Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestions, the liver, gallbladder, and pancreas.
  Achalasia
Achalasia is a rare disorder of the oesophagus (the tube leading to the stomach). It is characterised by obstruction at the junction between the oesophagus and the stomach. There is failure of the lower oesophageal sphincter to relax with swallowing, and weakening or absence of the normal muscular contraction (peristalsis) in the main part of the oesophagus.
Secondary achalasia may be caused by lymphoma, Chagas' disease, certain viral infections, eosinophilic gastroenteritis and neurodegenerative disorders. It may also be caused by gastric cancer that infiltrates the oesophagus, or it may predispose to oesophageal cancer.

Symptoms
Achalasia affects patients of all ages and both sexes, however it usually develops in middle life. Symptoms include difficulty in swallowing (dysphagia), chest pain and regurgitation. Dysphagia appears early and occurs with both solids and liquids. It is worsened by emotional stress and hurried eating.

Diagnosis
Achalasia is diagnosed by oesophageal motility studies that show loss of peristalsis (muscle contraction) in the body of the oesophagus and increased pressure in the lower oesophageal sphincter. Chest x-ray and upper gastrointestinal endoscopy may show some features that suggest diagnosis, but they are not diagnostic. An endoscopy may also be done to exclude any secondary causes of achalasia, especially gastric carcinoma.

Treatment/Therapy
Nitrates and calcium channel blockers give good short term benefit, but their use may be limited by side effects.
Dilatation (widening by balloon) of the lower oesophageal sphincter can be done by endoscope and will improve symptoms in most patients. However, some patients may require more than one dilatation and those needing frequent dilatation are best treated surgically.
Another endoscopic procedure can be performed, where an injection of botulinum toxin into the lower oesophageal sphincter induces clinical remission, but late relapse is common.
Surgery may reduce pressure in the lower oesophageal sphincter.

Barrett’s Esophagus
Barrett's Oesophagus (or Barrett's mucosa) is the term given to a change which occurs in the lining of the lower oesophagus. It occurs in a small proportion of patients with longstanding gastro-oesophageal reflux. Normally the oesophagus is lined with squamous (flat) cells, which makes the oesophagus smooth and slippery to aid the passage of food. For reasons which are not understood, in some patients with longstanding reflux, the squamous lining is replaced by columnar (tall) cells, similar to those which occur normally in the stomach. This can be identified by taking biopsies at the time of upper gastrointestinal endoscopy (gastroscopy).

Frequency in the Community
A small proportion of patients with Barrett's Oesophagus develop cancer (adenocarcinoma) in the Barrett's lining after many years. This usually develops slowly over a period of some years and can be predicted by the finding of pre-cancerous changes (dysplasia) on biopsies, thus allowing surgery at an early stage before the cancer has spread.

Cause
It is not known why some patients with acid reflux develop Barrett's mucosa whereas others do not. Nor is it known why some will progress to cancer.

Symptoms
There are no particular symptoms for Barrett's Oesophagus.

Diagnosis
Barrett's Oesophagus can only be diagnosed at endoscopy and confirmed by taking biopsies (tiny samples of tissue).

Treatment/Therapy
The ideal prevention is to treat gastro-oesophageal reflux before it leads to Barrett's Oesophagus. Patients with proven Barrett's Oesophagus are usually treated with proton pump inhibitor medication such as omeprazole, esomeprazole, pantoprazole, and rabeprazole, or sometimes with surgery. If dysplasia (pre-cancerous change) developes in the biopsies sometimes this will require treatment by surgery and other techniques.

Esophageal Cancer - Read More

Stomach (Gastric) Cancer - Read More

Gastroesophageal Reflux Disease (GERD)
The reflux of stomach contents into the oesophagus (tube leading to the stomach) is known as gastro-oesophageal reflux (GOR). The consequence is a chemical insult to the oesophagus from acid, enzymes, and sometimes bile.
Reflux occurs commonly, but infrequently, in most people, and probably causes little harm because the natural movement (peristalsis) of the oesophagus clears the acid and food back into the stomach. When acid reflux from the stomach is frequent and persistent, the result is damage to the lining of the oesophagus. This is known as reflux oesophagitis or peptic oesophagitis.
A hiatus hernia, while commonly associated with reflux, is not essential for reflux to occur.

Symptoms
The major symptoms are heartburn (burning feeling rising up the back of the breastbone), regurgitation of acid and food into the mouth with a sour taste (waterbrash), and burning pain on swallowing food (oesophageal sensitivity). Other symptoms include difficulty swallowing (dysphagia), irritation of the throat and chronic cough. Lung problems such as asthma and even lung infections can occur.

Diagnosis
The diagnosis of reflux is usually made by a combination of the typical clinical presentation in conjunction with investigations such as a barium swallow x-ray or gastroscopy.

Medical Treatment
The treatment of oesophageal reflux consists of weight reduction (if overweight), avoidance of foods causing the symptoms, avoidance of activities which cause the symptoms (e.g. lying flat or exercising after a meal), and the use of medication to reduce acid and help clear it from the oesophagus. Surgery has an increasingly important role.

Peptic Ulcer Disease
An "ulcer" is a break in the lining of an organ's surface; it usually means a break that has been present for some time. Peptic ulcer is the general term to describe an ulcer in the lining of the stomach (gastric) or duodenum (the first part of the small intestine forming the outlet of the stomach).
Peptic ulcers are not cancers, although a cancer can present as an ulcer.

Cause of Peptic Ulcers
Duodenal ulcers are usually caused by a combination of factors - helicobacter pylori infection (see Index), acid production by the stomach, and impaired resistance of the duodenum to acid. The cause of gastric (stomach) ulcers is less certain. However, it is known that non-steroidal anti-inflammatory drugs (NSAIDS) and aspirin are a common cause of ulcers in the stomach and duodenum.

Symptoms
Peptic ulcers may cause a number of symptoms including indigestion, loss of appetite, nausea, vomiting and weight loss. Less common symptoms include bleeding (either vomiting of blood or passage of blood from the bowel - the latter is usually black and is called melaena).
Very rarely an ulcer can cause a hole to develop in the wall of the stomach or duodenum, allowing food and gastric secretions to enter the abdominal cavity - this is known as a perforated ulcer and is a surgical emergency.

Diagnosis
Diagnosis of peptic ulcer can be made by endoscopy, or very rarely by double-contrast barium meal examination. The preferred investigation is endoscopy because it is more accurate and has the advantage that biopsies can be taken at the same time. Urea breath testing (or endoscopy) can accurately determine if the patient has a helicobacter pylori infection.

Medical Treatment
Peptic ulcers are treated by: (1) reducing acid secretion (2) treating helicobacter pylori infection, and (3) stopping NSAIDS.
Acid secretion is reduced with proton pump inhibitors (e.g. esomeprazole). Surgery - highly selective vagotomy - can also achieve this.

Other Treatment
Some lifestyle changes may be necessary for treating peptic ulcer. For instance, cigarette smoking may prolong ulcer healing and therefore smoking should be ceased. There is little role for dietary modification, although any foods which cause the symptoms to occur should be avoided. Excessive alcohol consumption should be avoided.

Constipation
Constipation is the term that refers to difficulty passing bowel movements (also known as stools) although there are a number of commonly used definitions ranging from reduced frequency of bowel movements, to the passage of hard bowel movements that are difficult to pass. There is also a wide range of "normal" bowel movement function in health people and therefore the concept that there is difficulty with bowel movements is important in the definition.
Frequency in the Community
Constipation is common - almost everyone will be constipated at some stage in their life. Severe constipation or longstanding constipation is much less common, and usually justifies investigation and treatment.

Cause
There are many causes of constipation ranging from not eating enough dietary fibre, to physical inactivity, medications, bowel diseases, dehydration, hormonal conditions, and chronic medical illnesses.

Symptoms
One of more of the following: reduced frequency of bowel movements, the passage of small hard bowel movements, difficulty passing bowel movements.

Diagnosis
The diagnosis is made on the clinical history and the cause determined by investigations.

Treatment/Therapy
The treatment usually involves understanding the primary cause and treating this. For instance, if the cause is insufficient fibre in the diet, this should be attended to. A fibre containing or "bulk" laxative may also be useful. Maintaining a good oral fluid intake eg 1.5 liters per day, is also important.

Helicobacter Pylori Infection
Previously called: Campylobacter Pylori
The discovery in 1983 of the helicobacter pylori organism by Drs Warren and Marshall is one of the major advances in gastroenterology in recent decades. This discovery has revolutionised the approach to many upper gastrointestinal disorders, especially peptic ulcer disease. Helicobacter pylori causes a spectrum of disease in humans, including gastritis, ulcer disease (gastric and duodenal), and probably gastric cancer and gastric lymphoma.
The links between helicobacter pylori infection and gastric carcinoma and lymphoma are less established, but it is highly likely that helicobacter pylori is at least one cause of these stomach cancers. Thus, helicobacter pylori infection is a condition of enormous importance throughout the world.

Symptoms
Indigestion (dyspepsia) is a very common symptom, and a high proportion of people with dyspepsia will have helicobacter pylori infection causing gastritis. Furthermore, up to 10% of the population will develop peptic ulcer disease at some time in their lives and most duodenal ulcers and many gastric ulcers are due to helicobacter pylori infection.

Diagnosis
Infection with helicobacter pylori can be diagnosed by biopsy with pathological examination and the urea breath test; both are accurate. A blood test can indicate previous exposure, but not necessarily active infection.

Medical Treatment
Treatment is based on a proton pump inhibitor (to reduce acid secretion in the stomach) taken simultaneously with two antibiotics for 7-10 days. Compliance, side effects and bacterial resistance to metronidazole (one of the antibiotics that can be taken) influence the success of therapy.

Other Treatment
Second-line therapy is offered to those patients who remain infected after initial treatment, once the reasons for failure of first-line therapy (e.g. compliance) have been established. For those who are still infected after two treatments, the choice lies between a third attempt with quadruple therapy (where bismuth is added to the triple therapy) or simple maintenance therapy with acid suppression.
It can be very difficult to eradicate helicobacter pylori in a small percentage of patients, due to antibiotic resistance.
  Cirrhosis of the liver
The term 'cirrhosis' refers to advanced liver damage, characterised by dense scarring where the lobes are covered with fibrous tissue. Cirrhosis is the end point of many types of liver damage.
While cirrhosis usually takes many years to develop, it can also develop in a few months. Once cirrhosis has developed, it is irreversible, but that damage may stabilise if the underlying cause is removed or treated.

Cause
Some causes include excessive alcohol consumption, iron overload, chronic viral hepatitis, autoimmune diseases, and chronic bile duct obstruction.

Symptoms
The symptoms of cirrhosis include: yellowing of the skin (jaundice); circulatory changes - reddening of the palms (palmar erythema), cyanosis, spider veins; endocrine changes - loss of libido and hair loss, males could experience breast enlargement (gynaecomastia), testicular atrophy and impotence while females may have breast atrophy, irregular menses or absence of periods (amenorrhoea). Bruising is also a symptom of cirrhosis and other symptoms may relate to portal hypertension - bleeding in the veins, an enlarged spleen etc.
Complications of cirrhosis include: build up of pressure in the veins that go to the liver (portal hypertension); collection of fluid in the abdominal cavity (ascites); alteration to the brain function caused by toxins not removed by the liver (hepatic encephalopathy); bleeding from dilated veins in the oesophagus (oesophageal varices); infection in the ascitic fluid (spontaneous bacterial peritonitis); malnutrition, and liver cancer.

Diagnosis
The diagnosis is made by microscopic examination of the liver (liver biopsy).

Treatment/Therapy
Treatment involves treating the cause of the cirrhosis, if known, maintenance of nutrition and treatment of the complications of cirrhosis.
Chronic liver failure due to cirrhosis can also be treated by liver transplantation.

Hemochromatosis
Hemochromatosis is an inherited rare disorder of iron metabolism, leading to iron overload. It is characterised by excess iron deposits throughout the body, leading to cirrhosis of the liver and damage to other organs.

Cause of Hemochromatosis
Proof that the disease is hereditary came with the discovery of a strong association with histocompatibility (HLA) antigens in the mid-1970s, and with the more recent cloning of the hemochromatosis (HFE) gene. HFE is a protein which is probably involved in the regulation of iron transport, although its precise role is not yet known.
Hemochromatosis is due to a single mutation, known as the C282Y mutation in HFE. Patients with hemochromatosis usually carry two mutations (they are known as homozygotes). People with one mutation (heterozygotes or carriers) may have abnormal serum iron and ferritin tests, and occasionally develop the disease. Close family members (parents, siblings and children) should be screened for the disease by measurement of the transferrin saturation and serum ferritin, and in some cases by genetic testing.
There are other causes of iron overload, e.g. secondary to thalassaemia and other haemolytic diseases, that may require frequent blood transfusions.

Symptoms
The earliest sign of the disease is usually lethargy followed by more specific symptoms due to diabetes, sexual dysfunction, joint involvement and heart problems. Usually there is a characteristic metallic grey skin pigmentation and enlargement of the liver. Since the symptoms are often mild and non-specific in the early stages, a high index of suspicion is required even if a patient's symptoms appear trivial or seem to be easily explained by another cause, such as alcohol excess. Pre-menopausal women can develop hemochromatosis, contrary to popular belief.

Diagnosis
A raised transferrin saturation (ratio of serum iron and iron-binding capacity) and / or serum ferritin concentration suggests the possibility of hemochromatosis. Liver biopsy, with assessment of the degree and distribution of excess iron, together with quantification of the hepatic (liver) iron is the "gold standard" in diagnosing hemochromatosis.
The hepatic iron index (hepatic iron concentration divided by the age of the patient) shows the distinction between homozygous hemochromatosis and other conditions associated with a minor increase in hepatic iron stores. An hepatic iron index of greater than 2 has been shown to be reliable in differentiating homozygous hemochromatosis from heterozygous hemochromatosis, alcoholic liver disease and chronic liver disease in general.
HLA (histocompatibility) typing is also useful in family studies. The majority (90%) of Australian patients with hemochromatosis are homozygous for the mutation C282Y. A second mutation, H63D, in conjunction with one copy of the C282Y mutation (compound heterozygotes) is also associated with iron overload.
Liver biopsy has an important role in diagnosis. Not only does it allow the diagnosis to be made with great confidence, it also detects associated conditions such as alcoholic liver disease, and it provides the most reliable prediction of the future for the patient. The finding of established cirrhosis in a patient with hemochromatosis indicates a risk of complications, in particular liver cancer. Such patients should be advised of the risks and offered periodic screening for liver cancer. The absence of cirrhosis makes it unnecessary to do this, provided the patient complies fully with venesection (releasing blood) treatment.
Some patients, knowing that a genetic test is available, will decline liver biopsy. Provided that the C282Y mutation has been shown to be associated with hemochromatosis in that particular family, it is reasonable to rely on this test in certain family members. However, patients should be aware that the test is not 100% reliable, and that avoidance of liver biopsy will reduce the prognostic information available to the patient and clinician, and will make it more difficult, or even impossible, to obtain life insurance.

Medical Treatment
Treatment involves removal of excess iron by venesection (releasing blood). About 450ml of blood is removed once a week until the iron stores are in the low normal range, as determined by the serum ferritin concentration. This may take 6-12 months. Thereafter, venesections are done approximately every 3 months to maintain the serum ferritin between 50 and 100ug/L. The treatment, which should be lifelong, is usually well tolerated.

Liver Failure and Liver Transplantation
Liver failure has also been discussed under 'Cirrhosis'. When end-stage liver failure occurs in a patient who otherwise has a reasonable life expectancy, and when other treatment options have failed, often the only remaining treatment for these patients is liver transplantation. In fact, liver transplantation is usually done well before the patient reaches an advanced stage of liver failure, since the outcome is likely to be better.

Symptoms
Some manifestations of end-stage liver disease (these alone are not necessarily reasons for liver transplantation) include: yellowing of skin, eyes etc. (progressive jaundice); fluid in the abdomen (severe ascites) and fluid retention; brain dysfunction due to liver failure (encephalopathy); itch (intractable pruritus); bleeding from oesophageal varices (enlarged, swollen veins at lower end of oesophagus); bleeding due to coagulation disorder; infection in the ascitic fluid (spontaneous bacterial peritonitis); and severe malnutrition.

Medical Treatment
Treatment of liver failure is largely supportive, with maintenance of a diet that is adequate in essential nutrients, avoiding excessive protein intake that may precipitate hepatic encephalopathy. Treatment of ascites, early treatment of infections, and management of gastrointestinal bleeding is also important. The underlying cause of liver failure should be treated where this is possible and patients with liver failure should avoid medications that have the potential to cause liver damage, which may be poorly tolerated in patients with compromised liver function.

Other Treatment
In general, there are three groups of patients who may benefit from liver transplantation:
1. Those with advanced chronic liver disease
2. Patients with severe acute (fulminant) liver failure, and
3. Patients with inherited metabolic liver diseases.
Typical indications for liver transplantation are primary biliary cirrhosis, sclerosing cholangitis, biliary atresia, autoimmune chronic hepatitis, advanced haemochromatosis, alcoholic liver disease (provided the patient has ceased alcohol for 12 months), chronic hepatitis C and B infection with cirrhosis.
Patients with primary liver cancer are sometimes also suitable for liver transplantation.
Liver transplantation has had a dramatic impact on the treatment of a number of previously fatal liver diseases, and is now an established therapy in selected patients.
Typical indications to refer a patient for transplantation include the following (not all these need be present):

• Presence of irreversible liver disease and a life expectancy of less than 1 year, with no effective alternatives to transplantation
• Chronic liver disease that has progressed to the point of significant interference with the patient's quality of life or ability to work
• Progression of liver disease with complications of liver failure that will predictably result in a survival rate less than that of transplantation (typically 85% one-year patient survival and 70% five-year survival)

Patients who may benefit from liver transplantation should be referred as early as possible, because the waiting time for a liver transplant may be one to three years. In addition, it is important for the patient to have time to adjust to the idea of liver transplantation, to allow time for a thorough medical and psychological assessment and for all other therapies to be explored.
Liver transplantation is not usually carried out for: HIV infection; cancer outside the liver; cancer of the bile duct (cholangiocarcinoma); severe infection; severe heart or lung disease; active alcoholism or substance abuse.

Hepatitis - Chronic
(Old terminology: chronic active hepatitis, chronic persistent hepatitis)
The term "hepatitis" means inflammation of the liver, from whatever cause. Chronic hepatitis means that inflammation of the liver lasts for a prolonged period of time. A period of 6 months is sometimes taken to mean chronic, although this is arbitrary. In contrast, acute hepatitis is an episode of liver inflammation, usually lasting a few weeks or months, which gets better.

Cause of Hepatitis - Chronic
There are many causes of chronic hepatitis. The cause may be a virus, a medication, a toxin (e.g. alcohol), autoimmune (an abnormality of the immune system which allows damage to occur to your own tissues), or other factors. Some of the more important ones are viral hepatitis B, viral hepatitis C, and autoimmune chronic hepatitis (previously known as lupoid chronic active hepatitis). Hepatitis A does not cause chronic hepatitis. Less common causes include some medications, Wilson's disease (due to excessive copper accumulation), alpha-1 antitrypsin deficiency, inflammatory bowel disease, and occasionally alcohol.

Symptoms
A person with chronic hepatitis may feel quite well, or may have symptoms such as tiredness, loss of appetite, nausea, easy bruising and fluid retention. Your doctor may notice clinical signs such as dilated blood vessels in the skin (spider angiomata), redness of the palms (palmar erythema), easy bruising, enlargement of the liver and spleen, and fluid retention (ankle swelling and fluid in the abdomen - ascites).

Diagnosis
Chronic hepatitis may be suspected on the basis of blood tests, but the diagnosis requires a liver biopsy that demonstrates a particular type and location of inflammation in the liver.
In chronic hepatitis, the liver function tests show higher levels of the transaminases (ALT and AST) than the other liver enzymes. Hepatitis B and C tests, autoantibodies, copper and caeruloplasmin levels, and other tests are also necessary. After blood tests confirm that there is no disturbance of blood coagulation, a liver biopsy will be done for examination by a pathologist. Once the diagnosis is confirmed, treatment will be commenced.

Medical Treatment
The treatment of autoimmune chronic hepatitis requires the use of anti-inflammatory medication such as corticosteroids (e.g. prednisolone) and immunomodulators (e.g. azathroprine). Regular blood tests will be required to confirm that the treatment is working and to look for side-effects of the medication. The duration of treatment is usually for several years, but this will depend on the response to treatment.

Hepatitis - Viral
The term "hepatitis" means inflammation of the liver, from whatever cause. This inflammation is associated with damage to liver cells (hepatocytes). Cellular damage, leading to cell death or necrosis, destroys the function of hepatocytes and releases enzymes and other molecules which can be detected in the blood. Inflammation and damage are diagnosed by microscopic examination of liver tissue, usually obtained by liver biopsy.

Cause of Hepatitis - Viral
Viral hepatitis is inflammation and damage to the liver caused by one of several possible viruses. Such viruses are usually widespread in the body, including the blood, liver and other organs.
There are many different viruses that can affect the liver. In Australia, the well-known ones are hepatitis A virus, hepatitis B virus, and hepatitis C virus. Of these, only hepatitis B and C can become chronic. In patients with acute hepatitis other viral infections need to be considered such as Epstein Barr virus and cytomegalovirus. In patients with chronic hepatitis, hepatitis D virus should also be considered (this occurs in conjunction with hepatitis B).

Symptoms
There are several possible outcomes for viral infections that affect the liver:
1. The virus may be dormant, causing no symptoms or damage at all, and can either remain in the body for a long time or clear from the body without the person being aware.
2. The virus may cause an acute (short-lived) illness which resolves over a period of weeks or months. There are usually symptoms of hepatitis (loss of appetite, tiredness, nausea, jaundice (yellowing of the whites of the eyes and skin), itch, and dark urine.
3. The virus may remain in the body for a long time. This is called chronic hepatitis and lasts for more than 6 months (see Hepatitis - chronic). Damage occurs to the liver - sometimes rapidly, but in other patients the damage is low-grade and continues for many years. The symptoms of chronic hepatitis may be mild, for instance lethargy and nausea, or there may be no symptoms. While symptoms are always of concern to the patient and doctor, the presence of only mild symptoms does not mean that serious liver damage will not occur. Blood tests and a liver biopsy are usually required to assess the severity of liver damage.
4. If the damage is severe or goes on for a long time, scarring of the liver (cirrhosis) results. This scar tissue eventually prevents the liver from working properly and causes complications (see Cirrhosis of the liver).
  Pancreatitis
The pancreas is a digestive and endocrine organ lying behind the stomach in the upper abdomen (see Your Digestive Tract). The pancreas secretes digestive juices containing enzymes into the small intestine (duodenum) to help break down food into smaller molecules that can be absorbed by the body. It also secretes the hormone insulin into the bloodstream to keep the concentration of glucose in our blood at the correct level (endocrine function).
Pancreatitis occurs when the pancreas becomes inflamed. Its own enzymes are released into the blood as well as within the organ itself, and into the surrounding tissues, further adding to tissue damage.

Frequency in the Community
Chronic pancreatitis is more frequent in men than women.

Cause of Pancreatitis
Pancreatitis may be either acute or chronic.
ACUTE PANCREATITIS: Common causes include excessive alcohol consumption and gallstones. Less common causes include medications, high blood fats, high blood calcium, inherited factors, congenital abnormalities of the pancreas, viral infections, severe injury to the upper abdomen (trauma), and idiopathic (no obvious cause).
CHRONIC PANCREATITIS: Chronic pancreatitis is often caused by alcohol abuse, but in some patients there is no obvious cause. Rarer causes include haemochromatosis and other unknown factors. Inflammation and scarring over a long period of time eventually destroys the glandular tissue in the pancreas. This results in an inability to properly digest fat due to a lack of pancreatic enzymes, and reduced production of insulin.

Symptoms
Most patients with acute pancreatitis suffer severe central upper abdominal pain, frequently radiating straight through to the back. Vomiting is common, and often early signs of shock (rapid pulse, low blood pressure) are seen. Shock occurs when large amounts of fluid pour into the abdominal cavity in response to the inflamed pancreas, combined with vomiting and poor oral fluid intake. Other conditions such as a perforated peptic ulcer may mimic acute pancreatitis, which requires careful differentiation from a surgically treatable "acute abdomen".
While the patient with chronic pancreatitis does not usually develop the severe life-threatening complications which may be seen in acute pancreatitis, chronic pain, weight loss, inability to digest food, and lack of insulin all combine to produce a disabling condition.
COMPLICATIONS: In a minority of patients, infection may occur from bacteria in the intestinal tract, an abscess may develop and bleeding may occur (from the stomach, duodenum or from blood vessels digested by pancreatic enzymes). A collection of fluid may occur (pseudocyst)in the abdomen.

Medical Treatment
Treatment is aimed at replacing the large amounts of body fluid by intravenous infusion. The pancreas and digestive system in general should be rested to minimise enzyme production. This is achieved by fasting the patient, using medications which reduce the secretions from the pancreas, and sometimes using a nasogastric tube (into the stomach) to remove upper gastrointestinal secretions. Large doses of injected narcotic pain relievers are usually necessary.

Bile Duct Cancer - Read More

Gallstones
Other name: biliary calculi
Gallstones are rounded solid deposits in the gallbladder or bile ducts. These range from a few millimetres to several centimetres in diameter. The most commonly found gallstones are compromised of a mixture of cholesterol and calcium salts. Some are pure cholesterol, but many are mixed. A small number are called "pigment" stones and contain bilirubin salts. Gallstones may be associated with chronic infection in the gallbladder.

Symptoms
Gallstones often produce no symptoms, but they cause pain when they are passed through the bile ducts or when there is infection.

Diagnosis
A plain abdominal x-ray will show calcified gallstones in 20% of patients. Ultrasound is the method of choice to diagnose gallstones, but cholecystography (gallbladder x-ray) and CT can also be used.

Medical Treatment
The main treatment is surgery, although this is not required unless the gallstones are causing problems.
  Colorectal Cancer - Read More

Microscopic Colitis
collagenous colitis, lymphocytic colitis
Lymphocytic colitis and collagenous colitis are uncommon disorders that have been studied and described in past decades, but remain poorly understood. They are being recognised more frequently, possibly because gastroenterologists and pathologists are now more aware of these diagnoses.
The terminology remains somewhat controversial. The term "microscopic colitis", while not recognised by some authorities, generally refers to the group of disorders.

Cause of Microscopic Colitis
The cause of these conditions is unknown. Possible causes include unidentified chronic gastrointestinal infections, immune disturbance (including autoimmune disease), and medications (e.g. some non-steroidal anti-inflammatory agents, ranitidine, carbemazepine).
Lymphocytic colitis is characterised by increased lymphocytes (type of white blood cell) in the lining of the colon. Collagenous colitis is characterised by a thickening of the sub-epithelial collagen layer and increased lymphocytes in the lining of the colon.

Symptoms
Patients with these disorders present with chronic diarrhoea. Abdominal pain, fatigue and weight loss are also common. A number of associated diseases may occur, including the connective tissue disorders, thyroid diseases, and coeliac disease.

Diagnosis
The diagnosis requires that other disorders first be ruled out (e.g. ulcerative colitis, Crohn's disease, gastrointestinal infections). The diagnosis can only be made by colonoscopy. The lining (mucosa) appears normal, although there may be some very subtle abnormalities. However, the diagnosis is made by the pathologist when the biopsies are examined under the microscope. Separate biopsies should be taken from several regions along the colon.

Medical Treatment
Although there is no proven treatment, a number of medications will help. These include bismuth subcitrate, mesalazine, cholestyramine and corticosteroids. Some patients will get better without any treatment.
Rarely, patients will require a diverting ileostomy (abdominal opening to remove faecal matter) because of intractable diarrhoea.

Crohn's Disease
Other name: Inflammatory Bowel Disease
Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract which can affect any part of the gut, from the mouth to the anus, but commonly affects the small and large intestine. It is one of the group of inflammatory bowel diseases (IBD) which run in families. Crohn's disease and ulcerative colitis are both associated with certain genetic diseases. However, the cause of IBD is unknown.
Crohn's disease increases the risk of colon cancer due to the constant inflammation and healing.
Smokers are at an increased risk of developing Crohn's disease.

Symptoms
Chronic inflammation results in pain, diarrhoea and weight loss, as well as other symptoms. Symptoms and signs vary according to the affected site and how much of the gut is involved.
If the small bowel is involved, patients may get abdominal pain after meals, diarrhoea and weight loss. With large bowel involvement, diarrhoea and rectal bleeding is common.
Symptoms in Crohn's disease may begin insidiously and the diagnosis is often delayed. Systemic features are common (fever, weight loss, etc) and perianal disease (lesions, abscesses) is a frequent early clue to the diagnosis.
Anaemia may also be diagnosed because of Crohn's disease.

Diagnosis
The diagnosis is made by a combination of x-rays, endoscopy, colonoscopy and biopsies. Exclusion of infective causes of diarrhoea and bleeding is important and hence stool culture and examination may also be performed. A full blood count may also be done to see if the patient is anaemic because of low iron, folate or vitamin B12, plus to look for signs that an inflammatory process is occurring.

Medical Treatment
Although there is at present no cure, the disease can be successfully treated with medication and occasionally with surgery.
Medications can be used either for acute episodes or for long term use and treatment depends upon the site of involvement and the severity of the disease. These include corticosteroids, anti-inflammatories (e.g. mesalazine), immunomodulators (e.g. azathioprine), and biologics (e.g. infliximab).
Some general measures can be done to correct things that Crohn's disease may have caused - such as anaemia, malnutrition or dehydration. Patients also need emotional support, both at the initial diagnosis and during relapses, and self-help groups are important (see links below).
A low fibre diet may reduce the symptoms in patients with significant small bowel disease. Vitamin and mineral supplements including iron, folate and vitamin B12 may be needed.
Most patients with Crohn's disease lead a relatively normal life despite the chronic nature of this condition.

Colorectal Polyps
(Other names: polyps of the colon and rectum, or large bowel)
A colorectal "polyp" is a small finger-like or flat lump growing from the lining of the colon. There are many types of polyps, some of which are rare. The two most common types are adenomas and hyperplastic polyps.
The most important colorectal polyp is the adenoma, a small benign tumour growing to about 2 cm in size. Colonic adenomas are common, occurring in more than 20% of the population, and in the majority of patients there is no ill effect on health. They are more common with increasing age. There is good evidence that colonic adenomas are the early stage of colorectal cancer, although only a very small percentage of adenomas undergo malignant change and this process is very slow (e.g. five to 15 years). The larger the polyp, the greater the probability that the polyp will have undergone malignant change and contain cancer (adenocarcinoma).
Hyperplastic (or metaplastic) polyps are usually small, pale curved elevations of the colon lining. These are very common. Although hyperplastic polyps themselves do not turn into colorectal cancer, occasionally hyperplastic polyps (particular those which are large and multiple) will contain adenomas, known as mixed hyperplastic adenomatous polyps. In these polyps, development of cancer may occur but it is very rare.

Symptoms
Most patients with colonic polyps have no symptoms, and often polyps are detected at the time of investigation for unrelated symptoms. Where symptoms occur these are usually bleeding and sometimes pass mucous (especially large villous adenomas). Colonic polyps usually do not cause abdominal pain, diarrhoea, or constipation.

Diagnosis
Colonoscopy is the preferred technique for diagnosis of colonic polyps because of its accuracy and because the polyp can usually be removed at the time of the procedure. A barium enema X-ray is an alternative, but is not as reliable. Colonoscopy may also fail to detect polyps depending on their size and location, quality of the bowel preparation, and the thoroughness of the colonoscopist.

Medical Treatment
Excision of colonic adenomas (polypectomy) and subsequent surveillance has been shown to reduce the long-term risk of colorectal cancer. In general, colonic polyps should be excised (cut out) in total rather that biopsied. Polyps are usually excised at colonoscopy by diathermy (heat) using a snare around the polyp base or by using a 'hot' biopsy forcep. All or part of the polyp is removed for examination by a pathologist. This allows the type of polyp to be determined and the presence of precancerous or cancerous change to be assessed. The risks of polypectomy should be discussed prior to the procedure. The major complications are bleeding and injury to the bowel wall, sometimes causing perforation. Death is rare. Polypectomy should have a complication rate of much less than 1 per cent (of patients) and complications need not be life threatening if detected and treated early. The benefits of polypectomy must be weighed against the risks, particularly in the elderly in whom tiny benign polyps are unlikely to cause any health problems and in whom complications are poorly tolerated. A small proportion of adenomas contain actual cancer. Removal of the polyp by colonoscopy is often sufficient treatment for such polyps provided the cancer is in a very early stage. If not, a surgeon would be asked to consider removing that section of the bowel to make absolutely certain that all the cancer has been removed. First degree relatives (parents, brothers and sisters, and offspring) of patients who have one or more colonic adenomas have an increased risk of colonic adenomas. The increased risk is related to the age of the patient (being higher where the patient is under age 60) and to the occurrence of colorectal cancer in additional relatives. In either of these circumstances it appears wise to recommend a colonoscopy in relatives who have reached the age of 40 years.

Other Treatment
A technically unsatisfactory colonoscopy, or inability to remove all visible polyps, will require a repeat examination. If there are multiple or large (> 1 cm) adenomas it is common practice to re-examine the colon after 3 years (provided all adenomas were excised at the initial examination) and thereafter 5 yearly. If one small (< 3 mm) colonic adenoma is completely excised at the first examination, and tissue obtained confirming complete excision with no cancer or precancerous change, a repeat colonoscopy at 5 years is usually adequate, although some experts advise a colonoscopy at 3 years if there is also a family history of colorectal cancer. If no further polyps are seen at the time of a satisfactory repeat examination, the colonoscopy may then be repeated in 5 years. There is no need to continue these examinations beyond about age 75 - 80 years. Recommendations about screening intervals vary even amongst experts and the above intervals are guidelines. In patients with hyperplastic polyps there is usually no need to repeat the colonoscopy.

Prevention
Colorectal polyps are most common in Western countries and are almost certainly related to lifestyle and diet, as well as genetic factors. However, there is no proven single dietary or environmental cause of colonic adenomas. Epidemiological studies suggest that a high intake of animal fat and red meat, and low intake of fibre, may predispose to colorectal cancer. While awaiting the results of large scale dietary intervention studies, patients can at least do no harm by modifying their diets to reduce these possible risk factors. There is some evidence that aspirin and non-steroidal anti-inflammatory agents such as sulindac reduce the risk of colonic adenomas, but this remains controversial.

Irritable Bowel Syndrome (IBS)
(old term: spastic colon)
Irritable bowel syndrome (IBS) is one of the most common disorders of the digestive system. IBS can affect any part of the gastrointestinal tract, which is one reason for the variety of symptoms that patients may experience.

Symptoms
The main symptoms of IBS are abdominal pain and changed bowel habit (e.g. diarrhoea). However, many other symptoms are reported by patients: abdominal bloating; flatulence; audible bowel noises; indigestion; nausea; headaches; fatigue; muscular aches and pains; and bladder or gynaecological symptoms.
Symptoms that are unlikely to be due to IBS include severe abdominal pain, diarrhoea which wakes the patient during the night, and weight loss. Symptoms that are not due to IBS include bleeding from the bowel and fever. IBS does not cause anaemia.

Diagnosis
The diagnosis is based on symptoms, although sometimes it is necessary to perform investigations to exclude other bowel disorders.

Medical Treatment
The treatment of IBS will depend on the type of symptoms. For instance, if the predominant bowel pattern is one of constipation, measures to improve bowel function will usually help the abdominal pain. If diarrhoea is the major symptom, factors which trigger the diarrhoea (such as specific foods) need to be assessed and eliminated. Analgesics and antispasmodics may be prescribed for control of pain, but are less useful than measures to improve bowel function, and are best used in brief courses.

Other Treatment
Antidepressant medication, relaxation therapy, psychological counselling, special diets, and alternative therapies all have a role in some patients.

Ulcerative Colitis
Other name: Inflammatory Bowel Disease
The term "colitis" is a general term, and can apply to infections and any other condition associated with an inflamed colonic lining.
Ulcerative colitis (UC) is one form of inflammatory bowel disease (IBD); Crohn's disease is another. Ulcerative colitis is distinct from Crohn's disease although in some patients it can be difficult to tell the difference, particularly in the early stages. Since the treatment is often the same for both conditions in the early stages it may not be essential to reach a final diagnosis at that time.
In ulcerative colitis, the inner lining of the large intestine (colon or bowel) and rectum becomes inflamed. The small intestine is not involved.
The inflammation may involve: the rectum alone (proctitis); the rectum and sigmoid colon (proctosigmoiditis or distal colitis); the rectum and a large part of the colon (sub-total colitis); or the rectum and the entire colon (total or universal colitis). These are descriptive terms - it is the same disease process although for reasons that are not understood, the disease may remain confined to one part of the colon.

Frequency in the Community
Ulcerative colitis affects all age groups but tends to be more common in young people (e.g. ages 15-40). It affects males and females equally and appears to run in some families.

Cause of Ulcerative Colitis
The cause of ulcerative colitis is not known.
There may be an interaction between environmental, genetic, immunological factors, and infectious agents (viruses or bacteria). There is no evidence that a particular diet causes ulcerative colitis, but unidentified dietary factors may make the disease worse. Psychological stress does not cause ulcerative colitis, but may make the symptoms worse. Cigarette smokers have about half the risk of developing ulcerative colitis as non-smokers, and the disease is likely to be more severe if a smoker has recently ceased smoking. In contrast, smokers are twice as likely as non-smokers to develop Crohn's disease.

Symptoms
The most common symptoms of ulcerative colitis are abdominal pain and diarrhoea, which may contain blood, mucous and pus. Patients may suffer fatigue, weight loss, appetite loss, dehydration and malnutrition. Severe bleeding can lead to anaemia. Occasionally patients develop mouth ulcers, skin problems, joint or back pains, inflammation of the eyes, or liver disorders.

Diagnosis
The diagnosis of ulcerative colitis is made by looking at the lining of the bowel (colon). This is done by passing a flexible tube (endoscope) into the rectum and colon through the anus. A full colonoscopy (see Gastrointestinal Investigations) may be done but the diagnosis can be made on a more limited examination. During the examination, a sample of tissue (biopsy) will be taken from the lining of the colon to view under the microscope.
Colonoscopy or flexible sigmoidoscopy is the preferred method of diagnosis; very rarely a barium enema examination is done.
Other useful investigations include blood tests to see if you are anaemic (as a result of blood loss), or if your white blood cell count is elevated (a sign of inflammation). Kidney and liver function tests will be done, and examination of a stool sample to see if an infection is causing the colitis.

Medical Treatment
The patient should be offered emotional and psychological support. It may be helpful to join a support group, such as the Crohn's and Colitis Association. There is no special diet for ulcerative colitis, although patients may find it necessary to avoid certain foods (e.g. highly seasoned foods or dairy foods) which worsen their symptoms.
There are 4 classes of medications which are useful in inflammatory bowel disease:
- Corticosteroids
- Mesalazine-delivering drugs
- Immunomodulators
- Antibiotics
Patients with ulcerative colitis occasionally have symptoms severe enough to require admission to hospital. This allows the bowel to be rested by limiting oral intake, the use of intravenous fluids and medications, intravenous feeding, correction of dehydration, and close observation for possible complications.
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Other Treatment
Most people with ulcerative colitis will never need to have surgery. However, a small proportion of patients eventually require surgery for removal of the colon because of chronic debilitating illness not responding to treatment, massive bleeding, perforation of the colon, or risk of cancer.
There are several surgical options, each of which has advantages and disadvantages. The surgeon and patient must decide on the best individual option. The most common operation is removal of the entire colon and rectum (proctocolectomy), with ileostomy. Ileostomy is the creation of a small opening in the abdominal wall where the lower small intestine (ileum) is brought to the skin's surface to allow drainage of waste. A special appliance is worn over the opening to collect waste and the patient empties this several times each day.
Proctocolectomy with continent ileostomy is an alternative to standard ileostomy. In this operation, the surgeon creates a pouch out of the ileum inside the wall of the lower abdomen. The patient is able to empty the pouch by inserting a tube through a small leak-proof opening in his or her side. Creation of this natural valve eliminates the need for an external appliance. However, the patient must wear an external pouch for the first few months after the operation.
Another operation that avoids the use of a pouch is ileoanal anastomosis. The diseased portion of the colon is removed and the outer muscles of the rectum are preserved. The surgeon attaches the lower small intestine (ileum) inside the rectum, forming a pouch, or reservoir, that holds the waste. This allows the patient to pass stool through the anus in a normal manner, although the bowel movements are usually more frequent and watery.
In addition to receiving advice from your gastroenterologist and surgeon, you may wish to talk to another patient who has been through surgery for ulcerative colitis. You can contact patients and obtain more information on ulcerative colitis and ileostomies from patient support organisations (see links below).
What to expect
Most patients respond to treatment over a period of a few weeks or months and will eventually be left with only mild bowel symptoms. Some patients have relapses and remissions. A small proportion suffer severe continuous symptoms that respond poorly to treatment, requiring larger doses of medication, or more complex medical treatments. Only in rare cases, when complications occur, is surgery required, and the disease is now very rarely fatal.
Prevention
The risk of colon cancer is greater than normal in patients with widespread ulcerative colitis, especially if the colitis has been present for many years. Your doctor will advise regular colonoscopy examinations, the frequency depending on the duration of the disease and other factors. At the time of colonoscopy biopsies are taken for pathological examination. A pre-cancerous change may occur in the cells lining the colon - these changes are called dysplasia. If your biopsies show dysplasia your doctor will advise close follow-up and possibly surgery to remove the colon and eliminate the risk of colon cancer.