Every year millions of people see their doctors for symptoms such as constipation, abdominal pain, diarrhea, or excessive gas. These are the most common indicators of gastrointestinal disorders. The diagnoses for digestive disorder range from an upset stomach to the potentially serious and life-threatening colon cancer, or colorectal cancer. The most common diagnoses are Irritable Bowel Syndrome, or IBS, Inflammatory Bowel Disease, also called IBD, and Gastro Esophageal Reflux Disease, GERD. Other possible conclusions that a doctor may come to are that there is an ulcer somewhere in the digestive tract, the esophagus, stomach or large or small intestine. While a family doctor can diagnose and treat these diseases, referral to a gastroenterologist is usually recommended.
Irritable Bowel Syndrome
Also called spastic colon, nervous stomach, irritable colon and spastic colitis, this syndrome is not generally considered to be a serious intestinal disorder. The large intestine, or large bowel, becomes inflamed and irritated. The inflammation is usually not chronic. However, the symptoms and irritation reappear on an irregular basis. IBS does not increase the threat of developing colorectal cancer. Approximately 20 % of adults in the United States are affected by Irritable Bowel Syndrome.
Characteristic symptoms for IBS are bloating, gas, abdominal pain and discomfort, and constipation and/or diarrhea. Excess mucus or frequent urgency in bowel movements, feelings of incomplete evacuation or changes in stool are other symptoms that might be experienced. Nausea, fatigue and vomiting are also associated with IBS.
Specific causes for IBS have not been found. Stress is thought to be a factor in the development of IBS symptoms. Food allergies, excessive alcohol use and use of antibiotics may also play a role in this disorder. Peristalsis, the contraction of the muscles in the colon which moves the waste through, may be involved also. The contractions may stop temporarily or may cause intense periodic spasms.
Testing
Since there is no diagnostic test for IBS, the majority of tests that are performed to will be conducted in an effort to rule out other diseases or disorders. Stool sampling, blood work and abdominal x-rays will probably be performed first. A colonoscopy or sigmoidoscopy will usually be ordered to take a look at the structure of the colon and search for abnormalities. CT scans and lactose intolerance tests are common diagnostic tools that may also be utilized. If the results of this testing is negative, a diagnosis of IBS may follow.
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Most doctors use the Rome criteria in addition to the tests mentioned to diagnose this disorder. The Rome criterion states that the following symptoms must be present for at least 3 months out of the past year. The three months of symptoms do not need to be consecutive. First, the patient has had abdominal pain coupled with at least two of the following: it is relieved with a bowel movement, it coincides with a change in frequency of bowel movements, or there is a change in stool consistency.
Treatment methods for irritable bowel syndrome include dietary changes and stress management. Increasing the amount of fiber in your diet or taking fiber supplements will usually decrease constipation. Over-the-counter or prescription anti-diarrheal medicines can be used to control this symptom. Reducing or eliminating salads, raw vegetables and fruits and carbonated beverages will help with bloating and gas symptoms. Antidepressant medications and/or counseling may be prescribed for patients having difficulty managing their stress.
Inflammatory Bowel Disease
There are two related but distinctly different diseases which fall into this category of intestinal disorders. Both of them are associated with chronic pain and swelling of the intestines. Ulcerative colitis, sometimes referred to as chronic ulcerative colitis or CUC, is an inflammation of the lining of the large intestine and rectum. The inflammation from Crohn’s disease can occur in any part of the digestive tract, from the mouth to the rectum. Most commonly it affects the lower part of the small intestine and the large intestine. Unlike colitis, the inflammation occurs in all of the layers of the intestinal wall.
Since both of these inflammatory bowel diseases involve bleeding into the digestive tract, the first symptoms noticed will be diarrhea, blood in the stools, weight loss, fatigue and anemia. Diminished appetite, fever and abdominal cramping are other symptoms common to patients suffering from IBD. Joint pain, skin rashes, and inflammation of the eyes are associated with IBD.
Along with noting the above symptoms, doctors will inquire about family history of IBD, history of cigarette smoking and alcohol intake as well as perform diagnostic tests as part of their examination process. Blood tests will be performed to determine if anemia and a high white blood cell count is present. Stool samples will be checked for the presence of abnormal bacteria, bleeding and infection. A barium enema, or lower GI series, is a procedure that examines the lower part of the small intestine, the entire large intestine and the rectal area.
This will show the presence of obstructions, blockages, or narrowed areas, strictures, in this part of the intestinal tract. A sigmoidoscopy or colonoscopy is usually performed. During this procedure samples of cells or tissue may be removed for a biopsy of the material under a microscope.
Time Period of Treatment
Since inflammatory bowel diseases are chronic they usually require treatment with medications over an extended period of time. Aspirin products, steroids and immune system modifiers are the most common medications used to treat IBD. Antibiotics may also be prescribed to treat or prevent infections. Anemia is treated with Vitamin B and Iron, either in the form of supplements or injections.
Surgery may be indicated for both of these forms of IBD. If the patient’s response to medications is minimal or non-existent or the side effects of the medicine are intolerable surgery will usually be performed. Formation of strictures, blockages or an abscess or changes that indicate a precancerous or cancerous condition are also reasons for surgical intervention. Depending on the severity of the disease, ulcerative colitis patients may have a portion of their large intestine removed, or the entire colon will be taken out. Removing the entire colon is the only cure for colitis patients. If only a part of the colon is removed the remaining sections will be sutured together and normal bowel function will return.
There is a possibility that the colitis will recur, requiring further medication treatment and/or surgery. When the entire large intestine is removed, there are a few options for waste removal. The small intestine can be attached to a stoma, or opening, in the lower abdominal area.
The patient will need to wear an external bag to collect fecal material. This bag is emptied frequently and changed on a regular basis. A procedure known as an ileoanal anastomosis, or pouch procedure, can be quite effective and eliminates the need for a permanent stoma.
The lower part of the small intestine is used to create a reservoir, which is then connected to the anus. Surgery for Crohn’s disease is often required to relieve symptoms and to remove portions of the small intestine that have been damaged by the chronic inflammation.
However, surgery cannot cure the disease. Almost three-fourths of Crohn’s patients require surgery at some time during the course of their treatment. In this surgery the section of intestine that is showing active involvement of the disease is removed and the remaining ends of the intestine are surgically connected. Approximately 75 % of patients will experience a recurrence of Crohn’s disease within 10-15 years following surgery.
Gastroesophageal Reflux Disease
Gastroesophageal reflux disease, or GERD, occurs when gastric juices from the stomach flow upwards into the esophagus. The muscle at the bottom of the esophagus, the lower esophageal sphincter or LES, is thought to be the cause of GERD. A hiatal hernia occurs at this location which causes the sphincter to relax too frequently or for too long a time, allowing gastric acid to reflux into the esophagus.
Other factors may be obesity, overeating, use of alcohol or tobacco, or consuming too much caffeine. Eating fatty, spicy or acidic foods or foods containing peppermint, chocolate or citrus may also cause reflux disease. The disease is chronic, meaning that once it starts patients will suffer from it for their entire life.
Acid indigestion, or heartburn, is the most common symptom of GERD. It is a burning sensation behind the breastbone that seems to move upward toward the neck and throat. Other symptoms may include frequent burping, stomach aches, a persistent cough, gagging or choking, and waking up with a sour taste in your mouth or a soar throat.
Diagnoses
GERD is diagnosed utilizing a number of tests. A chest x-ray will look for signs of aspiration. An upper gastrointestinal series, called an upper GI or barium swallow, will assess the structure of the digestive organs. An endoscopy will often be performed. This involves inserting a small flexible tube containing a light and camera lens into the throat, stomach and the upper portion of the small intestine. In addition to being able to visually examine these areas, the physician is also able to collect tissue samples for biopsy examination.
A pH monitoring device may be inserted in the esophagus just above the LES and attached to an external monitor. Over a period of 24 hours the device records the pH level at the sphincter. The patient records the time and circumstances when an episode occurs, allowing the physician to make a correlation between symptoms and pH levels.
Symptoms
Mild GERD symptoms may be alleviated using antacids. Patients should avoid eating 2 to 3 hours before lying down. Use of tobacco, alcohol, and caffeine should be curtailed or discontinued. Elevating the head of the bed 6 inches is helpful. Cutting back on the amount of food eaten in one sitting is also recommended.
Mild to moderate symptoms will respond to the above lifestyle changes. Foaming agents may be used to cover the contents of the stomach with foam which prevents reflux. H2 blockers are available over the counter but only provide relief in about 50 % of GERD sufferers. These medications only provide short term relief from the symptoms.
Proton pump inhibitors can be obtained over the counter or by prescription. They are more effective than H2 blockers as they not only relieve symptoms but also heal the lining of the esophagus. Prokinetic medications help empty the stomach faster, improve the peristalsis movement in the digestive tract and strengthen the LES. However, the side effects of fatigue, anxiety and depression make physicians cautious in prescribing them. Medications work differently in each individual. They also may have less desirable effects when taken in certain combinations. Patients should always consult their physician before adding new medications or changing dosage.
Ulcers
An ulcer occurs when the lining in part of the digestive tract develops a sore which can cause a hole, or lesion. An ulcer located in the lining of the stomach or the duodenum, the beginning of the small intestine, is called a peptic ulcer. In the stomach, peptic ulcers are classified as gastric ulcers. Peptic ulcers in the duodenum are duodenal ulcers.
In the past physicians felt that ulcers were caused by stress or by eating too much acidic foods. Later they thought that the hydrochloric acid and pepsin released in the stomach during digestion was the cause. It is now known that the bacteria Helicobacter pylori, or H. pylori, and the use of non-steroidal anti-inflammatory drugs, or NSAIDS, are the main factors that cause ulcers.
The H. pylori bacterium produces ammonia, which weakens the protective mucous coating in the stomach, allowing the acids produced during digestion to create sores. NSAIDS are weak acids and cause inflammation of the digestive tract. Smoking, alcohol use, caffeine and physical stress, such as major surgery or severe burns, are also contributory factors in the development of ulcers.
Symptoms
The symptoms of stomach ulcers may go unnoticed for a long time after the ulcer has formed. Duodenal ulcer symptoms present almost immediately after they have formed. A burning pain in the upper middle portion of the abdomen is the most common symptom. This pain may be temporarily relieved by eating or by taking an antacid, but returns with sometimes greater intensity. The pain may cause the patient to awaken suddenly in the middle of the night. Other symptoms may include nausea, frequent belching, blood in the stool, black stool, recurrent vomiting and anemia.
Since there are potentially serious complications from ulcers, it is important to seek medical attention when symptoms present themselves. Persistent bleeding can cause weakness and fatigue as well as anemia. An ulcer may perforate, or eat through, the wall of the stomach or intestine, releasing partially digested food and bacteria into the abdominal cavity.
This could cause peritonitis, an infection requiring prompt medical attention. Ulcers can also cause swelling and scar tissue to form, especially at the end of the stomach where the duodenum is attached. This can cause a narrowing or a complete obstruction at that point which will inhibit or stop the passage of food into the intestinal tract.
Diagnosing
An upper GI series, or barium swallow, is used to diagnose an ulcer. The barium, a chalky liquid, coats the inside of the upper digestive organs which will show the health of those organs on an x-ray. An endoscopic examination will allow the physician to see the extent of the ulcer damage. It also allows for the removal of tissue for biopsy examination. Detecting the H. pylori bacteria is done through blood, breath and stomach tissue tests. It is important for the physician to determine whether this bacterium is present or whether the ulcer has been caused by NSAID drugs as the treatment regimen will be quite different in each case.
People with ulcers should not smoke, as smoking causes delays in the healing process and also causes them to recur. For H. pylori caused ulcers, doctors will prescribe antibiotic medications to kill the bacteria. In addition, antacids, acid blockers, and proton pump inhibitors may be utilized to help reduce the amount of acid produced in the stomach.
Ulcers that do not heal are called refractory ulcers. Many of the reasons that ulcers fail to heal are often related to the choices that patients make. They may continue smoking or consuming alcohol. They may be taking NSAIDS after being told not to take them. They may not be taking their medications according to the directions given them by their doctor.
There are, however, medical reasons that ulcers do not respond favorably to treatment regimens. Some strains of the H. pylori bacteria are resistant to certain antibiotics. It is also possible that another bacterium is present. The patient may have stomach cancer, cirrhosis, or chronic obstructive pulmonary disease which are interfering with the healing process.
Surgery for Ulcers
Infrequently, ulcers that do not heal or respond to conventional treatment may require surgery. There are three types of surgery that may be performed. The first is called a vagotomy. The vagus nerve sends and receives messages from the brain which causes the stomach to produce acid. During a vagotomy, parts of this nerve are severed, interrupting messages sent through it and thus reducing acid production and secretion. A pyloroplasty is often performed along with the vagotomy procedure.
The pylorus is the opening between the stomach and duodenum. During this surgery, the pylorus is enlarged, allowing food from the stomach to pass more freely into the small intestine. An antrectomy is the removal of the lower part of the stomach. This area of the stomach produces a hormone which stimulates secretion of digestive juices. This procedure is also often performed in conjunction with a vagotomy.
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