by Dr. Bruno Salena
Dr. Bruno Salena answers patients' questions on digestive health and nutrition. He is a gastroenterologist at the McMaster University Medical Centre, part of the Hamilton Health Sciences Corporation. The articles below first appeared in the Hamilton Spectator.
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Q. My brother has been just diagnosed with celiac disease. What is celiac disease and how do I know if I am affected?
A. Celiac disease is also known as sprue or celiac sprue or gluten enteropathy. Prevalence varies from 1/300 to 50-75/10,000of the population, with peak incidence at age one and after age 60. Genetically, there is a 10% incidence in first order relatives and 71% in identical twins.
Celiac disease is a chronic diarrheal disease characterized by intestinal malabsorption of virtually all nutrients and is precipitated by eating gluten-containing foods. The cause is related to a sensitivity to gluten (specifically the gliadin fraction of gluten) leading to intestinal inflammation and blunting of the absorptive surface of the small intestine. The diagnosis is made by examining a small intestine biopsy demonstrating surface flattening and demonstrating improvement on a repeat biopsy after a trial of a gluten-free diet.
Anti-reticulum and anti-endomysial antibodies are laboratory tests useful in diagnosis as they are positive in about 90% of patients with celiac disease. Some nutrients can be measured in the blood to determine degree of malnutrition, if necessary. For example, calcium and iron are absorbed in the proximal small intestine and deficiency can lead to osteoporosis and anemia respectively. Sometimes a small bowel x-ray is helpful showing flattening and swelling of the mucosal folds suggesting a diagnosis of celiac disease.
Removing gluten from the diet means avoiding foods containing wheat, rye and barley flour, avoiding gluten additives and using rice, corn and soybean flour as safe, palatable substitutes. Patients may have a secondary lactase deficiency associated with celiac disease and in this instance, should avoid lactose or take Lactaid enzyme supplements. Meeting with a dietician and joining a local celiac society provides opportunity for patient education and even the exchange of recipes.
Ninety percent of patients respond to this dietary approach. Failure to respond may indicate non-compliance to the gluten-free diet or another diagnosis or refractory disease requiring drug therapy. Most commonly, prednisone, a steroid medication is used. Other supplemental drug therapy can include calcium and Vitamin D, particularly in those patients with osteoporosis.
The course and prognosis of celiac disease is good with correct diagnosis and adherence to a gluten-free diet. Patients often feel better in one or two weeks. All symptoms often disappear within six to eight weeks.
Complications are uncommon but include an increased cancer risk, particularly small bowel lymphoma and head and neck tumors. It is unknown whether strict dietary adherence decreases cancer risk.
Q: What can I do to decrease my risk of developing colon cancer?
A: In 1996 there were an estimated 16,300 new cases of colorectal cancer with 6,200 related deaths in Canada. Risk of disease increases with age. Rates begin to increase at age 40, but increase most rapidly after the age of 50. The average lifetime colorectal cancer risk for a Canadian adult is about 4-6%. This cancer is potentially preventable and specific steps to decrease your risk are included below:
1.Reduce total fat intake to 30% or less of calories. Reduce saturated fatty acid intake to less than 10% of calories.
This recommendation can be made in good faith in view of the adverse effect of fat with respect to heart disease. It might also be wise to limit consumption of meats cooked at high temperature to reduce exposure to heterocyclic amines which are potentially carcinogenic.
2.Eat five or more servings of a combination of fruits and vegetables, especially yellow and green vegetables and citrus fruits. Increase the intake of starches and other complex carbohydrates by eating six or more daily servings of a combination of breads, cereals and legumes.
Carbohydrates should be increased to more than 55% of total calories. The mechanism behind the link between frequent consumption of vegetables and fruit and decreased colon cancer risk is not understood but there is good evidence of a protective effect. Eating high fiber foods (contains other potential chemoprotective agents) is more likely to prevent cancer than taking a fiber supplement.
3.Balance food intake and physical activity to maintain an appropriate body weight.
Excess body weight increases colon cancer risk but also other diseases such as heart disease, diabetes, gallbladder disease and endometrial cancer. Regular physical activity reduces the risk of heart disease.
4.Ensure adequate calcium intake.
Low or non-fat dairy products and dark green vegetables provide rich sources of calcium. Calcium has been shown to offset the abnormal cellular proliferation in human studies.
There are a number of chemopreventive agents undergoing current testing in humans and animals. Aspirin and non-steroidal anti-inflammatory drugs are among the most promising although these agents may have a variety of adverse effects. Anti-oxidant vitamins (A,C,E) are known to prevent oxidant damage to DNA but current trials have mixed results. Folate is another vitamin currently undergoing investigation. Until more is known about the risks and benefits of these agents, their use should be reserved for approved indications or experimental studies.
5.Secondary prevention can include periodic medical assessment including digital rectal examination to detect palpable tumours, fecal occult blood screening, sigmoidscopy and/or colonoscopy. Individuals with a history of colon polyps or colo-rectal cancer, ulcerative colitis or Crohn's disease, radiation or a family history of colon cancer and polyps are at increased risk of colon cancer. Cholecystectomy may be associated with a modest right-sided colon cancer risk in women. A strong case can be made for these individuals to have regular periodic screening, perhaps at a three to five year interval. For the asymptomatic individual in the general population, a screening colonoscopy or barium enema once or twice in a lifetime has been suggested as a way of a screening for colon cancer although this is unproven.
Focusing on a healthy diet/lifestyle and consulting with your doctor will go a long way to decrease risks to your health.
Q: In your last column, you discussed the primary prevention of colorectal cancer. I have a family history of colon cancer and polyps. Am I at increased risk and how should I best be screened?
A: Although the average lifetime colorectal cancer risk for a Canadian adult is about 4 to 6 percent, a family history increases this risk. Advances in our understanding of the genetics of colon cancer has also broadened our ability to detect some disease at an early stage.
If you have one first degree relative (parent, sibling or child) who has had colon cancer, your risk increases 2- to 3-fold. If this first degree relative with colon cancer was less thasn 50 years of age at the time of diagnosis, your risk increases 3- to 6-fold. With two first degree relatives, this risk also increases 3- to 6-fold. If you have one second or third degree relative with colon cancer, there is about a 1.5-fold increase (second degree relatives include grandparents, aunts and uncles and third degree relatives include great grandparents and cousins). If you have a first degree relative with only an adenoma-type polyp, there is a 2-fold increase.
There are two known genetic syndromes for colon cancer: familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC). Both syndromes are inherited as an autosomal domininant type meaning if one parent carries the gene, you would have a 50 percent chance of getting the disease. FAP is characterized by the appearance of hundreds of adenoma-type polyps in the colon during adolescence and young adulthood. This disease confers a virtually 100 percent chance of developing cancer unless the colon is removed surgically. FAP accounts for less than 1% of all colon cancers in Canada. The disease can be diagnosed by sigmoidoscopy screening (a tube that looks into the colon) at the time of puberty. In first degree relatives of individuals affected by FAP, there is a commercially available genetic screening blood test. This test can detect the genetic mutation.
HNPCC accounts for about 5 percent of all cancers diagnosed in Canada. Individuals who carry this gene have an 80% over-all risk of developing colon cancer. This clinical syndrome has two main forms, one without family history of other cancers and the other with increased familial occurrence of other types of cancers, particularly of the ovary and uterus. Genetic tests are available for research purposes and might become available for commercial use in the near future.
The best screening method for individuals with a family history of colorectal cancer and polyps is direct visualization of the colon with colonoscopy or alternatively, a barium enema x-ray. Colonoscopy provides the added advantage of polyp biopsy and/or removal. Screening for colon cancer should start 10 years prior to the age of the index case in the family. I would suggest that you discuss these important issues with your family doctor.
Best wishes and good health.
Q: My brother has abdominal pain, weight loss and diarrhea and has been diagnosed with Crohn's disease. What is Crohn's disease and can I get it?
A: Crohn's disease is a chronic disorder that causes inflammation or ulceration throughout the digestive tract but most often in the small and/or large intestine. Involvement of the distal small intestine (the terminal ileum) is most frequently involved. Crohn's disease can recur at various times over a lifetime. There is no way to predict when a remission may occur or when symptoms will return.
The most common symptoms of Crohn's disease are abdominal pain, often in the lower right area of the abdomen, and diarrhea. Rectal bleeding, weight loss and fever can also occur. Bleeding may be serious and persistent, leading to an anemia (low red blood cell count). Children may suffer delayed development and stunted growth.
What causes Crohn's disease? There are many theories about causes, but none have been proven. One theory suggests that some agent such as a virus or bacterium may affect the body's immune system to trigger an inflammatory reaction in the wall of the intestine. While there is evidence to suggest that Crohn's disease patients have abnormalities of the immune system, it remains unclear whether the immune problems are a cause or the result of the disease.
Crohn's disease affects males and females equally and appears to run im some families. About 20 percent of people with Crohn's disease have a blood relative with some form of inflammatory bowel disease, most often a sister or brother and occasionally a parent or child.
If you have experienced chronic abdominal pain, diarrhea, fever, weight loss and anemia, your doctor will examine you for signs of Crohn's disease. The doctor will undertake a thorough history and physical exam including blood tests to find out if you are anemic or if there is an increased number of white blood cells suggesting an inflammatory process in your body. The doctor may look inside your bowel through a flexible tube (endoscope) that is inserted through the anus to obtain a sample of tissue (biopsy) from the lining of the bowel to confirm the diagnosis. X-ray examinations of the digestive tract helps determine the nature and extent of the disease. These procedures are done by putting barium, a chalky solution, into the upper and lower intestines to assist in imaging the inflammation or ulceration seen in Crohn's disease.
Can diet control Crohn's disease? No special diet has been proven effective for preventing or treating this disease. Symptoms can be aggravated by milk, alcohol, hot spices or fiber in some patients. Follow a good nutritious diet and try to avoid any foods that seem to make symptoms worse. Nutritional supplements may be helpful, particularly for children with delayed growth. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need periods of feeding by vein. This can help those Crohn's patients who temporarily need extra nutrition, those whose bowels need to rest, or those whose bowels cannot absorb enough nutrition from oral intake.
There is no known cure for Crohn's disease. You can help find a cure by supporting research in Crohn's disease. At present, several drugs are helpful in controlling Crohn's disease. The goals of therapy are to correct nutritional imbalances, control inflammation, and relieve abdominal pain, diarrhea and rectal bleeding. Abdominal cramps and diarrheas may improve with anti-inflammatory agents such as sulphasalazine (for inflammation in the colon) or similar agents known as 5-aminosalicylates (5-ASA). More serious cases may require the use of steroid drugs, antibiotics, or drugs that suppress the immune system such as azathioprine or 6-mercaptopurine (6-MP). New investigational drugs to treat Crohn's disease are often evaluated at university hospitals such as McMaster University Medical Centre in Hamilton on an on-going basis and may offer alternatives to current therapies that may be unsuccessful or have significant side-effects.
Crohn's disease can be helped but not cured by surgery. The inflammation tends to return in areas of the intestine next to the area that has been removed. Many patients require surgery either to relieve chromic symptoms of active disease that does not respond to medical therapy or to correct complications such as intestinal blockage, perforation, abscess, or bleeding. Abscess drainage or resection (removal of a section of bowel) due to blockage are common surgical procedures. Blockage occurs because the disease tends to thicken the bowel wall with swelling and fibrous scar tissue, thus narrowing the passage. Disease can often recur after surgery, so it is important to continue anti-inflammatory therapy to decrease the risk of recurrent disease. Most people with this disease continue to lead useful and productive lives. Patients may feel quite well and be symptom-free between periods of disease activity.
Q: When I walk into the pharmacy and other stores, I notice that there are multiple nutritional supplements being promoted for my health. Are they worthwhile and safe to take?
A: Supplements are just supplements and not a substitute for a good diet. Eat foods that are rich in vitamins, minerals and other essential nutrients.
Dietary or nutritional supplements are not regulated and manufacturers can suggest almost anything on their packages and in ads without proof of safety or efficacy. They cannot, however, make medical claims. Flawed studies are often vigorously cited in support of questionable products. Standard treatments are often called "unnatural" or motivated by greed. It is a seller's market so buyer beware.
Safe and Effective
Calcium supplements can prevent or slow osteoporosis. Postmenopausal women and men over 65 years of age may need supplements if they do not get 1,500 milligrams daily from food. Take calcium with meals and combine it with an exercise program. Calcium should also come from dietary sources, such as low-fat milk and leafy green vegetables.
Folic acid can prevent birth defects, heart disease, and possibly some cancers. This is supported by strong evidence. All women capable of becoming pregnant should get 400 micrograms of folic acid daily from a supplement in addition to that from food intake. Other people not eating a good diet with fruit, vegetables, fortified grains and cereals should take a multivitamin containing folic acid. A multivitamin is a good idea for the elderly.
Vitamin C and E are powerful antioxidants. Vitamin C can reduce cold symptoms and it is not a cold cure. It may also protect against chronic diseases including cancer, heart disease and cataracts. Get as much from produce which contain other important nutrients. Take 250 to 500 milligrams daily as a supplement. Vitamin E has similar protective effects but is not plentiful in foods, except vegetable oils, nuts and seeds. Take 200 to 800 IU daily as a supplement.
St. John's wort has preliminary evidence demonstrating efficacy against mild forms of depression. It should not be taken as a diet drug or with prescribed anti-depressant medications.
On Medical Advice Only
Beta-carotene may prevent cancer and heart disease and may boost immunity. Don't take it if you are a smoker as studies suggest in increased lung cancer risk for smokers taking beta-carotene. Beta-carotene and other carotenoids are found in yellow, red and deep green vegetables and fruits.
Zinc may slow macular degeneration (eye condition that causes blindness) but these effects are weak. There is no convincing evidence that zinc lozenges cure or prevent colds. It is not recommended for prostate symptoms in spite of claims.
Saw palmetto may reduce symptoms of benign prostatic hyperplasia and shrink the prostate. There is some positive evidence but results are mixed. Saw palmetto can alter results of a PSA test and make the diagnosis of prostatic cancer more difficult. If you take it, tell your physician.
Co-enzyme Q-10 is an anti-oxidant which may be effective against heart failure. It is expensive and its benefits for healthy individuals are unproven. Talk to your cardiologist about it if you have heart disease.
Other Unproven Supplements
Echinacea has been touted as curing colds and boosting immunity. It is prescribed in Europe for colds and flu. Little is known about its toxicity and there is inconsistent evidence of benefit.
Glucosamine and chondroitin sulfate has been promoted to halt, reverse or cure arthritis. Glucosamine may reduce pain for some people but it does not reverse arthritis. Although probably harmless, it should not be substituted for conventional treatment.
Garlic pills have no clear evidence of benefit despite claims of lowering blood pressure and blood cholesterol and preventing stomach cancer. You can certainly eat all the garlic you wish as it is not toxic although friends and colleagues may keep their distance.
Ginseng has been used for thousands of years as a cure-all and energizer but there is no evidence that it does anything. Many products on the market contain no ginseng at all.
Ginkgo biloba has been prescribed in Europe for circulatory disorders and shows promise against claudication (leg pain caused by obstructed blood flow commonly caused by atherosclerosis). Recent evidence suggests that there may be limited benefits for some Alzheimer's patients but otherwise it has no proven benefit for prevention or cure of absentmindedness or memory loss.
Evening primrose oil has been advocated for high cholesterol, rheumatoid arthritis and diabetic nerve damage but the quality of studies is poor and uneven. In England, it is an approved treatment for cyclic and non-cyclic breast pain, allergic dermatitis and eczema.
There are too many supplements to discuss in the space of this column. Discuss any supplements with your physician and find out if the evidence supporting health claims has been substantiated by blinded randomized controlled trials which attempt to eliminate bias. Always ask about toxicity and drug interactions. With an unregulated and unstandardized market, the buyer needs to be cautious.
Q: My doctor did an x-ray and told me that I have diverticulosis. What are the symptoms of diverticulosis and how can I treat it?
A: Diverticulosis is a condition in which outpouchings form in the walls of the intestine. These pouches are know as diverticula and are about the size of large peas. They form in weakened areas of the intestines, most commonly in the large bowel. No one knows for sure why the pouches form. One theory is that they may be due to increased pressure inside the colon due to muscle spasms or straining. The pouches might form when increased pressure acts on soft spots along the bowel wall, especially if the person has constipation problems or uses frequent laxatives.
Diverticulosis is very common, especially in older people, with 10 percent of people over the age of 40 and 50 percent of those over age 60 having it. Only about 20 percent of people with diverticulosis will develop complications related to the condition.
Most people with diverticula do not have any symptoms and may never know that they have the condition. Some people feel tenderness over the affected areas or muscles spasms in the abdomen, most commonly on the lower left side of the abdomen, or less often, in the middle or on the right side.
While the diverticula do not cause symptoms, complications can occur. Bleeding is an uncommon symptom and is usually not severe. Sometimes the pouches become inflamed and infected causing fever, acute abdominal pain and an increased white blood cell count. This more serious condition is known as diverticulitis. Diverticulitis may result in large abcesses (infected areas of pus) bowel blockage or even breaks or leaks through the bowel wall.
Often diverticulosis is unsuspected and discovered by an x-ray or intestinal examination done for an unrelated reason. It is most often diagnosed using the barium enema x-ray or alternatively, colonoscopy where a flexible tube (colonoscope) is inserted through the anus.
If you have diverticulosis with no symptoms, no treatment is needed. Some doctors advise eating a high fiber diet and avoiding certain foods. Abdominal cramps can be aggravated by fatty foods, caffeine and large meals, all of which stimulate the bowel wall muscle to contract. Laxatives should be avoided. Patients with diverticulitis may be hospitalized and treated with bed rest, pain relievers, antibiotics, fluids given by vein and attentive care. The vast majority of patients will recover from diverticulitis without surgery. Surgery is reserved for patients with very severe or multiple attacks, or abcess drainage.
A diet rich in fiber is healthy for most people and helps to prevent constipation and promote a healthy digestive tract. Fiber-rich foods include whole-grain cereals and breads, fruits and vegetables. A fiber-rich diet may help prevent diverticula from forming.
Q: My husband suffers from excessive flatulence and refuses to do much about it saying that it is normal, but I believe that there must be a problem. Is there any way of changing this situation?
A: Everyone has gas and eliminates it by burping or passing wind. Many people think they (or their significant other) have too much gas when they actually are passing normal amounts. Most people pass gas about 14 times a day. The gas is mostly made up of odourless vapours including carbon dioxide, oxygen, nitrogen, hydrogen and occasionally, methane. The unpleasant odour of flatulence comes from bacteria in the large intestine that release small amounts of sulphur gas.
Although having gas is common, it can be uncomfortable and embarrassing (as well as unpleasant for those nearby.) Understanding causes and ways to reduce symptoms can bring relief. Gas in the digestive tract comes from two sources, swallowed air or fermentation which occurs normally when harmless intestinal bacteria break down certain undigested foods.
Everyone swallows small amounts of air when eating and drinking. However, eating or drinking rapidly, drinking carbonated beverages, chewing gum, smoking or wearing loose dentures can contribute to increased air swallowing. Burping, or belching, relieves most of the swallowed air. The stomach also releases carbon dioxide when stomach acid and bicarbonate mix, but most of this gas is absorbed into the bloodstream and does not enter the large intestine.
The body does not digest and absorb some carbohydrates (some sugars, starches and fiber) in the small intestine because of a shortage or absence of certain enzymes. This undigested food then passes into the large intestine where harmless and normal bacteria break down the food, producing gas. Foods that produce gas in one person may not cause gas in another. Some common intestinal bacteria can destroy the hydrogen that other bacteria produce. The balance of the two types of bacteria may account for why some people have more gas than others.
Which foods cause gas? Most foods that contain carbohydrates can cause gas in contrast to fats and proteins which cause little gas. The sugars that cause gas are raffinose, lactose, fructose and sorbitol. Raffinose is found in beans, cabbage, brussels sprouts, broccoli, asparagus, other vegetables and whole grains. Lactose is found in milk and dairy products and in processed foods including bread, cereal and salad dressing. People of African, Native Canadian or Asian background may have low levels of the enzyme needed to digest lactose. As we age, that enzyme level can also decrease. Most starches, including potatoes, wheat, corn and noodles produce gas when broken down. Rice is the only starch that does not cause gas. Soluble fiber, found in oat bran, beans, peas and most fruits, produces gas in the large intestine. Insoluble fiber, found in wheat bran and some vegetables, produces little gas.
The most common symptoms of gas are belching, flatulence, abdominal bloating and abdominal pain. However, not everyone experiences symptoms. If lactose intolerance is suspected as the cause of gas, then avoiding milk products for a period of time may resolve symptoms. A blood or breath test may be used to diagnose lactose intolerance. Careful review of diet and amount of gas passed may help relate specific foods to symptoms.
Treatment includes eating fewer foods that cause gas and for some people this may include cutting out healthy foods such as fruits and vegetables, whole grains and milk products. Reducing high fat foods may reduce bloating and discomfort. Over-the-counter medications can include simethicone, activated charcoal or digestive enzymes. Lactaid is commonly used for lactose intolerance. Beano, a digestive aid, contains an enzyme to help digest the sugar in beans and many vegetables but has no effect on gas caused by lactose or fiber. Prescription drugs such as cisapride can help patients with significant bloating move gas through the digestive tract quickly. Belching can be lessened by reducing swallowed air, avoiding chewing gum and hard candy, eating slowly and wearing properly fitted dentures.
Although gas may be both uncomfortable and embarrassing for your husband, and unpleasant for you, the good news is that it is not life-threatening! One enterprising man named Joseph Pujol, actually made a living from his plight. Performing at the Moulin Rouge in Paris in the early 1900s, he was said to have earned up to 20,000 francs daily, producing musical tunes by passing gas.
Q: I had had two attacks of right-sided upper abdominal pain and my doctor tells me that I have gallstones. What should I do?
A: An estimated 2.5 million Canadians - over 10 percent of the population - have gallstones. In the next year, 100,000 Canadians will discover that they have them. Even though gallbladder disease is not usually fatal, approximately 600 people will die from complications this year.
Gallstones are lumps of solid material that form in the gallbladder. Though in many patients these stones remain "silent" and cause no problems, in many other patients they do. Each year 50,000 have their gallbladders removed in order to treat or prevent serious or even life-threatening complications.
The gallbladder is a sac located beneath the liver on the right hand side of the abdominal cavity. Its primary job is to store the bile secreted by the liver until it is needed in the small intestine for digestion, particularly fat digestion. Gallstones form when there is a precipitation of chemicals in the bile. Two types of gallstones can occur: cholesterol or pigment gallstones. Cholesterol and other components of bile are collected in the gallbladder during periods of fasting - for instance, during sleep or between meals. For some reason that is not yet understood, in those patients who develop gallstones, the cholesterol comes out of solution and forms crystals. These crystals provide the cores around which stones develop.
The people most likely to develop gallstones are women who have been pregnant or have used birth contol pills or estrogen replacement therapy; overweight men and women; people who go on crash diets or who lose a lot of weight quickly; and people over 60. In the 20 to 60 year age group, women are twice as likely to develop gallstones than men. By the age of 60 almost 30 percent of men and women have gallstones.
A great many people have gallstones but do not have symptoms. These people have silent gallstones and their stones may remain silent for the rest of their lives.
When symptoms are evident, a person with gallstones may have severe steady pain in the upper abdomen. It lasts at least 20 minutes and usually for one or several hours. There may be pain between the shoulder blades or in the right shoulder. There may be nausea or vomiting.
Gallstones can cause more severe problems when they make their way out of the gallbladder. Gallstones can lodge in the channel that allows the bile to enter and leave the gallbladder. This channel is called the cystic duct. If gallstones block the channel for a prolonged period, the gallbladder may become inflamed, a condition known as cholecystitis. Obstruction of the cystic duct is a relatively common complication of gallbladder disease. A less common but more serious complication occurs if the gallstones become lodged in the bile ducts between the liver and the intestine. This condition can block bile flow from the gallbladder and liver, causing pain and jaundice. Gallstones may also block the flow of digestive fluids from the pancreas, leading to pancreatitis (inflammation of the pancreas). Prolonged blockage can lead to severe damage to these organs which can be fatal. Warning signs are fever, jaundice and persistent pain.
When looking for gallstones, the most common diagnostic tool is ultrasound. An ultrasound examination uses sound waves. Pulses of sound waves are sent into the abdomen to create an image of the gallbladder with sound waves bouncing off stones, if present, revealing their location. It is a noninvasive, painless technique without radiation or side effects.
Gallbladder surgery (cholecystectomy) is the most common method for treating gallstones. Surgical options include the standard procedure called open cholecystectomy and a less invasive procedure called laparoscopic cholecystectomy. The standard cholecystectomy is a major abdominal surgery in which the gallbladder is removed through a 5-to-8-inch incision. Patients often remain in hospital for about a week with several weeks of recovery time at home. Laparoscopic cholecystectomy is a new alternative procedure for gallbladder removal involving several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. The surgeon has a close-up view of the organs and tissue on a video monitor and performs the gallbladder removal through separate small incisions with meticulous skill. Laparoscopic cholecystectomy does not require the abdominal muscles to be cut thus resulting in less pain, quicker healing, improved cosmetic results and fewer complicating infections. Recovery is usually one night in hospital and several days recuperation at home. Currently about 80 percent of cholecystectomies are performed using laparoscopes.
The most common complication with this new procedure is injury to the common bile duct, which connects the gallbladder to the liver. While minor injury to the bile duct can be managed nonsurgically, major injury to the duct is a very serious problem and may require corrective surgery.
Laparoscopic cholecystectomy is replacing open cholecystectomy for routine gallbladder removals with open cholecystectomy remaining the recommended approach for complicated cases.
Nonsurgical approaches are used only in special situations and only for small gallstones that are predominantly cholesterol. Bile salt therapy may take months to years before gallstones are dissolved with mild diarrhea being a minor side effect to drug therapy. Shock-wave lithotripsy uses high ultrasound pulses to shatter the stones and is still considered experimental along with contact dissolution with a form of ether instilled through a catheter placed in the gallbladder. Each of these nonsurgical approaches leaves the gallbladder intact with gallstones recurring in about 50 percent of cases.
Q: I have had some recurrent bright red bleeding from my rectum and believe I have hemorrhoids. What can I do?
A: If you are reading this while eating lunch, please forgive the subject matter.
Hemorrhoids are swollen veins. Everyone has veins around the anus that tend to stretch under pressure like varicose veins in the legs. When these veins swell, we call them "hemorrhoids". One set of veins is inside the rectum (internal) and another is under the skin around the anus (external).
As a rule, the veins do not cause pain or bleeding. Problems arise when they become swollen because the pressure is raised in them. Increased pressure may result from straining to move your bowels, from prolonged sitting on the toilet, or from other factors such as pregnancy, obesity, heavy lifting or liver disease.
Bright red blood on the toilet tissue or in the toilet bowl may be the only sign of internal hemorrhoids. If these veins stretch, they may prolapse and protrude outside the body potentially becoming irritated and painful. If you notice a tender lump on the edge of the anus, they may be thrombosed (blood clots form in them) and bleeding occurs when they are scratched or broken by straining or rubbing. Itching is common and subsequent scratching can lead to irritation.
Hemorrhoids are part of the human predicament and our upright posture, and affects men and women equally. Despite the fact that half of the population have hemorrhoids to some extent by the age of 50, it is seldom a topic of conversation.
Often all that is needed to reduce symptoms is to increase the fiber in your diet along with adequate water intake to soften the stool. Eat more fresh fruits, leafy vegetables, and whole grain breads and cereals (bran). I advise patients to drink six to eight glasses of water daily. Softer stools make it easier to empty the bowels and lessen pressure on the veins.
Good hygeine is also important, bathing the backside gently using soft, moist toilet tissue (a great invention) or a commercial moist pad such as Tucks. Avoid vigorous wiping. Dry gently.
Tell your family doctor anytime you see rectal bleeding to ensure that there are no other serious diseases. You may need an examination of your anus and rectum, and possibly a further examination of your bowel. Your doctor may recommend changes to your diet, use of a laxative or stool softener and occasionally ice, warm soaks, as well as a zinc oxide paste or medicated suppository. If symptoms persist, see your doctor.
Occasionally, removal of hemorrhoids is required to treat the symptoms of prolapse or bleeding. The surgeon may use a rubber band around the base of the hemorrhoid to cut off the circulation and the hemorrhoid withers away within a few days. This technique is used only for internal hemorrhoids. Sometimes a chemical is injected around the vein to shrink the hemorrhoid. Other methods include freezing, electrical or laser heat or infrared light to destroy hemorrhoid tissue. Remember that complications can occur if too much tissue is removed or destroyed and carries a small risk of incontinence. Prevention is best achieved by passing your bowel movements as soon as possible after the urge occurs and don't sit too long. Be physically active and less sedentary. Add fiber to your diet.