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Controversies in the Investigation and Treatment of Lower Gastrointestinal Bleeding. Practical Gastroenterology. 24(1): 42, 52, 54, 58. January 2000.

Lower gastrointestinal (GI) bleeding may be intermittent, self limited, or produce a life threatening emergency. There are several options for diagnostic evaluation, but the location and etiology of the bleeding source may remain elusive. In this article, the authors review the diagnostic and treatment options and provide recommendations for developing an organized patient algorithm. The majority of patients with lower GI hemorrhage will stop bleeding during resuscitation. Once the bleeding has stopped, investigation of the source of the bleed usually proceeds with routine endoscopic and radiological studies, followed by elective segmental resection, if indicated. In patients where it is impossible to determine the precise location and etiology, both patient and physician must await the next bleeding episode. Patients who present with lower GI bleeding are usually adults older than 50 years. The most common etiologies of lower GI bleeding include diverticulosis, vascular ectasia, ischemic colitis, inflammatory bowel disease (IBD), and neoplasm (cancer). Diagnostic options include colonoscopy, traditional imaging techniques (CT scan or contrast studies), nuclear scintigraphy, or mesenteric angiography. Colonoscopy and mesenteric angiography both offer the means for potentially controlling the hemorrhage whereas scintigraphy does not. Colonoscopy can provide the means to treat bleeding lesions through electrocautery, epinephrine injection, or sclerotherapy. Angiography can provide access for vasopressin infusion or embolization. The unstable patient without a determined site of bleeding represents the most challenging dilemma, as blind total abdominal colectomy is associated with potential rebleeding from the small intestine and significant morbidity and mortality. 26 references.

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Coping with the Pain and Annoyance of Hemorrhoids. Digestive Health and Nutrition. p. 20-23. January-February 2000.

This article helps readers understand and cope with hemorrhoids. The author describes how to distinguish between types of hemorrhoids, how to recognize the possible symptoms, and what treatment options are available. Following is a description of typical hemorrhoidal bleeding (bright red blood on the toilet tissue or in the toilet water); readers are encouraged to consult with a health care provider for even relatively minor rectal bleeding. Hemorrhoids are then defined in terms of their location. Internal hemorrhoids arise from blood vessels that lie up to 2 inches inside the anus, and external hemorrhoids form under the anal skin. Internal hemorrhoids, which are not usually seen or felt unless they protrude downward outside the anus, can cause other symptoms, including a feeling of fullness in the rectum (particularly after passing stool) or deep itching (pruritus). The author explores possible reasons why some people develop hemorrhoids, including certain working conditions (such as lots of sitting), weak muscles within the bowels, low fiber diets (which can result in straining with defecation), and pregnancy. Diagnostic tests can rule out other possible causes of rectal bleeding, including anal fissure, Crohn's disease or ulcerative colitis (inflammatory bowel diseases), Meckel's diverticulum, and cancer or noncancerous polyps in the bowel. Treatment options are reviewed, from lifestyle and dietary changes to topical therapy, to surgical treatments (rubber band ligation, laser treatment, and sclerosing injections).

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Digestive Diseases and Disorders Sourcebook. Detroit, MI: Omnigraphics. 2000. 300 p.

This sourcebook provides basic information for the layperson about common disorders of the upper and lower digestive tract. The sourcebook also includes information about medications and recommendations for maintaining a healthy digestive tract. The book's 40 chapters are arranged in three major parts. The first section, Maintaining a Healthy Digestive Tract, offers basic information about the digestive system and digestive diseases, information about tests and treatments, and recommendations for maintaining a healthy digestive system. The second section, Digestive Diseases and Functional Disorders, describes nearly 40 different diseases and disorders affecting the digestive system. These include appendicitis, bleeding in the digestive tract, celiac disease, colostomy, constipation, constipation in children, Crohn's disease, cyclic vomiting syndrome, diarrhea, diverticulosis and diverticulitis, gallstones, gas in the digestive tract, heartburn (gastroesophageal reflux disease), hemorrhoids, hernias, Hirschsprung's disease, ileostomy, indigestion (dyspepsia), intestinal pseudo-obstruction, irritable bowel syndrome (IBS), IBS in children, lactose intolerance, Menetrier's disease, rapid gastric emptying, short bowel syndrome, ulcerative colitis, ulcers, Whipple's disease, and Zollinger Ellison syndrome. The final section offers a glossary of terms, a subject index and a directory of digestive diseases organizations (which includes website and email addresses as available). Material in the book was collected from a wide range of government agencies, nonprofit organizations, and periodicals.

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Diseases and Conditions of the Digestive System. In: Frazier, M.S.; Drzymkowski, J.W.; Doty, S.J. Essentials of Human Diseases and Conditions. 2nd ed. Philadelphia, PA: W.B. Saunders Company. 2000. p. 214-255.

This chapter, from a comprehensive text on human diseases and conditions, familiarizes readers with the various conditions that can afflict the alimentary canal and the accessory organs of the digestive system. Gastrointestinal (GI) problems are common and often cause anxiety because of the way in which they interfere with a sense of well being. The 'gut' is also often associated with emotional responses. The chapter covers the processes of normal digestion and absorption; the importance of normal teeth and a normal bite; the presenting symptoms of temporomandibular joint (TMJ) syndrome; the etiology of herpes simple compared to the etiology of candidiasis (thrush); complications of esophageal varices; the pathology and etiology of peptic ulcers; the diagnosis of gastric cancer; hiatal and other types of abdominal hernias; the pathology involved in Crohn's disease and ulcerative colitis; the etiology of gastroenteritis; functional and mechanical obstruction of the bowel; intestinal obstruction; diverticulosis versus diverticulitis; the treatment of colorectal cancer; the relationship between broad spectrum antibiotics and pseudomembranous enterocolitis; the causes of inflammation of the peritoneum; the symptoms and signs of cirrhosis of the liver; the etiology, transmission, and prevention of hepatitis A and hepatitis C; the clinical picture of biliary colic and acute pancreatitis; the manifestations of malnutrition and malabsorption; the diagnostic criteria for celiac disease (gluten intolerance); the different presentations of anorexia nervosa and bulimia; and the components of a successful weight loss program. Each of the topics includes a brief discussion of symptoms and signs, etiology (causes), diagnosis, and treatment. The chapter is illustrated with line drawings and concludes with a list of review questions. A brief list of related information resource organizations is also included. 25 figures. 1 table.

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Diverticular Disease. In: King, J.E., ed. Mayo Clinic on Digestive Health. Rochester, MN: Mayo Clinic. 2000. p. 125-132.

Diverticular disease is the general term for the development of small, bulging pouches in the digestive tract. The most common site for diverticula is the large intestine (colon), particularly the lower part of the colon called the sigmoid colon. This chapter on diverticular disease is from a comprehensive guidebook from the Mayo Clinic that focuses on a variety of digestive symptoms, including heartburn, abdominal pain, constipation, and diarrhea, and the common conditions that are often responsible for these symptoms. Written in nontechnical language, the book includes practical information on how the digestive system works, factors that can interfere with its normal functioning, and how to prevent digestive problems. This chapter first reviews the key signs and symptoms of diverticular disease, including pain in the lower left abdomen, abdominal tenderness, fever, nausea, and constipation or diarrhea. The authors describe the two forms of diverticular disease: diverticulosis, which refers to the presence of diverticula in the digestive tract, and is very common; and diverticulitis, which is inflammation or infection in a diverticulum. Three factors seem to contribute to diverticula: weak spots in the colon wall, aging, and too little dietary fiber. Because diverticula usually do not cause problems, most people first learn they have diverticulosis during routine screening exams for colorectal cancer or during tests for another intestinal condition. Treatment begins with self care strategies, including increasing the amount of fiber in one's diet, drinking plenty of fluids, avoiding constipation, and exercising regularly. The authors outline how to know when medical care is necessary for diverticular disease, and review the care that may be provided, including rest and a restricted diet, antibiotics, painkillers (analgesics), and surgery. The chapter concludes by reminding readers that there is no evidence that diverticular disease increases one's risk of colon or rectal cancer; however, diverticular disease can make cancer more difficult to diagnose. 1 figure.

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Diverticulitis: A High-Fiber Diet May Prevent This Ailment. Mayo Clinic Women's Healthsource. 4(11): 6. November 2000.

This article, from a general health newsletter, offers suggestions for avoiding diverticulitis (infection of pockets of the colon) through the use of a high fiber diet. Diverticulosis, a condition that develops with aging, seems to be due to weakening and bulging of the colon wall that results in the pockets or pouches called diverticula. Some people with diverticulosis develop diverticulitis, a serious condition of infection or inflammation in the colon that needs prompt treatment. Symptoms of diverticulitis range from mild crampy abdominal pain to severe pain, nausea, and fever. Mild attacks can be treated at home with an antibiotic and a low fiber diet (to rest the colon). If the antibiotics do not work or if the physician suspects an obstruction or perforation of the colon wall, the patient will require treatment in the hospital. Eating a high fiber diet may help prevent diverticulosis or slow its progression. It is suspected, but unproven, that eating a high fiber diet can prevent diverticulitis. To help minimize pressure within the colon, the author advises readers to eat a varied diet rich in fiber, drink eight or more cups of liquid a day, and move the bowels whenever the urge is present (do not delay defecation). One sidebar offers brief specifics on how to increase the fiber in one's diet, including what items to note on food labels (at least 5 grams of fiber per serving, and ingredients including wheat bran, whole wheat, cracked wheat, barley, brown rice, bulgur).

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Feeling Good About Your Medical Care. In: Bolen, B.B. Breaking the Bonds of Irritable Bowel Syndrome: A Psychological Approach to Regaining Control of Your Life. Oakland, CA: New Harbinger Publications, Inc. 2000. p.29-43.

Irritable bowel syndrome (IBS) consists of recurrent episodes of abdominal pain related to altered bowel habit, which may consist of predominantly constipation or diarrhea, or an alternation between the two. This chapter on feeling good about one's medical care is from a book in which the author encourages an open discussion of the symptoms and feelings that accompany irritable bowel syndrome (IBS). Charts and worksheets help readers track the relationship between unpleasant symptoms and external triggers such as foods, stressful events, emotional states, and certain thoughts. Coping skills, such as relaxation exercises and assertiveness techniques, teach readers how to manage their stress more effectively and help them break free of the restrictions placed upon them by the disruptiveness of this digestive disorder. This chapter discusses how to locate a health care provider, how to establish a good relationship between patient and doctor, reasonable expectations of one's health care provider, how to be assertive in health care matters, what to expect during the first and subsequent visits to the doctor, diagnostic tests (sigmoidoscopy, barium enema, colonoscopy), other diseases that might be considered during diagnosis (inflammatory bowel diseases, diverticular disease, and colon cancer), treatments that may be utilized (dietary changes, medication), and prognosis. Throughout the chapter, the author emphasizes the importance of educating oneself and taking an active role in one's own disease management. 1 figure.

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Fiber-Restricted Diet. In: American Dietetic Association. Manual of Clinical Dietetics, Sixth Edition. Chicago, IL: American Dietetic Association. 2000. p.703-707.

This chapter describing a fiber-restricted diet is from a comprehensive manual of clinical dietetics designed to help dietitians, physicians, and nurses deliver quality nutrition care. The chapter includes the purpose of the fiber-restricted diet, the indications for use, a description of the diet, meal planning approaches, and a discussion section. The fiber-restricted diet is used to reduce the frequency and volume of fecal output while prolonging intestinal transit time; and to prevent blockage of a stenosed gastrointestinal tract. The diet can be used during acute phases of ulcerative colitis, Crohn's disease, and diverticulitis and when stenosis (narrowing) of the intestine occurs. The diet may also be used preoperatively to minimize fecal volume and residue and postoperatively during the progression to a general diet. 1 table. 18 references.

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Gastrointestinal Bleeding in Infancy and Childhood. Gastroenterology Clinics of North America. 29(1): 37-66. March 2000.

Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The author discusses the causes (etiology), diagnostic evaluation, and management, and highlights the differences with adult medicine. The more common causes of upper GI bleeding in children are ulcer and gastritis, esophagitis, and varices (enlarged veins or arteries). A detailed history and careful physical examination accompanied by limited laboratory studies may identify the underlying cause and predict the severity of gastrointestinal hemorrhage. Endoscopy is the preferred diagnostic procedure because it is sensitive and specific and, for some lesions, provides the means for immediate treatment. Medical therapy (drugs) is similar for adults and children, differing mostly in the dosage of medications. One table lists pediatric doses for medications commonly used in upper gastrointestinal bleeding. Endoscopic therapy may be used in children with an actively bleeding focal lesion or with a lesion at high risk of rebleeding. Surgery is reserved for bleeding that is uncontrollable by less invasive interventions. The latter part of the article reviews lower GI bleeding, noting that age is an important factor in diagnosis of etiology (cause). Colonoscopy is the preferred diagnostic modality for rectal bleeding. The article concludes with a brief description of small bowel hemorrhage, usually due to Meckel's diverticulum (a congenital anomaly), duplications of the bowel, or idiopathic necrotizing enteritis. 4 figures. 3 tables. 212 references.

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Gastrointestinal Bleeding in Older People. Gastroenterology Clinics of North America. 29(1): 1-36. March 2000.

Aging is associated with an increased rate of comorbidity, greater medication use, and atypical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding makes the evaluation and management of gastrointestinal bleeding in older people a special and increasingly common clinical challenge. In this article, the unique features and common causes of upper and lower gastrointestinal bleeding in older people are reviewed. The hospital course of elderly patients with upper gastrointestinal bleeding appears to be similar to that of younger patients with respect to the use of endoscopic therapy for bleeding and rebleeding, need for general anesthesia for endoscopy, rates of admission to an intensive care unit, blood transfusion requirements, frequency of surgery, and duration of hospital stay. The authors consider some important management issues including hemodynamic resuscitation, anticoagulation, and endoscopic and surgical therapy. The authors review specific upper gastrointestinal bleeding lesions, including esophagitis and gastritis, peptic ulcer disease (particularly that caused by nonsteroidal antiinflammatory drugs), and variceal bleeding; and specific lower gastrointestinal bleeding lesions, including colonic diverticula, angiodysplasia, colonic ischemia, and inflammatory bowel disease. The authors also conclude that planning for care beyond the acute bleeding episode in this population is critical and involves an understanding of the importance of rehabilitation and community based services and involvement of a caregiver. 11 tables. 153 references.

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