ULCERATIVE COLITIS

What is ulcerative colitis (UC)?

Ulcerative colitis (UC) is an ongoing health problem that causes inflammation and bleeding sores called ulcers in the top layers of the large intestine (colon) and rectum. It most often occurs in the lower part of the colon and rectum, but may affect the whole colon. When UC only occurs in the rectum, it is called proctitis. Most people find out they have UC between the ages of 15 and 40 years.

Ulcerative colitis is a form of inflammatory bowel disease. There are two main types of inflammatory bowel disease: ulcerative colitis (UC) and Crohn's disease (CD). The diseases are very similar. The main difference between UC and CD is the area of the digestive tract they affect -- CD can occur along the entire digestive tract and spread deep into the bowel wall. In contrast, UC usually only affects the top layer of the large intestine (colon) and rectum.

What are the symptoms of ulcerative colitis (UC)?

The two most common symptoms of UC are diarrhea (often bloody) and crampy abdominal pain. Inflammation causes these symptoms. An inflamed bowel doesn't allow as much water to be absorbed into the blood. This makes the colon empty often in the form of diarrhea. Inflammation also causes bleeding ulcers. The ulcers typical of UC also can make pus and mucus.

Other common signs of UC include:

• nausea
• loss of appetite
• weight loss
• frequent fever

For most people, the symptoms of UC come and go. When they feel well, the UC is said to have gone into remission. When they feel sick, they are having a relapse or flare-up.

About half of the people with UC have only mild symptoms. For others, the symptoms of UC may be very uncomfortable. In severe cases, people can become malnourished and may need a special diet or to be fed fluids through a vein.

Can ulcerative colitis (UC) cause health problems in parts of the body other than the colon?

Yes. UC can cause a number of problems outside of the colon including:

• joint pain or arthritis,
• inflammation in the eye,
• liver and bile duct disease,
• skin rashes,
• anemia, and
• kidney stones.

No one knows why these health problems are common in people with UC. The immune system may trigger inflammation in other parts of the body. These problems are usually mild and go away when the colitis is treated.

Osteoporosis is also more common among people with UC. This may be because their diets don't contain enough calcium and vitamin D. Plus, UC can prevent the body from absorbing enough calcium. Corticosteroids, medicines used to treat UC, can also boost a person's risk of osteoporosis.

How is ulcerative colitis (UC) diagnosed?

If you suspect you have UC, talk to your doctor. She will use your health history, a physical exam, and many different tests to figure out if you have UC.
Tests used to diagnose UC include:

• Blood tests: A sample of blood is studied in a lab to find signs of inflammation and anemia.
• Stool sample: A sample of a bowel movement is tested for blood or infection.
• Barium Enema: The doctor injects fluid containing a substance called barium into the rectum. The barium allows the doctor to see the colon on an x-ray. Using this x-ray, doctors can "see" if there are any ulcers or other signs of UC.
• Flexible Sigmoidoscopy: The doctor puts a thin tube with a light into the rectum. It allows the doctor to check the rectum and the lower part of the colon for signs of UC.
• Colonoscopy: The doctor puts a thin tube with a light through the rectum and into the colon. This allows her to "see" the lining of the whole colon and check for signs of UC.

Is inflammatory bowel disease (IBD) the same thing as Irritable Bowel Syndrome (IBS)?

No. Inflammatory bowel disease, including UC and CD, is different from irritable bowel syndrome (IBS). Unlike IBD, IBS does not cause inflammation, ulcers or other damage to the bowel. Instead, IBS is a much less serious problem called a functional disorder. This means that the digestive system looks normal but doesn't work as it should. Symptoms of IBS may include crampy pain, bloating, gas, mucus in the stool, diarrhea and constipation. IBS has also been called spastic colon or spastic bowel.

How is inflammatory bowel disease (IBD) treated?

Doctors treat IBD in order to improve symptoms and decrease the amount of inflammation. Treatment for IBD may include:

• dietary changes
• lifestyle changes like stress reduction
• medicine
• surgery

The recommended treatment for IBD depends on:

• the type and severity of symptoms
• location of disease
• complications

People who have mild or no symptoms may not need treatment at all. But most people with IBD take medicine to control their symptoms. And many people with severe IBD need surgery to control the disease.

Surgery for Ulcerative Colitis

About 20 to 40 percent of people with UC need surgery at some point in their lives. Doctors may suggest surgery for people with UC in the following cases:

• ongoing, severe symptoms
• symptoms that do not get better with medicine
• precancerous changes in the colon
• high risk for colon cancer

Some people with UC need emergency surgery. Doctors often perform emergency surgery to fix the following problems:

• severe bleeding
• a hole (perforation) in the colon
• build up of gas and bacteria inside the colon called toxic megacolon

Surgery that removes the entire large intestine can completely cure UC. Even though surgery can be risky, studies show it greatly improves the lives of people with UC. Surgery used to be considered a last resort for people with UC. But now some doctors suggest surgery for people in the earlier stages of the disease.

Types of surgery for UC include:

Proctocolectomy: The doctor removes the entire large intestine including the colon, rectum and anus during this surgery. This is the most commonly recommended surgery for people with UC. It can be performed with an iIeostomy or ileoanal pouch anal anastomosis (IPAA).

Ileal pouch anal anastomosis (IPAA): In this procedure, the very end of the small intestine (ileum) is made into a pouch. It is then connected to the anus. In this way, waste can once again leave the body through the anus. People who have IPAA do not need to wear a pouch outside their bodies. But people who have IPAA have more complications than those who have an ileostomy. The most common problems with this surgery are blockages in the intestine and pouch inflammation or infection.

SURGERY FOR GASTRIC REFLUX

Surgery for gastric reflux disease is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.

Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for gastro-oesophageal reflux (GERD). The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.

This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera.

Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.

In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn:

- The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle.

- The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle.

The long-term effects of these two procedures are unknown.

REHYDRATION FLUIDS (ELECTROLYTE SOLUTIONS)

Oral rehydration therapy (also called oral rehydration salts or oral electrolyte solutions) is a simple, cheap, and effective treatment for diarrhoea-related dehydration. It consists of a solution of salts and other substances such as glucose, sucrose, citrates or molasses, which is administered orally.

Oral rehydration therapy is widely considered to be the best method for combating the dehydration caused by diarrhea and/or vomiting.

Various diseases cause damage to the intestine, allowing water to flow from the blood into the intestine, depleting the body of both fluid and electrolytes. This may be

* a direct destruction of the cells lining the intestine (the enterocytes),
* a toxic effect causing them to lose their microvilli (the brush border),
* a toxic effect (by an enterotoxin) causing them to secrete water.

In the human body, water is absorbed and secreted passively; it follows the movement of salts, based on a principle called osmosis. So, in many cases, diarrhea is caused by intestine cells secreting salts (primarily sodium) and water following passively along.

Simply drinking water is ineffective for 2 reasons: (1) the large intestine is usually secreting instead of absorbing water, and (2) electrolyte losses also need compensating. As such, the standard treatment is to restore fluids intravenously with water and salts. This requires trained personnel and materials which are not sufficiently available in the Third World.

However, it was discovered that the body can absorb a simple solution containing both sugar and salt. The dry ingredients can be mixed and packaged, and then the solution can be prepared and delivered by people with minimal training. One diarrhea mechanism (like in cholera, which is a very dangerous form of profuse diarrhea), is an enterotoxin interfering with enterocyte cAMP and G-proteins. However, water can still be absorbed by cAMP-independent mechanisms, like the SGLT-transporter (sodium and glucose transporter, of which two types exist). This is achieved by combining salts and glucose.

Oral rehydration can be accomplished by drinking frequent small amounts of an oral rehydration salt solution.

It is important to rehydrate with solutions that contain electrolytes, especially sodium and potassium, so that electrolyte disturbances may be avoided. Sugar is important to improve absorption of electrolytes and water, but if too much is present in ORS solutions, diarrhea can worsen. Oral rehydration does not stop diarrhea, but keeps the body hydrated and healthy until the diarrhea passes.

Often sodium bicarbonate or sodium citrate is also added to formulas in an attempt to revert metabolic acidosis.

Adults and children with dehydration who are not vomiting can be allowed to drink these solutions in addition to their normal diet. People who are vomiting should be fed small frequent amounts of ORS solution until dehydration is resolved. Once they are rehydrated, they may resume eating normal foods when nausea passes.

Vomiting itself does not mean that oral rehydration cannot be given. As long as more fluid enters than exits, rehydration will be accomplished. It is only when the volume of fluid and electrolyte loss in vomit and stool exceeds what is taken in that dehydration will continue.

AN OVERVIEW OF REFLUX OESOPHAGITIS

Reflux oesophagitis, also known as gastrooesophageal reflux disease (GERD), occurs when the lower oesophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the oesophagus. The LES is a ring of muscle at the bottom of the oesophagus that acts like a valve between the oesophagus and stomach. The oesophagus carries food from the mouth to the stomach.

When refluxed stomach acid touches the lining of the oesophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion.

Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.

Anyone, including infants, children, and pregnant women, can have GERD.

What are the symptoms of GERD?

The main symptoms are persistent heartburn and acid regurgitation. Some people have GERD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GERD can also cause a dry cough and bad breath.

GERD in Children

Studies* show that GERD is common and may be overlooked in infants and children. It can cause repeated vomiting, coughing, and other respiratory problems. Children's immature digestive systems are usually to blame, and most infants grow out of GERD by the time they are 1 year old. Still, you should talk to your child's doctor if the problem occurs regularly and causes discomfort. Your doctor may recommend simple strategies for avoiding reflux, like burping the infant several times during feeding or keeping the infant in an upright position for 30 minutes after feeding. If your child is older, the doctor may recommend avoiding

• sodas that contain caffeine
• chocolate and peppermint
• spicy foods like pizza
• acidic foods like oranges and tomatoes
• fried and fatty foods

Avoiding food 2 to 3 hours before bed may also help. The doctor may recommend that the child sleep with head raised. If these changes do not work, the doctor may prescribe medicine for your child. In rare cases, a child may need surgery.

*Jung AD. Gastrooesophageal reflux in infants and children. American Family Physician. 2001;64(11):1853–1860.

What causes GERD?

No one knows why people get GERD. A hiatal hernia may contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the oesophagus. When a hiatal hernia is present, it is easier for the acid to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.

Other factors that may contribute to GERD include

• alcohol use
• overweight
• pregnancy
• smoking

Also, certain foods can be associated with reflux events, including

• citrus fruits
• chocolate
• drinks with caffeine
• fatty and fried foods
• garlic and onions
• mint flavorings
• spicy foods
• tomato-based foods, like spaghetti sauce, chili, and pizza

How is GERD treated?

If you have had heartburn or any of the other symptoms for a while, you should see your doctor. You may want to visit an internist, a doctor who specializes in internal medicine, or a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on how severe your GERD is, treatment may involve one or more of the following lifestyle changes and medications or surgery.

Lifestyle Changes

• If you smoke, stop.
  
  
• Do not drink alcohol.
  
  
• Lose weight if needed.
  
  
• Eat small meals.
  
  
• Wear loose-fitting clothes.
  
  
• Avoid lying down for 3 hours after a meal.
  
  
• Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts—just using extra pillows will not help.

Medications

Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production or help the muscles that empty your stomach.

Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and Riopan, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts—magnesium, calcium, and aluminum—with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhoea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.

Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.

Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. These drugs may help those who have no damage to the oesophagus.

H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.

Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are all available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.

Another group of drugs, prokinetics, helps strengthen the sphincter and makes the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent side effects that limit their usefulness.

Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD.

What if symptoms persist?

If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.

• A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the oesophagus. With this test, you drink a solution and then x rays are taken. Mild irritation will not appear on this test, although narrowing of the oesophagus—called stricture—ulcers, hiatal hernia, and other problems will.
  
  
• Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the oesophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the oesophagus, usually no other tests are needed to confirm GERD.
  
  The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found.
  
  
• In an ambulatory pH monitoring examination, the doctor puts a tiny tube into the oesophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid comes up into your oesophagus. This test is useful in people with GERD symptoms but no oesophageal damage. The procedure is also helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.
  

Surgery

Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.

Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for GERD. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.

This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.

In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown.

Implant

Recently the FDA approved an implant that may help people with GERD who wish to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the LES to keep stomach acid from flowing into the oesophagus. It is injected during endoscopy. The implant is approved for people who have GERD and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown.

What are the long-term complications of GERD?

Sometimes GERD can cause serious complications. Inflammation of the oesophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the oesophagus and make swallowing difficult. Some people develop Barrett's oesophagus, where cells in the oesophageal lining take on an abnormal shape and colour, which over time can lead to cancer.

Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD.

Points to Remember

• Heartburn, also called acid indigestion, is the most common symptom of GERD. Anyone experiencing heartburn twice a week or more may have GERD.
  
  
• You can have GERD without having heartburn. Your symptoms could be excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, burning in the mouth, or pain in the chest.
  
  
• In infants and children, GERD may cause repeated vomiting, coughing, and other respiratory problems. Most babies grow out of GERD by their first birthday.
  
  
• If you have been using antacids for more than 2 weeks, it is time to see a doctor. Most doctors can treat GERD. Or you may want to visit an internist—a doctor who specializes in internal medicine—or a gastroenterologist—a doctor who treats diseases of the stomach and intestines.
  
  
• Doctors usually recommend lifestyle and dietary changes to relieve heartburn. Many people with GERD also need medication. Surgery may be an option.

PROCTALGIA FUGAX

The term Proctalgia fugax refers to fleeting anorectal pain. It often occurs in the middle of the night and can last a variable amount of time; generally from a few seconds to 30 minutes. Many sufferers encounter it less than 6 times a year.

The pain can sometimes accompany the urge to defaecate (without success) or be associated with an erection (in males).

There is no known cause for proctalgia fugax, but it is thought to be related to a muscle spasm of the rectum. There is also no known cure.

There are remedies which range from warm baths (if the pain lasts long enough to draw a bath), relaxation techniques, and gentle massage of the anus. It has been suggested that salbutamol may shorten the duration of attacks, although its effectiveness in this capacity remains unproven.

Sedatives and antispasmodic drugs have been used to obtain pain relief.

After the onset of an episode, the most comforting measure to combat the pain is often to attempt defaecation for as long as the pain lasts, even if defaecation will not occur.

PEPTIC ULCER

What is a peptic ulcer?

A peptic ulcer is a sore on the lining of the stomach or duodenum, which is the beginning of the small intestine. Peptic ulcers are common: One in 10 Americans develops an ulcer at some time in his or her life. One cause of peptic ulcer is bacterial infection, but some ulcers are caused by long-term use of nonsteroidal anti-inflammatory agents (NSAIDs), like aspirin and ibuprofen. In a few cases, cancerous tumours in the stomach or pancreas can cause ulcers. Peptic ulcers are not caused by stress or eating spicy food, but these can make ulcers worse.

What is H. pylori?

Helicobacter pylori (H. pylori) is a type of bacteria. Researchers believe that H. pylori is responsible for the majority of peptic ulcers.

H. pylori infection is common in the United States: About 20 percent of people under 40 years old and half of those over 60 years have it. Most infected people, however, do not develop ulcers. Why H. pylori does not cause ulcers in every infected person is not known. Most likely, infection depends on characteristics of the infected person, the type of H. pylori, and other factors yet to be discovered.

Researchers are not certain how people contract H. pylori, but they think it may be through food or water.

Researchers have found H. pylori in the saliva of some infected people, so the bacteria may also spread through mouth-to-mouth contact such as kissing.

How does H. pylori cause a peptic ulcer?

H. pylori weakens the protective mucous coating of the stomach and duodenum, which allows acid to get through to the sensitive lining beneath. Both the acid and the bacteria irritate the lining and cause a sore, or ulcer.

H. pylori is able to survive in stomach acid because it secretes enzymes that neutralize the acid. This mechanism allows H. pylori to make its way to the "safe" area—the protective mucous lining. Once there, the bacterium's spiral shape helps it burrow through the lining.

What are the symptoms of an ulcer?

Abdominal discomfort is the most common symptom. This discomfort usually

• is a dull, gnawing ache
  
  
• comes and goes for several days or weeks
  
  
• occurs 2 to 3 hours after a meal
  
  
• occurs in the middle of the night (when the stomach is empty)
  
  
• is relieved by eating
  
  
• is relieved by antacid medications

Other symptoms include

• weight loss
  
  
• poor appetite
  
  
• bloating
  
  
• burping
  
  
• nausea
  
  
• vomiting

Some people experience only very mild symptoms, or none at all.

Emergency Symptoms If you have any of these symptoms, call your doctor right away: sharp, sudden, persistent stomach pain bloody or black stools bloody vomit or vomit that looks like coffee grounds They could be signs of a serious problem, such as perforation—when the ulcer burrows through the stomach or duodenal wall bleeding—when acid or the ulcer breaks a blood vessel obstruction—when the ulcer blocks the path of food trying to leave the stomach

How is an H. pylori-related ulcer diagnosed? Diagnosing an Ulcer

To see whether symptoms are caused by an ulcer, the doctor may do an upper gastrointestinal (GI) series or an endoscopy. An upper GI series is an x ray of the oesophagus, stomach, and duodenum. The patient drinks a chalky liquid called barium to make these organs and any ulcers show up more clearly on the x ray.

An endoscopy is an exam that uses an endoscope, a thin, lighted tube with a tiny camera on the end. The patient is lightly sedated, and the doctor carefully eases the endoscope into the mouth and down the throat to the stomach and duodenum. This allows the doctor to see the lining of the oesophagus, stomach, and duodenum. The doctor can use the endoscope to take photos of ulcers or remove a tiny piece of tissue to view under a microscope. This procedure is called a biopsy. If an ulcer is bleeding, the doctor can use the endoscope to inject drugs that promote clotting or to guide a heat probe that cauterizes the ulcer.

Diagnosing H. pylori

If an ulcer is found, the doctor will test the patient for H. pylori. This test is important because treatment for an ulcer caused by H. pylori is different from that for an ulcer caused by NSAIDs.

H. pylori is diagnosed through blood, breath, stool, and tissue tests. Blood tests are most common. They detect antibodies to H. pylori bacteria. Blood is taken at the doctor's office through a finger stick.

Urea breath tests are an effective diagnostic method for H. pylori. They are also used after treatment to see whether it worked. In the doctor's office, the patient drinks a urea solution that contains a special carbon atom. If H. pylori is present, it breaks down the urea, releasing the carbon. The blood carries the carbon to the lungs, where the patient exhales it. The breath test is 96 percent to 98 percent accurate.

Stool tests may be used to detect H. pylori infection in the patient's faecal matter. Studies have shown that this test, called the Helicobacter pylori stool antigen (HpSA) test, is accurate for diagnosing H. pylori.

Tissue tests are usually done using the biopsy sample that is removed with the endoscope. There are three types:

• The rapid urease test detects the enzyme urease, which is produced by H. pylori.
  
  
• A histology test allows the doctor to find and examine the actual bacteria.
  
  
• A culture test involves allowing H. pylori to grow in the tissue sample.

In diagnosing H. pylori, blood, breath, and stool tests are often done before tissue tests because they are less invasive. However, blood tests are not used to detect H. pylori following treatment because a patient's blood can show positive results even after H. pylori has been eliminated.

How are H. pylori peptic ulcers treated?

Drugs Used to Treat H. pylori Peptic Ulcers Antibiotics: metronidazole, tetracycline, clarithromycin, amoxicillin H2 blockers: cimetidine, ranitidine, famotidine, nizatidine

Proton pump inhibitors: omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprozole Stomach-lining protector: bismuth subsalicylate

H. pylori peptic ulcers are treated with drugs that kill the bacteria, reduce stomach acid, and protect the stomach lining. Antibiotics are used to kill the bacteria. Two types of acid-suppressing drugs might be used: H2 blockers and proton pump inhibitors.H2 blockers work by blocking histamine, which stimulates acid secretion. They help reduce ulcer pain after a few weeks. Proton pump inhibitors suppress acid production by halting the mechanism that pumps the acid into the stomach. H2 blockers and proton pump inhibitors have been prescribed alone for years as treatments for ulcers. But used alone, these drugs do not eradicate H. pylori and therefore do not cure H. pylori-related ulcers. Bismuth subsalicylate, a component of Pepto-Bismol, is used to protect the stomach lining from acid. It also kills H. pylori. Treatment usually involves a combination of antibiotics, acid suppressors, and stomach protectors. Antibiotic regimens recommended for patients may differ across regions of the world because different areas have begun to show resistance to particular antibiotics.The use of only one medication to treat H. pylori is not recommended. At this time, the most proven effective treatment is a 2-week course of treatment called triple therapy. It involves taking two antibiotics to kill the bacteria and either an acid suppressor or stomach-lining shield. Two-week triple therapy reduces ulcer symptoms, kills the bacteria, and prevents ulcer recurrence in more than 90 percent of patients.Unfortunately, patients may find triple therapy complicated because it involves taking as many as 20 pills a day. Also, the antibiotics used in triple therapy may cause mild side effects such as nausea, vomiting, diarrhoea, dark stools, metallic taste in the mouth, dizziness, headache, and yeast infections in women. (Most side effects can be treated with medication withdrawal.) Nevertheless, recent studies show that 2 weeks of triple therapy is ideal.Early results of studies in other countries suggest that 1 week of triple therapy may be as effective as the 2-week therapy, with fewer side effects.Another option is 2 weeks of dual therapy. Dual therapy involves two drugs: an antibiotic and an acid suppressor. It is not as effective as triple therapy.Two weeks of quadruple therapy, which uses two antibiotics, an acid suppressor, and a stomach-lining shield, looks promising in research studies. It is also called bismuth triple therapy.

Can H. pylori infection be prevented?

No one knows for sure how H. pylori spreads, so prevention is difficult. Researchers are trying to develop a vaccine to prevent infection.

Why don't all doctors automatically check for H. pylori?

Changing medical belief and practice takes time. For nearly 100 years, scientists and doctors thought that ulcers were caused by stress, spicy food, and alcohol. Treatment involved bed rest and a bland diet. Later, researchers added stomach acid to the list of causes and began treating ulcers with antacids.Since H. pylori was discovered in 1982, studies conducted around the world have shown that using antibiotics to destroy H. pylori cures peptic ulcers. The prevalence of H. pylori ulcers is changing. The infection is becoming less common in people born in developed countries. The medical community, however, continues to debate H. pylori's role in peptic ulcers. If you have a peptic ulcer and have not been tested for H. pylori infection, talk to your doctor.

Points to Remember

• A peptic ulcer is a sore in the lining of the stomach or duodenum.
  
  The majority of peptic ulcers are caused by the H. pylori bacterium. Many of the other cases are caused by NSAIDs. None are caused by spicy food or stress.
  
  H. pylori can be transmitted from person to person through close contact and exposure to vomit.
  
  Always wash your hands after using the bathroom and before eating.
  
  
• A combination of antibiotics and other drugs is the most effective treatment for H. pylori peptic ulcers.

PANCREATITIS

Pancreatitis is an inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum. The duodenum is the upper part of the small intestine. The pancreas secretes digestive enzymes into the small intestine through a tube called the pancreatic duct. These enzymes help digest fats, proteins, and carbohydrates in food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body use the glucose it takes from food for energy.

Normally, digestive enzymes do not become active until they reach the small intestine, where they begin digesting food. But if these enzymes become active inside the pancreas, they start "digesting" the pancreas itself.

Acute pancreatitis occurs suddenly and lasts for a short period of time and usually resolves. Chronic pancreatitis does not resolve itself and results in a slow destruction of the pancreas. Either form can cause serious complications. In severe cases, bleeding, tissue damage, and infection may occur. Pseudocysts, accumulations of fluid and tissue debris, may also develop. And enzymes and toxins may enter the bloodstream, injuring the heart, lungs, and kidneys, or other organs.

Acute Pancreatitis

Some people have more than one attack and recover completely after each, but acute pancreatitis can be a severe, life-threatening illness with many complications. About 80,000 cases occur in the United States each year; some 20 percent of them are severe. Acute pancreatitis occurs more often in men than women.

Acute pancreatitis is usually caused by gallstones or by drinking too much alcohol, but these aren't the only causes. If alcohol use and gallstones are ruled out, other possible causes of pancreatitis should be carefully examined so that appropriate treatment—if available—can begin.

Symptoms of Acute Pancreatitis

Acute pancreatitis usually begins with pain in the upper abdomen that may last for a few days. The pain may be severe and may become constant—just in the abdomen—or it may reach to the back and other areas. It may be sudden and intense or begin as a mild pain that gets worse when food is eaten. Someone with acute pancreatitis often looks and feels very sick. Other symptoms may include

• swollen and tender abdomen
• nausea
• vomiting
• fever
• rapid pulse

Severe cases may cause dehydration and low blood pressure. The heart, lungs, or kidneys may fail. If bleeding occurs in the pancreas, shock and sometimes even death follow.

Diagnosis of Acute Pancreatitis

Besides asking about a person's medical history and doing a physical exam, a doctor will order a blood test to diagnose acute pancreatitis. During acute attacks, the blood contains at least three times more amylase and lipase than usual. Amylase and lipase are digestive enzymes formed in the pancreas. Changes may also occur in blood levels of glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the pancreas improves, these levels usually return to normal.

A doctor may also order an abdominal ultrasound to look for gallstones and a CAT (computerised axial tomography) scan to look for inflammation or destruction of the pancreas. CAT scans are also useful in locating pseudocysts.

Treatment of Acute Pancreatitis

Treatment depends on the severity of the attack. If no kidney or lung complications occur, acute pancreatitis usually improves on its own. Treatment, in general, is designed to support vital bodily functions and prevent complications. A hospital stay will be necessary so that fluids can be replaced intravenously.

If pancreatic pseudocysts occur and are considered large enough to interfere with the pancreas's healing, your doctor may drain or surgically remove them.

Unless the pancreatic duct or bile duct is blocked by gallstones, an acute attack usually lasts only a few days. In severe cases, a person may require intravenous feeding for 3 to 6 weeks while the pancreas slowly heals. This process is called total parenteral nutrition. However, for mild cases of the disease, total parenteral nutrition offers no benefit.

Before leaving the hospital, a person will be advised not to drink alcohol and not to eat large meals. After all signs of acute pancreatitis are gone, the doctor will try to decide what caused it in order to prevent future attacks. In some people, the cause of the attack is clear, but in others, more tests are needed.

Complications of Acute Pancreatitis

Acute pancreatitis can cause breathing problems. Many people develop hypoxia, which means that cells and tissues are not receiving enough oxygen. Doctors treat hypoxia by giving oxygen through a face mask. Despite receiving oxygen, some people still experience lung failure and require a ventilator.

Sometimes a person cannot stop vomiting and needs to have a tube placed in the stomach to remove fluid and air. In mild cases, a person may not eat for 3 or 4 days and instead may receive fluids and pain relievers through an intravenous line.

If an infection develops, the doctor may prescribe antibiotics. Surgery may be needed for extensive infections. Surgery may also be necessary to find the source of bleeding, to rule out problems that resemble pancreatitis, or to remove severely damaged pancreatic tissue.

Acute pancreatitis can sometimes cause kidney failure. If your kidneys fail, you will need dialysis to help your kidneys remove wastes from your blood.

Gallstones and Pancreatitis Gallstones can cause pancreatitis and they usually require surgical removal. Ultrasound or a CAT scan can detect gallstones and can sometimes give an idea of the severity of the pancreatitis. When gallstone surgery can be scheduled depends on how severe the pancreatitis is. If the pancreatitis is mild, gallstone surgery may proceed within about a week. More severe cases may mean gallstone surgery is delayed for a month or more. After the gallstones are removed and inflammation goes away, the pancreas usually returns to normal.

Chronic Pancreatitis

If injury to the pancreas continues, chronic pancreatitis may develop. Chronic pancreatitis occurs when digestive enzymes attack and destroy the pancreas and nearby tissues, causing scarring and pain. The usual cause of chronic pancreatitis is many years of alcohol abuse, but the chronic form may also be triggered by only one acute attack, especially if the pancreatic ducts are damaged. The damaged ducts cause the pancreas to become inflamed, tissue to be destroyed, and scar tissue to develop.

While common, alcoholism is not the only cause of chronic pancreatitis. The main causes of chronic pancreatitis are

• alcoholism
• blocked or narrowed pancreatic duct because of trauma or pseudocysts have formed
• heredity
• unknown cause (idiopathic)

Damage from alcohol abuse may not appear for many years, and then a person may have a sudden attack of pancreatitis. In up to 70 percent of adult patients, chronic pancreatitis appears to be caused by alcoholism. This form is more common in men than in women and often develops between the ages of 30 and 40.

Hereditary pancreatitis usually begins in childhood but may not be diagnosed for several years. A person with hereditary pancreatitis usually has the typical symptoms that come and go over time. Episodes last from 2 days to 2 weeks. A determining factor in the diagnosis of hereditary pancreatitis is two or more family members with pancreatitis in more than one generation. Treatment for individual attacks is usually the same as it is for acute pancreatitis. Any pain or nutrition problems are treated just as they are for acute pancreatitis. Surgery can often ease pain and help manage complications.

Other causes of chronic pancreatitis are

• congenital conditions such as pancreas divisum
• cystic fibrosis
• high levels of calcium in the blood (hypercalcemia)
• high levels of blood fats (hyperlipidemia or hypertriglyceridemia)
• some drugs
• certain autoimmune conditions

Symptoms of Chronic Pancreatitis

Most people with chronic pancreatitis have abdominal pain, although some people have no pain at all. The pain may get worse when eating or drinking, spread to the back, or become constant and disabling. In certain cases, abdominal pain goes away as the condition advances, probably because the pancreas is no longer making digestive enzymes. Other symptoms include nausea, vomiting, weight loss, and fatty stools.

People with chronic disease often lose weight, even when their appetite and eating habits are normal. The weight loss occurs because the body does not secrete enough pancreatic enzymes to break down food, so nutrients are not absorbed normally. Poor digestion leads to excretion of fat, protein, and sugar into the stool. If the insulin-producing cells of the pancreas (islet cells) have been damaged, diabetes may also develop at this stage.

Diagnosis of Chronic Pancreatitis

Diagnosis may be difficult, but new techniques can help. Pancreatic function tests help a doctor decide whether the pancreas is still making enough digestive enzymes. Using ultrasonic imaging, endoscopic retrograde cholangiopancreatography (ERCP), and CAT scans, a doctor can see problems indicating chronic pancreatitis. Such problems include calcification of the pancreas, in which tissue hardens from deposits of insoluble calcium salts. In more advanced stages of the disease, when diabetes and malabsorption occur, a doctor can use a number of blood, urine, and stool tests to help diagnose chronic pancreatitis and to monitor its progression.

Treatment of Chronic Pancreatitis

Relieving pain is the first step in treating chronic pancreatitis. The next step is to plan a diet that is high in carbohydrates and low in fat.

A doctor may prescribe pancreatic enzymes to take with meals if the pancreas does not secrete enough of its own. The enzymes should be taken with every meal to help the body digest food and regain some weight. Sometimes insulin or other drugs are needed to control blood glucose.

In some cases, surgery is needed to relieve pain. The surgery may involve draining an enlarged pancreatic duct or removing part of the pancreas.

For fewer and milder attacks, people with pancreatitis must stop drinking alcohol, stick to their prescribed diet, and take the proper medications.

Pancreatitis in Children

Chronic pancreatitis is rare in children. Trauma to the pancreas and hereditary pancreatitis are two known causes of childhood pancreatitis. Children with cystic fibrosis, a progressive, disabling, and incurable lung disease, may also have pancreatitis. But more often the cause is not known.

Points To Remember

• Pancreatitis begins when the digestive enzymes become active inside the pancreas and start "digesting" it.
  
  
• Pancreatitis has two forms: acute and chronic
  
  
• Common causes of pancreatitis are gallstones or alcohol abuse.
  
  
• Sometimes no cause for pancreatitis can be found.
  
  
• Symptoms of acute pancreatitis include pain in the abdomen, nausea, vomiting, fever, and a rapid pulse.
  
  
• Treatment for acute pancreatitis can include intravenous fluids, oxygen, antibiotics, or surgery.
  
  
• Acute pancreatitis becomes chronic when pancreatic tissue is destroyed and scarring develops.
  
  
• Treatment for chronic pancreatitis includes easing the pain; eating a high-carbohydrate, low-fat diet; and taking enzyme supplements. Surgery is sometimes needed as well.

METOCLOPRAMIDE

BRANDS: Maxalon

USE: Anti-nausea/anti-emetic

Maxalon

Metoclopramide (INN)is a potent dopamine receptor antagonist used for its antiemetic and prokinetic properties. Thus it is primarily used to treat nausea and vomiting, and to facilitate gastric emptying in patients with gastric stasis.

It is available under various trade names including: Maxolon (Shire/Valeant), Reglan (Wyeth), Degan (Lek), Maxeran (Sanofi Aventis), Primperan (Sanofi Aventis), and Pylomid (Bosnalijek). It was protected under U.S. patent 3177252 until 6 April 1982.

Mode of action

Metoclopramide was first described by Louis Justin-Besançon and C. Laville in 1964. It appears to bind to dopamine D2 receptors where it is a receptor antagonist, and is also a mixed 5-HT3 receptor antagonist/5-HT4 receptors agonist.

The anti-emetic action of metoclopramide is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone (CTZ) in the central nervous system (CNS)—this action prevents nausea and vomiting triggered by most stimuli. At higher doses, 5-HT3 antagonist activity may also contribute to the anti-emetic effect.

The prokinetic activity of metoclopramide is mediated by muscarinic activity, D2 receptor antagonist activity and 5-HT4 receptor agonist activity. The prokinetic itself may also contribute to the anti-emetic effect. Clinical use

Antiemetic use

Metoclopramide is commonly used to treat nausea and vomiting (emesis) associated with conditions including: emetogenic drugs, uraemia, radiation sickness, malignancy, labour, and infection. It is also used by itself or in combination with paracetamol (acetaminophen) for the relief of migraine.

It is considered ineffective in post-operative nausea and vomiting (PONV) at standard doses, and ineffective for motion sickness. In nausea and vomiting associated with cancer chemotherapy, it has been superseded by the more effective 5-HT3 antagonists (eg. ondansetron).

Prokinetic use

Metoclopramide increases peristalsis of the jejunum and duodenum, increases tone and amplitude of gastric contractions, and relaxes the pyloric sphincter and duodenal bulb. These prokinetic effects make metoclopramide useful in the treamtent of gastric stasis (eg. after gastric surgery or diabetic gastroparesis), as an aid in gastrointestinal radiology by increasing transit in barium studies, and as an aid in difficult small intestinal intubation. It is also used in gastroesophageal reflux disease (GERD/GORD).

Other indications

By inhibiting the action of prolactin inhibiting hormone (ie. dopamine), metoclopramide has sometimes been used to stimulate lactation.

Contraindications/precautions

Metoclopramide is contraindicated in phaeochromocytoma. It should be used with caution in Parkinson's disease since, as a dopamine antagonist, it may worsen symptoms. Long-term use should be avoided in patients with clinical depression as it may worsen mental state.

Adverse effects

Common adverse drug reactions (ADRs) associated with metoclopramide therapy include: restlessness, drowsiness, dizziness, and/or headache. Infrequent ADRs include: extrapyramidal effects (EPSE) such as oculogyric crisis, hypertension, hypotension, hyperprolactinaemia leading to galactorrhoea, diarrhoea, constipation, and/or depression. Rare but serious ADRs associated with metoclopramide therapy include: agranulocytosis, supraventricular tachycardia, hyperaldosteronism, neuroleptic malignant syndrome and/or tardive dyskinesia.

The risk of EPSEs are increased in young adults (<20>

LOSEC

Drug: omeprazole

Brand name: Losec

Use: Gastric and duodenal ulcers, reflux oesophagitis

Losec is a proton-pump inhibitor used for the treatment of stomach ulcers, severe gastro-oesophageal reflux disease (GORD), Zollinger-Ellison syndrome (a rare condition with very high stomach acid), and NSAID-associated ulcers.

Losec works by blocking excess stomach acid production.

Cautions:

- liver disease
- pregnancy
- breast-feeding
- gastric cancer (may mask symptoms)

Side effects:

Occasional:

- GI upset (nausea, vomiting, abdominal pain, flatulence, diarrhoea, constipation), headache, dizziness.

Less common:

- Dry mouth, insomnia, drowsiness, malaise, blurred vision, rash, itch.

Interactions:

This medicine inhibits the metabolism of diazepam, phenytoin, and warfarin.

LAPAROSCOPIC HERNIA REPAIR

Herniorrhaphy (hernioplasty, hernia repair) is a surgical procedure for correcting hernia. A hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in the muscle wall. Hernias can occur in the abdomen, groin, and at the site of a previous surgery.

Herniorraphy, or hernioplasty, is now often performed as an ambulatory, or "day surgery", procedure.

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). This operation is called a 'hernioplasty'. The meshes used are typically made from polypropylene or polyester, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anaesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond aspirin or paracetamol. Patients are encouraged to walk and move around immediately post-operatively, and can usually resume all their normal activities within a week or two of operation. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair.

In recent years, laparoscopic repair of inguinal hernia has emerged as an increasingly popular option. "Lap" repairs are also tension-free, although the mesh is placed within the preperitoneal space behind the defect as opposed to in or over it. It has no proven superiority to the open method other than a slightly lower post-operative pain score. Unlike the open method, laparoscopic surgery requires general anesthesia.

NICE examined data on laparoscopic and open hernia repair -- they concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical. However, they found that laparoscopic repair:

- results in a more rapid recovery and less pain in the first few days
- has less risk of wound infection, less bleeding and less swelling after surgery (seroma)
- less chronic pain

IRRITABLE BOWEL SYNDROME

What is irritable bowel syndrome (IBS)?

Irritable bowel syndrome (IBS) is a collection of symptoms that occur when the nerves and muscles in a person's bowel (the colon, or large intestine) do not work like they should. With IBS, a person's bowel is extra sensitive, causing discomfort and changes in bowel activity. IBS is a chronic condition, meaning it lasts a long time.

Symptoms of IBS may include:

• cramping
• pain in the stomach area
• bloating
• gas
• mucus in the stool
• changes in bowel habits

Some people with IBS have constipation--infrequent stools that may be hard, dry, and painful. Others have diarrhea--frequent loose stools. Some people have both. Sometimes a person with IBS has a crampy urge to empty the bowels but cannot do so.

IBS is not a disease and it does not cause cancer. IBS is a "functional" disorder, which means that the bowel doesn't work as it should. The cause of IBS is not known, and there is no cure for IBS. But, there are things you can do to feel better.

For some people, IBS is simply a bother. For others, it keeps them from going out, going to work, or even traveling short distances. Most people with IBS, however, can ease their symptoms by eating better, reducing stress, or taking medicine.

What causes IBS?

The cause of IBS is not known, and there is no cure for IBS. But, there are things you can do to feel better.

Who gets IBS?

Up to one in five Americans has IBS. IBS often begins before the age of 35, but it can start at any age. IBS seems to run in families--people with IBS often report having a family member with IBS. Most people diagnosed with IBS (up to 75 percent) are women. But, it is not known for sure that IBS affects more women than men. It may be that women are more likely to talk to their doctors about their symptoms.

What are the symptoms of IBS?

The main symptoms of IBS include:

• crampy pain in the stomach area
• painful constipation - infrequent stools that may be hard and dry
• painful diarrhea - frequent loose stools

Most people have either diarrhea or constipation, but some people have both.

Other symptoms include:

• mucus in the stool
• swollen or bloated stomach area
• feeling like you haven't finished a bowel movement
• gas
• heartburn
• discomfort in the upper stomach area or feeling uncomfortably full or nauseous after eating a normal size meal

Some women with IBS have more or different symptoms during their menstrual periods. Constipation may be relieved or diarrhea may occur in the day or two before or when their period starts.

How is IBS diagnosed?

If you think you may have IBS, see your doctor. Your doctor will take a medical history and ask about your symptoms. Then your doctor will perform some medical tests.

There are no tests that can show for sure that you have IBS. But your doctor may do some medical tests to make sure you don't have any other diseases that could cause your symptoms. Other possible causes include polyps, inflammation, or intolerance of foods containing a protein called gluten. Medical tests that may be done include:

• physical exam
• blood tests
• x-ray of the bowel: This x-ray test is called a barium enema or lower GI (gastrointestinal) series. Barium is a thick liquid that makes the bowel show up better on the x-ray. Before taking the x-ray, the doctor will put barium into your bowel through the anus.
• endoscopy: The doctor inserts a thin tube into your bowel. The tube has a camera in it, so the doctor can look at the inside of the bowel to check for problems.

Sometimes other tests need to be done to check how fast or slow content moves through the colon, or to check to see if the anal muscles are working right.

What is the treatment for IBS?

There is no cure for IBS, but there are things you can do to feel better. Treatment may include:

Diet changes

Some foods make IBS worse:

• milk products, like cheese or ice cream (people who have trouble digesting lactose, or milk sugar could be extra sensitive)
• chocolate
• alcohol
• caffeine (found in coffee, tea, and some sodas)
• carbonated drinks like soda
• Sorbitol, a sweetener found in dietetic foods and in some chewing gums
• gas-producing foods including beans and certain vegetables like broccoli or cabbage

To find out which foods are causing your symptoms, write down:

• what you eat during the day
• what symptoms you have
• when symptoms occur
• what foods always make you feel bad

Try not to eat foods that cause IBS symptoms. Or try eating less of those foods.

Some foods make IBS better:

Fiber lessens IBS symptoms--mainly constipation because it makes stool soft, bulky, and easier to pass. Fiber is found in bran, bread, cereal, beans, fruits, and vegetables.

Here are some examples of foods with fiber:

Fruits	Vegetables	Breads, cereals, and beans
Apples

Peaches

Broccoli, raw

Cabbage

Carrots, raw

Peas	Kidney beans

Lima beans

Whole-grain bread

Whole-grain cereal

Add foods with fiber to your diet a little at a time to let your body get used to them. Too much fiber all at once might cause gas, which can trigger symptoms in a person with IBS. If you have constipation, start by adding 12 grams of fiber per day. You may have to raise or lower the amount of fiber to a maximum of 30 grams per day, based on how fiber affects your bowel function and gas production.

Besides telling you to eat more foods with fiber, your doctor might also tell you to get more fiber by taking a fiber pill or drinking water mixed with a special high-fiber powder.

How much you eat matters, too.

Large meals can cause cramping and diarrhea in people with IBS. If this happens to you, try eating four or five small meals a day. Or, have your usual three meals, but eat less at each meal.

Medicine

If necessary, your doctor may give you medicine to help with symptoms:

• laxatives: to treat constipation
• antispasmodics: to slow contractions in the bowel, which may help with diarrhea and pain
• antidepressants: to help with severe pain

Take your medicine exactly as your doctor tells you to. Some medicines, including laxatives, can be habit-forming, and all drugs have side effects. Remember to tell your doctor about any over-the-counter medicines you are taking.

Stress relief

Stress does not cause IBS, but it can worsen your symptoms. Learning to reduce stress can help. With less stress, you may find that you have less cramping and pain.

Meditation, yoga, massage, exercise, hypnotherapy, and counseling are some things that might help. You may need to try different activities to see what works best for you.

Other things that may help:

• Drink 6 to 8 glasses of water each day.
• Exercise can help with constipation and improve your overall health. Exercise helps relieve stress and depression and helps your bowel function as it should.