Gallstones
Gallstones affect 20 percent of women
and 10 percent of men, or approximately 20 million adult Americans. Each year
nearly 600,000 patients undergo surgery to have their gallbladders removed, at
an estimated cost of over $5 billion dollars. Most gallstones are solid
masses, primarily of cholesterol. Gallstones develop in the gallbladder or
less often in the bile ducts leading from the liver to the small intestine.
Most patients with gallstones never
develop symptoms. However, some patients will develop symptoms of mid- or
right-upper abdominal pain that may lead to complications such as acute
cholecystitis and pancreatitis. Gallstones are rarely associated with
gallbladder cancer.
Once a patient has been diagnosed with
symptomatic gallstones, treatment options include surgery by open
cholecystectomy or laparoscopic cholecystectomy, watchful waiting, or oral
bile acid therapy in patients who cannot tolerate surgery. Laparoscopic
cholecystectomy, introduced in the United States in 1988, has fast become the
most popular treatment for gallstones.
This procedure uses a miniature video
camera and several specialized instruments, which are inserted into the
patient's abdomen through tiny incisions. Viewing the gallbladder on an
external television monitor, the surgeon uses these instruments to dissect,
clamp, and remove the gallbladder without opening the abdomen.
The procedure has several advantages
over open surgery: less postoperative pain and disability, a shorter hospital
stay, and a quicker recovery period, resulting in less time lost from work.
While most patients with symptomatic
gallstones are candidates for laparoscopic cholecystectomy, the surgery is not
recommended for patients with abdominal inflammation (peritonitis), acute
pancreatitis, end-stage cirrhosis of the liver, or gallbladder cancer. Women
in the third trimester of pregnancy should not undergo laparascopic
cholecystectomy because of risk of damage to the fetus.
Gastroesophageal Reflux
Disease and Related Disorders
Gastroesophageal reflux disease (GERD)
is a digestive condition that affects nearly one-third of the American
population. GERD is the backward flow of the stomach's contents into the
esophagus. The lower esophageal sphincter (LES), the muscle that lies at the
base of the esophagus and the stomach and helps keep food in the stomach, is
usually weak in a patient with GERD.
Heartburn, which is characterized by burning pain that radiates through the
chest, neck, and throat, is the most common symptom of GERD. Heartburn may
occur when a person with GERD eats, bends, or lies down. Antacids may provide
temporary relief from heartburn.
Doctors also believe that diet and
lifestyle habits, hiatal hernia, obesity, and pregnancy contribute to GERD.
Certain foods,including chocolate, fried or fatty foods, and alcohol may
weaken the LES, permitting reflux and heartburn.
A complete clinical history is the
cornerstone of the evaluation of GERD. Depending on the nature and severity of
symptoms, patients may undergo an endoscopy or upper GI series. If baseline
diagnostic tests prove inconclusive, a patient's doctor may rarely order a
24-hour pH monitoring test to assess the episodes of reflux and type of
activity associated with the symptoms.
Lifestyle modifications such as
eliminating cigarettes and avoiding high-fat foods may be key to effective
antireflux treatment for patients. Patients who do not respond to lifestyle
changes alone may find relief if antacid treatment is added. Antacids such as
Tums and Gaviscon neutralize stomach acid for relatively short periods of
time. Therefore, patients may need to take them frequently, usually 1 to 3
hours after meals and at bedtime, depending on the severity of their symptoms.
Histamine 2 (or H2-blockers), which
suppress acid, are also prescribed to relieve symptoms of GERD. The
H2-remedies currently available include cimetidine (Tagamet), famotidine (Pepcid),
nizatidine (Axid), and ranitidine HCl (Zantac). H2-remedies, are now available
to patients without a prescription. They may be taken from one to four times a
day.
To treat resistent reflux symptoms,
doctors may use higher or more frequent doses of H2-blockers, or switch to a
more potent inhibitor of gastric acid secretion such as an acid pump
inhibitor, or recommend antireflux surgery. For convenience and effectiveness,
doctors are likely to prescribe an acid pump inhibitor to treat severe cases
of GERD.
Omeprazole (Prilosec, Losec, or Antra),
approved by the Food and Drug Administration (FDA) in 1989, is the first acid
pump inhibitor to dramatically inhibit an enzyme, H+(hydrogen), K+(potassium)-ATPase,
from producing stomach acid; lansoprazole (Prevacid) has also recently been
approved. Recent studies show that omeprazole and lansoprazole provide
complete relief of severe GERD symptoms within approximately 1 to 2 weeks.
Some patients with severe GERD or young
patients who require continuous medical therapy may be good candidates for
surgery. However, all patients should be given a trial of intensive medical
therapy first. GERD is a chronic condition, but with diligence and careful
medical evaluation and treatment, GERD patients can find relief.
Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) refers
to two chronic intestinal disorders: Crohn's disease and ulcerative colitis.
IBD affects between 2 to 6 percent of Americans or an estimated 300,000 to
500,000 people. The causes of Crohn's disease and ulcerative colitis are not
known, but a leading theory suggests that some agent, perhaps a virus or
bacterium, alters the body's immune response, triggering an inflammatory
reaction in the intestinal wall. The onset for both diseases peaks during
young adulthood. An individual with either disease may suffer persistent
abdominal pain, bowel sores, diarrhea, fever, intestinal bleeding, or weight
loss.
If your doctor thinks you have either
Crohn's disease or ulcerative colitis, a variety of procedures and tests such
as endoscopy and barium GI studies are available to confirm disease. Once
diagnosed, treatment options may include medications, dietary changes, and
sometimes surgery, to remove diseased bowel.
Remission is possible in either
condition, but both persist over an individual's lifetime.
Crohn's Disease
Crohn's disease primarily involves the small bowel and the colon. It may cause
the intestinal wall to thicken, which may narrow the bowel channel and block
the intestinal tract. About 90 percent of patients with Crohn's disease
experience frequent and progressive symptoms of abdominal pain, diarrhea, and
weight loss. The most commonly used drugs to treat Crohn's are sulfasalazine,
prednisolone, mesalamine, metronidazole, and azathioprine.
If a patient does not respond to oral
medications, the doctor may recommend surgery. Although surgery relieves
chronic symptoms, Crohn's disease often recurs at the location where the
healthy parts of the bowel were rejoined. The length of time that a Crohn's
patient is in remission is not predictable.
Ulcerative Colitis
Ulcerative colitis (UC) is an inflammatory disorder affecting the inner lining
of the large intestine. The inflammation originates in the lower colon and
spreads through the entire colon. Blood in the stool is the most common and
distinct symptom of ulcerative colitis. As with Crohn's disease, doctors
diagnose ulcerative colitis by conducting a complete physical exam and other
procedures such as barium enema and endoscopy.
Patients with mild or severe ulcerative
colitis are initially treated with sulfasalazine. Other experimental drugs to
treat ulcerative colitis include budesonide, tixocortol pivalate enema, and
beclomethasone dipropionate enema. Despite new therapies, an estimated 20 to
25 percent of ulcerative colitis patients will need surgery. Surgery cures
ulcerative colitis and most patients can go on to lead normal lives.
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a
common functional disorder of the intestines estimated to affect 5 million
Americans. The cause of IBS is not yet known. Doctors refer to IBS as a
functional disorder because there is no sign of disease when the colon is
examined. However, doctors believe that people with IBS experience abnormal
patterns of colonic movement. The IBS colon is highly sensitive, overreacting
to any stimuli such as gas, stress, or eating high-fat or fiber-rich foods.
Patients with IBS often experience
alternating bouts of constipation and diarrhea. Although abdominal pain and
cramps are among the most common IBS symptoms, pain or discomfort alone does
not suggest IBS. However, when a bowel movement or the passage of gas
temporarily relieves pain and cramps, a doctor may suspect IBS.
IBS is frequently diagnosed after
doctors exclude more serious intestinal diseases through a detailed medical
history and complete physical examination.
There is no standard way of treating
IBS. Treatment depends on the severity, nature, and frequency of a patient's
symptoms, and may range from lifestyle and dietary changes to antidepressants
and psychotherapy.
Peptic Ulcer Disease
Peptic ulcer disease, estimated to
affect 4.5 million people in the United States, is a chronic inflammation of
the stomach and duodenum. Peptic ulcer disease is responsible for substantial
human suffering and a large economic burden. Every year 4 million people
report missing approximately 6 days from work because of their ulcers.
Peptic ulcers result from the breakdown
of the lining of the stomach and duodenum caused by increased stomach acid and
pepsin and Helicobacter pylori (H. pylori). One type of ulcer occurs in
the stomach, the other in the duodenum, the first part of the small intestine.
Duodenal ulcers are much more common than stomach ulcers, which have a greater
risk of malignancy.
There are no specific symptoms of
gastric and duodenal ulcers. However, upper abdominal pain and nausea are the
most common symptoms of peptic ulcer disease. Ulcer pains usually occur an
hour or two after meals, or in the early morning hours and abate after food or
antacids have been eaten. Definitive diagnosis of peptic ulcer disease
requires endoscopy, which also allows a doctor to obtain biopsy samples, if
needed. The FDA's 1996 approval of a safe, effective breath test makes
noninvasive diagnosis of ulcers possible.
In the 1950's, doctors thought stress
and diet caused peptic ulcer disease. Treatment during those years
concentrated on bed rest, bland foods, and in some cases, hospitalization.
But in 1982, Helicobacter pylori
was isolated from gastric biopsies of patients with chronic gastritis, and is
now believed to be the major cause of peptic ulcer disease. H. pylori
is found in almost 100 percent of patients with duodenal ulcers and in 80
percent of patients with gastric ulcers.
Recently, an independent panel of
medical experts convened by the NIH confirmed that using a combination of
antimicrobial drugs for at least 2 weeks will eradicate H. pylori in a
majority of patients, thus reducing the relapse rate of ulcers. A combination
of Pepto-Bismol, tetracycline, and metronidazole effectively kills H.
pylori in approximately 90 percent of patients. The FDA recently approved
a two-drug combination of clarithromycin (Biaxin) and omeprazole (Prilosec) to
cure stomach ulcers and prevent them from coming back.
Viral Hepatitis
Viral hepatitis consists of at least
five different diseases (A, B, C, D, and E) caused by five different viruses.
All five viruses can lead to acute hepatitis. Hepatitis B, C, and D may also
cause chronic hepatitis.
Hepatitis A (HAV)
Hepatitis A virus (HAV), also known as infectious hepatitis, accounts for 32
percent of reported U.S. cases of hepatitis. HAV is spread by direct contact
with an infected individual's feces or indirect fecal contamination of food,
water, or food that comes from HAV-infected water sources. Failing to wash
one's hands after handling dirty diapers or using the toilet may also spread
HAV. Day care centers, restaurants, and crowded, unsanitary housing
developments have the highest rates of HAV transmission. Symptoms of HAV may
include fever, malaise, dark urine, light stool and jaundice.
An antibody blood test confirms the
presence of HAV. Deaths are rare. The elderly and people suffering with immune
system problems such as HIV/AIDS are most at risk of dying from HAV. A
recently FDA-approved HAV vaccine is available to prevent this disease.
Vaccine is recommended for travelers or for persons at high risk of acquiring
HAV and for patients with liver disease.
Hepatitis B (HBV)
An estimated 5 percent of the world's population is infected with hepatitis B
virus (HBV). In the United States, 300,000 new cases of HBV are reported
yearly. Chronic liver disease develops in about 5 to 10 percent of patients
with acute HBV infection. HBV may be spread by exposure to infected body
fluids, urine, semen, and blood clotting products; from a mother to her infant
at birth or soon after; or by unprotected sex with an infected person.
Patients infected with HBV may not
experience any symptoms. If symptoms occur, they may include abdominal pain,
anorexia, jaundice, malaise, nausea, and vomiting. Fever and joint pain may
also develop. A simple and specific blood test for HBV antibodies confirms the
presence of the virus.
No cure is available for HBV. Interferon
alfa, approved by the FDA to treat adults with chronic hepatitis B, is
effective in 40 to 50 percent of patients at most. However, an FDA-approved
HBV vaccine protects 90 to 95 percent of healthy persons. The Centers for
Disease Control and Prevention (CDC) recommend universal vaccination for all
infants and those at risk for infection either because of job or lifestyle
habits.
Hepatitis C (HCV)
Infecting about 200,000 Americans each year, HCV (formerly called non-A, non-B
hepatitis) is becoming the most commonly diagnosed hepatitis. HCV
disproportionately affects African-American and Hispanic males. Recent data
from the CDC indicate that HCV is now the second leading cause of death among
African-American males aged 18 to 34 living in Harlem.
Approximately 3 million people in the
United States are chronically infected with HCV. Hepatitis C is primarily
spread by exposure to contaminated blood or needles. While sex with an
infected person and mother-to-child transmission have been suspected to spread
HCV, the mode of transmission for 43 percent of cases is unknown. HCV-infected
patients rarely clear the virus and at least 80 percent of those infected
become chronic disease carriers. Symptoms for HCV are similar to other types
of hepatitis.
A specific blood test for hepatitis C
antibodies identifies persons with HCV. There is no vaccine and no cure for
HCV, but 50 percent of patients with acute cases of HCV recover without
treatment. Interferon alfa-2b has been approved for treating hepatitis C.
Interferon alfa appears to shorten recovery time and reduce the severity of
flare-ups. HCV, like hepatitis B, also increases a person's risk of developing
liver cancer.
Hepatitis D
Hepatitis D virus (HDV) was first described in 1977 in patients infected with
chronic hepatitis B virus (HBV). When HDV occurs in patients who already have
chronic HBV, it is considered a superinfection; when patients develop acute
cases of both HBV and HDV at the same time, HDV is considered a co-infection.
Persons co-infected with acute HBV-HDV usually go into remission. In contrast,
90 percent of individuals with HDV superinfection develop persistent HDV
infection, which eventually leads to chronic liver disease.
HDV may be spread by exposure to
contaminated blood products or needles and by unprotected sex with an infected
person. There are blood tests available to diagnose HDV, but they are less
accurate and sensitive than the tests used to diagnose HAV and HBV.
Controlling and preventing HBV would eliminate the spread of HDV.
Hepatitis E
The transmission of hepatitis E virus (HEV) has not been documented in the
United States. This is, however, a common cause of acute hepatitis in
underdeveloped areas of the world and travelers to these areas can acquire
this form of hepatitis. Hepatitis E causes acute hepatitis that usually
resolves itself. Pregnant women are prone to have severe hepatitis from this
virus. There are no known means of prevention or cure of hepatitis E other
than strict hygienic precautions when visiting areas where hepatitis E is
common.
The
digestive tract is a series of joined and coiled hollow tubes that stretch
from the mouth to the anus. Digestive diseases range from the occasional upset
stomach to the more life-threatening colon cancer and encompass disorders of
the gastrointestinal tract, the liver, the gallbladder, and the pancreas. A
digestive disease may be acute and self-limiting, chronic and debilitating, or
sudden and devastating.
