Mumps or epidemic parotitis is a viral disease of the human species, caused by the mumps virus. Prior to the development of vaccination and the introduction of a vaccine, it was a common childhood disease worldwide, and is still a significant threat to health in the third world.
Painful swelling of the salivary glands (classically the parotid gland) is the most typical presentationPainful testicular swelling and rash may also occur. The symptoms are generally not severe in children. In teenage males and men, complications such as infertility or subfertility are more common, although still rare in absolute terms. The disease is generally self-limited, running its course before receding, with no specific treatment apart from controlling the symptoms with painkillers.
Symptoms
Comparison of a person before and after contracting the mumps
The more common symptoms of mumps are:
* Parotid inflammation (or parotitis) in 60–70% of infections and 95% of patients with symptoms.[2] Parotitis causes swelling and local pain, particularly when chewing. It can occur on one side (unilateral) but is more common on both sides (bilateral) in about 90% of cases.[6]
* Fever
* Headache
* Orchitis, referring to painful inflammation of the testicle.[7] Males past puberty who develop mumps have a 30 percent risk of orchitis.[8]
Other symptoms of mumps can include sore face and/or ears and occasionally in more serious cases, loss of voice. In addition, up to 20% of persons infected with the mumps virus do not show symptoms, so it is possible to be infected and spread the virus without knowing it.[9]
Prodrome
Fever and headache are prodromal symptoms of mumps, together with malaise and anorexia.
Signs and tests
A physical examination confirms the presence of the swollen glands. Usually the disease is diagnosed on clinical grounds and no confirmatory laboratory testing is needed. If there is uncertainty about the diagnosis, a test of saliva, or blood may be carried out; a newer diagnostic confirmation, using real-time nested polymerase chain reaction (PCR) technology, has also been developed. An estimated 20%-30% of cases are asymptomatic. As with any inflammation of the salivary glands, serum amylase is often elevated.
Transmission
Mumps is a contagious disease that is spread from person-to-person through contact with respiratory secretions such as saliva from an infected person. When an infected person coughs or sneezes, the droplets aerosolize and can enter the eyes, nose, or mouth of another person. Mumps can also be spread by sharing food, sharing drinks, and kissing. The virus can also survive on surfaces and then be spread after contact in a similar manner.
A person infected with mumps is contagious from approximately 6 days before the onset of symptoms until about 9 days after symptoms start. The incubation period (time until symptoms begin) can be from 14-25 days but is more typically 16-18 days.
Treatment
There is no specific treatment for mumps. Symptoms may be relieved by the application of intermittent ice or heat to the affected neck area and by acetaminophen/paracetamol (Tylenol) for pain relief. Aspirin use is discouraged in young children because of studies showing an increased risk of Reye's syndrome. Warm salt water gargles, soft foods, and extra fluids may also help relieve symptoms.
Patients are advised to avoid fruit juice or any acidic foods, since these stimulate the salivary glands, which can be painful.
Prognosis
Death is very unusual. The disease is self-limiting, and general outcome is good, even if other organs are involved. Mumps viral infections in adult males carry a 25% risk that the testes may become infected which in rare cases leads to sterility. After the illness, life-long immunity to mumps generally occurs.
Complications
Known complications of mumps include:
* Infection of other organ systems
* Sterility in men (this is quite rare, and mostly occurs in older men)
* Mild forms of meningitis (rare, 40% of cases occur without parotid swelling)
* Encephalitis (very rare, rarely fatal)
* Profound (91 dB or more) but rare sensorineural hearing loss, uni- or bilateral
* Pancreatitis manifesting as abdominal pain and vomiting
* Oophoritis (inflammation of ovaries) but fertility is rarely affected.
* Though rare, spontaneous abortion can occur if infection happens in the first trimester of pregnancy.
Prevention
The most common preventative measure against mumps is immunization with a mumps vaccine. The vaccine may be given separately or as part of the MMR immunization vaccine which also protects against measles and rubella. In the US, MMR is now being supplanted by MMRV, which adds protection against chickenpox. The WHO (World Health Organization) recommends the use of mumps vaccines in all countries with well-functioning childhood vaccination programmes. In the United Kingdom it is routinely given to children at age 15 months. The American Academy of Pediatrics recommends the routine administration of MMR vaccine at ages 12-15 months and at 4-6 years. In some locations, the vaccine is given again between 4 to 6 years of age, or between 11 and 12 years of age if not previously given. The efficacy of the vaccine depends on the strain of the vaccine, but is usually around 80%. The Jeryl Lynn strain is most commonly used in developed countries but has been shown to have reduced efficacy in epidemic situations. The Leningrad-Zagreb strain commonly used in developing countries appears to have superior efficacy in epidemic situations.
Due to the outbreaks within college and university settings, many governments have established vaccination programs to prevent large-scale outbreaks. In Canada, provincial governments and the Public Health Agency of Canada have all participated in awareness campaigns to encourage students ranging from grade 1 to college and university to get vaccinated.
Some anti-vaccine activists protest against the administration of a vaccine against mumps, claiming that the attenuated vaccine strain is harmful, and/or that the wild disease is beneficial. Disagreeing, the WHO, the American Academy of Pediatrics, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, the American Academy of Family Physicians, the British Medical Association and the Royal Pharmaceutical Society of Great Britain currently recommend routine vaccination of children against mumps. The British Medical Association and Royal Pharmaceutical Society of Great Britain had previously recommended against general mumps vaccination, changing that recommendation in 1987. In 1988 it became United Kingdom government policy to introduce mass child mumps vaccination programmes with the MMR vaccine, and MMR vaccine is now routinely administered in the UK.
Before the introduction of the mumps vaccine, the mumps virus was the leading cause of viral meningoencephalitis in the United States. However, encephalitis occurs rarely (less than 2 per 100,000). In one of the largest studies in the literature, the most common symptoms of mumps meningo[24encephalitis were found to be fever (97%), vomiting (94%) and headache (88.8%). The mumps vaccine was introduced into the United States in December 1967: since its introduction there has been a steady decrease in the incidence of mumps and mumps virus infection. There were 151,209 cases of mumps reported in 1968. Since 2001, the case average was only 265 per year, excluding an outbreak of >6000 cases in 2006 attributed largely to university contagion in young adults.
Sunday, April 5, 2009
Saturday, April 4, 2009
Dengue fever
Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related dengue viruses. This disease used to be called "break-bone" fever because it sometimes causes severe joint and muscle pain that feels like bones are breaking, hence the name. Health experts have known about dengue fever for more than 200 years.
Dengue fever is found mostly during and shortly after the rainy season in tropical and subtropical areas of
* Africa
* Southeast Asia and China
* India
* Middle East
* Caribbean and Central and South America
* Australia and the South and Central Pacific
An epidemic in Hawaii in 2001 is a reminder that many locations in the United States are susceptible to dengue epidemics because they harbor the particular types of mosquitoes that transmit dengue virus.
Worldwide, 50 to 100 million cases of dengue infection occur each year. This includes 100 to 200 cases in the United States, mostly in people who have recently traveled abroad. Many more cases likely go unreported because some health care providers do not recognize the disease.
During the last part of the 20th century, many tropical regions of the world saw an increase in dengue cases. Epidemics also occurred more frequently and with more severity. In addition to typical dengue, dengue hemorrhagic fever (DHF) and dengue shock syndrome also have increased in many parts of the world. Globally, there are an estimated several hundred thousand cases of DHF per year.
Cause
Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4. You can be infected by at least two if not all four types at different times during your lifetime, but only once by the same type.
Transmission
You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite infected humans, and later transmit infection to other people they bite. Two main species of mosquito, Aedes aegypti and Aedes albopictus, have been responsible for all cases of dengue transmitted in this country. Dengue is not contagious from person to person.
Symptoms
Symptoms of typical uncomplicated (classic) dengue usually start with fever within 4 to 7 days after you have been bitten by an infected mosquito and include
* High fever, up to 105ºF
* Severe headache
* Retro-orbital (behind the eye) pain
* Severe joint and muscle pain
* Nausea and vomiting
* Rash
The rash may appear over most of your body 3 to 4 days after the fever begins, and then subsides after 1 to 2 days. You may get a second rash a few days later.
Symptoms of dengue hemorrhagic fever include all of the symptoms of classic dengue plus
* Marked damage to blood and lymph vessels
* Bleeding from the nose, gums, or under the skin, causing purplish bruises
This form of dengue disease can cause death.
Symptoms of dengue shock syndrome--the most severe form of dengue disease--include all of the symptoms of classic dengue and dengue hemorrhagic fever, plus
* Fluids leaking outside of blood vessels
* Massive bleeding
* Shock (very low blood pressure)
This form of the disease usually occurs in children (sometimes adults) experiencing their second dengue infection. It is sometimes fatal, especially in children and young adults.
Diagnosis
Your health care provider can diagnose dengue fever by doing two blood tests, 2 to 3 weeks apart. The tests can show whether a sample of your blood contains antibodies to the virus. In epidemics, a health care provider often can diagnose dengue by typical signs and symptoms.
Treatment
There is no specific treatment for classic dengue fever, and most people recover within 2 weeks. To help with recovery, health care experts recommend
* Getting plenty of bed rest
* Drinking lots of fluids
* Taking medicine to reduce fever
CDC advises people with dengue fever not to take aspirin. Acetaminophen or other over-the-counter pain-reducing medicines are safe for most people.
For severe dengue symptoms, including shock and coma, early and aggressive emergency treatment with fluid and electrolyte replacement can be lifesaving.
Prevention
The best way to prevent dengue virus infection is to take special precautions to avoid being bitten by mosquitoes. Several dengue vaccines are being developed, but none is likely to be licensed by the Food and Drug Administration in the next few years.
When outdoors in an area where dengue fever has been found
* Use a mosquito repellent containing DEET, picaridin, or oil of lemon eucalyptus
* Dress in protective clothing—long-sleeved shirts, long pants, socks, and shoes
Because Aedes mosquitoes usually bite during the day, be sure to take precautions, especially during early morning hours before daybreak and in the late afternoon before dark.
Other precautions include
* Keeping unscreened windows and doors closed
* Keeping window and door screens repaired
* Getting rid of areas where mosquitoes breed, such as standing water in flower pots, containers, birdbaths, discarded tires, etc.
Complications
Most people who develop dengue fever recover completely within 2 weeks. Some, especially adults, may be tired and/or depressed for several weeks to months after being infected with the virus.
The more clinically severe dengue hemorrhagic fever and dengue shock syndromes can result in vascular (blood vessel) and liver damage, and can be life-threatening.
Dengue fever is found mostly during and shortly after the rainy season in tropical and subtropical areas of
* Africa
* Southeast Asia and China
* India
* Middle East
* Caribbean and Central and South America
* Australia and the South and Central Pacific
An epidemic in Hawaii in 2001 is a reminder that many locations in the United States are susceptible to dengue epidemics because they harbor the particular types of mosquitoes that transmit dengue virus.
Worldwide, 50 to 100 million cases of dengue infection occur each year. This includes 100 to 200 cases in the United States, mostly in people who have recently traveled abroad. Many more cases likely go unreported because some health care providers do not recognize the disease.
During the last part of the 20th century, many tropical regions of the world saw an increase in dengue cases. Epidemics also occurred more frequently and with more severity. In addition to typical dengue, dengue hemorrhagic fever (DHF) and dengue shock syndrome also have increased in many parts of the world. Globally, there are an estimated several hundred thousand cases of DHF per year.
Cause
Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4. You can be infected by at least two if not all four types at different times during your lifetime, but only once by the same type.
Transmission
You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite infected humans, and later transmit infection to other people they bite. Two main species of mosquito, Aedes aegypti and Aedes albopictus, have been responsible for all cases of dengue transmitted in this country. Dengue is not contagious from person to person.
Symptoms
Symptoms of typical uncomplicated (classic) dengue usually start with fever within 4 to 7 days after you have been bitten by an infected mosquito and include
* High fever, up to 105ºF
* Severe headache
* Retro-orbital (behind the eye) pain
* Severe joint and muscle pain
* Nausea and vomiting
* Rash
The rash may appear over most of your body 3 to 4 days after the fever begins, and then subsides after 1 to 2 days. You may get a second rash a few days later.
Symptoms of dengue hemorrhagic fever include all of the symptoms of classic dengue plus
* Marked damage to blood and lymph vessels
* Bleeding from the nose, gums, or under the skin, causing purplish bruises
This form of dengue disease can cause death.
Symptoms of dengue shock syndrome--the most severe form of dengue disease--include all of the symptoms of classic dengue and dengue hemorrhagic fever, plus
* Fluids leaking outside of blood vessels
* Massive bleeding
* Shock (very low blood pressure)
This form of the disease usually occurs in children (sometimes adults) experiencing their second dengue infection. It is sometimes fatal, especially in children and young adults.
Diagnosis
Your health care provider can diagnose dengue fever by doing two blood tests, 2 to 3 weeks apart. The tests can show whether a sample of your blood contains antibodies to the virus. In epidemics, a health care provider often can diagnose dengue by typical signs and symptoms.
Treatment
There is no specific treatment for classic dengue fever, and most people recover within 2 weeks. To help with recovery, health care experts recommend
* Getting plenty of bed rest
* Drinking lots of fluids
* Taking medicine to reduce fever
CDC advises people with dengue fever not to take aspirin. Acetaminophen or other over-the-counter pain-reducing medicines are safe for most people.
For severe dengue symptoms, including shock and coma, early and aggressive emergency treatment with fluid and electrolyte replacement can be lifesaving.
Prevention
The best way to prevent dengue virus infection is to take special precautions to avoid being bitten by mosquitoes. Several dengue vaccines are being developed, but none is likely to be licensed by the Food and Drug Administration in the next few years.
When outdoors in an area where dengue fever has been found
* Use a mosquito repellent containing DEET, picaridin, or oil of lemon eucalyptus
* Dress in protective clothing—long-sleeved shirts, long pants, socks, and shoes
Because Aedes mosquitoes usually bite during the day, be sure to take precautions, especially during early morning hours before daybreak and in the late afternoon before dark.
Other precautions include
* Keeping unscreened windows and doors closed
* Keeping window and door screens repaired
* Getting rid of areas where mosquitoes breed, such as standing water in flower pots, containers, birdbaths, discarded tires, etc.
Complications
Most people who develop dengue fever recover completely within 2 weeks. Some, especially adults, may be tired and/or depressed for several weeks to months after being infected with the virus.
The more clinically severe dengue hemorrhagic fever and dengue shock syndromes can result in vascular (blood vessel) and liver damage, and can be life-threatening.
Friday, April 3, 2009
Irritable bowel syndrome (IBS)
Irritable bowel syndrome (IBS) is a blanket term for a variety of diseases causing discomfort in the gastro-intestinal tract. It is also called spastic colon, is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any organic cause. In some cases, the symptoms are relieved by bowel movements. Diarrhea or constipation may predominate, or they may alternate (classified as IBS-D, IBS-C or IBS-A, respectively). IBS may begin after an infection (post-infectious, IBS-PI) or a stressful life event. Other functional or pain disorders and certain psychological conditions are more common in those with IBS.
Although there is no cure for IBS, there are treatments which attempt to relieve symptoms, including dietary adjustments, medication and psychological interventions. Patient education and a good doctor-patient relationship are also important.
Several conditions may present as IBS including coeliac disease, mild infections, parasitic infections like giardiasis, several inflammatory bowel diseases, functional chronic constipation, and chronic functional abdominal pain. In IBS, routine clinical tests yield no abnormalities, though the bowels may be more sensitive to certain stimuli, such as balloon insufflation testing. The exact cause of IBS is unknown. The most common theory is that IBS is a disorder of the interaction between the brain and the gastrointestinal tract, although there may also be abnormalities in the gut flora or the immune system.
IBS does not lead to more serious conditions in most patients. But it is a source of chronic pain, fatigue and other symptoms, and it increases a patient's medical costs and contributes to work absenteeism. Researchers have reported that the high prevalence of IBS, in conjunction with increased costs produces a disease with a high societal cost. It is also regarded as a chronic illness and can dramatically affect the quality of a sufferer's life.
Contents
Classification
IBS can be classified as either diarrhea-predominant (IBS-D), constipation-predominant (IBS-C) or IBS with alternating stool pattern (IBS-A or pain-predominant[18]). In some individuals, IBS may have an acute onset and develop after an infectious illness characterized by two or more of the following: fever, vomiting, diarrhea, or positive stool culture. This post-infective syndrome has consequently been termed "post-infectious IBS" (IBS-PI).
Symptoms
The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation, a change in bowel habitsThere may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating or abdominal distention. People with IBS more commonly than others have gastroesophageal reflux, symptoms relating to the genitourinary system, psychological symptoms, fibromyalgia, headache and backache.
Diagnosis
There is no specific laboratory or imaging test which can be performed to diagnose irritable bowel syndrome. Diagnosis of IBS involves excluding conditions which produce IBS-like symptoms, and then following a procedure to categorize the patient's symptoms.
Differential diagnosis
Because there are many causes of diarrhea that give IBS-like symptoms, the American Gastroenterological Association has published a set of guidelines for tests to be performed to rule out other causes for these symptoms. These include gastrointestinal infections, lactose intolerance and Coeliac disease. Research has suggested that these guidelines are not always followed.Once other causes have been excluded, the diagnosis of IBS is performed using a diagnostic algorithm. Well-known algorithms include the Manning Criteria, the obsolete Rome I and II criteria, the Kruis Criteria, and studies have compared their reliability.The more recent Rome III Process was published in 2006. Physicians may choose to use one of these guidelines, or may simply choose to rely on their own anecdotal experience with past patients. The algorithm may include additional tests to guard against mis-diagnosis of other diseases as IBS. Such "red flag" symptoms may include weight loss, GI bleeding, anemia, or nocturnal symptoms. However, researchers have noted that red flag conditions may not always contribute to accuracy in diagnosis — for instance, as many as 31% of IBS patients have blood in their stool.
The diagnostic algorithm identifies a name which can be applied to the patient's condition based on the combination of the patient's symptoms of diarrhea, abdominal pain, and constipation. For example, the statement "50% of returning travelers had developed functional diarrhea while 25% had developed IBS" would mean that half the travelers had diarrhea while a quarter had diarrhea with abdominal pain. While some researchers believe this categorization system will help physicians understand IBS, others have questioned the value of the system and suggested that all IBS patients have the same underlying disease but with different symptoms.
Misdiagnosis
Published research has demonstrated that some poor patient outcomes are due to treatable causes of diarrhea being mis-diagnosed as IBS. Common examples include infectious diseases, celiac disease, helicobacter pylori, parasites, food allergies (though considered controversial), and lactose intolerance.See List of causes of diarrhea for other conditions which can cause diarrhea.
Celiac disease in particular is often misdiagnosed as IBS. The American College of Gastroenterology recommends that all patients with symptoms of IBS be tested for celiac disease. Chronic use of certain sedative-hypnotic drugs especially the benzodiazepines may cause irritable bowel like symptoms which can lead to a misdiagnosis of irritable bowel syndrome.
Medical conditions that accompany IBS
Researchers have identified several medical conditions, or comorbidities, which appear with greater frequency in patients diagnosed with IBS.
Headache, Fibromyalgia, and Depression: A study of 97,593 individuals with IBS identified comorbidities as headache, fibromyalgia, and depression. Fibromyalgia has also been identified in other studies as a comorbidity of IBS.
Inflammatory bowel disease: Some researchers have suggested that IBS is a type of low-grade inflammatory bowel disease. Researchers have suggested that IBS and IBD are interrelated diseases, noting that patients with IBD experience IBS-like symptoms when their IBD is in remission.A 3-year study found that patients diagnosed with IBS were 16.3 times more likely to develop IBD during the study period. Serum markers associated with inflammation have also been found in patients with IBS (see Causes).
Abdominal surgery: A recent (2008) study found that IBS patients are at increased risk of having unnecessary cholecystectomy (gall bladder removal surgery) not due to an increased risk of gallstones, but rather to abdominal pain, awareness of having gallstones, and inappropriate surgical indications. A 2005 study published in Digestive Disease Science reported that IBS patients are 87% more likely to undergo abdominal and pelvic surgery, and three times more likely to undergo gallbladder surgery. A study published in Gastroenterology came to similar conclusions, and also noted IBS patients were twice as likely to undergo hysterectomy.
Endometriosis: One study has reported a statistically significant link between migraine headaches, IBS, and endometriosis.
Other chronic disorders: Interstitial cystitis may be associated with other chronic pain syndromes, such as irritable bowel syndrome and fibromyalgia. The connection between these syndromes is unknown.[39]
Etiology
Initially, IBS was considered a psychosomatic illness and the involvement of biological and pathogenic factors was not verified until the 1990s, a process common in the history of emerging infectious diseases.[citation needed] The risk of developing IBS increases sixfold after acute gastrointestinal infection. Post-infection, further risk factors are young age, prolonged fever, anxiety and depression.
Psychosomatic illness
Publications suggesting the role of brain-gut "axis" appeared in the 1990s, such as a study entitled Brain-gut response to stress and cholinergic stimulation in IBS published in the Journal of Clinical Gastroenterology in 1993. A 1997 study published in Gut magazine suggested that IBS was associated with a "derailing of the brain-gut axis."
Immune reaction
From the late 1990s, research publications began identifying specific biochemical changes present in tissue biopsies and serum samples from IBS patients that suggested symptoms had an organic rather than psychosomatic cause. These studies identified cytokines and secretory products in tissues taken from IBS patients. The cytokines identified in IBS patients produce inflammation and are associated with the body's immune response.
* A study showed that intestinal biopsies from patients with constipation predominant IBS secreted higher levels of serotonin in-vitro. Serotonin plays a role in regulating gastrointestinal motility and water content, and can be altered by some diseases and infections.
* A study of rectal biopsy tissue from IBS patients showed increased levels of cellular structures involved in the production of the cytokine Interleukin 1 Beta.
* A study of blood samples from IBS patients identified elevated levels of cytokines Tumor necrosis factor-alpha, Interleukin 1, and Interleukin 6 in patients with IBS.
* A study of intestinal biopsies from IBS patients showed increased levels of protease enzymes used by the body to digest proteins, and by infectious agents to combat the host's immune system.
* A study of blood samples from IBS patients found elevated levels of antibodies to the protozoan Blastocystis.
Specific forms of immune response that have been implicated in IBS symptoms include Coeliac disease and other Food allergy conditions. Coeliac disease (also spelled "celiac") is an immunoglobulin type A-(IgA) mediated allergic response to the Gliadin protein in gluten grains, which exhibits wide variety of symptoms and can present as IBS. "Some patients with diarrhea-predominant irritable bowel syndrome (IBS-D) may have undiagnosed celiac sprue (CS). Because the symptoms of CS respond to a gluten-free diet, testing for CS in IBS may prevent years of morbidity and attendant expense. "Coeliac disease is a common finding among patients labelled as irritable bowel syndrome. In this sub-group, a gluten free diet may lead to a significant improvement in symptoms. Routine testing for coeliac disease may be indicated in all patients being evaluated for irritable bowel syndrome. Food allergies, particularly those mediated by IgE and IgG-type antibodies have been implicated in IBS.
Active infections
There is research to support IBS being caused by an as-yet undiscovered active infection. Most recently, a study has found that the antibiotic Rifaximin provides sustained relief for IBS patients.[57] While some researchers see this as evidence that IBS is related to an undiscovered agent, others believe IBS patients suffer from overgrowth of intestinal flora and the antibiotics are effective in reducing the overgrowth (known as small intestinal bacterial overgrowth).[58] Other researchers have focused on an unrecognized protozoal infection as a cause of IBS[4] as certain protozoal infections occur more frequently in IBS patients.[59][60] Two of the protozoa investigated have a high prevalence in industrialized countries and infect the bowel, but little is known about them as they are recently emerged pathogens.
Blastocystis is a single-celled organism which has been reported to produce symptoms of abdominal pain, constipation and diarrhea in patients, along with headaches and depression, though these reports are contested by some physicians. Studies from research hospitals in various countries have identified high Blastocystis infection rates in IBS patients, with 38% being reported from London School of Hygiene & Tropical Medicine, 47% reported from the Department of Gastroenterology at Aga Khan University in Pakistan and 18.1% reported from the Institute of Diseases and Public Health at University of Ancona in Italy. Reports from all three groups indicate a Blastocystis prevalence of approximately 7% in non-IBS patients. Researchers have noted that clinical diagnostics fail to identify infection, and Blastocystis may not respond to treatment with common antiprotozoals.
Further information: Blastocystosis
Prevalence of protozoal infections in industrialized countries (United States and Canada) in 21st century.
Dientamoeba fragilis is a single-celled organism which produces abdominal pain and diarrhea. Studies have reported a high incidence of infection in developed countries, and symptoms of patients resolve following antibiotic treatment. One study reported on a large group of patients with IBS-like symptoms who were found to be infected with Dientamoeba fragilis, and experienced resolution of symptoms following treatment.Researchers have noted that methods used clinically may fail to detect some Dientamoeba fragilis infections. It is also found in people without IBS.
Further information: Dientamoeba fragilis
Treatment
A questionnaire in 2006 designed to identify patients’ perceptions about IBS, their preferences on the type of information they need, as well as educational media and expectations from health care providers, revealed misperceptions about IBS developing into other conditions, including colitis, malnutrition, and cancer.
The survey found IBS patients were most interested in learning about foods to avoid (60%), causes of IBS (55%), medications (58%), coping strategies (56%), and psychological factors related to IBS (55%). The respondents indicated that they wanted their physicians to be available via phone or e-mail following a visit (80%), have the ability to listen (80%), and provide hope (73%) and support (63%).
Diet
Many different dietary modifications have been attempted to improve the symptoms of IBS. Some are effective in certain sub populations. As lactose intolerance and IBS have such similar symptoms a trial of a lactose free diet is often recommended. Fiber supplements have not been found to be effective in the general IBS population. They however might be beneficial in those who have a predominance of constipation.
Definitive determination of dietary issues can be accomplished by testing for the physiological effects of specific foods. The ELISA food allergy panel can identify specific foods to which a patient has a reaction. Other testing can determine if there are nutritional deficiencies secondary to diet that may also play a role. Removal of foods causing IgG immune response as measured using the ELISA food panel has been shown to substantially decrease symptoms of IBS in several studies.
There is no evidence that digestion of food or absorption of nutrients is problematic for those with IBS at rates different from those without IBS. However, the very act of eating or drinking can provoke an overreaction of the gastrocolic response in some patients with IBS due to their heightened visceral sensitivity, and this can lead to abdominal pain, diarrhea, and/or constipation.
Several of the most common dietary triggers are well-established by clinical studies at this point; research has shown that IBS patients are hypersensitive to fats and fructose.
It also appears that some foods are more difficult for the gut as evidenced by elevated food-specific IgG4 antibodies being present, while others increase colonic contractions, which may be painful, due to increased visceral sensitivity in IBS sufferers.
Fiber
In patients who have constipation predominant irritable bowel, soluble fiber at doses of 20 grams per day can reduce overall symptoms but will not reduce pain. The research supporting dietary fiber contains conflicting, small studies that are complicated by the heterogeneity of types of fiber and doses used. The one meta-analysis that controlled for solubility found that only soluble fiber improved global symptoms of irritable bowel and neither type of fiber reduced pain Positive studies have used 20-30 grams per day of psyllium seed. One study specifically examined the effect of dose and found that 20 grams of ispaghula husk was better than 10 grams and equivalent to 30 grams per dayAn uncontrolled study noted increased symptoms with insoluble fibers. It is unclear if these symptoms are truly increased compared to a control group. If the symptoms are increased, it is unclear if these patients were diarrhea predominant (which can be exacerbated by insoluble fiber), or if the increase is temporary before benefit occurs.
Medication
Medications may consist of stool softeners and laxatives in constipation-predominant IBS, and antidiarrheals (e.g., opiate, opioid or opioid analogs such as loperamide, codeine, diphenoxylate) in diarrhea-predominant IBS for mild symptoms.
Drugs affecting serotonin (5-HT) in the intestines can help reduce symptoms.Serotonin stimulates the gut motility and so agonists can help constipation-predominate irritable bowel, while antagonists can help diarrhea-predominant irritable bowel.
Laxatives
Main article: Laxative
For patients who do not adequately respond to dietary fiber, osmotic agents such as polyethylene glycol, sorbitol, and lactulose can help avoid 'cathartic colon' which has been associated with stimulant laxatives.Among the osmotic laxatives, 17 to 26 grams/day of polyethylene glycol (PEG) has been well studied.
* Lubiprostone (Amitiza), is a gastrointestinal agent used for the treatment of idiopathic chronic constipation and constipation-predominant IBS. It is well-tolerated in adults, including elderly patients. As of July 20, 2006, Lubiprostone had not been studied in pediatric patients. Lubiprostone is a bicyclic fatty acid (prostaglandin E1 derivative) which acts by specifically activating ClC-2 chloride channels on the apical aspect of gastrointestinal epithelial cells, producing a chloride-rich fluid secretion. These secretions soften the stool, increase motility, and promote spontaneous bowel movements (SBM). Unlike many laxative products, Lubiprostone does not show signs of tolerance, dependency, or altered serum electrolyte concentration.
Antispasmodics
Main article: Antispasmodic
The use of antispasmodic drugs (e.g. anticholinergics such as hyoscyamine or dicyclomine) may help patients, especially those with cramps or diarrhea. A meta-analysis by the Cochrane Collaboration concludes that if 6 patients are treated with antispasmodics, 1 patient will benefit.[91] Antispasmodics can be divided in two groups: neurotropics and musculotropics. Neurotropics, such as atropine, act at the nerve fibre of the parasympathicus but also affect other nerves and have side effects. Musculotropics such as mebeverine act directly at the smooth muscle of the gastrointestinal tract, relieving spasm without affecting normal gut motility.[citation needed] Since this action is not mediated by the autonomic nervous system, the usual anticholinergic side effects are absent.[citation needed]
Serotonin agonists
* Tegaserod (Zelnorm), a selective 5-HT4 agonist for IBS-C, is available for relieving IBS constipation in women and chronic idiopathic constipation in men and women. On March 30, 2007, the Food and Drug Administration (FDA) requested that Novartis Pharmaceuticals voluntarily discontinue marketing of tegaserod based on the recently identified finding of an increased risk of serious cardiovascular adverse events (heart problems) associated with use of the drug. Novartis agreed to voluntarily suspend marketing of the drug in the United States and in many other countries. On July 27, 2007 the Food and Drug Administration (FDA) approved a limited treatment IND program for tegaserod in the USA to allow restricted access to the medication for patients in need if no comparable alternative drug or therapy is available to treat the disease. The USA FDA had issued two previous warnings about the serious consequences of Tegaserod. In 2005, tegaserod was rejected as an IBS medication by the European Union. Tegaserod, marketed as Zelnorm in the United States, was the only agent approved to treat the multiple symptoms of IBS (in women only), including constipation, abdominal pain and bloating. A meta-analysis by the Cochrane Collaboration concludes that if 17 patients are treated with typical doses of tegaserod, 1 patient will benefit.
* Selective serotonin reuptake inhibitor anti-depressants (SSRIs), because of their serotonergic effect, would seem to help IBS, especially patients who are constipation predominant. Initial crossover studies[97] and randomized controlled trials support this role.
Serotonin antagonists
* Alosetron, a selective 5-HT3 antagonist for IBS-D, which is only available for women in the United States under a restricted access program, due to severe risks of side-effects if taken mistakenly by IBS-A or IBS-C sufferers.[citation needed]
* Cilansetron, also a selective 5-HT3 antagonist, is undergoing further clinical studies in Europe for IBS-D sufferers. In 2005, Solvay Pharmaceuticals withdrew Cilansetron from the United States regulatory approval process after receiving a "not approvable" action letter from the FDA requesting additional clinical trials.
Other agents
There is conflicting evidence about the benefit of antidepressants in IBS. Some meta-analysis have found a benefit well others have not. meta-analysis of randomized controlled trials of mainly TCAs found 3 patients have to be treated with TCAs for one patient to improve. A separate randomized controlled trial found that TCAs are best for patients with diarrhea-predominant IBS.
Recent studies have suggested that rifaximin can be used as an effective treatment for abdominal bloating and flatulence,] giving more credibility to the potential role of bacterial overgrowth in some patients with IBS.
The use of opioids is controversial due to the lack of evidence supporting their benefit and the potential risk of tolerance, physical dependence and addiction.
Psychotherapy
There is a strong brain-gut component to IBS. Cognitive behavioral therapy has been found to improve symptoms in a number of studies. Relaxation therapy has also been found to helpful.
Alternative treatments
Probiotics
A 2008 review has found probiotics to be beneficial in the treatment of IBS.Many different type have be found to be effective including: Lactobacillus plantarumand Bifidobacteria infantis;however, one review found that only Bifidobacteria infantis showed efficacy.
Iberogast
The multi-herbal extract Iberogast was found to be significantly superior to placebo via both an abdominal pain scale and an IBS symptom score after four weeks of treatment.
Peppermint oil
Enteric coated peppermint oil capsules has been advocated for IBS symptoms in adults and children however, results from trials have been inconsistent.
Acupuncture
A meta-analysis by the Cochrane Collaboration however concluded that most trials are of poor quality and that it is unknown whether acupuncture is more effective than placebo.
Although there is no cure for IBS, there are treatments which attempt to relieve symptoms, including dietary adjustments, medication and psychological interventions. Patient education and a good doctor-patient relationship are also important.
Several conditions may present as IBS including coeliac disease, mild infections, parasitic infections like giardiasis, several inflammatory bowel diseases, functional chronic constipation, and chronic functional abdominal pain. In IBS, routine clinical tests yield no abnormalities, though the bowels may be more sensitive to certain stimuli, such as balloon insufflation testing. The exact cause of IBS is unknown. The most common theory is that IBS is a disorder of the interaction between the brain and the gastrointestinal tract, although there may also be abnormalities in the gut flora or the immune system.
IBS does not lead to more serious conditions in most patients. But it is a source of chronic pain, fatigue and other symptoms, and it increases a patient's medical costs and contributes to work absenteeism. Researchers have reported that the high prevalence of IBS, in conjunction with increased costs produces a disease with a high societal cost. It is also regarded as a chronic illness and can dramatically affect the quality of a sufferer's life.
Contents
Classification
IBS can be classified as either diarrhea-predominant (IBS-D), constipation-predominant (IBS-C) or IBS with alternating stool pattern (IBS-A or pain-predominant[18]). In some individuals, IBS may have an acute onset and develop after an infectious illness characterized by two or more of the following: fever, vomiting, diarrhea, or positive stool culture. This post-infective syndrome has consequently been termed "post-infectious IBS" (IBS-PI).
Symptoms
The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation, a change in bowel habitsThere may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating or abdominal distention. People with IBS more commonly than others have gastroesophageal reflux, symptoms relating to the genitourinary system, psychological symptoms, fibromyalgia, headache and backache.
Diagnosis
There is no specific laboratory or imaging test which can be performed to diagnose irritable bowel syndrome. Diagnosis of IBS involves excluding conditions which produce IBS-like symptoms, and then following a procedure to categorize the patient's symptoms.
Differential diagnosis
Because there are many causes of diarrhea that give IBS-like symptoms, the American Gastroenterological Association has published a set of guidelines for tests to be performed to rule out other causes for these symptoms. These include gastrointestinal infections, lactose intolerance and Coeliac disease. Research has suggested that these guidelines are not always followed.Once other causes have been excluded, the diagnosis of IBS is performed using a diagnostic algorithm. Well-known algorithms include the Manning Criteria, the obsolete Rome I and II criteria, the Kruis Criteria, and studies have compared their reliability.The more recent Rome III Process was published in 2006. Physicians may choose to use one of these guidelines, or may simply choose to rely on their own anecdotal experience with past patients. The algorithm may include additional tests to guard against mis-diagnosis of other diseases as IBS. Such "red flag" symptoms may include weight loss, GI bleeding, anemia, or nocturnal symptoms. However, researchers have noted that red flag conditions may not always contribute to accuracy in diagnosis — for instance, as many as 31% of IBS patients have blood in their stool.
The diagnostic algorithm identifies a name which can be applied to the patient's condition based on the combination of the patient's symptoms of diarrhea, abdominal pain, and constipation. For example, the statement "50% of returning travelers had developed functional diarrhea while 25% had developed IBS" would mean that half the travelers had diarrhea while a quarter had diarrhea with abdominal pain. While some researchers believe this categorization system will help physicians understand IBS, others have questioned the value of the system and suggested that all IBS patients have the same underlying disease but with different symptoms.
Misdiagnosis
Published research has demonstrated that some poor patient outcomes are due to treatable causes of diarrhea being mis-diagnosed as IBS. Common examples include infectious diseases, celiac disease, helicobacter pylori, parasites, food allergies (though considered controversial), and lactose intolerance.See List of causes of diarrhea for other conditions which can cause diarrhea.
Celiac disease in particular is often misdiagnosed as IBS. The American College of Gastroenterology recommends that all patients with symptoms of IBS be tested for celiac disease. Chronic use of certain sedative-hypnotic drugs especially the benzodiazepines may cause irritable bowel like symptoms which can lead to a misdiagnosis of irritable bowel syndrome.
Medical conditions that accompany IBS
Researchers have identified several medical conditions, or comorbidities, which appear with greater frequency in patients diagnosed with IBS.
Headache, Fibromyalgia, and Depression: A study of 97,593 individuals with IBS identified comorbidities as headache, fibromyalgia, and depression. Fibromyalgia has also been identified in other studies as a comorbidity of IBS.
Inflammatory bowel disease: Some researchers have suggested that IBS is a type of low-grade inflammatory bowel disease. Researchers have suggested that IBS and IBD are interrelated diseases, noting that patients with IBD experience IBS-like symptoms when their IBD is in remission.A 3-year study found that patients diagnosed with IBS were 16.3 times more likely to develop IBD during the study period. Serum markers associated with inflammation have also been found in patients with IBS (see Causes).
Abdominal surgery: A recent (2008) study found that IBS patients are at increased risk of having unnecessary cholecystectomy (gall bladder removal surgery) not due to an increased risk of gallstones, but rather to abdominal pain, awareness of having gallstones, and inappropriate surgical indications. A 2005 study published in Digestive Disease Science reported that IBS patients are 87% more likely to undergo abdominal and pelvic surgery, and three times more likely to undergo gallbladder surgery. A study published in Gastroenterology came to similar conclusions, and also noted IBS patients were twice as likely to undergo hysterectomy.
Endometriosis: One study has reported a statistically significant link between migraine headaches, IBS, and endometriosis.
Other chronic disorders: Interstitial cystitis may be associated with other chronic pain syndromes, such as irritable bowel syndrome and fibromyalgia. The connection between these syndromes is unknown.[39]
Etiology
Initially, IBS was considered a psychosomatic illness and the involvement of biological and pathogenic factors was not verified until the 1990s, a process common in the history of emerging infectious diseases.[citation needed] The risk of developing IBS increases sixfold after acute gastrointestinal infection. Post-infection, further risk factors are young age, prolonged fever, anxiety and depression.
Psychosomatic illness
Publications suggesting the role of brain-gut "axis" appeared in the 1990s, such as a study entitled Brain-gut response to stress and cholinergic stimulation in IBS published in the Journal of Clinical Gastroenterology in 1993. A 1997 study published in Gut magazine suggested that IBS was associated with a "derailing of the brain-gut axis."
Immune reaction
From the late 1990s, research publications began identifying specific biochemical changes present in tissue biopsies and serum samples from IBS patients that suggested symptoms had an organic rather than psychosomatic cause. These studies identified cytokines and secretory products in tissues taken from IBS patients. The cytokines identified in IBS patients produce inflammation and are associated with the body's immune response.
* A study showed that intestinal biopsies from patients with constipation predominant IBS secreted higher levels of serotonin in-vitro. Serotonin plays a role in regulating gastrointestinal motility and water content, and can be altered by some diseases and infections.
* A study of rectal biopsy tissue from IBS patients showed increased levels of cellular structures involved in the production of the cytokine Interleukin 1 Beta.
* A study of blood samples from IBS patients identified elevated levels of cytokines Tumor necrosis factor-alpha, Interleukin 1, and Interleukin 6 in patients with IBS.
* A study of intestinal biopsies from IBS patients showed increased levels of protease enzymes used by the body to digest proteins, and by infectious agents to combat the host's immune system.
* A study of blood samples from IBS patients found elevated levels of antibodies to the protozoan Blastocystis.
Specific forms of immune response that have been implicated in IBS symptoms include Coeliac disease and other Food allergy conditions. Coeliac disease (also spelled "celiac") is an immunoglobulin type A-(IgA) mediated allergic response to the Gliadin protein in gluten grains, which exhibits wide variety of symptoms and can present as IBS. "Some patients with diarrhea-predominant irritable bowel syndrome (IBS-D) may have undiagnosed celiac sprue (CS). Because the symptoms of CS respond to a gluten-free diet, testing for CS in IBS may prevent years of morbidity and attendant expense. "Coeliac disease is a common finding among patients labelled as irritable bowel syndrome. In this sub-group, a gluten free diet may lead to a significant improvement in symptoms. Routine testing for coeliac disease may be indicated in all patients being evaluated for irritable bowel syndrome. Food allergies, particularly those mediated by IgE and IgG-type antibodies have been implicated in IBS.
Active infections
There is research to support IBS being caused by an as-yet undiscovered active infection. Most recently, a study has found that the antibiotic Rifaximin provides sustained relief for IBS patients.[57] While some researchers see this as evidence that IBS is related to an undiscovered agent, others believe IBS patients suffer from overgrowth of intestinal flora and the antibiotics are effective in reducing the overgrowth (known as small intestinal bacterial overgrowth).[58] Other researchers have focused on an unrecognized protozoal infection as a cause of IBS[4] as certain protozoal infections occur more frequently in IBS patients.[59][60] Two of the protozoa investigated have a high prevalence in industrialized countries and infect the bowel, but little is known about them as they are recently emerged pathogens.
Blastocystis is a single-celled organism which has been reported to produce symptoms of abdominal pain, constipation and diarrhea in patients, along with headaches and depression, though these reports are contested by some physicians. Studies from research hospitals in various countries have identified high Blastocystis infection rates in IBS patients, with 38% being reported from London School of Hygiene & Tropical Medicine, 47% reported from the Department of Gastroenterology at Aga Khan University in Pakistan and 18.1% reported from the Institute of Diseases and Public Health at University of Ancona in Italy. Reports from all three groups indicate a Blastocystis prevalence of approximately 7% in non-IBS patients. Researchers have noted that clinical diagnostics fail to identify infection, and Blastocystis may not respond to treatment with common antiprotozoals.
Further information: Blastocystosis
Prevalence of protozoal infections in industrialized countries (United States and Canada) in 21st century.
Dientamoeba fragilis is a single-celled organism which produces abdominal pain and diarrhea. Studies have reported a high incidence of infection in developed countries, and symptoms of patients resolve following antibiotic treatment. One study reported on a large group of patients with IBS-like symptoms who were found to be infected with Dientamoeba fragilis, and experienced resolution of symptoms following treatment.Researchers have noted that methods used clinically may fail to detect some Dientamoeba fragilis infections. It is also found in people without IBS.
Further information: Dientamoeba fragilis
Treatment
A questionnaire in 2006 designed to identify patients’ perceptions about IBS, their preferences on the type of information they need, as well as educational media and expectations from health care providers, revealed misperceptions about IBS developing into other conditions, including colitis, malnutrition, and cancer.
The survey found IBS patients were most interested in learning about foods to avoid (60%), causes of IBS (55%), medications (58%), coping strategies (56%), and psychological factors related to IBS (55%). The respondents indicated that they wanted their physicians to be available via phone or e-mail following a visit (80%), have the ability to listen (80%), and provide hope (73%) and support (63%).
Diet
Many different dietary modifications have been attempted to improve the symptoms of IBS. Some are effective in certain sub populations. As lactose intolerance and IBS have such similar symptoms a trial of a lactose free diet is often recommended. Fiber supplements have not been found to be effective in the general IBS population. They however might be beneficial in those who have a predominance of constipation.
Definitive determination of dietary issues can be accomplished by testing for the physiological effects of specific foods. The ELISA food allergy panel can identify specific foods to which a patient has a reaction. Other testing can determine if there are nutritional deficiencies secondary to diet that may also play a role. Removal of foods causing IgG immune response as measured using the ELISA food panel has been shown to substantially decrease symptoms of IBS in several studies.
There is no evidence that digestion of food or absorption of nutrients is problematic for those with IBS at rates different from those without IBS. However, the very act of eating or drinking can provoke an overreaction of the gastrocolic response in some patients with IBS due to their heightened visceral sensitivity, and this can lead to abdominal pain, diarrhea, and/or constipation.
Several of the most common dietary triggers are well-established by clinical studies at this point; research has shown that IBS patients are hypersensitive to fats and fructose.
It also appears that some foods are more difficult for the gut as evidenced by elevated food-specific IgG4 antibodies being present, while others increase colonic contractions, which may be painful, due to increased visceral sensitivity in IBS sufferers.
Fiber
In patients who have constipation predominant irritable bowel, soluble fiber at doses of 20 grams per day can reduce overall symptoms but will not reduce pain. The research supporting dietary fiber contains conflicting, small studies that are complicated by the heterogeneity of types of fiber and doses used. The one meta-analysis that controlled for solubility found that only soluble fiber improved global symptoms of irritable bowel and neither type of fiber reduced pain Positive studies have used 20-30 grams per day of psyllium seed. One study specifically examined the effect of dose and found that 20 grams of ispaghula husk was better than 10 grams and equivalent to 30 grams per dayAn uncontrolled study noted increased symptoms with insoluble fibers. It is unclear if these symptoms are truly increased compared to a control group. If the symptoms are increased, it is unclear if these patients were diarrhea predominant (which can be exacerbated by insoluble fiber), or if the increase is temporary before benefit occurs.
Medication
Medications may consist of stool softeners and laxatives in constipation-predominant IBS, and antidiarrheals (e.g., opiate, opioid or opioid analogs such as loperamide, codeine, diphenoxylate) in diarrhea-predominant IBS for mild symptoms.
Drugs affecting serotonin (5-HT) in the intestines can help reduce symptoms.Serotonin stimulates the gut motility and so agonists can help constipation-predominate irritable bowel, while antagonists can help diarrhea-predominant irritable bowel.
Laxatives
Main article: Laxative
For patients who do not adequately respond to dietary fiber, osmotic agents such as polyethylene glycol, sorbitol, and lactulose can help avoid 'cathartic colon' which has been associated with stimulant laxatives.Among the osmotic laxatives, 17 to 26 grams/day of polyethylene glycol (PEG) has been well studied.
* Lubiprostone (Amitiza), is a gastrointestinal agent used for the treatment of idiopathic chronic constipation and constipation-predominant IBS. It is well-tolerated in adults, including elderly patients. As of July 20, 2006, Lubiprostone had not been studied in pediatric patients. Lubiprostone is a bicyclic fatty acid (prostaglandin E1 derivative) which acts by specifically activating ClC-2 chloride channels on the apical aspect of gastrointestinal epithelial cells, producing a chloride-rich fluid secretion. These secretions soften the stool, increase motility, and promote spontaneous bowel movements (SBM). Unlike many laxative products, Lubiprostone does not show signs of tolerance, dependency, or altered serum electrolyte concentration.
Antispasmodics
Main article: Antispasmodic
The use of antispasmodic drugs (e.g. anticholinergics such as hyoscyamine or dicyclomine) may help patients, especially those with cramps or diarrhea. A meta-analysis by the Cochrane Collaboration concludes that if 6 patients are treated with antispasmodics, 1 patient will benefit.[91] Antispasmodics can be divided in two groups: neurotropics and musculotropics. Neurotropics, such as atropine, act at the nerve fibre of the parasympathicus but also affect other nerves and have side effects. Musculotropics such as mebeverine act directly at the smooth muscle of the gastrointestinal tract, relieving spasm without affecting normal gut motility.[citation needed] Since this action is not mediated by the autonomic nervous system, the usual anticholinergic side effects are absent.[citation needed]
Serotonin agonists
* Tegaserod (Zelnorm), a selective 5-HT4 agonist for IBS-C, is available for relieving IBS constipation in women and chronic idiopathic constipation in men and women. On March 30, 2007, the Food and Drug Administration (FDA) requested that Novartis Pharmaceuticals voluntarily discontinue marketing of tegaserod based on the recently identified finding of an increased risk of serious cardiovascular adverse events (heart problems) associated with use of the drug. Novartis agreed to voluntarily suspend marketing of the drug in the United States and in many other countries. On July 27, 2007 the Food and Drug Administration (FDA) approved a limited treatment IND program for tegaserod in the USA to allow restricted access to the medication for patients in need if no comparable alternative drug or therapy is available to treat the disease. The USA FDA had issued two previous warnings about the serious consequences of Tegaserod. In 2005, tegaserod was rejected as an IBS medication by the European Union. Tegaserod, marketed as Zelnorm in the United States, was the only agent approved to treat the multiple symptoms of IBS (in women only), including constipation, abdominal pain and bloating. A meta-analysis by the Cochrane Collaboration concludes that if 17 patients are treated with typical doses of tegaserod, 1 patient will benefit.
* Selective serotonin reuptake inhibitor anti-depressants (SSRIs), because of their serotonergic effect, would seem to help IBS, especially patients who are constipation predominant. Initial crossover studies[97] and randomized controlled trials support this role.
Serotonin antagonists
* Alosetron, a selective 5-HT3 antagonist for IBS-D, which is only available for women in the United States under a restricted access program, due to severe risks of side-effects if taken mistakenly by IBS-A or IBS-C sufferers.[citation needed]
* Cilansetron, also a selective 5-HT3 antagonist, is undergoing further clinical studies in Europe for IBS-D sufferers. In 2005, Solvay Pharmaceuticals withdrew Cilansetron from the United States regulatory approval process after receiving a "not approvable" action letter from the FDA requesting additional clinical trials.
Other agents
There is conflicting evidence about the benefit of antidepressants in IBS. Some meta-analysis have found a benefit well others have not. meta-analysis of randomized controlled trials of mainly TCAs found 3 patients have to be treated with TCAs for one patient to improve. A separate randomized controlled trial found that TCAs are best for patients with diarrhea-predominant IBS.
Recent studies have suggested that rifaximin can be used as an effective treatment for abdominal bloating and flatulence,] giving more credibility to the potential role of bacterial overgrowth in some patients with IBS.
The use of opioids is controversial due to the lack of evidence supporting their benefit and the potential risk of tolerance, physical dependence and addiction.
Psychotherapy
There is a strong brain-gut component to IBS. Cognitive behavioral therapy has been found to improve symptoms in a number of studies. Relaxation therapy has also been found to helpful.
Alternative treatments
Probiotics
A 2008 review has found probiotics to be beneficial in the treatment of IBS.Many different type have be found to be effective including: Lactobacillus plantarumand Bifidobacteria infantis;however, one review found that only Bifidobacteria infantis showed efficacy.
Iberogast
The multi-herbal extract Iberogast was found to be significantly superior to placebo via both an abdominal pain scale and an IBS symptom score after four weeks of treatment.
Peppermint oil
Enteric coated peppermint oil capsules has been advocated for IBS symptoms in adults and children however, results from trials have been inconsistent.
Acupuncture
A meta-analysis by the Cochrane Collaboration however concluded that most trials are of poor quality and that it is unknown whether acupuncture is more effective than placebo.
Jaundice
Jaundice is a yellowish discoloration affecting the skin, whites of the eyes (sclerae), and other mucous membranes in the body. It is brought on brought on by increased bilirubin levels in the blood, a condition known as hyperbilirubinemia. This causes the extracellular fluids in the body to also have abnormally high levels of bilirubin.
Symptoms
Jaundice may produce a range of symptoms, some of which include:
Dark urine colors
Itching (pruritis)
Light stool colors
Signs of liver disease or cirrhosis (if due to liver disease)
Vitamin deficiencies (if due to bile duct blockage)
Yellow mucous membranes
Yellow sclerae
Yellow skin
Causes
Jaundice may be caused by a variety of conditions. Some are: increased bilirubin production, acute liver inflammation (acute viral hepatitis, alcoholic hepatitis, etc.), chronic liver diseases (alcoholic liver disease with cirrhosis, autoimmune hepatitis, hepatitis B, hepatitis C), infiltrative liver diseases (liver cancer, hemochromatosis, Wilson's disease, alpha-one antitrypsin deficiency), bile duct inflammation (primary bilary cirrhosis, sclerosing cholangitis), genetic disorders (Dubin-Johnson syndrome, Rotor's syndrome), certain medications, as well as other conditions.
Neonatal jaundice is a type in newborn infants. It typically begins within the first few days after birth. This type of jaundice usually suggests a more serious underlying cause.
Diagnosis and Treatment
Jaundice is diagnosed by a doctor or medical professional. Certain considerations and tests may be used such as: accounting for personal history, blood tests, physical examination, liver biopsy, ultrasonography, computerized tomography (CT scan or CAT scan), magnetic resonance imaging (MRI), and endoscopic retrograde cholangiopancreatography (ERCP).
Jaundice may often be treated through treatment of the underlying medical condition. Therefore, it assists in treatment to discover the particular cause of the jaundice.
Symptoms
Jaundice may produce a range of symptoms, some of which include:
Dark urine colors
Itching (pruritis)
Light stool colors
Signs of liver disease or cirrhosis (if due to liver disease)
Vitamin deficiencies (if due to bile duct blockage)
Yellow mucous membranes
Yellow sclerae
Yellow skin
Causes
Jaundice may be caused by a variety of conditions. Some are: increased bilirubin production, acute liver inflammation (acute viral hepatitis, alcoholic hepatitis, etc.), chronic liver diseases (alcoholic liver disease with cirrhosis, autoimmune hepatitis, hepatitis B, hepatitis C), infiltrative liver diseases (liver cancer, hemochromatosis, Wilson's disease, alpha-one antitrypsin deficiency), bile duct inflammation (primary bilary cirrhosis, sclerosing cholangitis), genetic disorders (Dubin-Johnson syndrome, Rotor's syndrome), certain medications, as well as other conditions.
Neonatal jaundice is a type in newborn infants. It typically begins within the first few days after birth. This type of jaundice usually suggests a more serious underlying cause.
Diagnosis and Treatment
Jaundice is diagnosed by a doctor or medical professional. Certain considerations and tests may be used such as: accounting for personal history, blood tests, physical examination, liver biopsy, ultrasonography, computerized tomography (CT scan or CAT scan), magnetic resonance imaging (MRI), and endoscopic retrograde cholangiopancreatography (ERCP).
Jaundice may often be treated through treatment of the underlying medical condition. Therefore, it assists in treatment to discover the particular cause of the jaundice.
Cholecystitis
Cholecystitis is inflammation of the gall bladder.
Causes and pathology
Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species.
The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel.
Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis.
Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.
Symptoms
Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first.
This is usually accompanied by a low grade fever, vomiting and nausea.
More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction.
Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, diarrhea
Diagnosis
Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:
* fever (usually low grade in uncomplicated cases)
* tender right upper quadrant +/- Murphy's sign
Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes.
Differential diagnosis
Acute cholecystitis
* This should be suspected whenever there is acute right upper quadrant or epigastric pain.
o Other possible causes include:
+ Perforated peptic ulcer
+ Acute peptic ulcer exacerbation
+ Amoebic liver abscess
+ Acute amoebic liver colitis
+ Acute pancreatitis
+ Acute intestinal obstruction
+ Renal colic
+ Acute retrocolic appendicitis
Chronic cholecystitis
* The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:
o Peptic ulcer
o Hiatus hernia
o Colitis
o Functional bowel syndrome
Quick Differential
* Biliary colic - Cystic duct blocked. Sharp and constant pain without fever. Negative Murphy's sign. LFT WNL. Ultrasound scan.
* Cholecystitis - Cystic duct blocked with infection. Colicky brief pain at first, then constant pain in RUQ with fever caused by E coli, klebsiella, pseudomonas, B fragilis, enterococcus. Murphy's sign positive. Increased AST, ALT, AP, WBC. Ultrasound scan.
* Choledocholithiasis - Common bile duct blocked. Colicky pain. Jaundice. Increased bilirubin. Cholangiogram.
* Cholangitis - Infection of entire biliary tract. Charcot's triad. Jaundice and fever. Increased AST, ALT, AP, bilirubin. Cholangiogram.
Investigations
Blood
Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this may indicate choledocholithiasis), and possibly an elevation of the WBC count. CRP (C-reactive protein) is often elevated. The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.
Radiology
Sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The 2 major diagnostic criteria are cholelithiasis and sonographic Murphy's sign. Minor criteria include gallbladder wall thickening greater than 3mm, pericholecystic fluid, and gallbladder dilatation.
The reported sensitivity and specificity of CT scan findings are in the range of 90-95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.
Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.
Therapy
X-Ray during laparoscopic cholecystectomy
For most patients, in most centres, the definitive treatment is surgical removal of the gallbladder. Supportive measures are instituted in the meantime and to prepare the patient for surgery. These measures include fluid resuscitation and antibiotics. Antibiotic regimens usually consist of a broad spectrum antibiotic such as piperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate (Timentin), or a cephalosporin (e.g.ceftriaxone) and an antibacterial with good coverage against anaerobic bacteria, such as metronidazole. For penicillin allergic patients aztreonam and clindamycin may be used.
Gallbladder removal, cholecystectomy, can be accomplished via open surgery or a laparoscopic procedure. Laparoscopic procedures can have less morbidity and a shorter recovery stay. Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. A laparoscopic procedure may also be 'converted' to an open procedure during the operation if the surgeon feels that further attempts at laparoscopic removal might harm the patient. Open procedure may also be done if the surgeon does not know how to perform a laparoscopic cholecystectomy.
In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. The patient may later warrant cholecystectomy if their condition improves.
Complications of cholecystitis
* Perforation or rupture
* Ascending cholangitis
* Rokitansky-Aschoff sinuses
Complications of cholecystectomy
* bile leak ("biloma")
* bile duct injury (about 5-7 out of 1000 operations. Open and laparoscopic surgeries have essentially equal rate of injuries, but the recent trend is towards fewer injuries with laparoscopy. It may be that the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
* abscess
* wound infection
* bleeding (liver surface and cystic artery are most common sites)
* hernia
* organ injury (intestine and liver are at highest risk, especially if the gallbladder has become adherent/scarred to other organs due to inflammation (e.g. transverse colon)
* deep vein thrombosis/pulmonary embolism (unusual- risk can be decreased through use of sequential compression devices on legs during surgery)
* fatty acid and fat-soluble vitamin malabsorption
Gall bladder perforation
Gall bladder perforation (GBP) is a rare but life-threatening complication of acute cholecystitis. The early diagnosis and treatment of GBP are crucial to decrease patient morbidity and mortality.
Approaches to this complication will vary based on the condition of an individual patient, the evaluation of the treating surgeon or physician, and the facilities' capability. Perforation can happen at the neck from pressure necrosis due to the impacted calculus, or at the fundus. It can result in a local abscess, or perforation into the general peritoneal cavity. If the bile is infected, diffuse peritonitis may occur readily and rapidly and may result in death.
A retrospective study looked at 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis. Patients were treated with analgesics and antibiotics within the first 36 hours after admission (with a mean of 9 hours), and proceeded to surgery for a cholecystectomy. Two patients died and 6 patients had further complications. The morbidity and mortality rates were 37.5% and 12.5%, respectively in the present study. The authors of this study suggests that early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance.[1]
Causes and pathology
Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species.
The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel.
Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis.
Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.
Symptoms
Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first.
This is usually accompanied by a low grade fever, vomiting and nausea.
More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction.
Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, diarrhea
Diagnosis
Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:
* fever (usually low grade in uncomplicated cases)
* tender right upper quadrant +/- Murphy's sign
Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes.
Differential diagnosis
Acute cholecystitis
* This should be suspected whenever there is acute right upper quadrant or epigastric pain.
o Other possible causes include:
+ Perforated peptic ulcer
+ Acute peptic ulcer exacerbation
+ Amoebic liver abscess
+ Acute amoebic liver colitis
+ Acute pancreatitis
+ Acute intestinal obstruction
+ Renal colic
+ Acute retrocolic appendicitis
Chronic cholecystitis
* The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:
o Peptic ulcer
o Hiatus hernia
o Colitis
o Functional bowel syndrome
Quick Differential
* Biliary colic - Cystic duct blocked. Sharp and constant pain without fever. Negative Murphy's sign. LFT WNL. Ultrasound scan.
* Cholecystitis - Cystic duct blocked with infection. Colicky brief pain at first, then constant pain in RUQ with fever caused by E coli, klebsiella, pseudomonas, B fragilis, enterococcus. Murphy's sign positive. Increased AST, ALT, AP, WBC. Ultrasound scan.
* Choledocholithiasis - Common bile duct blocked. Colicky pain. Jaundice. Increased bilirubin. Cholangiogram.
* Cholangitis - Infection of entire biliary tract. Charcot's triad. Jaundice and fever. Increased AST, ALT, AP, bilirubin. Cholangiogram.
Investigations
Blood
Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this may indicate choledocholithiasis), and possibly an elevation of the WBC count. CRP (C-reactive protein) is often elevated. The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.
Radiology
Sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The 2 major diagnostic criteria are cholelithiasis and sonographic Murphy's sign. Minor criteria include gallbladder wall thickening greater than 3mm, pericholecystic fluid, and gallbladder dilatation.
The reported sensitivity and specificity of CT scan findings are in the range of 90-95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.
Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.
Therapy
X-Ray during laparoscopic cholecystectomy
For most patients, in most centres, the definitive treatment is surgical removal of the gallbladder. Supportive measures are instituted in the meantime and to prepare the patient for surgery. These measures include fluid resuscitation and antibiotics. Antibiotic regimens usually consist of a broad spectrum antibiotic such as piperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate (Timentin), or a cephalosporin (e.g.ceftriaxone) and an antibacterial with good coverage against anaerobic bacteria, such as metronidazole. For penicillin allergic patients aztreonam and clindamycin may be used.
Gallbladder removal, cholecystectomy, can be accomplished via open surgery or a laparoscopic procedure. Laparoscopic procedures can have less morbidity and a shorter recovery stay. Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. A laparoscopic procedure may also be 'converted' to an open procedure during the operation if the surgeon feels that further attempts at laparoscopic removal might harm the patient. Open procedure may also be done if the surgeon does not know how to perform a laparoscopic cholecystectomy.
In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. The patient may later warrant cholecystectomy if their condition improves.
Complications of cholecystitis
* Perforation or rupture
* Ascending cholangitis
* Rokitansky-Aschoff sinuses
Complications of cholecystectomy
* bile leak ("biloma")
* bile duct injury (about 5-7 out of 1000 operations. Open and laparoscopic surgeries have essentially equal rate of injuries, but the recent trend is towards fewer injuries with laparoscopy. It may be that the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
* abscess
* wound infection
* bleeding (liver surface and cystic artery are most common sites)
* hernia
* organ injury (intestine and liver are at highest risk, especially if the gallbladder has become adherent/scarred to other organs due to inflammation (e.g. transverse colon)
* deep vein thrombosis/pulmonary embolism (unusual- risk can be decreased through use of sequential compression devices on legs during surgery)
* fatty acid and fat-soluble vitamin malabsorption
Gall bladder perforation
Gall bladder perforation (GBP) is a rare but life-threatening complication of acute cholecystitis. The early diagnosis and treatment of GBP are crucial to decrease patient morbidity and mortality.
Approaches to this complication will vary based on the condition of an individual patient, the evaluation of the treating surgeon or physician, and the facilities' capability. Perforation can happen at the neck from pressure necrosis due to the impacted calculus, or at the fundus. It can result in a local abscess, or perforation into the general peritoneal cavity. If the bile is infected, diffuse peritonitis may occur readily and rapidly and may result in death.
A retrospective study looked at 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis. Patients were treated with analgesics and antibiotics within the first 36 hours after admission (with a mean of 9 hours), and proceeded to surgery for a cholecystectomy. Two patients died and 6 patients had further complications. The morbidity and mortality rates were 37.5% and 12.5%, respectively in the present study. The authors of this study suggests that early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance.[1]
appendicitis
Appendicitis is a painful swelling and infection of the appendix.
What is the appendix?
The appendix is a fingerlike pouch attached to the large intestine and located in the lower right area of the abdomen. Scientists are not sure what the appendix does, if anything, but removing it does not appear to affect a person’s health. The inside of the appendix is called the appendiceal lumen. Mucus created by the appendix travels through the appendiceal lumen and empties into the large intestine.
Drawing of the gastrointestinal tract with the liver, stomach, large intestine, small intestine, appendix, and anus labeled.
The appendix is a fingerlike pouch attached to the large intestine in the lower right area of the abdomen.
What causes appendicitis?
Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of obstruction include
* feces, parasites, or growths that clog the appendiceal lumen
* enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or elsewhere in the body
* inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
* trauma to the abdomen
An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the abdomen—a potentially dangerous condition called peritonitis.
Who gets appendicitis?
Anyone can get appendicitis, but it is more common among people 10 to 30 years old. Appendicitis leads to more emergency abdominal surgeries than any other cause.
What are the symptoms of appendicitis?
Most people with appendicitis have classic symptoms that a doctor can easily identify. The main symptom of appendicitis is abdominal pain.
The abdominal pain usually
* occurs suddenly, often causing a person to wake up at night
* occurs before other symptoms
* begins near the belly button and then moves lower and to the right
* is new and unlike any pain felt before
* gets worse in a matter of hours
* gets worse when moving around, taking deep breaths, coughing, or sneezing
Other symptoms of appendicitis may include
* loss of appetite
* nausea
* vomiting
* constipation or diarrhea
* inability to pass gas
* a low-grade fever that follows other symptoms
* abdominal swelling
* the feeling that passing stool will relieve discomfort
Symptoms vary and can mimic other sources of abdominal pain, including
* intestinal obstruction
* inflammatory bowel disease
* pelvic inflammatory disease and other gynecological disorders
* intestinal adhesions
* constipation
How is appendicitis diagnosed?
A doctor or other health care provider can diagnose most cases of appendicitis by taking a person’s medical history and performing a physical examination. If a person shows classic symptoms, a doctor may suggest surgery right away to remove the appendix before it bursts. Doctors may use laboratory and imaging tests to confirm appendicitis if a person does not have classic symptoms. Tests may also help diagnose appendicitis in people who cannot adequately describe their symptoms, such as children or the mentally impaired.
Medical History
The doctor will ask specific questions about symptoms and health history. Answers to these questions will help rule out other conditions. The doctor will want to know when the pain began and its exact location and severity. Knowing when other symptoms appeared relative to the pain is also helpful. The doctor will ask questions about other medical conditions, previous illnesses and surgeries, and use of medications, alcohol, or illegal drugs.
Physical Examination
Details about the abdominal pain are key to diagnosing appendicitis. The doctor will assess pain by touching or applying pressure to specific areas of the abdomen.
Responses that may indicate appendicitis include
*
Guarding. Guarding occurs when a person subconsciously tenses the abdominal muscles during an examination. Voluntary guarding occurs the moment the doctor’s hand touches the abdomen. Involuntary guarding occurs before the doctor actually makes contact.
*
Rebound tenderness. A doctor tests for rebound tenderness by applying hand pressure to a patient’s abdomen and then letting go. Pain felt upon the release of the pressure indicates rebound tenderness. A person may also experience rebound tenderness as pain when the abdomen is jarred—for example, when a person bumps into something or goes over a bump in a car.
*
Rovsing’s sign. A doctor tests for Rovsing’s sign by applying hand pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsing’s sign.
*
Psoas sign. The right psoas muscle runs over the pelvis near the appendix. Flexing this muscle will cause abdominal pain if the appendix is inflamed. A doctor can check for the psoas sign by applying resistance to the right knee as the patient tries to lift the right thigh while lying down.
*
Obturator sign. The right obturator muscle also runs near the appendix. A doctor tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is inflamed.
Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological conditions, which sometimes cause abdominal pain similar to appendicitis.
The doctor may also examine the rectum, which can be tender from appendicitis.
Laboratory Tests
Blood tests are used to check for signs of infection, such as a high white blood cell count. Blood tests may also show dehydration or fluid and electrolyte imbalances. Urinalysis is used to rule out a urinary tract infection. Doctors may also order a pregnancy test for women.
Imaging Tests
Computerized tomography (CT) scans, which create cross-sectional images of the body, can help diagnose appendicitis and other sources of abdominal pain. Ultrasound is sometimes used to look for signs of appendicitis, especially in people who are thin or young. An abdominal x ray is rarely helpful in diagnosing appendicitis but can be used to look for other sources of abdominal pain. Women of childbearing age should have a pregnancy test before undergoing x rays or CT scanning. Both use radiation and can be harmful to a developing fetus. Ultrasound does not use radiation and is not harmful to a fetus.
How is appendicitis treated?
Surgery
Typically, appendicitis is treated by removing the appendix. If appendicitis is suspected, a doctor will often suggest surgery without conducting extensive diagnostic testing. Prompt surgery decreases the likelihood the appendix will burst.
Surgery to remove the appendix is called appendectomy and can be done two ways. The older method, called laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.
Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the healthy appendix to eliminate the future possibility of appendicitis. Occasionally, surgery reveals a different problem, which may also be corrected during surgery.
Sometimes an abscess forms around a burst appendix—called an appendiceal abscess. An abscess is a pus-filled mass that results from the body’s attempt to keep an infection from spreading. An abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgery is performed to remove what remains of the burst appendix.
Nonsurgical Treatment
Nonsurgical treatment may be used if surgery is not available, if a person is not well enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract.
Recovery
With adequate care, most people recover from appendicitis and do not need to make changes to diet, exercise, or lifestyle. Full recovery from surgery takes about 4 to 6 weeks. Limiting physical activity during this time allows tissues to heal.
What should people do if they think they have appendicitis?
Appendicitis is a medical emergency that requires immediate care. People who think they have appendicitis should see a doctor or go to the emergency room right away. Swift diagnosis and treatment reduce the chances the appendix will burst and improve recovery time.
Points to Remember
* Appendicitis is a painful swelling and infection of the appendix.
* The appendix is a fingerlike pouch attached to the large intestine and located in the lower right area of the abdomen.
* Symptoms of appendicitis may include abdominal pain, loss of appetite, nausea, vomiting, constipation or diarrhea, inability to pass gas, low-grade fever, and abdominal swelling.
* A doctor can diagnose most cases of appendicitis by taking a person’s medical history and performing a physical examination. Sometimes laboratory and imaging tests are needed to confirm the diagnosis.
* Appendicitis is typically treated by removing the appendix.
* Appendicitis is a medical emergency that requires immediate care.
What is the appendix?
The appendix is a fingerlike pouch attached to the large intestine and located in the lower right area of the abdomen. Scientists are not sure what the appendix does, if anything, but removing it does not appear to affect a person’s health. The inside of the appendix is called the appendiceal lumen. Mucus created by the appendix travels through the appendiceal lumen and empties into the large intestine.
Drawing of the gastrointestinal tract with the liver, stomach, large intestine, small intestine, appendix, and anus labeled.
The appendix is a fingerlike pouch attached to the large intestine in the lower right area of the abdomen.
What causes appendicitis?
Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of obstruction include
* feces, parasites, or growths that clog the appendiceal lumen
* enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or elsewhere in the body
* inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
* trauma to the abdomen
An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the abdomen—a potentially dangerous condition called peritonitis.
Who gets appendicitis?
Anyone can get appendicitis, but it is more common among people 10 to 30 years old. Appendicitis leads to more emergency abdominal surgeries than any other cause.
What are the symptoms of appendicitis?
Most people with appendicitis have classic symptoms that a doctor can easily identify. The main symptom of appendicitis is abdominal pain.
The abdominal pain usually
* occurs suddenly, often causing a person to wake up at night
* occurs before other symptoms
* begins near the belly button and then moves lower and to the right
* is new and unlike any pain felt before
* gets worse in a matter of hours
* gets worse when moving around, taking deep breaths, coughing, or sneezing
Other symptoms of appendicitis may include
* loss of appetite
* nausea
* vomiting
* constipation or diarrhea
* inability to pass gas
* a low-grade fever that follows other symptoms
* abdominal swelling
* the feeling that passing stool will relieve discomfort
Symptoms vary and can mimic other sources of abdominal pain, including
* intestinal obstruction
* inflammatory bowel disease
* pelvic inflammatory disease and other gynecological disorders
* intestinal adhesions
* constipation
How is appendicitis diagnosed?
A doctor or other health care provider can diagnose most cases of appendicitis by taking a person’s medical history and performing a physical examination. If a person shows classic symptoms, a doctor may suggest surgery right away to remove the appendix before it bursts. Doctors may use laboratory and imaging tests to confirm appendicitis if a person does not have classic symptoms. Tests may also help diagnose appendicitis in people who cannot adequately describe their symptoms, such as children or the mentally impaired.
Medical History
The doctor will ask specific questions about symptoms and health history. Answers to these questions will help rule out other conditions. The doctor will want to know when the pain began and its exact location and severity. Knowing when other symptoms appeared relative to the pain is also helpful. The doctor will ask questions about other medical conditions, previous illnesses and surgeries, and use of medications, alcohol, or illegal drugs.
Physical Examination
Details about the abdominal pain are key to diagnosing appendicitis. The doctor will assess pain by touching or applying pressure to specific areas of the abdomen.
Responses that may indicate appendicitis include
*
Guarding. Guarding occurs when a person subconsciously tenses the abdominal muscles during an examination. Voluntary guarding occurs the moment the doctor’s hand touches the abdomen. Involuntary guarding occurs before the doctor actually makes contact.
*
Rebound tenderness. A doctor tests for rebound tenderness by applying hand pressure to a patient’s abdomen and then letting go. Pain felt upon the release of the pressure indicates rebound tenderness. A person may also experience rebound tenderness as pain when the abdomen is jarred—for example, when a person bumps into something or goes over a bump in a car.
*
Rovsing’s sign. A doctor tests for Rovsing’s sign by applying hand pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsing’s sign.
*
Psoas sign. The right psoas muscle runs over the pelvis near the appendix. Flexing this muscle will cause abdominal pain if the appendix is inflamed. A doctor can check for the psoas sign by applying resistance to the right knee as the patient tries to lift the right thigh while lying down.
*
Obturator sign. The right obturator muscle also runs near the appendix. A doctor tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is inflamed.
Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological conditions, which sometimes cause abdominal pain similar to appendicitis.
The doctor may also examine the rectum, which can be tender from appendicitis.
Laboratory Tests
Blood tests are used to check for signs of infection, such as a high white blood cell count. Blood tests may also show dehydration or fluid and electrolyte imbalances. Urinalysis is used to rule out a urinary tract infection. Doctors may also order a pregnancy test for women.
Imaging Tests
Computerized tomography (CT) scans, which create cross-sectional images of the body, can help diagnose appendicitis and other sources of abdominal pain. Ultrasound is sometimes used to look for signs of appendicitis, especially in people who are thin or young. An abdominal x ray is rarely helpful in diagnosing appendicitis but can be used to look for other sources of abdominal pain. Women of childbearing age should have a pregnancy test before undergoing x rays or CT scanning. Both use radiation and can be harmful to a developing fetus. Ultrasound does not use radiation and is not harmful to a fetus.
How is appendicitis treated?
Surgery
Typically, appendicitis is treated by removing the appendix. If appendicitis is suspected, a doctor will often suggest surgery without conducting extensive diagnostic testing. Prompt surgery decreases the likelihood the appendix will burst.
Surgery to remove the appendix is called appendectomy and can be done two ways. The older method, called laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.
Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the healthy appendix to eliminate the future possibility of appendicitis. Occasionally, surgery reveals a different problem, which may also be corrected during surgery.
Sometimes an abscess forms around a burst appendix—called an appendiceal abscess. An abscess is a pus-filled mass that results from the body’s attempt to keep an infection from spreading. An abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgery is performed to remove what remains of the burst appendix.
Nonsurgical Treatment
Nonsurgical treatment may be used if surgery is not available, if a person is not well enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract.
Recovery
With adequate care, most people recover from appendicitis and do not need to make changes to diet, exercise, or lifestyle. Full recovery from surgery takes about 4 to 6 weeks. Limiting physical activity during this time allows tissues to heal.
What should people do if they think they have appendicitis?
Appendicitis is a medical emergency that requires immediate care. People who think they have appendicitis should see a doctor or go to the emergency room right away. Swift diagnosis and treatment reduce the chances the appendix will burst and improve recovery time.
Points to Remember
* Appendicitis is a painful swelling and infection of the appendix.
* The appendix is a fingerlike pouch attached to the large intestine and located in the lower right area of the abdomen.
* Symptoms of appendicitis may include abdominal pain, loss of appetite, nausea, vomiting, constipation or diarrhea, inability to pass gas, low-grade fever, and abdominal swelling.
* A doctor can diagnose most cases of appendicitis by taking a person’s medical history and performing a physical examination. Sometimes laboratory and imaging tests are needed to confirm the diagnosis.
* Appendicitis is typically treated by removing the appendix.
* Appendicitis is a medical emergency that requires immediate care.
Peptic ulcer
Introduction:
Peptic ulcers are open sores or erosions in the lining of either the duodenum (duodenal ulcers) or the stomach (gastric ulcers). The duodenum is the first part of the small intestine. About 10% of all Americans get ulcers, and they can recur. Contrary to popular belief, ulcers are not caused by spicy food or stress but instead are most commonly due to either an infection or long-term use of certain medications.
Signs and Symptoms:
- Abdominal pain with a burning or gnawing sensation
- Pain 2 - 3 hours after eating
- Pain is often aggravated by an empty stomach; for example, nighttime pain is common
- Pain may be relieved by antacids or milk
- Heartburn
- Indigestion (dyspepsia)
- Belching
- Nausea
- Vomiting
- Poor appetite
- Weight loss
If you experience any of the following symptoms, this is considered an emergency and you should call your doctor immediately:
- Sudden increase in the abdominal pain or sharpness in the quality of the pain
- Vomiting blood or material that looks like coffee grounds
- Blood in your stool or black, tarry stools
Causes:
When the stomach's natural protections from the damaging effects of digestive juices (including acid and pepsin, an enzyme that helps breakdown protein) stop working or the acid production is too overwhelming for these protective defenses to work properly, you can get an ulcer. There are a few different ways this happens.
- Helicobacter pylori (H. pylori) -- H. Pylori, a bacterial organism, is responsible for most ulcers. This organism weakens the protective coating of the stomach and duodenum and allows the damaging digestive juices to irritate the sensitive lining below. Interestingly, as many as 20% of Americans over age 40 have this organism living in their digestive tract, but not all of these people develop ulcers -- most do not.
- Non-steroidal anti-inflammatory drugs (NSAIDs) -- ongoing use of this class of medications is the second most common cause of ulcers. These drugs (which include aspirin, ibuprofen, naproxen, diclofenac, tolmetin, piroxicam, fenoprofen, indomethacin, oxaprozin, ketoprofen, sulindac, nabumetone, etodolac, and salsalate) are acidic. They block prostaglandins, substances in the stomach that help maintain blood flow and protect the area from injury. Some of the specific drugs listed are more likely to produce ulcers than others. Therefore, if you must use long-term pain medications, talk to your doctor about which ones are safest.
- Zollinger-Ellison syndrome -- people with this uncommon condition have tumors in the pancreas and duodenum that produce gastrin, a hormone that stimulates gastric acid production. Diarrhea may precede ulcer formation.
- Other causes of ulcers are conditions that can result in direct damage to the wall of the stomach or duodenum, such as heavy use of alcohol, radiation therapy, burns, and physical injury.
Risk Factors:
- Genetic factors may predispose you to developing an ulcer
- Increasing age
- Chronic pain, from any cause such as arthritis, fibromyalgia, repetitive stress injuries (like carpal tunnel syndrome), or persistent back pain, leading to ongoing use of aspirin or NSAIDs
- Alcohol abuse
- Diabetes may increase your risk of having H. pylori
- Living in crowded, unsanitary conditions increases the risk of H. pylori infection
- Immune abnormalities may, in theory, make it more likely for H. pylori or other factors to cause damage to the lining of the stomach or duodenum
- Lifestyle factors, including chronic stress, coffee drinking (even decaf), and smoking, may make you more susceptible to damage from NSAIDs or H. pylori if you are a carrier of this organism. Again, however, these factors do not cause an ulcer on their own.
Diagnosis:
First, your doctor will take a detailed history of your symptoms and risk factors, including how long indigestion and pain have been present, how strong these sensations are, if you have lost weight recently, what medications (over the counter and prescription) you have been taking, your smoking and drinking habits, and if anyone in your family has had ulcers.
As part of the physical exam, your doctor will do a thorough check of your abdomen and chest as well as a rectal exam to look for, in part, any sign of bleeding. A blood test will be drawn to check to see if you are anemic. These types of tests are done to make sure that you have not had any bleeding about which you have been unaware (called occult bleeding).
If there are no signs of bleeding and your symptoms are mild and not serious or life-threatening, your doctor may have you try medications that suppress the amount of acid in your stomach. This is done to see if you feel better, before pursuing expensive and uncomfortable testing. If your symptoms persist or get worse despite the medication, further testing is necessary.
One of two tests will be performed to try to identify an ulcer:
- Upper gastrointestinal (GI) series
- Endoscopy
For an upper GI series, you will drink a chalky liquid called barium and then undergo a series of x-rays to check for an ulcer.
Endoscopy, amore accurate test, involves the careful insertion of a thin tube with a tiny camera at the end (called an endoscope) into your mouth, down your throat, through the esophagus to the stomach and duodenum. This allows both direct visualization of these organs for an ulcer or other problems and sampling of tissue from the walls (called biopsies) of the stomach and small intestines to test for H. pylori. You are lightly sedated for this procedure.
Other tests that may be performed to look for H. pylori include a blood test checking for antibodies to this organism, a breath test after drinking a substance called urea, and a stool test looking for the organism in the feces. The breath test, which is the least invasive, is proving to be at least 95% accurate.
Prevention:
Preventing NSAID-related ulcers involves finding different medications or alternative approaches to relieve your pain. Talk to your doctor about your options. If you have to take NSAIDs for a long time, your doctor may consider prescribing another medication to try to prevent the development of ulcers. This medicine may include an H2 blocker (such as cimetidine, famotidine, nizatidine, or ranitidine) or a proton pump inhibitor (such as omeprazole, lansoprazole, or rabeprazole).
You can also make lifestyle changes that make you less prone to get an ulcer from either NSAIDs or H. pylori.
Treatment:
The main goals for treating a peptic ulcer include eliminating the underlying cause (particularly H. pylori infection or use of NSAIDs), preventing further damage and complications, and reducing the risk of recurrence. Medication is almost always needed to alleviate symptoms and must be used to eradicate H. pylori. Surgery is required for certain serious or life-threatening complications of peptic ulcers and may be considered if medications are not working. Even with medications, many lifestyle factors, including making changes in your diet, are important. Plus, certain herbs, acupuncture, or homeopathy may prove to be a useful addition to usual medical care, especially to help relieve symptoms or prevent recurrence.
Lifestyle
Doctors used to recommend eating bland foods with milk and only small amounts of food with each meal. We now know that these eating habits are not necessary for the treatment of ulcers. Dietary and other lifestyle measures that should help, however, include:
- Eat a diet rich in fiber, especially from fruits and vegetables. This may reduce your risk of developing an ulcer in the first place and may speed your recovery if you already have one. The vitamin A may be an added benefit from these foods.
- Foods containing flavonoids, like apples, celery, cranberries (including cranberry juice), onions, garlic, and tea may inhibit the growth of H. pylori.
- Quit smoking.
- Receive treatment for alcohol abuse; your doctor can help get you appropriate care.
- Cut down on coffee, including decaffeinated coffee, as well as carbonated beverages all of which can increase stomach acid.
- Reduce stress with regular use of relaxation techniques, such as yoga, tai chi, qi gong, or meditation. These practices may also help lessen pain and reduce your need for the damaging NSAIDs discussed. To incorporate any one of these techniques into your daily activities, consider taking a class; some early information suggests that, if you have an ulcer, a formal stress reducing program may be more beneficial than listening to tapes on your own at home.
Medications
- If you have H. pylori, you will probably be prescribed three different medications. "Triple therapy" (including a proton pump inhibitor, such as omeprazole or Prilosec, to reduce acid production and two antibiotics to get rid of the organism) is commonly used to treat H. pylori -related ulcers. A medicine called bismuth salicylate may be recommended in place of one antibiotic. This drug, available over the counter, coats and soothes the stomach, protecting it from the damaging effects of acid. Two drug regimens are currently being developed.
Some of the same drugs are used for non-H. pylori ulcers as well as for symptoms (like indigestion) due to ulcers of any cause:
- Antacids, available over the counter, may relieve heartburn or indigestion but will not treat an ulcer. Antacids include aluminum hydroxide (Amphojel, AlternaGEL), magnesium hydroxide (Phillips' Milk of Magnesia), aluminum hydroxide and magnesium hydroxide (Maalox, Mylanta), calcium carbonate (Rolaids, Titralac, Tums), and sodium bicarbonate (Alka-Seltzer). Antacids may block medications from being absorbed and thereby decrease the medicine's effectiveness. It is recommended to take antacids at least 1 hour before or 2 hours after taking medications. Ask your pharmacist or doctor for more information.
- H2 blockers, such as cimetidine (Tagemet), ranitidine (Zantac), nizatidine (Axid®, and famotidine (Pepcid), reduce gastric acid secretion.
- Proton-pump inhibitors, including esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), and rabeprazole (Aciphex), decrease gastric acid production.
- Sucralfate (Carafate) makes a coating over the ulcer crater, protecting it from further damage.
Surgery and Other Procedures
Once hospitalized, if bleeding from an ulcer does not stop by using medications and supportive care (like fluids and, possibly, blood transfusion), it can almost always be stopped via endoscopy. The physician (a gastroenterologist) who performs the procedure first identifies the ulcer and the area that is bleeding. The physician will then inject adrenaline and other medications to stop the bleeding and stimulate the formation of a blood clot. If the bleeding recurs after that procedure or you have a perforated ulcer or an obstruction, surgery may be required. If you do not get better from medical or endoscopic treatment, surgery may be considered. About 30% of people who come to the hospital with a bleeding ulcer need endoscopy or surgery.
Nutrition and Dietary Supplements
Following these nutritional tips may help reduce symptoms:
- Foods containing flavonoids, like apples, celery, cranberries (including cranberry juice), onions, garlic, and tea may inhibit the growth of H. pylori.
- Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
- Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
- Avoid refined foods, such as white breads, pastas, and especially sugar.
- Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
- Use healthy oils, such as olive oil or vegetable oil.
- Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
- Avoid beverages that can irritate the lining of the stomach or increase acid production, including coffee (with or without caffeine), alcohol, and carbonated beverages.
- Drink 6 - 8 glasses of filtered water daily.
- Exercise at least 30 minutes daily, 5 days a week.
You may address nutritional deficiencies with the following supplements:
- A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-vitamins, and trace minerals, such as magnesium, calcium, zinc, and selenium.
- Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil 2 - 3 times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources, but supplementation is recommended.
- Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements may need to be refrigerated for best results. Your child may also take probiotic supplements. Talk to your health care provider before giving your child any dietary supplements.
- Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support.
- Vitamin C, 500 - 1,000 mg 1 - 3 times daily, as an antioxidant and for immune support.
- L-glutamine, 500 - 1,000 mg 3 times daily, for support of gastrointestinal health and immunity.
- Grapefruit seed extract (Citrus paradisi), 100 mg capsule or 5 - 10 drops (in favorite beverage) 3 times daily when needed, for antibacterial, antifungal, and antiviral activity, and for immunity.
- Resveratrol (from red wine), 50 - 200 mg daily, to help decrease inflammation and for antioxidant effects.
Herbs
Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.
- Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant, anti-inflammatory, and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
- Cat's claw (Uncaria tomentosa) standardized extract, 20 mg 3 times a day, for inflammation and antibacterial, or antifungal activity.
- Reishi mushroom (Ganoderma lucidum), 150 - 300 mg 2 - 3 times daily, for inflammation and for immunity. You may also take a tincture of this mushroom extract, 30 - 60 drops 2 - 3 times a day.
- Olive leaf (Olea europaea) standardized extract, 250 - 500 mg 1 - 3 times daily, for antibacterial or antifungal activity and immunity. You may also prepare teas from the leaf of this herb.
- DGL-licorice (Glycyrrhiza glabra) standardized extract, 250 - 500 mg 3 times daily, chewed either 1 hour before or 2 hours after meals. Glycyrrhizin is a chemical found in licorice that causes side effects and drug interactions. DGL is deglycyrrhizinated licorice, or licorice with the glycyrrhizin removed.
- Mastic (Pistacia lentiscus) standardized extract, 1,000 - 2,000 mg daily in divided dosages, for activity against H. Pylori.
- Peppermint (Mentha piperita) standardized, enteric coated tablet, 1 tablet 2 - 3 times daily, for symptoms of peptic ulcer. Each tablet contains 0.2 ml peppermint oil.
Homeopathy
Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of ulcers or its symptoms, based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for you individually. For the treatment of ulcers, even if you do seek homeopathic remedies as adjunctive care, conventional treatment recommendations must be followed.
- Argentum nitricum for abdominal bloating with belching and pain
- Arsenicum album for ulcers with intense burning pains and nausea; especially for people who cannot bear the sight or smell of food and are thirsty
- Kali bichromicum for burning or shooting abdominal pain that is worse in the hours after midnight
- Lycopodium for bloating after eating with burning that lasts for hours; especially for people who feel hungry soon after eating and wake hungry
- Nitric acid for sharp, shooting pain that worsens at night and is accompanied by feelings of hopelessness and even fear of dying
- Nux vomica for digestive disturbances (including heartburn and indigestion) that worsen after eating; particularly for those who crave alcohol, coffee, and tobacco
- Phosphorus for burning stomach pain that worsens at night; those for whom this remedy is appropriate tend to feel very thirsty, craving cold beverages
- Pulsatilla for symptoms that vary (that is, change abruptly) and pain that gets worse from fatty foods; appropriate people are distinctly not thirsty
Acupuncture
Acupuncture has been used traditionally for a variety of conditions related to the gastrointestinal tract, including peptic ulcers. A growing body of scientific evidence suggests that acupuncture can help reduce pain associated with endoscopy (the procedure used, as described earlier, to make a diagnosis of ulcer or to treat its complications).
Chiropractic
Chiropractors report and preliminary evidence suggests that spinal manipulation may benefit some individuals with uncomplicated gastric or duodenal ulcers. In one small clinical study, researchers compared the effectiveness of medication to spinal manipulation over a period of up to 22 days. Participants who received spinal manipulation experienced significant pain relief after an average of 4 days and were completely free of symptoms on average 10 days earlier than those who took medication. More research is needed to understand when and how chiropractic might be helpful if you have peptic ulcer disease.
Other Considerations:
Pregnancy
If you are pregnant or breastfeeding, talk to your doctor before taking any medication, including herbs.
Prognosis and Complications
With proper treatment, most ulcers heal within 6 - 8 weeks. However, they may recur, particularly if H. pylori is not treated sufficiently.
Complications from ulcers include bleeding, perforation (rupture) of either the stomach or the duodenum, and bowel obstruction. Each of these problems can be very serious, even life-threatening. Bleeding, which is much less common today because of appropriate and fast medical treatment, occurs in up to 15% of people with peptic ulcers. Obstruction tends to happen where the stomach meets the small intestines. If there is an ulcer at this junction, swelling can occur, blocking the passage of food products through the gastrointestinal tract. If this happens, significant vomiting is generally the main symptom.
H. pylori ulcers increase the risk of stomach cancer.
The good news is that the incidence of ulcers and their complications continue to decline as people seek treatment for symptoms early and doctors respond quickly to eliminate symptoms and the causes, like H. pylori and NSAIDs.
Gastroenteritis
Definition
Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the stomach and intestine. It is frequently referred to as the stomach or intestinal flu, although the virus is not associated with this illness. Major symptoms include , and abdominal cramps. These symptoms are sometimes also accompanied by and overall weakness. Gastroenteritis typically lasts about three days. Adults usually recover without problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to complications.
Description
Gastroenteritis is an uncomfortable and inconvenient ailment, but it is rarely life-threatening in the United States and other developed nations. However, an estimated 220,000 children younger than age five are hospitalized with gastroenteritis symptoms in the United States annually. Of these children, 300 die as a result of severe diarrhea and dehydration. In developing nations, diarrheal illnesses are a major source of mortality. In 1990, approximately three million deaths occurred worldwide as a result of diarrheal illness.
The most common cause of gastroenteritis is viral infection. Viruses such as rotavirus, adenovirus, astrovirus, and calicivirus and small round-structured viruses (SRSVs) are found all over the world. Exposure typically occurs through the fecal-oral route, such as by consuming foods contaminated by fecal material related to poor sanitation. However, the infective dose can be very low (approximately 100 virus particles), so other routes of transmission are quite probable.
Typically, children are more vulnerable to rotaviruses, the most significant cause of acute watery diarrhea. Annually, worldwide, rotaviruses are estimated to cause 800,000 deaths in children below age five. For this reason, much research has gone into developing a vaccine to protect children from this virus. Adults can be infected with rotaviruses, but these infections typically have minimal or no symptoms.
Children are also susceptible to adenoviruses and astroviruses, which are minor causes of childhood gastroenteritis. Adults experience illness from astroviruses as well, but the major causes of adult viral gastroenteritis are the caliciviruses and SRSVs. These viruses also cause illness in children. The SRSVs are a type of calicivirus and include the Norwalk, Southhampton, and Lonsdale viruses. These viruses are the most likely to produce vomiting as a major symptom.
Bacterial gastroenteritis is frequently a result of poor sanitation, the lack of safe drinking water, or contaminated food-conditions common in developing nations. Natural or man-made disasters can make underlying problems in sanitation and food safety worse. In developed nations, the modern food production system potentially exposes millions of people to disease-causing bacteria through its intensive production and distribution methods. Common types of bacterial gastroenteritis can be linked to Salmonella and Campylobacter bacteria; however, Escherichia coli 0157 and Listeria monocytogenes are creating increased concern in developed nations. and Shigella remain two diseases of great concern in developing countries, and research to develop long-term vaccines against them is underway.
Wednesday, April 1, 2009
Stomach (Gastric) Ulcer
A stomach ulcer is usually caused by an infection with a bacterium (germ) called H. pylori. A 4-8 week course of acid-suppressing medication will allow the ulcer to heal. In addition, a one week course of two antibiotics plus an acid-suppressing drug will usually clear the H. pyloriinfection. This usually prevents the ulcer recurring again. Anti-inflammatory drugs used to treat conditions such as arthritis sometimes cause stomach ulcers. If you need to continue with the anti-inflammatory drug, then you may need to take long term acid-suppressing medication.
Understanding your gut and digestion
Food passes down the oesophagus (gullet) into the stomach. The stomach makes acid which is not essential, but helps to digest food. After being mixed in the stomach, food passes into the duodenum (the first part of the small intestine). In the duodenum and the rest of the small intestine, food mixes with enzymes (chemicals). The enzymes come from the pancreas and from cells lining the intestine. The enzymes break down (digest) the food which is absorbed into the body.
Some terms explained
Peptic inflammation is inflammation caused by stomach acid. Inflammation may be in the stomach, the duodenum (as acid flows in with food), or the lower oesophagus (if acid splashes up to cause 'reflux oesophagitis').
A peptic ulcer is an ulcer caused by stomach acid. An ulcer is where the lining of the gut is damaged and the underlying tissue is exposed. If you could see inside your gut, an ulcer looks like a small, red crater on the inside lining of the gut.
A stomach ulcer is one type of peptic ulcer. A stomach ulcer is sometimes called a gastric ulcer. (The most common type of peptic ulcer is a duodenal ulcer.)
The rest of this leaflet deals only with stomach ulcers. See separate leaflets on 'Duodenal Ulcer', and 'Acid Reflux and Oesophagitis'.
What causes stomach ulcers?
Your stomach normally produces acid to help with the digestion of food and to kill bacteria. This acid is corrosive so some cells on the inside lining of the stomach and duodenum produce a natural mucus barrier which protects the lining of the stomach and duodenum. There is normally a balance between the amount of acid that you make and the mucus defense barrier. An ulcer may develop if there is an alteration in this balance allowing the acid to damage the lining of the stomach or duodenum. Causes of this include the following:
Infection with Helicobacter pylori
Infection by Helicobacter pylori (commonly just called H. pylori) is the cause in about 8 in 10 cases of stomach ulcer. More than a quarter of people in the UK become infected with H. pylori at some stage in their life. Once you are infected, unless treated, the infection usually stays for the rest of your life. In many people it causes no problems and a number of these bacteria just live harmlessly in the lining of the stomach and duodenum. However, in some people this bacterium causes an inflammation in the lining of the stomach or duodenum. This causes the defence mucus barrier to be disrupted (and in some cases the amount of acid to be increased) which allows the acid to cause inflammation and ulcers.
Anti-inflammatory drugs - including aspirin
Anti-inflammatory drugs are sometimes called non-steroidal anti inflammatory drugs (NSAIDs). There are various types and brands. For example: aspirin, ibuprofen, diclofenac, etc. Many people take an anti-inflammatory drug for arthritis, muscular pains, etc. Aspirin is also used by many people to protect against blood clots forming. However, these drugs sometimes affect the mucus barrier of the stomach and allow acid to cause an ulcer. About 2 in 10 stomach ulcers are caused by anti-inflammatory drugs.
Other causes and factors
Other causes are rare. For example, some virus infections can cause a stomach ulcer. Crohn's disease may cause a stomach ulcer in addition to other problems of the gut. Stomach cancer may at first look similar to an ulcer. Stomach cancer is uncommon, but may need to be 'ruled out' if you are found to have a stomach ulcer.
What are the symptoms of a stomach ulcer?
Pain in the upper abdomen just below the sternum (breastbone) is the common symptom. It usually comes and goes. It may be eased if you take antacid tablets. Sometimes food makes the pain worse. The pain may wake you from sleep.
Other symptoms which may occur include: bloating, retching, and feeling sick. You may feel particularly 'full' after a meal.
Complications develop in some cases, and can be serious. These include:
Bleeding ulcer. This can range from a 'trickle' to a life-threatening bleed.
Perforation. This is where the ulcer goes right through ('perforates') the wall of the stomach. Food and acid in the stomach then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.
What tests may be done?
Endoscopy is the test that can confirm a stomach ulcer. In this test a doctor looks inside your stomach by passing a thin, flexible telescope down your oesophagus. They can see any inflammation or ulcers. (See leaflet called 'Endoscopy' for details.)
A test to detect the H. pylori bacterium is usually done if you have a stomach ulcer. If H. pylori is found then it is likely to be the cause of the ulcer. See separate leaflet on Helicobacter Pylori & Stomach Pain and how it can be diagnosed. Briefly, it can be detected in a sample of faeces, or in a 'breath test', or from a blood test, or from a biopsy sample taken during an endoscopy.
Biopsies (small samples) are usually taken of the tissue in and around the ulcer during endoscopy. These are sent to the 'lab' to be looked at under the microscope. This checks for cancer (which is ruled out as the cause of the ulcer in most cases).
What are the treatments for a stomach ulcer?
Acid suppressing medication
A 4-8 week course of a drug that greatly reduces the amount of acid that your stomach makes is usually advised. The most commonly used drug is a proton pump inhibitor. Proton pump inhibitors (PPIs) are a class (group) of drugs that work on the cells that line the stomach, reducing the production of acid. They include: esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole, and come in various brand names. Sometimes a drug from another class of drugs called H2 blockers is used. H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include: cimetidine, famotidine, nizatidine and ranitidine, and come in various brand names. As the amount of acid is greatly reduced, the ulcer usually heals. However, this is not the end of the story ...
If your ulcer was caused by H. pylori
Most stomach ulcers are caused by infection with H. pylori. Therefore, a main part of the treatment is to clear this infection. If this infection is not cleared, the ulcer is likely to return once you stop taking acid-suppressing medication. Two antibiotics are needed to clear H. pylori. In addition, you need to take an acid-suppressing drug to reduce the acid in the stomach. This is needed to allow the antibiotics to work well. You need to take this 'combination therapy' (sometimes called 'triple therapy') for a week. One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. If H. pylori is cleared, then the chance of a recurrence of a stomach ulcer is greatly reduced. However, in a small number of people H. pylori infection returns at some stage in the future.
If your ulcer was caused by an anti-inflammatory drug
If possible, you should stop the anti-inflammatory drug. This allows the ulcer to heal. You will also normally be prescribed an acid-suppressing drug for several weeks. This stops the stomach from making acid and allows the ulcer to heal. However, in many cases the anti-inflammatory drug is needed to ease symptoms of arthritis or other painful conditions, or aspirin is needed to protect against blood clots. In these situations, one option is to take an acid-suppressing drug each day indefinitely. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again.
Treatment for other uncommon causes
Treatment depends on the underlying cause.
Surgery
In the past, surgery was commonly needed to treat a stomach ulcer. This was before it was discovered that H. pylori was the cause of most stomach ulcers, and before modern acid-suppressing drugs became available. Surgery is now usually only needed if a complication of a stomach ulcer develops such as severe bleeding or a perforation.
After treatment
A repeat endoscopy is usually advised a few weeks after treatment has finished. This is mainly to check that the ulcer has healed, and also to be doubly certain that the 'ulcer' was not due to stomach cancer. If your ulcer was caused by H. pylori then a test to check that H. pylori has gone is usually advised. This is done at least four weeks after the course of combination therapy has finished. In most cases, the test is 'negative' meaning that the infection has gone. If it has not gone, then a repeat course of combination therapy with a different set of antibiotics may be advised
Subscribe to:
Posts (Atom)
