Dr Graeme Dickson - Gastroenterologist 

Patient Information

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What is it?

        It is an abnormal change in the cells at the bottom of the oesophagus (swallowing tube or gullet). This is called “metaplasia” and is thought to result from longstanding acid reflux.

Why is it important?

        Unfortunately, it is associated with an increased risk of developing cancer of the oesophagus. This occurs in about 1 out of every 200 people with Barrett’s per year. However, most people with Barrett’s die from other causes.

How is it diagnosed?

        There is surprisingly little relationship between the severity of heartburn a patient feels and the risk of having Barrett’s. About 10% of patients undergoing endoscopy for heartburn will have Barrett’s. The abnormal oesophageal lining can be seen at the time of endoscopy and tissue samples (biopsies) are taken to confirm the diagnosis.

What about treatment?

        Acid reflux should be controlled with medication (eg losec) to prevent further damage regardless of whether the patient is experiencing heartburn. There is no evidence that surgery, to prevent ongoing reflux, is any better than tablets. Regular endoscopy (surveillance) is often recommended.

Why is endoscopic surveillance controversial?

          In principal, regular endoscopies should diagnose any cancerous changes early and enable curative surgery. However, extensive research so far has not proven that there is a survival benefit from surveillance. Despite the lack of evidence, international guidelines still recommend surveillance for theoretical reasons alone. This has lead to wide variations in individual practice often causing confusion with “mixed messages” being given to patients and family doctors. Detailed analysis of the research suggests that patients at highest risk are likely to benefit from surveillance.

Who is at highest risk?

            There are certain factors which increase an individual’s chance of developing cancer. These include obesity, smoking, ongoing heartburn, white males, age>45, Barrett’s segment >8cm, a long history of heartburn, bile reflux, ulceration, stricture and a family history of oesophageal cancer. In contrast, women with less than 3cm of Barrett’s are at low risk.

Should you have surveillance?

What causes it?

       Gas in the bowel results from a combination of swallowed air and fermentation of food. Bloating is likely to be due to a variety of problems including slow movement of gas through the small bowel (”trapped wind’), increased bowel sensitivity to distension (eg irritable bowel), excessive air swallowing and increased gas production from food fermentation (eg lactose intolerance).

What tests may help?

          Blood testing can check for lactose intolerance (dairy) and coeliac disease (wheat intolerance). Sometimes a scan (eg ultrasound) or endoscopy is advised.

What treatments can help?

          This is difficult as the underlying problem is not well understood. Dietary changes to minimise wind-forming foods, treatment of constipation, and reducing acid reflux (eg losec) can all help. Other medications are occasionally useful (eg charcoal, motilium, peppermint oil, amitriptyline)

 Dietary suggestions:

Change your carbohydrate intake from wheat to rice.

Avoid gas forming foods (eg cabbage, onions, baked beans). Gluten-free products may not be helpful as they are often wind producing too.

Fructose intolerance can occur if large amounts are consumed. Fructose is found in fresh fruit (eg pears, apples & grapes) but is also commonly used as a sweetener made from corn syrup (eg muesli bars, fizzy drinks).

          Avoid artificial sweeteners (eg sorbitol, xylitol). Carbonated drinks are frequent culprits especially diet ones. Chewing gum leads to more air swallowing so should also be avoided.

Constipation is a very common complaint and is estimated to affect 1 in 5 middle-aged women. It is also more common with increasing age. It reflects an inability to empty the bowels as often or as easily as desired. There is wide variation in what is considered “normal” but a soft formed stool from twice a day to every 2^nd day is common.

Symptoms

If the motion remains in the bowel for many days then the colon reabsorbs the water leaving a hard and dry stool which is difficult to pass. This can cause cramping abdominal pain and may cause a small tear in the anus as it passes (anal fissure). This is very painful and may cause bleeding. Occasionally the motion is so large it does not pass and stretches the back passage leading to loss of the sensation to go to the toilet. This results in “overflow” diarrhoea and soiling of the underwear. Women are predisposed to constipation for hormonal reasons and are often worse premenstrually and in early pregnancy.

Causes

Peri-anal problems (eg fissure): These cause pain around the back passage. “Numbing” ointments are often prescribed (eg lignocaine) to allow comfortable passage of stool.

Medical conditions & medications: Thyroid dysfunction, high calcium levels, stroke and certain medications (eg blood pressure tablets, antidepressants, codeine, calcium and iron supplements) can cause constipation.

Simple constipation: Can be due to poor diet with fatty foods and not enough fruit and vegetables. Ensure high fibre diet, good fluid intake (1500mls per day), adequate time to go to the toilet and regular exercise.

“Slow Transit” constipation: There is poor contraction of the bowel muscles often resulting in a week between bowel motions.  This is usually long standing and commoner in women. Avoid fibre supplements, which increase colonic work-load, and use stimulant laxatives with caution as they may result in further lack of sensitivity.

Pelvic floor weakness: This causes difficulty passing a stool and results in straining. A pocket (rectocoele) may form in the lower end of the bowel which does not empty at defaecation. This leaves the sensation of still having a full rectum. Sometimes a bulge is felt around the back passage or in the vagina. Lifting the knees above the hips by putting the feet on a small stool is often helpful. Physiotherapy or surgery to remove the excess tissue can be helpful.

Irritable Bowel Syndrome: Often associated with diarrhoea too- see  IBS section

Colorectal cancer: This is NOT a common cause of constipation but any changes in bowel habit should be discussed with your doctor. Colonoscopy may be recommended if the problem is new.

Dietary fibre

  Food remnants which are not absorbed end up in the large bowel and are known as fibre. They draw water into the stool and form a soft bulky motion. The recommended daily fibre intake is 20-30g. High fibre foods include brown bread, weet-bix, apples, prunes, baked potatoes, brown rice, and baked beans.

Laxatives

**Dietary eg prune or apple juice & kiwifruit

Herbal eg flaxseed oil, slippery elm

**Fibre supplements eg psyllium (Metamucil), ispaghula

Stool softeners eg paraffin, coloxyl

**Osmotic agents eg magnesium (Epsom salts, MgLax), lactulose, movicol

Stimulants eg senna, laxsol, dulcolax, alpine

May cause cramps

**=recommended as first choice and safe to take long term

             Diverticula are “pockets” which develop in the colon. They are found in 1 in 3 people over the age of 45. Only a quarter of people with diverticula develop any symptoms. A low fibre diet leads to increased pressure within the bowel causing the pockets to form.

What is diverticulitis?

        This is inflammation of the pockets which causes pain in the left lower abdomen and sometimes results in diarrhoea too. It can produce permanent narrowing of the colon which results in constipation and pain. Rarely, a diverticulum can burst and form an abnormal connection with the bladder or vagina allowing gas or faeces to pass through (fistula).

Bleeding

        Diverticular bleeds are typically sudden and dramatic with large amounts of fresh blood passing out of the anus. They usually stop spontaneously. 

Treatment

        Increased fibre is important to stop it getting worse. The old advice to avoid nuts and seeds is unnecessary. Diverticulitis is treated with antibiotics.

 Surgery

Emergency surgery is sometimes needed if there is severe bleeding, perforation of the bowel or diverticulitis which does not respond to antibiotics. Planned surgery is helpful if there is bowel narrowing or fistula formation.

        They are stones which form in the gallbladder. This is a small sac which stores bile from the liver until it is needed to digest food. The stones can pass out of the gallbladder down a narrow tube into the bowel. This is often very painful and the stones can get stuck causing jaundice.

What causes them?

          If the bile contains too much of a particular substance (eg cholesterol) then stones tend to form. Otherwise slow emptying of the gallbladder can be responsible. They are more common as you get older and also in women, especially if there is a family history.

What symptoms do they cause?

          70% of people with gallstones get no symptoms. The commonest problem is intermittent abdominal pain from small stones getting stuck on their way out of the gallbladder. Blocked stones can cause inflammation of the gallbladder (cholecystitis) or pancreas (pancreatitis). Indigestion, bloating and fatty-food intolerance are not normally due to gallstones.

How are they diagnosed?

          With an ultrasound scan which is a simple test but is highly accurate.

What is “ERCP”?

An “ERCP” (Endoscopic Retrograde CholangioPancreatogram) involves passing an endoscope through the mouth to the small bowel. Stones stuck in the main drainage tube (bile duct) can often be removed this way avoiding an operation.

 When is surgery recommended?

          If you have pain or other complications (eg cholecystitis or jaundice) then surgery is advised. This can often be done by a “keyhole” approach (laparoscopic).

What is it?

            It is an inherited disorder in which too much iron is absorbed by the body. This leads to damage of the liver, heart, pancreas, joints and hormonal glands. It is caused by an abnormal gene called HFE. There are two copies of each gene in the body and both must be abnormal to develop significant iron overload. People with only one abnormal gene (and one normal gene) are called carriers and do not develop haemochromatosis.

What are the symptoms?

            Most people have very few symptoms until they have developed significant organ damage. Symptoms can be very general (eg tiredness, weight loss, sore joints) which often results in a delay in diagnosis. Specific organ damage can cause palpitations, chest pain, shortness of breath and diabetes. People can develop a sun-tanned appearance without sun exposure.

How is it diagnosed?

            Genetic testing is available for close relatives of people known to have haemochromatosis. Otherwise a blood test to measure iron levels (transferrin saturation) is the best way of picking up iron overload. Sometimes a liver biopsy is necessary if there is any suspicion of significant liver disease.

Screening Relatives

            After the diagnosis is made all close relatives (parents, children & siblings) should be screened with a blood test. Early diagnosis allows treatment which prevents damage occurring.

What is the treatment?

            Removing 500mls blood at a time, just like donating blood, causes the body to use up iron to make more blood. This is called venesection. Initially, it is done weekly but eventually this can be reduced to 4 times per year. After approximately two years the excess iron has usually gone but the treatment needs to be continued lifelong to prevent reaccumulation. Clearly iron supplements and vitamin C (which increases iron absorption) should be avoided.

Does it work?

            After venesection, patients feel better and organ damage is often reversed. However, if the liver is severely damaged (cirrhosis) then this is usually irreversible. In this situation, venesection is still useful as it prevents further damage.

What are haemorrhoids?

They are enlarged veins just inside the anus. They can occur due to straining at defaecation or for hormonal reasons (eg pregnancy).

 What problems can they cause?

They can bleed or hang out of the anus (prolapse) which is uncomfortable. Sometimes they form a hard lump which can be felt outside the anus.

 How are they diagnosed?

In young people, the back passage (rectum) can be checked with a flexible camera test (sigmoidoscopy). In older people (>40yrs) it is important to check the whole colon to exclude other more serious problems (colonoscopy).

 How are they treated?

Suppositories or cream are given to treat itchiness, discomfort or bleeding (eg anusol). If the bleeding does not improve then they can be treated with rubber bands or injections. Occasionally an operation may be required.

What is an Anal Fissure?

It is a tear in the anus resulting from passage of a hard stool. It makes defaecation painful and often causes bleeding.

 How is it diagnosed?

Usually the diagnosis is obvious from the story. If not then examination of the rectum/colon may be necessary with a flexible camera test (sigmoidoscopy or colonoscopy).

 How is it treated?

H pylori is a bacterium which lives in the inner lining of the stomach. It affects about half the population over the age of 60yrs and is important due to the damage it causes. Most people are infected in childhood and it is thought to spread within families.

How is it diagnosed?

Blood tests, stool tests and tissue samples taken during endoscopy can all be used to detect H pylori.

What diseases does it cause?

Most infected people have no symptoms. However, it can cause ulcers in the stomach or small bowel (duodenum) and result in tummy pain without ulceration (“non-ulcer dyspepsia”). There is also an association with stomach cancer.

(i)Duodenal ulcers- 90% are due to H pylori

(ii)Stomach ulcers- 70% are due to H pylori. The rest are due to aspirin & anti-inflammatory medications.

Modern ulcer healing drugs (eg losec) will heal most ulcers regardless of the cause. However, if they are due to H pylori, and it has not been eradicated, then the ulcers often recur.

Who should be tested for H pylori?

People who have ulcers of the stomach or duodenum, or non-ulcer dyspepsia.

How is it treated?

Combination therapy with an ulcer drug and two antibiotics is taken for 7 days and results in a 90% cure rate. Unfortunately, taking 3 medications simultaneously increases the chance of side effects (eg nausea, diarrhoea, skin rash & an unpleasant reaction to alcohol). Successful eradication only needs to be checked if you have had a complicated ulcer (eg bleeding). All ulcer treatment needs to have finished 4 weeks prior to rechecking to get an accurate result. Reinfection is very unusual.

Irritable Bowel Syndrome (IBS) causes abdominal discomfort, bloating and either diarrhoea or constipation. The discomfort may get better or worse on opening your bowels. It is a very common problem, affecting 5-10% of the population, and occurs most frequently in women in their late teens or early twenties. Symptoms may be worse before menstruation.

What causes IBS?

This is unknown but experiments show that some people have a very sensitive bowel or evidence of abnormal bowel contractions (dysmotility). In some people this can be traced back to a previous episode of gastroenteritis but in most cases no cause is found.

What tests are needed to diagnose it?

 If symptoms are typical then no tests may be needed at all. However, if you are over 40yrs old, have unusual symptoms (eg bleeding from the bowel, weight loss or diarrhoea during the night) or a family history of bowel disease (eg cancer or coeliac disease) you may need blood tests and a colonoscopy, which is an examination of the large bowel.

What about lifestyle and diet?

Improving diet, exercising regularily and reducing alcohol, coffee and smoking all help. Sorbitol in sugar-free gum and drinks can produce IBS symptoms and should be avoided. Some people are unable to digest milk (lactose intolerance) and this can also cause abdominal pain and diarrhoea.

Does stress cause it?

IBS is not caused by stress but is often made worse by it. Symptoms can respond to therapy directed at improving stress such as hypnotherapy, relaxation and behavioural therapy.

How is it treated?

Often no treatment is needed once a clear explanation of what is causing the symptoms has been given. If symptoms are severe then medication can be given for the particular problem. Pain is treated with medication that reduces bowel spasm (eg buscopan, colofac) or directly affects pain perception (eg amitriptyline, cipramil). Diarrhoea can be reduced by agents which slow the bowel down (eg loperamide). Constipation is often helped by fibre supplements (eg mucilax) or laxatives (eg movicol). Bloating may respond to medications which encourage bowel movement (eg motilium). Otherwise, probiotics or peppermint may be useful.

Does IBS cause other illnesses?

  It does not cause bowel cancer which is often a major concern of patients. However, it is well recognised that IBS patients report more headaches, period pain, fibromyalgia and urinary symptoms than the general population. The reason for this is unknown.

What is it?

            It is leakage of faeces out of the back passage (rectum) either without warning or despite efforts to “hold on”.

What causes it?

            Problems with the muscular rings (sphincters) at the anus or diarrhoea are common causes. Sphincters can be damaged during childbirth but not cause problems until many years later. Nerve damage (eg diabetics or following a stroke) can also affect sphincter function.      Rectal problems such as prolapse, inflammation (ie colitis) or severe constipation can cause problems.

What tests are useful?

            An xray test to check that defaecation is normal (defaecating proctogram) or a pressure test (anorectal manometry) to check the function of the rectum and sphincters is often recommended.

What is the treatment?

            Loperamide can slow down the bowel which often restores continence. Fibre supplements (eg Metamucil) can be helpful if the rectum does not completely empty leaving faeces behind which can then leak out. Finally, an operation can sometimes help if the sphincter is torn.

This is an unpleasant reaction to the sugar in milk (lactose) due to the lack of an enzyme in the lining of the gut. It is not an allergy. The enzyme, called lactase, breaks down the lactose and allows it to be absorbed into the bloodstream. Otherwise, undigested lactose passes through the gut and acts as a laxative. When it reaches the colon bacteria produce hydrogen from it which can cause bloating and abdominal cramps.

How common is it?

Enzyme levels generally fall with age but can decline dramatically in certain populations (eg Asians, Africans & Eastern Europeans). Lactose intolerance can also occur after food poisoning as the lining of the bowel, containing the enzyme, is often damaged. This is usually temporary.

How is lactose intolerance diagnosed?

Often the problem is obvious but it can be confirmed by several tests. These include: a test dose of milk; biopsy of the small intestine (done during endoscopy); blood lactose tolerance; lactose tolerance breath test.

How is it treated?

Taking lactose causes no harm, so for most adults it is simply a question of working out how much milk they can consume without symptoms. For example, most people can take milk in tea or coffee but cannot tolerate a glass of milk. Soy or rice based milks can be used as an alternative. Yoghurt is often well tolerated as the bacteria in it have already broken down the lactose. Also, hard cheeses are naturally low in lactose compared to soft cheeses. Otherwise, supplements of the enzyme lactase are available in health food shops which can be taken when eating dairy products.

 It is important to try and eat some dairy foods regularily as they are an excellent source of vitamins and calcium. Otherwise, supplements of calcium and vitamin D may be required.

What is it?

            If you have a family history of bowel cancer you may be at increased risk. The risk depends on the number of relatives affected and their age at diagnosis.

Average Risk

            The average New Zealander has a 1 in 20 (5%) chance of developing colorectal cancer (CRC) by the age of 75yrs.

Which family members are likely to influence your personal risk?

        Only close relatives make a predictable difference to your personal risk. These are siblings, parents, children (first degree relatives), grandparents, aunties, uncles, nieces & nephews (second degree relatives).

Slightly increased risk

            This applies if you have a first degree relative (FDR) who developed colorectal cancer over the age of 55yrs. The risk is doubled which means a 1 in 10 (10%) chance of getting CRC. Routine colonoscopy is not recommended but you should see your doctor if you develop any bowel problems (eg constipation, diarrhoea, bleeding).

Moderately increased risk

            This applies if you have a FDR who developed cancer at a young age (<55) or you have two FDRs with colorectal cancer. The risk is up to five times higher equating to a 1 in 4 chance of CRC by age 75. Regular colonoscopy is advised from age 50 or from ten years before the earliest cancer in the family- whichever is earliest.

Potentially high risk

            This is possible if you have a FDR with CRC at a very young age (<50) or a FDR with CRC and multiple second degree relatives (SDRs) affected. If a relative with CRC had multiple bowel polyps this is also potentially high risk. The last group at high risk are those whose relatives have been diagnosed with a familial cancer syndrome (eg polyposis or HNPCC).

Non-alcoholic fatty liver disease (NAFLD) is the commonest reason for mildly abnormal liver blood tests. It usually does not cause any symptoms. There are many causes including obesity, diabetes mellitus, thyroid disorders, high cholesterol, polycystic ovarian syndrome and intestinal bypass surgery for obesity.

What is NASH?

This is liver inflammation due to fat accumulation (non-alcoholic steatohepatitis). It causes progressive liver damage over time and can lead to significant liver damage called cirrhosis. NASH typically occurs in middle-aged people who are overweight and diabetic with high cholesterol levels.

How is fatty liver diagnosed?

As it does not cause symptoms, it is usually picked up on routine blood tests. Then an ultrasound scan of the liver can often confirm the diagnosis. Occasionally a liver biopsy is necessary to confirm the diagnosis or rule out significant liver damage (cirrhosis).

What treatments are there?

  There are no specific treatments for fatty liver but several lifestyle changes can make a big impact. Weight loss, avoiding alcohol, regular exercise and treatment of high blood pressure and cholesterol all help.

A polyp is an abnormal growth on the inside of the bowel wall. There are many different types of polyps but the important ones are called adenomas. Roughly half the population is likely to develop one during their lifetime but most will remain undetected. A small percentage of these polyps will change into cancer.

Why are they important?

Bowel cancer is a common cause of death in New Zealand and it is thought to originate from polyps. Not all polyps carry the same risk but there is no way of knowing this until the polyp has been removed. This is why polyps are always removed during colonoscopy. This is done by snaring them with a wire and is painless.

Am I cured?

Usually the whole polyp is removed but sometimes this is not possible. If the polyp contains cancer then surgery may be necessary. The number, size and type of polyps removed determine the risk that further polyps might develop in the future. For this reason regular colonoscopy is usually recommended once an adenomatous polyp has been found.

Risks of polyp removal

  There is a small risk of bleeding and an even smaller risk of making a small hole in the bowel wall (perforation). If you have significant bleeding or prolonged discomfort after a colonoscopy you should seek medical attention.

Preventing polyps and bowel cancer

A healthy lifestyle with a good diet, plenty of exercise and not smoking is the best advice. Preventative treatments such as high dose aspirin or anti-inflammatories are not recommended for people at average risk for bowel cancer. Once a polyp has been found, regular colonoscopies are advised (usually 3-5yrly).

What are probiotics?

            They are “good bacteria” which are consumed in an effort to alter the balance of the different bacteria which naturally occur in the large bowel (colon). There is evidence that some people have excessive quantities of gas-forming bacteria which may be responsible for bloating & pain. Two of the commonest bacteria given as “probiotics” are lactobacillus and acidophilus. Although they are present in natural yoghurts they are only there in small amounts which is why probiotic capsules or tablets are usually necessary.

Is there any proof they work?

     The best evidence for probiotics is in preventing diarrhoea when using antibiotics. The probiotics are taken at the same time and for a week afterwards. They can also shorten the duration of infectious diarrhoea, if given within the first 48hrs. In the hospital setting, patients with pouchitis (inflammatory bowel disease) and diarrhoea due to clostridium difficile respond well to probiotics. Finally, there is some work showing a small benefit in patients with irritable bowel syndrome.

Which herbal products are useful?

            Slippery elm and aloe vera juice are both mild laxatives which are useful in constipation. Aloe vera juice also reduces bowel cramps and can be helpful in irritable bowel syndrome. Peppermint (eg colpermin) reduces bowel spasm but can aggrevate acid reflux. Finally, ginger is very good for treating nausea.

What is it?

It is a feeling of discomfort or burning in the chest caused by stomach acid getting into the oesophagus. Occasionally food and fluid can regurgitate all the way up into the mouth.

Does diet affect it?

For many people reflux occurs no matter what they eat. However, certain foods can make reflux worse including fatty foods, spicy foods, chocolate, coffee, alcohol, cigarettes, cola drinks and peppermint. It is helpful to avoid large meals or eating close to bedtime.

Tests your doctor may recommend

Reflux can often be diagnosed and treated without any tests. If the reflux is not responding to treatment or there are any concerns from your doctor (eg losing weight, vomiting, difficulty swallowing) then an endoscopy may be recommended. This allows inspection of the oesophagus and stomach with a flexible camera. Occasionally other tests may be needed in difficult cases (pH monitoring or manometry).

Treatment

Lifestyle changes such as weight loss and stopping smoking are very effective. Otherwise, occasional heartburn can be treated with antacids (eg gaviscon or Mylanta). More frequent symptoms require regular acid reduction (eg ranitidine or omeprazole) or medications to empty the stomach quicker (eg domperidone).  Unfortunately most people will continue to get symptoms if they don’t take medication.

Surgery for reflux

Vitamin B12 deficiency can cause poor memory or numbness in the arms or legs. It can also lead to a low blood count (anaemia).

What causes it?

Inadequate dietary intake is unusual but can occur in vegans, who eat no meat or dairy products. The commonest problem is failure for the body to absorb it. This can result from disorders of the stomach (eg pernicious anaemia), pancreas or small bowel (eg Crohn’s or coeliac disease). 

What is pernicious anaemia?

It is an immune disorder in which antibodies “attack” the lining of the stomach and cause inflammation. This interferes with vitamin B12 absorption. It can be diagnosed by measuring the antibodies in the blood. Gastroscopy to inspect the lining of the stomach is often recommended. 

How is it treated?

What is it?

            Vomiting is when stomach contents are expelled forcefully- usually out of the mouth. Regurgitation is much less dramatic but also results in food being brought back up into the mouth. Undigested food implies an oesophageal blockage whereas digested food is often due to reflux (Gastro-oesophageal reflux).

New onset (acute) vomiting

            Vomiting with diarrhoea is usually due to an infection or food poisoning (gastroenteritis). If pain is present it can signify important problems such as gallstones, liver disease or blockage of the bowel. Sometimes the problem is the inner ear or brain which usually causes a spinning sensation and visual problems (vertigo).

Longstanding (chronic) vomiting

            This can be due to problems with various parts of the body including the gut, brain and hormonal glands. Medications are also commonly responsible (eg voltaren). Investigations including blood tests, camera tests (endoscopy) or scans (eg xrays or CT scans) are often necessary. It is important to exclude pregnancy first as this is a common cause!

Treatment