Healthy Pilot #7: Sensitive Gut

The stomach is often called a second brain—connected, as it were, to the first brain by the vagus nerve. Although your stomach may play second fiddle, when it comes to your personal domain, it’s often supreme ruler. That’s why dealing with dyspepsia can be the first order of business prior to any flight. Matters of the gut are so important the FAA has placed “Stomach, liver or intestinal trouble” as item 18i on the Basic Med checklist.

For this installment of Healthy Pilot, we’ve once again turned to our friends at sister site University Health News, the health information mother lode sourced by America’s leading medical schools and hospitals.

UHN offers a free guide called Abdominal Pain that covers the major ailments of the alimentary canal, that wondrous collection of connected organs that transfers nutrients from food to the brain and other organs. From mastication at the top, to waste removal at the bottom, your gastrointestinal machinery processes the materials that sustain life. It offers pleasure when you tuck into a good steak, and pain when things go awry.

Here are just some of the issues we humans have to contend with. The disorders listed may be merely annoying, or persistent, painful conditions that need medical attention. A quick review may offer talking points for you and your doctor.

Acid Stomach

Gastro-esophageal reflux disorder, or GERD, is very often the first telltale signs of a sensitive gut. The sphincter at the bottom of the esophagus gets a little loose over time and stomach acid backs up into the plumbing above it. You’ll notice this heavy, burning sensation, particularly at night. Often, relieving symptoms is nothing more complicated than elevating your head with a second pillow. If GERD makes an infrequent visitation, tamping it down with an antacid might resolve the issue.

More persistent cases of GERD may need an over-the-counter omeprazole (trade name Prilosec; others). But there are side effects to these so-called proton pump inhibitors (ppi), so be advised. GERD that’s not easy to resolve requires a doctor’s attention, and the prospect of a closer inspection using an endoscope (think bore scope for the gut).

The stomach is the gut’s epicenter, the tool that quietly breaks down masticated food into the gruel that gets further processed downstream. The classic “stomach ache” can be any number of things—a microbial infection from tainted food, gas or bloating from overconsumption, or, more seriously, gastritis, an inflammation of the stomach lining. UHN advocates placing limitations on caffeine, alcohol, and salty foods if gastritis is suspected. The most common symptoms of gastritis are upset stomach, indigestion, and pain in the upper abdomen that can radiate to the back. Other symptoms are belching, nausea, vomiting, loss of appetite, a feeling of fullness, or burning sensations in the upper abdomen.

Treatment for gastritis will depend on the cause. If H.pylori is the culprit, antibiotic drugs will be prescribed. For most types of gastritis, drugs to reduce stomach acid are also prescribed to promote healing.

Ulcers

Stomach ulcers are not uncommon from middle age and beyond. A peptic ulcer is a sore that forms in the lining of the stomach (gastric ulcer) or the first section of the small intestine (duodenal ulcer). Gastric ulcers can occur anywhere in the stomach but are most common in the lower part of the stomach (called the antrum). Duodenal ulcers occur in the first few inches of the small intestine (the duodenum).

Ulcer symptoms usually begin with a burning sensation in the upper to middle abdomen within one to two hours after a meal. Other symptoms of an ulcer may include:

• Pain that feels like a dull, gnawing ache
• Pain that is intermittent or constant, lasting for days to weeks at a time before subsiding
• Pain that strikes in the middle of the night, or any other time the stomach is empty
• Pain that decreases after meals

Ulcer treatment can be highly effective. The three goals to treat ulcers caused by bacteria are to reduce stomach acid, protect the stomach lining, and kill the bacteria. This triple therapy allows the ulcer to heal and lowers the chance that it will come back. Antibiotics are used to destroy the bacteria. Reducing stomach acid is generally accomplished with short-term use of a proton pump inhibitor (see above), plus sucralfate or bismuth, typical medications to protect the stomach lining.

Liver, Pancreas, Spleen – the Mid-Gut

The liver, pancreas, spleen normally cause very little trouble, quietly cooperating to deliver fluids to aid in digestion, emulsify fat or cleanse the blood.

If there is a glitch in this well-operating system, the culprit is usually the gallbladder. The gallbladder is a small, pear-shaped pouch beneath the liver. The liver produces bile (a combination of water, acid, cholesterol, bilirubin, and lecithin), to digest fats in the small intestine. As the bile is produced, the gallbladder stores it until needed. When you eat fat, the gallbladder sends bile through a system of tubes (called ducts) leading into the small intestine, where it breaks up fat.

If there is too much cholesterol or bilirubin in bile, it can form crystals that clump together into gallstones. A problem arises when a gallstone gets caught in a duct and blocks the normal flow of bile. This causes inflammation of the gallbladder, a condition called cholecystitis.

Symptoms of gallstones

• Severe pain in the upper-right side of the abdomen (called biliary colic) that waxes and wanes and lasts from 30 minutes to several hours
• Pain that radiates to the back, between the shoulder blades, and under the right shoulder
• Nausea or vomiting
• Sweating, fever and chills
• Clay-colored stools
• Dark-colored urine

Common Pancreatic Problems

Pancreatitis is an inflammation of the pancreas that can be either short-lived (acute) or long lasting (chronic). While chronic pancreatitis tends to be more serious, either type can cause dangerous complications. Excessive alcohol is known to cause pancreatitis. Or a gallstone from the gallbladder may lodge in the bile duct in such a way that it blocks the pancreatic duct, trapping digestive enzymes inside. The enzymes may begin to digest pancreatic tissue, leading to inflammation.

In addition to gallstones and alcohol, acute pancreatitis can also result from certain types of prescription drugs, which raise the risk of pancreatitis.

Symptoms of acute pancreatitis include pain in the upper abdomen that comes on gradually or suddenly and lasts a few days. The pain may radiate to the back. Sometimes pain worsens after eating. Other symptoms are nausea, vomiting, fever, and rapid pulse. Severe cases may impact the heart, lungs, or kidneys. With a chronic condition, symptoms include nausea, vomiting, weight loss, and greasy or oily stools.

Common Liver Problems

When liver tissue becomes inflamed, thickened, and scarred, it cannot preform its essential function. The body cannot survive without the liver processes.

Alcoholism damages the liver by impeding the metabolism of protein, fats, and carbohydrates. It is the leading cause ofcirrhosis followed by hepatitis C in the U.S. and hepatitis B worldwide. Other causes for cirrhosis are rare.

In the early stages there are few symptoms. As it advances, symptoms of fatigue, weakness, weight loss, abdominal pain, and spider-like veins on the skin appear. Eventually, edema (swelling) affects the legs and trunk, and the skin and eyes take on a yellow tone from jaundice.

Hepatitis is an inflammation of the liver generally caused by viral infection. Certain medications, such as acetaminophen (Tylenol), can cause drug-induced hepatitis. An inflamed liver becomes swollen and tender, which can impair or permanently damage the organ.

The hepatitis viruses are identified as A, B, C, D, and E. Any of these viruses can cause short-term (less than six months) inflammation of the liver. Hepatitis A, B, and C may cause no symptoms or just flu-like symptoms (fatigue, nausea, fever, loss of appetite, stomachache, and diarrhea). Some people have dark-yellow urine, light-colored stools, or yellowish eyes and skin. Hepatitis A, B, and C can be detected with a blood test.

Hepatitis A is spread by personal contact or consuming food or water contaminated with human saliva or feces from someone infected with the virus. This is a problem in parts of the world with poor sanitary conditions so travelers in such regions are at risk. Hepatitis A can be prevented with a vaccine.

Hepatitis B can be contracted through contact with the blood, semen, or other body fluid of an infected person. People who travel to countries where hepatitis B is common are at risk of infection but there is a vaccine to prevent infection. Hepatitis B infection can resolve on its own without any treatment. However, sometimes the infection is chronic, and leads to serious liver damage, like cirrhosis.

Hepatitis C is transmitted through contact with the blood of an infected person. This generally occurs when drug users share needles. Hepatitis C is not spread by casual contact. People who had blood transfusions before 1992 are at risk because prior to that there was no test to check blood for the virus. The infection may resolve itself within a few months, but about 75 percent of patients become chronic.

Small Intestine Problems

The small intestine is approximately 20 feet long and connects the stomach to the large intestine. It does most of the digestive work, breaking down food matter and absorbing the majority of available nutrients. Issues involving the small intestine can include the following:

Lactose intolerance:During normal digestion, lactose, the predominant sugar in dairy products, is broken down in the small intestine into glucose to be used by the body. An enzyme called lactase, produced in the small intestine, is responsible for breaking down lactose. In lactose intolerance, there is a shortage of the lactase enzyme.

Lactose intolerance is not dangerous, but it can cause great discomfort. Undigested lactose ferments in the small intestine or colon and can cause such symptoms as nausea, cramps, bloating, gas, and diarrhea. The symptoms usually occur about 30 minutes to two hours after eating or drinking foods containing lactose.

Lactose intolerance can’t be cured, but avoiding or limiting milk products manages it. Lactase enzymes are also available to prevent the symptoms for people who react to even small amounts of lactose and wish to continue eating dairy. These are available without a prescription.

Celiac Disease:An essential process in digestion is the absorption of nutrients from the small intestine into the bloodstream. Disorders that interfere with this are called malabsorption disorders, and one of the most common is celiac disease. This condition, also called sprue, is where damage to the small intestine impedes absorption. The damage occurs when the immune systems mistakes the protein gluten for a dangerous intruder and attacks it. This causes inflammation that irritates and damages the small intestine.

Symptoms of celiac disease

• Chronic diarrhea
• Anemia (iron deficiency)
• Recurring abdominal bloating, gas, and pain
• Weight loss
• Bone and joint pain
• Muscle cramps
• Pale, foul-smelling stool
• Behavior changes
• Tingling and/or numbness in the legs
• Fatigue
• Mouth sores
• Itchy skin rash (called dermatitis herpetiformis)
• Seizures

If celiac disease is suspected, your physician can make the diagnosis with a blood test and possibly an endoscopic biopsy. The blood test can show whether the body’s immune system is making antibodies against gluten or other enzymes involved in the disease process. Antibodies are substances that are produced by the body to attack threatening invaders. Gene testing to help identify a genetic predisposition to the disease is also available.

The treatment for celiac disease is to avoid all gluten. Once gluten is removed from the diet, immune reaction to gluten is reduced and the inflammation resolves. The small intestine begins to heal, and absorption of nutrients goes back to normal. For older adults, the small intestine should be completely healed after two years on a gluten-free diet.

Large Intestine Problems

The large intestine, also known as the colon, is a multi-layered tube approximately 5 feet long that absorbs liquid from the waste material passed down from the small intestine. The bacteria that live in the large intestine take in any remaining nutrients in the stool before it moves into the rectum to be expelled through the anus.

Constipation:As undigested food passes through the colon, water is absorbed to form the solid waste (stool). If not enough water is removed diarrhea will result. If too much water is removed, the stool becomes hard, dry, and difficult to pass out of the body—constipation.

Many people believe they are constipated if they don’t have a bowel movement every day. In fact, the frequency of bowel movements considered normal ranges from three times a day to three times a week.

Constipation means passing small amounts of hard, dry stool, usually less than three times a week, and straining to have a bowel movement. Other symptoms are bloating, general discomfort, and sluggishness. Like diarrhea, constipation is very common and usually lasts only a short time. Even so, constipation accounts for about 2 million doctor visits each year in the United States.

Common laxative treatments

• Bulk or fiber laxatives (Metamucil, Citrucel, Fibercon, and Benefiber) serve to hold water in the intestines and soften stool. Patients using these must drink at least eight glasses of fluid (water, juice, milk, coffee or tea) per day to avoid side effects.
• Osmotic laxatives (Milk of Magnesia and MiraLax,) cause the intestines to secrete water into the colon to make stool soft. These also require adequate fluid intake.
• Stool softeners (Colace and Surfak) provide moisture to the stool.
• Stimulants (Correctol, Dulcolax, and Senokot) cause intestinal muscle contractions to help move the stool more quickly. Long-term use is not recommended.

A low-fiber diet, not drinking enough fluids, and lack of exercise are common causes of constipation. Many medications can cause constipation, including pain medications (opioids), antacids that contain aluminum and calcium, calcium channel blockers (for lowering blood pressure), anti-Parkinson’s drugs, antispasmodics, antidepressants, iron supplements, diuretics, and anticonvulsants.

Irritable Bowel Syndrome (IBS):About 10 to 15 percent of Americans suffer with irritable bowel syndrome (IBS). Characterized by symptoms such as cramp-like abdominal pain, bloating, diarrhea, and constipation, IBS can be uncomfortable and distressing. However, it does not cause permanent harm to the intestines, nor does it lead to intestinal bleeding or serious disease such as cancer.

What makes IBS worse?

• Large meals
• Wheat, rye, barley, chocolate, milk products, alcohol
• Caffeine
• High levels of fructose
• Carbohydrates in foods like wheat, beer, garlic, onions, artichokes, asparagus
• Sugar alcohols such as sorbitol, fruits, cabbage, beans, lentils, and soy
• Insoluble fiber found in wheat and bran
• Large amounts of fat
• Women with IBS may experience more symptoms during their menstrual periods, suggesting that reproductive hormones can exacerbate IBS.

Inflammatory Bowel Disease (IBD):Inflammatory bowel disease (IBD) is a collective term for abnormal immune system activity in the intestines that leads to inflammation. The two major diseases are ulcerative colitis and Crohn’s disease.

Ulcerative colitis causes inflammation and ulcers in the inside lining of the large intestine (rectum and colon). It affects just the top layer of the intestinal lining (called the mucosa). Crohn’s disease also causes inflammation, usually in the small intestine, but it can affect all areas of the gastrointestinal tract (mouth to anus). Crohn’s disease affects all four layers of the intestinal wall.

The exact cause of IBD is unknown, but some interaction between hereditary factors, environment, and the immune system is probably at work. It’s theorized that the body’s immune system reacts inappropriately to viruses or bacteria in the intestines. The immune system mistakes these for foreign invaders and launches an attack by sending white blood cells to the intestinal lining. This produces inflammation that becomes chronic, damaging the intestine. This reaction is thought to occur in people genetically predisposed to IBD.

The main symptoms of ulcerative colitis are cramp-like abdominal pain on the lower-left side and bloody diarrhea. Loss of appetite, weight loss, nausea, anemia, and fatigue also are common.

Crohn’s symptoms vary depending upon severity and which part of the intestine is affected, but generally include abdominal pain, diarrhea, and bloating. People with either type of IBD also can have symptoms outside the digestive system, such as joint inflammation (arthritis), eye inflammation, or skin, liver, or kidney problems. These symptoms are probably caused by the abnormal immune system response in these patients.

Diverticulosis and Diverticulitis:Diverticulosis is a condition where pockets form in the lining of the colon. Diverticulitis occurs when those pockets become infected and enflamed.

Half of Americans older than age 60 have diverticulosis, a condition where small pouches (about the size of large peas), called diverticula, bulge outward from the colon. Diverticulosis is not a disease in itself, but if the diverticula become inflamed or infected, it becomes diverticulitis and requires treatment. From 10 to 25 percent of people with diverticulosis develop diverticulitis.

Although the exact cause is unknown, it’s thought that diverticulosis results from a low-fiber diet. It is more common in industrialized countries, such as the United States, England, and Australia. It is uncommon in Asia and Africa, where people eat diets higher in vegetable fiber.

If diverticula become inflamed or infected, it can cause fever, pain or tenderness in the lower left abdomen, and a change in bowel function or blood in the stool. It is unknown why diverticula become infected, but it may stem from stool or bacteria getting caught in the pouches.

As diverticulitis symptoms can also mimic inflammatory bowel disease or infectious gastroenteritis, the doctor will likely perform a CT scan with contrast, to diagnosis the disease.

Diverticulitis is treated with antibiotics and pain relievers. A short stay in the hospital is sometimes required. In a few cases, diverticula burst and require surgery. Surgery may also be necessary if an infection is persistent or very severe.

Hemorrhoids:The word “hemorrhoid” is a medical term for the tissue cushions surrounding blood vessels in the anal area. What most consider a hemorrhoid when anal tissue prolapses through the sphincter muscle, exposing the delicate lining of the rectum. This can lead to bleeding, itching, and irritation.

Hemorrhoids can either be inside the anus (internal) or under the skin around the anus (external). The chief symptom of internal hemorrhoids is bright-red blood on your toilet tissue or in the toilet bowl. If the hemorrhoid protrudes through the anus, it may become irritated and painful. External hemorrhoids may not produce any symptoms unless a blood clot forms within the tissue. In this case, there may be painful swelling or a hard lump may form around the anus.

Increasing hemorrhoid risk

• Straining to expel stools
• Extended time spent standing or sitting
• Chronic constipation
• Passing hard, dry, small stools
• Diarrhea symptoms
• Laxative abuse

A diagnosis will require an examination of the anus and rectum and the doctor may need to use an anoscope (a lighted tube useful for viewing internal hemorrhoids), a proctoscope (which can be used to examine the entire rectum), or a sigmoidoscope (to view both the rectum and lower colon).

Careful cleansing of the anal area is also important, daily and after each bowel movement, while sitz baths (warm-water baths that cover only the hips and buttocks) may be soothing. Using cold compresses and topical creams on the area can ease pain. Procedures in the doctor’s office include tying off the hemorrhoid so it will fall off on its own or sclerotherapy, an injection that will shrink the hemorrhoid. Only about 10 percent of patients need more invasive surgery.