Constipation in Adults Overview

Constipation in Adults Overview

Constipation refers to a decrease in the frequency of bowel movements or difficulty in passing stools. The stool of a constipated person is typically hard because it contains less water than normal. Constipation is a symptom, not a disease.

Generally, constipation is difficult to define clearly because as a symptom it varies from person to person. In addition, because we generally don't discuss the frequency of our bowel movements or observe each other having them, it is often difficult for people to know whether they are having less frequent stools, or experiencing increased difficulty in moving their bowels than others.

• The "normal" frequency of bowel movements varies greatly, ranging from 3 movements per day to 3 per week. Such variation may occur among cultures and groups of people, among individuals, or even for an individual person without necessarily being a sign of disease. However, if a person has had a generally even frequency of bowel function that changes acutely and persists in its new form for longer periods of time, this may be a reason to consult a physician. Generally, if a person has not moved the bowels for 3 successive days, the intestinal contents harden, and the person experiences difficulty or even pain during defecation, medical care should be sought.
• A common misconception about constipation is that wastes stored in your body are absorbed, are dangerous to your health, and may shorten your life-span. Some people have an underlying fear that they will be "poisoned" by their own intestinal wastes (feces) if they retain the waste in their bodies for more than a certain length of time. None of this is true. There is little evidence that "colonic cleansing" improves health in individuals with normal bowel function.
• Older people are five times more likely than younger people to complain about the onset of new constipation.

Constipation in Adults Causes

Constipation may result from a poor diet, poor bowel habits, or problems in elimination of stool, whether physical, functional, or voluntary.

These are the most common causes of constipation:

Poor diet: Eating foods rich in animal fats (dairy products, meats, and eggs) or refined sugar but low in fiber (whole grains, fruits, and vegetables) .

Inadequate fluid intake: Not drinking enough water can lead to hard dry stools. Fluid is absorbed in the intestine, and people who don't drink enough water may not pass enough water into the colon to keep their stools soft.

Caffeine and alcohol: These induce increased urination of water. This leads to (relative) dehydration that increases water absorption from the intestine. This can in turn lead to constipation when not enough fluid is retained in the stool.

Poor bowel habits: Ignoring the desire to have bowel movements may initiate a cycle of constipation.

• After a period of time, the person may stop feeling the desire to move the bowels.
• This leads to progressive constipation. For example, some people may avoid using public toilets or ignore going to the toilet because they are busy.

Medications: Many medications can cause constipation.

• Antacids that contain aluminum hydroxide (Alternagel, Alu-Cap, Alu-Tab, Amphojel, Dialume) and calcium carbonate (Rolaids, Mylanta, Maalox, Tums, etc.)
• Antispasmodic drugs
• Antidepressants
• Iron tablets
• Anticonvulsant drugs
• Diuretics (because they can work like caffeine and alcohol as mentioned previously)

• Painkillers, narcotic-containing drugs, for example, may suppress bowel function.

Travel: Changes in lifestyle, low fluid intake, and eating fast food may cause constipation.

Irritable bowel syndrome (IBS, spastic colon):  Because of changes in bowel function, if a person has this disorder, he or she may have crampy abdominal pain, excessive gas, bloating, and constipation, sometimes alternating with diarrhea.

Laxative abuse: Habitually using laxatives will gradually produce dependency on them.

• The person may eventually require increasing amounts of laxatives to move the bowels.
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• In some instances, the bowel will become insensitive to laxatives and the person will not be able to move the bowels even with laxatives.

Pregnancy: Constipation during pregnancy may be due to several factors. Each of the following conditions produces severe pain on defecation, which may trigger a reflex spasm of the anal sphincter muscle. The spasm may delay bowel movement and decrease the desire for bowel opening as a means to avoid the anal pain.

• Mechanical pressure on the bowel by the heavy womb
• Hormonal changes during pregnancy
• Changes in food and fluid intake
• Anal fissure (cracks in the anus)
• Painful hemorrhoids (piles)
• Anal stenosis (narrow anus)

Intestinal obstruction: Mechanical compression and interference with the normal functions of the bowel may occur in the following ways:

• Scarring of the intestine from inflammation due to diseases such as diverticulitis or Crohn's disease (an inflammatory bowel disease)
• Inflammatory adhesions and joining of tissues
• Intestinal cancers
• Abdominal hernia, loops of the intestine become obstructed
• Gallstones that have become immovably wedged in the intestine
• Twisting of the intestine upon itself (volvulus)
• Foreign bodies (swallowed or introduced into the intestine from the anus)
• Intussusception refers to "telescoping of the intestine" in which one part of the intestine is drawn into another part (This occurs mainly in children.)
• Postoperative adhesions (internal scarring after previous abdominal surgery) can block the small intestine and cause the inability to pass gas or move the bowels, but relatively rarely blocks the large intestine (colon).

Mechanical problems of the anus and rectum (the bottom part of the colon) that includes the rectum pushing out the anus (rectal prolapse) or into the vagina.

Damage to nerves within the intestine: (Spinal cord tumors, multiple sclerosis, or spinal cord injuries may produce constipation by interfering with the function of the nerves supplying the intestine.)

Connective tissue diseases: Conditions such as scleroderma and lupus

Poor-functioning thyroid gland: A low production of thyroxin, a hormone produced by the thyroid gland, hypothyroidism, causing constipation

Lead poisoning and other metabolic disorders

Age: Older adults are more likely to have constipation for the following reasons:

• Poor diet and insufficient intake of fluids
• Lack of exercise
• Side effects of prescription drugs used to treat other conditions
• Poor bowel habits
• Prolonged bed rest, for example after an accident or during an illness
• Habitual use of enemas and laxatives

It should be noted that although that this is a long list of possibly scary causes of constipation, most chronic constipation is simply from inadequate intake of dietary fiber and water, and can be managed by substantially increasing the intake of both.

Constipation in Adults Symptoms

An individual may exhibit a broad range of symptoms of constipation depending on his or her normal bowel habits, diet, and age. These are common problems a person may have if he or she is constipated:

• Difficulty in starting or completing a bowel movement
• Infrequent and difficult passage of stool
• Passing hard stool after prolonged straining
• If the person has irritable bowel syndrome (IBS), crampy abdominal pain, excessive gas, a sense of bloating, and a change in bowel habits
• If the person has an intestinal obstruction, nausea, vomiting, no defecation, and inability to pass gas
• Distended abdomen, headaches, and loss of appetite
• Coated (furred) tongue, bad breath (halitosis), and bad taste in the mouth

When to Seek Medical Care for Constipation

Call your health care practitioner if you have these concerns:

• Symptoms are severe and last longer than 3 weeks
• Recent and significant change in bowel habits, for instance, constipation alternates with diarrhea
• Severe pain in the anus during a bowel movement
• Symptoms of other diseases in addition to constipation (for example, tiredness, fatigue, poor tolerance to cold weather may suggest the need to assess thyroid function for hypothyroidism, an underactive gland.)
• Constipation for 2 weeks or longer with returning abdominal pain, which might be a sign of lead poisoning

When to seek emergency medical care

Although constipation may be extremely uncomfortable, it is usually not serious. It may signal a serious underlying disorder, however, such as cancer of the bowel. Because constipation may lead to complications, go to a hospital's emergency department for any of the following reasons:

• Rectal bleeding
• Anal pain and hemorrhoids
• Anal fissures or cracks in the mucous lining (severe pain during defecation in the anal area)
• Fecal impaction (immovable intestinal contents) in very young children and in older adults
• Rectal prolapse or sagging (Occasionally, straining causes a small amount of the intestinal lining to push out from the rectal opening. This may lead to secretion of mucus that may stain the undergarments.)
• Recurrent vomiting with constipation and abdominal pain (This may suggest intestinal obstruction and needs urgent hospital treatment.)
• Severe abdominal pain with the constipation that is constant and worsening, especially if it is accompanied by a fever.

Constipation in Adults Diagnosis

Your health care practitioner may ask the affected individual several questions, conduct a physical exam, and perform certain lab tests to find out the possible causes of his or her constipation.

Answers to these questions will help the doctor assess the affected person's condition and plan treatment options.

• What are your normal bowel habits?
• How long have you had difficulty in passing stool?
• When was the last time you passed stool?
• Are you able to pass gas?
• Do you experience any abdominal or anal pain?
• Could you indicate with your finger the site of your pain?
• How would you describe your abdominal pain?
• Have you noticed any changes in your body temperature?
• Have you tried any medication? Did it help?
• Do you usually take laxatives or an enema? If yes, what type of laxatives and how many tablets per day do you usually take?
• Do you feel that you always need laxatives to pass stool?
• Do you have any other symptoms?
• Any changes in your appetite?
• Any changes in your body weight?
• Do you feel better after passing stools?
• Do you feel sick? Have you thrown up?
• Any hospital admission or investigations for similar illness?
• Are you pregnant?
• Do you smoke cigarettes? When did you start smoking? How many cigarettes do you smoke per day?
• Do you drink alcohol? Coffee? Tea?
How much?
• Do you use drugs? Any medications?
• Have you ever had surgery? What surgery? When?
• Any joint pain, eye problems, back or neck pain, or skin changes?
• Do you usually prefer the warm weather?
• Do you usually feel tired?
• Do you have a family history of constipation or bowel cancer?
• Have you ever been screened for colon cancer?

The health care practitioner will examine the patient's abdomen, anus, and other body systems including the nervous system, the thyroid gland (for any goiter), and the musculoskeletal system. What the health care practitioner examines will depend on the patient's answers to the questions and any history that may suggest certain disorders.

The health care practitioner will decide which tests the patient needs based on his or her symptoms, history, and exam. These tests will help assess the actual cause of the problem. The most commonly used tests may include the following:

Lab Tests

• Examining a stool sample under a microscope
• Complete blood count (CBC) and blood film
• Thyroid function tests if hypothyroidism is suspected

Imaging

• Upright plain X-ray of the chest and abdomen may show free air from intestinal perforation or signs of intestinal obstruction
• Barium enema may reveal a disease of the colon
• Assessment of food movement may demonstrate a prolonged and delayed transit time

Procedures

• Sigmoidoscopy may help to detect problems in the rectum and lower colon. The doctor will insert a flexible lighted instrument through the anus to visualize the rectum and the lower intestine.
• Colonoscopy uses an internal examination, your doctor can suspect the diagnosis of irritable bowel syndrome by ruling out more serious disorders. The doctor also may take tissue biopsies for further studies to assess the cause underlying your symptoms.

Constipation in Adults Treatment

If the patient's bowel is not blocked, realistic goals of medical treatment must be established between the patient and health care practitioner.

• All cases will require dietary advice. Treatment may be difficult, particularly in those with chronic constipation.
The doctor may prescribe bulk-forming agents in addition to dietary changes.
• Increased activity in the elderly and regular exercise in younger people will help.

Constipation in Adults Self-Care at Home

• Fiber: Get more fiber or bulk in the diet. If this cannot be done adequately by diet changes, consider adding a fiber supplement to the diet. There are many of these available, including psyllium (Metamucil) and methylcellulose (Citrucel). In general, these fiber supplements are not drugs and are safe and effective if taken together with sufficient water. They are not laxatives and must be taken regularly (whether you are constipated or not) in order for them to help you avoid future constipation. They are generally taken suspended in a glass of water one to three times daily. Start with once daily, and increase to twice daily after a week, and then to three times daily after another week if necessary.
• Exercise: Regular physical activity is an important component in bowel health. Try a daily exercise such as the knee-to-chest position. Such positions may activate bowel movements. Spend about 10-15 minutes in this position. Breathe in and out deeply.
• Hydration: Drink plenty of fluids, especially water and fruit juices. Drink 6-8 glasses of water daily in addition to beverages with meals.
• Alcohol and Caffeine: Decrease alcohol intake and caffeinated beverages, including coffee, tea, or cola drinks. In general, it is a good idea to have an extra glass of water (over and above the 6 to 8 daily mentioned previously) for every cup of coffee, tea, or alcoholic drink.
• Bowel Hygiene: Go to the toilet at the same time every day, preferably after meals, and allow enough time as not to strain.
• Laxatives: Avoid using over-the-counter laxatives. Try to avoid laxatives containing senna (Senokot) or buckthorn (Rhamnus purshiana) because long-term intake may damage the lining of the bowel and injure nerve endings to the colon.

Constipation in Adults Medications

If these initial measures fail, the health care practitioner may try a number of laxatives on a short-term basis. The patient must consult with his or her doctor before using any of these agents, particularly on long-term basis.

• Mineral oils can be very helpful in the short-term, but are associated with health risks for long-term use. They also can cause substantial diarrhea if too much is taken.
• Sodium docusate or calcium docusate may be useful when the patient must avoid straining for a short period of time, such as after a heart attack, during pregnancy, or after gastrointestinal surgery. They often will lose their effectiveness after several days.
• Fiber supplements as mentioned previously.

A doctor will treat any underlying diseases (intestinal obstruction, anal fissure, hemorrhoids, and bowel cancer).

• If the patient has irritable bowel syndrome (IBS), he or she should stop smoking and avoid coffee and milk-containing foods. A food diary may help to identify foods that seem to worsen the symptoms.
• Thyroxin will be prescribed if the doctor determines through clinical and laboratory tests that the patient has an underactive thyroid gland (hypothyroidism).

Constipation in Adults Home Remedies

Aloe juice and aloe latex have been used as laxatives, but should not be confused with aloe vera gel used for wound healing or sunburn. The FDA rules that aloe is not safe as a stimulant laxative. Rhubarb or any tonics containing it are also not proven safe as a laxative.

NOTE: If you choose to use remedies involving homeopathy, herbs, dietary and nutritional supplements, acupressure, aromatherapy, and other alternative or complementary healing methods, be advised that these products and techniques have usually not been scientifically proven to treat, prevent, or cure any disease. Serious interactions with prescription and nonprescription medications are always a possibility. Keep your doctor informed about every medication or medicine-like substance you use and seek medical advice before taking any medication or remedy.

Constipation in Adults Follow-up

• If the person has specific disorders such as hypothyroidism, scleroderma, and lupus, he or she may require regular follow-ups with a health care practitioner.
• Elderly people with a history of fecal impaction and fecal incontinence should be followed regularly to ensure that they do not develop further attacks.
• Young people with anorexia nervosa need a team of specialists to assess and follow the underlying illness, as well as to provide support and education.

Constipation in Adults Prevention

• Develop regular bowel habits. Set aside time before or after breakfast to use the toilet.
• Do not ignore the desire to defecate. Answer nature's call to empty your bowel as soon as possible.
• Eat a well-balanced diet that includes wheat grains, fresh fruits, and vegetables. Recent evidence suggests that increasing dietary fiber intake may help some people with hard stools, but is not necessarily of benefit in every person with constipation.
• Drink plenty of water and fruit juice.
• Exercise regularly. Walking is especially important.
• Avoid intake of medications that may cause constipation. Your doctor or pharmacist can help you in this regard.
• The use of laxatives can make a constipation problem worse in the long-term and should be avoided.

Constipation in Adults Prognosis

Most people with constipation have no physical disease of the digestive system nor any widespread disease associated with constipation. Most of the time, constipation is related to poor dietary habits, low fluid intake, and lack of exercise.

• For people with constipation caused by illness, recovery will be determined by how sick the affected individual is.
• The person will usually recover well if his or her constipation is caused by hemorrhoids or anal fissures.

Irritable Bowel Syndrome

Irritable Bowel Syndrome Overview

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder of unknown cause. Common symptoms include abdominal cramping or pain, bloating and gassiness, and altered bowel habits.

Irritable bowel syndrome has also been called spastic colon, functional bowel disease, and mucous colitis. However, IBS is not a true "colitis." The term colitis refers to a separate group of conditions known as inflammatory bowel disease (IBD).

Irritable bowel syndrome is not contagious, inherited, or cancerous. It is estimated that 20% of adults in the U.S. have symptoms of IBS. It occurs more often in women than in men, and the onset occurs before the age of 35 in about half of the cases.

Irritable Bowel Syndrome Causes

The cause of irritable bowel syndrome is currently unknown. IBS is thought to result from an interplay of abnormal gastrointestinal (GI) tract movements, increased awareness of normal bodily functions, and a change in the nervous system communication between the brain and the GI tract. Abnormal movements of the colon, whether too fast or too slow, are seen in some, but not all, people who have IBS.

Irritable bowel syndrome has also developed after episodes of gastroenteritis.

It has been suggested that IBS is caused by dietary allergies or food sensitivities, but this has never been proven.

Symptoms of irritable bowel syndrome may worsen during periods of stress or menses, but these factors are unlikely to be the cause that leads to the development of IBS.

Irritable Bowel Syndrome Symptoms

Irritable bowel syndrome affects each person differently. The hallmark of IBS is abdominal discomfort or pain. The following symptoms are also common:

• Abdominal cramping and pain that are relieved with bowel movements
• Alternating periods of diarrhea and constipation
• Change in the stool frequency or consistency
• Gassiness (flatulence)
• Passing mucus from the rectum
• Bloating
• Abdominal distension

The following are NOT symptoms or characteristics of IBS (but should still be brought to the attention of a physician since they may be signs and symptoms of other conditions):

• Blood in stools or urine
• Black or tarry stools
• Vomiting (rare, though may occasionally accompany nausea)
• Pain or diarrhea that interrupts sleep
• Fever
• Weight loss

When to Seek Medical Care

If a person has any of the symptoms of IBS as discussed previously, or if a person with known IBS has unusual symptoms, a health care practitioner should be consulted. Go to a hospital emergency department if problems are severe and/or come on suddenly.

Irritable Bowel Syndrome Diagnosis

Irritable bowel syndrome can be a very difficult diagnosis to make. IBS is called a diagnosis of exclusion, which means a doctor considers many other alternatives first, performing tests to rule out other medical problems. Some of these tests may include laboratory studies, imaging studies (such as a CT scan or small intestinal X-rays), or a lower GI endoscopy (colonoscopy). An endoscopy is a procedure in which a flexible tube with a tiny camera on one end is passed into the GI tract while the patient is under conscious sedation.

• A combination of history, physical examination, and selected tests are used to help diagnose irritable bowel syndrome.
• No single blood test or x-ray study confirms a diagnosis of IBS.

Irritable Bowel Syndrome Treatment

Irritable Bowel Syndrome Self-Care at Home

Many people may have already modified their diets before seeing a doctor. Temporarily avoiding dairy products may help assess whether symptoms of lactose intolerance are mimicking those of irritable bowel syndrome. Persons who avoid dairy products should exercise and consider taking calcium supplements.

• Certain foods, such as cruciferous vegetables (cauliflower, broccoli, cabbage, brussels sprouts) and legumes (beans) may worsen bloating and gassiness.
• Dietary fiber may lessen symptoms.
• Individuals with IBS should drink plenty of water, and avoid soda, which may cause gas and abdominal discomfort.
• Eating smaller meals may lessen the incidence of cramping and diarrhea.
• Low fat and high carbohydrate meals such as pasta, rice, and whole grain breads may help IBS symptoms (unless the affected individual has celiac disease).

Medical Treatment

Most people with irritable bowel syndrome have problems only occasionally. A few may experience long-lasting problems and require prescription medications.

• A common treatment for IBS is the addition of fiber to the diet. This theoretically expands the inside of the digestive tract, reducing the chance it will spasm as it transmits and digests food. Fiber also promotes regular bowel movements, which helps reduce constipation. Fiber should be added gradually, because it may initially worsen bloating and gassiness.
• Stress may cause IBS "flares." Doctors may offer specific advice on reducing stress. Regularly eating balanced meals and exercising may help reduce stress and problems associated with irritable bowel syndrome.
• Smoking may worsen symptoms of IBS, which gives smokers another good reason to quit.
• Since many patients with irritable bowel syndrome report food intolerances, a food diary may help identify foods that seem to make IBS worse.
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Medications

• Antispasmodic medicines, such as dicycomine (Bemote, Bentyl, Di-Spaz) and hyoscyamine (Levsin, Levbid, NuLev), are sometimes used to treat symptoms of irritable bowel syndrome. Antispasmodic medicines help slow the action of the digestive tract and reduce the chance of spasms. They may have side effects and are not for everyone. Other treatment plans are available, depending on symptoms and condition.
• Antidiarrheal medicines, such as loperamide (Imodium), a kaolin/pectin preparation (Kaopectate), and diphenoxylate/atropine (Lomotil), are sometimes used when diarrhea is a major feature of IBS. Do not take these on a long-term basis without first consulting a doctor.
• Antidepressants may be very effective in smaller doses than those typically used to treat depression. Imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), and desipramine (Norpramin) are some commonly used medicines that may alleviate irritable bowel syndrome symptoms. Some other antidepressants are more commonly prescribed when depression and IBS coexist.
• The following medications are typically reserved for patients with symptoms that do not improve with the above treatments:
• Lubiprostone (Amitiza) is a type of laxative used to treat irritable bowel syndrome with constipation in women who are at least 18 years of age. It is a capsule taken orally, twice a day with food. It is used to relieve stomach pain, bloating, and straining; and produce softer and more frequent bowel movements in people who have chronic idiopathic constipation.
• Alosetron (Lotronex) is a restricted drug approved only for short-term treatment of women with severe, chronic, diarrhea-predominant IBS who have failed to respond to conventional IBS therapy. Fewer than 5% of people with irritable bowel syndrome have the severe form, and only a fraction of people with severe IBS have the diarrhea-predominant type. Alosetron was removed from the United States market but was reintroduced with new restrictions approved by the FDA in 2002. Physicians must be registered with the pharmaceutical manufacturer in order to prescribe the medication. Serious and unpredictable gastrointestinal side effects (including some that resulted in death) were reported in association with its use following its original approval. The safety and efficacy of alosetron has not been sufficiently studied in men; therefore, the FDA has not approved the drug for treatment of IBS in men.
• Tegaserod (Zelnorm) was a medication used to treat IBS but was removed from the market in 2008 due to increased risk of heart attack, stroke, and ischemic colitis.

Irritable Bowel Syndrome Diet and Lifestyle Changes

Diet and lifestyle changes are important in decreasing the frequency and severity of IBS symptoms.

The first thing your doctor may suggest is to keep a food diary. This will help you figure out foods that trigger your symptoms.

• Limit foods that contain ingredients that can stimulate the intestines and cause diarrhea, such as:
  • Caffeine
  • Alcohol
  • Dairy products
  • Fatty foods
  • Foods high in sugar
  • Artificial sweeteners (sorbitol and xylitol)
• Some vegetables (cauliflower, broccoli, cabbage, brussels sprouts) and legumes (beans) may worsen bloating and gassiness and should be avoided.
• Dietary fiber may lessen symptoms of constipation.
• Drink plenty of water, and avoid carbonated drinks such as soda, which may cause gas and discomfort.
• Eat smaller meals and eat slowly to help reduce cramping and diarrhea.
• Low fat, high carbohydrate meals such as pasta, rice, and whole-grain breads may help (unless you have celiac disease).

In addition to dietary changes, there are some healthy habits that may also help reduce IBS symptoms.

• Maintain good physical fitness to improve bowel function and help reduce stress.
• Stop smoking for overall good health.
• Avoid coffee and chewing gum.
• Reducing or eliminating alcohol consumption may help.
• Stress management can help prevent or ease IBS symptoms.
  • Use relaxation techniques: deep breathing, visualization, yoga
  • Do things you find enjoyable: talk to friends, read, listen to music

Irritable Bowel Syndrome Prevention

Follow the diet and lifestyle recommendations as outlined above, and as discussed with your physician. Avoiding triggers is the best way to prevent symptoms of IBS.

Gastrointestinal Endoscopy Introduction

Gastrointestinal Endoscopy Introduction

With the procedure known as gastrointestinal endoscopy, a doctor is able to see the inside lining of your digestive tract. This examination is performed using an endoscope-a flexible fiberoptic tube with a tiny TV camera at the end. The camera is connected to either an eyepiece for direct viewing or a video screen that displays the images on a color TV. The endoscope not only allows diagnosis of gastrointestinal (GI) disease but treatment as well.

• Current endoscopes are derived from a primitive system created in 1806-a tiny tube with a mirror and a wax candle. Although crude, this early instrument allowed a first view into a living body.
• The GI endoscopy procedure may be performed on either an outpatient or inpatient basis. Through the endoscope, a doctor can evaluate several problems, such as ulcers or muscle spasms. These concerns are not always seen on other imaging tests.
• Endoscopy has several names, depending on which portion of your digestive tract your doctor seeks to inspect.
  • Colonoscopy: This procedure enables the doctor to see ulcers, inflamed mucous lining of your intestine, abnormal growths and bleeding in your colon, or large bowel.
  • Enteroscopy: Enteroscopy is a recent diagnostic tool that allows a doctor to see your small bowel. The procedure may be used in the following ways:
    • To diagnose and treat hidden GI bleeding
    • To detect the cause for malabsorption
    • To confirm problems of the small bowel seen on an x-ray
    • During surgery, to locate and remove sores with little damage to healthy tissue
  
  
• Doctors do have other diagnostic tests besides GI endoscopy, including echography to study the upper abdomen and a barium enema and other x-ray exams that outline the digestive tract. Doctors can study the stomach juices, stools, and blood to learn about GI functions. But none of these tests offers a direct vision of the mucous lining of the digestive tube.
• Endoscopy has little value for people with the following conditions:
  • Severe coronary artery disease and acute or recent heart attack
  • Uncontrolled high or low blood pressure
  • Shock
  • Massive upper GI bleeding
  • Acute peritonitis (inflammation of certain tissues in your abdomen)
  • Injuries of the cervical spine
  • Perforation of organs of the upper GI tract
  • A history of respiratory distress
  • Severe coagulopathy, a disease in which you continue bleeding because of inadequate clotting in your blood
  • Recent upper GI tract surgery
  • Long-standing and stable inflammatory bowel diseases (except for watching cancers)
  • Chronic irritable bowel syndrome
  • Acute and self-limiting diarrhea
  • Bloody or tarry stools with a clear source of the bleeding
  • Pregnancy in second or third trimester
  • History of severe chronic obstructive pulmonary disease
  • Recent colon surgery or past surgery of your abdomen or pelvis resulting in internal adhesions
  • Acute diverticulitis
  • Tear in a blood vessel in your abdomen
  • Sudden colon inflammation
  • Acute inflammation of the sac that lines your abdomen
  • Noncorrectable coagulopathy, a disease in which you continue bleeding due to inadequate clotting factors in your blood
  • Massive gastrointestinal bleeding

Risks

• Upper GI endoscopy (EGD): Although rare, bleeding and puncture of your esophagus or stomach walls are possible during EGD. Other complications include the following:
  • Severe irregular heartbeat
  • Pulmonary aspiration - When material, either particulate (food, foreign body) or fluid (gastric contents, blood, or saliva), enters from your throat into your windpipe
  • Infections and fever that come and go
  • Respiratory depression, a decrease in the rate or depth of breathing, in people with severe lung diseases or liver cirrhosis
  • Reaction of the vagus nerve system to the sedatives
• Lower GI endoscopy (colonoscopy, sigmoidoscopy, enteroscopy): Although uncommon (less than 1.5% of cases), possible complications of colonoscopy and sigmoidoscopy include the following:
  • Local pain
  • Dehydration (due to excess of laxatives and enemas for bowel preparation)
  • Cardiac arrhythmias
  • Bleeding and infection
  • Hole in your colon
  • Explosion of combustible gases in your colon (certain gases are produced within the bowel) during removal of polyps
  • Respiratory depression usually due to oversedation in people with chronic lung disease

Gastrointestinal Endoscopy Preparation

• Upper endoscopy
  • The doctor will explain the test to you, including the possibility of biopsy and risks such as the need to remove polyps or other surgical procedures.
  • The doctor will ask you to sign a consent form agreeing to the procedure. At the same time, you must inform the endoscopy team of any medications you may be taking and any allergies or bad reactions you have had to previous tests.
  • Wear clothing that is easily removed.
  • Remove all dentures and eyeglasses prior to beginning an upper endoscopy. For colonoscopy, dentures can be left in.
  
  
• EGD
  • Stop taking any medications, such as aspirin and sucralfate (Carafate), used to treat ulcers, that could cause false readings on tests.
  • People who have had cardiac valve replacement or blood vessel graft should receive antibiotics to prevent infection.
  • Do not eat or drink anything for 8-10 hours before your examination to allow a valid examination of the upper GI tract and to lower the risk of vomiting.
  • You will be given a topical anesthetic before the test to numb your throat to prevent gagging.
  
  
• Colonoscopy or sigmoidoscopy
  • Your rectum and colon should be cleaned of all fecal matter. Even a small amount of feces can reduce reliability of the test.
  • You will change your diet prior to the test-no fibers or foods with small seeds for 5-6 days before the examination. You will drink liquids such as tea, fruit juices, and clear broth.
  • You may be given laxatives 12-15 hours before the test. You will be asked to drink up to 4 liters (about 4 qt) of a special cleansing solution to clean out the colon. Several medications are available for bowel cleansing, including polyethylene glycol 3350 (GoLYTELY, NuLYTELY). Other laxatives to cleanse the bowel, such as magnesium citrate (Citroma) or senna (X-Prep), may also be prescribed.
  • You may be given 1 or 2 little enemas 2-3 hours before the procedure.
  • The doctor may perform a rectal examination to detect narrowings, polyps or abnormal growth, or hidden bleeding from your lower intestine.

During the Procedure

• Upper GI endoscopy
  • You will be placed on your left side and have a plastic mouthpiece placed between your teeth to keep your mouth open and make it easier to pass the tube.
  • The doctor lubricates the endoscope, passes it through the mouthpiece, then asks you to swallow it. The doctor guides the endoscope under direct visualization through your stomach into the small intestine.
  • Any saliva you have will be cleared using a small suction tube that is removed quickly and easily after the test.
  • The doctor inspects portions of the linings of your esophagus, stomach, and the upper portion of your small intestine and then reinspects them as the instrument is withdrawn.
  • If necessary, biopsies and removal of foreign bodies and polyps may be performed.
  • The procedure usually is completed within 10-15 minutes. Any surgical procedures will require several minutes, depending on the type.
  
  
• Lower GI endoscopy
  • You will be placed on your left side with your hips back, flexed beyond your abdominal wall.
  • The doctor lubricates the endoscope and inserts it into your anus and advances it under direct vision.
  • You may be asked to change position during the procedure to assist moving the endoscope. The doctor will study your colon and rectum walls and reinspect them as the endoscope is withdrawn. If necessary, surgeries may be performed.
  • You may feel uneasiness and abdominal pain. The procedure usually takes 15-20 minutes. Any surgeries will require additional time, depending on the type.

After the Procedure

• If you have been sedated, you will be moved to a recovery area to wake up.

• Once sedation has worn off, before you are discharged from medical center, you will be given instructions and told to call your doctor if complications develop.

• You should have someone there to take you home. You should not drive a car or use other machinery or drink alcohol for at least a day. You may feel drowsy.

• At home, it would be best to have a light meal and rest for the remainder of the day.

When to Seek Medical Care

If any of the following symptoms develop, you should call your doctor.

• Any unexplained and chronic abdominal or chest pain, even heartburn
• Vomiting or reflux
• Swallowing difficulties or pain on swallowing
• Bleeding in your esophagus
• Nausea
• Indigestion
• Weight loss
• Anemia
• Any long-standing and unexplained changes in bowel habits
• Abdominal pain
• Diarrhea
• Black or tarry stools or bleeding through your rectum

Gastrointestinal Tract Cancer and Digestive Endoscopy

Endoscopy is very important to detect early cancers developing from the mucous coverings in either the upper or lower tracts of the digestive tube. Colon cancers can develop if intestinal polyps are not removed. Polyps can grow until they become a cancer.

Several studies report that growth of these polyps may take as long as 10 years. People who are at low risk for cancer, or even have no symptoms, should schedule a colonoscopy every 3-5 years after age 50 years. Those who are high-risk should begin regular screening prior to age 40 years. The following conditions can put you at high risk for cancer.

• HP (Helicobacter pylori) infections: H pylori bacteria are thought to cause gastric tumors. People who test positive for H pylori should be scheduled for an EGD every 1-2 years to detect early signs of cancer.
• Bowel inflammatory diseases
• Ulcerative colon inflammation
• Family or personal history of GI cancer or cancer in other organs
• Family history of developing glandlike polyps
• People with gastroesophageal reflux disease, especially those who smoke and drink regularly and complain of chronic heartburn, are at high risk for a cancer of the esophagus-a dramatic and deadly disease. Cancer stems from chronic injury of the gastric juice on the mucous lining of your esophagus.
• Changes in the lining of your esophagus (Barrett's esophagus) may be detected early in a person with chronic heartburn only by means of EGD, because this first change is detectable only by direct vision. These people should be scheduled for an EGD once or twice a year.

Pancreatitis Overview

Pancreatitis Overview

Pancreatitis simply means inflammation of the pancreas. Located in the upper part of the abdomen, behind the stomach, the pancreas plays an important role in digestion. The pancreas is a gland, producing two main types of substances: digestive juices and digestive hormones.

• Digestive juices include enzymes and bicarbonate. They travel through a small tube called the pancreatic duct that connects the pancreas to the small intestine to the small intestine (duodenum).
  • There, the enzymes help in the break down of proteins and fats in the foods that you eat to permit the nutrients to be absorbed.
  • The bicarbonate neutralizes stomach acid.


• Digestive hormones, mainly insulin and glucagon, are released into the bloodstream. They control the body's blood sugar level, a major source of energy, and are an important role in the cause of diabetes.

Inflammation of the pancreas has various causes. Once the gland becomes inflamed, the condition can progress to swelling of the gland and surrounding blood vessels, bleeding, infection, and damage to the gland. There, digestive juices become trapped and start "digesting" the pancreas itself. If this damage persists, the gland may not be able to carry out normal functions.

Pancreatitis may be acute (new, short-term) or chronic (ongoing, long-term). Either type can be very severe, even life-threatening. Either type can have serious complications.

• Acute pancreatitis usually begins soon after the damage to the pancreas begins. Attacks are typically very mild, but about 20% of them are very severe. An attack lasts for a short time and usually resolves completely as the pancreas returns to its normal state. Some people have only one attack, whereas other people have more than one attack, but the pancreas always returns to its normal state.
• Chronic pancreatitis begins as acute pancreatitis. If the pancreas becomes scarred during the attack of acute pancreatitis, it cannot return to its normal state. The damage to the gland continues, worsening over time.

About 80,000 cases of acute pancreatitis occur in the United States each year. Pancreatitis can occur in people of all ages, although it is very rare in children. Pancreatitis occurs in men and women, although chronic pancreatitis is more common in men than in women.

Pancreatitis Causes

Alcohol abuse and gallstones are the two main causes of pancreatitis, accounting for 80% to 90% of all cases.

Pancreatitis from alcohol use usually occurs in individuals who have been long-term alcohol drinkers for at least five to seven years. Most cases of chronic pancreatitis are due to alcohol abuse. Pancreatitis is often already chronic by the first time the person seeks medical attention (usually for severe pain).

Gallstones form from a buildup of material within the gallbladder, another organ in the abdomen (please see previous illustration). A gallstone can block the pancreatic duct, trapping digestive juices inside the pancreas. Pancreatitis due to gallstones tends to occur most often in women older than 50 years of age.

The remaining 10% to 20% of cases of pancreatitis have various causes, including the following:

• medications,
• exposure to certain chemicals,
• injury (trauma), as might happen in a car accident or bad fall leading to abdominal trauma,
• hereditary disease,
• surgery and certain medical procedures,
• infections such as mumps (not common),
• abnormalities of the pancreas or intestine, or
• high fat levels in the blood.

In about 15% of cases of acute pancreatitis and 40% of cases of chronic pancreatitis, the cause is never known.

Pancreatitis Symptoms

Acute Pancreatitis Symptoms

The most common symptom of acute pancreatitis is pain. Almost everybody with acute pancreatitis experiences pain.

• The pain may come on suddenly or build up gradually. If the pain begins suddenly, it is typically very severe. If the pain builds up gradually, it starts out mild but may become severe.
• The pain is usually centered in the upper middle or upper left part of the belly (abdomen). The pain is often described as if it radiates from the front of the abdomen through to the back.
• The pain often begins or worsens after eating.
• The pain typically lasts a few days.
• The pain may feel worse when a person lies flat on his or her back.

People with acute pancreatitis usually feel very sick. Besides pain, people may have other symptoms and signs.

• Nausea (Some people do vomit, but vomiting does not relieve the symptoms.)
• Fever, chills, or both
• Swollen abdomen which is tender to the touch
• Rapid heartbeat (A rapid heartbeat may be due to the pain and fever, dehydration from vomiting and not eating, or it may be a compensation mechanism if a person is bleeding internally.)

In very severe cases with infection or bleeding, a person may become dehydrated and have low blood pressure, in addition to the following symptoms:

• Weakness or feeling tired (fatigue)
• Feeling lightheaded or faint
• Lethargy
• Irritability
• Confusion or difficulty concentrating
• Headache

If the blood pressure becomes extremely low, the organs of the body do not get enough blood to carry out their normal functions. This very dangerous condition is called circulatory shock and is referred to simply as shock.

Chronic Pancreatitis Symptoms

Pain is less common in chronic pancreatitis than in acute pancreatitis.

Some people have pain, but many people do not experience pain. For those people who do have pain, the pain is usually constant and may be disabling; however, the pain often goes away as the condition worsens. This lack of pain is a bad sign because it probably means that the pancreas has stopped working.

Other symptoms of chronic pancreatitis are related to long-term complications, such as the following:

• Inability to produce insulin (diabetes)
• Inability to digest food (weight loss and nutritional deficiencies)
• Bleeding (low blood count, or anemia)
• Liver problems (jaundice)

When to Seek Medical Care

In most cases, the pain and nausea associated with pancreatitis are severe enough that a person seeks medical attention from a health care practitioner. Any of the following symptoms warrant medical attention:

• Inability to take medication or to drink and eat because of nausea or vomiting
• Severe pain not relieved by nonprescription medications
• Unexplained pain
• Difficulty breathing
• Pain accompanied by fever or chills, persistent vomiting, feeling faint, weakness, or fatigue
• Pain accompanied by presence of other medical conditions, including pregnancy

The health care practitioner may tell the person to go to a hospital emergency department. If a person is unable to reach a health care practitioner, or if a person's symptoms worsen after having being examined by a health care practitioner, an immediate visit to an emergency department is necessary.

Pancreatitis Diagnosis

When a health care practitioner identifies symptoms suggestive of pancreatitis, specific questions are asked about the person's symptoms, lifestyle and habits, and medical and surgical history. The answers to these questions and the results of the physical examination allow the health care practitioner to rule out some conditions and make the correct diagnosis.

In most cases, laboratory tests are needed. The tests check the functioning of several body systems, including the following:

• Pancreas, liver, and kidney functions (including levels of pancreatic enzymes amylase and lipase)
• Signs of infections
• Blood cell counts indicating signs of anemia
• Pregnancy test
• Blood sugar, electrolyte levels (an imbalance suggests dehydration) and calcium level

Results of the blood tests may be inconclusive if the pancreas is still making digestive enzymes and insulin.

Diagnostic imaging tests are usually needed to look for complications of pancreatitis, including gallstones.

Diagnostic imaging tests may include the following:

• X-ray films may be ordered to look for complications of pancreatitis as well as for other causes of discomfort. This may include a chest X-ray.
• A CT scan is like an X-ray film, only much more detailed. A CT scan shows the pancreas and possible complications of pancreatitis in better detail than an X-ray film. A CT scan highlights inflammation or destruction of the pancreas.
• Ultrasound is a very good imaging test to examine the gallbladder and the ducts connecting the gallbladder, liver, and pancreas with the small intestine.
  • Ultrasound is very good at depicting abnormalities in the biliary system, including gallstones and signs of inflammation or infection.
  • Ultrasound uses painless sound waves to create images of organs. Ultrasound is performed by gliding a small handheld device over the abdomen. The ultrasound emits sound waves that "bounce" off the organs and are processed by a computer to create an image. This technique is the same one that is used to look at a fetus in a pregnant woman.
• Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging test that uses an endoscope (a thin, flexible tube with a tiny camera on the end) to view the pancreas and surrounding structures.
  • ERCP is usually used only in cases of chronic pancreatitis or in the presence of gallstones.
  • To perform an ERCP, a person is first sedated. After sedation, an endoscope is passed through the mouth, to the stomach, and into the small intestine. The device then injects a temporary dye into the ducts connecting the liver, gallbladder, and pancreas with the small intestine (biliary ducts). The dye makes is easier for the health care practitioner to see any stones or signs of organ damage. In some cases, a stone can be removed during this test.

Pancreatitis Treatment

Self-Care at Home

For most people, self-care alone is not enough to treat pancreatitis. People may be able to make themselves more comfortable during an attack, but they will most likely continue to have attacks until treatment is received for the underlying cause of the symptoms. If symptoms are mild, people might try the following preventive measures:

• Stop all alcohol consumption.
• Adopt a liquid diet consisting of foods such as broth, gelatin, and soups. These simple foods may allow the inflammation process to get better.
• Over-the-counter pain medications may also help. Avoid pain medications that can affect the liver such as acetaminophen (Tylenol and others). In individuals with pancreatitis due to alcohol use, the liver is usually also affected by the alcohol.

Pancreatitis Medical Treatment

Medical treatment is usually focused on relieving symptoms and preventing further aggravation to the pancreas. Certain complications of either acute pancreatitis or chronic pancreatitis may require surgery or a blood transfusion.

Acute Pancreatitis Treatment

In acute pancreatitis, the choice of treatment is based on the severity of the attack. If no complications are present, care usually focuses on relieving symptoms and supporting body functions so that the pancreas can recover.

• Most people who are having an attack of acute pancreatitis are admitted to the hospital.

• Those people who are having trouble breathing are given oxygen.

• An IV (intravenous) line is started, usually in the arm. The IV line is used to give medications and fluids. The fluids replace water lost from vomiting or from the inability to take in fluids, helping the person to feel better.

• If needed, medications for pain and nausea are prescribed.

• Antibiotics are given if the health care practitioner suspects an infection may be present.

• No food or liquid should be taken by mouth for a few days. This is called bowel rest. By refraining from food or liquid intake, the intestinal tract and pancreas are given a chance to start healing.

• Some people may need a nasogastric (NG) tube. The thin, flexible plastic tube is inserted through the nose and down into the stomach to suck out the stomach juices. This suction of the stomach juices rests the intestine further, helping the pancreas recover.

• If the attack lasts longer than a few days, nutritional supplements are administered through an IV line.

Chronic Pancreatitis Treatment

In chronic pancreatitis, treatment focuses on relieving pain and avoiding further aggravation to the pancreas. Another focus is to maximize a person's ability to eat and digest food.

• Unless people have severe complications or a very severe episode, they probably do not have to stay in the hospital.

• Medication is prescribed for severe pain.

• A high carbohydrate, low fat diet; and eating smaller more frequent meals help prevent aggravating the pancreas. If a person has trouble with this diet, pancreatic enzymes in pill form may be given to help digest the food.

• People diagnosed with chronic pancreatitis are strongly advised to stop drinking alcohol.

• If the pancreas does not produce sufficient insulin, the body needs to regulate its blood sugar, and insulin injections may be necessary.

Surgery

If the pancreatitis is caused by gallstones, an operation to have the gallbladder and gallstones removed (cholecystectomy) is likely.

If certain complications (for example, enlargement or severe injury of the pancreas, bleeding, pseudocysts, or abscess) develop, surgery may be needed to drain, repair, or remove the affected tissues.

Follow-up

The following recommendations may help to prevent further attacks or to keep them mild:

• Stop all alcohol consumption.
• Eat small frequent meals. If in the process of having an attack, avoid solid foods for several days to give the pancreas a chance to recover.
• Eat a diet high in carbohydrates and low in fats.
• If pancreatitis is due to chemical exposure or medications, the source of the exposure will need to be found and stopped, and the medication will need to be discontinued.

Pancreatitis Prevention

Completely eliminating alcohol is the only way to reduce the chance of further attacks in cases of pancreatitis caused by alcohol use, to prevent the pancreatitis from worsening, and to prevent the development of complications that can be very serious or even fatal.

Pancreatitis Prognosis

Most people with acute pancreatitis recover completely from their illness. The pancreas returns to normal with no long-term effects. Pancreatitis may return, however, if the underlying cause is not eliminated.

Some 5%-10% of people develop life-threatening pancreatitis and may be left with any of these chronic illnesses, or even die due to complications of pancreatitis:

• Kidney failure
• Breathing difficulties
• Diabetes
• Brain damage

Chronic pancreatitis does not resolve completely between attacks. Although the symptoms may be similar to those of acute pancreatitis, chronic pancreatitis is a much more serious condition because damage to the pancreas is an ongoing process. This ongoing damage can have any of the following complications:

• Bleeding in or around the pancreas: Ongoing inflammation and damage to the blood vessels surrounding the pancreas can lead to bleeding. Fast bleeding can be a life-threatening condition. Slow bleeding usually leads to low red blood cell count (anemia).
• Infection: Ongoing inflammation makes the tissue vulnerable to infection. The infection can form an abscess that is very difficult to treat without surgery.
• Pseudocysts: Small fluid-filled sacs can form in the pancreas as a result of ongoing damage. These sacs can become infected or rupture into the lower abdominal cavity (peritoneum), causing a serious infection called peritonitis.
• Breathing problems: The chemical changes in the body can affect the lungs. The effect is to reduce the amount of oxygen the lungs can absorb from the air a person breathes. The level of oxygen in the blood drops to lower than normal (hypoxia).
• Pancreas failure: The pancreas may become so severely damaged that it is unable to carry out its normal functions. Digestion of food and regulation of blood sugar - both very important functions - are affected. Diabetes and weight loss often result.
• Pancreatic cancer: Chronic pancreatitis can encourage the growth of abnormal cells in the pancreas, which can become cancer. The prognosis for pancreatic cancer is very poor.

ANAL FISSURE

What is an anal fissure?

An anal fissure is a tear in the lining of the lower rectum (anus) that causes pain during bowel movements. It is a common condition. Anal fissures do not lead to more serious conditions.

Most anal fissures heal with home treatment after a few days or weeks (acute anal fissures). If you have an anal fissure that has not healed after 6 weeks, it is considered a long-term problem (chronic). You may need medicine to help a chronic anal fissure heal. Surgery may be necessary for fissures that do not heal with medicine.

Anal fissures affect people of all ages, particularly young and otherwise healthy people. They are equally common in men and women.

Sometimes an anal fissure and a hemorrhoid develop at the same time.

What causes an anal fissure?

Anal fissures are caused by injury (trauma) to the anal canal. Injury can happen if:

• You pass a large stool that stretches the anal canal.
• You are constipated and try to pass a hard stool.
• You have repeated diarrhea.

Childbirth can also cause trauma to the anal canal. During childbirth, some women develop anal fissures. Fissures can also be caused by digital insertion (as during an examination), foreign body insertion, or anal intercourse.

Because many people get constipated or have diarrhea without getting anal fissures, many experts believe there is some other cause of anal fissures. Some people may have excessive tension in the two muscular rings (sphincters) controlling the anus. The external anal sphincter is under your conscious control. But the internal anal sphincter is not under your control. This muscle remains under pressure, or tension, all of the time. A fissure may develop if the internal sphincter's resting pressure becomes too high, causing spasm and reducing blood flow to the anus. This high resting pressure can also keep a fissure from healing.

In some cases, an anal fissure may be caused by Crohn's disease, an inflammatory bowel disease (IBD) that causes bloody diarrhea, abdominal (belly) pain, fever, weight loss, and fissures or fistulas near the anus.

What are the symptoms?

An anal fissure causes a sharp, stinging, or burning pain during a bowel movement. The pain, which can be severe, may last for a few hours.

Fissures may itch. They often bleed lightly or cause a yellowish discharge. You may see a small spot of bright red blood on toilet tissue or a few drops in the toilet bowl. The blood is separate from the stool. Very dark, tarry stools or dark red blood mixed with stool indicates some other condition, possibly inflammatory bowel disease (IBD) or colon cancer. You should contact a doctor if you have any bleeding with bowel movements.

Sometimes an anal fissure may be a painless wound that won't heal and that bleeds intermittently but causes no other symptoms.

How is an anal fissure diagnosed?

Most doctors can diagnose an anal fissure from symptoms and by looking at the anus. Usually, the doctor can see the fissure by gently separating the buttocks.

A doctor may use a gloved finger (digital rectal examination) or a lighted instrument (anoscope) to examine the fissure. But if the fissure is extremely painful, the doctor will usually wait until it has begun to heal before performing a rectal exam or using an anoscope (anoscopy) to rule out other problems. A topical anesthetic may be used if an immediate examination is necessary.

During an exam, a doctor can also find out whether another condition may be causing the fissure. If you have several fissures or have one or more in an area of the anus where fissures usually do not occur, you may have another condition such as inflammatory bowel disease, syphilis, a suppressed immune system, tuberculosis, HIV infection, or anal cancer. Most fissures occur along the midline—the top or bottom—of the anus.

How is it treated?

Most acute fissures need some home treatment, including soaking in a shallow tub of warm water (sitz bath) 2 or 3 times a day, increasing fiber in the diet, and taking stool softeners or laxatives. Some people find relief in a day or two of home treatment. Although your pain may go away, it may take several weeks for the fissure to heal completely. Sometimes fissures heal without treatment.

Try to prevent constipation, because it can keep a fissure from healing. The pain of a fissure may make you anxious about having bowel movements. But trying not to have bowel movements will only increase constipation and create a cycle that keeps the fissure open and painful.

Drinking lots of water or other fluids also will make stools softer and easier to pass.

You may want to use a nonprescription ointment such as zinc oxide, Preparation H, Anusol, or 1% hydrocortisone to soothe anal tissues. But evidence suggests that fiber and sitz baths help symptoms better than nonprescription creams.³ Talk with your doctor about whether you should use these medicines for a short period of time.

If a fissure lasts a long time, prescription medicine may help. Prescription medicines used to treat anal fissure include nitroglycerin, high blood pressure medicines, and botulinum toxin (Botox).

You may need to consider surgery if medicines do not stop your symptoms. The most commonly used surgery is lateral internal sphincterotomy. In this procedure, a doctor cuts into part of the internal sphincter to relax the spasm that is causing the fissure.

Learning about anal fissure:	What is an anal fissure? What causes an anal fissure? What are the symptoms? What is the treatment?
Being diagnosed:	How is an anal fissure diagnosed? What is anoscopy? Why is the location of a fissure important?
Getting treatment:	What can I do to treat an anal fissure? What medicines might I take? What is nitroglycerin ointment? How is Botox used to treat anal fissures? What surgery is done to heal an anal fissure?

Symptoms

Most anal fissures cause:

• A sharp, stinging or burning pain during a bowel movement. Pain from a fissure may be quite severe. It can be brief or last for several hours after a bowel movement.
• Itching.
• Bleeding, often a small spot of bright red blood on toilet tissue. Tell your doctor if you have any bleeding with a bowel movement.

An anal fissure can be a painless wound that won't heal and that bleeds intermittently but causes no other symptoms.

Exams and Tests

Your doctor can diagnose an anal fissure from your symptoms and a physical exam. The exam may include:

• Looking at the fissure by gently separating the buttocks.
• Digital rectal exam. The doctor uses a gloved finger to feel structures in the anal canal.
• Anoscopy. This exam involves using a short, lighted scope to look into the anal canal.

A doctor usually will wait until the fissure has begun healing before doing a digital rectal exam or anoscopy. If an exam needs to be done immediately, a topical anesthetic can be used to numb the area.

The location of a fissure is important in the diagnosis. If you have more than one fissure or have a fissure on the side of the anus (rather than at the top or the bottom), you may have another condition that is causing fissures. Possible conditions include inflammatory bowel disease (IBD), anal cancer, syphilis, tuberculosis, a suppressed immune system, or HIV infection.

A doctor may look for a small piece of loose skin (a skin tag) in the anus, often a sign of a long-term (chronic) fissure. Skin tags are often mistakenly identified as hemorrhoids.

Treatment Overview

Most short-term (acute) anal fissures can heal with home treatment in 4 to 6 weeks. Pain during bowel movements usually goes away within a couple of days of treatment.

Home treatment involves sitting in warm water (sitz bath) for 20 minutes 2 or 3 times a day, increasing fiber and fluids in the diet, and using stool softeners or laxatives to have pain-free bowel movements. Talk with your doctor about how long you should use laxatives.

Sometimes fissures do not heal with these remedies. A fissure that has not healed after 6 weeks is considered long-term, or chronic, and may need additional treatment.

Medication

Medicines are usually the first-line treatment for chronic fissures.

• A 0.2% nitroglycerin cream can reduce the pressure in the internal anal muscle (sphincter) and allow the fissure to heal. A pea-sized dot of cream is massaged into the fissure and the surrounding area. Do not use a larger amount at one time, because this medicine can cause headaches, lightheadedness, or fainting from low blood pressure. It is a good idea to either wear gloves when applying the nitroglycerin cream or wash your hands right after. The skin on your fingers can absorb the medicine and increase your chance of side effects.
• The calcium channel blockers nifedipine and diltiazem also may help healing, also by reducing the pressure in the internal anal sphincter. These two medicines are available as pills. Also, they can be made into a gel that can be massaged into the fissure and the surrounding area. The pill form of these medicines has more side effects than the gel form.
• Botulinum toxin (Botox) may be injected into the internal anal sphincter. Botox causes temporary paralysis of muscle, which can reduce muscle tension and help the anal fissure heal.

Surgery

Surgery may be done when more conservative treatments fail to heal an anal fissure.

The main surgery for chronic anal fissure is lateral internal sphincterotomy. The doctor makes a small incision into the internal anal sphincter to reduce anal resting pressure.

It is important to understand that, even with surgery, an anal fissure must heal on its own. A sphincterotomy involves operating on the sphincter muscles, not closing the actual fissure.

Lateral internal sphincterotomy has a better success rate than any medicine that is used to treat long-term anal fissures. The results last longer, and fewer people have anal fissures come back after surgery than after treatment with medicine.¹

In some studies, a greater number of people who had lateral internal sphincterotomy had some inability to control gas or stool (incontinence) after surgery compared to people treated with medicine. Despite these results, satisfaction with this surgery is high. And a review of many studies showed that the risk of incontinence was 8%. This means that about 8 out of 100 people who had the surgery had some problem with incontinence. But this rate was not very different from the rates seen in people who were treated with medicine for their chronic anal fissures.²

Another study showed that lateral internal sphincterotomy was better than nitroglycerin cream at healing chronic anal fissures. And there was no difference in long-term continence between the people who used nitroglycerin cream and the people who had surgery.⁴

In some cases, the risk of incontinence is too great to justify doing lateral internal sphincterotomy. This may be true for women who develop a fissure while giving birth, because they typically do not have a high resting pressure in their internal sphincter. A procedure called anal advancement flap may be done instead of sphincterotomy. In this procedure, the edges of the fissure are removed, and healthy tissue is sewn over the area.

Home Treatment

Most short-term (acute) and a few long-term (chronic) anal fissures will heal with home treatment.

• Avoid constipation:
  • Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fiber.
  • Drink plenty of fluids, enough so that your urine is light yellow or clear like water.
  • Get some exercise every day. Try to do moderate activity at least 2½ hours a week. Or try to do vigorous activity at least 1¼ hours a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.
  • Take a fiber supplement, such as Citrucel or Metamucil, every day if needed. Start with a small dose and very slowly increase the dose over a month or more.
  • Schedule time each day for a bowel movement. Having a daily routine may help. Take your time and do not strain when having a bowel movement.
• Stool softeners or laxatives can make bowel movements more comfortable. Ask your doctor how long you should take laxatives.
• Sitting in a tub filled with a few inches of warm water (sitz bath) for 20 minutes 2 or 3 times a day soothes the torn tissue and helps relax the internal anal sphincter. This may help heal the anal fissure.
• You may want to use ointments or creams such as zinc oxide, Preparation H, or Anusol (which includes an anesthetic). But evidence suggests that fiber and sitz baths help symptoms better than nonprescription creams.³ Creams with hydrocortisone (such as Anusol-HC) can reduce itching and inflammation.
• Although some people may be tempted to use a mirror or have a family member examine a fissure, do not separate the buttocks. Doing so might slow healing of the fissure.
• Instead of using toilet paper, use baby wipes or medicated pads, such as Tucks, to clean after a bowel movement. These products can be less irritating to an anal fissure.

Conservative treatment measures—including using stool softeners or bulking agents and taking regular sitz baths—allow about 9 out of 10 acute anal fissures to heal. And about 4 out of 10 long-term (or chronic) anal fissures will heal after conservative treatment is used.³