Gastrointestinal Disorders
Alcohol is toxic to the liver and excessive and prolonged use of alcoholic beverages causes liver disease. Alcoholic liver disease is the commonest form of chronic liver disease in western society. The quantity and duration of alcohol consumed are the most important factors in developing liver disease.
There is no convincing evidence that the form of alcohol whether it be wine, beer or spirits makes any material difference. Generally the threshold of alcohol considered likely to produce liver injury is 60 to 80 grams per day in men (10 grams of alcohol is equivalent to approximately one middie of beer, 100ml of wine or 30ml of spirits) and 20 to 40 grams per day in women for 10 years. It is important to note that individual variations do occur and lesser amounts may produce significant problems.
It has been consistently observed that women are at greater risk of developing alcohol-induced liver disease than men even when factors such as body weight are considered. Finally persons with chronic Hepatitis C are known to develop more advanced alcoholic liver disease than if alcohol was the only factor involved.
Symptoms - The symptoms of alcoholic liver disease are often minimal or absent in early disease. Alcoholic fatty liver is a condition where the liver accumulates fat in response to the toxic effects of alcohol. An enlarged liver accompanied by tenderness may result though often there are no symptoms and it is detected because of blood test abnormalities on routine screening. 90% to 100% of heavy drinkers develop fatty liver.
Alcoholic hepatitis is a more serious condition though its severity can range from a mild up to a life threatening illness. Symptoms include loss of appetite, nausea and vomiting, abdominal discomfort and jaundice (yellow discolouration of the skin and eyes). More severe symptoms include those of liver failure requiring hospital admission. Cirrhosis can develop as a result of chronic liver damage from alcohol. As cirrhosis progresses, symptoms of liver failure occur including fluid retention in the abdomen and legs, easy bruising, gastrointestinal bleeding and confusion. Patients with alcoholic cirrhosis have a small risk of developing liver cancer.
Treatment - The most important treatment for patients with alcoholic liver disease is abstinence from all alcohol. In many cases the liver is able to regenerate and the patient's symptoms may improve or totally resolve. There are therapies available to assist patients to remain abstinent when there is an alcohol dependence problem. Psychosocial supports via Drug and Alcohol counsellors or programs such as Alcoholics Anonymous are very important.
Despite abstinence, symptoms of liver decompensation may persist and need to be addressed individually. For end-stage liver failure, liver transplantation is an option if the patient has proven that they can remain abstinent for a prolonged period of time. Malnutrition is common in patients with alcohol related problems and therefore an adequate diet to improve the individual's nutritional status is important.
Prevention - Prevention of alcoholic liver disease is achievable if the problem is detected early and abstinence is undertaken.
Amoebiasis is defined as infection with Entamoeba Histolytica. This protozoan organism causes intestinal infection and also occasional extra intestinal infections of the liver and rarely the lungs and brain. Under the microscope it is identical with another organism Entamoeba dispar, which does not cause any disease even though it may be present in the bowel.
Symptoms - Most people who become infected do not develop symptoms, but those that have immune suppression, malnutrition, malignancy, are of a young age or other factors making them more susceptible will develop symptoms. These symptoms include diarrhoea, bloody motions, abdominal pain and fever and weight loss.
Treatment - Direct microscopic examination of the stools may confirm the diagnosis, however it can be difficult as the Entamoeba Dispar organism which causes no disease or symptoms looks identical. Blood tests for antibodies to Amoebae may also be helpful in confirming the diagnosis. Recently sophisticated immunologic tests on the stool have become available and are more accurate.
Prevention - Avoiding water that has not been boiled or using bottled water while travelling in endemic areas is the best prevention. Care to avoid food that has been washed in unboiled water is also necessary. No vaccine is currently available.
Barrett's oesophagus refers to a change in the lining tissue (mucosa) of the lower oesophagus from normal (squamous cells) to a lining composed of cells normally lining the intestine (columnar cells). This occurs in some people as a response to chronic oesophageal reflux.
Symptoms - Barrett's oesophagus by itself produces no symptoms but may be associated with reflux symptoms (see reflux), due to irritation and sometimes ulceration of the lining of the lower oesophagus.
Treatment - Currently trials of anti reflux measures; drugs and surgery are being performed to see whether Barrett's can be "treated" and made to disappear. Some researchers are trying to remove the abnormal lining tissue - hoping to replace it with 'normal' squamous mucosa.
Bowel Cancer (Colorectal Cancer)
Cancer of the colon and rectum - the large bowel - is the second most common cause of cancer-related death. It is also one of the most preventable. Approximately one in 20 people in western societies like Australia will at some time develop this condition. This cancer can occur at any age but the vast majority of them occur in people over the age of 40.
The colon is the last part of the intestine. It continues to absorb water and minerals from the material delivered to it by the small bowel. The final section is called the rectum, about 15cm from the anal opening. It acts as a storage organ. Cancer starts in the innermost layer of the bowel wall and can grow through the other layers. Colon cancer and rectal cancer have many features in common and can be considered together. The treatment is somewhat different however. Cancer can develop in any part of the colon and rectum. Before a cancer develops there are usually pre-cancerous changes, typically a type of polyp which is a small growth in the inner layer. Cancer usually develops slowly over months to years, invades the bowel wall and can spread to involve other parts of the body, especially the liver.
Treatment - Cancers of the colon and rectum are treated surgically. The section of bowel containing the cancer is removed together with the associated blood vessels and lymph glands. Usually the bowel is able to be joined back together after this operation. If the cancer has spread to the lymph glands or other organs, chemotherapy or radiotherapy may be advised. Cancers of the rectum are usually treated similarly. Sometimes, however the bowel cannot be rejoined and it is necessary to make a colostomy. This means the end of the bowel is brought out on the skin of the abdomen and it is necessary to wear a bag to collect the waste. These days a permanent colostomy is rarely necessary.
Prevention - Most colorectal cancer develops in a benign polyp so finding and removing such polyps should reduce the risk of cancer. Family members of people who have had polyps or cancer are at increased risk and need screening. Colonoscopy is usually recommended. Similarly screening is advised for people with ulcerative colitis and certain inherited conditions. Diet plays some role in the development of polyps and cancer. How great the role is unclear. A diet containing plenty of fruit, vegetables and cereal and low in fat seems beneficial and also reduces the risk of heart disease, diverticular disease and haemorrhoids among other benefits.
Cirrhosis is a condition where the liver becomes irreversibly scarred with changes to the liver's architecture. It can result from any disease which causes chronic liver injury or inflammation. Common causes of chronic liver injury in western society include alcohol and viral hepatitis. As cirrhosis progresses the development of liver failure can occur.
Symptoms - Cirrhosis is a condition where the liver becomes irreversibly scarred with changes to the liver's architecture. It can result from any disease which causes chronic liver injury or inflammation. Common causes of chronic liver injury in Western society include alcohol and viral hepatitis. As cirrhosis progresses the development of liver failure can occur.
Treatment - The treatment of cirrhosis is subdivided into the treatment of the underlying cause of the chronic liver disease and the treatment of the complications arising from cirrhosis such as bleeding and fluid retention. Currently there are no therapies available to reverse the scarring of the liver but this may be a possibility in the future with exciting advances being made at present at a research level. The only effective treatment at present for end-stage cirrhosis where the liver has failed is liver transplantation. Consultation with your general practitioner and gastroenterologist will advise you of your possible treatment options.
Prevention - Prevention of cirrhosis is possible when the diseases that cause chronic liver injury are detected early and where treatments are available.
People with coeliac disease have an immune reaction to gluten, resulting in intestinal damage. The treatment is a gluten-free diet for life. People with wheat allergy or who have been advised to follow a low-gluten diet, but who have not been diagnosed with coeliac disease should check with their doctor or dietician first before commencing a strict gluten-free diet.
Gluten is a protein found naturally in certain grains, namely wheat, barley, rye and triticale. Oats may also be contaminated with wheat and currently are not permitted on a gluten-free diet. Many common foods in Australia are therefore a source of gluten eg. bread, pasta, biscuits, because they have ingredients made from gluten-containing grains. Some food additives eg. malt extract, thickening agents, may also contain trace amounts of gluten.
Label reading is a vital part of shopping for gluten-free foods. The good news is that the choice of gluten-free products has expanded significantly over the last five years and new legislation requires food manufacturers to state on their labels if any of their ingredients contain wheat or gluten. Health food stores as well as the health food section of the major supermarkets usually display a range of commercial gluten-free foods and many ordinary foods are still suitable.
If you have newly-diagnosed coeliac disease, here are the basic recommendations to follow for the gluten-free diet.
- Replace gluten-containing foods with gluten-free alternatives.
- Eat a variety of foods from the different food groups for nutritional adequacy.
- See a dietician for individualised diet counselling. This is particularly important if you also have other related nutritional concerns such as weight loss, lactose intolerance, iron deficiency or low bone mineral density.
- Consider joining the Coeliac Society of Australia which provides invaluable support, information and practical advice to people with coeliac disease.
Constipation is when there are less than 3 bowel movements per week. Constipation is hardly ever harmful. If you pass only two bowel movements per week but are reasonably comfortable, no specific treatment is required. Constipation is a very common complaint, especially in women, children and the elderly.
Symptoms - Less than three bowel movements per week. There are many causes of constipation, with poor dietary fibre and fluid intake being amongst the most common.
If there has been a change in bowel habit, especially if you are over 50 years, you should discuss this with your doctor who may suggest a test for bowel cancer such as colonoscopy or barium enema (x-ray). Sometimes blood tests are performed to look for thyroid problems, or high calcium levels.
Treatment - Increasing the fibre in the diet clearly makes people have more frequent bowel movements. Fibre is contained within cereals, breads, fruit and vegetables and also in simple supplements such as psyllium. Increasing fibre should be done slowly, otherwise bloating and gas may be more of a problem. Fibre only works if you are having enough liquid with it. You should have 6-8 glasses per day.
Caffeinated beverages such as tea, coffee, and some soft drinks actually make you lose more fluid and should therefore be limited. Try taking a water bottle to work or when travelling! Regular gentle exercise may also help the bowels work. Simple advice: When you have the urge to open your bowels, you should try to make time to go to the toilet at that time. Putting it off can make constipation worse. You should avoid straining as this can cause further problems. Your bowel is naturally more active in the early morning and after meals and so you should consider attempting to have a bowel movement at these times.
Prevention - A diet high in fibre, along with a good liquid intake is important in preventing constipation. It is important to consume more fluids when exercising or travelling. Some medications that cause constipation should be avoided such as calcium tablets and iron tablets.
Crohn's disease is an inflammatory disease of the digestive tract which can involve any part of the gut from the mouth to the anus, although it commonly involves the small bowel (ileum) and colon (large bowel). The disease often is a patchy one with segments of normal bowel. The bowel wall becomes swollen, thickened and often ulcerated producing narrowing and sometimes perforation.
Treatment - Treatment may be medical (with drugs and diet), or by surgery when the disease fails to respond to drugs or when complications such as perforation or abscess occur. Drug treatments include cortiesteroid (cortisone), immunosuppressants, antibiotics, and aminosalicylic acid compounds.
Prevention - The cause of the disease is unknown and no preventive measures are known.
A postradiation cryptosporidiosis is an infection with the protozoan organism cryptosporidium. Although there are 20 different species of cryptosporidium, only one causes infection in humans - cryptosporidium parvum. Infection occurs following ingestion of contaminated food or water. It was first recognised as a cause of diarrhoea in 1976.
Symptoms - After a 7 day incubation period diarrhoea and abdominal cramping may occur. The illness is often mild in those people with a normal immune system. Severe and protracted diarrhoea with wasting and abdominal cramping is seen with immune suppression. Patients with HIV AIDS may also have the infection in the bile ducts and gall bladder.
Treatment - The diagnosis is usually made by examination of the stools microscopically or by examination of biopsy material taken from infected parts the gastrointestinal tract at the time of endoscopy. Although drugs such as paromomycin and azithromycin have been tried in those patients with HIV AIDS, the effects have only been temporary and the organism and the diarrhoea it causes continue long term, often with marked weight loss.
Prevention - Boiling or filtering water may be helpful in the immune suppressed, together with avoidance of oral contact with water from lakes, streams and public swimming pools. However these measures are unproven.
Diverticulosis is the presence of small pouches (diverticula) that bulge out through weak spots in the wall of the bowel. The pouches can occur anywhere in the digestive tract but most commonly in the large bowel, especially the sigmoid and descending colon. Diverticulitis is inflammation or infection of these pouches.
Symptoms - Most people with diverticulosis have no symptoms. Mild cramps, bloating and constipation may occur but these symptoms are common and occur with other conditions also. Diverticulitis causes abdominal pain and tenderness especially in the left side of the abdomen. Depending on the severity of the inflammation fever, nausea and vomiting may occur. Rarely, complications such as abscess formation, perforation of the bowel and peritonitis can occur. These complications can be serious and always require treatment, usually in hospital. Rarely, bleeding can occur from a weakened blood vessel in a diverticulum. The bleeding can be profuse but often stops by itself without treatment.
Treatment - Increasing the intake of dietary fibre (cereals, fruit and vegetables) may improve constipation and reduce symptoms of diverticulosis. It may also reduce the risk of developing complications like diverticulitis. In addition a fibre supplement may be advised. Some doctors used to advise avoiding food with small seeds and nuts because of the fear that these may get caught in the diverticula. Most doctors now believe that these foods are more beneficial than harmful. If diverticulitis develops, treatment is aimed at eradicating the infection and inflammation. Usually antibiotics are prescribed together with a liquid diet to rest the bowel. If the attack is severe or doesn't respond to antibiotics by mouth, admission to hospital for intravenous antibiotics may be necessary. Most attacks settle down with treatment and with attention to diet don't recur. Once the attack settles further investigation is usually required to make sure that the diagnosis was correct and that there is no other serious problem in the bowel. Bowel cancer can sometimes cause very similar symptoms and would need further treatment.
Prevention - Eating a healthy diet containing sufficient grains, fruit and vegetables from an early age should reduce the chance of developing diverticular disease. Diverticular disease is common in developed countries where low fibre diets are common. The disease is rare in the countries of Africa and Asia where people eat high fibre diets.
If there is a change in the way the bowels are functioning it should be discussed with your doctor. Sometimes testing to check for bowel cancer should be performed, especially if you are over 50, or have any bleeding from the bowel. Tests of the anal sphincter are relatively simple and easy. A simple, small measuring tube is placed in the anal canal and tests the strength of the muscles, the sensation and the nerve function. An ultrasound scan of this region may also be very useful to detect if the muscle is damaged.
Treatment - When the stool is loose, it is important to try things to bulk or firm up the stool. Adding some fibre to the diet, such as contained in breakfast cereal, fruit and vegetables should be tried in the first instance. If you prefer, you can take a supplemental fibre such as psyllium, available in supermarkets, chemists and health food stores. In a few patients, increasing the fibre will lead to ongoing loose stools, and sometimes trying to actually reduce the fibre in the diet may help. Medications are available over the counter to treat faecal incontinence.
Prevention - Effort should me made to avoid excess straining. Pelvic floor exercises in women may also be helpful.
Fatty infiltration of the liver is an accumulation of fat within liver. It is the commonest cause of abnormal liver blood tests which is sometimes associated with inflammation and scarring within liver, however it rarely progresses to cirrhosis and liver failure.
Treatment - Treatment is dependent on cause eg. a low fat diet; reduction in alcohol consumption; improvement in the control of diabetes.
FNH is a much more common tumour than liver cell adenomas. FNH is more common in women but the gender difference is less striking than that of liver cell adenoma.
Symptoms - The vast majority of patients with FNH do not have symptoms referable to their liver lesions. However, pain sometimes occurs and this may be due to bleeding.
Gallstones are collections of crystals made up of cholesterol, bile salts or bile pigments. These crystals solidify within the gallbladder or bile ducts in certain people and may result in the symptoms described below. Gallstones range in size from microscopic crystals to large stones the size of a golf ball. They occur commonly in western societies, with their frequency in the population increasing with age. Approximately 10-15% of the population of developed nations has gallstones.
Cholecystitis is inflammation of the gallbladder that usually occurs due to obstruction of the flow of bile by a gallstone. The symptoms associated with this condition are described in detail below.
Symptoms - Many gallstones do not cause any symptoms at all and are detected incidentally on tests done for other reasons. These stones do not usually require any treatment unless they become symptomatic at a later date. When a gallstone moves out of the gallbladder into the bile ducts this can lead to symptoms such as upper abdominal pain (which commonly radiates around the abdomen and up into the shoulder blades), nausea, vomiting, fever, night sweats, jaundice, dark coloured urine, and light coloured faeces. If the gallstone passes out of the bile duct into the duodenum spontaneously, these symptoms resolve without any specific medical intervention.
However, if the stone becomes blocked inside the bile ducts, these symptoms may be prolonged and may recur at intervals of days, weeks or months. One potential complication of the passage of a gallstone down the biliary tree that may occur is a condition known as pancreatitis.
Pancreatitis is inflammation of the pancreas gland caused by an elevation of pressure within the pancreatic duct, which may occur when a gallstone becomes impacted at the opening of the biliary tree into the duodenum. This is associated with severe abdominal pain that may radiate through to the back, and over the entire abdomen. It is diagnosed on blood tests, and by ultrasound or computerised tomography (CT) scanning, and requires hospital treatment. It is a potentially very serious condition and requires urgent medical attention. Prolonged obstruction to bile flow may also result in inflammation of the gallbladder itself known as cholecystitis.
Symptoms of cholecystitis are similar to those described above, and the diagnosis is usually confirmed on ultrasound or nuclear medicine scanning of the gallbladder. Cholecystitis usually requires admission to hospital for intravenous fluids, antibiotics and possible surgery to treat the disorder.
Treatment - During an episode of biliary colic where a gallstone is passing down the common bile duct, patients will often require significant amounts of pain relieving medication to relieve their symptoms of discomfort. Patients experiencing these symptoms should seek medical advice. Simple analgesics such as paracetamol may provide limited relief. More commonly smooth muscle relaxants such as hyoscine butyl bromide (Buscopan) are used orally or as an intravenous injection to relieve the pain. On some occasions it may be necessary for patients to be given narcotic analgesics such as pethidine if pain is not controlled by other measures. If there is evidence of infection within the biliary tree, patients may require oral or intravenous antibiotics.
Prevention - Most gallstones are made of cholesterol. Diets that are high in cholesterol or saturated fats, and low in fibre, may predispose to formation of gallstones. Dehydration and constipation also appear to play a role in predisposing to bile salts precipitating to form gallstones and should therefore be avoided.
Gastric cancer is a tumour of the stomach. There are different types of tumours of the stomach and these may be either benign or malignant. Benign stomach tumours include simple metaplastic polyps and small leiomyomas which have no potential to spread elsewhere. On the other hand, malignant tumours (cancers) have the potential to spread beyond the stomach and may be lethal. The most common type of malignant tumour of the stomach is an adenocarcinoma. Other rarer types include carcinoid tumours and gastric lymphomas.
Symptoms - Gastric cancer can be hard to detect early. Often there are no symptoms in the early stages and, in many cases, the cancer spreads before it is found. When symptoms do occur they are often vague and people usually ignore these symptoms. However, gastric cancer can cause the following: indigestion or heart burn; discomfort or pain in the upper abdomen; nausea and vomiting; diarrhoea or constipation; bloating of the stomach after meals; loss of appetite; weakness and fatigue; and bleeding (vomiting blood or having blood in the stool). Any of these symptoms can be caused by other problems and therefore may be confused with the symptoms of gastric cancer.
Treatment - Treatment for gastric cancer depends on the size, location and extent of the tumour. The treatment options also depend on the stage of the disease and the patient's general health. Cancer of the stomach is often difficult to cure unless it is found in the early stage before it has begun to spread. However, advanced cancer can be treated and certainly the symptoms can be relieved. Treatment of stomach cancer may include surgery, chemotherapy and/or radiation therapy.
Surgery is the most common treatment for stomach cancer and the operation to remove a stomach tumour is called a gastrectomy. The surgeon may remove part (sub total or partial gastrectomy) or all (total gastrectomy) of the stomach as well as some of the tissue around the stomach. After removing the stomach the surgeon reconnects the remaining part of the stomach or the lower part of the oesophagus to the small intestine. The lymph glands are also usually removed and the histopathologist will examine these to see if the tumour has spread beyond the stomach.
Other options for treating gastric cancer include chemotherapy which is the use of drugs to destroy cancer cells.
Prevention - There are a number of possible causes of gastric cancer. These include dietary factors, genetic factors and possibly infection by helicobacter pylori. There is evidence to link helicobacter pylori infection with the early changes associated with gastric cancer and some data to suggest that helicobacter pylori should be eradicated to prevent gastric cancer.
Gastro-Oesophageal Reflux Disease
Irritation and damage to the lining of the oesophagus due to the reflux or regurgitation of gastric juices (acid and pepsin) or bile (bile reflux). The condition usually relates to weakness of the lower oesophageal sphincter (reflux valve) and reduced oesophageal peristalsis (or contractions). This tends to produce heartburn and indigestion. Reflux is very common - up to 40% of the population experience some degree of heartburn occasionally. The condition may vary greatly in its severity and frequency.
Symptoms - Usually produces heartburn or 'acidity', felt in the chest often radiating to the throat. Occasionally reflux produces belching and food regurgitation and an acid taste in the mouth (waterbrash). When severe reflux may interfere with normal swallowing, or produce painful swallowing.
Treatment - Reflux tends to be aggravated by certain foods and drinks - spicy food, fat, acidic foods, alcohol and coffee. There is much individual variation, but dietary modification may help.
Prevention - Dietary observance, weight loss, position and posture - elevation bed head and surgery may help. Chronic reflux may be associated with the development of Barrett’s oesophagus, in which there is a change in the lining tissue of the lower oesophagus. It is thought that this ‘metaplastic’ tissue may have a malignant (cancerous) potential.
This is a larger organism than a bacteria or virus and it colonises the duodenum and upper small bowel.
Symptoms – Giardia Lamblia causes a wide variety of symptoms, varying from no symptoms at all to marked diarrhoea and malabsorption of nutrients in extreme cases. The diarrhoea may be intermittent and accompanied by a good deal of gas and wind. Weight loss may occur in severely affected people.
Treatment - It can be diagnosed by examination of the stool (bowel motion), although this may be unreliable. It can also be diagnosed by taking samples from the upper small bowel (duodenum) at endoscopy.
Prevention - As the organism is spread by contaminated water, a clean water supply is essential. If travelling overseas in areas of high risk, using a filter or boiling the water may be effective.
Gilbert’s syndrome is due to a congenital defect in clearance by liver of bilirubin (a waste product in bile). The condition is harmless.
Symptoms - Does not cause any symptoms apart from occasional jaundice. Fasting results in a sharp increase in bilirubin level in blood and may bring out jaundice.
Treatment - No treatment necessary.
This is a bacterium that was first discovered by an Australian, Dr. Barry Marshall, in 1983.
Symptoms - Apart from causing duodenal and gastric ulcers (which it does only in a minority of people infected), it also causes gastritis or inflammation of the stomach wall. Gastritis looks like a severe rash on the inside lining of the stomach when it is viewed by endoscopy. An ulcer is a defect or shallow crater and is a more serious problem than gastritis, as it can be complicated by bleeding or perforation.
Helicobacter Pylori can cause pain in the upper abdomen if it has caused an ulcer, but it can also cause indigestion, excessive burping and bad breath. It can be diagnosed by three main methods- a breath test which requires a person to breathe into a tube after fasting for hours; A blood test; or an endoscopy for direct visual inspection of the stomach, together with a sample taken directly from the stomach to analyse for the bacteria. Portocaval has the advantage of not only checking for the presence of the bacteria but also it can tell if the bacteria has caused any damage such gastritis or ulcer.
Treatment - Because it is a bacterium and not a virus, it can be treated with antibiotics. However it is sometimes difficult to eradicate and usually needs at least three medications taken for one or two weeks to get rid of the organism. Even with three different medications, upper to 20% of people will not eradicate the organism.
Prevention - Currently there is no effective vaccine and no easy way of preventing infection, which appears to the spread by person to person close contact.
Liver cell adenoma is an uncommon benign liver tumour that was found very rarely prior to the introduction of the oral contraceptive 40 years ago.
Symptoms - These tumours do not usually cause symptoms but may cause discomfort or pain in the right upper abdomen and rarely may cause life-threatening bleeding into the peritoneal cavity.
Treatment - Surgical removal is frequently recommended for these tumours to eliminate the risk of bleeding and to prevent the development of liver cell cancer.
A disease affecting the nerve cells of the colon, resulting in constipation. It usually presents in infancy and childhood as the child is unable to have normal bowel movements.
Symptoms - Symptoms include constipation, bloating, distended abdomen and vomiting.
A general term for any disease characterised by inflammation of the bowel. Examples include ulcerative colitis and Crohn's disease. Symptoms include abdominal pain, diarrhoea, fever, loss of appetite and weight loss. Inflammatory bowel disease should not be confused with Irritable Bowel Syndrome (IBS).
Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome is a disorder of the intestine that affects motility and causes abdominal pain, bloating and irregular bowel movements (constipation and/or diarrhoea). It used to be known in the past as spastic colon or colitis or irritable colon. IBS should not be confused with irritable bowel disease (IBD). IBS is one of the commonest gastrointestinal disorders.
Lactose is a dietary carbohydrate or sugar which is split into its two component single-sugars (glucose and galactose) by lactase, an enzyme found in the lining of the small intestine. Unless lactose is successfully broken down by lactase, it cannot be effectively absorbed across the small bowel lining into the body. It is then wasted, passing down through the small intestine and reaching the colon or large bowel. Here the unabsorbed lactose causes diarrhoea and is fermented by the normal bacterial flora in the colon. The generated gas contributes to pain, bloating, cramping and flatulence.
Symptoms - The symptoms, namely abdominal pain, cramping, diarrhoea, bloating and flatulence, overlap with those of irritable bowel syndrome and can be difficult to distinguish.
Treatment - There are a variety of ways in which lactase deficiency can be diagnosed. These include assessment of lactase levels in endoscopic biopsies of the small bowel, an oral lactose tolerance test (where blood levels of glucose are measured at times after ingesting a given amount of lactose) and a breath test.
Avoiding milk products usually alleviates symptoms. If dairy products are being restricted then consideration needs to be given to calcium supplementation to help prevent osteoporosis (weak bones) in the future.
Cysts are spaces occurring in organs that may contain only air or may be filled with liquid or solid contents. Most cysts that occur in the liver are filled with clear fluid.
Symptoms - They usually do not cause any symptoms. However, when small cysts become large they can cause abdominal discomfort or pain. They are usually hereditary and totally benign. Cysts may be due to parasites particularly amoebic and hydatid cysts.
Treatment - Ultrasound or CT scans of the abdomen are used to evaluate liver cysts. Simple (hereditary) cysts are common and do not require treatment unless they are causing symptoms. If treatment is required, the cysts can be drained through a needle placed in the cyst under radiological control. Rarely cysts need to be surgically repaired.
Non ulcer dyspepsia is a term often used to indicate the presence of dyspeptic symptoms for which no cause can be found after standard gastrointestinal investigations. Another term for this condition is "functional dyspepsia" - this is a more useful term, as it highlights that the symptoms are very likely due to a disturbance of stomach or upper bowel function, rather than physical disease.
The diagnosis is based on the presence of specific symptoms, and ruling out other conditions. Common tests to rule out the presence of a stomach ulcer include upper gastrointestinal endoscopy, and to exclude gall stone disease ultrasound scanning of the abdomen.
Treatment - The precise causes of functional dyspepsia are not known. Certain dietary changes and medications may, however, lessen the symptoms. For example, some symptoms can be reduced by avoiding spicy or fatty food. If fullness after eating, or bloating or nausea occurs it may be helpful to eat six small low fat meals per day. Some patients also find that the symptoms lessen if they avoid drinking coffee or alcohol or stop smoking. Medications are not generally helpful for the condition. Some patients, however, find that medications used for stomach ulcers can help, while other patients find that medications to improve the emptying of the stomach may help.
Prevention - Because the causes of non ulcer dyspepsia have not been clearly established, preventive measures are not known.However, some factors such as chronic stress can affect the muscular actions and sensitivity of the stomach, so that it is overly reactive when food enters and needs to be digested. When there are specific foods which can provoke the symptoms these can be identified and the symptoms improved by avoiding or reducing these type of foods in the diet.
Pancreatitis is inflammation of the pancreas. The two main forms of this condition are "acute" and "chronic". Both are relatively common reasons for people to consult gastroenterologists or present to hospital emergency departments.
Treatment - Acute pancreatitis - one of the main problems in treating an established episode of acute pancreatitis is the lack of effective medications for the condition. If gallstones are involved, a special form of endoscopy called ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is often helpful, as a relatively non-invasive way of clearing the offending gallstones form the ducts. Otherwise, treatment consists of resting the pancreas, by fasting, and maintaining hydration and nutrition intravenously. Chronic pancreatitis - the management of chronic pancreatitis revolves around attempts to control the pain and efforts to correct the disordered absorption which causes the diarrhoea, by using capsules of pancreatic enzymes taken with meals. ERCP and surgery sometimes play a role.
Prevention - Avoidance of excess alcohol intake.
A peptic stricture is a narrowing of the normal diameter of the oesophagus (gullet) due to (usually) longstanding gastro-oesophageal reflux, corrosive gastric acid and pepsin, (a digestive juice), and sometimes by bile reflux causing scarring and 'fibrosis' of the lower oesophagus.
Symptoms - Peptic strictures usually cause difficulty with swallowing (dysphagia), sometimes causing a lump of food acutely blocking the oesophagus (food bolus obstruction), slow or painful swallowing. This may also produce a cough or an inhalation of food into the windpipe or lungs and sometimes food regurgitation.
Treatment - Peptic strictures usually require to be stretched by a rigid dilator or balloon. This can be performed through the mouth at the time of an endoscopy. Ongoing treatment to prevent further acid reflux is very important. Occasionally surgery is required to treat the narrowed area.
Prevention - Peptic strictures can be prevented by the treatment of GORD (gastro-oesophageal reflux disease).
Primary Hepatocellular Carcinoma
Cancer arising from within the liver.
Treatment - Treatment include: surgical resection, liver transplantation, alcohol injection into tumour, radiofrequency ablation, chemotherapy.
Ulcerative colitis is a chronic disease of the colon (large bowel) caused by in inflammation of its lining (mucosa). Ulcerative colitis may involve just the rectum proctitis or a variable section of the bowel, usually in a continuous fashion. Its cause is unknown. It does not affect other parts of the gut.
Symptoms - People with ulcerative colitis complain of diarrhoea, usually with the passage of blood and mucus with the stool. Cramp-like pain and an urgency to go to the toilet are common symptoms. Bowel frequency is increased.
Treatment - Medical treatment includes the use of corticosteroids, (cortisone), administered as enemas or suppositories or as tablets or intravenous form. Salazopyrin is an aspirin like drug which is useful, especially in preventing relapse. Immunosuppressants are also commonly used. Surgery is occasionally needed when the disease cannot be controlled by drugs or when cancer risk is heightened.
Prevention - Regular colonoscopic screenings may be necessary to minimize risk of cancer developing, or finding it at an early stage. Surgery can usually be performed to avoid a colostomy and effectively 'cures' patients of the disease.
Viral hepatitis is an inflammation of the liver resulting from a viral infection. Numerous viruses can cause liver disease as part of their infection of humans.
There are however six viruses currently known that, when causing disease in humans, primarily affect the liver. These viruses have been named Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D (delta hepatitis), Hepatitis E and Hepatitis G. These viruses are not related to each other and whilst they can cause similar symptoms, have different patterns of disease. Hepatitis G has not been proven to cause symptoms or liver disease in humans and its relevance is still under investigation.
Symptoms - Viral hepatitis can affect the liver in two major ways. Acute hepatitis can cause symptoms ranging from being asymptomatic and in apparent to rarely, serious life threatening illness depending on the individual virus and circumstances. Hepatitis A and E only cause acute hepatitis and do not cause chronic liver disease. Hepatitis B, C and D however can cause hepatitis in a proportion of patients that continues and is classified as chronic. The symptoms of acute viral hepatitis are similar despite being caused by different viruses.
Prodromal symptoms may precede the onset of jaundice (yellow discolouration of the skin and sclera) by 1-2 weeks. These symptoms can be variable and include loss of appetite, nausea and vomiting, fatigue, muscle and joint pains, headache and fever. Dark urine and clay-coloured stools may be noticed from 1-5 days prior to the onset of noticeable jaundice. With the onset of jaundice, prodromal symptoms usually diminish though the liver can become tender and enlarged. As the jaundice resolves, a recovery phase where minor liver test abnormalities and liver enlargement are still evident, occurs that can last several months. A substantial proportion of patients with viral hepatitis never become jaundiced. The most serious complication of acute viral hepatitis is ‘fulminant hepatitis’. Fortunately this is a rare event. It is primarily seen in Hepatitis B and D but can occur with the other viral types.
Patients usually present with signs of liver failure. The mortality rate is high but patients who survive may have a complete recovery. Liver transplantation may be required. Depending on the type of viral hepatitis, the virus may persist after acute infection and cause chronic hepatitis. Chronic hepatitis may be associated with no symptoms but sometimes can cause non-specific symptoms such as fatigue and decreased appetite. If chronic hepatitis persists and causes increasing liver damage, cirrhosis may develop.
Patients may then have symptoms related to significant liver damage such as fluid retention manifested by abdominal or ankle swelling, gastrointestinal bleeding, bruising or confusion. In a small proportion of patients, progressive liver failure develops which finally leads to death if no treatment such as a liver transplant can be performed.
Treatment - The treatment of viral hepatitis depends on whether it is an acute or chronic infection, the type of virus involved and the symptoms of the patient. There is no specific treatment for acute viral hepatitis. Most patients do not require hospital care. Treatment is mainly supportive and rest is important. If severe symptoms develop, hospitalisation may be required and in some cases, if fulminant hepatitis occurs, a liver transplant may be necessary.
Chronic hepatitis occurs with Hepatitis B and Hepatitis C. There are now specific therapies available for treatment of these viruses. Patients with chronic hepatitis B or C require full evaluation by their medical practitioner and probable referral to a specialist gastroenterologist or liver clinic.
Prevention - Prevention of viral hepatitis can be subdivided into general and specific measures. General measures are important such as hygiene and avoiding infected water or foods by travellers to areas where hepatitis A or E are endemic. Hepatitis B and C are commonly spread via the injection of illicit drugs. Vaccination is a specific way to prevent viral infection. Vaccines are available for Hepatitis A and B.
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