Medical College of Wisconsin Gastroenterology and Hepatology Patient Care

The colon, or the large intestine, is at the end of the digestive system. Its primary function is to desiccate (dry), package, and store the waste left over after food is digested and absorbed by the small intestine. The colon very efficiently absorbs water and reduces the volume of waste that needs to be eliminated in the stool in a convenient form at a convenient time.

Colorectal Cancer

Cancer of the colon and rectum – called colorectal cancer (CRC) – is the second leading cause of cancer deaths among men and women in the United States. However, if detected early, colorectal cancer can be cured. With simple preventive steps, you can greatly reduce your risk of developing the disease. It is important for you to understand your risks for colorectal cancer, the symptoms, and screening tests that can detect cancerous growths.

Colorectal cancer develops from non-cancer polyps. A polyp is a grape-like growth on the inside wall of the colon or rectum. Polyps grow slowly over three to ten years. Most people do not develop polyps until after the age of 50. Some polyps become cancerous, others do not. In order to prevent colorectal cancer, it is important to get screened to find out if you have polyps, and to have them removed if you do. Removal of polyps has been shown to prevent colorectal cancer.

How Do I Know if I'm at Risk for Colorectal Cancer?

Everyone has a risk of developing CRC. However, your risk depends on several factors.

You are at average risk for colorectal cancer if you are:

50 years or older and have no other risk factors.

You are at increased risk for colorectal cancer if you:

• Have a personal history of CRC or adenomatous polyps.
• Have a family history – one or more parents, brothers and/or sisters or children – of CRC or adenomatous polyps.
• Have a family history of multiple cancers, involving the breast, ovary, uterus, and other organs.
• Have a personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn's Disease.

There are several inherited disorders that greatly increase your risk of CRC. However, they are not very common.

Other factors that increase your risk of developing CRC are:
A diet that is low in fiber and high in fat.

Aren't Women at Less Risk for Colorectal Cancer than Men?
Men and women are equally affected by colorectal cancer. In fact, colorectal cancer is the third leading cause of cancer death in women. Also, about 67,000 women are diagnosed with this cancer each year and more than 40% of them – 28,600 – die from the disease.

What are the Symptoms of Colorectal Cancer?
Colorectal cancer begins with no symptoms at all. However, over time, there are a number of warning signs:

• Rectal bleeding
• Blood in your stool (bright red, black, or very dark)
• A change in your bowel movements, especially in the shape of the stool (e.g. narrow like a pencil)
• Cramping pain in your lower abdomen
• Frequent gas pain
• Discomfort in or the urge to move your bowels
• Constant fatigue

What Should I Do if I have These Symptoms?
Call your doctor and schedule an appointment. Only your physician can determine if your symptoms are due to CRC.

Why is Screening Important if I Have No Symptoms?
Screening is important for two reasons. The early stage of CRC – which is when it is most curable – frequently does not cause any symptoms. And, just as important, screening is the only way to find polyps. If the polyp is removed, it cannot develop into cancer.

What Type of Screening Tests are Available?
There are several types of screening tests. Talk with your doctor about which one is best for you. People at average risk should start screening at age 50. People at increased risk start at age 40 or sooner.

Digital rectal examinations
In this test, the doctor manually inserts a gloved finger into the rectum to feel for abnormalities. While this test is easy to do, it is not very sensitive.

Fecal occult blood test (FOBT)
In this procedure, the stool is tested for the presence of blood that is invisible to the eye. The test is available in a kit and can be taken at home to collect stool samples. The stool cards can be mailed to your doctor. This test is relatively easy and inexpensive; however, many factors can interfere with its accuracy. This test is recommended annually for persons beginning at age 50 for people at average risk but is also not very sensitive.

Sigmoidoscopy
Your doctor will use a long flexible, lighted tube to check the rectum and the lower part of the colon for polyps and cancer. If a polyp is found, it can be sampled through the scope and sent to a lab to be tested. This test can be performed in a doctor's office, and does not require any anesthesia or sedation, but does require limited preparation such as an enema. Insertion of the tube may be somewhat uncomfortable, and some cramping may occur during the procedure, which takes about ten minutes. After the test, there may be mild abdominal gas pains. If the doctor took a biopsy, some traces of blood may be in the stool for a few days. This test is recommended every five years beginning at age 50 for people at average risk.

Colonoscopy
This procedure is done by a gastroenterologist. He or she will use a long, flexible, lighted tube – called the colonoscope – to view the entire colon and rectum for polyps or cancer. A bowel cleansing preparation of the colon is required before the procedure. The colonoscope has a camera at the end, which can project images on a TV screen. If a polyp is found, it can be removed by a wire loop that is passed through the colonoscope and is hooked around the base of the polyp. The doctor sends an electric current through the loop, which severs the polyp from the colon wall and pulls it out of the colon. The polyp is then sent to a laboratory to be tested to determine if it is cancerous. This procedure requires patients to be sedated, and usually takes about 20-60 minutes. There is some pressure that can be felt from the instrument's movements and some cramping afterwards, but this is usually all that occurs. Some traces of blood may be in the stool for several days after the procedure if a biopsy was taken.

Barium enema
This test is an X-ray examination of the entire colon and rectum and may be done instead of a colonoscopy. After cleansing of the colon, a soft, flexible tube is inserted into the rectum and a liquid called barium is inserted into the tube. Special X-rays follow the flow of the barium in the colon and outline any lumps, polyps or abnormalities. A person may feel some cramping and a strong urge to defecate during the test. This procedure is recommended as a substitute for colonoscopy at ten or more year intervals.

How Do I Prepare for These Screening Tests?
Proper preparation is the most important thing you can do to help ensure you get the most accurate screening possible. Your doctor will give you complete instructions on what to do. Before any test, let your doctor know about any medicines you are taking because they may affect the test results.

What if I Am Diagnosed with Colorectal Cancer?
If you are diagnosed with CRC, surgery is generally required to remove the cancerous polyps and other malignant tissue. The type of surgery and follow-up treatment will depend on how far advanced the cancer is. In the past, a colostomy was usually necessary. However, new surgical technologies can eliminate the need for a colostomy in many patients.

How Can Colorectal Cancer be Prevented?
There is no way to completely eliminate the risk of developing CRC. That is why screening is so important. However, there is evidence that you can reduce your chance of getting CRC by doing the following:

• Avoid food that are high in fat, particularly saturated fat.
• Eat foods that are high in calcium
• Exercise regularly

Researchers are also investigating the possibility that some drugs such as aspirin, ibuprofen, calcium supplements, folic acid and others may help prevent colorectal cancer.

What is Diarrhea?

Diarrhea is a common problem most frequently defined as more frequent or water bowel movements. “Acute” episodes of diarrhea usually improve spontaneously after a few days. “Chronic” diarrhea lasts for more than 3 weeks and is usually considered as more serious.

Symptoms of Diarrhea

Common symptoms of diarrhea are:

• Loose or watery stools
• Urgency with passage of stools
• More frequent stools than usual
• Crampy pain or rectal spasms
• Aggravation following meals

Normal Bowel Function

Following eating fluids are added to the food as it passes thru the digestive tract. Nutrients are absorbed during food transit (thru the small intestine 18 feet) and undigested debris empties into the color (3 feet of large intestine). The primary function of the colon is absorption of excess fluid from the debris as it passes out as stool, usually in 1 to 3 days.

Diarrhea

Diarrhea is the intestinal tract’s response to an infection, irritation or inflammation frequently resulting in secretion of excessive secretion into the digestive system. The colon is unable to absorb this over load and continuing excess of fluid results in frequent loose or watery stools. The stooling may occur both day and night and in the presence of an inflammatory process may contain blood. The loss of excessive fluid may lead to dehydration and/or electrolyte depletion in severe cases of diarrhea. Abdominal cramping is experienced often prior to defection.

Common causes of diarrhea

The most common causes of acute limited episodes of diarrhea are viral and bacterial sources and medications (especially antibiotics). Certain foods (seafoods) and spices may prompt an episode of diarrhea too. Other food products such as lactose, fructose, and gluten may cause recurrent diarrhea. Inflammation of the small bowel (“enteritis”) and the colon (“colonitis”) may result in chronic diarrhea and other systemic complications.

Assessment of the problem

The majority of cases of diarrhea are short lived. If the diarrhea is protracted, incapacitating or associated with blood in the stool you should consult your doctor promptly. An appropriate evaluation by your physician will direct you towards appropriate treatment and resolution of the diarrhea.

Clinical Evaluation

During assessment of your situation an accurate and hopefully detailed history is most important. The following questions are often asked by your physician.

• How long have you had the diarrhea?
• What is the pattern of the diarrhea?
• Is there associated cramping, bleeding?
• Did you eat out at a restaurant; food type?
• Have you taken antibiotics in the last few weeks?
• Have you had a fever, headaches, or muscle soreness?
• Have you traveled recently? Outside the USA?
• Is there a history of IBD in the family?
• Have you experienced similar episodes in the past?
• Have you lost weight, been anemic recently?

The physical exam will evaluate your overall condition including vital signs and temperature. A blood count, electrolyte panel, and often times, a stool culture will be obtained. Additional diagnostic testing depends upon the clinical situation e.g. colonoscopy, abdominal x-ray imaging and tissue sampling of the small intestine may be helpful.

Diarrhea Treatment

Acute episodes of diarrhea usually respond to a combination of rest, fluid replacement and restriction of food intake for a few days. Viral gastroenteritis, food “poisoning” and intolerance are the most frequent non-bacterial causes. However, the notorious bacteria, C. Difficile, is the most common cause of community diarrhea now and this organism is capable of causing severe diarrhea and requires specific antibiotic treatment and possibly hospitalization.

The question of using anti-diarrhea medication to reduce the diarrhea has not been resolved. Some authorities caution that these medications are contraindicated because they permit prolonged exposure to the offending agents. However, the judicious use of Pepto-Bismol or Imodium may be helpful in certain instances. Replenishment of fluid loss with clear fluids or Gatorade is often useful. Bed rest can be helpful. Other treatment modalities may be necessary depending on the nature of diarrhea. Your physicians will determine this.

When to contact your physician

Contact your physician if you experience:

• Extreme, protracted diarrhea
• Diarrhea lasting longer than 1 week
• Severe abdominal cramping
• High fever or bloody stools
• Severe dehydration (dizziness, dry mouth, rapid pulse, dark urine)

What Causes Dysphagia?

The causes of swallowing problems (dysphagia) vary widely. For instance, lack of coordination of the esophageal muscular contractions can make swallowing difficult or impossible. Swallowing can also be uncomfortable for a person with chronic heartburn, where the esophagus is damaged by excessive reflux of acid-containing stomach contents. Other serious medical causes of dysphagia include tumors and central nervous system disorders, such as stroke, multiple sclerosis, and Parkinson's disease.

Some other common causes of dysphagia are:

• Scar tissue or narrowing in the esophagus
• Pouches (diverticula) that protrude through the lining of the throat and esophagus
• Disorders of the central and peripheral nervous system
• Radiation or operative injury
• Drug-induced injury
• Infections

How Do I Know if I Have a Swallowing Disorder?

For some people, symptoms of dysphagia are relatively mild. Perhaps it takes longer to eat or swallow, or there is have difficulty getting the food down without drinking large quantities of liquids. In other cases, symptoms have become so severe that the person has difficulty ingesting even liquids.

Most people with dysphagia experience one or more of the following symptoms:

• Swallow hesitation or inability to swallow
• Food sticking in the throat
• Swallowed food backs up into nose
• Chest discomfort when swallowing
• Choking with swallowing
• Frequent, repetitive swallowing
• Hiccups frequently after swallowing
• Frequent throat clearing
• "Gargly" voice after eating
• Hoarse voice or recurrent sore throat
• Coughing during or after swallowing
• Necessity to "wash down" solid foods
• Weight loss because of swallowing difficulty
• Recurrent episodes or pneumonia
• Regurgitation of food

How is the Problem Diagnosed and Treated?

A range of diagnostic procedures are available at the Dysphagia Institute to help pinpoint the cause of swallowing difficulties. The tests ordered by the Dysphagia Institute physician will depend on the specific problems the patient is having and on the results of the comprehensive interview and examination. Likewise, treatment is individualized to the patient's needs.

How to Make an Appointment

Patients are seen in the MCW Dysphagia Clinic at the request of their physician or surgeon. The Clinic needs to receive the referral request, as well as copies of pertinent medical records and x-rays before the scheduled appointment date. Requests for consultation or referral can be made at the telephone numbers below.

For an appointment, please call (414) 955-6633

How do I know if I should be evaluated by a specialist for upper or lower GI tract problems such as heart burn, upper or lower abdominal pain, diarrhea, constipation, rectal bleeding, cancer screening, colitis, pancreatitis and other diseases?

Check with your primary care physician for the initial assessment of your needs. Depending on the results of the initial assessment and any therapies offered, your primary care physician will then refer you to a specialist for these issues (a gastroenterologist) if warranted. This referral may be for a clinic evaluation or directly for a specific test such as a colonoscopy.

How are diseases of the GI tract diagnosed?

The initial review of your symptoms and examination by your primary physician will determine the best approach. A full range of diagnostic and at times therapeutic procedures are available at Froedtert Hospital to evaluate these diseases. These include endoscopic procedures, x-ray studies, CT scans, MRI scans, abdominal ultrasound studies and nuclear medicine scans. Endoscopy has the advantage of providing direct visualization of the lining of the intestinal tract, the ability to sample tissue for microscopic examinations if necessary and at times, the capability to provide therapy directly through the instrument.

What is an EGD? What is a colonoscopy? What is a flexible sigmoidoscopy?

EGD (esophago-gastro-duodenoscopy) is the endoscopic examination of the upper gastro-intestinal tract including the esophagus (swallowing tube), stomach, and first portion of the small intestine, called duodenum. The instrument used is a flexible fiber-optic endoscope which is introduced through your mouth.

Colonoscopy is the endoscopic examination of the entire lower GI tract (colon or large bowel/intestine) with a fiberoptic flexible instrument inserted into the rectum and advanced to the beginning of the colon.

Sigmoidoscopy refers to the examination of only the lowest portion of the colon (sigmoid colon and rectum) with a fiberoptic flexible instrument inserted into the rectum and advanced to the sigmoid colon.

What preparation is required for an Upper GI Endoscopy (EGD)?

You will need to have an empty stomach and, therefore, will be instructed not to eat or drink anything after midnight before the scheduled examination except for sips of water. You may also be instructed not to take any medications by mouth on the morning of the examination. Since you will receive sedation during the examination you will not be able to drive home by yourself and, therefore, will have to arrange for a companion to drive you home.

What is the preparation for a colonoscopy?

For a successful examination your colon has to be completely clean. This requires that you take only liquids and purging solutions on the day prior to the examination. Detailed instructions and the necessary prescriptions will be given to you when you schedule the procedure. You should be fasting except for sips of water for 6 hours prior to the procedure. Since you will receive sedation during the examination you will not be able to drive home by yourself and, therefore, will have to arrange for a companion to drive you home.

What is the preparation for a flexible sigmoidoscopy?

You will be instructed to take one or two enemas an hour before the procedure. As a rule you will not be given any sedation, and, therefore, can take your medications on the morning of the procedure.

What should I expect before the procedure?

A nurse will review your medical history and medications. Prior to an EGD or colonoscopy an intravenous (I.V.) line will be placed for the administration of medications for your sedation. Prior to an EGD your throat will be sprayed with a local anesthetic to reduce gagging.

What should I expect during the procedure?

Since EGD and colonoscopy are generally performed with sedation you may not remember much of the procedure. During an upper GI endoscopy some patients may experience some gagging, during a colonoscopy some abdominal cramping. During a flexible sigmoidoscopy you may feel the urge to defecate. If you feel any significant discomfort your doctor will back off.

How long do these procedures take?

Your time in the laboratory is determined by the admission process, the duration of the actual procedure, and the recovery time from the sedation. For an EGD or colonoscopy you can expect to spend about two hours in the GI laboratory; the actual time for an EGD is about 6 - 15 minutes, for a colonoscopy about 15 - 45 minutes depending on the findings and difficulty of the procedure. A flexible sigmoidoscopy takes about 3-5 minutes.

What are potential complications?

EGDs, colonoscopies and sigmoidoscopies are very safe procedures in skilled hands.

Nevertheless on very rare occasions complications can occur, they include bleeding, perforation of an organ which would require surgery, infection, and an adverse reaction to the administered sedation. We are prepared to deal with these problems should they occur. Please advise us of any allergies and intolerance to medications and inform us about all medications you are taking. In case of delayed complication contact us immediately. If these delayed complications occur after hours, on weekends or on holidays you may have to go to the Emergency Room at Froedtert hospital immediately to receive proper evaluation and care.

What will my follow-up be like?

Follow-up arrangements will depend on your medical problem and the endoscopic findings. You and your referring physician will get a preliminary report at the time of discharge from the GI Lab. This will also contain instructions about any necessary follow-up. If biopsies are obtained, you and your physician will receive a written report usually within 10 to 14 days with further follow-up recommendations.

What is ERCP?

 ERCP stands for endoscopic retrograde cholangiopancreatography. This procedure is used to view and treat disorders of the bile ducts and the pancreatic duct. Most often, ERCP is used to treat blockages in these ducts, either from a stone or a narrowing. The procedure can sometimes find the source of abdominal pain and help plan surgery. It may also be used to locate problems in the pancreas. ERCP is done by a gastroenterologist, a doctor with special training in treating the digestive system.

Preparing for ERCP

• Talk to your doctor about any health problems you have or medications you take. Discuss any allergies, especially to contrast material (the special dye used for some x-rays)
• Ask your doctor about the risks of ERCP. These include pancreatitis, irritation or infection, bleeding, bowel perforation, and reactions to medications used during ERCP.
• You may be asked to take antibiotics ahead of time.
• Try to avoid blood-thinning medications such as aspirin for 1 week before ERCP.
• Be sure your stomach is empty. Do not eat or drink for 8-12 hours before ERCP.
• Have someone ready to drive you home and bring clothing and toiletries in case you stay.
• X-rays will be taken during the exam, so inform the doctor if you are pregnant.

The Procedure

ERCP is performed in our endoscopy suite. The doctor is assisted by nurses and technicians during the procedure, which usually takes 30-90 minutes. An IV is placed in your arm to give you. Your throat will be numbed with a spray to reduce gagging sensation. You will be asked to lie on your belly facing right. Adjustments can be made if this is not possible for you.

Placing the Endoscope

After you have been medicated to make you sleepy, a narrow tube (endoscope) is placed into your throat. The scope lets the doctor see the way through the esophagus, stomach and the duodenum to the opening of the bile duct. During this part you may have a gagging feeling. You may also feel temporary pressure on your stomach. Once the bile duct opening is reached, you should remain comfortable for the rest of the procedure.

Taking X-rays

During the procedure, x-rays are taken. Contrast dye is injected to make the ducts show up on the x-ray.

The Bile Ducts and Pancreatic Duct

The bile duct is a small tube that takes liquid bile from the liver/gallbladder to the duodenum, the beginning of the small intestine. Similarly, the pancreatic duct takes pancreatic digestive enzymes to the small intestine through the same opening as the bile duct, called the ampulla of Vater. Blockage of these ducts can occur by gallstones, tumors, strictures, and sphincter dysfunction. This can result in pain, infection and/or jaundice, which is yellowing of the skin. During ERCP, gallstones can be removed from the bile duct and a stent can be placed across any narrowed segments. Also, during ERCP, strictures can be stretched open and specimens can be collected for examination. Where appropriate, sphincter pressure can be measured and sphincter dysfunction treated.

After ERCP

After you wake up from the sedatives, your doctor will discuss the test results with you. A return visit may be scheduled. Most patients go home the same day but some need to spend the night in the hospital.

Gallstone disease is a common medical problem, affecting 10 to 15 percent of the population of the United States or more than 25 million people. About one million new cases of gallstone disease are diagnosed every year in this country. Half of these require treatment, with a cost to society of several billion dollars annually. In recent years, important advances have been made in the understanding of gallstone disease and in the development of new treatments.

What are Gallstones and How Do They Form?

 Gallstones are pieces of hard solid matter in the gallbladder. Gallstones form when the components of bile (especially cholesterol and bilirubin) precipitate out of solution and form crystals, much as sugar may collect in the bottom of a syrup jar. In general, either cholesterol or bilirubin precipitates out of solution to form stones, but not both. In the United States, almost 80% of patients with gallstones have cholesterol stones. Gallstones may be as small as a grain of sand or as large as a golf ball, and the gallbladder may contain anywhere from one stone to hundreds. Sometimes the gallbladder contains only crystals and stones too small to see with the naked eye. This condition is called biliary sludge. No one knows why some people develop gallstones and others don't. Any condition that increases the amount of cholesterol in bile increases the risk of stones. Conditions that increase bilirubin in bile increase the risk of pigment (bilirubin) stones. Other factors are important in gallstone development, such as poor contraction of the gallbladder muscle with incomplete emptying of the gallbladder, and the presence of substances in bile that speed up or delay precipitation of crystals. Many people with gallstones have a combination of factors. Exactly how diet affects gallstone formation is not well understood. Diets that are high in cholesterol and fat and low in fiber may increase the risk of developing gallstones.

Pigment (bilirubin) gallstones are found most often in:

• Patients with severe liver disease
• Patients with some blood disorders such as sickle cell anemia

Cholesterol gallstones are found most often in:

• Women over 20, especially pregnant women, and men over 60 years old
• Overweight men and women
• People on "crash diets" who lose a lot of weight quickly
• Patients who use certain medications including birth control pills and cholesterol lowering agents
• Native-Americans and Mexican-Americans

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, 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 and surgery.

More serious complications may occur when a gallstone passes out 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 the bile may back up into the liver.

Two excellent 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% effective in diagnosing gallstones. 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). These tests both carry small risks, 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 an 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.

Laparoscopic cholecystectomy has become common and is now used for more than 90% of all cholecystectomics in the United States.

Each approach has it's 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 laparoscopically. It may also be more difficult to remove a stone from the bile duct laparoscopically, if one is found at surgery to have passed out 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 laparoscopically 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.

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

Heartburn is the most common symptom of a condition called gastroesophageal reflux or acid reflux.

A muscle (lower esophageal sphincter) located between the esophagus (swallowing tube) and stomach normally opens after swallowing. This allows food to pass into the stomach. The lower esophageal sphincter muscle then closes quickly to prevent the return (reflux) of food and stomach juices back into the esophagus.

When the lower esophageal sphincter muscle either relaxes inappropriately or is very weak, the acidic contents of the stomach can back up, or reflux, into the esophagus. This is called gastroesophageal reflux. In addition to heartburn, symptoms may include persistent sore throat, hoarseness, chronic cough, asthma, heart-like chest pain, and a feeling of a lump in the throat. When the acid contents from the stomach regularly back up into the esophagus, a chronic condition called gastroesophageal reflux disease or GERD occurs.

There are several factors that influence the occurrence and severity of the gastroesophageal reflux and heartburn:

• The ability of the lower gastroesophageal sphincter muscle to open and close properly
• The type and amount of stomach juices that are backed up into the esophagus
• The neutralizing effect of saliva and other factors

People experience gastroesophageal reflux and heartburn in a variety of ways. Heartburn usually begins as a burning pain that starts behind the breastbone and radiates upward to the neck. Often there is a sensation of food coming back into the mouth, accompanied by an acid indigestion and usually occurs after meals.

What are the Symptoms of Heartburn?

• Burning pain behind the breastbone area
• Burning pain or regurgitation that is worse when lying down or bending over. 

What if Symptoms Persist?

People with severe esophageal reflux or with heartburn symptoms unresponsive to the measures described above may need more complete diagnostic evaluations. A variety of tests and procedures are currently used to further evaluate the patient with heartburn:

Endoscopy
A procedure where a flexible tube is placed into the esophagus whereby your physician will see the tissue lining of the esophagus.

Biopsy
The removal of a small sample of tissue of the lining of the esophagus to better determine the causes of the underlying disease.

Esophageal manometric studies
Pressure measurements of the esophagus, which identify critically low pressure in the lower esophageal sphincter muscle and determine the other disorders of the esophageal muscle function.

Twenty-four hour pH monitoring
Cone for those patients for whom the diagnosis is difficult to make. Many physicians find it helpful to measure the acid levels inside esophagus. This is done by placing a thin tube in the esophagus.

How Common is Heartburn?

Although heartburn is common in our society, it is rarely life-threatening. However, heartburn can severely limit daily activities and productivity. With proper understanding of the causes of heartburn and consistent approach to a treatment program, most people will find relief.

Is Heartburn Caused by Hiatal Hernia?

Heartburn is not caused by hiatal hernia, which is the pushing up of the stomach into the chest cavity through a hole in the diaphragm.

Hiatal Hernias do predispose individuals to heartburn. However, the majority of people over 60 years of age have hiatal hernias and most do not have any symptoms related to the condition.

Can Heartburn Require Surgery?

A small number of people with heartburn may need surgery because of severe reflux disease and poor response to medical treatment plans. Fundoplication is a surgical procedure that reduces reflux. Patients not wanting to take medication to control their symptoms are also candidates for surgery.

What are the Complications of Long Term Reflux and Heartburn?
The reflux that causes heartburn can result in serious complications. Esophagitis, an irritation of inflammation of the esophagus can occur as a result of the constant presence of stomach acid in the esophagus. Esophagitis may result in the esophageal bleeding or ulcers. In addition, a narrowing or closure (stricture) of the esophagus may occur.

Some people develop a condition known as Barrett's esophagus, a change in the cells lining the esophagus that predisposes the esophagus to the development of cancer. Individuals with Barrett's esophagus should be monitored with periodic surveillance endoscopies and biopsies.

• Decrease the size of the portions at mealtimes
• Meals should be eaten two to three hours before lying down to lessen the chance of reflux.
• Elevate the head of the bed four to six inches.
• Lose weight, if overweight.
• Take over-the-counter medicines as directed for relief of heartburn. Ask your pharmacist for a recommendation.
• Stop or decrease smoking, as cigarettes decrease the ability of the lower esophageal sphincter muscle to work properly.

What are hemorrhoids?

Hemorrhoids are cushions consisting of blood vessels and elastic tissue that are present in the anal canal and are commonly also referred to as “piles”. There are two types of hemorrhoids, which are called internal or external hemorrhoids depending upon their location in the anal canal. They are important in preventing stool leakage when you strain or cough. Sometimes, trouble with constipation, excessive straining, and increase in intra-abdominal pressure during pregnancy, obesity and absence of valves in blood vessels that feed them can cause these cushions to swell. This can result in bleeding, pain or anal irritation. Liver disease can also cause swollen vessels called “varices” which should not be mistaken for hemorrhoids. Your doctor should usually be able to tell the difference and may looks for other signs of liver disease, which may be a clue.

What are the symptoms of hemorrhoids?

There are several symptoms that may occur from hemorrhoids. You may notice bright red blood on the toilet paper or in the toilet bowl most commonly from internal hemorrhoids. Sometimes, these veins stretch, and may even fall down (prolapse) through the anus to outside the body (protruding hemorrhoids). When this happens, the vein may become irritated and painful.

When they prolapse or protrude outside, blood clots may form in them, which may make them large and painful, and these are called thrombosed external hemorrhoids. You may notice a tender lump on the edge of the anus. Bleeding starts when the swollen veins are scratched or broken by straining or rubbing. People who have external hemorrhoids may also feel itching at the anus. This might result from draining mucus and irritation caused by too much rubbing or cleaning of the anus, or alternatively by inadequate anal hygiene leading to particles of stool around the anus caught in between the hemorrhoid protrusions. Any stool particles on the perianal skin will cause itching and irritation in this area.

How common are problems with hemorrhoids?

Hemorrhoid problems occur equally in men and women and affect approximately 1 million Americans each year. About 50% of people over the age of 50 will have experienced symptoms related to hemorrhoids at some point in time. Many people have bleeding from hemorrhoids but the bleeding is usually not serious. Women may begin to have problems during pregnancy. The pressure of the fetus in the abdomen, as well as hormonal changes, causes hemorrhoidal veins to enlarge. These veins are also placed under severe pressure during the birth of the baby. For most women, however, such hemorrhoids are a temporary problem and usually get better rapidly after delivery.

What is the Treatment?

Often all that is needed to reduce symptoms is to include more fiber (about 25-30 gms/daily) in your diet to soften the stool. You should also eat more fresh fruits, leafy vegetables, whole grain breads and cereals (especially bran). There are several over the counter fiber supplements that you can use. Drinking six to eight glasses of water each day will also help. Softer stools make it easier to empty the bowels and lessen pressure on the veins.

Good hygiene is also important. Bathe the anus gently after each bowel movement using a soft, moist toilet paper (or a commercial moist pad) and avoid a lot of wiping. If necessary, you can even use a bath or shower as an alternative to wiping. After bathing, dry the anus gently with a soft cloth or towel. You can also try a sitz bath where you soak the perianal region in warm water.

When Do I Need to See My Doctor?

It is a good idea to see your doctor any time you see bleeding from the anus. This is important to make sure you don't have cancer or some other disease of the digestive system. You will need an examination of your anus and rectum and possibly further examination of the bowel. If the doctor finds hemorrhoids, you may be advised to change your diet or to use a fiber supplement that softens the stool, or a stool softener. Your doctor might also recommend ice tubs or warm soaks (sitz baths).

If you know you are having pain from hemorrhoids, you might try putting cold packs on the anus, followed by a tub bath, or sitz bath, three or four times a day. To protect against irritation, cleanse the anus carefully and apply Vaseline to the area. Medicated suppositories or creams are available at the drug store. Any of these home treatments may relieve the symptoms, and no other treatment may be needed. If symptoms persist see your doctor.

In some cases, internal hemorrhoids that have fallen outside of the anus (prolapsed) or that bleed too much need further treatment. Your gastroenterologist may be able to treat bleeding internal hemorrhoids with a simple outpatient procedure where rubber bands can be placed around the hemorrhoids, which will control the bleeding in most cases. If this does not work, you may need an operation by the surgeon though this is typically not necessary.

In summary, hemorrhoid problems are quite common and there are various treatment options including topical applications and simple office-based procedures to treat symptoms.

Hepatitis A, B & C: Hepatitis is more serious than you think

Hepatitis is a disease characterized by inflammation of the liver. Viral hepatitis refers to several common diseases caused by viruses that can lead to swelling and tenderness of the liver. The most common types of viral hepatitis are A, B and C. Hepatitis B and C can lead to permanent liver damage.

There are other forms of hepatitis that are less common; these include Hepatitis D and E, as well as three other lesser known viruses.

"A" for awareness

Hepatitis A virus (HAV) is contracted by eating food or drinking water that has been contaminated with human excrement. The Centers for Disease Control and Prevention (CDC) estimates that 150,000 people in the United States are infected each year by hepatitis A. Acute hepatitis A usually resolves within 6 months and does not develop into chronic disease. The CDC lists household or sexual contact, day care attendance or employment, and recent international travel as the major known risk factors for transmission of hepatitis A. Infected food handlers and those who have used contaminated needles are also sources of transmission.

"B" Informed

Hepatitis B virus (HBV) can cause a serious form of hepatitis. This disease is much more prevalent than HIV, the virus that causes AIDS. An estimated 1.2 million Americans are currently chronic carriers of HBV. Hepatitis B may develop into a chronic disease (which means lasting more than 6 months) in up to 10% of the 200,000 newly infected people each year. If left untreated, the risk of developing cirrhosis (scarring of the liver) and liver cancer is increased in patients with chronic hepatitis B.

"C" The Facts

Hepatitis C virus (HCV), once known as "non-A, non-B" hepatitis, develops into a chronic infection in up to 85% of the 150,000 newly infected people each year. Currently in the United States, there are approximately 3.5 million Americans who are chronically infected with HCV. If left untreated the chronic form of HCV has a greater chance of resulting in cirrhosis, liver cancer, or even liver failure. Liver failure due to chronic hepatitis C infection is the leading cause of liver transplants in the United States.

Cause For Concern?

People who are at risk of being infected with hepatitis B or C include health care workers, people with multiple sex partners, intravenous drug users, and hemophiliacs. Anyone who has had a tattoo, body piercing or a blood transfusion (prior to routine screening of donated blood that began in 1972 for hepatitis B and 1990 for hepatitis C) and those who are in close household contact with an infected person are also at higher risk of being infected. Hepatitis B or C can even be transmitted by sharing toothbrushes or nail files contaminated with infected blood however these forms of transmission rarely occur.

Infants born to HBV-infected mothers can contract the virus in up to 90% of cases, but HCV is only rarely spread from mother to baby at the time of delivery.

However, approximately one third or more of hepatitis A, B and C cases result from unknown sources. This means that you do not necessarily have to be among the "high-risk" groups to become infected with the viruses.

A Quiet Killer

Most people who get hepatitis B or C have no recognizable signs or symptoms. You can feel and appear perfectly healthy yet still be infected with hepatitis and infect others. But some people do experience flu-like symptoms, such as loss of appetite, nausea and vomiting, fever, weakness, tiredness, as well as mild abdominal pain. Less common symptoms are dark urine and yellowing of the skin and eyes (jaundice). Diagnosis of these diseases can be positively identified through blood test.

If you suspect that you have hepatitis or think you have been in contact with an infected person or a contaminated object, consult your physician as soon as possible.

Testing

There are specific tests your doctor can do to identify viral hepatitis A, B and C.

• The hepatitis A test, when positive, indicates a recent infection, or a developed immunity to the virus due to a prior infection.
• The tests for hepatitis B can identify: (a) whether you are infected, (b) if you are recovering from the disease, (c) if you have a chronic infection, or (d) if you are immune to hepatitis B.
• The tests for hepatitis C can show if you are infected with the virus or if you were infected in the past.

If you do test positive for hepatitis B or C treatment is available for eligible patients. So if you think you may be infected, be sure to consult your physician.

How to avoid hepatitis

Hepatitis can be avoided. You should always practice safe sex and never share objects such as needles, razors, toothbrushes, nail files and clippers. When getting a manicure, tattoo, or body piercing, make sure sterile instruments are used. Those who are exposed to blood in their workplace, such as health care workers, laboratory technicians, dentists, surgeons, nurses, emergency service workers, police officers, fire fighters, paramedics, military personnel, or those who live with an infected individual, should be vaccinated against hepatitis B. You should also consider being vaccinated for hepatitis A if you work in a day care center, come into close contact with someone who is infected, travel to geographic areas that have poor sanitation, or live in an area where there has been a recent outbreak of hepatitis A.

Don't Stop Here

If you need more information about hepatitis, ask your doctor, nurse, or pharmacist.

What is Inflammatory Bowel Disease (IBD)

Inflammatory Bowel Disease (IBD) is a chronic disease which can affect both the large intestine and the small intestines. There are two main types of inflammatory bowel diseases; ulcerative colitis and Crohn’s disease. Ulcerative colitis is an inflammatory disease restricted to the colon. Crohn’s disease can affect the small intestine and the colon. These diseases are due to unregulated inflammation. Uncontrolled inflammation can cause damage to the lining of the intestines. Crohn’s disease and ulcerative colitis can cause severe symptoms and lead to a poor quality of life if not taken care of appropriately.

IBD Statistics

IBD afflicts more than one million Americans and approximately 100,000 children with over 30,000 new cases being diagnosed each year.

Symptoms of IBD

• Persistent diarrhea
• Constipation
• Abdominal pain or cramps
• Blood passing through the rectum
• Fever, night sweats
• Weight loss
• Joint, skin or eye irritations, rashes
• Delayed growth and malnutrition

Treatment of Inflammatory Bowel Disease

Treatment of Crohn’s disease and ulcerative colitis can be medical, surgical or sometimes a combination of both.

There are many highly effective medications available for treatment and control of both ulcerative colitis and Crohn’s disease. Medical treatment has to be closely monitored for effectiveness and development of side effects.

Quality of life

The aim of medical and surgical treatment is to give complete control of ulcerative colitis and Crohn’s disease. Thus providing highest quality of life to the patients.

Our Program

At the Medical College of Wisconsin and Froedtert Hospital we have a long tradition of caring for patients with Crohn’s disease and Ulcerative colitis. We have a team of gastroenterologists, surgeons, physician assistants, radiologists and nurses who focus on the diagnosis and treatment of patients with these diseases.

Our program has always been in the forefront of inflammatory bowel disease research. This has helped us to more optimally utilize current drug therapies and offer state-of-the-art options for management. We believe in using available and novel therapies to provide personalized approach to those with inflammatory bowel disease care.

Our clinical experience has been a driving force for research driven discoveries leading to improved patient care:

• We identified factors related to increased treatment success and durability of immunosuppressive medication regimens.
• We identified the significant negative impact of Clostridium difficile infection on IBD and adapted treatment protocols to improve therapy.
• We identified the negative impact of vitamin deficiencies on IBD.
• We helped describe factors related to the improved quality of life in pregnant IBD patients.
• We optimized surgical outcomes with timely medical treatment with specialized surgical expertise.
• We have helped identify characteristics of IBD patients at risk for colon cancer, and instituted novel screening protocols with the aim to minimize colon cancer risk.
• We have helped maximize the yield of accepted radiological modalities by fine tuning their use for specific personalized conditions.

Ways to Manage Pain Caused by IBD

• Use warm sitz baths to reduce irritation and discomfort in the rectum.
• A heating pad placed on the abdomen can help reduce discomfort and cramping.
• Since it is widely known that stress can play an integral role in IBD flares, try to reduce the amount of stress in your daily life.
• Try to avoid taking narcotic pain medication as it can cause constipation.
• Proper dietary intake can reduce pain by decreasing the amount of symptoms caused by foods high in grease and those that are spicy.
• You only have one colon so take care of it. Follow instructions given to you by your physician. If you have a question, don’t be afraid to ask.

At the Medical College of Wisconsin, our hepatologists treat a wide variety of liver diseases. Our hepatology team manages the following diseases, and more:

Fatty Liver Disease

Fatty liver disease, also known NAFL-D (non-alcoholic fatty liver disease) is now the most common liver disorder in the United States. The disorder is associated with excess body weight, diabetes and high cholesterol and may be present in more than 20% of the US population. The severe form of fatty liver known as NASH (non-alcoholic steatohepatitis) can, in some cases progress to cirrhosis and liver cancer, requiring liver transplantation Treatment is focused on correcting the underlying risk factors such as weight control and diabetic control. Extensive research is ongoing regarding new therapies for fatty liver disease. Our team’s active research is focused on understanding the genetic risk factors for fatty liver and improving its diagnosis.

At the Medical College of Wisconsin, we are able to provide a multidisciplinary approach offers a better opportunity for successful weight loss. The treatment team includes hepatologists (physicians specializing in liver disease), endocrinologists, bariatric surgeons, dieticians and nutritionists who provide personalized dietary counseling for weight loss and maintenance.

Alcoholic Liver Disease

Alcohol related liver disease continues to be one of the leading causes of liver damage. Alcohol is a toxin which directly damages liver cells. In order to treat alcohol-related liver disease–including alcoholic hepatitis, alcoholic fatty liver disease, and alcoholic cirrhosis of the liver–maintaining abstinence from alcohol is crucial.

Primary Biliary Cirrhosis (PBC)

Primary Biliary Cirrhosis (PBC) is a disorder that affects the small bile ducts within the liver. Patients tend to present with complaints of itching because of the inability of the bile to drain through the damaged bile ducts. The disease also has other systemic complications including bone disease, increased risk of fluid retention and gastrointestinal bleeding. The cause of primary biliary cirrhosis appears to be a disorder of the immune system whereby the bile ducts are attacked aggressively by antibodies, the most common of which is the antimitochondrial antibody. A medication called ursodeoxycholic acid is effective therapy at slowing down the progression of this disease. Unfortunately, many patients progress to end-stage liver disease and need liver transplantation. For this reason, monitoring this disease at a liver transplant center is beneficial.

Primary Sclerosing Cholangitis (PSC)

Primary sclerosing cholangitis (PSC) is a condition similar to primary biliary cirrhosis, however, the large and medium-sized bile ducts are usually involved in this condition. PSC is often associated with concomitant inflammatory bowel disease (ulcerative colitis, Crohn's disease). Comprehensive treatment is offered at the Medical College of Wisconsin in conjunction with our Gastroenterology and Interventional Radiology colleagues. There is no effective medical therapy for primary sclerosing cholangitis and many of the patients progress to cirrhosis and are at increased risk for bile duct cancer (cholangiocarcinoma). Liver transplantation offers the only effective long-term therapy in patients with advanced disease, therefore monitoring the disease course at a liver transplant center is essential.

Autoimmune Liver Disease

Autoimmune hepatitis occurs when a person’s own immune system (antibodies) attacks the liver cells. The diagnosis is supported by typical blood tests, antinuclear antibodies and anti-smooth muscle antibodies in the blood. A liver biopsy may be performed to aid in the diagnosis and stage the disease. Symptoms may include fatigue, jaundice and malaise. Our team of hepatologists uses various oral medications that modulate the immune system and are effective for managing autoimmune liver disease. When this condition is diagnosed at an early stage, medical therapy is quite effective; however, patients with advance disease may require liver transplantation.

Hereditary Hemochromatosis

Heredity hemochromatosis is a disease in which iron accumulates in various organs in the body, including the liver, due to a genetic defect. When this occurs the liver can become cirrhotic and is also at an increased risk for liver cancer. Heredity hemochromatosis is found in about 1 out of every 250 Caucasian patients in the United States and more frequently in those of Northern European descent. Diagnosis can easily be confirmed by a blood test to evaluate the amount of iron in the body as well as a genetic test, which detects whether the gene responsible for this condition is present. Liver biopsy may be performed to stage the disease. Therapy aims at removing the excess iron from the blood and is typically done by phlebotomy or blood removal. More advanced cases may require liver transplantation.

Wilson Disease

Wilson disease is a disorder that occurs from a defective gene that causes copper accumulation in the body including the liver and various parts of the brain. Patients frequently present with a variety of neurologic symptoms and/or with evidence of liver failure. While not as common as hereditary hemochromatosis, Wilson disease when diagnosed early can be effectively treated. More advanced cases of Wilson disease may require liver transplantation.

Drug-Induced Liver Injury

A wide variety of medications and herbal supplements can damage the liver. Some may damage the liver rapidly and others over a period of time. Withdrawing the medication may reverse this problem; however, some patients may require liver transplantation due to severe drug-induced liver disease.

Cirrhosis

Cirrhosis is irreversible scarring of the liver. There are many causes and severities of cirrhosis but the most common causes in the US are hepatitis C, alcohol, and fatty liver disease. Cirrhosis can be diagnosed on a liver biopsy and occasionally on an ultrasound or CT scan of the abdomen. Laboratory testing usually suggests advanced liver disease including cirrhosis.

The complications of cirrhosis include bleeding from the gastrointestinal tract as accessory blood vessels known as varices form. Fluid accumulation in the abdomen, known as ascites, is also common and there is a possibility that this fluid may become infected presenting as a condition known as spontaneous bacterial peritonitis. Because the liver filters waste products from the bloodstream, a condition known as hepatic encephalopathy can develop if the liver is injured to a degree where it cannot remove these waste products from the body. The complication of this is a mental slowing or confusion, which is reversible and can be treated successfully with medications if properly diagnosed. At the Medical College of Wisconsin, our hepatology team has expertise in managing these complications and helping patients achieve a better quality of life. Cirrhosis may require liver transplantation; therefore, treatment at a transplant center is essential.

Liver Cancer Basics

The Medical College of Wisconsin offers a multidisciplinary highly experienced treatment team including hepatologists, oncologists, surgeons, interventional radiologists, transplant specialists and other specialists to offer the most comprehensive treatment of different types of liver cancer. Learn more about our approach to treating liver cancer.

Liver Transplant

The Medical College of Wisconsin hepatologists, transplant surgeons, nursing specialists and other members of the transplant team work together to provide comprehensive, ongoing care for individuals who need a liver transplant. Our transplant program outcomes are among the best in the nation. Learn more about our approach to liver transplantation.

Liver Biopsy

The liver biopsy is a safe procedure when standard precautions are taken. The risk of bleeding that may require transfusion is less than 2% and the risk to adjacent organs is also in the range of 2%. Because of this risk, blood thinners such as aspirin or NSAIDs should be held prior to the procedure. The procedure is typically done by localizing an area in the right upper quadrant immediately on top of the liver. The area is cleaned with a sterile solution and a local anesthetic is applied. Once the area has been anesthetized a slightly larger needle is passed through this area rapidly into the liver and then withdrawn. The sample is available immediately and is sent to pathology for microscopic examination. The patient is typically monitored for several hours in the hospital but is discharged to home, if there are no complications and normal activity can be resumed by the next day. No sutures are necessary and no scar forms.

Esophageal Manometry

What is Esophageal Manometry?

The esophagus is a tube-like muscle connecting the back of the mouth to the stomach. During swallowing it contracts and pushes food from the mouth to the stomach. Esophageal manometry is a way to test if the muscles in the esophagus are functioning properly. Manometry is done by passing a small tube through the nose into the esophagus. Tiny holes in the sides of the tube allow for the measurement of pressures within the esophagus and stomach. The pressure readings indicate whether or not the esophageal musculature is contracting normally. Problems such as difficulty swallowing, pain with swallowing, heartburn, chest pain, regurgitating and vomiting can be associated with abnormal esophageal muscle function.

What preparation is required?

Patients should not eat or drink for six (6) hours before the test. If you have diabetes, we will need to give you specific instructions. Please inform us if you are allergic to any drugs, such as lidocaine (similar to the anesthetic used by dentists when filling cavities).

Patients with diabetes should ask about specific instructions. When scheduling the test, patients should let the staff know of any drug allergies (especially lidocaine, an anesthetic similar to that used by your dentist). Patients should also list the drugs they are taking, since some may need to be stopped before the test.

What happens during the procedure?

Before the procedure, the nasal passage will be numbed with lidocaine jelly. This anesthetic is applied with a cotton swab. No other sedative or anesthetic is used. The tube will then be passed through the nose. The tube will not interfere with breathing. After the tube is passed, patients will lie down for the remainder of the test. Small amounts of water or Jell-O will be placed in the mouth and swallowed. Sometimes the medications are inhaled or given by vein during the test.

How long does manometry take? Can I travel home by myself?

The entire test takes about one hour to complete. Following the test, patients can drive home and resume their usual diet and activities. A report will be sent to the physician who requested the test.

Are there any complications from esophageal manometry?

Esophageal manometry is an extremely safe test. We have performed over 5,000 manometries with no serious complication. Patients may have a sore throat for a few hours afterward, and the nose may be slightly irritated form the passage of the tube. Rarely patients have nosebleeds. Patients should let the technician know if they have a tendency for nosebleeds or have suffered a broken nose.

Lower Gut or Anorectal Manometry

What is Lower Gut or Anorectal Manometry?

Lower Gut or Anorectal manometry is a test to measure pressures of the anal sphincter muscle and the ability to sense rectal distention. This is achieved by using a small, soft plastic water filled catheter. There is a small latex balloon attached to the end of the soft tube that is inflated during testing.

What preparation is required?

In most cases, there is no preparation. Patients should try to move their bowels before coming in for the test. If more thorough bowel preparation is required, they will be notified.

What should patients expect during the procedure?

There should be little, if any, discomfort during the manometry. Therefore, no anesthetic will be used. The catheter will be inserted into the rectum while patients lie on their left side. Patients will feel movement of the catheter and distension of the balloon.

How long does this procedure take?

The duration of this study will be approximately one hour.

What happens after a lower gut or anorectal manometry?

After the test patients can drive home and resume their usual work and diet. A report will be sent to the physician who requested the test.

Are there any complications from anorectal manometry?

Anorectal manometry is an extremely safe test. We have performed over 1,000 manometries with no serious complications. Make sure to inform the staff if you are allergic to latex rubber.

The pancreas is a gland that sits behind the stomach and spans across the belly. It is larger than your gallbladder, but smaller than the liver. The pancreas plays a key role in the digestive system. Specifically, the pancreas:

• Secretes digestive juices (enzymes and a substance called sodium bicarbonate) into the small intestine
• Produces the hormones, including insulin and glucagon, that control your body's ability to use sugar

The digestive juices enter the pancreatic duct, which is a small tube that drains into the small intestine. The digestive juices split the fats, proteins, and carbohydrates into small molecules that can easily be absorbed.

What is Pancreatitis?

Pancreatitis is inflammation, or irritation of the pancreas. This condition usually begins as a sudden episode known as acute pancreatitis, and in some cases, may result in long term damage after severe and/or recurrent attacks, known as chronic pancreatitis. When the pancreas becomes inflamed, the digestive enzymes attack the pancreas itself. One of these enzymes, called trypsin, can cause tissue damage and bleeding, and can cause the pancreas cells and blood vessels to swell. In chronic pancreatitis, scar tissue replaces the normal pancreas tissue and the pancreas may eventually stop producing the enzymes that are necessary for your body to breakdown food and absorb nutrients. When chronic pancreatitis is advanced, the pancreas can also lose its ability to make insulin resulting in diabetes. The main symptom of chronic pancreatitis, however, is severe abdominal pain.

There are two types of pancreatitis:

Acute pancreatitis
Sudden damage to the pancreas causes it to swell, resulting in pain. It is most often caused by gallstones or alcohol abuse, although there are many other causes as well. When gallstones pass through the bile duct, they may become stuck at the bottom, blocking both the bile duct and pancreatic duct. This causes enzymes to build up in the pancreas as they cannot drain, resulting in damage to the pancreas. In the case of alcohol, the pancreas may be sensitive to the toxic effect of alcohol. An attack may occur anywhere from a few hours to one or two days after drinking alcohol. The amount of alcohol needed to cause acute pancreatitis will vary from person to person. Other less common causes of acute pancreatitis are: excessive levels of fat particles known as triglycerides in the blood (hypertriglyceridemia), medications, surgery, genetics, tumor of the pancreas, and idiopathic (unknown cause). Acute pancreatitis affects about 80,000 Americans every year. Acute pancreatitis usually has a brief course of 2-5 days requiring hospitalization, but it can be severe enough to require a lengthy hospitalization and may even be life threatening.

Chronic pancreatitis
This occurs when repeated and/or severe damage to the pancreas results in extensive scar tissue that replaces the normal pancreas tissue. This condition is usually due to years of excessive alcohol consumption, but may also develop from other causes, including a hereditary gene defect. Rarely, it can lead to pancreatic cancer.

What are the Symptoms of Pancreatitis?
Acute pancreatitis:

• A sudden severe pain in the center part of the upper abdomen goes through to your back; this pain may get worse when you eat and builds to a persistent pain
  Nausea and vomiting
• Jaundice (a yellowing of the skin and eyes) due to blockage of the bile duct from the inflamed pancreas

Chronic pancreatitis (not all of these symptoms have to be present):

• Steady, gnawing upper abdominal pain that may radiate to the back. Tends to be always present.
• Loose, oily stools that are hard to flush and smell odd.
• Jaundice (a yellowing of the skin and eyes) due to blockage of the bile duct from the inflamed pancreas
• New onset of diabetes
• Weight loss

What Should I Do If I Think I Have Pancreatitis?

If your abdominal pain lasts more than 30 minutes call your doctor or go to the emergency room. Your doctor will take a medical history, ask you about your drinking history, and draw blood to check for pancreatitis. Imaging of the pancreas with an ultrasound, CT, or MRI may be obtained. The optimal management of severe acute pancreatitis often involves monitoring by specialists that may not be available in every hospital but is offered at Froedtert Hospital. In addition, for chronic pancreatitis, you may require a 48-72 hour stool collection to check for poor absorption of fat, and you may require a special type of endoscopy known as endoscopic ultrasound. This combines ultrasound technology with an endoscope to allow your doctor to examine your pancreas internally for subtle changes.

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

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 (pain medication). 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 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 endoscope used to put x-ray contrast dye into the bile and pancreas ducats. In severe cases, surgery will be required to drain the pancreatic duct or to remove part of the pancreas.

What Hope for the Future?

If their condition was caused by drinking, they will have a positive outcome if they stop drinking and continue follow-up treatment.

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

• Make sure that your doctor reviews and monitors all your medications because some prescription medications may cause pancreatitis.
• Stop smoking
• Stop drinking alcohol (or limit drinking if pancreatitis was not caused by alcohol)
• Low fat diet
• In some cases, pancreatic enzyme pills may be helpful

What is a 24 Hour Ambulatory pH Test?

Ambulatory 24 hour pH monitoring is a method of recording the amount and degree of acidic stomach contents backing up into the esophagus. The evaluation involves placing a small probe in the esophagus. The probe is connected to a small recording device. A strap is attached to the device to facilitate carrying it for 24 hours. Using a microprocessor, this unit is able to record the pH or acid levels in the esophagus over a 24 hour period. After the probe is in place, the patient will be free to leave the hospital. During this time the patient is encouraged to continue normal activities. Since the unit is small and worn on a strap, the patient is free to go about their usual daily routine. Resuming normal tasks is important so that the doctor can get a realistic picture of what is taking place in the esophagus.

Patients will be asked to return in approximately 24 hours, at which time the pH probe will be removed and the data will be transferred to a computer for analysis.

What preparation is required?

In most cases, the patient should not eat or drink anything for six (6) hours before the test. Since most tests are scheduled in the morning, skipping breakfast is usually sufficient. Patients should inform the staff of allergies to any drugs, especially lidocaine (similar to the anesthetic used by dentists when filling cavities). Before passage of the probe, the nasal lining will be swabbed with lidocaine to numb the nose. The probe is then passed through the nose into the esophagus. Once the probe is in place, patients can breathe, talk and eat with little or no disruption.

When scheduling the test, patients should inform the staff about any medicines they are taking, since some may need to be stopped before the test.

Are there any complications associated with my test?

The 24 hour Ambulatory pH Test is an extremely safe test. We have performed over 3,000 tests with no serious complications. Some patients have a sore throat for a few hours after the completion of the test and the nose may be slightly irritated from the passage of the probe. Occasionally, mild nosebleeds can occur.

• American Association for the Study of Liver Diseases
• American College of Gastroenterology
• American Gastroenterological Association
• American Liver Foundation
• Crohn's & Colitis Foundation of America
• National Institute of Diabetes & Digestive & Kidney Diseases