Palm Beach Gastroenterology Consultants, LLC

Abdominal Pain:

Abdominal pain is a symptom that we frequently see patients for. Many different gastroenterology diseases can lead to various types of abdominal pain. When trying to differentiate the different causes for these types of pains, the physician will want to know several characteristics and qualities about the pain. These questions might include:

Does food precipitate the pain?
Is the pain relieved by food?
Does the pain occur during the night?
Does the pain come in waves or is it present constantly?
In addition, the nature of the pain is also quite important in delineating its cause. Cramping pain is quite different than a sharp, steady, boring pain. Some of the conditions that can be associated with significant abdominal pain include:

Peptic Ulcer Disease.
Gallbladder Disease.
Kidney Stones.
Pancreatitis.
Diverticulitis.
Appendicitis.
Usually, colon cancers and polyps, do not cause abdominal pain. If someone experiences significant abdominal pain it is best to consult a physician immediately since serious disorders may be associated with this. For more information on each of the diagnoses discussed above, please refer back to our home page.

Bleeding:

Intestinal bleeding is a serious symptom of gastrointestinal disease. It can be present as vomiting blood related to a bleeding ulcer, black tarry stool related to a bleeding ulcer, or bright red blood from the rectum related to an ulcer, colitis, or hemorrhoids.

Chest Pain:

Some gastrointestinal disorders may present as atypical chest pain. This is chest pain not related to the heart. This usually is associated with gastroesophageal reflux (reflux of stomach acids) and esophageal spasm.

Cirrhosis of the Liver:

What is the Impact of Cirrhosis?
Cirrhosis is the eleventh leading cause of death by disease in the United States. Almost one-half of these are alcohol related. About 25,000 people die from cirrhosis each year. There also is a great toll in terms of human suffering hospital costs, and the loss of work by people with cirrhosis.

What Are the Major Causes of Cirrhosis?
Cirrhosis has many causes. It can result from direct injury to the liver cells (i.e., hepatitis) or from indirect injury via inflammation or obstruction to bile ducts which drain the liver cells of bile.

Common causes of direct liver injury include chronic alcoholism (most common cause in the United States), chronic viral hepatitis (types B, C, and D) and auto immune hepatitis. Common causes of indirect injury by way of bile duct damage include primary biliary cirrhosis, primary sclerosing cholangitis and biliary atresia (common cause of cirrhosis in infants).

Less common causes of cirrhosis include direct liver injury from inherited disease such as cystic fibrosis, alpha-l-antitrypsin deficiency, hemochromatosis, Wilson's disease, galactosemia, and glycogen storage disease.

Two inherited disorders result in the abnormal storage of metals in the liver leading to tissue damage and cirrhosis. People with Wilson’s disease store too much copper in their liver, brain, kidneys, and in the corneas of their eyes.

In another disorder, known as hemochromatosis, too much iron is absorbed, and the excess iron is deposited in the liver and in other organs, such as the pancreas, skin, intestine lining, heart and endocrine glands.

If a person's bile duct becomes blocked, this also may cause cirrhosis. The bile ducts carry bile formed in the liver to the intestines, where the bile helps in the digestion of fat. In babies, the most common cause of cirrhosis due to blocked bile ducts is a disease called binary atresia. In this case, the bile ducts are absent or injured, causing the bile to back up in the liver. These babies are jaundiced (their skin is yellowed) after their first month of life. Sometimes they can be helped by surgery in which a new duct is formed to allow bile to drain again from the liver. In adults, the bile ducts may become inflamed, blocked, and scarred due to another liver disease, primary biliary cirrhosis. Another type of biliary cirrhosis also may occur after a patient has gallbladder surgery in which the bile ducts are injured or tied off.

Very rare causes of cirrhosis include: reactions to drugs (e.g., vitamin A, methotrexate, amiodarone), exposure to environmental toxins, and repeated bouts of heart failure with liver congestion.

If after full evaluation of a patient with cirrhosis, the etiology still is not clear, the disease is called "cystogenic cirrhosis." As much as 10 percent of cirrhosis falls into this category.

What Are the Symptoms of Cirrhosis?
People with cirrhosis often have few symptoms at first. The two major problems that eventually cause symptoms are loss of functioning liver cells and distortion of the liver caused by scarring. The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with nausea and weight loss. Some patients present with menstrual abnormalities (amenorrhea), impotence, loss of sexual drive or painfully enlarged breasts (in men).

As liver function declines, less protein is made by the organ. For example, less of the protein albumin is made, which results in water accumulation in the legs (edema) or abdomen (ascites). A decrease in proteins needed for blood clotting makes it easy for the person to bruise or to bleed.

In the later stages of cirrhosis, jaundice (yellow skin) may occur, caused by the buildup of bile pigment that is normally passed by the liver into the intestines. Some people with cirrhosis experience intense itching due to bile products that are deposited in the skin. Gallstones often form in persons with cirrhosis because not enough bile reaches the gallbladder.

The liver of a person with cirrhosis also has trouble removing toxins, which may build up in the blood. These toxins can dull mental function and lead to personality changes and even coma (encephalopathy). Early signs of toxin accumulation in the brain may include neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleeping habits.

Drugs taken usually are filtered out by the liver, and this cleansing process is also slowed down by cirrhosis. The liver does not remove the drugs from the blood at the usual rate, so the drugs act longer than expected, building up in the body. People with cirrhosis are often very sensitive to medications and their side effects.

A serious problem for people with cirrhosis is pressure on blood vessels that flow through the liver. Normally, blood from the intestines and spleen is pumped to the liver through the portal vein. But in cirrhosis, this normal flow of blood is slowed, building pressure in the portal vein (portal hypertension). This blocks the normal flow of blood, causing the spleen to enlarge. So blood from the intestines tries to find a way around the liver through new vessels.

Some of these new blood vessels become quite large and are called "varices." These vessels may form in the stomach and esophagus (the tube that connects the mouth with the stomach). They have thin walls and carry high pressure. There is great danger that they may break, causing a serious bleeding problem in the upper stomach or esophagus. If this happens, the patient's life is in danger, and the doctor must act quickly to stop the bleeding.

How is Cirrhosis Diagnosed?
The doctor often can diagnose cirrhosis from the patients symptoms and from laboratory tests. During a physical exam, for instance, the doctor could notice a change in how your liver feels or how large it is. If the doctor suspects cirrhosis, you will be given blood tests. The purpose of these tests is to find out if liver disease is present. In some cases, other tests that take pictures of the liver are performed such as the computerized axial tomography (CAT) scan, ultrasound, and the radioisotope liver/spleen scan.

The doctor may decide to confirm the diagnosis by putting a needle through the skin (biopsy) to take a sample of tissue from the liver. In some cases, cirrhosis is diagnosed during surgery when the doctor is able to see the entire liver. The liver also can be inspected through a laparoscope, a viewing device that is inserted through a tiny incision in the abdomen.

What are the Treatments for Cirrhosis?
Treatment of cirrhosis is aimed to stop the development of scar tissue in the liver and prevent complications. When cirrhosis is due to an identifiable cause, treatment programs may be specific, such as for management of hepatitis B and C, or steroids and immunosuppressive agents for auto-immune chronic active hepatitis.

No matter what the cause of cirrhosis, every patient must avoid all substances, habits, and drugs that may further damage the liver, precipitate complications, or speed the progression to liver failure. Alcohol, in addition to causing cirrhosis, may accelerate the progression of liver scarring due to other causes, such as hepatitis C. All patients with liver disease should not drink alcoholic beverages. Even some non-prescription drugs and vitamins, acetaminophen, in relatively small doses (more than five doses a day) and vitamin A (more than 25,000 IU/day) may precipitate liver failure. Non-steroidal anti-inflammatory drugs, such as ibuprofen, may precipitate severe bleeding and/or kidney failure.

The cirrhotic patient is at increased risk of contracting other infections that may be more severe than in healthy patients. Immunizations for hepatitis A, B, influenza, and pneumococcal pneumonia are available and should be administered. Raw seafood may contain bacteria that can cause life-threatening infections and therefore should be avoided.

How Are the Complications of Cirrhosis Treated?
The abnormal accumulation of fluid may cause swelling of the ankles (edema) and abdomen (ascites). Therefore, patients should reduce the amount of fluid and salt in their diet or use drugs called "diuretics” that mobilize and excrete the excess fluid through the kidneys. Occasionally, the ascites may become infected, a condition known as Spontaneous Bacterial Peritonitis, and require treatment with antibiotics.

When the liver does not efficiently function to cleanse the body of toxins and drugs, the mental state of patients may change dramatically and lead to coma, called Hepatic Encephalopathy. Treatment is directed at reducing the protein in the diet, avoiding sedatives and pain medications, and using laxatives and/or antibiotics to decrease the absorption of toxins from the intestines.

Sometimes, bleeding from the esophagus or stomach caused by abnormal veins (varices) may occur and is a life-threatening emergency requiring hospitalization. Variceal bleeding can usually be controlled with the use of a flexible tube (endoscope) that is inserted through the mouth into the esophagus and stomach and used to inject clotting agents into the veins or to rubberband ligate the varices.

Liver failure refers to the end stage of liver disease and cirrhosis when the liver stops working and cannot support life. Liver failure is difficult to treat and survival is limited. Therefore, patients with any complication of cirrhosis are considered to be at risk of developing liver failure.

When complications develop, it may be possible to manage them. When it is likely that liver failure will develop, some patients with cirrhosis are able to undergo liver transplantation. The treating gastroenterologist may recommend liver transplantation when complications of cirrhosis develop in an attempt to avoid liver failure.

Colitis:

Colitis refers to inflammation in the large intestine. It may be due to infections like Salmonella, diseases like Ulcerative Colitis or Crohn's Disease or related to stress called Irritable Bowel Syndrome.

Constipation:

Constipation is the infrequent and difficult passage of stool. The frequency of bowel movements among healthy people varies greatly, ranging from three movements a day to three a week. As a rule, if more than 3 days pass without a bowel movement, the intestinal contents may harden, and a person may have difficulty or even pain during elimination. Stool may harden and be painful to pass, even after shorter intervals between bowel movements.

What Are Some Common Misconceptions About Constipation?

Many false beliefs exist concerning proper bowel habits. One of these is that a bowel movement every day is necessary. Another common fallacy is that wastes stored in the body are absorbed and are dangerous to health or shorten the life span. These misconceptions have led to a marked overuse and abuse of laxatives. Every year, Americans spend $725 million on laxatives. Many are not needed and some are harmful.

What Are Some of the Causes of Constipation?
Constipation is a symptom, not a disease. Like a fever, constipation can be caused by many different conditions. Most people have experienced an occasional brief bout of constipation that has corrected itself with diet and time. The following is a list of some of the most common causes of constipation:

Poor Diet.
A main cause of constipation may be a diet high in animal fats (meats, dairy products, eggs) and refined sugar (rich desserts and other sweets), but low in fiber (vegetables, fruits, whole grains). Some studies have suggested that high-fiber diets result in larger stools, more frequent bowel movements, and therefore less constipation.

Imaginary Constipation.
This is very common and results from misconceptions about what is normal and what is not. If recognized early enough, this type of constipation can be cured by informing the sufferer that the frequency of his or her bowel movements is normal.

Irritable Bowel Syndrome (IBS).
Also known as spastic colon, IBS is one of the most common causes of constipation in the United States. Some people develop spasms of the colon that delay the speed with which the contents of the intestine move through the digestive tract, leding to constipation.

Poor Bowel Habits.
A person can initiate a cycle of constipation by ignoring the urge to have a bowel movement. Some people do this to avoid using public toilets, others because they are too busy. After a period of time a person may stop feeling the urge. This leads to progressive constipation.

Laxative Abuse.
People who habitually take laxatives become dependent upon them and may require increasing dosages until, finally, the intestine becomes insensitive and fails to work properly.

Travel.
People often experience constipation when traveling long distances, which may relate to changes in lifestyle, schedule, diet, and drinking water.

Hormonal Disturbances.
Certain hormonal disturbances, such as an underactive thyroid gland, can produce constipation.

Pregnancy.
Pregnancy is another common cause of constipation. The reason may be partly mechanical, in that the pressure of the heavy womb compresses the intestine, and may be partly due to hormonal changes during pregnancy.

Fissures and Hemorrhoids.
Painful conditions of the anus can produce a spasm of the anal sphincter muscle, which can delay a bowel movement.

Specific Diseases.
Many diseases that affect the body tissues, such as scleroderma or lupus, and certain neurological or muscular diseases, such as multiple sclerosis, Parkinson's disease, and stroke, can be responsible for constipation.

Loss of Body Salts.
The loss of body salts through the kidneys or through vomiting or diarrhea is another cause of constipation.

Mechanical Compression.
Scarring, inflammation around diverticula, tumors, and cancer can produce mechanical compression of the intestine and result in constipation.

Nerve Damage.
Injuries to the spinal cord and tumors pressing on the spinal cord can produce constipation by affecting the nerves that lead to the intestine.

Medications.
Many medications can cause constipation. These include pain medications (especially narcotics), antacids that contain aluminum, antispasmodic drugs, antidepressant drugs, tranquilizers, iron supplements, and anti-convulsants for epilepsy.

What Causes Constipation in Children?
Constipation is common in children and may be related to any of the causes noted in the previous section. In a small number of children, constipation may be the result of physical problems. Children with such defects as the absence of normal nerve endings in portions of the bowel, abnormalities of the spinal cord, thyroid deficiency, mental retardation, and certain other inherited metabolic disorders often suffer symptoms of constipation. Constipation in children, however, usually is due to poor bowel habits.

Studies show that many children who suffer from constipation when they are older have a history of passing stools that are firmer than average in their early weeks of life. Because this occurs before there are significant variations in diet, habits, or attitudes, it suggests that many children who develop constipation have a normal tendency to have firmer stools. Such children suffer little from the tendency unless it is aggravated by poor bowel habits or poor diet.

Constipation may result in pain when the child has bowel movements. Cracks in the skin, called fissures, may develop in the anus. These fissures can bleed or increase pain, causing a child to withhold his or her stool.

Children may withhold their stools for other reasons as well. Some find it inconvenient to use toilets outside the home. Also, severe emotional stress caused by family crises or difficulties at school may cause children to withhold their stools. In these instances, the periods between bowel movements may become quite long, in some cases lasting longer than 1 or 2 weeks. These children may develop fecal impactions, a situation where the stool is packed so tightly in the bowel that the normal pushing action of the bowel is not enough to expel the stool spontaneously.

What Causes Constipation in Older Adults?
Older adults are five times more likely than younger adults to report problems with constipation. Poor diet, insufficient intake of fluids, lack of exercise, the use of certain drugs to treat other conditions, and poor bowel habits can result in constipation. Experts agree, however, that too often older people become overly concerned with having a bowel movement and that constipation is frequently an imaginary ailment.

Diet and dietary habits can play a role in developing constipation. Lack of interest in eating (a problem common to many single or widowed older people) may lead to heavy use of convenience foods, which tend to be low in fiber. In addition, loss of teeth may force older people to choose soft, processed foods, which also tend to be low in fiber.

Older people sometimes cut back on fluids, especially if they are not eating regular or balanced meals. Water and other fluids add bulk to stools, making bowel movements softer and easier to pass.

Prolonged bedrest, for example, after an accident or during an illness, and lack of exercise may contribute to constipation. Also, drugs prescribed for other conditions, such as antidepressants, antacids containing aluminum or calcium, antihistamines, diuretics, and antiparkinsonism drugs, can produce constipation in some people.

The preoccupation with bowel movements sometimes leads older people to depend heavily on laxatives, which can be habit-forming. The bowel begins to rely on laxatives to bring on bowel movements, and over time, the natural mechanisms fail to work without the help of drugs. Habitual use of enemas also can lead to a loss of normal function.

What Diagnostic Tests Can Help Determine the Causes of Constipation?
Constipation may be caused by abnormalities or obstructions of the digestive system in some people. A doctor can perform tests to determine if constipation is the symptom of an underlying disorder.

In addition to routine blood, urine, and stool tests, a sigmoidoscopy may help detect problems in the rectum and lower colon. In this procedure, which can be done in the doctor's office, the doctor inserts a flexible, lighted instrument through the anus to examine the rectum and lower intestine. The doctor may perform a colonoscopy to inspect the entire colon. In colonoscopy, an instrument similar to the sigmoidoscope, but longer and able to follow the twists and turns of the entire large intestine, is used. A barium enema x-ray will provide similar information. If bleeding is present, a double-contrast barium enema is preferred. Other highly specialized techniques are available for measuring pressures and movements within the colon and its sphincter muscles, but these are used only in unusual cases.

Is Constipation Serious?
Although it may be extremely bothersome, constipation itself usually is not serious. However, it may signal and be the only noticeable symptom of a serious underlying disorder such as cancer. Constipation can lead to complications, such as hemorrhoids caused by extreme straining or fissures caused by the hard stool stretching the sphincters. Bleeding can occur for either of these reasons and appears as bright red streaks on the surface of the stool. Fissures may be quite painful and can aggravate the constipation that originally caused them. Fecal impactions tend to occur in very young children and in older adults and may be accompanied by a loss of control of stool, with liquid stool flowing around the hard impaction.

Occasionally, straining causes a small amount of intestinal lining to push out from the rectal opening. This condition is known as rectal prolapse and may lead to secretion of mucus that may stain underpants. In children, mucus may be a feature of cystic fibrosis.

When Is Medical Attention Neded?
The doctor should be notified when symptoms are severe, last longer than 3 weeks, or are disabling; or when any of the complications listed above occur. The doctor should be informed whenever a significant and prolonged change of usual bowel habits occurs.

What Is the Treatment for Constipation?
The first step in treating constipation is to understand that normal frequency varies widely, from three bowel movements a day to three a week. Each person must determine what is normal to avoid becoming dependent on laxatives.

For most people, dietary and lifestyle improvements can lessen the chances of constipation. A well-balanced diet that includes fiber-rich foods, such as unprocessed bran, whole-grain breads, and fresh fruits and vegetables, is recommended. Drinking plenty of fluids and exercising regularly will help to stimulate intestinal activity. Special exercises may be necessary to tone up abdominal muscles after pregnancy or whenever abdominal muscles are lax.

Bowel habits also are important. Sufficient time should be set aside to allow for undisturbed visits to the bathroom. In addition, the urge to have a bowel movement should not be ignored.

If an underlying disorder is causing constipation, treatment will be directed toward the specific cause. For example, if an underactive thyroid is causing constipation, the doctor may prescribe thyroid hormone replacement therapy.

In most cases, laxatives should be the last resort and taken only under a doctor's supervision. A doctor is best qualified to determine when a laxative is needed and which type is best. There are various types of oral laxatives, and they work in different ways. (See box on page 5.) Above all, it is necessary to recognize that a successful treatment program requires persistent effort and time. Constipation does not occur overnight, and it is not reasonable to expect that constipation can be relieved overnight.

Oral Laxatives.
Bulk-forming laxatives are generally considered the safest laxative form but can interfere with theabsorption of some drugs. These laxatives, which should be taken with 8 ounces of water, absorb water in the intestine and make the stool softer. Bulk laxatives include psyllium (Metamucil), methylcellulose(Citrucel), calcium polycarbophil (FiberCon), and bran (in food and supplements).

Stimulants cause rhythmic muscular contractions in the small or large intestine. These agents can lead to dependency and can damage the bowel with prolonged daily use. These products include phenolphtha-lein (Correctol, Ex-Lax), bisacodyl (Dulcolax), castor oil (Purge, Neoloid), and senna (Senokot, Fletcher's Castoria).

Stool softeners, or wetting agents, provide moisture to the stool and prevent excessive dehydration.These laxatives often are recommended after childbirth or surgery. Products include those with docusate (Colace, Dialose, and Surfak).

Lubricants grease the stool and make it slip through the intestine more easily. Mineral oil is the most commonly used lubricant.

Osmotics are salts or carbohydrates that cause water to remain in the intestine for easier movement of stool. Laxatives in this group include milk of magnesia, citrate of magnesia, lactulose, and Epsom salts.

Summary:
The frequency of bowel movements among healthy people varies from three movements a day to three a week. Individuals must determine what is normal. As a rule, constipation should be suspected if more than 3 days pass between bowel movements or if there is difficulty or pain when passing a hardened stool. Most people experience occasional short bouts of constipation, but if a laxative is necessary for longer than 3 weeks, check with a doctor.

Doctors agree that prevention is the best approach to constipation. While there is no way to ensure never experiencing constipation, the following guidelines should help:

Know what is normal and do not rely unnecessarily on laxatives.
Eat a well-balanced diet that includes unpro-cessed bran, whole wheat grains, fresh fruits and vegetables.
Drink plenty of fluids.
Exercise regularly.
Set aside time after breakfast or dinner for undisturbed visits to the toilet.
Don't ignore the urge to defecate.
Whenever there is a significant or prolonged change in bowel habits, check with a doctor

Additional Readings
Cummings M. Overuse hazardous: laxatives rarely needed. FDA Consumer 1991; 25(3): 33-35. Article reprint available from the Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857, or in libraries. This article discusses the dangers of the overuse of laxatives and suggests alternative methods for treating constipation.

Diet, Nutrition, & Cancer Prevention: The Good News (NIH Publication No. 87-2878). Pamphlet available from the Cancer Information Service, Office of Cancer Communications, National Cancer Institute, 9000 Rockville Pike, Bethesda, MD 20892. 1-800-4-CANCER. Discusses high-fiber diet and fiber-rich foods.

Larson DE, Editor-in-chief. Mayo Clinic Family Health Book. New York: William Morrow and Company, Inc., 1990. General medical guide that includes a section on constipation. Available in libraries and bookstores.

Marshall JB. Chronic constipation in adults: how far should evaluation and treatment go? Postgraduate Medicine 1990; 88(3): 49-51, 54-59, 63. This article for primary care physicians offers advice on diagnosis and treatment of constipation.

Murray FE, Bliss CM. Geriatric constipation: brief update on a common problem. Geriatrics 1991; 46(3): 64-68. This article for health professionals discusses the causes and management of constipation in older adults.

National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892-3570

The National Digestive Diseases Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, under the U.S. Public Health Service. The clearinghouse was authorized by Congress to focus a national effort onproviding information to the public, patients and their families, and doctors and other health care professionals. The clearinghouse works with organizations to educate people about digestive health and disease. The clearinghouse answers inquires; develops, reviews, and distributes publications; and coordinates informational resources about digestive diseases.

Crohn's Disease:

Inflammatory bowel disease (IBD) is a group of chronic disorders that cause inflammation or ulceration in the small and large intestines. Most often IBD is classified as ulcerative colitis or Crohn's disease but may be referred to as colitis, enteritis, ileitis, and proctitis.

Ulcerative colitis causes ulceration and inflammation of the inner lining of the colon and rectum, while Crohn's disease is an inflammation that extends into the deeper layers of the intestinal wall.

Ulcerative colitis and Crohn's disease cause similar symptoms that often resemble other conditions such as irritable bowel syndrome (spastic colitis). The correct diagnosis may take some time.

Crohn's disease usually involves the small intestine, most often the lower part (the ileum). In some cases, both the small and large intestine (colon or bowel) are affected. In other cases, only the colon is involved. Sometimes, inflammation also may affect the mouth, esophagus, stomach, duodenum, appendix, or anus. Crohn's disease is a chronic condition and may recur at various times over a lifetime. Some people have long periods of remission, sometimes for years, when they are free of symptoms. There is no way to predict when a remission may occur or when symptoms will return.

What Are the Symptoms?
The most common symptoms of Crohn's disease are abdominal pain, often in the lower right area, and diarrhea. There also may be rectal bleeding, weight loss, and fever. Bleeding may be serious and persistent, leading to anemia (low red blood cell count). Children may suffer delayed development and stunted growth.

What Causes Crohn's Disease and Who Gets It?
There are many theories about what causes Crohn's disease, but none has been proven. One theory is that some agent, perhaps a virus or a bacterium, affects the body's immune system to trigger an inflammatory reaction in the intestinal wall. Although there is a lot of evidence that patients with this disease have abnormalities of the immune system, doctors do not know whether the immune problems are a cause or a result of the disease. Doctors believe, however, that there is little proof that Crohn's disease is caused by emotional distress or by an unhappy childhood.Crohn's disease affects males and females equally and appears to run in some families. About 20 percent of people with Crohn's disease have a blood relative with some form of inflammatory bowel disease, most often a brother or sister and sometimes a parent or child.

How Does Crohn's Disease Affect Children?
Women with Crohn's disease who are considering having children can be comforted to know that the vast majority of such pregnancies will result in normal children. Research has shown that the course of pregnancy and delivery is usually not impaired in women with Crohn's disease. Even so, it is a good idea for women with Crohn's disease to discuss the matter with their doctors before pregnancy. Children who do get the disease are sometimes more severely affected than adults, with slowed growth and delayed sexual development in some cases.

How Is Crohn's Disease Diagnosed?
If you have experienced chronic abdominal pain, diarrhea, fever, weight loss, and anemia, the doctor will examine you for signs of Crohn's disease. The doctor will take a history and give you a thorough physical exam. This exam will include blood tests to find out if you are anemic as a result of blood loss, or if there is an increased number of white blood cells, suggesting an inflammatory process in your body. Examination of a stool sample can tell the doctor if there is blood loss, or if an infection by a parasite or bacteria is causing the symptoms.The doctor may look inside your rectum and colon through a flexible tube (endoscope) that is inserted through the anus. During the exam, the doctor may take a sample of tissue (biopsy) from the lining of the colon to look at under the microscope.Later, you also may receive x-ray examinations of the digestive tract to determine the nature and extent of disease. These exams may include an upper gastrointestinal (GI) series, a small intestinal study, and a barium enema intestinal x-ray. These procedures are done by putting the barium, a chalky solution, into the upper or lower intestines. The barium shows up white on x-ray film, revealing inflammation or ulceration and other abnormalities in the intestine.If you have Crohn's disease, you may need medical care for a long time. Your doctor also will want to test you regularly to check on your condition.

What Is the Treatment?
Several drugs are helpful in controlling Crohn's disease, but at this time there is no cure. The usual goals of therapy are to correct nutritional deficiencies; to control inflammation; and to relieve abdominal pain, diarrhea, and rectal bleeding. Abdominal cramps and diarrhea may be helped by drugs. The drug Sulfasalazine often lessens the inflammation, especially in the colon. This drug can be used for as long as needed, and it can be used along with other drugs. Side effects such as nausea, vomiting, weight loss, heartburn, diarrhea, and headache occur in a small percentage of cases. Patients who do not do well on sulfasalazine often do very well on related drugs known as mesalamine or 5-ASA agents. More serious cases may require steroid drugs, antibiotics, or drugs that affect the body's immune system such as azathioprine or 6-mercaptopurine (6-MP).

Can Diet Control Crohn's Disease?
No special diet has been proven effective for preventing or treating this disease. Some people find their symptoms are made worse by milk, alcohol, hot spices, or fiber. But there are no hard and fast rules for most people. Follow a good nutritious diet and try to avoid any foods that seem to make your symptoms worse.
Large doses of vitamins are useless and may even cause harmful side effects. Your doctor may recommend nutritional supplements, especially for children with growth retardation. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need periods of feeding by vein. This can help patients who temporarily need extra nutrition, those whose bowels need to rest, or those whose bowels cannot absorb enough nourishment from food taken by mouth.

What Are the Complications of Crohn's Disease?
The most common complication is blockage (obstruction) of the intestine. Blockage occurs because the disease tends to thicken the bowel wall with swelling and fibrous scar tissue, narrowing the passage. Crohn's disease also may cause deep ulcer tracts that burrow all the way through the bowel wall into surrounding tissues, into adjacent segments of intestine, into other nearby organs such as the urinary bladder or vagina, or into the skin. These tunnels are called fistulas. They are a common complication and often are associated with pockets of infection or abcesses (infected areas of pus). The areas around the anus and rectum often are involved. Sometimes fistulas can be treated with medicine, but in many cases they must be treated surgically. Crohn's disease also can lead to complications that affect other parts of the body. These systemic complications include various forms of arthritis, skin problems, inflammation in the eyes or mouth, kidney stones, gallstones, or other diseases of the liver and biliary system. Some of these problems respond to the same treatment as the bowel symptoms, but others must be treated separately.

Is Surgery Often Necessary?
Crohn's disease can be helped by surgery, but it cannot be cured by surgery. The inflammation tends to return in areas of the intestine next to the area that has been removed. Many Crohn's disease patients require surgery, either to relieve chronic symptoms of active disease that does not respond to medical therapy or to correct complications such as intestinal blockage, perforation, abscess, or bleeding. Drainage of abscesses or resection (removal of a section of bowel) due to blockage are common surgical procedures. Sometimes the diseased section of bowel is removed. In this operation, the bowel is cut above and below the diseased area and reconnected. Infrequently some people must have their colons removed (colectomy) and an ileostomy created. In an ileostomy, a small opening is made in the front of the abdominal wall, and the tip of the lower small intestine (ileum) is brought to the skin's surface. This opening, called a stoma, is about the size of a quarter or a 50-cent piece. It usually is located in the right lower corner of the abdomen in the area of the beltline. A bag is worn over the opening to collect waste, and the patient empties the bag periodically. The majority of patients go on to live normal, active lives with an ostomy. The fact that Crohn's disease often recurs after surgery makes it very important for the patient and doctor to consider carefully the benefits and risks of surgery compared with other treatments. Remember, most people with this disease continue to lead useful and productive lives. Between periods of disease activity, patients may feel quite well and be free of symptoms. Even though there may be long-term needs for medicine and even periods of hospitalization, most patients are able to hold productive jobs, marry, raise families, and function successfully at home and in society.

Additional Readings
Bleeding in the Digestive Tract and Ulcerative Colitis.
National Digestive Diseases Information Clearinghouse, 2 Information Way, Bethesda, MD 20892-3570; (301) 654-3810. General patient information fact sheets.Brandt, LJ, Steiner-Grossman, P, eds. Treating IBD: A Patient's Guide to the Medical and Surgical Management of Inflammatory Bowel Disease. New York: Raven Press, 1989. General guide for patients with sections on treatment and descriptions and drawings of surgical procedures. Available from the Crohn's & Colitis Foundation of America.Hanauer, SB, Peppercorn, MD, Present, DH. Current concepts, new therapies in IBD. Patient Care, 1992; 26(13): 79-102. General review article for health care professionals.Steiner-Grossman, P, Banks PA, Present, DH, eds. The New People Not Patients: A Source Book for Living with IBD. Dubuque, Iowa: Kendall/Hunt Publishing Company, 1992. Book for patients with sections on diagnostic tests, medications, nutrition, coping with employment and health insurance problems, and IBD in children and teenagers, older adults, and during pregnancy. Available from the Crohn's & Colitis Foundation of America.

Additional Resources
Crohn's & Colitis Foundation of America, Inc., 386 Park Avenue South, 17th Floor, New York, NY 10016-8804; (800) 932-2423 or (212) 685-3440.Pediatric Crohn's & Colitis Association, Inc., P.O. Box 188, Newton, MA 02168; (617) 244-6678.Reach Out for Youth with Ileitis and Colitis, Inc., 15 Chemung Place, Jericho, NY 11753; (516) 822-8010.United Ostomy Association, 36 Executive Park, Suite 120, Irvine, CA 92714; (800) 826-0826 or (714) 660-8624.

National Digestive Diseases Information Clearinghouse

2 INFORMATION WAY
BETHESDA, MD 20892-3570

NIH Publication No. 95-3410
October 1992

Diarrhea:

Diarrhea is an increased frequency in the number of bowel movements in a 24 hour period.

This may be caused by many different disorders including food poisoning, infections, food allergy, malabsorption (not absorbing food properly), medications and antacids.

Digestive Diseases Statistics:

All Digestive Diseases
Prevalence: 60 to 70 million people affected by all digestive diseases (1985)
Mortality: 191,000, including deaths from cancer (1985)
Hospitalizations: 10 million (13 percent of all hospitalization) (1985)
Diagnostic and therapeutic procedures: 6 million (14 percent of all procedures) (1987)
Physician office visits: 50 million (1985)
Disability: 1.4 million people (1987)
Costs:
$107 billion (1992)
$87 billion direct medical costs
$20 billion indirect costs (e.g., disability and mortality) Specific Diseases

Abdominal Wall Hernia
Incidence: 800,000 new cases, including 500,000 inguinal hernias (1985)
Prevalence: 4.5 million people (1988-90)
Hospitalizations: 640,000 (1980)
Physician office visits: 2 to 3 million (1989-90)
Prescriptions: 184,000 (1989-90)
Disability: 550,000 people (1983-87)

Chronic Liver Disease and Cirrhosis
Prevalence: 400,000 people (1976-80)
Mortality: 26,050 deaths (1987)
Hospitalizations: 300,000 (1987)
Physician office visits: 1 million (1985)

Disability: 112,000 people (1983-87) Constipation
Prevalence: 4.4 million people (1983-87)
Mortality: 29 deaths (1982-85)
Hospitalizations: 100,000 (1983-87)
Physician office visits: 2 million (1985)
Prescriptions: 1 million (1985)
Disability: 13,000 people (1983-87)

Diverticular Disease
Incidence: 300,000 new cases (1987)
Prevalence: 2 million people (1983-87)
Mortality: 3,000 deaths (1985)
Hospitalizations: 440,000 (1987)
Physician office visits: 2 million (1987)
Disability: 112,000 people (1983-87)

Gallstones
Prevalence: 16 to 22 million people (1976-87)
Mortality: 2,975 (1985)
Hospitalizations: 800,000 (1987)
Physician office visits: 600,000 to 700,000 (1985)
Prescriptions: 195,000 (1985)
Surgical procedures: 500,000 cholecystectomies (1987)
Disability: 48,000 people (1983-87)

Gastritis and Nonulcer Dyspepsia (NUD)
Incidence:
Gastritis: 313,000 new cases (1975)
Chronic NUD: 444,000 new cases (1975)
Acute NUD: 8.2 million new cases (1988)
Prevalence:
Gastritis: 2.7 million people (1988)
NUD: 5.8 million people (1988)
Mortality:
Gastritis: 703 (1980s)
NUD: 49 (1980s)
Hospitalizations:
Gastritis: 600 (1980s)
NUD: 65,000 (1980s)
Physician office visits:
Gastritis: 3 million (1980s)
NUD: 800,000 (1980s)
Prescriptions:
Gastritis: 2 million (1985)
NUD: 649,000 (1985)
Disability:
Gastritis: 34,000 people (1983-87)
Chronic NUD: 42,000 people (1983-87)
Gastroesophageal Reflux Disease and Related Esophageal Disorders
Prevalence: 3 to 7 percent of U.S. population (1985)
Mortality: 1,000 deaths (1984-88)
Hospitalizations: 1 million (1985)
Physician office visits: 4 to 5 million (1985)
(1983-87)
Incidence: 1 million new cases
Prevalence: 10.4 million people
Mortality: 17 deaths
Hospitalizations: 316,000
Physician office visits: 3.5 million
Prescriptions: 1.5 million
Disability: 52,000 people

Infectious Diarrhea
Incidence: 99 million new cases (1980)
Mortality: 3,100 deaths (1985)
Hospitalizations: 462,000 to 728,000 (1987)
Physician office visits: 8 to 12 million (1985)
Prescriptions: 5 to 8 million (1985)
Inflammatory Bowel Disease (1987)
Incidence: 2 to 6 new cases per 100,000 people
Prevalence: 300,000 to 500,000 people
Mortality: Fewer than 1,000 deaths
Hospitalizations: 100,000 (64 percent for Crohn's disease)
Physician office visits: 700,000
Disability: 119,000 people (1983-87)

Irritable Bowel Syndrome
Prevalence: 5 million people (1987)
Hospitalizations: 34,000 (1987)
Physician office visits: 3.5 million (1987)
Prescriptions: 2.2 million (1985)
Disability: 400,000 people (1983-87)
Lactose Intolerance
Prevalence: 30 to 50 million people (1994)

Pancreatitis
Incidence: Acute: 17 new cases per 100,000 people (1976-88)
Mortality: 2,700 deaths (1985)
Hospitalizations:
Acute: 125,000 (1987)
Chronic: 20,000 (1987)
Physician office visits:
Acute: 911,000 (1987)
Chronic: 122,000 (1987)

Peptic Ulcer
Prevalence: 5 million people (1987)
Mortality: 6,500 deaths (1987)
Hospitalizations: 630,000 (1987)
Physician office visits: 3 to 5 million (1985)
Prescriptions: 2 million (1985)
Disability: 401,000 people (1983-87)

Viral Hepatitis
Incidence:
Hepatitis A: 32,000 new cases (1992)
Hepatitis B: 200,000 to 300,000 new cases (1990)
Hepatitis C: 150,000 new cases (1991)
Hepatitis D: 70,000 new cases (1990)
Prevalence:
Hepatitis A: 32 to 38 percent of U.S. population that have any history of disease (1991)
Hepatitis B: 4 percent of U.S. population that have any history of disease (1990)
Hepatitis C and D: Not determined
Mortality: Fewer than 1,000 deaths (1985)
Hospitalizations: 33,000 (1987)
Physician office visits: 500,000 (1985)
Additional Data

Liver Transplants

3,300 transplants performed (1993)

Number of gastroenterologists in the United States
7,493 (1990)

Sources

Unless noted, the data in this fact sheet are from:

Everhart, JE, editor. Digestive Diseases in the United States: Epidemiology and Impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH publication no. 94-1447.

The book answers hundreds of questions about the scope and impact of the major infectious, chronic, and malignant digestive diseases. National and special population based data provide information about the prevalence, incidence, medical care, disability, mortality, and research needs regarding specific digestive diseases. The data were compiled primarily from the surveys of the National Center for Health Statistics, supplemented by other Federal agencies and private sources.

The book is available for $15 from the National Digestive Diseases Information Clearinghouse at the address and phone number listed below. Please make checks payable to "NDDIC."

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

United Network for Organ Sharing Scientific Registry

American Medical Association Physician Characteristics and Distribution in the United States, 1992 Ed., Chicago, Illinois: American Medical Association, 1992, p. 20.

Glossary
Data for digestive diseases as a group and for specific diseases are provided in various categories. Data do not exist in all categories for some diseases. Following are definitions of the categories as used in this fact sheet:

Disability: The number of people in a year whose ability to perform major daily activities such as working, housekeeping, and going to school, is limited and reduced over long periods because of a disease.

Hospitalizations: The number of hospitalizations for a disease in a year.

Incidence: The number of new cases of a disease in the U.S. population in a year.

Mortality: The number of deaths resulting from the disease listed as the underlying or primary cause in a year.

Physician office visits: The number of outpatient visits to office-based physicians for a disease in a year.

Prescriptions: The number of prescriptions written annually for medications to treat a specific disease.

Prevalence: The number of people in the United States affected by a disease or diseases in a year.

Procedures: The number of diagnostic and therapeutic procedures performed annually in a hospital setting.

National Digestive Diseases Information Clearinghouse

2 Information Way
Bethesda, MD 20892-3570

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, under the U.S. Public Health Service. The clearinghouse, authorized by Congress in 1980, provides information about digestive diseases and health to people with digestive diseases and their families, heatlth care professionals, and the public. The NDDIC answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and government agencies to coordinate resources about digestive diseases.

Publications produced by the clearinghouse are reviewed carefully for scientific accuracy, content, and readability. Publications produced by other sources are also reviewed for scientific accuracy and are used, along with clearinghouse publications, to answer requests.

This etext is not copyrighted. The clearinghouse urges users of this epub to duplicate and distribute as many copies as desired.

NIH Publication No. 95-3873

Gallstones:

The gallbladder is a small pear-shaped organ located beneath the liver on the right side of the abdomen. The gallbladder's primary functions are to store and concentrate bile, and secrete bile into the small intestine at the proper time to help digest food.

The gallbladder is connected to the liver and the small intestine by a series of ducts, or tube-shaped structures, that carry bile. Collectively, the gallbladder and these ducts are called the biliary system.

Bile is a yellow-brown fluid produced by the liver. In addition to water, bile contains cholesterol, lipids (fats), bile salts (natural detergents that break up fat), and bilirubin (the bile pigment that gives bile and stools their color). The liver can produce as much as three cups of bile in 1 day, and at any one time, the gallbladder can store up to a cup of concentrated bile.

As food passes from the stomach into the small intestine, the gallbladder contracts and sends its stored bile into the small intestine through the common bile duct. Once in the small intestine, bile helps digest fats in foods. Under normal circumstances, most bile is recirculated in the digestive tract by being absorbed in the intestine and returning to the liver in the bloodstream.

What Are Gallstones?
Gallstones are pieces of solid material that form in the gallbladder. Gallstones form when substances in the bile, primarily cholesterol and bile pigments, form hard, crystal-like particles.

Cholesterol stones are usually white or yellow in color and account for about 80 percent of gallstones. They are made primarily of cholesterol.

Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They account for the other 20 percent of gallstones. Risk factors for pigment stones include cirrhosis, biliary tract infections, and hereditary blood cell disorders, such as sickle cell anemia.

Gallstones vary in size and may be as small as a grain of sand or as large as a golf ball. The gallbladder may develop a single, often large, stone or many smaller ones, even several thousand.

What Causes Gallstones?
Progress has been made in understanding the process of gallstone formation. Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, body weight, gallbladder motility (movement), and perhaps diet.

Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors seem to be important in causing gallstones. The first is how often and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone formation. The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones.

Other factors also seem to play a role in causing gallstones but how is not clear. Obesity has been shown to be a major risk factor for gallstones. A large clinical study showed that being even moderately overweight increases one's risk for developing gallstones. This is probably true because obesity tends to cause excess cholesterol in bile, low bile salts, and decreased gallbladder emptying. Very low calorie, rapid weight-loss diets, and prolonged fasting, seem to also cause gallstone formation.

In addition, increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the use of birth control pills, may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation.

No clear relationship has been proven between diet and gallstone formation. However, low-fiber, high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation.

Who Is at Risk for Gallstones?
This year, more than 1 million people in the United States will learn they have gallstones. They will join the estimated 20 million Americans--roughly 10 percent of the population--who already have gallstones.

Those who are most likely to develop gallstones are:

Women between 20 and 60 years of age. They are twice as likely to develop gallstones than men.
Men and women over age 60.
Pregnant women or women who have used birth control pills or estrogen replacement therapy.
Native Americans. They have the highest prevalence of gallstones in the United States. A majority of Native American men have gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women have gallstones by age 30.
Mexican-American men and women of all ages.
Men and women who are overweight.
People who go on "crash" diets or who lose a lot of weight quickly.

What Are the Symptoms of Gallstones?
Most people with gallstones do not have symptoms. They have what are called silent stones. Studies show that most people with silent stones remain symptom free for years and require no treatment. Silent stones usually are detected during a routine medical checkup or examination for another illness.

What Problems Can Occur?
A gallstone attack usually is marked by a steady, severe pain in the upper abdomen. Attacks may last only 20 or 30 minutes but more often they last for one to several hours. A gallstone attack may also cause pain in the back between the shoulder blades or in the right shoulder and may cause nausea or vomiting. Attacks may be separated by weeks, months, or even years. Once a true attack occurs, subsequent attacks are much more likely.

Sometimes gallstones may make their way out of the gallbladder and into the cystic duct, the channel through which bile travels from the gallbladder to the small intestine. If stones become lodged in the cystic duct and block the flow of bile, they can cause cholecystitis, inflammation of the gallbladder. Blockage of the cystic duct is a common complication caused by gallstones.

A less common but more serious problem occurs if the gallstones become lodged in the bile ducts between the liver and the intestine. This condition can block bile flow from the gallbladder and liver, causing pain and jaundice. Gallstones may also interfere with the flow of digestive fluids secreted from the pancreas into the small intestine, leading to pancreatitis, inflammation of the pancreas.

Prolonged blockage of any of these ducts can cause severe damage to the gallbladder, liver, or pancreas, which can be fatal. Warning signs include fever, jaundice, and persistent pain.

How Are Gallstones Diagnosed?
Many times gallstones are detected during an abdominal x-ray, computerized axial tomography (CT) scan, or abdominal ultrasound that has been taken for an unrelated problem or complaint.

When actually looking for gallstones, the most common diagnostic tool is ultrasound. An ultrasound examination, also known as ultrasonography, uses sound waves. Pulses of sound waves are sent into the abdomen to create an image of the gallbladder. If stones are present, the sound waves will bounce off the stones, revealing their location.

Ultrasound has several advantages. It is a noninvasive technique, which means nothing is injected into or penetrates the body. Ultrasound is painless, has no known side effects, and does not involve radiation.

How Are Gallstones Treated?

Surgery

Despite the development of nonsurgical techniques, gallbladder surgery, or cholecystectomy, is the most common method for treating gallstones. Each year more than 500,000 Americans have gallbladder surgery. Surgery options include the standard procedure, called open cholecystectomy, and a less invasive procedure, called laparoscopic cholecystectomy.

The standard cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 5-to 8-inch incision. Patients may remain in the hospital about a week and may require several additional weeks to recover at home.

Laparoscopic cholecystectomy is a new alternative procedure for gallbladder removal. Some 15,000 surgeons have received training in the technique since its introduction in the United States in 1988. Currently about 80 percent of cholecystectomies are performed using laparoscopes.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through separate small incisions. The gallbladder is identified and carefully separated from the liver and other structures. Finally, the cystic duct is cut and the gallbladder removed through one of the small incisions. This type of surgery requires meticulous surgical skill.

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection. Recovery is usually only a night in the hospital and several days recuperation at home.

The most common complication with the new procedure is injury to the common bile duct, which connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed nonsurgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. At this time it is unclear whether these complications are more common following laparoscopic cholecystectomy than following standard cholecystectomy.

Complications such as abdominal adhesions and other problems that obscure vision are discovered during about 5 percent of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder.

Many surgeons believe that laparoscopic cholecystectomy soon will totally replace open cholecystectomy for routine gallbladder removals. Open cholecystectomy will probably remain the recommended approach for complicated cases.

A Consensus Development Conference panel, convened by the National Institutes of Health in September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel noted, however, that laparoscopic cholecystectomy should be performed only by experienced surgeons and only on patients who have symptoms of gallstones.

In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly influenced by the training, experience, skill, and judgment of the surgeon performing the procedure. Therefore, the panel recommended that strict guidelines be developed for training and granting credentials in laparoscopic surgery, determining competence, and monitoring quality. According to the panel, efforts should continue toward developing a noninvasive approach to gallstone treatment that will not only eliminate existing stones, but also prevent their formation or recurrence.

What Are the Alternatives to Gallbladder Surgery?

In addition to surgery, nonsurgical approaches have been pursued but are used only in special situations and only for gallstones that are predominantly cholesterol.

Oral dissolution therapy with ursodiol (Actigallr) and chenodiol (Chenixr) works best for small, cholesterol gallstones. These medicines are made from the acid naturally found in bile. They most often are used in individuals who cannot tolerate surgery. Treatment may be required for months to years before gallstones are dissolved.

Mild diarrhea is a side effect of both drugs; chenodiol may also temporarily elevate the liver enzyme transaminase and mildly elevate blood cholesterol levels.

Two therapies, contact dissolution with methyltert butyl ether instillation through a catheter placed into the gallbladder and extracorporeal shock-wave lithotripsy (ESWL), are still experimental.

Each of these alternatives to gallbladder surgery leaves the gallbladder intact; so stone recurrence, which happens in about one-half the cases, is a major drawback.

Additional Readings
Gupta, KL. Cholelithiasis: New options for diagnosis and treatment of its complications. Senior Patient 1991; 3(1): 42, 44-46. Article for health professionals explores new options for diagnosis of gallstones and treatment of complications.

Lewis, R. Gallbladder: an organ you can live without. FDA Consumer 1991; 25(4): 13-15. Article for a lay audience reviews current information about gallbladder function and disease.

Traverso, LW. Laparoscopic cholecystectomy. Practical Gastroenterology 1991; 15(4): 16, 21, 25-27. Article for health professionals discusses surgical technique of laparoscopic cholecystectomy.

Your gallstones: diagnosis and treatment, 1991. Digestive Disease National Coalition, 711 Second Street, NE, Suite 2, Washington, DC 20002; (202) 544-7497. Brochure outlines causes, diagnosis, and treatments of gallstones.

National Digestive Diseases Information Clearinghouse

2 INFORMATION WAY
BETHESDA, MD 20892-3570

NIH Publication No. 95-2897

Gastroesophageal Reflux Disease:

Hiatal Hernia and Heartburn
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 Gastroesophageal Reflux?
Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus.

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

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

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 nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent such as alginic acid helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occuring.

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

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

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

Tips To Control Heartburn

Avoid foods and beverages that affect LES pressure or irritate the esophagus lining, including fried and fatty foods, peppermint, chocolate, alcohol, coffee, citrus fruit and juices, and tomato products.
Lose weight if overweight.
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 a 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.

Conclusion

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

Additional Readings

Cramer T. A burning question: When do you need an antacid? FDA Consumer 1992; 26(1): 19-22. This article for consumers provides general information about antacids.

Larson DE, Editor-in-chief. Mayo Clinic Family Health Book. New York: William Morrow and Company, Inc., 1990. This general medical guide includes sections about esophageal reflux and hiatal hernia.

Richter JE. Why does surgery work for GERD? Practical Gastroenterology 1993; XVII(10): 10-18. This article for physicians describes antireflux surgery.

Sutherland JE. Gastroesophageal reflux disease: when antacids aren't enough. Postgraduate Medicine 1991; 89(7): 45-53. This article for primary care physicians provides guidelines to determine if a patient has reflux disease and offers treatment methods.

National Digestive Diseases Information Clearinghouse

2 Information Way
Bethesda, MD 20892-3570

The National Digestive Diseases Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, under the U.S. Public Health Service. The clearinghouse, authorized by Congress in 1980, provides information about digestive diseases and health to people with digestive diseases and their families, health care professionals, and the public. The clearinghouse answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and government agencies to coordinate resources about digestive diseases.

Hemochromatosis:

Hemochromatosis is the #1 genetic killer in the U.S., affecting nearly two million Americans, yet most victims are unaware that they have it. Hemochromatosis is also very common in Europe and Western Africa. If left undetected and untreated, hemochromatosis is fatal in most cases.

Hemochromatosis is an inherited disorder of the small intestine that causes a person to absorb too much iron from their food. Over time, iron builds to toxic levels and destroys many organs. Symptoms of toxic iron excess can differ greatly from person to person. Symptoms might include fatigue or depression, arthritis, impotence and infertility, diabetes, heart disease, liver disease or liver cancer. Fortunately, early detection and treatment will prevent iron excess and its toxic effects.

Although hemochromatosis is widespread, the blood test for it, called a "fasting Percent TIBC Saturation" (% TIBC SAT), is rarely included in general screenings. A 1994 study in the Archives Of Internal Medicine showed the cost-effectiveness of the test "over a wide range" of conditions and recommended adding the test to routine blood screens. The test costs $40-$60 in most areas and is covered by many insurance plans.

The Hemochromatosis Foundation is a nonprofit organization that has worked for nearly twenty years to improve the lives of people with hemochromatosis. For more information about the disease, screening events in your area, or how you can help in finding the cure for hemochromatosis, contact your local chapter, or write to:

HF
PO Box 8569
Albany, NY 12208

Hemorrhoids:

What Are Hemorrhoids?

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

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

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

What Are the Symptoms of Hemorrhoids?

Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as hemorrhoids.
Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days.
Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid.
Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.

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 lasts more than a couple of days. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.

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

Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.
To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.

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 (laser coagulation) or infrared light (infrared photo coagulation) - Both techniques use special devices to burn hemorrhoidal tissue.

Hemorrhoidectomy - Occasionally, extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy. This is the best method for permanent removal of hemorrhoids.

How Are Hemorrhoids Prevented?

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass. In addition, a person should not sit on the toilet for a long period of time.

Additional Readings

Bleeding in the Digestive Tract. 1992. Fact sheet discusses many common causes of bleeding in the digestive tract and related diagnostic procedures and treatment. Available from the National Digestive Diseases Information Clearinghouse, Box NDDIC, 9000 Rockville Pike, Bethesda, Maryland 20892.

Cocchiara, J.L. Hemorrhoids: A practical approach to an aggravating problem. Postgraduate Medicine 1991; 89(1): 149-152. Article for health care professionals discusses causes, symptoms, and treatments.
Sohn, N. Hemorrhoids: Etiology, pathogenesis, classification, and medical therapy. Practical Gastroenterology 1991; XV(9): 21-24. General article for physicians.

Stehlin, D. No strain no pain: The bottom line in treating hemorrhoids. FDA Consumer 1992; 26(2): 31-33. General information article for patients and the public.

National Digestive Diseases Information Clearinghouse

2 Information Way
Bethesda, MD 20892-3570

Hepatitis:

Hepatitis refers to inflammation of the liver. Most commonly we think of viral hepatitis caused by several different viruses-A, B, C, Delta and Infectious Mononucleosis. Medications may also cause hepatitis.

Jaundice:

Jaundice is a symptom of liver disease and manifests as yellow discoloration of the skin and sclera (whites of the eyes). Usually when one is jaundiced the urine may be very dark in color and the stool very light.

Lactose Intolerance:

What is Lactose Intolerance?

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

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

Some causes of lactose intolerance are well known. For instance, certain digestive diseases and injuries to the small intestine can reduce the amount of enzymes produced. In rare cases, children are born without the ability to produce lactase. For most people, though, lactase deficiency is a condition that develops naturally over time. After about the age of 2 years, the body begins to produce less lactase. However, many people may not experience symptoms until they are much older.

Between 30 and 50 million Americans are lactose intolerant. Certain ethnic and racial populations are more widely affected than others. As many as 75 percent of all African-Americans and Native Americans and 90 percent of Asian-Americans are lactose intolerant. The condition is least common among persons of northern European descent.

How Is Lactose Intolerance Diagnosed?

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

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

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

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

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

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

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.

The recommended dietary allowance (RDA) for calcium, revised in 1989 by the Food and Nutrition Board of the National Academy of Sciences, varies by age group. Infants up to 5 months need 400 mg per day, and from 5 months to 1 year, 600 mg. Children 1 to 10 years need 800 mg and 11- to 24-year-olds need 1,200 mg. Pregnant and nursing women also need 1,200 mg per day, and people age 25 and older need 800 mg per day. However, the results of a 1984 conference at the National Institutes of Health (NIH) suggest that women who have not yet reached menopause and older women who are taking the hormone estrogen after menopause should consume about 1,000 mg of calcium daily (roughly the amount in a quart of milk).

In planning meals, making sure that each day's diet includes enough calcium is important, even if the diet does not contain dairy products. Many nondairy foods are high in calcium. Green vegetables, such as broccoli and kale, and fish with soft, edible bones, such as salmon and sardines, are excellent sources of calcium.

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

Clearly, many foods can provide the calcium and other nutrients the body needs, even when intake of milk and dairy products is limited. However, factors other than calcium and lactose content should be kept in mind when planning a diet. Some vegetables that are high in calcium (Swiss chard, spinach, and rhubarb, for instance) are not listed in figure 2 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 nonfat dry milk powder. If any of these are listed on a label, the item contains lactose.

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

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

Additional Readings

American Dietetic Association. Lactose Intolerance: A Resource Including Recipes, Food Sensitivity Series (1991). American Dietetic Association, 216 West Jackson Blvd. Chicago, IL 60606. (312) 899-0040. Resource book provides recipes and information about food products.

Kidder B. The Milk-Free Kitchen: Living Well Without Dairy Products: 450 Family-Style Recipes. New York: Henry Holt and Company, 1991. Cookbook with 450 lactose-free recipes.

Montes RG, Perman JA. Lactose intolerance: pinpointing the source of nonspecific gastrointestinal symptoms. Postgraduate Medicine 1991;89 (8):175-184. Article for health care professionals explains diagnosis and treatment of lactose intolerance.

Zukin J. Dairy-Free Cookbook. New York: St. Martin's Press, 1989. Commercial Writing Service, P.O. Box 3074, Iowa City, IA 52244. Book contains more than 150 recipes and practical information for living with lactose intolerance.

Zukin J. The Newsletter For People With Lactose Intolerance and Milk Allergy. Commercial Writing Service, P.O. Box 3074, Iowa City, IA 52244. Newsletter provides practical information, resources, and recipes.

National Digestive Diseases Information Clearinghouse

2 Information Way
Bethesda, MD 20892-3570

The National Digestive Diseases Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, under the U.S. Public Health Service. The clearinghouse, authorized by Congress in 1980, is designed to increase knowledge and understanding about digestive diseases and health among people with digestive diseases and their families, health care professionals, and the public. The clearinghouse answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and government agencies to coordinate informational resources about digestive diseases.

Liver Disease:

As gastroenterologists, we treat many types of liver disease. Most commonly we see Hepatitis
related to viral infections or medications and cirrhosis related to alcoholism. Other less common
disorders include Primary Biliary Cirrhosis, Fatty Liver Syndrome, Hemochromatosis and Sclerosing
Cholangitis.

Nervous Stomach:

There is a whole constellation of symptoms which fall into the realm of the Irritable Bowel Syndrome or nervous stomach. This frequently has been called Spastic Colitis. This is not a disease but rather a group of symptoms which may be attributed to stress, tension and anxiety. The symptoms may be diarrhea, diarrhea alternating with constipation, constipation, mucus in the stools and abdominal pain. Often the diagnosis is made after a reasonable medical evaluation is performed to rule out other causes of the symptoms.

Pancreatitis:

Pancreatitis is inflammation of the pancreas. This condition usually begins at an acute stage, and in some cases, may become chronic after a severe and/or recurrent attack. When the pancreas becomes inflamed, the digestive enzymes attack the tissue that produces them. One of these enzymes, called tryspin, can cause tissue damage and bleeding, and can cause the pancreas blood cells and blood vessels to swell. With chronic pancreatitis, the pancreas may eventually stop producing the enzymes that are necessary for your body to digest and absorb nutrients. This is called exocrine failure and fat and protein are not digested or absorbed. When chronic pancreatitis is advanced, the pancreas can also lose its ability to make insulin; this is called endocrine failure.

There are two stages of pancreatitis:

Acute Pancreatitis: This condition can occur suddenly, soon after the pancreas becomes damaged or irritated by its own enzymes. Although acute pacreatitis is not fully understood, it is usually caused by gallstones or alcohol abuse. When gallstones pass through the bile duct, they become stuck, causing enzymes to build up in the pancreas because they cannot drain through the duct, and damaging the pancreas. In the case of alcohol, the pancreas may be sensitive to the effects of excessive alcohol. An attack may occur anywhere from a few hours or one or two days after drinking alcohol. The amount of alcohol consumed will vary from person to person. Other less common causes of this condition are: excessive levels of fat particles in the blood, mumps, drugs, surgery, heredity, and idiopathic (unknown cause). Acute pancreatitis affects about 80,000 Americans every year.

Chronic Pancreatitis: This stage of pancreatitis begins as acute pancreatitis, and becomes chronic when the pancreas becomes scarred. This condition is usually due to years of excessive alcohol consumption, but may also develop from other causes of pancreatitis.

What Are The Symptoms of Pancreatitis?

The symptoms begin as those of acute pancreatitis:

A gradual or sudden severe pain in the center part of the upper abdomen goes through to the back; this pain may get worse when you eat and builds to a persistent pain.
Nausea and vomiting.
Fever
Jaundice (a yellowing of the skin) due to blockage of the bile duct from the inflamed pancreas.
Shock
Weight loss
Symptoms of Diabetes Mellitus
Most chronic pancreatitis is due to alcohol abuse and is already chronic at its first presentation. In rare cases this condition leads to cancer of the pancreas, an unchecked growth of abnormal cells in the pancreas.

What Should I Do If I Think I Have Pancreatitis?

If your abdominal pain lasts longer than 20 minutes, call your doctor or go to the emergency room. Your doctor will take a medical history, ask about your drinking history, and draw blood to test for pancreatic enzymes. You may also need to take pancreas function tests to determine the loss of pancreatic enzymes, a fecal fat collection test for evidence of malabsorption, and an ultrasound, CT scan or other tests to determine pancreas damage.
If you have unexplained weight loss that lasts more than a few weeks, call your doctor. This can be a warning sign of pancreatic cancer.

What Is The Difference Between Acute and Chronic Pancreatitis?

Most cases of acute pancreatitis are mild and involve a short hospital stay to help heal the pancreas. Chronic pancreatitis is a much more persistent condition, and occurs more often in men than women.

What Is The Treatment For Pancreatitis?

I will focus treatment on your nutritional and metabolic needs and on relieving your pain. Mild pain can be treated with analgesics. If the cause of acute pancreatitis is gallstones, you may have to have your gallbladder removed to prevent further attacks. If the bile duct is found to be enlarged, you may need an ERCP (endoscopic retrograde cholangiopancreatography) to drain it. An ERCP is a way your doctor can examine your pancreas, pancreatic duct, the common bile duct, and/or sphincter of Oddi. It involves passage of a long, narrow tube called an endoscope used to put X-ray contrast dye into the Biliary and Pancreatic ducts. In severe cases, surgery will be required to drain the pancreatic duct or to remove part of the pancreas.

Your doctor will also likely give you dietary guidelines to follow in order to reduce the amount of fat you eat, since your body has trouble digesting these substances. You may also need to take pancreatic enzymes supplements, which are in the form of a tablet, every time you have a meal. These supplements will help your body absorb food and help you regain some of the lost weight.

What Hope For The Future?

Most people who have chronic pancreatitis have a good prognosis if they follow the required dietary changes and take their medications and required supplements. If their condition was caused by drinking, they will have a positive outcome if they stop drinking and continue follow-up treatment.

Stomach and Duodenal Ulcers:

What Is an Ulcer?

During normal digestion, food moves from the mouth down the esophagus and into the stomach. The stomach produces hydrochloric acid and an enzyme called pepsin to digest the food. From the stomach, food passes into the upper part of the small intestine, called the duodenum, where digestion and nutrient absorption continue.

An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where acid and pepsin are present. Ulcers in the stomach are called gastric or stomach ulcers. Those in the duodenum are called duodenal ulcers. In general, ulcers in the stomach and duodenum are referred to as peptic ulcers. Ulcers rarely occur in the esophagus or in the first portion of the duodenum, the duodenal bulb.

Who Has Ulcers?

About 20 million Americans develop at least one ulcer during their lifetime. Each year:

Ulcers affect about 4 million people.
More than 40,000 people have surgery because of persistent symptoms or problems from ulcers.
About 6,000 people die of ulcer-related complications.
Ulcers can develop at any age, but they are rare among teenagers and even more uncommon in children. Duodenal ulcers occur for the first time usually between the ages of 30 and 50. Stomach ulcers are more likely to develop in people over age 60. Duodenal ulcers occur more frequently in men than women; stomach ulcers develop more often in women than men.

What Causes Ulcers?

For almost a century, doctors believed lifestyle factors such as stress and diet caused ulcers. Later, researchers discovered that an imbalance between digestive fluids (hydrochloric acid and pepsin) and the stomach's ability to defend itself against these powerful substances resulted in ulcers. Today, research shows that most ulcers develop as a result of infection with bacteria called Helicobacter pylori (H. pylori). While all three of these factors--lifestyle, acid and pepsin, and H. pylori--play a role in ulcer development, H. pylori is now considered the primary cause.

Lifestyle
While scientific evidence refutes the old belief that stress and diet cause ulcers, several lifestyle factors continue to be suspected of playing a role. These factors include cigarettes, foods and beverages containing caffeine, alcohol, and physical stress.

Smoking
Studies show that cigarette smoking increases one's chances of getting an ulcer. Smoking slows the healing of existing ulcers and also contributes to ulcer recurrence.

Caffeine
Coffee, tea, colas, and foods that contain caffeine seem to stimulate acid secretion in the stomach, aggravating the pain of an existing ulcer. However, the amount of acid secretion that occurs after drinking decaffeinated coffee is the same as that produced after drinking regular coffee. Thus, the stimulation of stomach acid cannot be attributed solely to caffeine.

Alcohol
Research has not found a link between alcohol consumption and peptic ulcers. However, ulcers are more common in people who have cirrhosis of the liver, a disease often linked to heavy alcohol consumption.

Stress
Although emotional stress is no longer thought to be a cause of ulcers, people with ulcers often report that emotional stress increases ulcer pain. Physical stress, however, increases the risk of developing ulcers particularly in the stomach. For example, people with injuries such as severe burns and people undergoing major surgery often require rigorous treatment to prevent ulcers and ulcer complications.

Acid and pepsin
Researchers believe that the stomach's inability to defend itself against the powerful digestive fluids, acid and pepsin, contributes to ulcer formation. The stomach defends itself from these fluids in several ways. One way is by producing mucus--a lubricant-like coating that shields stomach tissues. Another way is by producing a chemical called bicarbonate. This chemical neutralizes and breaks down digestive fluids into substances less harmful to stomach tissue. Finally, blood circulation to the stomach lining, cell renewal, and cell repair also help protect the stomach.

Nonsteroidal anti-inflammatory drugs (NSAIDs) make the stomach vulnerable to the harmful effects of acid and pepsin. NSAIDs such as aspirin, ibuprofen, and naproxen sodium are present in many non-prescription medications used to treat fever, headaches, and minor aches and pains. These, as well as prescription NSAIDs used to treat a variety of arthritic conditions, interfere with the stomach's ability to produce mucus and bicarbonate and affect blood flow to the stomach and cell repair. They can all cause the stomach's defense mechanisms to fail, resulting in an increased chance of developing stomach ulcers. In most cases, these ulcers disappear once the person stops taking NSAIDs.

Helicobacter pylori

H. pylori is a spiral-shaped bacterium found in the stomach. Research shows that the bacteria (along with acid secretion) damage stomach and duodenal tissue, causing inflammation and ulcers. Scientists believe this damage occurs because of H. pylori's shape and characteristics.

H. pylori survives in the stomach because it produces the enzyme urease. Urease generates substances that neutralize the stomach's acid--enabling the bacteria to survive. Because of their shape and the way they move, the bacteria can penetrate the stomach's protective mucous lining. Here, they can produce substances that weaken the stomach's protective mucus and make the stomach cells more susceptible to the damaging effects of acid and pepsin.

The bacteria can also attach to stomach cells further weakening the stomach's defensive mechanisms and producing local inflammation. For reasons not completely understood, H. pylori can also stimulate the stomach to produce more acid.

Excess stomach acid and other irritating factors can cause inflammation of the upper end of the duodenum, the duodenal bulb. In some people, over long periods of time, this inflammation results in production of stomach-like cells called duodenal gastric metaplasia. H. pylori then attacks these cells causing further tissue damage and inflammation, which may result in an ulcer.

Within weeks of infection with H. pylori, most people develop gastritis--an inflammation of the stomach lining. However, most people will never have symptoms or problems related to the infection. Scientists do not yet know what is different in those people who develop H. pylori-related symptoms or ulcers. Perhaps, hereditary or environmental factors yet to be discovered cause some individuals to develop problems. Alternatively, symptoms and ulcers may result from infection with more virulent strains of bacteria. These unanswered questions are the subject of intensive scientific research.

Studies show that H. pylori infection in the United States varies with age, ethnic group, and socioeconomic class. The bacteria are more common in older adults, African Americans, Hispanics, and lower socio- economic groups. The organism appears to spread through the fecal-oral route (when infected stool comes into contact with hands, food, or water). Most individuals seem to be infected during childhood, and their infection lasts a lifetime.

The History of Helicobacter pylori

In 1982, Australian researchers Barry Marshall and Robin Warren discovered spiral-shaped bacteria in the stomach, later named Helicobacter pylori (H. pylori). After closely studying H. pylori's effect on the stomach, they proposed that the bacteria were the underlying cause of gastritis and peptic ulcers.
Marshall and Warren came to this conclusion because in their studies all patients with duodenal ulcers and 80 percent of patients with stomach ulcers had the bacteria. The 20 percent of patients with stomach ulcers who did not have H. pylori were those who had taken NSAIDs such as aspirin and ibuprofen, which are a common cause of stomach ulcers.
Although their findings seem conclusive, Marshall and Warren's theory was hotly debated and remained in dispute. The debate continued even after Marshall and a colleague performed an experiment in which they infected themselves with H. pylori and developed gastritis.
Evidence linking H. pylori to ulcers mounted over the next 10 years as numerous studies from around the world confirmed its presence in most people with ulcers. Moreover, researchers from the United States and Europe proved that using antibiotics to eliminate H. pylori healed ulcers and prevented recurrence in about 90 percent of cases.
To further investigate these findings, the National Institutes of Health (NIH) established a panel to closely review the link between H. pylori and peptic ulcer disease. At the February 1994 Consensus Development Conference, the panel concluded that H. pylori plays a significant role in the development of ulcers and that antibiotics with other medicines can cure peptic ulcer disease.

What Are the Symptoms of Ulcers?

The most common ulcer symptom is a gnawing or burning pain in the abdomen between the breastbone and the navel. The pain often occurs between meals and in the early hours of the morning. It may last from a few minutes to a few hours and may be relieved by eating or by taking antacids.

Less common ulcer symptoms include nausea, vomiting, and loss of appetite and weight. Bleeding from ulcers may occur in the stomach and duodenum. Sometimes people are unaware that they have a bleeding ulcer, because blood loss is slow and blood may not be obvious in the stool. These people may feel tired and weak. If the bleeding is heavy, blood will appear in vomit or stool. Stool containing blood appears tarry or black.

How Are Ulcers Diagnosed?

The NIH Consensus Panel emphasized the importance of adequately diagnosing ulcer disease and H. pylori before starting treatment. If the person has an NSAID-induced ulcer, treatment is quite different from the treatment for a person with an H. pylori-related ulcer. Also, a person's pain may be the result of nonulcer dyspepsia (persistent pain or discomfort in the upper abdomen including burning, nausea, and bloating), and not at all related to ulcer disease. Currently, doctors have a number of options available for diagnosing ulcers, such as performing endoscopic and x-ray examinations, and for testing for H. pylori.

Locating and monitoring ulcers

Doctors may perform an upper GI series to diagnose ulcers. An upper GI series involves taking an x-ray of the esophagus, stomach, and duodenum to locate an ulcer. To make the ulcer visible on the x-ray image, the patient swallows a chalky liquid called barium.

An alternative diagnostic test is called an endoscopy. During this test, the patient is lightly sedated and the doctor inserts a small flexible instrument with a camera on the end through the mouth into the esophagus, stomach, and duodenum. With this procedure, the entire upper GI tract can be viewed. Ulcers or other conditions can be diagnosed and photographed, and tissue can be taken for biopsy, if necessary.

Once an ulcer is diagnosed and treatment begins, the doctor will usually monitor clinical progress. In the case of a stomach ulcer, the doctor may wish to document healing with repeat x-rays or endoscopy. Continued monitoring of a stomach ulcer is important because of the small chance that the ulcer may be cancerous.

Testing for H. pylori

Confirming the presence of H. pylori is important once the doctor has diagnosed an ulcer because elimination of the bacteria is likely to cure ulcer disease. Blood, breath, and stomach tissue tests may be performed to detect the presence of H. pylori. While some of the tests for H. pylori are not approved by the U.S. Food and Drug Administration (FDA), research shows these tests are highly accurate in detecting the bacteria. However, blood tests on occasion give false positive results, and the other tests may give false negative results in people who have recently taken antibiotics, omeprazole (Prilosec), or bismuth (Pepto-Bismol).

Blood tests--Blood tests such as the enzyme-linked immunosorbent assay (ELISA) and quick office-based tests identify and measure H. pylori antibodies. The body produces antibodies against H. pylori in an attempt to fight the bacteria. The advantages of blood tests are their low cost and availability to doctors. The disadvantage is the possibility of false positive results in patients previously treated for ulcers since the levels of H. pylori antibodies fall slowly. Several blood tests have FDA approval.

Breath tests--Breath tests measure carbon dioxide in exhaled breath. Patients are given a substance called urea with carbon to drink. Bacteria break down this urea and the carbon is absorbed into the blood stream and lungs and exhaled in the breath. By collecting the breath, doctors can measure this carbon and determine whether H. pylori is present or absent. Urea breath tests are at least 90 percent accurate for diagnosing the bacteria and are particularly suitable to follow-up treatment to see if bacteria have been eradicated. These tests are awaiting FDA approval.

Tissue tests--If the doctor performs an endoscopy to diagnose an ulcer, tissue samples of the stomach can be obtained. The doctor may then perform one of several tests on the tissue. A rapid urease test detects the bacteria's enzyme urease. Histology involves visualizing the bacteria under the microscope. Culture involves specially processing the tissue and watching it for growth of H. pylori organisms.

How Are Ulcers Treated?

Lifestyle changes
In the past, doctors advised people with ulcers to avoid spicy, fatty, or acidic foods. However, a bland diet is now known to be ineffective for treating or avoiding ulcers. No particular diet is helpful for most ulcer patients. People who find that certain foods cause irritation should discuss this problem with their doctor. Smoking has been shown to delay ulcer healing and has been linked to ulcer recurrence; therefore, persons with ulcers should not smoke.

Medicines
Doctors treat stomach and duodenal ulcers with several types of medicines including H2-blockers, acid pump inhibitors, and mucosal protective agents. When treating H. pylori, these medications are used in combination with antibiotics.

H2-blockers--Currently, most doctors treat ulcers with acid-suppressing drugs known as H2-blockers. These drugs reduce the amount of acid the stomach produces by blocking histamine, a powerful stimulant of acid secretion.

H2-blockers reduce pain significantly after several weeks. For the first few days of treatment, doctors often recommend taking an antacid to relieve pain.

Initially, treatment with H2-blockers lasts 6 to 8 weeks. However, because ulcers recur in 50 to 80 percent of cases, many people must continue maintenance therapy for years. This may no longer be the case if H. pylori infection is treated. Most ulcers do not recur following successful eradication. Nizatidine (Axid) is approved for treatment of duodenal ulcers but is not yet approved for treatment of stomach ulcers. H2-blockers that are approved to treat both stomach and duodenal ulcers are:

Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid).
Acid pump inhibitors--Like H2-blockers, acid pump inhibitors modify the stomach's production of acid. However, acid pump inhibitors more completely block stomach acid production by stopping the stomach's acid pump--the final step of acid secretion. The FDA has approved use of Omeprazole for short-term treatment of ulcer disease. Similar drugs, including Lansoprazole, are currently being studied.

Mucosal protective medications--Mucosal protective medications protect the stomach's mucous lining from acid. Unlike H2-blockers and acid pump inhibitors, protective agents do not inhibit the release of acid. These medications shield the stomach's mucous lining from the damage of acid. Two commonly prescribed protective agents are:

Sucralfate (Carafate). This medication adheres to the ulcer, providing a protective barrier that allows the ulcer to heal and inhibits further damage by stomach acid. Sucralfate is approved for short-term treatment of duodenal ulcers and for maintenance treatment.
Misoprostol (Cytotec). This synthetic prostaglandin, a substance naturally produced by the body, protects the stomach lining by increasing mucus and bicarbonate production and by enhancing blood flow to the stomach. It is approved only for the prevention of NSAID-induced ulcers.
Two common non-prescription protective medications are:

Antacids. Antacids can offer temporary relief from ulcer pain by neutralizing stomach acid. They may also have a mucosal protective role. Many brands of antacids are available without prescription.
Bismuth Subsalicylate. Bismuth subsalicylate has both a protective effect and an antibacterial effect against H. pylori.
Antibiotics--The discovery of the link between ulcers and H. pylori has resulted in a new treatment option. Now, in addition to treatment aimed at decreasing the production of stomach acid, doctors may prescribe antibiotics for patients with H. pylori. This treatment is a dramatic medical advance because eliminating H. pylori means the ulcer may now heal and most likely will not come back.

The most effective therapy, according to the NIH Panel, is a 2-week, triple therapy. This regimen eradicates the bacteria and reduces the risk of ulcer recurrence in 90 percent of people with duodenal ulcers. People with stomach ulcers that are not associated with NSAIDs also benefit from bacterial eradication. While triple therapy is effective, it is sometimes difficult to follow because the patient must take three different medications four times each day for 2 weeks.

Typical 2-week, triple therapy

Metronidazole 4 times a day
Tetracycline (or amoxicillin) 4 times a day
Bismuth subsalicylate 4 times a day
Typical 2-week, dual therapy

Amoxicillin 2 to 4 times a day, or clarithromycin 3 times a day
Omeprazole 2 times a day

In addition, the treatment commonly causes side effects such as yeast infection in women, stomach upset, nausea, vomiting, bad taste, loose or dark bowel movements, and dizziness. The 2-week, triple therapy combines two antibiotics, tetracycline (e.g., Achromycin or Sumycin) and metronidazole (e.g., Flagyl) with bismuth subsalicylate (Pepto-Bismol). Some doctors may add an acid-suppressing drug to relieve ulcer pain and promote ulcer healing. In some cases, doctors may substitute amoxicillin (e.g., Amoxil or Trimox) for tetracycline or if they expect bacterial resistance to metronidazole, other antibiotics such as clarithromycin (Biaxin).

As an alternative to triple therapy, several 2-week, dual therapies are about 80 percent effective. Dual therapy is simpler for Patients to follow and causes fewer side effects. A dual therapy might include an antibiotic, such as Amoxicillin or Clarithromycin, with Omeprazole, a drug that stops the production of acid.

Again, an accurate diagnosis is important. Accurate diagnosis and appropriate treatment prevent people without ulcers from needless exposure to the side effects of antibiotics and should lessen the risk of bacteria developing resistance to antibiotics.

Although all of the above antibiotics are sold in the United States, the FDA has not yet approved the use of antibiotics for treatment of H. pylori or ulcers. Doctors may choose to prescribe antibiotics to their ulcer patients as "off label" prescriptions as they do for many conditions.

When Is Surgery Needed?

In most cases, anti-ulcer medicines heal ulcers quickly and effectively. Eradication of H. pylori prevents most ulcers from recurring. However, people who do not respond to medication or who develop complications may require surgery. While surgery is usually successful in healing ulcers and preventing their recurrence and future complications, problems can sometimes result.

At present, standard open surgery is performed to treat ulcers. In the future, surgeons may use laparoscopic methods. A laparoscope is a long tube-like instrument with a camera that allows the surgeon to operate through small incisions while watching a video monitor. The common types of surgery for ulcers--vagotomy, pyloroplasty, and antrectomy--are described below:

Vagotomy
A vagotomy involves cutting the vagus nerve, a nerve that transmits messages from the brain to the stomach. Interrupting the messages sent through the vagus nerve reduces acid secretion. However, the surgery may also interfere with stomach emptying. The newest variation of the surgery involves cutting only parts of the nerve that control the, acid-secreting cells of the stomach, thereby avoiding the parts that influence stomach emptying.

Antrectomy
Another surgical procedure is the antrectomy. This operation removes the lower part of the stomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. Sometimes a surgeon may also remove an adjacent part of the stomach that secretes pepsin and acid. A vagotomy is usually done in conjunction with an antrectomy.

Pyloroplasty
Pyloroplasty is another surgical procedure that may be performed along with a vagotomy. Pyloroplasty enlarges the opening into the duodenum and small intestine (pylorus), enabling contents to pass more freely from the stomach.

What Are the Complications of Ulcers?
People with ulcers may experience serious complications if they do not get treatment. The most common problems include bleeding, perforation of the organ walls, and narrowing and obstruction of digestive tract passages.

Bleeding
As an ulcer eats into the muscles of the stomach or duodenal wall, blood vessels may also be damaged, which causes bleeding. If the affected blood vessels are small, the blood may slowly seep into the digestive tract. Over a long period of time, a person may become anemic and feel weak, dizzy, or tired.

If a damaged blood vessel is large, bleeding is dangerous and requires prompt medical attention. Symptoms include feeling weak and dizzy when standing, vomiting blood, or fainting. The stool may become a tarry black color from the blood.

Most bleeding ulcers can be treated endoscopically when the ulcer is located and the blood vessel is cauterized with a heating device or injected with material to stop bleeding. If endoscopic treatment is unsuccessful, surgery may be required.

Perforation
Sometimes an ulcer eats a hole in the wall of the stomach or duodenum. Bacteria and partially digested food can spill through the opening into the sterile abdominal cavity (peritoneum). This causes peritonitis, an inflammation of the abdominal cavity and wall. A perforated ulcer that can cause sudden, sharp, severe pain usually requires immediate hospitalization and surgery.

Narrowing and obstruction
Ulcers located at the end of the stomach where the duodenum is attached, can cause swelling and scarring, which can narrow or close the intestinal opening. This obstruction can prevent food from leaving the stomach and entering the small intestine. As a result, a person may vomit the contents of the stomach. Endoscopic balloon dilation, a procedure that uses a balloon to force open a narrow passage, may be performed. If the dilation does not relieve the problem, then surgery may be necessary.

Points to Remember
An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where the digestive fluids, acid and pepsin are present.

Recent research shows that most ulcers develop as a result of infection with bacteria called Helicobacter pylori (H. pylori). The bacteria produce substances that weaken the stomach's protective mucus and make the stomach more susceptible to damaging effects of acid and pepsin. H. pylori can also cause the stomach to produce more acid. Although acid, pepsin and lifestyle factors such as stress and smoking cigarettes play a role in ulcer formation, H. pylori is now considered the primary cause.

Nonsteroidal anti-inflammatory drugs such as aspirin make the stomach vulnerable to the harmful effects of acid and pepsin, leading to an increased chance of stomach ulcers.

Ulcers do not always cause symptoms. When they do, the most common symptom is a gnawing or burning pain in the abdomen between the breastbone and navel. Some people have nausea, vomiting, and loss of appetite and weight.
Bleeding from an ulcer may occur in the stomach and duodenum. Symptoms may include weakness and stool that appears tarry or black. However, sometimes people are not aware they have a bleeding ulcer because blood may not be obvious in the stool.

Ulcers are diagnosed with x-ray or endoscopy. The presence of H. pylori may be diagnosed with a blood test, breath test, or tissue test. Once an ulcer is diagnosed and treatment begins, the doctor will usually monitor progress.
Doctors treat ulcers with several types of medicines aimed at reducing acid production, including H2blockers, acid pump inhibitors, and mucosal protective drugs. When treating H. pylori, these medications are used in combination with antibiotics.

According to an NIH panel, the most effective treatment for H. pylori is a 2-week, triple therapy of metronidazole, tetracycline or amoxicillin, and bismuth subsalicylate.
Surgery may be necessary if an ulcer recurs or fails to heal or if complications such as bleeding, perforation, or obstruction develop.

Conclusion
Although ulcers may cause discomfort, rarely are they life threatening. With an understanding of the causes and proper treatment, most people find relief. Eradication of H. pylori infection is a major medical advance that can permanently cure most peptic ulcer disease.

Additional Reading
DeCross AJ, Peura DA. Role of H. Pylori in peptic ulcer disease. Contemporary Gastroenterology, 1992; 5(4): 18-28.

Fedotin MS. Helicobacter pylori and peptic ulcer disease: Reexamining the therapeutic approach. Postgraduate Medicine, 1993; 94(3): 38-45.

Gilbert G, Chan CH, Thomas E. Peptic ulcer disease: how to treat it now. Postgraduate Medicine, 1991; 89(4): 91-98.

Larson DE, Editor-in-Chief. Mayo Clinic Family Health Book. New York: William Morrow and Company, Inc., 1990. General medical guide with sections on stomach problems and ulcers.

National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892-3570

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, under the U.S. Public Health Service. The clearinghouse, authorized by Congress in 1980, provdes information about digestive diseases and health to people with digestive diseases and their families, health care professionals, and the public. The NDDIC answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and government agencies to coordinate resources about digestive diseases.

Ulcerative Colitis:

Ulcerative colitis causes ulceration and inflammation of the inner lining of the colon and rectum, while Crohn's disease is an inflammation that extends into the deeper layers of the intestinal wall. Crohn's disease also may affect other parts of the digestive tract, including the mouth, esophagus, stomach, and small intestine.

Ulcerative colitis and Crohn's disease cause similar symptoms that often resemble other conditions, such as irritable bowel syndrome (spastic colitis). The correct diagnosis may take some time.

In ulcerative colitis, the inner lining of the large intestine (colon or bowel) and rectum becomes inflamed. The inflammation usually begins in the rectum and lower (sigmoid) intestine and spreads upward to the entire colon. Ulcerative colitis rarely affects the small intestine except for the lower section, the ileum. The inflammation causes the colon to empty frequently, resulting in diarrhea. As cells on the surface of the lining of the colon die and slough off, ulcers (tiny open sores) form, causing pus, mucus, and bleeding. An estimated 250,000 Americans have ulcerative colitis. It occurs most often in young people ages 15 to 40, although children and older people sometimes develop the disease. Ulcerative colitis affects males and females equally and appears to run in some families.

What Are the Symptoms of Ulcerative Colitis?
The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may suffer fatigue, weight loss, loss of appetite, rectal bleeding, and loss of body fluids and nutrients. Severe bleeding can lead to anemia. Sometimes patients also have skin lesions, joint pain, inflammation of the eyes, or liver disorders. No one knows for sure why problems outside the bowel are linked with colitis. Scientists think these complications may occur when the immune system triggers inflammation in other parts of the body. These disorders are usually mild and go away when the colitis is treated.

What Causes Ulcerative Colitis?
The cause of ulcerative colitis is not known, and currently there is no cure, except through surgical removal of the colon. Many theories about what causes ulcerative colitis exist, but none has been proven. The current leading theory suggests that some agent, possibly a virus or an atypical bacterium, interacts with the body's immune system to trigger an inflammatory reaction in the intestinal wall.

Although much scientific evidence shows that people with ulcerative colitis have abnormalities of the immune system, doctors do not know whether these abnormalities are a cause or result of the disease. Doctors believe, however, that there is little proof that ulcerative colitis is caused by emotional distress or sensitivity to certain foods or food products or is the result of an unhappy childhood.

How Is Ulcerative Colitis Diagnosed?
If you have symptoms that suggest ulcerative colitis, the doctor will look inside your rectum and colon through a flexible tube (endoscope) inserted through the anus. During the exam, the doctor may take a sample of tissue (biopsy) from the lining of the colon to view under the microscope. You also may receive a barium enema x-ray of the colon to determine the nature and extent of disease. This procedure involves putting a chalky solution (barium) into the colon. The barium shows up white on x-ray film, revealing growths and other abnormalities in the colon.

The doctor will give you a thorough physical exam, including blood tests to see if you are anemic (as a result of blood loss), or if your white blood cell count is elevated (a sign of inflammation). Examination of a stool sample can tell the doctor if an infection, such as by amoebae or bacteria, is causing the symptoms.

If you have ulcerative colitis, you may need medical care for some time. Your doctor also will want to see you regularly to check on the condition.

How Serious Is This Disease?
About half of patients have only mild symptoms. Others suffer frequent fever, bloody diarrhea, nausea, and severe abdominal cramps. Only in rare cases, when complications occur, is the disease fatal. There may be 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 can make it hard for the doctor to tell when treatment has helped.

What Is the Treatment?
While no special diet for ulcerative colitis is given, patients may be able to control mild symptoms simply by avoiding foods that seem to upset their intestine. In some cases, the doctor may advise avoiding highly seasoned foods or milk sugar (lactose) for a while. When treatment is necessary, it must be tailored for each case, since what may help one patient may not help another. The patient also should be given needed emotional and psychological support.

Patients with either mild or severe colitis are usually treated with the drug Sulfasalazine. This drug can be used for as long as needed, and it can be used along with other drugs. Side effects such as nausea, vomiting, weight loss, heartburn, diarrhea, and headache occur in a small percentage of cases. Patients who do not do well on Sulfasalazine often do very well on related drugs known as 5-ASA agents.

In some cases, patients with severe disease, or those who cannot take Sulfasalazine-type drugs, are given adrenal steroids (drugs that help control inflammation and affect the immune system) such as Prednisone or Hydrocortisone. All of these drugs can be used in oral, enema, or suppository forms. Other drugs may be given to relax the patient or to relieve pain, diarrhea, or infection.

Patients with ulcerative colitis occasionally have symptoms severe enough to require hospitalization. In these cases, the doctor will try to correct malnutrition and to stop diarrhea and loss of blood, fluids, and mineral salts. To accomplish this, the patient may need a special diet, feeding through a vein, medications, or, sometimes, surgery.

The risk of colon cancer is greater than normal in patients with widespread ulcerative colitis. The risk may be as high as 32 times the normal rate in patients whose entire colon is involved, especially if the colitis exists for many years. However, if only the rectum and lower colon are involved, the risk of cancer is not higher than normal.

Sometimes precancerous changes occur in the cells lining the colon. These changes in the cells are called "dysplasia." If the doctor finds evidence of dysplasia through endoscopic exam and biopsy, it means the patient is more likely to develop cancer. Patients with dysplasia, or whose colitis affects the entire colon, should receive regular follow-up exams, which may involve colonoscopy (examination of the entire colon using a flexible endoscope) and biopsies.

About 20 to 25 percent of ulcerative colitis patients eventually require surgery for removal of the colon because of massive bleeding, chronic debilitating illness, perforation of the colon, or risk of cancer. Sometimes the doctor will recommend removing the colon when medical treatment fails or the side effects of steroids or other drugs threaten the patient's health.

Patients have several surgical options, each of which has advantages and disadvantages. The surgeon and patient must decide on the best individual option.

The most common surgery is the proctocolectomy, the removal of the entire colon and rectum, with ileostomy, creation of a small opening in the abdominal wall where the tip of the lower small intestine, the ileum, is brought to the skin's surface to allow drainage of waste. The opening (stoma) is about the size of a quarter and is usually located in the right lower corner of the abdomen in the area of the beltline. A pouch is worn over the opening to collect waste and the patient empties the pouch periodically.

The proctocolectomy with continent ileostomy is an alternative to the standard ileostomy. In this operation, the surgeon creates a pouch out of the ileum inside the wall of the lower abdomen. The patient is able to empty the pouch by inserting a tube through a small leak-proof opening in his or her side. Creation of this natural valve eliminates the need for an external appliance. However, the patient must wear an external pouch for the first few months after the operation.

Sometimes an operation that avoids the use of a pouch can be performed. In the ileoanal anastomosis ("pullthrough operation"), the diseased portion of the colon is removed and the outer muscles of the rectum are preserved. The surgeon attaches the ileum inside the rectum, forming a pouch, or reservoir, that holds the waste. This allows the patient to pass stool through the anus in a normal manner, although the bowel movements may be more frequent and watery than usual.

The decision about which surgery to have is made according to each patient's needs, expectations, and lifestyle. If you are ever faced with this decision, remember that getting as much information as possible is important. Talk to your doctor, to nurses who work with patients who have had colon surgery (enterostomal therapists), and to other patients. In addition, read pamphlets and books, such as those available from the Crohn's & Colitis Foundation of America, before you decide.

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

Additional Readings
Bleeding in the Digestive Tract and Crohn's Disease. National Digestive Diseases Information Clearinghouse, 1992. 2 INFORMATION WAY, BETHESDA, MD 20892-3570; (301) 654-3810. General patient information fact sheets.

Brandt LJ, Steiner-Grossman P, eds. Treating IBD: A Patient's Guide to the Medical and Surgical Management of Inflammatory Bowel Disease. New York: Raven Press, 1989. This book, produced by the Crohn's & Colitis Foundation of America, addresses many aspects of treatment and living with inflammatory bowel disease.

Hanaver SB, Peppercorn MD, Present DH. Current concepts, new therapies in IBD. Patient Care, 1992; 26 (13): 79-102. General review article for health care professionals.

Steiner-Grossman P, Banks PA, Present DH, eds. The New People Not Patients: A Source Book for Living with IBD. Dubuque, Iowa: Kendall/Hunt Publishing Company, 1992. This book for patients includes sections on diagnostic tests, medications, nutrition, coping with employment and health insurance problems, and IBD in children and teenagers, older adults, and during pregnancy. Available from the Crohn's & Colitis Foundation of America.

Resources
Crohn's & Colitis Foundation of America, Inc., 386 Park Avenue South, 17th floor, New York, NY 10016-8804; (800) 932-2423 or (212) 685-3440.

The Greater New York Pull-thru Network, 62 Edgewood Avenue, Wyckoff, NJ 07481; (201) 891-5977.

Pediatric Crohn's & Colitis Association, Inc., P.O. Box 188, Newton, MA 02168; (617) 244-6678.

Reach Out for Youth with Ileitis and Colitis, Inc., 15 Chemung Place, Jericho, NY 11753; (516) 822-8010.

United Ostomy Association, 36 Executive Park, Suite 120, Irvine, CA 92714; (800) 826-0826 or (714) 660-8624.

National Digestive Diseases Information Clearinghouse

2 Information Way
Bethesda, MD 20892-3570

NIH Publication No. 95-1597

GI-Symptoms

Palm Beach Gastroenterology Consultants, LLC

Abdominal Pain:

Bleeding:

Chest Pain:

Cirrhosis of the Liver:

Colitis:

Constipation:

Crohn's Disease:

Diarrhea:

Digestive Diseases Statistics:

Gallstones:

Gastroesophageal Reflux Disease:

Hemochromatosis:

Hemorrhoids:

Hepatitis:

Jaundice:

Lactose Intolerance:

Liver Disease:

Nervous Stomach:

Pancreatitis:

Stomach and Duodenal Ulcers:

Ulcerative Colitis: