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The Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions
American Gastroenterological Association Institute Guideline on the Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions
This document presents the official recommendations of the American Gastroenterological Association (AGA) on the role of upper gastrointestinal biopsy to evaluate dyspepsia in the absence of mucosal lesions. The guideline was developed by the AGA’s Clinical Practice Guidelines Committee and approved by the AGA Governing Board.
The authors of these guidelines present evidence-based recommendations for performing biopsies of normal mucosa in patients with dyspepsia who are undergoing EGD. The authors take into consideration the different segments of the upper GI tract as well as patient factors such as immune system status. Please make sure to review the entire paper as linked.
Esophagus:
- In patients undergoing EGD for dyspepsia as the sole indication, the AGA recommends against obtaining routine biopsies of the normal-appearing esophagus or GE junction regardless of immune status.
Stomach:
- In immunocompetent patients undergoing EGD for dyspepsia as the sole indication, the AGA recommends obtaining routine biopsies of the normal appearing gastric body and antrum for the detection of HP infection if the HP infection status is unknown.
- In immunocompromised patients undergoing EGD for dyspepsia as the sole indication, the AGA recommends obtaining routine biopsies of the normal-appearing gastric body and antrum for the detection of HP infection if the HP infection status is unknown.
- When obtaining biopsies from the normal-appearing gastric body and antrum for the detection of HP infection, the AGA suggests following the 5-biopsy Sydney System with all specimens placed in the same jar.
- When biopsies are obtained from the normal-appearing gastric body and antrum for the detection of HP infection, the AGA suggests not obtaining automatic special staining of the specimens.
Duodenum:
- In patients undergoing EGD for dyspepsia as the sole indication, and in the absence of signs or symptoms associated with an increased risk of celiac disease, the AGA suggests not obtaining routine biopsies of the normal-appearing duodenum to detect celiac disease.
- In immunocompromised patients undergoing EGD for dyspepsia as the sole indication, the AGA suggests obtaining routine biopsies of the normal-appearing duodenum for the detection of GVHD in post−allogeneic tissue transplantation patients and for opportunistic infections.
- When biopsies are obtained from the normal-appearing duodenum, the AGA suggests not performing routine special staining of the specimens.
Clarifications:
- The updated Sydney System protocol includes specimens from the lesser and greater curve of the antrum within 2−3 cm of the pylorus, from the lesser curvature of the corpus (4 cm proximal to the angularis), from the middle portion of the greater curvature of the corpus (8 cm from the cardia), and one from the incisura angularis. Although a 3-biopsy protocol (1 each from greater curvature of the corpus and antrum and 1 from incisura) also identifies 100% of HP, equivalency of the 3- vs 5-biopsy protocol cannot be definitively established. Given that the time and cost of specimen preparation and processing from the pathology standpoint are the same for a 3- vs 5-biopsy protocol, a conditional recommendation was made to follow the 5-biopsy protocol.
- Regarding Celiac disease the AGA argues that Celiac disease can be present in patients with endoscopically normal duodenum. The prevalence of biopsy-proven celiac disease among patients with dyspepsia is not significantly different from that in the US general population in which screening for celiac disease is not recommended. One must consider the potential for false-positive biopsy diagnosis in this setting, particularly when only early-grade celiac changes (eg, Marsh I−II) are detected. The AGA argues that this recommendation is primarily dependent on very-low-quality prevalence data, and thus a conditional recommendation is warranted (the possibility exists that the true prevalence of celiac disease among patients presenting with dyspepsia might be higher than what the current literature suggests, this recommendation might need to be updated when higher-quality evidence becomes available). Biopsy of the normal-appearing duodenum might be appropriate in patients who are at high risk for celiac disease, as specified by a previous AGA guideline on the diagnosis and management of celiac disease. If the suspicion for celiac disease is high, biopsies of the normal-appearing duodenum can be of value even if serologies (obtained while the patient is on a gluten-free diet) are negative.
http://www.gastro.org/guidelines/2015/10/19/endoscopic-biopsies
http://www.gastrojournal.org/article/S0016-5085%2815%2901065-3/pdf
Management of Benign Anorectal Disorders – ACG Clinical Guidelines
- Patient education – explain to patients that they unconsciously squeeze their anus when they are trying to defecate and this holds the stool in the rectum.
- Simulated defecation training – for patients who do not increase intraabdominal pressure during simulated defecation, the use of feedback on rectal balloon pressure teaches them to tighten their abdominal wall muscles and lower their diaphragm to push stool out.
- Training to relax pelvic floor muscles while simulating defecation — for patients who paradoxically contract their pelvic floor muscles during simulated defecation, provide visual feedback on anal canal pressure or averaged EMG activity from the anal canal to teach this skill.
- Practicing simulated defecation – patients practice defecation of a lubricated, inflated balloon while the therapist gently pulls on the catheter to assist them. Remind the patient to relax the pelvic floor muscles, increase abdominal pressure using abdominal wall muscles, and concentrate on the sensations produced by balloon passage.
- Anal sphincter weakness
- Traumatic: obstetric, surgical (e.g., fistulotomy, internal sphincterotomy)
- Nontraumatic: scleroderma, internal sphincter degeneration of unknown etiology
- Neuropathy: peripheral (e.g., pudendal) or generalized (e.g., diabetes mellitus)
- Disturbances of pelvic floor: rectal prolapse, descending perineum syndrome
- Inflammatory conditions: radiation proctitis, Crohn’s disease, ulcerative colitis
- Central nervous system disorders: dementia, stroke, brain tumors, multiple sclerosis, spinal cord lesions
- Diarrhea: irritable bowel syndrome, post-cholecystectomy diarrhea Other: fecal retention with overflow, behavioral disorders
Fecal Incontinence
Introduction:
Fecal incontinence is a difficult yet seldom talked about problem. The impaired ability to control gas or stool ranges from mild (difficulty with gas) to severe (loss of control of liquid and formed stools); symptoms can be continuous or recurrent. Nearly 18 million U.S. adults – about one in 12 – suffer from fecal incontinence. This number is likely underestimated as patients are reluctant to discuss this disabling problem. Incontinence causes emotional distress, loss of dignity, embarrassment, shame, frustration, anger, depression as well as social isolation. Perianal skin irritation may lead to pain, itching, and ulcers which may require medical or surgical treatments.
Causes of fecal incontinence include:
- diarrhea
- constipation
- muscle or nerve damage (due to constant straining, spinal cord injury, stroke)
- childbirth related trauma (episiotomy, forceps)
- anal operations
- traumatic injuries
- rectocele (a weakness of the recto-vaginal septum allows rectal tissue to bulge into the vagina. Rectoceles are uncommon in men as the prostate gland provides structural support)
- rectal prolapse
- inflammation (colitis)
- radiation
- tumors
- diseases such as diabetes, multiple sclerosis
- dementia (the prevalence of fecal incontinence is estimated at 47% for nursing home residents )
- aging (the prevalence of fecal incontinence is estimated at 15% in those 70 or older)
Other risk factors further include:
- poor general health
- physical disabilities
- chronic obstructive pulmonary disease
- irritable bowel syndrome
- urinary incontinence
- colectomy
- chronic diarrhea
- fecal impaction
- depression
Anorectal function and continence depend on factors such as stool volume, stool consistency, colonic transit, rectal distensibility, anal sphincter function, anorectal sensation and intact anorectal reflexes. Anatomical structures which help preserve continence include the rectum, the internal and external anal sphincter muscles, and the pubo-rectalis muscle. Defecation is initiated when stool enters the rectum, leading to rectal distention with reflex relaxation of the internal anal sphincter. The urge to defecate increases as more stool passes into the rectum. During defecation the anorectal angle is straightened and abdominal pressure is increased; pelvic floor descent, rectal contraction, and external anal sphincter relaxation then lead to emptying of stool.
Workup:
To better understand incontinence, a detailed history, physical exam and supplemental studies are required.
The clinical history should assess for onset of disease, duration, frequency, severity, precipitating events, and look for a history of difficult or traumatic vaginal delivery, anorectal surgery, pelvic irradiation, diabetes, and neurologic diseases.
A physical exam should include inspection of the perianal area which may reveal dermatitis (suggesting chronic incontinence), fistulizing disease, prolapsing hemorrhoids, or even rectal prolapse. Perianal sensation should be tested, with the absence of an anal wink reflex suggesting nerve damage. A digital rectal exam may provide information about the resting anal sphincte tone and may detect obvious anal pathology such as masses or fecal impaction . Inspection of the anus, rectum and large intestine via anoscopy, flexible sigmoidoscopy or colonoscopy may help to exclude mucosal inflammation, masses, or other pathology.
Anorectal manometry measures resting anal pressures, amplitude and duration of squeeze pressures, the rectoanal inhibitory reflex, threshold of conscious rectal sensation, rectal compliance, and anal rectal pressures during straining. Rectal sensation can be assessed by balloon inflation. Pudendal nerve terminal latency may assess potential nerve damage.
Endorectal ultrasound and magnetic resonance imaging are helpful to define structural abnormalities of the anal sphincters, the rectal wall, and the puborectalis muscle.
Defecography assesses anorectal anatomy at rest and during defecation; it assesses the anorectal angle, pelvic descent and may detect occult or overt rectal prolapse.
Intervention:
Three treatment approaches are commonly used for fecal incontinence:
- medical therapy such as dietary changes (i.e. avoidance of sphincter relaxing foods), constipating medications (treatment of diarrhea) and bulking agents (to enhance stool control)
- biofeedback and muscle strengthening exercises
- surgery, such a surgical sphincter muscle repair or implantation of an artificial anal sphincter
Medical therapy should be aimed at reducing stool frequency and improving stool consistency. Specific treatment for the underlying cause of diarrhea should be implemented, as formed stool is easier to control than liquid stool. While stool consistency can be improved with bulking agents (i.e. fiber supplements, bile binders), this may exacerbate incontinence in patients with decreased rectal compliance (i.e. in radiation proctitis or rectal stricture).
Stool frequency can be reduced with antidiarrheals such as loperamide (Imodium®) or diphenoxylate (Lomotil®); anticholinergic agents i.e. hyoscyamine (Levsin®, NuLev®, Anaspaz®, Levsinex®, Levbid®) may help with postprandial leakage if taken before meals.
Patients with fecal impaction should be disimpacted and treated with a bowel training regiment to prevent recurrent impaction.
Pelvic floor exercise and biofeedback may help retrain pelvic floor and abdominal wall musculature and may enhance the ability to sense rectal distention, thereby improving sensory as well strength components required for continence. Pelvic floor exercises involve squeezing and relaxing pelvic floor muscles 50-100 times a day. A health care provider can help with proper technique. Biofeedback therapy may help to perform these exercises properly and may improve anorectal sensation. Biofeedback uses special anal and rectal pressure sensors, as well as rectal balloons to produce graded sensations of rectal fullness. Measurements are displayed on a video screen and are used to modify or change abnormal function. Success depends on the cause of fecal incontinence, its severity, and the person’s ability to follow instructions; the role of biofeedback in the management of fecal incontinence is still debated, as the optimal protocol, equipment, and duration of treatment are undefined.
Surgical approaches to fecal incontinence include direct sphincter repair, plication of the posterior part of the sphincter, anal encirclement, implantation of an artificial sphincter, and muscle transfer procedures with or without electrical stimulation. Patients with a sphincter tear (obstetric trauma, fistula surgery) can be cured with a sphincteroplasty. It is the most common fecal incontinence surgery and reconnects the ends of a torn sphincter muscle.
A synthetic sphincter device or magnetic anal sphincter may be available in highly specialized centers. The Acticon (TM) neosphincter, consisting of an occlusive cuff (implanted around the anal canal), a pressure-regulating balloon (implanted in the prevesical space) and a control pump (implanted in the labium or scrotum) enables users to squeeze the control pump to permit defecation.
Sacral nerve electrical stimulation may restore continence in patients with structurally intact muscles. This approach appears to be effective in patients with neurologic disorders. The FDA approved the sacral nerve stimulator (InterStim®, Medtronics) for the treatment of chronic fecal incontinence in patients who have failed or are not candidates for more conservative treatments.
Injectable materials allow augmentation of the function of the internal anal sphincter. Injection of dextranomer-hyaluronic acid (Solesta®), used for the treatment of urinary incontinence, has also been approved for patients with fecal incontinence.
Anal plugs have been studied as a possible treatment for fecal incontinence. Fecal incontinence improved only in a minority of patients, anal plugs were poorly tolerated and their usefulness is thereby limited.
In extreme cases patients may need a colostomy to improve quality of life as a colostomy may be the only option for patients with intractable symptoms who are not candidates for any other therapy, or in whom other treatments have failed.
Gas and Bloating
Gas and bloating are common complaints for many patients, often quite bothersome and difficult to treat. Associated symptoms include belching, bloating, abdominal pain, constipation and flatulence, yet these are usually not due to “excess gas” production as commonly assumed.
A variety of diseases must be considered as a cause or contributing factor such as:
- Irritable Bowel Syndrome,
- Inflammatory Bowel Disease
- Celiac Disease
- Gastroparesis
- Superior Mesenteric Artery Syndrome
- Small Bowel Intestinal Overgrowth
- Disaccharide Deficiencies (i.e. Lactose Intolerance)
- Gastric Outlet Obstruction
- Post-Surgical States (i.e. Whipple, Roux-en-Y, ileo-colonic surgeries and anastomosis)
- Pancreatic Disases
- Aerophagia
- Rumination Syndrome
Complaints
If excessive gas is present, it may be due to swallowed air (aerophagia), increased intra-luminal gas production, decreased gas absorption (due to obstruction), or excessive gas intake such as with carbonated drinks.
- Aerophagia occurs if abnormal amounts of air are swallowed i.e. with food intake (due to poor dentures or rushed eating habits), due to anxiety, chewing gum and even due to smoking. Burping or belching is the way most swallowed air is expelled. The remaining gas moves into the small intestine where it is partially absorbed, while a small amount is released through the rectum. Studies have suggested that air may be swallowed into the esophagus rather than the stomach, resulting in excessive belching. This esophageal air can then easily be expelled, resulting in excessive belching.
- Increased intestinal gas can occur due to bacterial fermentation of non-digestible carbohydrates in the small bowel (small bowel bacterial overgrowth) or in the colon. Bacterial fermentation of ingested carbohydrates or proteins leads to hydrogen production, causing excessive gas. High concentrations of oligosaccharides or difficult to digest starches (flours made from wheat, oats, potatoes, and corn) lead to increased hydrogen production. This mechanism is the basis of the FODMAP diet, as malabsorption or maldigestion of carbohydrates may lead to increased intraluminal gas, complaints of abdominal pain and flatulence. These unabsorbed carbohydrates provide a substrate for rapid bacterial fermentation and lead to an increased osmotic load, altered gastrointestinal motility and a change in the profile of the bacterial flora. Furthermore patients with functional bowel disease (such as irritable bowel syndrome) may have a heightened sensitivity to the effects of malabsorbed carbohydrates, even though the rates of carbohydrate malabsorption may not differ from healthy subjects.
- To see a list of foods low and high FODMAP, visit the Australian-based MONASH University website, where this diet originated.
Diagnosis
Patients with bloating often lack an identifiable cause and can be classified as having a functional disorder.
- A careful history, physical exam and possibly a food diary review are the first important steps towards a diagnosis.
- Warning signs such as diarrhea, weight loss, abdominal pain, distention, anorexia or nutritional deficiency should prompt evaluation for other conditions such as inflammatory bowel disease, celiac disease or structural abnormalities as discussed above.
- Work up may include baseline laboratory testing, stool examination (fat, Giardia), a lactose tolerance test, celiac serology, and a small bowel radiograph vs. CT, an upper endoscopy and possibly a colonoscopy.
- Hydrogen breath testing may be used to assess for specific food issues and to test for small bowel bacterial overgrowth.
- Although abdominal distension is seen in patients with irritable bowel syndrome, an obstructing lesion should be considered.
- Pancreatic disease and cancer are in the differential, especially if malabsorption or steatorrhea are noted.
- Post surgical changes (i.e. Roux-en-Y, Whipple resection, ileo-colonic anastomoses etc) can lead to small bowel dysmotility as well as small bowel bacterial overgrowth. A cholecystectomy may lead to fat malabsorption due to lack of adequate bile presence, if larger fat-rich meals are consumed.
- Aerophagia can be diagnosed if troublesome repetitive belching at least several times a week is observed and/or if air swallowing is objectively noted.
Treatment
Treatment requires a multifactorial and often emperic approach.
- If aerophagia is suspected, then explaining this process to the patient may be beneficial.
- Discontinuation of habits such as gum chewing, smoking, drinking carbonated beverages, and gulping food and liquids as well as stress management may reduce the amount of ingested air. Eating at a slow pace and checking with a dentist to make sure dentures fit properly should also help.
- Avoidance of foods that may contribute to gas production is an initial step. This includes a temporary trial of lactose and fructose avoidance, avoidance of sorbitol (contained in diet foods and chewing gum), and avoidance of other gas-producing foods such as cabbage, onions, broccoli, brussel sprouts, wheat, and potatoes. This recommendation is part of the FODMAP diet (FODMAPs stands for Fermentable Oligo-, Di- and Mono-saccharides, and Polyols). FODMAPs include lactose in milk products, fructose and polyols found in fruits, fructans in wheat, onion or garlic, and galacto-oligosaccharides in beans and lentils. .
High FODMAP foods include
- fruits such as apples, apricots, cherries, mango, pears, nectarines, peaches, pears, plums, prunes, watermelon
- certain grains when consumed in large amounts such as rye, wheat
- lactose-containing foods such as custard, ice cream, margarine, milk (cow, goat, sheep), soft cheese, including cottage cheese and ricotta, yogurt
- legumes such as baked beans, chickpeas, lentils, kidney beans
- sweeteners such as fructose, high fructose corn syrup, isomalt, maltitol, mannitol, sorbitol, xylitol
- vegetables such as artichokes, asparagus, avocado, beets, broccoli, brussel sprouts, cabbage, cauliflower, garlic (with large consumption), fennel, leeks, mushrooms, okra, onions, peas, radiccio lettuce, scallions (white parts), shallots, sugar snap peas, snow peas
Simethicone (e.g., Gas-X, Mylanta Gas, Phazyme) is a foaming agent active in the stomach so that gas is more easily belched up. However, simethicone has no effect on intestinal gas. Simethicone preparations are widely used but have not proven clinical benefit.
Beano™, an alpha-galactosidase over-the-counter agent may reduce gas production in subjects taking non-digestable fibers, but its clinical value is questionable. Beano comes in liquid or tablet form. Beano has no effect on gas caused by lactose or fiber. Heat degrades the enzyme in Beano so it cannot be added to food while it is being cooked. Since Beano is made from an enzyme (alpha-galactosidase) extracted from a food-grade mold, patients with allergies to molds may react to Beano. Those with galactosemia (an inherited disorder characterized by the inability to metabolize galactose) should not use Beano.
The enzyme lactase, which aids with lactose digestion, is available in liquid and tablet form without a prescription (e.g., Dairy Ease, Lactaid). Adding a few drops of liquid lactase to milk before drinking it or chewing lactase tablets just before eating helps digest foods that contain lactose. Also, lactose-reduced milk and other products are available at many grocery stores.
If bacterial overgrowth or an altered flora are strongly suspected (best confirmed by breath-testing), a two-week trial of an antibiotic treatment may be helpful (i.e. Xifaxan® – rifaximin, a nonabsorbable antibiotic).
Probiotics such as ALIGN® – bifidobacterium infantis have been tried with varied success.
Smaller more frequent meals, less fatty foods and a trial of digestive pancreatic enzymes may all be of value.
Summary
In summary gas and bloating are difficult to treat symptoms which require vigilance and close cooperation between patients and providers in hope of partial or complete symptom relief. I typically approach this in a stepwise fashion. Laboratory testing will be used to screen for inflammation and celiac disease, while a trial of ALIGN may be initiated. If warning signs such as weight loss are present, aggressive work-up is immediately warranted. Otherwise a more conservative approach can be tried. Breath testing for lactose intolerance and work-up for small bowel overgrowth should be done. Dietary modifications will always be stressed and the FODMAP diet be reviewed.
You might find more info regarding functional gastrointestinal and motility disorders at the IFFGD website.
Irritable Bowel Syndrome
What is Irritable Bowel Syndrome?
Irritable bowel syndrome, or IBS, is a common condition and affects up to 15% of people over a lifetime. IBS is more common in women and tends to be more active during the reproductive years (after menstruation begins and before menopause). Although IBS is more commonly seen in women, many men also suffer from IBS.
IBS is a disturbance of gut function. The bowel looks normal when visualized during a colonoscopy, CT scan or x-ray. The problem arises from the way the bowel “works” and in the way the bowel processes sensory input.
Symptoms of IBS include abdominal pain, bloating, diarrhea and/or constipation. Many with IBS will experience alternating diarrhea and constipation. Having a bowel movement or passing gas often relieves pain and bloating. Bowel movements may be urgent, making it difficult to make it to the toilet in time. Others with IBS feel like the bowels do not empty completely. Symptoms often get worse with stress, with overeating, or with the ingestion of certain foods. Blood in the stool and unexplained weight loss are not typically seen with IBS alone, and should prompt additional evaluation.
What tests are appropriate in the evaluation of IBS?
The evaluation of IBS symptoms may vary, depending on one’s age and presenting symptoms. A health professional should perform a complete history and physical exam. Further testing may include labs, stool studies or imaging (ultrasound, x-ray, etc.). You may need a colonoscopy, especially if you are over 50 years old or having worrisome symptoms like blood in the stool.
What does “Irritable” mean?
Irritable means that the nerve endings in the lining of the bowel are extremely sensitive, and that the nerves that control the muscles of the bowel are unusually active. The result is that the bowel is too sensitive to “normal” events such as the passage of gas, fluid or stool. This leads to inappropriate muscular activity that can cause cramping, diarrhea or constipation.
What is the effect of diet on IBS?
Diet is almost always a contributing factor in IBS. Keeping a food and symptom diary may help identify certain foods that aggravate your IBS. Common offending foods are those that contain high fat, dairy/lactose, fructose (like that in high fructose corn syrup or many fruits), gluten, monosodium glutamate, artificial sweeteners or “gassy” vegetables such as beans, broccoli and cauliflower. But, just about every food has been implicated in the production of IBS symptoms, so it is important to identify which particular foods increase your symptoms.
What is the relationship of stress to IBS?
Emotional distress can significantly influence IBS. That is why IBS may flare during times of emotional upset such as family or job problems. That does not mean that IBS is “all in your head”. It does not mean that all IBS patients are crazy or anxious. As stated previously, IBS results from a complex interaction between the mind and the gut. In many IBS patients the mind is much too aware of what is going on in the gut and the gut is much too aware of what is going on in the mind. So, if you are under increased stress, some of that stress may be transmitted to your gut. When this happens, the gut may become under-active (constipation), over-active (diarrhea) or ultra-sensitive (pain, bloating).
If you have been diagnosed with depression or anxiety, IBS may become worse when these conditions are not under good control.
How is IBS treated?
There is no “magic pill” that can make IBS symptoms go away. IBS treatment is challenging and often frustrating, as it nearly always involves lifestyle change.
The first step in the treatment of IBS is a personal evaluation of your overall well-being. Do you eat a healthy diet? Do you eat a lot of processed food or fast food? Are there certain foods that tend to aggravate your IBS? Do you exercise regularly? How do you deal with the stress in your life? Do you have untreated depression, anxiety or posttraumatic stress disorder? You cannot expect to recover from IBS if any of these issues are neglected.
Proper rest and exercise can help to reduce stress levels. Your doctor may recommend that you speak to a therapist about coping mechanisms and stress reduction techniques.
Of course, foods that make your symptoms worse should be avoided. A high fiber diet and/or fiber supplements are often helpful. Not only is fiber used in the treatment of constipation, but also is useful in the treatment in IBS marked by pain or diarrhea. Laxatives such as Miralax or Milk of Magnesia are commonly recommended for constipation.
When these measures fail, medications can be prescribed that target specific symptoms of IBS. Some of these include a class of medications called “antispasmodics” to treat pain or cramping. Other medications treat discomfort by interfering with the overly sensitive connections between brain and gut. Low dose antidepressants are commonly used to reduce the pain associated with IBS. Other medications specifically treat constipation or diarrhea.
The key to achieving relief from IBS is for patients to realize that IBS is a complex disorder with physical and stress-related dimensions. A strong partnership between an empathetic health professional and a motivated patient can produce significant improvement.
5 TIPS to help you deal with Irritable Bowel Syndrome:
1. Remember that your digestive tract is a “barometer of your overall well-being”. That is, you won’t have a happy & healthy digestive system without a healthy mind & body.
2. Avoid foods that you know will make your symptoms worse.
3. Use medications wisely. For instance, if diarrhea is the issue then take an anti-diarrheal medication before leaving home if you are worried about having diarrhea in a situation where a toilet is not readily available, like an airplane.
4. Looks for sources of stress in your life and do something about them.
5. Above all, decide who is running your life… YOU or your GUT. Life is easier if you’ve made up your mind that you are in charge!
Constipation – What You Need To Know
Constipation refers to a change in bowel habits with bowel movements being either too hard in consistency, too difficult to pass, or too infrequent (less than three times per week). Often patients with constipation need to strain or sense that bowels do not empty completely. Constipation is a very common problem with 14% of people affected and over 2.5 million healthcare provider visits per year. Factors such as a low fiber intake, dehydration, thyroid disease, hypercalcemia, medications (i.e. narcotics, diuretics), lack of timely access to bathroom facilities and many others can contribute to constipation. A clear cause is often not found. Constipation may occur more frequently in older age. Constipation can usually be diagnosed based on symptoms and a physical examination including a rectal exam. Further testing such as blood tests, x-rays, sigmoidoscopy, colonoscopy, ano-rectal motility studies may be indicated.
Treatment of constipation includes a high fiber diet (20 to 35 grams of fiber per day), fiber supplementation, staying hydrated and being physically active. OTC laxatives or enemas may be needed, especially if behavioral changes and increased fiber intake do not improve constipation.
In general, laxatives can be categorized into the following groups:
Bulk forming laxatives: These include natural fiber and commercial fiber preparations such as: Psyllium (Konsyl®; Metamucil®; Perdiem®), Methylcellulose (Citrucel®), Calcium polycarbophil (FiberCon®; Fiber-Lax®; Mitrolan®), Wheat dextrin (Benefiber®)
Hyperosmolar laxatives: Polyethylene glycol (MiraLax®, Glycolax®), Lactulose, Sorbitol
Saline laxatives: i.e. magnesium hydroxide (Milk of Magnesia®) and magnesium citrate (Evac-Q-Mag®)
Stimulant laxatives: i.e. senna (Black Draught, ex-lax®, Fletcher’s®, Castoria®, Senokot®) and bisacodyl (Correctol®, Doxidan®, Dulcolax®)
Prescription medications such as Lubiprostone (Amitiza®) or Linaclotide (Linzess®) as well as treatment options such as biofeedback, pelvic floor physical therapy and even surgery should be reviewed with the treating provider. Diseases such as Colon Cancer, Colonic Inertia, Hirschsprung Disease, Pelvic Floor Dysfunction, and an Enterocele or Rectocele must be considered and can be addressed in that setting.
Utah Gastroenterology Blog 