Alliance Endoscopy Center Medical Infomation

This material is intended for patient education and information only. It does not constitute
advice, nor should it be taken to suggest or replace professional medical care from your
physician.Your treatment options may vary, depending upon medical history and current condition. Only your physician and you can determine your best option. Content provided by the National Digestive Diseases Information Clearinghouse (NDDIC), a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

• Upper Endoscopy
• Colonoscopy
• Barrett’s Esophagus
• Crohn’s Disease
• GERD
• H. pylori
• Sprue/Celiac Disease
• Colon Polyps
• Constipation
• Diverticular Disease
• Hemmorrhoids

Upper Endoscopy
Upper endoscopy enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain. Upper endoscopy is also called EGD, which stands for esophagogastroduodenoscopy.

What is the procedure like?
For the procedure you will swallow a thin, flexible, lighted tube called an endoscope. Right before the procedure the physician will spray your throat with a numbing agent that may help prevent gagging. You may also receive pain medicine and a sedative to help you relax during the exam. The endoscope transmits an image of the inside of the esophagus, stomach, and duodenum, so the physician can carefully examine the lining of these organs. The scope also blows air into the stomach; this expands the folds of tissue and makes it easier for the physician to examine the stomach. The physician can see abnormalities, like inflammation or bleeding, through the endoscope that do not show up well on xrays. The physician can also insert instruments into the scope to treat bleeding abnormalities or remove samples of tissue (biopsy) for further tests. Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will probably have nothing more than a mild sore throat after the procedure. The procedure takes 20 to 30 minutes. Because you will be sedated, you will need to rest at the endoscopy facility for 1 to 2 hours until the medication wears off.

Preparation for an Upper Endoscopy
Your stomach and duodenum must be empty for the procedure to be thorough and safe, so you will not be able to eat or drink anything for at least 6 hours beforehand. Also, you must arrange for someone to take you home – you will not be allowed to drive because of the sedatives. Your physician may give you other special instructions.

Colonoscopy
A colonoscopy allows a doctor to look inside the entire large intestine. The procedure enables the physician to see things such as inflamed tissue, abnormal growths, and ulcers. It is most often used to look for early signs of cancer in the colon and rectum. It is also used to look for causes of unexplained changes in bowel habits and to evaluate symptoms like abdominal pain, rectal bleeding, and weight loss.

The colon, or large bowel, is the last portion of your digestive tract, or gastrointestinal tract. The colon is a hollow tube that starts at the end of the small intestine and ends at the rectum and anus. The colon is about 5 feet long, and its main function is to store unabsorbed food waste and absorb water and other body fluids before the waste is eliminated as stool.

Preparation
You will be given instructions in advance that will explain what you need to do to prepare for your colonoscopy. Your colon must be completely empty for the colonoscopy to be thorough and safe. To prepare for the procedure you will have to follow a liquid diet for 1 to 3 days beforehand. The liquid diet should be clear and not contain food colorings, and may include:

• fatfree bouillon or broth
• strained fruit juice
• water
• plain coffee
• plain tea
• diet soda
• gelatin

Cleansing of the bowel is necessary before a colonoscopy. You will likely be asked to take a laxative the night before the procedure. In some cases you may be asked to give yourself an enema. An enema is per formed by inserting a bottle with water and sometimes a mild soap in your anus to clean out the bowels. Inform your doctor of any medical conditions you have or medica tions you take on a regular basis such as aspirin, arthritis medications, blood thinners, diabetes medication, and vitamins that contain iron. The medical staff will also want to know if you have heart disease, lung disease, or any medical condition that may need special attention. You must also arrange for some one to take you home afterward, because you will not be allowed to drive after being sedated.

Procedure
For the colonoscopy, you will lie on your left side on the examining table. You will be given pain medication and a moderate sedative to keep you com fortable and help you relax during the exam. The doctor and a nurse will monitor your vital signs, look for any signs of discomfort, and make adjust ments as needed. The doctor will then insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a colonoscope. The scope transmits an image of the in side of the colon onto a video screen so the doctor can care fully examine the lining of the colon. The scope bends so the doctor can move it around the curves of your colon. You may be asked to change positions at times so the doctor can more easily move the scope to better see the different parts of your colon. The scope blows air into your colon and inflates it, which helps give the doctor a better view. Most patients do not remember the procedure afterwards. The doctor can remove most abnormal growths in your colon, like a polyp, which is a growth in the lining of the bowel. Polyps are removed using tiny tools passed through the scope. Most polyps are not cancerous, but they could turn into cancer. Just looking at a polyp is not enough to tell if it is cancerous. The polyps are sent to a lab for testing. By identifying and removing polyps, a colonoscopy likely prevents most cancers from forming. The doctor can also remove tissue samples to test in the lab for diseases of the colon (biopsy). In addition, if any bleeding occurs in the colon, the doctor can pass a laser, heater probe, electrical probe, or special medicines through the scope to stop the bleeding. The tissue removal and treatments to stop bleeding usually do not cause pain. In many cases, a colonoscopy allows for accurate diagnosis and treatment of colon abnormalities without the need for a major operation. During the procedure you may feel mild cramping. You can reduce the cramping by taking several slow, deep breaths. When the doctor has finished, the colonoscope is slowly withdrawn while the lining of your bowel is carefully examined. Bleeding and puncture of the colon are possible but uncommon complications of a colonoscopy.

A colonoscopy usually takes 30 to 60 minutes. The sedative and pain medicine should keep you from feeling much discomfort during the exam. You may feel some cramping or the sensation of having gas after the procedure is completed, but it usually stops within an hour. You will need to remain at the colonoscopy facility for 1 to 2 hours so the sedative can wear off. Rarely, some people experience severe abdominal pain, fever, bloody bowel movements, dizziness, or weakness afterward. If you have any of these side effects, contact
your physician immediately. Read your discharge instructions carefully. Medications such as blood-thinners may need to be stopped for a short time after having your colonoscopy, especially if a biopsy was performed or polyps were removed. Full recovery by the next day is normal and expected and you may return to your regular activities.

Upper GI Diseases

Barrett’s Esophagus
The esophagus is the muscular tube that carries food and saliva from the mouth to the stomach. Barrett's esophagus is a condition resulting from ongoing irritation of the esophagus where its normal lining is replaced by the type of lining that is normally found in the stomach. Patients with Barrett’s esophagus lack symptoms that are noticeably different from gastroesophageal reflux disease (GERD), the underlying irritation in most cases. An endoscopy procedure uses a small tube with a camera inside that is inserted through the mouth and into the esophagus allowing the physician to see inside.

Who should be screened for Barrett’s esophagus?
Though opinions vary, patients who are between 35 to 50 years or older who have had at least five years of GERD symptoms (heartburn) should undergo a one time endoscopy to exclude Barrett's esophagus. The condition is especially prevalent among middleaged Caucasian men who have had heartburn for years. If the first screening is normal, there is typically no need to repeat it.

How is Barrett’s esophagus diagnosed?
Barrett’s esophagus is discovered when physicians view the abnormal lining of the esophagus with a special instrument (endoscope) and sample a piece of tissue (biopsy) that is evaluated under a microscope by a pathologist, preferably specializing in diseases of the gastrointestinal tract. An endoscopy procedure uses a small tube with a camera inside that is inserted through the mouth and into the esophagus allowing the physician to see inside. Your physician can also take a sample, or biopsy. This biopsy will be interpeted by a surgical pathologist, perferrably one with subspecialty training in gastrointestinal pathology, who can confirm the diagnosis and determine whether dysplasia, a precancerous change, or cancer is present.

How is Barrett’s esophagus treated?
Since Barrett's esophagus is related to GERD, medications are given to treat the reflux symptoms. Acid suppression is the mainstay of therapy, and patients may need to be on proton pump inhibitor medication for years. If dysplasia or cancer is present, surgery or topical therapy may be indicated. The type of surgery varies, ranging from laser ablation to surgical excision. Patients with Barrett's esophagus are typically put on a surveillance program. Random or directed biopsies of the mucosa are evaluated by the gastrointestinal pathologist to exclude the presence of dysplasia or cancer.

GERD
GERD (Gastroesophageal Reflux Disease) is a common condition involving the esophagus (the muscular tube that connects the back of the mouth to the stomach) that can occur at any age, but typically begins to appear around age 40. Many people refer to this disorder as heartburn or indigestion. GERD is caused when the muscular valve at the lower end of the esophagus relaxes, allowing the contents of the stomach to backwash, or reflux, into the esophagus. These gastric contents contain strong acids and bile that are very irritating to the lining of the esophagus.

What are the symptoms?
The most common symptom is pain located anywhere from the upper abdomen to the upper chest/neck. The pain is usually described as burning, but may be sharp or more like pressure. Severe chest pain that mimics a heart attack may occur. Other symptoms include difficulty in swallowing (known as dysphagia), nausea, and regurgitation. GERD can also
manifest itself with symptoms of the upper respiratory tract, such as frequent sore throats.
What causes GERD? As mentioned above, GERD occurs when the normal valve (or sphincter) between the stomach and the esophagus is weakened or whenever there are factors that will promote regurgitation of gastric contents into the esophagus. Patients with
hiatal hernias (where the stomach is free to slide into the chest temporarily), those who
produce excessive acid, and those who have delayed emptying of the stomach after meals
are therefore more likely to experi ence GERD. Triggers include obesity and excessive
consumption of fatty foods, chocolate, peppermints, greasy or spicy foods, tomato products, citrus products, caffeine, and alcohol. Smoking, tight clothing, and eating heavy meals before sleeping can also contribute to the condition.

Are there any serious conditions that GERD can cause?
One of the most common problems with GERD is the esophagitis resulting from the caustic irritation of the distal part of the esophagus. Acid splashing back into the esophagus can result in inflammation or even a narrowing scar (stricture) that causes people to have difficulty swallowing. Other complications include ulceration of the lining of the esophagus, asthma, pneumonia, and ear infection. Patients with chronic, untreated
heartburn can also develop Barrett's esophagus, a condition that requires monitoring to
avoid developing esophageal cancer.

How is GERD diagnosed?
Your physician will take a complete medical history and conduct a physical exam. Usually the physician makes a diagnosis based upon your symptoms. An endoscopy allows your physician to see the damage caused by reflux, such as redness, erosion, or ulcerations in the bottom part of the esophagus. Esophageal manometry uses a flexible tube that is inserted into your nose down to your stomach and is designed to measure the strength of the lower
esophageal sphincter. Another test is the pH monitor that records how much acid washes back into your esophagus during a 24-hour period. This procedure can be done using a thin catheter placed through the nose and down the esophagus or using a small capsule to measure the pH (or acidity) of the esophageal contents. Your physician may also wish to view the lining of the esophagus directly, using a small camera at the end of a narrow tube (endoscope) that is placed into the mouth or nose. At that time, a biopsy sample of the lining may be taken. This biopsy will be examined under a microscope by a surgical pathologist, preferably one specializing in gastrointestinal pathology, and a diagnosis of GERD or other unexpected abnormality can be established or excluded.

How is GERD treated?
The first step is to make lifestyle changes by avoiding the foods that cause the most symptoms and that may relax the tone of the lower esophageal sphincter. Patients should avoid eating and drinking too close to bedtime, as gravity when lying flat allows food and acid in the stomach to wash up into the esophagus. The dinner meal should be early and light. Digestion can be aided by elevating the head of your bed. Medications, such as antacids and Histamine-2 blockers, that are available over-the-counter, are the mainstay of treatment and are designed to help reduce stomach acid. If non-prescription medicine is not working, your physician may prescribe a proton pump inhibitor or a pro-motility medication. Surgical procedures, such as the Nissen fundoplication, involve taking the stomach and wrapping it around part of the esophagus to help strengthen the valve. Newer, less invasive treatment techniques using endoscopy are being developed as well.

H. pylori
What is Helicobacter pylori (H.pylori)?
This bacterium infects the lining of the stomach and thrives in the mucous environment.
It is common worldwide and especially impacts the elderly, the very young, and those in Third World countries where sanitation is problematic. However, just because you have been exposed to H. pylori doesn't necessarily mean you will be affected by its presence.
Often H. pylori does not cause any symptoms. Approximately 50 percent of people in the United States have it.

How is H. pylori infection diagnosed?
Your physician can use a blood test, a breath test, or an endoscopy to see if you have H. pylori.

Blood Test
Your physician sends a sample of your blood to a lab to confirm if you have H. pylori.

Breath Test
In this test you drink a special liquid, and in less than an hour, a sample of your breath is tested for a chemical reaction caused by H. pylori.

Endoscopy
A small tube with a camera inside is inserted through the mouth or nose, passing into the stomach to look for inflammation and ulcers. During the procedure, a biopsy, or small
sample of the stomach lining, can be obtained. This biopsy will be examined under a microscope by a surgical pathologist, preferably one specializing in gastrointestinal pathology, and a diagnosis of H. pylori infection or other unexpected abnormality can be established or excluded.

What are the risks of having H. pylori?
For many years, physicians thought ulcers in the upper gastroi ntesti nal tract
were related to stress, ‘Type A’ personality, and non-steroidal anti-inflammatory class of medicines that include aspirin and other over-the-counter pain relievers commonly used for arthritis and other conditions. Recently researchers have discovered that H. pylori is actually the cause for many, if not most ulcers. An ulcer is a defect in the lining of an organ, in this case, the stomach or duodenum (the first portion of the small intestine). The most common ulcer symptom is a burning pain in the abdomen. The pain often happens when the stomach is empty and may be relieved by eating food or taking antacids. Sometimes ulcers bleed. If the bleeding is heavy, blood may appear in vomit or bowel movements, which may appear dark red or black. H. pylori can also cause a painful inflammation of the stomach called gastritis. The symptoms of gastritis are upper abdominal burning/pain, bloating, and discomfort.

Long-term infection of the stomach with this bacterium may lead to chronic atrophic
gastritis (inflammation and damage to the lining of the stomach), which in turn is a risk factor for pre-cancerous changes and cancer of the lining of the stomach.

Sprue/Celiac Disease
Sprue/celiac disease is an intestinal disorder that results from an exaggerated immune response to gluten (also called Gluten-Sensitive Enteropathy). Gluten is a protein found in wheat, rye and barley, and is present in many foods other than the obvious breads, cereals, and pastas. When people with sprue eat foods containing gluten, an allergic-like reaction by their immune system results in damage to the normal, tiny, fingerlike protrusions (villi) of the lining of the small intestine. Nutrients from food are normally absorbed into the bloodstream through these villi. Damage to the villi results in reduced and ineffective absorption. Because the body's own immune system causes the damage, sprue/celiac disease is considered an autoimmune disorder.

Who gets sprue/celiac disease?
Sprue/celiac disease is an inherited disease found especially, but not exclusively in those of Northern European descent. Sprue/celiac disease is the most common genetic disease in Europe. Recent studies show that one in every 133 people in the United States has the disease.

What are the symptoms?
Many patients complain of abdominal bloating. Many suffer from nausea, diarrhea,
and even constipation. Other symptoms can include weight loss, gas, bone pain, anemia, fatigue, and muscle pain. Some patients develop an associated condition called dermatitis herpetiformis, an itchy, blistering skin condition that appears on the arms, legs, and sometimes the torso.

How is sprue/celiac disease diagnosed?
Diagnosing sprue/ celiac disease is difficult because many of the symptoms are similar to those of other disorders, such as irritable bowel syndrome, diverticular disease, intestinal infections, and ulcerative colitis. Physicians look for evidence of sprue/celiac disease using tests to check blood levels of certain antibodies. Detection of antiendomysial and anti-tissue transglutaminase antibodies are among two tests that produce positive results in 90 percent of people with sprue/celiac disease. Also, a biopsy may be performed endoscopically to absolutely confirm the diagnosis. An endoscope is a small tube with a camera inside which is inserted through the mouth and stomach that allows the physician to see the small intestine and obtain a biopsy sample. This sample is then examined under a microscope by a surgical pathologist, preferably one with subspecialty training in gastrointestinal pathology. The pathologist can confirm the diagnosis, evaluate the efficacy of treatment, and also ensure that no other abnormalities are present. Since sprue/celiac disease is a hereditary disease, it is typically recommended that first-degree relatives (parents, siblings, and children) be tested for the disease.

How is sprue/celiac disease treated?
Currently, there is no specific cure for sprue/celiac disease; however, by making a lifelong commitment to eating a gluten-free diet, patients can become symptom-free, and the lining of the intestines can return to normal. Since gluten protein may be present in many food items, it is prudent for patients to review their diet with their physician or a dietitian.

Lower GI Disease

Colon Polyps
A polyp in the colon can be defined as any extra tissue that protrudes into the inside (or lumen) of the large intestine (colon), but typically refers to excess of the lining (epithelium). They var y in size from microscopic to several inches in diameter.

What are the symptoms?
Typically there are no symptoms unless the polyps are large. However, patients may experience blood in the stool, constipation or diarrhea.

What are the risks of having polyps?
The greatest risk is that some types (primarily adenomas) may become cancerous. As adenomas grow in size, the chance of the growth eventually making a malignant transformation gets higher. It is estimated that it takes an average of approximately seven years for a small adenoma to become malignant. Another polyp type is hyperplastic polyp that has essentially no malignant potential, although recent evidence shows that a similar appearing polyp (once thought to be simply a large hyperplastic polyp), called a sessile serrated adenoma, carries a risk for the development of colonic cancer. Many other rare polyp types exist as well that are not asso- ciated with cancer risks.

How common are polyps?
For patients who are 50 years old, which is the recommended age for screening with a colonoscopy, the incidence is approximately 25 percent. The rate increases to 50 percent by age 70; so as we get older, the polyps are more frequently found.

What causes polyps?
There is a hereditary component to getting polyps. If family members have polyps, physicians strongly recommend that first-degree relatives (parents, siblings, children) have a colonoscopy at age 50 or earlier. Physicians believe that diet plays a role in the development of polyps. People on low fiber, high fat, high meat diets are more likely to have colon polyps. Also people in Western countries develop polyps more frequently than those from countries in the East.

How are polyps diagnosed?
There are several tests that are commonly used to diagnose colon polyps. During a
digital rectal exam, a physician feels for abnormalities in the lining of the rectum. A fecal
occult blood test can detect tiny amounts of blood in the stool. During a double contract barium enema, or lower GI series, the physician puts a liquid containing barium into your rectum before taking X-rays of your large intestine. Barium is imper-vious to X-rays, and therefore when coating the lining of the colon, polyps can be detected by a radiologist.

A sigmoidoscope and colonscope use a thin flexible tube that has a light and a tiny video camera. The physician uses these to look at the last third or entirety of the large intestine, respectively. Because it is not possible to reliably distinguish the different types of polyps by looking at them with a colonscope alone, a biopsy sample (or complete removal) of polyps is usually taken by the gastrointestinal physician. The biopsy is then examined under a microscope by a surgical pathologist, preferably one with subspecialty training in gastrointestinal pathology, who can precisely determine what type of polyp is present and if any malignancy or other disease is present.

How are polyps treated?
Most polyps can be completely removed during a sigmoidoscopy or colonoscopy. Polyps can be removed painlessly during either procedure by inserting a surgical tool through the scope. This procedure is called polypectomy. Physicians frequently use an electrical wire loop that cuts through the tissue coagulating the vessels at the same time. When very large, surgical removal may be necessary.

How can I prevent polyps?
While there is no absolute way to prevent polyps, you may be able to lower your risk if you do the following:
• Eat more fruits and vegetables and less fatty food
• Don’t smoke
• Avoid alcohol
• Exercise every day
• Lose weight if you are overweight

What is the recommendation for a follow-up colonoscopy?
Whether or not you will need follow-up depends on the kind of polyp the surgical pathologist determines that you have. Your physician will discuss your individual situation and make a recommendation that is appropriate for you.

Constipation
Constipation means that a person has three bowel movements or fewer in a week. The stool is hard and dry. Sometimes it is painful to pass. You may feel ‘draggy’ and full. Some people think they should have a bowel movement every day. That is not really true. There is no ‘right’ number of bowel movements. Each person's body finds its own normal number of bowel movements. It depends on the food you eat, how much you exercise, and other things. At one time or another, almost everyone gets constipated. In most cases, it lasts for a short time and is not serious. When you understand what causes constipation, you can take steps to prevent it.

What can I do about constipation?
Changing what you eat and drink and how much you exercise will help relieve and prevent constipation. Here are some steps you can take.

1. Eat more fiber. Fiber helps form soft, bulky stool. It is found in many vegetables, fruits, and grains. Be sure to add fiber a little at a time, so your body gets used to it slowly. Limit foods that have little or no fiber such as ice cream, cheese, meat, snacks like chips and pizza, and processed foods such as instant mashed potatoes or already-prepared frozen dinners. The chart below lists some high-fiber foods.

2. Drink plenty of water and other liquids such as fruit and vegetable juices and clear soups. Liquid helps keep the stool soft and easy to pass, so it's important to drink enough
fluids. Try not to drink liquids that contain caffeine or alcohol. Caffeine and alcohol tend to dry out your digestive system.

3. Get enough exercise. Regular exercise helps your digestive system stay active and healthy. You don't need to become a great athlete. A 20 to 30-minute walk every day
may help.

4. Allow yourself enough time to have a bowel movement. Sometimes we feel so hurried that we don't pay attention to our body's needs. Make sure you don't ignore the
urge to have a bowel movement.

5. Use laxatives only if a doctor says you should. Laxatives are medicines that will make you pass a stool. Most people who are mildly constipated do not need laxatives. However, if you are doing all the right things and you are still constipated, your doctor may recom-
mend laxatives for a limited time. Your doctor will tell you if you need a laxative and what type is best for you. Laxatives come in many forms: liquid, chewing gum, pills, and powder that you mix with water, for example.

6. Check with your doctor about any medicines you take. Some medicines can cause constipation. They include calcium pills, pain pills with codeine in them, some antacids, iron pills, diuretics (water pills), and medicines for depression. If you take medicine for another problem, ask your doctor whether it could cause constipation.

Points to Remember
• Constipation affects almost everyone at one time or another.
• Many people think they're constipated when really they aren't.
• In most cases, following these simple tips will help prevent constipation:
– Eat a variety of foods, especially beans, bran, whole grains, and fresh fruits and vegetables.
– Drink plenty of liquids.
– Exercise regularly.
– Don't ignore the urge to have a bowel movement.
– Understand that normal bowel habits are different for everyone.
– If your bowel habits change, check with your doctor.
• Most people with mild constipation do not need lax- atives. However, doctors may recommend laxatives for a limited time for people with chronic constipation.
• Medicines that you take for another problem might cause constipation.

Crohn’s Disease
Crohn’s disease causes inflammation of parts of the digestive tract. Inflammation is irritation and swelling. The inflammation, mostly caused by sores called ulcers, can cause pain and diarrhea. The digestive tract is the pathway food travels through in the body. This pathway is also called the gastrointestinal, or GI, tract. It goes from the mouth to the anus. Crohn’s disease can sometimes be hard to diagnose because its symptoms are like the symptoms of other GI diseases. Crohn’s disease can affect any area of the GI tract, but it most often affects a part of the small intestine called the ileum.

Who gets Crohn’s disease?
Crohn’s disease can run in families. As many as 20 percent of people with Crohn’s
disease have a relative with Crohn’s disease or another inflammatory bowel disease. It is most common in people between the ages of 20 and 30. Both men and women can have Crohn’s disease.

What are the symptoms of Crohn’s disease?
Crohn’s disease symptoms can be different for each person. The most common symptoms of Crohn’s disease are abdominal pain and diarrhea. Some people have bleeding in the rectum, which is the lower end of the GI tract, just before the anus. Rectal bleeding can be serious and may not stop without medical help. Bleeding can lead to anemia, meaning the body has lost too many red blood cells. Anemia makes a person feel tired. People can also have weight loss, skin problems, and fevers. Children with Crohn’s disease may develop and grow slower than most other children or they may not reach their expected full height.

What causes Crohn’s disease?
Scientists have many ideas about what causes Crohn’s disease. The immune system in
people with Crohn’s disease may mistake bacteria and foods as being ‘invaders.’ The immune system then attacks these invaders , causing white blood cells to gather in the lining of the intestines. This ‘gathering’ leads to swelling and intestinal damage. The immune system’s response to these invaders may be either a cause or a result of the disease. Many things are associated with inflammation in the GI tract, such as:
• a person’s genes
• the immune system not being able to recognize harmless GI bacteria
• unknown triggers caused by the environment

How is Crohn’s disease diagnosed?
A detailed personal history, a physical exam, and tests are needed to diagnose Crohn’s disease. During your visit the doctor will ask about your symptoms and health. The doctor may run blood tests. You may also be asked for a stool sample. Blood tests can uncover anemia. Anemia can mean you have bleeding in your intestines. Blood tests can also show a high white blood cell count, a sign of inflammation in the body. A stool sample can be used to check if you have bleeding and rule out an infection. X-rays may be needed. The
doctor may also do an upper GI series and small bowel follow-through to look at your small intestine. For this test, you will drink barium, a chalky liquid. The barium looks white on x-ray film, helping the doctor see ulcers or other problems.

The doctor may also do a sigmoidoscopy or a colonoscopy to get a better look inside the intestines. For both tests, the doctor places a long tube into the anus. The tube travels through about 3 feet of the large intestine and sometimes into the very end of your small intestine. The doctor can see any inflammation, ulcers, or bleeding because the tube is linked to a TV screen that shows pictures of the intestines.

The doctor may also do a biopsy. A biopsy is when the doctor snips a bit of tissue, in this case, from the lining of the intestine. The doctor will look at the tissue with a microscope to confirm the diagnosis of Crohn’s disease. You will be given medicine to make you sleepy during the procedure. You will not feel the biopsy.

What are the complications of Crohn’s disease?
Intestinal blockage can occur in people with Crohn’s disease. Blockage occurs because the intestinal wall thickens or swells from inflammation and scar tissue. Ulcers can also cause tunnels to form through the inflamed areas of the intestine or even the healthy parts. These
tunnels are called fistulas. Sometimes pockets of infection, called abscesses, can form in and around the fistulas. Fistulas can be treated with medicine, but sometimes surgery is needed. People with Crohn’s disease often don’t get the nutrients they need. If you have Crohn’s disease, you may not get enough protein, vitamins, or calories in your diet. If
you aren’t getting nutrients, it may be because you:
• have an upset stomach keeping you from eating enough
• may be losing protein in the intestine
• may not be able to absorb nutrients from your food
Other problems that some people with Crohn’s disease suffer from are arthritis, skin problems, swelling in the eyes or mouth, kidney stones, and gallstones. Some of these problems go away during treatment. But some must be treated with additional medicines.

How is Crohn’s disease treated?
Treatment for Crohn’s disease depends on:
• where the disease is located
• how bad the disease is
• what problems you already have from the disease
• what past treatments you have had

The goals of treatment are to:
• help the inflammation
• correct nutritional problems
• relieve symptoms such as abdominal pain, diarrhea, and rectal bleeding

Treatment may include:
• drugs
• minerals and vitamins
• surgery
• nutritional support

Drug Treatment
The doctor may first treat your Crohn’s disease with anti-inflammatory drugs. These drugs
help stop inflammation and help relieve the pain and diarrhea. Sometimes these drugs cause side effects, so you should talk with your doctor about what to expect. Your doctor may also need to treat you with steroids. Steroids are made from natural chemicals in the body. However, steroids are used only for a short time because long-term exposure is not good for a person. Immune system suppressors are also used. They work by keeping your body from attacking itself. Ask your doctor about side effects.

Your doctor may also prescribe infliximab (Remicade) or adalimumab (Humira). Remicade and Humira are very strong drugs that need to be given by an injection in the vein. You can speak with your doctor and discuss if one of these drugs is right for you. The goal for using these drugs is to avoid long-term steroid use, to get you better, and keep you better.

Diet
No foods are known to cause injury or inflammation to the bowel. But when people have Crohn’s disease, hot spices, alcohol, greasy foods, and sometimes milk products may make diarrhea and abdominal pain worse. Your doctor may start you on a special diet so you get extra nutrients. High-calorie liquid supplements are often used to give you the extra calories and right amount of vitamins and minerals to keep you healthy.

Surgery
Some people with Crohn’s disease may need surgery to treat blockage, fistulas, infection, and bleeding if medicines are no longer working. Surgery usually does not make a person disease-free forever. Sometimes people need to have many surgeries because the inflam mation and symptoms come back. The most common surgery for Crohn’s disease is remov ing only the diseased section of intestine. In this operation, after the diseased piece of the intestine is cut out, the intestine is put back together. On rare occasions the surgeon cannot put the two ends back together and needs to create an outlet, or stoma, also called an ostomy. To create a stoma, an end of the small intestine that was not connected is brought out through a small opening made on the lower abdominal wall. The stoma is about the size of a quarter. A small bag is worn over the opening to collect waste, and the person empties the bag as needed.

People who have Crohn’s disease involving all or part of the large intestine may need to have their entire colon removed in an operation called a colectomy. If the whole colon is removed, a stoma is usually needed.

Because people can have symptoms even after surgery, they should talk with their doctor and other patients before making a choice. People should know what to expect from surgery and decide what drugs, if any, would work best afterwards to try to stop the disease from coming back. Groups for people with Crohn’s disease can help a person find support. People with Crohn’s disease may feel well and be symptom-free for a long time. They may need to take drugs for long periods of time, but most are able to hold jobs, raise families, and live fulfilling lives.

Diverticular Disease
Diverticular disease affects the colon. The colon is part of the large intestine that removes waste from your body. Diverticular disease is made up of two conditions: diverticulosis and diverticulitis. Diverticulosis occurs when pouches, called diverticula, form in the colon. These pouches bulge out like weak spots in a tire. Diverticulitis occurs if the pouches become inflamed.

What causes diverticular disease?
Doctors are not sure what causes diverticular disease. Many think a diet low in fiber is the main cause. Fiber is a part of food that your body cannot digest. It is found in many fruits and vegetables. Fiber stays in the colon and absorbs water, which makes bowel movements easier to pass. Diets low in fiber may cause constipation, which occurs when stools are hard and difficult to pass. Constipation causes your muscles to strain when you pass stool. Straining may cause diverticula to form in the colon. If stool or bacteria get caught in the pouches, diverticulitis can occur.

Is diverticular disease serious?
Most people with the disease do not have serious problems, but some people have
severe symptoms. Diverticulitis can be sudden and cause:
• bleeding
• serious infections
• rips in the pouches
• fistula, which is a connection or passage between tissues or organs in the body that normally do not connect
• blockage in your digestive system
• an infection in which the colon ruptures causing stool to empty from the colon into the abdomen

What are the symptoms of diverticular disease?
The symptoms for diverticulosis and diverticulitis are different.

Diverticulosis. Many people don’t have symptoms, but some people have cramping, bloating, and constipation. Some people also have bleeding, inflammation, and fistulas. If you are bleeding, bright red blood will pass through your rectum. The rectum is the end of the colon that connects to the anus. The rectum and anus are part of the gastrointestinal tract, which is the passage that food goes through. Rectal bleeding is usually painless, but it can be dangerous. You should see a doctor right away.

Diverticulitis. People with diverticulitis can have many symptoms. Often pain is felt in the lower part of the abdomen. If you have diverticulitis, you may have fevers, feel sick to your stomach, vomit, or have a change in your bowel habits.

Who gets diverticular disease?
Many people get diverticular disease. Starting at age 40, the chance of getting it increases
about every 10 years. About half of people between the ages of 60 and 80 have diverticular
disease. Almost everyone over 80 has it.

How does the doctor test for diverticular disease?
The doctor can test for diverticular disease many ways. ACT scan is the most common test used. The doctor will inject a liquid in a vein in your arm that better highlights your
organs on x-rays. You may be asked to drink liquid called barium instead of getting an injection. You are then placed in a large doughnut-shaped machine that takes x-rays.

Other tests include:
• Medical history The doctor will ask about your health and symptoms such as pain. You will be asked about your bowel habits, diet, and any medications you take.
• Blood test This test can help detect infections.
• Stool sample This test may show bleeding in the digestive tract.
• Digital rectal exam The doctor will insert a gloved finger into your rectum to check for pain, bleeding, or a blockage.
• X-ray and barium enema The doctor will insert liquid called barium in the large intestine through your anus. The anus is the opening where stool leaves the body. The barium makes the diverticula show up on an x-ray.
• Colonoscopy The doctor will insert a small tube through your anus. A tiny video camera is in the tube and will show if there are any pouches.

How is diverticular disease treated?
Treatment for diverticular disease depends on how serious the problem is and whether you are suffering from diverticulosis or diverticulitis. Most people get better by changing their
diet. If you have rectal bleeding, you need to go to the hospital so a doctor can find the part of your colon that is bleeding. The doctor may use a special drug that makes the bleeding stop. The doctor may also decide to operate and remove the part of the colon that is bleeding.

How is diverticulosis treated?
Eating high-fiber foods can help relieve symptoms. Sometimes mild pain medications
also help.

How is diverticulitis treated?
A doctor may prescribe antibiotics and recommend following a liquid diet. Most people get better with this treatment. Some people may need surgery and other treatments.
• Surgery. Serious problems from diverticulitis are treated with surgery. Surgeons can clean the abdomen after infections and remove bleeding pouches and fistulas.
• Colon resection. If you get diverticulitis many times, your doctor might suggest taking out the part of the colon with diverticula. The healthy sections can be joined together. With the diverticula gone, you may avoid other infections.
• Emergency surgery. If you have severe problems, you may need emergency surgery to clear the infection and remove part of the colon. Later, a second surgery rejoins the healthy sections of the colon.

The colon is separated for a brief time between surgeries, because rejoining the colon during the first surgery is not always safe. A temporary colostomy is needed between the two surgeries. A colostomy is an opening made on the abdomen where a plastic bag is connected to collect stool after food is digested. The surgeon makes the opening, called a stoma, and connects it to the end of the colon.

What can I do about diverticular disease?
Eat a high-fiber diet to help prevent problems. Talk to your doctor about using fiber products like Benefiber, Citrucel, or Metamucil. Daily use can help you get the fiber you need if you do not get it through your diet.

Eating foods high in fiber is simple and can help reduce diverticular disease symptoms and problems.

Try eating more of the following:
• Fruit. Raw apples, peaches, pears, and tangerines.
• Vegetables. Fresh broccoli, squash, carrots, and brussels sprouts.
• Starchy vegetables. Potatoes, baked beans, kidney beans, and lima beans.
• Grains. Whole-wheat bread, brown rice, bran flake cereal, and oatmeal.
Talk with your doctor about making diet changes. Learn what to eat and how to put more of these high-fiber foods in your diet.

Points to Remember
• Diverticular disease is more common in people as they grow older.
• A low-fiber diet is the most likely cause of the disease.
• Most people are treated with a high-fiber diet and pain medication.
• Add whole grain foods, high-fiber fruits, and vegetables to your diet.
• Contact a doctor if you notice symptoms such as fever, chills, nausea, vomiting, abdominal pain, rectal bleeding, or change in bowel habits.

Hemmorrhoids
The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed. Hemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse. Hemorrhoids are either inside the anus – internal – or under the skin around the anus – external.

What are the symptoms of hemorrhoids?
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching, also called pruritus ani, have similar symptoms and are incorrectly referred to as hemorrhoids. Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days. Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid.Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/ or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.

How common are hemorrhoids?
Hemorrhoids are common in both men and women. About half of the population has hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The pressure of the fetus on the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.

How are hemorrhoids diagnosed?
A thorough evaluation and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer. The doctor will examine the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.

Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum. To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon, or sigmoid, with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.

What is the treatment?
Medical treatment of hemorrhoids is aimed initially at relieving symptoms. Measures
to reduce symptoms include
• tub baths several times a day in plain, warm water for about 10 minutes
• application of a hemorrhoidal cream or suppository to the affected area for a limited time

Preventing the recurrence of hemorrhoids will require relieving the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of fluid – not alcohol – result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.

Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel). In some cases, hemorrhoids must be treated endoscopically or surgically. These methods are used to shrink and destroy the hemorrhoidal tissue. The doctor will perform the procedure during an office or hospital visit. A number of methods may be used to remove or reduce the size of internal hemorrhoids. These techniques include:
• Rubber band ligation. A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.
• Sclerotherapy. A chemical solution is injected around the blood vessel to shrink the hemorrhoid.
•Infrared coagulation. A special device is used to burn hemorrhoidal tissue.
• Hemorrhoidectomy. Occasionally, extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy.

How are hemorrhoids prevented?
The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduceconstipation and straining by producing stools that are softer and easier to pass.