute hepatitis C cases and in 30 percent of chronic hepatitis C cases. These cases are also referred to as sporadic or community-acquired infections. These infections may have come from exposure to the virus from cuts, wounds, or medical injections or procedures. Toothbrushes, finger nail clippers and files and razors used to shave could potentially spread the virus and should therefore not be shared.

The Hepatitis C VirusHCV is a small (40 to 60 nm in diameter), enveloped, single-stranded RNA virus of the family Flaviviridae. Because the virus mutates rapidly, changes in the envelope protein may help it evade the immune system. There are at least 6 major genotypes and more than 50 subtypes of HCV. The different genotypes have different geographic distributions. Genotypes 1a and 1b are the most common in the United States. Genotypes 2 and 3 are present in only 10 to 20 percent of patients. There is little difference in the severity of disease or outcome of patients infected with different genotypes. However, patients with genotypes 2 and 3 are more likely to respond to alpha interferon treatment.

Clinical Symptoms and SignsMany people with chronic hepatitis C have no symptoms of liver disease. If symptoms are present, they are usually mild, non-specific, and intermittent. They may include:

  •     Fatigue
  •     Mild right-upper-quadrant discomfort or tenderness
  •     Nausea
  •     Poor appetite
  •     Muscle and joint pains.

Similarly, the physical exam is likely to be normal or show only mild hepatomegaly or tenderness. Some patients have vascular spiders or palmar erythema.

Clinical Features of CirrhosisOnce a patient develops cirrhosis or if the patient has severe disease, symptoms and signs are more prominent. In addition to fatigue, the patient may complain of muscle weakness, poor appetite, nausea, weight loss, itching, dark urine, fluid retention, and abdominal swelling. Physical findings of cirrhosis may include:

  •     Enlarged liver
  •     Enlarged spleen
  •     Jaundice
  •     Muscle wasting
  •     Excoriations
  •     Ascites
  •     Ankle swelling.

Extrahepatic ManifestationsComplications that do not involve the liver develop in 1 to 2 percent of people with hepatitis C. The most common is cryoglobulinemia, which is marked by:

  •     Skin rashes, such as purpura, vasculitis, or urticaria
  •     Joint and muscle aches
  •     Kidney disease
  •     Neuropathy
  •     Cryoglobulins, rheumatoid factor, and low complement levels in serum.

Other complications of chronic hepatitis C are:

  •     Glomerulonephritis
  •     Porphyria cutanea tarda.

Diseases that are less well documented to be related to hepatitis C are:

  •     Seronegative arthritis
  •     Keratoconjunctivitis sicca (Sjögren's syndrome)
  •     Non-Hodgkin's type, B-cell lymphomas
  •     Fibromyalgia
  •     Lichen planus

Serologic TestsEnzyme ImmunoassayAnti-HCV is detected by enzyme immunoassay (EIA). The third-generation test (EIA-3) used today is more sensitive and specific than previous ones. However, as with all enzyme immunoassays, false-positive results are occasionally a problem with the EIA-3. Additional or confirmatory testing is often helpful.

The best approach to confirm the diagnosis of hepatitis C is to test for HCV RNA using a sensitive polymerase chain reaction (PCR) assay. The presence of HCV RNA in serum indicates an active infection. Testing for HCV RNA is also helpful in patients in whom EIA tests for anti-HCV are unreliable. For instance, immunocompromised patients may test negative for anti-HCV despite having HCV infection because they may not produce enough antibodies for detection with EIA. Likewise, patients with acute hepatitis may test negative for anti-HCV when the physician first tests. Antibody is present in almost all patients by 1 month after onset of acute illness; thus, patients with acute hepatitis who initially test negative may need follow-up testing. In these situations, HCV RNA is usually present and confirms the diagnosis.

Recombinant Immunoblot Assay Immunoblot assays are used to confirm anti-HCV reactivity, too. These tests are also called "Western blots"; serum is incubated on nitrocellulose strips on which four recombinant viral proteins are blotted. Color changes indicate that antibodies are adhering to the proteins. An immunoblot is considered positive if two or more proteins react and is considered indeterminate if only one positive band is detected. In some clinical situations, confirmatory testing by immunoblotting is helpful, such as for the person with anti-HCV detected by EIA who tests negative for HCV RNA. The EIA anti-HCV reactivity could represent a false-positive reaction, recovery from hepatitis C, or continued virus infection with levels of virus too low to be detected (the last occurs only rarely when sensitive PCR assays are used). If the immunoblot test for anti-HCV is positive, the patient has most likely recovered from hepatitis C and has persistent antibody without virus. If the immunoblot test is negative, the EIA result was probably a false positive.

Immunoblot tests are routine in blood banks when an anti-HCV-positive sample is found by EIA. Immunoblot assays are highly specific and valuable in verifying anti-HCV reactivity. Indeterminate tests require further follow-up testing, including attempts to confirm the specificity by repeat testing for HCV RNA.

PCR AmplificationPCR amplification can detect low levels of HCV RNA in serum. Testing for HCV RNA is a reliable way of demonstrating that hepatitis C infection is present and is the most specific test for infection. Testing for HCV RNA by PCR is particularly useful when aminotransferases are normal or only slightly elevated, when anti-HCV is not present, or when several causes of liver disease are possible. This method also helps diagnose hepatitis C in people who are immunosuppressed, have recently had an organ transplant, or have chronic renal failure. At present, however, there are no PCR assays approved by the Food and Drug Administration for general use, although commercial test systems are available. Many commercial laboratories offer their own PCR assays, which are not subject to strict independent quality controls. Thus, the reliability and specificity of the PCR technique are not standardized. In addition, it is expensive and prone to technical or laboratory error. When ordering HCV RNA testing by PCR, the physician should use a high-quality laboratory willing to document standardization of the test.

Biochemical Indicators of Hepatitis C Virus Infection

  • In chronic hepatitis C, increases in the alanine and aspartate aminotransferases range from 0 to 20 times (but usually less than 5 times) the upper limit of normal.
  • Alanine aminotransferase levels are usually higher than aspartate aminotransferase levels, but that finding may be reversed in patients who have cirrhosis.
  • Alkaline phosphatase and gamma glutamyl transpeptidase are usually normal. If elevated, they may indicate cirrhosis.
  • Rheumatoid factor and low platelet and white blood cell counts are frequent in patients with cirrhosis, providing clues to the presence of advanced disease.
  • The enzymes lactate dehydrogenase and creatine kinase are usually normal.
  • Albumin levels and prothrombin time are normal until late-stage disease.
  • Iron and ferritin levels may be slightly elevated.

Quantification of HCV RNA in Serum Several methods are available for measuring the titer or level of virus in serum, which is an indirect assessment of viral load. These methods include a quantitative PCR and a branched DNA (bDNA) test. Unfortunately, these assays are not standardized, and different methods from different laboratories can provide different results on the same specimen. In addition, serum levels of HCV RNA can vary spontaneously by 3- to 10-fold over time. Nevertheless, when performed carefully, quantitative assays provide important insights into the nature of hepatitis C.

Viral load does not correlate with the severity of the hepatitis or with a poor prognosis (as it seems to in HIV infection); but viral load does correlate with the likelihood of a response to antiviral therapy. Rates of response to a course of alpha interferon and ribavirin are higher in patients with low levels of HCV RNA. There are several definitions of a "low level" of HCV RNA, but the usual definition is below 2 million copies per milliliter (mL).

In addition, monitoring viral load during the early phases of treatment may provide early information on the likelihood of a response. Yet because of the shortcomings of the current assays for HCV RNA level, these tests are not reliable guides to therapy. More sensitive and reliable methods of quantitating HCV RNA in serum are needed. Until that time, these tests should not be routinely used in practice.

Genotyping and Serotyping of HCVThere are 6 known genotypes and more than 50 subtypes of hepatitis C. The genotype of infection is helpful in defining the epidemiology of hepatitis C. Knowing the genotype or serotype (genotype-specific antibodies) of HCV is helpful in making recommendations and counseling regarding therapy. Patients with genotypes 2 and 3 are almost three times more likely to respond to therapy with alpha interferon or the combination of alpha interferon and ribavirin. Furthermore, when using combination therapy, the recommended duration of treatment depends on the genotype. For patients with genotypes 2 and 3, a 24-week course of combination treatment may be adequate, whereas for patients with genotype 1, a 48-week course is recommended. For these reasons, testing for HCV genotype is often clinically helpful. Once the genotype is identified, it need not be tested again;genotypes do not change during the course of infection.

Normal Serum ALT LevelsSome patients with chronic hepatitis C have normal serum alanine aminotransferase (ALT) levels, even when tested on multiple occasions. In this and other situations in which the diagnosis of chronic hepatitis C may be questioned, the diagnosis should be confirmed by testing for HCV RNA. The presence of HCV RNA indicates that the patient has ongoing viral infection despite normal ALT levels.

Liver BiopsyLiver biopsy is not necessary for diagnosis but is helpful for grading the severity of disease and staging the degree of fibrosis and permanent architectural damage. Special stains are used to grade the amount of necrosis and inflammation and to stage the degree of fibrosis. Specific immunohistochemical stains for HCV have not been developed for routine use. Liver biopsy is also helpful in ruling out other causes of liver disease, such as alcoholic liver injury or iron overload.

HCV causes the following changes in liver tissue:

  • Necrosis and inflammation around the portal areas, so-called "piecemeal necrosis" or "interface hepatitis."
  • Necrosis of hepatocytes and focal inflammation in the liver parenchyma.
  • Inflammatory cells in the portal areas ("portal inflammation").
  • Fibrosis, with early stages being confined to the portal tracts, intermediate stages being expansion of the portal tracts and bridging between portal areas or to the central area, and late stages being frank cirrhosis characterized by architectural disruption of the liver with fibrosis and regeneration.

Grading and staging of hepatitis by assigning scores for severity are helpful in managing patients with chronic hepatitis. The degree of inflammation and necrosis can be assessed as none, minimal, mild, moderate, or severe. The degree of fibrosis can be similarly assessed. Scoring systems are particularly helpful in clinical studies on chronic hepatitis.

ImmunostainingImmunostaining using polyclonal or monoclonal antibodies to detect HCV antigens in the liver has been reported to be useful. However, these tests are not commercially available, and, even in the hands of research investigators, immunostaining detects HCV antigens in liver tissue in only 60 to 70 percent of patients with chronic hepatitis C -- largely in those with high levels of HCV in serum. This test also requires special handling of liver tissue and thus, is not appropriate for routine clinical use.

DiagnosisHepatitis C is most readily diagnosed when serum aminotransferases are elevated and anti-HCV is present in serum. The diagnosis is confirmed by the finding of HCV RNA in serum.

Acute Hepatitis CAcute hepatitis C is diagnosed on the basis of symptoms such as jaundice, fatigue, and nausea, along with marked increases in serum ALT (usually greater than 10-fold elevation), and presence of anti-HCV or de novo development of anti-HCV.

Diagnosis of acute disease can be problematic because anti-HCV is not always present when the patient presents to the physician with symptoms. In 30 to 40 percent of patients, anti-HCV is not detected until 2 to 8 weeks after onset of symptoms. Acute hepatitis C can also be diagnosed by testing for HCV RNA, but another approach is to repeat the anti-HCV testing a month after onset of illness.

Chronic Hepatitis CChronic hepatitis C is diagnosed when anti-HCV is present and serum aminotransferase levels remain elevated for more than 6 months. Testing for HCV RNA (by PCR) confirms the diagnosis and documents that viremia is present; almost all patients with chronic infection will have the viral genome detectable in serum by PCR.

Diagnosis is problematic in patients who cannot produce anti-HCV because they are immunosuppressed or immunoincompetent. Thus, HCV RNA testing may be required for patients who have a solid-organ transplant, are on dialysis, are taking corticosteroids, or have agammaglobulinemia. Diagnosis is also difficult in patients with anti-HCV who have another form of liver disease that might be responsible for the liver injury, such as alcoholism, iron overload, or autoimmunity. In these situations, the anti-HCV may represent a false-positive reaction, previous HCV infection, or mild hepatitis C occurring on top of another liver condition. HCV RNA testing in these situations helps confirm that hepatitis C is contributing to the liver problem.

Differential DiagnosisThe major conditions that can be confused clinically with chronic hepatitis C include:

  •     Autoimmune hepatitis
  •     Chronic hepatitis B and D
  •     Alcoholic hepatitis
  •     Non-alcoholic steatohepatitis (fatty liver)
  •     Sclerosing cholangitis
  •     Wilson's disease
  •     Alpha-1-antitrypsin-deficiency-related liver disease
  •     Medication-induced liver disease.

TreatmentIn the United States, two different regimens have been approved as therapy for hepatitis C:

  •     Monotherapy with alpha interferon
  •     Combination therapy with alpha interferon and ribavirin.

Combination therapy consistently yields higher rates of sustained response than monotherapy. Combination treatment is more expensive and is associated with more side effects than monotherapy, but, in most situations, it is preferable. At present, interferon monotherapy should be reserved for patients who have contraindications to the use of ribavirin.

Several forms of alpha interferon are available (alfa-2a, alfa-2b, and consensus interferon). These interferons are given subcutaneously three times weekly in doses of 3 million units (MU) or, in the case of consensus interferon, 9 µg per injection. Ribavirin, in contrast, is an oral antiviral agent that is given twice a day in 200-mg capsules for a total daily dose of 1,000 mg for patients who weigh less than 75 kilograms (165 pounds) or 1,200 mg for those who weigh more than 75 kilograms.

Treatment with interferon alone or combination therapy with interferon and ribavirin leads to rapid improvements in serum ALT levels in 50 to 75 percent of patients and the disappearance of detectable HCV RNA from the serum in 30 to 50 percent. However, a long-term improvement in liver disease usually occurs only if HCV RNA disappears during therapy and stays undetectable when therapy is stopped.

A response is considered to be "sustained" if HCV RNA remains undetectable for 6 months or more after therapy stops. With interferon monotherapy, 30 to 35 percent of patients become HCV RNA negative with treatment, but almost half of these relapse when treatment stops: The sustained response rate, therefore, averages only 15 to 20 percent. Combination therapy with interferon and ribavirin, however, leads to loss of HCV RNA on treatment in 50 to 55 percent of patients and a sustained loss in 35 to 45 percent. Thus, combination treatment results in both a higher rate of loss of HCV RNA on treatment and a lower rate of relapse when treatment is stopped.

The optimal duration of treatment varies depending on whether interferon monotherapy or combination therapy is used, as well as by HCV genotype. For patients treated with interferon monotherapy, a 48-week course is recommended, regardless of genotype. For patients treated with combination therapy, the optimal duration of treatment depends on viral genotype. Patients with genotypes 2 and 3 have a high rate of response to combination treatment (60 to 70 percent), and a 24-week course of combination therapy yields results equivalent to those of a 48-week course. In contrast, patients with genotype 1 have a lower rate of response to combination therapy (25 to 35 percent), and a 48-week course yields a significantly better sustained response rate. Again, because of the variable responses to treatment, testing for HCV genotype is clinically useful when using combination therapy.

Who Should Be Treated?Patients with anti-HCV, HCV RNA, elevated serum aminotransferase levels, and evidence of chronic hepatitis on liver biopsy, and with no contraindications, should be offered therapy with the combination of alpha interferon and ribavirin. The National Institutes of Health Consensus Development Conference Panel recommended that therapy for hepatitis C be limited to those patients who have histological evidence of progressive disease. Thus, the panel recommended that all patients with fibrosis or moderate to severe degrees of inflammation and necrosis on liver biopsy should be treated and that patients with less severe histological disease be managed on an individual basis. Patient selection should not be based on the presence or absence of symptoms, the mode of acquisition, the genotype of HCV RNA, or serum HCV RNA levels.

Patients with cirrhosis found through liver biopsy can be offered therapy if they do not have signs of decompensation, such as ascites, persistent jaundice, wasting, variceal hemorrhage, or hepatic encephalopathy. However, interferon and combination therapy have not been shown to improve survival or the ultimate outcome in patients with preexisting cirrhosis.

Patients older than 60 years also should be managed on an individual basis, since the benefit of treatment in these patients has not been well documented and side effects appear to be worse in older patients.

The role of interferon therapy in children with hepatitis C remains uncertain. Ribavirin has yet to be evaluated adequately in children, and pediatric doses and safety have not been established. Thus, if children with hepatitis C are treated, monotherapy is recommended, and ribavirin should not be used outside of controlled clinical trials.

In people with both HCV and HIV infection, benefits of therapy for hepatitis C have not been shown. The decision to treat people co-infected with HIV must also take into consideration the concurrent medications and medical conditions. If CD4 counts are normal or minimally abnormal (> 400/ml), responses are similar in frequency to those in patients who are not infected with HIV. The efficacy of combination therapy has not been documented in HIV-infected people, and ribavirin may have significant interactions with other antiretroviral drugs.

In many of these indefinite situations, the indications for therapy should be reassessed at regular intervals. In view of the rapid developments in hepatitis C today, better therapies may become available within the next few years, at which point expanded indications for therapy would be appropriate.

In patients with clinically significant extrahepatic manifestations, such as cryoglobulinemia and glomerulonephritis, therapy with alpha interferon can result in remission of the clinical symptoms and signs. However, relapse after stopping therapy is common. In some patients, continual, long-term alpha interferon therapy can be used despite persistence of HCV RNA in serum if clinical symptoms and signs resolve on therapy.

Who Should Not Be Treated?Therapy is inadvisable outside of controlled trials for patients who have:

  • Clinically decompensated cirrhosis because of hepatitis C.
  • Normal aminotransferase levels.
  • A kidney, liver, heart, or other solid-organ transplant.
  • Specific contraindications to either monotherapy or combination therapy.

Contraindications to alpha interferon therapy include severe depression or other neuropsychiatric syndromes, active substance or alcohol abuse, autoimmune disease (such as rheumatoid arthritis, lupus erythematosus, or psoriasis) that is not well controlled, bone marrow compromise, and inability to practice birth control. Contraindications to ribavirin and thus combination therapy include marked anemia, renal dysfunction, and coronary artery or cerebrovascular disease, and, again, inability to practice birth control.

Alpha interferon has multiple neuropsychiatric effects. Prolonged therapy can cause marked irritability, anxiety, personality changes, depression, and even suicide or acute psychosis. Patients particularly susceptible to these side effects are those with preexisting serious psychiatric conditions and patients with neurological disease. Interferon therapy is also associated with relapse in people with a previous history of drug or alcohol abuse. Alpha interferon should not be given to a patient who has only recently stopped alcohol or substance abuse. Typically a 2-year abstinence is recommended before starting therapy. Strict abstinence from alcohol is recommended during therapy with interferon.

Alpha interferon therapy can induce autoantibodies, and a 6- to 12-month course triggers an autoimmune condition in about 2 percent of patients, particularly if they have an underlying susceptibility to autoimmunity (high titers of antinuclear or antithyroid antibodies, for instance). Exacerbation of a known autoimmune disease (such as rheumatoid arthritis or psoriasis) occurs commonly during interferon therapy.

Alpha interferon has bone marrow suppressive effects. Therefore, patients with bone marrow compromise or cytopenias, such as low platelet count (< 75,000 cells/mm3) or neutropenia (< 1,000 cells/mm3) should be treated cautiously and with frequent monitoring of cell counts.

Ribavirin causes red cell hemolysis to a variable degree in almost all patients. Therefore, patients with a preexisting hemolysis or anemia (hemoglobin < 11 g or hematocrit < 33 percent) should not receive ribavirin. Similarly, patients who have significant coronary or cerebral vascular disease should not receive ribavirin, as the anemia caused by treatment can trigger significant ischemia. Fatal myocardial infarctions and strokes have been reported during combination therapy with alpha interferon and ribavirin.

Ribavirin is excreted largely by the kidneys. Patients with renal disease can develop hemolysis that is severe and even life-threatening. Patients who have elevations in serum creatinine above 2.0 mg/dL should not be treated with ribavirin.

Finally, ribavirin causes birth defects in animal studies and should not be used in women who are not practicing adequate means of birth control. Alpha interferon also should not be used in pregnant women as it has direct antigrowth and antiproliferative effects.

Combination therapy should therefore be used with caution. Patients should be fully informed of the potential side effects before starting therapy.

Side Effects of TreatmentCommon side effects of alpha interferon (occurring in more than 10 percent of patients) include:

  •     Fatigue
  •     Muscle aches
  •     Headaches
  •     Nausea and vomiting
  •     Skin irritation at the injection site
  •     Low-grade fever
  •     Weight loss
  •     Irritability
  •     Depression
  •     Mild bone marrow suppression
  •     Hair loss (reversible).

Most of these side effects are mild to moderate in severity and can be managed. They are worse during the first few weeks of treatment, especially with the first injection. Thereafter, side effects diminish. Acetaminophen may be helpful for the muscle aches and low-grade fever, and side effects may be less troublesome if interferon is taken in the evening. Fatigue and depression are occasionally so troublesome that the dose of interferon should be decreased or therapy stopped early. Depression and personality changes can occur on interferon therapy and be quite subtle and not readily admitted by the patient. These side effects need careful monitoring.

Ribavirin also causes side effects, and the combination is generally less well tolerated than interferon monotherapy. The most common side effects of ribavirin are:

  •     Anemia
  •     Fatigue and irritability
  •     Itching
  •     Skin rash
  •     Nasal stuffiness, sinusitis, and cough.

Ribavirin causes a dose-related hemolysis of red cells; with combination therapy, hemoglobin usually decreases by 2 to 3 g/dl and the hematocrit by 5 to 10 percent. The amount of decrease in hemoglobin is highly variable. The decrease starts between weeks 1 and 4 of therapy and can be precipitous. Some patients develop symptoms of anemia, including fatigue, shortness of breath, palpitations, and headache.

The sudden drop in hemoglobin can precipitate angina pectoris in susceptible people, and fatalities from acute myocardial infarction and stroke have been reported in patients receiving combination therapy for hepatitis C. For these important reasons, ribavirin should not be used in patients with preexisting anemia or with significant coronary or cerebral vascular disease. If such patients require therapy for hepatitis C, they should receive alpha interferon monotherapy.

Ribavirin has also been found to cause itching and nasal stuffiness. These are histamine-like side effects; they occur in 10 to 20 percent of patients and are usually mild to moderate in severity. In some patients, however, sinusitis, recurrent bronchitis, or asthma-like symptoms become prominent. It is important that these symptoms be recognized as attributable to ribavirin, because dose modification (by 200 mg per day) or early discontinuation of treatment may be necessary.

Uncommon side effects of alpha interferon and combination therapy (occurring in less than 2 percent of patients) include:

  •     Autoimmune disease (especially thyroid disease)
  •     Severe bacterial infections
  •     Marked thrombocytopenia
  •     Marked neutropenia
  •     Seizures
  •     Depression and suicidal ideation or attempts
  •     Retinopathy (microhemorrhages)
  •     Hearing loss and tinnitus.

Rare side effects include acute congestive heart failure, renal failure, vision loss, pulmonary fibrosis or pneumonitis, and sepsis.

Deaths have been reported from acute myocardial infarction, stroke, suicide, and sepsis. A unique but rare side effect is paradoxical worsening of the disease. This is assumed to be caused by induction of autoimmune hepatitis, but its cause is really unknown. Because of this possibility, aminotransferases should be monitored. If ALT levels rise to greater than twice the baseline values, therapy should be stopped and the patient monitored. Some patients with this complication have required corticosteroid therapy to control the hepatitis.

Options for Patients Who Do Not Respond to TreatmentFew options exist for patients who either do not respond to therapy or who respond and later relapse. Patients who relapse after a course of interferon monotherapy may respond to a 24-week course of combination therapy, particularly if they became and remained HCV RNA negative during the period of monotherapy. Another approach is the use of long-term or continual interferon, which is feasible only if the interferon is well tolerated and has a clear-cut effect on serum aminotransferases and liver histology, despite lack of clearance of HCV RNA. New medications and approaches to treatment are needed. Most promising for the immediate future are newer forms of "long-acting" interferons, which are alpha interferons that are modified by polyethylene glycol (PEG) so that they can be given once a week and yet provide a sustained level of interferon. These "pegylated" formulations may avoid the peaks and troughs of interferon levels and interferon side effects that occur when it is given three times a week. Pegylated interferons are now being evaluated in prospective controlled trials. Other promising approaches are the use of other cytokines and the development of newer antivirals, such as RNA polymerase, helicase, or protease inhibitors.

Algorithm for Treatment

  • Make the diagnosis based on aminotransferase elevations, anti-HCV and HCV RNA in serum, and chronic hepatitis shown by liver biopsy.
  • Assess for suitability of therapy and contraindications.
  • Test for HCV genotype.
  • Discuss side effects and possible outcomes of treatment.
  • Start therapy with alpha interferon 3 million units by subcutaneous injection thrice weekly and oral ribavirin 1,000 or 1,200 mg daily.
  • At weeks 1, 2, and 4 and then at intervals of every 4 to 8 weeks thereafter, assess side effects, symptoms, blood counts, and aminotransferases.
  • At 24 weeks, assess aminotransferase levels and HCV RNA. In patients with genotypes 2 and 3, stop therapy. In patients with genotype 1, stop therapy if HCV RNA is still positive, but continue therapy for a total of 48 weeks if HCV RNA is negative, retesting for HCV RNA at the end of treatment.
  • After therapy, assess aminotransferases at 2- to 6-month intervals. In responders, repeat HCV RNA testing 6 months after stopping.

Before Starting Therapy

  • Do a liver biopsy to confirm the diagnosis of hepatitis C virus (HCV), assess the grade and stage of disease, and rule out other diagnoses. In situations where a liver biopsy is contraindicated, such as clotting disorders, combination therapy can be given without a pretreatment liver biopsy.
  • Measure serum HCV RNA by polymerase chain reaction (PCR) to document that viremia is present.
  • Test for HCV genotype (or serotype) to help determine the duration of therapy.
  • Measure blood counts and aminotransferases to establish a baseline for these values.
  • Counsel the patient about the relative risks and benefits of treatment. Side effects should be thoroughly discussed.

During Therapy

  • Measure blood counts and aminotransferases at weeks 1, 2, and 4 and at 4- to 8-week intervals thereafter.
  • Adjust the dose of ribavirin downward (by 200 mg at a time) if significant anemia occurs (hemoglobin less than 10 g/dl or hematocrit < 30 percent) and top ribavirin if severe anemia occurs (hemoglobin < 8.5 g/dl or hematocrit < 26 percent).
  • Measure HCV RNA by PCR at 24 weeks. If HCV RNA is still present, stop therapy. If HCV RNA is negative and patient had genotype 1 (1a or 1b), continue therapy for another 24 weeks.
  • Reinforce the need to practice strict birth control during therapy and for 6 months thereafter.
  • Measure thyroid-stimulating hormone levels every 3 to 6 months during therapy.
  • At the end of therapy, test HCV RNA by PCR to assess whether there is an end-of-treatment response.

After Therapy

  • Measure aminotransferases every 2 months for 6 months.
  • Six months after stopping therapy, test for HCV RNA by PCR. If HCV RNA is still negative, the chance for a long-term "cure" is excellent; relapses have rarely been reported after this point.

The Future of Hepatitis C: Research

Diagnostic TestsBasic Research: A major focus of hepatitis C research is developing a tissue culture system that will enable researchers to study HCV outside the human body. Animal models and molecular approaches to the study of HCV are also important. Understanding how the virus replicates and how it injures cells would be helpful in developing a means of controlling the virus and in screening for new drugs that would block it.

More sensitive and less expensive assays for measuring HCV RNA and antigens in the blood and liver are needed. Although current tests for anti-HCV are quite sensitive, a small percentage of patients with hepatitis C test negative for anti-HCV (false-negative reaction), and a percentage of patients who test positive are not infected (false-positive reaction). Also, there are patients who have resolved the infection but still test positive for anti-HCV. Convenient tests to measure HCV in serum and to detect HCV antigens in liver tissue would be helpful.

New Treatments: Most critical for the future is the development of new antiviral agents for hepatitis C. Most interesting will be specific inhibitors of HCV-derived enzymes such as protease, helicase, and polymerase inhibitors. Drugs that inhibit other steps in HCV replication may also be helpful in treating this disease, by blocking production of HCV antigens from the RNA (IRES inhibitors), preventing the normal processing of HCV proteins (inhibitors of glycosylation), or blocking entry of HCV into cells (by blocking its receptor). Nonspecific cytoprotective agents might also be helpful for hepatitis C by blocking the cell injury caused by the virus infection. Further, molecular approaches to treating hepatitis C are worthy of investigation; these consist of using ribozymes, which are enzymes that break down specific viral RNA molecules, and antisense oligonucleotides, which are small complementary segments of DNA that bind to viral RNA and inhibit viral replication. All of these approaches remain experimental and have not been applied to humans. The serious nature and the frequency of hepatitis C in the population make the search for new therapies of prime importance.

PreventionAt present, the only means of preventing new cases of hepatitis C are to screen the blood supply, encourage health professionals to take precautions when handling blood and body fluids, and inform people about high-risk behaviors. Programs to promote needle exchange offer some hope of decreasing the spread of hepatitis C among injection drug users. Vaccines and immunoglobulin products do not exist for hepatitis C, and development seems unlikely in the near future because these products would require antibodies to all the genotypes and variants of hepatitis C. Nevertheless, advances in immunology and innovative approaches to immunization make it likely that some form of vaccine for hepatitis C will eventually be developed.

What Is Hirschsprung's Disease?Hirschsprung's disease results from a lack of the nerve cells that enable the intestinal muscles to move stool through the large intestine (colon). Stool becomes trapped in the colon, filling the colon and causing it to expand. Hirschsprung's disease is also called megacolon. It is a congenital disease, which means a person is born with it. The disease may also be hereditary, which means a parent can pass it to a child. Hirschsprung's disease affects mainly infants and children.

What Are The Symptoms of Hirschsprung's Disease?Although symptoms usually begin within a few days after birth, some people don't develop them until childhood or even adulthood. In infants, the primary symptom is not passing meconium, an infant's first bowel movement, within the first 24 to 48 hours of life. Other symptoms include constipation, abdominal swelling, and vomiting. Symptoms in older children include passing small watery stools, diarrhea, and a lack of appetite.

How Is Hirschsprung's Disease Diagnosed?Physicians diagnose Hirschsprung's disease through rectal manometry, a lower gastrointestinal (GI) series, and rectal biopsy. Rectal manometry involves recording pressure changes within the colon and rectum. In a lower GI series, x-rays are used to measure the width of the colon and rectum. Rectal biopsy involves removing a piece of rectal tissue to learn whether the nerve cells that control intestinal muscle contractions are present.

How Is Hirschsprung's Disease Treated?Colostomy is the most effective treatment for Hirschsprung's disease. In a colostomy, the surgeon removes the affected part of the colon. The top half of the remaining colon is then connected to a surgically created hole, called a stoma, on the abdomen. Stool can leave the body through this hole while the lower part of the colon heals. Later, the surgeon will reconnect the colon inside the body and close the stoma. The patient will then be able to have normal bowel movements.

What Is Indigestion?Indigestion, also known as upset stomach or dyspepsia, is a painful or burning feeling in the upper abdomen, often accompanied by nausea, abdominal bloating, belching, and sometimes vomiting.

What Causes Indigestion?Indigestion might be caused by a disease or an ulcer in the digestive tract, but for most people, it results from eating too much, eating too quickly, eating high-fat foods, or eating during stressful situations. Smoking, drinking too much alcohol, using medications that irritate the stomach lining, being tired, and having ongoing stress can also cause indigestion or make it worse.

Some people have persistent indigestion that is not related to any of these factors. This type of indigestion-called functional or non-ulcer indigestion-is caused by a problem in how food moves through the digestive tract.

How is Indigestion Diagnosed?To diagnose the cause of indigestion, the doctor evaluates the stomach. In the process of diagnosis, a person may have x-rays of the stomach and small intestine or undergo endoscopy, in which the doctor uses an instrument to look closely at the inside of the stomach.

How Can I Avoid Indigestion?Avoiding the foods and situations that seem to cause indigestion is the most successful way to treat it. Excess stomach acid may not cause or result from indigestion, so antacids might not be an appropriate treatment, although some people report that they do help.

Smokers can help relieve their indigestion by quitting smoking, or at least not smoking right before eating. Exercising with a full stomach may cause indigestion, so scheduling exercise before a meal or at least an hour afterward might help.

How Is Indigestion Treated?To treat indigestion caused by a functional problem in the digestive tract, the doctor may prescribe medicine that affects stomach movement.

Because indigestion can be a sign of or mimic a more serious disease, an evaluation should be performed, worrisome symptoms may include:

  • Black tarry stools or blood in vomit.
  • Severe pain in the upper right abdomen.
  • Discomfort unrelated to eating.
  • Indigestion accompanied by shortness of breath, sweating, or pain radiating to the jaw, neck, or arm.

What Is An Inguinal Hernia?An inguinal hernia is a condition in which part of the intestine bulges through a weak spot or tear in muscles in the abdomen. An inguinal hernia occurs in the groin (the area between the abdomen and thigh). It is called "inguinal" because the intestines push through a weak spot in the inguinal canal, which is a triangle-shaped opening between layers of abdominal muscle near the groin. Obesity, pregnancy, heavy lifting, and straining to pass stool can cause the intestine to push against the inguinal canal.

What Are The Symptoms?Symptoms of inguinal hernia may include a lump in the groin near the thigh; pain in the groin; and, in severe cases, partial or complete blockage of the intestine. The doctor diagnoses hernia by doing a physical exam and by taking x-rays and blood tests to check for blockage in the intestine.

How Is An Inguinal Hernia Treated?The main treatment for inguinal hernia is surgery to repair the opening in the muscle wall. This surgery is called herniorrhaphy. Sometimes the weak area is reinforced with steel mesh or wire. This operation is called hernioplasty. If the protruding intestine becomes twisted or traps stool, part of the intestine might need to be removed. This surgery is called bowel resection. (Bowel is another word for intestine.)

What Is Intestinal Pseudo-Obstruction?Intestinal pseudo-obstruction (false blockage) is a condition that causes symptoms like those of a bowel obstruction (blockage). But when the intestines are examined, no obstruction is found. The symptoms of intestinal pseudo-obstruction are caused by a problem in how the muscles and nerves in the intestines work.

What Are The Symptoms?Symptoms of pseudo-obstruction include cramps, stomach pain, nausea, vomiting, bloating, fewer bowel movements than usual, and loose stools. Over time, pseudo-obstruction can cause bacterial infections, malnutrition, and muscle problems in other parts of the body. Some people with intestinal pseudo-obstruction also have bladder problems. Some diseases that affect muscles and nerves such as lupus erythematosus, scleroderma, or Parkinson's disease can cause symptoms of pseudo-obstruction. When a disease causes the symptoms, the condition is called secondary intestinal pseudo-obstruction. Medications that affect muscles and nerves such as opiates and antidepressants might also cause secondary pseudo-obstruction. Electrolyte abnormalities can also cause pseudo-obstruction.

Diagnosis And TreatmentTo diagnose the condition, the doctor will take a complete medical history, do a physical exam, and take x-rays and blood tests. The main treatment is nutritional support (intravenous feeding) to prevent malnutrition, and antibiotics to treat bacterial infections. Medicine might also be given to help with intestinal muscle problems. In severe cases, surgery to remove part of the intestines might be necessary.

What Is Irritable Bowel Syndrome?Irritable bowel syndrome (IBS) is a common disorder of the intestines that leads to crampy pain, gassiness, bloating, and changes in bowel habits. Some people with IBS have constipation (difficult or infrequent bowel movements); others have diarrhea (frequent loose stools, often with an urgent need to move the bowels); and some people experience both. Sometimes the person with IBS has a crampy urge to move the bowels but cannot do so.

Through the years, IBS has been called by many names -- colitis, mucous colitis, spastic colon, spastic bowel, and functional bowel disease. Most of these terms are inaccurate. Colitis, for instance, means inflammation of the large intestine (colon). IBS, however, does not cause inflammation and should not be confused with another disorder, ulcerative colitis.

The cause of IBS is not known, and as yet there is no cure. Doctors call it a functional disorder because there is no sign of disease when the body is examined. IBS causes a great deal of discomfort and distress, but it does not cause permanent harm to the intestines and does not lead to intestinal bleeding of the bowel or to a serious disease such as cancer. Often IBS is just a mild annoyance, but for some people it can be disabling. They may be unable to go to social events, to go out to a job, or to travel even short distances. Most people with IBS, however, are able to control their symptoms through medications prescribed by their physicians, diet, and stress management.

What Causes IBS?The colon, which is about 6 feet long, connects the small intestine with the rectum and anus. The major function of the colon is to absorb water and salts from digestive products that enter from the small intestine. Two quarts of liquid matter enter the colon from the small intestine each day. This material may remain there for several days until most of the fluid and salts are absorbed into the body. The stool then passes through the colon by a pattern of movements (peristalsis) to the left side of the colon, where it is stored until a bowel movement occurs.

Colon motility (contraction of intestinal muscles and movement of its contents) is controlled by nerves and hormones and by electrical activity in the colon muscle. The electrical activity serves as a "pacemaker" similar to the mechanism that controls heart function.

Movements of the colon propel the contents slowly back and forth but mainly toward the rectum. A few times each day strong muscle contractions move down the colon pushing fecal material ahead of them. Some of these strong contractions result in a bowel movement.

Because doctors have been unable to find an organic cause, IBS often has been thought to be caused by emotional conflict or stress. While stress may worsen IBS symptoms, research suggests that other factors also are important. Researchers have found that the colon muscle of a person with IBS begins to spasm after only mild stimulation. The person with IBS seems to have a colon that is more sensitive and reactive than usual, so it responds strongly to stimuli that would not bother most people.

Ordinary events such as eating and distention from gas or other material in the colon can cause the colon to overreact in the person with IBS. Certain medicines and foods may trigger spasms in some people. Sometimes the spasm delays the passage of stool, leading to constipation. Chocolate, milk products, or large amounts of alcohol are frequent offenders. Caffeine causes loose stools in many people, but it is more likely to affect those with IBS. Researchers also have found that women with IBS may have more symptoms during their menstrual periods, suggesting that reproductive hormones can increase IBS symptoms.

What Are the Symptoms of IBS?If you are concerned about IBS, it is important to realize that normal bowel function varies from person to person. Normal bowel movements range from as many as three stools a day to as few as three a week. A normal movement is one that is formed but not hard, contains no blood, and is passed without cramps or pain.

People with IBS, on the other hand, usually have crampy abdominal pain with painful constipation or diarrhea. In some people, constipation and diarrhea alternate. Sometimes people with IBS pass mucus with their bowel movements. Bleeding, fever, weight loss, and persistent severe pain are not symptoms of IBS but may indicate other problems and should be evaluated further.

How Is IBS Diagnosed?IBS usually is diagnosed after doctors exclude the presence of disease. To get to that point, the doctor will take a complete medical history that includes a careful description of symptoms. A physical examination and laboratory tests will be done. A stool sample will be tested for evidence of bleeding. The doctor also may do diagnostic procedures such as x-rays or endoscopy (viewing the colon through a flexible tube inserted through the anus) to find out if there is disease.

How Do Diet and Stress Affect IBS?The potential for abnormal function of the colon is always present in people with IBS, but a trigger also must be present to cause symptoms. The most likely culprits seem to be diet and emotional stress. Many people report that their symptoms occur following a meal or when they are under stress. No one is sure why this happens, but scientists have some clues.

Eating causes contractions of the colon. Normally, this response may cause an urge to have a bowel movement within 30 to 60 minutes after a meal. In people with IBS, the urge may come sooner with cramps and diarrhea.

The strength of the response is often related to the number of calories in a meal and especially the amount of fat in a meal. Fat in any form (animal or vegetable) is a strong stimulus of colonic contractions after a meal. Many foods contain fat, especially meats of all kinds, poultry skin, whole milk, cream, cheese, butter, vegetable oil, margarine, shortening, avocados, and whipped toppings.

Stress also stimulates colonic spasm in people with IBS. This process is not completely understood, but scientists point out that the colon is controlled partly by the nervous system. Stress reduction (relaxation) training or counseling and support help relieve IBS symptoms in some people. However, doctors are quick to note that this does not mean IBS is the result of a personality disorder. IBS is at least partly a disorder of colon motility.

How Does a Good Diet Help IBS?For many people, eating a proper diet lessens IBS symptoms. Before changing your diet, it is a good idea to keep a journal noting which foods seem to cause distress. Discuss your findings with your doctor. You also may want to consult a registered dietitian, who can help you make changes in your diet. For instance, if dairy products cause your symptoms to flare up, you can try eating less of those foods. Yogurt might be tolerated better because it contains organisms that supply lactase, the enzyme needed to digest lactose, the sugar found in milk products. Because dairy products are an important source of calcium and other nutrients that your body needs, be sure to get adequate nutrients in the foods that you substitute.

Dietary fiber may lessen IBS symptoms in many cases. Whole grain breads and cereals, beans, fruits, and vegetables are good sources of fiber. Consult your doctor before using an over-the-counter fiber supplement. High-fiber diets keep the colon mildly distended, which may help to prevent spasms from developing. Some forms of fiber also keep water in the stools, thereby preventing hard stools that are difficult to pass. Doctors usually recommend that you eat just enough fiber so that you have soft, easily passed, and painless bowel movements. High-fiber diets may cause gas and bloating, but within a few weeks, these symptoms often go away as your body adjusts to the diet.

Large meals can cause cramping and diarrhea in people with IBS. Symptoms may be eased if you eat smaller meals more often or just eat smaller portions. This should help, especially if your meals are low in fat and high in carbohydrates such as pasta, rice, whole-grain breads and cereals, fruits, and vegetables.

Can Medicines Relieve IBS Symptoms?There is no standard way of treating IBS. Your doctor may prescribe fiber supplements or occasional laxatives if you are constipated. Some doctors prescribe drugs that control colon muscle spasms, drugs that slow the movement of food through the digestive system, or tranquilizers, all of which may relieve symptoms. Antidepressant drugs also are used sometimes.

It is important to follow the physician's instructions when taking IBS medications -- particularly laxatives, which can be habit forming if not used carefully.

Is IBS Linked to Other Diseases?IBS has not been shown to lead to any serious, organic diseases. No link has been established between IBS and inflammatory bowel diseases such as Crohn's disease or ulcerative colitis. IBS does not lead to cancer. Some patients have a more severe form of IBS, and the pain and diarrhea may cause them to withdraw from normal activities. These patients need to work with their physicians to find the best combination of medicine, diet, counseling, and support to control their symptom

What Is Irritable Bowel Syndrome?Irritable bowel syndrome (IBS) is a digestive disorder that causes abdominal pain, bloating, gas, diarrhea, and constipation -- or some combination of these problems.

IBS affects people of all ages, including children. IBS is classified as a functional disorder because it is caused by a problem in how the intestines, or bowels, work. People with IBS tend to have overly sensitive intestines that have muscle spasms in response to food, gas, and sometimes stress. These spasms may cause pain, diarrhea, and constipation.

What Are The Symptoms Of IBS In Children?In children, IBS tends to be either diarrhea-predominant or pain-predominant. Diarrhea-predominant IBS is most common in children under age 3. The diarrhea is usually painless and alternates with bouts of constipation. These children usually have fewer than five stools a day, and the stools tend to be watery and soft. Pain-predominant IBS mainly affects children over age 5. In the younger children the pain tends to occur around the navel area, and in older children, in the lower left part of the abdomen. The pain is crampy and gets worse with eating and better after passing stool or gas.

In addition to the symptoms described above, children with IBS may also have headache, nausea, or mucus in the stool. Weight loss may occur if a child eats less to try to avoid pain. Some children first develop symptoms after a stressful event, such as teething, a bout with the flu, school problems, or problems at home. Stress does not cause IBS, but it can trigger symptoms.

How Is IBS Diagnosed In Children?To diagnose IBS, the doctor will ask questions about symptoms and examine the child to rule out the possibility of more serious problems or diseases. IBS is not a disease -- it is a syndrome, or group of symptoms that occur together. It does not damage the intestine, so if the physical exam and other tests show no sign of disease or damage, the doctor may diagnose IBS. Additional tests are often needed to rule out other more serious conditions.

How Is IBS Treated In Children?In children, IBS is treated mainly through changes in diet -- eating more fiber and less fat to help prevent spasms -- and through bowel training to teach the child to empty the bowels at regular, specific times during the day. Medications like laxatives are rarely prescribed because children are more susceptible to addiction than adults. When laxatives are necessary, parents must follow the doctor's instructions carefully. Learning stress management techniques may help some children.

What is Lactose Intolerance?Lactose intolerance is the inability to digest significant amounts of lactose, the predominant sugar of milk. This inability results from a shortage of the enzyme lactase, which is normally produced by the cells that line the small intestine. Lactase breaks down milk sugar into simpler forms that can then be absorbed into the bloodstream. When there is not enough lactase to digest the amount of lactose consumed, the results, although not dangerous, may be very distressing. While not all persons deficient in lactase have symptoms, those who do are considered to be lactose intolerant.

Symptoms caused by lactose intolerance results from the lactose reaching the colon. In the colon, lactose is digested by bacteria which causes gas and bloating. Also lactose in the colon causes fluid to enter the colon contributing to diarrhea.

What Are Some Symptoms of Lactose Intolerance?Common symptoms include nausea, cramps, bloating, gas, and diarrhea, which begin about 30 minutes to 2 hours after eating or drinking foods containing lactose. The severity of symptoms varies depending on the amount of lactose each individual can tolerate.

Some causes of lactose intolerance are well known. For instance, certain digestive diseases and injuries to the small intestine can reduce the amount of enzymes produced. In rare cases, children are born without the ability to produce lactase. For most people, though, lactase deficiency is a condition that develops naturally over time. After about the age of 2 years, the body begins to produce less lactase. However, many people may not experience symptoms until they are much older. Between 30 and 50 million Americans are lactose intolerant. Certain ethnic and racial populations are more widely affected than others. As many as 75 percent of all African-Americans and Native Americans and 90 percent of Asian-Americans are lactose intolerant. The condition is least common among persons of northern European descent.

How Is Lactose Intolerance Diagnosed?The most common tests used to measure the absorption of lactose in the digestive system are the lactose tolerance test, the hydrogen breath test, and the stool acidity test. These tests are performed on an outpatient basis at a hospital, clinic, or doctor's office.

The lactose tolerance test begins with the individual fasting (not eating) before the test and then drinking a liquid that contains lactose. Several blood samples are taken over a 2-hour period to measure the person's blood glucose (blood sugar) level, which indicates how well the body is able to digest lactose.

Normally, when lactose reaches the digestive system, the lactase enzyme breaks down lactose into glucose and galactose. The liver then changes the galactose into glucose, which enters the bloodstream and raises the person's blood glucose level. If lactose is incompletely broken down the blood glucose level does not rise, and a diagnosis of lactose intolerance is confirmed.

The hydrogen breath test measures the amount of hydrogen in the breath. Normally, very little hydrogen is detectable in the breath. However, undigested lactose in the colon is fermented by bacteria, and various gases, including hydrogen, are produced. The hydrogen is absorbed from the intestines, carried through the bloodstream to the lungs, and exhaled. In the test, the patient drinks a lactose-loaded beverage, and the breath is analyzed at regular intervals. Raised levels of hydrogen in the breath indicate improper digestion of lactose. Certain foods, medications, and cigarettes can affect the test's accuracy and should be avoided before taking the test. This test is available for children and adults.

The lactose tolerance and hydrogen breath tests are not given to infants and very young children who are suspected of having lactose intolerance. A large lactose load may be dangerous for very young individuals because they are more prone to dehydration that can result from diarrhea caused by the lactose. If a baby or young child is experiencing symptoms of lactose intolerance, many pediatricians simply recommend changing from cow's milk to soy formula and waiting for symptoms to abate.

If necessary, a stool acidity test, which measures the amount of acid in the stool, may be given to infants and young children. Undigested lactose fermented by bacteria in the colon creates lactic acid and other short-chain fatty acids that can be detected in a stool sample. In addition, glucose may be present in the sample as a result of unabsorbed lactose in the colon.

How Is Lactose Intolerance Treated?Fortunately, lactose intolerance is relatively easy to treat. No treatment exists to improve the body's ability to produce lactase, but symptoms can be controlled through diet.

Young children with lactase deficiency should not eat any foods containing lactose. Most older children and adults need not avoid lactose completely, but individuals differ in the amounts of lactose they can handle.

For example, one person may suffer symptoms after drinking a small glass of milk, while another can drink one glass but not two. Others may be able to manage ice cream and aged cheeses, such as cheddar and Swiss but not other dairy products. Dietary control of lactose intolerance depends on each person's learning through trial and error how much lactose he or she can handle. For those who react to very small amounts of lactose or have trouble limiting their intake of foods that contain lactose, lactase enzymes are available without a prescription. One form is a liquid for use with milk. A few drops are added to a quart of milk, and after 24 hours in the refrigerator, the lactose content is reduced by 70 percent. The process works faster if the milk is heated first, and adding a double amount of lactase liquid produces milk that is 90 percent lactose free. A more recent development is a chewable lactase enzyme tablet that helps people digest solid foods that contain lactose. Three to six tablets are taken just before a meal or snack.

Lactose-reduced milk and other products are available at many supermarkets. The milk contains all of the nutrients found in regular milk and remains fresh for about the same length of time or longer if it is super-pasteurized.

How Is Nutrition Balanced?Milk and other dairy products are a major source of nutrients in the American diet. The most important of these nutrients is calcium. Calcium is essential for the growth and repair of bones throughout life. In the middle and later years, a shortage of calcium may lead to thin, fragile bones that break easily (a condition called osteoporosis). A concern, then, for both children and adults with lactose intolerance, is getting enough calcium in a diet that includes little or no milk.

In 1997, the Institute of Medicine released a report recommending new requirements for daily calcium intake. How much calcium a person needs to maintain good health varies by age group. Recommendations from the report are as follows: 

Age Group
Amount of calcium to consume daily in milligrams (mg)
0-6 months
210 mg
6-12 months
270 mg
1-3 years
500 mg
4-8 years
800 mg
9-18 years
1,300 mg
19-50 years
1,000 mg
51-70 years
1,200 mg

Also, pregnant and nursing women under 19 need 1,300 mg daily, while pregnant and nursing women over 19 need 1,000 mg.

In planning meals, making sure that each day's diet includes enough calcium is important, even if the diet does not contain dairy products. Many non-dairy foods are high in calcium. Green vegetables, such as broccoli and kale, and fish with soft, edible bones, such as salmon and sardines, are excellent sources of calcium. To help in planning a high-calcium and low-lactose diet, this article lists some common foods that are good sources of dietary calcium and shows about how much lactose the foods contain.

  •     Calcium Alternatives
  •     Canned salmon with bones
  •     Sardines
  •     Collard Greens
  •     Turnip Greens
  •     Broccoli
  •     Tofu

Recent research shows that yogurt with active cultures may be a good source of calcium for many people with lactose intolerance, even though it is fairly high in lactose. Evidence shows that the bacterial cultures used in making yogurt produce some of the lactase enzyme required for proper digestion.

Clearly, many foods can provide the calcium and other nutrients the body needs, even when intake of milk and dairy products is limited. However, factors other than calcium and lactose content should be kept in mind when planning a diet. Some vegetables that are high in calcium (Swiss chard, spinach, and rhubarb, for instance) are not listed because the body cannot use their calcium content. They contain substances called oxalates, which stop calcium absorption. Calcium is absorbed and used only when there is enough vitamin D in the body. A balanced diet should provide an adequate supply of vitamin D. Sources of vitamin D include eggs and liver. However, sunlight helps the body naturally absorb or synthesize vitamin D, and with enough exposure to the sun, food sources may not be necessary.

Some people with lactose intolerance may think they are not getting enough calcium and vitamin D in their diet. Consultation with a doctor or dietitian may be helpful in deciding whether any dietary supplements are needed. Taking vitamins or minerals of the wrong kind or in the wrong amounts can be harmful. A dietitian can help in planning meals that will provide the most nutrients with the least chance of causing discomfort.

What Is Hidden Lactose?Although milk and foods made from milk are the only natural sources, lactose is often added to prepared foods. People with very low tolerance for lactose should know about the many food products that may contain lactose, even in small amounts. Food products that may contain lactose include:

  •     Bread and other baked goods.
  •     Processed breakfast cereals.
  •     Instant potatoes, soups, and breakfast drinks.
  •     Margarine.
  •     Lunch meats (other than kosher)
  •     Salad dressings.
  •     Candies and other snacks.
  •     Mixes for pancakes, biscuits, and cookies.

Some products labeled nondairy, such as powdered coffee creamer and whipped toppings, may also include ingredients that are derived from milk and therefore contain lactose.

Smart shoppers learn to read food labels with care, looking not only for milk and lactose among the contents but also for such words as whey, curds, milk by-products, dry milk solids, and non-fat dry milk powder. If any of these are listed on a label, the item contains lactose.

In addition, lactose is used as the base for more than 20 percent of prescription drugs and about 6 percent of over-the-counter medicines. Many types of birth control pills, for example, contain lactose, as do some tablets for stomach acid and gas. However, these products typically affect only people with severe lactose intolerance.

SummaryEven though lactose intolerance is widespread, it need not pose a serious threat to good health. People who have trouble digesting lactose can learn which dairy products and other foods they can eat without discomfort and which ones they should avoid. Many will be able to enjoy milk, ice cream, and other such products if they take them in small amounts or eat other food at the same time. Others can use lactase liquid or tablets to help digest the lactose. Even older women at risk for osteoporosis and growing children who must avoid milk and foods made with milk can meet most of their special dietary needs by eating greens, fish, and other calcium-rich foods that are free of lactose. A carefully chosen diet (with calcium supplements if the doctor or dietitian recommends them) is the key to reducing symptoms and protecting future health.

Points To Remember

  •     Eat fewer foods with lactose in them, like milk, cheese, and ice cream.
  •     Find out if you can eat small amounts of food with lactose.
  •     Read labels on foods to find out if they have lactose in them.
  •     Use a special pill or liquid to help you digest foods with lactose.
  •     Eat enough foods with calcium, like broccoli. Taking a pill to help digest lactose is one way to deal with lactose intolerance.

What Is Ménétrier's Disease?Ménétrier's disease causes giant folds of tissue to grow in the wall of the stomach. The tissue may be inflamed and may contain ulcers. The disease interferes with the body's absorption of a protein called albumin. Ménétrier's disease increases a person's risk of stomach cancer. People who have this rare, chronic disease are usually men between ages 30 and 60. The cause of the disease is unknown.

What Are The Symptoms?Symptoms include pain or discomfort and tenderness in the top middle part of the abdomen, loss of appetite, nausea, vomiting, diarrhea, vomiting blood, swelling in the abdomen, and ulcer-like pain after eating.

How Is Ménétrier's Disease Diagnosed?Ménétrier's disease is diagnosed through x-rays, endoscopy, and biopsy of stomach tissue. Endoscopy involves looking at the inside of the stomach using a long, lighted tube. Biopsy involves removing a piece of stomach tissue to examine under the microscope for signs of disease.

How Is Ménétrier's Disease Treated?Treatment may include medications to relieve ulcer symptoms and treat inflammation, and a high-protein diet. Part or all of the stomach may need to be removed if the disease is severe.

What Is A Peptic Ulcer?A peptic ulcer is a sore that forms in the lining of the stomach or the duodenum (the beginning of the small intestine). An ulcer can cause a gnawing, burning pain in the upper abdomen; nausea; vomiting; loss of appetite; bleeding and weight loss. Most peptic ulcers are caused by infection with the bacterium Helicobacter pylori (H. pylori). But some peptic ulcers are caused by prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) or pain relievers such as aspirin, ibuprofen, and naproxen sodium. NSAIDs cause ulcers by interfering with the stomach's ability to protect itself from acidic stomach juices.

What Can I Do About A Peptic Ulcer Caused By NSAIDs?NSAID-induced ulcers usually heal once the person stops taking the medication. To help the healing process and relieve symptoms in the meantime, the doctor may recommend taking antacids to neutralize the acid and drugs to decrease the amount of acid the stomach produces.

Medicines that protect the stomach lining also help with healing. Examples are bismuth subsalicylate, which coats the entire stomach lining, and sucralfate, which sticks to and covers the ulcer.

If a person with an NSAID ulcer also tests positive for H. pylori, he or she should be treated with antibiotics to kill the bacteria. Surgery may be necessary if an ulcer recurs or fails to heal, or if complications like bleeding, perforation, or obstruction develop.

Anyone taking NSAIDs who experiences symptoms of peptic ulcer should see a doctor for prompt treatment. Delaying diagnosis and treatment can lead to complications and the need for surgery.

Your pancreas is a large gland behind your stomach and close to your duodenum. The pancreas secretes powerful digestive enzymes that enter the small intestine through a duct. These enzymes help you digest fats, proteins, and carbohydrates. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones play an important part in metabolizing sugar.

Pancreatitis is a disease in which the pancreas becomes inflamed. Damage to the gland occurs when digestive enzymes are activated and begin attacking the pancreas. In severe cases, there may be bleeding into the gland, serious tissue damage, infection, and cysts. Enzymes and toxins may enter the bloodstream and seriously injure organs, such as the heart, lungs, and kidney.

There are two forms of pancreatitis. The acute form occurs suddenly and may be a severe, life-threatening illness with many complications. Usually, the patient recovers completely. If injury to the pancreas continues, such as when a patient persists in drinking alcohol, a chronic form of the disease may develop, bringing severe pain and reduced functioning of the pancreas that affects digestion and causes weight loss.

What Is Acute Pancreatitis?An estimated 50,000 to 80,000 cases of acute pancreatitis occur in the United States each year. This disease occurs when the pancreas suddenly becomes inflamed and then gets better. Some patients have more than one attack but recover fully after each one. Most cases of acute pancreatitis are caused either by alcohol abuse or by gallstones. Other causes may be use of prescribed drugs, trauma or surgery to the abdomen, or abnormalities of the pancreas or intestine. In rare cases, the disease may result from infections, such as mumps. In about 15 percent of cases, the cause is unknown.

What Are the Symptoms of Acute Pancreatitis?Acute pancreatitis usually begins with pain in the upper abdomen that may last for a few days. The pain is often severe. It may be constant pain, just in the abdomen, or it may reach to the back and other areas. The pain may be sudden and intense, or it may begin as a mild pain that is aggravated by eating and slowly grows worse. The abdomen may be swollen and very tender. Other symptoms may include nausea, vomiting, fever, and an increased pulse rate. The person often feels and looks very sick.

About 20 percent of cases are severe. The patient may become dehydrated and have low blood pressure. Sometimes the patient's heart, lungs, or kidneys fail. In the most severe cases, bleeding can occur in the pancreas, leading to shock and sometimes death.

How Is Acute Pancreatitis Diagnosed?During acute attacks, high levels of amylase, an enzyme produced by the pancreas, is found in the blood. Changes may also occur in blood levels of calcium, magnesium, sodium, potassium, and bicarbonate. Patients may have high amounts of sugar and lipids (fats) in their blood too. These changes help the doctor diagnose pancreatitis. After the pancreas recovers, blood levels of these substances usually return to normal.

What Is the Treatment for Acute Pancreatitis?The treatment a patient receives depends on how bad the attack is. Unless complications occur, acute pancreatitis usually gets better on its own, so treatment is supportive in most cases. Usually the patient goes into the hospital. The doctor prescribes fluids by vein to restore blood volume. The kidneys and lungs may be treated to prevent failure of those organs. Other problems, such as cysts in the pancreas, may need treatment too.

Sometimes a patient cannot control vomiting and needs to have a tube through the nose to the stomach to remove fluid and air. In mild cases, the patient may not have food for 3 or 4 days but is given fluids and pain relievers by vein. An acute attack usually lasts only a few days, unless the ducts are blocked by gallstones. In severe cases, the patient may be fed through the veins for 3 to 6 weeks while the pancreas slowly heals.

Antibiotics may be given if signs of infection arise. Surgery may be needed if complications such as infection, cysts, or bleeding occur. Attacks caused by gallstones may require removal of the gallbladder or surgery of the bile duct. Surgery is sometimes needed for the doctor to be able to exclude other abdominal problems that can simulate pancreatitis or to treat acute pancreatitis. When there is severe injury with death of tissue, an operation may be done to remove the dead tissue.

After all signs of acute pancreatitis are gone, the doctor will determine the cause and try to prevent future attacks. In some patients the cause of the attack is clear, but in others further tests need to be done.

What If the Patient Has Gallstones?Ultrasound is used to detect gallstones and sometimes can provide the doctor with an idea of how severe the pancreatitis is. When gallstones are found, surgery is usually needed to remove them. When they are removed depends on how severe the pancreatitis is. If it is mild, the gallstones often can be removed within a week or so. In more severe cases, the patient may wait a month or more, until he improves, before the stones are removed. The CAT (computer axial tomography) scan may also be used to find out what is happening in and around the pancreas and how severe the problem is. This is important information that the doctor needs to determine when to remove the gallstones.

After the gallstones are removed and inflammation subsides, the pancreas usually returns to normal. Before patients leave the hospital, they are advised not to drink alcohol and not to eat large meals.

What Is Chronic Pancreatitis?Chronic pancreatitis usually follows many years of alcohol abuse. It may develop after only one acute attack, especially if there is damage to the ducts of the pancreas. In the early stages, the doctor cannot always tell whether the patient has acute or chronic disease. The symptoms may be the same. Damage to the pancreas from drinking alcohol may cause no symptoms for many years, and then the patient suddenly has an attack of pancreatitis. In more than 90 percent of adult patients, chronic pancreatitis appears to be caused by alcoholism. This is more common in men than women and often develops between 30 and 40 years of age. In other cases, pancreatitis may be inherited. Scientists do not know why the inherited form occurs. Patients with chronic pancreatitis tend to have three kinds of problems: pain, malabsorption of food leading to weight loss, or diabetes.

Some patients do not have any pain but most do. Pain may be constant in the back and abdomen, and for some patients, the pain attacks are disabling. In some cases, the abdominal pain goes away as the condition advances. Doctors think this happens because pancreatic enzymes are no longer being made by the pancreas.

Patients with this disease often lose weight, even when their appetite and eating habits are normal. This occurs because the body does not secrete enough pancreatic enzymes to break down food, so nutrients are not absorbed normally. Poor digestion leads to loss of fat, protein, and sugar into the stool. Diabetes may also develop at this stage if the insulin-producing cells of the pancreas (islet cells) have been damaged.

How Is Chronic Pancreatitis Diagnosed?Diagnosis may be difficult but is aided by a number of new techniques. Pancreatic function tests help the physician decide if the pancreas still can make enough digestive enzymes. The doctor can see abnormalities in the pancreas using several techniques (ultrasonic imaging, endoscopic retrograde cholangiopancreatography (ERCP), and the CAT scan). In more advanced stages of the disease, when diabetes and malabsorption (a problem due to lack of enzymes) occur, the doctor can use a number of blood, urine, and stool tests to help in the diagnosis of chronic pancreatitis and to monitor the progression of the disorder.

How Is Chronic Pancreatitis Treated?The doctor treats chronic pancreatitis by relieving pain and managing the nutritional and metabolic problems. The patient can reduce the amount of fat and protein lost in stools by cutting back on dietary fat and taking pills containing pancreatic enzymes. This will result in better nutrition and weight gain. Sometimes insulin or other drugs must be given to control the patient's blood sugar.

In some cases, surgery is needed to relieve pain by draining an enlarged pancreatic duct. Sometimes, part or most of the pancreas is removed in an attempt to relieve chronic pain.

Patients must stop drinking, adhere to their prescribed diets, and take the proper medications in order to have fewer and milder attacks.

What Is A Peptic Ulcer?A peptic ulcer is a sore that forms in the lining of the stomach or the duodenum (the beginning of the small intestine). An ulcer can cause a gnawing, burning pain in the upper abdomen; nausea; vomiting; loss of appetite; bleeding and weight loss. Most peptic ulcers are caused by infection with the bacterium Helicobacter pylori (H. pylori). But some peptic ulcers are caused by prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) or pain relievers such as aspirin, ibuprofen, and naproxen sodium. NSAIDs cause ulcers by interfering with the stomach's ability to protect itself from acidic stomach juices.

What Can I Do About A Peptic Ulcer Caused By NSAIDs?NSAID-induced ulcers usually heal once the person stops taking the medication. To help the healing process and relieve symptoms in the meantime, the doctor may recommend taking antacids to neutralize the acid and drugs to decrease the amount of acid the stomach produces.

Medicines that protect the stomach lining also help with healing. Examples are bismuth subsalicylate, which coats the entire stomach lining, and sucralfate, which sticks to and covers the ulcer.

If a person with an NSAID ulcer also tests positive for H. pylori, he or she should be treated with antibiotics to kill the bacteria. Surgery may be necessary if an ulcer recurs or fails to heal, or if complications like bleeding, perforation, or obstruction develop.

Anyone taking NSAIDs who experiences symptoms of peptic ulcer should see a doctor for prompt treatment. Delaying diagnosis and treatment can lead to complications and the need for surgery.

What Is Peptic Ulcer Disease?Peptic ulcer disease, estimated to affect 4.5 million people in the United States, is a chronic inflammation of the stomach and duodenum. Peptic ulcer disease is responsible for substantial human suffering and a large economic burden. Every year 4 million people report missing approximately 6 days from work because of their ulcers.

Peptic ulcers result from the breakdown of the lining of the stomach and duodenum caused by increased stomach acid and pepsin. One type of ulcer occurs in the stomach, the other in the duodenum, the first part of the small intestine. Duodenal ulcers are much more common than stomach ulcers. Ulcers of the stomach have a greater risk of malignancy.

What Are The Symptoms Of Peptic Ulcer Disease?There are no specific symptoms of gastric and duodenal ulcers. However, upper abdominal pain and nausea are the most common symptoms of peptic ulcer disease. Ulcer pains usually occur an hour or two after meals, or in the early morning hours and abate after food or antacids have been eaten. Definitive diagnosis of peptic ulcer disease requires endoscopy, which also allows a doctor to obtain biopsy samples, if needed.

What Causes Peptic Ulcer Disease?In the 1950's, doctors thought stress and diet caused peptic ulcer disease. Treatment during those years concentrated on bed rest, bland foods, and in some cases, hospitalization.

But in 1982, Helicobacter pylori was isolated from gastric biopsies of patients with chronic gastritis, and is now believed to be the major cause of peptic ulcer disease. H. pylori is found in almost 100 percent of patients with duodenal ulcers and in 80 percent of patients with gastric ulcers.

How Is Peptic Ulcer Disease Treated?Recently, an independent panel of medical experts confirmed that using a combination of antimicrobial drugs for at least 2 weeks will eradicate H. pylori in a majority of patients, thus reducing the relapse rate of ulcers. A combination of Pepto-Bismol, tetracycline, and metronidazole effectively kills H. pylori in approximately 90 percent of patients. The FDA recently approved a two-drug combination of clarithromycin (Biaxin) and omeprazole (Prilosec) to cure stomach ulcers and prevent them from coming back.

What Is Porphyria?Porphyria is a rare disorder in which the body produces too much of the chemical porphyrin. Porphyrin is used to make heme, the part of blood that carries oxygen. Heme also gives blood its color. Any circulating porphyrin the body doesn't use is excreted in urine and stool. When the body produces and excretes too much porphyrin, as happens with porphyria, not enough heme remains to keep a person healthy.

What Are The Symptoms Of Porphyria?Porphyria affects either the nervous system or the skin. When porphyria affects the nervous system, it can cause chest pain, abdominal pain, muscle cramps, weakness, hallucinations, seizures, purple-red-colored urine, or mental disorders like depression, anxiety, and paranoia. When porphyria affects the skin, blisters, itching, swelling, and sensitivity to the sun can result.

Is Porphyria An Inherited Condition?Porphyria is an inherited condition. Attacks of the disease can be triggered by drugs (barbiturates, tranquilizers, birth control pills, sedatives), chemicals, certain foods, and exposure to the sun.

How Is Porphyria Diagnosed And Treated?Porphyria is diagnosed through tests on blood, urine, and stool. It can be treated with medicines to relieve symptoms, a drug called hemin (which is like heme), or a high-carbohydrate diet.

What Is Primary Biliary Cirrhosis?Primary biliary cirrhosis is a liver disease that slowly destroys the bile ducts in the liver. Bile, a substance that helps digest fat, leaves the liver through these ducts. When the ducts are damaged, bile builds up in the liver and damages liver tissue. Over time, the disease can cause cirrhosis and may make the liver stop working.

What Causes Primary Biliary Cirrhosis?The cause of primary biliary cirrhosis is unknown. The disease affects women more often than men, and usually occurs between the ages of 30 and 60 years. Some research suggests that the disease might be caused by a problem within the immune system.

What Are The Symptoms Primary Biliary Cirrhosis?The most common symptoms of primary biliary cirrhosis are itchy skin and fatigue. Other symptoms include jaundice (yellowing of the eyes and skin), cholesterol deposits on the skin, fluid retention, and dry eyes or mouth. Some people with primary biliary cirrhosis also have osteoporosis, arthritis, and thyroid problems.

How Is Primary Biliary Cirrhosis Diagnosed And Treated?Primary biliary cirrhosis is diagnosed through laboratory tests, x-rays, and in some cases, a liver biopsy (a simple procedure to remove a small piece of liver tissue). Treatment may include taking vitamin and calcium supplements, hormone therapy, and medicines to relieve symptoms. A liver transplant may be necessary if the liver is severely damaged.

What Is Primary Sclerosing Cholangitis?In primary sclerosing cholangitis (PSC), the bile ducts inside and outside the liver become inflamed and scarred. As the scarring increases, the ducts become blocked. The ducts are important because they carry bile out of the liver. Bile is a liquid that helps break down fat in food. If the ducts are blocked, bile builds up in the liver and damages liver cells. Eventually, PSC can cause liver failure.

Researchers do not know what causes PSC. Among the theories under investigation are the possible role of bacteria, viruses, and immune system problems. PSC appears to be associated with ulcerative colitis, a type of inflammatory bowel disease.

The disease usually begins between ages 30 and 60 and is more common in men than women. PSC progresses slowly, so a person can have the disease for years before symptoms develop. The main symptoms are itching, fatigue, and jaundice, which causes yellowing of the eyes or skin. An infection in the bile ducts can cause chills and fever.

How Is Primary Sclerosing Cholangitis Diagnosed And Treated?PSC is diagnosed through blood tests and cholangiography, which involves injecting dye into the bile ducts and taking an x-ray. Treatment includes medication to relieve itching, antibiotics to treat infections, and vitamin supplements, as people with PSC are often deficient in vitamins A, D, and K. In some cases, surgery to open major blockages in the common bile duct is also necessary. Liver transplantation may be an option if the liver begins to fail.

What Is Proctitis?Proctitis is inflammation of the lining of the rectum, called the rectal mucosa. Proctitis can be short term (acute) or long term (chronic). Proctitis has many causes. It may be a side effect of medical treatments like radiation therapy or antibiotics. Diseases like ulcerative colitis, Crohn's disease, and sexually transmitted diseases may also cause proctitis. Other causes include rectal injury, bacterial infection, allergies, and malfunction of the nerves in the rectum.

What Are The Symptoms Of Proctitis?Symptoms include constipation, diarrhea, a feeling of rectal fullness, left-sided abdominal pain, passage of mucus through the rectum, rectal bleeding, and anorectal pain.

How Is Proctitis Diagnosed?Physicians diagnose proctitis by looking inside the rectum with a proctoscope or a sigmoidoscope. A tiny piece of tissue from the rectum may be removed and tested for a bacterium, fungus, or virus.

How Is Proctitis Treated?Treatment depends on the cause of proctitis. For example, the physician may prescribe antibiotics for proctitis caused by bacterial infection. If the inflammation is caused by Crohn's disease or ulcerative colitis, the physician may recommend the drug 5-aminosalicyclic acid (5ASA), or corticosteroids applied directly to the area or taken in pill form.

What Is Rapid Gastric Emptying?Rapid gastric emptying, or dumping syndrome, happens when the lower end of the small intestine (jejunum) fills too quickly with undigested food from the stomach. "Early" dumping begins during or right after a meal. Symptoms of early dumping include nausea, vomiting, bloating, diarrhea, and shortness of breath. "Late" dumping happens 1 to 3 hours after eating. Symptoms of late dumping include weakness, sweating, and dizziness. Many people have both types.

Stomach surgery is the main cause of dumping syndrome because surgery may damage the system that controls digestion. Patients with Zollinger-Ellison syndrome may also have dumping syndrome. (Zollinger-Ellison syndrome is a rare disorder involving extreme peptic ulcer disease and gastrin-secreting tumors in the pancreas.)

How Is Rapid Gastric Emptying Diagnosed And Treated?Doctors diagnose dumping syndrome through blood tests. Treatment includes changes in eating habits and medication, which usually is very effective. People who have dumping syndrome need to eat several small meals a day that are low in carbohydrates and should drink liquids between meals, not with them. People with severe cases take medicine to slow their digestion.

What Is Short Bowel Syndrome?Short bowel syndrome is a group of problems affecting people who have had half or more of their small intestine removed. The most common reason for removing part of the small intestine is to treat Crohn's disease.

What Are The Symptoms Of Short Bowel Syndrome?Diarrhea is the main symptom of short bowel syndrome. Other symptoms include cramping, bloating, and heartburn. Many people with short bowel syndrome are malnourished because their remaining small intestine is unable to absorb enough water, vitamins, and other nutrients from food. They may also become dehydrated, which can be life threatening. Problems associated with dehydration and malnutrition include weakness, fatigue, depression, weight loss, bacterial infections, and food sensitivities.

How Is Short Bowel Syndrome Treated?Short bowel syndrome is treated through changes in diet, intravenous feeding, vitamin and mineral supplements, and medicine to relieve symptoms.

What Is Ulcerative Colitis?Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the top layers of the lining of the large intestine (colon). The inflammation usually occurs in the rectum and lower part of the colon, but it may affect the entire colon. Ulcerative colitis rarely affects the small intestine except for the lower section, called the ileum. Ulcerative colitis may also be called colitis, ileitis, or proctitis.

The inflammation makes the colon empty frequently, causing diarrhea. Ulcers form in places where the inflammation has killed colon lining cells; the ulcers bleed and produce pus and mucus.

Ulcerative colitis is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the intestines. Ulcerative colitis can be difficult to diagnose because its symptoms are similar to other intestinal disorders such as irritable bowel syndrome and to another type of IBD called Crohn's disease. Crohn's disease differs from ulcerative colitis because it causes inflammation deeper within the intestinal wall. Crohn's disease usually occurs in the small intestine, but it can also occur in the mouth, esophagus, stomach, duodenum, large intestine, appendix, and anus.

Ulcerative colitis occurs most often in people ages 15 to 40, although children and older people sometimes develop the disease. Ulcerative colitis affects men and women equally and appears to run in some families.

What Causes Ulcerative Colitis?Theories about what causes ulcerative colitis abound, but none have been proven. The most popular theory is that the body's immune system reacts to a virus or a bacterium by causing ongoing inflammation in the intestinal wall.

People with ulcerative colitis have abnormalities of the immune system, but doctors do not know whether these abnormalities are a cause or a result of the disease. Ulcerative colitis is not caused by emotional distress or sensitivity to certain foods or food products, but these factors may trigger symptoms in some people.

What Are the Symptoms of Ulcerative Colitis?The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may experience the following:

  •     Fatigue.
  •     Weight loss.
  •     Loss of appetite.
  •     Rectal bleeding.
  •     Loss of body fluids and nutrients.

About half of patients have mild symptoms. Others suffer frequent fever, bloody diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis may also cause problems such as arthritis, inflammation of the eye, liver disease (fatty liver, hepatitis, cirrhosis, and primary sclerosing cholangitis), osteoporosis, skin rashes, anemia, and kidney stones. No one knows for sure why problems occur outside the colon. Scientists think these complications may occur when the immune system triggers inflammation in other parts of the body. These problems are usually mild and go away when the colitis is treated.

How Is Ulcerative Colitis Diagnosed?A thorough physical exam and a series of tests may be required to diagnose ulcerative colitis.

Blood tests may be done to check for anemia, which could indicate bleeding in the colon or rectum. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. By testing a stool sample, the doctor can tell if there is bleeding or infection in the colon or rectum.

The doctor may do a colonoscopy. For this test, the doctor inserts an endoscope-a long, flexible, lighted tube connected to a computer and TV monitor-into the anus to see the inside of the colon and rectum. The doctor will be able to see any inflammation, bleeding, or ulcers on the colon wall. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the colon to view with a microscope. A barium enema x-ray of the colon may also be required. This procedure involves filling the colon with barium, a chalky white solution. The barium shows up white on x-ray film, allowing the doctor a clear view of the colon, including any ulcers or other abnormalities that might be there.

What Is the Treatment for Ulcerative Colitis?Treatment for ulcerative colitis depends on the seriousness of the disease. Most people are treated with medication. In severe cases, a patient may need surgery to remove the diseased colon. Surgery is the only cure for ulcerative colitis.

Some people whose symptoms are triggered by certain foods are able to control the symptoms by avoiding foods that upset their intestines, like highly seasoned foods or milk sugar (lactose). Each person may experience ulcerative colitis differently, so treatment is adjusted for each individual. Emotional and psychological support is important.

Most people have remissions-periods when the symptoms go away-that last for months or even years. However, most patients' symptoms eventually return. This changing pattern of the disease means one cannot always tell when a treatment has helped.

Someone with ulcerative colitis may need medical care for some time, with regular doctor visits to monitor the condition.

Drug TherapyMost patients with mild or moderate disease are first treated with 5-ASA agents, a combination of the drugs sulfonamide, sulfapyridine, and salicylate that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Sulfasalazine can be used for as long as needed and can be given along with other drugs. Patients who do not do well on sulfasalazine may respond to newer 5-ASA agents. Possible side effects of 5-ASA preparations include nausea, vomiting, heartburn, diarrhea, and headache.

People with severe disease and those who do not respond to mesalamine preparations may be treated with corticosteroids. Prednisone and hydrocortisone are two corticosteroids used to reduce inflammation. They can be given orally, intravenously, through an enema, or in a suppository, depending on the location of the inflammation. Corticosteroids can cause side effects such as weight gain, acne, facial hair, hypertension, mood swings, and increased risk of infection, so doctors carefully watch patients taking these drugs. Because of these side effects, Corticosteroids should not be taken for long periods of time.

Other drugs may be given to relax the patient or to relieve pain, diarrhea, or infection.

Occasionally, symptoms are severe enough that the person must be hospitalized. For example, a person may have severe bleeding or severe diarrhea that causes dehydration. In such cases the doctor will try to stop diarrhea and loss of blood, fluids, and mineral salts. The patient may need a special diet, feeding through a vein, medications, or sometimes surgery.

SurgeryAbout 25 percent to 40 percent of ulcerative colitis patients must eventually have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer. Sometimes the doctor will recommend removing the colon if medical treatment fails or if the side effects of corticosteroids or other drugs threaten the patient's health.

One of several surgeries may be done. The most common surgery is a proctocolectomy with ileostomy, which is done in two stages. In the proctocolectomy, the surgeon removes the colon and rectum. In the ileostomy, the surgeon creates a small opening in the abdomen, called a stoma, and attaches the end of the small intestine, called the ileum, to it. This type of ileostomy is called a Brooke ileostomy. Waste will travel through the small intestine and exit the body through the stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed.

An alternative to the Brooke ileostomy is the continent ileostomy. In this operation, the surgeon uses the ileum to create a pouch inside the lower abdomen. Waste empties into this pouch, and the patient drains the pouch by inserting a tube into it through a small, leak-proof opening in his or her side. The patient must wear an external pouch for only the first few months after the operation.

Possible complications of the continent ileostomy include malfunction of the leak-proof opening, which requires surgical repair, and inflammation of the pouch (pouchitis), which is treated with antibiotics.

An ileoanal anastomosis, or pull-through operation, allows the patient to have normal bowel movements because it preserves part of the rectum. This procedure is becoming increasingly common for ulcerative colitis. In this operation, the surgeon removes the diseased part of the colon and the inside of the rectum, leaving the outer muscles of the rectum. The surgeon then attaches the ileum to the inside of the rectum and the anus, creating a pouch. Waste is stored in the pouch and passed through the anus in the usual manner. Bowel movements may be more frequent and watery than usual. Pouchitis is a possible complication of this procedure.

Not every operation is appropriate for every person. Which surgery to have depends on the severity of the disease and the patient's needs, expectations, and lifestyle. People faced with this decision should get as much information as possible by talking to their doctors, to nurses who work with colon surgery patients (enterostomal therapists), and to other colon surgery patients. Patient advocacy organizations can direct people to support groups and other information resources.

Most people with ulcerative colitis will never need to have surgery. If surgery ever does become necessary, however, some people find comfort in knowing that after the surgery, the colitis is cured and most people go on to live normal, active lives.

Is Colon Cancer a Concern?About 5 percent of people with ulcerative colitis develop colon cancer. The risk of cancer increases with the duration and the extent of involvement of the colon. For example, if only the lower colon and rectum are involved, the risk of cancer is not higher than normal. However, if the entire colon is involved, the risk of cancer may be as great as 32 times the normal rate.

Sometimes pre-cancerous changes occur in the cells lining the colon. These changes are called "dysplasia." People who have dysplasia are more likely to develop cancer than those who do not. (Doctors look for signs of dysplasia when doing a colonoscopy and when examining tissue removed during the test.)

According to 1997 guidelines on screening for colon cancer, people who have had IBD throughout their colon for at least 8 years and those who have had IBD in only the left colon for at least 15 years should have a colonoscopy every 1 to 2 years to check for dysplasia. Such screening has not been proven to reduce the risk of colon cancer, but it may help identify cancer early should it develop.

What Is Whipple's Disease?Whipple's disease is a rare malabsorption disease. It interferes with the body's ability to absorb certain nutrients. The disease causes weight loss, irregular breakdown of carbohydrates and fats, resistance to insulin, and malfunctions of the immune system. When recognized and treated, Whipple's disease can be cured. Untreated, the disease is usually fatal.

What Causes Whipple's Disease?Whipple's disease is caused by bacteria. It can affect any system of the body, but occurs most often in the small intestine. The disease causes lesions on the wall of the small intestine and thickening of the tissue. The villi -- tiny, finger-like protrusions from the wall that help absorb nutrients-are destroyed.

What Are The Symptoms Of Whipple's Disease?Symptoms include diarrhea, intestinal bleeding, abdominal bloating and cramps, loss of appetite, weight loss, fatigue, and weakness. Arthritis and fever often occur several years before intestinal symptoms develop. Diagnosis is based on symptoms and results of a biopsy of tissue from the small intestine.

How Is Whipple's Disease Treated?Whipple's disease is treated with antibiotics to destroy the bacteria that cause the disease. The physician may use a number of different types, doses, and schedules of antibiotics to find the best treatment. Depending on the seriousness of the disease, treatment may also include fluid and electrolyte replacement. Electrolytes are salts and other substances in body fluid that the heart and brain need to function properly. Extra iron, folate, vitamin D, calcium, and magnesium may also be given to help compensate for the vitamins and minerals the body is not absorbing on its own.

Symptoms usually disappear after 1 to 3 months of treatment. Because relapse is common even after successful treatment, the health care team may continue to observe patients for some time.

What Is Wilson's Disease?Wilson's disease causes the body to retain copper. The liver of a person who has Wilson's disease does not release copper into bile as it should. Bile is a liquid produced by the liver that helps with digestion. As the intestines absorb copper from food, the copper builds up in the liver and injures liver tissue. Eventually, the damage causes the liver to release the copper directly into the bloodstream, which carries the copper throughout the body. The copper buildup leads to damage in the kidneys, brain, and eyes. If not treated, Wilson's disease can cause severe brain damage, liver failure, and death.

Is Wilson's Disease Hereditary And What Are The Symptoms?Wilson's disease is hereditary. Symptoms usually appear between the ages of 6 and 20 years, but can begin as late as age 40. The most characteristic sign is the Kayser-Fleischer ring -- a rusty brown ring around the cornea of the eye that can be seen only through an eye exam. Other signs depend on whether the damage occurs in the liver, blood, central nervous system, urinary system, or musculoskeletal system. Many signs would be detected only by a doctor, like swelling of the liver and spleen; fluid buildup in the lining of the abdomen; anemia; low platelet and white blood cell count in the blood; high levels of amino acids, protein, uric acid, and carbohydrates in urine; and softening of the bones. Some symptoms are more obvious, like jaundice, which appears as yellowing of the eyes and skin; vomiting blood; speech and language problems; tremors in the arms and hands; and rigid muscles. Cirrhosis, scarring of the liver, is one of the most serious complications of Wilson's Disease. In some cases liver transplantation is required to treat Wilson's Disease.

How Is Wilson's Disease Diagnosed And Treated?Wilson's disease is diagnosed through tests that measure the amount of copper in the blood, urine, and liver. An eye exam would detect the Kayser-Fleischer ring.

The disease is treated with lifelong use of D-penicillamine or trientine hydrochloride, drugs that help remove copper from tissue. Patients will also need to take vitamin B6 and follow a low-copper diet, which means avoiding mushrooms, nuts, chocolate, dried fruit, liver, and shellfish. Taking extra zinc may be helpful in blocking the intestines' absorption of copper.

Wilson's disease requires lifelong treatment. If the disorder is detected early and treated correctly, a person with Wilson's disease can enjoy completely normal health.

What Is Zollinger-Ellison Syndrome?Zollinger-Ellison syndrome is a rare disorder that causes tumors in the pancreas and duodenum and ulcers in the stomach and duodenum. The pancreas is a gland located behind the stomach. It produces enzymes that break down fat, protein, and carbohydrates from food, and hormones like insulin that break down sugar. The duodenum is the top part of the small intestine.

The tumors are cancerous in 50 percent of cases. They secrete a substance called gastrin that causes the stomach to produce too much acid, which in turn causes the stomach and duodenal ulcers (peptic ulcers). The ulcers caused by Zollinger-Ellison syndrome are more painful and less responsive to treatment than ordinary peptic ulcers. What causes people with Zollinger-Ellison syndrome to develop tumors is unknown, but the cause may be an abnormal tumor suppressor gene.

What Are The Symptoms Of Zollinger-Ellison Syndrome?Zollinger-Ellison syndrome usually occurs in people between ages 30 and 60. Symptoms include signs of peptic ulcers: gnawing, burning pain in the abdomen; diarrhea; nausea; vomiting; fatigue; weakness; and weight loss. Physicians diagnose Zollinger-Ellison syndrome through blood tests to measure levels of gastrin. They may check for ulcers by taking x-rays of the stomach and duodenum or by doing an endoscopy, which involves looking at the lining of these organs through a lighted tube.

How Is Zollinger-Ellison Syndrome Treated?Medications used to reduce stomach acid include cimetidine, ranitidine, famotidine, and omeprazole. Surgery to treat peptic ulcers or to remove tumors in the pancreas or duodenum are other treatment options. In serious cases, surgery to remove the entire stomach may be necessary.

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