Category Archives: Diseases Of The Digestive System

Hemorrhagic Colitis

Hemorrhagic colitis is an acute form of gastroenteritis resulting from a bacterial infection in the large intestine caused by a specific strain of Escherichia coli. It is a self limiting disease characterized by bloody diarrhea accompanied by abdominal cramps, and occasionally low grade fever.

This illness mostly affects children below 5 years as well as older people, but it may occur at any age. The strain E. coli O157:H7 is the usual cause of Hemorrhagic colitis in North America. Cattle are natural reservoirs of these bacteria and the infection does not produce any symptoms in them. The bacteria infect people when they consume under cooked beef, especially ground meat, or unpasteurized milk. Water and juice contaminated by the infective organism also can cause infection. An infected individual can transmit the disease through person to person contact and often an infection leads to an outbreak of hemorrhagic colitis. It usually spreads rapidly among young children who are in diapers.

Damage to the intestinal lining caused by the toxins produced by E. coli is the cause of the diarrhea. If the toxins reach the blood, other organs may be affected, mainly the kidneys.

Symptoms Of Hemorrhagic colitis

The onset of the disease is marked by sudden diarrhea accompanied by severe abdominal pain and cramping. Low grade fever may be present, but in many cases it is absent. Temperatures above 1020 F are rare.   The stools are watery but traces of blood may not be seen in the first one or two days. But by the third day, the stools may have become bloody and it may remain like that for up to 8 days after which it resolves by itself.

Hemolytic-uremic syndrome is a serious complication which arises in 2% to 7% of patients who have developed hemorrhagic colitis. The symptoms of developing hemolytic-uremic syndrome are thrombocytopenia or low platelet count, excessive breakdown of red blood cells called hemolytic anemia as well as the usual symptoms of anemia such as weakness, giddiness and fatigue. It may lead to sudden kidney failure.    Hemolytic-uremic syndrome in some cases may lead to further complications such as strokes or seizures due to nerve damage or damage to the brain. An increase in fever as the illness enters the second week may be an indication of complications developing. Complications like hemolytic-uremic syndrome usually develop in young children below the age of 5 years. It is frequent in older people also. Hemorrhagic colitis can have a fatal outcome in older people even when they have not developed hemolytic-uremic syndrome or other complications arising from it.

Diagnosis

Diarrhea with bloody stools is the typical symptom which alerts the doctor to the possibility of hemorrhagic colitis. Stool samples are tested for the presence of E. coli bacteria. The stool may be tested for the specific toxin (shiga toxin) which the E. coli bacteria produce. If any other reason for bloody diarrhea is suspected, a viewing test called colonoscopy may be done to examine the interiors of the large intestine.

Treatment

Keeping the patient rehydrated is the most crucial part of the treatment. The fluid lost through frequent watery bowel movements should be replenished as much as possible. In case of severe dehydration, intravenous administration of electrolyte solution may be necessary. Antibiotic therapy to treat the infection is not advisable as the chances of developing complications like hemolytic-uremic syndrome may be increase by those drugs. Intensive care treatment and kidney dialysis may be necessary for patients developing this complication.

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What Is Gastroenteritis

Gastroenteritis is the inflammation affecting the lining of the gastrointestinal tract, including both the intestines, and the stomach. Microbial infections and exposure to certain drugs and chemical substances are the usual causes for this condition.

  • Diarrhea accompanied by pain in the abdomen, as well as nausea and vomiting is the usual symptom.
  • Gastrointestinal infections are the usual reason for gastroenteritis, but it can also result from drug use and exposure to toxins.
  • Recent travel involving change in the source of food and water, and close contact with those who are having the disease, are the usual reasons for contracting this disease. Certain diagnostic tests using toxic chemicals, and antibiotic therapy, are the less common reasons for gastroenteritis.
  • Maintaining good hygiene, including frequent washing of hands, especially after bowel movements, and before handling food, help in avoiding microbial infections.
  • Infections caused by certain bacteria can be treated by antibiotic therapy.

Diarrhea is usually the most common, as well as the first sign of gastroenteritis. It can be severe diarrhea or a milder one. Nausea and vomiting, pain, and uneasiness in the stomach, abdominal cramps and loss of appetite are some of the accompanying symptoms. The disease is not usually longstanding and the difficulties caused by it are manageable in healthy people. However, frequent passage of watery stools may result in severe dehydration especially in patients who are very young. In older and weaker people also, gastroenteritis can lead to life threatening complications due to loss of electrolytes and complications developing from dehydration.

Gastroenteritis, due to food contamination, affects one out of every six people each year in the United States alone. The world over, one and a half million deaths occur due to epidemics of gastroenteritis among children. The death toll is highest in less developed countries due to lack of awareness about hygiene and non-availability of medical care.

Causes

Gastroenteritis due to microbial infections can spread quickly among people when good hygiene practices are lacking. A person with the disease has the potential to contaminate every object handled, if the hands are not washed thoroughly after every bowel movement. All those who touch contaminated surfaces and then accidentally touch their mouth or handle food with unwashed hands may contract the disease. Any object, which may have traces of stool on it, such as toys and diapers, are potential agents of spreading the disease. This kind of disease transmission is termed as fecal-oral transmission. Water can also be contaminated with fecal matter which may lead to large-scale spread of the disease, usually termed as an outbreak of epidemic. This is very common among people who live in crowded communities. Every time a person consumes uncooked food and water in an area having an outbreak, is at risk of contracting the disease.

Swimming in ponds and pools contaminated by fecal matter from an infected person using it, or from contaminated water entering it, may lead to gastroenteritis. Animals also can be carriers of infectious microbes.  Close interaction with animals or contamination with animal feces also can result in gastroenteritis. The infection causing gastroenteritis may be either bacterial or viral. Parasitic infestation, ingestion of toxic materials and certain drugs are some other causes precipitating gastroenteritis.

Viral Gastroenteritis: Gastroenteritis is often caused by viruses which attack the intestinal lining. They cause severe watery diarrhea accompanied by fever and vomiting. Viral gastroenteritis is a frequent occurrence in the United States.

Mainly there are four kinds of viruses which are responsible for almost all the cases of viral gastroenteritis: They include:

  • Rotavirus
  • Norovirus
  • Astrovirus
  • Enteric adenovirus

Rotavirus infection results in severe diarrhea in very small children aged 3-15 months. It is a highly contagious infection which spreads through the fecal-oral route and causes severe dehydration in the affected children. The infection can be contracted by adults also, but often a mild form of disease results. Rotavirus infections are prevalent in temperate climatic regions, appearing during winter. The infection causes symptoms severe enough to necessitate hospitalization of young children and infants. In the United States, the disease has assumed a recurrent pattern, appearing in the month of November in the Southwest regions, and travelling across the country, ending in March in the Northeast.

Norovirus infections are found in adults and older children, starting mainly from the month of November and lasting till April, even though they may occur at any time of the year. The infection usually spreads through contaminated water and food, but since it is highly infectious, people can directly get it from others on casual interaction.

Astrovirus is spread by the fecal-oral route, mostly affecting young children and infants. Adults also are prone to astrovirus infection, which normally strikes in winter.

Adenovirus is also transmitted via the fecal-oral route. Infants and toddlers below 2 years of age are most prone to this infection. Adenovirus infection can occur at any time of the year but higher incidence is observed in the summer months.

Enterovirus and cytomegalovirus are certain other infective agents generally affecting those who have immune deficiency conditions.

Bacterial Gastroenteritis: Gastroenteritis may be caused by bacterial infections too, but it is less frequent when compared to gastroenteritis due to viral infections. Different bacteria cause diarrhea by different means. Vibrio cholera, Clostridium difficile and certain types of Escherichia coli do not invade the intestinal lining but they attach to it, producing certain chemicals called enterotoxins. These toxic substances trigger the intestinal lining into secreting water as well as minerals precipitating watery diarrhea.

On the other hand, certain other bacteria infiltrate the lining of the intestines, causing damage to the cells. It results in the formation of ulcerations which bleed and leak fluid into the intestines, resulting in diarrhea. The stool may contain red and white blood cells and even traces of blood. Shigella, E. coliSalmonella, and Campylobacter are some of the bacteria of this type.

Diarrhea resulting from Salmonella infection is the most frequent and most dangerous bacterial gastroenteritis prevalent in the United States. Campylobacter bacterial infection also is as frequent. Undercooked meat products, especially poultry, and milk which is not pasteurized, are the major sources of Salmonella and Campylobacter infections. Stools of cats and dogs having diarrhea may spread Campylobacter infections. Salmonella is present in amphibians like salamanders and frogs, reptiles like lizards and turtles, as well as birds. Handling of these animals and raw eggs may result in Salmonella infection.

Another bacterium called Shigella is also responsible for bacterial gastroenteritis in the United States. Person-to-person transmission is the most common route of spreading Shigella infection. Daycare centers are often implicated in the spread of the disease. Occasionally, infection is spread through food.

There are a number of subtypes of E. coli which cause diarrhea. Enterohemorrhagic E. coli which are otherwise called Shiga toxin-producing E. coli results in hemorrhagic colitis. Another condition caused by them is hemolytic-uremic syndrome. E. coliO157:H7 is the most prevalent subtype affecting people in the United States. The source of the infection is usually unpasteurized milk or undercooked ground meat.

 Day care centers are major hubs of E. coli infections. Recreational water illnesses are also large scale infections of E. coli affecting people frequenting open water bodies like lakes, pools, oceans, as well as water parks. Enterotoxigenic E. coli, as the name suggests, produces toxins which result in thin watery stools. Traveler’s diarrhea, affecting visitors to developing countries especially in the tropics, are usually caused by these. Other types of E. coli prevalent in the developing countries may cause bloody diarrhea or nonbloody diarrhea, but it is rare case in the United States.

Certain bacteria, namely, Clostridium perfringens Bacillus cereus,Staphylococcus aureus etc., contaminate the food with a toxin produced by them. Consumption of such foods alone is capable of producing symptoms of gastroenteritis, even in the absence of infection. Symptoms such as nausea and vomiting, accompanied by severe diarrhea, usually start appearing within 12 hours of exposure to the toxin. They may eventually subside within a day or two.

Bacterial Gastroentertis may be caused by many other bacteria but they are not very common in the United States. Appendicitis-like symptoms are precipitated by the infection of Yersinia enterocolitica which may cause gastroenteritis too. The infection usually results from consuming unpasteurized milk, undercooked pork or from water contaminated with the bacteria. Undercooked seafood is the usual source of Vibrio parahaemolyticus infection. Another vibrio bacterium called Vibrio cholera is the cause of cholera epidemics in developing countries. It is characterized watery stools which results in the rapid dehydration of the patient, especially children, many of whom succumb to the infection. This infection quickly spreads in crowded areas like refugee camps. Food contaminated by Listeria can cause gastroenteritis. Plesiomonas shigelloides infection results from the consumption of raw shellfish. People who visit developing countries in the tropical region also contract this infection. Swimming in brackish water and accidentally swallowing the water is the usual reason for the Aeromonas infection.

Parasites: Giardia intestinalis is a parasite inhabiting the intestines and when they bore into the lining, it results in nausea and vomiting, and sometimes diarrhea too. This disease condition known as giardiasis is prevalent in colder regions of the world.  In chronic disease, absorption of nutrients may be impaired, resulting in deficiency diseases due to malabsorption. Contaminated drinking water is the usual channel of transmission, but children in day care centers seem to be getting the infection by contact.

Cryptosporidium parvum is a parasite found in the intestines causing watery stools and other symptoms such as nausea and vomiting as well as abdominal pain. This disease condition known as cryptosporidiosis is usually harmless in normal healthy individuals, but it can be an extremely dangerous and potentially fatal condition in immune-deficient people. Contaminated water is the channel by which Cryptosporidium parvum spreads. It is identified as the culprit of recreational water illness common in the United States, especially since chlorination of water does not affect this organism.

Cyclospora cayetanensis  and Isospora belli  also cause symptoms like that of cryptosporidiosis, especially in people with weakened immune system. Microsporidia is another group of organisms which too cause these symptoms.

 Amebiasis caused by Entamoeba histolytica usually affects the large intestine. Occasionally, it may affect the other organ too including the liver. Though amebiasis is not common in the United States, it is prevalent in many developing countries where bloody diarrhea resulting from it is a common form of gastroenteritis.

Chemical Gastroenteritis: When certain toxic chemicals are ingested it may result in gastroenteritis. The toxins may be biological in origin as in the case of mushroom poisoning and food poisoning from certain seafood. Since chemical gastroenteritis is not caused by any infection, it is not infectious. Toxic chemicals include lead, cadmium, arsenic and mercury. Nausea and vomiting, accompanied by stomach pain as well as diarrhea are the usual symptoms. Excessive consumption of certain food items like tomatoes and citrus fruits may cause gastroenteritis in some people.

Symptoms of Gastroenteritis

Symptoms are typically watery diarrhea as well as nausea and vomiting. But the severity of the symptoms varies from person to person. It usually depends on the causative organism and the toxins produced by them. The immune reaction of the body also determines the severity. Loud stomach sounds, pain and cramping in the abdomen and loss of appetite are other usual symptoms appearing. Blood as well as mucus may be present in the stool. Abdomen may become distended with gas. Fever may be present in some cases. Muscle aches and lethargy may be frequent.

Dehydration developing due to frequent diarrhea and vomiting is a complication of gastroenteritis. Decrease in urine output, dryness of mouth, listlessness and tiredness are some of the indications of dehydration. In infants, signs of dehydration include absence of tears while crying. Loss of minerals and salts may lead to abnormally low potassium levels in the blood called hypokalemia. Dehydration results in the development of low blood pressure due to lowered blood volume. Abnormally fast heart rate may develop. Hyponatremia or lowering of blood sodium levels is a complication if the salts, lost in the stool and vomit, are not replaced by the rehydration therapy. If plain water or light tea is the only liquids used for rehydration there is a high chance of developing low sodium and potassium levels which can become dangerous.  Using ORS solution for rehydration may help prevent this complication, which can otherwise lead to even kidney failure or shock.

Diagnosis Of Gastroenteritis

Gastroenteritis is diagnosed from the typical symptom of frequent watery stool, but the cause of the disease may not be apparent. If it is known that other people in the office or at home have been ill with similar symptoms, the possibility of contracting the same infection is very high. Consuming food contaminated with infectious agents is a major cause of infection. Improperly cooked food, unpasteurized dairy products; raw egg or egg based preparations like mayonnaise, carry the risk of infection with Salmonella. Antibiotic use is another cause of diarrhea; so is travel to other places and countries.

If diarrhea does not resolve in a day or two, a sample of the stool should be tested to identify the organism causing the disease such as bacteria or parasites.

A sigmoidoscopy is usually done if the diarrhea continues for more than a few days. With a viewing tube called sigmoidoscope, the large bowel is checked for abnormalities as well as for the presence of ulcerative colitis.

Prevention of Gastroenteritis

Oral vaccines available against rotavirus are effective against the most common strains of virus. These vaccinations help prevent viral gastroenteritis in young children, especially in those who spend time in daycare centers. Hygiene measures are important while changing diapers and feeding children. Diapers should be changed in designated areas and the areas should be cleaned with a bleach solution. Hands should be thoroughly scrubbed with soap and water after every diaper change. The soiled diapers and cleaning tissues should be disposed off promptly. When children have diarrhea, they should be kept away from daycare centers till the symptoms are resolved. Infections with Shigella, as well as E. coli infection resulting in bloody diarrhea, should be treated with care. Children affected should test negative twice, before returning to the day care.

To avoid contracting Salmonella infection, children should be kept away from amphibian and reptilian animals which are likely to carry the bacteria. Older individuals with lower immunity level also should avoid contact with animals.

Frequent washing of hands with soap and water will reduce the chances of contracting the disease to a great extent. Contact with people who are infected is the most common method of transmission. People who have diarrhea should wash their hands thoroughly after every bowel movement. Clothes contaminated with stool should not be mixed with other washing load. Soiled clothes should be washed separately. To avoid contaminating food, hand washing before meals as well as before touching any instruments such as knives, cutting boards, cooking vessels, spoons etc., associated with cooking and serving food should be strictly practiced. Instruments and vessels which have come in contact with raw meat and eggs should be washed separately. Meat should be cooked properly and should be quickly cooled down and refrigerated before microbes get chance to grow and multiply. Milk should be consumed after boiling thoroughly or pasteurized milk should be used. Raw egg products such as mayonnaise should also be pasteurized. Eating street foods should be avoided especially while traveling.

When a person is having diarrhea, swimming in a community pool should be strictly avoided to prevent the spread of recreational water illness. The diapers of toddlers and infants should be checked and changed away from the pool. Ingesting water during swimming should be avoided.

Treatment Of Gastroenteritis

Rehydration therapy is the most essential and effective treatment for gastroenteritis. With sufficient intake of fluids and a good rest the body may overcome the infection in a few days without any further treatment. Rehydration therapy should be tailored to the condition of the patient and the symptoms of the disease. If vomiting is present, the patient may not be able to tolerate oral intake of fluids. Very small quantities of liquids, mostly one sip at a time, may be administered frequently. If it is not sufficient to maintain satisfactory hydration, intravenous administration should be initiated without delay.

 A home-made salt sugar mixture advised for oral dehydration is found to be as effective as the commercially available oral rehydration (ORS) mixtures in saving lives, especially among children in underdeveloped countries. Breast feeding of younger babies should be continued during the disease in addition to spoon feeding of small quantities of ORS. Tea, coffee, colas, fruit juices, energy drinks, alcohol etc., should be avoided. A drug to reduce vomiting is often given to adult patients but it is not given to younger children and babies. The antiemetic drug can be given in the form of a suppository or it can be injected as oral administration may not be ideal in severe cases of vomiting.

Normal diet can be resumed as and when the disease is under control but new foods should be added with gradually depending on the patient’s reception. People generally limit their choice to bland and mild food items like rice, toast, bananas and cooked apple, though diet restrictions are unnecessary. Some people may not tolerate certain foods, especially milk, immediately following a bout of diarrhea. Use of lactobacillus culture, available in powder form also, often help people get over the intolerance of milk.

The stool is tested to identify the causative organism and for the presence of blood. Traces of blood in the stool may indicate a serious infection which should be tackled first. If blood is not detected, the patient may be given antidiarrheal drug if the watery stools do not stop in a day or two. diphenoxylate is an antidiarrheal drug often prescribed. Loperamide is another drug which is available over the counter. These antidiarrheal drugs are effective in controlling diarrhea, but children below five years should not use them.

The use of antibiotics in the treatment has certain problems. It may result in drug -induced diarrhea as the antibiotics destroy beneficial bacteria in the intestine making way for the proliferation of certain harmful bacteria like Clostridium difficile. During stool testing, if the cause is found to be certain organisms such as Shigella, Campylobacter and Vibrio, antibiotic therapy is initiated. Traveler’s diarrhea is another instance in which antibiotic therapy is used to treat gastroenteritis.

Intestinal parasites can be eradicated by the use of drugs metronidazole as well as nitazoxanide which are antiparasitic medication.

Some beneficial bacteria found in the gastrointestinal tract are useful in creating a favorable environment for the growth of good microbes while suppressing the proliferation of harmful organisms. Such bacterial cultures called probiotics are useful in managing the diarrhea and reducing the duration of the disease. An example of probiotics is yogurt containing the beneficial bacteria lactobacillus. In severe cases of gastroenteritis probiotics may not have much effect. To control fluid and electrolyte loss which may lead to severe complications, the patient with acute gastroenteritis should be hospitalized for intravenous dehydration therapy.

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What is Diverticulitis

Diverticulitis is a disease condition which results when the diverticula in the gastrointestinal tract become inflamed or infected.

  • The symptoms are pain as well as tenderness in the left side of the lower abdomen and fever.
  • Colon is the usual site of acute diverticulitis, especially the sigmoid colon.
  • CT scan and colonoscopy are the usual tests conducted to confirm the diagnosis.
  • Antibiotic therapy combined with a liquid diet and adequate rest may be sufficient to resolve the condition in mild cases of the disease.
  • When disease is acute with severe symptoms, patients may need hospitalization and intravenous administration of antibiotics. Occasionally, surgery may be necessary.

Diverticulitis is a condition which usually develops in those who are having diverticulosis. The last portion of the large bowel called sigmoid colon is the most usual location of diverticulitis. Since diverticulosis usually starts developing in people in their forties, the incidence of diverticulitis also is frequent in those above that age. The symptoms of the disease can be severe irrespective of the age of the person. However, older people are more prone to developing acute infections, and other complications due to diverticulitis, especially if they have lower immunity levels also, due to corticosteroids and certain other drugs taken. In some cases of acute diverticulitis, surgery may be necessary. Such surgeries are about three times more common in men compared to women in the age group below 50 years. However, this ratio is reversed in people above 70 years, surgeries being three times more frequent in women than in men of that age.

Symptoms and Diagnosis

Abdominal pain and tenderness to touch, usually felt in the lower abdomen on the left side, is often an indication of diverticulitis in the sigmoid colon. Fever is usually present, but bleeding from the rectum or blood in the stool is not a symptom normally encountered in diverticulitis.

When a person has a medical history of previously diagnosed diverticulosis, the typical symptoms are considered to be the sign of diverticulitis. Since there are several other disease conditions with similar symptoms, such as ovarian cancer, colon cancer, appendicitis, uterine fibroids etc., an accurate diagnosis of the condition is necessary. An ultra sound scan may be able to detect the possible cause of the symptoms.

 CT scan is a reliable test which can help diagnose diverticulitis as well as rule out other serious conditions like appendicitis. Colonoscopy is also a very useful viewing test which can confirm the diagnosis of diverticulitis but it is not performed when the disease is active with inflammation and infection.

 Once diverticulitis is successfully treated with antibiotics and other drugs, the large intestine is viewed through a flexible viewing tube called colonoscope, or, an imaging test called barium enema x-ray is conducted. These tests are not performed earlier due to the high risk of rupture or injury they can cause to the intestine when it is in an inflamed condition. However, these tests are useful in determining the severity and extent of the disease and to detect or rule out cancer of the colon.

Complications:  When the wall of the intestine becomes inflamed, it can lead to the development of abnormal channels known as fistulas which connect to other organs which are in contact with the affected parts of the intestine. For example, when a diverticulum which is in contact with the bladder gets inflamed due to a bacterial infection, it may rupture or start leaking exudates with a high bacterial content. The wall of the bladder picks up the infection and the tissue disintegration at the point of contact leads to the development of a channel between the intestine and the bladder. Fistulas are common between the sigmoid colon and the urinary bladder, especially in men. This disparity is due to the presence of uterus in women which lies between the colon and the bladder. Hence, women are equally prone to this condition if they have had hysterectomies done. Once the fistulas are established, the fecal matter as well as the intestinal bacteria can reach the bladder and cause infections there. Fistulas from the large intestine can open to other organs such as uterus, small intestine or vagina too. Some fistulas may have channels which open on the skin surface on the abdomen, chest or thigh.

Diverticulitis may lead to the development of other complications either related or unrelated to the digestive system. The intestinal complications include the rupture of the intestines and formation of abscesses and bleeding. Frequent episodes of diverticulitis may lead to the thickening of the intestinal wall, and scar tissue formation, which may result in obstructions to the passage of stool. Intestinal rupture almost always leads to life threatening peritonitis. Pus filled abscesses may develop, or fistulas may form connections to nearby organs such as urinary bladder and uterus.

Treatment

A short period of rest with fluid diet and antibiotic therapy administered orally may be effective in resolving mild cases of acute diverticulitis. As the symptoms lessen and disappear, a diet of easily digestible soft foods low in fiber may be started. A stool softener such as psyllium husk should be taken daily with the low-fiber diet to facilitate easy movement of the intestinal contents. Normal diet with high fiber content can be resumed after a month.

When symptoms such as fever above101°F or 38.3° C and severe abdominal pain are present, it may indicate acute diverticulitis which may have to be treated with hospitalization and intravenous administration of antibiotic drugs. Oral nutrition is stopped to provide rest to the digestive system and fluids are given intravenously. The patient is advised complete bed rest till symptoms lessen. If the condition of the patient doesn’t show improvement, surgical intervention may be necessary. Two out of every ten cases of diverticulitis usually require surgery. Removal of the diseased section of the intestine may be sufficient in most cases, when the site of bleeding is identified. In a few cases, complete removal of the large intestine called subtotal colectomy may be unavoidable, especially when the bleeding site is not detected.

Intestinal rupture is a medical emergency which requires immediate surgery. The almost certain risk of developing peritonitis or inflammation of the abdominal cavity makes it a potentially fatal situation. The affected portion of the intestine is removed and the remaining colon is connected to an opening created on the abdominal wall by a procedure called colostomy. This is usually a temporary measure, for a short period of 2 to 3 months, after which the intestinal sections will be joined to each other by a second surgery.

All cases of diverticulitis do not necessarily need surgery, but people can opt for the surgical removal of the affected section of the intestine to get permanent relief from diverticular diseases. Abscesses can be drained from the outside with a needle guided by computed tomography, to avoid more invasive surgical interventions.

To treat a fistula that connects to another organ such as the urinary bladder, the portion of the intestine where it originates should be surgically removed. The opening in the other end of the channel should be surgically repaired.

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What Is Diverticulosis

Diverticulosis is an abnormal condition of the digestive tract characterized by the presence of several pouch-like outgrowths called diverticula on the intestinal wall. The large intestine is the most common location of diverticulosis.

  • Muscular spasms of the intestinal wall may be causing the pouch-like bulges in areas of weakness.
  • Diverticulosis may remain asymptomatic or the diverticula may bleed, resulting in bloody stools.
  • Barium enema x-ray and colonoscopy help in diagnosing the condition.
  • Following a diet high in fiber content and use of bulking agents like psyllium help in the management of the condition, by reducing the spasms.

The last portion of the large intestine called sigmoid colon is the usual location of diverticulosis but diverticula can occur elsewhere in the large bowel also. Diverticula may differ in size, the small ones measuring 1/10 of an inch in diameter but the larger ones may be 1 inch or more in diameter. Diverticulosis usually start developing after 40 years of age and the number of diverticula may increase as people get older. Almost everyone nearing 90 years of age may be having diverticulosis. Occasionally, a very large diverticula measuring up to 6 inches in diameter may develop in some people, but they often occur singly.

Causes

The muscular spasms of the large intestine, as it tries to move its contents forward, may be causing certain weak spots in the wall to bulge out and become pouch-like structures. The exact reason for the development of diverticula is still not understood clearly, but it is assumed that the strong muscular contraction of the intestinal wall may be causing this condition. The muscles usually have to contract extra hard to push small quantities of stool resulting from a diet that is deficient in fiber. The higher pressure produced during the stronger contraction of the intestine causes the ballooning out of the intestinal wall in spots where the wall is thinner or weaker. The points of entry of arteries that supply the wall of the intestine are the usual weak spots prone to the development of diverticula. People who have diverticulosis of the sigmoid colon are found to be having a thicker muscular layer on the wall of the colon. It is not clear why a very large solitary diverticulum develop in some people.

Symptoms

Diverticulosis is not a dangerous condition as long as it remains asymptomatic. Many people do not even realize that they have this condition until it is discovered during the diagnostic testing of some other intestinal disorder. However, when diverticula start bleeding, resulting in bloody stools, and when abdominal pain and cramping are present, the condition becomes serious. Diverticular bleeding can be heavy and may come out of the rectum even when the person is not defecating. Pieces of stool may get stuck in the diverticula, leading to inflammation, bleeding and infections. It may develop into a disease condition called diverticulitis. The artery nearer to the diverticula may get damaged in the inflammation. Diverticula may interfere with the normal bowel movements also.

Diagnosis

Disturbances in the bowel movements along with bleeding from the rectum and painful abdominal cramps are the usual symptoms which lead to further investigations and subsequent diagnosis. A viewing test called colonoscopy or an imaging test called barium enema x-ray may be conducted to detect diverticulosis. In colonoscopy, a flexible viewing tube called colonoscope is inserted into large intestine to view its interiors. But, if signs of inflammation such as severe pain and cramping are present, invasive procedures like colonoscopy are avoided, and a CT scan is done instead, to avoid the risk of rupturing the intestine.

Colonoscopy can identify the source of diverticular bleeding, but it may not be enough to attempt surgical repair if required. Other imaging tests such as radionuclide scans or angiography conducted after the intravenous administration of radioactive markers may be necessary to locate the exact spots of bleeding.

 Treatment

The treatment focuses on decreasing muscular spasms of the intestine by bulking up the stool. A diet containing sufficient amounts of fruits, vegetables and unpolished cereals increase the fiber content and quantity of the stool. The larger bulk makes it easier for the muscular wall of the intestine to push the contents forward, reducing spasms as well as the pressure exerted on the wall. In addition to dietary modifications, bulking agents such as methylcellulose or psyllium may be taken too. Drinking plenty of water also helps in the smooth movement of stool.

Surgical intervention is not required when complications associated with diverticulosis such as infections, inflammation, severe bleeding or risk of rupture are not present. Slight diverticular bleeding may stop eventually without intervention. If bleeding continues, minimally invasive procedures using the colonoscope are often successful in stopping it. A drug is often injected into the bleeding site to form a clot which stems the bleeding. But if it recurs frequently or when the bleeding site could not be detected, partial or total removal of the large intestine may be required. But surgeries are done only when absolutely necessary.

A very large diverticulum may have to be surgically removed to prevent life threatening eventualities like severe infections and rupture.

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What is Diverticular Disease

What is Diverticular Disease ? Diverticular disease is a condition resulting  from the formation of balloon-like pouches called diverticula bulging out through the wall of the digestive tract, and, from these diverticula getting inflamed.

Large intestine is the most common location of diverticula. However, they occasionally occur in the small intestine as well as in the stomach. For example, a very common congenital condition called Meckel’s diverticulum is a diverticular disease affecting the small intestine. It is a small bulge present in the small intestine at birth in about 3% of the general population.

Diverticula usually start developing in people who are middle aged. A number of diverticula may develop at different locations along the intestine and their presence is termed as diverticulosis. Inflammation of these diverticula is the disease condition called diverticulitis.

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Clostridium Difficile Colitis (Clostridium Difficile Infection)

Clostridium difficile colitis is an inflammation developing in the large intestine due to the excessive growth of unfamiliar bacteria when the usual intestinal bacteria are destroyed by antibiotics. This condition, which causes diarrhea, is also known as antibiotic-associated colitis as well as pseudomembranous colitis.

  • Antibiotic use is the usual reason for developing Clostridium difficile  colitis.
  • Diarrhea with bloody stools and pain in the abdomen, accompanied by fever, are the usual symptoms.
  • The typical symptoms of colitis following a bout of antibiotic therapy help the doctor diagnose this condition. Stool tests, and less frequently, viewing tests such as sigmoidoscopy or colonoscopy are conducted to confirm the diagnosis.
  • When the antibiotic therapy which precipitated the Clostridium difficile-induced colitis is discontinued, the symptoms may disappear and most patients get well. When the infection is severe, specific drug therapy against the causative organism may be necessary.

Antibiotics may destroy some of the normal bacteria living in the gastro intestinal tract, resulting in an imbalance in the microbiotic environment there. In the absence of the normal set of bacteria, certain other harmful varieties take their place and grow excessively. The presence of these abnormal species of bacteria and the toxins they produce may irritate the lining of the intestines and cause inflammation. Clostridium difficile is a type of harmful bacteria which proliferates in the large intestine when other normal flora is destroyed by the antibiotics. Toxins released by these bacteria inflame the inner lining of the large bowel.

Penicillins like amoxicillin and ampicillin, and clindamycin, are the most common antibiotics resulting in Clostridium difficile-induced colitis. However, use of sulfonamides like sulfamethoxazole, cephalosporins like cephalexin and quinolones like asnorfloxacin also result in infection. Tetracycline, erythromycin and chloramphenicol are some of the other drugs known to be responsible for Clostridium difficile-induced colitis. Chemotherapy drugs used during the treatment of cancer also cause this condition.

Oral antibiotics are the major cause of Clostridium difficile-induced colitis, but intravenous and intramuscular administration of antibiotic drugs also may result in this condition. The risk of infection is higher in older people and it is significantly increases with long periods of hospitalization and confinement to nursing homes. Long-standing disease conditions and surgeries involving the gastrointestinal tract also make people prone to this bacterial infection. Drugs used for reducing the acidity in the stomach such as proton pump inhibitors are another reason for the overgrowth of the Clostridium difficile bacteria.

Clostridium difficile bacteria may be normally present in a person’s gastrointestinal tract without causing any symptoms. Only when suitable conditions are present, such as lowered immunity, or absence of competing organisms as at the time of antibiotic use, they proliferate rapidly and cause disease. People who have the bacteria without showing any symptoms are carriers capable of spreading the infection to susceptible people. Clostridium difficile bacteria are present in water and soil; pets also carry them. Frequent washing of hands is a good measure to control person to person spread of these bacteria.

Clostridium difficile infection seldom develops without recent antibiotic therapy. However, certain stressful situations, especially surgical procedures involving the gastrointestinal tract, may disturb the delicate balance in the micro biotic environment of the intestines, and facilitate the overgrowth of harmful bacteria. When the normal defense mechanisms of the digestive tract are compromised, it may allow the proliferation of bacteria like Clostridium difficile.

Symptoms

The typical symptoms may start developing anytime after the antibiotic therapy is started, but more often they appear within five to ten days. One third of those who develop this condition may have symptoms only after the antibiotic therapy is over. In such cases, Clostridium difficile infection can appear anytime from one day to two months of stopping the drugs.

The symptoms of Clostridium difficile  colitis depend on the severity of the inflammation. It can be mild with slight diarrhea, or severe with bloody stools accompanied with fever and pain in the abdomen. Nausea and vomiting are not common. Extremely severe cases may develop serious complications such as dangerously low blood pressure resulting from severe dehydration. If a potentially fatal condition called toxic megacolon develops, it may lead to perforation or rupture of the large bowel.

Diagnosis

When a patient without pre-existing diarrhea is found to have developed loose stools within 3 days of hospitalization, Clostridium difficile colitis is suspected. Diarrhea developing in people within two months of undergoing antibiotic therapy also may indicate this condition. When a stool sample is tested positive for any of the toxic substances Clostridium difficile infection produces, it confirms the diagnosis. Several stool tests may be necessary to identify the toxins which are usually present in one fifth of the people with a mild form of Clostridium difficile-induced colitis and in 90% of people with a severe form of the disease.

Clostridium difficile colitis may be confirmed by viewing tests such as sigmoidiscopy and colonoscopy. The sigmoid colon is the lower portion of the large bowel and it can be viewed with help of a viewing tube called sigmoidoscope. It can detect abnormalities and inflammations, especially a condition called pseudomembranous colitis indicative of an overgrowth of Clostridium difficile bacteria. When the inflammation is suspected to be higher up in the large intestine, a flexible viewing tube called colonoscope may be used to check the entire length of the large bowel. A tissue sample for biopsy also can be harvested during this test. However, these invasive tests are conducted only when necessary.

Treatment

When diarrhea starts in a person undergoing antibiotic therapy, and if Clostridium difficile colitis is diagnosed, the antibiotics are immediately stopped whenever possible. Anticholinergic, antidiarrheal medications are not given to stop the diarrhea as they may cause the toxins produced by the bacteria to remain longer in the bowels. In the majority of cases, the symptoms of Clostridium difficile colitis subside in ten to twelve days from the discontinuation of the antibiotic which initiated the disease. No further treatment is necessary unless symptoms return. A few remaining symptoms of a mild nature can be treated with cholestyramine resin which may neutralize the toxins by binding with them.

When Clostridium difficile colitis is severe, it is treated with an antibiotic which acts specifically against that bacteria. Metronidazole is an antibiotic drug used for treating this condition. Vancomycin is a drug which is used in very severe cases. Bacitracin is another antibiotic used in extreme situations. In some cases, a yeast based probiotic Saccharomyces boulardii may be required to bring the Clostridium difficile infection under control. In about one fifth of the cases, after the initial success of the drug therapy, the infection may recur and the antibiotics may have to be resumed. If there are frequent episodes of diarrhea, antibiotics are continued for longer periods.

Occasionally, measures have to be taken to repopulate the intestines with normal beneficial bacteria. Lactobacillus preparations can be given orally, or a solution containing stool particles are given as enema, to reintroduce the normal flora into the large bowel. Gamma globulin may be administered intravenously to boost the immunity of the patient. Rifaximin is an antibiotic being studied for its effectiveness in fighting Clostridium difficile infection. The possibility of effective disease control by vaccination is also being researched, especially for the treatment of patients with refractory disease which is resistant to the usual treatments. People who are at greater risk of developing Clostridium difficile colitis also would benefit from vaccination.

Occasionally, hospitalization of the patient and intravenous administration of electrolytes and fluids may be necessary if the Clostridium difficile-induced colitis is very severe. Essential minerals such as sodium, potassium, calcium, and magnesium lost by diarrhea, are replaced by the IV fluids. Blood transfusion is done if required. A surgical procedure called ileostomy may be done to divert the passage of stool away from the large bowel and the rectum by attaching the ileum part of the small intestine to an opening created on the wall of the abdomen. Colectomy, which is the removal of the large bowel, is an emergency surgery occasionally done to save life in very severe cases.

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What Is IBS (Irritable Bowel Syndrome)

What is IBS ?Irritable bowel syndrome is a functional disorder affecting the digestive system, characterized by abdominal cramping and pain often accompanied by variations in the bowel movements such as diarrhea or constipation.

  • Abdominal cramping and pain, gas and bloating are the usual symptoms. Either constipation or diarrhea may be present.
  • Symptoms of irritable bowel syndrome are triggered by various factors such as emotional stress and anxiety, as well as certain food items
  • Typical symptoms of IBS may be sufficient for diagnosis, but further investigations are done to eliminate other possible causes with similar symptoms.
  • Symptoms can be treated with appropriate drugs; regularity in dietary habits may help avoid the development of symptoms.

Irritable bowel syndrome or IBS is a functional disorder and is different from inflammatory conditions such as Crohn’s disease. There are no structural changes or abnormalities associated with this condition; the intestines look normal in imaging tests like x-rays and when viewed with endoscope. The symptoms are caused by certain abnormalities in the movement of the intestines and the workings of the nerves associated with the digestive system.

IBS is a very common condition occurring in about ten to fifteen percent of people irrespective of gender, but some studies have shown that women having the symptoms approach the doctor more frequently than men. Among the digestive disorders brought to the attention of gastroenterologists, IBS is usually the most probable condition diagnosed. Since the structural abnormalities usually associated with the different disorders of the digestive system are absent in the case of IBS, it is mainly diagnosed by the symptoms alone. There are no specific tests to identify the condition; tests only help to confirm the diagnosis by eliminating the possibility of other diseases.

Causes

The exact reason for the occurrence of IBS is unknown but an oversensitivity of the digestive system to various stimuli is regarded to be causing the symptoms. People who have IBS are affected by contractions of the gastro intestinal muscles and gas in the digestive tract more than other people, who generally feel no great discomfort from such frequent occurrences during the digestive process. Abnormal intestinal movements are considered to be the reason for alterations in the bowel movements such as diarrhea and constipation associated with IBS, but it is not necessarily so in all cases. Abnormal contractions are not present in all those who have IBS and even when they are present, the symptoms do not always occur at the same time.

Minor irritants, both emotional and physical stress, and changes in the diet, both in quantity and timings, are known to bring about episodes of symptoms or worsen existing symptoms. Emotional stress, depression, fear and anxiety often act as triggers. Heavy meals, diet rich in fats, consumption of tea or coffee, dairy products, wheat and citrus fruits are just a few of the dietary factors known to cause flare ups. Eating meals hurriedly, and going without food for longer than usual periods of time, also aggravate the condition. Since the reactions to certain foods are not always consistent, it is difficult identify and avoid irritants. It is not always a specific food allergy which causes symptoms but at different times, different substances precipitate adverse reactions. The reason for inconsistencies in the body’s reaction to the same agents is still not understood.

Symptoms

Symptoms of IBS usually start appearing in the teenagers and people in the early twenties. The symptoms appear without any warning and often disappear without any medication. The episodes recur frequently and unpredictably but they usually occur only when he person is conscious and awake. They rarely disturb sleep. IBS can start developing later in life too, but it is much less common than the early onset of the disease.

The most common symptom of IBS is abdominal cramping and pain which almost always gets relieved when the person has a bowel movement. The frequency of bowel movements and the consistency of stool keep changing. Distention or bloating of the abdomen and feeling of fullness in the rectum even after a bowel movement are some of the features of this condition. The stool may contain mucus too. Pain in the lower abdomen may be sharp and intermittent like cramps or it may be a dull constant ache lasting over a period of time. Nausea, gas, headache, depression general fatigue and anxiety are other symptoms usually found along with pain and bloating of the abdomen. The severity and duration of symptoms may change from time to time but some pattern may emerge with regard to the triggers that precipitate the symptoms and changes in the bowel movements.

Diagnosis

There may not be any outward symptoms in a person which indicate the presence of IBS. The doctor may not detect any abnormalities during a physical examination too, except for a slight tenderness felt when pressing the area above the large intestine. Several tests are done including stool tests, blood tests and viewing test such as colonoscopy or sigmoidoscopy. These tests are not for detecting IBS but to ensure that the person is not having other inflammatory diseases such as ulcerative colitis, Crohn’s disease, lymphocytic or collagenous colitis etc., which have symptoms similar to those of IBS. Colon cancer is another disease to be ruled out. If the person is having IBS and no other disorder, the test results will be normal. However, invasive tests like sigmoidoscopy usually result in the worsening of the symptoms in people who have IBS.

In people 40 years and older, the risk of inflammatory diseases and cancer are higher; hence more tests, including abdominal scans, x-rays, and colonoscopy, are conducted. If certain other symptoms such as bloody stools or bleeding from the rectum, fever, and vomiting or weight loss are also present, in addition to the typical symptoms of IBS, detailed testing is necessary. In a person diagnosed with IBS, other digestive disorders such as gastric ulcers, appendicitis, cancer or gall bladder disease may develop eventually as the person gets older. The additional symptoms precipitated by the new developments should be taken seriously and investigations should be conducted. Any change in the pattern or severity of existing symptoms also should be brought to the attention of the doctor.

What Is IBS Treatment

Treatment depends on the symptoms and the conditions which trigger flare ups in different people. If the triggers are identified, they can be avoided as much as possible. If emotional stress is aggravating the disease, people should learn ways to avoid such stressful situations or learn techniques to handle stress such as yoga, meditation, breathing exercises etc. Constipation can be avoided by physical activity on a regular basis, in addition to following a fiber-rich diet.

 A simple diet with regularity in mealtimes is ideal for managing irritable bowel syndrome. Several smaller meals evenly distributed throughout the day may be better than having two or three heavy meals. Cabbage, beans, and other food items which are hard to digest, and are known to produce gas, should be avoided by people who have complaints such as abdominal bloating and flatulence. Certain food additives like sorbitol, which is used as a sweetening agent in dietetic food items and chewing gums as well as in certain drugs, should be avoided as much as possible. Fruit sugar known as fructose, abundant in berries and as a food additive in some sweets, should be consumed in small quantities only. A diet low in fat content is found to be beneficial for some people who have frequent motions. If a person is lactase deficient in addition to having irritable bowel syndrome, lactose rich food items, mainly milk and milk products, should be avoided or taken in small quantities.

A diet rich in fiber content is usually sufficient to tackle constipation, but addition of bran to the diet or taking spsyllium preparations help in keeping the stool smooth. It is very important to take plenty of fluids and water while taking psyllium and extra bran. Bloating and flatulence are side effects of taking extra fiber. They may be avoided by taking methyl cellulose instead, which is a synthetic fiber product.

Some laxatives can be used safely to relive constipation. Drugs which contain lactulose, sorbitol or polyethylene glycol are usually used. Stimulant laxatives which contain glycerin or bisacodyl, as well as a new drug named lubiprostone, are also found to be beneficial.

Abdominal pain can be treated with muscle relaxants that work on the gastrointestinal muscles. Dicyclomine is effective in reducing pain, but being an anticholinergic drug, it may precipitate many side effects including blurring of vision, difficulty in passing urine and dry mouth.

The drugs loperamide or diphenoxylate are usually used to relieve diarrhea. Another drug used is alosetron which reduces the effect of the neurotransmitter serotonin. Peppermint oil is an active ingredient in formulations which help reduce abdominal cramping and flatulence. Cognitive-behavioral therapy, hypnosis, and other techniques to change behavior patterns are found to be effective in managing symptoms in people with IBS. Psychotherapy and antidepressants are included in the clinical options for managing IBS. Antidepressants in small doses are found to be effective in relieving not only the emotional symptoms such as anxiety, depression and sleep problems but also many of the physical symptoms like abdominal pain and cramping.

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Diversion colitis

Diversion colitis is an inflammatory condition developing in the remaining colorectal part of the large bowel, when the portion above it is diverted to an opening in the abdominal wall by surgical procedures like ileostomy or colostomy.

Diversion colitis starts within a year of the diversion surgery and results in mucus discharge and bleeding from rectum.

Ileostomy is a surgical procedure in which the last part of the small intestine called ileum is surgically attached to an opening created on the wall of the abdomen for excretion. In colostomy, part of the large intestine is connected to the abdominal opening created. Both theses surgical procedures are usually done as part of the treatment for various diseases affecting the intestines. Inflammatory bowel diseases such as ulcerative colitis, and Crohn’s disease, cancers of the intestines, diverticulitis, intestinal obstructions, ruptures, and perforations, are some of the reasons for the partial or complete removal of intestines. Injuries caused to the intestines also may require surgical diversion. Sometimes, ileostomy or colostomy may be temporary measures for diverting the passage of stool, till the diverted upper portion can be reattached to the remaining colorectal part.

The colorectal part left intact may get inflamed in about one third of cases, resulting in diversion colitis characterized by mucus discharge and bleeding from the rectum, often accompanied by pain. This inflammatory condition usually develops within a year following the diversion procedure. The symptoms are usually mild and may not require treatment. Surgical reattachment of the upper and lower parts of the intestines effectively resolves both the inflammation and the symptoms, in addition to restoring normal bowel movements.

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Collagenous colitis and lymphocytic colitis

Collagenous colitis is a chronic inflammatory disease in which white blood cells of a certain type infiltrate the lining of the large bowel, causing severe inflammation and thickening of the wall, and resulting in watery diarrhea. Lymphocytic colitis is another inflammatory condition similar to collagenous colitis.

The disease is not limited to any specific area of the large intestine and can affect the whole length of it, including the last part called sigmoid colon, as well as the rectum. Often the diseased areas are not continuous, but occur intermittently along the large bowel. A type of WBC called lymphocytes may accumulate in the walls in large numbers. A connective tissue called collagen develops as a thick layer on the lining of the large bowel making it less absorbent of fluids resulting in watery stools.

The exact reason for the development of these diseases is not known. Excessive reaction of the immune system to dietary or environmental triggers is thought to be resulting in the inflammation of the intestinal lining. These diseases are more frequently found in people who use non-steroidal anti-inflammatory drugs regularly, but there is no conclusive proof of the role of NSAIDs in causing them. Neither collagenous colitis nor lymphocytic colitis elevates colon cancer risk, unlike the other chronic inflammatory diseases like ulcerative colitis and Crohn’s disease.

The incidence of collagenous colitis is higher in women, especially among those who are middle aged and older. However, irrespective of age, both men and women are equally prone to developing lymphocytic colitis.

Symptoms and Diagnosis

Thin watery diarrhea is the most common symptom associated with both collagenous colitis as well as lymphocytic colitis. However, the diarrhea is not bloody, unlike other inflammatory diseases of the bowel such as ulcerative colitis and Crohn’s disease. Other symptoms include nausea, distention of abdomen, pain, and abdominal cramps. Loss of appetite and weight loss are also common. A few days of fasting has a beneficial effect of alleviating symptoms. The symptoms appear during flare ups, with periods of remission in between.

 Chronic watery diarrhea without bloody stools may alert the doctor to the possibility of these two inflammatory bowel diseases, especially when other causes are not detected.  These two inflammatory conditions are together known as microscopic colitis, because a microscopic analysis of a tissue sample of the lining of the large bowel is the diagnostic test for both collagenous colitis as well as lymphocytic colitis. A colonoscopy is conducted to view the interiors of the large intestine and to obtain a tissue sample of the lining.

Treatment

Drug therapy includes treating the diarrhea with diphenoxylate and loperamide which are antidiarrheal drugs having anticholinergic effect. Mesalamine and sulfasalazine are immonomodulating drugs used for their anti-inflammatory effect. Bismuth subsalicylate is another useful drug to relieve inflammation. Antibiotics, and another drug called cholestyramine which can bind to bile salts, are also used for the treatment.

Prednisone is a corticosteroid which is very effective in the treatment of inflammatory bowel diseases, but it is used only when other drug therapies are not effective because of the potential ill effects of long-term corticosteroid use.  Another corticosteroid called Budesonide which has lesser side effects may be tried.

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What Is Ulcerative Colitis

Ulcerative colitis is an inflammatory bowel syndrome affecting the large intestine, characterized by ulcers or sores which develop on the wall of the large bowel, resulting in recurrent bloody diarrhea accompanied by fever, and abdominal pain and cramping.

  • Intermittent bouts of diarrhea, with stools mixed with blood, abdominal pain and cramps, and fever, are the usual symptoms
  • The reason for the development of ulcerative colitis is unknown.
  • Colonoscopy to examine the interiors of the colon, and sigmoidoscopy to detect abnormalities in the sigmoid colon, which is the last part of the large intestine, are the usual tests for diagnosing this condition.
  • Ulcerative colitis for prolonged periods may lead to the development of colon cancer.
  • The treatment focuses on reducing the inflammation and alleviating the symptoms.

Ulcerative colitis usually start developing in people in the age group 15-30 years, but sometimes it appears as late as when a person is over 50 years also.

Ulcerative colitis is often restricted to the large intestine; the inflammation usually starting in the rectum and then spreading upward into the sigmoid colon, which is the last portion of the large intestine. The disease may gradually spread further, to cover the whole length of the large intestine. However, it rarely affects the small intestine. Ulcerative colitis is limited to the inner wall of the bowel too, usually not affecting the entire thickness.

When the inflammation is restricted to the rectum, it is termed as ulcerative proctitis, which is the more common and less troublesome form of ulcerative colitis. But in several cases, within a short period, the inflammation affects the colon too.

The exact reason for the development of ulcerative colitis is still unknown but is thought to be resulting from the over reaction of the immune system. Hereditary factor also is suspected, as most people suffering from this condition usually have a close relative with the same disease. Smoking is found to trigger flare ups of Crohn’s disease but contrary to expectation, it is found to reduce the risk of developing colitis. However, smoking, as a way to prevent ulcerative colitis, is not recommended at all, as the ill effects of smoking far outweighs the benefits.

Symptoms

Ulcerative colitis has active and passive phases which occur intermittently. The typical symptoms appear during the flare ups. During a severe flare up which may occur suddenly, it causes severe bloody diarrhea accompanied by pain in the abdomen and high fever. The peritoneal lining of the abdomen also may become inflamed leading to a condition called peritonitis. Flare ups may start any time, and each episode may last from several days to many weeks. People become severely ill during this time. Usually, the flare ups may be milder, and develop gradually, beginning with an urgency to defecate. It may be accompanied by milder abdominal cramps and blood stained stools.

When ulcerative colitis is restricted to the last portion of the colon and the rectum only, diarrhea may not be present. The stool may be well-formed and dry, but it may contain large amounts of blood stained mucus produced by the rectum. Other symptoms such as fever may be completely absent or may be present in a milder form.

When ulcerative colitis has spread to most parts of the large bowel, it results in frequent bowel movements, sometimes as frequent as ten to twenty times a day. The watery stools usually contain blood, mucus and pus. Often, the stool may be just pus and blood. The frequent urge to have a bowel movement is usually accompanied by painful abdominal spasms and cramping, even during the night. Fever may be present and loss of appetite may lead to weight loss.

Complications: Bleeding from the rectum is one of the complications which results in anemia. In one tenth of people with this condition, the initial attack is extremely severe, accompanied by fever as well as bleeding, and may result in spread of infections and perforations of the intestine.

Another complication of ulcerative colitis is the development of toxic colitis, a condition in which the disease damages the whole thickness of bowel wall. It may lead to ileus or the temporary halting of the normal peristaltic movements of the intestine. This causes the contents of the bowel to stagnate, resulting in the distention of the abdomen. Eventually, the muscle tone of the large intestine is lost, and the paralyzed parts start to enlarge, filling up with gas.

Toxic megacolon is a dangerous complication which develops when the large bowel becomes greatly distended. Abdominal pain and high fever are usually present, and the WBC count is elevated. There is a high risk of the intestine rupturing and leading to a potentially fatal situation. Toxic megacolon is a medical emergency, and with immediate treatment, the rupture of the intestine and the fatal outcome may be prevented.

Colon cancer is another potentially fatal complication developing in about 1% of those who have long-standing ulcerative colitis. The risk of developing colon cancer depends on the duration and extent of the disease; the risk being highest when the whole of the large intestine is involved, and the when the disease has been present for more than eight years. That is the reason why people suffering from ulcerative colitis should undergo a viewing test called colonoscopy every year or at least once in two years, especially after about eight years from the onset of the disease. In addition to viewing the interiors of the colon and the rectum for abnormalities, a tissue sample for biopsy is also collected using the colonoscope. The biopsy can detect precancerous conditions like dysplasia. Appropriate treatment initiated on the detection of dysplasia, or even in the initial stages of cancer, can be lifesaving. Surgical removal of colon effectively cures the cancer at this stage.

Several other complications of ulcerative colitis include inflammatory conditions in other parts of the body which develop during the flare-ups. Episcleritis, which is the inflammation of the sclera or the white part of the eye ball, arthritis characterized by painful inflammation and stiffness of the joints, or inflamed nodules developing on the hands and legs called erythema nodosum, and pyoderma gangrenosum, in which pus-filled, blue-red sores break out on the skin, are some of the complications.

In people with ulcerative colitis, even during the remission period, inflammatory conditions such as pyoderma gangrenosum, uveitis or eye inflammation, sacroiliitis or inflammation in the pelvic joint and ankylosing spondylitis or the inflammation occurring in the spine, are usually found. Blood clot formation in the veins is a rare but dangerous complication which may occur in people with ulcerative colitis.

Liver dysfunction is common in those who have ulcerative colitis, but it is usually a minor dysfunction. However, up to three cases out of every hundred may develop mild or severe forms of liver disease. When the liver disease is severe, wide ranging inflammations may occur, such as active hepatitis caused by liver inflammation and primary sclerosing cholangitis, which is bile duct inflammation. Chronic inflammation of the liver may cause the normal liver tissue to be replaced by scar tissue, resulting in cirrhosis. Inflamed bile ducts may become narrowed and get completely closed. Inflamed bile ducts have a higher risk of developing into cholangiocarcinoma or bile duct cancer. The risk of developing colon cancer is usually found to have a direct link to the incidence of cholangiocarcinoma.

Diagnosis

The typical symptoms of the ulcerative colitis, and a stool test, help the doctor to diagnose this disease. There are no specific blood tests to detect this condition. Low hemoglobin count, higher than normal WBC count, high ESR rate, and low blood levels of albumin, may be indicative of anemia and inflammation. When the sigmoid part of the colon is examined with a viewing tube called sigmoidoscope, the abnormalities and signs of inflammation observed, help confirm the disease. A biopsy is also done, and the detailed examination of the tissue sample may reveal inflammation, which is taken as a conclusive evidence of the disease.

An x-ray can show the location and spread of the inflammation, but barium enema x-ray is not done when the disease is in the active phase. Colonoscopy is also avoided during this time, but it is conducted later to examine the whole of the large intestine and determine the severity and spread of ulcerative colitis.

Prognosis and Treatment

This chronic inflammatory bowel syndrome is characterized by active and passive phases, which appear intermittently throughout a person’s life. The initial attack of ulcerative colitis, which is usually severe, results in the quick spread of the inflammation and the development of complications associated with it. In around ten cases out of a hundred, people recover completely after the first attack. However, there is a possibility that the typical symptoms of ulcerative colitis displayed during the attack may have been the result of some other severe infection. A biopsy of a tissue sample from the colon may help in proper diagnosis.

The prognosis of people with ulcerative proctitis is very good as they usually have no major complications. But in 10% to 30% of cases, the inflammation may progress into ulcerative colitis affecting the large bowel.

The treatment of ulcerative colitis is focused on bringing the inflammation under control and alleviating symptoms and ensuring quality of life. There is no permanent cure for this disease except the complete removal of the rectum as well as the large intestine.

Dietary Restrictions: People with ulcerative colitis are usually advised to avoid raw vegetables and fresh fruits, as they may worsen the inflammation of the intestinal lining. A dairy-free diet is found to be effective in reducing symptoms in some people. It can be tried, and if found to be beneficial, can be continued for better management of the disease. Supplemental iron should be taken to prevent anemia due to frequent bleeding from the rectum.

Antidiarrheal Drugs: Anticholinergic drugs, including antihistamines and certain antidepressants, are effective in controlling diarrhea. Depending on the severity of the diarrhea, the drug loperamide or another drug diphenoxylate may be taken in small or high doses. Codeine and deodorized tincture of opium are also used to control severe diarrhea. Antidiarrheal medication in high doses should be used under medical supervision to prevent the potentially fatal condition called toxic megacolon from developing.

Anti-Inflammatory Drugs:  Sulfasalazine, and related drugs mesalamine, olsalazine as well as balsalazide may help in treating ulcerative colitis, as they can bring down inflammation and the severity of symptoms. They are most effective in treating mild to moderate forms of the disease; and they help prevent frequent flare ups and maintain remission for longer periods. The risk of developing cancers of the colon or the rectum may be decreased by the use of these drugs.

The use of corticosteroids like prednisone has an immediate beneficial effect on patients with severe or moderately severe form of ulcerative colitis. Prednisone can be taken orally, but high doses may be needed initially, to bring the disease under control. After some amount of control is achieved, the drug sulfasalazine or other related drugs such as mesalamine or olsalazine are used for the maintenance of the remission. To reduce the side effects of long-term corticosteroid usage, predinisone is gradually weaned off. When the disease is mild and is restricted to the rectum and to the descending colon on the left side of the body, corticosteroids as well as mesalamine may be administered as suppositories or enemas.

Hospitalization of the patient may be necessary in severe cases of ulcerative colitis. All medications, nutritional support and rehydration therapy are administered intravenously till the condition improves. If blood loss has been heavy, blood transfusion may be given.

Immunomodulating Drugs: Mercaptopurine and  azathioprine  are immunomodulators used to treat ulcerative colitis. They reduce the immune response of the body by inhibiting the normal actions of T cells, and help avoid the log-term use of corticosteroids. The drawback is that their action is slow and it may take one to four months before any tangible benefits are felt. Their potential side effects are also a cause of concern, and the patients taking these medications have to be closely monitored during the therapy for adverse reactions.

The drug cyclosporine is found to be effective in some cases which show poor response to corticosteroids. But the beneficial effect is often temporary, and in some cases, surgery may have to be done eventually.

The comparatively new drug Infliximab, synthesized from monoclonal antibodies, is found to be effective in the treatment of ulcerative colitis in some people, whose response to immunomodulating drugs as well as corticosteroid therapy is not adequate.

Surgery: Around 30% of the ulcerative colitis cases may require surgical intervention at some time or the other. The surgery can be an emergency procedure or a pre-planned event. Perforations of the intestine, heavy bleeding, formation of blood clots, and toxic megacolon, are some of the potentially dangerous situations which necessitate emergency surgical intervention. Biopsy showing dysplasia, and colon cancer detected in the early stages, and narrowing of the large bowel, are the usual reasons for planned surgeries. When the symptoms of ulcerative colitis remain severe despite possible drug therapies, surgery is an option. Sometimes surgery is performed to avoid constant heavy use of corticosteroids, and to prevent growth retardation due to frequent flare ups, and malabsorption, in children.

Since ulcerative colitis is normally restricted to the large bowel and the rectum, surgical removal of these parts of the digestive tract effectively cures the disease. Earlier, this surgery used to be followed by an ileostomy, by which an outlet for excretion is created in the abdominal wall, to which the ileum or the last portion of the small intestine is attached. Patients had to carry a removable plastic bag to collect stool which is attached to the opening by a plastic tube. Now there are better options available, such as ileo-anal anastomosis in which normal defecation is made possible. After the removal of the large bowel and the major portion of the rectum, the cut end of small intestine is enlarged to form a reservoir for stool, which is then attached to the remaining portion of the rectum. Since the anal sphincter is left intact, it ensures fecal continence and the patient is able to lead a normal life. However, the reservoir may get inflamed, resulting in a condition called pouchitis.

Surgery is not necessary to treat ulcerative proctitis. But some cases may not be responsive to treatment and the symptoms may not subside easily. But it does not in any way affect the life span of a person.

When a potentially fatal complication called toxic megacolon is detected, it is treated as a medical emergency. The patient is put on fast and antidiarrheal medications are stopped. A suction tube is inserted into the small intestine via the nose, to remove the contents and secretions of the stomach and the intestine from time to time. All the necessary drugs and nutritional feeding are administered intravenously. The patient is kept under observation to detect perforation of the intestine and the development of peritonitis. Infliximab or cyclosporine may be given, depending on the patient’s condition. The large intestine is either partially, or totally, removed in an emergency operation, if the other measures do not improve the condition.

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