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TheScientific American White Papers
Digestive Disorders
2 015
Dear Reader:
Welcome to the 2015 Digestive Disorders White Paperyour up-to-date guide to the
prevention, diagnosis and management of conditions that can affect your upper and
lower digestive tract, liver, gallbladder and pancreas. I hope the information in this
White Paper will help guide you in working with your doctor to make informed medical
decisions about digestive disorders.
The main text provides a detailed overview of what the medical field knows about
digestive disorders. In many of the right margins, you will find reports on the latest
studies and advances or Ask the Doctor columns that answer queries from patients.
The longer feature articles (located in shaded boxes throughout the White Paper)
focus on special topics that we felt warranted particular attention this year.
This years highlights include:
Sleep apneas tie to Barretts esophagus. (page 13)
Is it OK to stop taking your acid blocker when you no longer have GERD symptoms?
(page 20)
Nonalcoholic fatty liver disease: Are you at risk? (page 28)
Settling your stomach: How to avoid and treat nausea and vomiting. (page 32)
The best ways to manage an attack of acute pancreatitis. (page 38)
Protect yourself against cancer after colon polyp removal. (page 44)
Is surgery necessary for patients with diverticulitis? (page 51)
Older medications may be better than new for treating Crohns disease. (page 57)
Irritable bowel syndrome: Is your diet to blame? (page 68)
Research affirms dietary fibers role in lowering risk for pre-cancerous colon
growths. (page 77)
Wishing you the best of health in 2015,

Assistant Professor of Medicine
Johns Hopkins University School of Medicine
Table of Contents
The Digestive Tract.................................................................................................................. 1
Anatomy of the Upper Digestive Tract................................................................................... 2
Tests for Examining the Upper Digestive Tract..................................................................... 4
Disorders of the Upper Digestive Tract.................................................................................. 6
Dysphagia......................................................................................................................... 7

Hiatal Hernia................................................................................................................... 8

Gastroesophageal Reflux Disease (GERD).................................................................... 9

Esophageal Motility Disorders...................................................................................... 17

Esophageal Stricture...................................................................................................... 19

Barretts Esophagus....................................................................................................... 19
Gastritis........................................................................................................................... 22

Peptic Ulcer Disease...................................................................................................... 23
Anatomy of the Liver, Gallbladder and Pancreas................................................................ 26
Disorders of the Liver, Gallbladder and Pancreas............................................................... 27
Hepatitis
........................................................................................................................ 27
Cirrhosis
........................................................................................................................ 31
Gallstones....................................................................................................................... 34
Pancreatitis..................................................................................................................... 37
Anatomy of the Lower Digestive Tract................................................................................. 40
Tests for Examining the Lower Digestive Tract................................................................... 41
Disorders of the Lower Digestive Tract................................................................................ 46
Constipation................................................................................................................... 46

Diverticulosis and Diverticulitis..................................................................................... 50
Diarrhea
........................................................................................................................ 51

Celiac Disease................................................................................................................. 54

Crohns Disease.............................................................................................................. 56

Ulcerative Colitis............................................................................................................ 62

Irritable Bowel Syndrome.............................................................................................. 64
Hemorrhoids.................................................................................................................. 67

Anal Fissure.................................................................................................................... 71

Fecal Incontinence........................................................................................................ 73

Colorectal Polyps........................................................................................................... 76

Colorectal Cancer.......................................................................................................... 77
Glossary................................................................................................................................... 80
Health Information Organizations and Support Groups.................................................... 83
Index....................................................................................................................................... 84
Introducing Your
Digestive Disorders Expert
Anne Marie Lennon, M.D., Ph.D., FRCPI, FASGE, is an Assistant Professor of Medicine and Surgery at the Johns Hopkins University School of Medicine. She is the Director of the Multidisciplinary Pancreatic Cyst Clinic and an attending gastroenterologist at The Johns Hopkins
Hospital.
Dr. Lennon received her medical degree in 1996 from the Royal College of Surgeons in
Ireland. In addition, Dr. Lennon has obtained a Ph.D. degree from The National University
of Ireland. She completed an internal medicine residency in Dublin and at the Cleveland
Clinic, followed by a Gastroenterology Fellowship in Edinburgh, United Kingdom. She then
completed a two-year Advanced Endoscopy Fellowship at Johns Hopkins. Dr. Lennon is certified in General Internal Medicine and Gastroenterology by the Joint Royal Colleges of Physicians Training Board of the United Kingdom and is a fellow of the Royal College of Physicians of Ireland and the Medical Society of Gastrointestinal Endoscopy.
Dr. Lennons major area of interest is the management of pancreatic cysts, precancerous
pancreatic lesions and pancreatic cancer.
About Scientific American

Scientific American, founded in 1845, is the longest continuously published magazine in the
U.S. and the leading authoritative consumer publication for science, health and medicine
in the world-reaching more than 5 million people each month. Scientific American has
long recognized the demand for quality reporting on breakthrough advances in health and
medical care. Our expanded product line now includes professional medical reference works
(Scientific American Medicine), the consumer health channel on our website, and our
Health After 50 newsletter, Special Reports and White Papers.
www.ScientificAmerican.com
Digestive Disorders
wide array of disorders can affect your digestive tracta

long tube of organs that begins at your mouth and ends at
your anus. Some digestive disorders, such as an occasional
bout of heartburn, are minor annoyances. But many disorders, such as Crohns disease or irritable bowel syndrome, can severely
affect your ability to perform daily activities, and some, like colorectal
cancer or a perforated ulcer, can be life threatening. This White
Paper covers many conditions that affect the digestive tract, including
diseases of the esophagus, stomach, liver, gallbladder, bile ducts, pancreas, small intestine, large intestine, rectum and anus. You will learn
how to help prevent these diseases and, when symptoms arise, understand the best ways for your doctor to diagnose and treat them.
Sixty to 70 million Americans have digestive disorders, which prompt
more than 118 million visits to doctors offices and hospitals each year.
Doctors who treat digestive disorders are called gas
troenterologists.
Although digestive disorders can affect people of any age, many of these
problems occur more frequently as we get older.
Digestive disorders have many possible causes, most commonly
infections and dietary factors. Some people have a genetic predisposition that makes them susceptible to these and other environmental
triggers. But the causes of some digestive disorders are still unknown.
Although many of the symptoms of digestive disordersgas,
diarrhea, constipation and blood in the stoolcan be embarrassing
to discuss, its important to contact your doctor if you develop any of
them. These symptoms can be a sign of something wrong with your
digestive tract, and detecting the problem early will improve the
chances of successful treatment. Fortunately, treatment options ranging from lifestyle measures to medications and surgery can alleviate
the symptoms, often completely.
The Digestive Tract

The digestive tract consists of a series of hollow and solid organs
that spans the length of the body from your mouth to your anus.
The major organs along the tract are the esophagus, stomach, small
D IG EST IV E D I SO R DE R S 2015
intestine, large intestine (colon) and rectum. The role of the digestive
tract is to break down food and fluids to provide the body with the
energy it needs to function properly as well as the substances required
to build and nourish cells. Through a pro
cess called peristalsis,
rhythmic muscle contractions push the food through the length of
the digestive tract. Nutrients from food are absorbed in the small
intestine, and what remains undigested passes into the colon and ends
up in the stool.
Anatomy of the Upper Digestive Tract

Your upper digestive tract consists of the mouth, pharynx (throat),
esophagus, stomach and duodenum (first part of the small intestine).
Mouth and Pharynx

Your mouth is the first part of your digestive tract. It is where food is
chewed and mixed with saliva until it becomes a soft mass that can be
swallowed. Saliva is released into the mouth even before food enters
itthe odor or thought of food can make you salivate. An enzyme
in saliva called amylase starts breaking down the carbohydrates from
food in your mouth. When you swallow, food moves into your pharynx, a passageway that is 5 inches long and carries both food and air.
Esophagus
From the throat, food enters the esophagusa hollow, muscular tube
about 10 inches long. At the upper end of the esophagus is a circular
area of muscle tissue called the upper esophageal sphincter. When
you swallow, this sphincter relaxes to allow food to enter the esophagus. After you swallow, the sphincter contracts to prevent air in the
throat from entering the esophagus. A structure called the epiglottis
closes over the trachea to prevent the food from entering the airways
or lungs. Peristalsis pushes food through your esophagus.
The esophagus descends into the stomach through an opening in
the diaphragm (a thin muscle that separates your chest cavity from
your abdominal cavity). At the lower end of the esophagus is a ring
of muscle tissue called the lower esophageal sphincter. When food
approaches, the lower esophageal sphincter relaxes to allow food to
pass through to the stomach. It then contracts to prevent reflux (the
backflow of stomach contents into the esophagus).
The esophagus contains a protective inner lining called the
mucosa. In a healthy esophagus, the mucosa is smooth and pink. The
When Things Go Wrong in the Digestive System
Esophagus
Dysphagia (difficulty swallowing)
Esophageal spasm
Esophageal stricture
Barretts esophagus
Cancer
Achalasia
Gastroesophageal reflux disease
(GERD)
Mouth
Dysphagia
(difficulty swallowing)
Lower esophageal sphincter

Achalasia
GERD
Hiatal hernia
Gallbladder
Gallstones
Cholecystitis
Stomach
Gastritis
Ulcers
Gastroparesis
Cancer
Small intestine
Ulcers (duodenum)
Crohns disease
Pancreas
Pancreatitis
Cancer
Rectum
Hemorrhoids
Anal fissure
Large intestine
Ulcerative colitis
Diarrhea
Constipation
Diverticulitis
Diverticulosis
Polyps
Cancer
Anus
Hemorrhoids
Anal fissure
Digestion begins in the mouth, where food is

chewed and mixed with saliva before it passes
into the throat (pharynx) and then the esophagus.
Rhythmic muscle contractions (peristalsis) in the
esophagus push the food past the lower esophageal sphincter and into the stomach.
The stomach does much of the work in breaking
down the food before it moves into the duodenum,
the first section of the small intestine. Here, digestive juices secreted by the pancreas help break
down the food further. (The liver produces bile that
is needed for absorption of fat and is stored in the
gallbladder before entering the duodenum.)

As food moves through the duodenum and the
remaining two sections of the small intestine (the jejunum and the ileum), cells in the wall of the small intestine release digestive enzymes and absorb nutrients.
Undigested food components pass into the large
intestine (colon), where they slowly move toward the
rectum. When enough waste accumulates in the rectum, the person feels the urge for a bowel movement
and eventually passes the stool through the anus.
Disorders of the digestive system can occur at almost
any point in this process. n
place where the esophagus makes contact with the stomach is called
the gastroesophageal junction; it forms an irregular white line called
the Z-line that can be seen by your doctor with an endoscope.
Stomach and Duodenum

Your stomach is a large, stretchy bag located slightly to the left in the
upper portion of your abdomen. Its function is to hold ingested food
and to continue the digestive process that began in your mouth by
secreting gastric acid and digestive enzymes.
Your stomach has four sections:
The cardia, a short part next to the gastroesophageal junction
The fundus, the top of the stomach, located under the left dome
of the diaphragm
The body, the largest portion of the stomach, located between
the fundus and the antrum
The antrum, a short, channel-like portion near the outlet of the
stomach
The pylorus is a circular muscle below the antrum that connects
the outlet of the stomach with the duodenum. The duodenum, the
first portion of the small intestine, is a C-shaped tube that curves
around the head of the pancreas. The part of the duodenum closest
to the stomach is called the duodenal bulb.
Farther along in the duodenum is the major duodenal papilla,
a protuberance where the common bile duct and main pancreatic duct enter the duodenum. The common bile duct carries bile
secreted from the liver after it is stored in the gallbladder into the
duodenum; the main pancreatic duct carries enzymes formed in
the pancreas. The bile and pancreatic enzymes help digest food in
the duodenum.
Tests for Examining the

Upper Digestive Tract
Your doctor usually cant assess the health of your upper digestive
tract from an external exam. He or she needs an internal view of your
digestive tract through an upper endoscopy, an upper gastrointestinal
(GI) series, esophageal manometry or pH monitoring.
Upper Endoscopy
An upper endoscopy examines the inside lining of the esophagus,
stomach and duodenum. A long, thin, flexible tube with a tiny light
and video camera at its tip (an endoscope) is inserted through the
throat and into the digestive tract to look for abnormalities such as
inflammation, ulcers and tumors. If youre experiencing difficulty
swallowing, nausea, vomiting with or without blood or coffee-groundslike material, heartburn, indigestion, upper abdominal pain or chest
pain, your doctor may perform an upper endoscopy.
Upper Gastrointestinal (GI) Series

An upper GI series (also called a barium X-ray) is usually used
to evaluate areas of the small intestine that an endoscope cannot
reach. In addition, if you cannot undergo an upper endoscopy
perhaps because you tend to bleed excessively or the number of
platelets in your blood is lowan upper GI series may be performed to examine the esophagus, stomach and duodenum.
An upper GI series is performed by a radiologist. First, you
drink a solution containing barium (a heavy metal). The radiologist follows the passage of the barium through the upper digestive
tract using a machine called a fluoroscope. X-rays also are taken.
The barium coats the inner layer of the digestive tract, making it
visible on the X-rays. The X-rays can reveal ulcers, tumors, strictures (abnormal narrowings due to scar tissue), areas of swelling
and inflammation, and fistulas (abnormal connections between
two organs).
Capsule Endoscopy
An upper endoscopy does not provide information about the
small intestine beyond the duodenum. For this, the Food and
Drug Administration (FDA) approved the use of a tiny ingestible
camera in a capsule that takes close-up pictures of the small intestine as the capsule moves through the digestive tract. For further
details, see page 46. (An ingestible camera is also approved for
esophageal endoscopy.)
Esophageal Manometry
This test measures pressure and evaluates contractions in the
esophagus. It is typically performed to diagnose gastroesophageal
reflux disease (GERD) and swallowing problems. During the test,
a physician or specially trained technician inserts a thin, pressuresensitive probe through the nose and into the esophagus to measure pressure in the esophagus while it contracts; it also measures
pressure of the lower eso
ph
a
geal sphincter. Abnormal muscle
contractions in the esophagus and decreased lower esophageal
sphincter pressure indicate weakening of the anti-reflux barrier.

The test takes about an hour.
pH Monitoring
A pH monitoring test is often given to determine if acid is refluxing
from the stomach into the esophagus and causing heartburn and
GERD. A tiny tube or wireless capsule is placed in your esophagus for
24 hours, while you go about your daily activities, to record fluctuations in acid backing up into your esophagus from your stomach. At
the end of the tube is a sensitive probe that detects fluctuations in
acidity. Two-day pH monitoring can detect GERD even more accurately than standard 24-hour pH monitoring.
The standard test involves a thin tube that is threaded through
your nose, which can make it difficult to move about. Another version
of the test that does not involve a nasal tube is the Bravo test, which
is a capsule that attaches to your lower esophagus during an endoscopy. The capsule detaches by itself after about a week. Both tests also
involve a small receiver that records information from the probe. Buttons on the receiver correspond to symptoms you may have; pressing
them will record additional information about your condition.
Esophageal Impedance Testing

This test also involves having a tiny tube inserted into your esophagus
and measures whether gas or liquid is backing up into the esophagus.
It is a helpful diagnostic tool for those with nonacidic reflux, since
these substances wouldnt be detected by pH monitoring.
Duodenal Gastroesophageal Reflux Testing

Duodenal gastroesophageal reflux (bile reflux) can be a complicating
factor in GERD. This test detects whether contents of the duodenum,
such as bile or pancreatic enzymes, are backing up into the esophagus. You go about your daily activities while wearing a tiny tube in
your esophagus. The attached fiberoptic tool detects the yellow color
of bilirubin, the major component of bile.
Disorders of the
Upper Digestive Tract
A number of disorders can arise in the upper digestive tract. They
include dysphagia (difficulty swallowing), a hiatal hernia, GERD and
other esophageal problems, gastritis and peptic ulcers.
Dysphagia
Dysphagia is difficulty swallowing. There are two types: oropharyngeal (which is related to problems in the mouth or pharynx) and
esophageal. In oropharyngeal dysphagia, individuals have problems
initiating a swallow; in esophageal dysphagia, the person can swallow,
but problems arise as food passes through the esophagus.
Causes of dysphagia
Oropharyngeal dysphagia is caused by problems getting food from
the mouth into the upper esophagus. Neurological disorders, such
as stroke or Parkinsons disease, are frequently to blame. Inflammation or cancer of the mouth or throat also can lead to oropharyngeal dysphagia.
Esophageal dysphagia can be caused by narrowing of the esophagus or by a disruption in normal esophageal motility (movement).
Cancer of the esophagus, esophageal strictures (caused by scar tissue),
esophageal diverticula (abnormal pouches in the esophageal wall)
and esophageal rings or webs (thin, fragile mucosal folds that partially
or completely block the esophagus) all can narrow the esophagus,
making the passage of food more difficult. Esophageal motility can
be disrupted by scleroderma (an autoimmune disease that affects the
skin and internal organs), diffuse esophageal spasm (prolonged and
excessive contractions of the esophagus) and achalasia (the inability
of the lower esophageal sphincter to relax).
Symptoms of dysphagia
Typically, the first symptom of both oropharyngeal and esophageal
dysphagia is a problem in swallowing solid food. Difficulty in beginning a swallow, coughing or inhaling food into the lungs while
attempting to swallow, and food coming up through the nose are
common symptoms of oropharyngeal dysphagia. If you have esoph
ageal dysphagia, it may feel as if food is stuck in the esophagus, and
you may have to strain or eat with your head turned to one side to
propel food through the esophagus into your stomach.
Diagnosis of dysphagia
Your doctor will try to identify your particular swallowing problem. Difficulty swallowing both liquids and solids usually results
from a motility problem. Difficulty swallowing only solids suggests
a structural problem.
You may need a radiological test called a barium swallow to
determine if your dysphagia is caused by a problem in the throat
7
or esophagus. If it appears the problem originates in the throat,

a laryngoscopy allows the doctor to look into your throat with a
lighted tube to observe you swallowing. If dysphagia is caused by
a problem in the esophagus, the doctor will perform an upper
endoscopy. Other tests, including video fluoroscopy and ultrasound, can produce video images while you swallow.
Treatment of dysphagia
The treatment of dysphagia depends on what is causing the problem. If the cause is esophageal strictures, rings or webs or if you have
achalasia, a procedure called endoscopic dilation may be performed
to expand the esophagus. In this procedure, the esophagus is gradually stretched using special dilators or a balloon inserted through an
endoscope and inflated. Surgery or radiation therapy may be necessary to treat esophageal tumors that have narrowed the esophagus.
You also may be referred to a speech-language pathologist who
diagnoses and treats dysphagia in addition to dealing with language,
voice and speech problems. Therapy may involve special exercises,
body positions and other techniques to improve your ability to swallow. The speech-language pathologist may also recommend foods and
liquids with textures that are safer and easier to swallow.
Hiatal Hernia
The esophagus passes through a small opening in the diaphragm,
which separates the chest cavity from the abdominal cavity. Normally, the lower esophageal sphincter at the bottom of the esophagus is aligned with this opening in the diaphragm (the hiatus).
The rest of the esophagus is located above the diaphragm in the
chest cavity, and the stomach is located below the diaphragm in
the abdominal cavity.
The incidence of a hiatal hernia increases with age, from 10 percent in people younger than 40, to 70 percent of people age 70 and
older. If youre in this group, your lower esophageal sphincter and a
small portion of your stomach have slipped through the opening in
the diaphragm and are now protruding into your chest cavity. The
resulting separation be
tween the lower esophageal sphincter and
the diaphragm weakens the barrier against reflux of acid from the
stomach into the esophagus, increasing the risk of GERD and erosive
esophagitis (damage to the lining of the esophagus).
Causes of hiatal hernia

A hiatal hernia can be congenital, meaning that you are born with it.
8
Or it can develop later in life, as the result of either a weakening of

the muscle that surrounds the opening of the diaphragm or a rise in
pressure in the abdominal cavity. Risk factors for a hiatal hernia
include being overweight and lifting heavy objects.
Symptoms of hiatal hernia

Most hiatal hernias produce no symptoms and are found by
chance during tests for other health problems. However, when the
lower esophageal sphincter is significantly displaced from its normal position in the hiatus, reflux symptoms (such as heartburn)
can occur.
Diagnosis and treatment of hiatal hernia
Hiatal hernias are diagnosed by an upper GI series or an upper
endoscopy. If a hiatal hernia is not causing symptoms, treatment
isnt needed. When symptoms such as recurrent heartburn arise,
they can often be relieved with lifestyle measures and medication.
If the hiatal hernia is causing severe reflux, it can be repaired surgically by pulling the stomach back into the abdominal cavity and
repairing the defect in the diaphragm that allowed the stomach to
slip into the chest cavity.
To prevent future slippage and to strengthen the lower esophageal sphincter, the surgeon may also perform a Nissen fundoplication, in which the top portion of the stomach is wrapped around the
bottom of the lower esophageal sphincter.
Gastroesophageal Reflux Disease (GERD)

The contents of your stomach empty into the small intestine, but
sometimes they flow backward into your esophagus. This phenomenon, known as gastroesophageal reflux, happens to everyone from
time to time. It usually produces no symptoms other than occasional heartburna burning sensation behind the breastbone.
When gastroesophageal reflux occurs often, however, you may
begin to experience significant discomfort related to the acid
refluxthen, it is considered gastroesophageal re
flux disease
(GERD). Many people in the United States have GERD: Heartburn affects about 10 to 20 percent of U.S. adults every day and
more than 60 million people at least once a month. Symptoms
of reflux are more common in individuals who are obese, smoke
cigarettes or drink alcohol.
GERD is a serious condition: The acid and digestive enzymes from
the stomach can damage tissues in the esophagus as well as in adjacent
organs such as the mouth, pharynx (throat), larynx (voice box), trachea (windpipe) and lungs.
Causes of GERD
Coordinated contractions of the lower esophageal sphincter and
the diaphragm produce an area of high pressure in the lower
segment of the esophagus that prevents stomach contents from
entering the esophagus.
This anti-reflux barrier does not always work properly. When it
fails occasionally, the esophagus has several defenses to help it deal
with the harsh stomach contents. First, the esophageal secretions and
your saliva are alkaline, which helps to neutralize the acid and inactivate the enzymes from the stomach. Second, peristalsis and gravity
work together to rapidly clear the esophagus of the acid and enzymes,
minimizing the length of time the lining of the esophagus is exposed
to the stomach contents. Third, the esophageal mucosa is able to
regenerate quickly following injury from acid or enzymes. However,
frequent reflux of the acidic stomach contents can overwhelm these
protective measures, resulting in damage to the tissues of the esoph
agus and adjacent organs.
A survey of 43,000 people found that smoking and excessive use
of table salt can increase the risk of GERD by 70 percent. A separate
study found that a diet high in calories and fat (especially saturated
fat) is linked to GERD. Excess weight also can cause GERD.
Medications that relax the lower esophageal sphincter, such as the
bronchodilator theophylline (Theo-24, Theo-Dur, Uniphyl, for asthma, emphysema and chronic bronchitis), calcium-channel blockers
(for angina or high blood pressure), nonsteroidal anti-inflammatory
drugs (NSAIDs, for arthritis and pain), bisphosphonate drugs (for
osteoporosis), some medications to treat menopausal symptoms, and
a class of antidepressant drugs called tricyclics also can trigger GERD.
If you are at risk for GERD or develop it while taking any of these
medications, discuss with your doctor the possibility of discontinuing
or reducing the dosage of the medication.
Symptoms of GERD
GERD most often produces heartburn, indigestion (discomfort in
the upper abdomen, nausea and sometimes vomiting) and regurgitation of undigested food from the stomach into the esophagus
and mouth. Acid from the stomach can even regurgitate into organs
connected to the esophagus, such as the larynx, trachea and lungs.
This acid exposure can cause voice changes such as hoarseness,
10
GERD Without Heartburn?

The most common symptom of gastroesophageal
reflux disease (GERD) is heartburn, which occurs
when the acidic contents of the stomach reflux (flow
backward) into the esophagus. But about 10 to 15
percent of people with GERD do not have heartburn. Instead, they experience asthma, a chronic
cough, chest pain or laryngitis.
These symptoms result when stomach acid
refluxes into organs connected to the esophagus,
such as the larynx, trachea and lungs. The chance
of developing these nonheartburn symptoms of
GERD increases with age.
If the symptoms go away within three months of
treatment with a proton pump inhibitorsuch as
esomeprazole (Nexium), lansoprazole (Prevacid),

omeprazole (Prilosec), pantoprazole (Protonix) or
rabeprazole (AcipHex)to suppress acid production
in the stomach, GERD was the problem. If not, its
back to the drawing board to find the cause.
So if you are wondering whether those bouts
of asthma, that nagging cough, those episodes of
chest pain or that hoarse voice could be GERD,
check out the table below and do not hesitate to
call your doctor if you have any concerns.
Many of the same treatments for heartburn
lifestyle measures, medications and surgery
may relieve the nonheartburn symptoms of GERD
as well. n
Nonheartburn symptom
You and your doctor should suspect GERD if
Asthma
Asthma symptoms first appear in adulthood

Asthma worsens after eating a large meal, drinking alcohol
or lying down
Your asthma medications are not working as well as usual
Chronic cough
Your cough is nonproductive and occurs mostly during the day

when you are in an upright position
Your cough persists even though you dont smoke and are not
taking a medication (such as an ACE inhibitor) that has cough as a
side effect
Youre still coughing despite a normal chest X-ray, and you dont
have asthma or postnasal drip
Chest pain
Youre experiencing chest pain even though you dont have heart
disease
Chest pain worsens after meals and may awaken you at night
Chest pain is promptly relieved when you take an antacid
Note: GERD-related chest pain is eerily similar to that of a heart
attack. So if in doubt about the cause of chest pain, err on the side
of caution by dialing 911 for an ambulance.
Laryngitis (hoarseness,
frequent throat clearing,
sore throat, difficulty
swallowing)
Laryngitis symptoms continue despite rest, fluids and treatment

with a corticosteroid or antibiotic
The symptoms continue even though you dont smoke, drink alcohol or use your voice excessively, and you dont have a cold, the
flu, postnasal drip or allergies
11
a chronic cough, episodes of asthma or pain behind the sternum

bone that resembles a heart attack. In some cases people with GERD
experience these symptoms instead of heartburn and regurgitation,
making diagnosis and treatment more difficult.
The chest pain associated with an intense episode of heartburn
can feel like a heart attack. If you think you are having a heart attack,
seek medical assistance immediately. Much of the damage done by a
heart attack occurs in the first hour. Therefore, waiting to see if chest
pain is due to heartburn could prove fatal.
How can you distinguish between a heart attack and GERD? Your
chest pain is more likely to be heartburn if it is accompanied by a
bitter or acid taste in your mouth or other symptoms such as belching and difficulty swallowing, and if the pain worsens when you lie
down or bend over and improves when you take an antacid. But if
the pain is accompanied by a cold sweat, a fast heartbeat, shortness
of breath or lightheadedness and the pain radiates down one or both
arms, theres a good chance youre having a heart attack. Again, if you
have any doubt about the cause of your chest pain, you should err on
the side of caution and call 911 immediately, chew an aspirin and lie
down until an ambulance arrives.
Diagnosis of GERD
To diagnose GERD, your doctor will perform an upper endoscopy as
well as other tests to measure the motility and pH (acid concentration) of your esophagus.
Treatment of GERD
Treatments for GERD include lifestyle measures, medication and surgery. Treating GERD is important. Untreated GERD can lead to serious complications, such as esophageal ulcers (nonhealing mucosal
defects), esophag
eal strictures, Barretts esophagus (a disorder of the
cells lining the esophageal mucosa, which may lead to cancer) and
esophageal cancer.
Lifestyle measures. The treatment of GERD starts with lifestyle
measures, which may eliminate symptoms in some people with mild
reflux. Traditionally, doctors recommend avoiding large meals that
can increase pressure in the stomach and promote reflux. Acidic
foods (tomato-based products and citrus fruits, for example) and
spicy foods may irritate an inflamed esophagus. Peppermint, spearmint, chocolate, cinnamon, coffee and tea may reduce the pressure
in the lower esophageal sphincter and promote reflux. Carbonated
beverages may worsen reflux by increasing pressure in the stomach.
12
Conflicting studies about the effects of these foods on GERD,

however, have cast some doubt on the subject. In 2013, the American College of Gastroenterology released updated clinical guidelines for treating GERD based on an extensive analysis of medical
research. The new guidelines highlight three key lifestyle modifications as a first step:
1. Lose weight if you are overweight or have recently gained
weight.
2. Elevate the head of your bed 6 to 8 inches at night with blocks
or a foam wedge (not pillows, which can cause an unnatural bend
in the body and increase pressure to the stomach) if you suffer from
nighttime GERD.
3. Avoid high-fat meals within two to three hours of bedtime.
Because of insufficient scientific evidence showing benefit, the
guidelines dont recommend dietary restrictions, although for
some patients with specific reflux triggers, dietary changes may still
be helpful.
Medication. If lifestyle modifications dont eliminate your symptoms, your doctor will recommend medication to neutralize or
decrease acid production in the stomach. The guidelines recommend antacids, histamine H2-receptor antagonists (also known as
H2-blockers) and proton pump inhibitors. Sometimes a single medication will work, but if it doesnt control your symptoms, you may
need to take a second medication.
Antacids. Over-the-counter antacids containing aluminum oxide,
magnesium carbonate and sodium bicarbonate (for example, Gaviscon, Gelusil, Maalox, Mylanta) rapidly neutralize stomach acid and
are taken after meals when you experience heartburn. These medications provide fast relief, but their effect is short lived.
H2-blockers. Over-the-counter or prescription H2-blockers, such as
cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid
AR) and ranitidine (Zantac 75), have a longer effect on gastric acid
than antacids. They usually need to be taken twice a day. A combination antacid/H2-blocker, Pepcid Complete, also appears to be more
effective at relieving symptoms than H2-blockers or antacids alone.
Proton pump inhibitors. These prescription drugs, which include
esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilo
sec, Zegerid), pantoprazole (Protonix), rabeprazole (AcipHex), dexlansoprazole (Dexilant) and an omeprazole/sodium bicarbonate
combination (Zegerid), are the most potent suppressors of gastric acid
secretion. They have a long-lasting effect and need to be taken only
once a day. Prilosec and Prevacid 24HR are available over the counter.
13
latest research
Sleep Apneas Tie to
Barretts Esophagus
Obesity and gastroesophageal
reflux disease (GERD) are both
common risk factors for Barretts esophagus and obstructive sleep apnea, a common
sleep-related breathing disorder. Now it appears that sleep
apnea itself is an independent risk factor for Barretts
esophagus, and that the risk
increases with greater severity
of sleep apnea.
To investigate the possible
correlation between sleep
apnea and Barretts esophagus, and to assess what role
obesity and GERD might play,
researchers analyzed data on
patients who had undergone
a diagnostic polysomnogram
(sleep study) and esophagogastroduodenoscopy (test to examine the upper gastrointestinal
tract) over a period of about a
dozen years. They divided the
subjects into four groups: Barretts esophagus without sleep
apnea; sleep apnea without
Barretts esophagus; both sleep
apnea and Barretts esophagus;
and neither condition.
They reported that people
with sleep apnea had an 80
percent higher risk for Barretts
esophagus than people without
sleep apnea. This finding was
independent of age, sex and
smoking history.
Further studies are needed to
confirm the findings. For now,
given that Barretts esophagus is
often asymptomatic, people with
sleep apnea may benefit from
Barretts esophagus screening.
CLINICAL GASTROENTEROLOGY &
HEPATOLOGY
Volume 12, page 583

April 2014
Prescription Drugs for the Treatment of Gastroesophageal Reflux Disease 2015

Drug type:
Brand (generic)
Typical daily
dosages*
How to take
Proton pump inhibitors

AcipHex (rabeprazole)
20 mg
One 20 mg tablet 1x/day with or without

food. Swallow whole (do not crush, chew or
split).
Dexilant (dexlansoprazole)
30 mg
One 30 mg tablet 1x/day with or without food.
Nexium (esomeprazole)
20-40 mg
One 20 or 40 mg capsule 1x/day at least 1

hour before a meal. Swallow whole.
Prevacid (lansoprazole)
15-30 mg
One 15 or 30 mg capsule in the morning 1

hour before eating. Swallow whole.
Prilosec (omeprazole)
20 mg
One 20 mg capsule 1x/day 1 hour before a

meal. Swallow whole.
Protonix (pantoprazole)
40 mg
One 40 mg tablet 1x/day with or without

food. Swallow whole.
Zegerid (omeprazole/
sodium bicarbonate)
Capsule: 40 mg/1,100 mg
Powder: 20 mg/1,680 mg
Capsule: One 40 mg/1,100-mg capsule on an

empty stomach 1x/day at least 1 hour before
a meal and with a full glass of water. Swallow whole. Powder: Empty one 20 mg/ 1,680
mg packet into 1-2 Tbsp of water 1x/day.
Mix and take immediately with a full glass of
water.
Axid (nizatidine)
300 mg
One 150 mg capsule 2x/day with or without

food.
Pepcid (famotidine)
20-40 mg
One 20 or 40 mg tablet 2x/day with or without food.
Tagamet (cimetidine)
1,600 mg
Two 400 mg tablets 2x/day or one 400 mg

tablet 4x/day with food.
Zantac (ranitidine)
300 mg
One 150 mg tablet 2x/day with or without food.
Histamine H2-antagonists (H2-blockers)||
See next page for legend.
Besides providing the most effective heartburn relief, PPIs are

best at healing erosive esophagitisinflammation of the esophaguscaused by GERD, the guidelines say.
Keep in mind, however, that there are concerns over long-term
suppression of gastric acid using proton pump inhibitors, particularly that it could lead to bone fractures and infection. In fact, the
FDA now requires PPI labels to include a warning about a possible
increased risk of hip, wrist and spine fractures.
14
Precautions
PPI therapy may be associated with an increased risk for

diarrhea caused by C. difficile infection. Long-term PPI
use may increase the risk of osteoporosis-related fractures
of the hip, wrist or spine. Patients should use the lowest
dosage and shortest duration possible. Hypomagnesemia (abnormally low blood magnesium level) has been
reported rarely in patients treated with PPIs for at least
three months. Doctors may monitor your magnesium levels before starting PPI therapy if you are expected to be
on prolonged therapy or you also take medications, like
diuretics, that lower your magnesium levels. If you are taking warfarin (Coumadin), your doctor may monitor your
prothrombin time (a measure of how fast your blood clots)
more closely.
Most common
side effects
Call your doctor if...
Headache, diarrhea,
nausea, dizziness,
constipation. Dexilant
only: Stomach pain,
common cold, vomiting, gas.
You experience a skin rash, signs of a

B12 deficiency (unusual weakness, sore
tongue, numbness or tingling of the
hands or feet), chest pain, dark urine,
severe stomach pain, fast or irregular heartbeat, diarrhea that does not
improve.
Headache, dizziness,
diarrhea, constipation.
You experience signs of liver problems:

unusual tiredness, persistent nausea or
vomiting, severe stomach or abdominal
pain, dark urine, yellowing eyes or skin.
Zegerid only: This medication contains sodium and thus

may not be appropriate for people on a low-salt diet. Longterm use (over one year) carries the risk of fracture of the
hip, wrist and spine.
People with kidney disease need to take a lower dosage to

prevent side effects such as confusion and dizziness.
continued on the next page
In addition, the effects of H2-blockers and proton pump

inhibitors can be enhanced by taking a promotility agent, such as
metoclopramide (Reglan, Metozolv ODT). This type of medication increases acid clearance from the esophagus, raises the pressure of the lower esophageal sphincter, and speeds emptying of
the stomach.
Surgery. Lifestyle measures and medications are so effective
at controlling reflux symptoms that few people need to undergo
15
Prescription Drugs for the Treatment of Gastroesophageal Reflux Disease 2015 (continued)
Drug type:
Brand (generic)

Typical daily
dosages*
How to take
Promotility agent
Reglan, Metozolv ODT (metoclopramide)
40-60 mg
One 10 mg tablet or one 10 mg and

one 5 mg tablet 30 minutes before
symptoms usually occur (e.g., before
meals and sleep) not more than 3-4x/
day for up to 12 weeks.
* These dosages represent the usual daily dosages for the treatment of gastroesophageal reflux disease. The precise effective dosage varies from person
to person and depends on many factors. Do not make any changes to your medication without consulting your doctor.
These instructions represent the typical way to take the medication. Your doctors instructions may differ. Always follow your doctors recommendations.
If you have difficulty swallowing pills, empty the contents of the capsule onto 1 Tbsp of cold applesauce. Mix and take immediately.
Over-the-counter formulations are available: Prevacid 24HR, Prilosec OTC, Zegerid OTC. Do not take for more than 2 weeks straight or more often than
every 4 months unless directed by your doctor.
|| Over-the-counter formulations are available: Axid AR, Pepcid AC, Pepcid Complete, Tagamet HB, Zantac 75, Zantac 150. Do not take for more than 2
weeks straight unless directed by your doctor.
surgery. When surgery is required, the most common procedure

is Nissen fundoplication. It involves lifting a portion of the stomach and tightening it around the gastroesophageal junction to
increase pressure in the lower esophageal sphincter and prevent
reflux.
The procedure is typically performed using a laparoscope, an
instrument that can be inserted through small incisions in the
abdomen. Five small incisions are made in the abdomen, and the
surgeon inserts a tiny camera and specialized instruments through
the incisions to perform the procedure.
Nissen fundoplication is performed in a hospital. You will
receive general anesthesia and need to stay in the hospital for one
to three days; you can return to work in two to three weeks.
Serious complications are rare but can include an adverse
reaction to the anesthesia, blood loss, infection and injury to the
esophagus, stomach or spleen. More common complications are
difficulty swallowing, stomach bloating, belching and vomiting.
These problems usually improve within one to three months.
Surgery reduces reflux symptoms in most people, but it
doesnt always eliminate symptoms. One study found that about
80 percent of people who underwent Nissen fundoplication still
require medication on a regular basis to control their symptoms
three years after surgery.
As an alternative to surgery, several methods for treating
16
Precautions
Most common
side effects
Avoid alcohol, because it can add to the drowsiness side

effect.
Diarrhea, drowsiness,
fatigue.
You experience involuntary movements of the eyes, face or limbs; muscle

spasms; trembling of the hands.
GERD endoscopically have been developed. These procedures

are performed during an upper endoscopy on an outpatient
basis and do not require incisions, general anesthesia or a hospital stay like surgery does. However, these procedures are relatively new, and their long-term effectiveness is not yet fully known.
Esophageal Motility Disorders

In a healthy esophagus, peristalsis propels food and fluid down
the esophagus. Sometimes, however, these contractions become
ineffective, resulting in an esophageal motility disorder.
The two most common esophageal motility disorders are diffuse esophageal spasm and achalasia. In diffuse esophageal spasm,
several segments of the esophagus contract strongly and simultan
eously, preventing the normal, wave-like contractions from moving
food and fluid down the esophagus. In achalasia, normal, wavelike contractions in the lower half of the esophagus are absent,
and the lower esophageal sphincter fails to relax and allow food to
enter the stomach.
Causes of esophageal motility disorders

The causes of esophageal spasm and achalasia are unknown. However, some believe that extremely hot or cold foods can trigger an
esophageal spasm. Older age, being female and having GERD also
may predispose you to having spasms.
17
Symptoms of esophageal motility disorders

People with diffuse esophageal spasm experience intermittent episodes of dysphagia (difficulty swallowing), usually with both liquids
and solids, as well as pain behind the breastbone. People with
achalasia have gradually worsening swallowing problems for both
solids and liquids, regurgitation of ingested food and weight loss.
Diagnosis of esophageal motility disorders
The best test for diagnosing achalasia is esophageal manometry.
In people with achalasia, manometry re
veals very weak esoph
ageal peristalsis as well as persistent elevated pressure in the lower
esophageal sphincter (indicating that the sphincter muscle cannot relax). With diffuse esophageal spasm, manometry will show
intense contractions of the esophageal wall.
An upper GI series also can be used to diagnose these disorders. In people with diffuse esophageal spasm, the radiologist will
see strong contractions of the esophagus, which interfere with
the movement of barium through the esophagus. Barium X-rays
in people with achalasia often reveal widening of the upper portion of the esophagus with a gradual narrowing at the lower end.
In many people with suspected achalasia, an upper endoscopy to
obtain a tissue sample from the gastroesophageal junction is necessary to rule out cancer.
Treatment of esophageal motility disorders
Achalasia is initially treated with medications like calcium-channel
blockers and nitroglycerin to relax the lower esophageal sphincter. Unfortunately, these treatments are often ineffective, and
most people require an endoscopic or surgical procedure to relax
the lower esophageal sphincter.
The two endoscopic procedures for achalasia are dilation and
injection of botulinum toxin A (Botox). Dilation involves inserting a balloon device to expand the lower esophageal sphincter.
Botox is injected into the lower esophageal sphincter to paralyze
and relax it. Because the effects of Botox appear to be temporary,
it is only recommended for people who are not good candidates
for endoscopic dilation or surgery.
Heller myotomy is the surgical procedure for achalasia. In this
procedure, a doctor makes an incision through the muscle of the
lower esophageal sphincter to weaken it. It can be done using a
traditional surgical approach (making a large incision in the abdomen) or through small incisions in the abdomen (laparoscopy)
18
or chest (thoracoscopy). In rare cases, doctors may perform an

esophagectomy (removal of part or all of the esophagus).
Drugs such as calcium-channel blockers, nitrates, Botox or tricyclic
antidepressants may be prescribed for diffuse esophageal spasm.
Esophageal Stricture
An esophageal stricture is a narrowing of the esophagus, typically in
the lower third of the organ.
Causes and symptoms of esophageal stricture

Esophageal stricture is the result of chronic inflammation and scar
tissue due to poorly controlled GERD. People with the disorder have
ongoing difficulties in swallowing solid food, and the problem gradually worsens over time.
Diagnosis and treatment of esophageal stricture
An upper endoscopy must be performed to obtain a tissue sample from the stricture to rule out cancer. Treatment may require
esophageal dilation followed by aggressive control of GERD with
medications to prevent recurrence of the stricture. If dilation cannot
widen the esophagus, surgery is recommended.
Barretts Esophagus
Barretts esophagus occurs when cells in the lining of the esophagus,
also known as the esophageal mucosa, are replaced by cells that are
more resistant to acid, a process called metaplasia.
Causes of Barretts esophagus

Normally, the esophageal mucosa is lined with multiple layers of
flattened, scalelike cells. When these cells are damaged by gastric
acid in individuals with GERD, they are replaced with a single layer
of cells that are similar to those that line the stomach and small
intestine. Research suggests that eating a diet high in meat, fast
food, soft drinks, alcohol and coffee may contribute to the risk of
Barretts esophagus.
Symptoms and diagnosis of Barretts esophagus
Typically, Barretts esophagus causes no symptoms, but it should
be suspected in people with chronic GERD. An upper endoscopy
(either traditional or via an esophageal capsule) is used to diagnose Barretts esophagus. If the condition is present, the doctor will see tonguelike protrusions above the gastroesophageal
19
latest research
Smoking Plus Drinking
Increases Esophageal
Cancer Risk
Smoking or drinking alcohol
may account for roughly 90 percent of esophageal squamouscell carcinoma (ESCC) cases.
Each behavior on its own is
associated with a 20 to 30 percent increased risk for this type
of cancer. Research now finds
that combining smoking and
drinking alcohol raises the risk
of ESCC much more than using
either substance alone.
To investigate how tobacco
and alcohol might interact with
each other to affect the risk of
developing ESCC, researchers
in Michigan conducted a review
of published medical research,
resulting in the first meta-analysis looking at the interaction
between alcohol and tobacco in
the risk of ESCC.
What they found suggests
there is synergy between the
two substances, meaning
that their interaction creates a
greater impact than what would
be expected from multiplying
their individual effects. The use
of alcohol and tobacco together
was associated with about a
three-fold risk for ESCC, almost
double what would be expected
if there were no synergistic
effect.
The researchers suggested
that prevention efforts should
focus on curtailing the use of
both alcohol and tobacco.
AMERICAN JOURNAL OF
GASTROENTEROLOGY
Volume 109, page 822

June 2014
Treating Your GERD on Demand

Can you quit taking your acid blocker when you dont have symptoms?
Gastroesophageal reflux disease
(GERD) is a chronic condition,
which means that it requires a
long-term strategy. For many
people, the recommended treatment for frequent heartburn is
taking a daily medication indefinitely, a regimen known as continuous maintenance therapy.
The goal is to prevent a
relapse of symptomsthat is,
heartburn, indigestion and food
regurgitation from the stomach into the esophagusand
medications like H2-blockers and
proton pump inhibitors that stop
acid production by the stomach
are fairly successful in most people with uncomplicated GERD.
However, many people resist
taking daily medications for
GERD, some of which are now
available over the counter. Factors like safety concerns and
inconveniencecombined with
skepticism about whether medication is really necessarysway
individuals to try a less frequent
form of drug therapy, even without their doctors approval.
Studies show that 20 to 29
percent of individuals prescribed
proton pump inhibitors take
their medication less often than
instructed by their physician,
and 79 percent do not refill their
prescriptions as often as they
should to comply with the dosing instructions provided by the
manufacturer. Thus, it appears
that many people with GERD

are willing to risk total symptom
relief for reduced medication
use. But do the benefits outweigh the risks?
Pros and cons of daily meds
Although acid blockers are generally associated with only minor
side effects, they do reduce
stomach acid, which is one of
your bodys defenses against
infection. When taking an acid
blocker, bacteria that would normally be killed off by stomach
acid may now thrive.
If bacteria-containing stomach
fluid refluxes into the trachea
and upper airways, it can lead to
pneumonia. Similarly, if a bacterium like Clostridium difficile
travels through the digestive
system to the colon, it can cause
colitis, diarrhea and cramps. Fortunately, the risks of these side
effects are small.
Taking acid blockers long term
can also deplete your body of vitamin B12, as stomach acid is necessary for the proper digestion of
this important vitamin. If youre on
continuous therapy, you may need
a monthly B12 injection.
Another drawback to longterm use of proton pump inhibitors is their possible association
with an increased risk for hip
fractures and osteoporosis.
There may also be an increased
risk of cardiovascular events in
junction. Samples of tissue (called biopsy samples) are taken from

these projections and examined under the microscope to look for
precancerous changes called dysplasia.
20
patients who are taking Plavix

(clopidogrel) at the same time.
Nonetheless, for most people
with GERD, the benefits of
medication far outweigh the
risks. For instance, people with
more serious disorders that can
result from uncontrolled GERD,
like Barretts esophagus (an
abnormal lining of the esophagus that can be associated with
the development of cancer) or
severe esophagitis (inflammation of the esophagus), require
continuous treatment with acid
blockers to prevent a relapse of
symptoms and to avoid further
damage to the esophagus. But
if you have mild to moderate
symptoms, you may not need
daily medication. Researchers
estimate that between 20 and 40
percent of people with GERD do
not need daily acid blockers to
stay symptom free.
Not quite once a day
If youre not going to take your
acid blocker every day, whats the
next best thing? Several methods
have been tried over the years:
Intermittent therapy. In this
approach, once your GERD
symptoms are relieved by medication for four weeks or so, you
stop taking it. Then, when symptoms reappear, you begin therapy again and continue for a fixed
period of time (often two to four
weeks), even if your symptoms
subside. Few large studies have

evaluated this therapy, but one
randomized, controlled study
from the journal BMJ found
that of 677 people with GERD
who tried intermittent treatment
with either ranitidine (Zantac) or
omeprazole (Prilosec), almost
half of the participants found it
effective for controlling symptoms and did not need to return
to daily treatment after one year.
Alternate therapy. Also
referred to as weekend therapy,
this approach involves taking
acid blockers only on specific
days of the weekoften Friday,
Saturday and Sunday. Alternately, the medication may be taken
every second or third day. The
idea is that regular, but not daily,
medication use may be enough
to control acid production.
Several studies have shown
that weekend or alternate therapy isnt effective for people with
erosive esophagitis. For example, a study in Gut found that
while 89 percent of people taking
daily Prilosec had no symptoms
after 12 months, only 32 percent
of people who took the medication on the weekends were
symptom free. Evidence is also
insufficient to definitively say
whether alternate therapy would
work for people with mild GERD.
On-demand therapy. This
appears to be the most promising
of the nondaily approaches. It is
similar to intermittent therapy, in

which you take the medication daily for a month or so until symptoms
are under control and then stay
off the medication until symptoms
reappear. But you only take the
medication until your symptoms
stopnot for a predetermined
length of time.
Using this approach means that
you will decide when to go off and
on your medication, and you will
be taking less medication than with
either the intermittent or continuous approaches.
Research has found that ondemand therapy with proton
pump inhibitors is an effective
long-term strategy for people
with mild GERD but not for those
with severe esophagitis. Another
finding was that about the same
amount of people were willing
to stick with on-demand therapy
as continuous therapy after six
months: One study found that 93
percent of on-demand esomeprazole (Nexium) takers were willing to continue treatment, compared with 88 percent of those
on continuous lansoprazole (Prevacid)suggesting that the possibility of occasional discomfort
from GERD symptoms was an
acceptable trade-off for reduced
medication use.
In its latest guidelines for the
management of GERD, issued
in 2013, the American College
of Gastroenterology noted that
Treatment of Barretts esophagus

Barretts esophagus increases the risk of esophageal cancer, with about
0.5 percent of people with Barretts esophagus developing cancer of
21
studies have demonstrated that

patients with uncomplicated GERD
can be managed successfully with
on-demand or intermittent proton
pump inhibitor therapy.
For patients requiring longterm therapy, the group gave a
conditional recommendation
to administering the medication in the lowest effective dose,
including for on-demand or
intermittent therapy, because
the evidence isnt strong enough
to recommend this treatment
strategy outright.
Going on demand
If youre interested in trying ondemand therapy, you should
have mild GERD and no evidence
of significant damage to your
esophageal lining, and your GERD
symptoms should be well controlled with a daily H2-blocker or
proton pump inhibitor for at least a
month or two.
When reflux symptoms return
while off your medication, first
try an over-the-counter antacid
for relief. If thats not enough,
restart your earlier medication
until symptoms subside. This
on-and-off approach does not
work for everyone, and you may
be better off with continuous
therapy if your symptoms reappear frequently. Always talk with
your doctor before making any
changes to your GERD treatment
regimen. n
the esophagus each year. To reduce the risk, its important to control
GERD and undergo an upper endoscopy and a biopsy of the esophageal mucosa every three to five years.
In the past, if biopsies indicated severe dysplasia or esophageal
cancer, surgery was usually performed. A portion of the esophagus
was removed, and the stomach pulled up into the chest cavity and
attached to what remained of the esophagus.
More recently, endoscopic therapy has provided an alternative
to surgery. Endoscopic mucosal resection can be used to remove
any nodules that are seen during a traditional endoscopy. The
doctor injects a solution into the nodule, to raise the lesion away
from the esophageal wall. A wire loop cauterizes the raised nodule
and removes it.
Other endoscopic treatments include radiofrequency ablation,
which uses radio waves to destroy abnormal cells on the esophageal
walls, and cryotherapy, which uses cold nitrogen or carbon dioxide
gas to freeze and destroy abnormal cells.
Gastritis
Gastritis occurs when the gastric mucosa, the inner lining of the stomach, becomes inflamed.
Causes of gastritis
Gastritis has many causes, including infections, medications, autoimmune reactions (in which the body begins to attack its own tissues), and food hypersensitivities or allergies.
The most common infection of the stomach is caused by a
bacterium called Helicobacter pylori (H. pylori). Infestation results
from ingesting food or water contaminated with H. pylori and
can result in a lifelong infection. In fact, an estimated 30 to 40 percent of Americans are infected with H. pylori. Infection irritates and
inflames the stomach lining and leads to overproduction of gastric
acid, which increases the risk of developing peptic ulcers (ulcers in
the stomach or duodenum; see pages 23-26) and gastric cancer.
The medications that most often cause gastritis are nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen
(Advil, Motrin) and naproxen (Aleve, Naprosyn). NSAIDs interfere
with protective substances in the stomach that prevent damage to
the mucosal lining; these drugs also inhibit the bodys ability to stop
bleeding.
The combination of NSAIDs and H. pylori is especially damaging to the gastric mucosa and may lead not only to gastritis but
22
also to the development of erosions (superficial defects) and ulcerations (deep defects) in the mucosal lining of the stomach and
duodenum.
Newer types of NSAIDs called COX-2 inhibitors were developed
to reduce the risk of gastritis and stomach ulcers associated with
traditional NSAIDs. However, not all studies have shown COX-2
inhibitors to be safer for the stomach than other NSAIDs. In fact,
the only COX-2 inhibitor currently available, celecoxib (Celebrex),
carries a black box warning on its label informing consumers of
the potential for gastrointestinal side effects. Two other COX-2 inhib
itorsrofecoxib (Vioxx) and valdecoxib (Bextra)were taken off the
market because they increase the risk of heart attacks and strokes.
Symptoms and diagnosis of gastritis

The symptoms of gastritis include indigestion (upset stomach) and
abdominal pain, particularly after meals.
The best way to diagnose gastritis is with an upper endoscopy.
Your doctor will look for changes in the gastric mucosa, such as swelling, redness and erosions. A definitive diagnosis is made by microscopic examination of a tissue sample removed during the endoscopy. The pathologist who examines the tissue will look for signs of
inflammation, the presence of H. pylori or evidence of autoimmune
gastritis. H. pylori infection can also be diagnosed by a blood test that
detects antibodies to the bacterium, a breath test or a stool test.
Treatment of gastritis
H. pylori infection can be cured with drugs that suppress gastric
acid production and oral antibiotics to eradicate the infection. If
a medication you are taking is causing gastritis, your doctor may
lower the dosage or switch you to another one. Your doctor may
also recommend taking medication to decrease gastric acid production and protect the lining of the stomach. (See the chart on
pages 14-17.)
Peptic Ulcer Disease

Peptic ulcers are deep, nonhealing defects or sores in the lining of the
stomach and duodenum. When they occur in the stomach, theyre
called gastric ulcers. Ulcers in the duodenum are duodenal ulcers.
Duodenal ulcers tend to affect young people, especially males. Gastric
ulcers are more common with advanced age, because older people are
more likely to be infected with H. pylori or to use NSAIDs. Both gastric
and duodenal ulcers tend to recur after theyve been treated.
23
Causes of peptic ulcer disease

Peptic ulcers occur when the lining of the stomach or duodenum
becomes damaged, usually by acid. More than half of peptic ulcers
result from H. pylori gastritis. NSAIDs and the osteoporosis drug alendronate (Fosamax) also can damage the lining of the stomach, increasing the risk of gastric ulcers. Smoking increases the risk of slow-healing
duodenal ulcers.
Symptoms of peptic ulcer disease
The symptoms of a peptic ulcer depend on whether the ulcer is in your
stomach or duodenum. A gastric ulcer results in pain in the upper
abdomen 15 to 30 minutes after eating. Because of the pain, you may
be afraid to eat and you may lose weight. With a gastric ulcer, pain
rarely occurs at night or when you are fasting. A duodenal ulcer, on
the other hand, results in pain in the upper abdomen two to three
hours after meals, when the stomach is empty. The pain can awaken
you at night and is relieved by eating.
If not treated, peptic ulcers can lead to complications such as
bleeding, perforation or penetration. Bleeding occurs when the ulcer
causes a blood vessel to rupture in the lining of the stomach or duodenum. Perforation results when an ulcer erodes through the wall of the
stomach or duodenum and into the abdominal cavity, leading to infection and inflammation of the abdominal cavity (peritonitis). Penetration happens when an ulcer erodes through the wall of the stomach
or duodenum and into adjacent organs, such as the liver, pancreas or
colon (large intestine).
Less often, an ulcer can deform the stomach or duodenum and
block the passage of food through the gastric outlet or duodenum,
resulting in nausea and vomiting that do not improve with treatment.
Diagnosis of peptic ulcer disease
Peptic ulcers can be diagnosed using an upper endo
scopy or an
upper GI series. During endoscopy, a peptic ulcer appears as a round
or elongated defect in the lining of the stomach or duodenum. On an
upper GI series, barium accumulates inside the ulcer or shows changes in the normal appearance of the folds of the lining (such as convergence of the folds toward the ulcer).
Treatment of peptic ulcer disease
Peptic ulcers can be healed temporarily by suppressing gastric acid
production, usually by taking H2-blockers and proton pump inhibitors. Ulcers often return once these drugs are stopped.
24
Drug Regimens for Treatment of Peptic Ulcers 2015

Regimen
Medications
Triple therapy 1) Biaxin (clarithromycin)

(two antibiotics
moxicillin or
and one proton 2) a
pump inhibitor
for 7-14 days.
metronidazole
The duration
of the regimen 3) AcipHex (rabeprazole) or
including AciNexium (esomeprazole) or
pHex is 7 days;
the duration of
Prevacid (lansoprazole) or
the other regimens is 10-14
Prilosec OTC (omeprazole) or
days.)
Quadruple
therapy
(bismuth, two
antibiotics and
one proton
pump inhibitor
or H2-blocker
for 14 days)
Combination
products
Dosage
Side effects/precautions
One 500 mg tablet 2x/day.
Biaxin, amoxicillin, metronidazole: Side

effects include diarrhea, nausea, vomiting,
stomach upset, changes in taste, headache.
Call your doctor immediately if you experience persistent diarrhea, abdominal pain
or cramping, blood or mucus in your stool.
Biaxin only: Take with milk if stomach upset
occurs. Amoxicillin only: Drink plenty of liquids. Metronidazole only: Avoid alcohol while
taking and for at least one day after finishing
the medication.
Two 500 mg capsules 2x/day.

One 40 mg capsule 1x/day.
Protonix (pantoprazole)
Proton pump inhibitors: See the chart on

pages 14-15.
1) P
epto-Bismol (bismuth
subsalicylate)
Two 262 mg tablets 3-4x/

day or 30 mL liquid 3-4x/
day.
Bismuth: May cause stools to become

gray-black.
2) metronidazole
Metronidazole: See above.
3) t etracycline
Tetracycline: Makes skin more sensitive to

sunlight. Wear sunscreen.
4) p
roton pump inhibitor
(AcipHex, Nexium, Prevacid,
Prilosec OTC, Protonix,
Zegerid) or
Same as for triple therapy

(see above).
Proton pump inhibitors: See the chart on

pages 14-15.
Axid (nizatidine) or
H2-blockers: See the chart on pages 14-15.
Pepcid AC (famotidine) or
Tagamet (cimetidine) or
Zantac 150 (ranitidine)
Helidac (for 14 days)

Pylera (for 10 days)
(bismuth/metronidazole/
tetracycline)
Helidac comes as separate

tablets for each agent. Pylera
comes as one capsule. For
both drugs, take 4x/day (after
meals and at bedtime). Follow directions carefully. With
Pylera, also take one 20 mg
omeprazole capsule at breakfast and dinner.
Side effects include nausea, diarrhea,

abdominal pain. Do not take if you have kidney or liver problems. For other precautions,
see separate entries for bismuth, metronidazole and tetracycline.
Prevpac
(amoxicillin/Biaxin/Prevacid)
for 14 days
Swallow two 500 mg amoxicillin capsules, one 500 mg

Biaxin tablet and one 30 mg
Prevacid capsule 2x/day
before eating.
Side effects include diarrhea, headache,

changes in taste. For precautions, see separate entries above for amoxicillin, Biaxin and
proton pump inhibitors.
25
The more common way to treat ulcers is to eradicate H. pylori

from the stomach. Once the infection is treated, gastric secretion
returns to normal and peptic ulcers are usually cured. The treatment regimen to eradicate H. pylori includes antibiotics and acidreducing medications. Usually doctors first prescribe triple therapy,
which consists of a proton pump inhibitor and two antibiotics.
If triple therapy does not produce a cure, a second triple therapy containing different drugs may be tried. Another option is
quadruple therapy: bismuth subsalicylate (Pepto-Bismol and other
brands), two antibiotics and a proton pump inhibitor or H2-blocker
(see the chart on page 25).
Antibiotic therapy cures 80 to 90 percent of ulcers caused by
H. pylori. If the H. pylori infection is not eradicated, the likelihood
is high that peptic ulcers will recur. Continued use of NSAIDs or
cigarette smoking lowers the chances that gastric ulcers will heal.
Bleeding ulcers are commonly treated with endoscopic therapy that stops the bleeding, followed by medication. Ulcers were
once commonly treated with surgery: either partial gastrectomy or
vagotomy. Partial gastrectomy involves removing the acid-producing portion of the stomach; vagotomy involves cutting the vagal
nerve to decrease acid production. Now that ulcers can be effectively treated with medication, surgery is rarely needed. Surgery
is still used, however, for people with ulcer complicationsfor
example, to stop bleeding, close perforations or open up the gastric outlet if an ulcer is blocking it. But these days, ulcers rarely
progress to this stage.
Anatomy of the Liver,

Gallbladder and Pancreas
To digest food, your digestive tract needs some help from nearby
organs, including the liver, gallbladder and pancreas, that produce
or store enzymes and other substances that help break down food.
Liver
The liver is a large organ on the upper right side of your torso, opposite the stomach and behind the ribcage. One of its main functions
is to make a substance called bile (composed mostly of bilirubin,
bile salts and cholesterol) that is required to digest food in the small
intestine. The liver is divided into two sections: a right lobe and a left
lobe. Both lobes are made up of cells called hepatocytes. These cells
26
produce bile and secrete it into the bile ducts, which carry bile to the
gallbladder, where it is stored until used by the small intestine.
Gallbladder and Bile Ducts

The gallbladder is a pear-shaped sac under the right lobe of the
liver. Between meals, it stores and concentrates bile, which is produced at a constant rate by the liver. When it is not full of bile, the
gallbladder is about 3 inches long and 1 inch wide at its thickest part.
After meals, the gallbladder releases bile into the duodenum to aid
with digestion. The cystic duct carries bile from the gallbladder to the
common bile duct, which empties into the duodenum. Entry of bile
into the duodenum is regulated by layers of muscle called the sphincter of Oddi. Between meals, the sphincter of Oddi closes and prevents
bile from entering the duodenum. During and after meals, this sphincter opens and allows bile to enter the duodenum.
Pancreas
The pancreas is a long, thin gland that lies horizontally behind the bottom part of your stomach. It makes digestive enzymes that flow through
the pancreatic duct to the small intestine. These enzymes, along with
bile from the gallbladder, break down food for use as energy by the
body. The pancreas also makes insulin and glucagon, hormones that
help regulate blood glucose (sugar) levels.
Disorders of the Liver,

Gallbladder and Pancreas
Disorders of the liver (such as cirrhosis and hepatitis), the gallbladder
(gallstones, for example) and the pancreas (for instance, pancreatitis)
can affect the proper function of your digestive tract.
Hepatitis
Hepatitis refers to any type of inflammation in the liver, and it can
be caused by a number of disorders. Heavy alcohol use can c ause
liver injury or hepatitis (alcoholic hepatitis).
Certain medications, such as isoniazid (Laniazid, Nydrazid) to
treat tuberculosis, methyldopa to treat high blood pressure and amiodarone (Cordarone, Pacerone) to treat irregular heart rhythms,
result in liver injury in susceptible individuals. Acetaminophen is a
common source of medication-induced liver damage. You run the
risk of liver damage by taking acetaminophen in quantities greater
27
Nonalcoholic Fatty Liver Disease: Are You at Risk?

Lifestyle modifications are necessary to prevent onset and progression
Most people tend to associate
fatty liver disease with drinking too much alcohol. However,
one type of fatty liver disease
has nothing to do with imbibing:
nonalcoholic fatty liver disease
(NAFLD). With the increase in
obesity and type 2 diabetes, the
most common causes of NAFLD,
its not surprising that the number
of cases of the disorder reported
in the United States is steadily
rising.
NAFLD is a buildup of fat in the
liver thats not caused by alcohol
consumption. The liver normally
contains some fat, but when
the percentage of fat in the liver
passes the 5 to 10 percent mark,
the liver is considered to be fatty,
a condition called steatosis. A fatty liver in a nondrinker indicates
the presence of NAFLD.
If you have diabetes, high
triglycerides or high blood pressure, or if youre obese, youre
at risk for NAFLD. Preventing
NAFLD is a matter of controlling

your risk factors.
NAFLD is usually symptomless,
so most people dont know they
have the condition. Its typically
discovered when a blood test for
another medical problem reveals
elevated levels of liver enzymes
that may point to NAFLD. An
ultrasound test can confirm the
presence of the disease.
Two types of NAFLD
NAFLD has two forms: nonalcoholic fatty liver (NAFL), which
is thought to be benign, and
the more serious nonalcoholic
steatohepatitis (NASH). You can
have NAFL and NASH at the
same time.
In NAFL, also called simple
fatty liver, the liver functions are
normal despite accumulations
of fat. Most people with NAFLD
have this form of the disease.
NASH is diagnosed in about
7 to 9 percent of people who
than directed, in multiple medications containing acetaminophen,

or while consuming three or more alcoholic drinks daily.
The liver also may be injured and become inflamed by the
immune system (autoimmune hepatitis) or from increased iron storage (hemochromatosis).
Obesity and diabetes are associated with fat accumulation in the
liver, causing a picture similar to alcoholic liver disease (nonalcoholic fatty liver disease). Nonalcoholic fatty liver disease is the most
common cause of chronic liver disease (see box above).
Viral hepatitis
Viral hepatitis is caused most often by one of five viruses: A, B, C, D or
E. About 17,000 new cases of hepatitis A, 38,000 new cases of hepatitis
B and 17,000 new cases of hepatitis C occur each year in the United
28
have NAFLD. NASH is characterized by accumulated fat that

also causes inflammation to the
liver and damage to liver cells.
It can progress if scar tissue
forms and replaces the damaged
cells, a condition called fibrosis. Although most people with
NASH dont develop serious liver
problems, the condition can lead
to more severe scarring, or cirrhosis, leaving the liver unable to
work properly.
Of those who go on to develop
cirrhosis, most are older women
with diabetes. In addition, taking
or overusing certain drugs, such
as steroids, anti-arrhythmics and
tamoxifen to prevent breast cancer, can sometimes cause NASH.
A diagnosis of NASH can be confirmed with a liver biopsy.
The American Association
for the Study of Liver Disease
(AASLD), the American College
of Gastroenterology and the
American Gastroenterological
Association issued guidelines in

2012 for the diagnosis and management of NAFLD. The need
for these guidelines, published in
Hepatology, is borne out with the
prevalence of NAFLDaccording
to the AASLD, it affects 30 to 40
million Americans.
Patients who have NAFLD

shouldnt consume large amounts
of alcohol. The guidelines
couldnt specify whether light
or moderate amounts were safe
because of limited scientific evidence, but many doctors suggest
avoiding alcohol altogether.
Managing NAFLD
NAFLD is a chronic condition that
has no cure. However, both NAFL
and NASH can be managed to
prevent progression.
The guidelines recommend
making lifestyle modifications to
control your risk factors, such as
lowering high triglycerides or high
blood pressure, monitoring blood
sugar levels or losing weight.
Losing 3 to 5 percent of your
body weight through diet alone
or diet combined with increased
physical activity appears to
improve NAFLD. A weight loss of
10 percent can reduce NASHs
inflammation.
Using drug therapy

According to the guidelines, certain patients with NASH might
benefit from taking the diabetes
drug pioglitazone (Actos), which
has been shown to improve the
condition in clinical trials. However, its overall long-term safety
and effectiveness havent been
established. It can also cause
weight gain.
The guidelines also say that
800 milligrams daily of vitamin E
may improve NASH, although it
shouldnt be used in people with
diabetes, nor should it be used
when cirrhosis is present. An
important consideration: Vitamin E
States. The other types of hepatitis rarely occur in the United States.
Hepatitis A is spread through contact with saliva or feces of
someone who has the virus, or ingestion of food or water contaminated with the virus. Hepatitis A is transmitted rarely through sexual contact. Hepatitis B is transmitted through tainted blood that
enters the body via contaminated needles (illegal injection drug
use or accidentally being stuck with a used needle), blood transfusions, transplants, hemodialysis, tattooing, body piercing and acupuncture. You can also become infected when you have sex with
someone who has the virus.
Vaccines are available to prevent hepatitis A and B. Hepatitis C
is the top cause of chronic viral hepatitis. Like hepatitis B, it is transmitted through infected blood exposure (often linked to illegal
injection of drugs) or sexual contact with an infected person.
29
was associated with an increased

risk of prostate cancer in a recent
clinical trial.
Bottom line
To reduce the degree of fatty
liver, weight loss of between one
and two pounds, but no more
than three and a half pounds, a
week is idealfaster weight loss
may worsen liver disease. While
losing 3 to 5 percent of body
weight can improve steatosis,
greater percentages of weight
loss may be needed to decrease
the inflammation associated with
fatty liver. Consultation with a
registered dietitian may also help
with safe and effective weightloss regimens and goals.
Medications such as pioglitazone and vitamin E may be useful adjuncts to lifestyle changes
to address NAFLD, but should be
initiated after a conversation with
your doctor, as these regimens
may not be safe for everyone. n
Symptoms of viral hepatitis

If you have viral hepatitis, it may not cause any symptoms at all, or
it can cause vague, flu-like symptoms including fever, fatigue, weight
loss, appetite loss and nausea. Other symptoms can include stomach
discomfort, dark urine and jaundice (yellowing of the skin and whites
of the eyes). Symptoms may come on suddenly.
Most people with hepatitis C have no symptoms and are diagnosed
when abnormal liver enzymes are identified through a routine blood
test. Between 75 and 85 percent of those with hepatitis C develop
chronic disease, and between 5 and 20 percent may develop cirrhosis
within 20 to 30 years of virus exposure.
Diagnosis of viral hepatitis
All three types of hepatitis can be detected with routine blood tests.
The Centers for Disease Control and Prevention now recommends
hepatitis C blood testing for everyone born between 1945 and 1965.
Analyses of national data show a disproportionately high prevalence
of hepatitis C infection among people born during these baby-boom
yearsabout five times greater than that seen in the general population. Many of those with hepatitis C infection either didnt recall having an exposure risk, or didnt report one. Early detection makes drug
treatment for hepatitis C more likely to clear the virus from the body,
preventing the development of cirrhosis and its complications.
Treatment of viral hepatitis
There is no treatment for hepatitis A beyond getting rest and drinking plenty of fluids. Most people recover within two to six months.
Most adults with hepatitis B recover within six months. However, about 5 percent become chronically infected and are at risk
for chronic liver disease. For those with acute hepatitis B (lasting
less than six months), treatment isnt usually prescribed. However, if
you know youve been exposed, getting the hepatitis B vaccine and
hyperimmune globulin (a drug containing large amounts of antibodies to the hepatitis B virus) immediately after exposure can significantly reduce infection risk.
Chronic hepatitis B (lasting longer than six months) can be treated with pegylated interferon, lamivudine (Epivir-HBV), telbivudine
(Tyzeka), adefovir (Hepsera) or entecavir (Baraclude). Pegylated
interferon is prescribed less often than the other four drugs because
of its many side effects.
Chronic hepatitis C is treated with pegylated interferon and
ribavirin, which results in clearance of the virus in up to 50 percent
30
of people with the most common genotype. Unfortunately, side

effects are common with this regimen and include worsening of
heart disease, retinal detachment, flu-like symptoms, depression,
anemia and alopecia.
Response has been improved with the addition of direct-acting
antiviral agents such as telaprevir (Incivek) and boceprevir (Victrelis), available for hepatitis C treatment in the United States
since 2011. The new medications may be difficult to tolerate but
have made hepatitis C infection more treatable.
If treatment is unsuccessful and the disease progresses, a liver
transplant may be necessary.
Cirrhosis
Cirrhosis is the development of scar tissue in the liver caused by
any form of chronic liver disease.
Symptoms of cirrhosis
Typically, people have few symptoms in the early stages of cirrhosis. However, as more healthy cells are replaced by scar tissue, symptoms such as loss of appetite, weight loss, weakness, easy
bruising, jaundice, and accumulation of fluid in the abdomen and
legs may develop.
Diagnosis of cirrhosis
Evidence of cirrhosis typically may be detected by a physical
exam, but more often blood tests or imaging studies of the liver
are required to determine if chronic liver disease has progressed
to cirrhosis. A liver biopsywhere a small sample of liver tissue is
removed for laboratory analysisalso may be performed to evaluate
how badly the liver is damaged and whether cancer has developed.
Treatment of cirrhosis
To prevent cirrhosis development, treatment is directed toward
the underlying cause (viruses, alcohol or autoimmune hepatitis).
Once scar tissue develops in the liver, it is irreversible. Therapy is
then directed at controlling the complications of the scarred liver.
Fluid accumulation in the abdomen or legs is treated with a lowsalt diet and diuretics. Large blood vessels (varices) that can rupture easily and bleed profusely may form around the stomach and
esophagus. These varices may require certain medications (betablockers) or endoscopic treatment. If these complications fail to
respond to medication, a liver transplant may be necessary.
31
ask the doctor

Q. I grew up eating three
square meals a day, but
Ive read that eating a lot of
smaller meals (grazing)
is better for maintaining
consistent energy. Is it really
a better way to eat?
A. While there are some arguments in favor of grazingthat
smaller meals may be easier to
digest and help maintain steady
glucose levelsrecent research
published in Hepatology suggests that snacking all day may
in fact be detrimental to various
aspects of your health, including
your waistline and your liver.
To test their hypothesis that
frequent meals would result
in the accumulation of intraabdominal and intra-hepatic
fat, a group of researchers in
the Netherlands randomized
36 lean, healthy men to six
weeks of a high-calorie diet or
a control diet. The caloric surplus in the high-calorie diet was
consumed with or between the
subjects three main meals.
While all the men on the highcalorie diets gained weight,
those whose extra calories
came from between-meal
snacks experienced an increase
in intra-hepatic triglycerides and
abdominal fat, while those who
simply ate larger meals did not.
The researchers concluded
that eating more often may
contribute toward the development of non-alcoholic fatty
liver disease, and that reducing
snacking and eating three meals
a day may be a more effective
dietary strategy.
Settling Your Stomach

How to avoid and treat nausea and vomiting
We all know what its like to feel
nauseatedthat queasy feeling that can mean an episode of
vomiting is imminent. Mercifully,
nausea typically lasts only a few
hours (although that may seem
like an eternity) and requires no
medical treatment.
The culprits
While nausea is often a sign of
harmless digestive upset, many
kinds of digestive disorders can
lead to nausea, including gastroesophageal reflux disease
(GERD), peptic ulcers, gallbladder
problems, hepatitis and pancreatitis. An upset stomach can also
accompany migraine headaches
as well as more serious conditions
like brain tumors, heart attacks
and strokes.
Sometimes, nausea may develop in reaction to intense stress,
anxiety or pain. You can even feel
the urge to throw up simply by
seeing someone else vomit. Most
commonly, though, eating certain
foods, taking specific medications
or traveling in a moving vehicle
causes nausea and vomiting.
Food. Eating and drinking can
lead to a bout of nausea in one
of three ways: from indulging in
too much food or alcohol, from
an allergy or sensitivity to food
(such as milk products that contain lactose), or from eating food
contaminated with bacteria, such
as Escherichia coli, salmonella and
shigella, or a norovirus.
Medication. Although medications are valuable to treat illnesses, a number of them can
cause an upset stomach as a
side effect: chemotherapy and

hormonal drugs for cancer, antidepressants, antibiotics (particularly erythromycin), pain medications containing opioids such as
codeine, theophylline (a drug for
asthma) and nonsteroidal antiinflammatory drugs (NSAIDs) like
aspirin and ibuprofen. Nausea is
also common after anesthesia for
surgery and following radiation
therapy for cancer. High doses of
zinc and potassium supplements
as well as fish oil capsules may
also make you feel nauseated.
Motion. Traveling in a moving
vehicle such as a car, plane, train
or boat or taking a spin on an
amusement park ride can bring
on waves of nausea, which in this
case is also known as motion
sickness. This occurs when the
movement of the vehicle causes
your eyes and ears to send conflicting messages to the brain
about your environment.
Warding off nausea
Nausea isnt inevitable, especially
when it comes to the most common causes. The following precautions can help minimize your
risk:
Eat smaller, more frequent
meals at a slower pace. This will
allow your stomach to digest
foods at a reasonable rate.
Be careful what you eat, especially while traveling in foreign or
tropical locales. Dont eat raw or
undercooked meat or seafood or
food that appears to have been
sitting out for a long time. Also
avoid spicy and fried foods. In
countries with poor sanitation,
32
dont drink tap water or consume

any fruits or vegetables that you
cant peel or boil before eating.
Wash your hands frequently
to cleanse away any bacteria or
viruses.
Monitor your medication use
closely, particularly when you
first start taking a drug, to see if
it causes stomach upset. Often
the nausea will go away within a
few days or weeks of taking the
medication. If it doesnt, talk with
your doctor; he or she may lower
the dosage, change the time or
way you take the medication,
or switch you to another drug.
When it comes to chemotherapy, your doctor will likely give
you antinausea drugs, such as
ondansetron (Zofran), to prevent
nausea and vomiting.
Sit in the front seat of a car, if
possible, and dont read while riding. If youre in a boat, focus on a
stationary object on the horizon
and stay in the midsection of the
ship, where its most stable. On
a train, sit facing the direction in
which the train is moving. Overthe-counter drugs such as dimenhydrinate (Dramamine) and meclizine (Bonine) or the prescription
medication scopolamine, which is
available as a patch (Transderm
Scop) or pill (Scopace), should
be taken 30 to 60 minutes before
you get in the vehicle.
Self-treatment
If a bout of nausea or vomiting
strikes, here are some ways to
relieve it:
Rest. Activity can make you
feel worse, so rest as much as
When to Call Your Doctor

If you have nausea or vomiting plus
these symptoms
You could
So you should
Fever, other cold and flu symptoms, dark

urine, and yellowing of skin or eyes
Have hepatitis
See your doctor immediately.
Fever, pain in right upper abdomen, worsening symptoms after a high-fat meal
Have gallstones, cholecystitis (infection of the

gallbladder) or pancreatitis
(inflammation of the pancreas)
See your doctor.
Vomiting blood and/or having black, tarry

stools
Have a bleeding ulcer or

other serious condition
See your doctor or visit the

emergency room immediately.
Headache, blurred vision, numbness or tingling following a blow to the head
Have a head injury
See your doctor or visit the

emergency room immediately.
Numbness on one side of the body or trouble seeing, speaking or moving
Be having a stroke
Call 911 immediately, even if

the symptoms go away after a
few minutes.
Chest pain that lasts longer than 10 minutes
Be having a heart attack
Call 911 immediately.
Excessive thirst, dry mouth, little or no

urination, severe weakness, dizziness and
lightheadedness
Be dehydrated
Drink water or sports drinks;

avoid coffee, tea and other
caffeinated beverages.
possible. If youre experiencing

motion sickness, stay as still as
possible and get out of the vehicle as soon as you can.
Sip clear fluids to settle your
stomach. Chamomile, lemon
balm or ginger tea as well as ginger ale are good choices for nausea. If youre vomiting, suck on
ice cubes and drink water, broth
or sports drinks like Gatorade to
prevent dehydration.
Avoid strong food odors.
Many odors can worsen nausea,
so avoid cooking, grocery shopping or going to a restaurant.
Eat bland foods, like crackers or dry toast, to absorb excess

stomach acid. You should also
avoid fatty, acidic or spicy foods,
which can upset the stomach
further. Wait about six hours after
the last time you vomited to eat
solid food.
Take antacids (Maalox,
Rolaids, Tums) to neutralize
stomach acid or bismuth subsalicylate (Kaopectate, PeptoBismol) to coat your stomach.
Talk with your doctor if youre
taking prescription medications or
aspirin; bismuth contains a drug
33
similar to aspirin, so you could

be taking a double dose without
knowing it.
Is it serious?
If your nausea or vomiting lasts
for more than 72 hours and you
havent been able to eat or drink
much, or if nausea is accompanied by abdominal pain, intense
dizziness or a severe headache,
call your doctor. While nausea
and vomiting usually arent serious, they could be if accompanied by the symptoms above. n
Gallstones
Gallstones are small, pebblelike substances that develop in the gallbladder. An estimated 25 million people in the United States have
gallstones. Women are twice as likely as men to have them. In fact,
nearly 25 percent of women develop gallstones by age 60, and as
many as 50 percent of women develop them by age 75. In contrast, 20
percent of men have had gallstones by age 75.
There are two types of gallstones. Nearly 80 percent are cholesterol gallstones, which are made up mostly of cholesterol. The remaining
20 percent are black- or brown-pigment gallstones, which have a
much lower cholesterol content and are primarily made of bilirubin
(a component of bile made by the liver).
Causes of gallstones
Gallstones form when the liquid (the bile) stored in the gallbladder
hardens into stones. This hardening occurs when there is too much
cholesterol or bilirubin in the bile or when the gallbladder doesnt
empty as it should. Its not known why these imbalances occur. Diet
may play a role: For instance, eating a diet high in cholesterol and fat
and low in fiber may increase the risk of gallstones.
Risk factors for the development of cholesterol gallstones include
a genetic predisposition (particularly in people of Pima Indian or
Scandinavian ancestry); age (older than age 50); obesity; pregnancy;
use of medications such as postmenopausal estrogen, oral contra
ceptives or the antibiotic ceftriaxone (Rocephin); prolonged intrave
nous feeding; rapid weight loss; and diseases of the terminal ileum
(the last portion of the small intestine, which is responsible for reabsorption of bile acids from the bowel into the blood). Research suggested that a deficiency of magnesiuman essential mineral found in
green vegetables, fish, whole grains, legumes, seeds and nutsmight
be a risk factor as well. People with hemolytic anemia or a bacterial
infection inside the bile ducts are at risk for pigment gallstones.
Symptoms of gallstones
Approximately 80 percent of gallstones produce no symptoms and
are discovered by accident during an imaging test for another health
problem. There is a 1 to 3 percent chance each year that a symptomfree gallstone will begin to cause symptoms.
The most common cause of symptoms is gallstone migration.
When gallstones migrate, they can obstruct the gallbladder neck (the
narrow portion between the gallbladder and the beginning of the
cystic duct), the cystic duct or the common bile duct. The resulting
34
increased pressure inside the gallbladder produces sharp pain in the

right upper portion of the abdomen. Intermittent episodes of such
pain, due to obstruction and spontaneous release (when the gallstone
dislodges), are called biliary colic.
When stones migrate from the gallbladder into the common
bile duct, they can cause partial or complete obstruction of bile
flow. Signs and symptoms of bile duct obstruction are intermittent
abdominal pain, jaundice (yellow discoloration of the skin and
eyes) and cholangitis (inflammation of the bile ducts). Gallstones
that lodge in the major duodenal papilla (a small elevation in the
second portion of the duodenum, where both the common bile
duct and the pancreatic duct openings are located) can cause acute
pancreatitis (inflammation of the pancreas; see pages 37-40), with
abdominal pain, nausea and vomiting.
If the obstruction persists, a condition called acute cholecystitis
may develop. In this condition, rising pressure inside the gallbladder
leads to decreased blood flow to the gallbladder wall, inflammation,
bacterial infection and, in some cases, a hole in the wall of the gallbladder (perforation). Symptoms of acute cholecystitis include severe
pain, fever, nausea and vomiting. The pain is located below the bottom edge of the right rib cage and often spreads to the back, right
shoulder or right side of the neck.
Diagnosis of gallstones
The best test to diagnose gallstones in the gallbladder is an abdominal ultrasound, which uses sound waves to create images of the
inside of the gallbladder. It is a noninvasive, painless test that is
performed by placing an ultrasound probe on the outside of your
abdomen. No special preparation is required aside from fasting for
six to eight hours. Abdominal ultrasound can detect gallstones as
small as 2 mm.
If you have acute cholecystitis, ultrasound can detect thickening
of the gallbladder wall as well as the presence of inflammatory fluid
(pus that contains bacteria and inflammatory cells) in and around the
gallbladder. Abdominal ultrasound can also detect widening of the
common bile duct due to obstruction by a stone.
If your doctor suspects that there is a gallstone in your common
bile duct, an endoscopic ultrasound may be performed. This test uses
a special endoscope with an ultrasound probe at its tip.
Computed tomography (CT) produces cross-sectional images
of the human body using high-resolution X-rays that are processed
by a computer. It involves lying on a special table while X-rays
35
are passed through your body. Like abdominal ultrasound, CT is

painless and noninvasive. Its better than ultrasound at detecting complications of acute cholecystitis, such as perforation of
the gallbladder or bile ducts and the formation of an abscess (a
localized accumulation of pus).
A hepatobiliary scintigram, also called a hepato-iminodiacetic
acid (HIDA) scan, is used to evaluate the passage of bile through
the bile ducts and gallbladder and to detect obstruction of the
cystic duct. This test involves the intravenous injection of a small
amount of a radioactive substance into a vein in your arm. The
radioactive substance is removed from the blood by the liver and
then secreted into the bile ducts. A special camera detects the
presence of the radioactivity and creates a computer image of the
bile ducts. The procedure is safe and exposes you to only small
amounts of radioactivity.
Endoscopic retrograde cholangiopancreatography (ERCP) is the
best way to diagnose stones in the bile ducts. It uses a special sideviewing endoscope to locate the opening to the duodenum and
to place a thin catheter in the bile ducts. A contrast agent is then
injected into the bile ducts and X-rays are taken, allowing your
doctor to study the anatomy of the ducts and identify any defects
or blockages caused by stones, strictures or masses.
A noninvasive, painless alternative to ERCP is magnetic resonance cholangiopancreatography (MRCP). It uses radiofrequency
waves to create pictures of the bile and pancreatic ducts. During
the procedure, you will lie very still in the magnetic resonance
imaging (MRI) scanner. The test takes about 20 minutes and may
not require the injection of a contrast agent.
Treatment of gallstones
If you have gallstones but no symptoms, you do not need treatment. But if youre having frequent episodes of biliary colic, your
physician will likely recommend that you have your gallbladder
removed, an operation called a cholecystectomy, to prevent recurrences. Nearly all cholecystectomies are performed by laparoscopy, which decreases the amount of pain following the surgery and
allows for a faster recovery than traditional open surgery. During
laparoscopic cholecystectomy, the surgeon may explore the common bile duct as well.
Pressure within the biliary tract, caused by stones that obstruct
the bile ducts, can also be relieved by using ERCP to place a small
tube (stent) into the common bile duct to keep it open. Stones
36
in the common bile ducts can also be removed during the procedure. ERCP uses a special device called a sphincterotome to cut
the bile duct sphincter and then extract the stones from the bile
duct with a special basket or balloon. Since stones are often still
present in the gallbladder, a cholecystectomy should also be performed to prevent further obstruction.
Acute cholecystitis usually requires a hospital stay. Fluids and
nutrients are given intravenously to let the digestive tract rest,
and antibiotics are administered to eliminate the bacterial infection. Once acute cholecystitis develops, the gallbladder should be
removed. If you are unable to undergo surgery, the gallbladder
can be drained by passing a tube into the gallbladder through a small
incision in the abdomen. Ultrasound or CT is used to guide placement of the draining tube.
Pancreatitis
Pancreatitis is an inflammation of the pancreas. When inflamed, the
digestive enzymes produced by the pancreas become active within the
pancreas instead of in the small intestine as they should. As a result,
the pancreas starts to attack itself.
Pancreatitis can be acute or chronic. Acute pancreatitis causes
attacks of pain within several hours of eating a large meal or drinking
a large amount of alcohol. Chronic pancreatitis occurs in people with
acute pancreatitis when the pancreas develops scar tissue and slowly
starts to malfunction. Eventually, the pancreas may stop producing
digestive enzymes. Both types of pancreatitis are more common in
men than in women.
Causes of pancreatitis
Gallstones blocking the bile duct and excessive alcohol consumption
are the major causes of pancreatitis. Less frequently, certain medications (in particular, the aminosalicylate anti-inflammatory compounds used to treat Crohns disease and ulcerative colitis; see the
chart on pages 58-61), a duodenal ulcer, an overactive parathyroid
gland or a stomach injury can cause pancreatitis. Smoking is also
associated with an increased risk of chronic pancreatitis.
Symptoms of pancreatitis
Acute pancreatitis is hard to miss. It causes excruciating pain in the
center of your upper abdomen extending through to your back, in
addition to nausea and vomiting. You may develop a fever or bruising
on your stomach from internal bleeding. You may also go into shock.
37
latest research
Sphincterotomy May Be
Ineffective for Pain Relief
A common and fairly invasive
approach to treating pain after
cholecystectomy may be no
more effective than a placebo
therapy.
More than 700,000 people in
the United States undergo gallbladder removal every year, and
at least 10 percent experience
abdominal pain after surgery.
Sometimes this pain is due to
a duct stone or some type of
functional bowel disease, but
for many the cause of pain
remains obscure.
In hopes of finding and treating the cause, patients often
undergo endoscopic retrograde
cholangiopancreatography
(ERCP) and sphincterotomy.
The effectiveness of this
approach, however, is unclear,
and it raises the risk of pancreatitis and other complications.
To investigate whether
sphincterotomy reduces disability due to this pain, researchers
randomized 214 patients, after
ERCP, to either sphincterotomy
or a sham treatment in a two-toone fashion. Of the 141 patients
who underwent sphincterotomy,
32 (23 percent) experienced
successful treatment, as did
27 of the 73 (37 percent) who
underwent sham treatment.
The researchers speculated
that the reduction in pain-related disability may be related to
patient optimism and the ongoing support of the research
staff, and they are following up
on groups of these patients to
assess this theory.
JOURNAL OF THE AMERICAN MEDICAL
ASSOCIATION

May 28, 2014
Best Ways to Manage Acute Pancreatitis

Latest guidelines aimed at treating a growing number of patients
It typically catches people off
guard, the severe upper abdominal pain brought on by inflammation of the pancreas. The pain
is typically worse after eating.
This sudden pain, which may
radiate to the back, as well as
nausea and vomiting are hallmark
symptoms of acute pancreatitis,
a commonly diagnosed gastrointestinal illness and the leading
reason for GI-related hospitalization in the United States.
Acute pancreatitis not only
causes pain but also can result
in fever, shortness of breath and
kidney problems. Fortunately,
most attacks of acute pancreatitis
do not lead to these complications and are considered mild,
and those who receive immediate
medical care recover uneventfully within 48 hours. In its severe
form, howeveraffecting 15 to
20 percent of patientsacute
pancreatitis will develop into a
complicated recovery, which may
result in infection, respiratory failure, organ failure or death.
Although acute pancreatitis is
a common ailment, researchers
have been giving it more attention
lately because of a steady climb
in its incidence over the past couple of decades. In 1998, slightly
more than 100,000 people were
hospitalized for acute pancreatitis. By 2002, the number had
more than doubled to 210,000. In
2009, it had climbed to 274,119.
Finding the cause
There is no mystery about why
the incidence of acute pancreatitis has increased; it follows a
trajectory similar to that for obesity. People who are obese are at
triple the risk of developing acute
pancreatitis. Thats because
obesity is a major risk factor
for gallstones, and gallstones
account for 40 to 70 percent of
acute pancreatitis cases, particularly in people over 60.
This occurs when a gallstone,
passing from the gallbladder into
the bile duct, lodges temporarily
in the sphincter of Oddi, a structure that allows bile and pancreatic secretions to ebb and flow.
The digestive enzymes headed
for the small intestine are then
forced back to the pancreas,
where they cause inflammation.
The stone may either pass
on its own or it may require an
endoscopic retrograde cholangiopancreatography (ERCP), a
procedure that removes stones
from the bile ducts. In both
situations, doctors recommend
the removal of the gallbladder
to prevent recurrence of acute
pancreatitis.
Alcohols role
The second most common
cause of acute pancreatitis is
heavy, long-term alcohol consumption, which is responsible
for 25 to 35 percent of all cases.
Non-drinkers are not immune to
pancreatitis, but alcohol definitely appears to raise the risk;
the prevalence of pancreatitis is
about four times higher in people
with a history of alcoholism than
in those without.
Alcohol-induced acute pancreatitis occurs hours to days
38
after consuming alcohol. It is not

entirely clear how drinking plays
a role in acute pancreatitis; its
possible that alcohol harms specific cells of the pancreas, causes
obstruction in the small ducts
of the pancreas, or affects the
sphincter of Oddi. At this point
there is no way to predict why
some heavy drinkers are more
vulnerable to developing acute
pancreatitis than others.
The third leading cause of
acute pancreatitis is high triglycerides. Typically, triglyceride levels higher than 1,000 mg/dL will
put people at risk for developing
acute pancreatitis. If this is the
case, then lowering triglyceride
levels is essential to prevent this
from occurring.
The fourth most common
cause of acute pancreatitis is
smoking. Smoking has been
shown to cause recurrent episodes of acute pancreatitis.
In addition, long-term heavy
smoking will increase the risk of
developing fibrosis of the pancreas (chronic pancreatitis) and
pancreatic cancer.
Acute pancreatitis can also be
caused by hereditary pancreatitis as well as genetic mutations
that have been linked to acute
pancreatitis, such as carrying a
mutated CFTR gene, which is the
gene linked to cystic fibrosis.
Certain conditions such as
inflammatory bowel disease and
lupus are associated with an
increased risk for acute pancreatitis. Other risk factors include complications from ERCP, traumatic
injury and certain medications.
The American College of

Gastroenterologys most recent
guidelines for managing acute
pancreatitis recommend that
doctors determine the underlying
cause and, if possible, treat the
condition to prevent a recurrence.
About 20 to 30 percent of
acute pancreatitis patients will
have a recurrence, and repeated
episodes of acute pancreatitis
can progress to chronic pancreatitis. No underlying cause can
be identified in about 20 percent
of people with acute pancreatitis,
but only a small proportion of this
group will experience additional
attacks over time.
First, head for the hospital
If you experience the symptoms
of acute pancreatitis, its important to seek medical help immediately. See page 37 for a list of
symptoms.
According to the current guidelines, a diagnosis is confirmed
when patients meet two of the
three following criteria: abdominal
pain consistent with the disease,
blood tests that show enzyme
levels three times higher than
normal, and/or abdominal imaging indicating acute pancreatitis.
Computed tomography (CT)
scans are not considered necessary unless the diagnosis remains
unclear or patients do not get
better within 72 hours after being
admitted to the hospital.
At the outset, it may be difficult
for doctors to distinguish mild
acute pancreatitis from severe
acute pancreatitis, which is characterized by persistent organ
failure. The first 12 to 24 hours

of hospitalization are critical,
because this is when the highest
incidence of organ dysfunction
occurs. Medical treatment of mild
acute pancreatitis is relatively
straightforward, but treatment of
severe acute pancreatitis involves
intensive care.
At this time, no medications
have shown to be effective in
managing acute pancreatitis, so
physicians rely on a number of
supportive and therapeutic interventions to help patients recover.
The current guidelines recommend aggressive intravenous
rehydration to replenish lost fluids and reduce the risk of serious
complications. Painkillers and
oxygen are also administered.
Most people with moderate to
severe pancreatitis will need a
temporary feeding tube. Those
with the mild form who are not
experiencing nausea and vomiting can have solid food once
their abdominal pain resolves.
Patients with infections outside
the pancreas, such as urinary
tract infections, cholangitis or
pneumonia, will need antibiotic
treatment.
Patients with acute cholangitis, an infection of the bile duct
usually associated with gallstone
obstruction, typically undergo
ERCP, preferably within the first
24 hours of admission. Some
patients will require surgery:
Surgical removal of the gallbladder (cholecystectomy) is
recommended in patients with
gallstone disease, and those with
extensive infection or damage to
39
the pancreatic tissue may need

radiological, endoscopic or
very occasionally surgical procedures to remove dead tissue
(necrosectomy).
Making healthy changes
Once an episode of acute pancreatitis is under way, there is no
course but to seek immediate
medical help. But considering that
the majority of cases are associated with gallstone disease and
alcoholism, there are steps people
can take to mitigate their risk.
Many lifestyle factors associated with gallstone disease are
modifiable, including diet. If you
need to lose weight, talk to your
doctor about a sensible plan of
action, but take it slowly. While
obesity itself is a risk factor for
acute pancreatitis, so is attempting to lose weight rapidly.
Large clinical trials have indicated that including the following
in a balanced diet may reduce
the risk of gallstone disease:
fruits and vegetables, particularly cruciferous and green
leafy vegetables, citrus fruits
and vitamin Crich fruits and
vegetables
polyunsaturated and monounsaturated fats
moderate amounts of coffee
As for alcohol-associated
acute pancreatitis, if you struggle
with drinking, talk to your doctor about the steps you will need
to take to achieve and maintain
abstinence from alcohol. Quitting
smoking, too, is very important,
and your doctor may be able to
help. n
If you experience severe abdominal pain that lasts more than 20 minutes, go to your doctor or a hospital emergency room for treatment.
With chronic pancreatitis, the abdominal pain can come on suddenly or gradually, usually after eating. It may develop into persistent abdominal pain. You can also develop jaundice, lose weight and
experience symptoms of diabetes (increased thirst and frequent urination) as the pancreas gradually deteriorates.
Diagnosis of pancreatitis
Pancreatitis is diagnosed with blood tests to assess levels of enzymes
made by the pancreas as well as other chemicals in the body. Other
tests used in diagnosis include X-rays, ultrasound, CT scans or magnetic resonance cholangiopancreatography (MRCP) of the pancreas.
Treatment of pancreatitis
For acute pancreatitis, you will probably need a hospital stay to completely rest your intestinal tract (that is, no food by mouth) and
to receive intravenous fluids, antibiotics and painkillers (for further details see Best Ways to Manage Acute Pancreatitis on pages
38-39). If you have gallstones, they may need to be removed. Likewise, collections of fluid around the pancreas that develop from
acute pancreatitis may be drained or surgically removed. Youll also
need to stop drinking alcohol and follow a nutritious, low-fat diet.
If you are diagnosed with chronic pancreatitis, you will likely be prescribed medications that contain pancreatic enzymes to
help your body absorb food. If the pain persists, surgery to remove
damaged tissue in the pancreas or to cut the nerves that transmit
pain may be needed. As with acute pancreatitis, stopping alcohol
use and eating a nutritious, low-fat diet are important.
Anatomy of the Lower Digestive Tract

Your lower digestive tract, also known as your bowel, is approximately 25 feet long and consists of the small and large intestines
(see the illustration on page 3). Food from the stomach passes
through the pyloric valve into the small intestine, a 20-foot tube
with three sections: the duodenum, the jejunum and the ileum.
The walls of the small intestine are lined with muscles that contract and relax to carry food along its path. The walls are also
covered in micro
villi, hairlike projections that help to absorb
nutrients into the bloodstream.
40
When food reaches the duodenum, it begins to get broken

down by digestive enzymes and bile. This process turns proteins
into amino acids, fats into fatty acids and carbohydrates into simple
sugars. The digested food then moves into the jejunum, where most
of its nutrients are absorbed. Vitamin B12 is absorbed in the ileum.
The material left behindmostly water, electrolytes (such as
sodium and potassium) and waste (such as fiber and dead cells)
moves into the cecum, the first part of the colon (also called the
large intestine). It then passes through the ascending, transverse
and descending colons; the sigmoid colon; and the rectum. No
nutrients are absorbed by the colon. Its job is to remove excess
water from the intestinal waste and return it to the bloodstream.
Thus, as the material moves along the colon, it slowly dries out and
forms a more solid substance called stool. Waste usually spends a
day or two in the colon before it is expelled from the body.
When stool moves into the rectum, it stretches the walls of the
rectum, which signals the need for a bowel movement. The stool
then moves into the anal canal. At the end of the anal canal is the
anal sphincter, which is a muscle that usually remains closed; however, it opens to allow stool to pass out of the body.
Tests for Examining the

Lower Digestive Tract
Various tests are available to obtain an inner view of the lower digestive tract: barium enema, sigmoidoscopy, colonoscopy, virtual colon
oscopy and capsule endoscopy. All of these procedures can be performed on an outpatient basis at your doctors office or a hospital.
The colon must be emptied before all of these procedures so that
your doctor can obtain a clear view of the inside of your lower digestive tract. Your doctor will give you specific instructions on how to do
this, but the process typically involves consuming a liquid diet for up
to three days before the procedure. Also, you will be told not to eat
or drink anything after midnight the night before the test and to use
laxatives the day before the procedure to cleanse the colon. On the
morning of the procedure, an enema (a liquid solution passed into
the anus) will be needed to cleanse the colon completely.
Barium Enema
Your doctor may order a barium enema, also called a lower gastro
intestinal (GI) series, to detect structural problems at the far end of
41
latest research
Laparoscopy Gaining Ground
in Pancreatic Surgery
Laparoscopic surgery is a safe
and effective approach for a large
number of surgical procedures
and in many patient populations.
New research suggests that
minimally invasive distal pancreatectomy (MIDP), too, is an
appropriate procedure for people
with pancreatic diseases.
Although the applications for
minimally invasive surgery have
expanded greatly in the past two
decades, the adoption of laparoscopy in pancreatic surgery
has been relatively slow, and data
about MIDP is limited. To investigate trends in the application of
MIDP and compare its outcomes
with those of open distal pancreatectomy, a group of researchers
scanned a nationwide database
of inpatient hospital stays for
information.
They found that the proportion
of MIDPs performed between
1998 and 2009 increased substantially, from 2.4 percent of
distal pancreatectomies to 7.3
percent. Furthermore, while
there were no differences in inhospital mortality or concomitant
splenectomy associated with
MIDP as compared with the open
approach, MIDP was associated
with fewer postoperative infections, fewer bleeding complications and shorter hospital stays.
The researchers found that
the use of MIDP has tripled in
practice, and concluded that it
has indeed evolved into a safe
surgical approach for pancreatic
diseases. They acknowledged
that further research is needed to
assess the long-term outcomes.
JAMA SURGERY

March 2014
your bowel. If a colonoscopy cannot be performed, a barium enema may be used to diagnose inflammatory bowel disease (Crohns
disease and ulcerative colitis) and colon cancer.
Barium sulfatea type of contrast dyeis administered through
the anus and into the colon to help produce X-ray images of the
lower digestive tract. During the exam, you lie on your side with
your knees bent toward your chest. A lubricated tube is gently inserted through the anus and into the rectum. Barium is then passed
through the tube into the rectum, allowing the colon to fill with
contrast dye. No sedation or pain medication is needed, but you
may feel some abdominal discomfort or an urge to pass stool during
the test.
A radiologist will take continuous X-rays of your abdomen and
view them on a screen. If any abnormalities are seen, the radiologist
will take spot X-rays for later analysis. When the procedure is complete (it typically takes 30 to 45 minutes), you will be taken to the
bathroom to expel some of the barium into the toilet. If a buildup
of barium prevents you from having a bowel movement in the days
after the test, your doctor may recommend a laxative or an enema.
Also, your stool may be whitish in color for up to three days after
the procedure because of the barium. Serious complications, such
as perforation of the colon, are rare.
Sigmoidoscopy
During a sigmoidoscopy, a gastroenterologist examines the inside
of your rectum and sigmoid colon (the last part of the large intestine) using a 2-foot, flexible viewing tube called a sigmoidoscope.
You might have this test to screen for colorectal cancer (although
a colonoscopy is the preferred method) or to investigate suspicious
rectal bleeding, diarrhea or pain.
Usually a sigmoidoscopy is done without a sedative, although
you can request one if you feel anxiety or pain. While you lie on
your left side, the doctor manually inspects the anus and rectum for
any blockages and then gently inserts the sigmoidoscope into the
anus, rectum and lower colon to view the inner lining of these parts
of the digestive tract. The physician may take biopsy samples and
remove any polyps (abnormal growths).
The procedure takes up to 30 minutes and, if no sedation is
necessary, you usually can drive home afterward. If you do receive
sedation, you wont be able to leave until it wears off and youll
need someone to drive you home. Some people experience gas
or a small amount of bleeding or abdominal cramping following
42
a sigmoid
oscopy. More serious complications, such as excessive
bleeding and perforation of the colon or rectum, can occur, but
they are rare.
Colonoscopy
A colonoscopy is similar to a sigmoidoscopy, but a longer flexible
viewing tube called a colonoscope is used to examine the entire
colon and (if necessary) the lower portion of the small intestine. It is
typically performed to detect colorectal cancer and to determine the
causes of rectal bleeding, chronic diarrhea, chronic constipation or
abdominal pain.
Since the doctor is going to carefully inspect your colon during the procedure, youll need to take steps beforehand to ensure
that the area is free of material that could impede the view. Expect
to follow a clear liquid diet starting the day before the procedure,
as well as take some type of laxative. You may also need to use
an enema to clean out the area. Be sure to follow your directions
carefully to help ensure that your colonoscopy provides useful
information.
Pain medication and a mild sedative are usually given intraven
ously just before a colonoscopy. While you lie on the examining
table, the doctor manually checks for blockages in the anus and
rectum. He or she then gently inserts the tube through the anus
and rectum and into the colon. As the colonoscope is slowly withdrawn, the physician inspects the lining of the intestines and may
take biopsy samples of any abnormal tissue and remove any polyps.
You may experience abdominal cramping, bloating and a need to
pass stool or gas during the procedure. The whole process can take
up to an hour.
The sedation will wear off about an hour after the procedure.
Youll need to have someone drive you home because of the lingering effects of the sedative. It is common to have gas after the
procedure and to have minor rectal bleeding if a biopsy was performed. Serious complications are rare (occurring in fewer than
0.1 percent of all colonoscopies) and can include excessive bleeding, labored breathing (from the sedative) and perforation of the
colon or rectum.
Virtual Colonoscopy
A virtual colonoscopy requires the same preparation to empty the
bowels as a standard colonoscopy, but instead of inserting a viewing tube into the colon and rectum, a CT scan of the abdomen
43
latest research
Measuring Quality in
Colonoscopy
The effectiveness of colonoscopy in preventing colon cancer
depends on the detection and
removal of abnormal growths
adenomas and polyps. Adenoma detection rates (ADR) and
polyp detection rates (PDR) vary
substantially among endoscopists, so researchers have been
trying to identify quality measures that ensure consistent,
high-quality exams.
One potential quality measure
is withdrawal timethe amount
of time the endoscopist takes to
examine the length of the colon.
Research suggests that endoscopists who spend more time
withdrawing the colonoscope
tend to find more adenomas and
polyps, especially sessile serrated polyps, a type often located
in the right side of the colon.
An analysis of colonoscopies
performed by 42 endoscopists
on nearly 8,000 patients found
higher ADRs and PDRs among
endoscopists with a median
withdrawal time of nine minutes;
eight or nine minutes appeared
optimal for sessile serrated polyp
detection. The researchers estimated a nine-minute minimum
withdrawal time could increase
the detection of sessile serrated
polyps by nearly 30 percent.
Many endoscopy centers are
forthcoming about their adherence to quality measures and
post such information on their
websites. If you cant find information about your endoscopy
centers performance standards, do not hesitate to ask.
AMERICAN JOURNAL OF
GASTROENTEROLOGY

March 2014
When to Have Your Next Colonoscopy

Protecting yourself against cancer after colon polyp removal
Colonoscopy can be an arduous form of screening, requiring
meticulous preparation. Fortunately, for most people it does
not need to be performed very
oftenevery 10 years if youre at
average risk for colorectal cancer
and have a clean colonoscopy.
But youll be advised to come
back sooner if youve had precancerous polyps removed
(polypectomy) during your colonoscopy. The timing for your
subsequent screenings will
depend on the number, size and
types of polyps found; their location in your colon; and other risk
factors for developing colorectal
cancer.
The most recent guidelines for
colonoscopy screening take into
account research confirming the
highly protective effect of colonoscopy in reducing colorectal
cancer death. The clinical evidence has only gotten stronger
in recent years, which means
that adhering to a colonoscopy
schedule appropriate for your risk
is definitely worth the trouble.
Polyps are not uncommon
It seems only logical that removing potentially cancerous tissue
early would reduce the likelihood

of cancer and cancer-related
death, a theory borne out by
long-term research. Researchers who followed 2,602 screened
patients with adenomas over a
period of about 15 years found
that colonoscopy with polypectomy reduced the rate of colon
cancerrelated deaths in their
study population by more than
half. In fact, the study, published
in The New England Journal of
Medicine in 2012, found that
in the first 10 years after colonoscopy, participants who had
polyps removed had about the
same risk for developing cancer
as patients who had no polyps to
begin with.
The United States Preventive
Services Task Force (USPSTF)
and other expert medical organizations recommend most people
start getting screened for colon
cancer at age 50; those with a
family history of colorectal cancer or polyps or a personal history of inflammatory bowel disease
or certain inherited conditions
should get screened sooner.
The surveillance intervalthat
is, how much time should elapse
before you are rescreened
is done to obtain two- and three-dimensional images of the intes

tines. Because the test will cause only minor discomfort, sedation is
not needed.
You might be wondering why your doctor wants to perform a standard colonoscopy when a virtual colonoscopy sounds like an easier
test to endure. Even though a three-dimensional CT virtual colonoscopy is considered to be as accurate as a standard colonoscopy
for detecting abnormal growths in the colon and rectum, the test
has a number of drawbacks.
44
hinges on a number of variables

that researchers have developed
a better understanding of in the
past several years. A key consideration is the number and types
of polyps detected during your
colonoscopy.
Up to 50 percent of adults are
found to have one or more polyps, but not all of these growths
are cause for concern. A type of
polyp known as hyperplastic, for
example, has virtually no chance
of becoming malignant. However, because its not always possible to distinguish a hyperplastic
polyp from a precancerous type,
a biopsy usually follows removal.
Patients who have small, hyperplastic polyps in their rectum or
sigmoid colon can usually wait
the full 10 years until their next
colonoscopy.
Another type of colon polyp is
an adenoma, which does carry
a cancer risk. But adenomatous
polyps are slow growing and usually take years to become cancer.
Generally, the larger the adenoma,
the more likely it is to become
malignant. Thus, the presence
of one or two tubular adenomas
less than 10 mm in size is considered low risk. (Adenomas have
several different growth patterns,

and tubular is less likely to be
cancerous.) If you have a low-risk
adenoma, you can safely wait
between five and 10 years until
your next colonoscopy.
The questionable types
Your endoscopist is likely to recommend another colonoscopy in
three years if you have between
three and 10 tubular adenomas,
or if one of those adenomas is
larger than 10 mm. If you have
more than 10 tubular adenomas,
you should undergo another colonoscopy in less than three years.
Shorter surveillance intervals
are also recommended for people who have adenomas with a
villous growth pattern, which are
more likely to quickly develop
into cancer, and for people
with adenomas that are found
to have high-grade cell abnormalities (dysplasia). People with
either of these two types should
have their next colonoscopy in
three years.
Researchers are still trying to
figure out the best way to manage patients who have serrated
polyps, which are flat and often
found in the right side of the
colon. At this point, serrated

polyps are handled like high-risk
adenomas if they are larger than
10 mm or contain dysplasia, with
a surveillance interval of three
years, and like low-risk adenomas if they are less than 10 mm
and do not contain dysplasia,
with a surveillance interval of
five years.
Serrated polyps can be difficult
to remove during colonoscopy,
and patients may be referred
for surgery. However, even the
most challenging growths can
be removed endoscopically in
the hands of a skilled specialist through a process called
endoscopic mucosal resection,
according to a study published
in Gastrointestinal Endoscopy in
January 2014. Patients should
have a repeat colonoscopy within
one year if there is any question
about the thoroughness of resection. The same holds true if bowel
preparation was inadequate,
which can result in missed adenomas during a screening.
Another factor doctors take into
consideration when determining a
screening schedule is the state of
findings after a patient has undergone a surveillance interval and
First, biopsy samples cannot be taken with a virtual colonoscopy.

This means that if any abnormalities are detected, you will need to
undergo a standard colonoscopy for confirmation of the diagnosis. Second, polyps cannot be removed during virtual colonoscopy
as they can during a standard colonoscopy. Third, virtual colonoscopy may not be able to distinguish stool from polyps or cancers.
Because of these drawbacks, your doctor wont perform a virtual
colonoscopy unless you have a medical condition that makes a standard colonoscopy risky or physically difficult.
45
repeat colonoscopy. For example,

if you had a low-risk adenoma
detected during your first colonoscopy and no adenomas
detected during a subsequent
screening, then you can wait 10
years before having the third. But
if you had a high-risk adenoma
found during your baseline colonoscopy and no adenomas at
your second screening, your doctor should advise you to wait no
more than five years before your
third colonoscopy.
Bottom line
If youre not sure why you were
given a certain time interval for
your next colonoscopy, be sure
to ask your gastroenterologist to
explain. You can also ask how
he or she handles the different
types of polyps.
The good news is that, at
some point, you can probably
stop worrying about having
colonoscopies. The USPSTF
recommends most people stop
getting colonoscopies after the
age of 75 unless prior findings
or other health issues suggest
it would be beneficial. Colonoscopy is not recommended for
people 85 and older. n
Capsule Endoscopy
When symptoms, such as GI bleeding or chronic abdominal pain,
cannot be explained using standard diagnostic procedures, capsule
endoscopy may be a useful technique. It allows for a full view of the
small intestine, particularly the areas that are usually unreachable
with an upper endoscopy or colonoscopy. However, capsule endoscopy cannot be used to view the esophagus or the stomach, and
biopsy samples cannot be taken.
Similar to the other imaging techniques described above, you
will need to follow a liquid diet and take a laxative to empty your
bowels before the procedure. On the day of the procedure, you
will swallow a camera-containing capsule with a full glass of water.
The capsule is then propelled through the digestive tract by peristalsis. You can go about your normal daily activities, although you
must wait two hours before drinking clear liquids and four hours
before eating a light meal.
The capsule is somewhat larger than a vitamin pill and contains a video camera, light and radio transmitter. It takes pictures (two per second) of the digestive tract and transmits these
images to an electronic device that is worn at your waist. After
about eight hours, you return the recording device to your doctor, who downloads the information from the device to a computer. The capsule is eliminated in your stool and does not need
to be returned. Your doctor, however, may ask you to watch for
the capsule in your stool; it gets stuck in the intestines of about
0.5 percent of people.
Disorders of the
Lower Digestive Tract
A large number of disorders can afflict your lower digestive tract,
including diverticulosis and diverticulitis, celiac disease, Crohns dis
ease, ulcerative colitis, irritable bowel syndrome, hemorrhoids, anal
fissures and colorectal cancer. Many of these disorders have constipation or diarrhea as a symptom.
Constipation
Nearly everyone has had a bout of constipationinfrequent bowel
movements and difficulty passing stoolat some point in their lives.
This common problem is not a disease but rather a symptom that
can stem from a number of medical conditions. It becomes more
46
common with age and occurs in at least 25 percent of people over

age 65. Older adults are five times as likely as younger people to
report constipation problems. In most cases, constipation is not a
serious condition and can be treated with lifestyle measures, such as
increasing your intake of dietary fiber and level of physical activity
or taking a laxative.
Causes of constipation
Constipation typically occurs when fecal matter moves too slowly
through the colon. This allows the body to absorb too much water
from the stool, leaving it dry and hard. Many experts no longer believe
that a low-fiber diet is a major contributor to constipation. However,
ignoring the urge to have a bowel movement and changing ones daily routine, such as during travel, are contributing factors.
Constipation can also be a side effect of medication, including
pain medications (mainly narcotics), antidepressants, diuretics, iron
supplements and aluminum-containing antacids. Some experts think
that excessive use of laxatives also may lead to constipation, because
the colon becomes dependent on the laxative to initiate defecation.
Overuse of enemas can have the same result.
Various medical conditions also can cause constipation. These
conditions include Parkinsons disease, diabetes, multiple sclerosis, stroke, lupus, decreased thyroid function and spinal cord
injuries. Constipation can also be a symptom of irritable bowel
syndrome. Tumors in the colon and diverticulosis can cause
constipation by blocking the passage of fecal matter. Last, constipation can result from mental health problems, for example,
depression and eating disorders.
Symptoms of constipation
What is considered normal in terms of the frequency of bowel movements varies from person to person. In fact, having only three bowel
movements a week is just as normal as having three bowel movements
a day. Therefore, a sudden decrease in your typical number of bowel
movements is a better indicator of constipation than your actual number of movements.
If untreated, constipation can lead to complications. Straining during bowel movements can irritate or cause hemorrhoids or rectal prolapse (when part of the lining of the rectum pushes out of the anus).
Hard stools may lead to anal fissurestears in the skin near the anus.
All of these conditions can cause pain, bleeding or excessive secretion of mucus. Another potential complication is fecal impaction, an
47
ask the doctor

Q. Im due for a colonoscopy.
Do I have any other options?
A. There are a number of alternatives to colonoscopy, and
each has its own appeal, such
as being less invasive, less
expensive or not requiring sedation. Each has its pitfalls as well,
such as exposure to radiation,
the need for more frequent
follow-up tests and relative lack
of accuracy.
For example, the Food and
Drug Administration recently
approved a noninvasive,
multi-target stool DNA test for
colorectal cancer. Stool samples can be collected at home
and mailed in, and the test
requires no dietary changes,
medication restrictions or bowel
preparation.
A study published last year
in The New England Journal of
Medicine compared the new
test with another stool test, the
fecal immunochemical test (FIT),
and found it detected far more
cancers. Unfortunately, the new
test also yielded a lot of false
positive results, so colonoscopy
remains the gold standard.
Do consider that if you have
a positive test by any other
modality, you will need a followup colonoscopy to determine
why your test was positive and
to remove any polyps or lesions.
inability to have a bowel movement because the stool has formed a

large, dense mass in the colon or rectum.
You should call your doctor if you experience sudden and
unexplained constipation, especially if it is accompanied by blood in
the stool or severe abdominal pain, or if you experience constipation
that lasts longer than a week despite making changes in your diet and
physical activity.
Diagnosis of constipation
You are considered to have chronic constipation if you consistently
average one or fewer bowel movements per week for at least a year or
have at least two of the following signs of constipation:
Two or fewer bowel movements per week
Straining during at least one-quarter of bowel movements
Passage of pellet-like or hard stools during at least one-quarter
of bowel movements
Feeling like not all of the fecal material is eliminated d
uring at
least one-quarter of bowel movements
If you have a bowel movement fewer than three times a week but experience no discomfort or change in the pattern of your bowel movements, you likely arent constipated.
Diagnostic tests like blood tests, abdominal X-rays, sigmoidosco
pies, colonoscopies and barium enemas are not helpfulor necessaryfor the diagnosis of constipation.
Treatment of constipation
The first therapies your doctor will recommend if you have con
stipation are diet and lifestyle modifications. One of these is an
increase in fiber consumption. The average American consumes
5 to 20 g of fiber a day; however, the Institute of Medicine recommends that men over age 50 get at least 30 g of fiber daily and that
women over age 50 consume at least 21 g. (Younger men and women
should aim for 38 g and 25 g of fiber d
aily, respectively.)
Although studies have found that a lack of dietary fiber probably
does not contribute to chronic constipation, fiber may help treat constipation by adding bulk (increased volume) and softening the texture
of your stools. Fresh fruits and vegetables, whole grains and beans are
examples of fiber-rich foods that you should add to your diet. Avoiding foods with a high-fat and low-fiber content, including meat and
full-fat dairy products, also may be helpful. In addition, dont ignore
the urge to have a bowel movement or delay a trip to the bathroom
when the urge develops.
48
Fiber supplements that act as laxatives (such as Citrucel, Fiberall, Konsyl or Metamucil) are useful for some people with constipation. These laxatives add bulk to the stool and are generally
safe to use for a week at a time. If you need to use them for longer
than that, you should consult your doctor. You should also slowly
increase the amount of fiber you take to avoid problems with gas,
and be sure to drink plenty of water or other fluids every day.
If bulk-forming laxatives fail to help, your doctor may recommend an enema or a non-bulk-forming laxative, including stimulants, stool softeners, lubricants and osmotic laxatives. Stimulants
such as bisacodyl (Correctol, Dulcolax) cause rhythmic muscle
contractions in the intestines, stool softeners such as docusate
sodium (Colace, Dialose, Surfak) add water to the stool which
makes it easier to pass, lubricants such as mineral oil (Fleet)
allow stool to move more easily through the colon, and osmotic
laxatives such as magnesium hydroxide (Milk of Magnesia) and
polyethylene glycol (Miralax) draw water into the colon, which
provides a flushing action. Even though these laxatives are available without a prescription, they should be used for only a week
at a time. If you need them for longer than that, ask your doctor
for guidance.
If constipation results in fecal impaction, your doctor may recommend a stool softener or enema. Then he or she will manually
remove the hardened stool. If a drug you are taking for another health problem is the suspected cause of your constipation,
your doctor may be able to lower the dosage of the medication or
switch you to another drug that does not have constipation as a
side effect. (Never stop taking a medication or change the dosage
without first consulting your doctor.) When a medical condition
is the source of the problem, treating that condition may relieve
the symptoms.
Biofeedbackin which you learn to strain more effectively,
coordinate your breathing, and properly relax and contract the
muscles involved in a bowel movementmay help a small number of people with constipation, particularly the type caused by an
inability to relax the pelvic floor muscles.
In 2012, the FDA approved a new prescription drug, linaclotide (Linzess), for adults who have constipation for unknown
reasons and dont respond to standard treatment. It comes in capsule form and is taken at least 30 minutes before the first meal of
the day. It is also approved to treat irritable bowel syndrome with
constipation (see page 66).
49
Diverticulosis and Diverticulitis

As we age, most of us develop small pouches (diverticula) that bulge
outward through weak points in the wall of the large intestinea
condition called diverticulosis. The condition is present in about half
of Americans over age 60. A disorder called diverticulitis, an infection
or inflammation of diverticula, develops in about 10 to 25 percent of
people with diverticulosis. Diverticulosis and diverticulitis are referred
to as diverticular disease.
Although diverticulosis can occur anywhere along the length of
the colon, the pouches typically develop in the sigmoid colon, the last
portion of the colon before the rectum. The number of diverticula
can range from one (called a diverticulum) to hundreds. Diverticula
are usually 5 to 10 mm in diameter but can exceed 2 cm.
Causes of diverticulosis and diverticulitis

A low-fiber diet has been considered the major culprit in diverticulosis
because it leads to hard stools. The reasoning is that when you strain
to move hardened stool, pressure inside the colon increases, which can
cause weak spots in the colon wall to bulge outward and become diverticula. But recent research suggests that a lack of fiber is not to blame.
Diverticulitis occurs when bacteria or hardened stool is trapped in
a diverticulum, causing an infection or inflammation. This may ultimately lead to a small hole in the tip of a diverticulum, which allows
bacteria to enter the abdomen and cause infection (peritonitis).
Symptoms of diverticulosis and diverticulitis
Although most people with diverticulosis have no discomfort or symptoms, some experience mild abdominal pain, bloating and constipation. The pain typically occurs in the lower abdomen, most often on
the left side. This area of the abdomen may feel full or tender when
touched. The pain can be severe and fluctuate in intensity and may
also occur with cramping, nausea, vomiting, chills, fever, a change in
bowel habits, painful or difficult urination and increased frequency
of urination. The severity of the symptoms depends on whether the
infection has spread beyond the colon and whether any complications
such as a perforation have occurred.
Rarely, people with diverticulosis experience mild, painless bleeding from the rectum, which occurs when a small blood vessel adjacent
to the diverticulum ruptures. The bleeding usually stops on its own. If
it persists or recurs, therapeutic endoscopy may be needed. If bleeding persists, surgery to remove the portion of the colon containing the
bleeding diverticulum may be necessary.
50
Diagnosis of diverticulosis and diverticulitis

Diverticulosis is often discovered by accident during an exam, such
as a barium enema, sigmoidoscopy or colonoscopy, for another
gastrointestinal ailment. If you have symptoms and your medical
history and examination suggest diverticular disease, your doctor
will do one or more tests. A barium enema or CT scan can diagnose diverticular disease and its complications. Your doctor may
also recommend a colonoscopy to check whether cancer is causing
the symptoms.
Treatment of diverticulosis and diverticulitis
People with diverticulosis may be advised to eat a high-fiber diet
to relieve symptoms and prevent the development of diverticulitis.
Diverticulitis is usually treated at home with bed rest, a liquid diet
to rest the colon and oral antibiotics. People with severe diverticulitis may be hospitalized and treated with intravenous antibiotics.
Most people with severe diverticulitis can be treated successfully
without surgery.
If antibiotics do not eradicate the infection associated with diverticulitis, an abscess (a collection of pus surrounded by inflamed tissue) may form in the abdominal cavity adjacent to the colon. The
abscess can be treated with more antibiotics, or it may need to be
drained by inserting a needle into the abscess through the skin and
draining the infected fluid through a catheter. Surgical treatment is
necessary in some people with a resistant infection.
Rarely, the infection may leak out of an abscess and spread into
the abdominal cavity, causing a condition called peritonitis. In such
cases, surgery is required immediately to clean the abdominal cavity
and remove the damaged region of the colon.
A fistula (an abnormal connection between two organs) can
form when an abscess erodes, creating a passage between the colon
and an adjacent organ such as the bladder, small intestine, vagina
or skin. The most common type of fistula connects the colon and
the bladder. This abnormality, which occurs far more often in men
than in women, can lead to severe, persistent urinary tract infections. Surgery to remove the fistula and the affected part of the
colon is needed to correct the problem.
Diarrhea
Diarrhea is a common health problem that causes loose, watery stools.
Acute diarrhea lasts for no more than two weeks. However, diarrhea
that lasts longer than two months is considered a chronic condition.
51
ask the doctor

Q. Im worried about
symptoms Im having that
might be diverticulitis. Will I
need to have surgery?
A. Not necessarily. Prior to the
availability of effective broadspectrum antibiotics, diverticulitis was potentially devastating
and often handled surgically to
prevent recurrences and other
problems. But research accrued
in the past decade has changed
the way doctors think about and
treat diverticulitis.
A recent large review of diverticulitis research, published in
the Journal of the American
Medical Association, shows
the majority of cases are managed non-operatively, and that
recurrences are relatively rare.
In one study of 2,366 people
hospitalized for diverticulitis and
followed for nearly nine years,
86 percent did not require any
further inpatient care for diverticulitis. Only 13.3 percent had a
recurrence, and 3.9 percent had
second recurrences. Incidentally,
none of those with a second
recurrence needed surgery.
The researchers also found
studies showing no advantage in
the use of intravenously administered antibiotics, and a shift
toward outpatient use of oral
antibiotics. Whatever treatment
your doctor recommends should
be tailored to your specific
needs, but you may take some
comfort in knowing that the current data supports a reduced
role for surgery.
Causes of diarrhea
Acute diarrhea is usually caused by an infectious agent. Most or
gan
isms that cause diarrhea originate in feces and enter the
mouth via the hands or contaminated food or water. Acute infectious diarrhea can be caused by a wide variety of bacteria, viruses and parasites. Bacteria implicated in acute diarrhea include
Salmonella, Shigella, Campylobacter jejuni, Escherichia coli O157:H7 and
Clostridium difficile. Viral causes of acute diarrhea include adenoviruses,
rotaviruses and the Norwalk-like viruses known as the noroviruses.
Parasitic causes include Entamoeba histolytica, Giardia lamblia and
Cryptosporidium.
Chronic diarrhea can be classified as osmotic, secretory or inflammatory. Osmotic diarrhea is caused by ingestion of poorly absorbed
substances (such as magnesium or aluminum salts in oral laxatives)
or by incomplete digestion and malabsorption of food components,
such as lactose or sorbitol.
Secretory diarrhea usually results in large amounts of watery
stools. This type of diarrhea is caused by production and secretion
of excessive fluid by the small intestine, usually the result of a rare,
cancerous neuroendocrine tumor occurring in the digestive tract.
The tumors release hormones into the bloodstream that stimulate
the small intestine to secrete excessive amounts of fluid and electrolytes such as sodium and potassium. Cholera outbreaks in developing
countries may cause secretory diarrhea.
Inflammatory diarrhea produces bloody, watery stools. It occurs
when inflammation in the lining of the colon increases stool volume
by decreasing the absorption of water from the stool. This type of
diarrhea is common in people with Crohns disease and ulcerative
colitis, the two main types of inflammatory bowel disease discussed
on pages 56-64. Diarrhea, as well as constipation, is also a hallmark of
irritable bowel syndrome (see pages 64-67).
Symptoms of diarrhea
The main symptom of diarrhea is an increased number of bowel
movements along with a decreased consistency of the stools, which
may be semisolid or watery. Other symptoms of diarrhea include feelings of urgency and abdominal discomfort and pain.
Diagnosis of diarrhea
Most cases of acute diarrhea do not require a call to your doctor. However, if diarrhea persists for 48 hours or more, is severe
(more than six stools per day) or is accompanied by fever, severe
52
abdominal pain or blood in the stool, you should see a doctor.

You may be asked to give a stool sample to identify the infectious
agent causing the diarrhea.
Diagnosing chronic diarrhea is more involved. It requires a
detailed evaluation that includes an upper endoscopy and/or a
colonoscopy with a biopsy to rule out infections or inflammation.
Treatment of diarrhea
Most times, a bout of acute diarrhea requires no treatment
beyond rest and drinking plenty of fluids to prevent dehydration
until the symptoms subside on their own. Medications to control
acute diarrhea are not recommended; you should allow the illness
to run its course. However, if the diarrhea is causing you much
inconvenience, you can take an anti-diarrheal product such as bismuth subsalicylate (Pepto-Bismol, Kaopectate and other brands) or
kaolin/pectin (Kao-Spen, Kapectolin) to solidify the stool. Other
anti-diarrheal medications, such as loperamide (Imodium A-D) or
diphenoxylate/atropine (Lomotil), also are helpful because they
slow the movement of the GI tract.
Intravenous fluid administration in the hospital is required in
some cases of severe diarrhea. Certain cases of infectious diarrhea,
particularly those caused by bacteria like Salmonella typhi and E.
coli O157:H7, can be serious. Antibiotics to eradicate the organism
are usually recommended if symptoms have not improved after 48
hours of treatment with fluids and an anti-diarrheal product. Antibiotics most frequently used to treat diarrhea caused by bacteria
are ciprofloxacin (Cipro) and trimethoprim plus sulfamethoxazole
(Bactrim). Cases of acute diarrhea caused by a parasite are often
treated with metronidazole (Flagyl). In 2011, the FDA approved
fidaxomicin (DIFICID) for the treatment of diarrhea associated
with Clostridium difficile. Antibiotics are most effective when started
in the first three days of the illness.
Treatment of osmotic diarrhea involves avoiding foods, drinks
or medications that cause the condition. For example, stimulant
laxatives such as Correctol or Dulcolax should not be used, and
people should limit their use of chewing gum and foods that contain the artificial sweetener sorbitol. If the pancreas produces insufficient digestive enzymes to break down fats, supplemental digestive
enzymes can be taken with meals. Treatment of secretory diarrhea
caused by a neuroendocrine tumor requires locating and removing
the tumor. Treatment of inflammatory diarrhea involves treating
the underlying inflammatory bowel disease.
53
Celiac Disease
People with celiac disease are sensitive to gluten, a component of
wheat and other grains. The disorder was once thought to be rare
in the United States, but research now shows that about one in 100
Americans has the disease. Many people dont know they have celiac disease, either because they or their doctors have attributed the
symptoms to another illness or because they have no symptoms.
Causes and symptoms of celiac disease

Celiac disease is an autoimmune disorder (the bodys immune system
attacks itself) and a malabsorption disorder (nutrients from foods are
not absorbed). Gluten, which is found in wheat and other grains, contains a protein called gliadin. In people with celiac disease, consuming
gliadin produces an immune reaction that causes the villi (fingerlike
projections in the intestines) to flatten or disappear. This decreases the ability of the villi to absorb nutrients from food. As a result,
diarrhea, bloating, weight loss, anemia and vitamin deficiencies are
common and are some of the first signs of the disorder. Eventually,
long-term damage to the small intestine may result.
Osteoporosis is common in people with celiac disease because of
poor absorption of vitamin D and calcium. Other possible symptoms
related to poor nutrient absorption include fatigue and muscle or
bone pain. Long-term malabsorption of nutrients can even damage
the nerves, bones, teeth, pancreas and liver. In addition, a type of cancer called lymphoma is more likely to occur in people with celiac disease than in those without the condition.
Risk factors for celiac disease
Celiac disease is most common in whites and people of European
ancestry. Seventy percent of cases occur in women. A family history of
the disease is another important risk factor. If you have a first-degree
relative (a parent, child or sibling) with celiac disease, your risk is 4.5
percent. If you have no close relatives with the disease, however, your
risk of celiac disease is less than 1 percent.
Screening and diagnosis of celiac disease
Many people have celiac disease for years but do not know it
because they dont have the most common symptomsdiarrhea,
bloating, gas and weight lossor they have no symptoms at all.
Celiac disease is especially difficult to diagnose in older adults
because they are more likely to have nonspecific symptoms (for
instance, pain in the joints or numbness in the legs) or nutritional
54
deficiencies because of their age or other health problems. The

good news, however, is that being diagnosed at an older age usually means the course of the disease will be relatively mild compared
with people who are diagnosed at an early age.
If you have a close relative with celiac disease, you should be
screened for the condition with a blood test. Screening should
also be considered if you have thyroid disease or type 1 diabetes,
unexplained digestive symptoms or weight loss. The blood test
measures three specific antibodies that are present when a person with celiac disease ingests gluten. If these three antibodies are
found, a biopsy of the small intestine is usually performed to look
for damaged villi.
The biopsy involves in
serting an endoscope down the throat,
through the stomach and into the small intestine. It is important not
to avoid foods that contain gluten before these tests, since avoidance
could make blood test and biopsy results appear normal and prevent
an accurate diagnosis. Screening for celiac disease may also involve
a blood test and a skin biopsy for dermatitis herpetiformis (DH), an
itchy, blistering rash occurring in up to 25 percent of people with
celiac disease.
Treatment of celiac disease

No medication or surgical procedure can cure celiac disease. The
only way to treat it is to adopt a completely gluten-free diet: avoiding
all food and drink containing wheat, barley, rye and other grains. You
must also look out for hidden sources of gluten, like medications, lipstick, communion wafers and even postage stamps.
A gluten-free diet can be difficult to follow, since gluten is naturally present in many foods and is added to other products such as
ice cream and salad dressings. Moreover, some labels do not indicate that a product contains gluten. Thus, you will need to ask about
ingredients at restaurants, learn to substitute gluten-free ingredients in recipes, and make sure your foods dont become crosscontaminated with gluten from other foods (for example, from
knives, toasters or cutting boards).
A registered dietitian can help you recognize what foods you
can and cannot eat, and the Celiac Sprue Association/USA (see
page 83 for contact information) sells publications that list glutenfree foods and medicines. Joining a support group for people with
celiac disease also can be helpful.
A gluten-free diet eliminates symptoms in most people with
celiac disease. Symptoms usually improve within a few days of
55
eliminating gluten, although complete recovery may take anywhere from a few months to several years. But for many adults,
the damage to the small intestine may be permanent. One study
found that two years after being diagnosed with celiac disease and
beginning a gluten-free diet, 34 percent of the participants had
reduced intestinal damage (mucosal recovery); the rate was 66
percent after five years. Most people who experienced mucosal
recovery did so within four years. To remain symptom free and
avoid further damage to the small intestine, you must follow a
gluten-free diet for life.
People who do not improve on a gluten-free diet usually have
severe damage to the small intestine. In these individuals, medications such as the aminosalicylate anti-inflammatory compound mes
alamine (Pentasa) or the corticosteroid prednisone (see the chart
on pages 58-61) may control inflammation in the small intestine
and any problems from poor absorption of nutrients.
Crohns Disease
Crohns disease is a chronic inflammatory disorder that primarily affects the small intestine, but it also can affect any segment of
the digestive tract, including the colon, anus, mouth and stomach.
Crohns disease can even affect the skin. About 700,000 p
eople in
the United States have Crohns disease.
Causes of Crohns disease

Despite extensive research, the cause of Crohns disease is poorly
understood. Three factors likely play a role. Genetics is one of them:
Certain people inherit a susceptibility to the disease. The second
factor is environmental: A stimulus (perhaps a virus or bacterium)
triggers the disease by causing the immune system to mount an
attack against the digestive tract. Once the immune system gets
turned on, it doesnt turn off properly. The third factor is race
and ethnicity: Whites (particularly American Jews of European
descent), followed by blacks, are more likely to get Crohns than
are Hispanics and Asians.
Symptoms of Crohns disease
Most often, Crohns disease causes chronic inflammation of the
small intestine. The inner lining of the small intestine becomes swollen and may develop erosions and ulcerations. These inflammatory
changes usually result in abdominal pain and bloody diarrhea. The
chronic inflammation can also lead to complications such as bowel
56
perforation, peritonitis, abscesses, fistulas and strictures. Symptoms

of Crohns disease usually begin in the teen or young adult years.
Once you have the disease you will have it for life. However, you will
have symptom-free periods (remissions) that can last for years. A
reappearance of symptoms is called a flare-up.
Diagnosis of Crohns disease

The tests used to diagnose Crohns disease depend on where your
doctor thinks the inflammation is occurring. An upper GI series is
the best test for Crohns disease of the small intestine. Increasingly,
capsule endoscopy is being used for diagnosis, although there is a
risk that the capsule could get stuck in the digestive tract of people with Crohns disease who have strictures (which are common).
Sometimes before a capsule endoscopy, doctors will prescribe a
patency capsule, which can detect the presence of strictures and
(if it gets stuck) dissolve within 40 to 80 hours.
Colonoscopy or sigmoidoscopy may be used to detect Crohns
disease of the large intestine. If these tests arent possible because
of narrowing of the rectum or colon, a barium enema may be performed instead. If a fistula is suspected, the doctor may choose a
more watery contrast dye called Gastrografin instead of barium.
Genetic tests and blood tests are currently in development to detect
Crohns disease, but they are not yet sensitive or specific enough to
be useful.
Treatment of Crohns disease
No drug or surgical procedure can cure Crohns disease. Treatment
is aimed at preventing and treating flare-ups and complications.
Commonly prescribed drugs are listed in the chart on pages 58-61.
Because eating can irritate an inflamed bowel, severe flare-ups
usually require hospital treatment with intravenous nutrition and
fluids to allow the bowel to rest. You will also be given intravenous
corticosteroids like methylprednisolone and mesalamine capsules
(Pentasa) or sulfasalazine (Azulfidine) tablets to reduce inflammation. Pentasa can be used to treat disease in both the small and the
large intestine. If the disease is present only in the colon, Azulfidine
can be used.
If the disease responds to these treatments, you can switch
from intravenous to oral corticosteroids such as prednisone or
budesonide (Entocort EC). Eventually, you will likely be weaned
off corticosteroids, but you will still take mesalamine or sulfasalazine. When Crohns disease is limited to the far end of the colon
57
latest research
Older IBD Drugs May Reduce
Surgeries
Guidelines for inflammatory
bowel disease have played
down the use of thiopurines
(azathioprine, mercaptopurine)
in recent years in favor of newer
and more expensive biologic
agents. But new research shows
that thiopurinesinflammationsuppressing drugs that have
been around since the 1970s
may reduce the need for surgery
in people with Crohns disease
by about 60 percent.
In the past two decades, the
use of thiopurines has risen
dramatically and the number of
intestinal surgeries in people with
Crohns disease has fallen, but
the association between these
trends was neither clear nor
proven. To find out if thiopurines
reduce the need for surgery,
researchers examined data on
5,640 people living with Crohns
disease for more than 20 years.
They found that patients who
took thiopurines for six months
had a 44 percent lower risk of
surgery, while those who took the
medications for a year or more
reduced their risk by 69 percent.
No additional benefit was seen in
patients who started thiopurines
soon after diagnosis.
Long known to help maintain
remission in people with Crohns
disease, it appears that thiopurines also modify the disease
to the point that surgery can be
avoided in a significant number
of patients, even if they start the
medication more than a year after
diagnosis.
AMERICAN JOURNAL OF
GASTROENTEROLOGY
Published online
January 28, 2014
Drug Therapy for Crohns Disease and Ulcerative Colitis 2015

Drug type:
Brand (generic)
Typical daily
dosages*
How to take
Aminosalicylate anti-inflammatory compounds

Oral
Azulfidine, Azulfidine-EN (sulfasalazine)
2,000 mg
Four 500 mg tablets 1x/day with food or

after meals with a glass of water.
Colazal (balsalazide)
6,750 mg
Three 750 mg capsules 3x/day with or

without food.
2,400 mg
Two 400 mg capsules 3x/day with water

one hour before or two hours after a
meal. Swallow whole (do not open, chew
or break).
Dipentum (olsalazine)
1,000 mg
Two 250 mg capsules 2x/day with food

or after meals.
Lialda (mesalamine, delayed-release)
2.4-4.8 g
Two to four 1.2 g tablets taken once

daily with a meal. Swallow whole.
Pentasa (mesalamine, controlled-release)
4,000 mg
Four 250 mg capsules 4x/day or two

500 mg capsules 4x/day with or without
food. Swallow whole.
Rectal
Canasa (mesalamine suppositories)
1,000 mg
Insert one 1,000 mg suppository at

bedtime. For best results, have a bowel
movement before using and keep in your
rectum for at least 2 hours.
Rowasa (mesalamine enema)
4g
At bedtime, insert the tip of one bottle

into your rectum and empty the bottles
contents. For best results, use after a
bowel movement and hold the medicine
in your rectum overnight.
Oral
Entocort EC (budesonide)
Uceris (budesonide extended release)
6-9 mg
Entocort EC: Two or three 3 mg capsules

1x/day in the morning. Swallow whole
(do not chew or break). Uceris: One 9 mg
tablet 1x/day.
(prednisone)
40-60 mg
A combination of 1, 2.5, 5, 10, 20 or 50

mg tablets 1x/day in the morning with
food to prevent stomach upset.
Intravenous
(methylprednisolone)
32-60 mg
Requires administration by a health professional who will infuse the medication

into your body through a needle placed
in a vein in your arm.
Rectal
Colocort (hydrocortisone enema)
100 mg
At bedtime, insert the tip of one bottle

into your rectum and empty the bottles
contents. For best results, use after a
bowel movement and hold the medicine
in your rectum for at least 1 hour (and
preferably overnight).
Delzicol (mesalamine, delayed-release)
Corticosteroids
58
Precautions
Most common
side effects
Do not take if you are allergic to aspirin. Tell your doctor if you have (or have had) kidney or liver problems.
Avoid alcohol when taking any of these medications to
reduce the risk of dizziness and stomach bleeding.
Azulfidine only: Youll need regular blood and urine tests
to monitor the health of your blood, liver and kidneys.
Canasa only: Handle as little as possible, because heat
from your hands can melt the suppository. Canasa and
Rowasa only: May stain surfaces such as your clothing,
floors or countertops.
Headache, upset
stomach, nausea,
abdominal pain,
diarrhea, gas.
Azulfidine only: May
cause skin or urine to
turn orange-yellow.
This is harmless and
goes away when the
medication is stopped.
You experience worsening stomach

pain or cramping, worsening bloody
diarrhea, rash, itching, yellowing eyes
or skin, dark urine, fever, fatigue, head
ache. Azulfidine only: You notice intact
or partially intact tablets in your stool.
Avoid consumption of grapefruit and grapefruit juice;

these foods can increase the amount of corticosteroids
in your blood. Avoid exposure to people with chicken
pox or measles, and get your doctors permission
before having any vaccinations. If you have diabetes,
monitor your blood glucose levels more closely; corticosteroids can cause your blood glucose levels to rise.
Do not stop taking abruptly; to go off the drug, you
need to slowly decrease the dose over time to prevent
extreme fatigue, weakness, stomach upset or dizziness. Corticosteroids can increase your risk of osteoporosis; be sure to get 1,200-1,500 mg of calcium and
400-800 IU of vitamin D a day, and have your bone
density measured on a regular basis.
Headache, nausea,
stomach upset, dizziness, trouble sleeping,
weight gain.
You exhibit signs of high steroid levels

in your body: swelling of your face and
neck, acne, bruising. You have signs of
infection: fever, fatigue, cough, flu-like
symptoms.
* These dosages represent the usual daily dosages (unless indicated otherwise) for the treatment of Crohns disease or ulcerative colitis. The precise
effective dosage varies from person to person and depends on many factors. Do not make any changes to your medication without consulting your doctor.
continued on the next page
59
Drug Therapy for Crohns Disease and Ulcerative Colitis 2015 (continued)
Drug type:
Brand (generic)
Typical daily
dosages*
How to take
Immunomodulators
Oral
Imuran (azathioprine)
50-150 mg
One or more 50 mg tablets 1-2x/day. Take

with food to reduce stomach upset.
Purinethol (mercaptopurine)
50-100 mg
One to two 50 mg tablets 1x/day.
Intramuscular injection
(methotrexate)
15-25 mg/week
Visit your doctor 1x/week for an injection.
Cipro (ciprofloxacin)
1,000 mg
One 500 mg tablet with or without food in the

morning and evening.
Flagyl (metronidazole)
1,000-2,000 mg
One or two 500 mg tablets 2x/day in the

morning and evening with food or a glass of
water or milk to reduce stomach upset.
Cimzia (certolizumab pegol)
400 mg every 2
weeks for first 3
doses, then every
4 weeks
You will go to your doctor to receive an

injection.
Humira (adalimumab)
40 mg every 2
weeks
You inject the medication under your skin via a

single-use injection pen once every 2 weeks.
Remicade (infliximab)
5 mg every 8
weeks
You will go to your doctor every 8 weeks to

receive the medication through a needle in a
vein in your arm. This takes about 2 hours.
Tysabri (natalizumab)
300 mg every 4
weeks
You will go to an infusion center every 4

weeks to receive the medication through a
needle in a vein in your arm. This takes about
1 hour.
Antibiotics
Monoclonal antibodies
* These dosages represent the usual daily dosages (unless indicated otherwise) for the treatment of Crohns disease or ulcerative colitis. The precise
effective dosage varies from person to person and depends on many factors. Do not make any changes to your medication without consulting your doctor.
and the rectum, you may receive hydrocortisone (Colocort) or

mesalamine (Rowasa) enemas in addition to the treatments just
mentioned.
If Crohns disease does not improve with corticosteroids and
mesalamine or sulfasalazine, immunosuppressive medications may
be tried. The most commonly used are mercaptopurine(Purinethol)
60
Precautions
Most common
side effects
You should have a blood test called a complete blood

count at least once a month to check for bone marrow
suppression. Methotrexate only: Avoid alcohol, because
it can cause dizziness. You will also be more sensitive
to the sun, so wear sunscreen and avoid excessive sun
exposure and sun lamps.
Nausea, vomiting,
diarrhea, loss of appetite, stomach pain,
drowsiness, dizziness.
You experience unusual bleeding or

bruising or signs of infection: fever,
fatigue, cough, flu-like symptoms.
Drink plenty of liquids. Consumption of dairy products

(milk, yogurt or calcium-fortified juice) greatly reduces
absorption. Can cause sun sensitivity; use sunscreen
and avoid excessive sunlight or sun lamps.
Stomach upset, loss of

appetite, diarrhea, nausea, headache, vision
changes, dizziness.
You experience a rash or signs of

peripheral neuropathy: pain, burning,
tingling, numbness, weakness in your
hands or feet.
Alcohol should be avoided for at least 1 day afterward;

the drug slows the breakdown of alcohol, which can lead
to nausea and vomiting. Can cause sun sensitivity; use
sunscreen and avoid excessive sunlight or sun lamps.
Diarrhea, nausea,
metallic taste in the
mouth, darkened urine
(which is harmless).
You experience unsteadiness, seizures,

mental or mood changes, numbness
or tingling of your hands or feet, painful
urination.
Before administering, your doctor will do a skin test to

see if you have been exposed to tuberculosis (TB). If
the test is positive, you will receive treatment for TB,
because these medications can activate a latent (silent)
TB infection. Patients should also be tested for hepatitis
B before beginning therapy. Tysabri increases the risk
of progressive multifocal leukoencephalopathy, a serious brain infection. To receive this drug, you must be
enrolled in a program that tracks safety information.
Headache; nausea,
vomiting or stomach
pain; redness, itching,
pain or swelling at the
injection site.
You experience signs of an infection:

fever, fatigue, cough, flu-like symptoms.
Signs of new or worsening heart failure:
shortness of breath, swelling of the ankles
or feet. Signs of a blood disorder: persistent fever, bruising, bleeding, paleness.
Humira and Cimzia: Signs of lymphoma
(unusual lumps or growths, swollen
glands).
and azathioprine (Imuran), both given orally. The immunosuppres

sant infliximab (Remicade) is especially effective when fistulas are
present. It is injected about once every two months and is usually
tried only when you do not respond to conventional therapy. However, serious complications have been reported in people using
Remicade, a drug that comes with an increased risk of infections and
61
hypersensitivity reactions. In addition, because Remicade can allow

latent (silent) tuberculosis to develop into full-blown tuberculosis,
you should receive a tuberculin skin test before beginning therapy.
Adalimumab (Humira) is also available for the treatment of
moderately to severely active Crohns disease. Humira is also an
immunosuppressant, but it does not require intravenous injectionthe drug is packaged in an injection pen that can be selfadministered once every two weeks. Humira is intended for people
who cannot tolerate Remicade or who become resistant to it over
time. Like Remicade, Humira carries a risk of infection, and it may
increase your risk of lymphoma and leukemia.
Two newer immunosuppressants to treat Crohns disease,
natalizumab (Tysabri) and certolizumab pegol (Cimzia), are
similar to Remicade and Humira. They are administered by injection at your doctors office. The first three injections are given
two weeks apart; if the medication appears to be helping, youll
receive additional doses every four weeks. Tysabri is a multiple
sclerosis drug that has a risk of severe side effects, including a serious and potentially deadly brain infection called progressive multifocal leukoencephalopathy (PML).
Surgical removal of a section of the bowel is required if you
develop problems such as intestinal obstruction due to serious
strictures or complications like fistulas or abscesses that wont
heal. In this procedure, the affected portion of the small or large
intestine is removed and the two ends are reattached. This is not
a cure for Crohns disease, since the remaining bowel is still susceptible to the disease.
Ulcerative Colitis
Ulcerative colitis is a chronic inflammatory disease of the large
intestine caused by an abnormal autoimmune reaction. It affects
about 700,000 Americans and usually surfaces between ages 15 and
40. The inflammation starts in the rectum and gradually progresses
to the sigmoid, descending, transverse and ascending colon and,
eventually, the cecum. The inflammation does not extend beyond
the colon to affect the small intestine.
Causes of ulcerative colitis

The cause of ulcerative colitis is unknown, but some people appear
to have a genetic predisposition. Like Crohns disease, ulcerative colitis is hypothesized to be activated by an environmental factor, such as
an infection or food allergy, which triggers an abnormal response by
62
the immune system. The disease is more common in Caucasians and

people of eastern and central European (Ashkenazi) Jewish descent.
Symptoms of ulcerative colitis

Active ulcerative colitis usually causes abdominal pain and bloody,
mucusy diarrhea. Severe attacks may also produce nausea, vomiting
and fever. Like Crohns disease, ulcerative colitis cycles between flareups and remissions.
Diagnosis of ulcerative colitis
The best diagnostic tests for ulcerative colitis are sigmoidoscopy
and colonoscopy. The disease is diagnosed when the inner lining
of the colon appears swollen and red and contains erosions and
ulcerations. Biopsies of the affected areas may be done to distinguish ulcerative colitis from other conditions affecting the colon,
for example, cancer, infections, ischemia (reduced blood flow) or
Crohns disease. Blood tests, stool samples and additional scans such
as barium enemas or CT scans may be used.
Treatment of ulcerative colitis
The medications used to treat ulcerative colitis are similar to those
for Crohns disease (see the chart on pages 58-61). If you have mild
disease limited to the rectum and sigmoid colon, corticosteroid- or
mesalamine-containing enemas may help to control flare-ups. If this
therapy fails, you may need to take oral drugs such as Azulfidine, balsalazide (Colazal), olsalazine (Dipentum) or Pentasa.
If you have extensive ulcerative colitismeaning that it affects
most of the colonyou may need intravenous or oral corticosteroids and oral mesalamine to treat a flare-up, followed by maintenance therapy with mesalamine to prevent future flare-ups. Severe
cases may also require immunosuppressive drugs such as Purinethol
or Imuran or a tumor necrosis factor (TNF) inhibitor like Humira
or Remicade to keep the disease under control. If there is a stressrelated component to the disease, stress reduction techniques like
hypnosis may be helpful.
Surgical removal of the entire colon (called a colectomy) may be
necessary if you have severe flare-ups that do not respond to cortico
steroids and mesalamine, complications such as a perforation, colon
cancer or symptoms that significantly impair your quality of life.
Between 25 and 40 percent of people with ulcerative colitis will eventually have their colons removed. Surgery can be performed either in
the traditional manner (open) or through laparoscopy.
63
latest research
Vitamin D Deficiency Puts
IBD Patients at Risk
People with inflammatory
bowel disease (IBD) tend to
have subpar vitamin D levels,
which may put them at risk for
colorectal cancer. They also
tend to be more vulnerable to
melanoma, a dangerous skin
cancer strongly associated with
sun exposure, one of the main
sources of vitamin D.
About a third of people with
IBD have deficient vitamin D
levels, which is associated with
IBD-related hospitalization and
surgery. Some studies of the
general population have suggested that vitamin D deficiency
is also associated with cancer.
New research specifically involving people with IBD found an
increased risk of cancer in those
with low vitamin D levels, but
their risk of colon cancer fell as
their vitamin D levels rose.
Since the human body does
not produce vitamin D, we need
to get it from external sources,
such as sun exposure. It takes
only about 10 to 15 minutes
of direct, midday summer sun
exposure to boost vitamin D
stores, but sun exposure is associated with all forms of skin cancer. People with IBD are known
to be at risk for non-melanoma
skin cancers; a recent study suggests they are also more likely to
develop melanoma.
If you have IBD, talk with your
doctor about ways to achieve
beneficial vitamin D levels without
too much sun exposure, and be
sure to get screened regularly for
skin cancer.
CLINICAL GASTROENTEROLOGY AND
HEPATOLOGY
Volume 12, pages 210 and 821

May 2014
After a colectomy, an opening called an ileostomy is made in

the skin to allow fecal material to pass directly from the small intestine into an external plastic bag. Most people with an ileost omy lead
normal, active lives and engage in the same job and recreational
activities they did before the surgery. As an alternative, a surgeon
may perform an ileoanal anastomosis, which preserves a part of the
anus and allows you to have normal bowel movements (although
they may be more frequent and watery). Ulcerative colitis predisposes individuals to colon cancer and requires surveillance colonoscopy to look for dysplasia (abnormal cells that can become cancer).
When dysplasia is identified, colectomy is required.
Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is one of the most commonand
frequently misunderstooddigestive disorders. One in five adults in
the United States has symptoms of IBS, yet only a small number of
people with symptoms seek treatment.
The good news is that: 1) IBS can often be effectively managed
once an accurate diagnosis is madealthough you will require a number of tests to rule out other diseases; and 2) it appears that the disorder does not cause long-term damage to the digestive tract or lead to
serious complications.
Causes of irritable bowel syndrome

The cause of IBS is not well understood. Some researchers have proposed that IBS may result from malfunctions in the rhythmic muscle
contractions that propel food through the small and large intestines.
Contractions that are too strong can push food contents through the
intestines too quickly, causing diarrhea and bloating; weak contractions can lead to constipation.
Because women develop IBS two to three times more often
than men, some experts hypothesize that symptoms may be related to hormone levels. Other proposed causes include hypersensitivity to pressure in the small and large intestines, an imbalance in
neurotransmitters (chemicals found in both the brain and digestive tract) and infection. A number of studies have associated IBS
with an overgrowth of intestinal bacteria (also see IBS: Is Your
Diet to Blame? on pages 68-69).
Psychological factors may also play a role. IBS and mental stress
appear to be closely related, and people with depression or anxiety
tend to be more susceptible to IBS. Studies also show an increased
risk of IBS in women who have been physically or sexually abused.
64
Symptoms of irritable bowel syndrome

The symptoms of IBS usually first appear during the teenage years or
young adulthood, although the condition can develop at any time,
even in older adults. One of the most common symptoms is abdominal
discomfort or pain, accompanied by diarrhea, constipation or alternating bouts of constipation and diarrhea. Other symptoms include
abdominal bloating, a feeling of incomplete emptying of the bowels
after passing stool, and mucus in the stool.
If you have IBS, you may find the symptoms distressing and disruptive to your life. The severity of symptoms varies: Most people
experience mild symptoms, although they can become more severe
and even disabling at times. Some women report that IBS symptoms
are worse before and during their menstrual periods. The symptoms may even awaken some people in the middle of the night.
Diagnosis of irritable bowel syndrome
IBS is difficult to diagnose because the disease causes no known
physical abnormalities that doctors can identify through physical
exams, imaging studies or lab testing. And because the symptoms of
IBS overlap with so many other digestive disorders, people with the
syndrome are sometimes misdiagnosed. IBS can easily be confused
with diverticulitis, colon cancer, intestinal obstruction, ulcerative
colitis, Crohns disease, gastrointestinal infection, celiac disease and
lactose intolerance.
Because IBS is more commonly diagnosed in those under age
50, older adults need to first determine that another disease more
common in the elderly isnt causing their symptoms. A doctor will
take a medical history, perform a physical exam and order blood
tests. Older individuals should have a colonoscopy or sigmoidoscopy to rule out the possibility of colorectal polyps or cancer and
colitis. You should also have a blood test for celiac disease if your
IBS symptoms involve mostly diarrhea or an alternating pattern of
diarrhea and constipation. Your doctor also may perform a breath
test for lactose intolerance if your symptoms seem to worsen when
eating dairy products.
Once your doctor determines that your abdominal pain is not due
to a physical abnormality, two of the following three criteria must be
met to make a diagnosis of IBS:
Bowel movements alleviate pain
Pain is accompanied by constipation or diarrhea
Pain is associated with a change in the form of the stool (watery,
loose or pelletlike)
65
These symptoms must be present, all of the time or occasionally, for at

least three months.
Treatment of irritable bowel syndrome

Once diagnosed, treatment of IBS focuses on relieving the most bothersome symptoms.
Constipation-predominant IBS. In 2012 the FDA approved
a new type of prescription medication for treating constipationpredominant IBS. In clinical trials, subjects taking a daily dose of
the drug, called linaclotide (Linzess), had more frequent spontaneous bowel movements and less abdominal pain than subjects taking
a placebo. Linaclotide causes elevated concentrations of an enzyme,
guanylate cyclase-C, to form in the intestine, which is thought to
speed up gastrointestinal transit as well as decrease the activity of
pain-sensing nerves. Linzess is taken once a day at least 30 minutes
before eating. The most common side effect reported during clinical trials was diarrhea. The drug should not be used in patients 17
years of age or younger.
Another medication available for individuals with constipationpredominant IBS is the prescription laxative lubiprostone (Amitiza).
Approved in 2008, this selective C-2 chloride-channel activator initiates chloride secretion into the intestine, which helps promote bowel
movements. Amitiza is taken twice a day; common side effects include
nausea, diarrhea and headaches.
Selective serotonin reuptake inhibitors (SSRI) antidepressants like
fluoxetine (Prozac) can improve abdominal pain and other symptoms
of constipation-predominant IBS. SSRIs are thought to increase food
transit speed through the gastrointestinal tract.
Another prescription medication that was approved for women
with constipation-predominant IBS, tegaserod (Zelnorm), was taken
off the market in 2007 due to serious cardiovascular side effects and is
now available only in emergency situations.
Diarrhea-predominant IBS. The over-the-counter antidiarrheal
medication loperamide (Imodium) is an effective treatment, helping
to reduce stool frequency and improve consistency. However, it does
not have any effect on abdominal pain or bloating.
Low-dose tricyclic antidepressants (TCAs) such as desipramine
(Norpramin) reduce pain and symptoms of diarrhea-predominant
IBS by slowing food transit speed through the gastrointestinal tract.
The prescription medication alosetron (Lotronex) has been
shown to relieve symptoms in women with diarrhea-predominant IBS
but poses a risk of serious side effects, including severe constipation
66
and reduced blood flow to the colon. It is available only through a special prescribing program to women with severe diarrhea-predominant
IBS when more traditional treatments have failed.
Constipation-/diarrhea-predominant IBS. The latest research
also shows that psychological therapies including cognitive behavioral therapy, dynamic psychotherapy and hypnotherapy can provide some relief from IBS symptoms, whether they be constipationpredominant or diarrhea-predominant. Mindfulness traininga
form of meditation characterized by the nonjudgmental observation of thoughts, feelings and sensationsmay reduce symptom
severity and improve the quality of life in people with IBS.
Hemorrhoids
Hemorrhoidsclusters of swollen veins in and around the anus
and rectumare a common condition. More than half of all Americans develop hemorrhoids by age 50, and men and women are at
equal risk. In fact, the condition is so ubiquitous that hemorrhoid
sufferers have their own patron saint, St. Fiacre. Hemorrhoids are
thought to result from increased pressure on the veins in the anus
or rectum, for example, by straining to move the bowels. Hemorrhoids usually can be managed with lifestyle and self-care measures,
but surgical removal is required in some cases.
There are two types of hemorrhoids: internal and external. Internal hemorrhoids are located in the lower portion of the rectum and
cannot be seen from outside the rectum. External hemorrhoids are
visible beneath the skin around the anus.
Causes of hemorrhoids
A number of factors increase the risk of hemorrhoids or can make
them worse. For example, they are more common with age, peaking at around age 65. Hemorrhoids are also associated with obesity, pregnancy and childbirth, liver disease, prostate enlargement,
chronic cough and diarrheaall of which can increase pressure
on veins in the anus and rectum.
Contrary to popular belief, heavy lifting, long periods of sitting,
and chronic constipation do not lead to hemorrhoids, although
these factors can irritate existing hemorrhoids. Excessive rubbing or
cleaning of the anal area also can irritate an existing condition.
Symptoms of hemorrhoids
The most common symptom of internal hemorrhoids is bleeding during a bowel movement. Such bleeding ranges in severity from blood
67
IBS: Is Your Diet to Blame?

Studies are examining the effects of certain foods on bowel health
If you have irritable bowel syndrome (IBS), you may wonder if its
symptoms are triggered by what
youre eating and drinking. Studies
have found that many people avoid
certain foods in order to control
their IBS symptoms, yet the impact
of diet on IBS has remained poorly
understood.
In recent years, however, a
number of trials have investigated
the idea that a specific cluster of
carbohydrates may trigger IBS
symptomsand that patients
who avoid foods containing these
carbohydrates may be able to get
their symptoms under control.
The carbohydratesfermentable
oligosaccharides, disaccharides,
monosaccharides and polyols, collectively referred to as FODMAPs
are found in a wide variety of plantbased foods. So far, findings from
the trials have indeed supported
the FODMAPIBS connection, and
the concept of a low-FODMAP diet
is rapidly gaining ground.
What the science says
In the most recent high-quality
study to add to this momentum,
published in Gastroenterology
in 2014, a group of Australian
researchers randomly assigned 30
people with IBS, along with eight
healthy individuals as a control
group, to either a low-FODMAP
diet or a typical Australian diet with
a moderate intake of FODMAPs.
After 21 days on their assigned
diets, all participants resumed
their original diet long enough for
any IBS symptoms to fully return,
which took at least three weeks.
Participants then crossed over to
the alternate assigned diet (that is,
those assigned to the low-FODMAP diet first would follow the typical Australian diet in this phase).
The difference between the
effects of the two diets was striking: Most participants with IBS who
were assigned to the low-FODMAP
diet experienced a 50 percent
reduction in symptoms such as
bloating, abdominal pain and flatulence. The relief from symptoms
peaked about seven days after
they started the diet and remained
stable. Those on the Australian diet
experienced an increase in IBS
symptoms. (In the healthy control
group, symptom scores were low
and did not change during either
diet period.)
The researchers concluded that
their study further supports the
theory that a diet low in FODMAPs
helps most patients with IBS and
should be used as a first-line treatment for IBS.
FODMAPs explained
FODMAPs comprise a collection of short-chain carbohydrates
that are poorly absorbed and
rapidly fermented, including fructose, lactose, polyols, fructans,
and galacto-oligosaccharides. In
healthy people, the malabsorption
and fermentation of FODMAPs is
important for maintaining gut flora
and bowel health. People with IBS,
however, whose gut flora is altered,
appear to be hypersensitive to the
effects of FODMAPs in the small
intestine, which results in uncomfortable symptoms.
Fructose, a simple sugar often
occurring in combination with
glucose, is found in fruits, fruit
juices and some vegetables, and in
68
sweeteners such as high fructose

corn syrup and honey. Fructose is
absorbed in two different ways. If
its in food containing glucose as
well, the glucose helps propel the
fructose across the small intestine
barrier. When there is more fructose than glucose, or no glucose, a
different mode of absorption goes
into effect, but some people dont
absorb fructose very effectively
by this pathway. About a third of
healthy individuals and about 45
percent of people with functional
gastrointestinal disorders experience fructose malabsorption.
Lactose, comprising two sugars,
is found in milk and other dairy
products. It is poorly absorbed by
people deficient in the enzyme lactase, which includes about threequarters of the worlds population.
Polyols are alcohol sugars, most
common in our diet as sorbitol
and mannitol. They occur naturally
in mushrooms and in some fruits
and vegetables, and show up as
sweeteners in low-calorie or lowsugar candies and chewing gum.
Polyols are a slow-absorbing carbohydrate, and most people can
only absorb about one-third of the
amount they actually consume.
Oligosaccharides are carbohydrates made up of three to 10 simple sugars, including fructans and
galacto-oligosaccharides. They
occur naturally in many plant foods
and grains, and are also used as
sugar and fat substitutes and texture enhancers in some processed
foods. Humans do not produce the
enzyme that helps break down oligosaccharides, so they are poorly
absorbed in general.
You may not have IBS and still
struggle with any of these carbohydrates. They are osmotic,

pulling liquid into the bowel, and
highly fermentable, producing
gas. In anyone, this combination
of fluid and gas may distend the
gut and trigger diarrhea or constipation; with IBS, your bodys
reaction is more extreme. Your
gut bacteria may produce a
greater volume of gas and your
gut motility may be more severely
affected, making you more prone
to diarrhea or constipation.
Restrictions abound
As promising as the low-FODMAP
diet may be for IBS sufferers, it
is not on the radar of everyone

who treats them. Nutrition is its
own separate specialty, and while
some gastroenterologists have
the time and knowledge to guide
IBS patients in diet management,
others will need to refer you to
someone with expertise in that
area. Dont hesitate to askyou
may need a little help. The lowFODMAP diet is quite restrictive.
Eliminating wheat and most dairy
alone is difficult for most people,
but the low-FODMAP diet crosses
off an abundance of common and
popular fruits and vegetables as
well. The list of foods to avoid or
eat included in the chart below is
just a beginning; a nutritionist or

dietitian can help you further identify safe foods and map out a plan
of daily meals and snacks.
You may need guidance in
deciding how restrictive your diet
needs to be (low-FODMAP versus
no-FODMAP) and how long you
will need to follow it. One recommended approach is to follow a
fairly strict low-FODMAP diet for
several weeks, and then reintroduce FODMAPs gradually while
assessing tolerance. Ultimately
youll want to establish a diet that
allows for the greatest variety and
flexibility while still keeping your
symptoms in check. n
A Low-FODMAPs Diet
Food types
Avoid
Eat
Fruit
apple, apricot, avocado, blackberries,

mango, nectarine, peach, pear, plum, watermelon; keep dried fruit to a minimum
banana, blueberries, cantaloupe, citrus (orange, lemon, lime, grapefruit), grapes, honeydew melon, kiwi, rhubarb, strawberries
Vegetables
artichoke, asparagus, bell pepper, cruciferous vegetables (cabbage, broccoli, cauliflower, Brussels sprouts), fennel, garlic,
leeks, mushroom, all types of onion, sweet
corn
bok choy, carrot, celery, eggplant, endive,

ginger, green beans, lettuce, olives, potato,
spinach, sweet potato, tomato, zucchini;
herbs such as basil, mint, oregano, parsley,
rosemary, thyme
Grains and
legumes
wheat and rye, baked beans, chickpeas,

kidney beans, lentils
rice, oats, polenta, millet, quinoa, sorghum
Dairy
all forms of animal milk (cow, sheep, goat),

ice cream, yogurt, soft cheeses, unripened
cheeses (cottage cheese, ricotta)
lactose-free milk and yogurt, milk derived

from soy, oat or rice; hard cheeses
Sweeteners
anything ending in ol (sorbitol, mannitol),

isomalt, honey
sugar, maple syrup, molasses
NOTE: Many condimentsincluding ketchup, salad dressing and barbecue saucescontain wheat, corn syrup and other FODMAPs,
so read labels carefully.
Meat and eggs can be eaten; these are considered proteins, not carbohydrates.
Garlic-infused olive oil and scallions (the green part only) can help replace garlic and onions.
69
on the toilet paper or on the outside of stools to blood in the toilet

bowl. Because the membranes inside the rectum lack pain-sensitive
nerves, internal hemorrhoids typically cause no pain or discomfort.
However, you may experience a sensation of fullness in the rectum after a bowel movement. Internal hemorrhoids may also prolapsemeaning that the hemorrhoid protrudes outside of the anus.
Prolapse can occur after straining during a bowel movement.
Unlike internal hemorrhoids, external hemorrhoids frequently cause irritation and pain, usually lasting no more than 10 days.
Acute pain and inflammation can occur when a blood clot in an
external hemorrhoid forms a hard lump near the anus. Mucus
draining from an external hemorrhoid can cause mild itching.
See your doctor if you suspect that you have hemorrhoids and
if the condition causes pain or frequent rectal bleeding.
Diagnosis of hemorrhoids
Doctors diagnose hemorrhoids by first asking about any changes
in your bowel patterns and about any symptoms of pain, bleeding
or itching. The doctor may then perform an external inspection
of the anus, a digital rectal exam (placing a gloved finger into the
rectum to feel for hemorrhoids) and an anoscopy (an examination of the anus and lower rectum using a device called an anoscope, a short, rigid, hollow tube with a light source). Sigmoidoscopy (to view the rectum and lower colon) or colonoscopy (to
view the entire colon) may be performed to see if the bleeding is
originating from a source other than the hemorrhoids.
Treatment of hemorrhoids
If you have mild symptoms, lifestyle and self-care measures are frequently effective. To treat constipation that can exacerbate symptoms, you should increase your fiber and fluid intake to make stools
bulkier, softer and easier to pass. Also, you should not ignore the
urge to have a bowel movement and should try not to strain when
passing stool. Regular physical activity also may be helpful.
To avoid irritation of hemorrhoids, do not rub your anus too
much with toilet paper after a bowel movement. Instead, try wiping gently with wet toilet paper or moist towelettes. Also, avoid sitting on the toilet for long periods.
Although research has not shown that over-the-counter suppositories, ointments or hydrocortisone creams are effective for treating
hemorrhoids, many people report that they are beneficial. You may
also get relief from pads containing witch hazel or a numbing agent.
70
To reduce irritation, try to keep the anal area clean. Avoid

using soap, because it can be an irritant. Soaking in a warm bath
or using a sitz water bath (a plastic basin of warm water that fits
over the toilet) three to four times a day for 10 minutes at a time
may be helpful. Afterwards, dry the anal area with a hair dryer
to reduce moisture that can cause irritation. Applying cold compresses or ice packs to the anal area up to four times a day can
reduce swelling.
If these conservative measures do not provide sufficient symptom relief, there are additional treatments for hemorrhoids. Rubber band ligation is the most common treatment for internal
hemorrhoids. A small rubber band is placed at the base of the
hemorrhoid to cut off its blood supply. After about a week, the
hemorrhoid withers and falls off. This technique works about
three-quarters of the time.
Sometimes, a chemical solution is injected into the hemorrhoid to shrink ita procedure called sclerother
apy. Other
options for internal hemorrhoids use freezing, electrical or laser
heat, or infrared light to destroy hemorrhoids. In addition, a procedure called hemorrhoid stapling, or hemorrhoidopexy, uses
a device to staple and cut out internal hemorrhoids (it is not as
effective for external ones). Most internal hemorrhoids can be
treated effectively with one or more of these techniques.
A small percentage of people with internal hemorrhoids are
not helped by the above therapies and need surgery to remove the
hemorrhoids. This procedure, called a hemorrhoidectomy,
requires a one- to two-day hospital stay and is the best way to
ensure permanent removal of internal hemorrhoids.
For external hemorrhoids, oral pain relievers such as acetamin
ophen (Tylenol) or aspirin can provide some relief. However, if
a hemorrhoid forms into a hard lump due to a blood clot and
severe pain lasts longer than seven to 10 days, surgical removal of
the clotted hemorrhoid often provides relief from symptoms.
Anal Fissure
An anal fissure is a tear in the skin that lines the anal canal, the
part of the rectum closest to the anus. Most experts believe that
anal fissures are caused by passing hard stool, which can tear the
skin of the anal canal and cause pain and bleeding. Anal fissures
are a common problem that affects most people at some point in
their life. Many anal fissures heal on their own, but medication or
surgery is needed if they become a chronic problem.
71
Causes of anal fissure

Although constipation is a common cause of anal fissures, other
causes include diarrhea, childbirth, colonoscopy or sigmoidoscopy, and surgery. A high resting anal pressure (tight anus) also
appears to be a factor. Tightness, or spasm, within the anus also
interferes with blood supply to the anal canal, which may prevent
healing of a tear. Furthermore, an anal fissure may be a sign of a
more serious condition, such as syphilis, herpes, gonorrhea, chlamydia, HIV infection or AIDS, Crohns disease, ulcerative colitis,
tuberculosis or a tumor.
Symptoms of anal fissure
The hallmark of anal fissures is pain, sometimes severe, during or
after a bowel movement. The pain may be brief or continue for
hours afterwards. Bleeding frequently accompanies the bowel movement, and the blood appears on the outside of the stool. About half
of individuals with anal fissures also experience anal itching.
Anal fissures are frequently confused with hemorrhoids, but
hemorrhoids usually do not cause pain while passing stool. None
theless, you can have both hemorrhoids and an anal fissure.
Diagnosis of anal fissure
To diagnose anal fissures, the doctor spreads apart your buttocks
to view the anus. The fissure appears as a tear, most often in the
middle of the anus toward the back of the body. While an anal fissure is usually easy to see, your doctor may use an instrument called
an anoscope to view the inside of the anal canal.
Treatment of anal fissure
More than 80 percent of anal fissures heal on their own or with
simple treatments such as eating a high-fiber diet, in
creasing
your intake of water and other fluids, using stool-softening laxatives, and taking warm sitz baths for 10 to 15 minutes following
each bowel movement. Topical corticosteroids and anesthetics
are not effective.
If an anal fissure does not heal after six weeks of the simple
treatments described above, you have a chronic anal fissure. This
usually requires additional treatment, the most common of which
is nitroglycerin ointment. A pea-sized amount of the ointment is
placed on the fissure two to three times a day for up to eight weeks.
This treatment heals between 70 and 80 percent of chronic anal fissures. The most common side effect of the ointment is headaches,
72
which can be severe, although pain relievers such as acetaminophen (Tylenol) and aspirin may relieve the pain.
Other medications used for anal fissures are calcium-channel
blockers, commonly used to treat high blood pressure and chest
pain. The oral calcium-channel blocker nifedipine (Procardia and
other brands) heals 60 percent of chronic anal fissures when used
for eight weeks. Nifedipine may work by decreasing anal pressure.
Another calcium-channel blocker, diltiazem (Cardizem), which is
available in oral and cream forms, also appears to be beneficial
for the treatment of chronic anal fissures. Common side effects
include headache and swelling of the feet and ankles.
Low doses of botulinum toxin A (Botox), a paralyzing agent,
also can be used to treat anal fissures. Studies show that a single
injection can heal up to 80 percent of chronic anal fissures, possibly by lowering anal pressure. Although it has a high success
rate, some people find the injections painful. Rare complications
include bleeding, blood clots under the skin around the anus, loss
of bowel control and sepsis (a bacterial infection of the blood).
If a chronic anal fissure does not heal with medications, sur
gery may be necessary. Sphincterotomy, which involves cutting
part of the muscle in the anal canal, is the surgery of choice. It
helps heal about 98 percent of anal fissures. Sphincterotomy
decreases the spasms and pressure in the anal canal and is a good
option for people with chronic anal fissures and a high resting
anal pressure.
Another surgical treatment, anal dilation or a four-fingered
anal stretch, heals 40 to 90 percent of chronic anal fissures. In this
procedure, the physician uses four fingers to hold the anus open
for four minutes to reduce spasms and pressure in the anal canal.
However, almost 40 percent of people who undergo anal dilation
have difficulty controlling flatulence or soil themselves occasionally; some 16 percent experience loss of bowel control.
Fecal Incontinence
Fecal incontinence (the involuntary loss of bowel control) affects
nearly 18 million Americans. Although it is a relatively common
problem in older adults, it is not a normal part of aging. The inability to control your bowels can lead to embarrassment and cause you
to avoid social situations, but fecal incontinence is often treatable
with medication, lifestyle measures or surgical repair of the damaged sphincter muscles. In addition, some people can benefit from
an implanted device called an artificial sphincter.
73
Causes of fecal incontinence

Fecal incontinence is not a disease but a symptom of another gastrointestinal problem. The most common causes are:
Damage to the sphincter muscles in the anus (usually due to
hemorrhoid surgery or childbirth). These muscles normally
contract to prevent stool from leaving the rectum.
Damage to nerves in the anal sphincter muscles or rectum
(due to chronic constipation, stroke, diabetes, multiple sclerosis or childbirth). Nerve damage in the sphincter muscles
leads to a loss of proper functioning of the muscles, while
nerve damage in the rectum leads to loss of sensation in that
area, so that you no longer recognize that stool is present.
Loss of storage capacity in the rectum (due to rectal surgery,
radiation therapy for cancer or inflammatory bowel disease).
Normally, the rectum stretches to hold stool until you reach
the toilet; with loss of elasticity, an accident is much more
likely.
Diarrhea. Loose, watery stools are much harder to control
than solid stools.
Pelvic floor dysfunction (such as rectal prolapse, in which
the rectum sags). By supporting the organs in the pelvis and
lower abdomen, the muscles of the pelvic floor play a role in
preventing fecal incontinence.
Symptoms of fecal incontinence
The symptoms of fecal incontinence are easily recognizable, ranging from the occasional leakage of liquid or solid stool and gas to
the inability to hold a bowel movement until you reach the toilet.
Other possible symptoms include diarrhea and constipation.
Diagnosis of fecal incontinence
Because self-treatment of fecal incontinence is rarely successful,
you should see your doctor if you experience any of the symptoms
above. The doctor will take a medical history, do a thorough physical examination, and may order one or more diagnostic tests.
These tests could include anal manometry to measure the tightness of the anal sphincter, anorectal ultrasonography to examine
the structure of the anal sphincter, proctography/defecography
to determine how well the rectum holds and eliminates stool,
proctosigmoidoscopy to detect signs of diseases or other problems
inside the rectum and sigmoid colon, and anal electromyography
to test for nerve damage.
74
You should bring to your doctors appointment a list of all the

medications that you take. Some medications, such as sedatives,
antacids and muscle relaxants, can cause or increase the frequency of fecal incontinence, especially in older adults.
Treatment of fecal incontinence

Treatment depends on the cause and severity of fecal incontinence and may include dietary changes, bowel training, drugs or
surgery.
Dietary changes. Because it is difficult for the anal sphincter to
handle large amounts of waste material, changes in your diet may
be necessary to make the stool firmer and more compact. Foods
that thicken the stool include rice, bananas, yogurt and cheese.
Increasing fiber intaketo 21 g daily if youre a woman over age
50 and to 30 g daily if youre a man over age 50by consuming
more whole grains, fruits and vegetables also may help.
Alcohol and caffeine may cause diarrhea and should be eliminated. Some people are unable to digest lactose (a sugar found in
dairy products) or food additives and flavorings like sorbitol and
nutmeg. Because improper digestion of these substances could
contribute to diarrhea and fecal incontinence, they should be
avoided as well.
Bowel training. Some people with fecal incontinence need to
relearn how to control their bowels. One way to retrain the bowels
is through biofeedback, which uses a computer to monitor muscle
contractions as you learn exercises to strengthen the rectum and
pelvic muscles. Stronger muscles can help retain stool. If fecal incontinence is caused by constipation, your doctor may recommend
starting a routine of having a bowel movement at the same time
daily.
Medication. Drugs may be used if fecal incontinence is caused
by diarrhea. Imodium A-D is an anti-diarrheal medication that
thickens the stool and also increases the strength of the rectal
muscles. Other medications help treat fecal incontinence in other
ways, for example, by decreasing intestinal secretions, contracting the muscle that closes the rectum or slowing the movement of
stool through the bowel.
External incontinence devices. If youre unable to regain fecal
continence, you can wear an external device to collect any leaking stool. These prescription devices, available at medical supply stores and some pharmacies, typically consist of a drainable
pouch attached to an adhesive wafer. The hole in the center of the
75
wafer is placed over the rectum to allow stool to pass through.

These devices can remain in place for 24 hours, but they must be
changed if any stool leakage occurs.
Surgical repair. If fecal incontinence is caused by injury to
the pelvic floor, anal canal or anal sphincter, surgery may be
performed to repair the problem. For example, damaged muscles
in the anus may be replaced with muscle from the leg or arm.
Artificial sphincter. If your anal sphincter muscles are not
capable of holding in stool, an artificial anal sphincter can be
surgically implanted. This sphincter consists of a fluid-filled cuff
that surrounds the anal canal, a pressure-regulating balloon in
the anal canal, and a control pump located just under the skin.
Normally, the cuff is full of fluid, which squeezes the anal canal
closed. When you need to have a bowel movement, you squeeze
the pump several times; the fluid then drains from the cuff into
the balloon, and stool can pass through the open anal canal. After
the bowel movement, the cuff automatically refills with fluid from
the balloon.
Colostomy. Severe fecal incontinence that doesnt respond to
treatment may require a colostomy, in which the large intestine is
connected to the abdominal wall. Instead of entering the rectum,
stool goes directly from the intestine into a special bag on the outside of the body.
Colorectal Polyps
Colorectal polyps are small, noncancerous (benign) clumps of cells
that grow in the rectum and colon. Over the course of 10 to 15
years, some of these polypsusually the ones that are larger than
a peacan become cancerous. Fortunately, regular screening for
colorectal cancer helps to identify and remove polyps, often before
they progress to cancer. (See When to Have Your Next Colonoscopy on pages 44-45.)
Causes of colorectal polyps

It is not known why polyps develop, but some people are more
prone than others. For instance, the older you getespecially
after age 50the more likely you are to have them. Youre also
more likely to develop polyps if youve had them before or if
someone in your family has had polyps or cancer of the colon.
Behavior also influences your risk: Eating a lot of fatty foods,
smoking, drinking alcohol, not exercising and being overweight
can all contribute to polyp formation.
76
Symptoms of colorectal polyps

Most colorectal polyps dont cause any symptoms. You might not
know you have them until your doctor finds one or more during a
physical examination or colorectal cancer screening test.
However, some people notice rectal bleeding, constipation
or diarrhea that lasts longer than a week, or blood in their stool
(the stool looks black or contains red streaks). If you experience
symptoms like these, youll need to see your doctor.
Diagnosis of colorectal polyps
Colorectal polyps can be diagnosed by a digital rectal exam, bar
ium enema, sigmoidoscopy or colonoscopy (see pages 41-45).
Treatment of colorectal polyps
Polyps are removed during a sigmoidoscopy or colonoscopy, then tested to see if they are cancerous and if any further treatment is needed.
Colorectal Cancer
Colorectal cancercancer of the colon or rectumis diagnosed in
more than 135,000 people annually in the United States. Its the second most common cause of death due to cancer (for men and women
combined), killing more than 50,000 Americans each year. The good
news is that most colorectal cancers and deaths can be prevented.
Causes of colorectal cancer

Cancer occurs when a genetic mutation causes cells in the body
to reproduce in a rapid, disorderly and dangerous manner. The
precise cause of this mutation is unclear, but it appears to result
from a combination of individual and environmental risk factors.
Risk factors for colorectal cancer include:
Increasing age
Polyps in the colon or rectum or a history of these polyps,
especially an inherited condition called familial polyposis
Breast, endometrial or ovarian cancer
Ulcerative colitis or Crohns disease
Inherited syndromes such as hereditary non-polyposis colon
cancer (Lynch syndrome), Turcot syndrome or Peutz-Jeghers
syndrome
A close relative (mother, father or sibling) diagnosed with
colorectal cancer before age 60
Dietary factors, such as eating red and processed meats
Obesity and inactivity
77
latest research
More Support for
Dietary Fiber
The role of dietary fiber in helping to prevent the development
of colorectal adenomas, which
are the precursor to colorectal
cancer, has always been a bit
vague. A recent review of medical literature, however, suggests
that fiber does indeed have a
protective effect.
Theoretically, dietary fiber,
which may have a beneficial
influence on gut microbiota while
also increasing stool bulk and
decreasing stool transit time,
should have a protective effect.
To this end, its role has been
investigated intensively since the
1970s, but research findings have
been inconsistent.
To assess the relationship
between fiber intake and the risk
for colorectal adenomas, a group
of researchers in China recently
conducted a meta-analysis of 20
studies involving nearly 11,000
people with colorectal adenomas. They found an inverse relationshippeople who consumed
more fiber had lower risk than
those who consumed less.
The type of fiber consumed
seemed to matterthe inverse
association held up with fruit
and cereal fiber consumption,
but not with vegetable fiber
consumption. However, these
findings dont mean you should
stop eating vegetables, which
provide a number of nutrients.
The researchers noted that their
findings need to be validated by
further studies.
GASTROENTEROLOGY

March 2014
Smoking
Type 2 diabetes
Heavy alcohol use
African American or Eastern European Jewish ethnicity
Symptoms of colorectal cancer

Colorectal cancer often produces no symptoms in its early stages,
which is why screening is so important. However, any of the following
symptoms should prompt a visit to your doctor:
Frequent, unexplained abdominal pain or cramps
Blood in or on your stool or blood in the toilet or on your
underwear after passing stool
An increase or decrease in bowel movements
Alternating between frequent bowel movements and
constipation
Passing narrowed stools
Weakness and fatigue
A feeling of having to move your bowels when its not necessary
A temporary change in your bowel movements
Unexplained weight loss
Screening for colorectal cancer
Adults age 50 and over should be screened for colorectal cancer
to detect polyps before they become cancerous. (See When to
Have Your Next Colonoscopy on pages 44-45.) Screening methods
include:
Colonoscopy every 10 years
Flexible sigmoidoscopy every five years
Barium enema every five years
Virtual colonoscopy every five years
The following tests can also help detect cancer but not polyps:
Fecal occult blood test every year
Fecal immunochemical test every year
Stool DNA test (ideal interval not determined)
Besides regular screening, lifestyle measures may reduce colorectal
cancer risk. These include eating a diet low in animal fat and high
in fruits and vegetables, exercising regularly, maintaining a healthy
weight, not smoking and not drinking alcohol excessively.
Diagnosis of colorectal cancer
Fecal occult blood testing, barium enema, sigmoidoscopy and colon
oscopy are used to diagnose colorectal cancer. Because colorectal
78
cancer can cause intestinal bleeding, a blood test is used to check

for anemia (a low red blood cell count). Imaging tests such as ultrasound, CT scans, MRI, chest X-rays and angiography (an X-ray technique that uses an injected contrast material) may be used to visualize the intestines or to see if the cancer has spread. If cancer is
diagnosed, the stage of the cancer must be identified to determine
the best course of treatment. The cancer stage is based on how
large the tumor is and whether it has spread to the lymph nodes or
other parts of the body.
Treatment of colorectal cancer

Surgery is the most common colorectal cancer treatment, and it
can eliminate the cancer in about half of all cases. The surgery
involves removing part of the colon or rectum that contains the
cancer, some of the healthy tissue that surrounds it, and nearby
lymph nodes. Common side effects of surgery include diarrhea or
constipation, which usually improves on its own.
Other treatments for colorectal cancer include chemotherapy
and radiation therapy, which can be used alone, in combination
or with surgery. Chemotherapy delivers medication intravenously
to attack cancer cells throughout the body. It can be used after
surgery (to increase the odds that all cancer cells have been eliminated) or before surgery to help shrink a tumor. If colorectal cancer has spread, chemotherapy may be used to slow the progression
of the cancer and relieve symptoms (without the expectation of a
cure). Adverse effects may include nausea, vomiting, fatigue, diarrhea, mouth sores, hair loss and bone marrow suppression.
Radiation therapy involves directing X-rays at the cancer cells. It
is used only for rectal cancer. Unlike chemotherapy, which affects
the whole body, radiation therapy specifically targets cancer cells
while minimizing damage to healthy cells. As with chemotherapy,
it may be used before or after surgery, or for symptom relief when
cancer has spread and a cure is not possible. The radiation may be
delivered internally from implanted radioactive seeds or externally from an X-ray machine. Common adverse events include
fatigue, nausea, diarrhea, appetite loss, bloody stool and damage
to the skin and other organs near the radiation site. n
latest research
Bariatric Surgery: Will It
Prevent Cancer?
Obesity is associated with a
number of health issues, not the
least of which is cancer, which
tends to be not only more prevalent in people who are obese
(a body mass index, or BMI, of
30 and above) but also more
difficult to treat. New research
shows that bariatric surgery may
reduce the risk of cancer in morbidly obese patients (BMI of 40
and above), but how that happens is not yet known.
Bariatric surgery has been
shown to produce significant
long-term weight loss and
increase longevity. But its been
unclear whether the weight loss
resulting from bariatric surgery
has any influence on the development of cancer.
To investigate this question,
researchers culled data from 13
studies that included information on cancer diagnosed after a
bariatric procedure. The studies
included more than 54,000 participants who did or did not undergo
surgery. The incidence of cancer
turned out to be lower in patients
who had bariatric surgery.
The researchers were unable
to clarify whether this was due
to metabolic changes related to
weight loss. Also, the researchers noted that bariatric surgery
is often performed on younger
people, while the risk of cancer
increases with age. Despite the
limitations of this study, bariatric
surgery should be considered
when appropriate. That and other
treatments for obesity, including
lifestyle changes and medication,
offer many other health benefits.
OBESITY SURGERY
79
Published online
May 12, 2014
GLOSSARY
GLOSSARY
abscessA localized accumulation of pus resulting from

an infection.
achalasiaA disorder of the esophagus caused by the
inability of the lower esophageal sphincter to relax and
by abnormal esophageal contractions. Results in difficulty
swallowing.
acute cholecystitisInflammation of the gallbladder producing severe pain, fever, nausea and vomiting.
anal fissureA tear in the skin that lines the anal canal,
the part of the rectum closest to the anus.
anti-reflux barrierA mechanical impediment created by
the lower esophageal sphincter and the diaphragm that
prevents the contents of the stomach from entering the
esophagus.
anusThe opening at the end of the digestive tract
through which stool is expelled. It is controlled by two
sphincters and is only open during defecation.
autoimmune diseaseA health problem in which the
bodys immune system begins to attack its own tissues.
barium X-raySee upper GI series.
Barretts esophagusA disorder in which the cells that
normally line the inside of the esophagus are replaced by
more acid-resistant cells; associated with an increased risk
of esophageal cancer.
bileA substance synthesized by the liver, stored and
concentrated in the gallbladder, and released into the
duodenum to aid digestion and absorption of dietary fat.
bile ductsTubes that carry bile from the left and right
lobes of the liver to the gallbladder.
biliary colicIntermittent episodes of sharp pain in the
right upper portion of the abdomen that occur when gallstones block the flow of bile from the g
allbladder.
bilirubinA component of bile made by the liver. Pigment gallstones are primarily made up of bilirubin.
bowelThe lower digestive tract, which is about 25 feet
long and consists of the small and large intestines.
capsule endoscopyA noninvasive test that allows for
a full view of the small intestines, particularly the areas
that are usually unreachable with an upper endoscopy or
colonoscopy. You ingest a capsule that contains a video
camera, which takes pictures of the digestive tract and
transmits these images to a recording device.
cecumThe first part of the colon (large intestine).
celiac diseaseA disorder that occurs in people who
are sensitive to gluten, a component of wheat and other
grains. Can cause diarrhea, bloating, weight loss, a nemia
and vitamin deficiencies.
cholangitisInfection and inflammation of the bile
ducts.
cholecystectomySurgical removal of the gallbladder.
cirrhosisA disease that causes the liver to slowly deteriorate and eventually malfunction as a result of the replacement of healthy tissue with scar tissue. Typically caused by
alcohol abuse.
colectomySurgical removal of part or all of the colon.
colonThe part of the digestive tract that is connected
to the small intestine. The colon absorbs water and electrolytes such as potassium from undigested foods before
passing waste on to the rectum for release from the body.
Also called the large intestine.
colonoscopyA diagnostic procedure in which an endoscope is inserted through the anus and rectum to view the
colon and the final portion of the small intestine (terminal ileum).
colorectal cancerCancer of the colon or rectum. Often
preceded by the development of colorectal polyps.
common bile ductA tube that carries bile from the liver
and gallbladder to the small intestine.
constipationA common but typically benign condition
characterized by infrequent bowel movements and difficulty passing stool.
Crohns diseaseA chronic inflammatory disorder that
primarily affects the small intestine but can involve any
segment of the gastrointestinal tract.
cystic ductA tube that carries bile from the gallbladder
to the common bile duct.
diaphragmThe muscle that separates the chest from
the abdomen; its movements play an important role in
breathing.
diarrheaAn increase in the number of bowel movements and a decrease in the consistency of stools.
diffuse esophageal spasmProlonged and excessive contractions of the esophagus.
digital rectal examInsertion of a gloved finger into the
rectum to feel for polyps and other abnormalities.
diverticulitisA disorder in which small pouches in the
wall of the large intestine (diverticula) become inflamed
or infected.
diverticulosisThe development of small pouches (diverticula) that bulge outward through weak points in the
wall of the large intestine.
duodenal bulbThe portion of the duodenum that is
closest to the stomach.
duodenal ulcerA nonhealing defect or sore that occurs
in the lining of the duodenum.
duodenumThe first portion of the small intestine.
dysphagiaDifficulty swallowing food or liquids.
endoscopic dilationAn endoscopic procedure to treat
achalasia in which a balloon device is inserted into the
esophagus to expand the lower esophageal sphincter.
80
cavity. These parts of the gastrointestinal tract are normally located in the abdominal cavity.
H2-blockersDrugs that inhibit gastric acid secretion.
Also known as histamine H2-antagonists.
ileostomyA procedure that attaches the last part of the
small intestine (ileum) to an opening in the skin of the
abdomen so that fecal material can pass out of the body.
ileumThe last portion of the small intestine.
irritable bowel syndromeA common and frequently
misunderstood digestive disorder that affects more
women than men and can cause diarrhea, bloating or
constipation.
ischemiaA reduced supply of oxygen to any part of the
body due to the obstruction of blood flow.
jejunumThe middle section of the small intestine.
laparoscopic surgeryA minimally invasive surgery performed through small incisions in the abdomen using
specialized instruments and a tiny c amera.
large intestineThe part of the digestive tract that is connected to the small intestine. It absorbs water and electrolytes such as potassium from undigested foods before
passing waste on to the rectum for release from the body.
Also called the colon.
liverA large organ located on the upper-right side of
your torso, opposite your stomach and behind your rib
cage. Its main function is to make a substance called bile
that is needed to digest food in the small intestine.
lower esophageal sphincter (LES)A ring of muscle at
the lower end of the esophagus that contracts to prevent
the reflux of stomach contents into the esophagus.
main pancreatic ductA tube that carries digestive juices
from the pancreas to the duodenum.
major duodenal papillaA protuberance in the duodenum that contains openings for the common bile duct
and the main pancreatic duct.
metaplasiaA change in the cells in a tissue from a
normal to an abnormal state, as occurs in Barretts
esophagus.
mucosal protectantsDrugs that increase the resistance
of the inner lining of the digestive tract to damaging acid
from the stomach.
Nissen fundoplicationA surgical procedure for gastroesophageal reflux disease and hiatal hernia that involves
lifting a portion of the stomach and tightening it around
the gastroesophageal junction to increase lower esophageal sphincter pressure.
pancreasA long, thin gland that lies horizontally
behind the bottom part of the stomach and makes
digestive enzymes that flow through the pancreatic duct
to the small intestine. These enzymes, along with bile
from the gallbladder, break down food for use as energy.
81
GLOSSARY
endoscopic retrograde cholangiopancreatography

(ERCP)A diagnostic test that combines endoscopy with
X-rays to view the pancreatic ducts and bile ducts.
endoscopyA procedure that uses a thin, lighted viewing
tube to visually examine the interior of a hollow organ,
such as the esophagus, stomach, or small intestine.
esophageal manometryA diagnostic test for esophageal
disorders that measures lower esophageal sphincter pressure and evaluates esophageal contractions.
esophageal rings and websThin, fragile folds in the
inner lining of the esophagus that partially or completely
block the esophagus.
esophageal strictureA narrowing of the esophagus
caused by chronic inflammation and scar tissue.
esophageal ulcersNonhealing defects in the inner lining of the esophagus.
esophagusA muscular tube that is part of the upper
digestive system. Food moves from the mouth to the
throat and then to the esophagus.
fecal incontinenceThe involuntary loss of bowel control; a relatively common problem in older adults.
fistulaAn abnormal channel or connection in the
body caused by disease. May develop between different
segments of the digestive tract, or between the digestive
tract and other organs, usually the bladder, vagina or
skin.
gallbladderA pear-shaped sac located under the liver
that stores bile. Plays an important role in the digestion
and absorption of dietary fat.
gallstonesSmall pebbles that form in the gallbladder
and cause pain. Most gallstones are made of cholesterol,
but some are made of bilirubin (a component of bile
made by the liver).
gastritisAn inflammation of the inner lining of the
stomach.
gastroesophageal junctionThe place where the esophagus meets the stomach.
gastroesophageal reflux disease (GERD)A backflow of
the stomachs contents into the esophagus that leads to
heartburn and indigestion.
Heller myotomyA surgical procedure for the treatment
of achalasia in which an incision is made through the
muscle of the lower esophageal sphincter to weaken it.
hemorrhoidsClusters of swollen veins in and around
the anus and rectum that can cause pain.
hepatobiliary scintigramA test for acute cholecystitis in
which a small amount of radioactive m
aterial is injected
into a vein to visualize the bile duct system. Also called a
hepato-iminodiacetic acid (HIDA) scan.
hiatal herniaA protrusion of the gastroesophageal
junction and a portion of the stomach into the chest
GLOSSARY
pancreatitisInflammation of the pancreas.

peptic ulcerA nonhealing defect or sore in the inner
lining of the stomach or duodenum.
perforationA hole in an organ.
peristalsisA series of wavelike muscle contractions that
occur automatically to move food and fluid through the
digestive tract.
peritonitisInflammation or infection of the lining of
the abdominal cavity.
pHA measurement of acidity or alkalinity.
polypA small, noncancerous (benign) clump of cells
that grows in the rectum and colon. Over the course of
10 to 15 years, some polypsusually those larger than a
peamay become cancerous.
promotility agentsDrugs that increase digestive tract
motility, resulting in faster removal of acid from the
esophagus, greater esophageal sphincter pressure and
better emptying of the stomach.
proton pump inhibitorsDrugs that strongly suppress
acid production in the stomach.
pylorusA circular muscle that connects the opening at
the end of the stomach with the duodenum.
rectumThe area into which the colon pushes waste
products for storage before they are released through the
anus during a bowel movement.
sigmoidoscopyA procedure in which the last 25 inches
of the colon are examined with a short, flexible endoscope inserted through the anus.
small intestineThe portion of the digestive tract that
absorbs nutrients from foods. The stomach passes food
into the small intestine where digestive juices help break
it down. Undigested food components (waste) pass from
the small intestine to the large intestine.
sphincter of OddiThe layers of muscle that control the
entry of bile and pancreatic juices into the duodenum
from the common bile duct and the pancreatic duct.
stomachThe part of the digestive tract that breaks down
food and mixes it with digestive juices. When the food
becomes a thick liquid, it passes into the small intestine.
strictureAn abnormal narrowing of hollow tubes in the
body, such as the esophagus or bile ducts, due to the formation of scar tissue.
tracheaThe windpipe.
ulcerA nonhealing defect or sore in the mucosal lining
of organs such as the stomach and duodenum.
ulcerative colitisA chronic inflammatory disease of the
large intestine caused by an abnormal autoimmune reaction that causes the body to attack its own bowel.
upper endoscopyA procedure that examines the inside
lining of the esophagus, stomach and duodenum using a
long, thin, flexible tube with a light and tiny video camera
at its tip to look for abnormalities such as inflammation,
ulcers and tumors.
upper esophageal sphincterA muscular tissue area at
the upper end of the esophagus that contracts to prevent
air from entering the esophagus when not swallowing.
upper GI seriesX-rays of the esophagus, stomach, and
duodenum that are taken after the patient swallows barium to make the organs visible on X-ray film.
virtual colonoscopyA noninvasive test in which a CT
scan of the abdomen is done to obtain two- and threedimensional images of the colon and rectum. It has a
number of drawbacks and typically is not performed
unless standard colonoscopy cannot be done.
Z-lineAn irregular white line seen on endoscopy that
corresponds to the gastroesophageal junction, the place
where the esophagus meets the stomach.
82
HEALTH INFORMATION ORGANIZATIONS AND SUPPORT GROUPS

The American College of
Gastroenterology
6400 Goldsboro Road, Suite 200
Bethesda, MD 20817
% 301-263-9000
www.gi.org
A professional organization that provides general information and health
tips on gastrointestinal disorders as
well as help finding a physician.
American Gastroenterological
Association
4930 Del Ray Ave.
Bethesda, MD 20814
% 301-654-2055
www.gastro.org
A nonprofit professional organization offering publications about
digestive health. Website provides
message boards and help finding a
gastroenterologist.
American Society of Colon & R

ectal
Surgeons
85 W. Algonquin Rd., Ste. 550
Arlington Heights, IL 60005
% 847-290-9184
www.fascrs.org
Professional society representing
board-certified colon and rectal surgeons. Can help you find a surgeon.
American Speech-LanguageHearing Association

2200 Research Blvd.
Rockville, MD 20850-3289
% 800-638-8255/301-296-5700
301-296-5650 (TTY)
www.asha.org
International Foundation for

Functional Gastrointestinal
Disorders
700 W. Virginia St., Ste 201
Milwaukee, WI 53204
% 888-964-2001/414-964-1799
www.iffgd.org
Gives information on communication

and swallowing disorders and referrals
to speech-language pathologists who
can help with swallowing disorders.
A nonprofit education and research

organization that informs and supports
patients with gastrointestinal disorders.
Celiac Sprue Association

P.O. Box 31700
Omaha, NE 68131-0700
% 877-272-4272
www.csaceliacs.org
Sponsors a network of local chapters
and support groups and publishes a
newsletter and additional educational
materials relating to celiac disease.
Crohns & Colitis Foundation

of America
733 Third Ave., Ste. 510
New York, NY 10017
% 800-932-2423
www.ccfa.org
Nonprofit health organization dedicated to improving the lives of people with
Crohns disease or ulcerative colitis.
83
National Digestive Diseases

Information Clearinghouse
2 Information Way
Bethesda, MD 20892-3570
% 800-891-5389/
866-569-1162 (TTY)
www.digestive.niddk.nih.gov
A branch of the National Institutes of
Health. Provides publications on the
treatment of digestive diseases.
INDEX
INDEX
Abscesses, 36, 51, 57, 62

Achalasia, 7, 8, 1718
AcipHex (rabeprazole), 11, 13, 1415, 25
Actos (pioglitazone), 29
Acute cholecystitis, 3536, 37
Adenomas, 43, 4445, 77
Advil (ibuprofen), 22, 32
Aleve (naproxen), 22
Aminosalicylate anti-inflammatory compounds,
37, 56, 5859
Amitiza (lubiprostone), 66
Amoxicillin, 25
Amylase, 2
Anal dilation (four-fingered anal stretch), 73
Anal fissures, 47, 7173
Anal manometry, 74
Anal sphincter, 41, 74, 75, 76
Anoscopes, 70, 72
Antacids, 11, 12, 13, 21, 33, 47
Antidepressants, 10, 19, 47, 66
Artificial anal sphincter, 73, 76
Aspirin, 12, 22, 32, 33, 71
Axid (nizatidine), 13, 1415, 25
Azathioprine, 57, 6061, 63
Azulfidine (sulfasalazine), 57, 5859, 63
Bactrim (trimethoprim and sulfamethoxazole),

53
Baraclude (entecavir), 30
Bariatric surgery, 79
Barium enema, overview, 4142
Barium swallow, 7
Barium X-rays, 5, 18
Barretts esophagus, 12, 13, 1922
Beta-blockers, 31
Bextra (valdecoxib), 23
Biaxin (clarithromycin), 25
Bile, 3, 4, 6, 2627, 34, 41
Bile ducts, 4, 27, 3437, 38, 39
Bile reflux, 6
Biliary colic, 35, 36
Bilirubin, 6, 26, 34
Biofeedback, 49, 75
Biopsy, definitions, 20, 31
Bisphosphonate drugs, 10
Body mass index (BMI), 79
Bonine (meclizine), 32
Botox (botulinum toxin A), 1819, 73
Bravo test, 6
Bronchodilators, 10
Calcium-channel blockers, 10, 18, 19, 73

Canasa (mesalamine), 5859
Capsule endoscopy, 5, 19, 46, 57

Cardizem (diltiazem), 73
Cecum, 41, 62
Celebrex (celecoxib), 23
Celiac disease, 5456, 65
Chemotherapy, 32, 79
Cholangitis, 35, 36
Cholecystectomy, 3637, 39
Cholesterol, 26, 34
Cimzia (certolizumab pegol), 6061, 62
Cipro (ciprofloxacin), 53, 6061
Cirrhosis, 28, 29, 30, 31
Citrucel, 49
Clostridium difficile (C. difficile), 20, 52, 53
Colace (docusate sodium), 49
Colazal (balsalazide), 5859, 63
Colectomy, 6364
Colocort (hydrocortisone), 5859, 60
Colon cancer. see Colorectal cancer
Colon (large intestine), anatomy, 3, 41
Colonoscopy, overview, 4345
Colorectal cancer
and alcohol, 78
causes and risk factors, 44, 63, 64, 76
diagnosis, 42, 7879
exercise and colon cancer, 7778
screening tests, 44, 47, 78
symptoms, 78
treatment, 79
and ulcerative colitis, 64
Colorectal polyps
adenomas, 43, 4445, 77
biopsy, 43, 44
causes, 76
diagnosis, 43, 77
hyperplastic polyps, 44
removal, 43, 4445, 76, 77
serrated polyps, 43, 45
symptoms, 77
Colostomy, 76
Computed tomography (CT), 3536, 37, 39,
40, 4344, 51
Constipation, 4649
see also Irritable bowel syndrome
Cordarone (amiodarone), 27
Correctol (bisacodyl), 49, 53
Corticosteroids
anal fissure, 72
celiac disease, 56
Crohns disease, 57, 5859, 60
GERD, 11
ulcerative colitis, 5859, 63
COX-2 inhibitors, 23
Crohns disease
causes, 56
84
diagnosis, 42, 57
inflammatory diarrhea, 52, 56
symptoms, 5657
treatment, 37, 5762
Cryotherapy, 22
Delzicol (mesalamine, delayed-release), 5859

Dermatitis herpetiformis (DH), 55
Dexilant (dexlansoprazole), 13, 1415
Diabetes, 2829, 40, 47, 55, 74
Dialose (docusate sodium), 49
Diaphragm, anatomy, 2
Diarrhea, overview, 5153
see also Irritable bowel syndrome
Dietary fiber
anal fissure, 72
colorectal adenomas, 77
constipation, 47, 48
diverticulosis, 50, 51
fecal incontinence, 75
gallstone risk, 34
hemorrhoids, 70
supplements, 49
Diffuse esophageal spasm, 7, 1718, 19
DIFICID (fidaxomicin), 53
Digestion, 3
Digestive disorders, overview, 1, 3
Digestive tract anatomy, overview, 14
Dipentum (olsalazine), 5859, 63
Diverticulitis, 5051
Diverticulosis, 47, 5051
Dramamine (dimenhydrinate), 32
Dulcolax (bisacodyl), 49, 53
Duodenal gastroesophageal reflux, 6
Duodenal ulcers, 23, 24, 37
See also Peptic ulcer disease
Duodenum, anatomy, 4
Dysphagia, 78, 18
Dysplasia, 20, 22, 45, 64
Endoscopes, 45, 8, 35, 36, 55

Endoscopy
capsule endoscopy, 5, 19, 46, 57
endoscopic dilation, 8, 18, 19
endoscopic mucosal resection, 22, 45
endoscopic retrograde
cholangiopancreatography (ERCP),
3637, 3839
endoscopic ultrasound, 35
GERD treatment, 17, 22
upper endoscopy, description, 45
Entocort EC (budesonide), 57, 5859
Epiglottis, 2
Epivir-HBV (lamivudine), 30
Erythromycin, 32
Escherichia coli O157:H7, 52, 53
Esophageal cancer, 7, 12, 19, 2122
Esophageal dilation, 8, 18, 19
Esophageal diverticula, 7, 50
Esophageal dysphagia, 78, 18
Esophageal impedance testing, 6
Esophageal manometry, 56, 18
Esophageal motility disorders, 7, 1719
Esophageal rings or webs, 7
Esophageal squamous cell carcinoma, 19
Esophageal strictures, 7, 8, 12, 19
Esophagectomy, 19
Esophagitis, 8, 14, 20, 21
Esophagogastroduodenoscopy, 13
Esophagus
anatomy, 2, 4
dysplasia, 20, 22
gastroesophageal junction, 4
mucosa, 2, 10, 19
See also Lower esophageal sphincter
Gallbladder
acute cholecystitis, 3536, 37
anatomy, 27
perforation, 35, 36
Gallstones
acute cholecystitis, 3536, 37
causes, 34
cholangitis, 35, 36
diagnosis, 3536
gallstone migration, 3435
overview, 34
symptoms, 3435
treatment, 3637
Gastric ulcers, 23, 24, 26
See also Peptic ulcer disease
Gastritis, 2223, 24
Gastroenterologist, definition, 1
Gastroesophageal junction, 4
Gastroesophageal reflux disease (GERD)
causes, 10
diagnosis, 56, 12
H2-blockers (histamine H2-receptor

antagonists)
GERD, 13, 1415, 2021
peptic ulcers, 24, 25, 26
Helicobacter pylori (H. pylori), 2224, 26
Helidac (bismuth/metronidazole/tetracycline),
25
Heller myotomy, 1819
Hemochromatosis, 28
Hemorrhoid stapling (hemorrhoidopexy), 71
Hemorrhoidectomy, 73
Hemorrhoids, 47, 67, 7071
Hepatitis
autoimmune hepatitis, 28
hepatitis C (HVC) screening, 30
nonalcoholic fatty liver disease, 2829, 31
nonalcoholic steatohepatitis, 2829
overview, 2728
treatment, 3031
viral hepatitis, 2831
Hepatitis vaccines, 29, 30
Hepatobiliary scintigram, 36
Hepatocytes, 2627
Hepsera (adefovir), 30
Hiatal hernia, 89
Histamine H2-receptor antagonists. see
H2-blockers
Humira (adalimumab), 6061, 62, 63
Hydrocortisone, 60
Hyperimmune globulin, 30
Ileoanal anastomosis, 64
Ileostomy, 64
Ileum, 3, 34, 4041
Immunomodulators, 6062
Imodium A-D (loperamide), 53, 66, 75
Imuran (azathioprine), 57, 6061, 63
Incivek (telaprevir), 31
Inflammatory bowel disease. See Crohns
disease; Ulcerative colitis
Inflammatory diarrhea, 52, 53
85
Insulin, 27
Irritable bowel syndrome (IBS)
causes, 64, 6869
and diet, 6869
overview, 64
psychological therapies, 67
symptoms and diagnosis, 6566
treatment, 49, 6667
Jaundice, 30, 31, 35, 40

Jejunum, 3, 4041
Kao-Spen, Kapectolin (kaolin/pectin), 53

Kaopectate (bismuth subsalicylate), 33, 53
Konsyl, 49
Lactose intolerance, 32, 52, 65, 68, 75

Laniazid (isoniazid), 27
Laparoscopy, 16, 18, 36, 41
Large intestine (colon), anatomy, 3, 41
Laxatives, 47, 49, 52, 53, 66, 72
Lialda (mesalamin), 5859
Linzess (linaclotide), 49, 66
Liver anatomy, 2627
Liver disorders, 2731
Liver transplants, 31
Lomotil (diphenoxylate/atropine), 53
Lotronex (alosetron), 66
Lower digestive tract anatomy, 4041
Lower digestive tract tests, 4146
Lower esophageal sphincter (LES)
achalasia, 7, 8, 1718
anatomy, 2, 3
GERD, 2, 3, 5, 10
hiatal hernia, 89
relaxation by medications, 10, 18
See also Esophagus
Lower gastrointestinal (GI) series, 4142
Lymphoma, 54, 62
Maalox, 13, 33
Magnetic resonance cholangiopancreatography
(MRCP), 36, 40
Magnetic resonance imaging (MRI), 36, 40, 79
Major duodenal papilla, 4, 35
Melanoma, 63
Mercaptopurine, 57, 6061, 63
Metamucil (psyllium), 49
Metaplasia, 19
Methotrexate, 6061
Methyldo pa, 27
Methylprednisolone, 57, 5859
Metozolv ODT (metoclopramide), 1617
Metronidazole, 25, 53, 6061
Microvilli, 40
Milk of Magnesia (magnesium hydroxide), 49
INDEX
Fecal immunochemical test (FIT), 47

Fecal impaction, 4748, 49
Fecal incontinence, 7376
Fecal occult blood testing, 7879
Fermentable oligosaccharides, disaccharides,
monosaccharides and polyols (FODMAP),
6869
Fiber in diet. See Dietary fiber
Fiberall, 49
Fish oil, 32
Fistulas, 5, 51, 57, 61
Flagyl (metronidazole), 53, 6061
Fleet (mineral oil), 49
Fosamax (alendronate), 24
hiatal hernia, 89
lifestyle measures for treatment, 12
medications, 1317, 2021
Nissen fundoplication, 9, 16
overview, 910
surgery, 1517
symptoms, 9, 1012
treatment, 1217, 2021
Gastrografin, 57
Gaviscon, 13
Gelusil, 13
GERD. See Gastroesophageal reflux disease
Gliadin, 54
Glucagon, 27
Gluten, 54, 5556
Grazing, 31
Mindfulness training, 67
Minimally invasive distal pancreatectomy
(MIDP), 41
Miralax (polyethylene glycol), 49
Monoclonal antibodies, 6061
Motrin (ibuprofen), 22, 32
Mouth anatomy, 2
Mylanta, 13
Naprosyn (naproxen), 22
Nausea, prevention and treatment, 3233
Nexium (esomeprazole), 11, 13, 1415, 21,
25
Nissen fundoplication, 9, 16
Nitrates, 19
Nitroglycerin, 18, 72
Nonacid reflux, 6
Nonalcoholic fatty liver disease, 2829, 31
Nonalcoholic steatohepatitis, 2829
Nonsteroidal anti-inflammatory drugs (NSAIDs),
10, 2223, 24, 26, 32
Norpramin (desipramine), 66
Nydrazid (isoniazid), 27
INDEX
Oropharyngeal dysphagia, 78
Osmotic diarrhea, 52, 53
Osteoporosis, 20, 54
Pacerone (amiodarone), 27
Pancreas, anatomy and function, 3, 27
Pancreatic cancer, 38
Pancreatic duct, 4, 27, 35, 36
Pancreatic enzymes, 4, 6, 27, 37, 38, 40
Pancreatitis
causes, 35, 3839
diagnosis, 39, 40
overview, 27, 37
symptoms, 32, 35, 37, 38, 40
treatment, 39, 40
Partial gastrectomy, 26
Pegylated interferon, 30
Pentasa (mesalamine), 56, 57, 5859, 63
Pepcid (famotidine), 13, 1415, 25
Peptic ulcer disease
causes, 24
complications, 24, 26
diagnosis, 24
duodenal ulcers, 23, 24, 37
gastric ulcers, 23, 24, 37
Helicobacter pylori (H. pylori), 2224, 26
overview, 23
symptoms, 24
treatment, 2426
Pepto-Bismol (bismuth subsalicylate), 25, 26,
33, 53
Perforation
colon, 43, 50
gall bladder, 35, 36, 57, 63

peptic ulcer disease, 1, 24, 26
Peristalsis, 2, 3, 10, 17, 18, 46
Peritonitis, 24, 50, 51, 57
pH monitoring, 6
Pharynx anatomy, 2
Polyps. see Colorectal polyps
Polysomnograms, 13
Potassium supplements, 32
Prednisone, 56, 57, 5859
Prevacid (lansoprazole), 11, 13, 1415, 21, 25
Prevpac (amoxicillin/Biaxin/Prevacid), 25
Prilosec (omeprazole), 11, 13, 1415, 21, 25
Procardia (nifedipine), 73
Progressive multifocal leukoencephalopathy
(PML), 62
Promotility agents, 15, 1617
Proton pump inhibitors
GERD, 11, 1315, 2021
peptic ulcers, 24, 25, 26
Protonix (pantoprazole), 11, 13, 1415, 25
Prozac (fluoxetine), 66
Purinethol (mercaptopurine), 57, 6061, 63
Pylera (bismuth/metronidazole/tetracycline), 25
Pylorus or pyloric valve, 4, 40
Radiation therapy (radiotherapy), 8, 32, 74, 79

Radiofrequency ablation, 22
Rectal cancer. see Colorectal cancer
Rectal prolapse, 47, 70, 74
Rectum, anatomy and function, 3, 41
Reglan (metoclopramide), 15, 1617
Remicade (infliximab), 6062, 63
Ribavirin, 30
Rocephin (ceftriaxone), 34
Rolaids, 33
Rowasa (mesalamine enema), 5859, 60, 63
Saliva, 2, 3, 10
Salmonella typhi, 53
Scleroderma, 7
Sclerotherapy, 71
Scopace (scopolamine), 32
Secretory diarrhea, 52, 53
Selective serotonin reuptake inhibitors (SSRIs),
66
Sigmoid colon, 42, 44, 50, 63
Sigmoidoscopy, overview, 4243
Sleep apnea, 13
Small intestine anatomy, 3, 4041
Smoking, 10, 19, 24, 26, 37, 3839, 76
Sorbitol, 52, 53, 68, 75
Sphincter of Oddi, 27, 38
Sphincterotome, 37
Sphincterotomy, 36, 37, 73
Stomach anatomy, 4
Stool softeners, 49
Surfak (docusate sodium), 49
86
Tagamet (cimetidine), 13, 1415, 25

Tetracycline, 25
Theo-24 (theophylline), 10
Theo-Dur (theophylline), 10
Theophylline, 10, 32
Thiopurines, 57
Thoracoscopy, 19
Transderm Scop (scopolamine), 32
Tricyclic antidepressants (TCAs), 10, 19, 66
Tuberculosis, 27, 62, 72
Tumor necrosis factor (TNF) inhibitors, 63
Tums, 33
Tylenol (acetaminophen), 71, 73
Tysabri (natalizumab), 6061, 62
Tyzeka (telbivudine), 30
Uceris (budesonide extended release), 5859

Ulcerative colitis
causes, 6263
inflammatory diarrhea, 52
symptoms and diagnosis, 42, 63
treatments, 37, 5861, 6364
Ultrasound, 8, 28, 3536, 37, 40, 79
Uniphyl (theo phylline), 10
Upper digestive tract anatomy, 24
Upper digestive tract tests, 46
Upper endoscopy, description, 45
Upper esophageal sphincter, 2
Upper gastrointestinal (GI) series, 5, 9, 18,
24, 57
Urecholine (bethanechol), 15
Vagotomy, 26
Victrelis (boceprevir), 31
Vioxx (rofecoxib), 23
Viral hepatitis, 2831
Virtual colonoscopy, 4345
Vitamin B12, 20, 41
Vitamin D, 54, 63
Vitamin E, 29
Vomiting, prevention and treatment, 3233
Z-line, 4
Zantac (ranitidine), 13, 1415, 21, 25
Zegerid (omeprazole/sodium bicarbonate), 13,
1415, 25
Zelnorm (tegaserod), 66
Zinc supplements, 32
Zofran (ondansetron), 32
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Behind the overtreatment of low-risk cancer
January 2015 Volume 26 Issue 6 $5.00

The cure is worse than the disease
that keeps a close eye on their cancer as
youve probably heard that sentiment
an alternative to immediate treatment.
before, and nowhere does it seem to ring
So why are many doctors choosing to
truer than when youre talking about
go the aggressive treatment route when
treating early-stage prostate cancer.
it comes to low-grade and early-stage
One in six American men will be
prostate cancer? First, its important to
Cardiology groups update guidelines to treat atrial fibrillation
diagnosed with prostate cancer during
know the science behind prostate cancer.
their lifetime, and many will go on to be
If youre one of the roughly 2.7 million
as those who dont have the disorder.
The slow-growing
cancer
treated with surgery, radiation or a horAmericans who has atrial fibrillation
Updated clinical guidelines reflect new,
The truth is that more men die with
mone regimen known as androgen(AF), the most common form of abnorapproved options for managing AF and
prostate cancer than of it. Thats because
deprivation therapy (ADT). Each of
mal heart rhythm, you may be due for an
urge doctors and patients to revisit their
its typically a slow-growing cancer that
these treatments comes with significant
in-depth discussion with your doctor about
current treatment with these drugs and
would otherwise never cause symptoms
side effects and risks that can include
Not all older men need immediate treatment for
your treatmentyou could stand to benstrategies in mind. The guidelines
were
low-risk prostate cancer. Discuss this possibility
or be a threat to the patient. Thanks to
sexual dysfunction, urinary incontinence,
efit from new, game-changing drugs and
jointly issued in March by the
withAmerican
your doctor and make sure you thoroughly
increased screenings measuring prostatebowel dysfunction and bone loss. While
understand
all your options before making any
strategies for managing the condition that
Heart Association (AHA), the
American
specific antigen (PSA) in the blood,
the pros of these treatments may outtreatment decisions.
have emerged during the past few years.
College of Cardiology (ACC) and the
more than 90 percent of prostate cancers
weigh the cons for those with aggressive
AF produces a rapid, irregular heartHeart Rhythm Society (HRS), in colare now diagnosed in the early stages,
an aggressive disease, a strategy called
prostate cancers, older men (typically 65
beat (arrhythmia) and symptoms that
laboration with the Society of Thoracic
and 60 to 70 percent are low-grade canactive surveillance is considered the best
and up) with cancers that appear early or
include
chest
discomfort
or pain, toSurgeons,
and published online
cers considered
be nonaggressive.
option by
forthe
initial treatment, particularly
are considered low
risk fatigue,
are often
better
In AF the atrias electrical activity becomes chashortness
of
breath
and
reduced
blood
flow
Journal
of
the
American
College
of
Cardiology.
Because low-grade prostate cancer isnt
if the patient is older
other health
suited to an active surveillance program
oticand
andhas
uncoordinatedunlike
normal rhythm
to the brain that can lead to fainting or
While not everyone may be
a candidate
so heart
the atria
quiver and
problems,
such as
disease,
thatblood is pumped less
effectively into the ventricles.
confusion. But, many people with AF have
for a fully revised treatmentshorten
strategy,
the
his life expectancy. In active surKNOW YOUR
OPTIONS
no symptoms. With or without symptoms,
2014 AHA/ACC/HRS
guidelines
veillance,will
patients forego immediate
the condition significantly increases the
likely affect many AF patients
in one way
easier undergo
to use; a careful
diminished role for daily
treatment
and instead
for blood clots
that can
cause should
stroke, notorask
another.
They addressfollow-up
four major
and broader use of radioMen who haverisk
early-stage
prostate
cancer
their doctors,
by theiraspirin
doctors,therapy;
who typically
What treatment
would
be best?
but instead
ask,health
Do I need
treatment
at all?to patientsnamely,
heart
failure
and other
serious
changes
of concern
a
frequency
a minimally invasive
monitor patients
with PSAablation,
measureA patients personal
preference
and concerns
always
making
threats.
In fact, people
who haveare
AF
have critical
morewhen
effective
waya to assessments,
strokedigital
risk; rectal
procedure
restore
normal heart rhythm.
exams to
twice
yearly
decision. Some five
mentimes
are OK
side
if aitstroke
means wealternatives
can eradicate
their thatand
the with
chance
of effects
a having
to warfarin
are safer
andbiopsies of the prostate.
repeat
cancer; others simply cant cope with having the lower quality of life that can
1. Reevaluate
risk
Patients are treated
only if theres stroke
evicome with surgery or radiation, and they opt for surveillance. Because prostate
The has
treatment
planusuyour doctor prescribes
dence that the disease
changed,
ATRIAL
GUIDELINES
cancer tends to grow very slowly,
patientsFIBRILLATION
have time to think through
their deci- EXPLAINED
depends
partly on your overall stroke risk.
ally based on a prostate
biopsy.
sion. I encourage them to discuss the treatment experience not only with their
Simply having
raises your odds, but
active surveillance
poses aAF
quanatrial fibrillation
were
issued
in sure
2010they
and revised inBut
2012
doctors but withSimilar
other patients
who have guidelines
been through
it, just
to be
your vulnerability
to a stroke increases
dary for some patients:
Being told you
thethe
European
of Cardiology
are comfortableby
with
realities Society
of posttreatment
life. (ESC), so some recommendations may
with
the presence
of other risk factors. In
continued
on next page
sound familiar to patients whose doctors have already adopted the earlier ESC
the past, most doctors estimated a patients
guidelines. The 2014 AHA/ACC/HRS guidelines emphasize the importance
stroke risk using a tool called CHADS2,
of doctors and patients working closely together to decide the best managewhich
calculates a risk score by assigning
In This Issue ment options.
Time toMost
Nix the
Niacin? doctors
Wrinkle
Fillers:
Are They
Safe? values
Get Up and
Dance!
important,
should
be guided
by patient
one point for each risk factor a patient has,
and preferences. Other factors to consider include symptoms, comorbidities,
with the exception of past stroke, which
potential drug interactions, whether the patient is a good candidate for ablation
scores 2 points. The acronym CHADS2
and cost. Overall, the 2014 guidelines are a welcome step toward encouraging
refers to those risk factors,
which
are:
SA_HA50_02_15_MOCK.indd 1 shared decision making and ongoing discussions about managing AF between
12/2/14 2:27
PM
continued on next page
doctor and patient.
New Ways to Assess Stroke Risk

and Tame an Abnormal Heartbeat
In This Issue
Treating Thyroid Cancer in Older Adults Strange Brew: Caffeine Use Disorder
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PaGe 70

eimers Disease Angina Atrial Fibrillation Bipolar

Alzheimers Disease Angina Atrial Fibrillation Bipolar

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an in-depth interview with a medical expert

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t see what youre looking for? Try our Digital Special

eimers Disease Angina Atrial Fibrillation Bipolar

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Scientific Americans White Papers

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