Natural IBS Treatment Ebook
Inflammatory bowel disease (IBD) is reviewed in Chapter 6. It is well recognised that psychosocial factors play a major role in the morbidity of Crohn's disease and ulcerative colitis. Increasing attention is now paid to the patient's subjective views of well-being, including emotional and psychosocial assessment, to provide an holistic measure of disease severity. To evaluate the effect of psychosocial factors on symptoms in IBD it is essential to examine the illness in terms of health-related quality of life (HRQoL). HRQoL differs from objective disease measurement in that it evaluates the patient's perception, beliefs, experience, and function as related to an illness or condition. It incorporates disease-related factors with sociocultural and psychosocial factors. A review of HRQoL assessment is provided in Chapter 14.
Irritable bowel syndrome, also known as spastic colon, is a condition in which the intestinal muscles go into spasm. It can be caused by food sensitivities, caffeine, and other stimulants including alcohol, tobacco, and drugs malabsorption of sugars the lactose in milk, high fructose content in fruit juices and dried fruit, and sorbitol and xyl-itol used in dietetic products or as the result of a bacterial imbalance in the colon.
Approximately 2 of all patients with inflammatory bowel disease (IBD) present before the age of 10 years, but 30 present between the age of 10 and 19 years (117). Diagnosis is easy when patients present with the classical triad of bloody diarrhea, abdominal pain, and weight loss, but not infrequently, young people will present with extraintestinal manifestations such as arthritis, cutaneous disease, uveitis, depression, and growth or pubertal delay. These extraintestinal expressions are more common in Crohn's disease, but are also well recognized in ulcerative colitis. Rarely, these manifestations, particularly arthritis, can be the only initial symptom for months to years in children with IBD (117). Usually, arthritis develops after diagnosis of bowel disease and is seen in 7 to 21 of children with IBD (118,119). The most typical pattern of disease is peripheral polyarticular presentation particularly affecting lower limbs (118,119). This form of arthritis tends to improve with...
Crohn's disease and ulcerative colitis are idiopathic chronic diseases. Although they are generally recognised as distinct clinical syndromes they are very closely related illnesses and are commonly grouped together under the term inflammatory bowel disease (IBD). In this section nursing care will be examined without distinction between Crohn's disease and ulcerative colitis. Current best practice in IBD has been published by the BSG (1996).
IBS is one of the most common co-morbidities in FM, affecting 30 to 80 percent of FM patients. Previously, IBS has been known by names such as irritable colon, spastic colon, nervous indigestion, and functional colitis. Sometimes IBS is predominated by constipation, at other times by diarrhea, but it can also occur as constipation alternating with diarrhea. Symptoms include chronic constipation or frequent diarrhea associated with abdominal pain, tenderness, bloating, and gas. Sometimes symptoms are exacerbated by meals or stress and relieved by bowel movement. A smaller percentage of patients also have nausea, vomiting, and loss of appetite. Additionally, pain from bowel stretching is amplified by central sensitization. Although the pathophysiology is not completely understood, some believe that the syndrome is associated with altered gastrointestinal mobility and permeability. Fortunately, there is agreement that IBS is not associated with structural problems in the bowel and does...
Having the pain, achiness, and mental confusion that can accompany fibromyalgia is bad enough. But many people with FMS also suffer from irritable bowel syndrome (IBS), a colonic condition that, very simply put, causes the person to feel bloated and alternate between having constipation and diarrhea. (Another name for IBS is spastic colon.) Diagnosing irritable bowel syndrome Treating irritable bowel syndrome For more on irritable bowel syndrome, turn to IBS For Dummies, by Carolyn Dean, MD, ND, and L. Christine Wheeler, MA (Wiley).
Gadolinium chelate enhancement is routinely useful because it permits visualization of the pattern of blood delivery (i.e., capillary enhancement) and the size and or rapidity of drainage of the interstitial space (i.e., interstitial enhancement) both of which improve the detection and characterization of disease 4,37 . Arterial-phase image acquisition is achieved using a short-duration sequence initiated immediately after gadolinium injection. A spoiled gradient-echo (SGE) sequence, performed as a multisection 2D or 3D acquisition, is an ideal sequence to use for arterial phase imaging. The majority of focal mass lesions are best evaluated in the arterial phase of enhancement, particularly lesions that do not distort the margins of the organs in which they are located (e.g., focal liver, spleen, or pancreatic lesions). Images acquired 1.5-10 min after contrast administration are in the equilibrium phase of enhancement, with the optimal window being 2-5 min after contrast agent...
Fatty liver infiltration is a common, metabolic complication of a variety of toxic, ischemic and infectious insults to the liver, such as obesity, diabetes mellitus, alcoholic liver disease, malnutrition, and chemotherapy. Other causes include hy-peralimentation, inherited metabolic disturbance, inflammatory bowel disease, severe hepatitis, endogenous and exogenous steroid use, and pregnancy 1 . Generally, fat is deposited in response to different metabolic changes, such as increased hepatic synthesis of fatty acids (ethanol), decreased hepatic oxidation or utilization of fatty acids (carbon tetrachloride, tetracycline), impaired release of hepatic lipoproteins (steroids), or excessive mobilization of fatty acids from adipose tissue (alcohol, steroids). The prevalence of focal fatty infiltration of the liver increases significantly with advancing age whereas it is uncommon in infants and young children, it is present in roughly 10 of the adult population 23 .
Mucosal disorders, including inflammatory bowel disease, allergic diseases, and celiac disease, are additional examples of disorders causing protein malabsorption. Once intestinal inflammation is reduced with appropriate medical or nutritional therapy, absorption of protein is usually improved. In Shigella infections, some studies have demonstrated improved nutritional outcomes with a high-protein diet during recovery from the acute symptoms of diarrhea.
Traditionally, the clinical applications of oral colonic drug delivery have been limited to the local treatment of inflammatory bowel disease (IBD). Enteric coatings, sustained release systems, and bacterially triggered treatments have all been used to deliver anti-inflammatory molecules to the colon to treat this debilitating condition. However, for many years the treatment of colonic cancer has been postulated as an ideal candidate for colonic drug delivery but little has been delivered in this field although there are some potential avenues which are starting to be explored. Also, there are other local diseases of the large intestine which could benefit from topical delivery to the colonic mucosa, and the potential of the colon for systemic
Department of Medicine, Division of Gastroenterology, Inflammatory Bowel Disease Center, Mount Sinai School of Medicine, New York, New York, U.S.A. Crohn's disease (CD) and ulcerative colitis, collectively part of the inflammatory bowel diseases (IBD), are both diseases of the gastrointestinal tract that arise in genetically susceptible individuals. Both CD and ulcerative colitis, though clinically different entities, are thought to be part of a spectrum of diseases where environmental and immunologic factors determine the extent and severity of clinical manifestations. Inflammatory Bowel Diseases Inflammatory Bowel Diseases 1. Loftus EV Jr. Clinical epidemiology of inflammatory bowel disease incidence, prevalence, and environmental influences. Gastroenterology 2004 126(6) 1504-1517. 2. Gilat T, Grossman A, Fireman Z, et al. Inflammatory bowel disease in Jews. In McConnell R, Rosen P, Langman M, et al., eds. The Genetics and Epidemiology of Inflammatory Bowel Disease. Basel,...
Protein-losing enteropathy is a broad term including all the conditions that cause an abnormal loss of plasma proteins from the gut. Three main mechanisms are responsible for protein-losing enteropathy enhanced mucosal permeability to proteins (as in eosinophilic gastroenteritis and Menetrier's disease), mucosal erosions or ulceration (as in erosive gastritis and inflammatory bowel disease), and lymphatic obstruction (congenital or secondary). Enteric loss of protein may be revealed noninvasively by an increased stool concentration of -antitrypsin or, more expensively, by radioactive methods (intravenous administration of 51Cr albumin or chloride).
Inflammatory bowel disease (IBD) The general name for diseases that cause inflammation of the bowels, including ulcerative colitis and Crohn's disease. Although these two diseases are similar, there are also some important distinctions. Inflammatory bowel disease (IBD) occurs most often among people aged 15 to 30, but it can affect younger children. There are significantly more reported cases in western Europe and North America than in other parts of the world. Scientists do not yet know what causes inflammatory bowel disease, although they suspect that a number of factors may be involved, including the environment, diet, and heredity. Smoking appears to increase the likelihood of developing Crohn's disease. A new theory suggests that Crohn's disease may be caused by infection (similar to cat scratch disease).
As previously mentioned, exhibition of antioxidative activity is one typical example of the pharmacological consequences of all the bioactive components, most especially phenolics, identified in GK seed. Pro-oxidation or generation of radicals is inevitable in nature, because they are a by-product of the metabolic process in all living systems. Free radicals have been implicated in playing some role in more than 100 diseases, including cancer, atherosclerosis, rheumatoid arthritis, inflammatory bowel disease, and cataracts. Therefore, the identified bioactive components in the GK seed suggest that it could exhibit antioxidative activity and, consequently, a reduction of free radicals. Reduction of free radicals by antioxidants can lead to a decrease in vulnerability to the named degenerative diseases.
Matory cell infiltration in the arthritic model. Reactive oxygen species such as superoxide, H2O2, OH radical, and hypochlorous acid are believed to mediate human and experimental inflammatory bowel disease (IBD). Nitric oxide and peroxynitrite have also been suggested to mediate the induction of colitis (44).
LPS-induced circulating TNFa and IL-1 , as well as IFNy, were suppressed by SAHA (Leoni et al. 2002). The use of LPS as an inducer of cytokines is widely accepted as a model of disease. However, with the exception of inflammatory bowel disease, most cytokine-mediated autoimmune diseases are triggered by nonmicrobial products such as autoantibodies and several endogenous cytokines themselves, particularly CD4+ T cell products. IL-12 and IL-18 are primarily macrophage products, which in turn stimulate T lymphocytes to produce IFNy and IL-6. SAHA reduces both LPS- as well as IL-12 IL-18-induced IFNy and IL-6. IL-6 is an important mediator of inflammation, primarily as a B-cell growth factor and an inducer of hepatic acute-phase protein synthesis in diseases such a multiple myeloma (Lust and Donovan 1999), and antibodies to the IL-6 receptor are used to treat multiple myeloma, rheumatoid arthritis, and other autoimmune diseases (Iwamoto et al. 2002). Gene expression for IFNy in resting...
One specialist that may be called on is a gastroenterologist (a specialist in the digestive system and its disorders), also commonly known as a GI doctor. A gastroenterologist may be helpful for people with GI distress such as irritable bowel syndrome that does not respond to traditional therapies. Ideally, the gastroenterologist would screen for other GI conditions such as inflammatory bowel disease or celiac disease (autoimmune disorders that are often genetic), symptomatic diverticulitis (inflamed areas in the intestinal lining), and peptic ulcer disease (caused by erosions to the lining of the digestive system). Many patients who are diagnosed by a gastroenterologist with irritable bowel syndrome find it reassuring that their GI distress is not caused by a malignancy like cancer or any other progressive illness.
Surgical gastrostomy and jejunostomy In a patient undergoing complex abdominal or trauma surgery, thought should be given during surgery to the possible routes for subsequent nutritional support because laparotomy affords direct access to the stomach or small bowel. The only absolute contraindication to feeding jejunostomy is distal intestinal obstruction. Relative contraindications include severe edema of the intestinal wall, radiation enteritis, inflammatory bowel disease, ascites, severe immunodeficiency, and bowel ischemia. Needle catheter jejunostomies can also be used with a minimal learning curve. The drawback is usually related to clogging and knotting of the 6-Fr catheter.
If a child presents with an AIE, the onset is often within the first 3 or 4 months in the form of severe diarrhea which can be bloody 15 . The majority of boys with AIE present in addition with severe atopic skin disease, hema-tological abnormalities along with endocrinopathy, such as insulin-dependent diabetes mellitus or thyroiditis. This association was described as IPEX (immune dysregulation, polyendocrinopathy, autoimmune enteropathy, X-linked) syndrome 15, 17, 18 . It is interesting to note that boys with IPEX also show severe immunoallergic symptoms with a strong Th2 response and hyper-IgE syndrome having some similarities with extremely severe food allergy. Isolated or oligosymptomatic forms of severe AIE exist in both, boys and girls. Prior to the onset of AIE IPEX, these children develop completely normal, and no antenatal or neonatal particularities exist 19 . It is important to stress that the family history is most often positive for various autoimmune diseases. This...
Sugar, turbinado Washed raw sugar, with a thin film of molasses. sugarware Edible seaweed, Laminaria saccharina. sulphaguanidine (sulfaguanidine) Poorly absorbed antibacterial agent (a sulphonamide) used in treatment of persistent bacterial diarrhoea and gastrointestinal infection. sulphasalazine (sulfasalazine) A sulphonamide drug (salicyl-azosulphapyridine) used in treatment of inflammatory bowel disease. Inhibits absorption of folic acid. sulphites (sulfites) Salts of sulphurous acid (H2SO3) used as
Since elucidating the structure and biosynthetic pathway of leukotrienes, researchers have further demonstrated their potency in smooth muscle constriction in both human and animal models, in vitro and in vivo, and have shown that 5-LO products stimulate smooth muscle proliferation (37-39). For example, inhaled LTC4 and LTD4 resulted in potent airway obstruction as manifest by decreased specific airway conductance (SGaw) (40), and Bisgaard et al. (41) demonstrated that asthmatic subjects were 100 to 1000 times more responsive to LTD4 than controls. Subsequent studies demonstrated that prior inhalation of leukotrienes caused an increase in airway responsiveness to both histamine and methacholine that lasted as long as one week. 5-LO products may also cause tissue edema (42,43) and stimulate smooth muscle proliferation (44-46) as well as eosinophil and neutrophil recruitment and activation (47-50). Invoked as causative agents in a host of inflammatory conditions such as inflammatory...
It is evident that the commensal flora greatly influences the development and maturation of the local mucosal immune system and also has profound effects upon systemic immunity (Macpherson and Harris, 2004). Indeed, the presence of commensal bacteria greatly alters the pattern of gene expression in intestinal epithelial cells (Macpherson and Harris, 2004). This raises the intriguing possibility that live beneficial commensal organisms (probiotics) or defined pharmaceutical extracts from such organisms may have far-reaching effects, including influencing the outcome of vaccine administration or controlling local inflammation. Recent studies indicate a clear role for probiotic commensals in controlling local inflammatory responses in animal models of colitis (Madsen et al., 1999 McCarthy et al., 2003). These findings have also been extended to human populations where feeding of Bifidobacterium infantis has been shown to significantly alleviate symptoms in patients with irritable bowel...
FM usage Irritable bowel syndrome pain Patient example Lucinda is a 32-year-old woman with long-standing constipation-prone IBS. Recently she was diagnosed with FM. Interestingly, she has tried no medication for either her IBS or FM. After a history, physical exam, and laboratory tests ruled out both IBD (inflammatory bowel disease) and lactose intolerance, her provider asked if she was more concerned about the IBS or the FM. Lucinda reported she felt IBS limited her life more than FM. The provider prescribed Dicyclomine and peppermint oil and referred her to a registered dietitian who helped Lucinda start a gradual dietary program to reduce food additives, especially MSG and aspartame. They gradually have added fiber and increased her water intake. After six months, Lucinda's IBS is at least 50 percent improved. She says she was not aware how much she relied on fast foods and now cooks at home 90 percent of the time. She states she is now ready to explore treatment options for her...
Apart from the ruddy complexion, specific head and neck manifestations are unusual. Epistaxis in addition to bleeding from other sites may occur in up to 40 of patients. Pyoderma gangrenosum is reported to occur with the MPD. This is a necrotizing skin ulceration that occurs most commonly on the limbs of patients with inflammatory bowel disease. It can also occur on the face. Manifestations of iron deficiency may include glossitis and cheilosis.
Once a child is diagnosed with a spondyloarthropathy, it is important to recognize that this pattern of joint involvement may be associated with a variety of other diseases (discussed later). Many children have a nonspecific spondyloarthropathy, meaning there is no associated condition. However, the associated condition may not become evident until years after the arthritis begins. It's important to be aware of these associations so that the child can be evaluated appropriately. This is particularly true of children who develop recurrent abdominal pain that might be inflammatory bowel disease (IBD) while most children with IBD develop arthritis after their bowel disease is recognized, this is not always the case.
The most common cause of protein malabsorption is so-called protein-losing enteropathy. Etiologies include diffuse mucosal disease such as celiac disease or Crohn's disease, elevated right heart pressure with resultant dilatation of lymphatics and leakage of lymph into the lumen, and colitides such as Shigella or Salmonella infections. Since protein is a relatively minor component of dietary energy compared with carbohydrate and fat, symptoms of protein malabsorption can sometimes be minimal. However, infectious colitis or exacerbations of inflammatory bowel disease often present with frequent loose stools, which may be bloody. Rare, congenital etiologies of protein malabsorption include enterokinase and trypsinogen deficiencies (Table 1).
The first description of DNA in plasma or serum was by Mandel and Metais in 1948.9 Using a perchloric acid precipitation method, they detected both DNA and RNA at a concentration of between 0.3 to 1.0mg l of plasma in healthy and sick individuals. This concentration is higher than that reported in more recent studies, probably reflecting both methodological and sample differences. It was not until the 1960s that the field was revisited when high levels of DNA were reported in the serum of patients with systemic lupus erythmatosis.10 Subsequent studies showed increased concentrations of free DNA in plasma or serum from patients with rheumatoid arthritis, pancreatitis, pulmonary embolism, ulcerative colitis, inflammatory bowel disease, peptic ulcer, and other inflammatory conditions.11-14 Increasingly sensitive assays were also able to detect small amounts of free DNA, up to 30 ng of soluble DNA ml, in the serum and plasma of healthy individuals.15
Their role in diagnosis is limited because of moderate sensitivity and specificity. The antiglia-din antibodies are found in intestinal secretions as well as in serum of patients with untreated celiac disease. However, these antibodies are also found in a variety of autoimmune disorders including rheumatoid arthritis, Sjogren's syndrome, sarcoidosis, inflammatory bowel disease, and cows' milk protein intolerance. IgA antigliadin antibodies have sensitivity of 75-90 and specificity of 82-95 . The IgG antigliadin antibodies range in sensitivity from 69 to 85 and have specificity of 73-90 they are useful in the diagnosis of celiac patients with IgA deficiency. Other than this use gliadin antibodies have fallen from favor as a screening test for celiac disease (National Institute of Health consensus panel).
Adalimumab has recently been approved as therapy for inflammatory bowel disease. This agent is extremely effective for the arthritis of IBD as well as for the disease itself. Use of adalimumab is increasing, as there is growing hesitation on the part of gastroenterologists to use NSAIDs in children with inflammatory bowel disease because of the medications' propensity to cause gastrointestinal side effects.
Until the diagnosis of systemic-onset arthritis is clear, it is far better to continue to look for infections and treat with antibiotics if necessary. It is also far better to have done a bone marrow aspiration to exclude the possibility of leukemia than to delay that diagnosis, thinking the child has systemic-onset arthritis. Children sent to me for possible systemic-onset arthritis have had cancers, infections, polyarteritis nodosa, Kawasaki's disease, inflammatory bowel disease, and many other illnesses.
Ciated with DC activation, and also to promote release of the immunoregulatory cytokine IL-10 (Drakes et al., 2004). Certain species of Lactobacilli have recently been shown to prime monocyte-derived DCs to promote the development of regulatory T cells, leading to increased IL-10 production (Smits et al., 2005). The surface molecule through which these probiotics interact with DC have also been identified as the DC-specific intercellular adhesion molecule 3-grabbing non-integrin (DC-SIGN), and it has been suggested that probiotic bacteria able to bind to DC-SIGN may be those best able to exert antiinflammatory effects. Interactions of probiotic bacteria through DC-SIGN leading to DC activation may be responsible for anti-atopic activity and anti-inflammatory effects of probiotics in inflammatory bowel disease. Interactions between resident gut bacteria and specialized DCs in the GALT are essential in establishing oral tolerance, and it is possible that probiotics could also act...
Antibiotics have long been viewed as a potential treatment option in inflammatory bowel disease in specific clinical situations. Metronidazole is a useful agent for managing peri-anal disease and may also suppress Crohn's disease activity. Other antibiotics have a role in treating septic complications.
Most pediatric rheumatologists make distinctions based on the presence or absence of rheumatoid factor (RF) in the blood (it is normally absent). These children may also be subcategorized according to whether the disease is symmetric (both elbows or both knees, etc.) or asymmetric (only one elbow or one knee, along with other joints). Children with tendon insertion inflammation (enthesitis), a family history of psoriasis, a family history of inflammatory bowel disease, or the presence of HLA B27 are included in this group by some physicians but are excluded by others. I exclude children with these findings because I believe most of them have spondyloarthropathies that behave differently (see Chapter 7). Even when all the children with these findings are excluded, the remaining children are a diverse group and most likely have one of several different diseases.
Irritable bowel syndrome There is a rationale for investigating the effect of probiotics in the treatment of this common disorder where intestinal motility and dysfunctions in the intestinal microflora are important factors to consider. In a recent study using L. plantarum 299v, a reduction of symptoms was reported. Enterococcus faecium preparations have also been evaluated for the treatment of patients with irritable bowel syndrome, and although patient-recorded symptoms did not show significant differences, the physician's subjective clinical evaluation revealed an improvement. Inflammatory bowel disease Inflammatory bowel disease (IBD) comprises a heterogeneous group of diseases of unknown etiology (Crohn's, ulcerative colitis, and pouchitis), but here also factors related to the intestinal microflora seem to be involved, providing a rationale for the application of probio-tics. From reviewing studies on the use of probiotics in IBD it can be concluded that, although there are some...
Multiple diseases can present with findings similar to those seen with Adamantiades-Behget's disease and should be considered when a patient presents with recurrent oral or genital ulcers, inflammatory eye disease, or other manifestations of vasculitis. Included in the differential diagnosis are systemic lupus erythematosus (Chapter 1), seronegative spondyloarthropathies, inflammatory bowel disease (Crohn's or ulcerative colitis) (Chapter 20), herpes or other viral infections (Chapter 10), other forms of vasculitis (Chapter 8), and inflammatory skin diseases such as pemphigus vulgaris or pemphigoid lesions (Chapter 37). All patients presenting with oral and genital ulcerations should undergo testing for herpes simplex virus using culture or polymerase chain reaction methods, to ensure that viral infection is not present. aFindings applicable only in the absence of other clinical explanations (systemic lupus erythematosus, inflammatory bowel disease, seronegative spondyloarthropathies,...
More than 400 species of bacteria can be found throughout the GIT. The greatest number is present in the distal small intestine and large intestine in man and rabbit 5, 33 . Gastrointestinal bacteria primarily function to hydrolyze carbohydrates and proteins that are not metabolized in the upper intestine. Another important aspect of bacterial metabolism in the intestine is the hydrolysis of glucuronide conjugates these are important components of the enterohepatic circulation of compounds 34 . In guinea pig, rat, mouse, monkey, dog and pig not only are there significant numbers of bacteria in the distal small intestine and colon but also in the stomach and proximal small intestine 5 . An additional observation has been the variability in the types of microorganisms present in these segments 5 . Approaches to target the colon by taking advantage of bacterial metabolism present in this intestinal segment have been most successful for treating local disease (e.g. ulcerative colitis)...
Laboratory findings in children with pauciarticular-onset disease are usually normal or display only mild abnormalities. If a child has significant laboratory abnormalities during the first six months of treatment, the diagnosis of pauci-articular JA should be regarded with suspicion. Children who have a hemoglobin level below 11 gm dl without explanation, a sedimentation rate greater than 40 mm hr, immunoglobulin A (IgA) deficiency, the genetic marker HLA B27, or a family history of psoriasis or inflammatory bowel disease likely do not have true pauciarticular-onset disease and are at greater risk for additional arthritis-related problems in the future. By contrast, the prognosis for children with well-defined pauciarticular-onset disease is good.
The indications for long-term nutrition support, specifically for home, include any patient who is unable to meet nutrient requirements by oral intake to avert the consequences of malnutrition. In the United States, cancer patients represent the most frequent use ( 40 ) of home parenteral and enteral nutrition support. Inflammatory bowel disease is the second most common reason for home parenteral
The debate continues regarding the management of a normal-appearing appendix found at the time of surgery for presumed appendicitis. There are three possible situations (1) normal-appearing appendix and no other pathology, (2) normal-appearing appendix and medically treated pathology (e.g., inflammatory bowel disease or pelvic inflammatory disease), and (3) normal-appearing appendix and surgically treated pathology (e.g., acute cholecystitis or perforated duodenal ulcer). The appendix should be removed in all but the last circumstance. This eliminates confusion should the patient return with similar symptoms.
Irritable bowel syndrome Irritable bowel syndrome (IBS) is characterised by abdominal pain and altered bowel function. The impact of IBS on quality of life has been shown to be clinically significant in patients. Inflammatory bowel disease Inflammatory bowel disease (IBD) has been exposed to extensive evaluation in the HRQoL literature. IBD encompasses both ulcerative colitis and Crohn's disease and is a significant chronic disease affecting primarily young individuals. There is little doubt that inflammatory bowel disease can have a major adverse impact upon many patients' lives. The manifestations of IBD are often severe and affect multiple aspects of a patient's life. Patients with IBD have also been characterised as having psychological problems, such as anxiety and maladaptive coping mechanisms. The disease processes of both Crohn's disease and ulcerative colitis are characterised by cycles of remission and exacerbation of physical symptoms such as altered bowel habit, bowel...
Sho-saiko-to has also been reported to modulate in vitro cytokine production in peripheral blood mononuclear cells, downregulating the synthesis of IL-4 and -5 in favor of IL-10 in patients with chronic hepatitis C. IL-10 production in mononuclear cells of hepatitis C patients was reported to be lower than that of healthy subjects (19). IL-10 would be expected to have an effective activity for inflammatory bowel disease (20), endotoxin shock (21), and experimental liver injury (M. Tanaka, unpublished data, presented at the 37th annual meeting of the Japanese Society of Gastroenterology, 1995).
The final section of the book, Section 3, looks at living with gastrointestinal disorders. Chapter 13 covers the psychosocial aspects both as causes and consequences of gastrointestinal disorders, especially inflammatory bowel disease, and Chapter 14 looks at the impact of gastrointestinal disorders on quality of life. Clearly, there is a strong link between the two chapters. In common with developments in endoscopy and nurses prescribing, these are areas where nursing roles are extending with the development of nurse counsellors and the use of alternative treatments such as hypnotherapy.
Lower gastrointestinal perforations can be either spontaneous or mechanical. Conditions such as inflammatory bowel disease, ischaemic colitis, adhesions, strictures, diverticular disease or malignancy are believed to put patients at higher risk. Lower gastrointestinal perforations occur most often from mechanical trauma related to the manipulation of the endoscopic instrument during colonoscopy.
In vitro data has shown that nettle leaf extract (IDS 30) reduces the induction of primary T-cell responses and TNF-alpha in T-cell mediated diseases such as RA (Broer & Behnke 2002). Faecal IL-1 -beta and TNF-alpha concentrations were significantly reduced in mice with induced Crohn's disease treated with IDS 30 (Konrad et al 2005). Mice treated with nettle extract displayed fewer histological changes and general disease symptoms. The authors conclude that the effect may be due to a decrease in Th1 response and may constitute a new treatment option for prolonging remission in inflammatory bowel disease.
Notwithstanding the genetic and environmental predisposing factors, the aetiology of both Crohn's disease and ulcerative colitis remains unknown. It is still debated whether Crohn's disease and ulcerative colitis are separate diseases or whether they represent a continuous spectrum of inflammatory bowel disease. The pathogenesis of the disease is also unclear. The major hypothesis of the pathogenesis of inflammatory bowel disease relates to abnormal immune responses and dysfunctional immune-regulation within the bowel wall. Psychosocial factors related to IBD are addressed in Chapter 13.
Normal epithelial cells express relatively low levels of TLR4 and demonstrate low responsiveness to LPS (Jump and Levine, 2004). In contrast, epithelial biopsies from patients with inflammatory bowel disease are seen to express high levels of TLR4 consistent with a hyperinflammatory condition (Cario and Podolsky, 2000). Recent work suggests that cytokines such as gamma interferon have the potential to increase the expression of TLR4 in healthy epithelial cells particularly within the crypts, suggesting that potential for TLR4 signalling may be further upregulated during the infectious process (Alvarado et al., 2005).
Cyclosporine may be very beneficial in children with spondyloarthropathies, systemic-onset arthritis, arthritis associated with inflammatory bowel disease, dermatomyositis, and other vasculitic illnesses. It is also useful for the treatment of ocular inflammation (uveitis). However, a child's response to cyclosporine is unpredictable. Some children who have not responded to other medications have dramatically improved with the addition of cyclosporine. I have also used it in other children in seemingly identical situations without benefit.
The risk of colon and rectum cancer increases with age more than 90 of cases are diagnosed in people over 50 years old. Other risk factors for colon cancer are obesity (especially in men), physical inactivity, heavy consumption of alcohol and of red or processed meat, a history of inflammatory bowel disease, and a family history of colon or rectum cancer, especially in persons under 40 years old. Tobacco-smoking is an established risk factor for ademomatous polyps, the main precursor of colon cancer. Studies suggest that treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, and estrogen alone or in sequential use with progestin hormone therapy may reduce colorectal-cancer risk. However, no
Enterectomy with anastomosis is indicated in a variety of conditions, including congenital atresia or stenosis of the small bowel, blunt and penetrating injuries of the small bowel, benign and malignant small bowel tumors, bleeding Meckel's di-verticulum, inflammatory bowel disease, intestinal fistula, intestinal gangrene, intussusception in adults, some cases of meconium ileus or intestinal duplication, mesenteric tumors that in the course of removal could produce vascular compromise to adjacent small bowel, and when small bowel is adherent to intraabdominal tumors arising in other organs.
Abstract The colon is a challenging target for drug delivery, as reaching the distal regions of the gastrointestinal tract presents significant physiological challenges and environmental barriers. Many approaches have been used to surmount these, with mixed success rates. Colonic delivery has historically been limited to treatment of local conditions such as inflammatory bowel disease. Latterly, efforts have also concerned delivery for treating colon cancer and for systemic delivery of selected compounds. Such approaches have concerned use of enteric coatings, sustained release systems, bacterially triggered treatments, or combinations of these. Possibilities are discussed in this chapter, along with historical experiences with systems for treating ulcerative colitis and Crohn's disease.
These scales have been used to measure psychological and psychiatric morbidity in both inflammatory bowel disease and irritable bowel syndrome. The HDS is inappropriate for use in this patient population due to its emphasis on physical symptoms and the high number of items that concern somatic problems. The BDI has high validity and reliability but has been used predominantly in psychiatric populations and is dependent on subjects' ability to accurately report their emotional state. The HAD scale is widely used in clinical trials for a wide range of conditions, including arthritis, cancer, bowel disorders and dental phobias. The tool of choice for nurses measuring psychological well-being in patients with gastrointestinal illnesses is HAD, as it is short and easy to administer and analyse.
Gastrointestinal nurses have a responsibility as educators. This educational role covers nursing students, trained and untrained nursing staff. The development of advanced nurse practitioners and specialists in gastrointestinal nursing has led to nurses being involved in medical education and the teaching of other professionals who are allied to medicine. Nurse specialists in inflammatory bowel disease who disseminate both their academic and clinical knowledge in presentations, papers and abstracts are a good example of this widening educational role of gastrointestinal nurses. Through presentation at professional meetings, such as the British Society of Gastroenterology or the Royal College of Nursing Gastroenterology and Stoma Care Nurses Forum, nurses meet the responsibility of expanding current knowledge. Related to education is research in gastrointestinal nursing. Nurses who embark upon research are required to have a sound knowledge of research techniques this facilitates...
The clinical presentation of coeliac disease is highly variable, depending on the severity and extent of small bowel involvement. Symptoms include recurrent attacks of diarrhoea, steatorrhoea, abdominal distension, flatulence and stomach cramps. Coeliac disease is associated with autoimmune disorders (thyroid disease, insulin-dependent diabetes mellitus, IgA deficiency, Down's syndrome and inflammatory bowel disease). The pathology of coeliac disease also varies considerably in severe cases the mucosa looks flat with complete loss of surface villi. Histology shows 'subtotal villous atrophy', accompanied by crypt hyperplasia and an accumulation of plasma cells and lymphocytes in the lamina propria. In cases with less severe atrophy the changes are milder and a few patients may show only partial villous with an increase in the intraepithelial lymphocyte count.
How and why pANCA and cANCA occur is unclear. Their importance lies in their association with Wegener's granulomatosis, pauci-immune glomeru-lonephritis, Churg-Strauss syndrome, other systemic vasculitis syndromes, and inflammatory bowel disease. If a child has unusual symptoms or symptoms that suggest one of these disease, the rheumatologist may test for ANCAs if the antibodies are present, then more extensive testing is indicated. Unfortunately, the
PN is often used when continued use of the gastrointestinal tract may not be advisable. PN may be selected for inflammatory bowel disease patients with severe acute exacerbations or for perioperative care. For patients with Crohn's disease, PN may aid the management of complications such as intestinal obstruction, fistula formation, short bowel syndrome, and severe diarrhea. Otherwise, enteral nutrition support is frequently used for nutrition support in inflammatory bowel disease with comparable efficacy. Perioperative support in severe malnutrition Inflammatory bowel disease and related complications Short bowel syndrome Severe acute pancreatitis
Colonic risk of cancer from inflammatory bowel disease (Crohn's disease and ulcerative colitis) Bayless TM and Hanauer S (eds.) (2001) Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario, Canada BC Decker. Griffiths AM and Bueller HB (2000) Inflammatory bowel disease. In Waker WA, Durie P, Hamilton R, Watkins J, and Walker-Smith J (eds.) Pediatric Gastroenterology Pathophysiology, Diagnosis, Management, 3rd edn, pp. 28-38. Hamilton, Ontario, Canada BC Decker.
Several substances produced by animals and fungi have been investigated for immune-modulating effects. Fish oils are the most studied. As a source of n-3 fatty acids, fish oil consumption by humans has been shown to influence the synthesis of inflammatory signaling molecules like prostaglan-dins, leukotrienes, and cytokines. In addition to direct effects on prostanoid synthesis, n-3 fats have also been shown to directly alter the intracel-lular availability of free calcium ions, the function of ion channels, and the activity of protein kinases. Generally administered as nutraceuticals rather than as functional foods, fish oil supplements have demonstrated anti-inflammatory and immune sup-pressive effects in human adults. A high intake of the n-3 fatty acids eicosapentaenoic (20 5n-3) and docosahexaenoic (22 6n-3) acid (DHA) from seafood or fish oil supplements has also been associated with prevention of several types of cancer, myocardial infarction, ventricular arrhythmias, migraine...
Adolescents with back pain related to JIA are most likely to have either enthesitis-related arthritis (ERA) or psoriatic arthritis. Back pain in these disorders results from inflammation of the spine and or sacroiliac (SI) joints. In contrast to the pattern seen with mechanical back pain, inflammatory back pain is worsened by rest (i.e., morning stiffness), and improved by activity. ERA is more common in adolescent Caucasian boys and in those with a family history of HLA-B27-associated diseases (57,58,84,85). These adolescents often present with enthesitis of the heel or knee, peripheral arthritis, and less commonly acute anterior uveitis (57,83,84). Although adults with ankylosing spondylitis (AS) frequently have inflammatory spinal pain at onset, only a minority of children with ERA (12.8-24 ) has been reported to have pain, stiffness, or limitation of movement of the lumbo-sacral or SI region during the first year of disease (57,83). Instead, most develop back symptoms after 5-10...
Ulcerative colitis and regional enteritis are collectively referred to as inflammatory bowel disease (IBD). It is well known that some children with these diseases have arthritis that typically takes the form of a spondyloarthropathy and which may become evident before the IBD. Studies have demonstrated that many individuals with spondyloarthropathy have an unusual appearance to their gastrointestinal mucosa (lining). Exactly how this relates to developing arthritis is uncertain.
It is not known whether folic acid supplementation can help control these side effects without decreasing the effectiveness of methro-threxate. Low-dose methothrexate is used to treat a variety of diseases, such as rheumatoid arthritis, lupus, psoriasis, asthma, and inflammatory bowel disease. Low-dose treatment can deplete folate stores and cause side effects similar to folate deficiency. In this case, supplemental folic acid may help reduce the undesirable effects of low-dose methothrexate without decreasing treatment effectiveness.
Conditions that cause excessive bleeding additionally compromise iron status. Approximately 1 mg of iron is lost in each 1 ml of packed red blood cells. Excessive losses of blood may occur from the gastrointestinal tract, urinary tract, and lung in a variety of clinical pathologies, including ulcers, malignancies, inflammatory bowel disease, hemorrhoids, hemoglobinuria, and idiopathic pulmonary hemosi-derosis. In developing countries, parasitic infestation with hookworm and schistosomiasis can contribute substantially to gastrointestinal blood loss and iron deficiency.
Additionally, a standard upper gastrointestinal contrast series utilizing barium is required for assessment of anatomy of the gastrointestinal tract. Children with repetitive vomiting or abdominal pain require endoscopic evaluation, and many will also need colonoscopy to rule out the possibility of underlying inflammatory bowel disease. Some children will need cranial imaging, such as computed tomography or magnetic resonance imaging, to search for evidence of intracranial mass lesions, hydrocephaly, or posterior fossa anomalies such as the Chiari malformation. Fiberoptic endo-scopic evaluation of swallowing (FEES) allows for direct visualization of the hypopharynx and larynx during swallowing by use of a flexible laryngoscope. This will allow evaluation of the valleculae and pyriform sinuses as well as the assessment of anatomy during swallowing and potential aspiration problems. This procedure, however, does not provide information on the oral phase of swallowing. FEES may also be...
More than 30 of patients with RP have another associated systemic disease, including necrotizing vasculitis, autoimmune rheumatic disease (rheumatoid arthritis and others), hematologic disorders (especially myelodysplastic syndromes), endocrine disease (Graves' disease and others), inflammatory bowel disease, or another autoimmune disease (Table 1). Additionally, isolated cases have been described following ear piercing and intravenous substance abuse (6,7). How these associated conditions lead to RP is unknown. Tissue inflammation with release of sequestered connective tissue or cell membrane antigenic epitopes leading to an autoimmune response has been postulated.
Spondyloarthropathies, including ankylosing spondylitis, are accompanied by acute anterior uveitis in about one-third of patients during the course of their disease. Anterior uveitis is typically acute in onset and unilateral it lasts four to eight weeks, and subsides without sequelae, if treated early (13). Cervical spondylitis is the other common head and neck manifestation of spondyloarthropathy. Examination of the neck may reveal decreased range of motion in all planes. Temporomandibular joints are affected in about 10 of patients with spondyloarthropathy. Other sites of involvement often include the thoracic and lumbar spine, sacroiliac joints, hip, and shoulder the smaller peripheral joints also can be affected. Spondyloarthropathy occurs in a subset of patients with psoriasis, inflammatory bowel disease, and reactive arthritis.
Digestive ailments such as irritable bowel syndrome or ulcerative colitis are believed to result from, among other factors, an unsuitable diet or chemical imbalances in the metabolic process. IRRITABLE BOWEL SYNDROME (IBS) Irritable bowel syndrome is the most common intestinal disorder. It afflicts 10-20 percent of adults in parts of the developed world, and twice as many women as men. It often starts in early adulthood and, although distressing, is not life-threatening. Formerly known as irritable colon syndrome or spastic colon, IBS tends to be intermittent.
There was only limited information available relevant to biologic plausibility. Colorectal tumors in humans are most commonly adenocarcino-mas that arise in polyps. Multiple risk factors are associated with colon cancer, including familial predisposition, age, obesity, physical inactivity, and inflammatory bowel disease. The potential role of asbestos fibers as a cofactor has not been investigated in epidemiologic or experimental studies. Asbestos bodies and asbestos fibers have been identified in the colon, including for a small cohort of asbestos workers who had colon cancer. Ani
The irritable bowel syndrome (IBS) is a 'functional' disorder of the bowel, which is said to affect up to 15 of the population and is characterized by some, but not necessarily all, of a range of symptoms including abdominal pain relieved by constipation, alternating diarrhea and constipation, recurrent abdominal pain, and urgent or frequent defecation. An important part of management is the exclusion of other serious organic disease such as inflammatory bowel diseases. In IBS the gut is abnormally sensitive to distension, and symptoms may be related to or In inflammatory bowel disease (IBD) high fiber diets have no special part to play in the management of Crohn's disease where enteral feeding (with formula low-residue, low-fiber preparations) is especially beneficial where there is acute extensive small bowel disease. In ulcerative colitis specific dietary advice is usually unnecessary though fiber supplements may be of benefit in patients whose disease is limited to proctitis...
This is one of the most important parts of evaluating children with chronic disease. Many diseases have a tendency to run in families. Often I request extra tests for a disease that I would not initially have suspected because there is a strong family history of the disease. I have discovered children with inflammatory bowel disease long before they were having abdominal symptoms because I requested the appropriate tests when I realized that they had joint pains and a family history of bowel disease. Celiac disease (in which the child cannot tolerate the gluten found in many grains), rheumatic fever, psoriatic arthritis, spondyloarthropathies, and many other diseases tend to run in families.
In the first section of this chapter the measurement of psychosocial well-being will be addressed and this is followed by an examination of the clinical relationship between psychosocial factors and common gastrointestinal conditions, with particular emphasis on inflammatory bowel disease and irritable bowel syndrome. The role of the nurse in the management of psychosocial problems will conclude the chapter.
Hawthorn fruit has been shown to be protective in experimental models of inflammatory bowel disease in mice with restoration of body weight and colon length, increased haemoglobin count, reduced signs of inflammation, such as infiltration by polymorphonuclear leukocytes and multiple erosive lesions, along with improved survival (Fujisawa et al 2005).
Eating disorders should be suspected in any adolescent below normal weight ranges or with recent weight loss, but other medical conditions such as intestinal malabsorption, inflammatory bowel disease, and malignancy should also be considered. It is important to realize that most height and weight charts represent cross-sectional population norms, which may not be as sensitive as longitudinal tracking or height velocity of individuals, since puberty occurs at different ages. For example, a 12-year-old who does not gain weight for 6 months may just be entering puberty, or might be severely affected by growth failure due to a malignancy or inflammatory bowel disease.
Crohn's disease is a chronic inflammatory condition, characterised by periods of remission and exacerbation. It can affect any part of the gastrointestinal tract but occurs most commonly in the terminal ileum. Patients with Crohn's disease develop classical symptoms of diarrhoea and abdominal pain, often associated with weight loss. Crohn's disease and ulcerative colitis are often grouped together under the term inflammatory bowel disease (IBD). The
TNF antagonists have had a dramatic impact on the course and management of several chronic autoimmune diseases, including RA, inflammatory bowel disease, and the spondyloarthropathies. In light of these successes, it was anticipated that TNF antagonists would be of significant value in the management of additional disorders for which similar autoimmune disease mechanisms are well documented, including SS. Early open-label studies suggested that infliximab might be useful for the treatment of constitutional and sicca manifestations of SS. Steinfeld and colleagues33 performed an open-label, pilot trial of infliximab on 16 patients who had active SS who met AECC and who were not receiving oral DMARDs. All patients received three infusions of infliximab (0, 2, and 6 weeks) (dose of 3 mg kg) and were studied through week 14. All patients demonstrated improvement in physician and patient global assessment, tender joint counts, and fatigue. USF remained significantly improved at all...
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Curing Irritable Bowel Syndrome
Everyone has an upset stomach from time to time. You probably know the sort of thing I mean – sometimes you’ve got gas and at other times you feel queasy or nauseous. There may be times<br />when you can’t seem to go to the toilet for days, constipated as can be, but there are other days when diarrhea strikes and you can’t stop going!