Gastroparesis

Gastroparesis

This tough looking word, pronounced gas-tro-par-EES-is, is simple enough in its meaning.  Gastro means stomach.  Paresis means weakness.  Gastroparesis is a weak stomach.  This condition is very common.  It can be the cause of a number of abdominal complaints.  It is usually not a serious problem and there are effective treatments available.

How the stomach works

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

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

Gastroparesis

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

  • Diabetes is the most common known cause.  Adrenal and thyroid gland problems can also be a cause although these are infrequent
  • Scars and fibrous tissue from ulcers and tumors can block the outlet of the stomach and mimic gastroparesis
  • Certain drugs weaken the stomach (tricyclic antidepressants such as Elavil, calcium blockers such as Cardizem and Procardia, L-dopa, hyoscyamine, Bentyl, narcotics)
  • Previous stomach surgery
  • Anorexia and bulimia
  • Neurologic or brain disorders such as Parkinson’s disease, strokes and brain injury
  • Certain diseases such as lupus erythematosus and scleroderma
  • In up to 40% of cases the cause of gastroparesis is not known

 

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

Symptoms

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

Diagnosis

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

  • An upper GI barium x-ray measures how liquid barium leaves the stomach.  Often this exam is normal.
  • Upper endoscopy is a visual exam of the stomach using a lighted flexible tube.  Mild sedation is usually given for this procedure.  This exam should always be done to be certain there is not a blockage in the stomach.
  • A gastric or stomach emptying test is presently the best method of making the diagnosis.  In this test, a food, such as scrambled eggs, is labeled with a marker which can be seen by a scanner.  Following ingestion, the scanner tracks the time it takes for the food to leave the stomach.  In general, half the stomach contents should leave within about 90 minutes.  A final test, which is not available everywhere, is the electrogastrogram (EEG).  This test, like the EKG on the heart, measures the electrical waves that normally sweep over the stomach and precede each contraction.

Treatment:

First, if there is an underlying disorder, it needs to be treated effectively.  Examples are good blood sugar control in the diabetic patient or thyroid medicine for someone with an underactive thyroid.  Second, there may be a need to address diet and nutrition.  When gastroparesis is mild, there are usually few food problems.  However, if there is marked delay in stomach emptying, then attention to the diet is necessary.  Fats, including vegetable oils, normally cause delay in emptying of the stomach, so foods that are high in fat need to be avoided.  High fiber foods such as broccoli and cabbage tend to stay in the stomach, so these foods should be restricted when symptoms are severe.  Liquids always leave the stomach faster than solid food so liquid type foods such a low-fat milkshakes should be used.  Finally, frequent small feedings, 4-6 times per day, are usually more effective than larger meals, 2 or 3 times per day.  A registered dietitian can be very helpful in providing advice in severe cases. The third treatment is medications.

Medications

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

  • Metoclopramide (trade name:  Reglan):  This is an effective drug although it may have side effects such as restlessness, fatigue, agitation and depression.  The dose is 5-20 mg.  This drug is available in generic form.
  • Domperidone (trade name:  Motilin):  This drug is available in Canada and Europe, but not in the U.S. as of January 2001.
  • Bethanechol (trade name:  Urecholine):  and erythromycin, an old antibiotic are occasionally used but generally are not effective or even desirable long-term.

Summary

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

 

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Eosinophilic Esophagitis

Eosinophilic Esophagitis

Eosinophilic esophagitis is an inflammatory condition in which the wall of the esophagus becomes filled with large numbers of eosinophils, a type of white blood cell.

The esophagus is a muscular tube that propels swallowed food from the mouth into the stomach.  Esophagitis refers to inflammation of the esophagus that have several causes.  The most common cause of esophagitis is acid reflux which most frequently results in heartburn, although acid reflux also can cause ulcers in the inner lining of the esophagus.  Other less common causes of esophagitis include viruses (such as herpes simplex), fungi (such as Candida),  medications that get stuck in the esophagus (such as the antibiotic, tetracycline), and radiation therapy (such as during treatment of lung cancer).  Doctors believe that eosinophilic esophagitis is a type of esophagitis that is caused by allergy for two reasons.  First eosinophils are prominent in other diseases associated with allergy such as asthma, hay fever, allergic rhinitis, and atopic dermatitis.  Second, patients with eosinophilic esophagitis are more likely to suffer from these other allergic diseases.  Nevertheless, the exact substance that is causing the allergic reaction in eosinophilic esophagitis is not known.  The hallmark of eosinophilic esophagitis is the presence of large numbers of eosinophils in the tissue just beneath the inner lining of the esophagus.

Eosinophils are white blood cells (leukocytes) manufactured in the bone marrow and are one of the many types of cells that actively promote inflammation.  They are particularly active in the type of inflammation caused by allergic reactions.  Thus, large number of eosinophils can accumulate in tissues such as the esophagus, the stomach, the small intestine, and sometimes in the blood when individuals are exposed to an allergen.  The allergen(s) that causes eosinophilic esophagitis is not known.  It is not even known whether the allergen is inhaled or ingested.

Eosinophilic esophagitis affects both children and adults.  For unknown reasons, men are more commonly affected than women, and it is commonly found among young boys and men.

What are the symptoms of eosinophilic esophagitis?

The major symptom in adults with eosinophilic esophagitis is difficulty in swallowing solid food (dysphagia).  Specifically, the food gets stuck in the esophagus after it is swallowed.  Less common symptoms include heartburn and chest pain.  In children, the most common symptoms are abdominal pain, nausea, vomiting, coughing, and failure to thrive.

How does eosinophilic esophagitis cause dysphagia?

Eosinophilic esophagitis decreases the ability of the esophagus to stretch and accommodate mouthfuls of swallowed food probably as a result of the presence of so many eosinophils but also, perhaps as a result of some scaring that occurs in the wall of the esophagus.  As a result, solid foods (particulary solid meats) have difficulty passing through the esophagus.  When solid food sticks in the esophagus, it causes an uncomfortable sensation in the chest.  The sticking of food in the esophagus is referred to as dysphagia.  If the solid food then passes into the stomach, the discomfort subsides, and the individual can resume eating.  If the solid food does not pass into the stomach, individuals often must regurgitate the food by inducing vomiting before they can resume eating.  Rarely, the solid food becomes impacted, that is, it can neither pass into the stomach nor be regurgitated.  The impacted solid food causes chest pain that can mimic a heart attack, and repeated spitting up of saliva that cannot be swallowed because of the obstruction in the esophagus.  Individuals with impacted food are unable to eat or drink.  To relieve the obstruction, a doctor usually will have to insert a flexible endoscope through the mouth and into the esophagus to remove the impacted food.

How eosinophilic esophagitis causes symptoms of abdominal pain, vomiting, and failure to thrive in children is not clear.

What are the other causes of dysphagia for solid food?

The most common causes of dysphagia for solid food are esophageal strictures and Schatzki (lower esophageal) rings.  Esophageal strictures are narrowings of the esophagus that result from inflammation and scarring, most commonly from chronic acid reflux. Strictures usually are located in the lower esophagus near the entrance of the esophagus into the stomach where the acid reflux is most severe. Schatzki rings are thin webs of tissue of unclear cause that can narrow the lumen (center) of the esophagus through which food passes. They also are located in the lower esophagus. A less common cause of dysphagia for solid food is esophageal cancer  that narrows the esophageal lumen. A still less common cause of dysphagia is disorders of the muscles of the esophagus. For example, achalasia, a disease of the nerves and the muscles of the esophagus that prevents the muscle at the lower end of the esophagus (the lower esophageal sphincter) from relaxing and allowing swallowed food to pass into the stomach. Unlike the other causes of motility disorders, achalasia usually results in problems with swallowing both solid and liquid food.

How is eosinophilic esophagitis diagnosed?

The diagnosis of eosinophilic esophagitis is suspected whenever dysphagia for solid food occurs, even though it is not one of the most common causes of dysphagia. Dysphagia almost always is evaluated by endoscopy  (esophagogastroduodenoscopy or EGD) in order to determine its cause. During the EGD, a flexible viewing tube or endoscope is inserted through the mouth and into the esophagus. It allows the doctor to see the inner lining of the esophagus (as well as the stomach and duodenum ). Cancers, esophageal strictures, Schatzki rings, and usually achalasia, all can be diagnosed visually at the time of EGD.

The doctor performing the EGD also may see abnormalities that suggest eosinophilic esophagitis. For example, some patients with eosinophilic esophagitis have narrowing of most of the esophagus. Others have a series of rings along the entire length of the esophagus. Still others have furrows running up and down the esophagus and a few have small white spots on the esophageal lining which represent pus made up of dying mounds of eosinophils. The diagnosis of eosinophilic esophagitis is established with a biopsy of the inner lining of the esophagus. The biopsy is performed by inserting a long thin biopsy forceps through a channel in the endoscope that pinches off a small sample of tissue from the inner lining of the esophagus. A pathologist  then can examine the biopsied tissue under the microscope to look for eosinophils.

In many patients with eosinophilic esophagitis, however, the esophagus looks normal or will show only minor abnormalities. Unless biopsies are taken of a normal-appearing esophagus, the diagnosis of eosinophilic esophagitis can be missed. In fact, not taking biopsies has resulted in some patients having dysphagia for years before the diagnosis of eosinophilic esophagitis is made, and doctors are now more likely to perform biopsies of the esophagus in individuals with dysphagia–even those with a normal-appearing esophagus–who have no clear cause for their dysphagia.

The incidence of eosinophilic esophagitis is on the rise in the U. S. This rise in incidence may reflect either increased awareness of the disease among the doctors treating patients with dysphagia or an actual increase in the prevalence of this disease.

How is eosinophilic esophagitis treated?

The treatment of eosinophilic esophagitis is with gentle esophageal dilatation, and medications. The goal of treatment is to relieve symptoms of dysphagia.

Esophageal dilatation

For decades, gastroenterologists have been treating patients with dysphagia from eosinophilic esophagitis in the same manner as patients with dysphagia due to esophageal strictures and Schatzki rings  i.e., esophageal dilatation. Esophageal dilatation involves physically stretching the strictures or fracturing of the strictures or fracturing the rings, thus allowing freer passage of solid food. Stretching or fracturing of the strictures or rings can be performed with endoscopes, long and flexible dilators of different diameters inserted through the mouth, or with balloons inserted into the esophagus through a channel in the endoscope. The balloons are positioned at the level of the stricture or ring and then inflated to break the stricture or ring.

While esophageal dilatation has been an effective and usually safe treatment, doctors have observed that some patients with eosinophilic esophagitis develop tears in the esophageal lining that can lead to severe chest pain after dilation. Rare cases of esophageal perforations (tears through the entire esophageal wall) also have been reported. Esophageal perforations are a serious complication that can lead to infections in the chest. Thus, although doctors may still use dilatation to treat dysphagia from eosinophilic esophagitis, they now are more likely to use smaller dilators and less force than they would when treating esophageal strictures and rings. Moreover, doctors also are more commonly using medications to treat dysphagia from eosinophilic esophagitis and using dilation only when medications fail.

Medications

The medications primarily used in treating eosinophilic esophagitis are fluticasone propionate (Flovent) and proton pump inhibitors (Protonix, Nexium, Aciphex, Prevacid, Prilosec, and Zegarid).

Fluticasone propionate (Flovent)

Although oral steroids are effective in treating eosinophilic esophagitis, the side effects of orally-administered steroids limit their use. One new oral steroid that is being tested is budesonide, an orally-administered steroid that is absorbed into the body but is rapidly destroyed, resulting in fewer serious side effects. The current treatment of eosinophilic esophagitis is with swallowed (not inhaled) fluticasone propionate. Fluticasone propionate is a synthetic (man-made) steroid that is related to the naturally occurring steroid hormone, cortisol or hydrocortisone, produced by the adrenal glands. These steroids have potent anti-inflammatory actions. When used as an inhaler, fluticasone propionate reduces inflammation in the airways of patients with asthma, thus relieving wheezing and breathing difficulties. When fluticasone propionate is swallowed, it has been shown to reduce the eosinophils in the esophagus and relieve dysphagia in patients with eosinophilic esophagitis.

In treating eosinophilic esophagitis, fluticasone propionate is administered with the same inhaler as for asthma but without the usual spacer in the inhaler. The removal of the spacer causes the fluticasone propionate to deposit in the mouth rather than enter the lungs. The fluticasone propionate that deposits in the mouth is then swallowed with a small amount of water, usually twice daily for several weeks. Patients are instructed not to eat or drink for two hours after each treatment. Improvement in dysphagia usually is prompt, within days or weeks. Most patients develop recurrent  symptoms after stopping treatment require treatment and/or continuous retreatment.

When used in low doses, little of the fluticasone propionate is absorbed into the body and therefore side effects are minimal. One possible side effect is thrush  (infection of the mouth and throat by a fungus, candida), which is relatively easy to treat. When higher doses are used for a prolonged period, enough fluticasone propionate may be absorbed to cause side effects throughout the body. Side effects of high doses of fluticasone propionate are similar to the side effects of oral steroids such as prednisone  and cortisone .

Proton pump inhibitors

Proton pump inhibitors, pantoprazole  (Protonix), esomeprazole  (Nexium), rabeprazole  (Aciphex), lansoprazole  (Prevacid), and omeprazole  (for example, Prilosec, Zegarid, Kapodex) reduce production of acid by the stomach. They are very safe and effective treatment for the symptoms of acid reflux and esophagitis. Since acid reflux may aggravate esophagitis in some patients with eosinophilic esophagitis, doctors frequently use proton pump inhibitors for treating eosinophilic esophagitis. Proton pump inhibitors do not treat the underlying eosinophilic esophagitis; however, and treatment with fluticasone or another steroid usually is required as well.

What about elimination diets for treating eosinophilic esophagitis?

The leading theory about the cause of eosinophilic esophagitis is that it represents allergy to some protein found in food. Evidence has accumulated in children that diets that eliminate the allergy-inducing food can result in reversal of the esophagitis and disappearance of the eosinophils. Similar evidence now is accumulating in adult patients. Doctors have used elimination diets to define what the allergy-inciting foods might be.

There are several ways in which elimination diets can be attempted. The first is to do skin and blood tests looking for specific foods that might be causing the allergy and then eliminating these foods from the diet. The second is to eliminate the major groups of food to which allergy is common, specifically milk protein, soy , peanut/tree nuts, eggs, wheat, and seafood. Finally, individuals may be placed on an elemental liquid diet (a diet of digested food that no longer contains proteins that can provoke allergy), and then different foods can be added to the diet until the allergy-inducing food is found. None of these elimination diets are easy for physicians to perform or for patients to follow, especially children, and each has its pros and cons. Nevertheless, if one or two foods can be found that are responsible for the allergy, a near-normal diet can be resumed, and the need for medications can be eliminated

What is the future of eosinophilic esophagitis?

Eosinophilic esophagitis in adults is a newly-recognized disease. Therefore, understanding of the cause(s), natural history, diagnosis and management is limited and will evolve over the coming years. Currently, the recommended treatments (for example, with oral fluticasone propionate) are based on a limited number of small studies. More studies involving larger numbers of patients followed for longer periods of time are necessary to determine the long-term efficacy and safety of treatment.

Montelukast  (Singulair) is an oral leukotriene receptor antagonist that is used for treating asthma and seasonal allergic rhinitis (hay fever). Leukotrienes are a group of naturally occurring chemicals in the body that promote inflammation in asthma, seasonal allergic rhinitis, and other diseases involving allergy. They are formed by cells, released, and then bound to other cells that participate in inflammation. It is the binding to these other cells that stimulates the cells and promotes inflammation. Montelukast blocks the binding of some of these leukotrienes and has been used with success in treating a small number of patients with eosinophilic esophagitis. It improves symptoms but does not reduce teh numbers of eosinophils. More studies are needed.

Cromolyn  is a synthetic compound that is used to prevent allergic reactions. Many of the symptoms and signs of allergic reactions are caused by chemicals, for example, histamine, that are released from mast cells, a type of cell that is found throughout the body as well as in the lungs, nose, and eyelids. Cromolyn works by preventing the release of these chemicals from the mast cells. Cromolyn is inhaled to prevent episodes of asthma due to allergy. It also is used as a nasal inhaler to treat seasonal allergic rhinitis (due to inflammation of the lining of the nose) and as an ophthalmic (eye) solution to treat allergic conjunctivitis  (due to inflammation of the lining of the eyelids). More studies are needed to determine whether cromolyn is effective in treating eosinophilic esophagitis.

Eosinophilic Esophagitis At A Glance

  •   Eosinophilic esophagitis is an inflammatory condition of the esophagus that affects both children and adults, and men more than women.
  •   Eosinophilic gastroenteritis  may be due allergy to an as yet unknown food allergen.
  •   The major symptom in adults with eosinophilic esophagitis is dysphagia for solid food.
  •   Eosinophilic esophagitis stiffens the esophagus so that solid foods have difficulty passing through the esophagus and into the stomach.
  •   Other common causes of dysphagia for solid food are esophageal strictures and Schatzki rings.
  •   The diagnosis of eosinophilic esophagitis usually is made during an EGD, performed for the evaluation of dysphagia. The diagnosis is confirmed by biopsy of the esophagus.
  •   The treatment of eosinophilic esophagitis is with proton pump inhibitors and swallowed fluticasone propionate.  Gentle esophageal dilatation is used when meditations fail to relieve dysphagia.

 

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Diseases of the Pancreas

Diseases of the Pancreas

What is the pancreas?

The pancreas is an organ that is located in the back of the upper abdomen. It is about 6-8 inches long and 2 inches wide. The pancreas has two basic functions; one is to produce the hormone called insulin, which regulates the main sugar glucose in the body. The other is to make enzymes to aid in the digestion of food. These enzymes are secreted into the small intestine via a tube-like structure called the pancreatic duct.

Diabetes and pancreatic insufficiency

When the production of insulin by the pancreas is impaired, diabetes mellitus can result. This can result in high blood glucose levels, which if left untreated, can result in damage to the eyes, heart, kidneys and nerves. It can even eventually lead to coma. Fortunately, many of these problems can be avoided if diabetes is diagnosed and treated properly. Treatment usually consists of dietary modifications and medications.

Pancreatic enzymes are needed for the digestive system to break down fats, protein and carbohydrates so that they can be absorbed. When there is a deficiency of these enzymes, the body cannot absorb essential nutrients, and weight loss and malnourishment can result. Diarrhea can also occur. Synthetically manufactured digestive enzymes can be taken by mouth to replace lack of pancreatic enzyme production. Pancreatic enzyme deficiency can result from chronic inflammation, infection, tumor, or trauma to the pancreas.

Pancreatitis

Inflammation of the pancreas is termed pancreatitis. The major symptom of pancreatitis is severe pain, often accompanied by nausea, vomiting, and fever. Acute pancreatitis can be caused by a number of things. The two most common causes are heavy (or binge) alcohol consumption and gallstones. Other causes include drugs, trauma, high triglyceride levels, and hereditary conditions. Chronic pancreatitis can result from repeated episodes of acute pancreatitis, alcoholism, or certain other rare diseases. Acute pancreatitis may require hospitalization for treatment. It is diagnosed by examination of the abdomen, blood tests, ultrasound and x-rays. Most patients recover, but some patients, usually heavy alcohol users, may have a life-threatening illness. Long term complications such as chronic pain, diabetes and malabsorption may occur. Endoscopic exam with ERCP (see a separate pamphlet for explanation of this procedure) is often useful both for diagnostic and therapeutic purposes. In certain instances, surgery may be indicated.

Pancreas tumors

Tumors of the pancreas can develop. These may be either benign or malignant. Benign tumors can be relatively asymptomatic and require little treatment. Other benign tumors can secrete hormones, which can cause problems in various parts of the body. Malignant or cancerous tumors of the pancreas usually occur in middle-aged and older patients. At times they can cause blockage of the bile duct system and result in yellow jaundice. This is a serious illness that may be difficult treat. Endoscopically placed stents (with ERCP), and surgery may be helpful in relieving symptoms.

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Gallstones

Gallstones

What is the gallbladder?

The gallbladder is a small pear-shaped sack-like organ located beneath the liver in the right upper abdomen.  Bile produced in the liver is carried by bile ducts to the gallbladder where the bile is stored.  During a meal, the gallbladder contracts and pushes the bile into the small intestine where the bile serves mainly to digest fats.  Fatty meals tend to cause the gallbladder to contract more vigorously and oftentimes cause more symptoms in patients with gallbladder disease.  Gallstones are small hard collections of bile that can accumulate within the gallbladder.

What are the symptoms of gallstones?

Interestingly, most patients with gallstones never experience symptoms. Symptoms occur when gallstones either block the outlet of the gallbladder or bile ducts or when the stones irritate the gallbladder and cause gallbladder inflammation (cholecystitis).  Stones that obstruct the outlet of the gallbladder (cystic duct) cause steady pain in the upper abdomen, usually on the right side under the ribs.  The pain may radiate to the midback or under the right shoulder blade.  Pain oftentimes occurs after eating when the gallbladder contracts and may last for several minutes up to several hours.  Nausea or vomiting may also occur.

Stones that obstruct the bile ducts may cause pain, nausea, vomiting or jaundice.  Stones that cause bile duct obstruction may also lead to bacterial infection in the bile ducts called bacterial cholangitis, which generally causes fever, chills and jaundice.  Occasionally bacteria can spread to the blood stream (sepsis) and be life threatening.  Gallstones can also block the opening of the pancreatic duct and cause inflammation of the pancreas (gallstone pancreatitis).

How do I know if I have gallstones?

An ultrasound of the abdomen is usually the initial diagnostic test in patients with a clinical history suggesting gallbladder disease.  This test looks at the anatomy and structure of the gallbladder, liver and bile ducts.  Stones within the gallbladder or thickening of the gallbladder wall may be seen in patients with symptomatic gallstones.  Enlarged or dilated bile ducts can be seen by ultrasound in some patients with bile duct obstruction.

Some patients with symptoms suggestive of gallbladder disease may have a normal abdominal ultrasound. In these patients a study of gallbladder function called a hepatobiliary (HIDA) scan is often done.  During this test a small amount of radioactive material is injected into the bloodstream through an intravenous catheter.  The radioactive material circulates to the liver and concentrates in the gallbladder.  An agent is then given through the IV that will cause the gallbladder to contract and empty.  A diseased gallbladder usually does not contract and empty very well indicating a poorly functioning gallbladder.  During this test patients with a diseased gallbladder oftentimes experience pain when the gallbladder is made to contract.  ERCP (endoscopic retrograde cholangiopancreatography) can be helpful in detecting and removing stones from the bile ducts.

Treatment

Treatment of symptomatic gallbladder disease usually involves surgical removal of the gallbladder (cholecystectomy).  Most patients undergo laparoscopic surgery in which three or four tiny incisions are made in the abdomen and small instruments are used to remove the gallbladder.

Rarely and only in special circumstances gallstone dissolving medication can be used to treat symptomatic gallstones.  Most gallstones take one to two years to completely dissolve and often recur after medication is stopped.

Most patients function quite well without the gallbladder.  The liver continues to produce and secrete bile into the small intestine allowing fat digestion and absorption to occur normally.  Occasionally after cholecystectomy patients may experience diarrhea with meals.  Postcholecystectomy diarrhea generally improves or resolves with time and is easily treated with dietary modification and occasionally medication.

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Helicobacter Pylori

Helicobacter Pylori

What is Helicobacter pylori?

Helicobacter pylori, commonly abbreviated H pylori, is a bacteria, which can cause infection of the lining of the stomach. It is a relatively new discovery first identified in 1982 by Australian researchers. It subsequently turns out that this is a relatively common bacteria, and may be the most common infection in the world. Only a small number of people who are infected by this bacteria experience any symptoms or problems from it. Infection is common in developing countries or areas where sanitation is poor. The rate of infection tends to increase with age. H pylori infects people after it is swallowed in food or fluids. Because the inside of the stomach is a very difficult place for bacteria to live due to the high acid content in the stomach, H pylori tends to be a very hardy organism.

Why is H pylori important?

As mentioned above, most people who are infected with H pylori remain asymptomatic. However, some conditions such as ulcers, some types of stomach cancer, and gastritis have been linked to H pylori. Gastritis is inflammation of the lining of the stomach that usually causes burning or pain in the upper abdomen. It is important to know that there are many other causes of gastritis besides H pylori. Ulcers occurring in the stomach or the duodenum (the first part of the small intestine) have a 60% likelihood of having an association with H pylori. In addition, there are usually other factors involved in ulcer disease, such as NSAID (anti-inflammatory) medication use and smoking.

Two types of cancer have been identified in which H pylori play a role. These are gastric cancer and gastric lymphoma. Determining whether or not H pylori is a causative factor is a complicated matter and requires diagnostic testing and consultation with a physician familiar with the bacteria. Diagnosis can be done with blood tests, breath tests measuring carbon dioxide, and biopsies from the lining of the stomach taken during endoscopy. Each test has unique pros and cons.

What is the treatment?

Since the infection is so common, in some cases no treatment is recommended. But in individuals with proven ulcer disease, symptoms due to gastritis, or gastric cancer or lymphoma, treatment may be necessary. As previously mentioned, H pylori is a hardy organism and can be somewhat difficult to eradicate. Effective treatment regimes include 2-3 different antibiotics and one antacid medication. It is not uncommon for treatment plans to require that a patient take eight pills per day for two weeks. Fortunately, most of these regimes are highly effective and side effects tend to be minimal.

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Peptic Ulcer Disease

Peptic Ulcer Disease

What is peptic ulcer disease?

Peptic ulcer disease is a common medical problem in the United States. Ulcers form in the lining of the esophagus, stomach and/or the small intestine.

What causes peptic ulcers to form?

The two most common causes of peptic ulcers are arthritis-type medications known as nonsteroidal anti-inflammatory drugs (NSAIDS) and a bacteria that can be present in the lining of the stomach known as Helicobacter pylori (H. pylori). Examples of medications that can cause ulcers include aspirin, ibuprofen, Motrin, Advil and Aleve. Some of these medications are also contained in over-the-counter remedies for colds or combination narcotic prescriptions. Therefore, it is important to review medication labels. Other factors that can contribute to ulcers are smoking, alcohol and spicy food intake.

What are the symptoms and possible complications of peptic ulcer disease?

Ulcers may cause a burning pain in the middle portion of the upper abdomen. This usually occurs about one hour or more after eating and can last from a few minutes to several hours. Less common symptoms of peptic ulcer disease are nausea, vomiting, decreased appetite, or becoming full quickly while eating. A serious complication of peptic ulcer disease is bleeding.  Bleeding can cause vomiting of red blood clots or black material that resembles coffee grounds, or passage of black, tarry stools. Another complication is a perforation or hole in the stomach or small intestine. This would generally cause severe abdominal pain and a potentially life-threatening infection.

How is a peptic ulcer diagnosed?

A peptic ulcer may be suspected based on a patient’s symptoms and physical examination. Blood, breath and stool tests can be done to check for the Helicobacter pylori bacteria. If the test is positive, a patient may be treated with antibiotics to clear the infection. More direct studies to evaluate for a peptic ulcer are an upper GI endoscopy or upper GI x-ray (a patient drinks white, chalky liquid while x-ray pictures are taken). With an upper endoscopy, biopsies of the ulcer can be done. The tissue can be tested for H. pylori.

What is the treatment of peptic ulcer disease?

If Helicobacter pylori infection is diagnosed it can be treated with antibiotics for about 2 weeks. Treatment of ulcers related to arthritis-type medications includes stopping the offending medication if possible and starting medications that significantly decrease the acid levels in the stomach.

How can peptic ulcer disease be prevented?

Reducing or eliminating the use of nonsteroidal anti-inflammatory drugs is one way that peptic ulcers can be prevented. If a patient has to take one of these medications, the physician may advise the patient to stay on an acid-lowering medication to protect the stomach. The source of Helicobacter pylori infection is not certain but it appears to be spread from person to person. Adequate hygiene may be useful in preventing transmission of the bacteria.

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Hiatal Hernia

Hiatal Hernia

What is a hiatal hernia?

The stomach is normally positioned in the abdominal cavity below a large, thin, dome-shaped muscle, the diaphragm.  The diaphragm separates the abdominal cavity from the chest cavity.  The esophagus, in the chest cavity, passes through an opening or hole in the diaphragm called the hiatus where the esophagus joins the stomach.  A hiatal hernia results when a portion of the stomach protrudes or herniates upwards through the hole (hiatus) in the diaphragm and into the chest cavity.  Usually only a small portion of the stomach herniates up through the diaphragm.  Occasionally the whole stomach can herniate through the diaphragm up into the chest cavity.

There are two main types of hiatal hernias, sliding and paraesophageal.  A sliding hiatal hernia is the most common.  In a sliding hiatal hernia, the junction between the esophagus and stomach as well as a portion of the stomach itself, protrude above the diaphragm.  The herniated portion of the stomach may slide back and forth into and out of the chest cavity.  In a paraesophageal hiatal hernia, the junction between the esophagus and stomach is in its normal place below the diaphragm but a portion of the stomach is pushed above the diaphragm and lies beside the esophagus.

Why do hiatal hernias occur?

Hiatal hernias are common, occurring in 60% of people by age 60.  The cause is unknown and is thought to result from weakening and enlargement of the hiatus or hole in the diaphragm.  Heredity may play a role in some, while in others obesity, straining or heavy lifting may cause the stomach to push up through the enlarged opening.

What are the symptoms of a hiatal hernia?

Most patients with a sliding hiatal hernia have no symptoms.  Acid reflux is associated with a hiatal hernia and can cause heartburn or regurgitation.  Excess belching or upper abdominal and lower chest pressure or pain can also occur.  Prolonged and frequent reflux of acid into the esophagus may cause damage to the esophagus resulting in ulceration and bleeding.  Scarring and narrowing of the esophagus can also occur with chronic reflux and cause difficult or painful swallowing.  Other symptoms of gastroesophageal reflux can include sore throat, hoarseness, excess salivation, the sensation of a lump in the throat (globus), sinusitis, frequent throat clearing, cough, wheezing or asthma.  Chronic reflux can also lead to a condition called Barrett’s esophagus, which can lead to the development of esophageal cancer.

A paraesophageal hernia is not as common as the sliding hiatal hernia.  Paraesophageal hernias can sometimes get trapped or squeezed by the diaphragm and lose blood supply.  This condition, called strangulation, is a serious and often painful condition that requires immediate surgery.

How do I know if I have a hiatal hernia?

Hiatal hernias are diagnosed by either upper GI x-ray or by endoscopy.  Treatment of symptomatic hiatal hernias involves treating gastroesophageal reflux with dietary modifications and medications.  The majority of patients do well with medical treatment.

More patients are now being referred for surgical repair of hiatal hernias, particularly younger patients who may require life-long medical treatment, or patients who do not respond to medical treatment.  The procedure is called laparoscopic fundoplication and involves wrapping the upper part of the stomach, called the fundus, around the lower part of the esophagus.  The wrapped fundus is sutured together around the esophagus (fundoplication).

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Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD)

What is GERD?

Gastroesophageal reflux disease (GERD) is a disease where the contents of the stomach move upwards into the esophagus.  At times this phenomenon happens in everyone and is considered normal.  When it happens frequently or causes symptoms, it is considered abnormal and is referred to as GERD.

Why does reflux happen?

The connection between the esophagus and stomach is a round muscular band known as the lower esophageal sphincter.  This sphincter is designed to hold pressure at the esophagus and stomach connection and prevent reflux of stomach materials, namely acid.  For a variety of reasons, the sphincter can become “lazy” and allow frequent stomach content reflux.  “Laziness” can occur due to medications, age, smoking, and hiatal hernia.

What are the symptoms of GERD?

Symptoms of GERD are most commonly heartburn and regurgitation.  Heartburn is different for each person, but commonly described as a burning or painful feeling in the low chest.  Regurgitation usually refers to the sensation of food or fluid moving up into the chest or even back of the throat.  Other symptoms associated with GERD include difficulty swallowing, sore throat, hoarse voice, chest pain, chronic chough or choking, and frequent sinus or ear infections.

How do I know if I have GERD?

Your physician generally makes the diagnosis of GERD based on your symptoms.  Other examinations that aid in the diagnosis of difficult or complicated cases include upper GI endoscopy, 24-hour pH monitoring (this involves a tube into your esophagus via your nose that measures reflux of acid into the esophagus), barium swallow tests/upper GI series, and esophageal manometry (another tube into the esophagus via the nose that measures esophageal squeezes).

What is the treatment?

There are a variety of medications that can be used to manage GERD symptoms.  Simple therapies such as TUMS, Rolaids or Mylanta can be very helpful.  Over-the-counter medications that help decrease acid include ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) or omeprazole (Prilosec OTC).  The strongest drugs available for acid suppression must be prescribed by your doctor and include Prevacid, Nexium, Protonix, and Aciphex.  This class of medication acts to block acid secretion within the stomach.  These have been extremely successful medications and are very well tolerated.

Other novel approaches to treatment of GERD exist.  Surgical antireflux procedures are successful and well tolerated.  Your physician can help you to decide if you are a good candidate for such an intervention.

Complications of GERD

Unfortunately, complications of acid reflux do sometimes occur.  One of the most common problems associated with GERD is narrowing of the lower esophagus, called a stricture or ring.  Strictures can form in patients both with and without regular symptoms of GERD!  Strictures cause difficulty with swallowing and often must be stretched via upper GI endoscopy.  Barrett’s esophagus is another complication, defined as an alteration of the tissue lining of the lower esophagus due to chronic acid damage.  Barrett’s is a pre-cancerous condition diagnosed by upper GI endoscopy and needs to be watched regularly by your Gastroenterologist.  Some lung issues such as asthma and pneumonias can be associated with frequent regurgitation of stomach contents into the mouth and ultimately lungs.

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Hemochromatosis

Hemochromatosis

What is hemochromatosis?

Hemochromatosis is a disease characterized by iron overload. It affects many organs in the body including the liver, heart, pancreas, joints and skin. Iron is normally absorbed in the small intestine in proper amounts necessary for the body’s function. In patients with hemochromatosis, a genetic mutation affecting the small intestinal cells allows for excess absorption of iron. The excessive amount of iron eventually gets deposited in organs like the liver, where it causes damage. Hemochromatosis is one of the most common inherited diseases, affecting one out of every 300-400 people. The disease is often silent until irreparable damage has been done.

Genetics

The gene is present in one out of every ten people. Not all people who have the gene will get the disease. One must inherit two abnormal gene copies, one from each parent, to get hemochromatosis. Due to the common nature of the abnormal gene, it is important that family members of patients with hemochromatosis be tested.

What are the symptoms of hemochromatosis?

Symptoms are often not detectable until damage to organs has been done. Most patients are between the ages of 40 and 60 when the diagnosis is made. Women can be older at diagnosis due to menstruation throughout their lives. The specific symptoms are based on the damaged organ – in the case of liver disease symptoms can include weakness, jaundice, easy bleeding, swelling of the legs or abdomen, or abdominal pain. Iron damage to other organs can cause congestive heart failure, diabetes, and arthritis.

How is a diagnosis made?

Early diagnosis is important to prevent further organ damage due to excess iron. When a family history of hemochromatosis exists, family members should be screened. The diagnosis of hemochromatosis can be suggested by laboratory tests such as iron levels and liver enzymes. Liver biopsy usually confirms the diagnosis. A genetic test to look for the most common genetic mutations associated with the disease is available and can be ordered by your physician.

What is the treatment?

Red blood cells are one of the richest sources of iron in the human body. In patients with hemochromatosis, blood is usually removed from the patient to lower the number of red blood cells, and thus lower the overall levels of iron. It may take multiple sessions of blood removal over several months to accomplish the proper iron levels. If excessive liver damage has occurred and caused cirrhosis, liver transplantation can be performed with great success. Alcohol seems to make progression of any liver disease faster in patients with hemochromatosis, thus it should be avoided. Iron supplements should be avoided, as should vitamin C supplements, since vitamin C helps to increase bowel absorption of iron. Consumption of iron rich foods like red meat are not prohibited, but excessive consumption should be avoided.

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Autoimmune Hepatitis

Autoimmune Hepatitis

The liver is a large organ located in the right upper abdomen behind the rib cage. There are a variety of problems that can affect the liver such as viruses, alcohol, fat, medications, genetic disorders, and autoimmune diseases. Some of these may cause irritation or inflammation of the liver. Inflammation of the liver from any cause is called hepatitis.

What is autoimmune hepatitis?

The immune system consists of a variety of white blood cells that can help fight against infections including bacteria and viruses, foreign cells, or organs such as with transplants. Sometimes the immune system can be triggered to attack tissues in our own body. This is known as an autoimmune disease. In the case of autoimmune hepatitis the immune system mistakenly attacks cells in the liver. The factors that trigger the immune system to do this are unknown. Autoimmune hepatitis occurs mostly in women (70 %).

What are the symptoms of autoimmune hepatitis?

Symptoms of autoimmune hepatitis can include tiredness, muscle and joint aches, decreased appetite, nausea, vomiting, and right upper abdominal pain. If there is more serious liver injury patients may notice yellowing of the eyes and skin called jaundice, itching, abdominal swelling or confusion.

How is autoimmune hepatitis diagnosed?

Liver blood tests are the initial tests that can indicate there is a liver problem. More specific blood tests looking for antibodies to one’s own tissues can be done.  Examples of blood tests that are done when autoimmune hepatitis is suspected include anti-nuclear antibody (ANA), anti-smooth muscle antibody (ASMA) and anti-liver/kidney microsome (anti-LKM). A liver biopsy can also be helpful to diagnose autoimmune hepatitis and also to determine if there is any damage to the liver.

How is autoimmune hepatitis treated?

The treatment of autoimmune hepatitis consists of medications that decrease the activity of the immune system. Prednisone is commonly used in the treatment of autoimmune hepatitis. Another medicine called azathioprine (Imuran) is sometimes added to the treatment to further decrease the inflammation of the liver. These medicines can improve both symptoms and the liver blood tests. Prednisone has a number of potential side effects including insomnia, weight gain, diabetes, hypertension, and osteoporosis. The addition of azathioprine can help reduce the dose of prednisone. Azathioprine can cause a decrease in the blood cells (such as white blood cells) made by the bone marrow. Frequent blood testing (approximately monthly) is done to follow the blood counts closely. The lowest dose of medicines is used to try and lessen these potential side effects.

Patients with autoimmune hepatitis need to be monitored closely. As the symptoms and blood tests improve, the dosage of the medications can be slowly decreased.  If the medications are discontinued some patients have a relapse of autoimmune hepatitis and may need to stay on medicines long-term to decrease the immune system. Autoimmune hepatitis can cause permanent scarring of the liver also known as cirrhosis. If a patient with cirrhosis shows signs of liver failure then liver transplantation may need to be considered.

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Fatty Liver Disease

Fatty Liver Disease

What is fatty liver disease?

Fatty liver disease is when fat accumulates in the liver.  Fat is commonly found in the liver and does not necessarily cause abnormalities or disease.  In some individuals, however, the fat present can stimulate inflammation or even scarring in the liver.  Fat can be deposited in the liver for many reasons, including alcohol abuse or even viral hepatitis.

Definitions

Fatty liver disease is the presence of fat in the liver without the coexistence of damage.  When fat leads to inflammation, the process is called steatohepatitis .  When the nidus for liver inflammation is something other than alcohol, the process is referred to as nonalcoholic steatohepatitis (NASH).  When inflammation becomes severe, scarring of the liver ensues, and this is known as cirrhosis.

Symptoms and diagnosis

Fat in the liver is most commonly asymptomatic.  If the liver swells in response to the fat, right upper abdominal pain or shoulder pain can develop.  Fatigue can also be present.  Most commonly, mild abnormalities in blood liver tests will be found.  Fat may be seen on ultrasound, CT scanning and can be quantitated by liver biopsy.  Your physician will likely eliminate other causes of liver disease before settling on a diagnosis of fatty liver disease.

What are the causes of fatty liver disease?

There are many causes of fatty liver and steatohepatitis.  The most common of these include alcohol, obesity, hepatitis C, diabetes, high cholesterol or triglycerides, and certain medications, such as corticosteroids.

What is the treatment?

The treatment of fatty liver is related to the cause. It is important to remember that simple fatty liver does not require treatment, since it does not result in damage to liver cells. Obese patients with fatty liver will have reduction or loss of excess fat in liver cells if substantial weight loss can be achieved. It is very important that weight loss be slow and controlled, however.  In alcoholic fatty liver, discontinuation or a decrease in alcohol consumption are required.  Good control of diabetes mellitus with diet, medication, or insulin also decreases the fat content in the liver.

To date, there are no proven medications to improve or cure steatohepatitis.  Preliminary data and anecdotal data suggest vitamin E and vitamin C may be helpful.  Your doctor may also suggest ursodeoxycholic acid or milk thistle.  There is hope that some anti-diabetic medications may be helpful for the disease, but research is still ongoing.

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Hepatitis C

Hepatitis C

What is hepatitis C?

Hepatitis is the term used to describe inflammation within the liver.  There are many causes of hepatitis such as alcohol, medications, drugs, hereditary diseases, and other viruses.  Hepatitis C is a virus, which affects many parts of the body, but the liver is the area that can be most seriously damaged.  Hepatitis C can be acute, meaning the patient is infected and becomes ill, then completely recovers from the infection.  Most cases, however, are chronic.  The patient may not even know they have become infected with hepatitis C.  They harbor the hepatitis C virus in their system long after initial infection and damage can be done over many years.  It is estimated that about 4 million Americans are infected with the hepatitis C virus.

How do I get hepatitis C?

Hepatitis C is transmitted through blood products.  The most common means of becoming infected include sharing needles for intravenous drug use or tattoo placement, nasal cocaine use, or blood transfusions prior to 1992.  Prior to that year, testing of our blood supply was not accurate, and some hepatitis C was spread.  We now have excellent testing to detect hepatitis C in the blood, although a very small risk of hepatitis C transmission still exists with certain diseases requiring repeated blood transfusions.  Health care workers are also at risk of acquiring hepatitis C through accidental blood and needle exposure.  Risk of transmission through sexual contact is controversial; although a slight risk exists, it is heightened in the setting of coexistent sexually transmitted diseases and having multiple sexual partners.  The best protection from any sexually transmitted disease is barrier contraception.  Patients in long-term monogamous sexual relationships are generally considered safe for unprotected sex.  Spread of hepatitis C from mother to fetus is extremely low.  Women wishing to become pregnant should speak with their physician.  Hepatitis C cannot be passed between family members by casual contact like hugging or kissing.  The smartest way to prevent transmission is to use common sense regarding any items in the home that may be exposed to the infected person’s blood – avoid sharing razors, toothbrushes, and manicure items.

Symptoms and Diagnosis

The vast majority of patients with hepatitis C have no idea they are infected.  Only rarely does the initial infection cause jaundice, nausea, fatigue, diarrhea and generalized illness, which are the hallmark symptoms of acute infection with hepatitis A and hepatitis B.  Blood testing must be performed to look for the presence of hepatitis C.  Approximately 75 percent of patients exposed to hepatitis C will develop chronic infection.

Course of Disease

Cirrhosis, or scarring of the liver, is the dreaded complication of chronic hepatitis C infection.  It is estimated that only 25 percent of those with chronic hepatitis C will develop advanced cirrhosis within their natural course of life.  Unfortunately, predicting which patients fall into that 25 percent group is impossible.  Thus therapy is considered for all who are infected.  Alcohol will speed up development of cirrhosis significantly, so avoidance of alcohol is imperative for patients infected with hepatitis C.

What is the treatment?

There is no vaccine to prevent hepatitis C.  Once infection has occurred, treatment is a complicated topic that your physician will approach very thoughtfully.  Many tests may need to be performed prior to considering therapy, such as laboratory testing, CT or ultrasound of the liver, and liver biopsy.  The medication is twofold:  ribavirin is an oral medication taken daily, and peg-interferon is an intramuscular shot given once a week by the patient.  These medications can be dangerous if not used properly, so routine lab work is necessary during the course of therapy.  It is very important that you and your physician are in close contact, and the patient is compliant with lab testing and office visits as requested by their doctor.  Alcohol should be strictly avoided during therapy.  Therapy is given from 12-48 weeks, depending on which subtype of virus the patient has (called the genotype), the patient’s response to therapy, and side effects, which can include many problems from lab abnormalities to depression.  Anywhere from 40-80 percent of patients are cured of hepatitis C with therapy.  The goal of hepatitis C therapy is to prevent cirrhosis.  In some instances, hepatitis C causes advanced cirrhosis, requiring liver transplantation.

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Hepatitis B

Hepatitis B

What is Hepatitis B?

Hepatitis B is a virus that can infect the liver and cause damage. It is estimated that there are 80,000 new cases of hepatitis B each year in the United States. The virus can persist in the body of some individuals. It is estimated that 1.25 million Americans are chronic carriers of the hepatitis B virus.

How is the Hepatitis B virus transmitted?

The hepatitis B virus is spread by exposure to infected body fluids. The virus can be found in blood, saliva, semen, vaginal secretions and breast milk of infected individuals. Hepatitis B is most commonly transmitted by sharing contaminated needles (such as in intravenous drug abuse), sexual intercourse, or from an infected mother to her baby at the time of birth. Potential blood donors are carefully tested for the hepatitis B virus and excluded if they test positive. Therefore, blood transfusions do not cause hepatitis B infection.

How is Hepatitis B diagnosed?

Hepatitis B can be diagnosed through a series of blood tests. There are different parts of the hepatitis B virus that can be looked for. The basic part of the virus named Hepatitis B surface antigen (sometimes abbreviated HBsAg ) is the initial blood test to determine if the virus is present.  Other parts of the virus that can be tested for are called core and envelope (known as c and e ) and the hepatitis B DNA. By performing this panel of blood tests one can determine if the hepatitis B virus is a recent or long-standing infection and also whether or not the virus is active.

What happens to a person that is infected with the Hepatitis B virus?

Some patients infected with Hepatitis B do not have significant symptoms. There is a period of time between the time a patient contracts the virus and the onset of symptoms. This is called the incubation period and ranges from 1 to 3 months. Symptoms associated with Hepatitis B infection can include muscle and joint aches, decreased appetite, nausea, vomiting, right upper abdominal pain, fever and weakness. Other patients with more significant irritation of the liver may have jaundice with yellowing of the skin and eyes, dark urine and light-colored stools. Most adult patients (95%) will clear the Hepatitis B virus and not have any damage to the liver. If a person does not clear the virus after 6 months, he or she is considered to be a carrier or to have chronic Hepatitis B.  Hepatitis B virus carriers are patients with no symptoms who only have the inactive part of the virus in their blood (HBsAg) and normal liver blood tests. A patient with chronic Hepatitis B can have both the inactive (HBsAg) and active (e and DNA) parts of the virus in their blood that can cause ongoing liver damage. Patients with chronic hepatitis B can go on to develop scarring of the liver known as cirrhosis, liver failure, or liver cancer. These patients may need to be considered for liver transplantation.

How is Hepatitis B infection treated?

The most effective treatment for hepatitis B is to prevent it.  If a patient is not able to eliminate the virus after 6 months and has ongoing active virus in their blood he or she may be a candidate for treatment. Currently approved therapies for chronic Hepatitis B are lamivudine (Epivir-HBV), adefovir (Hepsera) and interferon. The goal of these therapies is to make the Hepatitis B virus inactive. Rarely the virus is eliminated completely from the blood. The first two medications are given orally and are tolerated well. Interferon is a medication given as an injection under the skin at least weekly for 3 to 6 months. Interferon has many side effects including flu-like symptoms, irritability, depression and decreased blood counts. There are pros and cons to using these medications. The decision is based on a variety of factors including how long a person has had the infection and blood test results.

How can Hepatitis B infection be prevented?

There is a safe vaccine to protect a person against Hepatitis B. The vaccination is given as a series of three muscle injections over 6 months. It is now part of the routine vaccinations given to newborns. It is also recommended that health care personnel, hemodialysis patients, chronic liver disease patients, people with multiple sexual partners, injection drug users, and household or sexual contacts of persons with chronic Hepatitis B infection be vaccinated. The vaccination is safe and effective in preventing Hepatitis B infection.

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Hepatitis A

Hepatitis A

What is hepatitis A?

Hepatitis A is a viral infection that attacks the liver.  Infection usually results in a short illness that spontaneously resolves.  Symptoms vary from flu-like complaints to yellow jaundice.  Most infections are mild and patients do not need to seek medical care.  Rarely, the disease is severe and life threatening.  In these instances liver transplantation may be necessary.

Unlike hepatitis B or hepatitis C, hepatitis A does not cause chronic disease, meaning the virus does not stay in your liver for many years.  For this reason, hepatitis A does not cause an increased risk of liver failure over time or liver cancer.

How do I know if I have hepatitis A?

Since symptoms of hepatitis A mimic those of other common ailments, such as the flu, not everyone realizes they have been infected.  Initial symptoms may include fatigue, nausea, vomiting, loss of appetite, fever, and abdominal pain.  A week into the illness you may develop jaundice, dark urine or itching.  The liver may enlarge and you may notice arthritis, rashes, or enlargement of lymph nodes.

The incubation period of the infection ranges from 15 to 49 days (average of 30 days).  This means that it may take several weeks after you are exposed to the virus to develop illness and symptoms.  If you suspect infection, you should see your doctor for blood testing.  Hepatitis A infection is diagnosed by specific blood tests, which detect antibody to the virus.  Blood tests will usually turn positive within one month of contracting the virus.

What is the treatment?

Because the vast majority of cases of hepatitis A resolve on their own, treatment is supportive.  There are no specific anti-viral medications that speed up resolution of the disease.  Approximately 85% of patients infected with hepatitis A have full recovery within three months and over 99% are well by six months.  It is rare for hepatitis A to cause such severe infection as to require liver transplantation.

A vaccine for hepatitis A exists and is effective.  Vaccines stimulate your immune system to create antibodies against hepatitis A, but that can take several months.  The vaccine is indicated for certain groups of people at increased risk of the disease, such as individuals with other forms of liver disease, intravenous drug users, individuals with clotting factor deficiencies, men who have sex with men, and people traveling to areas with high infection rates.  For family members or contacts of someone known to be infected with hepatitis A, serum immune globulins are available to prevent disease.  These are “pre-formed” antibodies that can be injected into the person at risk in an attempt to prevent onset of disease.

How can I prevent hepatitis A?

Hepatitis A is transmitted by the “fecal-oral” route.  Anything that improves sanitation, such as adequate hand washing, thoroughly washing fresh fruits and vegetables, properly cooking meats (particularly seafood) and avoiding contaminated water sources are all vital.

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Celiac Disease

Celiac Disease

What is celiac disease?

Celiac disease, also called nontropical sprue, gluten-sensitive enteropathy or celiac sprue, is a condition in which gluten, a protein found in wheat, barley and oats, injures the lining of the small intestine causing malabsorption of nutrients.  The normal small intestinal lining consists of small projections called villi and even smaller projections called microvilli, which create an enormous surface area for absorption of nutrients.  Normally, foods are digested and nutrients are absorbed into the blood stream through the villi of the small intestine.  When the villi are damaged, as with celiac disease, absorption is impaired.

What are the symptoms of celiac disease?

Symptoms are caused by the increased passage of unabsorbed nutrients through the gastrointestinal tract or by nutritional deficiencies.  The severity of symptoms varies and depends upon how severe the small intestine is damaged.  Weight loss, diarrhea, gas, bloating, abdominal cramping or vitamin and mineral deficiencies can occur to varying degrees.  Many people have little or no symptoms at all.  A small percentage of people with celiac disease develop a skin rash called dermatitis herpetiformis.  Malabsorption of fats in the gastrointestinal tract often results in stool that is light colored, soft or loose and unusually foul smelling.  Grease droplets may be seen in the toilet water with fat malabsorption.  Inadequate absorption of sugars can cause explosive diarrhea, gas and abdominal bloating.  Nutritional deficiencies can cause additional symptoms.  Anemia develops as a result of iron deficiency and may cause fatigue and weakness.  Vitamin B12 deficiency can also contribute to anemia and also lead to nerve damage.  Malabsorption of calcium can result in abnormal bone growth, osteoporosis, painful bones and joints and a higher risk of broken bones, as well as tooth discoloration and tooth decay.  Protein malabsorption can lead to fluid retention and tissue swelling.

How is a diagnosis of celiac disease made?

A blood test that measures specific antibodies produced when a person with celiac disease consumes gluten can be helpful in diagnosis.  A small intestinal biopsy is needed to definitively establish a diagnosis of celiac disease.  A small intestinal biopsy is obtained during upper GI endoscopy, which involves passing a camera into the small bowel to obtain biopsies.

What treatment is available?

Gluten must be completely eliminated from the diet in patients with celiac disease.  Once gluten is avoided, the small intestine heals and its absorptive function returns to normal.  Removing gluten from the diet is not easy because gluten is so widely used in food products.  Expert advice from a dietician and detailed lists of foods to be avoided are crucial in treatment.  The response to a gluten free diet is usually dramatic and rapid, however some patients continue to have symptoms even when gluten is avoided.  In such cases, either the diagnosis is incorrect, or unknown sources of gluten are being ingested, or rarely the disease has progressed to a condition called refractory celiac disease.  In refractory celiac disease, treatment with corticosteroids may help.  Although most people with celiac disease do well on a strict gluten free diet, a small percent of patients can develop intestinal lymphoma, a type of intestinal cancer that can be fatal.

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Crohn’s Disease

Crohn’s Disease

What is Crohn’s disease?

Crohn’s disease is an inflammatory condition of the digestive tract. It is an “autoimmune” disease in which the immune system attacks the gastrointestinal tract.  The cause of Crohn’s disease is unknown.  Heredity may play a role in some patients.  Smoking and some anti-inflammatory drugs, such as ibuprofen and aspirin, exacerbate the disease.  The disease is not caused by foods nor is it an allergy to foods, but during attacks food intolerances may occur.

What are the symptoms of Crohn’s disease?

Crohn’s disease most commonly involves the small intestine and colon. The most common symptoms are abdominal pain and diarrhea, but can also include other symptoms such as mouth sores, weight loss, fever, rash, joint pain, bloating, constipation, anemia and draining lesions on the buttocks.

How is a diagnosis made?

Since many other diseases may cause similar symptoms, scope tests, particularly colonoscopy, as well as x-rays, blood tests, and other tests are typically used to diagnose Crohn’s disease.  Although Crohn’s disease is usually chronic, medical and surgical treatment can help control the course of the disease and many patients experience long periods of symptom-free remission. Most patients with Crohn’s disease have a normal life, even though they may have to be on treatment for many years or lifelong.

How is Crohn’s disease treated?

Crohn’s usually follows a pattern of exacerbations and remissions. About 10 to 20 percent of patients will enter remission after their first exacerbation of Crohn’s disease. The pattern in other patients can be quite variable.  Treatment can help drive active disease into remission and then prolong remission.

Crohn’s disease is not curable, but it is very treatable in the vast majority of patients.  Many different drugs are used to treat Crohn’s disease. Your doctor’s choice of medications will depend upon the area of the digestive tract affected by the disease and your symptoms. A minority of patients requires surgery in this day and age.

Many patients with Crohn’s disease become undernourished by inappropriate dietary experimentation, rather than due to the effects of the disease.  Thus, it is important that you discuss your dietary concerns with your doctor.  Over time, the intestinal problems of Crohn’s disease can lead to other health problems such as weight loss, anemia, and osteoporosis.  In addition, medications used to treat Crohn’s disease may have predictable side effects over time.  Fortunately, many of these problems can be anticipated and prevented.  Crohn’s disease also increases the risk of intestinal cancer to some extent.  A minority of Crohn’s patients may also develop related problems outside the intestines, such as arthritis, skin conditions, visual problems, liver disease and others.

Additional Reading

The most reliable source of information for patients regarding Crohn’s disease is the Crohn’s and Colitis Foundation.

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Ulcerative Colitis

Ulcerative Colitis

Ulcerative colitis is a chronic ulcerating condition of the colon, otherwise known as the large bowel.  It affects all age and ethnic groups, although most disease begins at a young age.  The disease can affect any portion of the large bowel, or just sections of the bowel.  The disease is also called by various other names depending on the location of involved colon, including pancolitis (entire colon involved) or proctitis (only rectum involved).  Ulcerative colitis is characterized by ulcers and inflammation affecting the colon lining.

What causes ulcerative colitis?

No one is yet certain what exactly causes ulcerative colitis.  There is likely a genetic predisposition to acquiring the disease.  Environmental factors such as diet and infections may contribute.  It is believed the body’s immune system targets the colon with antibodies, causing ulcers and inflammation to form.

What are the symptoms of ulcerative colitis?

Ulcerative colitis can cause life threatening disease or be very subtle.  Each patient develops his or her own set of symptoms, but there is not one particular set of problems that makes the diagnosis of ulcerative colitis.  Symptoms can develop slowly over months to years and symptoms vary based on the location within the colon of the ulcerations.  Symptoms include abdominal pain, diarrhea (both bloody and non-bloody), rectal pain, weakness, weight loss, rectal urgency, and passage of mucus or pus.  Anemia can be found on blood testing due to chronic blood loss from the colon.  Some patients also develop joint pain or skin rashes associated with ulcerative colitis.

How do I know if I have ulcerative colitis?

The diagnosis is often suspected from the symptoms.  Visualization of the colon via colonoscopy or flexible sigmoidoscopy is usually necessary to identify the location of ulcers and obtain tissue biopsies.  Sometimes barium tests of the small bowel or colon are helpful, and blood tests to look for anemia and inflammation may be requested by your physician.

What treatment is available?

Your physician will discuss with you treatment options.  Each patient is treated individually based on his or her specific pattern of disease.  Multiple treatments exist including steroids (prednisone or budesonide), 5-ASA compounds, immunomodulators and infliximab.  Although surgery is not recommended as first-line treatment for ulcerative colitis, removal of the colon is curative.  In cases where medications cannot control the disease or the patient’s life is being adversely affected by the disease, surgery can be a welcome option.  New techniques often allow for surgical pouch formation rather than a colostomy (a bag on the abdomen wall).

What are the possible complications of ulcerative colitis?

The dreaded complication of long-term ulcerative colitis is colon cancer.  The risk is significantly increased after having the disease for 8-10 years.  Your doctor will likely suggest routine colonoscopy screening of your colon due to this increased risk.

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High Fiber Diet

High Fiber Diet

Dietary fiber is the undigestible carbohydrate from plants that passes through our guts into the colon.  Also known as “roughage,” fiber helps to pull water into the colon, aiding in multiple GI-related and non-GI-related conditions.

Fiber is found in a variety of plant sources including vegetables, fruit, grains, seeds, nuts and legumes.  There are two main types, soluble and insoluble fiber.  Soluble fibers dissolve in water, and the insoluble varieties do not.  Regardless of their ability to dissolve, fibers reach the colon (or large intestine) completely undigested.  Here they add bulk and act to pull water into the colon contents.  This helps to “wet” stools, make them softer, and generally aid with stool evacuation.  Fibers also have other positive benefits such as lowering cholesterol, decreasing the risk of coronary artery disease, lowering the risk of stroke, and helping to prevent colorectal cancer.

Your Gastroenterologist may suggest daily fiber supplementation for a variety of reasons.  Daily fiber is treatment for irritable bowel syndrome (IBS), hemorrhoids, anal fissures, diverticulosis, and constipation.  The National Cancer Institute recommends adults consume between 20-30 grams of fiber daily.  The average American uses only 5-20 grams.  Occasionally increased gas production will be noticed when fiber supplements are begun – slowly increasing fiber doses to the goal dose will help to eliminate this problem.  It is imperative that adequate water be used with fiber supplementation.  Although no specific recommendations exist as to amount, consider using 8-12 ounces of water for each 5 grams of fiber consumed.

Fibers can be found in a variety of natural and synthetic forms.  Over-the-counter formulations of available fiber include Metamucil, Citrucel, Benefiber, and Hydrocil.  Powder forms of these fibers are most useful, although capsules and wafers do exist.  Solid pill forms of fiber should be avoided.  Fiber content of commonly consumed foods is outlined in the box below.

Serving Size Food Grams dietary fiber
1 medium Bran muffin 3
1 slice Whole wheat bread 2
1 slide White bread 1
½ cup Kidney beans 9
½ cup Baked beans 7
½ cup Navy beans 5
½ cup Pinto beans 5
½ cup Frozen peas 4
1 medium Baked potato with skin 4
½ cup Broccoli tops 3
3.5 ounces Dried figs 18
3.5 ounces Prunes 8
3.5 ounces Raspberries 7
¼ cup Almonds 5
1 medium Apple with skin 3
1 ounce Kellogg’s All Bran Ex Fiber 14
1 ounce General Mills Fiber One 12
1 ounce Kellogg’s All Bran 9
1 cup Whole wheat pasta 5
1 ounce Kellogg’s Raisin Bran 4
1 ounce Post Grape Nuts 2

 

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Lactose Intolerance

Lactose Intolerance

What is lactose intolerance?

Lactose intolerance is difficulty digesting dairy products.  Lactase is the enzyme normally found within the small bowel that is responsible for digesting lactose.  Lactose is found in dairy and milk products.  When the intestine does not contain lactase, or the lactase does not work properly, milk and dairy intolerance occurs.

What are the symptoms of lactose intolerance?

When lactose does not get properly digested, it reaches the colon and gets broken apart by bacteria.  This process is called bacterial fermentation, and its by-product is gas production.  Gas can lead to many symptoms, including nausea, bloating, belching, abdominal cramps, diarrhea and rectal gas.

How do I know if I have lactose intolerance?

Your medical history, or story, often gives away the answer.  Many people recognize that dairy and milk products produce gastrointestinal symptoms.  Patients may already be avoiding dairy products due to these symptoms.  If you have not tried eliminating dairy products, this is a very easy place to start.  Discontinue all dairy products for two weeks and see if your gastrointestinal symptoms improve.  Then add a large glass of milk and see if new symptoms arise.

More scientific ways exist to prove lactose intolerance.  Hydrogen is produced when lactose is fermented abnormally.  A hydrogen breath test involves measuring the amount of hydrogen expressed after consumption of milk or other dairy products.

What is the treatment?

For patients with mild symptoms, avoidance of large amounts of milk or dairy can be adequate to control symptoms.  For more serious disease, lactose avoidance is best.  Labels must be checked carefully.  Lactose alternatives, such as soy, are becoming more commonly available.  Milk is now available with lactase added.  Lactase tablets are over-the-counter, and can be ingested prior to taking milk products.

Are there any problems with avoiding milk products?

Milk and dairy products are a major source of calcium.  Although many other sources of calcium exist, people who strictly avoid dairy products must be conscious to consume adequate amounts of calcium.  Most people need 1000mg of calcium daily.  Nursing mothers should consume 1200mg daily, and postmenopausal women 1500mg daily.  Discuss with your physician the best way to ingest or supplement calcium.

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Diverticular Disease

Diverticular Disease

Definitions

A diverticulum is a sac-like protrusion that forms in the muscular wall of the colon, particularly at points where blood vessels enter.  The pleural of diverticulum is diverticula Diverticular disease of the colon refers to diverticulosis, diverticulitis, and diverticular bleeding.  Diverticulosis is the disease where multiple diverticula are present within the colon.  Diverticulitis means that the diverticula are inflamed or infected.   Diverticular bleeding refers to one diverticulum actively losing blood.

Diverticulosis

Diverticulosis occurs mostly in older adults, and is a normal part of aging.  Typical low fiber American diets, as well as one’s family history, also affect the likelihood of developing diverticulosis.  Diverticulosis alone probably does not cause any symptoms, such as pain or alteration of bowel function. Diverticulosis is usually diagnosed incidentally in people undergoing colonoscopy, barium enema, and other tests for unrelated reasons.   Your doctor may ask you to increase the amount of daily fiber in an attempt to prevent further diverticula from developing.

Diverticulitis

Although many adults have diverticulosis, a relatively small number ever develop diverticulitis.  Diverticulitis typically presents with acute abdominal pain, constipation, and fever.  It usually is not associated with bleeding.  Diverticulitis can be triggered by ingestion of high “residue” foods, such as seeds, nuts, and popcorn, as well as by anti-inflammatory drugs (ibuprofen, naprosyn, aspirin).   It usually responds well to antibiotics and dietary modifications.  Surgery is usually reserved for cases of diverticulitis that do not respond to antibiotics or for recurrent cases of infection.  On occasion, an episode of diverticulitis will lead to infection of the whole abdomen, known as peritonitis, which requires surgery to correct.  Diverticulitis can be diagnosed on the basis of symptoms, physical examination and blood tests, as well as with imaging studies such as CT scans.

Diverticular Bleeding

Diverticular bleeding can be mild or life threatening and may require hospitalization.  Most cases of diverticular bleeding resolve without any specific therapy. However, some patients have continued bleeding that requires colonoscopy, nuclear medicine scans or angiography in an attempt to stop or slow the bleeding.  When bleeding continues, surgery may be recommended.

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Rectal Bleeding

Rectal Bleeding

Bleeding from the rectum is not normal.  Many patients with rectal bleeding blame the blood on hemorrhoids, and in many instances this is the case.  In some patients, however, rectal bleeding can be a symptom of a far more worrisome problem.  Considering the possible causes of rectal bleeding will help you and your physician decide what tests need to be performed to find the cause.

What are the causes of rectal bleeding?

Hemorrhoids – These are dilated blood vessels that can be located outside the rectum, or inside where you neither see nor feel them.  When outside the rectum, they look like small purple grapes and can be felt as small bumps.  They may develop with chronic straining to pass stools or pregnancy.  Your doctor may be able to see external hemorrhoids during a simple rectal exam, but the internal hemorrhoids must be visualized in a more advanced manner.  Treatment usually involves softening the stool, thus lessening straining with stool passage.

Fissure – This is a small tear in the canal where stool is passed from the rectum.  Usually bleeding is accompanied by pain when the stool moves past the tear.  Your doctor may be able to diagnose this problem with a simple digital rectal exam.  Most fissures heal spontaneously, but local creams, sitz baths, and stool softeners can be helpful.

Fistula – This is an abnormal connection between your colon and skin.  The most common cause is ulcerating disease in the colon, namely Crohn’s disease.  Ulcers in the colon burrow deep through the colon walls, through the soft tissues around the colon, and eventually open up a passage to the skin.  Fistulas drain pus, mucous, stool, and sometimes blood.  Fistulas are usually a marker of significant problems within the colon and require evaluation.  They can be healed with antibiotics, treatment for Crohn’s disease, or surgery.

Colitis/Proctitis – These are general terms meaning inflammation within the colon and rectum, respectively.  Inflammation can be in the form of swelling of the colon walls, redness, or ulcers.  Along with rectal bleeding, other symptoms include abdominal pain and diarrhea.  The most common causes of colitis and proctitis are ulcerative colitis and Crohn’s disease.  Other causes of colitis include poor blood flow to the colon (ischemic colitis), infections, NSAID ulcerations (anti-inflammatory medications), and sliding of the rectal tissue in and out of the rectum resulting in ulcer formation.

Diverticulosis – Not to be confused with diverticulitis, which is an infection of a diverticulum, diverticulosis is the presence of small sacs projecting from the colon.  These sacs can spontaneously bleed.  Most bleeding diverticula stop bleeding spontaneously, but sometimes the bleeding can be life threatening.  The diagnosis is made by colonoscopy or radiologic testing.

Polyps and colorectal cancer – These are by far the most worrisome causes of rectal bleeding.  Polyps are benign growths that can bleed.  Treatment of polyps is imperative, not only to prevent blood loss, but because they are the precursors to colon cancer.  If left untreated, small polyps may eventually grow larger and become cancerous.  Once a cancer has formed in the colon, bleeding is a very common means of presentation.  Colonoscopy is the hallmark method to detect polyps and colorectal cancers.

How is the cause of rectal bleeding determined?

Each person is an individual, thus each patient’s case must be considered as such.  Every person with rectal bleeding does not need a colonoscopy, just as not all bleeding is due to cancer.  Rectal bleeding should be considered serious, however, until some evaluation is made.  Most importantly, talk to your doctor about the nature of your rectal bleeding.  Your medical history regarding the blood loss is extremely important in deciding if your problem is serious or a simple nuisance.  Your age is key in this decision – general health recommendations include colonic examination for all persons over the age of 50.  Thus if you are in this age group, colonoscopy will more likely be suggested to you as the proper way to determine the cause of your rectal bleeding.

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Hemorrhoids

Hemorrhoids

What are hemorrhoids?

Hemorrhoids are a nuisance, but rarely a serious problem.  Most adults will deal with hemorrhoids at some point in life.  The rectum and anal canal is rich in blood supply.  Hemorrhoids are dilated blood vessels in these areas.  They are not growths, polyps, nor tumors.  Unfortunately, the symptoms of hemorrhoids can mimic symptoms of more serious disorders, such as colorectal cancer.

There are two types of hemorrhoids, internal and external.  The external hemorrhoids can be seen and felt outside of the anal canal.  Internal hemorrhoids are up inside the rectum and cannot be easily seen or felt.  An examination to evaluate the inside of the rectum is needed to diagnose internal hemorrhoids.

What causes hemorrhoids?

Everyone may experience symptoms of hemorrhoids at some point or another.  Common causes of hemorrhoids include constipation, diarrhea, obesity, prolonged standing, pregnancy or straining to pass stools.  Any activity that increases pressure in the rectal area can cause hemorrhoids.  You do not need to have any of these issues to develop hemorrhoids, however.  Some individuals have significant hemorrhoids without obvious risk factors.

What are the symptoms of hemorrhoids?

The most common symptoms of hemorrhoids include pain, itching, burning, bleeding and a palpable lump near the anal canal.  On occasion, a hemorrhoid can develop a blood clot within the vessel that causes increased pain and hardness of the hemorrhoid.  This is called a thrombosed hemorrhoid.  Hemorrhoids can bleed, sometimes significantly.  The classic pattern of bleeding is fresh red blood seen streaking the outside of the stool, dripping into the toilet water, or on the toilet paper.  Hemorrhoids do not cause cancer.  Unfortunately, hemorrhoidal bleeding can mimic rectal cancer, as well as other problems within the rectum.  Colonoscopy or flexible sigmoidoscopy is the only certain way to assure there is not a rectal cancer as the source of rectal bleeding.  Your doctor can help you to decide if minor rectal bleeding is from a hemorrhoid or a more serious source.

What treatments are available for hemorrhoids?

Treatment of hemorrhoids can be challenging.  The first rule of treatment is to keep stools soft and easy to pass.  This is best accomplished with increased fiber.  Increase dietary fiber or use bulking agents, such as Metamucil, Citrucel or Benefiber, for a goal of 20-30 grams per day.  Make sure to drink plenty of water, as fiber without water is less helpful.  Avoid straining when passing stools, as straining exerts extra pressure on already dilated hemorrhoids.

For bothersome external hemorrhoids, avoid rubbing after bowel movements and instead dab for cleanliness.  Keep the area clean and dry.  Don’t be afraid to apply talcum powder to assist with drying or even use a hair dryer.  When itching occurs, local remedies such as witch hazel or Preparation H can be soothing.  Sitz baths can help decrease swelling – these are accomplished by adding Epsom salts to lukewarm bath water.

For internal hemorrhoids, a couple of options exist to eliminate large, swollen hemorrhoids.  Ligation is performed during colonoscopy or flexible sigmoidoscopy, and involves placing a tiny rubber band around the base of a dilated hemorrhoid.  Circulation is stopped and the hemorrhoid falls off.  Repeat treatments are often necessary.  Infrared photocoagulation is also performed during colonoscopy or flexible sigmoidoscopy and involves treating a hemorrhoid with an infrared laser, which burns and destroys the hemorrhoid.  Again, repeat treatments may be necessary.

Surgery is available for both internal and external hemorrhoids.  Since it can be quite painful, oftentimes surgery is reserved for thrombosed hemorrhoids, hemorrhoids which bleed profusely, or otherwise recurrently problematic hemorrhoids.  Your physician can help you to decide which, if any, treatment is best for you.

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Colon Polyps and Cancer

Colon Polyps and Cancer

Why should I be concerned about polyps and colon cancer?

Cancer of the colon and rectum is a major health problem in the United States.  It ranks second as a cause of death from cancer.  Colorectal cancer is treatable, but more importantly, it is one of the most preventable forms of cancer.  Finding and removing polyps before they have a chance to become malignant is incredibly effective in avoiding colorectal cancer.

What is a colon polyp?

A polyp is a growth on the lining of the colon.  They look like tiny pink grapes.  Polyps are benign, but if left unattended, they can turn into cancers over time.  The larger the polyp and the longer it has been present, the greater the risk it contains cancer cells.

How does a colon polyp become a colorectal cancer?

As the polyp enlarges, genetic mutations accumulate within the polyp tissue.  There is now strong medical evidence suggesting some people inherit abnormal genes that don’t know when to turn “off.”  This leads to overactive growth within the polyp and allows an accelerated course to cancer.  There are likely other factors contributing to the transformation from polyp to cancer, including age, diet, chronic inflammatory conditions (like ulcerative colitis and Crohn’s disease), lack of ingested fiber, and other forms of cancer (such as breast or ovarian).

How do I know if I have colon polyps?

Early detection and removal of colon polyps is key to prevention of colon cancer because polyps seldom cause symptoms in their earliest stages.  The only way to know if you have them is to have an examination of the colon.  Currently, the best examination of the colon is colonoscopy, where a flexible, lighted tube with a camera is inserted into the colon.  If polyps are identified, they are removed immediately.  Future methods of detection may include a blood genetic test or CT colography (virtual colonoscopy).

Colon polyp removal is quick and painless.  Your physician has a variety of means by which to remove polyps including a wire lasso called a snare that snips the polyp off at its base, or a biopsy forceps, which is used on small polyps.

When should I have my first colonoscopy?

If you are of average risk, which means no one else in the family has colon polyps or colorectal cancer, your first colonoscopy should be at age 50.  If immediate family members have had a colorectal cancer, you should start colonoscopy at age 40 or at ten years younger than the age your family member was diagnosed.  Colonoscopy should be considered in patients who have regular gastrointestinal complaints.  Your physician can help you to determine when your first colonoscopy is indicated.

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Diarrhea

Diarrhea

What is diarrhea?

This is a somewhat difficult question to answer, because everyone has diarrhea on occasion, which is normal.  Pathologic diarrhea has several definitions – several loose stools per day, stools greater than a cup in size, stools that occur throughout the night, and loose stools that persist for several weeks.  Most cases of diarrhea simply resolve, so determining the appropriate time to pursue the cause of diarrhea is another issue.

When is diarrhea concerning?

Again, most cases resolve despite efforts by you or your doctor.  On occasion diarrhea is severe and requires prompt attention from a physician.  Any diarrheal illness that lasts over a month should be evaluated.  Bloody diarrhea is cause for concern.  Fevers, chills, abdominal pain, dizziness, or change in consciousness accompanying diarrhea signifies potentially serious illness and should be promptly evaluated.

What are the causes of diarrhea?

The list of diarrheal etiologies is endless.  Some of the more common causes will be reviewed below.

Infections – We have hundreds of bacteria that normally live in our intestines and perform an important function.  Once in a while, one of these can become overgrown and wreak havoc.  Bacteria such as E coli 0157:H7, Salmonella, Shigella and Campylobacter are typically ingested from contaminated food or water sources.  Parasites like Giardia or amoeba come from similar sources.  Clostridium difficile is associated with antibiotic use.  A whole host of viruses can cause diarrhea.  Patients whose immune systems function improperly, as in AIDS or chronic steroid use, are at particular risk for intestinal infections.

Medications – It is not unusual to develop diarrhea when new medication is started.  Sometimes the diarrhea will resolve, and sometimes it is necessary to stop the medication.

Inflammatory conditions – Inflammation can occur at any spot along the entire GI tract.  When enough inflammation accumulates, diarrhea can result from improper management of water and nutrients.  A number of inflammatory conditions exist including Crohn’s disease, ulcerative colitis, ischemic colitis, microscopic colitis and various other ulcerating diseases.

Irritable bowel syndrome – Also called spastic colon or functional bowel disorder, IBS is poorly understood in terms of cause and treatment.  We believe the bowels squeeze in an uncoordinated manner and manage fluid within the GI tract improperly, which can at times cause diarrhea, and other times constipation.  Other symptoms include abdominal pain and bloating.  This condition may be aggravated by increased stress.

Food and other oral substances – This category can be daunting, as practically anything we put in our mouths at one point or another can cause diarrhea.  Sometimes there are patterns, however.  Certain foods such as dairy products, spicy foods or greasy food may cause diarrhea.  Celiac sprue is a disease where the small bowel is allergic to gluten, a common ingredient in many grains.  Patients can have diarrhea, weight loss, skin rashes and lactose intolerance. Artificial sweeteners, particularly sorbitol, will cause excessive diarrhea in some patients.  Laxatives can be mistakenly or intentionally ingested, and their purpose is to induce loose stools.  Milk of Magnesia, Ex-Lax, Senna, and Dulcolax are some of the more popular brands.  Any over-the-counter preparation containing magnesium can cause diarrhea, such as Maalox or Mylanta.

Cancer or growths – On rare occasions, partial obstruction of the colon from cancer will result in diarrhea.  Other benign and malignant growths in the bowel can also produce diarrhea by stimulating flow of excessive water into your colon.

Diagnosis and Treatment

Your physician can learn a great deal from the history of your diarrheal illness.  He or she may choose to collect stool for studies, perform radiographic imaging like CT scan, or do colonoscopy.  Therapy depends on how ill you are in general, and whether a cause of diarrhea can be found.  In some cases it is safe to use over-the-counter or prescription anti-diarrheal agents like Imodium, Pepto-Bismol, Kaopectate or lomotil.

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Constipation

Constipation

What is constipation?

Constipation is an imprecise term that refers to several different stool problems.  Constipation can be defined as abnormalities in the frequency or consistency of stool.  Constipation can also refer to stool being difficult to pass.  Unfortunately, there is no “correct” definition of “normal” stools.  What is normal to one person in terms of stool quantity, consistency and ease of passage may be highly abnormal for the next person.  In general, when the inability to pass stool satisfactorily exists due to hardness, infrequency, pain or straining, we refer to this as constipation.

The normal role of the gastrointestinal tract is to process the foods we eat, absorb important nutrients, and pass the leftover waste into the colon to be prepared for excretion.  The intestines are packed full of good bacteria to aid in this digestive process.  Once the small intestines have processed foods appropriately, liquid waste is passed down into the large intestine, also known as the colon.  The colon’s main job is to remove water from the waste, ultimately leading to formed waste material, which we call stool or feces.  About half of the feces we pass are made up of the good bacteria from higher in the gastrointestinal tract.  When something goes wrong with the removal of water, amount of good bacteria, or the time it takes to move waste through the colon, constipation can result.

What are the causes of constipation?

The list of medical problems that can cause constipation is extremely long.  Some of the more common causes of constipation include low thyroid activity, diabetes mellitus, pregnancy, irritable bowel syndrome, medications (the most common offenders are narcotic pain medications, psychiatric medications, some blood pressure pills, calcium, and iron), Parkinson’s syndrome, spinal cord disorders, multiple sclerosis, and colonic inertia (“lazy colon”).

Obstruction of the colon can also causes constipation.  Any process that mechanically blocks stool moving through the colon will cause partial or full colon obstructions.  These processes can include colon polyps, cancers, ulcers, inflammatory conditions known as colitis, or infections (such as diverticulitis).

How do I know if I have constipation?

Your Gastroenterologist will help to guide you through the steps necessary to determine why you suffer from constipation.  He or she may recommend colonoscopy, barium enema, flexible sigmoidoscopy, CT scan, laboratory studies, rectal pressure tests known as anorectal manometry, x-rays following ingested radiologic markers known as colonic transit studies, or specialized x-rays of defecation called defecography.

What is the treatment for constipation?

The treatment for constipation is largely dependent on the cause, thus finding out why you are constipated is very important.  Lifestyle changes such as a diet high in fiber, plenty of daily water intake, and regular exercise can significantly improve stool habits.  Constipation due to medical illnesses such as thyroid or diabetes can often be improved by fixing the underlying medical illness.  In other cases, your physician will prescribe laxatives.  Many laxatives exist ranging from dietary fiber, supplemental fiber, over-the-counter remedies such as milk of magnesia or senna, or prescription laxatives like Miralax or lactulose.  Laxatives come in many forms including oral, suppository, and enema.  On an infrequent basis is surgery necessary or appropriate for the treatment of constipation.

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Surgical Correction of Reflux Disease

Surgical Correction of Reflux Disease

What is GERD?

Gastroesophageal reflux disease (GERD) is very common in the United States, with up to 40% of Americans having symptoms monthly.  Gastroesophageal reflux is defined as the movement of contents within the stomach, mainly acid, upwards into the esophagus.  This causes heartburn, regurgitation and other problems.

The majority of patients with GERD are placed on acid-suppression medication.  The medications are safe and effective in eliminating symptoms in most people.  In a few, however, medication alone does not control symptoms.  It is these people who are usually considered for antireflux surgery.

Do I need surgery?

Normal anatomy has the esophagus and stomach merging where the chest and abdomen meet.  Their meeting point is a muscular ring called a sphincter.  The sphincter’s normal job is to maintain pressure so that stomach contents cannot pass upwards into the esophagus.  In some people, their sphincter has become loosened and no longer acts as a protective barrier between stomach and esophagus.  Antireflux surgery acts to retighten the sphincter between esophagus and stomach and reclaim the protective pressure barrier.

Your GI physician will help you to choose an experienced general surgeon, who performs the surgery.  The procedure is called a laparoscopic fundoplication.  Laparoscopic refers to making 4 small incisions on the abdomen surface through which the surgeon passes equipment.  Fundoplication refers to the internal repair work performed by your surgeon.  The upper portion of the stomach, called the fundus, is tightly wrapped around the bottom of the esophagus (wrapping is referred to as plicating) to recreate pressure in the same location the sphincter used to be.  Thus, fundoplication, or stomach wrapping, is performed.

Recovery is usually rapid, as the small skin incisions heal quickly and most patients return to work within two weeks.  Most patients are able to stop using their acid-suppression medication and remain symptom-free.

What are the possible complications of the surgery?

Complications of the procedure include an excessively tight stomach wrap that makes swallowing difficult.  This can usually be solved with a gentle stretch of the newly wrapped area during upper GI endoscopy.  Most patients lose the ability to vomit after a stomach wrap.

What other tests are necessary prior to surgery?

Prior to consideration for fundoplication, patients must undergo esophageal manometry, which is a test to measure esophageal pressures.  The esophagus uses squeezing pressure to move swallowed materials downwards.  If squeezing pressures prior to fundoplication are not adequate, tightening of the esophageal-stomach connection may make swallowing more difficult or impossible.

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Liver Biopsy

Liver Biopsy

The liver is a large, football-shaped organ located in the right upper abdomen behind the lower rib cage. There are a variety of problems that can affect the liver such as viruses, alcohol, fat, medications, genetic disorders, liver tumors and autoimmune diseases. Some of these may lead to permanent liver damage. The liver can be evaluated by performing blood tests or imaging via ultrasound, CT or MRI. Sometimes a liver biopsy is needed to obtain additional information about the cause or amount of liver injury.

What is a liver biopsy?

A liver biopsy is a procedure in which a small sample of liver tissue is obtained. The tissue is then processed in the laboratory where it is analyzed under the microscope. Even though it is a small sample of the liver (about a one inch thin strand), the biopsy can provide information about the whole liver.

What should I expect the day of my procedure?

Before a liver biopsy is done, blood tests are obtained to check a patient’s clotting factors. Adequate clotting of the blood is important to minimize the risk of bleeding after the biopsy. A patient is instructed to completely avoid aspirin or arthritis-type medications that may thin the blood such as Aleve, Motrin, Ibuprofen and Advil for at least 5 days prior to the procedure. If a patient is on other blood thinners such as Coumadin or Plavix additional instructions may be needed after consulting with the patient’s physicians.  Physicians have different preferences in terms of fasting or not fasting prior to the biopsy. Please check with your physician prior to having a liver biopsy for specific instructions.   If you are unclear as to your instructions, please call our office.

A liver biopsy is usually performed as an outpatient in a hospital by either a gastroenterologist or radiologist. The procedure is generally done in the radiology department. The patient lies on a stretcher, ultrasound is used to find an appropriate place for the biopsy, the skin is cleaned and then local numbing medication is used.  Following this a tiny incision is made in the skin so that the small needle can pass easily into the liver.  The liver biopsy is done by passing a small needle quickly into and out of the liver for approximately one second while the patient holds their breath. Infrequently the biopsy needle needs to be passed again in order to obtain an adequate sample. Stitches are not necessary and a bandage is placed over the biopsy site. Patients are generally monitored for about 4 hours after the biopsy with frequent vital signs. For the first two hours of recovery patients generally lie on their right side to apply pressure to the biopsy site. For the remainder of the monitoring period patients generally lie in bed with the head of the bed raised. During this time a patient may eat.

What are the possible complications of a liver biopsy?

Overall a liver biopsy is a safe procedure. Infrequently patients may experience brief discomfort or pain at the biopsy site or the right shoulder. Internal bleeding is a rare complication that can occur in less than 1% of patients. If this happens patients may require blood transfusions or surgery. An infrequent complication is accidentally puncturing organs adjacent to the liver such as the gallbladder, lungs, kidney and intestine. Also bile can rarely leak from the liver biopsy site or gallbladder and cause peritonitis.

Are there any restrictions after the biopsy?

Generally patients should plan to take it easy the day of the biopsy. Patients cannot drive the day of the biopsy particularly if any sedating medications were used for the procedure. Aspirin or other arthritis-type medications that may thin the blood need to be avoided for an additional 5 days after the biopsy to allow the site to heal. Lifting objects heavier than 20 pounds should be avoided for 5 days following the biopsy.

When are the biopsy results available?

The liver tissue is processed in the laboratory where slides are made and evaluated under the microscope by the pathologist. The results are usually available within one week of the procedure. Results are discussed with the patient by phone or during a follow-up clinic visit, depending on your physician’s preference.

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Esophageal Manometry

Esophageal Manometry

What is esophageal manometry?

The esophagus is the tube that conducts food from your mouth to stomach.  Food propulsion is accomplished by muscles in the wall of the esophagus squeezing in a coordinated fashion.  In some people, the muscles do not function properly, or may squeeze too hard.  Patients often complain of difficulty swallowing.  Manometry is a method by which muscle contraction can be measured.  Esophageal manometry allows the muscles of the esophagus to be examined for coordination of contractions and pressure of squeeze.

The second important feature of esophageal manometry involves the connection between the esophagus and stomach.  A small ring of muscle at the connection site called the lower esophageal sphincter can be too tight or too loose, contributing to heartburn, pain and other symptoms.  Esophageal manometry allows measurement of this muscular ring.

Why have this test?

Your doctor may request this examination if you have swallowing problems, heartburn, regurgitation, chest pain, lump in your throat, or are planning to have anti-reflux surgery.  There are other tests to evaluate the esophagus, such as gastroscopy and upper GI, but only manometry allows for pressure measurements.  Many times manometry will be used in combination with these other tests to define your medical problem.

How do I prepare for the test?

Preparation is simple, and requires that you have nothing to eat or drink for 6-8 hours prior to the exam.  Your physician will provide these details.  You may also be asked to stop certain medications on the day of the test, or several days prior.  Again, your doctor will give you instruction.

Procedure

A thin tube smaller than a straw is passed through the nose into your esophagus.  While lying flat, you are asked to swallow multiple times, both dry (saliva only) and wet (sips of water).  Pressure measurements are taken during the swallows.  The tube is then removed, and you can return to normal daily functions.  The computer will generate a graphic representation of your swallows.  Your doctor will analyze the graphs and provide you an interpretation of your swallowing function.

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BRAVO pH study

BRAVO pH study

pH is a measure of acidity or alkalinity.  Most people are familiar with pH tests done on soil or swimming pools.  As esophageal pH test measures how often stomach acid flows into the lower esophagus and the degree of acidity during a 12-24 hour period

What is Bravo pH monitoring?

Bravo pH monitoring is a test for identifying the cause of heartburn. This test allows your doctor to evaluate if you reflux acid into your esophagus, and for how long and how frequently. It also helps to see if acid reflux is the cause for symptoms such as heartburn, cough, or chest pain.
The test involves a miniature pH capsule, approximately the size of a gel cap that is attached to your esophagus. Throughout the test period, the Bravo pH capsule measures the pH in the esophagus and transmits this information to a small receiver worn on your belt or waistband.

What to expect during the procedure?

The capsule takes only moments to place in the esophagus. Then the test period lasts 48 hours or more, depending on what your doctor requests. A thin tube is used to pass the capsule over the tongue into the esophagus. A small amount of tissue is suctioned into the capsule and a small pin secures it. The catheter is then removed leaving the capsule inside.  The majority of patients tolerate this with very little discomfort. You will then be asked to keep a symptom diary and keep the receiver box close to you for the duration of the test. The usual test period lasts 48 hours.

How is the capsule placed?

The capsule can be placed during an endoscopy or at a later date to be determined by your physician. If the procedure is done at a later date you will not be sedated for the capsule placement. Your throat will be sprayed to assist you in swallowing the capsule. The capsule is small so you may eat normally and go about your daily routine.

Who should not undergo BRAVO testing?

The Bravo pH test is not for everyone. If you have a severe bleeding condition, blockages or narrowing of the esophagus, severe esophageal inflammation, varices, a pacemaker, or an implantable cardiac defibrillator, you should not undergo a Bravo pH test. Additionally, because the capsule contains a small magnet, you should not have an MRI study within 30 days of undergoing the Bravo pH test.

What are the potential risks of the test?

  • Premature detachment of the pH capsule
  • Failure of the pH capsule to detach from the esophagus within several days  or discomfort associated with the pH capsule, requiring another procedure to remove the capsule
  • Tears in the mucosal and sub mucosal layers of the esophagus, causing bleeding and requiring possible medical intervention
  • Perforation
  • Minor complications associated with capsule placement also include: sore throat, discomfort, and tissue damage resulting in bleeding.

 

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24-hour pH Study

24-hour pH Study

pH is a measure of acidity or alkalinity.  Most people are familiar with pH tests done on soil or swimming pools.  As esophageal pH test measures how often stomach acid flows into the lower esophagus and the degree of acidity during a 12-24 hour period.

Why do I need a 24-hour pH test?

A measurement of esophageal pH is of great importance in evaluating heartburn and non-cardiac chest pain.  It can also be useful in determining the success of treatment for acid reflux.  Some patients with acid reflux do not have typical heartburn.  pH testing is particularly helpful in making the correct diagnosis.

What should I expect the day of the procedure?

To prepare for the test, you should take no food or liquid for 8 hours prior to the exam.  In most cases, you should not take any medicine that can affect the function of the esophagus or control of stomach acid.  Your physician will give you specific instructions about which medications you should or should not take.

The test is initiated at the hospital and takes about 30 minutes to start.  A small, thin tube is gently inserted through the nose, down to the end of the esophagus.  Sometimes a separate test, called esophageal manometry, is performed at the same time to assure proper placement of the pH tubing within your esophagus.  The pH tubing is attached to a portable recorder that you carry at your waist.  You can then leave the hospital and go about your usual daily business.  It is important that you carry out all of your usual activities in order to assess the presence or absence of esophageal acid under real life situations.  The acid content in the lower esophagus is recorded throughout the day and night.  When you experience reflux or other symptoms, you press a button on the recorder.  This marks the time so it can be determined if acid was present in the esophagus at the time of the symptom.  When your study time is complete, you will return the recorder to the hospital and have the tube removed.

When will I receive results?

Generally, the esophageal pH test will show a small amount of acid seeping into the esophagus at various times during the day and night.  This is normal for almost everyone.  However, if protective actions of the esophagus do not function properly, the test will show a greater degree and duration of stomach acid in the esophagus.  Your physician will read the pattern of pH changes recorded during your test and provide you with results and interpretation.  You and your physician will decide on treatment plans and changes based on the results of the 24-hour pH study.

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Capsule Endoscopy

Capsule Endoscopy

What is capsule endoscopy?

Capsule endoscopy is a fairly new method used to evaluate the lining of the small bowel.  It is otherwise known as the “pill cam.”  The bowels are divided into three portions – the upper portion includes your stomach and can be easily reached by gastroscopy.  The lower portion is your colon, which can be thoroughly seen via colonoscopy.  The middle section, the small bowel, is too long and winding to be reached effectively with an endoscope.  Capsule endoscopy is a means by which the small bowel lining can be seen.  Capsule endoscopy involves swallowing a small capsule with a battery and camera inside.  As the capsule meanders through your small bowel, images are taken of the small bowel lining.

What can I expect the day of the procedure?

The capsule is about the size of a vitamin pill.  Once it is swallowed, images of your bowel are obtained continuously for eight hours.  You will wear a sensor device to store the images.  At the end of the day you will return to the office, the sensor will be removed, and the images will be downloaded to a computer, so that your physician can review the images.  The capsule will spontaneously pass through your system and be eliminated within a bowel movement.  Passage of the capsule does not hurt and you may not realize when the capsule passes. Most patients consider the test comfortable.  You should not be near MRI equipment while wearing the sensor.

Images will be clearer if the bowel is free of waste material, so you will be asked to drink a flushing solution the day prior to swallowing the capsule.  Once you have ingested the pill camera, you can drink clear liquids after two hours and eat a light meal after four hours, unless instructed otherwise by your physician.  You should avoid vigorous activity like running or jumping during the capsule exam.  Results are generally available within one week.

As is the case with all new tests, some insurance companies do not provide benefits for capsule endoscopy.  Please check with your insurer and our office prior to arranging for your capsule endoscopy appointment.

Why perform capsule endoscopy?

As alluded to earlier, evaluating the lining of the small bowel can be difficult.  There are several tests available, such as CT scan, x-rays, or upper GI with small bowel follow-through.  None of these tests, however, provides images of the bowel lining.  Capsule endoscopy is unique in this sense – it allows your physician to see inside of the bowel.  Although any suspected condition of the small bowel can be a reason to have capsule endoscopy, some of the more common causes include Crohn’s disease, gastrointestinal bleeding of unclear source, malignancy, polyps, and ulcers.  Capsule endoscopy is not an adequate test for evaluating the colon and cannot be used in place of colonoscopy.

Risks of the procedure

The most serious complication is entrapment of the capsule within the gastrointestinal tract.  If this occurs, surgery or conventional endoscopy could be necessary to remove the capsule.   Please alert your physician if you have had prior abdominal surgery, bowel obstructions, adhesions, or inflammatory bowel disease.  If you experience abdominal pain, bloating or vomiting during the capsule test, call your doctor immediately.  If you develop chest pain, difficulty swallowing or a fever after the test, please call your physician immediately.  Be careful not to prematurely disconnect the sensor, as data could be lost.

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Esophageal Dilation

Esophageal Dilation

What is the esophagus?

The esophagus is the long narrow tube that carries food from the mouth to the stomach.  When the esophagus does not function properly, patients often complain of difficulty swallowing, also known as dysphagia .  There are many causes of dysphagia, including mechanical obstruction of the esophagus, poor muscular activity within the esophagus, or inflammation.  When mechanical obstruction is present, stretching of the esophagus, called esophageal dilation, can help restore the patient’s ability to swallow normally.

What causes mechanical obstruction of the esophagus?

The most common cause of obstruction is a ring or stricture within the esophagus.  This is usually made up of scar tissue, often caused by repeated reflux of acid contents from the stomach.  Other less common causes of scar tissue occur in the esophagus, such as burns due to lye or acid ingestion.  Tumors and cancers can cause the same symptoms.  Achalasia is a rare condition where the lower esophagus will not relax properly to allow food and fluids to pass.

What is esophageal dilation?

There are several methods by which the esophagus can be stretched or dilated.  Esophageal dilation involves gently opening the closed esophagus.  Most interventions involve upper GI endoscopy, which is passage of a lighted endoscope through the mouth and into the esophagus.  Once inside the esophagus, your doctor has a number of ways to dilate the esophagus, including plastic expanders or fluid filled balloons.  Your physician will determine which method of dilation is most effective and safest for your particular problem.  In rare instances, surgery or even injection of botox into the esophagus can be helpful.

When the esophagus is stretched open, complications are possible.  Bleeding, perforation (tearing a hole in the esophagus), and aspiration (passage of secretions into the lungs) can occur.  If you experience chest pain or difficulty breathing after dilation alert your physician immediately.

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Flexible Sigmoidoscopy

Flexible Sigmoidoscopy

What is flexible sigmoidoscopy?

Sigmoidoscopy is visualization of the sigmoid portion of the colon, which is the lower third of the colon.  A lighted, flexible tube called an endoscopy is inserted via the rectum.  Your physician performs the exam.  Your physician will help you to decide if flexible sigmoidoscopy is right for you.

Why should I have flexible sigmoidoscopy?

Sigmoidoscopy is used to evaluate for problems in the lower portion of the colon.  These problems can include ulcers, polyps, and cancers.  Sigmoidoscopy is also sometimes used to assist in treatment of hemorrhoids.  Other reasons to perform sigmoidoscopy include rectal bleeding, diarrhea, and rectal or anal pain.

Procedure

For the exam to be fully beneficial, it is imperative your colon be clean.  Cleansing preparations may include enemas or oral solutions.  Specific instructions will be issued by our office prior to the exam.

Flexible sigmoidoscopy is an outpatient procedure.  You will be asked to lie on your left side for the examination. Your physician will gently place the endoscope into your rectum then guide the endoscope through your lower colon, looking at the colon walls on a video monitor the entire time.  Some patients experience mild cramps due to air being placed into the colon via the endoscope during the exam, but flexible sigmoidoscopy is not generally a painful procedure.  The exam takes between 5-15 minutes and most patients are awake and unsedated for the test.  If you have concerns about pain, discuss these with your physician prior to the beginning of the examination.

Safety and alternatives

Flexible sigmoidoscopy is a very safe procedure with a low risk of complications.  Your physician will discuss the possibility of complications with you before the exam is begun.  Other possible means of colon examination include colonoscopy, barium enema and CT scanning.  Again, your physician will help you to decide which test is appropriate for you.

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ERCP – Endoscopic Retrograde Cholangiopancreatography

ERCP – Endoscopic Retrograde Cholangiopancreatography

What is ERCP?

Endoscopic retrograde cholangiopancreatography, or ERCP, is an endoscopic exam in which dye is injected into the duct systems of the liver and/or pancreas. The exam is similar to a cardiac (heart) catheterization in that x-rays are taken once the dye is injected to show the outline of the ducts.  The bile and pancreatic ducts empty into the early portion of the small bowel (duodenum), which your doctor reaches by passing an endoscope via your mouth and stomach once you are adequately sedated.

Why would I need an ERCP?

The reasons for doing the tests are many, but ERCP is most helpful for diagnosing and treating disorders of the liver, gallbladder and pancreas. The liver produces bile, which flows down the biliary ducts or gets store in the gallbladder. The bile duct empties into the part of the small intestine known as the duodenum. The pancreas is an organ that makes digestive enzymes, which flow from the pancreas through the pancreatic duct. The pancreatic duct also empties into the duodenum, in the same place the bile duct empties into the duodenum. Both bile and pancreatic enzymes are needed for digestion. ERCP is useful in diagnosing or treating diseases causing blockage of either of these duct systems, and diseases affecting the liver and pancreas. Gallstones, inflammation, tumors, or infection can cause these diseases. ERCP can also be helpful in finding causes of upper abdominal pain, yellow jaundice and pancreatitis.

What should I expect on the day of my ERCP?

An ERCP is done in a special hospital procedure room equipped with x-ray machines. In this procedure, a nurse, an endoscopic technician and an x-ray technician assist the physician. The patient’s throat is anesthetized and the patient receives sedation medications intravenously.  An endoscope is then inserted via the patient’s mouth and passed into the duodenum. Special catheters and instruments are passed through the scope and used to inject the dye into the biliary and pancreatic ducts as x-rays are taken. If a gallstone is found in the duct, it may be possible to remove it. A tiny cut may be made inside the duodenum to assist with stone removal.  If a stricture or narrowed area of a duct is encountered, a stent may be placed to open or dilate it. A stent is either plastic or metal and looks like a tiny straw.  If a tumor or mass is seen, biopsies may be taken. The exam usually takes 20-60 minutes, after which the patient is taken to the recovery area.

What are the potential complications?

ERCP is a safe exam when performed by a specially trained endoscopist, however, as with any medical or surgical procedure, there are potential risks or side effects. Serious complications are rare. The most common complication of ERCP is pancreatitis (inflammation of the pancreas). This can occur in 5-15 percent of cases. It results in abdominal pain, and may require hospitalization. Other specific complications, which are much less common can include, bleeding, infection, or perforation. Your doctor can discuss appropriate indications, preparation, and alternative testing before performing an ERCP.

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Colonoscopy

Colonoscopy

Colonoscopy is a visual examination of the colon, otherwise known as the large bowel. A video endoscope is inserted through the rectum and advanced to the end of the colon. The endoscope is a long, flexible black tube with a camera at the end, which projects constant images of the colon onto a video screen for your doctor to watch.

Why have a colonoscopy?

There are many diseases that can occur within the colon. Making a proper diagnosis sometimes involves examining the colon lining with colonoscopy. Although there are many reasons for having a colonoscopy, some of the more common reasons include looking for the following – colon cancer, benign growths called polyps, inflammation or ulcers termed colitis, sources of bleeding, causes of diarrhea, and reasons for anemia.

What is the preparation for the examination?

In order to safely maneuver through the natural curves of the colon and adequately see the lining, the colon must be cleaned and free of stool. Your doctor will prescribe a cleansing method, which usually involves drinking a flushing solution, laxatives, and/or enemas. In most cases, you are asked to consume only clear liquids and eat no solid food the day before your procedure. Your physician will provide advice on which medications are safe to use up until the day of your colonoscopy.

What should I expect the day of the procedure?

Colonoscopy is typically an outpatient procedure. You can expect to spend less than half a day for completion. You may be given sedative medications through an IV that will produce a light sleep or relaxed state of mind. Once you are comfortable, your doctor will maneuver the colonoscope through your bowel. Air is placed into the colon to allow good visualization, and this can create cramping in some people. Turning the colonoscope around corners can also cause discomfort, and these are two of the main reasons patients are given sedation. One of the medications can produce short-term amnesia, so some patients forget or simply sleep through the colonoscopy. Your doctor can discuss the details of these medications with you prior to beginning your colonoscopy. If polyps are found in your colon, your physician will remove them with a heated lasso or biopsy teeth. Polyp removal does not produce pain. Biopsies will also be obtained if any other abnormal tissue is seen. The exam usually lasts 15-45 minutes. You will recover from the medication effects quickly. You should not drive a vehicle the rest of the day. For complete instructions see our website at www.idahogastro.com

When will I get results?

Your doctor will be able to explain what was found on your exam directly after its completion and provide specific recommendations. If biopsies or other specimens were taken during the exam, pathology results usually return within 4-10 working days.

Alternatives to colonoscopy

Other methods to evaluate the colon include flexible sigmoidoscopy, barium enema, virtual colonoscopy, and stool blood testing. Most of these testing methods do not allow for polyp removal, tissue biopsy, or direct visualization of the entire colon. Colonoscopy remains the most comprehensive means for complete evaluation of the colon.

What are the risks and side effects of colonoscopy?

Due to the air placed inside the colon during the exam, some patients feel gassy or bloated after colonoscopy. This usually resolves once you are able to pass gas. Serious risks of the exam include, but are not limited to, bleeding, infection, adverse reaction to the sedative medication, and bowel perforation, which is inadvertently causing a hole in the colon. The chances of these serious side effects are small, but any adverse outcome can result in hospitalization, surgery, or even death.

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Upper GI Endoscopy

Upper GI Endoscopy

What is upper GI endoscopy?

Upper GI endoscopy, otherwise known as esophagogastroduodenoscopy (EGD) is a video examination of the upper third of the GI tract.  Using a flexible scope with a camera and bright light at the end, your physician will guide the instrument through your mouth and into your GI tract.  Images are displayed on a video monitor your doctor watches throughout the exam.  Your physician will be able to evaluate multiple organs including your esophagus (esophago-), stomach (gastro-) and early portion of your small bowel, known as the duodenum (duodeno-).  Tissue biopsies, stretching of tissue narrowings, laser and heat treatments, and medication administration can be accomplished through the scope.  The examination should be performed by a board certified Gastroenterologist, who has extensive training in management of digestive system diseases.

Why should I have upper GI endoscopy?

There are many reasons why your physician may recommend upper GI endoscopy.  The most common reasons include long-standing GERD (acid reflux disease), difficulty swallowing, nausea with or without vomiting, bleeding from the gastrointestinal tract, abdominal pain, chest pain, suspected celiac sprue disease, loss of appetite or weight loss.  Your doctor will help you to determine if upper GI endoscopy is right for you.

What should I expect the day of my upper GI endoscopy?

Most procedures are outpatient, so patients should plan to spend about 2 hours for their examination and plan to return home afterward.  On the day of the procedure, you will be asked not to consume food or beverages for 6 hours prior to your exam.  Discuss routine medication use with your physician or endoscopy staff.  Patients using coumadin and insulin require special instruction.  An IV will be placed to administer sedation medication for the examination.  You must have a driver to assist you home after the procedure and we ask that you avoid alcohol the rest of the day.  For complete preparation instructions visit our Preparation instructions page.

Upper GI endoscopy is a very safe procedure, but risks do exist.  The most common side effect from the procedure is redness at the IV site.  Less common side effects include adverse reactions to the sedation medications, bleeding from a biopsy site, infection, and perforation.  Perforation is a tear in the lining of the digestive tract and can be very dangerous, necessitating hospitalization, antibiotics, and sometimes surgery.

Other options for evaluation of your upper GI tract do exist.  Your physician may requests laboratory testing, barium swallow tests, ultrasound, CT scan, esophageal manometry or 24-hour esophageal pH testing in addition to or in place of upper GI endoscopy.  Discuss these options with your Gastroenterologist.

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