Microsoft word - treatment of gastro intestinal disorders.doc

Treatment of gastro-intestinal disorders – Dr Stephen Middleton
Before starting any treatments it is vital to make sure that you know
what is wrong with you. It is crucial to get the correct diagnosis from a
doctor before embarking on a treatment.

1. Heartburn (gastro- oesophageal reflux disorder, GORD)

Treatment of this condition can be divided into simple measures such as lifestyle
changes, medicines that provide a protective barrier between the oesophagus (gullet) and
the acid and other irritants which reflux up from the stomach, and acid blockers which
reduce the production of acid by the stomach so that less acid is available to reflux.
Medical Treatment
There are two main types of acid blockers; the H2 antagonists that block the histamine
receptors on the acid producing cells of the stomach such as Ranitidine (Zantac) and
Cimetidine (Tagamet). These reduce the amount of acid to a moderate degree, but often
these are not powerful enough to resolve the symptoms of reflux.
 The strongest acid blockers are called proton pump inhibitors, these block the pump that makes the acid, acting directly on the acid producing mechanism and are very effective. They have a very powerful acid blocking effect. Examples of these drugs are Omeprazole or Lansoprazole. A small number of patients (less than 10%) are quite resistant to these drugs and require large doses to control symptoms. Specialists may use doses above those licensed in certain cases.  Another type of drug used in some cases has an effect of the movement of food down the oesophagus and stomach. These are known as prokinetic agents and they speed the transit of food and liquid through the oesophagus and stomach, so that there is less food and acid residue to reflux up. These can be useful in certain cases, but do not tend to be the first treatment of choice. There are two general ways to use drug therapy, either starting with the weakest treatment and building up to the strongest treatments if required, or starting with the strongest treatment to control symptoms rapidly and then reduced in potency until the minimum effective strength of treatment is found. Lifestyle changes can be extremely useful in helping to control symptoms and thereby reducing the amount of medication needed.  Raising the head of the bed by at least 15cm, usually by placing blocks  Retiring to bed with an empty stomach. The stomach usually takes 2-3 hours to empty and one should therefore eat and drink early and refrain from having the last minute drink before retiring. Treatment of gastro-intestinal disorders – Dr Stephen Middleton Surgical treatment
Where medical treatment and lifestyle changes fail, surgical treatment can be considered.
This is often quite useful for people who have volume reflux of liquids into the mouth
which can be very disturbing and difficult to treat. Surgical treatment is usually offered
to those whose symptoms can not be controlled by drug therapy, or who want to either
avoid drugs for personal reasons or are unable to tolerate them. Some prefer the surgical
option. There are two types of surgery the traditional operation and the new keyhole type
surgery. Surgeons quote success rate of between 80 – 90 % but it should be remembered
that even in the best hands there can be serious complications of surgery and some of
these complications can lead to permanent damage to the stomach which causes
symptoms that can not be corrected very easily and are sometimes permanent. In most
cases however the surgery is very successful.
2. Swallowing problems
When people have a problem swallowing this is called dysphagia.  Transfer dysphagia
This can be very high in the throat, where food can not be moved from the mouth to the oesophagus. It is often due to discoordination of muscle activity in the throat. Sometimes it is caused by a pharyngeal pouch and rarely by a tumour.  Oesophageal dysphagia.
This is difficulty in swallowing food once it has entered the oesophagus. It can be caused by narrowing (stricture) in the oesophagus, sometimes caused by acid burning the oesophagus and causing scaring, tumours and occasionally by muscle or nerve disorders that cause spasm or discoordination of oesophageal movement. Once the problem has been identified and the cause found by oesophageal xray studies and/or an endoscopy. A narrowing can often be stretched using a balloon and then the cause, which is usually acid reflux, is treated with an acid blocker. People who have spasms in the oesophagus, if caused by acid reflux find acid blocker treatment helps. Otherwise injection of Botox into the oesophageal wall to relieve the spasm works well (as illustrated in the photograph ) (link to photo)
3. Irritable bowel syndrome.

The underlying problem in irritable bowel syndrome is over sensitivity of the gut (hypersensitivity) and it can affect any part of the gastrointestinal tract but usually most of the symptoms arise from the large intestine. Most foods are not completely digested by the stomach and small intestine and therefore some residue enters the large bowel where the majority of bacteria reside and break down the food. We call this process fermentation. This produces side products such as organic acids and gas and it is these that are believed to cause symptoms in patients with irritable bowel syndrome. Some patients report specific food intolerances. Studies have been done to try and test these scientifically, but it has proven very difficult to get consistent results. There are however Treatment of gastro-intestinal disorders – Dr Stephen Middleton a number of conditions that are caused or provoked by specific food intolerances and are well substantiated such as :  Lactose intolerance.
Is an intolerance to milk sugar. People with this condition lack the enzyme (lactase) to required to digest the sugar lactose (lactase) which is usually present in the small intestine. If they ingest lactose it can not be digested and passes into the large bowel where the bacteria are fermented and cause production of large amounts of gas and acidic by products which produce diarrhoea and bloating, similar to those experienced by those with irritable bowel
Dietary treatment for irritable bowel syndrome

Dr Middleton advises dietary manipulation as the first line treatment for irritable bowel
syndrome. An exclusion diet is used, there are various types of diet depending upon the
symptoms experienced. Initially the diet is relatively strict, once symptoms are under
control, foods can be reintroduced to establish which foods tend to provoke symptoms.
Often by avoiding a small number of foods the symptoms can be controlled without
unduly restricting the diet. Where there seem to be many food intolerances it is not wise
to use the dietary strategy as this may lead to an inadequate diet that is unhealthy. Even
if the dietary restrictions seem minor it is always important to have the diet assessed by a
professional Dietitian to ensure any ongoing dietary restriction will not affect health in
any way.
At the hospital Dr Middleton works in, in Cambridge where the dietary mode of
treatment is used as the first strategy there is a good success rate of around 70% and most
people do not need drug therapy.
Drug therapy for irritable bowel syndrome

This can be divided into:
 drugs that are taken when symptoms occur. As many of the symptoms are caused by spasm of the gut anti-spasmodic drugs are used when the pain occurs such as Mebeverine, Hyoscine, Propantheline, Alvarine and Peppermint oil. These drugs tend not to work if taken all the time.  drugs that are taken all the time to prevent symptoms. To prevent symptoms occurring one of the best drugs available is Amitriptyline, taken in a low dose and built up slowly. Although it is licensed as an anti-depressive agent, in lower doses it is given for the smooth muscle relaxing effects rather than for its anti depressive action. Treatment of gastro-intestinal disorders – Dr Stephen Middleton
Avoiding provoking factors

In addition to avoiding foods that provoke irritable bowel syndrome, factors such as
stress may aggravate symptoms. Medication may be taken before a predictable stressful
event such as examinations, interviews or performing in public.
4. Stomach and duodenal ulceration (peptic ulcers)

These are caused by acid and peptic juices produced by the stomach. If acid blockers are
used and have reduced the acid to a sufficient degree the ulcers heal. It has relatively
recently been discovered that in most cases the primary trigger for ulceration in the
stomach and duodenum is an infection called Helicobacter pylori. If untreated it can
lead to an increased risk of developing cancer. People with ulcers should be checked to
see if they have this infection, this can be done at endoscopy or by a stool test via GP
surgery or a urea breath test. If the infection is present, treatment with two antibiotics
and an acid blocker for one week is generally recommended. After six weeks a test can
be done to check the infection has been successfully eradicated. If the infection is still
present, further antibiotics can be given depending upon the individual situation. If the
infection proves to be resistant, it is possible to take small samples at endoscopy so that
the laboratory can test to check what antibiotics will be best to treat the infection.
5. Constipation
Constipation is a common and often troubling symptom which can lead to abdominal pain, bloating, haemorrhoids, anal fissures and can make people feel very nauseated and generally lethargic. Initially a lifestyle assessment is helpful:  Dietary assessment to check fibre and fluid intake is adequate  Availability of toileting facilities (particularly in the work place) and time to use  Current drug therapy which may cause constipation, for example pain killers such as codeine, but there are many other drugs that If these points are not relevant, the next stage is to consider the type of constipation:  hard infrequent motions
This is best treated with bulking agents, usually in the form of fibre bought as supplementary fibre from the chemist. Along with the fibre, a faecal softener such as Magnesium Hydroxide based preparation is often useful. It is important adequate fluids are taken with these. It is best to avoid stimulant laxatives such as Senna or products Treatment of gastro-intestinal disorders – Dr Stephen Middleton such as Lactulose which can cause bloating and therefore not ideal for long term use. Liquid paraffin based preparations if taken long term can cause vitamin deficiency and anal leakage.  difficulty in passing soft stools
This may be due to a problem controlling pelvic muscles and is called an evacuatory disorder. This condition can be improved greatly with specialist treatment and patients should be referred to a gastroenterologist with a particular interest in constipation and who has access to biofeedback which is a form of physiotherapy to improve the function of the muscles involved in evacuating a bowel motion. It is obviously very important there are no other conditions causing the constipation and your GP or Consultant will know which conditions need to be excluded and may undertake tests such as thyroid hormone measurements, colonoscopy to exclude polyps or other diseases in the large bowel. It is important to understand the cause of symptoms and exclude any sinister underlying diseases before embarking long term treatments.
6. Inflammatory bowel disease
The treatment of inflammatory bowel disease can be divided into two stages; 1. Inducing
disease remission, 2. Maintaining disease remission.
The types of treatment available range from dietary modification to very potent
immunosuppression, some of these are aimed at inducing disease remission others at
maintaining remission. Several treatments achieve both these aims.
Dietary Treatment.

It has been known for many years that liquid elemental diets can induce remission in
Crohn’s disease. They have not been shown to be effective in ulcerative colitis. The
elemental diets are based on a very simple diet which is made up of nutritional
components in their simplest forms. This means that very little digestion is required and
most of the feed is absorbed easily in the small intestine. This type of treatment is very
effective in inducing disease remission and can also maintain disease remission, but is
often found unpleasant to taste and may need to be delivered by a naso-gastric tube. It is
often used as the primary treatment in children and can also be used effectively in adults.
After achieving remission on an elemental diet some centres proceed on to an exclusion
diet. This is designed to identify foods that provoke symptoms and therefore might be
causing a recurrence of inflammation.
Drug treatments.

Treatment of gastro-intestinal disorders – Dr Stephen Middleton Crohn’s disease
Drugs used to induce remission in Crohn’s disease

1. 5-aminosalicylic acids (5-ASAs)
2. Steroids
3. Anti –TNF antibodies
( Some physicians use antibiotics although the evidence for their effectiveness is not
5-aminosalicylic acids. – can be used either orally or topically as an enema depending
upon the site of the disease. If the disease is distal it is always better to use the treatment
directly by topical application through an enema formulation, rather than oral
administration which then must pass through the body system before getting to the site of
the disease in the bowel. They can also be used to maintain disease remission.
Steroids. – used either orally or topically as an enema depending upon the site of the
disease, as for 5-ASA compounds above. When the disease is severe they can be given
intravenously and this is more effective that the oral route. Some steroid preparations
limit the amount of steroid drug that enters the body thus reducing the side effects.
Steroids such as Budesonide treat at the point where they are absorbed, rather than going
through the blood stream. Any drug that is absorbed is largely removed from the blood
stream by the liver. Budesonide preparations are mainly used for small intestine and right
colon disease but new formulations are being developed which may prove to be effective
for treatment of the left colon also. They should not be used to maintain disease
Anti-TNF antibodies
This type of treatment uses antibodies which attack a substance called TNF- a (Tumour
necrosis factor alpha). This substance is released during inflammation and is a very
strong promoter of further inflammation especially in Crohn’s disease. These drugs can
either be infused into a vein every few months or given at home by injection every two
weeks. They have side effects including an increased risk of infections and can cause
allergic reactions but are generally well tolerated. They can also be used to maintain
disease remission.

Treatment of gastro-intestinal disorders – Dr Stephen Middleton
Drugs used to maintain remission in Crohn’s disease

Certain drugs are known to have a suppressing effect on the immune system. Some of
these have been demonstrated to be effective as treatments for Crohn’s disease.
Azathioprine :
This is the most frequently used immunosuppressing drug in the UK. It can take up to 3
months to have its effect and can adversely effect bone marrow function and the liver.
Patients need to e closely monitored when starting the is drug and continue to have
regular check ups whilst on it. It can have extremely beneficial effects.

Another immunosuprreessive drug which has been shown to be beneficial in Crohn’s
disease but is not as well established as azathioprine. Again, close monitoring is required
and long term side effects such as lung fibrosis and liver fibrosis can rarely occur. Drug
interactions should be watched for and alcohol intake minimised.
Anti-TNF alpha antibodies:
Also used as maintenance tx in Crohn’s disease.
Drugs used to induce remission in ulcerative colitis
These are broadly similar to those used in Crohn’s disease.
However, Anti TNFa antibodies are not used as often as the evidence for their
effectiveness is less compelling. Nevertheless the studies available do demonstrate a
beneficial effect in ulcerative colitis.
Drugs used to maintain remission in ulcerative colitis

These are broadly similar to those used in Crohn’s disease, above.
However, 5-ASA compounds have been found to be effective as maintenance treatment
for UC, although they are not thought to be effective in Crohn’s disease to maintain
Methotrexate has not been demonstrated to be very effective in ulcerative colitis although
there have not been many studies undertaken.


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