FAQs on Gastroenterology

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Why do some people get fat while others don't?

There is a strong genetic tendency to obesity. This is why fatness runs in families. Studies have been done of identical twins who were adopted out at birth and they always ended up being almost exactly the same weight even though eating differently and brought up in separate families. People are born with the tendency to be fat or lean. To try to fight against this and be something else is very difficult. If one parent is fat you have a 50% chance of being likewise. If both parents are fat then there is an 80% chance of being fat too.

Appetite and hunger are behind the problem of obesity. It has nothing at all to do with greed or gluttony as some people think. Fat people are just plain hungry even when they have eaten enough for their energy needs. Their stomachs just keep sending messages to the brain that they are hungry and hunger is one of the hardest feelings to ignore. The story about people having bottomless pits is pretty close to the truth and a lot of big people have never had the sensation of fullness – until they have surgery! The bottom line is that obese people eat much more than thin people because they have a much bigger appetite.

What is obesity?

Obesity is always due to consumption of more calories than needed by the body for energy. These extra calories are then converted by the body into fat which is the body's way of storing energy for a rainy day. When there is plenty of food available, we don’t need this stored energy and so it stays with us as fat. It may come on quickly if large amounts of food are eaten over a few weeks, or slowly over many years if there is only a small excess of calories.

What is morbid obesity?

Morbid obesity is a disease of excess energy stores in the form of fat. Clinically this correlates with a Body Mass Index (BMI) of 40kg/m2 or with being 40kg. overweight. The biological basis for morbid obesity is unknown, though recent work has demonstrated a genetic component of 25 to 50 per cent. The genetically determined protein found in gastric cells called leptin has a place in the control of satiety through central nervous system. This confirms that morbid obesity is a disease and not a disorder of will–power, as sometimes implied.

Why is it called morbid obesity?

Being overweight is associated with real physical problems which are now well recognized. The most obvious is an increased mortality rate directly related to weight increase. It was found that the mortality rates for men who are 50% above average weight increased approximately two times. For those suffering additionally from digestive tract diseases, it was four times higher, and for male diabetics it was five times higher. In women who are 50% above average weight, mortality rate was twice that for normal weights, three times higher for who had associated digestive tract diseases, and eight times higher for female diabetics. Overweight people of both sexes, especially the young, tend to die sooner than their lean contemporaries.

While obesity itself is a risk factor, most of the associated mortality and morbidity is associated with the co–morbid conditions. These conditions include hypertension, hypertrophy cardiomyopathy, hyperlipidemia, diabetes, cholelithiasis, obstructive sleep apnea, hypoventilation, degenerative arthritis and psycho–social impairment.

This morbidity and mortality in severely obese people cannot be overstated. The Guinness Book of Records has recorded that none of the world’s heaviest individuals lived beyond the age of forty.

The treatment goals for morbid obesity are: an improvement in health achieved by a durable weight loss that reduces life threatening risk factors and improves performance of activities of daily life.

What are the treatment options?

There are only two ways of losing weight. First, by consuming fewer calories than you need (that is virtually starving) and thus burning up fat; or, secondly, by burning up fat by vigorous physical exercise. Which means, one must do a large amount of exercise very consistently for a long time to lose any reasonable amount of weight; and, of course, the fatter you are the harder it is to exercise. To lose weight successfully and over a reasonable time, you must have your intake cut down to about 400 – 500 Calories per day. The big problem with a diet like this of course will be hunger.
Non–operative treatments
It is mandatory for the surgeon to consider medical as well as so–called non–operative treatments before surgical options. Published scientific reports document that non–operative methods alone have not been effective in achieving a medically significant long–term weight loss in morbidly obese adults. Weight reduction trials conducted under medical supervision over a period of 10 to 12 weeks shows average weight loss of 2.5 kg. These trials consist of dieting and regular exercises. The problem with this therapy is that weight loss is not significant and not sustained, since after a few weeks of trials patient compliance is reduced and they regain weight – sometimes more than what they started out with.

The use of anorectic medications has recently been advocated as a long–term therapeutic modality in management of what is clearly a chronic disease. In a study conducted over a nearly four–year period, utilizing a two–drug regimen of Phenteramine and Fenfluramine or Dexfenfluramine, the initially optimistic results were not sustained – there was drop out rate of one–third and a final average weight loss of only 1.5 to 2.0 kg. These drug combinations cause serious side–effects including cardiac valvular diseases and psychological disturbances. Fenfluramine Dex–fluramine are no longer marketed in India on orders from the drug regulatory authorities.

Bulking agents which give a feeling of fullness also have been tried. These drugs, when taken with water before meals, swell in the stomach. Though they don't have side effects like the previously discussed CNS drugs, their prolonged use leads to developing tolerance.

The fact is, there is an extremely high incidence of failure to sustain even a 10% long–term weight loss in morbidly obese patients with any form of non–operative treatment.

Jaw–wiring and intra–gastric balloons have been tried in the past but have not successful.

The surgical option
Surgical treatment is medically necessary because it is the only proven method of achieving long–term weight control for the morbidly obese patient. Surgical treatment is not a cosmetic procedure. It does not involve the removal of adipose tissue (fat) by suction or excision, like liposuction.

It involves reducing the size of the gastric reservoir, with or without a degree of associated malabsorption. This reduces solid food intake with in turn reduces total caloric consumption. It induces early satiety and provides satisfaction of hunger even after eating small amounts of food.

Who can go in for surgery?

Surgery for obesity is a very major step and should never be entered into lightly without considering carefully its advantages and disadvantages. Current surgical opinion is that patients should be at least 50% above their ideal weight and have had a severe weight problem for at least five years. It is important of course that patients should have tried less drastic methods of weight loss.

Patients with a Body Mass Index (BMI) of more than 40kg/m2 are potential candidates for surgery – provided they strongly desire a substantial weight loss – because obesity severely impairs the quality of their life. There are other related indications such as diabetes, hypertension, sleep apnea, asthma, angina, claudication, infertility, stress incontinence, intertrigo, depression, gastric reflux, arthritis and clumsiness.

What is the stomach exactly?

The stomach is a hollow bag which joins up to the mouth via the esophagus (throat) and empties into the small intestine where most of the digestion of food occurs. The main function of the stomach is to act as a temporary reservoir (it can hold 1 to 1.5 litres) for swallowed foods and fluids since the bowel cannot cope with digesting a large amount of food at once. A valve called the pylorus controls the rate at which the stomach contents drain into the small bowel.

When the stomach is full, the nerves in the wall of the stomach send messages to the brain to let you know you are “full”. When the stomach is empty the message is “hungry”. The trouble with obesity is that fat people keep getting more “hungry” messages than “full” messages – so they eat more than they need.

What happens in the stapling operation?

The actual surgery involves creating a small pouch in the upper part of the stomach that effectively becomes a new `baby stomach’. The staples join the walls of the stomach together to form this pouch but leave a narrow opening called the stoma between the pouch and the rest of the stomach. Three strong stitches are put around the stoma to make sure it stays 12 mm wide and doesn't stretch. The food still goes down the normal way and is digested in the bowel normally.

The big difference is that the pouch will only allow a very small amount of food to be fitted in at one time. When this happens, satisfaction is achieved and hunger will subside until the pouch eventually empties into the duodenum. So you feel full after eating a small amount of solid food and your intake of food can be kept to two or three tiny meals a day with no desire to eat between meals.

How does gastroplasty work?

Gastric stapling works by drastically restricting the amount of solid food you can fit into the stomach at each meal – but it has the advantage of giving satisfaction in the stomach as soon as this amount is eaten. After gastric stapling you eat just 50 to 90 ml of solid food and you actually

How did obesity surgery originate?

The first known surgical procedure aimed at reducing body weight was performed in Sweden in 1952 by Victor Henrikson, who resected 105 cms of small bowel in a 32–year old woman. The procedure was unacceptable because of its irreversibility. The first real obesity surgery procedure was the jejuno–ileal by–pass performed by Kremen and Linner in USA in 1954. The operation was very successful for weight loss but was associated with serious side effects including chronic diarrhea, kidney stones, arthritis and major liver disease.

The gastric by–pass was first performed by Edward Mason of the USA in 1967. This operation did away with most of the side effects of earlier operation . However, gastric by–pass is a technically difficult operation and does raise some long term problems like vitamin and mineral deficiency.

In 1971 Edward Mason developed the gastroplasty or gastric stapling operation. It was not popular for several technical reasons. In 1978 a better technique was introduced simultaneously by Michael Long in Melbourne, Australia, and Gomez in USA which came to be accepted widely all over the world. Today gastroplasty in one of its forms is the most commonly performed obesity operation.

In 1976, a bilio–pancreatic bypass was developed by Nicola Scopinaro which became popular in Europe and some centers in USA, but it has the disadvantage of being a very major surgery. In 1980, the trend was towards using gastric balloons but they proved to be expensive and unsuccessful.

In 1982 Andrew Jamieson, Melbourne, Australia, started practicing the technique adopted by Michael Long. He further modified it by reducing the size of the gastric pouch.

Later, the gastric banding technique was introduced by Lubomyr Kuzmak. It is an excellent operation with the obvious advantage being its adjustability and it can be performed endoscopically.

What is gall bladder?

A gall bladder is an organ attached to the underside of your liver. It stores bile produced in the liver and releases it into the small intestine when fatty foods are eaten. Bile helps the body break down fatty food, aiding in the digestive process.

Sometimes gall bladders can become diseased, or gallstones may form. Gallstones, which are crystallized bile, are the result of chemical imbalances. While some gallstones have no noticeable symptoms, more often they are the cause of pain and other problems.

Are you a candidate for Lap Chole?

Most patients with gallbladder disease can be treated with the lap chole procedure; however, a thorough evaluation by your physician and a surgeon trained in laparoscopy is the best way to determine whether the procedure is right for you.

What is a Hernia?

An abnormal opening in the inner layer of the muscular wall of the abdomen. This muscular wall supports internal organs, as any weakness or hole in this area can result in a protrusion of the internal organs that can be seen or felt.

The most common hernia is the inguinal, or groin hernia. An inguinal hernia occurs in the extreme lower part of the abdomen and can be found in males and females of any age. However, because of anatomical differences, it occurs most often in males.

Hernias may cause no symptoms, allowing some people to live with their hernias for years. More commonly, hernias may produce a dull aching sensation or an occasional sharp pain. Other symptoms may include nausea, constipation, or a sense of fullness. Once an inguinal hernia occurs, it cannot heal itself; in fact, left untreated it can get larger and lead to other complications (like bowel obstruction) Surgery is the only way to repair the hernia.

Are You a Candidate for Lap Hernia?

While the benefits of lap hernia can be brought to many patients who suffer from painful hernias, a thorough evaluation by your physician and a surgeon trained in laparoscopy is the best way to determine your eligibility.

What is Endoscopic Surgery?

Explaining endoscopic surgery is best accomplished by comparing it to traditional surgery. With traditional, or “open,” surgery, the surgeon must make an incision that exposes the area of the body was the only way a surgeon could perform the procedure.

Now, Endoscopy eliminates the need for a large incision. Instead, the surgeon uses an endoscope, a thin, telescope–like instrument that provides interior views of the body.

The endoscope is inserted into the patient’s body through a small tube (called a trocar) placed in a tiny, half–inch incision. It is equipped with a tiny camera and light source that allow it to send images through a fiber optic cord to a television monitor.

Watching the monitor, the surgeon can perform procedure. The surgeon uses instruments inserted through other small tubes. Though instruments vary according to the procedure typical ones include “graspers” that manipulate tissue; scissors that cut tissue; and devices that use a laser beam or electric current to seal tissue and control bleeding.

What is chronic Viral Hepatitis?

The liver is an organ that plays an important role in managing the body’s functions including:

What is Hepatitis?

Hepatitis is an inflammation of the liver. Inflammation usually produces swelling, tenderness, and sometimes permanent damage. Hepatitis is caused by a number of things including alcohol, drugs, chemicals, and viral infections. If the inflammation of the liver continues at least six months or longer, it is called chronic hepatitis. Currently there are at least five different viruses known to cause viral hepatitis:
Viral Hepatitis A
Sometimes called "Infectious Hepatitis." It is spread by eating food or drinking water contaminated with human feces. This type of viral hepatitis is infrequently life–threatening.
Viral Hepatitis B
Sometimes called "Serum Hepatitis." It is spread from mother to child at birth or soon after, through sexual contact, contaminated blood transfusions and needles. This form of viral hepatitis may lead to cirrhosis, or scarring, of the liver.
Viral Hepatitis C
Formerly known as "non–A, non–B Hepatitis." This form of viral hepatitis is the most common. It can be spread through blood transfusions and contaminated needles. However, for a substantial number of patients, the cause is unknown. This form of viral hepatitis may lead to cirrhosis, or scarring, of the liver.
Viral Hepatitis D
This form of viral hepatitis is found most often in IV drug users who are carriers of the hepatitis B virus. It is spread only in the presence of the hepatitis B virus and is transmitted in the same way. This type of viral hepatitis occurs in people who have viral hepatitis B, and is a serious health problem.
Viral Hepatitis E
This form of viral hepatitis is similar to viral hepatitis A. It is found most often in people who live in countries with poor sanitation. It is rare in North America, and rarely life–threatening.

What are the Symptoms of Viral Hepatitis?

Many cases of viral hepatitis are not diagnosed because the symptoms are vague and similar to a flu–like illness. Sometimes, there are no symptoms at all. Some individuals with viral hepatitis may develop fatigue, nausea, vomiting, diarrhea, abdominal discomfort, muscle and joint aches, and changes in the color of urine and stools. A few of the individuals with viral hepatitis may develop jaundice. Jaundice means that the skin and whites of the eyes turn yellow. Itching of the skin may also occur with jaundice.

What Should I Do if I Have Been Exposed to or Think that I Have Viral Hepatitis?

Call your doctor and schedule an urgent appointment. Your doctor will take a history, do a physical examination, and order blood tests to determine your diagnosis.

Will I Need a Liver Biopsy?

Liver biopsy is a procedure by which a needle is used to remove a small piece of liver to be analyzed under a microscope. This procedure is done to confirm the diagnosis of viral hepatitis and to determine the degree of damage the virus has caused. A liver biopsy is usually not needed to determine the cause of hepatitis.

What is the Difference Between Acute and Chronic Hepatitis?

Acute hepatitis is the initial infection, and may be mild or severe. If the infection lasts for six months or longer the condition is called chronic hepatitis. Hepatitis A and E do not cause chronic hepatitis. The hepatitis viruses B, C, and D can produce both an acute and chronic episode of illness. Chronic hepatitis B and C are major health concerns.

Is Hospitalization Required for People with Hepatitis?

Usually hospitalization is not required. If a person cannot keep food or liquids down over a period of time, the doctor may decide hospitalization is needed.

What is a Carrier?

A carrier is a person who has hepatitis B, C, or D virus in the blood. This person may or may not have any symptoms of the disease. Because the virus is in the blood, it can be transmitted to others. Blood tests can determine if someone is a carrier.

What is the Treatment for Chronic Viral Hepatitis?

After the doctor has determined which type of hepatitis virus is present, treatment programs can be discussed. Some helpful hints for people with chronic viral hepatitis are listed below:

Should I Cook Meals?

People with hepatitis A or E should not prepare or handle food to be eaten by others. Limitations on food handling are not necessary for people with hepatitis B, C, or D.

What Hope for the Future?

During the past ten years, tremendous advances through research have been made in the field of viral hepatitis. Identifying the specific viruses that cause the disease is the first step in finding effective treatment programs.

Tips for prevention Hepatitis A & E

Vaccines are available to protect people against hepatitis A. Good sanitation and personal hygiene will reduce the spread of hepatitis A and E. Water should be boiled if there is any question about contamination. Food should be cooked well and fruits peeled if there is any question about sanitation in the area. Avoid eating shell fish that feed in contaminated waters. To prevent the spread of hepatitis A and E in the family or with close personal contacts, wash hands, eating utensils, bedding and clothing in soap and water.

Hepatitis B
Vaccines are available to protect people against hepatitis B. Avoid exposure to blood or body fluids of an infected person. Do not have sexual contact with a hepatitis B infected person without the use of condoms. Do not share scissors, razors, nail files, toothbrushes, or needles with hepatitis B infected persons. Needles used for intravenous drugs or to give tattoos and body piercing can be other means of spreading hepatitis B.

Hepatitis B is frequently passed from infected mothers to newborns. It is important that all newborns of hepatitis B infected mothers be immunized against the virus at the time of birth.

A treatment plan to prevent liver damage may also be prescribed by your doctor.

Hepatitis C
Blood banks screen blood to insure the safety of the blood supply. This has greatly reduced the number of hepatitis C cases resulting from transfusions.

Avoid exposure to blood or body fluids of persons known to have or carry the hepatitis virus. Sharing needles with anyone must not be done.

What are the symptoms of Gallstones?

The most typical symptom of gallstone disease is severe steady pain in the upper abdomen or right side. The pain may last for as little as 15 minutes or as long as several hours. The pain may also be felt between the shoulder blades or in the right shoulder. Sometimes patients also have vomiting or sweating. Attacks of gallstone pain may be separated by weeks, months, or even years.

It is thought that gallstone pain results from blockage of the gallbladder duct (cystic duct) by a stone. When the blockage is prolonged (greater than several hours), the gallbladder may become inflamed. This condition, called acute cholecystitis, may lead to fever, prolonged pain and eventually infection of the gallbladder. Hospitalization is usually necessary for observation, treatment with antibiotics and pain medications, and frequently for surgery.

More serious complications may occur when a gallstone passes out of the gallbladder duct and into the main bile duct. If the stone lodges in the main bile duct, it can lead to a serious bile duct infection. If it passes down the bile duct, it can cause an inflammation of the pancreas, which has a common drainage channel with the bile duct. Either of these situations can be extremely dangerous. Stones in the bile duct usually cause pain, fever, and jaundice (yellow discoloration of the eyes and skin).

Many people with gallstones have no symptoms. Often the gallstones are found when a test is performed to evaluate some other problem. So–called "silent gallstones" are likely to remain silent, and no treatment is recommended.

What tests are used to diagnose Gallstones?

The most important parts of any diagnostic process are the patient’s description of symptoms and the doctor’s physical examination. When gallstones are suspected, routine liver blood tests are helpful since bile flow may be blocked and bile may back up into the liver.

Two excellent radiographic (X–ray) tests are used to determine the presence of gallstones. The first is abdominal ultrasound, in which a microphone is used to bounce sound waves against hard objects like stones. The second is an oral cholecystogram (OCG), in which an X–ray of a dye–filled gallbladder is taken after the patient swallows dye–containing pills. Both tests are about 95 percent effective in diagnosing gallstones. Ultrasound is more commonly performed because it is completely non–invasive (no injections), does not involve exposure to X–rays, and there are no pills to swallow.

Unfortunately it is more difficult to diagnose gallstones once they have entered the common bile duct. Ultrasound is much less sensitive in the bile duct, and OCG cannot be used at all. The best tests involve putting X–ray dye directly into the bile ducts. A flexible swallowed tube can be used (endoscopic retrograde cholangiopancreatography or ERCP), or a needle can be passed through the liver and into the bile ducts (percutaneous transhepatic cholangiography or PTC). These tests both carry small risks, require X–ray exposure, and may be uncomfortable or require use of sedation. Their use is therefore reserved for certain patients.

What treatments are available for Gallstones?

Many new approaches to gallstone treatment have been tried over the past several years, but surgical removal of the gallbladder (Cholecystectomy) remains the most widely used therapy. This is partly because the newer non–surgical treatments are useful in only some gallstone patients, but surgery can be used in virtually all patients. Patients generally do well after surgery and have no difficulty with digesting food, even though the gallbladder’s function is to aid digestion. Surgical options include the standard procedure, called open Cholecystectomy, and a newer, less invasive procedure called laparoscopic Cholecystectomy ("belly–button surgery").

In open Cholecystectomy, the surgeon removes the gallbladder through a five– to eight–inch incision. This procedure has been performed for more than 100 years and is quite safe, although four or five days of hospitalization and several weeks of recuperation at home are usually needed.

Laparoscopic Cholecystectomy is a recent technique which was introduced in the United States in 1988. The surgeon makes several incisions in the abdomen through which a tiny video camera and surgical instruments are passed. The video picture is viewed in the operating room on a TV screen, and the gallbladder can be removed by manipulating the surgical instruments. Because the abdominal muscles are not cut there is less postoperative pain, quicker healing, and better cosmetic results. The patient can usually go home from the hospital within a day and resume normal activities within a few days.

Each approach has its advantages, and a doctor can recommend the best method for each patient depending upon the clinical situation. For instance, it may be difficult or dangerous to remove a severely inflamed gallbladder laparo–scopically. It may also be more difficult to remove a stone from the bile duct laparo–scopically, if one is found at surgery to have passed out of the gallbladder and into the duct. However, stones in the bile duct can frequently be left in place and removed at a later date using a non–operative method such as ERCP.

Gallbladder surgery may be complicated by injury to the bile duct, leading either to leakage of bile or scarring and blockage of the duct. Mild cases can frequently be treated without surgery, but severe injury generally requires bile duct surgery. Bile duct injury is the most common complication of laparoscopic Cholecystectomy, and may be more common with the laparoscopic than the standard approach.

What are alternatives to Cholecystectomy?

There are alternatives to surgery for both stones in the gallbladder and stones in the bile duct. ERCP can be used to find stones in the bile duct, as described above. When duct stones are seen, the doctor can widen the bile duct opening and pull the stones into the intestine. This is commonly done when the gallbladder is being removed laparo–scopically or when a stone is found in the duct long after gallbladder surgery. It may also be done to relieve symptoms from a bile duct stone, even when other stones are present in the gallbladder, if a patient is too frail to undergo gallbladder surgery.

Gallbladder stones can be dissolved by a chemical (ursodiol or chenodiol), which is available in pill form. This medicine thins the bile and allows stones to dissolve. Unfortunately, only small stones composed of cholesterol dissolve rapidly and completely, and its use is therefore limited to patients with the right size and type of stones.

Two experimental approaches to gallbladder stones have been studied, but the results have thus far been disappointing. Patients with one or two larger cholesterol stones have been successfully treated with lithotripsy, a technique in which sound waves are focused onto stones which causes them to disintegrate. However, the fragments remain in the gallbladder unless ursodiol or chenodiol is taken to dissolve them. Patients with cholesterol stones have also been treated with methyl tertbutyl ether, a chemical which can be injected into the gallbladder until the stones dissolve. This chemical is harsh and some complications have been reported.

A problem with all non–surgical approaches is that gallstones return several years later in about half the patients successfully treated.

What is the liver?

The liver weighs about three pounds and is the largest organ in the body. It is located in the upper right side of the abdomen, below the ribs. When chronic diseases cause the liver to become permanently injured and scarred, the condition is called cirrhosis.

The scar tissue that forms in cirrhosis harms the structure of the liver, blocking the flow of blood through the organ. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also slowed is production of proteins and other substances made by the liver.

What is the impact of Cirrhosis?

Cirrhosis is the eleventh leading cause of death by disease in the United States. Almost one–half of these are alcohol related. About 25,000 people die from cirrhosis each year. There also is a great toll in terms of human suffering, hospital costs, and the loss of work by people with cirrhosis.

What are the major causes of Cirrhosis?

Cirrhosis has many causes. It can result from direct injury to the liver cells (i.e., hepatitis) or from indirect injury via inflammation or obstruction to bile ducts which drain the liver cells of bile. Common causes of direct liver injury include chronic alcoholism (most common cause in the United States), chronic viral hepatitis (types B, C, and D) and auto immune hepatitis. Common causes of indirect injury by way of bile duct damage include primary biliary cirrhosis, primary sclerosing cholangitis and biliary atresia (common cause of cirrhosis in infants).

Less common causes of cirrhosis include direct liver injury from inherited disease such as cystic fibrosis, alpha–1–antitrypsin deficiency, hemochromatosis, Wilson’s disease, galactosemia, and glycogen storage disease.

Two inherited disorders result in the abnormal storage of metals in the liver leading to tissue damage and cirrhosis. People with Wilson’s disease store too much copper in their liver, brain, kidneys, and in the corneas of their eyes.

In another disorder, known as hemochromatosis, too much iron is absorbed, and the excess iron is deposited in the liver and in other organs, such as the pancreas, skin, intestinal lining, heart and endocrine glands.

If a person’s bile duct becomes blocked, this also may cause cirrhosis. The bile ducts carry bile formed in the liver to the intestines, where the bile helps in the digestion of fat.

In babies, the most common cause of cirrhosis due to blocked bile ducts is a disease called biliary atresia. In this case, the bile ducts are absent or injured, causing the bile to back up in the liver. These babies are jaundiced (their skin is yellowed) after their first month of life. Sometimes they can be helped by surgery in which a new duct is formed to allow bile to drain again from the liver.
In adults, the bile ducts may become inflamed, blocked, and scarred due to another liver disease, primary biliary cirrhosis. Another type of biliary cirrhosis also may occur after a patient has gallbladder surgery in which the bile ducts are injured or tied off.

Very rare causes of cirrhosis include: reactions to drugs (e.g., vitamin A, methotrexate, amiodarone) exposure to environmental toxins, and repeated bouts of heart failure with liver congestion.

What are the Symptoms of Cirrhosis?

People with cirrhosis often have few symptoms at first. The two major problems that eventually cause symptoms are loss of functioning liver cells and distortion of the liver caused by scarring. The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with nausea and weight loss. Some patients present with menstrual abnormalities (amenorrhea), impotence, loss of sexual drive or painfully enlarged breasts (in men).

As liver function declines, less protein is made by the organ. For example, less of the protein albumin is made, which results in water accumulating in the legs (edema) or abdomen (ascites). A decrease in proteins needed for blood clotting makes it easy for the person to bruise or to bleed.

In the later stages of cirrhosis, jaundice (yellow skin) may occur, caused by the buildup of bile pigment that is normally passed by the liver into the intestines. Some people with cirrhosis experience intense itching due to bile products that are deposited in the skin. Gallstones often form in persons with cirrhosis because not enough bile reaches the gallbladder.

The liver of a person with cirrhosis also has trouble removing toxins, which may build up in the blood. These toxins can dull mental function and lead to personality changes and even coma (Encephalopathy). Early signs of toxin accumulation in the brain may include neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleeping habits.

Drugs taken usually are filtered out by the liver, and this cleansing process is also slowed down by cirrhosis. The liver does not remove the drugs from the blood at the usual rate, so the drugs act longer than expected, building up in the body. People with cirrhosis are often very sensitive to medications and their side effects.

A serious problem for people with cirrhosis is pressure on blood vessels that flow through the liver. Normally, blood from the intestines and spleen is pumped to the liver through the portal vein. But in cirrhosis, this normal flow of blood is slowed, building pressure in the portal vein (portal hypertension). This blocks the normal flow of blood, causing the spleen to enlarge. So blood from the intestines tries to find a way around the liver through new vessels.

Some of these new blood vessels become quite large and are called "varices." These vessels may form in the stomach and esophagus (the tube that connects the mouth with the stomach). They have thin walls and carry high pressure. There is great danger that they may break, causing a serious bleeding problem in the upper stomach or esophagus. If this happens, the patient's life is in danger, and the doctor must act quickly to stop the bleeding.

How is Cirrhosis diagnosed?

The doctor often can diagnose cirrhosis from the patient’s symptoms and from laboratory tests. During a physical exam, for instance, the doctor could notice a change in how your liver feels or how large it is. If the doctor suspects cirrhosis, you will be given blood tests. The purpose of these tests is to find out if liver disease is present. In some cases, other tests that take pictures of the liver are performed such as the computerized axial topography (CAT) scan, ultrasound, and the radioisotope liver/spleen scan.

The doctor may decide to confirm the diagnosis by putting a needle through the skin (biopsy) to take a sample of tissue from the liver. In some cases, cirrhosis is diagnosed during surgery when the doctor is able to see the entire liver. The liver also can be inspected through a laparoscope, a viewing device that is inserted through a tiny incision in the abdomen.

What are the treatments for Cirrhosis?

Treatment of cirrhosis is aimed to stop the development of scar tissue in the liver and prevent complications. When cirrhosis is due to an identifiable cause, treatment programs may be specific, such as for management of hepatitis B and C, or steroids and immunosuppressive agents for auto–immune chronic active hepatitis.

No matter what the cause of cirrhosis, every patient must avoid all substances, habits, and drugs that may further damage the liver, precipitate complications, or speed the progression to liver failure. Alcohol, in addition to causing cirrhosis, may accelerate the progression of liver scarring due to other causes, such as hepatitis C. All patients with liver disease should not drink alcoholic beverages. Even some non–prescription drugs and vitamins, acetaminophen, in relatively small doses (more than five doses a day) and Vitamin A (more than 25,000 IU/day) may precipitate liver failure. Non–steroidal anti–inflammatory drugs, such as ibuprofen, may precipitate severe bleeding and/or kidney failure.

The cirrhotic patient is at increased risk of contracting other infections that may be more severe than in healthy patients. Immunizations for hepatitis A, B, influenza, and pneumococcal pneumonia are available and should be administered. Raw seafood may contain bacteria that can cause life–threatening infections and therefore should be avoided.

How are the complications of Cirrhosis treated?

The abnormal accumulation of fluid may cause swelling of the ankles (edema) and abdomen (ascites). Therefore, patients should reduce the amount of fluid and salt in their diet or use drugs called "diuretics" that mobilize and excrete the excess fluid through the kidneys. Occasionally, the ascites may become infected, a condition known as Spontaneous Bacterial Peritonitis, and require treatment with antibiotics.

When the liver does not efficiently function to cleanse the body of toxins and drugs, the mental state of patients may change dramatically and lead to coma, called Hepatic Encephalopathy. Treatment is directed at reducing the protein in the diet, avoiding sedatives and pain medications, and using laxatives and/or antibiotics to decrease the absorption of toxins from the intestines.

Sometimes, bleeding from the esophagus or stomach caused by abnormal veins (varices) may occur and is a life–threatening emergency requiring hospitalization. Variceal bleeding can usually be controlled with the use of a flexible tube (endoscopes) that is inserted through the mouth into the esophagus and stomach and used to inject clotting agents into the veins or to rubber band ligate the varices.

Liver failure refers to the end stage of liver disease and cirrhosis when the liver stops working and cannot support life. Liver failure is difficult to treat and survival is limited. Therefore, patients with any complication of cirrhosis are considered to be at risk of developing liver failure.

When complications develop, it may be possible to manage them. When it is likely that liver failure will develop, some patients with cirrhosis are able to undergo liver transplantation. The treating gastroenterologist may recommend liver transplantation when complications of cirrhosis develop in an attempt to avoid liver failure.

What is gas in the Digestive Tract?

Gas in the digestive tract is not a subject that most people like to talk about, but the truth is that all of us have it and must get rid of it in some way. Normally, the gas passes out through the rectum or is belched through the mouth. These are both necessary functions of the body that allow us to eliminate gas.

When gas does not pass out of the body easily, it can collect in some part of the digestive tract, causing bloating and discomfort. Even normal amounts of gas in the body can bother people who are sensitive to this pressure. Although gas usually is not a sign of a medical problem, it can be. So if you have persistent or extreme gassiness (flatulence), mention it to your doctor when you have a checkup.

What causes Gas?

A common source of upper intestinal gas is swallowed air. Each time we swallow, small amounts of air enter the stomach. This gas in the stomach is usually passed into the small intestine where part of it is absorbed. The rest travels into the colon (large intestine) to be passed out through the rectum.

In some people, part of the gas is belched out instead of being passed from the stomach into the intestine. This happens for several reasons. People under a lot of stress often swallow large amounts of air. Some people swallow air frequently because they have post–nasal drip, chew gum, or smoke. Rapid eating or poorly fitting dentures also may cause too much air to be swallowed. Also, drinking beverages that contain carbonated water may increase gas in the digestive tract. These drinks contain carbon dioxide, which can produce large amounts of gas when warmed in the stomach. People with a gas problem should avoid carbonated or "sparkling" drinks.

What causes repetitive Belching?

Some people experience frequent belching. This might occur after a person has swallowed air without realizing it. Sometimes belching accompanies movement of stomach material back up (reflux) into the esophagus (swallowing tube). To clear material from the esophagus, a person may swallow frequently, which leads to more intake of air and further belching.

Another cause of repeated belching is gastritis (inflammation of the stomach). There are many causes of acute or chronic gastritis, but the most common cause is infection with a bacterium called Helicobacter pylori. When this organism gets into the stomach, it can produce bloating. This condition usually can be diagnosed by a specialist in digestive diseases (gastroenterologist). The doctor may detect the infection with a breath test or a blood test. The doctor also may take a sample of tissue (biopsy) from the stomach, using a lighted, flexible tube (endoscopes) that is inserted through the mouth. For Helicobacter pylori infection, physicians can prescribe a treatment plan.

Do any foods cause Gas?

The foods we eat can be a factor in the production of gas in the lower intestine. Some foods such as cauliflower, Brussels sprouts, dried beans, broccoli, cabbage, and bran are not completely digested in the small intestine. When the undigested bits of food reach the colon, they are fermented by the bacteria that live in the colon, causing gas.

Today, many people are trying to improve their nutrition and health by eating more fiber. However, some people discover that adding large amounts of fiber to their diets causes gassiness. This can happen when someone begins eating more whole–grain cereals such as whole bran, oatmeal, or oat bran, or whole–grain breads or fresh fruits, and vegetables. They get a feeling of being bloated when they first begin the high–fiber diet, but within three weeks or so, they may adapt to it. Some people, however, don’t adapt, and the bloating from eating a lot of fiber can be a permanent problem.

A common cause of excess lower intestinal gas is that a person’s body may not have enough lactase, an enzyme normally found in the small intestine. Lactase is needed to digest lactose, the sugar found in milk and other dairy products. When this sugar passes undigested into the colon, it is fermented by bacteria, and gas forms. This can be a cause of excessive flatulence.

If lactase deficiency is suspected of causing your gas, your doctor may tell you to stop eating dairy products for a while to see if you will have less gas. The doctor also may give you a blood test or a breath test to find out if you are lactose intolerant. The breath test detects hydrogen that is released by the bacteria as the undigested lactose ferments in the colon.

How much Gas does the body produce?

The amount of gas that people produce varies. Most people produce between a pint and a half gallon of gas each day. Oxygen, carbon dioxide, and nitrogen from swallowed air make up a large part of flatus. Fermenting foods in the colon produce hydrogen and methane as well as carbon dioxide and oxygen. All of these components of flatus (gas) are odorless. The unpleasant odor of some flatus is the result of trace gases, such as hydrogen sulfide, indole, and skatole, which are produced when foods decompose in the colon.

What causes abdominal pain and bloating?

Eating a lot of fatty foods can cause bloating and discomfort because the fat delays stomach emptying, allowing gas to build up. This problem can be avoided by eating less fatty meals.

The feeling of bloating in the abdomen may increase during the day and become most severe after a large meal. Many people think the bloated feeling after eating is caused by large amounts of gas. Researchers, however, have not found any connection between this symptom and the total amount of gas in the abdomen. Studies show that in some people even modest amounts (one ounce to one–half pint) of gas in the intestine can cause spasms, especially after eating.

Gas in the upper abdomen often is relieved by belching. Sometimes people try to swallow air to make themselves belch. This doesn’t work, however, because it only adds to the amount of gas in the stomach and does not reduce the discomfort.

Gas can collect anywhere in the lower intestine. Often it collects on the left side of the colon, and the pain can be confused with heart disease. When gas collects on the right side of the colon, the pain can be like that caused by gallbladder disease or even appendicitis.

A bloated feeling is probably not anything to be concerned about, but it can be a symptom of a more serious problem, such as an intestinal obstruction. If your problem is chronic, or if you are experiencing a severe increase in gassiness, you should talk to your doctor.

Is gassiness caused by a disease?

If excess gas is your only symptom, it is probably not caused by a disease. The problem may occur simply because you swallow air or digest food incompletely. It could be that your intestines have the kind of bacteria that produce a lot of gas. You could have a sluggish bowel that does not get rid of air readily. You might have an irritable bowel, often called spastic colon, which means that you cannot tolerate gas accumulation inside of the intestines, so even small amounts of air feel uncomfortable.

Do over–the–counter drugs relieve Gas?

Many claims are made for over–the–counter drugs intended to relieve gassiness. Often people find that these drugs do not help much, but some of them do help some people. Simethicone, activated charcoal, and digestive enzymes, such as the lactose supplement lactase, are among those doctors often recommend. Sometimes doctors prescribe a treatment plan to help move gas through the intestines more readily and which may help relieve gassiness in some cases.

Prevention of Gas

If you are bothered by excessive belching or flatus, and your physician has determined that you have no serious disease, the following suggestions may be helpful:

What is Pancreas?

The pancreas is a gland that sits behind the stomach. Larger than your gallbladder, but smaller than the liver, the pancreas plays a key role in the digestive system. Its juices join bile from the liver and gallbladder to drain into the small intestine. Specifically, the pancreas:

Secretes digestive juices (enzymes and a substance called sodium bicarbonate) into the small intestine
Produces the hormones, including insulin and glucagons, that control your body’s ability to use sugar. The digestive substances split the fats, proteins, and carbohydrates into digestible molecules.

What is pancreatitis?

Pancreatitis is inflammation of the pancreas. This condition usually begins at an acute stage, and in some cases, may become chronic after a severe and/or recurrent attack. When the pancreas becomes inflamed, the digestive enzymes attack the tissue that produces them. One of these enzymes, called trypsin, can cause tissue damage and bleeding, and can cause the pancreas blood cells and blood vessels to swell. With chronic pancreatitis, the pancreas may eventually stop producing the enzymes that are necessary for your body to digest and absorb nutrients. This is called exocrine failure and fat and protein are not digested or absorbed. When chronic pancreatitis is advanced, the pancreas can also lose its ability to make insulin; this is called endocrine failure.

There are two stages of pancreatitis

Acute pancreatitis:
This condition can occur suddenly, soon after the pancreas becomes damaged or irritated by its own enzymes. Although acute pancreatitis is not fully understood, its causes are usually gallstones or alcohol abuse. When gallstones pass through the bile duct, they may become stuck, causing enzymes to build up in the pancreas because they cannot drain through the duct, and damaging the pancreas. In the case of alcohol, the pancreas may be sensitive to the effects of excessive alcohol. An attack may occur anywhere from a few hours or one to two days after drinking alcohol. The amount of alcohol consumed will vary from person to person. Other less common causes of this condition are: excessive levels of fat particles in the blood, mumps, drugs, surgery, heredity, and idiopathic (unknown cause).
Chronic pancreatitis:
This stage of pancreatitis begins as acute pancreatitis, and becomes chronic when the pancreas becomes scarred. This condition is usually due to years of excessive alcohol consumption, but may also develop from other causes of pancreatitis.

What are the symptoms of pancreatitis?

The symptoms begin as those of acute pancreatitis: Most chronic pancreatitis is due to alcohol abuse and is already chronic at its first presentation. In rare cases this condition leads to cancer of the pancreas, an unchecked growth of abnormal cells in the pancreas.

What should I do if I think I have pancreatitis?

If your abdominal pain lasts more than 20 minutes, call your doctor or go to the emergency room. Your doctor will take a medical history, ask about your drinking history, and draw blood to test for pancreatic enzymes. You may also need to take pancreas function tests to determine the loss of pancreatic enzymes, a fecal fat collection test for evidence of malabsorption, and an ultrasound, CT scan or other test to determine pancreas damage.

If you have unexplained weight loss that lasts more than a few weeks, call your doctor. This can be a warning sign of pancreatic cancer.

What is the difference between acute and chronic pancreatitis?

Most cases of acute pancreatitis are mild and involve a short hospital stay to help heal the pancreas. Chronic pancreatitis is a much more persistent condition, and occurs more often in men than women.

What is the treatment for pancreatitis?

Your doctor will focus treatment on your nutritional and metabolic needs and on relieving your pain. Mild pain can be treated with analgesics. If the cause of acute pancreatitis is gallstones, you may have to have your gallbladder removed to prevent further attacks. If the bile duct is found to be enlarged, you may need an ERCP (endoscopic retrograde cholangiopancreatography) to drain it. An ERCP is a way your doctor can examine your pancreas, pancreatic duct, the common bile duct, and/or sphincter of Oddi. It involves passage of a long, narrow tube called an endoscopes used to put X-ray contrast dye into the bile and pancreas ducts. In severe cases, surgery will be required to drain the pancreatic duct or to remove part of the pancreas.

Your doctor will also likely give you dietary guidelines to follow in order to reduce the amount of fat you eat, since your body has trouble digesting these substances. You may also need to take pancreatic enzyme supplements, which are in the form of a tablet, every time you have a meal. These supplements will help your body absorb food and help you regain some of the lost weight.

What hope for the future?

Most people who have chronic pancreatitis have a good prognosis if they follow the required dietary changes and take their medications and required supplements. If their condition was caused by drinking, they will have a positive outcome if they stop drinking and continue follow-up treatment.

Prevention of pancreatitis

While pancreatitis is still not fully understood, there are some steps you can take to prevent pancreatitis from occurring again:

What is upper GI endoscopy?

The term "Endoscopy" refers to a special technique for looking inside a part of the body. "Upper GI" is the portion of the gastrointestinal tract, the digestive system, that includes the esophagus, the swallowing tube leading to the stomach, which is connected to the duodenum, the beginning of the small intestine. The esophagus carries food from the mouth for digestion in the stomach and duodenum.

Upper GI Endoscopy is a procedure performed by a gastroenterologist, a well-trained sub specialist who uses the endoscope to diagnose and, in some cases, treat problems of the upper digestive system.

The endoscope is a long, thin, flexible tube with a tiny video camera and light on the end. By adjusting the various controls on the endoscope, the gastroenterologist can safely guide the instrument to carefully examine the inside lining of the upper digestive system.

The high quality picture from the endoscope is shown on a TV monitor; it gives a clear, detailed view. In many cases, upper GI Endoscopy is a more precise examination than X-ray studies.

Upper GI Endoscopy can be helpful in the evaluation or diagnosis of various problems, including difficult or painful swallowing, pain in the stomach or abdomen, and bleeding, ulcers, and tumors.

How do I prepare for the procedure?

Regardless of the reason upper GI Endoscopy has been recommended for you, there are important steps you can take to prepare for and participate in the procedure. First, be sure to give your doctor a complete list of all the medicines you are taking and any allergies you have to drugs or other substances.

Your medical team will also want to know if you have heart, lung, or other medical conditions that may need special attention before, during, or after upper GI Endoscopy. You will be given instructions in advance that will outline what you should and should not do in preparation for the upper GI Endoscopy. Be sure to read and follow these instructions.

One very important step in preparing for upper GI Endoscopy is that you should not eat or drink within eight to ten hours of your procedure. Food in the stomach will block the view through the endoscope, and it could cause vomiting.

Upper GI Endoscopy can be done in either a hospital or outpatient office. You’ll be asked to sign a form that verifies that you consent to having the procedure and that you understand what is involved.

What can you expect during an upper GI endoscopy?

During the procedure, everything will be done to help you be as comfortable as possible. Your blood pressure, pulse, and the oxygen level in your blood will be carefully monitored. Your doctor may give you a sedative medication; the drug will make you relaxed and drowsy, but you will remain awake enough to cooperate.

You may also have your throat sprayed or be asked to gargle with a local anesthetic to help keep you comfortable as the endoscope is passed. A supportive mouthpiece will be placed to help you keep your mouth open during the Endoscopy. Once you are fully prepared, your doctor will gently maneuver the endoscope into position.

As the endoscope is slowly and carefully inserted, air is introduced through it to help your doctor see better. During the procedure, you should feel no pain and it will not interfere with your breathing.

Your doctor will use the endoscope to look closely for any problems that may require evaluation, diagnosis, or treatment.

In some cases, it may be necessary to take a sample of tissue, called a biopsy, for later examination under the microscope. This, too, is a painless procedure. In other cases, this endoscope can be used to treat a problem such as active bleeding from an ulcer.

What are the possible complications from an upper GI endoscopy?

Years of experience have proved that upper GI Endoscopy is a safe procedure. Typically, it takes only 15-20 minutes to perform. Complications rarely occur. These include perforation - a puncture of the intestinal wall, which could require surgical repair, and bleeding, which could require transfusion. Again, these complications are unlikely. Be sure to discuss any specific concerns you may have with your doctor. When your Endoscopy is completed you’ll be cared for in a recovery area until most of the effects of the medication have worn off. Your doctor will inform you about the results of the procedure and provide any additional information you need to know.

What can I expect after my upper GI endoscopy?

You will be given instructions regarding how soon you can eat and drink, plus other guidelines for resuming your normal activity. Occasionally, minor problems may persist, such as mild sore throat, bloating, or cramping; these should disappear in 24 hours or less. By the time you’re ready to go home, you’ll feel stronger and more alert. Nevertheless, you should plan on resting for the remainder of the day. This means not driving, so you’ll need to have a family member or friend take you home. In a few days, you will hear from your doctor with additional information such as results of the biopsy, or you may have questions you want to ask the doctor directly.

How Endoscopy Works

Working of Endoscopy Working of Endoscopy Working of Endoscopy Working of Endoscopy
The Endoscopy is inserted in your mouth and gently edged down your esophagus.
The endoscope will be inserted until it reaches your stomach.
Once in the stomach, your doctor will look closely for any problems areas.
If anything suspicious is found, your doctor will take a sample for biopsy.
Additional text
Upper GI endoscopy is a proven technique – An effective way to help you maintain your digestive health!