Adhesions

Adhesions can be defined as abnormal connections between two surfaces or organs. Adhesions are made of tissue that closely resembles scar tissue and they often occur after patients have had previous surgery or infection in the abdomen.

Inside an abdomen that has never had surgery, or never had any infection, there are no adhesions. People who have had previous infections inside their abdomen are at risk of adhesions when their infection heals. This is because there has been the presence of pus or inflammatory tissue which irritates the surface or organs within the abdomen and a thickening of that tissue becomes sticky. Then, other surfaces and nearby organs or tissues can become adherent to those areas and then a mature adhesion develops. Mature adhesions act like permanent connections between those two surfaces and this is what causes the symptoms.

Contents within the abdomen usually enjoy relatively free movement so that during digestion, organs can contract and move as they wish for their proper function. Adhesions impede this because they act like anchors preventing organs to move freely. This is what causes the pain and dragging sensations that patients with adhesions seem to experience. Of course, many patients have adhesions and are not at all aware of them and they have no symptoms. However, some patients with adhesions have considerable symptoms depending on where those adhesions are located and how the nearby organs are functioning.

Sometimes medications are required to prevent an adhered bowel having spasms. Sometimes surgery is required to divide the adhesions and in severe cases this is often resorted to even though there is a risk of further adhesion formation. Currently there is no medical way to prevent adhesions developing, but research is being done into various washes and gels that can be applied to the abdomen when surgery is being performed in order to try and prevent adhesions developing in the future. Such materials will become available in the near future for use in routine surgery. The main risk of adhesions is the development of obstruction in the gut. This can be an emergency and requires surgery swiftly. Some patients with adhesions have to rely on pain killers so that they can function normally

A Guide to Reflux Disease

Gastro-oesophageal reflux disease is a common cause of indigestion. It is caused by the washing back (reflux) of food and stomach acid into the gullet (oesophagus). This occurs because a muscular valve (sphincter) at the junction of the oesophagus and stomach fails to work properly.

What are the symptoms?

The stomach contents irritate the oesophagus and cause a painful burning sensation in the chest rising up to the throat (heartburn). Sometimes this is accompanied by a bitter taste in the mouth. Those symptoms typically occur after eating food. Large meals and fatty or spicy foods are most likely to cause problems. Lying down or bending over may cause or worsen symptoms. Stomach contents may rise as far as the throat and be experienced as regurgitation. When severe, it may resemble vomiting. Occasionally they may irritate the breathing passages and cause coughing, hoarseness, a sore throat and asthma. If this happens at night it may cause awakening with choking attacks.

Is reflux the same as a hiatus hernia?

No. Hiatus hernia is a protrusion of the top of the stomach through the diaphragm up into the chest cavity. Although a hernia helps to cause reflux disease, many people have a hiatus hernia but no reflux problems because their sphincter still functions properly. Similarly, people who do have reflux problems do not always have a hiatus hernia.

Is reflux serious?

Not usually. In most sufferers reflux disease is no more than a nuisance, bothering them only on some occasions like after eating spicy meals. In some people it causes regular discomfort which disrupts their lives. Most people with reflux disease do not have any significant damage to their oesophagus. In severe cases, irritation caused by the refluxed stomach juices damage the lining of the oesophagus. This ulceration can cause painful swallowing and also bleeding. Stricture is narrowing of the oesophagus caused by scarring because of long standing oesophagitis. Stricture causes difficulty with swallowing because food sticks at the narrowing.

Is it my lifestyle?

Reflux can be made worse by things you do or have some control over, including:

• Diet – heartburn is typically more frequent after large, fatty or spicy meals. Many people find that specific foods provoke symptoms e.g. curries, fish and chips, pastries, roasts, chocolate, onions and citrus fruits.

• Eating habits – eating just before you go to bed or before you exercise can lead to symptoms.

• Smoking – may aggravate reflux.

• Alcohol – may make reflux more irritant, provoking symptoms.

• Pregnancy – probably due to hormonal factors and pressure of the baby. Usually resolves once baby is born.

Is there something I can do?

The occasional heartburn episode is often diet related. Simple self-help measures are worth trying first. If these give adequate relief you do not need to do anything further. To help relieve symptoms:

• Avoid eating large or fatty meals and any foods that aggravate your symptoms.

• Avoid eating within two hours of lying down or before going to bed.

• Eat smaller, more frequent meals and eat slowly, chewing your food well.

• Lose weight if you are overweight.

• Limit alcohol consumption.

• Stop smoking.

• Prop up the head of your bed ten centimetres or use a wedge pillow under the mattress, particularly if your symptoms bother you at night.

• Try an antacid when heartburn occurs.

• Tablets are most convenient as they are easily carried. Choose an antacid form and flavour that appeals to you.

How can the doctor help me?

Your doctor can check your self-diagnosis. After this check, your doctor may try a course of prescription treatment, or determine a need for tests or evaluation by Dr White. Your local doctor may ask Dr White to give advice on your symptoms and organise some tests. These tests include:

• Endoscopy – under sedation, the inside of your oesophagus and stomach is examined directly with a flexible telescope to see if there is any oesophagitis. Endoscopy also excludes other problems such as stomach ulcers.

• Barium meal or swallow – x-ray pictures are taken as you swallow a thick yellow liquid which outlines the oesophagus and stomach. It is most useful for seeing why food sticks.

Other special tests include:

• Oesophageal acidity or PH monitoring – a fine wire is passed through the nose into the gullet to record acidity in the oesophagus, usually for 24 hours at home. A small box carried on a belt makes the recordings. It is especially useful when the diagnosis is still uncertain, even after endoscopy.

• Oesophageal pressure testing or manometry – measures how the muscles of the oesophagus work. This information is sometimes useful in people with reflux symptoms.

What prescription treatment is available?

There are several types of medications that prevent reflux symptoms and heal oesophagitis. These usually need to be taken regularly rather than when you get the symptoms. Medications include:

• Stomach acid suppressants - Cimetidine, Ranitidine, Famotidine, Omeprazole, Pantoprazole and Lansoprazole reduce the amount of acid that the stomach produces.

• Muscular stimulants – e.g. Motilium aims to tighten the sphincter and improve the return of refluxed juices back to the stomach.

• Lining (mucosal) protectants – e.g. Sucralfate sticks to the ulcerated lining of the oesophagus and help to protect it from stomach juices.

• Medication can relieve symptoms and heal oesophagitis in almost everyone. In some people several adjustments to treatment may be needed.

Will reflux disease go away and what long-term choices are there?

Not usually. Medication has no permanent effect on the abnormalities that cause reflux, thus it usually recurs if treatment is stopped. Recurrent reflux problems can usually be prevented by continuous medication. Sometimes an operation which improves the function of the valve may be appropriate. The merits of these two choices should be discussed with Dr White.

All text herein is the intellectual property of Dr Melissa White. Updated July 2014.

Barrett’s Oesophagus

Barrett’s Oesophagus is the replacement of the normal ‘skin-like’ lining of the lower oesophagus by lining that is similar to what is seen in the stomach. This occurs as a consequence of chronic reflux disease and is possibly an initial attempt to adjust the lower oesophagus to the presence of excess acid.

This condition can affectively be silent, in that you may not be aware that you have or have had reflux disease. The significance of having tissue in an area where it is not supposed to be is the possibility that it can become malignant. In effect, Barrett’s Oesophagus is potentially a pre-malignant condition. It is important that the area of abnormal lining is biopsied at regular intervals to make sure nothing sinister develops. This pre-malignant process is called ‘dysplasia’. We look for dysplasia on the biopsies we take. We cannot see dysplasia with the naked eye, so biopsies are very important. If we see dysplasia on the biopsies we may make your interval to your next endoscopy and biopsies less than 2 years. When Barrett’s is first diagnosed, the interval for endoscopy is usually every 2 to 3 years.

The abnormal lining, or epithelium, extends for a variable distance above the end of the oesophagus and can also be shown to increase with time if the disease is not treated, as in, the acid is not suppressed. This is why we recommend you take a medication in a class of drugs called Proton Pump Inhibitors. The current medications in this group include Zoton, Somac, Nexium and Pariet.

The exact statistical risk of developing cancer in the oesophagus related to Barrett’s Oesophagus is unknown, but, in some studies, it has been reported to occur eventually in up to 10% of these patients. This is why your surveillance biopsies are extremely important. There are now cases in medical literature of reversal, or improvement, of the progression from Barrett’s to cancer and thus long-term Proton Pump Inhibitor therapy is very important. This is the only medical therapy available that could result in a decreased risk of developing cancer of the oesophagus.

Bloating

Bloating is one of the most common and frustrating conditions that patients present the Gastroenterologist with. Approximately 30% of Dr White’s patients have bloating as their major complaint. The vast majority of these patients have a type of functional bowel disorder called Irritable Bowel Syndrome (IBS) and further information may be given to you if your doctor feels that this is the primary problem. However, bloating can be associated with many other conditions and it is for this reason that further tests may be required to exclude those conditions as the cause for your bloating.

Bloating can occur when there is a blockage to the lower bowel and thus a colonoscopy may be required to exclude that. Similarly, blockage of the stomach or weakness of the muscular contraction of the stomach can cause bloating after meals. Tests may be required to exclude those conditions also.

Certainly, many causes of bloating are dietary related, specifically related with the ingestion of fizzy drinks and numerous types of fruits and vegetables. Dr White may give you a list of things to try and avoid in order to relieve the bloating that you have. Lactose intolerance can also be associated with bloating and tests may be required to exclude that condition.

Many people with lower abdominal bloating make their symptoms worse by not passing intestinal wind. We all make intestinal gas and we all pass it. However, some people, especially women, seem reluctant to pass the quantity of wind that they actually produce because of social circumstances or embarrassment. Men have less of this problem. Certain opportunities should be taken advantage of, where possible, to release the trapped intestinal wind and this may relieve the degree of lower abdominal bloating you have.

Excess wind is made because of sluggishness in the sections of the intestine which cause carbohydrates to be present for longer than they otherwise would be, followed by fermentation of that carbohydrate by the bacteria that are normally present in the bowel.

Some of the food exclusions tried in patients with bloating includes dairy products, diet soft drinks, chewing gum and lollies because of the air swallowed with their consumption. Some vegetables associated with excess intestinal gas production include onions, capsicum, broccoli, cauliflower, canned beans, Brussels sprouts, cabbage, chick peas, asparagus, garlic and peas. All text herein is the intellectual property of Dr Melissa White. Article update June 2014.

Many patients feel that wheat causes bloating and this is often because they have Irritable Bowel Syndrome, not because they have a wheat or gluten allergy. True gluten allergy is being increasingly recognised and is excluded by biopsies from the small bowel during an endoscopic examination.

Patients with bloating from IBS often do not have excess gas, but their bowel perceives there to be. This is called hypersensitivity. If Dr White feels that you have IBS, further information will be given to you. Approximately 1 in 5 women have symptoms, of varying severity, that are of IBS in nature. It is less common in men. This is an irritating condition and one that requires lifelong management and a firm diagnosis.

Bowel Cancer

Bowel cancer (also known as colorectal cancer) is cancer in any part of the colon or rectum. If caught early, bowel cancer is one of the most curable cancers. However, if it is not detected or treated early, bowel cancer will continue to grow, spreading beyond the bowel to other organs where it is much harder to treat.

Symptoms of bowel cancer

It is vitally important to recognise possible symptoms and have them investigated if they persist. What to look out for:

• A persistent change in bowel habit, especially going more often or looser, more diarrhoea-like motions, for several weeks

• Rectal bleeding

• Abdominal pain, especially if severe

• Unexplained anaemia causing tiredness or weight loss

• A lump or mass in the stomach

While these symptoms may also be due to other conditions such as haemorrhoids, irritable bowel syndrome, anal fissures or inflammatory bowel disease, don’t delay in talking to a doctor. It is better to visit a GP early and be reassured or treated than to hope symptoms will improve without treatment. Early detection saves lives!

How common is bowel cancer? 

• Bowel cancer is the second most common cause of cancer deaths in Australians

• More than 14,000 people are diagnosed with the disease each year and about 1,000 are under the age of 50

• Bowel cancer affects men and women almost equally

• Bowel cancer causes more deaths than either breast or prostate cancer

• You should never be told you are too young to have bowel cancer

Reducing the risk

Some risk factors such as age or a genetic pre-disposition to bowel cancer cannot be modified but they can be monitored. Diet and lifestyle can also help reduce the risk of bowel cancer. For example:

• Don’t smoke

• Limit alcohol consumption – no more than 2 standard drinks on any day

• Maintain a healthy body weight

• Be physically active – at least 30 minutes of moderate-intensity physical activity on most, preferably all, days

• Replace some red meat meals with white meat or vegetarian alternatives

• Focus on high-fibre foods including a variety of fruit, vegetables, wholegrain cereals, nuts, seeds, beans and legumes.

All text herein is the intellectual property of Bowel Screen Australia and Bowel Cancer Australia

Bowel Cancer Screening

Medical guidelines recommend screening using a faecal immunochemical test (FIT) every 1 to 2 years from age 50

• Free screening via the National Bowel Cancer Screening Program is currently available for people aged 50, 55, 60 and 65 only

• The Bowel Screen Australia program uses the ColoVantage Home Test. This take-home test is simple to use and does not require any diet or medication changes

The aim of a FIT is to detect any early evidence of bowel polyps or cancer.

• A positive test means blood has been detected in the sample. It does not necessarily mean bowel cancer but it does need further investigation by a doctor and usually a colonoscopy

• A negative test means there is no current evidence of bleeding from the bowel. The test should be repeated every 1 to 2 years.

A FIT is not appropriate for people with:

• Bowel cancer symptoms

• A personal history of bowel cancer or bowel polyps

• A family history of bowel cancer

If any of the above applies to you consult your doctor for individual advice

For more information on bowel cancer visit: bowelcanceraustralia.org

Chronic Diarrhoea

Diarrhoea that lasts for more than 4 weeks is considered chronic and is evaluated differently from diarrhoea of shorter duration. A number of small intestinal infections can cause symptoms that last for months or years if untreated and should be excluded with appropriate studies.

Similarly, easily treated problems such as lactose intolerance and hyperthyroidism should be ruled out. A careful history also helps to direct diagnostic attention to the small or large bowel and distinguish organic from functional diarrhoea.

Colonoscopies play a central role in the evaluation of chronic diarrhoea. This is an easily performed test that has specific advantages in further examining the bowel. Biopsies are taken at the time of your procedure to determine if any underlying abnormalities are present. It is an invaluable diagnostic tool when looking for causes of chronic diarrhoea.

A detailed past medical history helps to direct testing to the colon when the patient complains of small volume diarrhoea, squeezing pain (even in the absence of proctitis), rectal bleeding or lower abdominal cramps. Diarrhoea that emanates from the small bowel tends to be of greater volume and is associated with abdominal distension, bloating and pain. Weight loss is more common with small bowel disease. Several characteristics suggest that an organic cause will not be found for a patient’s diarrhoeal disorder. The symptoms of functional causes for chronic diarrhoea are as follows: 

• Diarrhoea that occurs only during the day

• The absence of blood or white cells in the stool

• The absence of substantial weight loss

• A long history of bowel problems dating back to adolescence or childhood

On careful questioning, many patients are actually found to have alternating diarrhoea and constipation or diarrhoea that turns out to be frequent, incomplete evacuations of small pellet-like stools. In all patients with chronic diarrhoea, the possibility of surreptitious ingestion of laxatives or diuretics should be considered. Daily stool weight is also often helpful.

Patients who continue to have diarrhoea, but in whom a specific organic cause has not been documented, may require some medical therapy to reduce the frequency and volume of diarrhoeal movements. In general, initial attempts should employ non-addictive medications because the problem can be expected to last for a considerable length of time. Sequential 2 to 3 week trials of psyllium (hydrophilic), cholestyramine and loperamide can be undertaken. Loperamide is not addictive and is quite effective in this setting.

When a colonoscopy is performed during the course of the evaluation of chronic diarrhoea and the visual appearance is normal, it is important to obtain random mucosal biopsies. Occasionally, patients with chronic watery diarrhoea are found to have a visually normal colon but abnormal mucosal biopsies. The histology may show an abnormality of the mucosa of a layer of collagen thickening of the membrane under the colonic epithelium. All text herein is the intellectual property of Dr Melissa White. Article update June 2014.

This entity has been called lymphocytic, microscopic or collagenous colitis. Most of the microscopic changes in lymphocytic and collagenous colitis are seen in the proximal colon and can be missed in sigmoidoscopic biopsies. Some patients have associated changes in the small bowel and stomach. A wide spectrum of treatments can be used such as sulfasalazine, steroids and loperamide, with a variable response. This is a treatment that should be guided by a specialist in these rare conditions.

Collagenous colitis is most commonly seen in women, with 80% of women with chronic diarrhoea developing this disease. Alternatively, lymphocytic colitis is found equally in both sexes. There is no difference in the response to many of the therapies that have been provided for this entity. Most investigators attempt administering antidiarrhoeal therapy before corticosteroids because spontaneous remission has been reported and serious complications of the diarrhoea are unusual.

Coeliac Disease

Coeliac Disease, sometimes called ‘Sprue’, is a condition in which the lining of the small intestine becomes damaged when it is exposed to even small amounts of gluten. This is a substance found in wheat, barley, rye, oats and millet. As a result, affected patients absorb food and nutrients poorly, resulting in deficiencies of vitamins, minerals and sometimes protein, carbohydrates and fats. Coeliac Disease is easily treated by scrupulously avoiding the consumption of all gluten-containing products, ergo a gluten-free diet. In Australia, Coeliac Disease is relatively uncommon with about one in two or three thousand having the condition

Despite there being no specific symptoms of the disease, diarrhoea, weight loss, nausea, flatulence and abdominal discomfort are common complaints. Tiredness and weakness are also common. Other symptoms that are presenting features in adults, although less common, include mouth ulceration, skin eruptions and recurring miscarriages or infertility. In children, Coeliac Disease often causes delayed growth and development, irritability and a poor appetite in addition to gastro-intestinal problems and anaemia. Of course many of the above mentioned complaints are very common in the community and are not necessarily due to Coeliac Disease. Nonetheless, it is widely accepted now that this condition is under-diagnosed and should be considered in a broader range of patients than has been the practice in the past.

If Coeliac Disease is suspected, a gluten-free diet should never be started until the condition has been properly diagnosed. Otherwise, this will interfere with establishing a correct diagnosis. The diet should always be undertaken with medical supervision. Coeliac Disease can only be properly diagnosed by a pathology examination of a biopsy taken from the intestine. Your doctor can take blood tests prior to this procedure to determine whether Coeliac Disease is likely.

All that is needed is a strict diet that avoids all gluten-containing foods. Medication is rarely necessary. This diet needs to be continued for life because all coeliac patients remain sensitive to gluten indefinitely. Removing glutencontaining foods from your diet does not cure you of Coeliac Disease. You will always have intolerance to gluten. This simple measure can transform the lives of people affected by the disease.

Gluten is not only found in just breads and cereals. It can even be found in some medications. Therefore, after a biopsy has returned consistent with Coeliac Disease, patients should be seen by a dietician before commencing a gluten-free diet. With dietary compliance, patients often have a remarkable clinical improvement and, over time, most of the symptoms which lead to this investigation will revert to normal.

State Coeliac Societies are invaluable in providing advice regarding recipes and general support. In addition, they have up-to-date information in the gluten content of most commercial foods. The diet does cause problems at times, mostly due to expense and difficulties eating out or going on holidays. Again, in particular, compliance with the diet may be difficult because of peer group pressures. Occasionally, constipation and unwanted weight gain can occur as absorption and nutritional status normalise.

Gluten-free bread, biscuits and other products are now widely available from supermarkets and health food shops. Below is a table outlining which food products you should include and avoid in your gluten-free diet.

Flours

AVOID Wheat flour, rye flour, millet meal and corn flour made with wheat and custard powder.

INCLUDE Rice flour, arrowroot, cornmeal, pure corn flour, soya flour, potato flour, lentil flour, wheat starch and glutenfree baking powder.

Bread

AVOID All bread including rye and commercial soya bread, biscuits, pastries, buns, muffins, pikelets, crumpets, croissants and bread crumbs (unless labelled gluten-free).

INCLUDE Rice cakes, slice of rice, some rice crackers (check label), gluten-free bread, biscuits, cakes and rolls, pastries and desserts all made from allowed flours, gluten-free bread, biscuit, cake and muffin mixes.

Cereals

AVOID Breakfast cereals containing wheat, oats, semolina, barley, rye, malt, millet, wheat germ, wheat bran and oat bran.

INCLUDE Rice and corn breakfast cereals, homemade muesli using allowed ingredients.

Pasta

AVOID Spaghetti, noodles, vermicelli, pasta meals (unless labelled gluten-free).

INCLUDE Rice - brown, white or fragrant, corn meal, tapioca, buckwheat, infant rice cereal, taco shells, gluten-free pasta.

Fruit

AVOID Commercial thickened fruit pie filling (unless checked).

INCLUDE Fresh, canned, frozen and dried fruits and fruit juices.

Vegetables

AVOID Canned or frozen in a sauce, commercially prepared vegetables and potato salad (unless checked).

INCLUDE Fresh, frozen or canned without sauces, dehydrated vegetables and vegetable juices.

Meat, Fish and Poultry

AVOID Foods prepared or thickened with flour, battered or crumbed, sausages, processed meats and fish (unless checked), meat pies and frozen dinners.

INCLUDE Fresh, smoked and corned, canned meat or fish without sauce or cereal, ham, bacon, corned beef and gluten-free sausages.

Dairy Products

AVOID Cheese mixtures, pastes and spreads (unless checked), malted milks, artificial cream, icecream with a cone or crumbs.

INCLUDE Block or processed cheese, creamed and cottage cheese, UHT, evaporated, powdered or condensed milk, yoghurt, buttermilk, plain-flavoured ice-cream and fresh or canned cream.

Legumes and Nuts

AVOID Processed varieties of legumes if thickened, textured vegetable protein products.

INCLUDE Dried or fresh beans, nuts and seeds, peanut butter and gluten-free canned baked beans.

Takeaway Foods

AVOID Hamburgers, pizza, souvlaki, sausages, all battered and crumbed food.

INCLUDE Steamed rice, grilled fish, chicken, steak and steamed vegetables.

Snacks

AVOID Packet savoury snacks, some sweets and filled chocolates, liquorice, many frozen desserts.

INCLUDE Plain chocolate, popcorn, jelly, meringue, gluten-free corn chips, rice cakes and slices.

Beverages

AVOID Coffee substitutes, Ovaltine, milo, aktavite, drinking chocolate, milk flavourings, malt, ale, stout and most beers.

INCLUDE Water, tea, coffee, cocoa, milk, cordials, soft drink, soda water, mineral water and fruit and vegetable juices.

Miscellaneous

AVOID Malt vinegar, soy sauce containing wheat, baking powders, mixed seasonings, beef extracts (eg. Marmite, Promite), sauces, pickles, relish, chutney, salad dressing (unless checked).

INCLUDE Tomato sauce, vinegar, honey, jam, yeast extracts (e.g. vegemite), peanut butter, salad dressings without flour, gelatin, gluten-free baking powder and custard powder, gluten-free soy sauce, sugar and golden syrup

Colonic Polyps

Polyps look like small mushroom-like growths and are often on a stalk, but some are flat. Polyps in the colon are clinically important for two reasons:

• They may result in symptoms such as bleeding

• Some colonic polyps develop into cancers

There are polyps that are not pre-cancerous. However, only laboratory analysis can reliably detect the difference between those that do carry the risk of cancer development and those that don’t. This is why the polyps are removed and then sent to the lab for testing. Polyps that are not pre-cancerous do not require any further therapy unless they result in symptoms. Those polyps that do predispose you to cancer development are usually called adenomas. Most often, these are benign at the time of removal.

Patients with adenomatous polyps of the colon are followed up carefully over the years to make sure that they do not grow any further polyps, or have them removed if they do. This is called surveillance. At this stage, you will be automatically entered into our surveillance program and a reminder letter will be sent to your referring doctor at a specified interval when Dr White feels that you are due for your next colonoscopy. By looking at your bowel at certain intervals over the years and picking up any polyps when they are still in their benign form, Dr White should be able to prevent you developing bowel cancer. Polyps should be removed when they are discovered.

Colonoscopy is the most sensitive means of determining whether you have polyps and how many polyps are present. Barium enema or virtual colonography is satisfactory only for detecting large legions. Small lesions (less than 1cm) may not be detected by barium enema. Also, polyps cannot be removed by x-ray examination. Patients who have many polyps (greater than 100) are likely to have one of the hereditary polyp syndromes and further questions will be asked about your family history at this stage. The risk of cancer developing in a benign polyp increases with the size of the polyp. Patients with documented adenomatous polyps of the colon are at a high risk (10 to 30%) for the subsequent development of additional polyps or colon cancer (2 to 5-fold increase) and should be screened regularly with a colonoscopy. Dr White will let your doctor know when you are next due and an indication will be given to you when that is likely to be.

The incidence of bleeding following polyp removal is said to be about 1%. The risk increases with the size of the polyp. Most patients who are going to bleed will do so within 1 to 2 days of the procedure. Many patients notice some blood spotting in the toilet bowl after a colonoscopy within the clot falls from the surface of the bowel where the polyp has been removed. This is not serious and usually settles. Further action is very rarely required. After many years’ experience in performing polyp removal, the percentage for complications is well below the world average.

All text herein is the intellectual property of Dr Melissa White. Article update June 2014

Constipation

A normal pattern of bowel movement can vary considerably from person to person. Most people will empty their bowel between three times daily and three times per week. Everyone has their own regular bowel habit, depending on your diet, fluid intake and how much and when you exercise.

Constipation is a common problem, resulting in less frequent bowel actions. In most cases, the stool is hard and dry and small amounts may be passed with difficulty. You may experience cramps, swelling, pain with straining and a feeling of incomplete emptying of the bowel.

There are a number of factors which cause or contribute to constipation, including:

• Not eating enough fibre (e.g. cereals, breads, fresh fruit and vegetables)

• Not drinking enough fluid

• Not getting enough exercise

• Long term laxative abuse

• Some medications (check with your doctor)

• Debility or frailty

• Resist the urge to defecate

• Pregnancy or recently had a baby

• Anxiety, depression or grief (stressed and feeling low)

• Disorders of the bowel which may require further investigation

• Chronic illness e.g. underactive thyroid, Parkinson’s Disease, Multiple Sclerosis

Constipation may cause faeces to pack the intestine and rectum so tightly that the normal pushing action fails and the colon is not strong enough to expel the stool. This is called faecal impaction. Accidental loss of faeces, known as faecal incontinence, can occur in those with constipation when the bowel becomes too full. Haemorrhoids can be caused by straining to have a bowel movement. Anal fissures (tears in the skin around the anus) are caused when a hard stool stretches the sphincter muscle. In extreme cases, straining can cause a small amount of intestinal lining to push out from the anal opening, causing a rectal prolapse.

Weakening of the pelvic floor muscles is due to chronic straining when emptying the bowels. A full bowel pressing on the bladder can obstruct the outflow of urine, or affect the capacity of the bladder, making you feel that you need to go to the toilet more frequently than normal.

In order to prevent constipation, you may like to try simple changes to your lifestyle. Drink at least 6 to 8 glasses of fluid per day (approximately 1.5L), unless otherwise advised by your doctor. People with bladder control problems often do not drink very much fluid for fear of becoming wet, which often results in them becoming constipated or worsening the problem.

Try adding more fibre to your diet. Fibre comes from the non-digestible part of fruit and vegetables. You need approximately 30grams of fibre per day. Natural foods rich in fibre include:

• All vegetables

• All fruit including dried fruit

• Whole grain and whole meal cereals

• Legumes e.g. baked beans, kidney and soya beans

If you can only tolerate soft foods try banana’s, rolled oats, fruit juices (with pulp), pureed vegetables and stewed or canned fruit.

Daily exercise like walking encourages the movement of faeces through the bowel and promotes regular bowel habits.

If you become constipated, increase the fluid and fibre in your diet. You should also review with your doctor any medications you are using. Consult with your doctor or continence adviser if you need further assistance. If these measures do not bring success, only then consider the use of appropriate medications. There are different types of laxatives and you should consult your doctor regarding which one suits your needs best. Different laxatives include:

• Bulking agents – these increase the bulk of the stool. An adequate fluid intake is essential with these laxatives

• Lubricant laxatives – these soften the faeces

• Stimulant/Irritant laxatives – these promote bowel movements by irritating/stimulating the bowel wall

• Epsom Salts – not absorbed and very safe in small prescribed doses

If your constipation persists, take a night time does of a stimulant laxative, followed the next morning by a suppository or enema. In extreme cases repeated enemas may be required. If you continue to have problems with constipation or diarrhoea, or are experiencing a change from your usual bowel pattern, with or without pain or blood, please see your doctor. Constipation can sometimes be a symptom of a more serious condition. Weight loss, vomiting, headaches and generally feeling tired and unwell are symptoms of what could possibly be an underlying condition

Coping with Heartburn and Reflux

If you are one of the millions of people who suffer from heartburn, the most common symptom of reflux, there are measures you can take to improve your health and your lifestyle.

In order to relieve symptoms of heartburn and reflux, try these tips:

• Avoid spicy, acidic, tomato-based or fatty foods like chocolate, tomatoes, citrus fruits and juices

• Limit your intake of coffee, tea, alcohol and colas

• Have meals at least 3 to 4 hours before lying down

• Don’t gorge yourself at mealtime

• Eat slowly and chew your food well

• Don’t exercise too soon after eating

• Watch your weight – being overweight increases the intra-abdominal pressure, which can aggravate reflux

• Stop, or at least reduce smoking

• Elevate the head of your bed

Make sure to see your doctor if you are taking antacids three or more times per week

Ditching gluten ‘a risk to health’

More than a million Australians may be compromising their health by needlessly adopting gluten-free diets due to ‘pseudoscience’ and celebrity fads, a food science conference has been told.

Despite only one percent of Australians being diagnosed with coeliac disease, more than one in ten adults now follow a gluten-free diet or wheat-avoidance diet, said Peter Gibson, the director of gastroenterology at The Alfred and Monash University.

Presenting his research at a conference in Melbourne, Professor Gibson said those needlessly avoiding gluten were risking their nutrition and a range of mental health concerns, eating too much sugar and facing an unnecessary economic burden.

While many people have been able to overcome bloating and other gut issues by cutting down on wheat, Professor Gibson said the benefit had more to do with reducing carbohydrates than gluten, and progressing to a full glutenfree diet was a mistake for many people.

“Gluten has been blamed for many things and there are a lot of people who are arguing that gluten is the cause of many illnesses, from irritable bowel syndrome through to autism and depression,” Professor Gibson said.

“It started off with people avoiding wheat because they felt better without it and then assuming it was the gluten and going totally gluten-free. Then there were others looking on the internet and in books about how gluten is causing all these problems.”

In a recent trial, Professor Gibson and his team could find no evidence of gluten causing the symptoms in patients suffering gut conditions. A preliminary study of those claiming to suffer depression due to gluten found participants actually suffered more intense symptoms when on the gluten-free diet.

He said a host of authors and celebrities used ‘pseudoscience’ to link scientific research out of context and incorrectly claimed that gluten was responsible for a range of conditions and was driving the problem.

While whole sections of supermarkets are now devoted to products cashing in on the gluten-free demand, Professor Gibson believes it is a case of industry responding to demand rather than driving the controversy.

Gluten is a composite of proteins found in wheat and other grains, including barley and rye. In modern diets, it is commonly found in breads and pastas but it is also added to other foods like beer and soy sauce and even some ice creams and tomato sauces. Rice based flours can be used as a substitute for other grains containing gluten.

Courtesy of the Courier Mail

Diverticular Disease

Diverticular Disease of the colon is very common. It is more commonly found in western cultures, particularly older people because diverticulosis actually increases with age. It is virtually unknown in communities where the diet is very high in dietary fibre. Diverticular Disease looks like pockets in the bowel lining that make it more difficult for waste to pass through the bowel. They can also trap waste material, becoming inflamed.

Many people can have Diverticular Disease without realising it because they may not have any symptoms. Some of the more noticeable symptoms include:

• Abdominal pain

• Variable bowel habits

• Gas

• Bloating

• Urgency of defaecation

Abdominal pain is usually in the lower abdomen, more frequently on the left side and can be worse in the morning being relieved by passing wind or defaecating. Diverticular Disease can also co-exist with Irritable Bowel Syndrome and therefore the symptoms for both may be similar. These symptoms can also be similar to those of diseases such as Bowel Cancer or Colitis. To exclude these other conditions and correctly diagnose Diverticular Disease, investigations such as a colonoscopy will need to be performed.

A good healthy diet is essential in managing Diverticular Disease. You should follow a high fibre diet and use bulking agents made from natural plant products such as Metamucil or Benefibre. You should also drink lots of water and do regular exercise. By eating more dietary fibre, you may find constipation and abdominal pain improve, but initially you may have more bloating. Unprocessed bran is usually the cause of this, especially if it has been finely milled to produce small flakes. Eating this type of bran can often cause more problems than it usually fixes. Some windy foods that cause problems for people include dairy products, cabbage, Brussels sprouts, cauliflower, broccoli, canned beans, onions, legumes and artificial sweeteners. What you should eat:

• MOST – Fruit, vegetables, breads and cereals

• MODERATE – Lean meat, chicken, fish, milk, cheese, yoghurt and eggs

• LEAST – Fats, salt and sugar

High fibre foods include: whole meal bread, wholegrain cereals, legumes (dried beans, peas and lentils), fruits (but not juices) and vegetables (cooked vegetables often have more fibre than salads).

All text herein is the intellectual property of Dr Melissa White. Updated June 2014

Fatty Liver

The diagnosis of fatty liver is usually confirmed on liver biopsy or ultrasound. Prior to that, the suspicion may be there because your doctor has found abnormal liver function tests, often in the setting of being overweight, having diabetes or having cholesterol or triglyceride problems. Sometimes fatty liver can be found on ultrasound so that a liver biopsy is not needed. However, fatty liver is often present even if a CAT scan or an ultrasound is negative. Sometimes liver biopsies are required to confirm the diagnosis which reveals the amount and distribution of fat, as well as if there is any associated liver damage or inflammation.

The liver plays a central role in cholesterol metabolism. This process is complicated and a variety of biomechanical reactions can occur which can make the liver store excess fat. Fatty liver is very common and it is usually benign, but can become serious if not treated. Usually, the background function of the liver is reasonable and the majority of problems that the fatty liver causes are abnormal liver function tests which worry your General Practitioner. There are some drugs that can cause fatty liver and certainly excess alcohol can cause it as well. Sometimes, discontinuing drugs is required but this advice should be given by a specialist. Up to 90% of overweight and diabetic people have some degree of fatty liver on liver biopsy and in general these patients have no symptoms and have underlying normal liver function. Very occasionally the condition can progress to cirrhosis.

The best treatment is to achieve an ideal weight. No drug therapy will reverse the effects of fatty liver and the only way to improve the fat content in the liver is to decrease it by decreasing your weight. As fat comes off the rest of the body, the fat should redistribute back out of the liver and the liver function tests that are abnormal should improve. In the first instance, weight loss may have been recommended to you as a way of avoiding a liver biopsy and this is certainly a very worthwhile exercise. I often give 6 months for this to occur. If your liver function tests normalise just by reducing your weight, then we can often avoid more invasive tests.

Not only will regular exercise help you to lose weight but it will also tone your muscles making them look trimmer. Exercise is also good for your heart, bone health, and general wellbeing. The trick is to choose something that you will enjoy doing such as walking, swimming or aqua aerobics. There is no need to puff and sweat to benefit from exercise. Simply try to do a regular amount on a regular basis. The more exercise you do the better, but remember that any exercise is better than none at all.

In regards to diet, low fat foods are generally high in fibre so they will fill you up without adding excess fat. Dietary fibre also keeps your bowels regular. Don’t skip meals. Many people make the mistake of skipping meals to save on calories. This can mean that they get so hungry that they snack on anything that is available. Try to eat three meals every day. If you prefer, the fruit from your allowance can be saved for snacking between meals.

Tips for healthy weight loss:

• Count fat first, then kilojoules. Studies have shown that not all calories are the same and it is the fat content in the diet that is more likely to cause you to put on weight. Therefore, try to eat low fat foods such as breads, cereals, fruit and vegetables. Use low fat dairy foods and lean meats. You will then have to have a healthy eating plan which will enable you to lose weight gradually and keep it off for good.

• Don’t talk ‘diet’. Talk ‘healthy eating for life’.

• Set realistic weight loss goals. Your body will fluctuate day by day. The fit of your clothes is usually the best sign that you are headed in the right direction.

• Make meals attractive end enjoyable even if you are eating alone. Take time to sit down at the table and eat slowly.

• Put variety in your diet. Try out some new low fat recipes, choose different types of bread for sandwiches and vary the fillings.

• Recognise the triggers to over-eating. For many people theses are boredom, stress or anger. Identify another activity to do at these times such as exercise, relaxation or craft work.

• Accept that there are no ‘good’ or ‘bad’ foods. Any food can be eaten as part of a healthy eating plan, simply choose lower fat foods more often and in larger amounts.

• Read labels on foods to get an idea of the fat content. Low fat foods generally have less than 3g of fat per 100g serving.

• Use butter, margarine and oil sparingly. A smear of margarine is all you need.

• Choose non-stick cookware and use a cooking spray in place of oil.

• Grill, bake or roast using a drip tray to catch the fat.

• Cut fat off all meat and remove the skin from poultry.

• Enjoy low fat and reduced fat milk and dairy products

Fermentable Fruit & Vegetables

(maximum allowed in brackets)

FRUITS:

Apples

Custard Apples

Apple and Pear based Fruit Juice/Cider

Clingstone Peaches

Apricots

Blackberries

Pears

Tamarillo

Mango

Rambutan

Nashi Pears

Dried Fruit

Peaches

Lychees (5)

Papaya

Cherries (3)

Plums

Grapefruit (½)

Tinned Fruit in Natural Juice

Watermelon

Pomegranate

Persimmon

Nectarines

VEGETABLES:

Garlic

Cabbage

Onion Family – Spring, Spanish, Shallots,

Sweet potato (1/4 cup)

Leeks, White & Brown Onions

Beans – baked/cannellini/broad/butter

Broccoli

Chick peas/lentils

Cauliflower

Celery (½ stick)

Avocado

Okra

Asparagus

Artichokes

Beetroot

Brussel Sprouts

Green beans (6)

Peas – Green, Sugar Snap & Snow

Mushrooms

Fennel

Fibre Levels in Food

Dietary Fibre shown in grams

• BREADS

  Wholemeal roll 15.1

  Wholemeal bread 2.4

  Multigrain 2.0

  High fibre white 1.8

  White roll 1.4

  Muffin (half) 1.2

  Rye crisp bread 1.2

  Fruit loaf 1.0

  Toast (thick white) 0.9

  White 0.6

• BREAKFAST CEREALS

  All Bran 9.5

  Muesli 8.0

  Branflakes 7.0

  Porridge 5.0

  Muesli Flakes 3.6

  Unprocessed Bran 3.0

  Weetbix 2.8

  Nutri-Grain, Rice Bubbles 0

  Cornflakes, Special K 0

• FRUITS

  Blackberries – ½ punnet 9.0

  Figs – dried 9.0

  Raspberries – ½ punnet 9.3

  Prunes x 6 8.0

  Passionfruit x 2 6.5

  Banana 4.0

  Rhubarb – cooked 4.0

  Paw Paw – 150g 3.5

  Pear 3.5

  Mango 3.5

  Apple – with skin 3.3

  Plums x 2 3.2

  Raisins/sultanas 3.0

  Orange 3.0

  Strawberries 2.8

  Figs – fresh 2.5

  Cherries – 150g 2.5

  Nectarine x 2 2.5

  Kiwifruit 2.2

  Pineapple – 1 slice 2.1

  Apricots – 100g 2.0

  Grapefruit 2.0

  Melon – 200g 2.0

  Avocado – half 2.0

  Grapes – 200g 1.8

  Peach 1.8

• VEGETABLES

  Kidney beans 9.5

  Soya beans 9.5

  Peas 7.5

  Corn (1 cob) 6.5

  Spinach 4.5

  Broccoli 4.0

  Yam 4.0

  Beans – green 3.0

  Brussels sprouts 3.0

  Parsnip 3.0

  Potato – with skin 3.0

  Mushrooms 2.5

  Sweet Potato 2.5

  Cabbage 2.0

  Cauliflower 2.0

  Tomato 2.0

  Zucchini 2.0

  Asparagus 1.5

  Potato – peeled 1.5

  Pumpkin 1.5

  Celery 1.0

  Lentils 1.0

  Lettuce 1.0

  Bean sprouts 0.5

  Cucumber 0.2

• OTHER FOODS

  Coconut – fresh 10.0

  Popped corn – 1 cup 1.0

  Almonds – 30g 4.3

  Corn chips – 1 pkt 0.5

  Coconut – dried 3.5

  Meat – all types 0.0

  Peanut paste – 1 serve 3.0

  Dairy products 0.0

  Brazil nuts – 30g 2.7

  Eggs 0.0

  Peanuts 2.4

  Fats 0.0 Cashews – 30g 2.4

  Sugars 0.0

  Hazel nuts – 30g 1.8

Food Allergies/Intolerances

Food allergy and food intolerance are commonly confused, as symptoms of food intolerance occasionally resemble those of food allergy. However, food intolerance does not involve the immune system and does not cause severe allergic reactions (known as anaphylaxis). Food intolerance also does not show on allergy testing. Food intolerance can be a difficult concept to understand and is poorly understood by doctors as well.

Sometimes, substances within foods can increase the frequency and severity of migraine headaches, rashes (such as hives) or the stomach upset of irritable bowel. Coincidence can often confuse the issue, as we spend many of our waking hours eating or drinking. Professional diagnosis and confirmation of allergens is important. In Australia, about one in 10 infants, one in 20 children up to five years of age, and two in 100 adults have food allergies

Food allergy is increasing

Allergies in general are on the increase worldwide and food allergies have also become more common, particularly peanut allergy in preschool children. About 60 per cent of allergies appear during the first year of life. Cow’s milk allergy is one of the most common in early childhood. Most children grow out of it before they start school.

Allergy can be inherited

Children who have one family member with allergic diseases (including asthma or eczema) have a 20 to 40 per cent higher risk of developing allergy. If there are two or more family members with allergic diseases, the risk increases to 50 to 80 per cent. Most of the time, children with food allergy do not have parents with food allergy. However, if a family has one child with food allergy, their brothers and sisters are at a slightly higher risk of having food allergy themselves, although that risk is still relatively low.

Allergy is an immune response

Allergies are an overreaction of the body’s immune system to a protein. These proteins may be from foods, pollens, house dust, animal hair or moulds. They are called allergens. The word “allergy” means that the immune system has responded to a harmless substance as if it were toxic. Food intolerance is a chemical reaction Food intolerance is a ‘chemical’ reaction that some people have after eating or drinking some foods; it is not an immune response. Food intolerance has been associated with asthma, chronic fatigue syndrome and irritable bowel syndrome (IBS).

Symptoms of food allergy and intolerance

It can be difficult to tell the difference between the symptoms of food allergy and food intolerance. Usually, symptoms caused by food allergy develop very soon after consuming the food but, while symptoms caused by food intolerance can be immediate, they may also take 12 to 24 hours to develop. Food intolerance reactions are usually related to the amount of the food consumed. They may not occur until a certain amount (threshold level) of the food is eaten; this amount varies for each person. The symptoms of food allergy and intolerance can also be caused by other conditions, so it’s important to see a doctor experienced in this area for a medical diagnosis.

Kindly reproduced from information leaflet from Buderim Pharmacy, Shop 13/67 Burnett Street, Buderim, with their permission.

Haemorrhoids

Haemorrhoids (also known as piles) are cushions of blood vessels and bowel lining tissue that swell and budge into the back passage. These cushions are located in the anal area and help to ease stool passage. There are two types of haemorrhoids – internal and external. It is possible to have both at any time, and both may protrude. They often bleed, but bleeding from the back passage is not always due to haemorrhoids. Any bleeding should be checked by your doctor. An internal haemorrhoid forms inside the rectum under the mucous membrane. When internal haemorrhoids enlarge greatly, they may prolapse (fall down) and protrude through the anus. An external haemorrhoid forms at the anal opening and is covered with skin.

Signs and symptoms include:

• Bulge or tag of skin around the anus.

• Bright red blood on toilet paper or around the outside.

• Itching around the anus

• Pain when passing a bowel motion

Causes of haemorrhoids include:

• Pregnancy and straining during childbirth

• Putting off going to the toilet or straining to pass a bowel motion

• Constipation or diarrhoea

• Coughing, sneezing or vomiting

• Holding your breath while doing heavy lifting and carrying

• Anything that increases the pressure of blood in blood vessels around the back passage such as

  • Low fibre diet

  • Wearing tight pants

  • Severe liver disease

  • Cancer of the rectum or pelvic area

  • Being overweight

  • Chronic cough

Haemorrhoids are very common in our society, particularly in older people. Up to half of the population will suffer from them at some time in their lives. Haemorrhoids are less common in people younger than 40, although they may suffer from anal or rectal discomfort due to other causes.

The above list of factors that contribute to haemorrhoids indicates the people who are most at risk. Constipation is the biggest factor and it’s also one that we can do something about. The enormous changes in the body associated with being pregnant and having a child also hasten the development of haemorrhoids.

Abdominal strain from coughing or lifting heavy weights may be difficult to avoid, but at least if you use the correct lifting technique you will help reduce the problem.

Internal haemorrhoids develop from the veins in the lower part of the rectum. Usually they are not painful to start with, although they may cause a vague aching sensation. Often the first sign will be a small amount of bright red blood on the toilet paper or in the toilet bowl after passing a motion, or on the surface of the bowel motion itself.

Haemorrhoids tend to grow in size over time. Pain and discomfort also become more likely, particularly if the haemorrhoid becomes inflamed or infected, or if it develops a blood clot inside it. The haemorrhoid may become so large that it’s pushed through the anus (prolapsed) when passing a bowel motion and it may become ‘strangulated’.

Sometimes, when an internal haemorrhoid prolapses through the anus it is called ‘external’. However, the phrase ‘external haemorrhoids’ usually refers to changes in the blood vessels lying under the skin around the anus. These veins too can become enlarged and cause difficulties. An aching pain is often the first symptom of external haemorrhoids. The biggest problems occur when a blood clot inside the vein causes a blood blister to form just beneath the skin. Because the skin is rich in nerve endings, this can be very painful.

In order to prevent haemorrhoids, try these tips:

• Increase the fibre content of your diet so that motions are soft and easy to pass.

• Drink at least 6 to 8 large glasses of water each day.

• Learn to lift heavy objects correctly.

• Regular exercise for good muscle tone.

• Don’t strain to pass a motion and do not sit on the toilet for more than 2 minutes trying to pass a motion.

• Avoid regular use of laxatives.

External haemorrhoids should clear within a week. Using a haemorrhoid product can help relieve symptoms, however, some products are stronger than others so ask your pharmacist which one is best for you. If using an applicator, lubricate it before use and wash it well afterwards. For best results, use the haemorrhoid product after you pass a motion or have a bath and also at bedtime.

Examples of haemorrhoid product ingredients include:

• Adrenaline – Narrows blood vessels to reduce swelling and sometimes itching.

• Benzocaine/Lignocaine/Cinchocaine – Local anaesthetics to relieve pain and numb the area below the rectum (not needed in the rectum as there are no pain fibres here).

• Hamamelis/Allantion/Zinc Oxide/Sulphate – Astringents to make the area drier and relieve itching and burning.

• Hydrocortisone/Bufezamec/Prednisolone/Fluocortolone – Reduces swelling and relieves itching.

• Vitamin A/Balsam Peru – Wound healers.

Applying a cold compress to relieve symptoms can also be of comfort. It shrinks the surrounding blood vessels, therefore relieving the inflamed area. An ideal cold pack for this problem is frozen rubber glove fingers. If you fill a rubber glove with water and place it in the freezer, the fingers (cut off from the glove) are actually an ideal pack for relief within the anal passage. The glove component will pass once the ice has melted.

Helicobacter Pylori

Helicobacter Pylori (H.Pylori) is a bacterium that infects the human stomach and was first recognised as a cause of symptoms in 1985. It is very common and can be found in up to 1 in 5 normal people. About 40% of persons over 40 years of age are infected with this germ compared to less than 10% of children. How it is spread is not known at this stage, but it is most likely from person to person and it can sometimes be found in several members of the same family. Once the infection is present it persists for many years, if not for life.

Most infected people have no symptoms, but H.Pylori is found in almost all patients with duodenal ulcers and in half of those with stomach (gastric) ulcers. However, it can also cause symptoms in patients who do not have an ulcer, in particular, abdominal pain related to meals, nausea, loss of appetite, belching and wind, bloating and distention after meals with a feeling that the food is not digesting, and a feeling of fullness after eating only a small amount. These symptoms can be the same as those caused by the ulcers themselves, and can be present for a few weeks, a few years or longer.

Endoscopic examinations of the stomach and duodenum can be necessary to diagnose H.Pylori infection. A small piece of tissue is taken from the stomach to test for bacterium. The test is usually positive within 2 hours but can take up to 24 hours. The endoscopic examination will also look for the presence of ulcers. Breath tests determine if you are infected by analysing a sample of your exhaled breath. This is because H.Pylori in the stomach is able to convert a naturally occurring substance called ‘urea’ into the gas carbon dioxide. If specially labelled urea is swallowed, labelled carbon dioxide can be detected for a short time in the breath of an infected individual. Breath tests are accurate, safe and quick to perform. They are particularly useful to check whether the infection has been successfully treated. The test accuracy is reduced if you have been taking certain drugs (E.g. antibiotics in the previous month and some ulcer healing drugs in the previous 2 to 3 weeks). Blood tests can detect current or recent infections. However, the accuracy of these tests varies and overall they are less accurate than other methods. Bloods tests are not useful for checking whether the infection has been successfully eradicated.

Helicobacter Pylori can cause these diseases:

• Inflammation of the lining of the stomach (Gastritis)

• Duodenal ulcers (ulcers in the first part of the small bowel)

• Stomach (gastric) ulcers

• Some cancers of the stomach

All people infected with H.Pylori have inflammation of the lining of the stomach. However, most infected people have no symptoms. In some people this inflammation progresses to other diseases and needs to be treated. It will disappear if the infection is successfully treated.

H.Pylori infection increases the risk of some forms of cancer of the stomach. Other factors may also increase this risk (e.g. a high salt diet or a low intake of green vegetables in certain populations). Although stomach cancer is very common in parts of the world, it is becoming an uncommon cancer in Australia as the number of people infected declines. It should be noted that only a small minority of infected people ever develop this problem.

H.Pylori can also be the cause of different types of stomach or gastric ulcers. An ulcer is a break in the lining of the stomach or upper bowel (the duodenum). Ulcers occurring in these areas are often called peptic ulcers. H.Pylori is the cause of about 90% of ulcers in the duodenum. The common symptom is pain in the upper part of the abdomen. However, it is important to recognise that pain is often not due to ulcers as some ulcers cause no symptoms. A small proportion of ulcers cause serious complications such as bleeding or perforation (bursting).

H.Pylori is also the cause of about 70% of stomach ulcers. Most of the remaining 30% are due to drugs taken for arthritis (non-steroidal anti-inflammatory drugs), or aspirin taken to prevent heart attacks or strokes. Some patients have both risk factors. The symptoms and complications of stomach ulcers are the same as for duodenal ulcers. Modern anti-ulcer drugs heal virtually all duodenal and stomach ulcers but there is a high chance that the ulcer will come back if H.Pylori is not eradicated. If H.Pylori infection is cured, the risk of the ulcer returning is very low, unless aspirin or anti-inflammatory drugs need to be taken.

Dyspepsia is a word used to describe pain, discomfort or other symptoms in the upper abdomen. Most people with dyspepsia do not have an ulcer found when they have tests (e.g. gastroscopy) to find the cause of the symptom. If no cause is found, they are described as having non-ulcer dyspepsia. This is a very common problem and is thought to have many possible causes. Some of these people have H.Pylori infection (many do not), but only in a small number does the pain subside when the germ is treated.

In people who have, or have had, an ulcer, testing and treatment are important. This is because successful treatment will speed ulcer healing and prevent ulcers recurring. People with dyspepsia can be considered for testing also. Some of these people will have ulcers so treatment is important for them also. In some of the remainder, symptoms may improve with treatment. However, if they decide to have the infection treated, part of any benefit may be from reducing the chances of getting ulcers (or possibly stomach cancer) in the future. In each case, the decision to test and by which test should be discussed with your doctor. Testing should generally not be done unless treatment is contemplated. The side-effects and cost of treatment need to be weighed against the possible benefits.

Everyone with a duodenal ulcer should be considered for testing for H.Pylori with a view to treatment if infection is proven. This includes people with active ulcers and those who have had a duodenal ulcer in the past. If they are taking anti-ulcer drugs to prevent ulcers coming back and H.Pylori is eradicated, the anti-ulcer drug can often be stopped. There are few exceptions, such as when the doctor and patient decide that the risk of getting ulcers again may be unimportant in the context of some other severe illness. In the same way, everyone infected with H.Pylori who has had a stomach ulcer should be considered for testing and treatment. One exception may be people who develop an ulcer while taking anti-inflammatory drugs, where the benefits of treating H.Pylori infection are more controversial. In this situation, your doctor can give you individual advice.

Not everyone infected with H.Pylori should be treated. Most infected people have no symptoms and therefore do not require treatment. Those people who do have an ulcer present or have had a past history of ulcers should have H.Pylori eliminated.

There are a number of drug combinations used at the present time to treat H.Pylori. The most effective of these are successful in 80 to 90% of people; however this success rate is much lower if the drugs are not taken exactly as directed. Unfortunately, there is no single drug that is effective against H.Pylori. Treatment combinations include at least three drugs. The use of drug combinations reduces the risk of H.Pylori becoming resistant to treatment.

The drugs most commonly used include ulcer healing drugs (e.g. Omeprazole, Lansoprazole, Pantoprazol, Bismuth and Ranitidine-Bismuth-Citrate) and antibiotics (e.g. Amoxycillin, Clarithromycin, Metronidazole, Tinidazole and Tetracycline). Several combination packs containing all the drugs needed for a course of treatment are now available in Australia.

Taking this combination of drugs increases the risk of side-effects. Side-effects which may occur include nausea, taste disturbances, diarrhoea, skin rashes and interactions with other medications. Some people take Metronidazole or Tinidazole have an unpleasant reaction to alcohol while they are using these antibiotics. Very rarely more serious side-effects may occur such as bacterial infection of the large bowel or a sudden drop in blood pressure. It is important to tell your doctor if you have ever had any side-effects with antibiotics.

If you take the treatment exactly as directed, the chance of success is high, so it is not always necessary to check that H.Pylori has been eliminated, although many people wish to know. However, H.Pylori eradication success should be checked before stopping anti-ulcer drugs especially if you have had a serious ulcer complication or if your ulcer has often recurred. If you have to have another gastroscopy, it is very simple to look for H.Pylori using one of the tests described. If you do not need another gastroscopy, your doctor may order a breath test. It is important that these tests are performed at least four weeks after all treatment is stopped as H.Pylori can grow again within this time.

If treatment has not been successful, a different combination of drugs may be tried. Once you have had successful eradication of H.Pylori, the risk of being reinfected in very low (only about 0.5 to 1% per year). This is because most infection is acquired in childhood. There are no long-term complications of H.Pylori once it has been eradicated from the stomach.

Hepatitis C

The following fact sheet information is from the Australian Society of HIV Medicine Inc.

The information below is for people who have received a positive Hepatitis C antibody test result and for people who want to know more about Hepatitis C. A positive test result means that you have been exposed to the Hepatitis C virus. This may be a shock and you may have questions that you need answered.

One in four people exposed to Hepatitis C will clear the virus. Your doctor can order more tests to find out if you are one of these people. If further tests reveal that you do have active Hepatitis C, your doctor and the organisations listed here are able to provide further information and support.

What is Hepatitis C?

Hepatitis C is a blood-borne virus that can damage the liver. Hepatitis C can be a chronic (long term) condition. You may have had it for many years without experiencing any symptoms. However, common symptoms include fatigue, nausea, pain under the ribs and intolerance to fatty foods and alcohol. There are at least six major types of Hepatitis C called genotypes which are all slightly different. Unlike other Hepatitis viruses, Hepatitis C does not usually cause illness when you are first infected. Many people might not know that they have been infected, even after having the virus for many years. How can you get Hepatitis C? Hepatitis C is transmitted through blood-to-blood contact. Most people in Australia and New Zealand with Hepatitis C are infected through re-using drug-injecting equipment. Transmission can also occur through unsterile tattooing or body piercing, from a needlestick injury, or from blood, or blood product transfusion in Australia prior to 1990. Hepatitis C can also be spread by unsterile medical or vaccination practices in some countries. There is a small risk of mother-to-baby transmission through sharing household utensils such as cups or plates or through sharing food.

Treatment

Treatment aims to clear Hepatitis C from your body and minimise damage to your liver. Not everyone needs treatment as Hepatitis C is often mild and will not affect long-term health. The most effective treatment for Hepatitis C is a combination course of drugs pegylated interferon and ribavirin. Hepatitis C treatment has advanced rapidly in the past few years and around 80% of people with some genotypes and about 50 to 60% of all people treated with current therapy clear the virus. Some genotypes are more responsive to treatment than others. This means that many people with Hepatitis C can clear the virus and become symptom free. Interferon is injected just under the skin and ribavirin is taken as a pill. Treatment is usually given for 6 to 12 months. Regular check-ups by Dr White are essential during your treatment to monitor your progress and respond to any issues you may have.

Monitoring Your Health

To find out how your body is coping with Hepatitis C, you need to monitor your health. This can help in deciding whether or when to start treatment. Regular monitoring of your health will involve consultation with your local GP and Dr White. It is most important to maintain a healthy diet, cut out or limit alcohol and exercise regularly. Once a person has been exposed to Hepatitis C, a Hepatitis C antibody test will usually come back positive, even after the body has cleared the virus or after successful treatment. Several tests are used to determine whether your Hepatitis C has been cleared or whether it is still active. If it is cleared, you are no longer infectious and the virus is no longer damaging your liver.

Tests

Liver function test look at how your liver is performing. One of these tests is called an ALT test. It indicates current liver damage. It can go up and down over time for many reasons including alcohol use, other drug use or if your body is fighting another infection. It can also fluctuate as a result of Hepatitis C. If your ALT is raised on one or more occasions, your doctor may perform a PCR test to determine whether you have cleared the Hepatitis C virus or if it is still active. You may also have a genotype test, which is the type of the virus you have been exposed to, and a viral load test, which measures how much of the virus is in your system. The genotype and viral load tests give an indication of treatment outcome. A PCR test will be repeated sometime after treatment to determine whether you have cleared the Hepatitis C virus. Your doctor is a good person to talk to about Hepatitis C in a private and confidential manner.

Confidentiality

Under most circumstances, you have no obligation to tell anyone that you have Hepatitis C. However, there is a legal requirement to inform the Red Cross of your Hepatitis C status if you are donating blood, and similarly, you must indicate your Hepatitis C status to the Australian Defence Force if you are applying as an entrant. If you are a health care worker with Hepatitis C you must not perform exposure-prone procedures. You should tell doctors, dentists and blood collection nurses caring for you.

If you have Hepatitis C it is important to ask questions and find the kind of support that suits you. Hepatitis organisations offer a range of information and services including confidential counselling and referrals. They can often put you in contact with others who have Hepatitis C. You may want to do some more reading before talking to others. A list of helpful resources can be found at www.ashm.org.au/resources and at www.hepatitisc.org.au.

Australian Hepatitis Council

Tel: 02 6232 4257 (metro)

Help Line: 1300 301 383 (regional)

Web: www.acthepc.org

Hiatus Hernia

A Hiatus Hernia is the protrusion (or herniation) of the upper part of the stomach into the chest cavity through a weakness in the diaphragm. Hiatus hernia is diagnosed in 30% of the GORD (gastro-oesophageal reflux disease) population. This disorder is associated with delayed oesophageal acid clearance and with a higher frequency of retrograde flow episodes due to sphincter relaxation.

Gastric acid secretion plays a critical role in the digestive process. Hydrochloric acid acts in the stomach which is protected from this acidity by the structure of the gastric mucosa. The oesophagus, however, has no protection against acid damage and gastro-oesophageal reflux may result in significant lesions that impair quality of life and increase the symptoms of patients.

The gastro-oesophageal junction is represented by the Lower Oesophageal Sphincter (LOS) and exhibits tonic contraction at rest which makes it a high pressure area. It acts as a barrier to prevent reflux of the gastric contents to the thoracic portion of the oesophagus.