Many people have heartburn after eating a large meal, and will be familiar with the unpleasant burning feeling in their chest, just behind their breastbone. Occasional acid reflux is normal too. Up to 20 out of 100 people living in Western countries regularly have problems like heartburn or acid reflux. Although both of these can be unpleasant, they do not usually lead to other health problems. If the stomach is stretched a lot – for instance after a large meal – the sphincter at the entrance to the stomach might temporarily loosen. Gas or stomach contents might leak up into the food pipe as a result. The sphincter may also sometimes open for no apparent reason. The digestive fluid in the stomach contents irritates the lining of the food pipe, and that is felt as heartburn. If stomach juices stay on the lining of the food pipe for some time, the food pipe might become inflamed and painful.
Heartburn is felt as a burning pain that spreads from the upper stomach, up into the throat. As well as acid reflux and heartburn, gastroesophageal reflux disease (GERD) can also be associated with problems in swallowing. Other possible symptoms include a burning sensation in your throat, a bad taste in your mouth, and stomach noises. People who have GERD often feel very full. They sometimes also feel nauseous and feel they need to vomit.
GERD can also cause symptoms that may not be obviously associated with the disease. For example, the stomach juices that leak out can get into the windpipe and induce cough, or attack the teeth. Other non-typical symptoms include a chronic cough, chest pain, asthma, laryngitis and tooth erosion.
Causes and risk factors
In GERD, the sphincter muscle between the food pipe and stomach does not close properly. It is often not clear why. Many people with GERD find that stress triggers their symptoms, or makes them worse. Certain postures, such as leaning forward or lying down, or eating particular types of food may also make the problem worse.
GERD occurs when there is an imbalance between the normal defense mechanisms of the esophagus and offensive factors such as acid and other digestive juices and enzymes in the stomach. Often, the barrier between the stomach and the esophagus is impaired by weakening of the muscle (lower esophageal sphincter) or the presence of a hiatus hernia, where part of the stomach is displaced into the chest. Hiatus hernias, however, are common and not all people with a hiatus hernia have reflux. A major cause of reflux is obesity whereby increased pressure in the abdomen overcomes the barrier between the stomach and the esophagus. Obesity, pregnancy, smoking, excess alcohol use and consumption of a variety of foods such as coffee, citrus drinks, tomato-based products, chocolate, peppermint and fatty foods may also contribute to reflux symptoms.
GERD is usually a chronic condition and is typically characterized by recurrent attacks. The food pipe does not always become inflamed. In up to two out of three people with reflux symptoms, the membranes lining the food pipe are not affected.
GERD can usually be diagnosed based on typical symptoms. When a patient experiences common symptoms of gastroesophageal reflux disease, namely heartburn and/or acid regurgitation, additional tests prior to starting treatment are typically unnecessary. If symptoms do not respond to treatment, or if other symptoms such as weight loss, trouble swallowing or internal bleeding are present, additional testing may be necessary. Upper endoscopy is a test in which a small tube with a light at the end is used to examine the esophagus, stomach and duodenum.
People with severe heartburn or GERD can often relieve their symptoms by changing some of their lifestyle habits. For instance, they might try to avoid certain types of food, or drink less alcohol. This is not always easy to do, but it can be worth the effort.
Reflux symptoms sometimes disappear if dietary or lifestyle excesses that cause the symptoms are reduced or eliminated. Should symptoms persist, over-the-counter antacids may decrease discomfort. Antacids, however, only work for a short time and for this reason, they have a limited role in treating reflux disease. Histamine H2 receptor antagonists (such as cimetidine, ranitidine, nizatidine, and famotidine) decrease acid production in the stomach. Proton pump inhibitors (such as omeprazole, lansoprazole, DE lansoprazole, pantoprazole, esomeprazole, and rabeprazole) are all highly effective in treating reflux symptoms. These medications act by blocking the final step of acid production in the stomach and are typically taken once or twice daily prior to meals. For reflux symptoms that occur frequently, proton pump inhibitors are the most effective medical treatment.
Surgery should be considered in patients with well-documented reflux disease who cannot tolerate medications or continue to have regurgitation as a primary symptom.
Rectal bleeding is a very common symptom in adults of all ages. In most people, it is intermittent and often self-limiting. The majority of patients with rectal bleeding will have benign anal conditions such as haemorrhoids or an anal fissure, but rectal bleeding may also be a symptom of inflammatory bowel disease or colorectal cancer.
Other potential causes of rectal bleeding include, but are not limited to:
• diverticular disease
• colonic polyps
• radiation proctitis
• infectious gastroenteritis
• ischaemic colitis
• solitary rectal ulcer
• anal cancer
• sexually transmitted diseases
• anorectal trauma
Hemorrhoids are swollen blood vessels in the anus and rectum that become engorged from increased pressure, similar to that which occurs in varicose veins in the legs. Hemorrhoids can either be internal (inside the anus) or external (under the skin around the anus). Hemorrhoids are the most common cause of minor rectal bleeding, and are typically not associated with pain. Bleeding from hemorrhoids is usually associated with bowel movements.
Primary care management
In low risk patients with rectal bleeding who are not overly anxious, it is reasonable to manage symptoms with treatment and adopt a ‘watch and wait’ policy. Minimally symptomatic haemorrhoids may be safely observed. Patients with symptomatic haemorrhoids should be given advice about topical treatment, oral fluid intake, high fiber diet and fiber supplementation.
An acute anal fissure is a tear in the skin of the anal canal, and may be treated with dietary advice and a bulking agent. Topical glyceryl trinitrate (GTN) 0.4% ointment should be considered for chronic fissures (duration of symptoms >6 weeks or clinical appearances of chronicity) with appropriate advice about application and duration of treatment. Low risk patients with rectal bleeding who are concerned about colorectal malignancy should be considered for direct access flexible sigmoidoscopy.
Any patient with rectal bleeding who meets the following criteria should be referred urgently under the two week wait guidelines as recommended by NICE Referral Guidelines for Suspected Cancer (NICE CG27):
• aged ≥40 years with rectal bleeding and change in bowel habit towards looser and/or more frequent stools for 6 weeks or more
• aged ≥60 years with rectal bleeding persisting for 6 weeks or more without change in bowel habit and without anal symptoms
• rectal bleeding and a palpable rectal mass
Secondary care management
Treatment of bleeding haemorrhoids depends on the degree of prolapse and severity of symptoms. Rubber band ligation is currently the best available outpatient treatment for haemorrhoids with up to 80% of patients satisfied with short term outcomes. About 20% of patients require a second banding procedure within six months for symptom control. Local service providers may offer outpatient injection sclerotherapy with oily phenol or infra-red coagulation (laser) therapy, but neither is as effective as suction banding.
At present surgery is reserved for bleeding or prolapsing haemorrhoids that have not responded to outpatient treatment (ASCRS Practice Parameters for the Management of Hemorrhoids). Doppler-guided haemorrhoidal artery ligation and stapled haemorrhoidopexy are alternatives to formal haemorrhoidectomy. These are associated with lower pain scores but neither procedure has long term outcomes data available yet.
After any treatment for haemorrhoids or fissures, patients should be advised to remain on a high fiber diet with good oral fluid intake to prevent recurrence. Patients with new or recurring symptoms should be reassessed.
Inflammatory bowel disease, or IBD, is an autoimmune, long-term health issue that causes inflammation, or swelling, and ulcerations, or sores, in the gastrointestinal (GI) tract. There are two main types of inflammatory bowel disease: ulcerative colitis and Crohn’s disease.
The GI tract is responsible for digestion of food, absorption of nutrients, and elimination of waste. Inflammation impairs the ability of affected GI organs to function properly, leading to symptoms such as persistent diarrhea, abdominal pain, rectal bleeding, weight loss and fatigue. While ongoing inflammation in the GI tract occurs in both Crohn’s disease and ulcerative colitis, there are important differences between the two diseases.
Crohn’s disease can affect any part of the GI tract, from the mouth to the anus. It most commonly affects the end of the small intestine (the ileum) where it joins the beginning of the colon. Ulcerative colitis is limited to the large intestine (colon) and the rectum. The inflammation occurs only in the innermost layer of the lining of the intestine. It usually begins in the rectum and lower colon, but may also spread continuously to involve the entire colon.
The immune system usually attacks and kills foreign invaders, such as bacteria, viruses, fungi, and other microorganisms. However, in people with IBD, the immune system mounts an inappropriate response to the intestinal tract, resulting in inflammation.
The symptoms of IBD vary from person to person, may change over time, and can range from mild to severe. People with IBD often go through periods when the disease is quiescent with few or no symptoms (remission), alternating with times when the disease is active and causing symptoms (flares).
Symptoms related to inflammation of the GI tract:
• Abdominal pain
• Rectal bleeding
• Urgent need to move bowels
• Sensation of incomplete evacuation
General symptoms that may also be associated with IBD:
• Loss of appetite
• Weight loss
• Night sweats
• Loss of normal menstrual cycle
Treatment with medication is the first therapeutic option. The main goals of medical treatment are to achieve remission (the absence of symptoms), maintain remission (prevent flare-ups of symptoms) and improve quality of life.
There are five main categories of medications used to treat IBD:
• Amino salicylates
• Biologic therapies
Medication may not adequately control symptoms for everyone with IBD, and some people with these conditions develop complications that require surgery.
Peptic Ulcer Disease or PUD, one of the most common ulcers, refers to an ulcer of the gastrointestinal tract in the region of the stomach. It is characterized by high acidity resulting in mucosal erosions causing extreme pain and discomfort. By definition, a mucosal erosion should be equal to or exceed 0.5 cm. It is the end result of an imbalance between the digestive fluids in the stomach and the duodenum. Most ulcers are caused by an infection, not spicy food, acid or stress.
The stomach and the duodenal lining have several mechanisms that prevent ulcers from developing. A coating of mucus protects the stomach lining from the effects of acidic digestive juices. Food and other substances in the stomach neutralize acid. Certain chemicals produced by the stomach protect the cells lining the stomach.
Peptic Ulcers can be broadly classified into Gastric or stomach ulcer and Duodenal Ulcer. Gastric Ulcers occur mainly in the elderly, on the lesser curve.
Duodenal Ulcers are four times as common as gastric ulcers. They are identified by the most common symptom i.e. epigastric pain occurring typically before meals or at night and which is relieved by eating or drinking milk.
Another type of PUD is Idiopathic PUD (IPUD). This is defined as a peptic ulcer without definite causes such as H. pylori infection, NSAIDs use or hypergastrinemia.
For many years, excess acid was believed to be the major cause of ulcer disease. Accordingly treatment emphasis was on neutralizing and inhibiting the secretion of stomach acid. While acid is still considered significant in ulcer formation, the leading cause of ulcer disease, accounting for about 70-90%, is currently believed to be infection of the stomach by a bacterium called “Helicobacter pylori ” (H. pylori). Other risk factors include anticoagulants, NSAIDs, corticosteroids, aspirin, ibuprofen, alcohol, diet (Spicy Food), stress, past history of PUD and gender. Another cause of PUD is the excess acid production from tumors of the acid producing cells of the stomach known as gastrinomas.
NSAIDs cause gastric injury through damage to the gastric epithelium by intracellular accumulation of these drugs in an ionized state.
H. Pylori infection or NSAID use alone may not be sufficient to cause peptic ulcer disease. Other factors like genetic and environment factors also contribute. People with duodenal ulcers are more likely to have family members with duodenal ulcers compared to the general population. Another risk factor for developing an ulcer is the use of tobacco. Alcohol consumption to some extent also causes the same effect.
PUD may or may not have symptoms. When the symptoms occur, they include a burning pain in the middle or upper abdomen between meals or at night, bloating, heart burn, nausea or vomiting. In severe cases, the symptoms include dark or black stools, vomiting of blood, weight loss and severe pain in the mid to upper abdomen.
Peptic ulcers can heal spontaneously and may occur intermittently. But they can also have serious effects. The complications might be life threatening without any warning signs. This is most common in elderly patients on NSAIDs. The most serious complication that might occur includes bleeding and perforation. Bleeding can be both gradual and abrupt. If abrupt bleeding occurs, it causes black, tarry stools and a drop in blood pressure. Only about 2 to 5 percent of people with a peptic ulcer require surgery. Perforation usually causes sudden abdominal pain and usually requires surgery.
Hepatitis A, caused by infection with HAV, has an incubation period of approximately 28 days (range: 15–50 days). HAV replicates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clinical illness. HAV infection produces a self-limited disease that does not result in chronic infection or chronic liver disease (CLD). However, 10%–15% of patients experience a relapse of symptoms during the 6 months following the primary acute illness. Acute liver failure from hepatitis A is rare (overall case-fatality rate: 0.5%).
HAV infection is primarily transmitted by the fecal-oral route, by either person-to-person contact or through consumption of contaminated food or water. Bloodborne transmission of HAV is uncommon.
The diagnosis of hepatitis A cannot be made on clinical grounds alone; serologic testing also is required. The presence of IgM antibody to HAV is diagnostic of acute HAV infection.
Patients with acute hepatitis A usually require only supportive care, with no restrictions in diet or activity. Hospitalization might be necessary for patients who become dehydrated because of nausea and vomiting and is critical for patients with signs or symptoms of acute liver failure. Medications that might cause liver damage or which are metabolized by the liver should be used with caution among persons with hepatitis A.
Hepatitis B is caused by infection with the hepatitis B virus (HBV). The incubation period from the time of exposure to onset of symptoms is 6 weeks to 6 months. HBV is more infectious and relatively more stable in the environment than other blood-borne pathogens like HCV and HIV.
HBV infection can be self-limited or chronic. In adults, only approximately half of newly acquired HBV infections are symptomatic, and only approximately 1% of reported cases result in acute liver failure and death.
HBV is transmitted by percutaneous or mucous membrane exposure to blood or body fluids that contain blood. The primary risk factors associated with infection among adolescents and adults are unprotected sex with an infected partner, men who have sex with men (MSM), history of other sexually transmitted diseases (STDs), and non-sterile (illegal) intravenous drug use.
Diagnosis of acute or chronic HBV infection requires serologic testing.
Because HBsAg (surface antigen) is present in both acute and chronic infection, the presence of IgM antibody to hepatitis B core antigen (IgM anti-HBc) is diagnostic of an acute or recently acquired HBV infection. Antibodies to HBsAg (anti-HBs) are produced after a resolved infection and is the sole HBV antibody marker present after vaccination. The presence of HBsAg and anti-HBs, with a negative test for IgM anti-HBc, indicates chronic HBV infection.
No specific therapy is available for persons with acute hepatitis B; treatment is supportive. Persons with chronic HBV infection should be referred for evaluation to a physician experienced in the management of chronic liver disease (CLD). Several highly effective nucleos(t)ide analogues to treat hepatitis B have been licensed in the past 10 years. The newer agents, such as entecavir and tenofovir, have low resistance profiles, no significant drug-drug interactions, and an excellent safety record, which makes them suitable for long-term use.
Hepatitis B vaccine contains HBsAg produced in yeast by recombinant DNA technology and provides protection from HBV infection when used for both pre-exposure vaccination and post-exposure prevention (PEP). When selecting a hepatitis B vaccination schedule, the health-care provider should consider the need to achieve completion of the vaccine series.
Although HCV is not efficiently transmitted sexually, persons at risk for infection through injected drug use might seek care in STD treatment facilities. Persons newly infected with HCV typically are either asymptomatic or have a mild clinical illness. HCV RNA can be detected in blood within 1–3 weeks after exposure. The average time, from exposure to HCV, to (anti-HCV) seroconversion is 8–9 weeks, and anti-HCV can be detected in >97% of persons by 6 months after exposure. Chronic HCV infection develops in 70%–85% of HCV-infected persons; 60%–70% of chronically infected persons develop evidence of active liver disease. HCV is transmitted through parenteral exposures to contaminated blood, usually through use of injection drugs (sharing of needles or syringes) and to a lesser extent through exposures in health-care settings as a consequence of inadequate infection-control practices. Transmission may rarely follow receipt of blood, tissues, and organs from unrecognized HCV-infected donors.
Sexual transmission of HCV had been considered to occur rarely. However, recent data indicate that sexual transmission of HCV can occur, especially among HIV-infected persons. CDC surveillance data demonstrate that 10% of persons with acute HCV infection report contact with a known HCV-infected sex partner as their only source of infection.
Anti-HCV testing is recommended for routine screening of asymptomatic persons based on their risk for infection or based on a recognized exposure. Nucleic acid testing, including reverse transcriptase polymerase chain reaction (RT-PCR) to detect HCV RNA, is necessary to confirm the diagnosis of current HCV infection, and an elevated ALT level is biochemical evidence of CLD.
Combination therapy with pegylated interferon and ribavirin is the treatment of choice for patients with chronic hepatitis C. Treatment of chronic hepatitis C virus (HCV) infection has improved considerably in the last 5 years with the introduction of direct-acting antiviral (DAA) agents that target key steps of the HCV replication cycle. DAAs are able to halt HCV replication by inhibiting the activity of 3 nonstructural (NS) viral proteins: the NS3 protease, the NS5B polymerase, and the NS5A protein. Combinations of 2 or 3 DAAs have been shown to be highly effective and safe in phase III clinical trials and large real life cohorts, providing sustained virologic response (SVR) rates of >90%.
No vaccine for hepatitis C is available, and prophylaxis with immune globulin is not effective in preventing HCV infection after exposure.
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