Ulcerative Colitis

What is ulcerative colitis?

Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon. Ulcers form where inflammation has killed the cells that usually line the colon, then bleed and produce pus. Inflammation in the colon also causes the colon to empty frequently, causing diarrhea.

When the inflammation occurs in the rectum and lower part of the colon it is called ulcerative proctitis. If the entire colon is affected it is called pancolitis. If only the left side of the colon is affected it is called limited or distal colitis.

Ulcerative colitis is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the small intestine and colon. It can be difficult to diagnose because its symptoms are similar to other intestinal disorders and to another type of IBD called Crohn’s disease. Crohn’s disease differs because it causes inflammation deeper within the intestinal wall and can occur in other parts of the digestive system including the small intestine, mouth, esophagus, and stomach.

Ulcerative colitis can occur in people of any age, but it usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age. It affects men and women equally and appears to run in families, with reports of up to 20 percent of people with ulcerative colitis having a family member or relative with ulcerative colitis or Crohn’s disease. A higher incidence of ulcerative colitis is seen in Whites and people of Jewish descent.

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What are the symptoms of ulcerative colitis?

The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may experience

• anemia
• fatigue
• weight loss
• loss of appetite
• rectal bleeding
• loss of body fluids and nutrients
• skin lesions
• joint pain
• growth failure (specifically in children)

About half of the people diagnosed with ulcerative colitis have mild symptoms. Others suffer frequent fevers, bloody diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis may also cause problems such as arthritis, inflammation of the eye, liver disease, and osteoporosis. It is not known why these problems occur outside the colon. Scientists think these complications may be the result of inflammation triggered by the immune system. Some of these problems go away when the colitis is treated.

What causes ulcerative colitis?

Many theories exist about what causes ulcerative colitis. People with ulcerative colitis have abnormalities of the immune system, but doctors do not know whether these abnormalities are a cause or a result of the disease. The body’s immune system is believed to react abnormally to the bacteria in the digestive tract.

Ulcerative colitis is not caused by emotional distress or sensitivity to certain foods or food products, but these factors may trigger symptoms in some people. The stress of living with ulcerative colitis may also contribute to a worsening of symptoms.

How is ulcerative colitis diagnosed?

Many tests are used to diagnose ulcerative colitis. A physical exam and medical history are usually the first step.

Blood tests may be done to check for anemia, which could indicate bleeding in the colon or rectum, or they may uncover a high white blood cell count, which is a sign of inflammation somewhere in the body.

A stool sample can also reveal white blood cells, whose presence indicates ulcerative colitis or inflammatory disease. In addition, a stool sample allows the doctor to detect bleeding or infection in the colon or rectum caused by bacteria, a virus, or parasites.

A colonoscopy or sigmoidoscopy are the most accurate methods for making a diagnosis of ulcerative colitis and ruling-out other possible conditions, such as Crohn’s disease, diverticular disease, or cancer. For both tests, the doctor inserts an endoscope—a long, flexible, lighted tube connected to a computer and TV monitor—into the anus to see the inside of the colon and rectum. The doctor will be able to see any inflammation, bleeding, or ulcers on the colon wall. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the colon to view with a microscope.

Sometimes x rays such as a barium enema or CT scans are also used to diagnose ulcerative colitis or its complications.

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What is the treatment for ulcerative colitis?

Treatment for ulcerative colitis depends on the severity of the disease. Each person experiences ulcerative colitis differently, so treatment is adjusted for each individual.

Drug Therapy

The goal of drug therapy is to induce and maintain remission, and to improve the quality of life for people with ulcerative colitis. Several types of drugs are available.

• Aminosalicylates, drugs that contain 5-aminosalicyclic acid (5-ASA), help control inflammation. Sulfasalazine is a combination of sulfapyridine and 5-ASA. The sulfapyridine component carries the anti-inflammatory 5-ASA to the intestine. However, sulfapyridine may lead to side effects such as nausea, vomiting, heartburn, diarrhea, and headache. Other 5-ASA agents, such as olsalazine, mesalamine, and balsalazide, have a different carrier, fewer side effects, and may be used by people who cannot take sulfasalazine. 5-ASAs are given orally, through an enema, or in a suppository, depending on the location of the inflammation in the colon. Most people with mild or moderate ulcerative colitis are treated with this group of drugs first. This class of drugs is also used in cases of relapse.
• Corticosteroids such as prednisone, methylprednisone, and hydrocortisone also reduce inflammation. They may be used by people who have moderate to severe ulcerative colitis or who do not respond to 5-ASA drugs. Corticosteroids, also known as steroids, can be given orally, intravenously, through an enema, or in a suppository, depending on the location of the inflammation. These drugs can cause side effects such as weight gain, acne, facial hair, hypertension, diabetes, mood swings, bone mass loss, and an increased risk of infection. For this reason, they are not recommended for long-term use, although they are considered very effective when prescribed for short-term use.
• Immunomodulators such as azathioprine and 6-mercapto-purine (6-MP) reduce inflammation by affecting the immune system. These drugs are used for patients who have not responded to 5-ASAs or corticosteroids or who are dependent on corticosteroids. Immunomodulators are administered orally, however, they are slow-acting and it may take up to 6 months before the full benefit. Patients taking these drugs are monitored for complications including pancreatitis, hepatitis, a reduced white blood cell count, and an increased risk of infection. Cyclosporine A may be used with 6-MP or azathioprine to treat active, severe ulcerative colitis in people who do not respond to intravenous corticosteroids.

Other drugs may be given to relax the patient or to relieve pain, diarrhea, or infection.

Some people have remissions—periods when the symptoms go away—that last for months or even years. However, most patients’ symptoms eventually return.

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Hospitalization

Occasionally, symptoms are severe enough that a person must be hospitalized. For example, a person may have severe bleeding or severe diarrhea that causes dehydration. In such cases the doctor will try to stop diarrhea and loss of blood, fluids, and mineral salts. The patient may need a special diet, feeding through a vein, medications, or sometimes surgery.

Surgery

About 25 to 40 percent of ulcerative colitis patients must eventually have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer. Sometimes the doctor will recommend removing the colon if medical treatment fails or if the side effects of corticosteroids or other drugs threaten the patient’s health.

Surgery to remove the colon and rectum, known as proctocolectomy, is followed by one of the following:

• Ileostomy, in which the surgeon creates a small opening in the abdomen, called a stoma, and attaches the end of the small intestine, called the ileum, to it. Waste will travel through the small intestine and exit the body through the stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed.
• Ileoanal anastomosis, or pull-through operation, which allows the patient to have normal bowel movements because it preserves part of the anus. In this operation, the surgeon removes the colon and the inside of the rectum, leaving the outer muscles of the rectum. The surgeon then attaches the ileum to the inside of the rectum and the anus, creating a pouch. Waste is stored in the pouch and passes through the anus in the usual manner. Bowel movements may be more frequent and watery than before the procedure. Inflammation of the pouch (pouchitis) is a possible complication.

Not every operation is appropriate for every person. Which surgery to have depends on the severity of the disease and the patient’s needs, expectations, and lifestyle. People faced with this decision should get as much information as possible by talking to their doctors, to nurses who work with colon surgery patients (enterostomal therapists), and to other colon surgery patients. Patient advocacy organizations can direct people to support groups and other information resources.

Is colon cancer a concern?

About 5 percent of people with ulcerative colitis develop colon cancer. The risk of cancer increases with the duration of the disease and how much the colon has been damaged. For example, if only the lower colon and rectum are involved, the risk of cancer is no higher than normal. However, if the entire colon is involved, the risk of cancer may be as much as 32 times the normal rate.

Sometimes precancerous changes occur in the cells lining the colon. These changes are called “dysplasia.” People who have dysplasia are more likely to develop cancer than those who do not. Doctors look for signs of dysplasia when doing a colonoscopy or sigmoidoscopy and when examining tissue removed during these tests.

According to the 2002 updated guidelines for colon cancer screening, people who have had IBD throughout their colon for at least 8 years and those who have had IBD in only the left colon for 12 to 15 years should have a colonoscopy with biopsies every 1 to 2 years to check for dysplasia. Such screening has not been proven to reduce the risk of colon cancer, but it may help identify cancer early. These guidelines were produced by an independent expert panel and endorsed by numerous organizations, including the American Cancer Society, the American College of Gastroenterology, the American Society of Colon and Rectal Surgeons, and the Crohn’s & Colitis Foundation of America.

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Proctitis

Proctitis is inflammation of the lining of the rectum, called the rectal mucosa. Proctitis can be short term (acute) or long term (chronic). Proctitis has many causes. It may be a side effect of medical treatments like radiation therapy or antibiotics. Sexually transmitted diseases like gonorrhea, herpes, and chlamydia may also cause proctitis. Inflammation of the rectal mucosa may be related to ulcerative colitis or Crohn’s disease, autoimmune conditions that cause inflammation in the colon or small intestine. Other causes include rectal injury, bacterial infection, allergies, and malfunction of the nerves in the rectum.

The most common symptom is a frequent or continuous sensation or urge to have a bowel movement. Other symptoms include constipation, a feeling of rectal fullness, left-sided abdominal pain, passage of mucus through the rectum, rectal bleeding, and anorectal pain.

Physicians diagnose proctitis by looking inside the rectum with a proctoscope or a sigmoidoscope. A biopsy (a tiny piece of tissue from the rectum) may be removed and tested for diseases or infections. A stool sample may also reveal infecting bacteria. If the physician suspects Crohn’s disease or ulcerative colitis, colonoscopy or barium enema x rays may be used to examine areas of the intestine.

Treatment depends on the cause of proctitis. For example, the physician may prescribe antibiotics for proctitis caused by bacterial infection. If the inflammation is caused by Crohn’s disease or ulcerative colitis, the physician may recommend the drug 5-aminosalicyclic acid (5ASA) or corticosteroids applied directly to the area in enema or suppository form, or taken orally in pill form. Enema and suppository applications are usually more effective, but some patients may require a combination of oral and rectal applications.

Lower GI Series

A lower gastrointestinal (GI) series uses x rays to diagnose problems in the large intestine, which includes the colon and rectum. The lower GI series may show problems like abnormal growths, ulcers, polyps, diverticuli, and colon cancer.

Before taking x rays of your colon and rectum, the radiologist will put a thick liquid called barium into your colon. This is why a lower GI series is sometimes called a barium enema. The barium coats the lining of the colon and rectum and makes these organs, and any signs of disease in them, show up more clearly on x rays. It also helps the radiologist see the size and shape of the colon and rectum.

You may be uncomfortable during the lower GI series. The barium will cause fullness and pressure in your abdomen and will make you feel the urge to have a bowel movement. However, that rarely happens because the tube used to inject the barium has a balloon on the end of it that prevents the liquid from coming back out.

You may be asked to change positions while x rays are taken. Different positions give different views of the colon. After the radiologist is finished taking x rays, you will be able to go to the bathroom. The radiologist may also take an x ray of the empty colon afterwards.

A lower GI series takes about 1 to 2 hours. The barium may cause constipation and make your stool turn gray or white for a few days after the procedure.

Preparation

Your colon must be empty for the procedure to be accurate. To prepare for the procedure you will have to restrict your diet for a few days beforehand. For example, you might be able to drink only liquids and eat only nonsugar, nondairy foods for 2 days before the procedure; only clear liquids the day before; and nothing after midnight the night before. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. To make sure your colon is empty, you will be given a laxative or an enema before the procedure. Your physician may give you other special instructions.

Hemorrhoids

What are hemorrhoids?

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 reduce constipation and straining by producing stools that are softer and easier to pass.

Fecal Incontinence

Fecal incontinence is the inability to control your bowels. When you feel the urge to have a bowel movement, you may not be able to hold it until you get to a toilet. Or stool may leak from the rectum unexpectedly, sometimes while passing gas.

More than 5.5 million Americans have fecal incontinence. It affects people of all ages—children and adults. Fecal incontinence is more common in women and older adults, but it is not a normal part of aging.

Loss of bowel control can be devastating. People who have fecal incontinence may feel ashamed, embarrassed, or humiliated. Some don’t want to leave the house out of fear they might have an accident in public. Most try to hide the problem as long as possible, so they withdraw from friends and family. The social isolation is unfortunate but may be reduced with treatment that improves bowel control and makes incontinence easier to manage.

What causes fecal incontinence?

Fecal incontinence can have several causes:

• constipation
• damage to the anal sphincter muscles
• damage to the nerves of the anal sphincter muscles or the rectum
• loss of storage capacity in the rectum
• diarrhea
• pelvic floor dysfunction

Constipation

Constipation is one of the most common causes of fecal incontinence. Constipation causes large, hard stools to become lodged in the rectum. Watery stool can then leak out around the hardened stool. Constipation also causes the muscles of the rectum to stretch, which weakens the muscles so they can’t hold stool in the rectum long enough for a person to reach a bathroom.

Muscle Damage

Fecal incontinence can be caused by injury to one or both of the ring-like muscles at the end of the rectum called the anal internal and external sphincters. The sphincters keep stool inside. When damaged, the muscles aren’t strong enough to do their job and stool can leak out. In women, the damage often happens when giving birth. The risk of injury is greatest if the doctor uses forceps to help deliver the baby or performs an episiotomy, which is a cut in the vaginal area to prevent it from tearing during birth. Hemorrhoid surgery can also damage the sphincters.

Nerve Damage

Fecal incontinence can be caused by damage to the nerves that control the anal sphincters or the nerves that sense stool in the rectum. If the nerves that control the sphincters are injured, the muscles don’t work properly and incontinence can occur. If the sensory nerves are damaged, they don’t sense that stool is in the rectum so you won’t feel the need to use the bathroom until stool has leaked out. Nerve damage can be caused by childbirth, a long-term habit of straining to pass stool, stroke, physical disability due to injury, and diseases that affect the nerves such as diabetes and multiple sclerosis.

Loss of Storage Capacity

Normally, the rectum stretches to hold stool until you can get to a bathroom. But rectal surgery, radiation treatment, and inflammatory bowel disease can cause scarring that makes the walls of the rectum stiff and less elastic. The rectum then can’t stretch as much to hold stool and fecal incontinence results. Inflammatory bowel disease also can irritate rectal walls, making them unable to contain stool.

Diarrhea

Diarrhea, or loose stool, is more difficult to control than solid stool because with diarrhea the rectum fills with stool at a faster rate. Even people who don’t have fecal incontinence can leak stool when they have diarrhea.

Pelvic Floor Dysfunction

Abnormalities of the pelvic floor muscles and nerves can cause fecal incontinence. Examples include

• impaired ability to sense stool in the rectum
• decreased ability to contract muscles in the anal canal to defecate
• dropping down of the rectum, a condition called rectal prolapse
• protrusion of the rectum through the vagina, a condition called rectocele
• general weakness and sagging of the pelvic floor

Childbirth is often the cause of pelvic floor dysfunction, and incontinence usually doesn’t appear until the midforties or later.

How is fecal incontinence diagnosed?

Doctors understand the feelings associated with fecal incontinence, so you can talk freely with your doctor. The doctor will ask some health-related questions, do a physical exam, and possibly run some medical tests. Your doctor may refer you to a specialist, such as a gastroenterologist, proctologist, or colorectal surgeon.

The doctor or specialist may conduct one or more tests:

• Anal manometry checks the tightness of the anal sphincter and its ability to respond to signals, as well as the sensitivity and function of the rectum. Magnetic resonance imaging (MRI) is sometimes used to evaluate the sphincter.
• Anorectal ultrasonography evaluates the structure of the anal sphincters.
• Proctography, also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate it.
• Proctosigmoidoscopy allows doctors to look inside the rectum and lower colon for signs of disease or other problems that can cause fecal incontinence, such as inflammation, tumors, or scar tissue.
• Anal electromyography tests for nerve damage, which is often associated with injury during childbirth.

How is fecal incontinence treated?

Effective treatments are available for fecal incontinence and can improve or restore bowel control. The type of treatment depends on the cause and severity of fecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary for successful control because continence is a complicated chain of events.

Dietary Changes

Food affects the consistency of stool and how quickly it passes through the digestive system. If your stools are hard to control because they are watery, you may find that eating high-fiber foods adds bulk and makes stool easier to control. But people with well-formed stools may find that high-fiber foods act as a laxative and contribute to the problem. Foods and drinks that may make the problem worse are those containing caffeine—like coffee, tea, or chocolate—which relaxes the internal anal sphincter muscles.

You can adjust what and how you eat to help manage fecal incontinence.

• Keep a food diary. List what you eat, how much you eat, and when you have an incontinent episode. After a few days, you may begin to see a pattern involving certain foods and incontinence. After you identify foods that seem to cause problems, cut back on them and see whether incontinence improves. Foods and drinks that typically cause diarrhea, and so should probably be avoided, include
  • drinks and foods containing caffeine
  • cured or smoked meat such as sausage, ham, or turkey
  • spicy foods
  • alcoholic beverages
  • dairy products such as milk, cheese, or ice cream
  • fruits such as apples, peaches, or pears
  • fatty and greasy foods
  • sweeteners, such as sorbitol, xylitol, mannitol, and fructose, which are found in diet drinks, sugarless gum and candy, chocolate, and fruit juices
• Eat small meals more frequently. In some people, large meals cause bowel contractions that lead to diarrhea. You can still eat the same amount of food in a day, but space it out by eating several small meals.
• Eat and drink at different times. Liquid helps move food through the digestive system. So if you want to slow things down, drink something half an hour before or after meals, but not with meals.
• Eat the right amount of fiber. For many people, fiber makes stool soft, formed, and easier to control. Fiber is found in fruits, vegetables, and grains, like those listed below. You need to eat 20 to 30 grams of fiber a day, but add it to your diet slowly so your body can adjust. Too much fiber all at once can cause bloating, gas, or even diarrhea. Also, too much insoluble, or undigestible, fiber can contribute to diarrhea. If you find that eating more fiber makes your diarrhea worse, try cutting back to two servings each of fruits and vegetables and removing skins and seeds from your food.
• Eat foods that make stool bulkier. Foods that contain soluble, or digestible, fiber slow the emptying of the bowels, including bananas, rice, tapioca, bread, potatoes, applesauce, cheese, smooth peanut butter, yogurt, pasta, and oatmeal.
• Get plenty to drink. Drink eight 8-ounce glasses of liquid a day to help prevent dehydration and keep stool soft and formed. Water is a good choice. Avoid drinks with caffeine, alcohol, milk, or carbonation if you find they trigger diarrhea.

Over time, diarrhea can keep your body from absorbing vitamins and minerals. Ask your doctor if you need a vitamin supplement.

What Foods Have Fiber? Examples of foods that have fiber include
Breads, cereals, and beans	Fiber
½ cup of black-eyed peas, cooked	4.0 grams
½ cup of kidney beans, cooked	5.7 grams
½ cup of lima beans, cooked	4.5 grams
Whole-grain cereal, cold ½ cup of All-Bran ¾ cup of Total ¾ cup of Post Bran Flakes	9.6 grams 2.4 grams 5.3 grams
1 packet of whole-grain cereal, hot (oatmeal, Wheatena)	3.0 grams
1 slice of whole-wheat or multigrain bread	1.7 grams
Fruits
1 medium apple	3.3 grams
1 medium peach	1.8 grams
½ cup of raspberries	4.0 grams
1 medium tangerine	1.9 grams
Vegetables
1 cup of acorn squash, raw	2.1 grams
1 medium stalk of broccoli, raw	3.9 grams
5 brussels sprouts, raw	3.6 grams
1 cup of cabbage, raw	2.0 grams
1 medium carrot, raw	1.8 grams
1 cup of cauliflower, raw	2.5 grams
1 cup of spinach, cooked	4.3 grams
1 cup of zucchini, raw	1.4 grams

Medication

If diarrhea is causing your incontinence, medication may help. Sometimes doctors recommend using bulk laxatives to help people develop a more regular bowel pattern. Or the doctor may prescribe antidiarrheal medicines such as loperamide or diphenoxylate to slow down the bowel and help control the problem.

Bowel Training

Bowel training helps some people relearn how to control their bowel movements. In some cases, bowel training involves strengthening muscles; in others, it means training the bowels to empty at a specific time of day.

• Use biofeedback. Biofeedback is a way to strengthen and coordinate the muscles and has helped some people with incontinence. Special computer equipment measures muscle contractions while you do exercises—called Kegels—to strengthen the rectum and improve rectal sensation. These exercises work muscles in the pelvic floor, including those involved in controlling stool. Computer feedback about how the muscles are working shows whether you’re doing the exercises correctly and whether the muscles are getting stronger. Whether biofeedback will work for you depends on the cause of your fecal incontinence, how severe the muscle damage is, and your ability to do the exercises.
• Develop a regular pattern of bowel movements. Some people—particularly those whose fecal incontinence is caused by constipation—achieve bowel control by training themselves to have bowel movements at specific times during the day, such as after every meal. The key to this approach is persistence—it may take awhile to develop a regular pattern. Try not to get frustrated or give up if it doesn’t work right away.

Surgery

Surgery to repair the anal sphincter may be an option for people who have not responded to dietary treatment and biofeedback and for those whose fecal incontinence is caused by injury to the pelvic floor, anal canal, or anal sphincter. People who have severe fecal incontinence that doesn’t respond to other treatments may benefit from injection of bulking agents in the anus or nerve stimulation in the lower pelvic area. A colostomy may be indicated for people with severe fecal incontinence who haven’t been helped by other procedures. This procedure involves disconnecting the colon and bringing one end through an opening in the abdomen—called a stoma—through which stool leaves the body and is collected in a pouch. The colostomy may be temporary or permanent.

What to Do About Anal Discomfort

The skin around the anus is delicate and sensitive. Constipation and diarrhea or contact between skin and stool can cause pain or itching. Here’s what you can do to relieve discomfort:

• Wash the area with water, but not soap, after a bowel movement. Soap can dry out the skin, making discomfort worse. If possible, wash in the shower with lukewarm water or use a sitz bath. Or try a no-rinse skin cleanser. Try not to use toilet paper to clean up—rubbing with dry toilet paper will only further irritate the skin. Premoistened, alcohol-free towelettes are a better choice.
• Let the area air dry after washing. If you don’t have time, gently pat yourself dry with a lint-free cloth.
• Use a moisture barrier cream, which is a protective cream to help prevent skin irritation from direct contact with stool. You should first clean the area well to avoid trapping bacteria that could cause further problems. However, talk with your health care professional before you try anal ointments and creams because some have ingredients that can be irritating. Your health care professional can recommend an appropriate cream or ointment.
• Try using nonmedicated talcum powder or cornstarch to relieve anal discomfort.
• Wear cotton underwear and loose clothes that “breathe.” Tight clothes that block air can worsen anal problems. Change soiled underwear as soon as possible.
• If you use pads or disposable undergarments, make sure they have an absorbent wicking layer on top. Products with a wicking layer protect the skin by pulling stool and moisture away from the skin and into the pad.

How can I cope with my feelings about fecal incontinence?

Because fecal incontinence can cause distress in the form of embarrassment, fear, and loneliness, taking steps to deal with it is important. Treatment can improve your life and help you feel better about yourself. If you haven’t been to a doctor yet, make an appointment. Also, consider contacting the organizations listed at the end of this fact sheet. Such groups can help you find information and support and, in some cases, referrals to doctors who specialize in treating fecal incontinence.

Everyday Practical Tips

• Take a backpack or tote bag containing cleanup supplies and a change of clothing with you everywhere.
• Locate public restrooms before you need them.
• Use the toilet before leaving home.
• If you think an episode is likely, wear disposable undergarments or sanitary pads.
• If episodes are frequent, use oral fecal deodorants to add to your comfort level.

What if my child has fecal incontinence?

If your child has fecal incontinence, he or she needs to see a doctor to determine the cause and treatment. Fecal incontinence can occur in children because of a birth defect or disease, but in most cases it’s because of chronic constipation.

Potty-trained children often get constipated simply because they refuse to go to the bathroom. The problem might stem from embarrassment over using a public toilet or unwillingness to stop playing and go to the bathroom. But if the child continues to hold in stool, the feces will accumulate and harden in the rectum. The child might have a stomachache and not eat much, despite being hungry. And it can be painful when he or she eventually does pass the stool, which can lead to fear of having another bowel movement.

Children who are constipated may soil their underpants. Soiling happens when liquid stool from farther up in the bowel seeps past the hard stool in the rectum and leaks out. Soiling is a sign of fecal incontinence. Try to remember that your child cannot control the liquid stool and may not even know it has passed.

The first step in treating the problem is passing the built-up stool. The doctor may prescribe one or more enemas or a drink that helps clean out the bowel, such as magnesium citrate, mineral oil, or polyethylene glycol.

The next step is preventing future constipation. You will play a big role in this part of your child’s treatment. You may need to teach your child bowel habits, which means training your child to have regular bowel movements. Experts recommend that parents of children with poor bowel habits encourage them to sit on the toilet four times each day—after meals and at bedtime—for 5 minutes. Give rewards for bowel movements and do not punish children for incontinent episodes.

Some changes in eating habits may also be necessary. Your child should eat more high-fiber foods to soften stool, avoid dairy products if they cause constipation, and drink plenty of fluids every day, including water and juices such as prune, grape, or apricot, which help prevent constipation. If necessary, the doctor may prescribe laxatives.

It may take several months to break the pattern of withholding stool and constipation, and episodes may occur again in the future. The key is to pay close attention to your child’s bowel habits. Some warning signs to watch for include

• pain with bowel movements
• hard stool
• constipation
• refusal to go to the bathroom
• soiled underwear
• signs of holding back a bowel movement, such as squatting, crossing the legs, or rocking back and forth

Why Children Get Constipated

• They were potty-trained too early.
• They refuse to have a bowel movement because of painful ones in the past, embarrassment, stubbornness, or even a dislike of public bathrooms.
• They are in an unfamiliar place.
• They are reacting to family stress such as a new sibling or their parents’ divorce.
• They can’t get to a bathroom when they need to go so they hold it. As the rectum fills with stool, the child may lose the urge to go and become constipated as the stool dries and hardens.

Flexible Sigmoidoscopy

Flexible sigmoidoscopy (SIG-moy-DAH-skuh-pee) enables the physician to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid or descending colon. Physicians may use the procedure to find the cause of diarrhea, abdominal pain, or constipation. They also use it to look for early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. Flexible sigmoidoscopy is not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon).

For the procedure, you will lie on your left side on the examining table. The physician will insert a short, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a sigmoidoscope (sig-MOY-duh-skope). The scope transmits an image of the inside of the rectum and colon, so the physician can carefully examine the lining of these organs. The scope also blows air into these organs, which inflates them and helps the physician see better.

If anything unusual is in your rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing.

Bleeding and puncture of the colon are possible complications of sigmoidoscopy. However, such complications are uncommon.

Flexible sigmoidoscopy takes 10 to 20 minutes. During the procedure, you might feel pressure and slight cramping in your lower abdomen. You will feel better afterward when the air leaves your colon.

Preparation

The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe, so the physician will probably tell you to drink only clear liquids for 12 to 24 hours beforehand. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. The night before or right before the procedure, you may also be given an enema, which is a liquid solution that washes out the intestines. Your physician may give you other special instructions.

Colonoscopy

What is a colonoscopy?

A colonoscopy (koh-luh-NAH-skuh-pee) 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.

What is the colon?

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

• fat-free bouillon or broth
• strained fruit juice
• water
• plain coffee
• plain tea
• diet soda
• gelatin

Thorough 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 performed by inserting a bottle with water and sometimes a mild soap in your anus to clean out the bowels. Be sure to inform your doctor of any medical conditions you have or medications you take on a regular basis such as

• aspirin
• arthritis medications
• blood thinners
• diabetes medication
• 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 someone 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 comfortable 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 adjustments 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 (koh-LON-oh-skope). The scope transmits an image of the inside of the colon onto a video screen so the doctor can carefully 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.

Bleeding in the Digestive Tract

Bleeding in the digestive tract is a symptom of a disease rather than a disease itself. Bleeding can occur as the result of a number of different conditions, some of which are life threatening. Most causes of bleeding are related to conditions that can be cured or controlled, such as ulcers or hemorrhoids. The cause of bleeding may not be serious, but locating the source of bleeding is important.

The digestive or gastrointestinal (GI) tract includes the esophagus, stomach, small intestine, large intestine or colon, rectum, and anus. Bleeding can come from one or more of these areas, that is, from a small area such as an ulcer on the lining of the stomach or from a large surface such as an inflammation of the colon. Bleeding can sometimes occur without the person noticing it. This type of bleeding is called occult or hidden. Fortunately, simple tests can detect occult blood in the stool.

What causes bleeding in the digestive tract?

Stomach acid can cause inflammation that may lead to bleeding at the lower end of the esophagus. This condition, usually associated with the symptom of heartburn, is called esophagitis or inflammation of the esophagus. Sometimes a muscle between the esophagus and stomach fails to close properly and allows the return of food and stomach juices into the esophagus, which can lead to esophagitis. In another, unrelated condition, enlarged veins (varices) at the lower end of the esophagus may rupture and bleed massively. Cirrhosis of the liver is the most common cause of esophageal varices. Esophageal bleeding can be caused by a tear in the lining of the esophagus (Mallory-Weiss syndrome). Mallory-Weiss syndrome usually results from vomiting but may also be caused by increased pressure in the abdomen from coughing, hiatal hernia, or childbirth. Esophageal cancer can cause bleeding.

The stomach is a frequent site of bleeding. Infections with Helicobacter pylori (H. pylori), alcohol, aspirin, aspirin-containing medicines, and various other medicines (NSAIDs, particularly those used for arthritis) can cause stomach ulcers or inflammation (gastritis). The stomach is often the site of ulcer disease. Acute or chronic ulcers may enlarge and erode through a blood vessel, causing bleeding. Also, patients suffering from burns, shock, head injuries, cancer, or those who have undergone extensive surgery may develop stress ulcers. Bleeding can also occur from benign tumors or cancer of the stomach, although these disorders usually do not cause massive bleeding.

A common source of bleeding from the upper digestive tract is ulcers in the duodenum (the upper small intestine). Duodenal ulcers are most commonly caused by infection with H. pylori bacteria or drugs such as aspirin or NSAIDs.

In the lower digestive tract, the large intestine and rectum are frequent sites of bleeding. Hemorrhoids are the most common cause of visible blood in the digestive tract, especially blood that appears bright red. Hemorrhoids are enlarged veins in the anal area that can rupture and produce bright red blood, which can show up in the toilet or on toilet paper. If red blood is seen, however, it is essential to exclude other causes of bleeding since the anal area may also be the site of cuts (fissures), inflammation, or cancer.

Benign growths or polyps of the colon are very common and are thought to be forerunners of cancer. These growths can cause either bright red blood or occult bleeding. Colorectal cancer is the third most frequent of all cancers in the United States and often causes occult bleeding at some time, but not necessarily visible bleeding.

Inflammation from various causes can produce extensive bleeding from the colon. Different intestinal infections can cause inflammation and bloody diarrhea. Ulcerative colitis can produce inflammation and extensive surface bleeding from tiny ulcerations. Crohn’s disease of the large intestine can also produce bleeding.

Diverticular disease caused by diverticula—pouches in the colon wall—can result in massive bleeding. Finally, as one gets older, abnormalities may develop in the blood vessels of the large intestine, which may result in recurrent bleeding.

Patients taking blood thinning medications (warfarin) may have bleeding from the GI tract, especially if they take drugs like aspirin.

How is bleeding in the digestive tract recognized?

The signs of bleeding in the digestive tract depend upon the site and severity of bleeding. If blood is coming from the rectum or the lower colon, bright red blood will coat or mix with the stool. The stool may be mixed with darker blood if the bleeding is higher up in the colon or at the far end of the small intestine. When there is bleeding in the esophagus, stomach, or duodenum, the stool is usually black or tarry. Vomited material may be bright red or have a coffee-grounds appearance when one is bleeding from those sites. If bleeding is occult, the patient might not notice any changes in stool color.

If sudden massive bleeding occurs, a person may feel weak, dizzy, faint, short of breath, or have crampy abdominal pain or diarrhea. Shock may occur, with a rapid pulse, drop in blood pressure, and difficulty in producing urine. The patient may become very pale. If bleeding is slow and occurs over a long period of time, a gradual onset of fatigue, lethargy, shortness of breath, and pallor from the anemia will result. Anemia is a condition in which the blood’s iron-rich substance, hemoglobin, is diminished.

How is bleeding in the digestive tract diagnosed?

The site of the bleeding must be located. A complete history and physical examination are essential. Symptoms such as changes in bowel habits, stool color (to black or red) and consistency, and the presence of pain or tenderness may tell the doctor which area of the GI tract is affected. Because the intake of iron, bismuth (Pepto Bismol), or foods such as beets can give the stool the same appearance as bleeding from the digestive tract, a doctor must test the stool for blood before offering a diagnosis. A blood count will indicate whether the patient is anemic and also will give an idea of the extent of the bleeding and how chronic it may be.

Endoscopy

Endoscopy is a common diagnostic technique that allows direct viewing of the bleeding site. Because the endoscope can detect lesions and confirm the presence or absence of bleeding, doctors often choose this method to diagnose patients with acute bleeding. In many cases, the doctor can use the endoscope to treat the cause of bleeding as well.

The endoscope is a flexible instrument that can be inserted through the mouth or rectum. The instrument allows the doctor to see into the esophagus, stomach, duodenum (esophago-duodenoscopy), colon (colonoscopy), and rectum (sigmoidoscopy); to collect small samples of tissue (biopsies); to take photographs; and to stop the bleeding.

Small bowel endoscopy, or enteroscopy, is a procedure using a long endoscope. This endoscope may be used to localize unidentified sources of bleeding in the small intestine.

A new diagnostic instrument called a capsule endoscope is swallowed by the patient. The capsule contains a tiny camera that transmits images to a video monitor. It is used most often to find bleeding in portions of the small intestine that are hard to reach with a conventional endoscope.

Other Procedures

Several other methods are available to locate the source of bleeding. Barium x rays, in general, are less accurate than endoscopy in locating bleeding sites. Some drawbacks of barium x rays are that they may interfere with other diagnostic techniques if used for detecting acute bleeding, they expose the patient to x rays, and they do not offer the capabilities of biopsy or treatment. Another type of x ray is CT scan, particularly useful for inflammatory conditions and cancer.

Angiography is a technique that uses dye to highlight blood vessels. This procedure is most useful in situations when the patient is acutely bleeding such that dye leaks out of the blood vessel and identifies the site of bleeding. In selected situations, angiography allows injection of medicine into arteries that may stop the bleeding.

Radionuclide scanning is a noninvasive screening technique used for locating sites of acute bleeding, especially in the lower GI tract. This technique involves injection of small amounts of radioactive material. Then, a special camera produces pictures of organs, allowing the doctor to detect a bleeding site.

How is bleeding in the digestive tract treated?

Endoscopy is the primary diagnostic and therapeutic procedure for most causes of GI bleeding.

Active bleeding from the upper GI tract can often be controlled by injecting chemicals directly into a bleeding site with a needle introduced through the endoscope. A physician can also cauterize, or heat treat, a bleeding site and surrounding tissue with a heater probe or electrocoagulation device passed through the endoscope. Laser therapy is useful in certain specialized situations.

Once bleeding is controlled, medicines are often prescribed to prevent recurrence of bleeding. Medicines are useful primarily for H. pylori, esophagitis, ulcer, infections, and irritable bowel disease. Medical treatment of ulcers, including the elimination of H. pylori, to ensure healing and maintenance therapy to prevent ulcer recurrence can also lessen the chance of recurrent bleeding.

Removal of polyps with an endoscope can control bleeding from colon polyps. Removal of hemorrhoids by banding or various heat or electrical devices is effective in patients who suffer hemorrhoidal bleeding on a recurrent basis. Endoscopic injection or cautery can be used to treat bleeding sites throughout the lower intestinal tract.

Endoscopic techniques do not always control bleeding. Sometimes angiography may be used. However, surgery is often needed to control active, severe, or recurrent bleeding when endoscopy is not successful.

Intestinal Adhesions

Intestinal adhesions are bands of fibrous tissue that can connect the loops of the intestines to each other, or the intestines to other abdominal organs, or the intestines to the abdominal wall. These bands can pull sections of the intestines out of place and may block passage of food. Adhesions are a major cause of intestinal obstruction.

Adhesions may be present at birth (congenital) or may form after abdominal surgery or inflammation. Most form after surgery. They are more common after procedures on the colon, appendix, or uterus than after surgery on the stomach, gall bladder, or pancreas. The risk of developing adhesions increases with the passage of time after the surgery.

Symptoms

Some adhesions will cause no symptoms. If the adhesions cause partial or complete obstruction of the intestines, the symptoms one would feel would depend on the degree and the location of the obstruction. They include crampy abdominal pain, vomiting, bloating, an inability to pass gas, and constipation.

Diagnosis

X rays (computed tomography) or barium contrast studies may be used to locate the obstruction. Exploratory surgery can also locate the adhesions and the source of pain.

Treatment

Some adhesions will cause no symptoms and go away by themselves. For people whose intestines are only partially blocked, a diet low in fiber, called a low-residue diet, allows food to move more easily through the affected area. In some cases, surgery may be necessary to remove the adhesions, reposition the intestine, and relieve symptoms. But the risk of developing more adhesions increases with each additional surgery.

Prevention

Methods to prevent adhesions include using biodegradable membranes or gels to separate organs at the end of surgery or performing laparoscopic (keyhole) surgery, which reduces the size of the incision and the handling of the organs.

Additional Information on Intestinal Adhesions

The National Digestive Diseases Information Clearinghouse collects resource information on digestive diseases for National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Reference Collection. This database provides titles, abstracts, and availability information for health information and health education resources. The NIDDK Reference Collection is a service of the National Institutes of Health.

To provide you with the most up-to-date resources, information specialists at the clearinghouse created an automatic search of the NIDDK Reference Collection. To obtain this information, you may view the results of the automatic search on Intestinal Adhesions.

If you wish to perform your own search of the database, you may access and search the NIDDK Reference Collection database online.

CANCER TYPES

As the largest internal organ, the liver performs a variety of vital functions. Different cell types are responsible for these diverse functions. The basic liver cells (known as hepatocytes) produce blood clotting factors, synthesize bile, metabolize proteins and remove toxins from the blood. The liver has a rich network of blood vessels carrying nutrients and toxins from the intestine to the liver and back to the circulation. The liver also has a system of bile ducts which carry bile (a green fluid that helps digestion of food) from the liver and gall bladder into the intestine. Tumors may arise from any of these types of cells and thus there is a wide variety in types of liver cancer.

Tumors can be generally thought of as benign or malignant. Benign tumors are unlikely to metastasize (spread throughout the body) while malignant tumors are cancerous and are likely to spread to other organs.

Liver Cancer types listed by cell of origin

List of benign tumors and cell of origin	List of malignant (cancerous) tumors and cell of origin
Hepatocytes	Hepatocytes
- Adenoma	- Hepatocellular carcinoma
- Focal nodular hyperplasia	- Hepatoblastoma
	- Fibrolamellar carcinoma
Vessels	Vessels
- Hemangioma	- Angiosarcoma
Bile duct	Bile duct
- Adenoma	- Cholangiocarcinoma
- Hamartoma (Von Myenberg Complex)