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Contents
Introduction
If you are occasionally slowed down by an upset stomach, indigestion,
heartburn or even an ulcer, you certainly are not alone. Over 95
million Americans experience some kind of digestive problem. Over
10 million people are hospitalized each year for care of gastrointestinal
problems and the total health care costs exceed $40 billion annually.
While many digestive problems are more common as people get older,
they can occur at any age, even in children. All Americans are susceptible
to digestive problems, regardless of gender, ethnic or socioeconomic
backgrounds.
Common GI Problems
Gastrointestinal problems are very common. Most Americans have
experienced some form of stomach upset in their lives: nausea, vomiting
or diarrhea associated with the flu, or indigestion after eating
excessively.
This brochure will address three of the most common gastrointestinal
ailments requiring medical treatment or evaluation by a doctor.
- Gastroesophageal Reflux Disease (GERD) or Heartburn
- Ulcers
- Colorectal Cancer
When To See A Physician About GI Problems
Most patients contact their family doctor, or primary care physician,
when they experience GI problems. Many of these disorders can be
treated readily by your primary care doctor. In the case of recurring
or more serious problems you may need to see a specialist in gastrointestinal
conditions, a gastroenterologist.
What is a Gastroenterologist?
A gastroenterologist is a physician who specializes in disorders
and conditions of the gastrointestinal tract. Most gastroenterologists
are board-certified in this subspecialty. After completing the same
training as all other physicians, gastroenterologists study for
an additional 2-3 years to train specifically in conditions of the
gastrointestinal tract.
The Gastrointestinal Tract
The organs comprising the gastrointestinal (GI) tract permit food
to be converted into nutrients that provide energy and a wide range
of by-products essential to normal health, and then allow the unused
matter to be removed from the body. The GI tract starts with the
mouth, where food is ingested, and follows through the digestive
system to the esophagus, the stomach, the small and large intestine
(colon) and the rectum. Other organs associated with the GI system
include the liver, pancreas and gall bladder.
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Gastroesophageal Reflux
Disease (GERD)
What is GERD or Heartburn?
Gastroesophageal reflux refers to the backward flow of acid from
the stomach up into the esophagus. People will experience heartburn,
also known as acid indigestion, when excessive amounts of acid reflux
into the esophagus. Most people describe heartburn as a feeling
of burning chest pain, 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 as long as 2 hours and are
often worsened by eating food.
How Common is GERD?
Over 60 million Americans experience acid indigestion at least
once a month and some studies have suggested that over 15 million
Americans experience acid indigestion daily. Symptoms of acid indigestion
are more common among the elderly and women during pregnancy.
What Are the Treatments of GERD?
In many cases, doctors find that acid indigestion can be controlled
by modifying lifestyles and proper use of over-the-counter medicines.
- Avoid foods and beverages which contribute to acid indigestion:
chocolate, coffee, peppermint, greasy or spicy foods, tomato products
and alcoholic beverages.
- Stop smoking. Tobacco stimulates stomach acid production and
relaxes the muscle between the esophagus and the stomach, permitting
acid reflux to occur.
- Reduce weight if obese.
- Avoid eating 2-3 hours before sleep.
- Take an over-the-counter antacid or an H2 blocker, some of which
are now available without a prescription.
When Should You See a Doctor about GERD?
When symptoms of acid indigestion are not controlled with modifications
in lifestyle, and over-the-counter medicines are needed more often
than twice a week, you should see your doctor.
When GERD is left untreated 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 Barrett's
esophagus (a pre-malignant condition of the esophagus). Symptoms
suggesting that serious damage has already occurred include:
- Dysphagia: A feeling that food is trapped behind the breast
bone.
- Bleeding: Vomiting blood or tarry, black bowel movements.
- Choking: Sensation of acid refluxed into the windpipe causing
shortness of breath, coughing, hoarseness of the voice.
What Type of Tests are Needed to Evaluate GERD?
Your doctor may wish to evaluate your symptoms with additional
tests when it is unclear whether your symptoms are caused by acid
reflux, or if you suffer from complications of GERD such as dysphagia,
bleeding, choking, or if your symptoms fail to improve with prescription
medications.
- Barium Esophagram or Upper GI X-Ray
- This is a test where you are given a chalky material to drink
while X-rays are taken to outline the anatomy of the digestive
tract.
- Endoscopy
- This test involves insertion of a small lighted flexible tube
through the mouth into the esophagus and stomach to examine
for abnormalities. The test is usually performed using medicines
to sedate you.
- Esophageal Manometry or Esophageal pH
- This test involves inserting a small flexible tube through
the nose into the esophagus and stomach in order to measure
pressures and function of the esophagus. With this test, the
degree of acid refluxed into the esophagus can be measured as
well.
Surgery
Surgeons perform anti-reflux surgery on patients with longstanding
gastroesophageal reflux disease not controlled with medication.
The surgical technique attempts to improve the natural barrier between
the stomach and the esophagus that prevents acid reflux from occurring.
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Ulcers
About 20 million Americans will suffer from an ulcer in their lifetime.
Duodenal ulcers often occur between the ages of 30 and 50, and are
twice as common among men. Stomach ulcers are more common after
the age of 60 and are more commonly seen in women.
What is an Ulcer? An ulcer is a focal area of the stomach
or duodenum that has been destroyed by digestive juices and stomach
acid. Most ulcers are no larger than a pencil eraser, but they can
cause tremendous discomfort and pain.
What are the Symptoms of Ulcers?
The most common symptom of an ulcer is a gnawing or burning pain
in the abdomen located between the navel and the bottom of the breastbone.
The pain often occurs between meals and sometimes awakens people
from sleep. Pain may last minutes to hours and is often relived
by eating and taking antacids. Less common symptoms of an ulcer
include nausea, vomiting and loss of appetite and weight.
What Causes Ulcers?
In the past, ulcers were incorrectly thought to be caused by stress.
Doctors now know that there are two major causes of ulcers. Most
often patients are infected with the bacteria Helicobacter pylori
(H. pylori). Others who develop ulcers are regular users of pain
medications called non-steroidal anti-inflammatory drugs (NSAIDS),
which include common products like aspirin and ibuprofen. The use
of antibiotics to fight the H. pylori infection is a major scientific
advance. Studies now show that antibiotics can permanently cure
80-90 percent of peptic ulcers. Blocking stomach acid remains very
important in the initial healing of an ulcer. Helicobacter pylori
The largest number of ulcers arise because of the presence of Helicobacter
pylori. Because H. pylori exists in the stomachs of some people
who do not develop ulcers, most scientists now believe that ulcers
occur in persons who have a combination of a genetic predisposition,
plus the presence of the bacteria, Helicobacter pylori.
Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
The second major cause for ulcers is irritation of the stomach
arising from regular use of non-steroidal anti-inflammatory drugs.
NSAID-induced gastrointestinal side effects can best be avoided
by using alternative therapy whenever possible. Low-dose corticosteroids
or supportive drugs such as acetaminophen are alternatives to NSAIDS
to consider. Four grams per day of acetaminophen has been shown
to be comparable to analgesic and anti-inflammatory doses of ibuprofen
for osteoarthritis pain and is not associated with an increased
risk of gastrointestinal side effects.
If you are taking over-the-counter pain medications on a regular
basis, you will want to talk with your physician about the potential
for ulcers and other GI side effects. Your doctor may recommend
a change in the medication you are using, that you take some other
medication in conjunction with your pain medication. These could
range from use of antacids or a prescription product (such as misoprostol)
in conjunction with your pain medication.
What are the Complications of Ulcers?
Bleeding: Bleeding from an ulcer can occur in the stomach
or the duodenum and is sometimes the only sign of an ulcer. Bleeding
from an ulcer may be slow, causing anemia and fatigue. More rapid
bleeding can cause bowel movements to become sticky and tarry
black or even bloody. Bleeding ulcers may cause nausea and vomiting
of acidified blood that looks like "old coffee grounds."
Perforation: When ulcers are left untreated digestive
juices and stomach acid can literally eat a hole in the intestinal
lining. Bacteria, food and digestive juices can spill into the
abdominal cavity causing sudden, intense pain that requires hospitalization,
and often surgery.
Obstruction: Chronic inflammation from an ulcer can cause
swelling and scarring to occur. Over time scarring may close the
outlet of the stomach, preventing food to pass and causing vomiting
and weight loss.
How are Ulcers Diagnosed?
Most doctors recommend that a test be performed to evaluate for
the presence of an ulcer if symptoms are not improved after 2 weeks
of treatment with an acid blocking medicine (cimetidine, ranitidine,
famotidine, omeprazole or lansaprazole etc.). The two tests most
commonly used to evaluate for ulcer are an X-ray known as an Upper
GI Series or UGI, and a procedure called an Endoscopy or EGD.
Upper GI Series
This is an X-ray test where you are given a chalky material
to drink while X-rays are taken to outline the anatomy of the
digestive tract.
Endoscopy
This test involves insertion of a small lighted flexible tube
through the mouth into the esophagus and stomach to examine
for abnormalities. The test is usually performed using medicines
to sedate you. During the test biopsies of tissue can be taken
for examination. A biopsy will not cause any pain or discomfort
and is usually only the size of a match head.
Tests for Helicobacter pylori
There are several tests available to your doctor to evaluate for
the presence of the bacteria, H. pylori. Samples of blood can be
examined for evidence of antibodies to the bacteria; a breath test
can be examined for by-products from the bacteria; or biopsies from
the stomach can be examined.
How are Ulcers Treated?
In the past, doctors advised patients to avoid spicy, fatty and
acidic foods. We now know that diet has little to do with ulcer
healing. Doctors now recommend that patients with ulcers only avoid
foods that worsen their symptoms. Ulcer patients who smoke cigarettes
should stop. Smoking has been shown to inhibit ulcer healing and
is linked to ulcer recurrence. In general, ulcer patients should
not take NSAIDS like aspirin or ibuprofen.
When is Surgery Necessary?
Most ulcers can be healed with medications. When an ulcer fails
to heal or if complications of bleeding, perforation or obstruction
develop, surgery is often necessary.
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Understanding Some
of the Medications Often Prescribed for GERD & Ulcers
Prescription medications to treat ulcers and GERD include drugs
called H2 receptor antagonists (H2 blockers) and proton pump inhibitors
which help to reduce the stomach acid which tends to exacerbate
symptoms and to promote healing, as well as promotility agents which
aid in the clearance of acid from the esophagus.
H2 Receptor Antagonists
Since the mid-1970's H2 receptor antagonists have been used to
treat GERD and ulcer disease. In GERD, H2 receptor antagonists improve
the symptoms of heartburn and regurgitation and heal mild-to-moderate
esophagitis. Symptoms are eliminated in up to 50% of patients with
twice a day prescription dosage of the H2 receptor antagonists,
while the healing of esophagitis in up to 50% of patients require
higher or more frequent dosing. These agents maintain remission
in about 25% of patients.
In ulcer disease, H2 receptor antagonists have made major contributions
to treatment. While recent research has defined the role of Helicobacter
pylori in causing ulcer disease, stomach acid continues to be a
major contributing cause through increasing irritation in the area
of the ulcer, as well as adding to patient discomfort. H2 receptor
antagonists provide an excellent mechanism to control the flow of
stomach acid to aid in the healing process.
H2 receptor antagonists are generally less expensive than proton
pump inhibitors and provide adequate, cost-effective approaches
as the first-line treatment and maintenance agents in GERD and ulcer
disease. In mid-1995, the FDA approved availability of some H2 blockers
without prescription in dosage levels appropriate for treatment
of heartburn. The FDA has not approved any H2 blocker formulation
for non-prescription sale for the treatment of ulcers.
Proton Pump Inhibitors
Proton pump inhibitors (PPIs), such as omeprazole, and more recently
lansoprazole, have been found to heal erosive esophagitis (serious
forms of GERD) more rapidly than H2 receptor antagonists. PPIs provide
not only symptom relief, but also symptom resolution in most cases,
including those involving more significant ulcers and/or damage
to the esophagus. Studies have shown PPI therapy can provide complete
endoscopic mucosal healing of esophagitis at 6 to 8 weeks--ranging
from 75% to 100% of cases. Daily PPI treatment provides the best
long-term maintenance of esophagitis, particularly in keeping symptoms
and disease in remission for those patients with moderate-to-severe
esophagitis, and has been shown to retain remission for up to 5
years.
PPIs have also taken on a major role in treating ulcer disease.
Because they offer the most effective means of impeding acid production,
they are useful in treating serious ulcer conditions. As is indicated
below, proton pump inhibitors are also included in most of the standard
regimes for treating Helicobacter pylori infection.
Promotility Agents
Promotility drugs are effective in the treatment of mild to moderately
symptomatic GERD. These drugs increase lower esophageal sphincter
pressure, which helps decrease acid reflux, and improve the movement
of food from the stomach. They decrease heartburn symptoms, especially
at night, by improving the clearance of acid from the esophagus.
Cisapride is the most effective of the promotility agents with an
excellent safety profile.
Over-the-Counter Medications
Large numbers of Americans medicate minor GI discomforts, infrequent
heartburn or acid indigestion using over-the-counter antacids and
other agents that are available without a prescription. Recently,
FDA approved the non-prescription availability of important acid
suppression agents, call H2 blockers (Tagamet, Pepsid, Zantac and
Axid) for treatment of heartburn. Over-the-counter antacids alone
account for over $1 billion in sales per year. Early indications
are that over-the-counter H2 blockers will also account for major
consumer purchases.
Over-the-counter medications have an important 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 addressed
in a systematic treatment plan. 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 treatment plan.
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Treatment of Ulcers
Caused by H. pylori Infection
Triple Therapy
There is no single medication which has achieved good results in
eradicating H. pylori, hence combinations of drugs have been used
to achieve increased success in eliminating the presence of the
organism. The first therapeutic regimen with demonstrated success
in widespreaqd eradication of H. pylori involved triple therapy
(three medications taken concurrently). Triple therapy has a demonstrated
success in 80-95% of cases and is the standard of therapy at present.
TRIPLE THERAPY
(two week course) |
Bismuth subsalicylate (e.g. 2 tablets 4x daily)
Tetracycline (e.g. 500 mg 4x daily)
Metronidazole* (e.g. 250 mg 3x daily) |
*Clarithromycin can be substituted for metronidazole, of particular
benefit in metronidazole resistant patients.
Dual Therapies
Problems with triple therapy include difficulties for patients
in taking so many medications regularly, side effects and the fact
that 15-25% of patients have a resistance to metronidazole. Dual
therapies, with simpler patient compliance, have been tested, such
as daily amoxicillin plus metronidazole.
DUAL THERAPY
(two week course) |
Amoxicillin (e.g. 750 mg 3x daily)
Metronidazole* (e.g. 500 mg 3x daily) |
*Clarithromycin can be substituted for metronidazole, of particular
benefit in metronidazole resistant patients.
Emerging Therapies
Therapies for 1995 also include triple therapy combining metronidazole*,
omeprazole** and clarithromycin, which often has better patient
compliance than the more complicated standard triple therapy regimen.
The dual therapy combination of omeprazole and clarithromycin, has
been submitted to the FDA. Cure rates in clinical trials have ranged
from 70% to 83%. A number of studies are investigating whether one
week's therapy may approach the effectiveness of a 2 week regimen.
| EMERGING THERAPIES |
| (one or two week course) |
(two week course) |
Metronidazole* (e.g. 500mg 2x daily)
Omeprazole** (e.g. 20 mg 2x daily)
Clarithromycin (250 mg 2x daily) |
Amoxicillin (e.g. 1 gram/2X daily)
Omeprazole** (e.g. 20 mg/2X daily)
Clarithromycin (e.g. 500 mg/2X daily) |
Omeprazole** (e.g. 40 mg a.m.)
Clarithromycin (e.g. 500 mg 3x daily)
|
*Clarithromycin can be substituted for metronidazole, of particular
benefit in metronidazole resistant patients.
**Lansoprazole can be substituted for omeprazole.
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Colorectal Cancer
Colorectal cancer is the second most common cancer killer in the
United States, causing an estimated 55,000 deaths each year. More
than 138,000 new cases of colorectal cancer are diagnosed each year.
Men and women are equally affected by this disease.
Colorectal cancer is cancer of the colon and rectum, two parts
of the digestive system also know as the large intestine.
Insert Figure 4. Title: "Colon and Rectum"
All colon cancers arise from polyps, abnormal growths on the wall
of the colon that may become cancerous over time. If polyps are
identified at a very early stage, they can be removed before they
become cancerous.
Complications of colorectal cancer can be reduced or even prevented
with the simple step of regular screening. The screening program
recommended by the American Cancer Society includes an annual fecal
occult blood test and a screening flexible sigmoidoscopy every 3-5
years for all Americans over the age of 50. Those individuals with
a high risk for colorectal cancer because of prior cancer, a family
history of cancer, or a history of chronic digestive condition that
predisposes them to cancer, should undergo regular surveillance
know as colonoscopy. A recent study in the New England Journal of
Medicine stated that more than 90 percent of lives could be saved
through early detection of colorectal cancer.
Who is At Risk for Colorectal Cancer?
- Women are just as likely as men to develop colorectal cancer.
- Colon cancer is most common after age 50, but the chances of
developing this disease increase after age 40.
- Close relatives of a person who has had colorectal cancer, or
persons with one of several chronic digestive conditions have
a higher than average risk of developing colorectal cancer.
What are the Symptoms of Colorectal Cancer?
- Frequent gas pains
- Blood in or on the stool
- Diarrhea or Constipation
- A feeling that the bowel has not emptied completely
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Regular Screening:
The Absolute Best Protection Against Colorectal Cancer
When Should People be Screened for Colorectal Cancer?
People over 50 should be screened for colorectal cancer by their
physician. Several tests are recommended.
- An annual fecal occult blood test, which checks for minute traces
of blood in the stool.
- A flexible sigmoidoscopy once every 3-5 years to detect colorectal
cancer at its earliest and most treatable stage.
- An annual colonoscopy is recommended for high risk patients
of any age with prior history of cancer, a strong family history
of the disease, or a predisposing chronic digestive condition
such as inflammatory bowel disease.
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