How to assess your bowel habits

The Bristol Stool Chart or Bristol Stool Scale is a medical aid designed to classify stools (known as ‘faeces’ or ‘poo’) into seven groups.

Image credit Continence Foundation of Australia

Increasing Intake of Dietary Fibre

A high fibre diet involves much more than taking unprocessed wheat bran. The wide variety of different types of dietary fibre should be included in your daily diet. In this respect, it is also worth noting that dietary fibre is usually a marker of other important nutrients. By contrast, low fibre foods frequently lack other nutritional benefits. Dietary fibre occurs only in foods of vegetable origin. These include:

• Breads, cereals, grains and grain products

• Fruits

• Vegetables

• Legumes

Most foods within these groups contribute some dietary fibre, but some foods have more than others. For example, white bread contains some dietary fibre, whereas wholemeal breads have four times as much. Some highly processed breakfast cereals are almost totally devoid of fibre while oats and whole wheat products are good sources. The best food choices can be made as follows:

Bread and related products

• Choose breads from wholemeal, wholegrain, high fibre and added oats, oatbran, wholemeal Lebanese or pita breads.

• Purchased or home-made muffins made from wholemeal flour with added oats, oatbran or wheatbran.

• Wholegrain biscuits such as Ryvita, Wholemeal Crackerbread. Bran and Malt Cruskits, Vogels Crispbread (these all have no added fats or sugars)

• Wheat, Scottish Oatcakes and Shredded Wheatmeal all contain fibre, but also contain fat.

• Cakes, biscuits or scones made with wholemeal flour.

Cereal Foods

• Rolled Oats (traditional or one minute), wholemeal porridge.

• Oatbran (can be made into porridge) or unprocessed wheat bran (2 tablespoons)

• Wheatgerm

• Bran cereals (All Bran, Bran Flakes, Sultana Bran)

• Wholegrain breakfast cereals such as Weetbix, Ready Weets, Vita Brits, Bran Bix, Puffed Wheat, Wheat Flakes, Sheed Wheat, Natural Muesli (toasted muesli has a high content of saturated fat and in most brands; added sugar), Sustain and Fibre Plus.

• Wholemeal pasta, brown rice or cracked wheat (use as rice).

Grains 

• Oats, wheat, cracked wheat, brown rice, millet, corn, buckwheat, rye and barley. These can be used in casseroles, soups, with vegetables in chicken and meat dishes, and also in some desserts.

Legumes

• Pease, baked beans, haricots, kidney, navy, soya, black-eyed and butter beans.

Root Vegetables 

• Potatoes, carrots, kumara, celery, beetroot, sweet potatoes, parsnips and turnips.

Other Vegetables

• Peas, spinach, broccoli, mushrooms, Brussels sprouts, beans, cabbage, leeks, eggplant and cauliflower.

Fruits 

• Dried apricots, passionfruit, prunes, berries, raisins, dates, pears, apples, bananas, mandarins, oranges, avocados, mangoes, nectarines, rhubarb and melons. When practical, include the skin of these fruits.

Nuts and Seeds

• All nuts, sunflower seeds, sesame seeds and pepitas (pumpkin seeds).

Foods to AVOID

• Refined products made with white flour, refined breakfast cereals, most biscuits, cakes and pastries.

• Fruit and vegetable juices – eating the whole fruit is a much better source of fibre.

• Fatty foods and large quantities of sugar.

Fluids 

• Dietary fibre absorbs water and it is important to drink plenty of fluids. A minimum of 8 glasses of water per day is recommended.

Many people confuse filling with fattening. Foods with plenty of dietary fibre are filling but that does not necessarily make them fattening. A bowl of porridge for example, is much more filling than a bowl of cornflakes yet each contain a similar number of kilojoules. Eating more filling foods can actually help reduce the total amount eaten and can be valuable for those you need to lose weight.

The average Australian diet contains about 15g of dietary fibre, less than half the usual recommendation. Amount greater than 40-50g of fibre per day will do no harm; however, any increase in fibre should be introduced gradually to prevent excessive flatulence (wind).

Inflammatory Bowel Disease

Colitis has been recognised in humans for many centuries. Until the 19th century, when a classical description of ulcerative colitis was made, all episodes of colitis were thought to be due to infection. In 1932 Dr Crohn and his co-workers described inflammation in the last section of the small bowel (also called the terminal ileum) and this condition is now known as Crohn’s disease. It was not until the 1960’s that a clear distinction was made between ulcerative colitis and Crohn’s disease of the colon.

The term inflammatory bowel disease is now used to describe both ulcerative colitis and Crohn’s disease. These disorders are chronic inflammatory conditions of the wall of the gastrointestinal tract. The cause is still unknown. At the time of diagnosis, it is sometimes hard to differentiate which condition is present, but later it usually becomes clear whether it is ulcerative colitis or Crohn’s disease.

Ulcerative Colitis

Ulcerative colitis is inflammation of the mucous membrane or lining of the large bowel (the colon) and the last sections of the large bowel (the rectum). If only the rectum is involved, it is called ulcerative proctitis. This is less serious and rarely progresses to involve the whole colon.

Crohn’s Disease

Crohn’s disease is inflammation of the full wall thickness of the intestine rather than just the lining. It may involve any part of the digestive tract, but most frequently occurs in:

• The terminal ileum (the last section of the small bowel) – and is called ileitis

• The large bowel – called colitis

• Both the small and large bowel – called ileo-colitis

Both ulcerative colitis and Crohn’s disease involve chronic inflammation of the bowel wall. Microscopic examination of the tissue obtained by biopsy or surgery can help a pathologist differentiate between the two conditions. Ulcerative colitis is confined to the superficial layers lining the bowel wall. It is most severe in the rectum and may spread throughout the colon. Crohn’s disease, on the other hand, can appear in any part of the gastrointestinal tract. Most commonly it involves the colon or small bowel, especially the ileum. It can involve the mouth, oesophagus, stomach or anus, but this is rare. Crohn’s disease may be discontinuous, skipping areas of the bowel so that part of the bowel is inflamed and ulcerated and part is normal. Crohn’s disease involves all layers of the bowel wall and tends to form strictures (areas of narrowing) and fistulae (connections between the bowel and another loop of the bowel or between the bowel and other organs such as skin, bladder or vagina).

The cause of ulcerative colitis and Crohn’s disease is unknown. It is thought the factors within the body as well as environmental factors may be important in causing a change in the gut of individuals who are susceptible to inflammatory bowel disease. The specific nature of these factors is unknown.

Genetic Factors

The exact nature of genetic factors that are important in the development of inflammatory bowel disease are obscure. Family and twin studies show an increased frequency of inflammatory bowel disease in related individuals. However, children of those with inflammatory bowel disease are rarely affected and family screening is not needed.

Diet

Despite many studies, no specific dietary factors have been shown to cause inflammatory bowel disease

Infectious Agents

There have been many studies, but there is no convincing evidence that inflammatory bowel disease is caused by infectious agents such as viruses or bacteria. Inflammatory bowel disease is not contagious.

Drugs

Drugs used to treat arthritis and rheumatism (non-steroidal anti-inflammatory drugs or NSAIDS), may precipitate relapses or inflammatory bowel disease.

Smoking

Ulcerative colitis is less common in smokers. There is evidence that both initial attacks and relapses may be associated with stopping smoking. However, smoking is not recommended as therapy.

Psychogenic Factors

There is no evidence that a particular personality type or emotional stress cause inflammatory bowel disease. However, emotional stress may increase suffering and the severity of symptoms. The disease or its treatment may have a psychological influence which may cause depression.

Immune System

A disturbance of the immune system may be involved in inflammatory bowel disease

Irritable Bowel Syndrome

Irritable bowel syndrome or IBS is a chronic disorder of the colon. The cause is as yet unknown. Doctors call it a functional disorder because there is no sign of the disease when the colon is examined by x-ray or colonoscopy. However, IBS causes a variety of symptoms including lower abdominal pain, gas, bloating, constipation, diarrhoea or alternating constipation and diarrhoea. Through the years, IBS has been called many names – mucous colitis, spastic colon, spastic bowel and functional bowel disease. Most of the terms are inaccurate. Colitis, for instance, means inflammation of the colon. IBS on the other hand, does not cause inflammation and should never be confused with the more serious disorder colitis.

Though IBS can cause a great deal of discomfort, it is not serious and does not lead to any serious disease. With attention to proper diet, sometimes stress management and sometimes medication, most people with IBS can keep their symptoms under control.

What are the symptoms?

It is important to remember that normal bowel function varies widely from person to person. Doctors generally agree that normal bowel function ranges from three stools a day to three each week. A normal movement is one that is formed but not hard, contains no blood and is passed without cramps or pain. People with IBS usually have some combination of constipation and diarrhoea as well as pain, gas and abdominal bloating. Most people with IBS have episodes of lower abdominal pain and constipation, sometimes followed by diarrhoea. People in this group may have loose bowel movements after breakfast almost every day. These may be followed by episodes of diarrhoea after other meals, following stressful events or for no apparent reason. Although IBS is usually a mild annoyance, for some people it can be disabling. Patients in the latter group may be afraid to go to dinner parties, seek employment or travel on public transportation.

What causes IBS?

Because doctors have been unable to pinpoint its organic cause, IBS has often been considered to be caused by emotional conflict or stress. While stress may certainly be a factor, recent studies indicate that other factors may be involved. Most IBS symptoms are related to an abnormal motility (movement) pattern of the colon. The colon connects the small intestine with the anus (bottom). Approximately 5 feet long, the colon’s major function is absorbing water and salts from digestive contents that enter from the small intestine. Two litres of liquid matter enters the colon from the small intestine each day. This material remains there for one to two days until most of the fluid and salts are absorbed back into the body. The stool then passes through the colon by a delicate pattern of movements to the rectum where it is stored until a bowel movement occurs. Movements of the colon are controlled by nerves and hormones and by electrical activity in the colon muscle. The electrical activity serve as a ‘pacemaker’ similar to the mechanism that controls heart function. Movements of the colon propel the contents slowly back and forth, but mainly toward the rectum. Segments of the colon also contract periodically to promote the absorption of water from the faeces. In people who have IBS, the muscle of the lower portion of the colon contracts abnormally. An abnormal contraction or spasm may be related to episodes of crampy pain. Sometimes the spasm delays the passage of stool, leading to constipation. At other times, the spasm leads to more rapid passage of faeces and the result is diarrhoea.

How is IBS diagnosed?

IBS is a diagnosis that doctors reach after more serious organic diseases have been excluded. This process is necessary because IBS offers doctors no signposts to help identify the disorder. A complete medical history that includes a careful description of symptoms, a physical examination and specific laboratory tests will be done. Also, Dr White will most likely order some diagnostic tests such as a colonoscopy to eliminate organic causes of your symptoms. Unless your symptoms change, you usually do not need to undergo these tests again.

How does diet and stress affect IBS?

The potential for abnormal function of the colon is always present in people with IBS, but something must trigger it to cause symptoms. The factors that seem to be the most likely culprits are diet and emotional stress. Many people note that their symptoms occur following a meal or when they are under stress. Why this happens no one is sure, but scientists have some clues. Eating causes contractions of the colon. Normally this response may cause an urge to have a bowel movement within 30 to 60 minutes after a meal. In people with IBS, the exaggerated reflex can lead to cramps and sometimes diarrhoea.

The strength of the response is directly related to the number of calories in a meal and especially the amount of fat in a meal. Fat in any form is the strongest stimulus of colonic contractions after a meal. Fat is primarily found in meats, especially bacon and sausages, poultry skin, dairy products including milk, cream, cheese and butter, vegetable oils, margarine spreads, shortenings and whipped toppings.

Stress also stimulates colonic spasms in people with IBS. This process is not clearly understood, but scientists point out that the colon is partially controlled by the nervous system. Counselling is sometimes helpful for alleviating the symptoms due to IBS. However, doctors are quick to note that this does not mean IBS is the result of a personality problem. IBS is at least partially a disorder of colon motility.

How does a proper diet help IBS?

For many people, eating the proper diet helps lessen IBS symptoms. Before considering a change in diet, you should note whether any particular foods seem to cause distress and then discuss them with your doctor. If dairy products cause your symptoms to flare up, try decreasing the amount consumed at any one time. Yoghurt can also be a satisfactory substitute. Dietary fibre, present in wholegrain breads and cereals and in fruits and vegetables, has also been shown to be helpful in lessening IBS symptoms. Your doctor should be consulted prior to using an over-thecounter supplement such as Metamucil. High fibre diets keep the colon mildly distended, which helps to prevent spasms from developing. Some forms of fibre also keep water in the stools, thereby preventing hard, difficult to pass stools from forming. Doctors usually recommend that you eat just enough high fibre so that soft, easily passed, painless bowel movements are produced. Diets too may cause gas and bloating, however, over time these symptoms may dissipate as the digestive tract becomes used to increased fibre intake.

Large meals may also cause cramping and diarrhoea in some people suffering from IBS. Therefore, eating smaller meals more frequently, or eating smaller portions of food at mealtimes, especially if the foods are low in fat and rich in carbohydrates and protein may also alleviate symptoms. Foods high in carbohydrates and low in fat include pastas, rice, breads, cereals and fruits and vegetables. Foods high in protein and low in fat include chicken and turkey without the skin, lean meats, most fish and low fat dairy products such as skim milk and low fat cheeses.

Can drugs relieve IBS?

No consensus exists amongst doctors about the drugs to be used in treating IBS. Some doctors prescribe a combination of antispasmodic drugs and tranquilisers and these may relieve symptoms. Other physicians feel that first they should reassure patients and discuss means of controlling stress-inducing factors in their life situations. The variable nature of the disorder makes it difficult to conduct a well-designed clinical trial, which would help to establish the best form of treatment for IBS. The major concerns in drug therapy of IBS are dependency and the effects the disorder can have on lifestyle. In an effort to regulate colonic activity or minimise stress, some patients become dependent on laxatives. If this becomes the case, we generally try to withdraw these drugs slowly and use natural fibre instead. It is probably best to start with a fibre supplement like Metamucil or Benefibre and go from there. Some patients benefit from the bowel calming effect of Doxepin or Dothiepin. Treatment is always prescribed on an individual basis by Dr White.

Is IBS linked to more serious problems?

IBS has not been shown to lead to any serious organic diseases. There is NO link between IBS and Inflammatory Bowel Diseases such as Crohn’s disease or Ulcerative Colitis. IBS does NOT lead to cancer.

Lactose Intolerance

Are you unsure what lactose intolerance is and how it’s treated? Here’s a closer look at this often misunderstood condition.

Dairy foods constitute a key element of a healthy diet, however, in some cases they can create uncomfortable symptoms and lactose intolerance may be the culprit. People with lactose intolerance may have difficulty digesting the sugar in dairy products called lactose. When they eat too much lactose, it passes through the digestive system without being digested and absorbed, often causing gas, bloating, cramps and/or diarrhoea. There is an enzyme in the body called lactase that breaks down lactose so it can be absorbed. People become lactose intolerant when their bodies don’t make enough lactase. This can happen naturally as people get older and is often an inherited trait. It is also seen in infants with colic.

Temporary lactose intolerance can be caused by conditions that damage the gut, such as chronic diarrhoea. Once the gut has healed, people can then resume eating lactose. The exact number of people with lactose intolerance in Australia is unknown, but certain cultures are more affected by it, including Aborigines, Maoris, South East Asians and some people of Mediterranean decent.

Suspicious Signs

If you suspect you might be lactose intolerant, take the time to see your GP. You can rest assured that they will be well acquainted with this condition. GP’s are well versed in the diagnosis and treatment of lactose intolerance. Importantly, they can also determine whether another more serious condition is causing your symptoms. So your first port of call should be your family doctor.

Never self-diagnose. If you are lactose intolerant but leave it untreated, further complications can occur. On the other hand, if you treat yourself by cutting out all dairy products without seeking proper dietary advice, you may be missing out on calcium and other valuable nutrients.

The Sensible Approach

If lactose intolerance is confirmed, there are some simple steps you can take to treat it while at the same time meeting your need for calcium and other nutrients. We suggest you:

• Avoid high lactose foods and beverages such as dairy products and milk powders.

• Use lactose-free milk substitutes such as soy or rice milk.

• Use lactose-reduced products such as lactaid milk.

• Consider using tablets or drops that add lactase to food and drinks before you eat or drink it. These are available from your local pharmacy.

Some lactose intolerant people may need specialist help to modify their diet. A dietician can provide a list of low lactose foods, explain which foods to avoid and at the same time ensure you are maintaining a well-balanced diet.

Liver Biopsy

Liver biopsy allows a small sample of liver tissue to be obtained which can be processed and examined under a microscope. It is frequently the only means of precisely diagnosing a variety of liver conditions. Your doctor will usually recommend a liver biopsy only after a variety of other tests have failed to make a precise diagnosis. Liver biopsy may also be necessary to assess the progress of certain liver disorders.

How are you prepared?

It is essential that your blood clotting ability has been tested before the biopsy is carried out. You should not take blood thinning tablets such as Warfarin and Aspirin or arthritis tablets one week prior to your procedure.

What happens during a Liver Biopsy?

You will be given an anaesthetic sedation through a vein to make you relaxed and sleepy. The biopsy itself involves preparing the skin over the right lower ribs with an antiseptic solution. A local anaesthetic is then injected into the area. The skin should be numb in a few minutes. Subsequently, the liver biopsy needle is passed quickly in and out of the liver. It is essential that you follow the instructions of the doctor performing the biopsy regarding holding your breath for a second or two during the actual procedure.

Safety and Risks

Complications of liver biopsy can include bleeding or leakage of bile into the abdominal cavity from the puncture site. Usually such bleeding will stop without intervention; however, occasionally blood transfusion may be required. In extremely rare cases of severe bleeding, an operation may be necessary to stop the bleeding. Other complications include damage to other organs such as the right lung, gall bladder or bowel. Another rare complication of liver biopsy is stimulation of the vagal nerve which can result in fainting. Reactions to the sedation are also a possibility. Death is a remote possibility, as with any interventional procedure. If you wish to have further details of any of these complications, you should contact your doctor before the procedure to allow all possible complications to be discussed in detail.

After the liver biopsy

If you do not stay in hospital overnight following your procedure, you should not stay alone. In the case of severe pain, abdominal distention, faintness or shortness of breath, you should not hesitate in contacting either your doctor or the hospital for further advice.

Appointment Preparation

Two to three hours prior to your procedure you must eat a small fatty breakfast - e.g. bacon, sausages and eggs and avocado and/or cheese.

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

Melanosis Coli

Some foods act as laxatives, hurrying food and faeces through the bowel. These include prunes and prune juice, molasses, liquorice, chocolate, citrus, black coffee, alcohol and spices. You will know what works for you. However, many people rely not on food but on common commercial laxatives. An enormous amount of money is spent each year on laxatives in the western world. Much of this laxative use is not necessary and long term use must be on the advice of your doctor. Laxatives may be given orally in tablet or liquid form, or rectally by suppository or microenema. Laxatives are classified into different groups depending on how they work. These include:

• Simple bulking agents – e.g. Psyllium and Normacol.

• Faecal softeners – e.g. Coloxyl.

• Osmotic agents – e.g. Epsom salts.

• Stimulants which act on the nerves and muscles of the bowel wall - these are often found in herbal or natural laxatives such as Frangula.

• Parrafin and Castor Oil.

• There may be a combination of these substances in oral and rectal laxatives. Simple small doses of bulking agents are usually safe as these make stools ‘teflon-coated’ and easier to pass.

Much has been said about natural products. Senna and Cascara are commonly used preparations found in herbal laxatives. Both are refined from plants and act as stimulants. Over a long period of continued use, they deposit a brown discolouration on the normal, healthy bowel lining. In time, the bowel muscle relies on this stimulation to continue to squeeze the contents along. This is called Melanosis Coli. The fact that a product is natural doesn’t necessarily mean it is harmless and without side effects, so you should consider carefully before taking herbal laxatives, particularly long term. Always check with your doctor and be sure that you read and understand the label before taking any medication.

Many people may require long-term combinations of laxatives to treat their symptoms of slow transit constipation or obstructed defecation. This must be strictly under medical supervision. Suppositories are used to help poorly contracting rectums to empty properly. To be effective, the suppository must be inserted into the rectum, that is, past the anus. It must be placed next to the rectal wall, not in the faecal contents.

Microscopic Colitis

Microscopic Colitis is a collective term used to describe a group of conditions characterised by a normal endoscopic appearance of the colon, but colitis on biopsy. Subgroups of this condition include the more common Lymphocytic Colitis and Collagenous Colitis and the less common drug-induced Colonopathies and Microscopic Colitis associated with infection.

The term Inflammatory Bowel Disease is usually reserved for patients with either Ulcerative Colitis or Crohn’s Disease. Microscopic Colitis is not just less severe Inflammatory Bowel Disease, but it has distinctive histological features and a different clinical presentation. Patients describe waxing and waning watery diarrhoea often for several years prior to diagnosis. Rectal bleeding and abdominal pain are not usually features of this disease and complications associated with Inflammatory Bowel Disease (such as stricture, perforation, carcinoma or extraintestinal manifestations) are not observed. It is, therefore, preferable not to refer to such patients as having Inflammatory Bowel Disease.

What treatments are available?

The fact that patients with Microscopic Colitis have a variety of treatments and that success is not great reflects the lack of controlled trials of treatments for the condition. Most treatments have been extrapolated from those used in patients with Inflammatory Bowel Disease or Irritable Bowel Syndrome. Since Microscopic Colitis appears to be a benign condition and since no therapy is curative, every effort should be made to ensure that the treatment is not long term, or at least be in recurrent courses.

There are four lines of attack:

• Treatment of other causes of the symptoms

• Dietary modifications

• Symptomatic therapy

• Treating mucosal inflammation

Identifying and treating factors other than the colitis itself that might be contributing to the symptomatology is one approach to the treatment of Microscopic Colitis. Since Coeliac Disease occurs in up to 25% of patients with Microscopic Colitis, small bowel biopsy should be seriously considered in patients with troublesome symptoms, particularly if colonic biopsies have shown Collagenous Colitis.

A weak association with the thyroid disease has been noted, so thyroid function tests should be performed. An increasing number of drugs have been associated with this condition, but the most common drugs implicated are non-steroidal anti-inflammatory agents. If the use of one of these drugs is temporarily associated with the development of the diarrhoea, they should be discontinued.

Oesophageal Candidiasis

Candida Oesophagitis is the most common type of non-peptic inflammation of the gullet. Oesophageal candidiasis is a thrush infection of the gullet or oesophagus and is associated with numerous medical conditions or use of medications. The most common symptom it causes is difficulty swallowing or pain on swallowing and sometimes pain behind the breastbone. It is important to diagnose and treat because of the other associations. The best way to diagnose the condition is by endoscopy with biopsies.

The infection usually occurs in patients receiving either a course of antibiotics or whose immune system is suppressed by therapy for other medical conditions such as steroids. Asthmatic patients who use inhaled steroids are also at risk for this infection as are patients with HIV infection. Diabetics are also at risk and those who have obstruction to the gullet or other forms of malignancy. Patients with malnutrition are also at risk. The gullet infection may be accompanied by infection of the mouth.

At endoscopy, white plaques on a red background are seen which can progress to ulceration and more invasive diseases. Diagnosis is confirmed by a biopsy with those specimens being sent to the laboratory for confirmation.

Therapy is aimed at treating the yeast infection as well as excluding other conditions that may be associated with it. The usual treatment is Nysyatin as a first line. Amphotericin lozenges may also be prescribed. For severe and invasive cases other anti-fungal therapy such as Ketoconzole or Fluconazole may be prescribed. Patients taking antacid therapy should receive Fluconazole as it does not require acid in the stomach for absorption.

Your doctor may suggest a blood test looking for diabetes or HIV infection if that is clinically appropriate and may even investigate your immune system further if recurrent problems with this infection become evident.

Pelvic Floor Exercises

The floor of the pelvis is made up of layers of muscles and other tissues. These layers stretch like a hammock from the tailbone at the back to the pubic bone in front. A woman’s pelvic floor supports the bladder, the womb (uterus) and the bowel. The urethra (front passage), the vagina (birth canal) and the rectum (back passage) pass through the pelvic floor muscles. The pelvic muscles play an important role in bladder and bowel control and sexual sensation.

Reasons why the pelvic floor muscles may weaken include:

• Pregnancy and childbirth in women

• Continual straining to empty your bowels (constipation)

• Persistent heavy lifting

• A chronic cough (such as smokers cough, chronic bronchitis and asthma)

• Being overweight

• Changes in hormone levels at menopause

• Lack of general fitness

It is important for women of all ages to maintain pelvic floor strength. Women with stress incontinence, that is, those who regularly lose urine when coughing, sneezing or exercising should benefit from these exercises. For pregnant women these exercises help the body to cope with the increasing weight of the baby. Healthy, fit muscles prenatally will recover more readily after the birth.

As women grow older it is important to keep the pelvic floor muscles strong because during and after menopause the muscles change and may weaken. A pelvic floor exercise routine helps to minimise the effects of menopause on pelvic support and bladder control. Pelvic floor exercise may also be useful in conjunction with a bladder training program aimed at improving bladder control in people who experience the urgent need to pass urine frequently (urge incontinence).

How to contract the pelvic floor muscles

The first thing to do is correctly identify the muscles that need to be exercised.

• Sit or lay down comfortably with the muscles of your thighs, buttocks and abdomen relaxed

• Tighten the ring of muscle around the back passage as if you are trying to control diarrhoea or wind. Relax it. Practice this movement several times until you are sure you are exercising the correct muscle. Try not to squeeze your buttocks.

• When you are passing urine, try to stop the flow mid-stream then restart it. Only do this to learn which muscles are the correct ones to use and then do it no more than once a week to check your progress as this may interfere with normal bladder emptying.

If you are unable to feel a definite squeeze and lift action of your pelvic floor muscles or are unable to even slow the stream of urine as described above, you should seek professional help to get your pelvic floor muscles working correctly. Even women with very weak pelvic floor muscles can be taught these exercises by a physiotherapist or continence advisor with experience in this area.

Good results take time. In order to build up your pelvic floor muscles to their maximum strength, you will need to work hard at these exercises. The best results are achieved by seeking help from a physiotherapist or continence advisor who will design an individual exercise program especially suited to your muscles.

There are many health professionals qualified to assist you with bladder control problems. You may seek assistance from your doctor who may offer treatment directly or refer you to a specialist or to a qualified continence advisor. You may also seek help and obtain information directly from the following sources:

• Continence Foundation of Australia helpline 1800 330 066

• Continence services and clinics

• Continence nurse advisors

• Local community health centres

• Local doctors

• Domiciliary nursing services

• Independent living centres

• Australian Physiotherapy Association

All text (only) herein is the intellectual property of Dr Melissa White. Update July 2014.

Proctitis

Proctitis is defined as an inflammation of the anus and the lining of the rectum, affecting only the last six inches of the rectum. Symptoms include:

• Ineffectual straining to empty the bowels

• Diarrhoea

• Rectal bleeding

• Involuntary spasms

• Cramping during bowel movements

• Left side abdominal pain

• Passage of mucus through the rectum

• Anorectal pain

A common symptom is a continual urge to have a bowel movement. The rectum could feel full or have constipation. Another is tenderness and mild irritation in the rectum and anal region. A serious symptom is pus and blood in the stool accompanied by cramps and pain during bowel movements. If there is severe bleeding, anaemia can also be caused showing symptoms such as pale skin, irritability, weakness, dizziness, brittle nails and shortness of breath.

Proctitis is commonly caused by auto-immune diseases of the colon (such as Crohn’s disease and Ulcerative Colitis), harmful physical agents, chemicals, foreign objects placed in the rectum, trauma to the anorectal area and sexually transmitted infections. It may also occur independently (Idiopathic Proctitis). More rare causes include damage by irradiation (e.g. cervical and prostate cancer radiation therapy) or a sexually transmitted infection such as lympogranuloma venereum and herpes Proctitis. Proctitis is also linked to stress.

Sexually transmitted Proctitis

Gonorrhoea (Gonococcal Proctitis)

The most common cause is strongly associated with anal intercourse. Symptoms include soreness, itching, bloody or pus-like discharge or diarrhoea. Other rectal problems that may be present are anal warts, anal tears, fistulas and haemorrhoids.

Chlamydia (Chlamydia Proctitis)

This accounts for approximately 20% of cases. People may show no symptoms, mild symptoms or severe symptoms. Mild symptoms include rectal pain with bowel movements, anal discharge and cramping. With severe cases people may have discharge containing blood or pus, severe rectal pain and diarrhoea. Some people suffer from rectal strictures; a narrowing of the rectal passageway. The narrowing of the passageway may cause constipation, straining and thin stools.

Herpes Simplex Virus 1 and 2 (Herpes Proctitis)

Symptoms may include multiple vesicles that rupture to form ulcers, tenesmus, rectal pain, discharge and haemotochezia. The disease may run its natural course of exacerbations and remissions but is usually more prolonged and severe in patients with immunodeficiency disorders. Presentations may resemble dermatitis or decubitus ulcers in debilitated, bedridden patients. A secondary bacterial infection may be present.

Syphilis (Syphilis Proctitis)

The symptoms are similar to other causes of infectious Proctitis including rectal pain, discharge and spasms during bowel movements. Some people have no symptoms. Syphilis occurs in three stages. The primary stage; one painless sore less than an inch across with raised borders found at the site of sexual contact, and during acute stages of infection the lymph nodes in the groin become diseased, firm and rubbery. In the secondary stage, wart-like growths resembling cauliflower are produced around the anus and rectum. The third stage occurs late in the course of syphilis and affects mostly the heart and nervous system.

Treatment

By looking inside the rectum with a proctoscope or a sigmoidoscope, Dr White can diagnose Proctitis. A biopsy is taken, in which Dr White scrapes a tiny piece of tissue from the rectum and is then sent for testing. The physician may also take a stool sample to test for infections or bacteria. If the physician suspects that the patient suffers from Crohn’s disease or Ulcerative Colitis, a colonoscopy or barium enema x-rays are used to examine the rest of the colon.

Treatment for Proctitis varies depending on severity and the cause. For example, Dr White may prescribe antibiotics for Proctitis caused by bacterial infection. If the Proctitis is caused by Crohn’s disease or Ulcerative Colitis, Dr White may prescribe different drugs in enema or suppository form or taken orally in pill form. Enema and suppository applications are usually more effective, but some patients may require a combination of oral and rectal applications.

The Low FODMAP Approach to Diet

F - Fermentable
O - Oligosaccharides > Fructans Galactans
D - Disaccharides > Lactose
M - Monosaccharides > Fructose
A - and
P - Polyols

Patients who may benefit from following a Low FODMAP Diet are:

• People that have abnormal GIT fructose/fructans/galactans handling and absorption. 

• 30 % of Irritable Bowel Syndrome patients may benefit. 

• 40 % of recovered Coeliac Disease patients may benefit.

There is no accurate test for this at this stage on the Sunshine Coast. There is a fructose breath test only. There is no breath test for fructans, galactans or polyols.

What can patients do?

Try a Low FODMAP Approach to Diet. The aim is to decrease dietary small chain fermentable carbohydrates and to decrease fermentation and bloating.

Initially, it is best to AVOID these foods for two months to see if you respond. All patients should at least avoid fructose and galactans. In the long term you may be able to just limit these foods. Some patients benefit from a clinical review and dietary discussion with Dr White for specific advice.

This is NOT a gluten free diet. Gluten is NOT the issue.

Summary of FODMAP Food Sources

• FRUCTOSE

  AVOID these foods containing excess FRUCTOSE. Limit concentrated fruit sources, such as large serves of fruit at one sitting (Dried Fruit, Wine, Fruit Juice):

  Apple

  Pear

  Mango

  Watermelon

  Clingstone Peaches

  Sugar snap peas

  Broad beans

  Nashi Pears

  Dried Fruits

  Tinned fruit – in natural juice

  Honey

  High fructose corn syrup

  Wine (sweet, rose, cider)

  Rum

  Cider vinegar/Molasses

  BBQ Sauce/Ketchup/Chutneys

  LIMIT these foods to the amount stated in the brackets ( ):

  Asparagus (1)

  Artichoke (1/4 cup)

  Cherries (2)

  Boysenberries (4)

  Figs (2)

• FRUCTANS

  FRUITS

  AVOID these:

  Watermelon

  Peaches (white)

  Nectarines

  Dates

  Persimmon

  Tamarillo

  LIMIT these to the amounts shown in brackets ( ):

  Grapefruit (½)

  Pomegranate (½)

  Rambutan (2)

  Figs (2)

  VEGETABLES

  AVOID these:

  Onion family (white and brown)

  Spring onion (white part)

  Leeks

  Spanish shallots

  Garlic

  Onion and garlic salt/powders

  Squash

  LIMIT these to the amounts shown in brackets ( ):

  Broccoli (up to 1/4 cup)

  Cabbage (up to ½ cup)

  Beetroot (up to 4 slices)

  Artichoke (up to ¼ cup)

  Fennel (up to ½ cup)

  Green beans (up to 6)

  Asparagus (up to 2)

  Snow peas (up to 6)

  Sweet corn (up to ½ cob)

  Brussel sprouts (up to ½ cup

  BREADS / CEREALS

  AVOID these:

  Wheat (in large amounts), eg: bread, pastas

  Couscous

  Rye bread (in large amounts )

  Muesli/Fruit bars

  LIMIT

  Crackers (up to 3) and Biscuits (up to 3)

  Barley

  Chia seeds

  Wheat bran

• GALACTANS

  LEGUMES

  AVOID these:

  Chick Peas / hummus

  Baked beans

  Savoy cabbage

  Soy beans/soy milk

  Split peas

  Haricot beans

  Okra

  Kidney beans

  Lima/Berlotti beans

  Custard Apples

  LIMIT these to the amounts shown in brackets ( ):

  Lentils (up to ¼ cup)

  Peas (up to ¼ cup)

  Green Beans (up to 6)

  OTHER

  AVOID these:

  Inulin (a fibre in some dairy products including probiotics)

  Cashews

  Pistachios

  Tahini and Tzatziki

  Dandelion tea

  Ecco, Caro

  Chicory

  Soy Milk

  Whey powder

  LIMIT

  Almonds to < 10

• LACTOSE

  Avoid/Limit foods containing lactose ONLY if you are lactose intolerant. You can be tested for this by having an endoscopy with biopsies or a breath test.

  AVOID these:

  Cow’s milk – regular and low fat

  Goats Milk / Sheep’s Milk

  Ice Cream – regular and low fat

  Butter Milk

  Yoghurt – regular and low fat

  Mascarpone/Ricotta

  Custard Haloumi

  Cream – including sour cream

  A2 Milk

  Condensed Milk

  Processed cheese

  Most people can tolerate 1/3 cup milk per day for coffee/tea/cooking.

  LIMIT

  Cottage Cheese (< 4 tablespoons)

• POLYOLS

  SORBITOL

  AVOID these:

  Apples

  Pears

  Apricots

  Broccoli

  Nectarines

  Clingstone Peaches

  Peaches/Plums

  Prunes

  Blackberries

  Pomegranate

  LIMIT these to the amounts shown in brackets ( ):

  Avocado (½)

  Cherries (up to 2)

  Lychees (up to 4)

  MANNITOL

  AVOID these:

  Mushrooms

  Cauliflower

  Watermelon

  Coconut Cream

  Isomalt/Xylitol

  Guava

  Any diet products (eg: mayonnaise, sauces)

  LIMIT these to the amounts shown in brackets ( ):

  Snow peas (4)

  Celery (½ stalk)

  Sweet Potato (½ cup)

  Coconut Milk (½ cup)

Ulcerative Colitis

Inflammatory Bowel Disease (IBD) is a medical term that describes a group of conditions in which the intestines become inflamed (red and swollen). Two major types of IBD are Crohn’s disease and Ulcerative Colitis.

Ulcerative Colitis affects the large intestine (colon) whereas Crohn’s disease can occur in any part of the intestines. No one knows for certain yet what causes IBD but it is believed to be a combination of genetic, environmental and immunological factors. Exposure to environmental triggers – possibly but not necessarily viruses, bacteria and/or proteins or a combination of such triggers prompts the immune system to switch on its normal defence mechanism (inflammation) against a foreign substance. In most people, this immune response gradually winds down once the foreign substance is destroyed. In some people (possibly those with a genetic susceptibility to IBD), the immune system fails to react to the usual ‘switch off’ signals so the inflammation continues unchecked. Prolonged inflammation eventually damages the walls of the gastrointestinal tract and causes the symptoms of IBD.

The ways in which IBD affects a person with the condition is highly variable. It depends on where the disease is located in the gastrointestinal tract and how severe the inflammation is within the affected area. Symptoms of IBD may range from mild to severe but tend to include the following:

• Abdominal cramps and pains

• Frequent, watery diarrhoea (may be bloody)

• Severe urgency to have a bowel movement

• Fever during active stages of disease

• Loss of appetite and weight loss

• Tiredness and fatigue

• Anaemia (due to blood loss)

A small percentage of people with IBD may also experience problems outside the gastrointestinal tract including joint pain, skin conditions, eye inflammation, liver disorders and thinning of the bones (osteoporosis). Although IBD is a chronic (ongoing) condition, symptoms may come and go depending on the presence and degree of inflammation in the gastrointestinal tract. When inflammation is severe, the disease is considered to be in an active stage. When inflammation is less (or absent), symptoms may disappear altogether and the disease is considered to be in remission. For most people with IBD, the usual course of disease involves periods of remission interspersed with occasional flare-ups.

IBD cannot be cured as yet but it can be managed effectively, especially with the use of medications to control the abnormal inflammatory response. Controlling inflammation allows the intestinal tissues to heal and relieves the symptoms of abdominal pain and diarrhoea. Types of medications most commonly used to manage IBD include aminosalicylates, corticosteroids, immunomodulators, biological agents and antibiotics.

In ulcerative colitis, inflammation occurs on the lining (mucosa) of the large intestine or colon. The inflammation is usually located in the rectum and lower colon but may involve other parts of the colon and sometimes even the entire colon. Tiny open sores or ulcers form on the surface of the lining and these may bleed. The inflamed lining also produces a larger than normal amount of intestinal lubricant or mucus which sometimes contain pus. Inflammation in the colon reduces its ability to reabsorb fluid from the faeces which causes diarrhoea. Inflammation in the rectum can lead to a sense of urgency to a bowel movement.

Long term management with small doses of medication are the aim of treatment to achieve remission. It is believed that this reduces your risk of bowel cancer. Long term care by Dr White or your gastroenterologist is essential. Eventually, reviews are yearly.

What you CAN eat on a Low FODMAP Diet

Here is a list of foods YOU CAN EAT:

FRUITS:

Banana

Strawberry

Grapes

Orange/Mandarin

Pineapple

Kiwi Fruit

Passionfruit

Paw Paw

Lime/Lemon

Cranberries/Blueberries/Raspberries/Loganberries

Rhubarb

Star anise

Tangelo

Dragon fruit

And you are allowed a small amount of these (up to)

Grapefruit (½)

Cherries (3)

Lychees (4)

Rambutan (3)

Boysenberry (4)

Dried banana chips (10)

VEGETABLES

Potato

Pumpkin (Jap)

Tomato

Zucchini

Carrot

Cucumber

Capsicum

Iceberg lettuce

Cabbage/Spinach

Eggplant/Parsnip

Olives

Spring onions – green part

Choko/Kale

Radicchio/Radish

Choy sum/Bok Choy

Alfalfa/Silver beet/pickles

Bamboo shoots Bean shoots/sprouts

Endive

Squash

Witlof

Okra

Water chestnuts

Taro

Turnip

And you are allowed a small amount of these (up to)

Broccoli (½ cup)

Sweet Potato (½ cup)

Butternut Pumpkin (1/4 cup)

Avocado (1/3)

Celery (½ stick)

Green beans (6)

Artichoke (1/4)

Beetroot (4 slices)

Peas (½ cup)

Snow peas (10)

Fennel (½ cup)

Corn (½ cob)

GRAINS/SEEDS/NUTS

Oats

Psyllium

100% Spelt bread/Sourdough

Gluten Free bread/pasta/flour

Buckwheat

Rice - noodles/puffed/cakes

Cornflour/Corn flakes/Corn biscuits

Muesli – wheat free, fruit free

Quinoa/Polenta

Tapioca

Millet/Sorghum

Arrowroot flour

Nuts (< 1 handful) – peanut/pecan/hazelnut/macadamia/walnut

Seeds – sesame/sunflower

DAIRY

Hard cheese

Camembert/Brie/Feta

Lactose free milk

Yoghurt low fat/Ice-cream low fat

Almond milk

Rice milk

Soy milk (only if made from soy protein NOT whole soy beans)

Oat milk

OTHER FOODS

Normal table sugar

Meat/Chicken/Fish

Eggs

Olive oil (including garlic infused)

Herbs – Basil/Dill/Coriander/Chilli/Ginger/Lemongrass/Chives/Cumin/ Cinnamon/Mint/Marjoram/Oregano/Parsley/Rosemary/Thyme

Vinegar/Balsamic

Tofu/Tempeh

Soy sauce/Hoisin Sauce/Oyster Sauce

Vegemite/Peanut Butter

Pickles/Mustard

Golden syrup/Treacle

Turmeric/Wasabi/Seaweed

Dry coconut (1/4 cup)

Asafoetida powder (onion-like powder)

Pretzels (½ cup)

Potato crisps

Quorn mince