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What is a Gastroenterologist?

A Gastroenterologist is a physician with dedicated training and unique experience in the management of diseases of the gastrointestinal tract and Liver.

A Gastroenterologist must first complete a three-year Internal Medicine residency and is then eligible for additional specialized training (fellowship) in Gastroenterology. This fellowship is generally 2-3 years long so by the time Gastroenterologists have completed their training, they have had 5-6 years of additional specialized education following medical school.

Gastroenterology fellowship training is an intense, rigorous program where future Gastroenterologists learn directly from nationally recognized experts in the field and develop a detailed understanding of gastrointestinal diseases. They learn how to evaluate patients with gastrointestinal complaints, treat a broad range of conditions, and provide recommendations to maintain health and prevent disease. They learn to care for patients in the office as well as in the hospital.

Gastroenterologists also receive dedicated training in endoscopy (upper endoscopy, sigmoidoscopy, and colonoscopy) by expert instructors. Endoscopy is the use of narrow, flexible lighted tubes with built-in video cameras, to visualize the inside of the intestinal tract. This specialized training includes detailed and intensive study of how and when to perform endoscopy, optimal methods to complete these tests safely and effectively, and the use of sedating medications to ensure the comfort and safety of patients. Gastroenterology trainees also learn how to perform advanced endoscopic procedures such as polypectomy (removal of colon polyps), esophageal and intestinal dilation (stretching of narrowed areas), and hemostasis (injection or cautery to stop bleeding). Importantly, Gastroenterologists learn how to properly interpret the findings and biopsy results of these studies in order to make appropriate recommendations to treat conditions and/or prevent cancer.

The most critical emphasis during the training period is attention to detail and incorporation of their comprehensive knowledge of the entire gastrointestinal tract to provide the highest quality endoscopy and consultative services. The final product is a highly trained specialist with a unique combination of broad scientific knowledge, general Internal Medicine training, superior endoscopic skills and experience, and the ability to integrate these elements to provide optimal health care for patients. This advanced fellowship training is overseen by national societies committed to ensuring high quality education.

These groups include the American Board of Internal Medicine, the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. These groups carefully scrutinize the educational experience of each program to ensure that every Gastroenterology trainee receives the highest quality training. Once fellows successfully complete their training they are considered "Board Eligible." They are then qualified to take the Gastroenterology board certification test administered by the American Board of Internal Medicine. Once they have successfully completed this examination they are "Board Certified.

What makes Gastroenterologists different?

The unique training that Gastroenterologists complete provides them with the ability to provide high quality, comprehensive care for patients with a wide variety of gastrointestinal problems. Gastroenterologists perform the bulk of research involving gastrointestinal endoscopic procedures as well as the interpretation of results, and are considered experts in the field. Studies have shown that Gastroenterologists perform higher quality colonoscopy examinations and comprehensive consultative services when compared to other physicians. This translates into more accurate detection of polyps and cancer by colonoscopy when performed by Gastroenterologists, fewer complications from procedures and fewer days in the hospital for many gastrointestinal conditions managed by trained gastroenterology specialists. It is this ability to provide more complete, accurate, and thorough care for patients with gastrointestinal conditions, which distinguishes Gastroenterologists from other physicians that provide some similar services.

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About Ulcerative Colitis

When you first learn that you have ulcerative colitis, you will probably feel overwhelmed. You may not even have heard of ulcerative colitis until now. And even if you are familiar with the disorder, the information you have may be pretty limited. That's all about to change. Clearly, you will have many questions about how this disease will affect you -- both now and down the road. For example, you'll want to know:

• Will I be able to work, travel, and exercise?
• Should I be on a special diet?
• How will other people react to my illness?
• Could my medications have side effects?
• How will ulcerative colitis change my life?

Learning all you can is an important step toward taking charge of your illness -- and your life. The following is an overview of ulcerative colitis. It is designed to help you understand more about the diagnosis and treatment of this illness, and its impact on the day-to-day lives of patients and their families. The better informed you are about ulcerative colitis, the more equipped you'll be to participate as an active member of your healthcare team.

What is Ulcerative Colitis?

Ulcerative colitis is a chronic (ongoing) disease of the colon, or large intestine. The disease is marked by inflammation and ulceration of the colon mucosa, or innermost lining. Tiny open sores, or ulcers, form on the surface of the lining, where they bleed and produce pus and mucus. Because the inflammation makes the colon empty frequently, symptoms typically include diarrhea (sometimes bloody) and often crampy abdominal pain.

The inflammation usually begins in the rectum and lower colon, but it may also involve the entire colon. When ulcerative colitis affects only the lowest part of the colon -- the rectum -- it is called ulcerative proctitis. If the disease affects only the left side of the colon, it is called limited or distal colitis. If it involves the entire colon, it is termed pancolitis.

Ulcerative colitis differs from another inflammatory bowel disease (IBD), Crohn's disease. Crohn's can affect any area of the gastrointestinal (GI) tract, including the small intestine and colon. Ulcerative colitis, on the other hand, affects only the colon. The inflammation involves the entire rectum and extends up the colon in a continuous manner. There are no areas of normal intestine between the areas of diseased intestine. In contrast, such so-called "skip" areas may occur in Crohn's disease. Ulcerative colitis affects only the innermost lining of the colon, whereas Crohn's disease can affect the entire thickness of the bowel wall.

Both illnesses do have one strong feature in common. They are marked by an abnormal response by the body's immune system. The immune system is composed of various cells and proteins. Normally, these protect the body from infection. In people with IBD, however, the immune system reacts inappropriately. Mistaking food, bacteria, and other materials in the intestine for foreign or invading substances, it launches an attack. In the process, the body sends white blood cells into the lining of the intestines, where they produce chronic inflammation. These cells then generate harmful products that ultimately lead to ulcerations and bowel injury. When this happens, the patient experiences the symptoms of IBD.

Neither ulcerative colitis nor Crohn's disease should be confused with irritable bowel syndrome (IBS), a disorder that affects the motility (muscle contractions) of the colon. Sometimes called "spastic colon" or "nervous colitis," IBS is not characterized by intestinal inflammation. It is, therefore, a much less serious disease than ulcerative colitis. IBS bears no direct relationship to either ulcerative colitis or Crohn's disease.

What Causes Ulcerative Colitis?

Although considerable progress has been made in IBD research, investigators do not yet know what causes this disease. Studies indicate that the inflammation in IBD involves a complex interaction of factors: the genes the person has inherited, the immune system, and something in the environment. Foreign substances (antigens) in the environment may be the direct cause of the inflammation, or they may stimulate the body's defenses to produce an inflammation that continues without control. Researchers believe that once the IBD patient's immune system is "turned on," it does not know how to properly "turn off" at the right time. As a result, inflammation damages the intestine and causes the symptoms of IBD. That is why the main goal of medical therapy is to help patients regulate their immune system better.

CCFA-sponsored research has led to progress in the fields of immunology, the study of the body's immune defense system; microbiology, the study of microscopic organisms with the power to cause disease; and genetics. Many scientists now believe that the interaction of an outside agent (such as a virus or bacterium) with the body's immune system may trigger the disease, or that such an agent may cause damage to the intestinal wall, initiating or accelerating the disease process. Through CCFA's continuing research efforts, much more will be learned and a cure will eventually be found.

How Common is IBD and Ulcerative Colitis?

It is estimated that as many as one million Americans have IBD, with that number evenly split between Crohn's disease and ulcerative colitis. Males and females appear to be affected equally.

On average, people are diagnosed with ulcerative colitis in their mid-30s, although the disease can occur at any age. Men are more likely than women to be diagnosed with ulcerative colitis in their 50s and 60s. There is a greater incidence of ulcerative colitis among whites than in non-whites, and a higher incidence in Jews than in non-Jews.

Is Ulcerative Colitis Inherited?

We know that ulcerative colitis can tend to run in families. Studies have shown that up to 20 percent of people with ulcerative colitis will have a close relative with either ulcerative colitis or Crohn's disease. Most often, the affected relative of the colitis patient will also have ulcerative colitis. However, based on current research, there does not appear to be a clear-cut pattern to this inheritance. Researchers continue to seek specific genes involved in the cause of the diseases. At this time, however, there is no way to predict which, if any, family members will develop ulcerative colitis or Crohn's disease.

What Are the Symptoms of Ulcerative Colitis?

The first symptom of ulcerative colitis is a progressive loosening of the stool. The stool is generally bloody and may be associated with crampy abdominal pain and severe urgency to have a bowel movement. The diarrhea may begin slowly or quite suddenly. Loss of appetite and subsequent weight loss are common, as is fatigue. In cases of severe bleeding, anemia may also occur. In addition, there may be skin lesions, joint pain, eye inflammation, and liver disorders. Children with ulcerative colitis may fail to develop or grow properly.

Approximately half of all patients with ulcerative colitis have relatively mild symptoms. However, others may suffer from severe abdominal cramping, bloody diarrhea, nausea, and fever. The symptoms of ulcerative colitis do tend to come and go, with fairly long periods in between flare-ups in which patients may experience no distress at all. These periods of remission can span months or even years, although symptoms do eventually return. The unpredictable course of ulcerative colitis may make it difficult for physicians to evaluate whether a particular course of treatment has been effective or not.

Types of Ulcerative Colitis and Their Associated Symptoms

The symptoms of ulcerative colitis, as well as possible complications, will vary depending on the extent of inflammation in the rectum and the colon. Because of this, it is very important for you to know which part of your intestine the disease affects.

One common subcategory of ulcerative colitis is ulcerative proctitis. For approximately 30% of all patients with ulcerative colitis, the illness begins as ulcerative proctitis. In this form of the disease, bowel inflammation is limited to the rectum. Because of its limited extent (usually less than the six inches of the rectum), ulcerative proctitis tends to be a milder form of ulcerative colitis. It is associated with fewer complications and offers a better outlook than more widespread disease.

In addition to ulcerative proctitis, there are several other types of ulcerative colitis. The following is a description of each type, together with some commonly associated symptoms and potential intestinal complications:

• Proctosigmoiditis: Colitis affecting the rectum and the sigmoid colon (the lower segment of colon located right above the rectum). Symptoms include bloody diarrhea, cramps, and tenesmus. Moderate pain on the lower left side of the abdomen may occur in active disease.
• Left-sided colitis: Continuous inflammation that begins at the rectum and extends as far as the splenic flexure (a bend in the colon, near the spleen). Symptoms include loss of appetite, weight loss, diarrhea, severe pain on the left side of the abdomen, and bleeding.
• Pan-ulcerative (total) colitis: Affects the entire colon. Symptoms include diarrhea, severe abdominal pain, cramps, and extensive weight loss. Potentially serious complications include massive bleeding and acute dilation of the colon (toxic megacolon), which may lead to perforation (an opening in the bowel wall). Serious complications may require surgery.

How is Ulcerative Colitis Diagnosed?

Physicians make the diagnosis of ulcerative colitis based on the patient's clinical history, a physical examination, and a series of tests. The first goal of these tests is to differentiate ulcerative colitis from infectious causes of diarrhea. Accordingly, stool specimens are obtained and analyzed to eliminate the possibility of bacterial, viral, or parasitic causes of diarrhea. Blood tests can check for signs of infection as well as for anemia, which may indicate bleeding in the colon or rectum. Following this, the patient generally undergoes an evaluation of the colon, using one of two tests -- a sigmoidoscopy or total colonoscopy.

To perform a sigmoidoscopy, the doctor passes a flexible instrument into the rectum and lower colon. This test allows the doctor to visualize the extent and degree of inflammation in these areas. A total colonoscopy is a similar exam, but it visualizes the entire colon. Using these techniques, your physician can detect inflammation, bleeding, or ulcers on the colon wall, as well as determine the extent of disease. During these procedures, the doctor may take samples of the colon lining, called biopsies, and send these to a pathologist for further study. Ulcerative colitis can thus be distinguished from other diseases of the colon that cause rectal bleeding -- including Crohn's disease of the colon, diverticular disease, and cancer.

Another diagnostic procedure that may be used is a barium enema X-ray of the colon. After the colon is filled with barium, a chalky white solution, an X-ray is taken. The barium shows up white on the X-ray, providing a detailed picture of the colon and any signs of disease.

What Medications are Used to Treat Ulcerative Colitis?

Currently, there is no medical cure for ulcerative colitis. However, effective medical treatment can suppress the inflammatory process. This accomplishes two important goals: It permits the colon to heal and it also relieves the symptoms of diarrhea, rectal bleeding, and abdominal pain. As such, the treatment of ulcerative colitis involves medications that decrease the abnormal inflammation in the colon lining and thereby control the symptoms.

Five major classes of medication are used today to treat ulcerative colitis:

• Aminosalicylates (5-ASA): This class of anti-inflammatory drugs includes sulfasalazine and oral formulations of mesalamine, such as Asacol®, Colazal®, Lialda®, Dipentum®, or Pentasa®, and 5-ASA drugs also may be administered rectally (Canasa® or Rowasa® ). These medications typically are used to treat mild to moderate symptoms. Without inflammation, symptoms such as diarrhea, rectal bleeding, and abdominal pain can be diminished greatly. Aminosalicylates are effective in treating mild to moderate episodes of ulcerative colitis, and are also useful in preventing relapses of this disease.
• Corticosteroids: Prednisone and methylprednisolone are available orally and rectally. Corticosteroids nonspecifically suppress the immune system and are used to treat moderate to severely active ulcerative colitis. (By "nonspecifically," we mean that these drugs do not target specific parts of the immune system that play a role in inflammation, but rather, that they suppress the entire immune response.) These drugs have significant short- and long-term side effects and should not be used as a maintenance medication. If you cannot come off steroids without suffering a relapse of your symptoms, your doctor may need to add some other medications to help manage your disease.
• Immune modifiers: Azathioprine (Imuran®), 6-MP (Purinethol®), and methotrexate. Immune modifiers, sometimes called immunomodulators, are used to help decrease corticosteroid dosage . Azathioprine and 6-MP have been useful in reducing or eliminating some patients' dependence on corticosteroids. They also may be helpful in maintaining remission in selected refractory ulcerative colitis patients (that is, patients who do not respond to standard medications). However, these medications can take as long as three months before their beneficial effects begin to work.
• Antibiotics: metronidazole, ampicillin, ciprofloxacin, others.
• Biologic therapies: Infliximab (Remicade®). Biologic therapies are the newest class of drugs used for people suffering from moderate-to-severe ulcerative colitis. These drugs are made from antibodies that bind with certain molecules to block a particular action. The intestinal inflammation of ulcerative colitis is a result of various processes, or "pathways." Because a biologic drug targets a specific pathway, it can help reduce inflammation. That targeted action also keeps side effects to a minimum.

Complications of Ulcerative Colitis

Complications are by no means an inevitable or even a frequent consequence of ulcerative colitis, especially in appropriately treated patients. But they are sufficiently common and cover such a wide range of manifestations that it is important for patients and physicians to be acquainted with them. Early recognition often means more effective treatment.

Local complications of ulcerative colitis include profuse bleeding from deep ulcerations, perforation (rupture) of the bowel, or simply failure of the patient to respond appropriately to the usual medical treatments.

Another complication is severe abdominal distension. A mild degree of distention is common in individuals without any intestinal disease and is somewhat more common in people with ulcerative colitis. However, if the distention is severe or of sudden onset, and if it is associated with active colitis, fever, and constipation, your physician may suspect a serious complication of colitis, called toxic megacolon. Fortunately, this is a rare development. It is produced by severe inflammation of the entire thickness of the colon, with weakening and ballooning of its wall. The dilated colon is then at risk of rupturing. Treatment is aimed at controlling the inflammatory reaction and restoring losses of fluid, salts, and blood. If there is no rapid improvement, surgery may become necessary to avoid rupture of the bowel.

What Is the Role of Surgery in Ulcerative Colitis?

In one-quarter to one-third of patients with ulcerative colitis, medical therapy is not completely successful or complications arise. Under these circumstances, surgery may be considered. This operation involves the removal of the colon (colectomy). Unlike Crohn's disease, which can recur after surgery, ulcerative colitis is "cured" once the colon is removed.

Depending on a number of factors,including the extent of the disease and the patient's age and overall health, one of two surgical approaches may be recommended. The first involves the removal of the entire colon and rectum, with the creation of an ileostomy or external stoma (an opening on the abdomen through which wastes are emptied into a pouch, which is attached to the skin with adhesive). Today, many people are able to take advantage of new surgical techniques, which have been developed to offer another option. This procedure also calls for removal of the colon, but it avoids an ileostomy. By creating an internal pouch from the small bowel and attaching it to the anal sphincter muscle, the surgeon can preserve bowel integrity and eliminate the need for the patient to wear an external ostomy appliance. (Further information on surgery and ulcerative colitis can be found on this Website in the section on surgery.)

The Role of Nutrition

There is no evidence that any particular foods cause or contribute to ulcerative colitis or other types of IBD. Once the disease has developed, however, paying special attention to diet may help reduce symptoms, replace lost nutrients, and promote healing. For example, when your disease is active, you may find that bland, soft foods may cause less discomfort than raw vegetables, spicy or high-fiber foods.

Maintaining proper nutrition is important in the medical management of ulcerative colitis. Good nutrition is essential in any chronic disease but especially in this illness, because diarrhea and rectal bleeding can rob the body of fluids, electrolytes, and nutrients. Except for restricting milk products in lactose-intolerant patients or restricting caffeine when severe diarrhea occurs, most gastroenterologists recommend a well-balanced diet for their patients with ulcerative colitis. A healthy diet should contain a variety of foods from all food groups. Meat, fish, poultry, and dairy products (if tolerated) are sources of protein; bread, cereal, starches, fruits, and vegetables are sources of carbohydrate; margarine and oils are sources of fat.

Emotional Stress and Coping With Ulcerative Colitis

Because body and mind are so closely interrelated, emotional stress can influence the course of ulcerative colitis -- or, for that matter, any other chronic illness. Although people occasionally experience emotional problems before a flare-up of their disease, this does not imply that emotional stress causes the illness. There is no evidence to show that stress, anxiety, or tension is responsible for ulcerative colitis. No single personality type is more prone to develop ulcerative colitis than others, and no one "brings on" the disease by poor emotional control.

It is much more likely that the emotional distress that patients sometimes feel is a reaction to the symptoms of the disease itself. It is not surprising that some patients find it difficult to cope with a chronic illness. Such illnesses seem to pose a threat to their entire quality of life-their physical and emotional well-being, social functioning, and sense of self-esteem. People with ulcerative colitis should receive understanding and emotional support from their families and physicians. Although formal psychotherapy is generally not necessary, some patients are helped considerably by speaking with a therapist who is knowledgeable about IBD or about chronic illness in general. CCFA offers local support groups to help patients and their families cope with IBD.

Coping techniques for dealing with ulcerative colitis may take many forms. Attacks of diarrhea, pain, or gas may make people fearful of being in public places. In such a situation, some practical advance planning may help alleviate this fear. For instance, find out where the restrooms are in restaurants, shopping areas, theaters, and on public transportation ahead of time. Some people find it helps to carry along extra underclothing or toilet paper for particularly long trips. When venturing further afoot, always consult with your physician. Travel plans should include a large enough supply of your medication, its generic name in case you run out or lose it, and the name of physicians in the area you may be visiting.

People with ulcerative colitis accept the diagnosis with a wide range of emotions. Some people are angry for a time. Others feel a sense of relief at finally knowing what it is that has made them ill. While it certainly may help to come to terms with ulcerative colitis in a straightforward manner, since this approach may maximize your ability to be part of your health care team right from the start, everyone is different. Each person with the disease must adjust to living with ulcerative colitis in his or her own way. There should be no guilt, no self-reproaches, or blame placed on others as you come to grips with your illness. There are resources and information available, such as local support groups and IBD education seminars. No one with ulcerative colitis should ever feel alone. As you go about your daily life as normally as possible, try pursuing some of the same activities that you did before your diagnosis. Some days, you may not feel up to it. Other days, you will want to give it all you've got. Only you can decide what's right for you. It will help to follow your physician's instructions and maintain a positive outlook, and to take an active role in your care. That's the basic (and best!) prescription.

While ulcerative colitis is a serious chronic disease, it is not considered a fatal illness. Most people with the illness may continue to lead useful and productive lives, even though they may be hospitalized from time to time, or need to take medications. In between flare-ups of the disease, many individuals feel well and may be relatively free of symptoms. But again, everyone is different, and it is up to you and your physician to find the treatment that works best for you.

Even though there is no cure at this time, CCFA's research and education programs already have improved the health and quality of life of people with ulcerative colitis.

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What is heartburn or GERD?

Gastroesophageal reflux is a physical condition in which acid from the stomach flows backward up into the esophagus. People will experience heartburn symptoms when excessive amounts of acid reflux into the esophagus. Many describe heartburn as a feeling of burning discomfort, localized behind the breastbone, that moves up toward the neck and throat. Some even experience the bitter or sour taste of the acid in the back of the throat. The burning and pressure symptoms of heartburn can last for several hours and often worsen after eating food. All of us may have occasional heartburn. However, frequent heartburn (two or more times a week), food sticking, blood or weight loss may be associated with a more severe problem known as gastroesophageal reflux disease or GERD.

What causes heartburn and GERD?

To understand gastroesophageal reflux disease or GERD, it is first necessary to understand what causes heartburn. Most people will experience heartburn if the lining of the esophagus comes in contact with too much stomach juice for too long a period of time. This stomach juice consists of acid, digestive enzymes, and other injurious materials. The prolonged contact of acidic stomach juice with the esophageal lining injures the esophagus and produces a burning discomfort.

Normally, a muscular valve at the lower end of the esophagus called the lower esophageal sphincter or "LES"-keeps the acid in the stomach and out of the esophagus. In gastroesophageal reflux disease or GERD, the LES relaxes too frequently which allows stomach acid to reflux, or flow backward into the esophagus.

What are the treatments for infrequent heartburn?

In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modification and proper use of over-the-counter medicines.

• Avoid foods and beverages which contribute to heartburn: chocolate, coffee, peppermint, greasy or spicy foods, tomato products and alcoholic beverages.
• Stop smoking. Tobacco inhibits saliva, which is the body's major buffer. Tobacco may also stimulate stomach acid production and relax the muscle between the esophagus and the stomach, permitting acid reflux to occur.
• Reduce weight if too heavy.
• Do not eat 2-3 hours before sleep.
• For infrequent episodes of heartburn, take an over-the-counter antacid or an H2 blocker, some of which are now available without a prescription.

Over-the-Counter Medications

Large numbers of Americans use over-the-counter antacids and other agents that are available without a prescription to treat minor GI discomforts and infrequent heartburn. Recently, the U.S. Food and Drug Administration (FDA) approved the non-prescription availability of important acid blockers, also called H2 blockers, for treatment of heartburn.

Over-the-counter medications have a significant role in providing relief from heartburn and other occasional GI discomforts. More frequent episodes of heartburn or acid indigestion may be a symptom of a more serious condition which could worsen if not treated. If you are using an over-the-counter product more than twice a week, you should consult a physician who can confirm a specific diagnosis and develop a treatment plan with you.

What are the complications of GERD?

When symptoms of heartburn are not controlled with modifications in lifestyle, and over-the-counter medicines are needed more often than twice a week, or symptoms remain unresolved on the medication you are taking, you should see your doctor.

When GERD is not treated, serious complications can occur, such as severe chest pain that can mimic a heart attack, esophageal stricture (a narrowing or obstruction of the esophagus), bleeding, or a pre-malignant change in the lining of the esophagus called Barrett's esophagus. Symptoms suggesting that serious damage may have already occurred include:

• Dysphagia: difficulty swallowing or a feeling that food is trapped behind the breast bone.
• Bleeding: vomiting blood, or having tarry, black bowel movements.
• Choking: sensation of acid refluxed into the windpipe causing shortness of breath, coughing, or hoarseness of the voice.
• Weight Loss

Stronger medicines which are only available with a prescription.

What are the treatment goals for GERD?

GERD is a problem which is symptomatic by day but in which much damage is done by night. Treatment should be designed to: 1) eliminate symptoms; 2) heal esophagitis; and 3) prevent the relapse of esophagitis or development of complications in patients with esophagitis. In many patients, GERD is a chronic, relapsing disease. Long term maintenance is the key to therapy.

All treatments are based on attempts to a) decrease the amount of acid that refluxes from the stomach back into the esophagus, or b) make the refluxed material less irritating to the lining of the esophagus.

What are the treatments for GERD?

Lifestyle Modification

In order to decrease the amount of gastric contents which reach the lower esophagus, certain simple guidelines should be followed:

• Raise the Head of the Bed. The simplest method is to use a 4" x 4" piece of wood to which two jar caps have been nailed an appropriate distance apart to receive the legs or casters at the upper end of the bed. Failure to use the jar caps inevitably results in the patient being jolted from sleep as the upper end of the bed rolls off the 4" x 4." Alternatively, one may use an under-mattress foam wedge to elevate the head about 6-10 inches. Pillows are not an effective alternative for elevating the head in preventing reflux.
• Change Eating and Sleeping Habits. Avoid lying down for two hours after eating. Do not eat for at least two hours before bedtime. This decreases the amount of stomach acid available for reflux.
• Avoid Tight Clothing. Reduce your weight if obesity contributes to the problem.
• Change Your Diet. Avoid foods and medications which lower LES tone (fats and chocolate) and foods which may irritate the damaged lining of the esophagus (citrus juice, tomato juice, and probably pepper).
• Curtail Habits Which Contribute to GERD. Both smoking and the use of alcoholic beverages lower LES pressure which contributes to acid reflux.

Medical Treatment of GERD

GERD has a physical cause, and frequently is not curtailed by these lifestyle factors alone. If you are using over-the-counter medications more than twice a week, or are still having symptoms on the prescription or other medicines you are taking, you need to see your doctor. If results are not forthcoming, medications may be used to neutralize acid, increase LES tone, or improve gastric emptying.

What are the medications often prescribed for GERD?

Prescription medications to treat GERD include drugs called H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs), which help to reduce the stomach acid which tends to worsen symptoms, and work to promote healing, as well as promotility agents which aid in the clearance of acid from the esophagus.

H2 Receptor Antagonists

Since the mid-1970s, acid suppression agents, known as H2 receptor antagonists or H2 blockers, have been used to treat GERD. H2 blockers improve the symptoms of heartburn and regurgitation and provide an excellent means of decreasing the flow of stomach acid to aid in the healing process of mild-to-moderate irritation of the esophagus, known as "esophagitis." Symptoms are eliminated in up to 50% of patients with twice a day prescription dosage of the H2 blockers. Healing of esophagitis may require higher dosing. These agents maintain remission in about 25% of patients.

H2 blockers are generally less expensive than proton pump inhibitors and can provide an adequate approach as the firstline treatment as well as maintenance agent in GERD for some patients. In mid-1995, the FDA approved availability of some H2 blockers without a prescription in dosage levels appropriate for treatment of mild, infrequent heartburn.

Proton Pump lnhibitors

Proton pump inhibitors (PPIs), have been found to heal erosive esophagitis (a serious form of GERD) more rapidly than H2 blockers. Proton pump inhibitors provide not only symptom relief, but also elimination of symptoms in most cases, even in those with esophageal ulcers. Studies have shown proton pump inhibitor therapy can provide complete endoscopic mucosal healing of esophagitis at 6 to 8 weeks in 75% to 100% of cases. Daily proton pump inhibitor treatment provides the best long-term maintenance therapy of esophagitis, particularly in keeping symptoms and the disease in remission for those patients with moderate to severe esophagitis, plus this form of treatment has been shown to retain remission for up to five years.

Promotility Agents

Promotility drugs are effective in the treatment of mild to moderate symptoms of GERD. These drugs increase lower esophageal sphincter pressure, which helps prevent acid reflux and improves the movement of food from the stomach. They decrease heartburn symptoms, especially at night, by improving the clearance of acid from the esophagus and stomach

.

Can surgery be an option when medical treatments for GERD fail?

Surgical measures to prevent reflux can be considered if other measures fail or complications occur such as bleeding, recurrent stricture, or metaplasia (abnormal transformation of cells lining the esophagus) which is progressive. The surgical technique improves the natural barrier between the stomach and the esophagus that prevents acid reflux from occurring. Consultation with both a gastroenterologist and a surgeon is recommended prior to such a decision.

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What is inflammatory bowel disease?

Inflammatory bowel disease (IBD) refers to two related but different diseases: ulcerative colitis and Crohn's disease. These diseases cause chronic inflammation of the intestinal tract, which leads to a variety of symptoms. The inflammation can also lead to involvement of organs other than the intestines. IBD is a lifelong disease with periods of active disease alternating with periods of disease control (remission). IBD is sometimes confused with but is different than irritable bowel syndrome.

There are more than 1 million people with IBD in the United States with new cases diagnosed at a rate of 10 cases per 100,000 people. These diseases account for 700,000 physician visits per year and 100,000 hospitalizations per year in the United States. Ulcerative colitis can be cured with surgery but Crohn's disease cannot be cured. There are good medical therapies available for both diseases.

Who gets IBD?

IBD is generally a disease of young people because it most commonly develops between the ages of 10 and 30. However, a second smaller peak of developing IBD is seen between ages of 50 and 60.

There are racial and ethnic differences in the risk for developing IBD. Whites have a higher risk of developing IBD than non-whites. Similarly persons of Jewish ethnic background have a higher risk of developing IBD than those of non-Jewish background. In addition, among persons of Jewish ethnic background, the risk of IBD is higher for those of Ashkenazi Jewish descent compared to those of Sephardic Jewish descent.

What causes IBD?

The exact cause of IBD is not known but is related to protective immune cells that are present in the lining of the intestines. This immune system normally turns on and off to fight harmful substances like bacteria and viruses that pass through intestines. In IBD it appears that there is an initial trigger such as an infection or something taken in from the diet or the surrounding environmental that activates the immune system. However, the difference in those who develop IBD is that the immune system does not turn off once this initial trigger is eliminated. This leads to uncontrolled inflammation and attack on normal intestinal cells. The exact contributions of such factors are poorly understood and are difficult to define.

The best-documented environmental factor associated with IBD is cigarette smoking. Smokers are more likely to develop Crohn's disease than non-smokers. In addition, among those with Crohn's disease, smokers tend to have a more aggressive form of disease than non-smokers. Interestingly, the opposite is true for ulcerative colitis, that is, smokers are less likely to develop ulcerative colitis and tend to have a less severe course than non-smokers. The exact effects of cigarette smoking on the intestinal tract and risk for IBD are not well understood.

Finally, there is a genetic (hereditary) risk of developing IBD: 10-20% of IBD patients have one or more other family members affected with IBD. The occurrence of Crohn's disease is increased among relatives of Crohn's disease patients while the occurrence of ulcerative colitis is increased among relatives of ulcerative colitis patients. Both diseases can also exist in the same family with one family member having ulcerative colitis and another family member having Crohn's disease.

What are the differences between ulcerative colitis and Crohn's disease?

In ulcerative colitis, inflammation occurs only in the large intestine (colon) and is limited to the inner lining of the intestinal wall. The inflammation nearly always starts in the lowest part of the colon (the rectum) and extends upwards in continuous pattern. The length of colon that is involved varies between patients. In some patients, the inflammation is confined to the rectum only, in others it extends part of the way up the colon, and in others it involves the entire colon. Because the inflammation is confined to the colon, ulcerative colitis is curable by surgical removal of the colon. Crohn's disease, on the other hand, can involve any part of the intestinal tract from the mouth to the anal area. The most commonly involved areas are the lower part of the small intestine (the ileum) and the colon. Unlike ulcerative colitis, "skip" lesions can be found in Crohn's disease- this means that there can be normal areas in between areas that are inflamed. In addition all layers of the intestinal wall can be involved which may lead to particular complications that are seen only in Crohn's disease including: 1. fistula- an abnormal connection between the intestine and other organs, 2. abscess- collection of pus, 3. stricture- an area of narrowing that can lead to intestinal blockage. Because Crohn's disease usually comes back after surgery, it is generally not curable.

What are the symptoms of IBD?

The most common symptoms seen in both ulcerative colitis and Crohn's disease are diarrhea, rectal bleeding, urgency to have bowel movements, abdominal cramps and pain, fever, and weight loss. In Crohn's disease, symptoms can result from complications of the disease. Fistulas can lead to openings in the skin and around the anal region that drain stool and infected material. An abscess can lead to symptoms of severe pain and fever. A stricture can lead to intestinal blockage with symptoms of filling up quickly after meals, nausea and vomiting.

In addition, organs other than the intestinal tract can be involved by the underlying inflammation of IBD. These organs include the eyes (symptoms of red eye or blurred vision), the mouth (symptoms of sores in the mouth), joints (symptoms of joint pain with or without joint swelling and redness), and skin (symptoms of rashes or skin ulcers most commonly involving the lower legs).

How is the diagnosis of IBD made?

The initial part of the evaluation of a patient with the above symptoms includes a full medical history and physical examination. Doctors collect information such as the details and duration of symptoms, whether there is a family history of IBD, and cigarette smoking history. Blood tests can help detect changes such as low red blood cell counts (anemia), high white blood cell counts (indicate inflammation or infection), and low nutrient levels. Stool samples are sometimes checked to rule out intestinal infections, which can lead to similar symptoms as those of IBD

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The most direct way to make a firm diagnosis of IBD involves the use of endoscopy (putting a tube with a light at the end into the intestines), biopsies, or special X-rays. With endoscopy, the lining of the intestinal tract can be directly seen by the doctor performing the procedure and biopsies can be obtained. Typical changes of IBD can be detected by endoscopy and by examining biopsies under a microscope. Barium X-rays known as small bowel series are also commonly used to diagnose IBD. Patients drink barium (a white fluid), which allows doctors to take X-ray pictures of the small intestine and to look for changes typical of IBD. This test is particularly helpful in evaluating the small intestine, which is the part of the intestinal tract that cannot be fully examined with endoscopes. Another type of X-ray that is sometimes done in patients with IBD is a CAT scan, which is used to look for the presence of an abscess in the abdomen of patients with Crohn's disease. Capsule endoscopy is a newer test in which a pill is swallowed and then travels through the small intestine taking pictures that are transmitted to a recorder and later viewed on a computer. Recent studies indicate that capsule endoscopy is more sensitive for Crohn's in the small intestine than x-rays, but the role of capsule endoscopy in Crohn's disease is not yet identified.

What medications can be used to treat IBD?

Because ulcerative colitis and Crohn's disease are chronic illnesses, they often require long-term treatment with medications. In general there are two main goals of medical therapy for IBD: 1. Bring active disease under control (into remission), and 2. Keep the disease in remission. Fortunately, there are several good medical therapies available to treat IBD and the most commonly used drugs will be reviewed below.

Aminosalicylates:

These types of medications are among the most commonly used to treat IBD and include agents such as sulfasalazine (Azulfidine®) and mesalamine (Asacol®, Pentasa®, Colazal®). The active component of these medications is a compound named 5-aminosalicylic acid, which works to reduce inflammation in the intestinal wall. These compounds are prepared differently and based on this release 5-aminosalicylic acid in different parts of the intestinal tract. All the above preparations come as pills taken by mouth but there are also suppository and enema forms of mesalamine that are applied directly into the rectum and used to treat patients with inflammation in the bottom part of the colon.

These medications work well for mild to moderate ulcerative colitis and Crohn's disease affecting the colon. They are not as effective for Crohn's inflammation of the small intestine or for more severe IBD. When effective, they work both to bring active disease under control and to maintain disease in remission. They are generally well tolerated with minimal side effects.

Steroids:

Steroids such as prednisone and methylprednisolone are commonly used to treat patients with both ulcerative colitis and Crohn's disease. These particular types of steroids are called glucocorticoids and work as anti-inflammatory agents. They are different from anabolic steroids, which are known for their use by body builders and athletes.

The main role of these medications in IBD is to bring the disease into remission. For patients whose disease seems to require repeated or chronic steroid courses, other medical treatment options described below are available and should be pursued (see discussion of side effects below). Most commonly these medications are given orally. However, in moderate to severe cases of IBD, patients are brought into the hospital and intravenous steroids are used to bring the disease under control. There are also enema and suppository preparations of steroids available.

There are multiple possible side effects from steroids most of which are more likely to develop with higher doses and longer duration of therapy. Early side effects can include mood changes, irritability, difficulty sleeping, increased appetite, and increased blood sugar levels. Side effects associated with long-term use include osteoporosis (weakening of the bones), cataracts, acne, development of a fatty hump at the base of the neck, and a rounded/swollen appearance to the face (moon facies). Although there are possible side effects from these types of steroids, they remain an important part of the medical management of inflammatory bowel disease. With appropriate dosing and tapering regimens, most patients tolerate steroids well.

More recently a new steroid preparation named budesonide (Entocort®) has been made available in the United States for treatment of Crohn's disease. This steroid is specifically designed to release in the intestines with very little of it reaching the bloodstream. Because of this, budesonide has less in terms of side effects when compared to conventional steroids. In its current formulation, this agent works mostly in treating inflammation in the bottom part of the small intestine (the ileum) and the right part of the colon.

6-Mercaptopurine and Azathioprine:

6-mercaptopurine (Purinethol®) and azathioprine (Imuran®) work to decrease the activity of the immune system, which then leads to reduced inflammation in the intestines. They are used both in ulcerative colitis and Crohn's disease to bring active disease under control and to maintain disease in remission. They are given orally as pills.

These agents may take a few weeks to months to take their full effect, so other medications such as steroids are sometimes needed on a short-term basis to keep disease under control when starting 6-mercaptopurine or azathioprine. These medications have less long-term side effects than steroids. Approximately 5-10% of patients cannot tolerate these medications due to side effects such as allergic reactions, pancreatitis (inflammation of the pancreas), and abnormal liver tests. Because these medications affect the immune system, patients have a higher risk of developing infections. Therefore, it is recommended that blood counts be monitored on a frequent and regular basis when on these medications.

Methotrexate:

Methotrexate is another medication that works to decrease the activity of the immune system. It is used in Crohn's disease both to bring disease into remission and to maintain remission. There have been some reports of methotrexate for treatment of ulcerative colitis but there are no controlled studies that have shown a benefit. Methotrexate can be given either as pills or as an injection under the skin or into the muscle, but the studies that have shown that it works in IBD have used the injection approach. A vitamin named folate (or folic acid) should be given with methotrexate to decrease some of the side effects. Potential side effects and risks include nausea, vomiting, infections, bone marrow suppression, liver inflammation, and rarely scarring in the lungs. Methotrexate is also known to cause birth defects and therefore should not be used in either males or females who are trying to have a baby.

Infliximab:

Infliximab (Remicade®) may be used in moderate to severe Crohn's disease. It is a medication that is given intravenously and works on reducing intestinal inflammation by blocking a part of the immune system know as TNF (tumor necrosis factor). A single infusion or a short series of three infusions have been shown to bring inflammation into remission and to allow closure of fistulas. The benefit may last approximately two months. However, recent studies have shown that repeated infusions of infliximab over a one-year period are generally well tolerated and can maintain remission. Side effects of this agent include infusion reactions, which are usually mild, and infections. Occasionally the infections are quite serious.

When is surgery indicated for IBD?

For ulcerative colitis, there are two main indications for surgery: 1. Lack of response or intolerance to medications, and 2. Precancerous or cancerous changes in the colon. Patients with ulcerative colitis have a higher risk of developing colon cancer so careful monitoring of the colon by colonoscopy is recommended in those who have had the disease for many years. As previously discussed, surgery allows for a cure in ulcerative colitis. However, removal of the colon used to mean that patients would have to have a permanent stoma (wearing an external bag to drain stool). Currently, a procedure known as the pouch procedure can be done in most patients with ulcerative colitis and this prevents the need for a permanent stoma. In this type of surgery, the colon is removed, a reservoir is created out of the lower part of the small intestine (the ileum), and the reservoir is connected to the anal region. For Crohn's disease, indications for surgery include lack of response or intolerance to medications and complications of Crohn's such as a fistula, an abscess, or a stricture. Up to 70% of patients with Crohn's disease require surgery at some point in the course of their disease. The risk of having Crohn's disease return after surgery is approximately 70-85% within 10-15 years after surgery. There is growing evidence that medications can be used to decrease the risk of Crohn's returning following surgery.

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Liver Disease

The liver is the largest organ in the body. It is found high in the right upper abdomen, behind the ribs. It is a very complex organ and has many functions. They include:

• Storing energy in the form of sugar (glucose)
• Storing vitamins, iron, and other minerals
• Making proteins, including blood clotting factors, to keep the body healthy and help it grow
• Processing worn out red blood cells
• Making bile which is needed for food digestion
• Metabolizing or breaking down many medications and alcohol
• Killing germs that enter the body through the intestine

The liver shoulders a heavy work load for the body, and almost never complains. It even has a remarkable power to regenerate itself. Still, it should not be taken for granted. The liver is subject to illnesses that can lead to permanent damage. One example is autoimmune hepatitis, a condition in which the body fights against its own liver.

What is Hepatitis?

When cells in the body are injured by such things as chemicals or infection, the area that is wounded becomes inflamed. Hepatitis is inflammation of the liver, which in turn causes damage to individual liver cells. It is most often caused by viral infection. However, it can also be caused by alcohol, certain drugs, chemicals or poisons, or other diseases.

Hepatitis may be either acute or chronic. In acute hepatitis, the inflammation develops quickly and lasts only a short period of time. The patient usually recovers completely, but it can take up to several months. Occasionally, a person fails to recover fully, and the hepatitis becomes chronic. In other words, it continues at a smoldering pace. Chronic hepatitis can develop over a number of years without the patient ever having acute hepatitis or even feeling sick. As the liver repairs itself, fibrous tissue develops, much like a scar forms after a cut or injury to the skin heals. Advanced scarring of the liver is called cirrhosis. Over time, cirrhosis irreversibly damages the liver, eventually ending in liver failure.

What is Autoimmune Hepatitis?

The immune system consists of different types of white blood cells that help to fight infections. Some of these cells produce antibodies. Antibodies act as warriors. They defend the body by destroying bacteria, viruses and other foreign materials. There are different kinds of antibodies, each fighting against a specific foreign substance. Thus, the immune system protects the body against outside invasion by germs. But sometimes, the immune system mistakenly recognizes the body's own organs as foreign. It can develop antibodies against these organs. This can cause various illnesses, such as rheumatoid arthritis and lupus. These illnesses are called autoimmune disorders because the body is literally fighting against itself.

When the immune system attacks the liver in this way, it is called autoimmune hepatitis. Autoimmune hepatitis is not caused by a virus or bacteria, so it is not a contagious disease. Exactly what triggers the immune system against the liver is unknown. The inflammation is usually chronic, and without treatment it can cause serious injury to the liver.

Symptoms and Diagnosis

Autoimmune hepatitis occurs mainly in adolescent or young adult women (about 70% of the time). However, there have also been cases of older women and men developing the disease. Early symptoms are the same as those for most types of hepatitis: fatigue, abdominal discomfort, and aching joints. These early symptoms are sometimes mild and mistaken for other illnesses, such as the flu. So, it is wise for people with these symptoms to consult a physician. When autoimmune hepatitis progresses to severe cirrhosis, there may be jaundice (yellow coloring to the skin and eyes), marked swelling of the abdomen from fluid inside the abdomen, intestinal bleeding, or mental confusion.

The physician often suspects autoimmune hepatitis from the patient's medical history. For example, patients with other autoimmune diseases -- thyroiditis, ulcerative colitis, diabetes mellitus, vitiligo (a patchy loss of pigment in the skin), Sjogren's syndrome (a condition causing dry eyes and mouth) -- are more likely to have autoimmune hepatitis. A definite diagnosis of autoimmune hepatitis is obtained with blood testing. Two antibodies that may develop in the blood are the ANA (antinuclear antibody) and the SMA (smooth muscle antibody). Also, a certain type of blood protein called gamma globulin is frequently elevated. A liver biopsy is always needed to determine how much inflammation and scarring has developed. This exam is performed under local anesthesia. A slender needle is inserted through the right lower chest to extract a small piece of liver tissue. The tissue is then examined under a microscope. This information allows the physician to tailor the treatment to each individual patient

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Treatment

The treatment of autoimmune hepatitis is aimed at curbing the autoimmune response, and therefore the damage to liver cells. It is most effective when begun at an early stage of the disease. In most cases, the initial treatment is with a cortisone drug, usually prednisone (trade names: Deltasone, Orasone). Sometimes a second drug, such as Imuran, may be added. The medication is taken daily, usually for at least a year. The physician may attempt to taper and stop treatment if the patient is doing well. However, a relapse often occurs, and the medication then must be restarted and taken indefinitely. There may be side effects with prednisone, such as swelling of the face, retention of fluid, and weight gain. Long-term treatment with these drugs may also cause loss of bone. This can lead to osteoporosis, or even severe damage to joints such as the shoulder and knee. Therefore, the physician uses the lowest dosage possible to decrease symptoms, improve liver tests, and slow liver damage.

Unfortunately, a few patients do not respond well to treatment, especially if the disease is diagnosed late and cirrhosis is well advanced. When the patient no longer responds to treatment with medication and liver damage is severe, a liver transplant is considered.

Liver Transplantation

Liver transplantation is now an accepted form of treatment for chronic, severe liver disease. Advances in surgical techniques and the use of new drugs to suppress rejection have dramatically improved the success rate of transplantation. The outcome for patients with autoimmune hepatitis is excellent. Survival rates for this condition at transplant centers are well over 90 percent, with a good quality of life after recovery.

Summary

Autoimmune hepatitis is inflammation of the liver. The inflammation is a result of the immune system developing antibodies against the liver. It is not a contagious disease, but it is a serious chronic disease that can lead to irreversible cirrhosis, and eventually to liver failure. However, the outlook for patients with autoimmune hepatitis is generally very favorable. With early diagnosis, drug treatment to prevent serious liver damage is effective in most patients. For those few patients who do not respond to other treatment, successful liver transplantation is now a standard form of therapy when liver damage is severe.

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What is ERCP?

Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized technique used to study the ducts of the gallbladder, pancreas and liver. Ducts are drainage routes; the drainage channels from the liver are called bile or biliary ducts. If your doctor has recommended an ERCP, this brochure will give you a basic understanding of the procedure - how it's performed, how it can help, and what side effects you might experience. It can't answer all of your questions, since a lot depends on the individual patient and the doctor. Please ask you doctor about anything you don't understand.

During ERCP, your doctor will pass an endoscope through your mouth, esophagus and stomach into the duodenum (first part of the small intestine). An endoscope is a thin, flexible tube that lets your doctor see inside your bowels. After your doctor sees the common opening to ducts from the liver and pancreas, your doctor will pass a narrow plastic tube called a catheter through the endoscope and into the ducts. Your doctor will inject a contrast material (dye) into the pancreatic or biliary ducts and will take X-rays.

What preparation is required?

You should fast for at least six hours (and preferably overnight) before the procedure to make sure you have an empty stomach, which is necessary for the best examination. Your doctor will give you precise instructions about how to prepare. You should talk to your doctor about medications you take regularly and any allergies you have to medications, or intravenous contrast material. Although an allergy doesn't prevent you from having ERCP, it's important to discuss it with your doctor prior to the procedure.

Also, be sure to tell your doctor if you have heart or lung conditions, or other major diseases.

What can I expect during ERCP?

Your doctor might apply a local anesthetic to your throat or give you a sedative to make you more comfortable. Some patients also receive antibiotics before the procedure. You will lie on your left side on an X-ray table. Your doctor will pass the endoscope through your mouth, esophagus, stomach and into the duodenum. The instrument does not interfere with breathing, but you might feel a bloating sensation because of the air introduced through the instrument.

What are possible complications of ERCP?

ERCP is a well-tolerated procedure when performed by doctors who are specially trained and experienced in the technique. Although complications requiring hospitalization can occur, they are uncommon. Complications can include pancreatitis (an inflammation or infection of the pancreas), infections, bowel perforation and bleeding. Some patients can have an adverse reaction to the sedative used. Sometimes the procedure cannot be completed for technical reasons.

Risks vary, depending on why the test is performed, what is found during the procedure, what therapeutic intervention is undertaken, and whether a patient has major medical problems. Patients undergoing therapeutic ERCP, such as for stone removal, face a higher risk of complications than patients undergoing diagnostic ERCP. Your doctor will discuss your likelihood of complications before you undergo the test.

What can I expect after ERCP?

If you have ERCP as an outpatient, you will be observed for complications until most of the effects of the medications have worn off. You might experience bloating or pass gas because of the air introduced during the examination. You can resume your usual diet unless you are instructed otherwise.

Someone must accompany you home from the procedure because of the sedatives used during the examination. Even if you feel alert after the procedure, the sedatives can affect your judgment and reflexes for the rest of the day.

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What is upper endoscopy?

Upper endoscopy lets your doctor examine the lining of the upper part of your gastrointestinal tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine). Your doctor will use a thin, flexible tube called an endoscope, which has its own lens and light source, and will view the images on a video monitor. You might hear your doctor or other medical staff refer to upper endoscopy as upper GI endoscopy, esophagogastroduodenoscopy (EGD) or panendoscopy. If your doctor has recommended upper endoscopy, this brochure will give you a basic understanding of the procedure - how it's performed, how it can help, and what side effects you might experience. It can't answer all of your questions, since a lot depends on the individual patient and the doctor. Please ask your doctor about anything you don't understand.

Why is upper endoscopy done?

Upper endoscopy helps your doctor evaluate symptoms of persistent upper abdominal pain, nausea, vomiting or difficulty swallowing. It's an excellent test for finding the cause of bleeding from the upper gastrointestinal tract. It's also more accurate than X-ray films for detecting inflammation, ulcers and tumors of the esophagus, stomach and duodenum.

Your doctor might use upper endoscopy to obtain a biopsy (small tissue samples). A biopsy helps your doctor distinguish between benign and malignant (cancerous) tissues. Remember, biopsies are taken for many reasons, and your doctor might order one even if he or she does not suspect cancer. For example, your doctor might use a biopsy to test for Helicobacter pylori, bacterium that causes ulcers. Your doctor might also use upper endoscopy to perform a cytology test, where he or she will introduce a small brush to collect cells for analysis.

Upper endoscopy is also used to treat conditions of the upper gastrointestinal tract. Your doctor can pass instruments through the endoscope to directly treat many abnormalities with little or no discomfort. For example, your doctor might stretch a narrowed area, remove polyps (usually benign growths) or treat bleeding.

How should I prepare for the procedure?

An empty stomach allows for the best and safest examination, so you should have nothing to eat or drink, including water, for approximately six hours before the examination. Your doctor will tell you when to start fasting.

Tell your doctor in advance about any medications you take; you might need to adjust your usual dose for the examination. Discuss any allergies to medications as well as medical conditions, such as heart or lung disease.

Also, alert your doctor if you require antibiotics prior to undergoing dental procedures, because you might need antibiotics prior to upper endoscopy as well.

What can I expect during upper endoscopy?

Your doctor might start by spraying your throat with a local anesthetic or by giving you a sedative to help you relax. You'll then lie on your side, and your doctor will pass the endoscope through your mouth and into the esophagus, stomach and duodenum. The endoscope doesn't interfere with your breathing, Most patients consider the test only slightly uncomfortable, and many patients fall asleep during the procedure.

What happens after upper endoscopy?

You will be monitored until most of the effects of the medication have worn off. Your throat might be a little sore, and you might feel bloated because of the air introduced into your stomach during the test. You will be able to eat after you leave unless your doctor instructs you otherwise.

Your doctor generally can tell you your test results on the day of the procedure; however, the results of some tests might take several days.

If you received sedatives, you won't be allowed to drive after the procedure even though you might not feel tired. You should arrange for someone to accompany you home because the sedatives might affect your judgment and reflexes for the rest of the day.

What are the possible complications of upper endoscopy?

Although complications can occur, they are rare when doctors who are specially trained and experienced in this procedure perform the test. Bleeding can occur at a biopsy site or where a polyp was removed, but it's usually minimal and rarely requires follow-up. Other potential risks include a reaction to the sedative used, complications from heart or lung diseases, and perforation (a tear in the gastrointestinal tract lining). It's important to recognize early signs of possible complications. If you have a fever after the test, trouble swallowing or increasing throat, chest or abdominal pain, tell your doctor immediately.

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What is a colonoscopy?

A test to look inside the entire large intestine. The doctor uses a flexible tube that contains a light and tiny video camera. The device is called a colonoscope.

A colonoscope is a long, thin, flexible, tube-like instrument that the doctor uses to visually inspect the lining of the colon. The scope bends, so the doctor can move it around the curves of your colon. The scope also blows air into your colon, which inflates the colon and helps the physician see better. Color photographs are usually taken, and polyps can be removed by biopsy or using a wire snare that cuts, cauterizes and removes the polyp.

Understanding colonoscopy?

Colonoscopy is a procedure which enables the gastroenterologist to directly image and examine the entire colon. It is effective in the diagnosis and/or evaluation of various GI disorders (e.g. colon polyps, colon cancer, diverticulosis, inflammatory bowel disease, bleeding, change in bowel habits, abdominal pain, obstruction and abnormal x-rays or CT scans) as well as in providing therapy (for example, removal of polyps or control of bleeding). It is also used for screening for colon cancer. A key advantage of this technique is that it allows both imaging of abnormal findings and also therapy or removal of these lesions during the same examination. This procedure is particularly helpful for identification and removal of precancerous polyps.

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What is a polyp?

A polyp is a protrusion from the lining of the large intestine, or colon, caused by an abnormal growth of cells. It may be small raised bumps, look like a mushroom, or lie flat like a piece of shag rug carpet.

What are the symptoms of polyps?

Most polyps cause no symptoms. Sometimes they bleed easily, and the blood can be seen mixed with the stool or on the surface.

A polyp may also secrete clear mucous which is passed with the stool. Very rarely, a polyp can cause a partial or complete blockage of the bowel which leads to unexpected constipation or diarrhea with abdominal pain, bloating and in severe cases, vomiting.

How do you treat a polyp?

When polyps are detected, they can be removed painlessly during your colonoscopy, although occasionally for large polyps an operation is required. When using a colonoscope, a wire loop or "snare" is maneuvered around the polyp, tightened and the polyp is cut free and cauterized from the bowel wall using a small electric current. Small polyps may be removed with biopsy forceps that remove a small "nip" of tissue.

What happens after removal of a polyp?

It will be examined by a pathologist using a microscope. The microscopic appearance will help decide whether the polyp has been removed completely and determine the kind of polyp.

What is the follow-up after polyp removal?

There are two main kinds of polyps, benign and pre-cancerous. Benign polyps (like "hyperplastic" or "juvenile") do not develop into cancer. If you have this kind of polyp, often no further treatment or follow up is necessary except for routine screening as scheduled.

However, there are polyps which do carry a risk of becoming cancerous or are cancerous. This kind of polyp is called an "adenoma". It has a risk of becoming a cancer over a ten to twelve year span. If an adenoma was present and was fully removed at colonoscopy no further treatment at this time is necessary. Even after complete removal of an adenoma there is a risk of developing new adenomas, so you will need repeated colonoscopies. We currently recommend a repeat colonoscopy after three to five years, and then every five years after removal of an adenomatous polyp.

Occasionally, the microscopic analysis of the polyp will suggest that there is a risk that the polyp was not completely removed, or had cancerous cells within it. A second colonoscopy or even an operation may then be needed to try to ensure that the abnormal tissue is removed completely.

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What is Crohn's Disease?

Crohn's disease is a chronic, recurrent inflammatory disease of the intestinal tract. The intestinal tract has four major parts: the esophagus, or food tube; the stomach, where food is churned and digested; the long, small bowel, where nutrients, calories, and vitamins are absorbed; and the colon and rectum, where water is absorbed and stool is stored. The two primary sites for Crohn's disease are the ileum, which is the last portion of the small bowel (ileitis, regional enteritis), and the colon (Crohn's colitis). The condition begins as small, microscopic nests of inflammation which persist and smolder. The lining of the bowel can then become ulcerated and the bowel wall thickened. Eventually, the bowel may become narrowed or obstructed and surgery would be needed.

What Causes Crohn's Disease?

There is now evidence of a genetic link as Crohn's frequently shows up in a family group. In addition, there is evidence that the normal bacteria that grow in the lower gut may, in some manner, act to promote inflammation. The body's immune system, which protects it against many different infections, is known to be a factor. There are still a number of unknowns about the cause of the disease. Fortunately, a great deal is known about the disease and especially its treatment.

Who Develops Crohn's Disease?

The condition occurs in both sexes and among all age groups, although it most frequently begins in young people. Jewish people are at increased risk of developing Crohn's, while African Americans are at decreased risk, which indicates the genetic link in this disease.

Symptoms

The symptoms of Crohn's disease depend on where in the intestinal tract the disorder appears. When the ileum (ileitis) is involved, recurrent pain may be experienced in the right lower abdomen. At times, the pain mimics acute appendicitis. When the colon is the site, diarrhea (sometimes bloody) may occur, along with fever and weight loss. Crohn's disease often affects the anal area where there may be a draining sinus tract called a fistula.

When the disease is active, fatigue and lethargy appear. In children and adolescents there may be difficulty gaining or maintaining weight.

Diagnosis

There is no one conclusive diagnostic test for Crohn's disease. The patient's medical history and physical exam are always helpful. Certain blood and stool tests are performed to arrive at a diagnosis. X-rays of the small intestine and colon (obtained through an upper GI series and barium enema) are usually required. In addition, a visual examination (sigmoidoscopy) of the lining of the rectum and lower bowel is usually necessary. A more thorough exam of the entire colon (colonoscopy) is often the best way of diagnosing the problem when the disease is in the colon.

Course and Complications

The disorder often remains quiet and easily controlled for long periods of time. Most people with Crohn's disease continue to pursue their goals in life, go to school, marry, have a family, and work with few limitations or inconveniences.

Some problems, outside the bowel, can occur. Arthritis, eye and skin problems, and -- in rare instances -- chronic liver conditions may develop. As noted, the disease can occur around the anal canal. Open sores called fissures can develop, which are often painful. A fistula can also form. This is a tiny channel that burrows from the rectum to the skin around the anus. In addition, when inflammation persists in the ileum or colon, narrowing and partial obstruction may occur. Surgery is usually required to treat this problem. When Crohn's disease has been present for many years there is an increased risk of cancer.

Treatment

Effective medical and surgical treatment is available for Crohn's disease. It is particularly important to maintain good nutrition and health with a balanced diet, adequate exercise, and a positive, upbeat attitude. Five types of medications are available to treat this disease:

Cortisone or Steroids: These powerful drugs provide highly effective results. A large dose is often used initially to bring the disorder under quick control when the disease is severe. The drug is then tapered to a low maintenance dose, perhaps taken just every other day. Hopefully the drug may eventually be stopped altogether. This medicine is administered by pill or enema. Prednisone is a common generic name.

Anti-inflammation drugs: sulfasalazine (Azulfidine), Dipentum, Asacol, Rowasa, and Pentasa belong to a group of drugs called the 5-aminosalicylates. These drugs are most useful in maintaining a remission, once the disease is brought under control. They are most effective when the disease is present in the colon. These are available in oral and enema preparations.

Immune System Suppressors: These medications suppress the body's immune system, which appears to be overly active and somehow aggravates the disease. The names of two of these commonly used medications are azathioprine (trade name: Imuran) and 6 MP (trade name: Purinethol). These drugs are particularly useful for long-term care. There are other potent immune-suppressing drugs that may be used in difficult cases.

Infliximab (trade name: Remicade): This drug is the first of a group of medications that blocks the body's inflammation response. It is given by intravenous infusion over several hours. These blocking antibody drugs are proving to be very effective in many patients with severe disease.

Antibiotics: Since there is frequently a bacterial infection along with Crohn's disease, antibiotics are often used to treat this problem. Two that are commonly used are ciprofloxacin (trade name: Cipro) and metronidazole (trade name: Flagyl). Diet and Emotions

There are no foods known to actually injure the bowel. However, during an acute phase of the disease, bulky foods, milk, and milk products may increase diarrhea and cramping. Generally, the patient is advised to eat a well-balanced diet, with adequate protein and calories. A multivitamin and iron supplement may be recommended by the physician.

Stress, anxiety, and extreme emotions may aggravate symptoms of the disorder, but are not believed to cause it or make it worse. Any chronic disease can produce a serious emotional reaction, which can usually be handled through discussion with the physician.

Surgery

Surgery is commonly needed at some time during the course of Crohn's disease. It may involve removing a portion of diseased bowel, or simply the draining of an abscess or fistula. In all cases, the guiding principle is to perform the least amount of surgery necessary to correct the problem. Surgery does not cure Crohn's disease.

Summary

Most people with Crohn's disease lead active lives with few restrictions. Although there is no known cure for the disorder, it can be managed with present treatments. For a few patients, the course of the disease can be more difficult and complicated, requiring extensive testing and therapy. Surgery sometimes is required. In all cases, follow-up care is essential to treat the disease and prevent or deal with complications that may arise.

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