Many of my friends are taking Probiotics; what are they?

Probiotics are oral supplements which contain living bacteria, usually Lactobacillus or Bifidobacterium species. These bacteria are beneficial; they usually live in large numbers throughout the large intestine, and their presence is useful for stabilizing the microflora (bacterial population) of the large intestine. These bacteria process leftover nutrients that are not digested in the small bowel and convert these nutrients into chemicals which are nutritious to the lining layer of the large intestine but not useful to other bacterial species residing in the large bowel. These good bacteria compete more effectively than certain harmful bacteria for nutrients and reproduce more effectively than many bad bacterial species which can be harmful in the intestine of the person that harbors them. The mere presence of Lactobacilli or Bifidobacteria helps suppress the population growth and the harmful actions of the bad bacteria in the large intestine by limiting their access to nutrients.

Why do people eat these bacteria?

There are some very specific uses for these bacteria. Lactobacilli and related species are very susceptible to antibiotics. After a course of antibiotics for, say, bronchitis or a urinary tract infection, it is not uncommon for a person to develop antibiotic associated diarrhea. The destructive effect of antibiotics on Lactobacilli and other good bacteria of the colon may permit disease causing bacteria to multiply. One particular pathogenic bacterium, Clostridium difficile, is often acquired when visiting hospitals or other health care facilities. It is a very hardy bacterium which is more resistant to the bactericidal effects of most antibiotics than Lactobacilli. Treatment with specific antibiotics such as Metronidazole, Vancomycin, or Rifampin is needed to get rid of this bacterium. Clostridium difficile elaborates an endotoxin which damages the small blood vessels of the intestine. Ordinarily, the numbers of Clostridium difficile are suppressed to low numbers by the coexistence of the Lactobacilli in the colon. If the Lactobacilli are wiped out by antibiotics, the Clostridium multiplies wildly, and a larger population of Clostridia secretes a greater amount of the endotoxin, creating intense diarrhea and cramps or colitis with bleeding. Maintaining a healthy population of Lactobacilli in the colon may keep the Clostridia in check so that this does not happen.

It is not an unreasonable idea to take a few doses of Lactobacilli after a course of antibiotics in order to restore their numbers to the large intestine. The problem is that most people take too much of these bacteria. It only takes 3-4 doses of a probiotic to repopulate the colon after a person takes a course of antibiotics, and taking more than that can cause other problems. While there are trillions of bacteria in the large bowel under normal circumstances, the small bowel needs to be sterile for digestion to proceed properly. Bacteria in the small bowel interfere with the small bowel's digestion of food and may lead to symptoms of bloating, cramps, flatulence, or diarrhea. Continued use of probiotics can lead to small bowel bacterial overgrowth with these symptoms. Continuous usage of a probiotic, accordingly, is not a good idea. One would never guess that from some of the advertisements for probiotics on television.

Some authorities believe that ingesting probiotics regularly stimulates the immune system which, in turn, protects the body from other digestive diseases. There are some very specific instances where this might be so, but it is not a general principle. Some authorities believe that probiotics help improve irritable bowel symptoms and certain specific situations in inflammatory bowel disease. My experience with people who take probiotics continuously for weeks or months is that they have more indigestion than benefit from this practice because of the small bowel bacterial overgrowth problem.

I went on a low carb diet recently, and I have been gassy ever since. Why?

Some of the sugar substitutes on a low carbohydrate or sugar free diet are actually man-made artificial sweeteners which are indigestible sugars. These include sorbitol, mannitol, maltitol, xylitol, and Splenda. The first four of these sugars are found in sugar free chewing gum, dietetic candies, and dietetic cookies. Splenda is a man-made sugar which is found in many diet beverages and which is available in large boxes with a recommendation to be used as a sugar substitute for baking. The small intestine does not contain the necessary enzymes to digest (break down) these artificial sugars, and as a result, the undigested (intact) artificial sugar molecules travel through the small bowel to reach the colon, where the colonic bacteria ferment them, producing carbon dioxide, methane, or hydrogen gas. These gases can be produced in sufficient quantities to produce cramps and flatulence. Sometimes, the passage of these sugars to the colon draws fluid into the channel of the bowel so that the person experiences diarrhea. Symptoms can be particularly intense for the person who takes these sugar substitutes regularly and probiotics regularly, since the probiotic bacteria will ferment these sugars in the small and large bowel.

Are there any sweeteners which don't do this?

Aspartame and saccharin products are amino acids which happen to taste sweet but are not sugars; they are not fermented by the bowel bacteria and do not produce gas and cramps.

I am anemic and have been taking iron tablets forever; why don't they help?

There are many answers to this question. First of all, there are many causes of anemia, and if your anemia is not the result of iron deficiency, taking iron won't be helpful. You need to have your doctor determine the cause of the anemia before undertaking treatment for it. If you are taking over the counter iron pills or vitamins with iron, these preparations have less iron than prescription strength iron. It can take a very long time (months or years) to correct iron deficiency. Iron absorption takes place in the duodenum, the beginning of the small intestine. It is a very inefficient process with only about 2% of ingested iron being absorbed under the best of circumstances. If you have any disease of the first part of the small bowel, iron absorption will be even less efficient with maybe as little as 0.5% of the ingested iron being absorbed. Iron absorption in the duodenum also requires the presence of stomach acid to convert the ingested iron to a form which is absorbed more efficiently. If you need to take acid lowering medications for other gastrointestinal problems such as gastroesophageal reflux or ulcer, the reduction of stomach acid will also reduce the efficiency of iron absorption from your duodenum.

What can I do for iron deficiency anemia if I can't absorb iron from my intestine?

Iron can be given by injection; this type of injection is usually given by a Hematologist (blood disease specialist). Intravenous iron delivers much more iron at one time to the bone marrow than oral iron, and the time required to complete injectable iron treatment is shorter than the time needed to correct iron deficiency with oral iron. There are some risks of allergic reactions to the injectable iron, so the iron injections must be monitored and performed in the physician's office.

If iron pills don't work, will vitamin B12 correct my anemia?

B12 injections or pills will help only if your anemia is due to a vitamin B12 deficiency.

What is heartburn?

Heartburn is a burning sensation a person experiences when stomach juices flow up into the esophagus. It is usually felt directly under the breastbone or sometimes in the upper part of the abdomen.

When is heartburn significant?

Some people have occasional bouts of heartburn after eating a spicy meal or while drinking alcohol. Burning or pressure under the breastbone which occurs at least twice a week, occurs regularly after meals, or which occurs while you are lying down at night is indicative of gastroesophageal reflux disease (GERD) and should be evaluated. If unrecognized and not properly treated, GERD could lead to structuring of the esophagus, cancer in the esophagus, or lung problems. GERD is the most common reason people consult gastroenterologists. If the symptom is pressure, it may be confused with angina which is a symptom of coronary artery disease.

What is reflux?

Reflux occurs when stomach juices flow up into the esophagus and possibly the mouth. Reflux may cause irritation of the esophagus, the throat, and even the lungs. When reflux is chronic, it may produce structuring of the esophagus, cancer in the esophagus, reflux laryngitis, etching of the teeth, asthma, bronchitis, and lung abscess. Diagnosis and proper lifelong treatment is necessary to prevent these complications.

What is a hiatus hernia?

The diaphragm is a muscle which partitions the body horizontally so that it divides the body cavity into chest and abdomen compartments. Everything above the diaphragm, by definition, is located in the chest. Everything below the diaphragm, by definition is located in the abdomen. Since the esophagus begins in the neck, passes through the chest, and enters the stomach in the abdomen, it must somehow pass through an opening in the diaphragm to get to the stomach. That opening is called the hiatus. When the support structures around the hiatus loosen up, the hiatus enlarges. In that instance, the upper part of the stomach may slide (herniated) up above the diaphragm and into the chest. The part of the stomach which has slid up into the chest is called a hiatus hernia. People with a hiatus hernia may or may not reflux. People who reflux may or may not have a hiatus hernia.

Why do I burp?

Burping is not necessarily a sign of disease. If the lower end of the esophagus (food pipe) is somewhat loose, swallowed air will not remain in the stomach when you eat. When swallowed, food will replace any air which is already in your stomach; the air then comes up into the esophagus and makes a noise as it escapes.

What is an ulcer?

An ulcer is a hole in the wall of the esophagus, stomach, small bowel, or colon; the hole goes all the way through the lining tissue layer of the organ and possibly deeper. If the hole is shallower than that and only goes part of the way through the lining tissue layer, it is called an erosion. Erosions and ulcers may bleed. Ulcers may cause pain and may even burrow through the entire wall of the organ, but erosions do not. Erosions and ulcers may occur singly or in groups.

What is a peptic ulcer and what causes it?

Many years ago, ulcers of the lower end of the stomach and the duodenum (the first part of the small intestine) were thought to be caused by excessive secretion of stomach acid. Because of the enzyme pepsin found in stomach juice, these ulcers were named "peptic ulcers". In the 1960's, the medical literature stated that stress caused ulcers. In the 1970's, doctors believed that high stomach acid levels were the main cause of ulcers; ulcers were treated with antacids and acid lowering drugs. It was always puzzling why the ulcers kept coming back year after year. After 1985, medical research demonstrated that acid plays only a secondary role in ulcer formation. Most ulcers in the bottom part of the stomach and in the duodenum are caused by an infection with a bacterium called Helicobacter pylori or by the use of NSAID's (nonsteroidal anti-inflammatory drugs) such as Ibuprofen, Advil, Motrin, Aleve Naprosyn, or Clinoril. After the bacterium or the drug damages the lining tissue layer, stomach acid seeps into the wall of the stomach or duodenum, causing further damage or inflammation. The reason that ulcers kept returning before this discovery stemmed from the fact that, although the acid was eliminated temporarily, the bacterium was never treated and remained in the stomach to continue causing problems. At present, successful eradication of the Helicobacter pylori infection heals the ulcer and prevents recurrence of the ulcer.

What is the best ulcer diet?

Generally speaking, most foods will neither help nor hurt the healing of an ulcer. However, Aspirin, nonsteroidal anti-inflammatory drugs, alcohol, nicotine, and caffeine are the substances which impair ulcer healing. In the past, people were told to "avoid acid-containing foods" and to eat a "bland diet" of creamy or milky foods. Based upon more modern medical research, following both of those pieces of advice is unnecessary. The foods which may bother an individual person will be very unique to that person. Generally, most gastroenterologists tell people to avoid the substances listed in the second sentence above and to eat whatever "doesn't cause pain within a few hours".

I have been told that I have a "nervous stomach". What is that?

A misnomer. Doctors and patients have noticed for years that some people experience a variety of abdominal symptoms when under extreme stress. There are many functional disorders of the bowel which result in symptoms when no anatomic cause can be found. For the last 30 years, these have been labeled "Irritable Bowel Syndrome"; more recently, these disorders have been called "Gastrointestinal Hypersensitivity and Dysmotility Syndrome". See irritable bowel discussion later in this document.

So many medicines that lower stomach acid are advertised on television and in magazines. Don't we need stomach acid?

As with many things in medicine, there are good things and bad things about stomach acid. Much of medicine is an evaluation of relative risks and benefits of competing or contradictory imperatives. Stomach acid is good as long as it remains in the stomach. It helps kill swallowed mouth bacteria so that they don't travel into the small intestine and interfere with digestion and absorption. Stomach acid also converts ingested food iron and medicinal iron into a form which is better absorbed from the first part of the small intestine. Stomach acid also helps with the release of Intrinsic Factor, a material which helps vitamin B12 absorption at the end of the small bowel. When stomach acid gets into the esophagus, it causes inflammation of the lining of the esophagus (esophagitis) and increases the risk of stricturing (scarring shut) the bottom end of the esophagus or the risk of cancer in the lower esophagus. When stomach acid comes up all the way into the throat or mouth, it can cause vocal cord damage (reflux laryngitis), can etch the teeth, or it can get into the lungs where it can cause a severe chemical pneumonia. In fact, the leading cause of adult asthma is nocturnal reflux and aspiration of stomach acid into the lungs. Acid lowering medicines reduce the risk of harmful problems caused by stomach acid getting out of the stomach, but at the same time may reduce some of the benefits of stomach acid within the stomach. Again it is a matter of weighing one set of benefits against another and weighing one set of risks against another.

Don't we need stomach acid to digest food in the stomach?

Actually, most digestion (breaking food down to its component elements such as sugars, amino acids, and fatty acids) occurs in the small intestine, not the stomach. The stomach churns chewed food much like a cement mixer tosses cement, but the acid plays a minor role in that process. The stomach also serves as a reservoir, releasing food into the small intestine at a rate at which the small bowel can process it. When food exits the stomach and passes into the first part of the small intestine (duodenum), it is sprayed by a series of sodium bicarbonate glands (much like a car going through a carwash) to neutralize the acid and make the semisolid material slightly alkaline (ph = 8, for those who remember high school or college chemistry classes). That is no accident; our pancreatic enzymes, which actually catalyze the digestion of food in the beginning of the small intestine, actually work their best at ph=8.

The television ad says that the purple pill heals erosions in the esophagus. Is that true?

All of the proton pump inhibitors heal esophageal erosions if taken properly and if the patient follows antireflux measures such as sleeping on a slant, staying up 90 minutes after eating, and minimizing the use of alcohol, caffeine, nicotine, aspirin, non-steroid anti-inflammatory drugs, chocolate, and peppermint. Only 1 drug manufacturer brags about it on television. In fact, the Food and Drug Administration only permits onto the market those proton pump inhibitors which have demonstrated the ability to heal esophageal erosions in patients who suffer from gastroesophageal reflux disease.

How often should I have a colonoscopy?

It depends on the situation and the clinical setting. There is a great deal of confusion and disinformation on this topic. People with inflammatory bowel disease of more than eight years duration and people who have had a colon cancer removed might require a surveillance colonoscopy every year. People who have had 1-2 hyperplastic polyps or adenomatous polyps may require surveillance colonoscopy at three year intervals. People who have a family history of colon cancer might require surveillance colonoscopy at five year intervals. Insurance companies and the Federal government would like to have people have colonoscopy at ten year intervals. Medicare will not pay for an elective colonoscopy done sooner than 366 days from the last colonoscopy. There are many other scenarios which dictate follow up colonoscopy at regular intervals. Whenever one reads medical articles which purport to study the cost effectiveness of certain practices, the research methodology usually asks the question "how little can be done for patients without a noticeable increase in bad results"? Such articles seem to search for the minimum amount of care that can be given, but most physicians prefer to practice above the minimally acceptable level of care. A review article published in the July 2, 2003 issue of the Journal of the American Medical Association noted that there was a trend for commercial health insurance companies and Medicare to convince people to have less frequent colonoscopy at 10 year intervals, but many more cancers and polyps were discovered if people followed a three year follow up colonoscopy schedule.

Ten years ago my internist told me that I should have a flexible sigmoidoscopy every three years by him. Now he tells me that I should see a gastroenterologist for a colonoscopy. Why the different advice?

In the 1960's, before colonoscopy was found to be feasible, the only diagnostic modalities which were available for detecting colorectal pathology were the barium enema and the rigid ten inch proctoscope. These tools were rudimentary and inaccurate, and as a result, much of the pathology in the colon went undiagnosed. Medical textbooks and journals of the time stated that 2/3 of colon polyps and cancers were found in the last two feet of colon closest to the rectum. When colonoscopy first became a reality in the early 1970's, the Office of the Surgeon General announced that the best colon cancer detection and control program for this country would have every family physician and internist perform rigid or flexible sigmoidoscopy; patients would be referred to gastroenterologists for total colonoscopy only if a polyp was found on in the last two feet of the colon during sigmoidoscopy. As more gastroenterologists became trained and proficient in colonoscopic technique in the 1970's and 1980's, more colonoscopies were performed each year. The more widespread use of colonoscopy led to the discovery that there were more polyps and cancers further up in the colon than the area served by the flexible sigmoidoscope. Furthermore, by the 1990's, statistics showed that the colonoscopic removal of adenomatous polyps of the colon reduced the expected rate of colon cancer formation in this country.

When US public health officials realized that there were more polyps and cancers 3, 4, and 5 feet into the colon than previously expected and that colonoscopic removal of polyps could reduce the number of colon cancers that developed, colonoscopy became the recommended procedure for colon cancer screening and surveillance; this was only logical since it was apparent that the entire colon was at risk for polyp and cancer development. In response to the recommendation that colonoscopy be the procedure of choice, the Health Care Financing Administration (the 1980's name of the agency which operates Medicare) in the late 1980's cut the professional fees paid to doctors for performing colonoscopy to an amount which was less than the amount Medicare previously paid for flexible sigmoidoscopy. The logical paradigm shifted, colonoscopy became the more prevalent procedure, and family physicians were taught that they should refer patients to gastroenterologists at the outset for colonoscopy and that they should not fool around with the flexible sigmoidoscope any more.

How often should I move my bowels?

Many people believe they are constipated if they do not have a bowel movement every day. That belief stems from a pre-20th century European concern about the possibility of bowel obstruction. Prior to the era of modern anesthesia and antibiotics, bowel obstruction was often fatal. A daily bowel movement generally reassured people that their bowels were not obstructed. In fact, the frequency of bowel movements is not nearly as important as the consistency. In other words, if the bowel movement is not so hard that it requires excessive work to get it out, there is no problem. On the other extreme, liquid runny bowel movements are not desirable either. There is a great deal of latitude between such extremes as to what constitutes "normal".

I have hemorrhoids, and I bleed from the rectum. How can I tell if the bleeding comes from my hemorrhoids?

The first time this question arises, the safest thing for you to do is to have a colonoscopy to make sure that any rectal bleeding you have is not coming from anything in your bowel that is more serious. There is a general rule that bleeding should not be attributed to hemorrhoids except as a diagnosis of exclusion - in other words, until your doctor has ruled out other causes. If you have been colonoscoped and found to have no other credible source of bleeding and if you do not have your hemorrhoids treated some way to stop the bleeding, you subsequently lose bleeding as a warning sign of future problems (because you will keep bleeding).

What is the difference between a colonoscopy and a flexible sigmoidoscopy?

The flexible sigmoidoscope is two feet long and only reaches part of the colon. The colonoscope is six feet long and can be used to reach the very beginning of the colon and even to reach into the end of the small bowel. Because the colonoscope involves a deeper insertion into the bowel, patients are usually given heavy sedation so they will sleep through the exam. Flexible sigmoidoscopy is often done without sedation. The bowel preparation for a colonoscopy is usually done by drinking laxatives, while the bowel preparation for a flexible sigmoidoscopy may only involve the use of enemas. Since the entire colon is at risk for the development of polyps, cancers, and inflammatory bowel disease, colonoscopy is the more revealing diagnostic and therapeutic examination.

What is virtual colonoscopy?

Virtual colonoscopy is not a colonoscopy at all. It is an air contrast barium cat scan (computerized tomography x-ray test) of the abdomen. It is very similar to the old-fashioned barium enema x-ray except that this examination is performed with a cat scan machine instead of a plain x-ray machine. Like the barium enema, this examination is performed by a radiologist. The patient must still undergo a laxative bowel cleanout procedure before this examination. Like the barium enema, a tube with a balloon is placed in the rectum. Barium sulphate and air are introduced into the rectum under pressure until the entire colon is distended, and pictures are taken with a spiral cat scan machine. Patients who have had this examination report that the pressure during the examination is more uncomfortable than any sensations during a regular colonoscopy since no sedation or pain medication is given for the "virtual" examination. This is purely a diagnostic examination, and no therapy such as polyp removal or cauterization of a bleeding lesion is possible with the cat scan machine.

What is the advantage of a virtual colonoscopy?

When it comes to the individual patient, none. The government has hoped to find an inexpensive colon cancer screening technique that would be inexpensive, accurate, sensitive, and which would become widely accepted by the public. To this end, the government has funded research to find a "noninvasive" technique that could be used to screen large populations of people at risk for developing colorectal cancer so only a small number would need to go fort the "invasive" procedure of endoscopic colonoscopy. The virtual colonoscopy really does not fulfill this dream, given the human condition and the present state of the technology. Most people who undergo a colonoscopy usually don't mind the procedure itself; the requirement for a laxative bowel preparation prior to the examination deters the squeamish. The "virtual" examination does not eliminate this problem because it still requires a bowel preparation. The second problem is that most people undergoing standard bowel preparations in the typical American community (as opposed to those who are having the examination in a research setting at a university medical center) still have a small amount of fecal material in the colon which can confound the interpretation of the virtual examination much more than the interpretation of a directly visualized endoscopic colonoscopy. The radiologist cannot always tell the difference between a growth in the colon, fecal material in the colon, and a small growth covered by a layer of fecal material; the gastroenterologist merely turns on a water jet in the colonoscope to wash away any interfering fecal material. The virtual examination also is not very good for finding inflamed areas of the colon, superficial ulcerations, blood vessel abnormalities, and bleeding areas. These abnormalities are easily seen and treated under direct vision at standard colonoscopy. Finally, the radiologist has no ability to biopsy inflamed areas, to cauterize bleeding areas, or to remove polyps during the "noninvasive" examination. The disclaimer that patients with these findings can be sent immediately for the endoscopic examination is not realistic since the gastroenterologist could very well be occupied with a full endoscopic schedule at that time.

If virtual colonoscopy has all of these disadvantages and no real advantages compared to standard colonoscopy, why is the virtual examination getting so much publicity?

Barium enema was the standard technique for diagnosing colorectal disease from the 1930's until the 1970's. When colonoscopy became widely available in the late 1970's, radiologists found themselves no longer performing many barium enemas. The specialty of Radiology developed other diagnostic techniques such as cat scanning and magnetic resonance imaging during the last three decades, but the loss of colon work to the gastrointestinal endoscopist was a sore point for radiologists. The research into "virtual colonoscopy" has been the radiologists' effort to discover a way to regain the colorectal diagnostic business which was lost to colonoscopy. The term "virtual colonoscopy" is brilliant marketing, but it is also misleading since it is not a scoping (looking into) the colon at all. Virtual colonoscopy offers the government and the private health insurance companies which pay the bills for colonic examinations the hope of a lower cost per procedure; the physician fees for the two examinations are similar, but the facility costs for the radiological examination and the absence of anesthesia charges for the radiological examination give the virtual examination a potential financial edge when macroeconomics are considered. Since there is no good estimate of how many people undergoing the radiological examination will also need to go on to have the endoscopic examination anyway, the cost of duplicate procedures has not been factored into the economic comparisons between the two procedures, suggesting that virtual colonoscopy may very well be a false economy as well as a technically inferior examination.

What is the difference between diverticulosis and Diverticulitis?

In middle age, about 50% of people experience thickening of the circular muscles in the sigmoid colon. These thick muscles become very strong and squeeze out knuckles of the colon lining tissue between gaps in the muscles, leading to the development of lining tissue sacs which project outward from the bowel wall. These sacs are called "diverticula", and the condition is known as diverticulosis. If these sacs become infected or inflamed, the inflamed or infected diverticula constitute "diverticulitis". If the diverticula rupture, intestinal contents leak into the abdominal cavity leading to peritonitis or abscess formation.

What is the difference between a polyp and a diverticulum?

A polyp is a solid growth which arises from the lining tissue of the esophagus, stomach, small bowel or large bowel (colon). It may appear as a flat or round bump on the lining tissue, or it may be raised up on a stalk to look like a mushroom. A diverticulum is a sac which protrudes from the stomach or intestinal wall. See the discussion in the previous paragraph.

What is a hemorrhoid?

A hemorrhoid is a dilated or varicose vein which arises in the rectal area. When the vein becomes stretched, it may rupture; this results in hemorrhage. Bleeding from hemorrhoids more commonly is minor, and the blood appears as spots on the toilet tissue rather than turning the entire toilet bowl red. The blood in the hemorrhoid may stagnate, resulting in thrombosis (clotting); a thrombosed hemorrhoid can be quite painful.

What is the difference between an internal and an external hemorrhoid?

The junction between the skin of the anus and the glandular tissue is called the "Z line". Hemorrhoids which arise above the Z line in the mucous tissue of the rectum are known as internal hemorrhoids, whether the prolapse down (hang down) below the Z line or not. Hemorrhoids which arise from the skin below the Z line are known as external hemorrhoids. Internal hemorrhoids are more amenable to banding than external hemorrhoids.

Five years ago, I only had to drink 2 small bottles of something for my colonoscopy preparation. Now my doctor wants me to drink a gallon of something. Why the difference?

Generally, the main ingredient of a colonoscopy bowel preparation is either sodium phosphate or polyethylene glycol. Gastroenterologists recommend many different bowel preparation recipes with different additives, but bowel preparation instructions almost always involve the use of one of these two substances. The small bottles you had at an earlier time contained sodium phosphate. The larger volume material your doctor wants you to have now is likely to be the polyethylene glycol. Sodium phosphate bowel preparations are more convenient to take because there is less liquid to drink, but they are not as safe as polyethylene glycol-based bowel preparations; therein is the crux of the matter.

There are many individuals who just hate to drink liquid; either they are just too busy to drink the daily amount that is healthy, they don't like the taste of the tap water in their community, or they worry about having to spend too much time in the bathroom urinating. Sodium phosphate bowel preparations appeal to these individuals because they require less fluid to drink than the polyethylene glycol bowel preparations. The problem with sodium phosphate bowel preparations is that the amount of this material needed to clean out the bowel contains too much sodium and too much phosphate. The typical American diet contains 4 grams of sodium per day. The diet that is recommended for a person over age sixty or a person with heart problems, kidney problems, liver problems, or high blood pressure is a diet which has only 2 grams of sodium per day. The sodium phosphate bowel preparations contain between 15 and 28 grams of sodium to be taken on a single afternoon or evening the day before the colonoscopy. Since the year 2000, there have been numerous case reports of people on a sodium phosphate bowel preparation experiencing a hypertensive (high blood pressure) crisis, congestive heart failure, a heart attack, stroke, pulmonary edema, or shock. The Food and Drug Administration issued a warning about sodium phosphate bowel preparations in 2002, cautioning physicians to not use sodium phosphate under the circumstances listed above. In 2006, the Food and Drug administration issued a second warning about sodium phosphate when several cases of irreversible kidney failure were reported from its use.

Another problem with sodium phosphate is the phosphorus. Phosphorus can be absorbed from the small intestine, and the body can only get rid of it by excreting it into the urine. Kidneys have to work very hard to excrete phosphorus, and sixty year old kidneys don't excrete phosphorus as well as thirty year old kidneys do. If the blood levels of phosphorus get too high because the kidneys can't keep up with the amount of phosphorus absorbed from the gut, high blood levels of phosphorus can be very irritating to the heart and cause many different types of arrhythmias.

I would not be surprised if the FDA removes sodium phosphate from the market some day in the future as the full significance of its dangers become more apparent. It seems as if your doctor considers you to be a person who could be harmed by the sodium phosphate and, therefore, is now recommending that you use the polyethylene glycol bowel preparation.

Why do I have gas?

Intestinal gas results from swallowed air (a condition known as "aerophagia"), from the inadequate digestion of a carbohydrate or complex sugar, or from small bowel bacterial overgrowth (the small bowel should be sterile; bacteria in the small bowel interfere with digestion in many ways). The most common complex sugar to be associated with this problem is Lactose (milk sugar); some people also have a problem digesting Trehalose, a sugar found in all species of mushrooms. Some children also have problems digesting Maltose, Isomaltose, or Fructose. The sugar which is not absorbed then passes from the small intestine to the colon where it is fermented by the colonic bacteria, creating Hydrogen, Methane, or Carbon Dioxide, resulting in cramps or flatulence. Swallowed air differs from the fermentation gaseous products because it has the same composition as room air. We have a noninvasive test (Breath Hydrogen gas chromatography) to determine whether you are Lactose intolerant or whether you have small bowel bacterial overgrowth; we are the only practice in a 60 mile radius with the equipment and the expertise to do this test.

I have been told that I have a wheat allergy. What is that?

Probably not an entirely accurate statement. There is a growing recognition of a problem known as gluten sensitivity, gluten enteropathy, celiac disease, celiac sprue, or non tropical sprue. All of these conditions are caused by an intestinal allergy to gluten. Gluten is a glycoprotein found in wheat, rye, barley, and oats. Exposure of the small intestine to gluten causes inflammation and damage to the small bowel resulting in a variety of malabsorption problems, bloating, gas, pain, or diarrhea. Treatment is purely dietary, involving foods and medicines (including vitamins and minerals) which contain gluten.

I was told that I was a "celiac" as an infant, but it went away. How can that be?

Probably not so. Celiac disease is a lifelong process that does not go away. The diagnosis of "Celiac" was overused many years ago to explain why some babies were colicky, but it was probably not a valid diagnosis. See the discussion in the previous paragraph about wheat allergy.I have been told that I have a milk allergy. Why can I have some milk products without problems but not others?

People may not tolerate milk and milk products because they are Lactose intolerant or because they have a milk protein allergy. Lactose intolerance by far is the more common problem. People who are Lactose intolerant may have symptoms when they ingest foods containing a large amount of Lactose and not have symptoms when they ingest foods which contain a little bit of Lactose. People who are allergic to bovine (cow) milk protein may be able to eat milk products derived from goat milk, llama milk, or other non-bovine sources.

I have been told that I have IBS. What is that?

The irritable bowel syndrome actually is a group of functional disorders of the gastrointestinal tract which are not associated with any anatomic abnormality to explain their symptoms. People who are labeled as having IBS may have symptoms which result from problems with the emptying of an anatomically normal stomach, from a small bowel which empties too rapidly, from an unusual sensitivity to normal pressures within the intestinal tract, with cramping, from diarrhea, from constipation, from alternating constipation and diarrhea, from mucus secretion from the bowel, or from any combination of these symptoms. The diagnosis of IBS rightfully requires an initial evaluation to make sure that there are no anatomical abnormalities, infections, or diseases to account for the symptoms the patient experiences. Unfortunately too often, a patient may only have a colonoscopy which is normal and no further evaluation before being labeled as an irritable bowel patient. The evaluation for seemingly functional symptoms should also include a Lactose tolerance test, solid phase gastric emptying test, and blood tests to look for gluten enteropathy, malabsorption, or pancreatobiliary disease. Treatment is symptomatic, depending upon the nature of the symptom.

What causes bloating?

The sensation of bloating can result from many disorders, some functional and some representing an anatomical disease state. Bloating can occur from carbohydrate malabsorption, IBS, partial bowel obstruction, fluid accumulation in the abdominal cavity, or gastroparesis (a stomach which empties too slowly), to name a few. The evaluation of a patient with bloating requires an evaluation which is determined by the setting and circumstances in which this symptom occurs.

How do you get Hepatitis C?

Hepatitis C is caused by a blood borne virus, the Hepatitis C virus. The virus was not discovered until 1990, so blood donors or blood products transfused before that time could not be tested for the presence of the Hepatitis C virus and eliminated from the transfusion pool. Transmission of the disease is from an infected person's blood to the blood of another person. Most cases can be traced to recreational injectable drug usage, intranasal cocaine usage, nonsterile body piercing or tattoos, transfusions prior to 1990, or medical needle stick from an infected source. Often, the exposure to the infected blood occurred 20-30 years before the disease became apparent. About 5% of cases have no obvious risk factors to explain the cause. Body fluids of an infected person other than blood generally are not infective unless they are contaminated by the blood of the infected person. The risk of sexual transmission is low (one study suggested 3% after 40 years of exposure) if the partners are monogamous, exclusively heterosexual, and generally avoiding behaviors which are designed to cause bleeding.

How do you get Hepatitis B?

The Hepatitis B virus is found in all body fluids and, therefore, is more infective than the Hepatitis C virus. In addition to the blood borne routes of infection described in the preceding paragraph for Hepatitis C, Hepatitis B is also found in urine, semen, tears, joint fluid, and any other body fluid you can imagine. Exposure to any of these fluids may result in infection.

What is the difference between Hepatitis A, B, C, and so forth?

Each of the Hepatitis viruses causes a different disease, each with its own features. Just because these viruses have sequential names such as A, B, C, and so forth, the fact that they are all named hepatitis viruses does not mean that the different viruses produce the same disease. As of this writing, hepatitis viruses have been given letter names from A-H.

I have a gallstone. What should I do about it?

Gallstones may be silent or may cause problems. The art and science of medicine relevant to the person with one or more stones is to determine which gallstones are causing a problem and which are not. Blood tests, ultrasound examination, and functional nuclear medicine biliary scans may be helpful for that determination. If a gallstone is not causing any problem, most of the time there is no need to remove the gallbladder. However, in some diabetic patients, it is best to remove a gallbladder which contains stones before a problem arises because infection from the biliary tract can be devastating to a diabetic patient. Some diabetic patients have neuropathy (derangement of various sensory or motor nerves) and cannot feel the pain that a person has with an inflamed gallbladder. For those patients, the gallbladder could become gangrenous and rupture without the person having warning symptoms. Gallbladder rupture can be fatal because it spreads infected bile throughout the abdominal cavity.

Where is the pancreas?

The pancreas sits in the back of the abdomen. It runs from slightly to the right of the midline across to the left. It is behind the stomach.

What does the pancreas do?

The simplest answer is that the pancreas consists of two different components which reside intermixed with each other throughout the entire gland. The endocrine portion of the pancreas is made up of special Islet Cells which make hormones such as insulin and glucagon to regulate blood sugar levels. The endocrine secretions are released into the bloodstream. The exocrine or digestive portion of the pancreas makes digestive enzymes such as amylase, lipase, and various proteases which are secreted into the intestinal tract to digest starch, fat, and protein, respectively.

What is pancreatitis?

Infection or inflammation of the pancreas. In the United States, the two leading causes of pancreatitis are gallstones obstructing the pancreatic duct and the ingestion of alcohol. Other causes of pancreatitis include autoimmune (vasculitis), familial, hypertriglyceridemia, inflammatory bowel disease, tumor obstruction of the pancreatic duct, or "idiopathic" (no known or discernible cause).

I just signed up for a new drug plan offered by my health insurance company, and they tell me I need to change some of my medicines to other drugs which do the same thing. Why?

The simple answer is "profit". The drug plan can purchase the alternative medicines at a lower cost than the drugs you are taking and, therefore, wants to supply you the cheaper substitutes. A more complete answer requires an explanation of economic issues associated with drug plans.

Drug plans, also known as prescription benefit plans, work like a pharmaceutical HMO in the health care industry. The pharmaceutical HMO's client, however, is your health insurance company, not you. Health insurance companies cannot control the medical service and drug needs of their insurance subscribers, but they can control what they spend on services and drugs. Health insurance companies want to keep the amount of money they spend on drugs to be a fixed, predictable amount each year dependent on the number of people who buy their insurance. They accomplish this goal by creating a "pharmaceutical set aside" by paying a fixed amount of the premium dollars they collect to a prescription benefit plan to manage the drug needs of the insurance company's subscribers. The health insurance companies put out for bid a contract to several prescription drug management companies to provide prescription drugs at a defined dollar amount per person per month. For example, the winning bidder may say that its company can provide all prescription services to the insurance company for $200 per person per month. The insurance company pays this amount and tells the prescription management company that this amount will be all the money the prescription management company will get for prescription services; the health insurance company informs the prescription benefit company that it does not expect requests from the prescription benefit company for additional funds to pay for drugs during the term of the contract. If the prescription management company can provide the insurance company's defined patient population its drug needs for less money, the prescription management company gets to keep the excess. By the same token, if the prescription management company spends more to provide the contracted medications than the contracted amount, the prescription management company must eat the loss.