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De-stress to treat IBS
Meditation may offer relief
PAGE 65
GERDbut no heartburn?
Other symptoms that can indicate reflux
PAGE 13
Celiac disease and lactose intolerance
How to get enough calcium when you have
both conditions
PAGE 53
Your liver and your drugs
Take these precautions to prevent
drug-induced liver damage
PAGE 30
The gut workout
Exercise can reduce digestive disorder risks
PAGE 45
THE YEARS LATEST RESEARCH
H. Franklin Herlong, M.D.
The Johns Hopkins White Papers
Digestive Disorders
Your annual guide to prevention, diagnosis and treatment
The Johns Hopkins Hospital
2013
Digestive Disorders
Adjunct Professor of Medicine
Johns Hopkins University School of Medicine
P.S. Please visit www.HopkinsDigestion.com for the latest news on digestive disorders and
other information that will complement your Johns Hopkins White Paper.
Dear Reader:
Welcome to the 2013 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:
Is it possible to have GERD without heartburn? (page 13)
Steps to take to reduce your risk of esophageal cancer. (page 23)
How to avoid the most common cause of acute liver damage. (page 30)
Exercise your way to a healthy gut. (page 45)
Surprising news about diverticulitis and your diet. (page 49)
Getting enough calcium if you have celiac disease and lactose intolerance. (page 53)
Research confirms a link between bacteria and irritable bowel syndrome. (page 63)
Mindfulness training may provide relief from irritable bowel syndrome. (page 65)
Fresh fish: Will it help prevent colorectal cancer? (page 73)
Choose the colorectal cancer screening method thats right for you. (page 74)
Wishing you the best of health in 2013,
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 ................................................................................. 7
Dysphagia ........................................................................................................................ 7
Hiatal Hernia ................................................................................................................ 10
Gastroesophageal Reflux Disease (GERD) ................................................................. 11
Esophageal Motility Disorders ..................................................................................... 20
Esophageal Stricture ..................................................................................................... 21
Barretts Esophagus ...................................................................................................... 22
Gastritis .......................................................................................................................... 24
Peptic Ulcer Disease ..................................................................................................... 25
Anatomy of the Liver, Gallbladder and Pancreas ............................................................... 28
Disorders of the Liver, Gallbladder and Pancreas .............................................................. 29
Hepatitis ....................................................................................................................... 29
Cirrhosis ....................................................................................................................... 33
Gallstones ...................................................................................................................... 33
Pancreatitis .................................................................................................................... 37
Anatomy of the Lower Digestive Tract ................................................................................ 38
Tests for Examining the Lower Digestive Tract .................................................................. 39
Disorders of the Lower Digestive Tract ............................................................................... 43
Constipation .................................................................................................................. 43
Diverticulosis and Diverticulitis .................................................................................... 47
Diarrhea ....................................................................................................................... 49
Celiac Disease ................................................................................................................ 51
Crohns Disease ............................................................................................................. 54
Ulcerative Colitis ........................................................................................................... 57
Irritable Bowel Syndrome ............................................................................................. 62
Hemorrhoids ................................................................................................................. 66
Anal Fissure ................................................................................................................... 69
Fecal Incontinence ....................................................................................................... 71
Colorectal Polyps .......................................................................................................... 73
Colorectal Cancer ......................................................................................................... 76
Glossary .................................................................................................................................. 79
Health Information Organizations and Support Groups ................................................... 82
Index ...................................................................................................................................... 83
Introducing Your
Digestive Disorders Expert
T
he Johns Hopkins Hospital is No. 3 in the United States for the treatment of digestive
disorders, according to U.S. News & World Reports Best Hospitals rankings for 2012. Your
Johns Hopkins expert for this White Paper is Dr. H. Franklin Herlong.
H. Franklin Herlong, M.D., has been an Associate Professor of Medicine
at the Johns Hopkins University School of Medicine. He was Associ-
ate Dean for Student Affairs for 15 years, receiving numerous teaching
awards from the Department of Internal Medicine and the School of
Medicine. Dr. Herlong completed residency training at the Osler Medi-
cal Service at The Johns Hopkins Hospital, also serving as Assistant Chief
of Service. He received his undergraduate degree from Duke University
and his M.D. degree from the Medical University of South Carolina. In
October 2012, he became an Adjunct Professor of Medicine at Hopkins
after joining the University of Texas M.D. Anderson Cancer Center in
Houston as a Professor of Medicine.
Dr. Herlongs areas of research include viral hepatitis, autoimmune liver disease, alcoholic hep-
atitis and hepatic transplantation. He has published numerous sci entific papers and presented at
multiple national and international medical meetings.
Digestive Disorders
A
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 disor-
ders, such as Crohns disease or irritable bowel syndrome, can severely
affect your ability to perform daily activities, and some, like co lorectal
cancer or a perforated ulcer, can be life threatening. This White Paper
covers many conditions that affect the digestive tract, including diseas-
es 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 predisposi-
tion that makes them susceptible to these and other environmental
triggers. But the causes of some di gestive 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 rang-
ing 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
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DI GESTI VE DI SORDERS 2013 Hopki nsDi gesti ve.com
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 phar-
ynx, 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 esopha-
gus. 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
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Your Aging Digestive Tract
You can develop a digestive disorder at any age, but
the chances are much greater as you get older.
Mouth and esophagus. Swallowing can become
difficult as a result of dry mouth or tooth decay. A
stroke, dementia or neurodegenerative disease such
as Parkinsons can also lead to swallowing difficul-
ties. The esophagus and lower esophageal sphincter
become weaker as we age, although these changes
dont seem to contribute to the greater likelihood
of heartburn and gastroesophageal reflux disease
(GERD).
Stomach. The stomach takes longer to empty into
the small intestine, making older adults more vulner-
able to ulcers and bleeding from medications such as
nonsteroidal anti-inflammatory drugs (NSAIDs). The
stomach also becomes less elastic and can hold less
food, meaning that older adults feel full more quickly.
Small intestine. The small intestine doesnt seem
to change dramatically with age, although it does
become less able to absorb certain vitamins and min-
erals, including vitamin D, vitamin B
12
and calcium.
Bacterial overgrowth can cause diarrhea and uninten-
tional weight loss in older adults.
Large intestine. A loss of muscle strength can result
in diverticulosissmall pouches that bulge outward
through weak points in the intestinal wall. Undigested
food components take longer to move through the
large intestine, leading to constipation. Polyps and
colon cancer are more common in older adults.
Other organs. The liver becomes less able to
metabolize medications, so it is more susceptible to
damage. The gallbladder produces less bile, which
may lead to gallstones. The pancreas, however,
doesnt seem to change much with age. n
Liver
Gallbladder
Small
intestine
Mouth
Pharynx
(throat)
Esophagus
Lower
esophageal
sphincter
Stomach
Pancreas
Large
intestine
(colon)
Rectum
4
mu cosa. In a healthy esophagus, the mucosa is smooth and pink. The
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 gastro esophageal 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 mano metry or pH monitoring.
Upper Endoscopy
An upper endoscopy examines the inside lining of the eso ph agus,
stomach and duodenum. A long, thin, flexible tube with a tiny light
and video camera at its tip (an endoscope) looks for abnormalities
such as inflammation, ulcers and tumors. If youre ex periencing dif-
ficulty swallowing, nausea, vomiting with or without blood or coffee
grounds-like mater ial, heartburn, indigestion, up per abdominal pain
or chest pain, your doctor may perform an upper endoscopy.
This test is performed in a hospital or doctors office and takes
about 30 minutes. A numbing agent is often sprayed into your throat
to prevent gagging when the endoscope is inserted. A pain medica-
tion and a sedative also are given to keep you relaxed and sleepy.
While you lie on your left side, the doctor slowly and gently passes the
endoscope through your mouth and into your esophagus, stomach
and duodenum. Air is blown through the endoscope to make it easier
for the doctor to see the lining of the digestive tract.
The doctor views the images from the endoscope on a televi-
sion monitor. If he or she notices anything abnormal in the lining
of the upper digestive tract, a sample of the tissue may be removed
(biopsied) and examined under a microscope. Instruments can be
inserted through the endoscope to stop bleeding from an ulcer, to
remove a growth, or to stretch a narrowed area of the esophagus,
stomach or duodenum.
Upper endoscopy is safe when performed by a doctor who is
trained and experienced in the procedure. Serious complications,
such as excessive bleeding, allergic reactions to the sedative, aspira-
tion of stomach contents or saliva into the lungs, and puncture of the
stomach or intestinal wall, are rare. Some people have mild complica-
tions, such as a sore throat or bloating. These problems usually disap-
pear within 24 hours. If you experience signs of a serious complica-
tion after the procedure (for example, fever, swallowing difficulties,
or increasing throat, chest or abdominal pain), you should contact
your doctor immediately.
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 endoscopyperhaps
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 bar ium coats
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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 Admin-
istration (FDA) approved the use of a tiny ingestible camera in a cap-
sule that takes close-up pictures of the small intestine as the capsule
moves through the digestive tract. For more, see page 42. (An ingest-
ible camera is also approved for esophageal endoscopy.)
Esophageal Manometry
This test measures pressure and evaluates contractions in the esopha-
gus. It is typically performed to diagnose gas tro esophageal reflux dis-
ease (GERD) and swallowing problems. During the test, a physician
or specially trained technician inserts a thin, pressure-sensitive probe
through the nose and into the esophagus to measure pressure in the
eso ph agus while it contracts; it also measures pressure of the lower
eso ph a geal sphincter. Abnormal muscle contractions in the esopha-
gus and decreased lower esophageal sphincter pressure indicate weak-
ening of the an ti- 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 fluctua-
tions in acid backing up into your eso phagus 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 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 dif-
ficult to move about. Another version of the test that does not involve
the nose 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. There are also buttons on the receiver
that correspond to certain symptoms you may have; pressing them
when you have symptoms will record additional information about
your condition.
7
Esophageal Impedance Testing
This test also involves having a tiny tube inserted into your es ophagus
and measures whether gas or liquid is backing up into the es ophagus.
It is a helpful diagnostic tool for those with nonacidic re flux, 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 esoph-
agus. 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 esopha-
geal. In oropharyngeal dysphagia, individuals have problems initiat-
ing 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 dis orders, such
as stroke or Parkinsons disease, are frequently to blame. Inflamma-
tion or cancer of the mouth or throat also can lead to oropharyngeal
dysphagia.
Esophageal dysphagia can be caused by narrowing of the esoph-
agus or by a disruption in normal esophageal motility (movement).
Can cer 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 par tially
or completely block the esophagus) all can narrow the esophagus,
making the passage of food more difficult. Esopha geal motility can
be disrupted by scleroderma (an autoimmune disease that affects the
skin and internal organs), diffuse esopha geal spasm (prolonged and
ex cessive 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 begin-
ning 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.
8
The most common known cause is diabetes
Gastroparesisliterally paralyzed
stomachis a serious condition
manifested by delayed empty-
ing of stomach contents into the
small intestine after a meal. There
is no cure for gastroparesis, but
treatment can speed gastric
emptying and relieve gastrointes-
tinal symptoms such as nausea
and vomiting.
Who gets gastroparesis?
Gastroparesis most often occurs
in people with type 1 or type 2
diabetes, especially those who
have had diabetes for more
than 10 years. (About half of all
patients with diabetes may devel-
op gastroparesis.) But diabetes
isnt the only cause of gastropa-
resis. Other possible causes are:
postviral syndromes
anorexia nervosa
surgery on the stomach or
vagus nerve
medications that slow contrac-
tions in the intestine, particularly
anti-cholinergics and narcotics
smooth muscle disorders, such
as amyloidosis and scleroderma
nervous system diseases,
including abdominal migraine
and Parkinsons disease
metabolic disorders, including
hypothyroidism
What are the symptoms?
The symptoms of gastroparesis
include a feeling of fullness too
soon after you start eating, bloat-
ing, heartburn, upset stomach,
nausea and vomiting. These
symptoms may be constant or
may flare up from time to time
with periods of relief in between.
Some patients have no overt
symptoms of gastroparesis and,
in people with diabetes, the only
sign may be difficulty controlling
blood glucose. This poor blood
glucose control in people with
diabetes can lead to diabetic
complications, such as eye,
kidney and nerve problems.
If the gastroparesis remains
untreated, it can lead to additional
complications, including malnutri-
tion, dehydration and electrolyte
imbalances.
How is it diagnosed?
The gold standard for diagnosing
gastroparesis is a test called
gastric emptying scintigraphy.
During this study, patients have
their stomach scanned after
ingesting solid food containing a
radioactive substance to observe
how quickly the radioactive iso-
tope leaves the stomach.
Other tests to detect delayed
gastric emptying include a radio-
isotope breath test (to detect
levels of carbon dioxide in the
breath), ultrasonography (a non-
invasive technique that uses
sound waves to evaluate gastric
function) and an upper gastro-
intestinal series (in which X-rays
are taken of the stomach after the
patient drinks a barium-containing
Gastroparesis: Delayed Stomach Emptying
Diagnosis of dysphagia
Your doctor will try to identify your particular swallowing prob-
lem. Difficulty swallowing both liquids and solids usually results
from a mo tility 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
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.
9
liquid). Also available is the Smart-
Pill, a small electronic device in
capsule form that is swallowed
and moves through the entire
digestive tract, sending informa-
tion to a cell-phone-sized receiver
worn around the persons waist
or neck. The recorded information
provides a detailed record of how
quickly food travels through each
part of the digestive tract.
How is it treated?
Treatment of gastroparesis is
often twofold. Health care provid-
ers aim first to improve gastric
emptying and control symptoms
and second to treat the underly-
ing disease causing gastropare-
sis, if present.
Treatments that target the
digestive system. People with
gastroparesis should eat a diet
low in fat and fiber. Fat slows the
emptying of the stomach, and
some high-fiber foods can remain
in the stomach for a long time.
(High-fiber foods to avoid include
apples, berries, Brussels sprouts,
coconuts, green beans, figs and
oranges.) Also, eating six small
meals a day, rather than three
large ones, may allow the stom-
ach to empty its contents more
easily. Some people may benefit
from replacing some solid meals
with liquid meals, which pass
through the stomach more easily.
A number of medications are
somewhat effective in promoting
gastric emptying and relieving
the nausea and vomiting. These
include metoclopramide (Reglan,
Metozolv ODT), erythromycin
(ERY-C and other brands), cisap-
ride (available in the United States
only through a restricted program
with the manufacturer because of
rare but dangerous side effects)
and domperidone (not available in
the United States).
Other medications known as
anti-emetics are used to directly
target symptoms such as nausea
and vomiting, if needed. Doc-
tors may also recommend use
of a device called Enterra, which
provides intermittent or continu-
ous stimulation to the stomachs
muscles via electrodes implanted
under the skin that covers the
stomach. The treatment can
improve symptoms but has little
effect on gastric emptying.
Treatments to improve the
underlying disease. Achieving
better control of blood glucose
can minimize symptoms of gas-
troparesis caused by diabetes.
This is often difficult because the
delayed gastric emptying causes
food to be absorbed at unpre-
dictable times. To overcome
this difficulty, patients may need
more frequent insulin injections
and may need to inject insulin
after, rather than before, meals.
Similarly, taking medication to
increase thyroid levels can relieve
gastroparesis symptoms resulting
from hypothyroidism. n
Treatment of dysphagia
The treatment of dysphagia depends on what is causing the prob-
lem. 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 gradu-
ally stretched using special dilators or a balloon inserted through an
en doscope and inflated. Surgery or radiation therapy may be neces-
sary 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. Ther apy may involve special exercises,
body positions and other techniques to improve your ability to swal-
low. 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. Nor-
mally, the lower esophageal sphincter at the bottom of the esoph-
agus is aligned with this opening in the diaphragm (the hiatus).
The rest of the esophagus is located above the dia phragm 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 per-
cent 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 dia phragm 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.
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 pres-
sure in the abdominal cavity. Risk factors for a hiatal hernia include
being overweight and lifting heavy objects.
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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
esoph a geal sphincter is significantly displaced from its normal posi-
tion 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 endos-
copy. If a hiatal hernia is not causing symptoms, treatment isnt need-
ed. 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 backwards into your esophagus. This phenom-
enon, 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 reflux
then, 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 indi-
viduals 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 adja-
cent 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
11
LATEST RESEARCH
Study Reports Unnecessary
Use of Acid Reflux Drugs
A substantial proportion of peo-
ple who take acid suppressive
medications known as proton
pump inhibitors (PPIs) continue
taking the drugs even after tests
show they do not actually have
gastroesophageal reflux disease
(GERD).
Researchers analyzed data on
90 patients whose endoscopic
results and pH tests showed
they had no evidence of GERD,
to find out how many of them
were using PPIs. The research-
ers wanted to identify reasons
patients might continue to take
drugs for a condition they dont
have.
More than 40 percent of the
patients reported ongoing PPI
usein essence, taking drugs
that can be costly and, although
generally well tolerated, are not
without some risk of side effects,
to treat a (for them) nonexistent
disease. Furthermore, only 17
of these patients recalled being
instructed by their doctor to stop
taking the drugs.
This is not to suggest that
these patients do not suffer from
some other gastrointestinal ail-
ment; the study found that those
taking a PPI were more likely
than those not taking one to
report troublesome symptoms
affecting their daily life. People
who test negative for GERD
may want to talk with their doc-
tors about pursuing alternative
treatments for controlling symp-
toms that cause discomfort and
impede their quality of life.
CLINICAL GASTROENTEROLOGY AND
HEPATOLOGY
Volume 10, page 620
June 2012
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 inac-
tivate 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 esoph a geal 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 recent survey of 43,000 people found that smoking and exces-
sive use of table salt can increase the risk of GERD by 70 percent. A
2005 study found that a diet high in calories and fat (especially satu-
rated 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 chan-
nel blockers (for angina or high blood pressure), nonster oidal
anti-inflammatory drugs (NSAIDs, for arthritis and pain), bis-
phosphonate drugs (for osteoporosis), some medications to treat
meno pausal 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 regurgi-
tation of undigested food from the stomach into the esophagus and
mouth. Acid from the stomach can even regurgitate into organs con-
nected to the esophagus, such as the larynx, trachea and lungs. This
acid exposure can cause voice changes such as hoarseness, a chronic
cough, epi sodes of asthma or pain behind the sternum bone that
resembles a heart attack. In some cases people with GERD experi-
ence these symptoms instead of heartburn and regurgitation, making
diagnosis and treatment more difficult.
The chest pain associated with an intense episode of heartburn
12
13
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
backwards) into the esophagus. But about 10 to 15
percent of people with GERD do not have heart-
burn. 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
Asthma
Chronic cough
Chest pain
Laryngitis (hoarseness,
frequent throat clearing,
sore throat, difficulty
swallowing)
You and your doctor should suspect GERD if
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
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
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 symptoms continue despite rest, fluids and treatment
with a corticosteroid or antibiotic
The symptoms continue even though you dont smoke, drink alco-
hol or use your voice excessively, and you dont have a cold, the
flu, postnasal drip or allergies
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 bit-
ter 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 up per endoscopy as
well as other tests to measure the motility and pH (acid concentra-
tion) of your esophagus.
Treatment of GERD
There are four types of treatments for GERD: lifestyle measures,
medication, surgery and endoscopic procedures. Treating GERD is
important. Untreated GERD can lead to serious complications, such
as esophageal ulcers (nonhealing mucosal defects), esoph a geal stric-
tures, Barretts esophagus (a disorder of the cells lining the esoph-
ageal 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 can irritate an inflamed esophagus. Peppermint, spear-
mint, chocolate, cinnamon, coffee and tea can reduce the pressure
in the lower esophageal sphincter and promote reflux. Carbon ated
beverages can worsen reflux by increasing pressure in the stomach.
Conflicting studies about the effects of these foods on GERD, how-
ever, have cast some doubt on the subject.
The only lifestyle interventions that consistently relieve GERD
symptoms are sleeping with the head of the bed elevated and losing
weight. It also may help to avoid lying down for three hours after a
14
15
meal; eat small, frequent meals instead of fewer, larger ones; and
wear loose-fitting clothing.
Medication. If lifestyle modifications do not eliminate all of your
symptoms, your doctor will recommend that you take medication to
neutralize or decrease acid production in the stomach. These medica-
tions include antacids, histamine H
2
-receptor antagonists (also known
as H
2
-blockers), foaming agents, mu cosal protectants, proton pump
inhib itors and promotility agents. 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 ox ide,
magnesium carbonate and sodium bicarbonate (for example, Gavis-
con, Gelusil, Maalox, Mylanta) rapidly neutralize stomach acid and
are taken after meals when you experience heartburn. These medica-
tions provide fast relief, but their effect is short lived.
H
2
-blockers. Over-the-counter or prescription H
2
-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 combina-
tion antacid/H
2
-blocker, Pepcid Complete, also appears to be more
effective at re lieving symptoms than H
2
-blockers or antacids alone.
Mucosal protectants. A prescription mucosal protectant called
sucralfate (Carafate), which is taken one hour before a meal, coats
the esophagus and increases its resistance to reflux from the stomach.
Proton pump inhibitors. These prescription drugs, which include
esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilo-
sec, Zegerid), pantoprazole (Protonix), rabeprazole (Aciphex), dex-
lansoprazole (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.
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.
Promotility agents. The effects of H
2
-blockers and proton pump
inhibitors can be enhanced by taking a promotility agent, such as
metoclopra mide (Reglan) or bethanechol (Urecholine). This type
of medication in creases acid clearance from the esophagus, raises
the pressure of the lower esoph ageal sphincter, and speeds empty-
ing of the stomach.
LATEST RESEARCH
GERD Can Contribute to
Tooth-Surface Loss
Besides damaging the tissues
of the esophagus, chronic
exposure to acid associated
with gastroesophageal reflux
disease (GERD) can also cause
harm farther up the alimentary
canal by contributing to ongoing
erosion of dental surfaces.
To examine the impact
of GERD on tooth surfaces,
researchers used an optical
scanner to analyze replicas of
dental impressions from 12
people with GERD and six peo-
ple without GERD, comparing
volumes of tooth enamel loss in
both groups. The analysis was
conducted at two intervals six
months apart.
Over that half-year period,
subjects with GERD expe-
rienced significantly greater
volume loss than those without
GERD. This erosion was seen
on both the front and back of
teeth, and was twice as high on
surfaces where teeth come into
contact with each other, when
there already was evidence of
wear.
Dental erosion can progress
quickly in people with GERD.
People with GERD may want to
consult with their dentist and
should work with their physician
to control GERD and minimize
further dental damage.
THE JOURNAL OF THE AMERICAN
DENTAL ASSOCIATION
Volume 143, page 278
March 2012
16
Prescription Drugs for the Treatment of Gastroesophageal Reux Disease 2013
Typical daily
dosages*
20 mg
30 mg
20-40 mg
15-30 mg
20 mg
40 mg
Capsule: 40 mg/1,100 mg
Powder: 20 mg/1,680 mg
300 mg
20-40 mg
1,600 mg
300 mg
40-60 mg
How to take
One 20 mg tablet 1x/day with or without

food. Swallow whole (do not crush, chew
or split).
One 30 mg tablet 1x/day with or without food.
One 20 or 40 mg capsule 1x/day at least 1
hour before a meal. Swallow whole.

One 15 or 30 mg capsule
in the morning 1 hour before eating. Swal-
low whole.

One 20 mg capsule 1x/day
1 hour before a meal. Swallow whole.

food. Swallow whole.
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.
One 150 mg capsule 2x/day with or with-
out food.
One 20 or 40 mg tablet 2x/day with or
without food.
Two 400 mg tablets 2x/day or one 400 mg
tablet 4x/day with food.
food.
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.
Drug type:
Brand (generic)
AcipHex (rabeprazole)
Dexilant (dexlansoprazole)
Nexium (esomeprazole)
Prevacid (lansoprazole)
Prilosec (omeprazole)
Protonix (pantoprazole)
Zegerid (omeprazole/
sodium bicarbonate)
Axid (nizatidine)
Pepcid (famotidine)
Tagamet (cimetidine)
Zantac (ranitidine)
Reglan, Metozolv ODT (metoclopramide)
Proton pump inhibitors

Histamine H
2
-antagonists (H
2
-blockers)
||

Promotility agent
17
Prescription Drugs for the Treatment of Gastroesophageal Reux Disease 2013
Precautions

PPI therapy may be associated with an increased risk for
osteoporosis-related fractures of the hip, wrist or spine.
Patients should use the lowest dosage and shortest dura-
tion 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.
Zegerid only: This medication contains sodium and thus
may not be appropriate for people on a low-salt diet. Long-
term 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.
Avoid alcohol, because it can add to the drowsiness side
effect.
Most common
side effects
Headache, diarrhea,
nausea, dizziness,
constipation. Dexilant
only: Stomach pain,
common cold, vomit-
ing, gas
Headache, dizziness,
diarrhea, constipation.
Diarrhea, drowsiness,
fatigue.
Call your doctor if...
You experience a skin rash, signs of a
B
12
deficiency (unusual weakness, sore
tongue, numbness or tingling of the
hands or feet), chest pain, dark urine,
severe stomach pain, fast or irregular
heartbeat.
You experience signs of liver problems:
unusual tiredness, persistent nausea or
vomiting, severe stomach or abdominal
pain, dark urine, yellowing eyes or skin.
You experience involuntary move-
ments of the eyes, face or limbs; muscle
spasms; trembling of the hands.
continued on the next page See next page for legend.
Surgery. Lifestyle measures and medications are so effective at
controlling reflux symptoms that few people need to undergo sur-
gery. When surgery is required, the most common procedure is Nis-
sen fundoplication. It involves lifting a portion of the stomach and
tightening it around the gastro eso ph ageal junction to increase pres-
sure in the lower esophageal sphincter and prevent reflux. The pro-
cedure 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 re ceive
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 complica-
tions 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 stomach bloating, difficulty swallow-
ing, 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.
18
Prescription Drugs for the Treatment of Gastroesophageal Reux Disease 2012 (continued)
Typical daily
dosages*
4 g
How to take
One 1 g tablet 4x/day on an

empty stomach (1 hour before
or 2 hours after each meal and
at bedtime).
Drug type:
Brand (generic)
Carafate (sucralfate)

Mucosal protectant
* 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.
A 2010 review of 32 studies on Nissen fundoplication and Toupet
fundoplication (a partial version of Nissen fundoplication) found that
Toupet fundoplication produced similar results to Nissen fundoplica-
tion but caused fewer side effects, such as dysphagia or gas bloating.
Furthermore, a fundoplication procedure called the Transoral
Incisionless Fundoplication (TIF) can be done without incisions by
going through the esophagus while the patient is under general anes-
thesia using a tool called the EsophyX. TIF is less painful and requires
less recovery time than a traditional Nissen fundoplication.
And yet another new procedure called magnetic sphincter aug-
mentation uses magnets to create a small ring around the gastro-
esophageal sphincter to help increase its pressure. The device used is
called the LINX Reflux Management System.
Endoscopic procedures. These procedures are performed during
an upper endoscopy on an outpatient basis and do not require inci-
sions, general anesthesia or a hospital stay like surgery does. However,
these procedures are relatively new and their long-term ef fectiveness
is not yet fully known.
One of these procedures is called endoscopic gastroplication,
and there are three types: the Bard EndoCinch system, the NDO
Plicator and the Stretta system. In the Bard EndoCinch procedure,
a gastroenterologist places a pair of stitches in the upper stomach
about a centi meter below the lower esophageal sphincter and pulls
19
Prescription Drugs for the Treatment of Gastroesophageal Reux Disease 2012 (continued)
Precautions

Can interfere with the absorption of other medications;
take other drugs 2 hours before or 2 hours after using
Carafate. Can be taken with an antacid, but take the
antacid 30 minutes before or after Carafate.
Most common
side effects
Constipation, dry
mouth, upset stomach.
You experience an unusual or persistent
feeling of fullness in the stomach, nau-
sea or vomiting, stomach pain (especi-
ally after meals).
the stitches together to form a pleat. Usually, two to four pleats are
created. By reducing the size of the opening between the stomach and
eso phagus, the pleats help prevent reflux of stomach contents into the
esophagus. A second procedure, full-thickness plication (or the NDO
Plicator procedure), places a stitch in the gastroesophageal junction
to prevent the reflux of acid into the esophagus.
In the Stretta procedure, a doctor delivers radio frequency ener-
gy to the far end of the esophagus as well as to the up per stomach,
creating multiple burns in the tissue there. As the tissue heals, it
contracts and narrows the esophagus, helping to reduce reflux. The
procedure works moderately well, but serious side ef fects, including
death, have been reported.
Esophageal Motility Disorders
In a healthy esophagus, peristalsis propels food and fluid down the
esophagus. Sometimes, however, these contractions become ineffec-
tive, 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 e ously, pre-
venting the normal, wave-like contractions from moving food and flu-
id down the esophagus. In achalasia, normal, wave-like 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 esopha-
geal spasm. Older age, being female and having GERD also may pre-
dispose you to having spasms.
Symptoms of esophageal motility disorders
People with diffuse esophageal spasm experience intermittent epi-
sodes of dysphagia (difficulty swallowing), usually with both liquids
and solids, as well as pain behind the breastbone. People with achala-
sia 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 peri-
stalsis as well as persistent elevated pressure in the lower esophageal
20
21
sphincter (indicating that the sphincter muscle cannot relax). With
diffuse esophageal spasm, mano metry will show intense contrac-
tions 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 move-
ment of barium through the esophagus. Barium X-rays in people with
achalasia often reveal widening of the upper portion of the esopha-
gus 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 peo-
ple re quire 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. Bo tox is
injected into the lower esophageal sphincter to paralyze and relax it.
Because the effects of Botox appear to be temporary, it is only recom-
mended for people who are not good candidates for endoscopic dila-
tion or surgery.
Heller myotomy is the surgical procedure for achalasia. In this
procedure, a doctor makes an incision through the muscle of the
lower eso phageal sphincter to weaken it. It can be done using a trad-
itional surgical approach (making a large incision in the abdomen) or
through small incisions in the abdomen (laparo scopy) or chest (tho-
racoscopy). In rare cases, doctors may perform an esophagectomy
(removal of part or all of the esophagus).
Drugs such as calcium channel blockers, nit rates, 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
LATEST RESEARCH
Chemo Before Esophageal
Surgery May Improve
Outcomes
Preoperative chemotherapy
may improve the odds of sur-
vival in people with esophageal
cancer, with a relatively accept-
able degree of side effects.
Past studies examining the
role of neoadjuvant chemo-
therapy (therapy preliminary to
surgery) in patients with esoph-
ageal or esophagogastric-
junction cancer (where the
esophagus connects to the
stomach) had found little sur-
vival benefit. But many of those
trials were criticized for being
flawed by poor trial design.
To further examine this issue,
researchers recently compared
the outcomes of 178 patients
given preoperative chemother-
apy with those of 188 patients
who had surgery alone. Patients
in the first group were randomly
assigned to receive five weekly
intravenous doses of carbopla-
tin and paclitaxel with radio-
therapy followed by surgery.
Patients in the chemotherapy
group experienced a median
overall survival of nearly 50
months, compared with 24
months in the surgery alone
group. This five-course regimen
of preoperative chemotherapy,
which was administered on an
outpatient basis, appeared to
be well tolerated.
THE NEW ENGLAND JOURNAL OF
MEDICINE
May 2012
ongoing difficulties in swallowing solid food, and the problem gradu-
ally worsens over time.
Diagnosis and treatment of esophageal stricture
An upper endoscopy must be performed to obtain a tissue sam-
ple 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 eso phagus, 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 flat-
tened, 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 intes-
tine. A 2008 study 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 tongue-
like protrusions above the gastroesoph a geal junction. Samples of
tissue (called biopsy samples) are taken from these projections and
ex amined under the microscope to look for precancerous changes
called dysplasia.
Treatment of Barretts esophagus
Barretts esophagus increases the risk of esopha geal cancer. In fact,
about 0.5 percent of people with Barretts esophagus develop can-
cer of 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.
If biopsies indicate severe dysplasia or esophageal cancer, sur-
gery is usually performed. Most of the esophagus is removed, and the
22
stomach is pulled up into the chest cavity and attached to what
remains of the esophagus.
However, new guidelines suggest that an alternative to surgery
may be endoscopic mucosal resection. This procedure can be used to
remove any nodules or small polyps that are seen during a traditional
endoscopy. The doctor injects a solution into the nodule that forms a
blister under it and decreases bleeding. The nodule is then lifted up
while a wire loop cauterizes it from underneath and removes it.
A less invasive option is photodynamic therapy, a relatively new
treatment that uses a light-sensitizing agent (such as Pho to frin) plus
a laser to kill sensitized cancerous and precancerous cells. The light-
sensitizing agent is injected into a vein. When the agent is exposed to
the laser, it produces a chemical reaction that destroys the cancerous
and precancerous cells. In a recent study, individuals who underwent
photodynamic therapy were more likely to have a complete reversal
of their dysplasia than people who did not receive the therapy. Two
years after treatment with Photofrin, only 20 percent of these patients
23
Protect Yourself from Esophageal Cancer
Although esophageal cancer
is relatively rare in the United
States, the number of individuals
who are diagnosed with can-
cer of the esophagus is rapidly
increasing.
Forty years ago, only four in
one million people were diag-
nosed with esophageal adenocar-
cinomathe most common type
of esophageal cancercompared
with 23 in one million people in
2001.
While the exact cause of
esophageal cancer is unknown,
research suggests that the follow-
ing measures may help reduce
your risk:
Turn your back on tobacco.
Because smoking damages
the DNA in the cells lining your
esophagus, smoking significantly
increases your risk of cancer.
Eat more vegetables and
fruits. About 15 percent of
esophageal cancers can be linked
to a diet low in fruits and veg-
etables, according to the Ameri-
can Cancer Society. Eating these
foods raw may offer even more
protection.
Hold off on hot liquids.
Drinking very hot liquids may
damage esophageal cells, poten-
tially leading to cancer, according
to some studies.
Reduce alcohol consump-
tion. Research shows that people
who drink more than three alco-
holic beverages a day are more
likely than nondrinkers to develop
cancer of the esophagus.
Maintain a healthy weight.
Being obese, especially around
the abdomen, has been linked to
esophageal cancer.
Get a grip on GERD. If you
have gastroesophageal reflux
disease (GERD), the constant
exposure of your esophageal lin-
ing to stomach acids and bile can
seriously damage your esophagus,
possibly causing esophageal can-
cer. Having Barretts esophagus,
a complication of GERD, further
increases esophageal cancer risk.
If you have GERD or Barretts
esophagus, schedule an upper
endoscopy on a routine basis to
look for precancerous changes in
the lining of your esophagus, and
be sure to follow all of your doc-
tors treatment recommendations.
For more information on manag-
ing GERD, order the Johns Hop-
kins Digital Special Report at
www.johnshopkinshealthalerts.
com/dsr n
Lifestyle changes may improve your odds of preventing this rare but life-threatening cancer
had cancer, compared with 50 percent of those who did not receive
the therapy. The risks of photodynamic therapy include esophageal
strictures and temporary sensitivity to the sun.
Two new ablation therapieswhich use heat or radiofrequency
energy to destroy the abnormal cells on the esophageal wallsshowed
promise in a 2006 clinical trial. About 70 percent of participants who
had radiofrequency ablation or argon plasma coagulation benefited,
but these procedures are still considered experimental.
Gastritis
Gastritis occurs when the gastric mucosa, the inner lining of the stom-
ach, becomes inflamed.
Causes of gastritis
Gastritis has many causes, including infections, medications, autoim-
mune 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 overproduc-
tion of gastric acid, which increases the risk of developing peptic
ulcers (ulcers in the stomach or duodenum; see pages 25-28) and
gastric cancer.
The medications that most often cause gastritis are nonsteroi-
dal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen
(Ad vil, Mo trin) and naproxen (Aleve, Naprosyn). NSAIDs inter-
fere with the 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 also to the development of erosions (superfi-
cial 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 tradi-
tional NSAIDs. However, not all studies have shown COX-2 inhib itors
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
24
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 inflamma-
tion, 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 pro-
duction and protect the lining of the stomach. (See the chart on
pages 16-19.)
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 duode-
nal 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.
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.
25
ASK THE DOCTOR
Q. Should I take a daily
aspirin as preventive therapy
for heart disease? Ive read
that aspirin has side effects,
such as gastrointestinal
bleeding.
A. Many people take a daily
low-dose aspirin to reduce
their risk for cardiovascular dis-
ease (CVD). The benefit, how-
ever, may be modest at best in
people without symptoms or a
history of CVD, and long-term
aspirin use carries a risk of side
effects, especially gastrointes-
tinal bleeding.
Researchers examined data
on 186,425 subjects taking
low-dose aspirin, and an equal
number of matched controls.
Their findings, published in the
Journal of the American Medical
Association in 2012, determined
that aspirin use was significantly
associated with an increased
risk of major gastrointestinal
bleeding episodes. Those taking
aspirin also had an increased
risk of cerebral hemorrhaging
(which can lead to a stroke).
The rise in excess hemor-
rhaging associated with aspirin
consumption was about the
same magnitude as the number
of cardiovascular events avoid-
ed by people taking daily low-
dose aspirin. The researchers
concluded, therefore, that the
potential harm associated with
aspirin use might well outweigh
its benefit.
Given the side effects asso-
ciated with long-term aspirin
use, youll want to discuss your
individual risk for cardiovascular
disease with your doctor before
embarking on this preventive
regimen.
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. Be cause 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 duo-
denum. 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 duode-
num, 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 ap pears as a round
or elongated defect in the lining of the stomach or duo denum. On an
upper GI series, barium accumulates in side the ul cer or shows chang-
es in the normal appearance of the folds of the lining (such as conver-
gence 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 H
2
-blockers and proton pump inhibi-
tors. Ulcers often return once these drugs are stopped.
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 anti biotics and acid-reducing medications.
Usually doctors first prescribe triple therapy, which consists of a pro-
ton pump inhibitor and two antibiotics.
If triple therapy does not produce a cure, a second triple therapy
26
27
Drug Regimens for Treatment of Peptic Ulcers 2013
Regimen
Triple therapy
(two antibiotics
and one proton
pump inhib itor
for 7-14 days.
The duration
of the regimen
in cluding Aci-
pHex is 7 days;
the duration of
the other regi-
mens is 10-14
days.)
Quadruple
therapy
(bismuth, two
antibiotics and
one proton
pump inhibitor
or H
2
-blocker
for 14 days)
Combination
products
Medications
1) Biaxin (clarithromycin)
2) amoxicillin or
metronidazole
3) AcipHex (rabeprazole) or
Nexium (esomeprazole) or
Prevacid (lansoprazole) or
Prilosec OTC (omeprazole) or
Protonix (pantoprazole)
1) Pepto-Bismol (bismuth
subsalicylate)
2) metronidazole
3) tetracycline
4) proton pump inhibitor
(AcipHex, Nexium, Prevacid,
Prilosec OTC, Protonix,
Zegerid) or
Axid (nizatidine) or
Pepcid AC (famotidine) or
Tagamet (cimetidine) or
Zantac 150 (ranitidine)
Helidac
(bismuth/metro nidazole/
tetracycline) for 14 days
Prevpac
(amoxicillin/Biaxin/Prevacid)
for 14 days
Dosage
One 500 mg tablet 2x/day.
Two 500 mg capsules 2x/day.
One 40 mg capsule 1x/day.
Two 262 mg tablets 3-4x/
day or 30 mL liquid 3-4x/
day.
Same as for triple therapy
(see above).
Chew two 262 mg bismuth
tablets, then swallow one
250 mg metronidazole tablet
and one 500 mg tetracycline
capsule with a glass of water
4x/day (at breakfast, lunch,
dinner and bedtime).
Swallow two 500 mg amoxi-
cillin capsules, one 500 mg
Biaxin tablet and one 30 mg
Prevacid capsule 2x/day
before eating.
Side effects/precautions
Biaxin, amoxicillin, metronidazole: Side
effects include diarrhea, nausea, vomiting,
stomach upset, changes in taste, headache.
Call your doctor immediately if you experi-
ence persistent diarrhea, ab dominal pain
or cramping, blood or mucus in your stool.
Biaxin only: Take with milk if stomach upset
occurs. Amoxicillin only: Drink plenty of liq-
uids. Metronidazole only: Avoid alcohol while
taking and for at least one day after finishing
the medication.
Proton pump inhibitors: See the chart on
pages 16-19.
Bismuth: May cause stools to be come
gray-black.
Metronidazole: See above.
Tetracycline: Makes skin more sensitive to
sunlight. Wear sunscreen.
Proton pump inhibitors: See the chart on
pages 16-19.
H
2
-blockers: See the chart on pages 16-19.
Side effects include nausea, diarrhea,
abdominal pain. Do not take if you have kid-
ney or liver problems. For other precautions,
see separate entries for bismuth, metronida-
zole and tetracycline.
Side effects include diarrhea, headache,
changes in taste. For precautions, see sepa-
rate entries above for amoxicillin, Biaxin and
proton pump inhibitors.
containing different drugs may be tried. Another option is quadru-
ple therapy: bismuth subsalicylate (Pepto-Bismol and other brands),
two an tibiotics and a proton pump inhibitor or H
2
-blocker (see
the chart on page 27). 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 re cur. 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 vagoto-
my. 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 medi-
cation, surgery is rarely needed. Sur gery 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 pro gress 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 pan creas, 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 func-
tions is to make a substance called bile (composed mostly of biliru-
bin, 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 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 liv-
er. Between meals, it stores and concentrates bile, which is produced
28
at a constant rate by the liver. When it is not full of bile, the gall-
bladder is about 3 inches long and 1 inch wide at its thickest part.
After meals, the gallbladder re leases 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 cause
liver injury or hepatitis (alcoholic hepatitis). Certain medica-
tions (such as isoniazid [Laniazid, Nydrazid] to treat tuberculosis,
methyldopa to treat high blood pressure and amiodarone [Cord-
arone, Pacerone] to treat irregular heart rhythms) result in liv-
er injury in susceptible individuals. (See Medication and Your
Liver on pages 30-31.) 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 com-
mon cause of chronic liver disease.
29
LATEST RESEARCH
Fish May Prevent Liver
Cancer in Those at Highest
Risk
The consumption of fish and
the types of fatty acids found
in fish may protect against the
development of liver cancer,
even in people who have hepa-
titis B virus (HBV) or hepatitis C
virus (HCV) infection, according
to the results of a recently pub-
lished study.
Intake of fish and n-3 poly-
unsaturated fatty acids (PUFAs)
has been shown to protect
against some types of cancers,
but its role in prevention of
hepatocellular carcinoma, for
which chronic infection with
HBV or HCV is a major risk fac-
tor, has been unclear.
To examine the effect of fish
and n-3 PUFA consumption on
liver cancer, researchers stud-
ied the dietary habits of more
than 90,000 Japanese subjects
ages 45 to 74 over more than a
decade. During that time, about
400 people developed hepato-
cellular carcinoma. The partici-
pants completed 138-question
surveys that included 19 ques-
tions specific to the frequency,
amounts and types of fish they
ate.
Those who ate the most n-3
PUFA-rich fish, such as salmon,
mackerel, trout, sea bream and
eel, had the lowest incidence
of hepatocellular carcinoma.
This inverse association held
true even in subjects who were
infected with HCV or HBV.
GASTROENTEROLOGY
June 2012
Viral hepatitis
Viral hepatitis is caused most often by one of five viruses: A, B, C,
D or E. About 22,000 new cases of hepatitis A, 38,000 new cases of
hepatitis B and 18,000 new cases of hepatitis C occur each year in
the United States. The other types rarely occur in the United States.
30
Awareness is key to protecting yourself from drug-induced injury
Your liver is a multitasker, handling
a wide range of important bodily
functions. It stores nutrients for
your body, creates bile to help
you digest food and produces
substances that aid in blood clot-
ting. However, its probably more
commonly known as a gatekeeper
of sortseverything you consume
is processed by your liver, and
its up to this organ to weed out
potentially harmful substances,
such as toxins and medications,
from what nourishes your body.
In the course of doing its job, the
liver sometimes suffers damage.
In the United States, injury
caused by medication is the most
common cause of acute liver dam-
agethat is, damage that comes
on suddenly. While efforts are
made to ensure the safety of med-
ications before theyre introduced
to the marketplace, the reality is
that some approved drugs still
may cause harmand liver dam-
age (which in rare cases can lead
to liver failure) is the number-one
reason a particular medication is
pulled from the shelves.
The watch list
The list of medications that are
potentially detrimental to the liver
is long and varied. Among the
products implicated are:
Acetaminophen. Found in
more than 600 medications, it
is the active ingredient in such
common, over-the-counter fever-
and pain-relieving products as
Tylenol, as well as prescription
medications such as Percocet
(prescription medications may list
acetaminophen as APAP on the
label). Acetaminophen is the most
common source of medication-
induced liver damage, according
to research. You run the risk of
liver damage by taking acetamino-
phen in quantities greater than
directed, in multiple medications
containing acetaminophen, or
while consuming three or more
alcoholic drinks daily.
Dietary supplements. They
may be considered natural, but
supplements are not necessarily
safe, as research has determined.
In fact, certain herbal supple-
mentsincluding chaparral, com-
frey tea, kava, skullcap and yohim-
beare known to be toxic to the
liver. In excessive amounts, iron
and vitamin A can both cause seri-
ous damage to the liver as well.
Cholesterol medications. Sta-
tins have the potential to cause
liver damage, although its rare.
Statins used to come with a Food
and Drug Administration (FDA)
recommendation that patients
undergo periodic liver-enzyme
monitoring to ensure no problems
were developing. However, the
FDA lifted this recommendation in
2012, finding that this occasional
testing didnt seem to help in pre-
dicting those patients who were
susceptible to liver damage from
the medication. Instead, the agen-
cy now recommends testing to
determine liver function only when
you begin taking a statin or switch
to a new one. Testing at other
times is recommended only if you
start experiencing problems.
Signs of possible injury
Medication-induced damage to
the liver ranges from mild injury to
liver failure. If youre experiencing
unusual fatigue, itchiness, loss of
appetite, upper right abdominal
discomfort, dark urine or jaundice
(yellowing) of the skin or whites of
the eyes, call your physician right
away. Many people do not exhibit
symptoms, however, and signifi-
cant injury to the liver can occur
before symptoms appear.
Damage can be detected using
a series of blood tests, referred to
as a liver panel. Slight elevations in
these tests do not necessarily indi-
cate liver damage; levels three to
five times the normal level indicate
a problem.
Besides the medications
themselves, various factors can
increase your chances of develop-
ing liver problems:
Age. In general, increased age
is a risk factor for drug-induced
Medication and Your Liver
31
Hepatitis A is spread through contact with saliva or feces of some-
one who has the virus, or ingestion of food or water contaminated
with the virus. Hepatitis A is transmitted rarely through sexual con-
tact. Hepatitis B is transmitted through tainted blood that enters
the body via contaminated needles (illegal injection drug use or
liver injury because theres an
increased likelihood of older
people taking more than one
medication.
Gender. Women appear to be
more susceptible, for reasons
that arent clear.
Concurrent drugs. Combina-
tion treatment with multiple
medications can raise your risk.
Other health problems. Alco-
holism, diabetes, HIV infection,
obesity or underlying liver dis-
ease such as hepatitis C infec-
tion can affect the way your liver
processes medication.
Genetics. Heredity plays an
important role in your suscepti-
bility to liver injury.
Taking precautions
Spotting liver problems early on
is the best way to minimize any
damage. To accomplish this,
your physician may recommend
occasional monitoring of your liver
function through blood testing,
depending upon the medication
youre taking.
The first course of action when
medication-induced liver damage
is detected is to discontinue tak-
ing the offending medication. (If
youre worried about your medica-
tion and liver toxicity, make sure to
discuss your concerns with your
physician. Do not simply stop tak-
ing your medication.)
In the early stages of liver
damage, other medicines may
sometimes be used to try to rid
the body of the toxin. In severe
cases, liver transplantation may
be required.
Here are some suggestions for
preventing potential liver damage:
Inform your doctor. Let your
physician(s) and pharmacist know
about any prescription or nonpre-
scription drugs, herbs, vitamins
and supplements youre taking.
Read labels. Prescription
medication instructions are usu-
ally clear about when and how to
take the medicine. For over-the-
counter drugs, make sure youre
not taking more than the recom-
mended dosage. If youre taking
multiple medications, check for
similar ingredients in each of them
to avoid an overdose.
Watch your alcohol intake.
Adhere to instructions about limit-
ing or avoiding alcoholespecially
if you are taking acetaminophen.
If you already have liver disease,
make sure all physicians treating
you know about it. Consult your
primary care physician before
starting any new medication. n
Liver Inflammation: A Drug Checklist
One of the most common types of liver damage is drug-induced
hepatitisinflammation of the liver triggered by certain medications.
The inflammation can occur within days of taking a medicine or
supplement, but it can also develop even after months of using the
medicine or supplement.
Drugs that can lead to liver inflammation include:
Amiodarone (Cordarone, Pacerone)
Anabolic steroids
Birth control pills
Chlorpromazine (Thorazine)
Erythromycins
Halothane (Fluothane)
Methyldopa
Nonsteroidal anti-inflammatory drugs
Isoniazid (Laniazid, Nydrazid)
Methotrexate (Rheumatrex, Trexall)
Sulfonamides
Tetracyclines
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. Hep-
atitis 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.
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.
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. How-
ever, 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 anti-
bodies to the hepatitis B virus) immediately after exposure can sig-
nificantly reduce infection risk.
Chronic hepatitis B (lasting longer than six months) can be treat-
ed 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 riba-
virin, which results in clearance of the virus in up to 50 percent of
people with the most common genotype. Unfortunately, side effects
32
33
are common with this regimen and in clude worsening of heart dis-
ease, retinal detachment, flu-like symptoms, depression, anemia and
alopecia. In 2011, the FDA approved two drugs for the treatment of
chronic hepatitis C: boceprevir (Victrelis) and telaprevir (Invicek).
Each drug is to be used only in combination with pegylated interferon
and ribavirin. 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 low-salt 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 (beta-blockers) or endoscopic
treatment. If these complications fail to respond to medication, a liver
transplant may be necessary.
Gallstones
Gallstones are small, pebblelike substances that develop in the gall-
bladder. An estimated 25 million people in the United States have
gallstones. Wo men are twice as likely as men to have them. In fact,
LATEST RESEARCH
Aspirin May Protect Against
Several GI Cancers
Taking aspirin every day may
significantly reduce the risk of
several cancers that affect the
gastrointestinal system and
prevent their spread to distant
organs or lymph nodes, a recent
analysis has confirmed.
Long-term randomized tri-
als have already established an
association between aspirin con-
sumption and a reduction in the
incidence of colorectal and other
types of cancers. Those trials,
however, were not designed
to examine the effect of aspirin
on less common cancers and
cancers specific to women.
Researchers sought to deter-
mine aspirins preventive effect
on these other types of cancers
through the interpretation of
observational studies.
When the researchers com-
pared data from observational
studies with data from recent
randomized trials, findings were
consistent regarding the effect
of daily aspirin use: It reduced
the long-term risk of several
cancersincluding colorectal,
esophageal, gastric, biliary and
breast cancerand reduced the
risk of distant metastases (can-
cers that have spread to distant
organs or lymph nodes).
With cancer on the rise glob-
ally, inexpensive chemopreven-
tion for certain risk groups is
appealing. However, further
detailed analyses are needed
before recommendations can be
made, particularly because aspi-
rin therapy has side effects.
THE LANCET ONCOLOGY
Volume 13, page 518
May 2012
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 per-
cent of men have had gallstones by age 75.
There are two types of gallstones. Nearly 80 percent are cholester-
ol gallstones, which are made up mostly of cholesterol. The re maining
20 percent are black- or brown-pigment gallstones, which have a much
lower cholesterol content and are primarily made of bilirubin (a com-
ponent 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 Scan-
dinavian ancestry); age (older than age 50); obesity; pregnancy; use
of medications such as postmenopausal estrogen, oral contra ceptives
or the antibiotic ceftriaxone (Rocephin); prolonged intra ve nous feed-
ing; rapid weight loss; and diseases of the terminal ileum (the last por-
tion of the small intestine, which is responsible for reabsorption of
bile acids from the bowel into the blood). A 2008 study suggested that
a deficiency of magnesiuman essential mineral found in green veg-
etables, 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 symptom-
free 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
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.
34
35
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 cho-
langitis (inflammation of the bile ducts). Gallstones that lodge in
the major duodenal papilla (a small elevation in the second por-
tion 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 37-38), 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 gall-
bladder (perforation). Symptoms of acute cholecystitis include severe
pain, fever, nausea and vomiting. The pain is located below the bot-
tom 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 abdomi-
nal 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
ab do men. 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 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 radioac-
tive 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 side-
viewing endoscope to locate the opening to the duodenum and to
place a thin catheter in the bile ducts. A contrast agent is then inject-
ed 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 proce-
dure, 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 treat-
ment. 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 recur-
rences. Nearly all cholecystectomies are performed by laparosco-
py, which decreases the amount of pain following the sur gery and
allows for a faster recovery than traditional open sur gery. During
laparoscopic cholecystectomy, the surgeon may explore the com-
mon 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 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.
36
Acute cholecystitis usually requires a hospital stay. Fluids and
nu trients 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 re moved. 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 abdo men. 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. About 210,000 people in
the United States suffer a bout of acute pancreatitis each year. 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 medica-
tions (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 para thyroid gland or a
stomach in jury 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 bruis-
ing on your stomach from internal bleeding. You may also go into
shock. 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
37
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 com-
pletely rest your intestinal tract (that is, no food by mouth) and to
receive intravenous fluids, anti biotics and pain killers. 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 like-
ly 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 approxi-
mately 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 con-
tract 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.
When food reaches the duodenum, it begins to get broken down
by digestive enzymes and bile. This process turns proteins into ami-
no acids, fats into fatty acids, and carbohydrates into simple sugars.
The digested food then moves into the jejunum, where most of its
38
39
nutrients are absorbed. Vitamin B
12
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 mate-
rial 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 rec-
tum, 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, vir-
tual 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 diges-
tive 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
your bowel. If a colon oscopy (see page 41) cannot be performed, a
barium enema may be used to diagnose in flam ma tory 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 gen-
tly 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 radiolo-
gist 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 complica-
tions, 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 intes-
tine) 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 (ab normal 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 a sigmoid oscopy. More serious
complications, such as excessive bleeding and perforation of the
colon or rectum, can occur but they are rare.
40
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 dur-
ing 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 with-
drawn, 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 lin-
gering effects of the sedative. It is common to have gas after the
procedure and to have minor rectal bleeding if a biopsy was per-
formed. Serious complications are rare (occurring in fewer than
0.1 percent of all colonoscopies) and can include excessive bleed-
ing, 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 view-
ing tube into the colon and rectum, a CT scan of the abdomen
is done to obtain two- and three-dimensional images of the in tes-
tines. Because the test will cause only minor discomfort, sedation is
not needed.
You might be wondering why your doctor wants to perform a
41
LATEST RESEARCH
Interval Cancer Can Arise
After Negative Colonoscopy
Nearly 20 years ago, authors of
the National Polyp Study report-
ed that colonoscopy prevents
cancer, and the most recent
data to come out of that long-
running trial support the hypoth-
esis that colonoscopy saves
lives. Some patients, however,
develop colorectal cancers,
often called interval cancers,
after a negative colonoscopy.
Researchers looking into the
frequency with which interval
cancers occur and the reasons
for them gathered data on
57,839 patients ages 69 and
older diagnosed with colorectal
cancer between 1994 and 2005.
Interval cancers, defined as
cancers occurring in patients
who had undergone colonos-
copy six to 36 months prior to
diagnosis, were found in 7.2
percent of the study population.
These cancers were more likely
to be in the right side of the
colon and were associated with
diverticulosis and past polypec-
tomy (surgical excision of a pol-
yp). Interval cancers were also
associated with colonoscopy
performed by a physician not
specialized in gastroenterology.
Patients may have little con-
trol over their biologic risks
for interval cancers, but they
should make sure that the
physician who performs their
colonoscopy is board certified
in gastroenterology. Look for
one who can prove that he or
she meets or exceeds national
quality standards.
CANCER
June 2012
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 colonos-
copy for detecting abnormal growths in the colon and rectum, the
test has a number of drawbacks.
First, biopsy samples cannot be taken with a virtual colon-
oscopy. 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 colon-
oscopy 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 vir-
tual colonoscopy unless you have a medical condition that makes
a standard colonoscopy risky or physically difficult.
Capsule Endoscopy
When symptoms, such as gastrointestinal bleeding or chronic
ab dominal pain, cannot be explained using standard diagnos-
tic 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 colonos-
copy. 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 peri-
stalsis. You can go about your normal daily activities, al though 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 con-
tains a video camera, light and radio transmitter. It takes pic-
tures (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 doc-
tor, who downloads the information from the device to a com-
puter. 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.
42
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 constipa-
tion 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
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. How ever,
ignoring the urge to have a bowel movement and changing ones dai-
ly 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 scle-
rosis, 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, con-
stipation can result from mental health problems, for example,
depression and eating disorders.
43
Symptoms of constipation
What is considered normal in terms of the frequency of bowel move-
ments 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 num-
ber of movements.
If untreated, constipation can lead to complications. Straining dur-
ing bowel movements can irritate or cause hemorrhoids or rectal pro-
lapse (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 secre-
tion of mucus. Another potential complication is fe cal impaction, an
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 unex-
plained 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 during at
least one-quarter of bowel movements
If you have a bowel movement fewer than three times a week but expe-
rience no discomfort or change in the pattern of your bowel move-
ments, you likely arent constipated.
Diagnostic tests like blood tests, abdominal X-rays, sigmoidosco-
pies, colonoscopies and bar ium enemas are not helpfulor neces-
saryfor 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
44
45
Exercise Your Way to a Healthy Gut
Having a digestive disorder cer-
tainly doesnt put you in the mood
for physical activities like walking
or swimming. Yet research shows
that exercise may be just what
you need to feel better. And thats
not all. Exercise can also protect
your digestive tract from numer-
ous digestive diseases, just like it
protects against such chronic
illnesses as heart disease and
diabetes.
Exercising to stay healthy
The payoffs of regular physical
activity in preventing digestive
disorders are impressive. The
strongest evidence so far exists for
colon cancer. A review published
in Southern Medical Journal in
2011 determined that studies were
consistent in finding that physically
active men and women have a
reduced risk of colon cancer. One
study involving more than 400,000
people concluded that engaging
in two hours of moderate physical
activity per dayor one hour of
vigorous activitywas associated
with a risk reduction for colon can-
cer of 20 to 25 percent.
Exercise can also reduce the risk
of Crohns disease and symptom-
atic diverticular disease (diverticu-
losis and diverticulitis).
How does exercise keep your
digestive tract healthy? First, many
inactive people are also over-
weight, and these excess pounds
are associated with a wide range
of digestive problemsfrom mild
ailments such as heartburn and
constipation to more serious condi-
tions like colon cancer. Second,
aerobic exercise stimulates mus-
cular contractions in the digestive
tract. These contractions move
food through the digestive tract
more quickly, reducing the risk
of constipation and symptomatic
diverticular disease. Third, exercise
can enhance the function of the
immune system. A faulty immune
response may contribute to
Crohns disease and colon cancer.
Exercising to relieve
symptoms
Even if its too late to prevent these
and other digestive diseases,
exercise can help you manage the
symptoms.
A study of nearly 1,000 over-
weight people found that exercise
was the strongest lifestyle factor
in reducing symptoms of digestive
disorders. More than 10 percent of
the study participants had irritable
bowel syndrome. Many others had
abdominal pain, constipation,
diarrhea or bloating common
symptoms of digestive disorders.
All of them were offered weight-
loss counseling. After two years,
those who exercised the most
were least likely to have abdominal
pain, constipation, diarrhea
or bloating.
If youre concerned that exer-
cise might make your symptoms
worse, you could be right. But this
is a temporaryand worthwhile
inconvenience. If you can over-
come the hurdle of getting started,
the resulting weight loss should
help relieve digestive problems.
Exercising when you have a
digestive disorder
While regular exercise can help
keep your digestive tract disease
free, it does have the potential to
worsen symptoms of a digestive
disorder. Heres some advice on
exercising safely.
Check with your doctor
before beginning an exercise
program. He or she may give you
an exercise prescription that out-
lines the types, amount and inten-
sity of exercise appropriate for you.
Wait two hours after a large
meal. Exercise diverts blood flow
from the digestive tract to the
muscles and skin. Thus, exercis-
ing too soon after eating can slow
digestion and worsen symptoms.
A short stroll after a meal, however,
can aid digestion.
Wear loose-fitting clothes.
Clothing that fits tightly around
the waist can exacerbate symp-
toms of GERD and other diges-
tive problems.
Time your heartburn medi-
cation. If you take heartburn
medication only when you feel
symptoms, try taking it one hour
before your workout (in case
exercise exacerbates your heart-
burn). Stay hydrated. Dehydration
can worsen constipation, so drink
water before, during and after
your workout.
Listen to your body. At any
sign of chest pain, weakness, diz-
ziness, stomach pains or other
digestive symptoms, stop and
rest. If symptoms continue, call
your doctor. n
Physical activity can reduce disease risk
5 to 20 g of fiber a day; however, the Institute of Medicine recom-
mends 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 daily, respectively.)
Although a 2006 review concluded that a lack of dietary fiber prob-
ably 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.
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 in crease 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 nonbulk-forming laxative, including stimulants, stool
softeners, lubricants and osmotic laxatives. Stimulants such as bisaco-
dyl (Correctol, Dulcolax) cause rhythmic muscle contractions in the
intestines, stool softeners such as doc u sate 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 recom-
mend a stool softener or enema. Then he or she will manu ally remove
the hardened stool. If a drug you are taking for another health prob-
lem 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 tak-
ing 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.
46
47
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 num-
ber 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 64).
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 diverticu litis, 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 ex ceed 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. However, recent research suggests that a lack of fiber is
not to blame. (See Ask the Doctor on page 49.)
Diverticulitis occurs when bacteria or hardened stool is trapped in
a diverticulum, causing an infection or inflammation. This may ulti-
mately 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 symp-
toms, some experience mild abdominal pain, bloating and constipa-
tion. 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 bleed-
ing 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 bleed-
ing persists, surgery to remove the portion of the colon containing the
bleeding diverticulum may be necessary.
Diagnosis of diverticulosis and diverticulitis
Diverticulosis is often discovered by accident during an ex am, such as
a barium enema, sigmoidoscopy or colon os copy, for another gastro-
intestinal ailment. If you have symptoms and your medical history
and examination suggest diverticular disease, your doctor will do one
or more tests. A bar ium enema or CT scan can diagnose diverticular
disease and its complications. Your doctor may also recommend a
colon oscopy 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 anti biotics. Most
people with severe diverticulitis, however, can be treated successfully
without surgery.
If antibiotics do not eradicate the infection associated with diver-
ticulitis, an abscess (a collection of pus surrounded by in flamed 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.
48
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 blad-
der. 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.
Causes of diarrhea
Acute diarrhea is usually caused by an infectious agent. Most
organisms causing diarrhea originate in feces and enter the
mouth via the hands or contaminated food or water. Acute infec-
tious diarrhea can be caused by a wide variety of bacteria, virus-
es and parasites. Bacteria implicated in acute diarrhea include
Salmonella, Shigella, Campylobacter jejuni, Escherichia coli O157:H7
and Clostridium difficile. Viral causes include adenoviruses,
rotaviruses and the Norwalk-like viruses known as the noroviruses;
parasites 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 in complete 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 re lease hormones into the bloodstream that stimulate
the small in testine to secrete excessive amounts of fluid and electro-
lytes 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
49
ASK THE DOCTOR
Q. I have diverticulitis and
I wonder if my diet and
occasional constipation are
to blame. Should I be eating
more fiber?
A. Until recently, most doctors
and patients thought that eating
a high-fiber diet would protect
against diverticulitis, partly by
promoting regular bowel move-
ments. According to research
published in Gastroenterology
in 2012, eating a high-fiber diet
may make you more vulnerable
to developing diverticulosis (the
precursor to diverticulitis) than
those who dont.
Researchers reviewed data
on 2,104 people between 30
and 80 years of age whod had
colonoscopies, assessing their
reported diet and physical activ-
ity habits. They hypothesized
that subjects who developed
diverticulosis would have diets
low in fiber and would experi-
ence fewer bowel movements
than those who did not.
It turned out that a high-fiber
diet did not protect against
diverticulosis. Diverticulosis
was more often found in those
who ate the most fiber than in
those who ate the least. Also,
constipation did not appear to
contribute to diverticulosis risk;
in fact, just the opposite. Those
who had 15 bowel movements
per week had a 70 percent
higher risk for diverticulosis than
those who had seven. Clearly
it would be helpful if adjust-
ing fiber intake could prevent
diverticulosisbut these find-
ings suggest that diverticulosis
stems from something other
than dietary choices.
colitis, the two main types of inflammatory bowel disease discussed
on pages 54-62. Diarrhea, as well as constipation, is also a hallmark
of irritable bowel syndrome (see pages 62-66).
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 feel-
ings 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 abdomi-
nal 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 of the time, 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
in convenience, you can take an anti-diarrheal product such as bis-
muth subsalicylate (Pepto-Bismol, Kaopectate and other brands) or
kaolin/pectin (Kao-Spen, Kapectolin) to solidify the stool. Other
anti-diarrheal medications, such as loperamide (Imo dium A-D) or
di phen oxylate/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,
parti cularly 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. The antibiotics
most frequently used to treat di arrhea caused by bacteria are cipro-
floxacin (Cipro) and trimeth oprim plus sulfa meth ox azole (Bactrim).
Cases of acute diarrhea caused by a parasite are often treated with
50
metronidazole (Fla gyl). 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 laxa-
tives such as Correctol or Dulcolax should not be used, and people
should limit their use of chewing gum and foods that contain the arti-
ficial sweetener sorbitol. If the pancreas produces insufficient diges-
tive enzymes to break down fats, supplemental digestive en zymes
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.
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 celi-
ac disease, either because they or their doctor 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, con-
tains 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 decreas-
es 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. (Also see Celiac Disease
and Lactose Intolerance on page 53.) Other possible symptoms relat-
ed 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 six times more likely in people with celiac disease
than in those without the condition.
51
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 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 per-
son with celiac disease ingests gluten. If these three antibodies are
found, a biopsy of the small intestine is usu ally 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, lip-
stick, communion wafers and even postage stamps.
52
53
Celiac Disease and Lactose Intolerance
If you have celiac disease, dont
be surprised if drinking milk or
consuming other dairy products
leaves you feeling bloated or
nauseated, or you experience
cramping and diarrhea afterward.
Up to two-thirds of people with
celiac disease are also lactose
intolerant. The symptoms they
endure can be blamed on the
digestive systems inability to
sufficiently break down and
absorb the simple carbohydrate
lactose, present in milk and other
dairy products.
Lactose intolerance results
from a deficiency of lactase,
the enzyme responsible for the
digestion of lactose, the major
sugar in milk. In people with
celiac disease, the difficulty in
absorbing foods with lactose
may be a mechanical issue.
Long-term exposure to gluten
causes inflammation that short-
ens, flattens or otherwise com-
promises the villi and microvilli
hairlike projections located in the
small intestine, where lactase is
produced. This damage com-
monly results in decreased
lactase production. Some scien-
tists suspect that celiac disease-
related lactose intolerance stems
from exocrine pancreatic insuffi-
ciency, or the inability of the pan-
creas to activate the appropriate
digestive enzymes.
People with celiac disease and
lactose intolerance face a major
dietary challenge: At the same
time they need to adopt a diet
free from wheat, barley, rye and
any other food containing gluten,
they also need to avoid milk,
cheese, ice cream and any other
dairy product that could provoke
symptoms.
Furthermore, low bone density
afflicts more than a third of peo-
ple with celiac disease, putting
them at risk for bone fractures.
This makes it crucial for them to
consume and absorb sufficient
calcium, and for many people
dairy products are a primary
source.
The good news is that lactose-
free alternatives are available,
with an increasing number of
stores now stocking lactose-free
milk and cheeses. And many
people with lactose intoler-
ance find that they are able to
digest some types of dairy, such
as yogurt. Taking an over-the-
counter lactase supplement when
consuming dairy products may
also help.
For those less concerned
about giving up dairy and who
focus instead on getting enough
calcium, many gluten-free
options exist. These include
calcium-fortified soy products,
such as soymilk and tofu. But be
sure to check for calcium con-
tent and fortification with vitamin
D; nearly two-thirds of people
with celiac disease are deficient
in the latter, which is critical for
absorbing calcium.
Some fish, such as sardines,
mackerel and salmon, are rich
in calcium. Certain vegetables,
too, are surprisingly good sources
of calcium, although some work
better than others in providing the
amount you need. For example,
spinach is high in calcium, but
its also high in oxalic acid, which
can bind with calcium and reduce
absorption. Kale, on the other
hand, is high in calcium and low
in oxalic acid; other high-calcium
vegetables in the kale family
include mustard greens, broc-
coli and collard greens. The latter
pack up to 350 mg of calcium in
a one-cup serving (about 50 mg
more than youd find in a serving
of low-fat milk).
People who restrict their dairy
intake may need to take a cal-
cium supplement. The recom-
mended daily intake for calcium is
1,000 mg for adult men ages 51
to 70, 1,200 mg for adult women
ages 51 to 70, and 1,200 mg for
all adults over age 71. Because
the body cannot absorb more
than 600 mg of calcium at one
time, divide any amount larger
than that into two doses. Its also
best to take calcium supplements
with food; stomach acid, as well
as other nutrients, enhances the
absorption of calcium.
Whats encouraging for a
substantial proportion of people
whose celiac disease is being
treated through diet is that they
will no longer experience lac-
tose intolerance once their small
intestine heals. However, it may
take a year or more after starting
a strict gluten-free diet before
dairy can be reintroduced. n
How to get enough calcium when you have both conditions
A gluten-free diet can be difficult to follow, since gluten is natu-
rally present in many foods and is added to other products such as
ice cream and salad dressings. Moreover, some labels do not indi-
cate that a product contains gluten. Thus, you will need to ask about
ingredients at restaurants, learn to substitute gluten-free ingre-
dients in recipes, and make sure your foods dont become cross-
contaminated 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 82
for contact information) sells publications that list gluten-free 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 celi-
ac disease. Symptoms usually improve within a few days of eliminat-
ing 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. A 2010 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 peo-
ple 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
(Asacol, Pentasa) or the corticosteroid predni sone (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 primar-
ily 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 people in the
United States have Crohns disease.
Causes of Crohns disease
Despite extensive research, the cause of Crohns disease is poorly
un derstood. Three factors likely play a role. Genetics is one of them:
Certain people inherit a susceptibility to the disease. The second
54
55
factor is environmental: A stimulus (perhaps a virus or bacter-
ium) triggers the disease by causing the im mune 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 Hispan-
ics 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 perfora-
tion, 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. How-
ever, 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,
cap sule en do s copy 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). Some-
times 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 dis-
ease of the large intestine. If these tests arent possible because of nar-
rowing 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 usu-
ally require hospital treatment with intravenous nutrition and fluids
to allow the bowel to rest. You will also be given intravenous cortico-
steroids like methylprednisolone and mesalamine capsules (Pentasa)
or tablets (Asacol or Apriso) or sulfa salazine (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, Asacol or 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 cortico steroids, but you will still take mesalamine or sulfasala-
zine. When Crohns disease is limited to the far end of the colon
and the rectum, you may receive hydrocortisone (Colocort) or
mesal amine (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) 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 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 mod-
erately to severely active Crohns disease. Humira is also an immuno-
suppressant, but it does not require intravenous injectionthe drug is
packaged in an injection pen that can be self-administered once every
two weeks. Humira is intended for people who cannot tolerate Remi-
cade 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, natali-
zumab (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
56
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).
Other drugs to treat Crohns disease are currently in clinical trials:
abatacept (Orencia), a rheumatoid arthritis drug, and an experimen-
tal stem-cell drug called Prochymal.
Surgical removal of a section of the bowel is required if you devel-
op problems such as intestinal obstruction due to serious strictures or
complications like fistulas or abscesses that wont heal. In this proce-
dure, the affected portion of the small or large intestine is removed
and the two ends are reattached. This is not a cure for Crohns dis-
ease, since the remaining bowel is still susceptible to the disease.
Ulcerative Colitis
Ulcerative colitis is a chronic inflammatory disease of the large intes-
tine 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, eventu-
ally, 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 the
immune system. The disease is more common in whites and Jews.
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 be tween flare-
ups and remissions.
Diagnosis of ulcerative colitis
The best diagnostic tests for ulcerative colitis are sigmoid oscopy
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 distin-
guish ulcerative colitis from other conditions affecting the colon,
for example, cancer, infections, ischemia (reduced blood flow) or
57
58
Drug Therapy for Crohns Disease and Ulcerative Colitis 2013
Typical daily
dosages*
1,600-2,400 mg
2,000 mg
6,750 mg
1,000 mg
2.4-4.8 g
4,000 mg
1,000 mg
4 g
6-9 mg
40-60 mg
32-60 mg
100 mg
How to take
One 400 mg tablet 4x/day, two 400 mg

tablets 2x/day or two 400 mg tablets
3x/day. Swallow whole (do not crush,
chew or break). Take with or without food.
Four 500 mg tablets 1x/day with food or
after meals with a glass of water.
Three 750 mg capsules 3x/day with or
without food.
Two 250 mg capsules 2x/day with food
or after meals.
Two to four 1.2-g tablets taken once
daily with a meal. Swallow whole.
Four 250 mg capsules 4x/day or two
500 mg capsules 4x/day with or without
food. Swallow whole.
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.
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.
Two or three 3 mg capsules 1x/day in the
morning. Swallow whole (do not chew or
break).
A combination of 1, 2.5, 5, 10, 20 or 50
mg tablets 1x/day in the morning with
food to prevent stomach upset.
Requires administration by a health pro-
fessional who will infuse the medication
into your body through a needle placed
in a vein in your arm.
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).
Drug type:
Brand (generic)
Oral
Asacol (mesalamine, delayed-release)
Azulfdine, Azulfdine-EN (sulfasalazine)
Colazal (balsalazide)
Dipentum (olsalazine)
Lialda (mesalamine, delayed-release)
Pentasa (mesalamine, controlled-release)
Rectal
Canasa (mesalamine suppositories)
Rowasa (mesalamine enema)
Oral
Entocort EC (budesonide)
(prednisone)
Intravenous
(methylprednisolone)
Rectal
Colocort (hydrocortisone enema)
Aminosalicylate anti-inammatory compounds

Corticosteroids

59
Drug Therapy for Crohns Disease and Ulcerative Colitis 2013
Precautions

Do not take if you are allergic to aspirin. Avoid alcohol
to reduce the risk of dizziness and stomach bleeding.
Azuldine 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, be cause heat
from your hands can melt the suppository. Canasa and
Rowasa only: May stain surfaces such as your clothing,
foors or countertops.
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; corti-
costeroids 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 dizzi-
ness. Corticosteroids can increase your risk of osteo-
porosis; 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.
Most common
side effects
Headache, upset
stomach, nausea,
abdominal pain,
diarrhea, gas.
Azuldine only: May
cause skin or urine to
turn orange-yellow.
This is harmless and
goes away when the
medication is stopped.
Headache, nausea,
stomach upset, dizzi-
ness, trouble sleeping,
weight gain.
You experience worsening stomach
pain or cramping, worsening bloody
diarrhea, rash, itching, yellowing eyes
or skin, dark urine, fever, fatigue, head-
ache. Asacol and Azulfidine only: You
notice intact or partially intact tablets in
your stool.
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
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
60
Drug Therapy for Crohns Disease and Ulcerative Colitis 2013 (continued)
Typical daily
dosages*
50-150 mg
50-100 mg
15-25 mg/week
1,000 mg
1,000-2,000 mg
400 mg every 2
weeks for frst 3
doses, then every
4 weeks
40 mg every 2
weeks
5 mg every 8
weeks
300 mg every 4
weeks
How to take
One or more 50-mg tablets 1-2x/day. Take

with food to reduce stomach upset.
One to two 50-mg tablets 1x/day.
Visit your doctor 1x/week for an injection.
One 500-mg tablet with or without food in the
morning and evening.
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.
You will go to your doctor to receive an
injection.
You inject the medication under your skin via a
single-use injection pen once every 2 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.
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.
Drug type:
Brand (generic)
Oral
Imuran (azathioprine)
Purinethol (mercaptopurine)
Intramuscular injection
(methotrexate)
Cipro (ciprofoxacin)
Flagyl (metronidazole)
Cimzia (certolizumab pegol)
Humira (adalimumab)
Remicade (infiximab)
Tysabri (natalizumab)
Immunomodulators
Antibiotics
Monoclonal antibody
* 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.
61
you have mild disease limited to the rectum and sigmoid colon,
cortico ste roid- or mesalamine-containing enemas may help to
control flare-ups. If this therapy fails, you may need to take oral
drugs such as Asacol, Azulfidine, balsalazide (Colazal), olsalazine
(Dipentum) or Pentasa.
If you have extensive ulcerative colitismeaning that it affects
Drug Therapy for Crohns Disease and Ulcerative Colitis 2013 (continued)
Precautions

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.
Drink plenty of liquids. Consumption of dairy products
(milk, yogurt or calcium-fortifed juice) greatly reduces
absorption. Can cause sun sensitivity; use sunscreen
and avoid excessive sunlight or sun lamps.
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.
Before receiving, 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 seri-
ous brain infection. To receive this drug, you must be
enrolled in a program that tracks safety information.
Most common
side effects
Nausea, vomiting,
diarrhea, loss of appe-
tite, stomach pain,
drowsiness, dizziness.
Stomach upset, loss of
appetite, diarrhea, nau-
sea, headache, vision
changes, dizziness.
Diarrhea, nausea,
metallic taste in the
mouth, darkened urine
(which is harmless).
Headache; nausea,
vomiting or stomach
pain; redness, itching,
pain or swelling at the
injection site.
You experience unusual bleeding or
bruising or signs of infection: fever,
fatigue, cough, flu-like symptoms.
You experience a rash or signs of
peripheral neuropathy: pain, burning,
tingling, numbness, weakness in your
hands or feet.
You experience unsteadiness, seizures,
mental or mood changes, numbness
or tingling of your hands or feet, painful
urination.
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: persis-
tent fever, bruising, bleeding, paleness.
Humira and Cimzia: Signs of lymphoma
(unusual lumps or growths, swollen
glands).
most of the colonyou may need intravenous or oral corticoster-
oids and oral mesalamine to treat a flare-up, followed by mainte-
nance 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 stress-
related 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 perfo-
ration, colon cancer or symptoms that significantly impair your
quality of life. Between 25 and 40 percent of people with ulcer-
ative colitis will eventually have their colons removed. Surgery can
be performed either in the traditional manner (open) or through
laparoscopy.
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 ileo s tomy lead nor-
mal, 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 dyspla-
sia (abnormal cells that can become cancer). When dysplasia is identi-
fied, 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 num-
ber of tests to rule out other diseases; and 2) it appears that the disor-
der 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 re searchers have pro-
posed that IBS may result from malfunctions in the rhythmic muscle
62
63
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 contrac-
tions can lead to constipation.
Because women develop IBS two to three times more often
than men, some experts hypothesize that symptoms may be relat-
ed to hormone levels. Other proposed causes include hypersensi-
tivity to pressure in the small and large intestines, an im balance in
neurotransmitters (chemicals found in both the brain and diges-
tive tract) and infection.
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 in creased
risk of IBS in women who have been physically or sexually abused.
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 abdomi-
nal discomfort or pain, accompanied by diarrhea, constipation or
alternating bouts of constipation and diarrhea. Other symptoms
in clude 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 dis-
ruptive to your life. The severity of symptoms varies: Most people
experience mild symptoms, although they can be come more severe
and even disabling at times. Some women report that IBS symptoms
are worse before and during their menstrual periods. The symp-
toms 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 phys-
ical 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 syn-
drome are sometimes misdiagnosed. IBS can eas ily be confused with
diverticulitis, colon cancer, intestinal obstruction, ulcerative colitis,
Crohns disease, gastrointestinal infection, celiac disease and lactose
intolerance.
In 2009, the American College of Gastroenterology issued new
guidelines on diagnosing and managing IBS based on the most cur-
rent research. Because IBS is more commonly diagnosed in those
LATEST RESEARCH
More Evidence Links
Bacteria to IBS
The cause of irritable bowel
syndrome (IBS) has long been
a bit of a mystery. A number
of studies have found an over-
growth of intestinal bacteria in
people with IBS based on the
results of breath testsmean-
ing they have too much of the
bacteria normally found in the
gut. Now a new study, using a
more quantitative type of test,
validates this hypothesis.
To assess the association
between IBS and bacterial over-
growth, researchers studied
bacterial cultures, considered
the gold standard for detecting
bacteria, from 320 subjects.
They found small intestinal bac-
terial overgrowth in 37.5 percent
of the patients who had IBS,
and in 60 percent of those who
had IBS with diarrhea.
These findings reinforce
those of recent clinical trials
showing promise for rifaximin,
an antibiotic that is absorbed
only in the gut, for the manage-
ment of IBS symptoms. That is,
if bacteria cause IBS, its rea-
sonable to expect antibiotics to
work as a potential treatment.
Further studies are needed
to investigate the association
between bacteria and IBS and
the role of antibiotics. These
findings, however, do suggest
a better therapeutic future for
sufferers of IBS, whose current
treatment options often do little
more than mask the symptoms
of their ailment.
DIGESTIVE DISEASES AND SCIENCES
May 2012
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. A 2010 study suggests that younger people
may not need a colonoscopy if they do not have other risk factors
for polyps, colorectal cancer or inflammatory bowel diseases. You
should also have a blood test for celiac disease if your IBS symp-
toms 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)
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 both-
ersome symptoms.
Constipation-predominant IBS. In 2012 the FDA approved
a new type of prescription medication for treating constipation-
predominant IBS. In clinical trials, subjects taking a daily dose of
the drug, called linaclotide (Linzess), had more frequent spontane-
ous 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 clini-
cal trials was diarrhea. The drug should not be used in patients 17
years of age or younger.
Another medication available for individuals with constipation-
predominant IBS is the prescription laxative lubiprostone (Amitiza).
Approved in 2008, this selective C-2 chloride channel activator initi-
ates chloride secretion into the intestine, which helps promote bowel
64
65
A Meditative Approach to Helping Your Gut
Medication offers many people
with irritable bowel syndrome
(IBS) temporary relief from their
symptoms. Others, however, find
standard medical care for IBS
inadequate, with available drug
treatment merely masking their
symptoms.
Researchers are beginning to
home in on the underlying causes
of IBS, hoping that a better under-
standing of the condition will lead
to more sophisticated and tailored
pharmacological therapies for it.
Until such therapies become avail-
able, however, many people turn
to alternative and complementary
treatments to manage symptoms
and improve their quality of life.
Research on the efficacy and
safety of herbal remedies has
been mixed, and because these
remedies are unregulated they
should be used with caution. Acu-
puncture, according to a recent
review, doesnt seem to improve
symptoms any better than a pla-
cebo. But one strategy that does
appear to help is meditation.
According to research published
in 2011 in the American Journal
of Gastroenterology, mindfulness
traininga form of meditation
characterized by the nonjudgmen-
tal observation of thoughts, feel-
ings and sensationsmay reduce
the severity of IBS symptoms and
improve the quality of life in peo-
ple with IBS. In the first random-
ized, controlled trialconsidered
the gold standard for clinical
researchto examine the effect
of mindfulness training on IBS,
researchers from the University
of North Carolina at Chapel Hill
assigned 75 women with IBS to
either eight weeks of mindfulness
training or eight weeks of support
group meetings. The participants
met for two-hour sessions each
week, and attended one four-hour
retreat.
The training used by the
researchers was modeled on a
mindfulness-based stress reduc-
tion program first implemented at
the University of Massachusetts
Medical Centers Stress Reduc-
tion Clinic in 1979. Since that
time, the program has been stud-
ied in the context of many other
conditions, including chronic
disease states such as HIV,
back pain and arthritis, in which
psychological and emotional
distress appear to have a pro-
found impact on the experience
of physical symptoms and well-
being. At its essence, mindful-
ness training helps people let go
of past associations and anxiet-
ies and focus instead on the here
and now, to observe their experi-
ences in a detached way, without
critical labeling.
During the study period, partici-
pants in the mindfulness therapy
group practiced sitting and walk-
ing meditations, along with yoga,
under the guidance of a certified
health coach with training in
mindfulness-based stress reduc-
tion. Sessions were typical of such
programs used in other health
care settings, but were tailored
to IBS. For example, participants
were instructed to focus specifi-
cally on their gut. While doing so,
they were asked to distinguish
between actual sensations and
mere thoughts about sensations,
in order to differentiate between
sensory perception and height-
ened anxiety about pain, referred
to as catastrophizingwhich
is shown to exacerbate irritable
bowel symptoms. In addition to
the weekly meetings, participants
did homework consisting of daily
mindfulness exercises and reading
educational material about IBS.
Participants in the support
group, which was led by social
workers, met weekly to discuss
their experiences with IBS and
their reactions to it. Homework
consisted of reading educational
material.
Both groups were evaluated
on their IBS severity and other
measures before and immedi-
ately after treatment, and at three
months after the programs end.
IBS severity scores fell by 26.4
percent in the mindfulness group
immediately after training, while
the support group had a 6.2 per-
cent reduction. At three months,
the mindfulness groups symp-
tom severity had been reduced
by 38.2 percent, compared with
the support group reduction of
11.8 percent.
Patients in the mindfulness
therapy group also reported sig-
nificantly greater improvement in
their quality of life than the sup-
port group at the three-month
follow-up.
The researchers concluded that
eight weeks of mindfulness train-
ing could reduce IBS symptom
severity substantially and produce
benefits that last for at least three
months after the intervention. n
Mindfulness training may relieve IBS symptoms
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 constipa-
tion 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 constipation-predominant
or diarrhea-predominant. Relaxation therapy, however, has not prov-
en effective. (Also see A Meditative Approach to Helping Your Gut
on page 65.)
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 hem orrhoid 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. Inter-
66
67
nal 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, preg-
nancy 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 clean-
ing of the anal area also can irritate an existing condition.
Symptoms of hemorrhoids
The most common symptom of internal hemorrhoids is bleeding dur-
ing a bowel movement. Such bleeding ranges in sever ity from blood
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 prolapse
meaning 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 en tire 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 fre-
quently effective. To treat constipation that can exacerbate symptoms,
you should increase your fiber and fluid intake to make stools bulk ier,
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 supposi-
tories, 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.
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. Some-
times, 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 ef fectively 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
68
hemorrhoids. This procedure, called a hemorrhoidectomy, re quires 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 prob-
lem 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.
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 seri-
ous 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 indi-
viduals with anal fissures also experience anal itching.
Anal fissures are frequently confused with hemorrhoids, but hem-
orrhoids 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
69
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 sim-
ple 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 after each bowel movement. Top-
ical 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 fis-
sures. The most common side effect of the ointment is headaches,
which can be severe, although pain relievers such as acetamino-
phen (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 ef fects include
head ache 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 sur-
gical treatment, anal dilation or a four-fingered anal stretch, heals
70
40 to 90 percent of chronic anal fissures. In this procedure, the phy-
sician 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 con-
trolling 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 com-
mon 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 surgi-
cal repair of the damaged sphincter muscles. In addition, some
people can benefit from an implanted device called an artificial
sphincter.
Causes of fecal incontinence
Fecal incontinence is not a disease but a symptom of another gastroin-
testinal 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 prevent-
ing fecal incontinence.
71
ASK THE DOCTOR
Q. I drink a glass of red wine
every day for heart health,
but Im concerned about the
role of alcohol in colorectal
cancer. Should I eliminate
my one drink a day?
A. In a recently published study,
researchers concerned about
your very question investigated
the association between alcohol
consumption and colorectal
cancer. They also examined
whether this association differed
between people with a family
history of colorectal cancer and
those without.
Over a 26-year follow-up of
87,861 women and a 20-year
follow-up of 47,290 men, they
found 1,801 documented cases
of colorectal cancer. An associa-
tion between drinking and
colorectal cancer was seen in
only the heaviest drinkers, those
who consumed 30 or more
grams per day by ethanol con-
tent (a 4-ounce glass of wine is
about 11 grams by this descrip-
tion). This association was
strongest in people with a family
history of colon cancer.
Its not clear why alcohol is
associated with colorectal can-
cer; chronic consumption may
damage tissues or cause nutri-
tional deficiencies, and there
may be other lifestyle and envi-
ronmental factors at play. Your
alcohol intake is fairly moderate,
but if you have a family history
of colorectal cancer, you may
want to restrict it further.
Symptoms of fecal incontinence
The symptoms of fecal incontinence are easily recognizable, rang-
ing 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 symp-
toms 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 tight-
ness 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, procto-
sigmoidoscopy to detect signs of diseases or other problems inside
the rectum and sigmoid colon, and anal electromyography to test
for nerve damage. 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 fre-
quency 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 eliminat-
ed. 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 bow-
els 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
72
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 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 pel-
vic 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 sur-
gically 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 con-
nected to the abdominal wall. Instead of entering the rectum, stool
goes directly from the intestine into a special bag outside 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 pea
can become cancerous. Fortunately, regular screening for colorectal
cancer helps to identify and remove polyps, often be fore they prog-
ress to cancer.
73
LATEST RESEARCH
Eating Fresh Fish May
Prevent Colorectal Cancer
Some experts estimate that as
many as half of all colorectal
cancers derive in part from what
people eat and drink. Recom-
mendations tend to focus on
what to avoid, such as alcohol
and red and processed meat.
New research, however, sug-
gests something to include:
fresh fish.
Colorectal cancer tends to
be seen much less frequently
among populations such as
Swedish fishermen, whose
diets are high in fish. But stud-
ies examining the association
between fish consumption and
colorectal cancer have been
inconsistent, so researchers
conducted a rigorous review of
high-quality studies to deter-
mine if eating fish does have a
preventive effect.
In their analysis of 22 pro-
spective and 19 case-control
studies published between
1990 and 2011, the researchers
found that populations with the
highest fish consumption had
a significantly reduced risk of
colorectal cancer. When they
looked at colon and rectal can-
cer incidence separately, they
found that the protective effect
of fish consumption was more
prominent in rectal cancer than
in colon cancer, attributed to
differences in the two cancer
types. Fish consumptions pro-
tective effect held true only for
fresh fish consumption, which
was the focus of this meta-
analysis.
THE AMERICAN JOURNAL OF MEDICINE
June 2012
74
Choosing the screening method thats right for you
Its probably safe to say that
nobody loves to undergo a
colonoscopy, a screening test
that allows a doctor to view the
inside of the entire colon with
a flexible scope in a search for
precancerous growths known
as polyps. Millions of Americans
have undergone the testbut
millions also have skipped it or
delayed getting it.
Because the test allows direct
inspection of the colon and also
allows a physician to remove any
suspicious growths, experts have
long assumed that the screening
is the best test for reducing the
risk of developing colorectal can-
cer. Many health experts credit
the increasing use of colonos-
copy, along with other screening
tests, for playing a significant role
in the decline in colorectal cancer
rates over the past 20 years.
Yet, until recently, no trial has
shown that colonoscopy and
polyp removal actually saved lives.
Moreover, studies have indicated
that colonoscopies miss some
polyps that turn into cancer
and that most polyps detected
and removed wouldnt have pro-
gressed to cancer. Added to this
are other facts about the test: Its
invasive, it can be expensive and
its preparation is unpleasant.
A study now shows that
colonoscopy significantly reduc-
es the risk of dying of colon
cancerwhich helps confirm its
value as a screening tool. At the
same time, other screening meth-
ods have some advantages over
colonoscopy.
New evidence
with limitations
The study, published in The New
England Journal of Medicine, is
the first to prove that colonos-
copy with polypectomy (polyp
removal) prevents death in peo-
ple at higher-than-average risk.
A person is considered at higher
risk if he or she:
Is 50 or older
Is African American
Has a parent, sibling or child
with colorectal cancer
Has a history of inflammatory
bowel disease, adenomatous
polyps or certain inherited
syndromes such as famil-
ial adenomatous polyposis
or hereditary nonpolyposis
colon cancer
Researchers from Memorial
Sloan-Kettering Cancer Center
looked at the data from 2,602
patients enrolled in the National
Polyp Study who were followed
for as long as 23 years. The
records showed that finding
and removing noncancerous
polyps during colonoscopies
resulted in 53 percent fewer
deaths than would be expected
from a group of people similar in
race, age and gender. In fact, the
death rate of patients who had
polyps removed was the same
as in people who didnt have any
polyps.
The study is not without limita-
tions, however. The American
Cancer Society (ACS), comment-
ing on the results, notes, The
National Polyp Study followed a
group of people who had already
had polyps removed during
colonoscopy. It was not a ran-
domized, controlled trial compar-
ing people who were screened
with colonoscopy to a group of
people who were not screened.
Studies of this type of design are
now under way.
Looking at all the options
Colorectal cancer is highly pre-
ventablebut only if people get
regular screenings. Most major
medical groups recommend regu-
lar screening for people ages 50
and older, but many differ in their
recommendations about screening
frequency and which test to use.
Last March, the American
College of Physicians (ACP),
whose members are internists
specializing in adult care, pub-
lished a paper in the Annals of
Internal Medicine that reviewed
the screening recommendations
of several medical organizations,
including the ACS, the U.S. Pre-
ventive Services Task Force and
the American College of Radiol-
ogy. The ACP considered all the
evidence and made the following
Your Best Weapons Against Colorectal Cancer
75
recommendations:
When considering screening
for colorectal cancer, doc-
tors should assess patients to
determine whether theyre at
average risk or high risk.
Adults at average risk should
start screening at age 50.
Adults at high risk should begin
screening at 40 years or, if
applicable, 10 years younger
than the age at diagnosis of
the patients youngest affected
relative (whichever is younger).
Adults older than 75 or likely to
die within 10 years do not need
to undergo screenings.
For high-risk patients, the ACP
recommends colonoscopy. For
average-risk adults, the ACP
encourages doctors and patients
to choose a screening method
based on patient preferences,
availability, and the tests bene-
fits and potential adverse effects.
They recommend choosing from
colonoscopy, flexible sigmoidos-
copy and stool testing.
Colonoscopy. Preparation
includes a clear liquid diet the
day before and laxatives to
purge the entire large intestine
of fecal matter. Dehydration can
be an issue following the laxa-
tive purge. Details about how the
test is performed can be found
on page 41. Colonoscopy should
be repeated every 10 years if no
polyps are detected.
Flexible sigmoidoscopy.
Before testing, the patient must
purge the lower colon of all fecal
matter. Details about the proce-
dure itself can be found on page
40. Sigmoidoscopy should be
repeated every five years.
Stool testing. Stool, or fecal,
testing is meant to detect the
presence of blood proteins or
antigens, markers associated
with cancer and polyps in the
stool. You collect stool samples
at home and return them to a lab-
oratory where they can be tested.
There are two main types:
Fecal occult blood testing
(FOBT). The more traditional of
the two stool tests detects hid-
den blood in the stool. However,
certain foods or medication can
cause false-positive results. It
also cant detect some advanced
polyps and cancers that dont
bleed or bleed intermittently. If
you decide on this test, make
sure youre screened using the
newer, more sensitive guaiac
test instead of an earlier version.
Fecal immunochemical
test (FIT). Considered to be
more accurate and sensitive than
FOBT, FIT detects blood from
only the colon or rectum and isnt
affected by drugs or food. The
tests processing and readings
are also more sophisticated than
FOBTs.
Stool testing is noninvasive,
painless and inexpensive. How-
ever, its less likely to detect
polyps than other, more invasive
screening methods. A posi-
tive result usually means youll
need a follow-up colonoscopy.
Stool testing should be repeated
yearly.
Another screening test, called
virtual colonoscopy, uses com-
puted tomography (CT) instead
of a scope to view images of the
colon and rectum. (Learn more
about virtual colonoscopy on
pages 41-42.) The ACP doesnt
recommend virtual colonoscopy
for routine screening because not
enough evidence is available to
prove its effectiveness.
Talk with your doctor about
which option is best for you.
While many medical profession-
als consider colonoscopy the
gold standard of colon cancer
screeningwith good reasonit
does have some drawbacks. For
instance, its accuracy can be
compromised when the test is
performed by a less-experienced
doctor instead of a gastroenter-
ologist and when the bowels are
not completely emptied.
Whats more, many people
dread the preparation so much
that they put off getting a
colonoscopy. If that sounds like
you, remember that finding polyps
early with any test is the best
way to prevent or cure colorectal
cancer. And cancer treatment is
a lot more uncomfortable than
screening. n
76
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 exercis-
ing and being overweight can all contribute to polyp formation.
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). In these cases, you should see your doctor.
Diagnosis of colorectal polyps
Polyps can be diagnosed by a digital rectal exam, bar ium enema, sig-
moidoscopy or colonoscopy. For more about testing, see pages 39-41.
Treatment of colorectal polyps
Polyps are removed during a sigmoidoscopy or colonoscopy. The
removed polyps are then tested to see if they are cancerous and if any
further treatment is needed.
Colorectal Cancer
In 2012, colorectal cancercancer of the colon or rectumwas diag-
nosed in an estimated 143,460 people in the United States. Its the sec-
ond most common cause of death due to cancer (for men and women
combined), killing about 51,000 Americans annually. 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
77
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
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 Your Best Weap-
ons Against Colorectal Cancer on pages 74-75.)
Diagnosis of colorectal cancer
Fecal occult blood testing, barium enema, sigmoidoscopy and
colon oscopy are used to diagnose colorectal cancer. Because colo-
rectal 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
LATEST RESEARCH
Many Physicians
Recommend Unnecessary
Cancer Screenings
A recent study suggests that
although primary care physi-
cians adjust their screening
recommendations based on a
patients age and health, a sub-
stantial portion of doctors still
recommend screening for col-
orectal cancer in people unlikely
to benefit from early cancer
detection.
Researchers surveyed 1,266
primary care physicians across
the country to get an idea of
how patient characteristics
influence screening recommen-
dations. The survey included
nine examples of patients rang-
ing in age from 50 to 80 with or
without serious illnesses.
The physicians were more
likely to recommend the less
invasive fecal occult blood test
over colonoscopy for patients
80 and older. All the same, 25
percent would recommend
colorectal cancer screening
for an 80-year-old patient with
non-small-cell lung cancer, and
71 percent would recommend
screening for an 80-year-old
patient with ischemic cardiomy-
opathy, a serious form of heart
disease.
With the U.S. Preventive
Services Task Force guidelines
recommending against routine
screening for colorectal cancer
in elderly patients, this practice
may become less common.
But older patients may want to
seek assurance from their doc-
tors that any screenings they
undergo are warranted.
JOURNAL OF GENERAL INTERNAL
MEDICINE
June 2012
78
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 in clude 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 ex pectation of a cure). Adverse effects
may in clude 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 radio active seeds or externally from an
X-ray machine. Common adverse events include fatigue, nausea, diar-
rhea, appetite loss, bloody stool and damage to the skin and other
organs near the radiation site. n
G
L
O
S
S
A
R
Y
79
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 pro-
ducing 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 gall-
stones block the flow of bile from the gallbladder.
bilirubinA component of bile made by the liver. Pig-
ment 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, anemia
and vitamin deficiencies.
cholangitisInfection and inflammation of the bile
ducts.
cholecystectomySurgical removal of the gallbladder.
cirrhosisA disease that causes the liver to slowly deterio-
rate and eventually malfunction as a result of the replace-
ment 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 elec-
trolytes 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 endo-
scope is inserted through the anus and rectum to view the
colon and the final portion of the small intestine (termi-
nal 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 diffi-
culty 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 move-
ments and a decrease in the consistency of stools.
diffuse esophageal spasmProlonged and excessive con-
tractions 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 (diver-
ticula) 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.
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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 pres-
sure 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 lin-
ing 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 con-
trol; 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 esopha-
gus 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 material 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
cavity. These parts of the gastrointestinal tract are nor-
mally located in the abdominal cavity.
H
2
-blockersDrugs that inhibit gastric acid secretion.
Also known as histamine H
2
-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 per-
formed through small incisions in the abdomen using
specialized instruments and a tiny camera.
large intestineThe part of the digestive tract that is con-
nected to the small intestine. It absorbs water and elec-
trolytes 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 duode-
num 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 gastroe-
sophageal reflux disease and hiatal hernia that involves
lifting a portion of the stomach and tightening it around
the gastroesophageal junction to increase lower esopha-
geal sphincter pressure.
pancreasA long, thin gland that lies horizontally
be hind 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.
80
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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 endo-
scope 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 for-
mation 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 reac-
tion 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 bari-
um 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 three-
dimensional 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 I NFORMATI ON ORGANI ZATI ONS 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 pro-
vides 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 organiza-
tion offering publications about
digestive health. Website provides
message boards and help finding a
gastroenterologist.
American Society of Colon & Rectal
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 sur-
geons. Can help you find a surgeon.
American Speech-Language-
Hearing Association
2200 Research Blvd.
Rockville, MD 20850-3289
% 800-638-8255/301-296-5700
301-296-5650 (TTY)
www.asha.org
Gives information on communication
and swallowing disorders and referrals
to speech-language pathologists who
can help with swallowing 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
386 Park Ave. South, 17th Fl.
New York, NY 10016
% 800-932-2423
www.ccfa.org
Nonprofit health organization dedicat-
ed to improving the lives of people with
Crohns disease or ulcerative colitis.
International Foundation for
Functional Gastrointestinal
Disorders
P.O. Box 170864
Milwaukee, WI 53217-8076
% 888-964-2001/414-964-1799
www.iffgd.org
A nonprofit education and research
organization that informs and supports
patients with gastrointestinal disorders.
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.
I NDEX
83
I
N
D
E
X
A
Ablation therapies, 24
Abscesses, 35, 4849, 55, 57
Achalasia, 8, 10, 2021
AcipHex (rabeprazole), 13, 15, 1617, 27
Acupuncture, 32, 65
Acute cholecystitis, 35, 37
Advil (ibuprofen), 24
Age, effects on digestive tract, 3
Aleve (naproxen), 24
Aminosalicylate anti-inflammatory compounds,
37, 54, 5859
Amitiza (lubiprostone), 64, 66
Amoxicillin, 27
Amylase, 2
Anal dilation (four-fingered anal stretch),
7071
Anal fissures, 44, 6971
Anal manometry, 72
Anal sphincter, 39, 71, 72, 73
Anoscopes, 67, 70
Antacids, 13, 14, 15, 43, 72
Anti-emetics, 9
Antidepressants, 12, 21, 43, 66
Apriso (mesalamine), 61
Argon plasma coagulation, 24
Artificial anal sphincter, 73
Asacol (mesalamine), 54, 56, 5859, 61
Ascending colon, 39, 57
Aspirin, 14, 24, 25, 33, 69, 70
Axid (nizatidine), 15, 1617, 27
Azulfidine (sulfasalazine), 56, 5859, 61
B
Bactrim (trimethoprim and sulfamethoxazole),
50
Baraclude (entecavir), 32
Bard EndoCinch system, 1920
Barium enema, overview, 3940
Barium X-rays, 56, 89, 21
Barretts esophagus, 14, 2224
Beta-blockers, 33
Bextra (valdecoxib), 25
Biaxin (clarithromycin), 27
Bile, 3, 4, 2829, 34, 38
Bile ducts, 4, 2829, 3436, 37
Bile reflux, 7
Biliary colic, 34, 36
Bilirubin, 7, 28, 34
Biofeedback, 47, 72
Biopsy, definitions, 5
Bisphosphonate drugs, 12
Botox (botulinum toxin A), 21, 70
Bravo test, 6
Bronchodilators, 12
C
Calcium, 3, 51, 53
Calcium channel blockers, 12, 21, 70
Canasa (mesalamine), 5859
Capsule endoscopy, 6, 42, 55
Carafate (sucralfate), 15, 1819
Carboplatin, 21
Cardizem (diltiazem), 70
Cecum, 39, 57
Celebrex (celecoxib), 2425
Celiac disease, 5154, 64
Chemotherapy, 21, 78
Cholangitis, 35
Cholecystectomy, 36
Cholesterol, 28, 34
Cimzia (certolizumab pegol), 56, 6061
Cipro (ciprofloxacin), 50, 6061
Cirrhosis, 32, 33
Cisapride, 9
Citrucel, 46
Clostridium difficile (C. difficile), 49, 51
Colace (docusate sodium), 46
Colazal (balsalazide), 5859, 61
Colectomy, 62
Colocort (hydrocortisone), 56, 5859
Colon cancer. see Colorectal cancer
Colon (large intestine), anatomy, 3, 39
Colonoscopy, overview, 41, 7475
Colorectal cancer
and alcohol, 71, 73
diagnosis, 39, 40, 41, 7778
exercise and colon cancer, 45
and fish in diet, 73
interval cancer, 41
risk factors, 62, 71, 73, 74, 7677
screening tests, 7375, 77
symptoms, 77
treatment, 7778
and ulcerative colitis, 62
Colorectal polyps, 3, 4041, 64, 7377
Colostomy, 73
Computed tomography (CT), 35, 37, 38,
4142, 48, 75
Constipation, 4344, 4647
see also Irritable bowel syndrome
Cordarone (amiodarone), 29
Correctol (bisacodyl), 46, 51
Corticosteroids
anal fissure, 70
celiac disease, 54
Crohns disease, 56, 5859
ulcerative colitis, 5859, 6162
COX-2 inhibitors, 24
Crohns disease
causes, 45, 5455
diagnosis, 39, 55
inflammatory diarrhea, 49, 55
symptoms, 55
treatment, 5557, 5861
D
Dermatitis herpetiformis (DH), 52
Descending colon, 39, 57
Dexilant (dexlansoprazole), 15, 1617
Diabetes, 89, 29, 38
Dialose (docusate sodium), 46
Diaphragm, anatomy, 2
Diarrhea, overview, 4951
see also Irritable bowel syndrome
Dietary fiber
anal fissure, 70
constipation, 43, 44, 46
diverticulosis, 47, 49
fecal incontinence, 72
gallstone risk, 34
gastroparesis, 9
hemorrhoids, 68
supplements, 46
Diffuse esophageal spasm, 8, 2021
DIFICID (fidaxomicin), 51
Digestive tract anatomy, overview, 12, 3
Dipentum (olsalazine), 5859, 61
Diverticulitis, 3, 45, 4749
Diverticulosis, 41, 43, 45, 4749
Domperidone, 9
Dulcolax (bisacodyl), 46, 51
Duodenal gastroesophageal reflux, 7
Duodenal ulcers, 25, 26, 37
See also Peptic ulcer disease
Duodenum, anatomy, 4, 38
Dysphagia, 710
Dysplasia, 22, 23, 62
E
Endoscopes, 45
Endoscopy
Bard EndoCinch system, 1920
capsule endoscopy, 6, 42, 55
endoscopic dilation, 10, 21, 22
endoscopic gastroplication, 1920
endoscopic mucosal resection, 23
endoscopic procedures for GERD, 1920
endoscopic retrograde
cholangiopancreatography (ERCP), 36
endoscopic ultrasound (EUS), 35
NDO Plicator (full-thickness plication), 20
peptic ulcer treatment, 28
Stretta procedure, 20
upper endoscopy, description, 45
Enterra, 9
Entocort EC (budesonide), 56, 5859
84
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Epiglottis, 2
Epivir-HBV (lamivudine), 32
Erythromycin, 9, 31
Escherichia coli O157:H7, 49, 50
Esophageal cancer, 7, 14, 21, 2224
Esophageal dilation, 10, 21, 22
Esophageal diverticula, 7
Esophageal dysphagia, 7, 8
Esophageal impedance testing, 7
Esophageal manometry, 6, 2021
Esophageal motility disorders, 78, 2021
Esophageal rings or webs, 7, 10
Esophageal strictures, 7, 10, 14, 2122, 24
Esophagitis, 10
Esophagus
anatomy, 24
dysplasia, 22, 23
gastroesophageal junction, 4, 18, 20, 21, 22
mucosa, 4, 7, 12, 14, 22
See also Lower esophageal sphincter
Exercise and physical activity, 45
F
Fecal immunochemical test (FIT), 75
Fecal impaction, 44, 46
Fecal incontinence, 7173
Fecal occult blood testing (FOBT), 75, 77
Fiber in diet. See Dietary fiber
Fiberall, 46
Fistulas, 6, 46, 55, 56
Flagyl (metronidazole), 51, 6061
Fleet (mineral oil), 46
Fosamax (alendronate), 23
G
Gallbladder
acute cholecystitis, 35, 37
anatomy, 2829
perforation, 35
Gallstones
acute cholecystitis, 35, 37
causes, 3, 34
cholangitis, 35
diagnosis, 3536
gallstone migration, 3435
overview, 3334
symptoms, 3435
treatment, 3637
Gastric emptying scintigraphy, 8
Gastric ulcers, 25, 26
See also Peptic ulcer disease
Gastritis, 2425
Gastroenterologist, definition, 1
Gastroesophageal junction, 4, 18, 20, 21, 22
Gastroesophageal reflux disease (GERD)
causes, 3, 1112
diagnosis, 6, 14
hiatal hernia, 10
lifestyle measures for treatment, 1415
medications, 1519
Nissen fundoplication, 11
obesity, 11, 12
overview, 11
surgery, 1819
symptoms, 11, 1214, 15
treatment, 1420
Gastrografin, 55
Gastroparesis, 89
Gaviscon, 15
Gelusil, 15
GERD. See Gastroesophageal reflux disease
Gliadin, 51
Glucagon, 29
Gluten, 51, 5254
H
H2-blockers. See Histamine H2-receptor
antagonists
Helicobacter pylori (H. pylori), 2426, 28
Helidac (bismuth/metronidazole/tetracycline),
27
Heller myotomy, 21
Hemorrhoid stapling (hemorrhoidopexy), 68
Hemorrhoidectomy, 69
Hemorrhoids, 44, 6669
Hepatitis, 2933
Hepatitis vaccines, 32
Hepatobiliary scintigram, 36
Hepatocytes, 28
Hepsera (adefovir), 32
Hiatal hernia, 1011
Histamine H2-receptor antagonists
(H2-blockers)
GERD, 15, 1617
peptic ulcers, 2628
Humira (adalimumab), 56, 6061, 62
Hydrocortisone, 56, 5859, 68
Hyperimmune globulin, 32
I
Ileoanal anastomosis, 62
Ileostomy, 62
Ileum, 34, 3839
Imodium A-D (loperamide), 50, 66, 73
Imuran (azathioprine), 56, 6061, 62
Inflammatory bowel disease. See Crohns
disease; Ulcerative colitis
Inflammatory diarrhea, 4950, 51
Insulin, 9, 29
Invicek (telaprevir), 33
Irritable bowel syndrome (IBS)
alternative and complementary treatment,
65, 66
causes, 6263
symptoms and diagnosis, 43, 50, 6364
treatment of constipation-predominant IBS,
64, 66
treatment of diarrhea-predominant IBS, 66
J
Jaundice, 30, 32, 33, 35, 38
Jejunum, 38
K
Kaopectate (bismuth subsalicylate), 50
Kapectolin, Kao-Spen (kaolin/pectin), 50
Konsyl, 46
L
Lactase, 53
Lactose intolerance, 53, 63, 64, 72
Laniazid (isoniazid), 29
Laparoscopy, 18, 21, 36, 62
Large intestine (colon), anatomy, 3, 39
Laxatives, 43, 46, 51, 6465
Lialda (mesalamin), 5859
LINX Reflux Management System (magnetic
sphincter augmentation), 19
Linzess (linaclotide), 47, 64
Liver anatomy, 3, 28
Liver cancer, 29, 33
Liver disorders, 2933
Liver transplants, 31, 33
Lomotil (diphenoxylate/atropine), 50
Lotronex (alosetron), 66
Lower digestive tract anatomy, 3839
Lower digestive tract tests, 3942
Lower esophageal sphincter (LES)
achalasia, 8, 20, 21
anatomy, 2, 3
GERD, 6, 1112, 14, 15, 18
hiatal hernia, 10, 11
relaxation by medications, 12, 21
See also Esophagus
Lower gastrointestinal (GI) series, 3940
Lymphoma, 51, 56
M
Maalox, 15
Magnetic resonance cholangiopancreatography
(MRCP), 36, 38
Magnetic resonance imaging (MRI), 36
Major duodenal papilla, 4, 35
Meditation, 65
Metamucil (psyllium), 46
Metaplasia, 22
Methotrexate, 31, 6061
Methyldopa, 29
Methylprednisolone, 56, 5859
Metozolv ODT (metoclopramide), 9, 1617
Metronidazole, 27, 51, 6061
Microvilli, 38, 53
Milk of Magnesia (magnesium hydroxide), 46
Mindfulness training, 65
Miralax (polyethylene glycol), 46
Motrin (ibuprofen), 24
Mouth anatomy, 2, 3
Mucosal protectants, 15, 1819
Mylanta, 15
I
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85
N
Naprosyn (naproxen), 24
NDO Plicator (full-thickness plication), 20
Nexium (esomeprazole), 13, 15, 1617, 27
Nissen fundoplication, 11, 1819
Nitrates, 21
Nitroglycerin, 21, 70
Nonacid (bile) reflux, 7
Nonsteroidal anti-inflammatory drugs (NSAIDs),
12, 24
Norpramin (desipramine), 66
Nydrazid (isoniazid), 29
O
Orencia (abatacept), 57
Oropharyngeal dysphagia, 7, 8
Osmotic diarrhea, 49, 51
Osteoporosis, 12, 51
P
Pacerone (amiodarone), 29
Paclitaxel, 21
Pancreas, anatomy and function, 3, 29
Pancreatic duct, 4, 29, 35, 36
Pancreatic enzymes
chronic pancreatitis treatment, 38
digestive role, 4
in pancreatitis, 37
reflux, 7
Pancreatitis, 35, 3738
Partial gastrectomy, 28
Pegylated interferon, 3233
Pentasa (mesalamine), 54, 56, 5859, 61
Pepcid (famotidine), 15, 1617, 27
Peptic ulcer disease
causes, 24, 25
complications, 26, 28
duodenal ulcers, 25, 26, 37
gastric ulcers, 25, 26
Helicobacter pylori (H. pylori), 2426, 28
symptoms and diagnosis, 26
treatment, 2628
Pepto-Bismol (bismuth subsalicylate), 27, 28,
50
Perforation
colon, 40, 41, 48, 55, 62
diverticulitis, 48
gall bladder, 35
peptic ulcer disease, 26, 28
Peristalsis, 2, 12, 20, 42
Peritonitis, 26, 47, 48, 55
pH monitoring, 6
Pharynx anatomy, 3
Photodynamic therapy, 2324
Photofrin, 23
Polyps, 3, 23, 4041, 64, 7377
Polyunsaturated fatty acids (PUFAs), 29
Prednisone, 54, 56, 5859
Preoperative chemotherapy, 21
Prevacid (lansoprazole), 13, 15, 1617, 27
Prevpac (amoxicillin/Biaxin/Prevacid), 27
Prilosec (omeprazole), 13, 15, 1617, 27
Procardia (nifedipine), 70
Prochymal, 57
Progressive multifocal leukoencephalopathy
(PML), 57
Promotility agents, 15, 1617
Proton pump inhibitors
GERD, 11, 13, 15, 1617
peptic ulcers, 2628
Protonix (pantoprazole), 13, 15, 1617, 27
Prozac (fluoxetine), 66
Psychological therapies, 66
Purinethol (mercaptopurine), 56, 6061, 62
Pylorus or pyloric valve, 4, 38
R
Radiation therapy (radiotherapy), 10, 21, 71,
78
Radiofrequency ablation, 24
Rectal cancer. see Colorectal cancer
Rectal prolapse, 44, 71
Rectum, anatomy and function, 3
Reglan (metoclopramide), 9, 1617
Remicade (infliximab), 56, 6061, 62
Ribavirin, 3233
Rifaximin, 63
Rocephin (ceftriaxone), 34
Rowasa (mesalamine), 56, 5859
S
Saliva, 2, 12
Salmonella typhi, 50
Scleroderma, 8
Sclerotherapy, 68
Secretory diarrhea, 49, 51
Selective serotonin reuptake inhibitors (SSRIs),
66
Sigmoid colon, 39, 40, 47, 57, 61, 72
Sigmoidoscopy, overview, 40, 75
Small intestine anatomy, 3, 3839
SmartPill, 9
Smoking, 12, 23, 25, 28, 37
Sphincter of Oddi, 29
Sphincterotome, 36
Sphincterotomy, 70
Statins, 30
Stomach anatomy, 3, 4
Stool softeners, 46, 70
Stretta procedure, 20
Surfak (docusate sodium), 46
T
Tagamet (cimetidine), 15, 1617, 27
Tetracycline, 27, 31
Theo-24 (theophylline), 12
Theo-Dur (theophylline), 12
Thoracoscopy, 21
Toupet fundoplication, 19
Transoral Incisionless Fundoplication (TIF), 19
Transverse colon, 39, 57
Tricyclic antidepressants (TCAs), 12, 21, 66
Tuberculosis, 29, 56, 69
Tylenol (acetaminophen), 30, 31, 69, 70
Tysabri (natalizumab), 5657, 6061
Tyzeka (telbivudine), 32
U
Ulcerative colitis
causes, 57
inflammatory diarrhea, 4950
symptoms and diagnosis, 39, 57, 60
treatments, 5862
Ultrasound, 35, 37, 38
Uniphyl (theophylline), 12
Upper digestive tract anatomy, 24
Upper digestive tract tests, 47
Upper endoscopy, description, 45
Upper esophageal sphincter, 2
Upper gastrointestinal (GI) series, 56, 89, 21
Urecholine (bethanechol), 15
V
Vagotomy, 28
Victrelis (boceprevir), 33
Vioxx (rofecoxib), 25
Viral hepatitis, 29, 3033
Virtual colonoscopy, 4142, 75
Vitamin A, 30
Vitamin B
12
, 3, 39
Vitamin D, 3, 51, 53
Z
Z-line, 4
Zantac (ranitidine), 15, 1617, 27
Zegerid (omeprazole/sodium bicarbonate), 15,
1617, 27
Zelnorm (tegaserod), 66
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DOCTORS VIEWPOINT
It bodes well to try drug therapy first for uncompli-
cated stable angina. Some patients dont want to wait to
see whether drugs will improve their symptoms over time.
Also, patients may not distinguish between stable and unsta-
ble angina because both produce chest pain, which people
tend to associate with a heart attack. But if you have stable
angina, you should know angioplasty wont put you at any
less risk for a heart attack than you were before the proce-
dure. And even if you have an angioplasty, drug therapy will
be a necessary part of managing your angina afterward.
JohnsHopkinsHealthAlerts.com
After 50 Health
Doctors also use angioplasties in non-

life-threatening situationsprimarily to
ease symptoms of stable angina (chest pain
that occurs with exertion) and improve
quality of life (lasting for up to three years).
But drug therapy can be just as effective
an outcome that was first established by
the COURAGE(Clinical Outcomes Uti-
lizing Revascularization and Aggressive
Drug Evaluation) clinical trial in 2007.
The trial showed that, in patients with
stable angina, drug therapy with angio-
plasty had no better outcome than drug
therapy without angioplasty.
In 2009, the American College of Car-
diology, the American Heart Association
and several other medical societies estab-
lished criteria to assist cardiologists when
they consider coronary revascularization
procedures like angioplasty and coronary
artery bypass graft (CABG) surgery that
restore blood flowto the heart. The crite-
Each year, more than a million angioplasty
proceduresalso called percutaneous
coronary interventions, or PCIsare per-
formed in the United States to open nar-
rowed or clogged arteries. Used chiefly to
treat acute coronary syndromes such as
heart attacks and the severe cardiac-related
chest pain known as unstable angina, an
emergency angioplasty can be a life-saving
procedure that restores blood flow to the
heart and reduces heart muscle damage.
During angioplasty, a catheter with a
balloon at its tip is directed through a
puncture into an artery in the leg or arm
to the site where a coronary artery is nar-
rowed by plaques. The balloon is inflated
to compress the plaques against the artery
wall, stretch the artery and improve blood
flowto the heart. Astent, which resembles
a wire mesh tube, is usually inserted into
the artery during angioplasty to help keep
the vessel open.
In This Issue
September 2012 Volume 24 Issue 8 $5.00
SPECIAL REPORT
M
inim
ally Invasive
Hernia Repair
continued on next page
ABadFeelinginthe Gut PreventingFalls CouldYouHave Asthma andNot KnowIt?
NewQuestions About aPopular
Heart Procedure
Research finds that angioplasty is used on those who may not need it
James L. Weiss, MD
Michael J. Cudahy Professor of
Cardiology, Johns Hopkins
University School of Medicine
Stent
A
B
Inflated balloon with
expanded stent
Flattened
plaque
Stent-widened
artery
Angioplasty with Stenting
ria favor drug therapy over angioplasty as
the first-line treatment approach for stable
angina. But it seems that some cardiolo-
gists are straying from these suggested
medical protocols.
Too many elective angioplasties
According to a study published online in
the Journal of the American College of Cardi-
ology in May, one in seven nonemergency
angioplasties may be inappropriate and
unlikely to improve patients health or sur-
vival outcomes.
For the study, a team of researchers
from several prominent medical institu-
tions, including Johns Hopkins, investi-
gated whether cardiologists were following
After guiding a catheter to the blockage in the
artery, a cardiologist infates a balloon at its
tip to compress plaques. A stent is opened,
serving as a scaffold to keep the artery open
(A). The catheter is then removed, and the
stent left in place (B).
HA50_09_2012_V2.indd 1 9/5/12 3:22:42 PM
N
EW
FO
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Lee H. Riley III, M.D., and Suzanne M. Jan de Beur, M.D.
Back Pain
and Osteoporosis
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o
p
k
in
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W
h
ite
P
a
p
e
rs
2
0
1
3 $39.95
Stopping back spasms
Strategies for pain relief
PAGE 18
New guidance on osteoporosis drugs
Who should stop, who should not
PAGE 70
Yoga for low back pain
Improvements in mobility and performing
everyday tasks
PAGE 24
Whole body vibration
Should you try it to build bone strength?
PAGE 58
Pain-free travel
Reducing neck and back pain
when driving or flying
PAGE 40
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There is now reason to think that a variety
of lifestyle measures to help your heart
including dietary changesmight help ward
off age-related memory problems.
ALSO IN THIS ISSUE: IS IT REALLY A MIGRAINE?
In our December 2011 issue of Health After 50, an article on migraine head-
aches discussed a study showing that people with regular, severe migraines
(three or more a month) can benefit from a combination of preventive medi-
cine and behaviorial therapy. But how do you know that the headaches you
have are actually migraines? On page 5, Jason Rosenberg, M.D., director of
the Johns Hopkins Headache Center, provides an in-depth look at the signs
and symptoms that distinguish migraines from other types of headaches.
JohnsHopkinsHealthAlerts.com
After 50 Health
so has the marketing and promotion of

dietar y supplements that cl ai m to
enhance memory. But as I ll explain,
evidence points to the foods you eat as
offering a more likely way to combat
cognitive decl ine. Recent research
strongly suggests that dietary changes
in particular, the adoption of a Medi-
terranean-style eating plancan help
prevent the onset or slow the rate of
cognitive decline.
Eating Mediterranean
Over the past decade, a number of stud-
ies have linked adhering to a Medi-
terranean diet with a reduced risk of
cardiovascular disease and risk factors
associated with cardiovascular disease,
including diabetes and hypertension.
Not surprisingly, foods that are good
for your heart are also good for your
brain.
The Mediterranean diet consists of
foods traditionally consumed by people
living along coastal areas of the Medi-
terranean Sea. The diet is characterized
We now know that Alzheimers disease
is not something that occurs suddenly
in old age. Rather, its a continuum of
illness that gets its start decades earlier.
With a cure for Alzheimers still way in
the future, many experts are shifting
their focus on prevention decades earlier
in life, emphasizing important lifestyle
changes as a way to preserve memory
and protect the brain.
A number of studies, for example,
have found promising links between
regular physical activity and a reduction
i n cogni t i ve dec l i ne and many
researchers now believe that exercise
may guard memory and help reduce the
risk of Alzheimers. Here I want to
focus on another aspect of lifestyle that
evidence suggests has links to prevent-
ing or forestalling memory lossyour
diet.
As concern over Alzheimers disease
and other forms of dementia has grown,
by the following eating patterns:
Smaller portion sizes than a West-
ern diet
A focus on fresh rather than pro-
cessed foods
A high intake of plant-based foods
such as vegetables, fruits, legumes
and whole grains
Moderate amounts of nuts, olive oil
and fish, which are high in healthy
monounsaturated and omega-3 fats
Moderate consumption of wine,
typically with meals
Regular consumption of skinless
poultry and low-fat dairy in smaller
portions
Infrequent consumption of meat,
which is high in saturated fats, and
sweets
Summer 2012 Volume 24 Issue 6 $5.00
continued on next page
ADietThat Builds BrainHealth
Evidence points tokey foods andeatingpatterns for protectingmemory
SPECIAL ISSUE
Sum
m
er
2012
by Peter V. Rabins, M.D., M.P.H.
Director, the Division of Geriatric Psychiatry and
Neuropsychiatry at the Johns Hopkins School of Medicine
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Peter V. Rabins, M.D., M.P.H.
Memory
Your annual guide to Alzheimers disease and dementia
Could it be Alzheimers?
A new tool helps spot telltale
signs earlier
PAGE 48
Not thinking clearly?
A potential culprit: sleep apnea
PAGE 6
The exercise prescription
Can being active slow cognitive decline?
PAGE 16
Preserving memory with insulin
New research reveals a promising therapy
PAGE 24
When dementia triggers bad behavior
Strategies for handling a
patients aggression
PAGE 66
MEM_WPCOVER_2013.indd 1 11/12/12 11:34:24 AM
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W
F
O
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2
0
1
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D
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2
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1
3
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The power of prevention
5 steps to lower diabetes risk
PAGE 12
Keys to sustaining weight loss
The strategies of successful maintainers
PAGE 30
Foot protection
Expert advice to help prevent nerve
damage and circulatory problems
PAGE 72
When diabetes increases driving risks
How hypoglycemia can impair safety behind
the wheeland protective steps to take
PAGE 56
Diabetes and sleep apnea
The potential impact on glucose control
PAGE 26
Rita Rastogi Kalyani, M.D., and Simeon Margolis, M.D., Ph.D.
Diabetes
DIA_WPCOVER_2013.indd 1 11/12/12 11:30:17 AM
N
E
W
F
O
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2
0
1
3
A
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Arthritis and back pain
Is the cause spinal stenosis?
PAGE 8
Supplements for arthritis pain
Safety is an issueespecially if youre
scheduled for joint replacement
PAGE 28
Improve your range of motion
An illustrated guide to exercises that can
help maximize joint function
PAGE 14
Persistent pain from bursitis?
New alternatives to surgery
PAGE 68
RA drugs and skin cancer risk
What you should know
PAGE 56
John A. Flynn, M.D., and Carl A. Johnson, M.D.
Arthritis
ART_WPCOVER_2013.indd 1 11/12/12 11:26:49 AM
N
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O
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2
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1
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Team-based weight loss
Using social networks to
boost your odds of success
PAGE 56
New dairy choices
A guide to milk and milk alternatives
PAGE 24
The benefits of snacking
Smart ways to make snacks part of your
weight-loss regimen
PAGE 60
Healthy meals in minutes
Tips for meal planning on your busiest days
PAGE 43
Herbals for weight loss?
How to assess the benefits and risks
PAGE 76
Lawrence J. Cheskin, M.D., F.A.C.P., Carmen Roberts, M.S., R.D.,
and Simeon Margolis, M.D., Ph.D.
Your annual guide to eating healthy and managing weight
Nutrition and
Weight Control
NUT_WPCOVER_2013.indd 1 11/12/12 11:34:52 AM
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2
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Roger S. Blumenthal, M.D., and Simeon Margolis, M.D., Ph.D.
Heart Attack
Prevention
Your annual guide to risk, screening and precautions
H
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P
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For healthy people at risk
The right strategy with statins
PAGE 50
Choosing and using NSAIDs
Too much use carries an increased risk of
heart attack and stroke
PAGE 25
Cholesterol-busting foods
Focusing on diet to lower your cholesterol
PAGE 37
A closer look at aspirin therapy
Sorting through the recommendations
PAGE 62
Anger and heart attack risk
How you can safeguard your heart from
negative emotions
PAGE 21
HA_WPCOVER_2013.indd 1 11/12/12 11:31:43 AM
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O
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2
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Lee H. Riley III, M.D., and Suzanne M. Jan de Beur, M.D.
Back Pain
and Osteoporosis
B
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2
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Stopping back spasms
Strategies for pain relief
PAGE 18
New guidance on osteoporosis drugs
Who should stop, who should not
PAGE 70
Yoga for low back pain
Improvements in mobility and performing
everyday tasks
PAGE 24
Whole body vibration
Should you try it to build bone strength?
PAGE 58
Pain-free travel
Reducing neck and back pain
when driving or flying
PAGE 40
BP_WPCOVER_2013.indd 1 11/12/12 11:27:54 AM
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2
0
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P
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2
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Stroke in women
New insights on symptoms
PAGE 54
If you have prehypertension
Should you start on medication
to cut your stroke risk?
PAGE 12
Sidestep the side effects
Tips on taking antihypertensives
PAGE 33
Preventing major stroke
A new focus on outpatient clinics
PAGE 50
Find your balance
The right therapy can reduce the risk
of falls after a stroke
PAGE 71
Lawrence Appel, M.D., and Rafael H. Llinas, M.D.
Hypertension
and Stroke
HTN_WPCOVER_2013.indd 1 11/12/12 11:32:14 AM
N
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2
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P
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1
3
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Potassium matters
Getting the right amount
of a key mineral
PAGE 28
Weather-proof your heart
Reducing a risk posed by cold temperatures
PAGE 14
Heart valve implant
A new minimally invasive procedure
for positioning artificial valves
PAGE 72
Playing it safe
Starting to exercise after a heart attack
PAGE 62
Seeking a second opinion
When should you consult another doctor?
PAGE 54
Gary Gerstenblith, M.D., and Simeon Margolis, M.D., Ph.D.
Coronary
Heart Disease
CHD_WPCOVER_2013.indd 1 11/12/12 11:28:48 AM
N
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O
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2
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L
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g
D
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rs
T
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J
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in
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Living with COPD
18 energy-saving strategies
PAGE 27
Long-term steroid use
Understanding the adverse effectsand
the safeguards to protect your health
PAGE 22
Who needs a pneumonia shot?
New vaccine, new recommendation
PAGE 64
Antibiotics for COPD flares
New research on preventing acute
attacksand who can benefit
PAGE 30
The lung disease flight manual
Keys to safe air travel
PAGE 44
Peter B. Terry, M.D., M.A.
Lung Disorders
LUNG_WPCOVER_2013.indd 1 11/12/12 11:33:43 AM
N
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F
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2
0
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3
Karen L. Swartz, M.D.
Depression
and Anxiety
D
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p
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s
s
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n
a
n
d
A
n
x
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ty
T
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J
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When meds are the culprit
Depression as a side effect
PAGE 7
Treatment-resistant depression
A quick-acting drug shows promise
for reducing symptoms
PAGE 35
Anxiety, depression and . . . arthritis
Researchers discover a link;
what you can do about it
PAGE 54
Music therapy for depression
Is it right for you?
PAGE 51
Newresearch: depression and stroke
A potential risk for women?
PAGE 19
DEP_WPCOVER_2013.indd 1 11/12/12 11:29:40 AM
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O
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2
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P
ro
s
ta
te
D
is
o
rd
e
rs
T
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J
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in
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P
a
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2
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Proton beam therapy
Expensivebut is it better?
PAGE 54
New discovery:
a prostate cancer gene
A step towards detecting increased risk
PAGE 28
Two popular prostate supplements
The latest research concludes:
Dont bother.
PAGE 12
Hormonal therapy and hot flashes
Where to turn for relief
PAGE 64
Treatment for prostatitis
First, get the right diagnosis
PAGE 76
H. Ballentine Carter, M.D.
Prostate Disorders
PRO_WPCOVER_2013.indd 1 11/12/12 11:35:20 AM
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2
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Laser surgery for cataracts
A new treatment option
PAGE 13
Gaining focus
Latest lens options for correcting presbyopia
PAGE 5
Coping with watery eyes
A host of causes; what to do
PAGE 42
New therapy to halt keratoconus
An effectiveand saferalternative to
corneal transplants
PAGE 24
Floaters and flashes
When these common symptoms
require medical attention
PAGE 54
Susan B. Bressler, M.D., Harry A. Quigley, M.D., and
Oliver D. Schein, M.D., M.P.H.
Vision
Your annual guide to sight-saving therapies
VIS_WPCOVER_2013.indd 1 11/12/12 11:36:56 AM
$39.95

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