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Aminosalicylates for inflammatory bowel disease

Examples balsalazide disodium Colazal mesalamine Asacol Lialda Pentasa Rowasa olsalazine sodium Dipentum sulfasalazine Azulfidine How It Works These medicines may relieve symptoms and inflammation in the intestines and help IBD go into remission (a period without symptoms). They also may help prevent the disease from becoming active again. Why It Is Used Aminosalicylates usually are the first medicines used to treat inflammatory bowel disease (IBD). These medicines have been used to treat IBD for more than 30 years. Ulcerative colitis Oral and topical aminosalicylates are used to treat mild to moderate ulcerative colitis. They also are used to help keep the disease in remission. Oral aminosalicylates are used to treat mild to moderate extensive disease (pancolitis). Mesalamine (Rowasa) is placed in the rectum as a retention enema or suppository. Enemas are useful if the disease affects only the lower third of the large intestine . Suppositories may be used if the disease affects only the lower rectum (proctitis).

Crohn's disease Oral aminosalicylates are used to treat mild Crohn's disease.

How Well It Works These medicines are effective for mild to moderate ulcerative colitis and mild Crohn's disease. Their use depends on the type of medicine (oral or topical) and whether it treats disease that is active or in remission. Ulcerative colitis Treatment for mild to moderate ulcerative colitis often begins with sulfasalazine. But it cannot be used by people who are allergic to or cannot tolerate sulfa drugs. Sulfasalazine works 40% to 80% of the time to make ulcerative colitis symptoms better or keep them from coming back.1 Mesalamine, olsalazine, and balsalazide do not contain sulfa, so they may be used to treat mild to moderate ulcerative colitis if you cannot take sulfasalazine. About 80% of people who can't take sulfasalazine can use mesalamine without problems.1 Mesalamine is becoming the medicine that doctors use first to treat mild to moderate ulcerative colitis. Mesalamine enemas are effective in treating symptoms of mild to moderate distal (left-sided) ulcerative colitis and in maintaining remission. Topical mesalamine enemas and suppositories work more quickly, have fewer side effects, and do not need to be used as often as oral mesalamine. They are most effective when used while you are sleeping. Mesalamine suppositories are preferred for people who have proctitis.

Mesalamine, balsalazide, and olsalazine can be used to maintain remission in ulcerative colitis.

Crohn's disease Sulfasalazine may be used for mild Crohn's disease of the colon. Some people are allergic to sulfa drugs and cannot take sulfasalazine. Mesalamine has been shown to stop the symptoms of Crohn's disease in some people. Studies show that about 45% to 55% of people treated with mesalamine go into remission (a period without symptoms).2 Aminosalicylates do not seem to keep symptoms from coming back when a person is in remission caused by drugs (like corticosteroids). But aminosalicylates sometimes keep symptoms from coming back in people who have had surgery.3

Side Effects Sulfasalazine Side effects may include headache, nausea, loss of appetite, vomiting, rash, fever, and decreased white blood cell count. Sulfasalazine also can temporarily reduce sperm production in men while they are taking the medicine. Most side effects can be relieved by taking smaller doses with food at intervals throughout the day (instead of a single large dose), using coated tablets, or lowering the dose. Folic acid supplements and regular blood tests to check the white blood cell count may be needed while taking sulfasalazine. Mesalamine Side effects may include stomach pain and cramps, diarrhea, gas, nausea, headache, and dizziness. The medicine may cause kidney problems if taken in high doses or for a long time. Olsalazine Diarrhea is the most common side effect. Uncommon side effects may include headache, rash, fatigue, hair loss, inflammation of the pancreas (pancreatitis), or inflammation of the tissue surrounding the heart (pericarditis). Balsalazide The most common side effects are headaches and abdominal pain. Other possible side effects are nausea, diarrhea, and vomiting. See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.) What To Think About Aminosalicylates are used for long-term maintenance in ulcerative colitis. They are not as effective for long-term treatment of Crohn's disease.

Corticosteroids for inflammatory bowel disease


Examples betamethasone Celestone budesonide Entocort EC dexamethasone Decadron hydrocortisone acetate (intrarectal foam) Proctofoam HC hydrocortisone (oral) Cortef hydrocortisone (retention enema) Cortenema methylprednisolone (retention enema) prednisolone Orapred prednisone triamcinolone Clinacort Kenalog

Some of these medicines may be taken as pills. If the disease affects only the lower part of the colon, corticosteroids can be given by enema. For disease that only affects the rectum, suppositories and topical creams can be used. In severe cases, some corticosteroids are given through a needle in a vein (IV) . How It Works These medicines reduce inflammation. Why It Is Used Corticosteroids are used to treat ulcerative colitis and Crohn's disease (inflammatory bowel disease, or IBD). Ulcerative colitis Corticosteroid pills are used to stop symptoms of moderate to severe ulcerative colitis when aminosalicylates, such as sulfasalazine or mesalamine, have not worked. Corticosteroid enemas, suppositories, creams, or foam can be used to treat mild to moderate ulcerative colitis that is limited to the rectum or lower part of the colon. Severe extensive disease sometimes requires treatment with intravenous (IV) corticosteroids.

Crohn's disease Oral or intravenous (IV) corticosteroids can be used to treat: Mild to moderate Crohn's disease. Budesonide (Entocort EC), a corticosteroid you take as a pill, affects only the intestinal tract. Because of this, it causes less side effects than other corticosteroids.1 Budesonide doesn't work as well for Crohn's disease as other corticosteroids. But it has worked to put mild to moderate disease in remission (a period without symptoms). It is not used long-term. Moderate to severe disease. The corticosteroids prednisone and prednisolone lead to disease remission in 60% to 70% of people.2 Severe disease. For severe disease, you will most likely get corticosteroids (like hydrocortisone) through a vein (intravenous or IV). This is usually done in the hospital.

How Well It Works Corticosteroids improve or stop the symptoms of ulcerative colitis and Crohn's disease. These medicines are used to put the disease in remission (a period without symptoms). They are not used long-term. Corticosteroids do not keep ulcerative colitis or Crohn's disease in remission for the long term. When the disease has gone into remission, your doctor will gradually reduce the strength and the amount of corticosteroid you are taking. Only people who do not get better with other medicines-less than half of people with IBD-need to take corticosteroids. Of these people, most people get better after taking corticosteroids (84%).3 Some people with IBD may need to keep taking a small dose of corticosteroids to help keep them in remission. Steroid enemas may be especially helpful for inflammation in the lower colon and the rectum.

Side Effects Some common side effects of corticosteroids include: Increased risk of infection. High blood pressure (hypertension).

Other side effects may appear after you take this medicine for a long time. These include: Weight gain. Acne. Mood swings. Psychosis. Increased facial hair. Osteoporosis. Cataracts. Higher blood sugar level. Bone damage without infection (aseptic necrosis).

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.) What To Think About Long-term use of corticosteroids is discouraged because of the high risk of longlasting side effects. Symptoms of inflammatory bowel disease may come back after a person stops taking corticosteroids. Your doctor may have you take an aminosalicylate (such as sulfasalazine or mesalamine) or an immunomodulator (such as azathioprine or 6-mercaptopurine) at the same time you are taking corticosteroids. These medicines will help keep your symptoms from coming back when you stop taking the corticosteroid. People who take corticosteroids for more than 2 to 3 months should take calcium and vitamin D supplements or other medicines, such as bisphosphonates, to prevent osteoporosis. For more information, see the Medications section of the topic Osteoporosis. Your doctor may want you to have a bone density test to check for osteoporosis. Short-term use of corticosteroids by children generally is considered safe. Long-term use carries the risk of a delay in growth, as well as the side effects that occur in adults. However, the negative effects of severe IBD on a child's growth and development are worse than the possible side effects of steroids, if the child needs steroids to control the disease. Corticosteroids are safe during pregnancy to treat a flare-up of symptoms. Newer steroids in enema form may be useful for longer-term management of IBD, because the enema form causes fewer side effects that affect the whole body.

Immunomodulators for inflammatory bowel disease


Examples azathioprine (AZA) Imuran methotrexate (MTX) Mexate Rheumatrex mycophenolate mofetil CellCept tacrolimus Prograf thalidomide Thalomid 6-mercaptopurine (6-MP) Purinethol

How It Works Immunomodulator medicines, such as azathioprine (AZA), 6-mercaptopurine (6-MP), and methotrexate, weaken or suppress the immune system. These medicines are used most often to prevent the body from rejecting a newly transplanted organ, but they are also helpful in treating inflammatory bowel disease (IBD). Why It Is Used Immunomodulators are used for inflammatory bowel disease (IBD) that: Has not responded to other treatments. Can be controlled only with long-term use of corticosteroids.

Immunomodulators may be used so that the doctor can lower the dose of corticosteroids that a person is taking. This is called "steroid sparing." How Well It Works Immunomodulator medicines are effective against inflammatory bowel disease. AZA and 6-MP are used to maintain remission (a period without symptoms) in ulcerative colitis and Crohn's disease. Both medicines are effective in treating fistulas in Crohn's disease. Crohn's disease It may take 4 months or more for azathioprine (AZA) and 6-mercaptopurine (6-MP) to improve symptoms. These medicines are used to keep a person in remission and allow the person to stop using corticosteroids. These are the most commonly used immunomodulators. They usually work well, but the disease often comes back after you stop taking the medicine.1 Methotrexate improves symptoms more quickly than 6-MP, but it has not been studied as extensively. A few studies have shown that methotrexate stops the symptoms of Crohn's disease and keeps the disease in remission.1 Usually, methotrexate is used when azathioprine (AZA) and 6-mercaptopurine (6-MP) don't work. Tacrolimus can be used in Crohn's disease when corticosteroids do not work or fistulas develop. It also may be applied topically for Crohn's disease that affects the mouth or perineal area.2 Mycophenolate mofetil has been studied in active Crohn's disease, with mixed results. More research is needed to confirm its role.3 Thalidomide has been shown to work in Crohn's disease when corticosteroids did not. It has also been used to treat fistulas. Controlled studies still need to be done. There is some worry about serious side effects of thalidomide.1 Ulcerative colitis Azathioprine (AZA) and 6-mercaptopurine (6-MP) are used for moderate to severe ulcerative colitis to keep symptoms of the disease from coming back after a person has reached a period without symptoms (remission). Azathioprine has been shown to keep 80% to 90% of people in remission for over 2 years. It also allows people to stop taking corticosteroids.4 Oral azathioprine (taken by mouth) is used with steroids or cyclosporine in moderate or severe colitis. Using azathioprine to maintain remission in this way reduces the

chances that symptoms will come back. It also makes it less likely that a person will need a colectomy.4 Side Effects Side effects of immunomodulator medicines include: Nausea, vomiting, diarrhea, or stomach ulcers. Rash. General feeling of being ill (malaise). Liver inflammation.

Rare side effects include: Suppression of blood cell production (bone marrow suppression), which may increase the risk of infection or serious bleeding. Return to normal blood cell production may take several weeks after the medicine is stopped. Fever. Inflammation of the pancreas (pancreatitis). This may occur with AZA and 6MP.

Extremely rare side effects of azathioprine include a possible increased risk of cancer. Mycophenolate mofetil may increase the risk of cancer of the lymph system (lymphoma) and other types of cancer. See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.) What To Think About Regular blood tests are needed to check for effects that these medicines may have on the bone marrow, liver, and kidneys. Immunomodulator medicines are less likely than corticosteroid medicines to cause growth failure in children. Since these medicines weaken or suppress the immune system, they increase your risk of infection. If you are pregnant or want to become pregnant, talk to your doctor about whether you can take immunomodulator medicines. Some of these medicines are used in pregnancy, but only when the benefit outweighs the potential risk of harm to the fetus. Methotrexate and thalidomide should not be used because they can cause birth defects and pregnancy loss.

Tumor necrosis factor (TNF) antagonists for inflammatory bowel disease


Examples adalimumab Humira infliximab Remicade How It Works A tumor necrosis factor (TNF) antagonist is a type of antibody that inhibits tumor necrosis factor, a protein that increases inflammation in the body. Infliximab and adalimumab block the inflammatory response that happens in Crohn's disease and ulcerative colitis. They are both given as a shot. Infliximab is given as a shot in a

vein (intravenous, or IV) and adalimumab is given as a shot under the skin (subcutaneous). Why It Is Used Infliximab was first used to treat abnormal connections (fistulas) between the intestines and organs in moderate to severe Crohn's disease. Now it is used to induce and maintain remission (a period without symptoms) in people who have Crohn's disease or ulcerative colitis that has not improved with other medicines. Adalimumab is used to induce and maintain remission in people with Crohn's disease who have not improved with other medicines and who no longer respond to or cannot tolerate treatment with infliximab. How Well It Works Infliximab can induce remission in people with moderate to severe Crohn's disease, including the closing of fistulas. In one study, some people who were treated with infliximab had symptoms that came back after 3 months. It is now recommended that people treated with infliximab continue to get the medicine at regular intervals. This is called maintenance therapy. In multiple studies, almost 70% of people taking infliximab had fewer symptoms or had healed fistulas.1 In one study, between 60% and 70% of people with ulcerative colitis were better 8 weeks after getting infliximab treatment. In another study, twice as many people got better after receiving infliximab compared to those taking a placebo.2 Adalimumab has shown promise in treating Crohn's disease in multiple studies.3 It works like infliximab and may be good for people who are allergic to infliximab. The long-term effectiveness of both medicines is still being studied. Side Effects Infliximab is given only in a vein (intravenously). Adalimumab is given under the skin (subcutaneously). Side effects include: Chest pain. Nausea. Fever. Chills. Itching (pruritus). Facial flushing. Headache. Rash. Fatigue. Dizziness.

Warnings about serious side effects of TNF antagonists have been issued. The U.S. Food and Drug Administration (FDA) and the drugs manufacturers have warned about: An increased risk of blood or nervous system disorders, some potentially fatal. Contact your health professional if you have symptoms of blood disorders (such as bruising or bleeding) or symptoms of nervous system problems (such as numbness, weakness, tingling, or vision problems).

An increased risk of a serious infection (such as tuberculosis). If you have had tuberculosis (TB) or know someone who has, tell your doctor. TNF antagonists also affect your body's ability to fight all infections, so if you are taking the medicine and get a fever, cold, or flu, let your doctor know right away. An increased risk of liver injuries, some potentially fatal. Call your doctor if your skin starts to look yellow, if you have dark brown urine or a fever, or if you are very tired. A possible increased risk of developing lymphoma (a type of blood cancer). It is not clear if this increase is because of the drug or because people with Crohn's disease may already have a higher risk.4 There have been reports of a rare kind of lymphoma, occurring mostly in children and teens taking TNF antagonists, that often results in death. A possible reaction to the shot. Some people will have hives, trouble breathing, or low blood pressure after an infusion of infliximab. Some people can have an allergic reaction to a shot of adalimumab. Signs of a serious allergic reaction include a skin rash, a swollen face, or trouble breathing. These reactions most often occur right away, and your doctor may give you medicines to prevent or stop the reaction.

What To Think About Infliximab is more expensive than other medicines used to treat Crohn's disease. This medicine is used for Crohn's disease and ulcerative colitis that has not improved (refractory disease) when treated with corticosteroids, aminosalicylates, antibiotics, azathioprine, or 6-mercaptopurine. Infliximab is recommended to be used when other medicines don't work. The use of infliximab during pregnancy is still being studied. It may be used when other medicines have not worked and the health of the mother or of the fetus (or both) is at risk. It is not known if infliximab can pass from the mother to the baby in breast milk. If you have inflammatory bowel disease and you are pregnant, thinking about becoming pregnant, or breast-feeding, talk to your doctor about what medicines are safe for you to use. Because adalimumab is given as a shot under the skin, you may be able to do the shots yourself after your doctor has shown you how.

Osteoporosis

Osteoporosis is a progressive disease that causes bones to become thin and brittle, making them more likely to break. Both women and men are more apt to have osteoporosis if they fail to reach their optimum bone mineral density during the childhood and teenage years, critical times for building bones. Osteoporosis is related to the loss of bone mass that occurs as part of the natural process of aging. Although osteoporosis can occur in men, it is most common in women who have gone through menopause. Not getting adequate calcium and phosphorus-two minerals needed for bone density and strength-and a lack of vitamin D can also contribute to the development of osteoporosis. Not being physically active can also lead to osteoporosis. Prevention and treatment of osteoporosis include eating a diet with sufficient calcium and vitamin D, getting regular exercise, quitting smoking, avoiding excess alcohol, and taking medicine to reduce bone loss and increase bone thickness.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain and fever and to reduce swelling and inflammation caused by injury or diseases such as arthritis. Aspirin, ibuprofen, ketoprofen, and naproxen are commonly used NSAIDs. NSAIDs may cause side effects. The most common are stomach upset, heartburn, and nausea. Taking NSAIDs with food may help prevent these problems. Frequent or long-term use of NSAIDs may lead to stomach ulcers or high blood pressure. They can also cause a severe allergic reaction. NSAIDs have the potential to increase the risk of heart attack, stroke, skin reactions, and serious stomach and intestinal bleeding. These risks are greater if NSAIDs are taken at higher doses or for longer periods than recommended. Aspirin, unlike other NSAIDs, has been shown to reduce the risk of heart attack and stroke. It does carry the risks of serious stomach and intestinal bleeding as well as skin reactions.

NSAIDs should be taken exactly as prescribed or according to the label. Taking a larger dose or taking the medicine longer than recommended can increase the risk of dangerous side effects. People who are older than 65 or who have existing heart, stomach, or intestinal disease are at higher risk for problems. Aspirin should not be given to anyone younger than 20 because of the risk of Reye's syndrome, a rare but serious disease

Short bowel syndrome

Short bowel syndrome is a condition that prevents a person from digesting food and absorbing nutrients properly. It occurs when a large amount of the small intestine has been surgically removed or is affected by disease (such as Crohn's disease). The main symptom of short bowel syndrome is watery diarrhea. A person with short bowel syndrome usually needs a special diet along with vitamin and mineral supplements. Complications may include kidney stones, gallstones, and significant weight loss.

Toxic megacolon

Toxic megacolon is a rare but dangerous condition that occurs when the colon swells to many times its normal size. It is usually a complication of an inflammatory bowel disease, such as ulcerative colitis or Crohn's disease. Severe inflammation and ulceration can weaken muscles in the colon, causing the colon to swell. Symptoms may include a swollen belly, abdominal pain or tenderness, rapid heartbeat, or fever. Over time, holes (perforations) may form in the colon, and stool may spill into the abdominal cavity, causing a serious infection. This can be lifethreatening. Toxic megacolon is an emergency that requires immediate medical treatment to prevent dehydration and shock. Surgery may be needed to remove all or part of the colon (colectomy).

Pancreatitis

Pancreatitis is an inflammation of the pancreas, which is an organ in the upper abdomen that makes insulin and digestive enzymes. Pancreatitis may cause sudden, severe abdominal pain. Pancreatitis is most commonly caused by excessive use of alcohol or by a blockage of the tube (duct) that leads from the pancreas to the beginning of the small intestine (duodenum), usually by a gallstone. Other causes include an infection, an injury, or certain medicines. It may develop suddenly (acute), or it may be a longterm, recurring (chronic) problem. Treatment in the hospital includes pain medicine and fluids given through a vein (IV) until the inflammation goes away. Nutrition is given through a tube to avoid stimulating the pancreas. Although most people recover fully from pancreatitis, complications such as bleeding, infection, or organ failure may develop.

Sprue

Sprue is a disorder in which the intestines are unable to absorb nutrients from food. It can cause loss of appetite, diarrhea, weight loss, muscle cramps, pale skin, and bone pain. Sprue occurs in two forms, tropical and nontropical. Tropical sprue affects people who live in tropical areas. Its exact cause is unclear, but it likely results from a viral or bacterial infection of the lining of the intestine and, possibly, poor nutrition. Tropical sprue is treated by taking antibiotics for 3 to 6 months along with vitamin supplements. Nontropical sprue, sometimes called celiac disease, is present from birth, although some people may not develop symptoms until later in life. This type of sprue is treated by permanently adopting a strict gluten-free diet. This means a person can not eat foods that contain gluten, which is a form of protein found in many grains, such as wheat, barley, and rye.

Rotavirus infection

Rotavirus infection is an infection of the digestive tract. It is the most common cause of vomiting and severe diarrhea in babies and young children; other symptoms include fever and stomach pain. Rotavirus is spread by oral contact with stool (feces) containing the virus. A rotavirus infection in babies or young children is usually minor, generally lasting for about 3 to 8 days. The infection usually goes away on its own. Occasionally, rotavirus infection can lead to severe loss of body fluids (dehydration), which can be life-threatening. Preventing dehydration is an important part of treatment for rotavirus infection. By 2 years of age, most children have had a rotavirus infection and have developed some immunity to the virus.

Fecal Occult Blood Test (FOBT)


A fecal occult blood test finds blood in the stool by placing a small sample of stool on a chemically treated card, pad, or wipe. Then a special chemical solution is put on top of the sample. If the card, pad, or cloth turns blue, there is blood in the stool sample. Fecal occult blood may be done to check for some intestinal conditions or colorectal cancer. Colorectal cancer affects the large intestine (colon ) and the rectum. In

the United States, colorectal cancer is the second leading cause of all cancer deaths. Blood in the stool may be the only symptom of colorectal cancer, but not all blood in the stool is caused by cancer. Other conditions that can cause blood in the stool include: Hemorrhoids. These are enlarged, swollen veins in the anus. Hemorrhoids can develop inside the anus (internal hemorrhoids) or outside of the anus (external hemorrhoids). Anal fissures. These are thin tears in the tissue from the muscles that control the anus (anal sphincters) up into the anal canal. Colon polyps. These small growths of tissue often look like a stem or stalk with a round top that is attached to the colon. Peptic ulcers. These craterlike sores develop when the digestive juices made in the stomach eat away the lining of the digestive tract. Ulcerative colitis. This type of inflammatory bowel disease (IBD) causes inflammation and craterlike sores (ulcers) in the inner lining of the colon and rectum. Gastroesophageal reflux disease (GERD). This is the abnormal backflow (reflux) of food, stomach acid, and other digestive juices into the esophagus. Crohn's disease. This type of inflammatory bowel disease causes inflammation and ulcers that may affect the deep layers of the lining of the digestive tract. Use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).

A fecal occult blood test may be used to check for colorectal cancer, but it is never used to diagnose this condition. Other tests for colorectal cancer include a digital rectal examination, barium enema, flexible sigmoidoscopy, colonoscopy, or CT scan. Checking for hidden (occult) blood in the stool can be done at home. You can buy a test kit at a pharmacy without a prescription, or your health professional can order a test kit for you to use at home. If a home fecal occult blood test finds blood in your stool, call your health professional.

Bowel Transit Time


A bowel transit time test measures how long it takes for food to travel through the digestive tract . Bowel transit time depends on what types of food you eat and how much you drink. For example, people who eat lots of fruits, vegetables, and whole grains tend to have shorter transit times than people who eat mostly sugars and starches. Because different people have different transit times, experts disagree about how useful this test is. After you chew and swallow your food, it moves into your stomach, where it is mixed with acid and digestive enzymes. After your food leaves your stomach, it is squeezed through your small intestine, where, vitamins and water are absorbed for use by your body. The food then goes into your large intestine (colon). Whatever hasn't been digested and absorbed by your intestines combines with water, bacteria, and other waste products and becomes stool (feces). Stool is expelled from your body through your anus. The time it takes for food to travel from your mouth to your anus as stool is your bowel transit time. There are several methods to test your bowel transit time. Each method uses a swallowed substance (called a food marker) that goes through your body and leaves in your stool without being digested. Because the results of these tests are not

consistent, experts disagree about their usefulness. Some doctors do not recommend bowel transit time testing. Dye test For a dye test, you swallow a pill that has dye in it and keep track of how long it takes before the dye shows up in your stool. Home test For a home test, you will drink some red vegetable dye or eat a food like corn kernels or beets. You will then keep track of how long it takes for the dye or vegetable to show up in your stool. Pellet test For a pellet test, you swallow small pills (pellets) before having X-rays of your belly. The pellets look like white spots or rings in the X-ray pictures. You will have X-rays over 2 or 3 days to keep track of how fast the pellets move through your intestines. Why It Is Done Bowel transit time tests may be done to: Help find the cause of severe constipation. Show how different foods speed up or slow down the movement of food through the body.

Bowel transit time tests are not done to find the cause of diarrhea. How To Prepare If you plan to use food markers (such as corn or beets) to measure bowel transit time at home, do not eat these foods for about a week before starting the test. If you are using a red vegetable dye, do not eat or drink foods that contain red dye, such as red gelatin or fruit drinks, for about a week before starting the test. Tell your doctor if you are or might be pregnant before having a pellet test. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done Dye test or home test For the dye test or home test, swallow two gelatin capsules filled with a dye called carmine red (Cochineal) or eat a large helping of seeds, beets, or corn kernels to serve as markers. Look at your next couple of bowel movements and write down how many hours it takes after eating until the markers appear in your stool. Pellet test Your doctor will give you small, indigestible pellets to swallow with instructions about when to take the pellets. You may have to take them at a certain time for 2 or 3 days in a row. You will then have X-rays taken of your belly. These are usually done on day 4 and again on day 7. Your doctor will compare how many pellets show up on the first X-ray with the number of pellets that can be seen on the later X-ray pictures and also compare where the pellets show up in each picture. This time it takes for

the pellets to show up and how fast they move through your intestines is your bowel transit time. How It Feels Bowel transit time tests do not cause pain. You will not feel discomfort from the X-rays used for the pellet test. The X-ray table may feel hard and the room may be cool. You may find that the positions you need to hold are uncomfortable. Risks There is no chance for problems from dye tests and the home tests. The pellet test is not recommended if you are pregnant because the radiation from the X-ray can harm your developing baby (fetus). Results A bowel transit time test measures how long it takes for food to travel through the digestive tract . Bowel transit time depends on what types of food you eat and how much you drink. Different people have different bowel transit times. Talk to your doctor if you do a bowel transit test at home and you do not think that the results are normal. Bowel transit time The dye, food marker, or first pellets show up in the stool within 14 to 24 hours. The last pellets show up within 36 to 48 hours.

Normal:

The dye, food marker, or pellets take more than 72 hours to show up in Slowed: the stool.

What Affects the Test You may have an abnormal bowel transit time if you: Have an infection in your intestines. Do not drink enough fluids (dehydration). Have a disease, such as a narrowing (stricture) in your intestine, an underactive thyroid gland (hypothyroidism), diabetes, or Hirschsprung's disease. Are eating less than you usually do or you are eating different kinds of food than usual. Take medicines, such as cold medicines, iron, or medicine used to control blood pressure and pain.

Women normally have slower bowel transit times than men.

What To Think About The red dye in the gelatin capsules used for home testing is harmless and passes out of your body in your stool. Pellet testing is not recommended if you are or might be pregnant. Many doctors do not think that bowel transit time testing is useful. Different people have different bowel transit times on different days. You can usually speed up bowel transit time if you increase the amount of fruits, vegetables, and whole grains that you eat each day. For more information, see the topic Healthy Eating. It is possible to have a daily bowel movement but still have a slow bowel transit time.

D-xylose Absorption Test


The D-xylose absorption test measures the level of D-xylose, a type of sugar, in a blood or urine sample. This test is done to help diagnose problems that prevent the small intestine from absorbing nutrients in food. D-xylose is normally easily absorbed by the intestines. When problems with absorption occur, D-xylose is not absorbed by the intestines, and its level in blood and urine is low. Why It Is Done A test for D-xylose is done to: Check to see if malabsorption syndrome is causing symptoms, such as chronic diarrhea, weight loss, and weakness. A person with malabsorption syndrome is unable to absorb nutrients, vitamins, and minerals from the intestinal tract into the bloodstream. Find the cause of a child's failure to gain weight, especially when the child seems to be eating enough food.

How To Prepare For 24 hours before a D-xylose test, do not eat foods high in pentose, a sugar similar to D-xylose; these foods include fruits, jams, jellies, and pastries. Medicines such as aspirin and indomethacin can interfere with the results of a Dxylose test. For this reason, your health professional may instruct you to temporarily stop these medicines before the test. Do not eat or drink anything except water for 8 to 12 hours before having this test. Children younger than 9 years old should not eat or drink anything except water for 4 hours before the test. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done The amount of D-xylose in urine and blood samples is measured before and after you drink a D-xylose solution. To begin the test, a sample of your first urine of the day and a sample of your blood is collected.

Next you will drink a D-xylose solution. For adults, a blood sample is usually taken 2 hours after drinking the solution. For children, a blood sample may be taken 1 hour after drinking the solution. Another blood sample may be drawn 5 hours after drinking the solution. You will need to collect all of the urine you produce for 5 hours after drinking the sugar solution. Sometimes urine is collected for 24 hours after drinking the sugar solution. Blood test The health professional taking a sample of your blood will: Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with alcohol. Put the needle into the vein. More than one needle stick may be needed. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected. Put a gauze pad or cotton ball over the needle site as the needle is removed. Put pressure to the site and then put on a bandage.

Urine test You start collecting your urine in the morning. When you first get up, empty your bladder but do not save this urine. Write down the time that you urinated to mark the beginning of your 5-hour collection period. For the next 5 hours, collect all your urine. Your doctor or lab will usually provide you with a large container that holds about 1 gal. The container has a small amount of preservative in it. Urinate into a small, clean container and then pour the urine into the large container. Do not touch the inside of the container with your fingers. Keep the large container in the refrigerator during the collection period. Empty your bladder for the final time at or just before the end of the 5-hour period. Add this urine to the large container and record the time. Do not get toilet paper, pubic hair, stool (feces), menstrual blood, or other foreign matter in the urine sample.

You will not be allowed to eat until the test is completed.

Sweat Test
A sweat test measures the amount of salt chemicals (sodium and chloride) in sweat. It is done to help diagnose cystic fibrosis. Normally, sweat on the skin surface contains very little sodium and chloride. People with cystic fibrosis have 2 to 5 times the normal amount of sodium and chloride in their sweat. During the sweat test, medicine that causes a person to sweat is applied to the skin (usually on the arm or thigh). The sweat is then collected on a paper or a gauze pad, and the amount of salt chemicals in the paper or gauze is measured in a lab. Generally, chloride (sweat chloride) is measured. See a picture of a sweat test . A sweat test is done on any baby suspected of having cystic fibrosis. An initial test may be done as early as 48 hours of age. However, a sweat test done during the

first month of life may need to be repeated. Younger babies may not produce enough sweat to give reliable test results. Also, younger babies may naturally have lower sweat chloride levels than older babies and children with cystic fibrosis. Why It Is Done The sweat test is done to help diagnose cystic fibrosis. It also may be used to test people with a family history of cystic fibrosis and for anyone with symptoms of cystic fibrosis. How To Prepare No special preparation is needed before having this test. Your child may eat, drink, and exercise normally before the test. If your child takes any medicines, he or she may take them on the usual schedule. You may help with the test and stay with your child during the test. If you cannot stay, you may want to ask a family member or friend to stay with your child. Bring your child's favorite book or toy to help pass the time while the test is done. See if your child might be able to watch a movie during the test. Talk with your health professional about any concerns you have regarding the need for the test, its risks, or how it will be done. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done The sweat test is usually done on a baby's right arm or thigh. On an older child or adult, the test is usually done on the inside of the right forearm. Sweat may be collected and analyzed from two different sites. The skin is washed and dried, then two small gauze pads are placed on the skin. One pad is soaked with a medicine that makes the skin sweat, called pilocarpine. The other pad is soaked with salt water. Other pads called electrodes are placed over the gauze pads. The electrodes are hooked up to an instrument that produces a mild electric current, which pushes the medicine into the skin. Another testing method collects the sweat into a coil (macroduct technique). After 5 to 10 minutes, the gauze pads and electrodes are removed, and the skin is cleaned with water and then dried. The skin will look red in the area under the pad that contained the medicine. A dry gauze pad, paper collection pad, or special tubing is taped to the red patch of skin. This pad is covered with plastic or wax to prevent fluid loss (evaporation). The new pad will soak up the sweat for up to 30 minutes, then it is removed and placed in a sealed bottle. It is then weighed to measure how much sweat the skin produced, and it is checked to find out how much salt chemical (sodium and/or chloride) the sweat contains. After the collection pad is removed, the skin is washed and dried again. The test site may look red and continue to sweat for several hours after the test.

The sweat test usually takes 45 minutes to 1 hour. How It Feels This test does not cause pain. Some children feel a light tingling or tickling when the electric current is applied to the skin. If the gauze pads are not properly placed, the electric current may produce a burning sensation.

Risks There is very little risk of complications from this test. However, the test should always be done on an arm or leg (not the chest) to prevent the possibility of electric shock. The electric current may cause skin redness and excess sweating for a short time after the test is done. In rare cases, the current may make the skin look slightly sunburned. Results A sweat test measures the amount of salt chemicals (sodium and chloride) in sweat. Generally, chloride (sweat chloride) is measured. Results are usually available in 1 or 2 days. Normal results vary from lab to lab. Sweat chloride Normal: Less than 40 millimoles per liter (mmol/L)

Borderline: 4060 mmol/L Abnormal: More than 60 mmol/L

Many conditions can change sodium and chloride levels. Your health professional will discuss any significant abnormal results with you in relation to your symptoms and medical history. The test results do not indicate how severe the cystic fibrosis is. The test only shows if a person could have the disease. Abnormal (high) values High values: Usually mean a person has cystic fibrosis. Some people with cystic fibrosis have borderline or even normal sweat chloride levels. May be caused by other conditions. However, the sweat test is not used to diagnose these conditions, which include: o Adrenal gland problems, such as adrenal insufficiency or Addison's disease. o Hypothyroidism. o Kidney failure.

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: A baby's age. Babies younger than 4 weeks may not produce enough sweat to give reliable test results and may have lower sweat chloride levels than older babies and children. A minimum amount of sweat is needed for accurate test results regardless of the child's age. A skin rash or sore on the area of the skin where the gauze pads are attached.

Acute or severe illness. Dehydration or heavy sweating. Decreased sweating. Normal fluctuations in sodium and chloride during puberty. A decrease in the hormone aldosterone. Steroid medicines, such as fludrocortisone (Florinef).

What To Think About Usually, two sweat tests are done to confirm a diagnosis of cystic fibrosis. Younger babies may not produce enough sweat to give reliable test results and may have lower sweat chloride levels than older babies and children with cystic fibrosis. A sweat test cannot identify carriers of the cystic fibrosis gene. If your child is diagnosed with cystic fibrosis, you may wish to talk with your health professional about genetic counseling. For more information, see the topic Cystic Fibrosis Carrier Screening. Adults generally have higher salt concentrations in their sweat than children. Also, sweat test results in adults can vary widely. This is especially true in women, because the amount of salt in their sweat can vary with the phase of their menstrual cycle. Enough sweat must be collected to get accurate test results. If results of a sweat test are positive or unclear (especially in babies), a blood test may be done to detect changes in the genetic material (DNA) that causes cystic fibrosis. Blood test results are usually ready in 10 to 21 days. For more information, see the medical test Genetic Test. Sweat tests should be done at labs that are certified by the Cystic Fibrosis Foundation. These labs perform a large number of sweat tests and are skilled at sweat test techniques and interpretation.

Intravenous pyelogram (IVP)

An intravenous pyelogram (IVP) is an X-ray test that uses a special dye (contrast material) to outline the structure of the kidneys and the tubes leading away from the kidneys (ureters). IVP helps a health professional evaluate symptoms that may be related to the kidneys. An intravenous pyelogram can help reveal problems with: The structure of the kidneys Blood flow through the kidneys Urine flow from the kidneys to the bladder (for example, caused by obstruction from a kidney stone).

Upper Gastrointestinal Endoscopy


An upper gastrointestinal (UGI) endoscopy is a procedure that allows your doctor to look at the interior lining of your esophagus, your stomach, and the first part of your small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope. The tip of the endoscope is inserted through your mouth and then gently moved down your throat into the esophagus, stomach, and duodenum (upper gastrointestinal tract).

Since the entire upper gastrointestinal (GI) tract can be examined during this test, the procedure is sometimes called esophagogastroduodenoscopy (EGD). Using the endoscope, your doctor can look for ulcers, inflammation, tumors, infection, or bleeding. Tissue samples can be collected (biopsy), polyps can be removed, and bleeding can be treated through the endoscope. Endoscopy can reveal problems that do not show up on X-ray tests, and it can sometimes eliminate the need for exploratory surgery. Why It Is Done An upper gastrointestinal endoscopy may be done to: Find problems in the upper gastrointestinal (GI) tract. These problems can include: o Inflammation of the esophagus (esophagitis). o Gastroesophageal reflux disease (GERD). o A narrowing (stricture) of the esophagus. o Barrett's esophagus, a condition that increases the risk for developing esophageal cancer. o Hiatal hernia. o Ulcers. o Cancer. Find the cause of vomiting blood (hematemesis). Find the cause of symptoms, such as upper abdominal pain or bloating, difficulty in swallowing (dysphagia), vomiting, or unexplained weight loss. Find the cause of an infection. Document the healing of stomach ulcers. Look at the inside of the stomach and upper small intestine (duodenum) after surgery. Look for a blockage in the opening between the stomach and duodenum (gastric outlet obstruction).

Endoscopy may also be done to: Check for an esophageal injury in an emergency (for example, if the person has swallowed poison). Collect tissue samples (biopsy) for examination in the laboratory. Remove growths from inside the esophagus, stomach, or small intestine (gastrointestinal polyps). Treat upper gastrointestinal bleeding, including bleeding caused by engorged veins in the esophagus (esophageal varices). Remove foreign objects that have been swallowed. Look for bleeding that may be causing a decrease in the amount of oxygencarrying substance (hemoglobin) found in red blood cells (anemia).

How To Prepare Before having an upper gastrointestinal endoscopy, tell your doctor if you: Are allergic to any medicines, including anesthetics. Are taking any medicines. Have bleeding problems or take blood-thinning medicine, such as warfarin (Coumadin).

Have heart problems. Are or might be pregnant. Are diabetic and take insulin. Have had surgery or radiation treatments to your esophagus, stomach, or the upper part of your small intestine.

How To Prepare continued... You may be asked to stop taking aspirin products or iron supplements 7 to 14 days before the test. If you take blood-thinning medicines regularly, discuss with your doctor how to manage your medicine. Do not take sucralfate (Carafate) or antacids the day of the test. These medicines can interfere with your doctor's ability to view the gastrointestinal tract. If biopsy samples are taken or polyps are removed during the test, bleeding may also occur. This bleeding usually stops on its own without treatment. To reduce this risk, avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) for several days before the endoscopy. If you take blood-thinning medicine, you may be instructed to stop the medicine temporarily before the test. Do not eat or drink anything for 6 to 8 hours before the test. An empty stomach helps your doctor see your stomach clearly during the test. It also reduces your chances of vomiting. If you vomit, there is a small risk that your stomach contents could enter your lungs (aspiration). If the test is done in an emergency, a tube may be inserted through your nose or mouth to empty your stomach. Before the test, you will put on a hospital gown; if you are wearing dentures, jewelry, contact lenses, or glasses, remove them. For your own comfort, empty your bladder before the test begins. Arrange to have someone take you home after the test because you will be given a sedative before the test. How It Is Done A gastrointestinal endoscopy may be done in a doctor's office, clinic, or a hospital. An overnight stay in the hospital usually is not needed. The test is most often performed by a doctor who specializes in problems of the digestive system (gastroenterologist). The doctor may also have an assistant. Some family medicine doctors, internists, and surgeons are also trained to do endoscopy. Before the procedure, blood tests may be done to check for a low blood count or clotting problems. Your throat may be numbed with an anesthetic spray, gargle, or lozenge to relax your gag reflex and make it easier to insert the endoscope into your throat. During the test, you may receive a pain medication and a sedative through an intravenous (IV) line in your arm or hand. These medications reduce pain and will make you feel relaxed and drowsy during the test. You may not remember much about the actual test. You will be asked to lie on your left side with your head bent slightly forward. A mouth guard may be placed in your mouth to protect your teeth from the endoscope. Then the lubricated tip of the endoscope will be guided into your mouth and your doctor may gently press your tongue out of the way. You may be asked to swallow to help move the tube along. It is helpful to remember that the instrument is no thicker than many foods you swallow and will not cause problems with breathing

How It Is Done continued... Once the endoscope is in your esophagus, your head will be tilted upright; this makes it easier for the scope to slide down your esophagus. During the procedure, try not to swallow unless requested to. An assistant may remove the saliva from your mouth with a suction device, or you can allow the saliva to drain from the side of your mouth. Your doctor will slowly advance the endoscope while looking through an eyepiece or watching on a video monitor to examine the walls of your esophagus, stomach, and duodenum. Air or water may be injected through the scope to help clear a path for the scope or to clear its lens, and suction may be applied to remove air or secretions. A camera attached to the endoscope takes pictures for viewing on the monitor and stores some pictures for later study. The doctor may also insert tiny instruments (forceps, loops, swabs) through the colonoscope to collect tissue samples (biopsy) or remove growths. The biopsy test is completely painless. To make it easier for your doctor to see different parts of your upper gastrointestinal (GI) tract, you may be repositioned or have gentle pressure applied to your belly. When the examination is completed, the endoscope is slowly withdrawn. See an illustration of upper gastrointestinal endoscopy .

Upper gastrointestinal endoscopy

After the test The test usually takes 30 to 45 minutes, but it may take longer, depending upon what is found and what is done during the test. After the test, you will be observed for 1 to 2 hours until the medications wear off. If your throat was numbed before the test, you should not eat or drink until your throat is no longer numb and your gag reflex has returned to normal. When you are fully recovered, you can go home. You will not be able to drive or operate machinery for 12 hours after the test. Your doctor will tell you when you can

resume your usual diet and activities. Do not drink alcohol for 12 to 24 hours after the test. How It Feels You may notice a brief, sharp pain when the intravenous (IV) needle is placed in a vein in your arm. The local anesthetic sprayed into your throat usually tastes slightly bitter and will make your tongue and throat feel numb and swollen. Some people report that they feel as if they cannot breathe at times because of the tube in their throat, but this is a false sensation caused by the anesthetic. There is always plenty of breathing space around the tube in your mouth and throat. Remember to relax and take slow, deep breaths. During the test, you may feel very drowsy and relaxed from the sedative and pain medicines. You may have some gagging, nausea, bloating, or mild abdominal cramping as the tube is moved. If you are having pain, alert your doctor with an agreed-upon signal or a tap on the arm. Even though you won't be able to talk during the procedure, you can still communicate. How It Feels continued... The suction machine used to remove secretions may be noisy but does not cause pain. The removal of biopsy samples is also painless. You will feel groggy after the test until the medicine wears off, usually in a few hours. Many people report that they remember very little of the test because of the sedative given before and during the test. After the test, you may belch and feel bloated for a while. You may also have a tickling, dry throat; slight hoarseness; or a mild sore throat. These symptoms may last several days. Throat lozenges and warm saltwater gargles can help relieve the throat symptoms. Do not drink alcohol after the test. Risks Complications from gastrointestinal endoscopy are rare. There is a slight risk of puncturing your throat (esophagus), stomach, or upper small intestine (duodenum) and require surgery to repair. There is also a slight chance of infection after an endoscopy. Bleeding may also occur from the test or if a tissue sample (biopsy) is taken, but this usually stops on its own without treatment. If you vomit during the examination and some of the material you vomit enters your lungs, aspiration pneumonia is a possible risk. If it develops, it can be treated with antibiotics. People who have certain types of heart murmurs, artificial heart valves, or previous infections of a heart valve will need antibiotics before and after the test to prevent infection. An irregular heartbeat may occur during the test but nearly always subsides on its own without treatment. People with abnormal heart valves or an artificial heart valve may receive antibiotics before and after the procedure to prevent infection. The procedure has more risk for people with serious heart disease, older adults, and those who are frail or physically weakened. Although complications are rare, you should discuss your specific risks with your doctor. After the test After the test, call 911 or other emergency services immediately if you develop:

Chest pain. Moderate to severe difficulty breathing.

After the test, call your doctor immediately if you: Feel short of breath or dizzy. Have symptoms of infection, such as fever or chills. Vomit blood, whether it is fresh and red or is old and looks like coffee grounds.

Results An upper gastrointestinal (UGI) endoscopy is a procedure that allows your doctor to look at the interior lining of your esophagus, your stomach, and the first part of your small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope. Your doctor may be able to talk to you about some of the findings with you immediately after your upper gastrointestinal endoscopy. However, the medicines given to help relax you may impair your memory, so your doctor may wait until the medicines wear off completely. Other results are usually available in 2 to 4 days. Tests for certain infections may take several weeks. Upper gastrointestinal endoscopy Normal: The esophagus, stomach, and upper small intestine (duodenum) look normal. Stomach or duodenal ulcers or inflammation are found in the esophagus (esophagitis), stomach (gastritis), or small intestine. Bleeding, an ulcer, a tumor, a tear, or dilated veins (esophageal varices) are found in the esophagus, stomach, of duodenum. A hiatal hernia or narrowing (stricture) or widening (dilation) is found in the esophagus, stomach, or duodenum. A foreign object is found in the esophagus, stomach, or duodenum. A biopsy sample may be taken to: Find out if tumors or ulcers contain cancer cells. Identify a type of bacteria called Helicobacter pylori (H. pylori).

Abnormal:

Many conditions can change the results of an upper gastrointestinal endoscopy.Your doctor will talk with you about any abnormal results that may be related to your symptoms and medical history. What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include:

Having had another test that uses barium contrast material. An upper gastrointestinal endoscopy should not be done less than 2 days after you have an upper gastrointestinal (GI) series so your doctor can see your stomach and small intestine. Moderate to severe bleeding in the gastrointestinal tract.

What To Think About An upper gastrointestinal endoscopy is the best way to examine your esophagus, stomach, and upper small intestine (duodenum). Your doctor can take a tissue sample to test for Helicobacter pylori infection, which is believed to be the main cause of stomach or duodenal ulcers. For more information, see the medical test Helicobacter pylori Tests. Cancer can be identified or ruled out using endoscopy. Endoscopy may be done after an upper gastrointestinal series test identifies a problem. For more information, see the medical test Upper Gastrointestinal Series. Endoscopy can be safely performed on small children. Endoscopic retrograde cholangiopancreatogram (ERCP) is a test of the ducts that drain the liver, gallbladder, and pancreas. It can be done to find the cause of jaundice if your doctor thinks you may have blockage of the bile or pancreatic ducts and when other tests (such as ultrasound, liver scan, and Xray studies) are not clear. For more information, see the medical test Endoscopic Retrograde Cholangiopancreatogram (ERCP).

Perineum

The perineum is the muscle and tissue near the anus. In a woman, the perineum is between the anus and the vulva, while in a man, it is between the anus and the scrotum.

Crohn's Disease - Topic Overview


What is Crohn's disease? Crohn's disease is a lifelong inflammatory bowel disease (IBD). Parts of the digestive tract get swollen and have deep sores called ulcers. Crohns disease usually is found in the last part of the small intestine and the first part of the large intestine. But it can develop anywhere in the digestive tract, from the mouth to the anus. What causes Crohn's disease? Doctors don't know what causes Crohns disease. You may get it when the bodys immune system has an abnormal response to normal bacteria in your intestine. Other kinds of bacteria and viruses may also play a role in causing the disease. Crohns disease can run in families. Your chances of getting it are higher if a close family member has it. People of Eastern European (Ashkenazi) Jewish family background may have a higher chance of getting Crohns disease. Smoking also puts you at a higher risk for the disease. What are the symptoms? The main symptoms of Crohns disease are belly pain and diarrhea (sometimes with blood). Some people may have diarrhea 10 to 20 times a day. Losing weight without trying is another common sign. Less common symptoms include mouth sores, bowel blockages, anal tears (fissures), and openings (fistulas) between organs. Infections, hormonal changes, smoking, and stress can cause your symptoms to flare up. You may have only mild symptoms or go for long periods of time without any symptoms. A few people have ongoing, severe symptoms. Its important to be aware of signs that Crohns disease may be getting worse. Call your doctor right away if you have any of these signs: You You You You feel faint or have a fast and weak pulse. have severe belly pain. have a fever or shaking chills. are vomiting again and again.

How is Crohn's disease diagnosed? Your doctor will ask you about your symptoms and do a physical exam. You may also have X-rays and lab tests to find out if you have Crohns. Tests that may be done to diagnose Crohn's disease include: Barium X-rays of the small intestine or colon. In this test, you will drink a white liquid to coat the inside of your intestine so that the doctor can see it more clearly on an X-ray. Colonoscopy or flexible sigmoidoscopy. In these tests, the doctor uses a thin, lighted tube to look inside the colon. Biopsy. The doctor takes a sample of tissue and tests it to find out if you have Crohns or another disease, such as cancer. Stool analysis. This is a test to look for blood and signs of infection in a sample of your stool.

How is it treated? Your treatment will depend on the type of symptoms you have and how bad they are. The most common treatment for Crohns disease is medicine. Mild symptoms of Crohn's disease may be treated with over-the-counter medicines to stop diarrhea. But talk with your doctor before you take them, because they may cause side effects. You may also use prescription medicines. They help control inflammation in the intestines and keep the disease from causing symptoms. (When you don't have symptoms, you are in remission.) These medicines also help heal damaged tissue and can postpone the need for surgery. If your symptoms are severe and these medicines don't help, you may need stronger treatment. You may get medicine through a vein (IV). In rare cases, you may need surgery to remove part of the intestine. Crohn's disease often comes back after surgery. There are a few steps you can take to help yourself feel better. Take your medicine just as your doctor tells you to. Cut back on sugar. Exercise, and eat healthy meals. Don't smoke. Smoking makes Crohns disease worse. Crohns disease makes it hard for your body to absorb nutrients from food. A meal plan that focuses on high-calorie, high-protein foods can help you get the nutrients you need. Eating this way may be easier if you have regular meals plus two or three snacks each day. How do you cope with Crohn's disease? Having Crohns disease can be stressful. The disease affects every part of your life. Seek support from family and friends to help you cope. Get counseling if you need it. Many people with inflammatory bowel diseases look to alternative treatments to improve their well-being. These treatments have not been proven effective for Crohns disease, but they may help you cope. They include massage, supplements such as vitamins D and B12, and herbs like aloe and ginseng. Frequently Asked Questions Learning about Crohn's disease: What is Crohn's disease? What causes it? What are the symptoms of Crohn's disease? Who gets it? What are the types of inflammatory bowel disease?

Being diagnosed: What tests are used to diagnose Crohn's disease? What other conditions have symptoms similar to it? What happens during a medical history and physical exam? How can a colonoscopy be used to diagnose Crohn's disease? How can a stool analysis be used to diagnose it? How does a barium enema show Crohn's disease?

Getting treatment: How is Crohn's disease treated? What medicines are used to treat it? What types of surgery can be used to treat Crohn's disease? What other treatments are available?

Ongoing concerns: Can I prevent flare-ups of Crohn's disease? When should I see a doctor? What can I do at home to treat symptoms? How can I eat a healthy diet when I have Crohn's disease? How will Crohn's disease affect pregnancy?

Crohn's Disease - Health Tools


Health tools help you make wise health decisions or take action to improve your health.

Actionsets are designed to help people take an active role in managing a health condition. Caring for your ostomy Eating plan for inflammatory bowel disease

Eating plan for inflammatory bowel disease


Crohns disease and ulcerative colitis are types of inflammatory bowel disease. They cause inflammation and sores (ulcers) in the digestive tract . This can lead to symptoms such as diarrhea, belly pain, loss of appetite, fever, bloody stools, and weight loss. Often symptoms are worse after eating. If you have an inflammatory bowel disease, it may be hard to get important nutrients such as vitamins, minerals, and protein. Your intestines may not be able to take all the nutrients from the food you eat. You may lose nutrients through diarrhea. This can lead to problems such as anemia or low levels of vitamins, such as vitamin B12 and folic acid. To control their symptoms, some people eat only bland foods, like pasta, and they avoid fruits and vegetables. But you need to eat a variety of foods to get the nutrients you need for good health. This Actionset can help you learn more about how to eat so you can manage your symptoms but still get the nutrition you need. Key Points Inflammatory bowel disease can make it hard to get the nutrients you need. It is important to eat a healthy, varied diet to help you keep your weight up and stay strong.

Some foods can make symptoms worse. Avoiding these foods may help reduce your symptoms. No one diet is right for everyone with an inflammatory bowel disease. Keep a food diary to find out which foods cause problems for you. Then you can avoid those foods but choose others that supply the same nutrients. Because you may not be absorbing all the nutrients from the food you eat, you will need to eat a high-calorie, high-protein diet. This may be easier to do if you eat regular meals plus 2 or 3 snacks each day. You may need to take vitamin and mineral supplements to help you get the nutrients you need.

Crohn's Disease - Cause


The cause of Crohn's disease is unknown. Studies suggest that this and other inflammatory bowel diseases may result from an abnormal response by the body's immune system to normal intestinal bacteria.1 Disease-causing bacteria and viruses also may play a role in causing the condition. Crohn's disease can run in families, so some people may be more likely than others to develop the condition when exposed to something that triggers an immune reaction. Environmental factors may also play a role in causing the disease.

Crohn's Disease - Symptoms


The main symptoms of Crohn's disease include: Abdominal pain. The pain often is described as cramping and intermittent, and the abdomen may be sore when touched. Abdominal pain may turn to a dull, constant ache as the condition progresses. Diarrhea. Some people may have diarrhea 10 to 20 times per day. They may wake up at night and need to go to the bathroom. Crohn's disease may cause blood in stools, but not always. Loss of appetite. Fever. In severe cases, fever or other symptoms that affect the entire body may develop. A high fever may mean that you have a complication involving infection, such as an abscess. Weight loss. Ongoing symptoms, such as diarrhea, can lead to weight loss. Too few red blood cells (anemia). Some people with Crohn's disease develop anemia because of low iron levels caused by bloody stools or the intestinal inflammation itself. People with Crohn's disease also may have: Sores in the mouth. Nutritional deficiencies, such as lowered levels of vitamin B12, folic acid, iron, and fat-soluble vitamins, because the intestines may not be able to absorb nutrients from food. Bowel obstruction. Signs of disease in or around the anus. These may include: Abnormal tunnels or openings called fistulas that sometimes form between organs. These develop because Crohn's disease causes inflammation and ulcers in the deep layers of the intestinal wall. Fistulas may form between parts of the

intestine or between the intestine and another organ such as the bladder, vagina, or skin. A fistula may be the first sign of Crohn's disease. Pockets of infection (abscesses). Small tears in the anus (anal fissures). Skin tags that may resemble hemorrhoids. These are caused by inflamed skin.

Because there is some immune system involvement, you also may have symptoms and complications outside the digestive tract, such as joint pain, eye problems, a skin rash, or liver disease. Other conditions with symptoms similar to Crohn's disease include diverticulitis and an intestinal abscess. Crohn's disease is an ongoing (chronic) condition that may flare up throughout your life. The course of the disease varies greatly from one person to another. Some people may have only mild symptoms, while others may have severe symptoms or complications that, in unusual cases, may be life-threatening. Crohn's disease may be mild, moderate, severe, or not active (in remission). It may be defined by the part of the digestive tract involved, such as the rectum and anus (perianal disease) or the area where the small intestine joins the large intestine (ileocecal disease). Some people may have features of both Crohn's disease and ulcerative colitis, the other major type of inflammatory bowel disease (IBD). Crohn's disease can cause complications outside the digestive tract, such as joint pain, eye problems, a skin rash, or liver disease, suggesting a possible immune system response. Because Crohn's disease can cause inflammation in parts of the intestines that absorb nutrients from food, it can cause deficiencies in vitamin B12, folic acid, or other nutrients. The disease can increase the risk of gallstones, kidney stones, and certain uncommon forms of anemia. In long-term Crohn's disease, scar tissue may replace some of the inflamed or ulcerated intestines, forming blockages (bowel obstructions) or narrowed areas (strictures) that can prevent stool from passing through the intestines. Blockages in the intestines also can be caused by inflammation and swelling, which may improve with medicines. Sometimes blockages can only be treated with surgery. If sores break through the wall of the intestines, abnormal connections or openings (fistulas) may develop between two parts of the intestines, between the intestines and other organs (such as the bladder or vagina), or between the intestines and the skin. Rarely, this can lead to infection of the abdominal wall. Crohn's disease of the colon and rectum that has been present for 8 to 10 years or longer increases the risk of cancer. However, the risk of colorectal cancer may be higher with ulcerative colitis than with Crohn's disease. With regular screening, some cancers can be detected early and treated successfully. Most women who have Crohn's disease are able to become pregnant and usually have healthy babies. Symptoms may become worse during the first 3 months of pregnancy. Some medicines used to treat the disease can be used during pregnancy.

Crohn's Disease - What Increases Your Risk


Factors that may increase your risk of developing Crohn's disease include: Having a family history of Crohn's disease. Your risk increases if an immediate family member, such as a parent, brother, or sister, has the disease. Smoking cigarettes. Having Ashkenazi Jewish ancestry.

Factors that may cause Crohn's disease symptoms to flare up include: Medicines. Infections. Hormonal changes. Lifestyle changes, including increased stress. Smoking.

Crohn's Disease - When To Call a Doctor


Call a health professional immediately if you have been diagnosed with Crohn's disease and you have one or more of the following: Fever or shaking chills Lightheadedness, passing out, or rapid heart rate Stools that are almost always bloody Severe dehydration Severe abdominal pain or severe pain and bloating Evidence of pus draining from the area around the anus or pain and swelling in the anal area Repeated vomiting Not passing any stools or gas

If you have any of these symptoms and you have been diagnosed with Crohn's disease, your condition may have become significantly worse. Some of these symptoms also may be signs of toxic megacolon, a rare complication of Crohn's disease that requires emergency treatment. Untreated toxic megacolon can cause the colon to leak or rupture, which can be fatal. People who have Crohn's disease usually know their normal pattern of symptoms. Call your health professional if there is a change in your usual symptoms or if: Your symptoms become significantly worse than usual. You have persistent diarrhea for more than 2 weeks. You have lost weight.

Watchful Waiting Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. Watchful waiting is not appropriate when you have any of the above symptoms. If your symptoms are caused by Crohn's disease, delaying the diagnosis and treatment may make the disease worse and increase your risk of complications.

Even when the disease is not active (in remission), your health professional will want to see you regularly to check for complications, some of which can be hard to detect. It is always appropriate to call your health professional's office for advice. Who To See The following health professionals can diagnose most cases of Crohn's disease: Family medicine doctor Internist

To help you manage Crohn's disease, you will probably be referred to a gastroenterologist. To be evaluated for surgery, you may be referred to a: General surgeon. Colon and rectal surgeon.

To prepare for your appointment, see the topic Making the Most of Your Appointment

Crohn's Disease - Exams and Tests


Crohn's disease is diagnosed through a medical history and physical exam, imaging tests to look at the intestines, and laboratory tests. Crohn's disease can be difficult to diagnose. The disease may go undiagnosed for years because symptoms usually develop gradually and the same part of the intestine is not always involved. Other diseases can also have the same symptoms as Crohn's disease. But Crohn's disease tends to cause the intestine to have a cobblestone appearance, which can help doctors diagnose it. The pattern results from the repeated formation and healing of sores (ulcers) in the intestine.

The colon and rectum can be examined with flexible sigmoidoscopy or colonoscopy, in which a lighted viewing instrument is used to examine the inside of the colon. In general, colonoscopy is the preferred test because it can be used to examine the entire colon, while sigmoidoscopy reaches only the last 2 ft of the colon. Both procedures can be used to take a sample (biopsy) of intestinal tissue. Imaging tests such as barium enema, computed tomography (CT) scan, and magnetic resonance imaging (MRI) may be helpful in locating abnormal openings (fistulas). A stool analysis is often done, depending on symptoms, to look for blood, signs of bacterial infection, malabsorption, parasites, or the presence of white blood cells. This test can be used to distinguish Crohn's disease from irritable bowel syndrome (IBS), which is a less serious condition that sometimes has similar symptoms. White blood cells in stool indicate inflammation and possibly infection and are also a sign of Crohn's disease; their presence means you do not have IBS. Stool analysis may be done during a flare-up if there is concern that new symptoms are caused by another problem. You can collect a stool sample, or the doctor may take a sample during sigmoidoscopy or colonoscopy. Other exams and tests that may also be used to evaluate Crohn's disease include:

Abdominal X-ray, which provides a picture of possible obstruction in the abdomen. Upper gastrointestinal (UGI) series with small-bowel follow-through to examine all of the small intestine. In this test the doctor examines the upper and part of the middle portions of the digestive tract. After you swallow a "shake" made of a white liquid (barium) and water, continuous X-rays (fluoroscopy) are taken to track the movement of the barium through the esophagus, stomach, and the small intestine. A video monitor displays the images. Upper gastrointestinal endoscopy, which allows your doctor to look at the interior lining of your esophagus, stomach, and duodenum with a thin, flexible imaging instrument called an endoscope. Barium enema, a test that allows the doctor to examine the large intestine (colon). For a barium enema, a white liquid (barium) is inserted through the rectum into the colon and large intestine. The barium outlines the inside of the colon so that it can be more clearly seen on an X-ray. Computed tomography (CT) scan, which uses X-rays to produce detailed pictures of structures inside the body. Magnetic resonance imaging (MRI), which uses a magnetic field and pulses of radio wave energy to provide pictures of organs and structures inside the body. Video capsule endoscopy (VCE), in which you swallow a tiny camera that records its trip through your digestive tract by sending images to a recording device that you wear on a belt. Your doctor later examines the images by downloading them from the recording device. The camera passes out of your body in stool within 10 to 48 hours. VCE is particularly useful in examining the small intestine, which is difficult to see with other endoscopic tests. Small bowel enteroscopy, which uses a longer, lighted flexible tube with a tiny camera that sends pictures of the small intestine to a video screen. This helps the doctor look at the small intestine. The doctor can also take small samples (biopsy) of the tissue.

Standard blood tests and urine tests may be used to check for anemia, inflammation, or malnutrition. Depending on the symptoms, an erythrocyte sedimentation rate (ESR, or sed rate) or C-reactive protein (CRP) blood test may be done to look for infection or inflammation. C-reactive protein is a substance produced by the liver as a result of inflammation in the body. A biopsy of a sample of tissue from the lining of the intestine, collected during sigmoidoscopy or colonoscopy, can be used to confirm the diagnosis of Crohn's disease. A biopsy also may be done to find out whether a tumor is present. Multiple biopsies for cancer screening are often done in people who have had Crohn's disease of the colon or rectum for 8 to 10 years or more. Bowel biopsies are painless (other than the potential discomfort of the scope procedure) and remove only a tiny piece of tissue. Early Detection No screening test exists for Crohn's disease at this time. However, if you have had Crohn's disease affecting the colon or rectum for 8 to 10 years or longer, discuss with your doctor whether you need screening for colon cancer. Screening usually involves taking multiple-tissue biopsies during routine colonoscopy.

Crohn's Disease - Treatment Overview


The main treatment for Crohn's disease is medicine to stop the inflammation in the intestine and medicine to prevent flare-ups and keep you in remission. A few people have severe, persistent symptoms or complications that may require a stronger medicine, a combination of medicines, or surgery. The type of symptoms you have and how bad they are will determine the treatment you need. Initial treatment Your doctor will most likely start with the traditional first-line treatment for Crohn's disease. He or she will then add or change medicines if you are not getting better. Mild symptoms may respond to an antidiarrheal medicine such as loperamide (Imodium A-D, for example), which slows or stops the painful spasms in your intestines that cause symptoms. For mild to moderate symptoms, your doctor will probably have you take: Aminosalicylates (such as sulfasalazine or mesalamine). These medicines help manage symptoms for many people who have Crohn's disease. Antibiotics such as ciprofloxacin and metronidazole may be tried if aminosalicylates are not helping your symptoms. These medicines work especially well for disease in the colon. Antibiotics are also used to treat fistulas, which are abnormal connections or openings between two organs or parts of the body. But 50% of fistulas come back when antibiotics are stopped.2 Corticosteroids (such as budesonide or prednisone) may be given by mouth for a few weeks or months to control inflammation. But corticosteroids have serious side effects, such as high blood pressure, osteoporosis, and increased risk of infection. o Budesonide causes remission in mild or moderate Crohn's disease of the ileum and the right colon. It does not work as well as prednisone or other corticosteroids. But it also does not have as many side effects as other corticosteroids. The long-term side effects are not well known, so your doctor will probably not have you take it for a long time. o Prednisone may help if budesonide does not. Medicines that suppress the immune system (called immunomodulator medicines), such as azathioprine (AZA), 6-mercaptopurine (6-MP), or methotrexate. You may take these if the medicines listed above do not work, if your symptoms come back when you stop taking corticosteroids, or if your symptoms come back often, even with treatment.

If you have tried all the medicines listed above and none of them have worked, your doctor may give you a tumor necrosis factor (TNF) antagonist such as infliximab (Remicade). This drug may work for people who have not had any success with other medicines for Crohn's disease. Infliximab is also used to treat fistulas if antibiotics do not heal them. Another TNF antagonist that may be used to treat Crohn's disease is adalimumab (Humira). It may work for people for whom infliximab has stopped working and for people who have a bad reaction to infliximab. Severe symptoms may be treated with corticosteroids given through a vein (intravenous, IV) or TNF antagonists. With severe symptoms, the first step is to control the disease. When your symptoms are gone, your doctor will probably have

you start taking one of the medicines listed above to keep you symptom-free (in remission). Ongoing treatment Ongoing treatment is designed to find a medicine or combination of medicines that keeps Crohn's disease in remission. If aminosalicylates (such as sulfasalazine or mesalamine) or immune system suppressors (such as azathioprine [AZA], 6-mercaptopurine [6-MP], or methotrexate) keep your disease in remission, you will continue taking the medicines. Your health professional will want to see you about every 6 months if your condition is stable or more frequently if you have flare-ups. You may have laboratory tests every 2 to 3 months. Corticosteroids (such as budesonide, hydrocortisone, or prednisone) may be given to stop inflammation if you have flare-ups of symptoms. If you need to take corticosteroids for an extended time, you also may receive calcium, vitamin D, and prescription medicine to prevent osteoporosis. Tumor necrosis factor (TNF) antagonists such as infliximab (Remicade) and adalimumab (Humira) are also used as maintenance medicines. Treatment if the condition gets worse If you have severe Crohn's disease, you will most likely be given infliximab (Remicade). This drug may be prescribed if Crohn's disease does not get better with medicines that suppress the immune system (such as azathioprine [AZA], 6mercaptopurine [6-MP], or methotrexate). Infliximab may also be given if your symptoms come back when you try to stop taking corticosteroids. Infliximab is given in a vein (intravenous, IV). If infliximab does not work for you, or if you cannot take it because of a serious side effect, you may be given adalimumab (Humira). Adalimumab is given as a shot under the skin (subcutaneous). If you have a very bad flare-up of Crohn's disease, you will most likely need IV corticosteroids (like hydrocortisone) to get the disease under control. Some severe cases of Crohn's disease need to be treated in the hospital where you would receive supplemental nutrition through a tube placed in your nose and down into the stomach (enteral nutrition). In other cases, the bowel may need to rest, and you will be fed liquid nutrients in a vein (total parenteral nutrition, TPN). Supplemental nutrition may be necessary if you are malnourished because of severe Crohn's disease in the small intestine. Nutritional support is especially important for children who are not growing normally because of severe disease. Surgery may be needed if no medicine is effective, you have serious side effects from medicine, your symptoms can be controlled only with long-term use of corticosteroids, or you develop complications such as fistulas, abscesses, or bowel obstructions. Surgery involves removing the affected portion of the intestines, preserving as much of the intestines as possible to maintain normal function. Unfortunately, Crohn's disease tends to return to other areas of the intestines after surgery.

Crohn's Disease - Prevention


Crohn's disease cannot be prevented because the cause is unknown. However, you can take steps to reduce the severity of the disease. Medicines taken regularly may reduce sudden (acute) attacks and keep the disease in remission (a period without symptoms). Most experts recommend acetaminophen (Tylenol, for example) for pain relief rather than nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. NSAIDs have been linked to flare-ups.3 Do not smoke. Smoking makes Crohn's disease worse. Cut down on the amount of sugar and processed foods you eat, such as packaged sweets and snacks. Eat a healthy diet. Never use antibiotics unless they have been prescribed for you by a doctor. Get regular exercise.

Crohn's Disease - Home Treatment


If Crohn's disease does not cause symptoms, no treatment is needed. Mild symptoms may respond to antidiarrheal medicines or changes in diet and nutrition. For more information about making good food choices, see: Eating plan for inflammatory bowel disease. Generally, doctors recommend that you do not use nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen. Studies have linked these pain relievers with flare-ups of Crohn's disease.3 However, some people may be more likely to have flare-ups from NSAIDs than others. Talk to your doctor about whether to avoid these medicines. If you have had or are planning to have surgery that will create an opening from the intestines to the outside of the body through which stool passes (ostomy), you may feel self-conscious or embarrassed. After a period of adjustment, most people are able to resume all of their usual activities. In fact, life may be better than it was before surgery because you may no longer suffer painful symptoms. Support groups are available for people with ostomies. Caring for your ostomy Children who have Crohn's disease may feel self-conscious if they do not grow as fast as other children their age. Encourage your child to take medicine as prescribed. Offer help with the treatment so that your child can feel better, start growing again, and lead a more normal life. Children tend to have a harder time managing the disease than adults, so your support is especially important.

Crohn's Disease - Medications


Medicines usually are the treatment of choice for Crohn's disease. They can control or prevent inflammation in the intestines and help: Relieve symptoms. Promote healing of damaged tissues. Put the disease into remission and keep it from flaring up again. Postpone the need for surgery.

Medication Choices The choice of medicine usually depends on the severity of the disease, the part of the intestines that is affected, and whether complications are present. Treatment of mild to moderate Crohn's disease often begins with aminosalicylates (such as sulfasalazine or mesalamine), which help prevent inflammation. Antibiotics (ciprofloxacin or metronidazole) will probably be tried if aminosalicylates don't help your symptoms. Antibiotics are also useful for some complications of Crohn's disease and are used to treat fistulas. Corticosteroids may be added if symptoms continue. Corticosteroids usually stop symptoms and put the disease in remission. But they are not used as long-term treatment to keep symptoms from coming back. Stronger treatment with medicines that suppress the immune system (such as azathioprine [AZA], 6-mercaptopurine [6-MP], and methotrexate), cyclosporine, and intravenous (IV) corticosteroids may be needed for severe cases. Additional medicines, such as tumor necrosis factor (TNF) antagonists, may be used for people who develop abnormal connections between the intestines and other organs (fistulas) or who have severe Crohn's disease that does not respond to other medicines. These medicines can be used to keep symptoms from coming back.

Other medicines that suppress the immune system are being studied for Crohn's disease. These include CDP870, interleukins 10, 11, and 12, tacrolimus, mycophenolate mofetil, natalizumab, and thalidomide. Natalizumab (Tysabri), which is approved for treating multiple sclerosis, has been shown to have some benefit in treating Crohn's disease.2 Natalizumab is very tightly controlled because of the risk of developing progressive multifocal leukoencephalopathy, a neurological disease. What To Think About Most of these medicines also can be used in children. Infliximab is approved by the U.S. Food and Drug Administration (FDA) for use in children. If you are pregnant, talk to your doctor about which medicines might be okay to take for Crohn's disease. Sometimes, severe Crohn's disease can harm your baby more than the medicines you are taking to keep it under control. Some medicines, though, should never be taken when you are pregnant. Your doctor can tell you which medicines are okay for you while you are pregnant and nursing.

Crohn's Disease - Surgery


Surgery is rarely done for Crohn's disease and it is not a cure. When surgery is needed, as little of the intestines as possible is removed to preserve normal function. The disease tends to return in areas that were previously not affected, and you may need surgery again. Surgery may be needed for Crohn's disease if no medicine can control your symptoms, you have serious side effects from medicines, your symptoms can be controlled only with long-term use of corticosteroids, or you develop complications such as fistulas, abscesses, or bowel obstructions. Surgery may be needed when you have: Bowel blockage (obstruction). Abscesses or tears (fissures) in the anal area or when abnormal connections (fistulas) form between two parts of the intestine or between the intestine and other internal organs. Holes (perforations) in the large intestine. Cancer or precancerous tissue. Severe disease that does not respond to other treatment. Severe bleeding that requires ongoing blood transfusions.

Surgery Choices Surgery is not usually done for Crohn's disease. If you do have surgery, it will most likely be one of the following: Resection: The diseased portion of the intestines is removed, and the healthy ends of the intestine are reattached. Resection surgery does not cure Crohn's disease, which often comes back near the site of surgery. Proctocolectomy and ileostomy: The surgeon removes the large intestine and rectum , leaving the lower end of the small intestine (the ileum). The anus is sewn closed, and a small opening called a stoma is made in the skin of the lower abdomen. The ileum is connected to the stoma, creating an opening to the outside of the body, where stool empties into a small plastic pouch called an ostomy bag that is applied to the skin around the stoma. Strictureplasty: The surgeon makes a lengthwise cut in the intestine and then sews the opening together in the opposite direction. This makes the intestine wider and helps with obstruction of the bowels. This is sometimes done at the same time as resection, or when a person has had resection in the past. Strictureplasty is used when the doctor is trying to save as much of the intestines as possible.

Another procedure that may be done is balloon dilation. This is not a surgery. The doctor runs an endoscope through your intestines from your anus. The endoscope is a long, thin tube that has a video camera on the end. Next, the doctor uses the endoscope to thread an uninflated balloon across the stricture (the narrowed part of the intestine). When the balloon is inflated, it makes that part of the intestine wider. The balloon is deflated and then removed. Balloon dilation is a new technique and not as much is known about its long-term success compared to the surgical procedures listed above. Balloon dilation might be done if you want to put off a more complicated surgery for a while or if you have had surgery before and the doctor wants to save as much of the intestines as possible.

What To Think About These surgeries can be done on children. Surgery can improve a child's well-being and quality of life and restore normal growth and sexual development. In rare cases, intestinal transplant is used to treat Crohn's disease. In this complex procedure, the small intestine is removed and replaced with the small intestine of a person who has recently died and donated his or her organs. In very rare cases, when the risk of other surgery is high, bypass surgery may be done to preserve the bowel. In this procedure, the intestine is cut above the diseased area and reconnected to a healthy section below the diseased area. The diseased part of the intestine remains but is no longer used. This surgery is not done often because the diseased loop remains and may cause problems later.

Crohn's Disease - Other Treatment


Some people who have Crohn's disease need additional nutrition because severe disease prevents their small intestine from absorbing nutrients. Supplemental liquid feedings may be done through a tube placed in the nose and down into the stomach (enteral nutrition) or through a vein (total parenteral nutrition, or TPN). Supplemental feeding may be needed when: Crohn's disease is not controlled with standard treatment. Short bowel syndrome occurs. This happens when so much of the small intestine has been surgically removed or is affected by the disease that you cannot properly digest food and absorb enough nutrients. Bowel blockage occurs.

Nutritional therapy may restore good nutrition to children who are growing more slowly than normal. It also can build strength if you need surgery or have been weakened because of severe diarrhea and poor nutrition. Total parenteral nutrition allows the intestines to rest and heal. It may relieve an acute attack and allow surgery to be delayed or avoided. However, it is common for symptoms to return when TPN is stopped and a you go back to a regular diet. TPN does not change the long-term outcome of Crohn's disease. Counseling for Crohn's disease Crohn's disease can affect every aspect of your life. It may make you feel isolated or depressed. But you can take steps to improve your outlook and coping skills. You may want to seek professional counseling and social support from family, friends, or clergy. Research has shown that strong social support can reduce stress and disease activity.4

Other Treatment Choices Nutritional supplements Enteral nutrition or total parenteral nutrition (TPN) provides liquid nutrition, which is more easily digested, through either a tube inserted through the nose and into the stomach or a needle inserted into a vein.

Complementary medicine Many people with inflammatory bowel disease consider nontraditional or complementary medicine in addition to prescription medicines. They may turn to these alternatives because there is no cure for Crohn's disease. People may also use complementary medicine to help in coping with: The difficult side effects from standard medicines. The emotional strain of dealing with a chronic illness. The negative impact of severe disease on daily life.

These therapies have not been proven effective for Crohn's disease, but they may improve your overall well-being. The various complementary therapies include: Special diets or nutritional supplements, such as probiotics, evening primrose, and fish oils. Vitamin supplements, such as vitamins D and B12. Herbs, such as aloe and ginseng. Massage. Stimulation of the feet, hands, and ears to try to affect parts of the body (reflexology).

Early studies of fatty acids found in oily fish such as salmon and tuna show that they may help relieve the symptoms of Crohn's disease and ulcerative colitis.3 However, they are not yet recommended. What To Think About Nutritional supplements can help people receive enough essential nutrients, but they are expensive. TPN can cause metabolic imbalances. It also can raise the risk of a bloodstream infection from the catheter in the vein, which is needed to give TPN. Long-term use of TPN may raise the risk of liver problems or liver failure.

Complications of Crohn's disease outside the digestive tract

Sometimes complications of Crohn's disease can develop outside the digestive tract in other parts of the body (systemic symptoms), including the eyes, liver, blood, and bones. These systemic symptoms suggest that the immune system is involved in Crohn's disease. Complications can include:1 Joint problems, which occur in 5% to 20% of people with Crohn's disease. Some people develop colitis-related arthritis, which may resemble rheumatoid arthritis. Eye problems, which happen in up to 11% of people with Crohn's disease. These can include ulcers on the cornea, inflammation of the iris and blood vessels (uveitis), and inflammation of the white part of the eyes (sclera). Skin conditions, which happen in about 10% to 20% of people. Examples include mouth ulcers and pyoderma gangrenosum, which is an eruption of painful, spreading ulcers that usually occur on the legs. The ulcers may be blue in the center with red edges. Mouth ulcers are more common than pyoderma gangrenosum, which is fairly rare. Disorders of the liver and gallbladder, which affect 10% to 35% of people. These can include gallstones, cirrhosis of the liver, bile duct inflammation and scarring (sclerosing cholangitis) or, rarely, bile duct cancer. Growth problems in children. Affected children may not grow as quickly or as tall as their peers. Children with Crohn's disease need attention to their diet to ensure that they get enough nutrients. Problems with blood clots in the legs or other areas of the body. Low bone mass. This happens in 3% to 30% of people with Crohn's disease. The risk is greater for people who take corticosteroid medicines. It can lead to broken bones and, later, osteoporosis. More than half of people who take steroids for the long term get osteoporosis. Kidney stones.

Crohn's Disease - Other Places To Get Help


Organizations American College of Gastroenterology P.O. Box 342260 Bethesda, MD 20827-2260 Phone: Web Address: (301) 263-9000 www.acg.gi.org

The American College of Gastroenterology is an organization of digestive disease specialists. The Web site contains information about common gastrointestinal problems. Crohn's and Colitis Foundation of America (CCFA), Inc., National Headquarters 386 Park Avenue South, 17th Floor New York, NY 10016-8804 Phone: Fax: E-mail: Web Address: 1-800-932-2423 (212) 685-3440 (212) 779-4098 info@ccfa.org http://www.ccfa.org

Crohn's and Colitis Foundation of America (CCFA) is a nonprofit, voluntary organization dedicated to finding the cure for Crohn's disease and ulcerative colitis. This organization sponsors basic and clinical research, offers educational programs for patients and health professionals, and provides supportive services. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) National Institutes of Health 9000 Rockville Pike Bethesda, MD 20892-2560 Phone: Web Address: 1-800-860-8747 (301) 496-3583 www.niddk.nih.gov

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) provides information and conducts research on a wide variety of diseases as well as issues such as weight control and nutrition.

Topic Overview
Is this topic for you? Ulcerative colitis and Crohn's disease are the most common types of inflammatory bowel disease. Ulcerative colitis affects only the colon and rectum. Crohns can affect any part of the digestive tract. To learn more about Crohns disease, see the topic Crohns Disease. What is ulcerative colitis? Ulcerative colitis is a disease that causes inflammation and sores (ulcers) in the lining of the large intestine, or colon. It usually affects the lower section (sigmoid colon) and the rectum. But it can affect the entire colon. In general, the more of the colon thats affected, the worse the symptoms will be. See a picture of the colon .

Ulcerative colitis can affect people of any age, but most people who have it are diagnosed before the age of 30. What causes ulcerative colitis? Experts are not sure what causes ulcerative colitis. They think it might be caused by the immune system overreacting to normal bacteria in the digestive tract. Or other kinds of bacteria and viruses may cause the disease. Ulcerative colitis is not caused by stress, as people once thought. But if you have ulcerative colitis, stress can make it worse. You are more likely to get ulcerative colitis if other people in your family have it. What are the symptoms? The main symptoms are: Belly pain or cramps. Bloody diarrhea or an urgent need to have a bowel movement. Bleeding from the rectum.

Some people also may have a fever, may not feel hungry, and may lose weight. In severe cases, people may have diarrhea 10 to 20 times a day. Ulcerative colitis can also cause other problems, such as joint pain, eye problems, or liver disease. But these symptoms are more common in people who have Crohns disease. In most people, the symptoms come and go. Some people go for months or years without symptoms (remission). Then they will have a flare-up. About 5 to 10 out of 100 people with ulcerative colitis have symptoms all the time.1 Ulcerative colitis sometimes leads to more serious problems. It can cause scarring of the bile duct. This can lead to liver damage. In rare cases, severe disease causes the colon to swell to many times its normal size (toxic megacolon). This can be deadly and needs emergency treatment. People who have ulcerative colitis for 8 years or longer have a greater chance of getting colon cancer.2 Talk to your doctor about your need for cancer screening. Screening tests help find cancer early, when it is easier to treat.

How is ulcerative colitis diagnosed? To diagnose ulcerative colitis, doctors ask about the symptoms, do a physical exam, and do a number of tests. Testing can help the doctor rule out other problems that can cause similar symptoms, such as Crohns disease, irritable bowel syndrome, or diverticulitis. Tests that may be done include: A colonoscopy. In this test, a doctor uses a thin, lighted tool to look at the inside of your entire colon. At the same time, the doctor may take a sample (biopsy) of the lining of the colon. A barium enema X-ray or an X-ray of your belly to show pictures of the colon. Blood tests, which are done to look for infection or inflammation. Stool sample testing to look for blood, infection, and white blood cells.

How is it treated? Ulcerative colitis affects everyone differently. Your doctor will help you find treatments that reduce your symptoms and help you avoid new flare-ups. If your symptoms are mild, you may only need to use over-the-counter medicines for diarrhea (such as Imodium A-D). Talk to your doctor before you take these medicines. Doctors often prescribe medicines to reduce inflammation, such as: Steroid medicines. These can help reduce or stop symptoms. They are only used for short periods because they can cause side effects, such as bone thinning (osteoporosis). Aminosalicylates. After your symptoms are under control, these medicines may help prevent flare-ups. Medicines that control the immune system (immunomodulators). You may need these if your disease is severe and aminosalicylates don't keep it from flaring up.

Some people find that certain foods make their symptoms worse. If this happens to you, it makes sense to avoid those foods. But be sure to eat a healthy, varied diet to keep your weight up and stay strong. If you have severe symptoms and medicines don't help, you may need surgery to remove part or all of your colon. Removing the entire colon cures ulcerative colitis. It also prevents colon cancer. But it does have some serious risks. Still, most people who have surgery are glad they did.3, 4 How will ulcerative colitis affect your life? Ulcerative colitis can be hard to live with. During a flare-up it may seem like you are always running to the bathroom. This can be embarrassing and can take a toll on how you feel about yourself. Not knowing when the disease will strike next can be stressful. Stress may actually make the problem worse. If you are having a hard time, seek support from family, friends, or a counselor. Or look for an ulcerative colitis support group. It can be a big help to talk to others who are coping with this disease.

Frequently Asked Questions What is ulcerative colitis? What causes it? How severe can it be? What are the symptoms? What are the types of inflammatory bowel disease? Who is affected by ulcerative colitis? What tests are used to diagnose ulcerative colitis? What happens during a medical history and physical exam? What other conditions have symptoms similar to ulcerative colitis? How does a colonoscopy help diagnose it? How does a stool analysis help diagnose it? How does a barium enema X-ray help diagnose it? How is ulcerative colitis treated? What medicines are used? What types of surgery are used? Should I have surgery to cure ulcerative colitis? Are there other treatments? Can I prevent flare-ups of inflammatory bowel disease? When should I see a doctor? What can I do at home to treat symptoms? How can I eat a healthy diet when I have ulcerative colitis?

Symptoms
The symptoms of ulcerative colitis may include: Diarrhea or rectal urgency. Some people may have diarrhea 10 to 20 times per day. The urge to go to the bathroom may wake you up at night. Rectal bleeding. Ulcerative colitis usually causes bloody diarrhea and mucus. You also may have rectal pain and an urgent need to empty your bowels. Abdominal pain, often described as cramping. Your abdomen may be sore when touched. Constipation. This symptom may develop depending on what part of the colon is affected. Constipation is much less common than diarrhea. Loss of appetite. Fever. In severe cases, fever or other symptoms that affect the entire body may develop. Weight loss. Ongoing (chronic) symptoms, such as diarrhea, can lead to weight loss. Too few red blood cells (anemia). Some people develop anemia because of low iron levels caused by bloody stools or intestinal inflammation.

You also may develop symptoms and complications outside the digestive tract, such as joint pain, eye problems, skin rash, or liver disease. However, some of these problems are generally more common in Crohn's disease, the other major inflammatory bowel disease.

Other conditions with symptoms similar to ulcerative colitis include Crohn's disease, diverticulitis, irritable bowel syndrome (IBS), and colon cancer.

When To Call a Doctor


Call a doctor immediately if you have been diagnosed with ulcerative colitis and you have any of the following: Fever over 101 F or shaking chills Lightheadedness, passing out, or rapid heart rate Stools that are almost always bloody Severe dehydration Severe abdominal pain with or without bloating Pus draining from the area around the anus or pain and swelling in the anal area Repeated vomiting Not passing any stools or gas

If you have any of these symptoms and you have been diagnosed with ulcerative colitis, your disease may have gotten significantly worse. Some of these symptoms also may be signs of toxic megacolon, a condition in which the colon swells to many times its normal size. Toxic megacolon requires emergency treatment. Untreated toxic megacolon can cause the colon to leak or rupture, which can be fatal. People who have ulcerative colitis usually know their normal pattern of symptoms. Call your doctor if there is a change in your usual symptoms or if: Your symptoms become significantly worse than usual. You have persistent diarrhea for more than 2 weeks. You have lost weight.

Watchful Waiting Watchful waiting is not appropriate when you have any of the above symptoms. If your symptoms are caused by ulcerative colitis, delaying the diagnosis and treatment may make the disease worse and increase your risk of complications. Even when the disease is in remission, your doctor will want to see you regularly to check for complications, some of which can be hard to detect. It is always appropriate to call your doctor's office for advice. Who To See Health professionals who can diagnose ulcerative colitis include: Family medicine doctor. Internist. Gastroenterologist.

For the treatment and management of ulcerative colitis, you are likely to be referred to a gastroenterologist. To be evaluated for surgery, you may be referred to a: General surgeon. Colon and rectal surgeon.

Diagnosis & Tests The diagnosis of ulcerative colitis is suggested by the symptoms, yet other diagnostic tests help determine and confirm this disease. Read more. Diagnosis Exam and Tests Here are the exams and tests doctors use to diagnose and evaluate ulcerative colitis. Treatment & Care Medications and surgery help control ulcerative colitis. Patients typically experience relapse and remission; there is no cure. Treatment Treatment Overview Treatment for ulcerative colitis depends on the severity of the disease. It usually includes medications to control symptoms, along with changes in diet. Home Treatment If your symptoms are mild, anti-diarrheal medications and changes in diet may help. Medications Medications are usually the treatment of choice for ulcerative colitis. Surgery In some situations, people may need surgery for ulcerative colitis. Other Treatment Most alternative or complementary treatments for ulcerative colitis have not been proven to work. Should I have surgery to cure ulcerative colitis? Here are factors to consider when deciding whether to have surgery for ulcerative colitis. Living & Managing Ulcerative colitis can be controlled, but it's important to follow your doctor's advice. Living & Coping Caring for Your Ostomy Follow these tips for proper care for your ostomy Support & Resources To learn more about ulcerative colitis -- and to find support groups -- these resources can help. Finding Help Other Places to Get Help Here's where to find more information about ulcerative colitis. Resources References References for articles on ulcerative colitis used in this guide.

Credits Credits for articles on ulcerative colitis used in this guide. Health Tools This information can help you take an active role in managing and treating ulcerative colitis.

Inflammatory bowel disease (IBD)

Inflammatory bowel disease (IBD) is a condition that causes ongoing inflammation of the intestines. The condition can affect only the large intestine (ulcerative colitis) or any part of the entire digestive tract, from the mouth to the anus (Crohn's disease). Symptoms of inflammatory bowel disease may include abdominal pain, frequent diarrhea that may contain blood or pus, fever, chills, weight loss, and fatigue. The condition may be mild or severe. The inflammation can also affect other parts of the body, such as the eyes or joints, and may cause a form of arthritis. Inflammatory bowel disease may recur many times in a person's life. It is treated with medications and sometimes with diet changes. If the disease is in remission (not causing symptoms), treatment may not be needed, although medications may help keep the disease in remission. A severe attack may require that the person be hospitalized for treatment. In some cases, surgery may be needed.

Immune system

The immune system is the body's natural defense system that helps fight infections. The immune system is made up of antibodies, white blood cells, and other chemicals and proteins that attack and destroy substances such as bacteria and viruses that they recognize as foreign and different from the body's normal healthy tissues. The immune system is also responsible for allergic reactions and allergies, which may occur when the immune system incorrectly identifies a substance (allergen), such as pollen, mold, chemicals, plants, and medications, as harmful. Sometimes the immune system also mistakenly attacks the body's own cells, which is known as an autoimmune disease.

Anal fissure

An anal fissure is a narrow tear that extends from the muscles that control the anus (anal sphincter) up into the anal canal. These tears usually develop when anal tissue is damaged during a hard bowel movement or when higher-than-normal tension develops in the anal sphincters. Symptoms of an anal fissure include a sharp, stinging, or burning pain during a bowel movement. The pain, which can be severe, may last a few hours. You may also notice spots of bright red blood on toilet tissue. This blood is separate from the stool. Minor anal fissures can often be helped to heal by drinking more fluids, eating a high-fiber diet, allowing enough time for a bowel movement, and using stool softeners.

Fistula

A fistula is an abnormal connection or opening between two organs or parts of the body that are not normally connected, such as between two parts of the intestine.

A fistula may be present at birth or may develop as a complication of an infection or a disease, such as Crohn's disease. A fistula may close on its own or may require surgery to repair it.

Colonoscopy

Colonoscopy is the inspection of the entire large intestine (colon) using a long, flexible, lighted viewing scope (colonoscope), which is usually linked to a video monitor similar to a TV screen. A colonoscopy may be done to screen for cancer or to investigate symptoms, such as bleeding. Colonoscopy is done in the hospital or a doctor's office that has the necessary equipment. Preparation for the test includes emptying the bowels ahead of time using a laxative or enema. The person undergoing colonoscopy is given medication to relieve pain and to make him or her drowsy. The test usually takes 30 to 45 minutes, but it may take longer, depending upon what is found and what is done during the test. A health professional will collect a tissue sample (biopsy) from any abnormal area. The tissue is then analyzed by a pathologist.

Biopsy

A biopsy is a sample of tissue collected from an organ or other part of the body. A biopsy can be done by cutting or scraping a small piece of the tissue or by using a needle and syringe to remove a sample, which is then examined for abnormalities, such as cancer, by a doctor trained to look at tissue samples (pathologist).

Remission

Remission refers to periods of time when a person with a long-lasting illness does not have symptoms. During a remission, a person returns to his or her usual state of health.

Complementary medicine

Complementary medicine is any treatment that is outside the traditional medicine or practice of a person's primary health system. A treatment that is complementary in one culture may be traditional in another; for example, acupuncture, although traditional in China, is considered alternative or complementary in the United States. A central concept of many types of complementary medicine is to give thought and care to the whole person (holistic) rather than providing treatment for a specific disease or symptom. This holistic view and the emphasis on maintaining good health may be appealing for those with chronic illness or for those who want to improve their quality of life through lifestyle changes. The use of complementary medicine in the U.S. is on the rise. People often seek out complementary therapies for long-term (chronic) conditions that have not been successfully treated with conventional medicine as well as to maintain and improve wellness and quality of life.

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of actions to better control the condition's effect on you and to prevent long-term problems. Actionsets: Provide action-oriented tools and information that you can use in day-to-day management of your health conditions. Contain information that will help you better understand the effect of the actions you take. Include interactive quizzes that allow you to measure your knowledge.

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Medical information or key concepts related to the action The purpose of the action

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Crohn's disease

Crohn's disease is a form of inflammatory bowel disease that causes inflammation and ulcers that may affect the deepest layers of the lining of the digestive tract. It can also cause abnormal openings or connections (fistulas) in the diseased intestine. Crohn's disease is different from ulcerative colitis in that it can affect any part of the digestive tract. Symptoms of Crohn's disease include episodes of diarrhea, abdominal pain, fever, nausea, loss of appetite, and weight loss. People with Crohn's disease may sometimes need to be hospitalized for treatment of their symptoms.

Treatment depends on the severity of the attacks and the person's age. It may include medications and, sometimes, surgery for serious cases.

Abscess

An abscess is a pocket of pus that forms at the site of infected tissue. An abscess can form on the skin or on tissues within the body and cause pain, swelling, and tenderness. Bacteria are a common cause of the infections that form abscesses. Depending on the size and location of the abscess, your health professional may treat the abscess by: Using a needle to drain it. Cutting open the abscess to remove the pus and infectious material. Prescribing antibiotics (pills or a shot). This may be adequate treatment if the abscess is small and treatment is not delayed.

Anemia

Anemia is a decrease in the amount of oxygen-carrying substance (hemoglobin) found in red blood cells. Anemia causes weakness, pale skin, and general tiredness (fatigue). Anemia can be caused by blood loss or bleeding, an increase in the destruction of red blood cells, or a decrease in the production of red blood cells. Types of anemia include iron deficiency anemia, folic acid deficiency anemia, and vitamin B12 deficiency anemia, among others. Each type of anemia is treated differently.

Anal fistula and Crohn's disease

Crohn's disease may cause sores, or ulcers, that tunnel through the intestine and into the surrounding tissue, often around the anus and rectum. These abnormal tunnels, called fistulas, are a common complication of Crohn's disease and may become infected. Crohn's disease can also cause anal fissures, which are narrow tears that extend from the muscles that control the anus (anal sphincters) up into the anal canal. An anal fistula can often be treated with medications, though sometimes surgery to repair the fistula may be necessary. Conservative treatment, including antibiotics and medications to reduce pain and inflammation, is usually tried before surgery. Surgery for an anal fistula, which is usually done only in cases of complications such as an abscess, sometimes results in persistent nonhealing. Anyone with an unusual anal fistula that does not respond to conservative treatment should be examined for Crohn's disease, since a fistula is often the first sign of Crohn's disease. An examination may include anoscopy or sigmoidoscopy, procedures that allow a health professional to view the lower rectum and lower large intestine through a viewing scope. Complete evaluation may require sedation because examination of the area can cause discomfort.

Diverticulitis

Diverticulitis is a condition in which pouches (diverticula) that form in the wall of the large intestine (colon) become inflamed or infected. Symptoms can include pain, fever, and other signs of infection and may last from a few hours to several days. Diverticulitis is usually treated with a high-fiber diet, antibiotics for infection, and pain relievers. Hospitalization or even surgery to remove the diseased part of the

colon may be necessary if complications such as an abscess or peritonitis develop or if repeated attacks are not helped by other treatment.

Crohn's disease

Crohn's disease can affect any part of the digestive tract (which goes from the mouth to the anus). Most common is Crohn's disease that affects the ileum (the part of the small intestine that joins the large intestine). But Crohn's disease can be in multiple places in the digestive tract at the same time. The picture above shows Crohn's disease that is affecting the ileum and parts of the large intestine (colon), including the rectum. This kind of disease pattern is called ileocolitis.

Ulcerative colitis

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that causes inflammation and sores (ulcers) in the inner lining of the colon and rectum. It causes diarrhea, abdominal pain, and rectal bleeding. Ulcerative colitis is a chronic condition that may flare up many times during a person's life. Some people may have long periods without symptoms or may have only mild symptoms, while other people have symptoms that are more persistent and severe.

Ulcerative colitis is treated with medicines or with surgery to remove the diseased colon. Treatment depends on the severity of the attacks and the person's age. Children and older people may have specific problems that require special care.

Medical history and physical exam for Crohn's disease


A medical history and physical exam are standard tests for people who have abdominal pain and a change in bowel habits. They allow a health professional to determine the seriousness and extent of disease. The medical history for Crohn's disease includes questions about:

Bowel function, including how many bowel movements you have per day or per week, whether you have constipation or diarrhea, whether you have noticed any blood or mucus in your stool, and any recent changes in your bowel habits or the shape of your stools. Whether your bowel movement patterns have any relationship to your abdominal pain (for example, if passing a stool relieves your pain). Whether your family has any history of similar symptoms. Your use of laxatives or antacids. Factors that may increase your risk of an intestinal infection, such as traveling to a foreign country, drinking untreated water, or recently taking antibiotics. Your sexual history. Some sexually transmitted diseases may infect the rectum and cause symptoms similar to those of Crohn's disease.

Your health professional will do a standard physical exam, which may include: Feeling the abdomen. Performing a digital rectal exam. Listening for bowel sounds with a stethoscope. Examining the eyes, skin, joints, and inside of the mouth. Performing a pelvic exam for women.

Crohn's disease cannot be diagnosed based on the medical history or physical findings alone. The diagnosis may be suggested if: The abdomen is tender. Fissures, fistulas, or abscesses around the anus can be seen or felt during the digital rectal exam. You report frequent episodes of diarrhea, sometimes with blood. You may be awakened at night by an urgent need to have a bowel movement. You appear feverish and pale or look underweight. Children may be small or underdeveloped for their age. You have a family history of Crohn's disease, especially in the immediate family.

Sigmoidoscopy (Anoscopy, Proctoscopy)


Anoscopy, proctoscopy, and sigmoidoscopy tests allow your health professional to look at the inner lining of your anus, rectum, and the lower part of the large intestine (colon). These tests are used to look for abnormal growths (such as tumors or polyps), inflammation, bleeding, hemorrhoids, and other conditions (such as diverticulosis).

These test use different scopes look at different sections of the colon. Anoscopy. During an anoscopy, a short, rigid, hollow tube (anoscope) that may contain a light source is used to look at the last 2 in. of the colon (anal canal). Anoscopy can usually be done at any time because it does not require any special preparation (enemas or laxatives) to empty the colon. Proctoscopy. During a proctoscopy, a slightly longer instrument than the anoscope is used to view the inside of the rectum. You usually will have to use enemas or laxatives to empty the colon before the test is done. Sigmoidoscopy. During a sigmoidoscopy, a lighted tube that may be either rigid or flexible is inserted through the anus. Your health professional can remove small growths and collect tissue samples (biopsy) through a sigmoidoscope. You will have to use enemas or laxatives (or both) to empty the colon before the test is done. o The flexible sigmoidoscope is about 2.3 ft long and 0.5 in. wide with a lighted lens system. This instrument allows your health professional to see around bends in the colon. A flexible sigmoidoscope allows a more complete view of the lower colon than a rigid scope and usually makes the examination more comfortable. The flexible sigmoidoscope generally has replaced the rigid sigmoidoscope. o The rigid sigmoidoscope is used less often. It is about 10 in. to 12 in. long and 1 in. wide. It allows your health professional to look into the rectum and the bottom part of the colon, but it does not reach as far into the colon as the flexible sigmoidoscope.

Health Tools Health tools help you make wise health decisions or take action to improve your health. Decision Points focus on key medical care decisions that are important to many health problems. Which test should I have to screen for colorectal cancer? Why It Is Done These tests are done to: Detect problems or diseases of the anus, rectum, or lower large intestine (sigmoid colon). These tests are often done to investigate symptoms such as unexplained bleeding from the rectum, long-lasting diarrhea or constipation, blood or pus in the stool, or lower abdominal pain. Remove polyps or hemorrhoids. Monitor the growth of polyps or the treatment of inflammatory bowel disease. Screen for colon cancer or polyps.

How To Prepare Anoscopy Usually, no preparation is needed for an anoscopy. Proctoscopy and sigmoidoscopy Test preparation for a proctoscopy and sigmoidoscopy may be similar. Before the test:

Talk with your health professional to find out if you need to stop taking some medicines, such as warfarin, before the test. Talk with your health professional to find out if you need to take antibiotics before the test, especially if you have a heart murmur, an artificial heart valve, or an artificial implant (such as a replacement joint). Tell your health professional if you have been diagnosed with peritonitis, diverticulitis, or toxic megacolon or if you have had recent bowel surgery.

The preparation for these tests usually involves a thorough cleaning of the lower colon, because it must be completely clear of stool (feces). Even a small amount of fecal material can affect the accuracy of the test. You may be instructed to follow a liquid diet for 1 to 2 days before the test. You may be instructed to not eat for up to 12 hours before the test. You may need to have an enema the night before the test and another enema an hour before the examination. You may not need special preparation, especially if you have watery or bloody diarrhea.

Talk to your health professional about any concerns you have regarding the need for this test, its risks, how it will be done, or what the results may indicate. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done You will usually lie on your left side during the test. You may also be asked to kneel on the table with your bottom raised in the air. Once you are in position: Your health professional will gently insert a gloved finger into your anus to check for tenderness or blockage. For men, your health professional will also check the condition of the prostate gland. The lubricated scope is then inserted. The scope is moved slowly forward into the rectum and lower colon. During a sigmoidoscopy, puffs of air sometimes are blown through the scope to open the colon so that your health professional can see more clearly. Suction may be used to remove watery stool, enema liquid, mucus, or blood through the scope. Once your health professional has moved the scope forward as far as possible, it is slowly withdrawn while tissue is carefully inspected. Your health professional may also insert tiny instruments (forceps, loops, swabs) through the scope to collect tissue samples (biopsy) or to remove growths. Tissue samples may be sent to a laboratory for examination.

See the following pictures: Step 1: The sigmoidoscope is inserted . Step 2: The health professional examines the wall of the sigmoid colon

After the scope is removed, your anal area will be cleaned with tissues. If you are having cramps, passing gas may help relieve them. The entire examination usually takes 5 to 15 minutes, slightly longer if tissue samples are taken or if polyps are removed. If you received a sedative during the test, do not drive, operate machinery, or sign legal documents for 24 hours after the test. Arrange to have someone drive you home after the test. After the test you may resume your regular diet, unless your health professional gives you other directions. Be sure to drink plenty of liquids to replace those you have lost during the preparation for the sigmoidoscopy.

How It Feels An anoscopy, proctoscopy, and sigmoidoscopy examination can be embarrassing and uncomfortable. You may have cramping, a feeling of pressure or bloating, or feel a brief, sharp pain when the scope is moved forward or when air is blown into your colon. The removal of tissue samples (biopsy) from the colon does not cause discomfort. A local anesthetic is used when a biopsy of the anal area is done. Your anus may be sore for a few days. You may have mild gas pains and may need to pass some gas after the procedure. Walking may help relieve the gas pains. If a biopsy was done or a polyp removed, you may have traces of blood in your stool for a few days. Risks There is very little risk of complications from having an anoscopy, proctoscopy, or sigmoidoscopy. There is a slight chance of piercing the colon (perforation) or causing severe bleeding by damaging the wall of the colon. However, these problems are rare. There is also a slight chance of a colon infection (very rare).

Call your health professional immediately if you have: Heavy rectal bleeding. Severe abdominal pain. A fever.

Results Anoscopy, proctoscopy, and sigmoidoscopy tests allow your health professional to look at the inner lining of your anus, rectum, and the lower part of the large intestine (colon).

Your health professional should be able to discuss some of the findings with you immediately after the test. Lab results (such as from a biopsy) may take several days. Anoscopy, proctoscopy, and sigmoidoscopy Normal: The lining of the colon appears smooth and pink, with numerous folds. No abnormal growths, pouches, bleeding, or inflammation is present.

Abnormal: Some of the more common abnormal findings include: Hemorrhoids, which are the most common cause of blood in the stool. Colon polyps . Cancer in the colon . A sore (ulcer). Pouches in the wall of the colon (diverticulosis). Redness and swelling of the lining of the colon (colitis).

Your health professional will discuss any significant abnormal results with you in relation to your symptoms and past health. What Affects the Test Factors that can interfere with your test or the accuracy of the results include: Stool in the colon or rectum. The structure of the colon, such as a colon that has many turns. A barium enema done within a week before sigmoidoscopy. Rectal bleeding.

What To Think About Follow-up tests, such as colonoscopy, may be needed after sigmoidoscopy. A colonoscopy may also be needed to examine the upper section of the colon if growths were seen during sigmoidoscopy. For more information, see the medical test Colonoscopy. In some cases, the sigmoidoscope may be attached to a video monitor and a recording device that lets your health professional see the inside the colon and record the findings. Most medical experts recommend colon cancer screening beginning at age 50 for people who have an average risk and earlier for those who have an increased risk for colon cancer, such as those with a family history of colon cancer. Talk with your health professional about which colon cancer screening test is best for you. You may not be able to have this test if you have peritonitis, diverticulitis, toxic megacolon, or if you have had recent bowel surgery.

Colonoscopy
Colonoscopy is a test that allows your doctor to look at the inner lining of your large intestine (rectum and colon). He or she uses a thin, flexible tube called a colonoscope to look at the colon. A colonoscopy helps find ulcers, polyps, tumors, and areas of inflammation or bleeding. During a colonoscopy, tissue samples can be collected (biopsy) and abnormal growths can be taken out. Colonoscopy can also be used as a screening test to check for cancer or precancerous growths in the colon or rectum (polyps). The colonoscope is a thin, flexible tube that ranges from 48 in. to 72 in. long. A small video camera is attached to the colonoscope so that your doctor can take pictures or video of the large colon. The colonoscope can be used to look at the whole colon and the lower part of the small colon. A test called sigmoidoscopy shows only the rectum and the lower part of the colon. Before this test, you will need to clean out your colon (colon prep). Colon prep takes 1 to 2 days depending on which type of prep your doctor recommends. Some preps may be taken the evening before the test. For many people, the prep for a colonoscopy is more trying than the actual test. Plan to stay home during your prep time since you will need to use the bathroom often. The colon prep causes loose, frequent stools and diarrhea so that your colon will be empty for the test. The colon prep may be uncomfortable and you may feel hungry on the clear liquid diet. If you need to drink a special solution as part of your prep, be sure to have clear fruit juices or soft drinks to drink after the prep because the solution tastes salty. For more information on screening tests for colon cancer, see: Which test should I have to screen for colorectal cancer? Health Tools Health tools help you make wise health decisions or take action to improve your health. Decision Points focus on key medical care decisions that are important to many health problems. Which test should I have to screen for colorectal cancer?

Why It Is Done Colonoscopy is done to: Find problems or diseases of the anus, rectum, or colon. These tests are often done to because you have had problems such as bleeding from the rectum, ongoing diarrhea or constipation, blood or pus in the stool (feces), or ongoing lower belly pain. Check the colon after abnormal results from a barium enema test. Check for colorectal cancer or polyps. o Most experts, including the American Gastroenterological Association, recommend that people with no risk factors for colorectal cancer start screening tests at age 50. Fecal occult blood testing (FOBT) or a sigmoidoscopy test may be recommended or a colonoscopy or doublecontrast barium enema (DCBE) may be used. If results from FOBT or sigmoidoscopy show a problem, a follow-up colonoscopy is recommended. o The American Gastroenterological Association recommends that people with risk factors for colorectal cancer start screening tests at age 40. Tests may include FOBT, sigmoidoscopy, barium enema, or colonoscopy. If you are at increased risk of colon cancer, talk to your doctor about which test is best for you and how often you should do the tests. If you have a family history of colon cancer, you may need a colonoscopy at age 40 or before age 40 in special cases.

Colonoscopy also may be done to: Check for colon or rectal cancer that has come back in people who had treatment. Watch the growth of polyps that cannot be completely removed. See whether treatment of inflammatory bowel disease is working. Take out polyps or take tissue samples (biopsy). Take out foreign bodies. Check for the cause of chronic diarrhea. Check for the cause of bleeding inside the colon.

How To Prepare Before you have a colonoscopy, tell your doctor if you: Are taking any medicines, such as insulin or medicines for arthritis. Check with your doctor about which medicines you need to take on the day of your test. Are allergic to any medicines, including anesthetics. Have bleeding problems or take blood thinners, such as aspirin or warfarin (Coumadin) Have heart disease or heart problems. If you take antibiotics before dental procedures, ask your doctor whether you will need them before your colonoscopy. Had an X-ray test using barium, such as a barium enema, in the last 4 days. Are or might be pregnant.

You may be asked to stop taking aspirin products or iron supplements 7 to 14 days before the test. If you take blood-thinning medications regularly, discuss with your doctor how to manage your medicine. You will be asked to sign a consent form that says you understand the risks of colonoscopy and agree to have the test done. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). Before this test, you will need to clean out your colon. The following information gives you a general idea of the preparation for a colonoscopy. Your doctor will give you specific instructions before your test. One to two days before a colonoscopy, you will stop eating solid foods and drink only clear fluids, such as water, tea, coffee, clear juices, clear broths, Popsicles, and gelatin (such as Jell-O). Do not eat or drink red food items such as red juice or red Jell-O. Some new products, such as the Nutraprep meal kit or Visicol tablets or oral phospho-soda, are other methods of preparing for a colonoscopy. Ask your doctor whether another method will work for you. Your doctor may have you take a prescription laxative tablet or drink a laxative solution (such as Nulytely or Golytely) the evening before your colonoscopy. This solution will be given to you as a powder that you will mix with 1 gal of water. You are often asked to drink this laxative solution over 1 to 2 hours. This solution may taste very salty and may make you feel sick to your stomach. Each time you drink some of the solution, you may also drink some water or clear fluids (like apple juice) to help get rid of the salty taste in your mouth. You will want to stay home the evening before the test because the colon prep will make you use the bathroom often. Drink plenty of clear fluids during the prep so you will not get dehydrated. This will also help clean out your colon completely after you finish the colon prep. Do not eat any solid foods after drinking the laxative solution. Stop drinking clear liquids 6 to 8 hours before the colonoscopy. Your doctor may have you use an enema 30 to 60 minutes before the test to completely clean out your colon.

Arrange to have someone take you home after the test because you may be given a medicine (sedative) to help you relax before the test. How It Is Done Colonoscopy may be done in a doctor's office, clinic, or a hospital. The test is most often done by a doctor who works with problems of the digestive system (gastroenterologist). The doctor may also have an assistant. Some family doctors, internists, and surgeons are also trained to do colonoscopy. During the test, you may get a pain medicine and a sedative put in a vein in your arm (IV) . These medicines help you relax and feel sleepy during the test. You may not remember much about the test. You will need to take off most of your clothes. You will be given a gown to wear during the test.

You will lie on your left side with your knees pulled up to your belly. The doctor will gently put a gloved finger into your anus to check for blockage. Then he or she will put the thin, flexible colonoscope in your anus and move it slowly through your colon. The doctor can look at the lining of the colon through the scope or on a computer screen hooked to the scope. You may feel the need to have a bowel movement while the scope is in your colon. You may also feel some cramping. Breathe deeply and slowly through your mouth to relax your belly muscles. This should help the cramping. You will likely feel and hear some air escape around the scope. There is no need to be embarrassed about it. The passing of air is expected. You may be asked to change your position during the test. Your doctor will look at the whole length of your colon as the scope is gently moved in and then out of your colon. View a slideshow about how a colonoscopy is done.

The doctor may also use tiny tools, such as forceps, loops, or swabs, through the scope to collect tissue samples (biopsy) or take out growths. You will not feel anything if a biopsy is done or if polyps are taken out. The scope is slowly pulled out of your anus and the air escapes. Your anal area will be cleaned with tissues. If you are having cramps, passing gas may help relieve them. The test usually takes 30 to 45 minutes, but it may take longer, depending upon what is found and what is done during the test. After the test, you will be watched for 1 to 2 hours. When you are fully awake, you can go home. You will not be able to drive or operate machinery for 12 hours after the test. Your doctor will tell you when you can eat your normal diet and do your normal activities. Drink a lot of fluid after the test to replace the fluids you may have lost during the colon prep but do not drink alcohol. How It Feels This test can be uncomfortable and you may feel embarrassed. The colon prep will cause diarrhea and cramping which may make you use the bathroom often during the night. During the test, you may feel very sleepy and relaxed from the sedative and pain medicines. You may have cramping or feel brief, sharp pain when the scope is moved or air is blown into your colon. As the scope is moved up the colon, you may feel the need to have a bowel movement and pass gas. If you are having pain, tell your doctor. The suction machine used to remove stool (feces) and secretions may be noisy but does not cause pain. You will feel sleepy after the test for a few hours. Many people say they do not remember very much about the test because of the sedative. After the test, you may have bloating or crampy gas pains and may need to pass some gas. If a biopsy was done or a polyp taken out, you may have traces of blood in your stool (feces) for a few days. If polyps were taken out, your doctor may instruct you to not take aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) for 7 to 14 days. Risks

There is a small chance for problems from a colonoscopy. The scope or a small tool may tear the lining of the colon or cause bleeding. People who have certain types of heart murmurs, artificial heart valves, or past infections of a heart valve will need antibiotics before and after the test to prevent infection. An irregular heartbeat may occur during the test but usually goes away without treatment.

After the test After the test, call your doctor immediately if you: Have heavy rectal bleeding. Have severe belly pain. Develop a fever. Are very dizzy. Are vomiting. Have a swollen and firm belly.

Results Colonoscopy is a test that allows your doctor to look at the inner lining of your large intestine (rectum and colon). If a sample of tissue (biopsy) was collected during the colonoscopy, it will be sent to a lab for tests. Samples of colon tissue are usually sent to a pathology lab, where they are looked at under a microscope for diseases. Other samples of colon tissue may be sent to a microbiology lab to see whether an infection is present.

Your doctor may be able to tell you the results immediately after the procedure. Other test results are ready in 2 to 4 days. Test results for certain infections may be ready in several weeks. Colonoscopy Normal: The lining of the colon looks smooth and pink, with a lot of normal folds. No growths, pouches, bleeding, or inflammation are present.

Abnormal: Some common abnormal findings of colonoscopy include hemorrhoids (the most common cause of blood in the stool), polyps, tumors, one or more sores (ulcers), pouches in the wall of the colon (diverticulosis), or inflammation. A red, swollen lining of the colon (colitis) may be caused by infection

or inflammatory bowel disease. Types of colon polyps Cancer in the colon

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: Having a barium enema a week before the test. Barium can block your doctor's view of the colon. Having stool (feces) in the colon, a colon that has many turns, past surgery on the colon, or a lot of pain during the test. Taking iron supplements. This may make your stool turn black and make it hard to clean out the colon. Do not take iron supplements for several days before a colonoscopy. Drinking red fluids or eating red gelatin. This can change the color of secretions in the colon and may be mistaken for blood.

What To Think About In general, pregnant women or people who have severe heart disease, an abdominal infection, or diverticulitis should not have a colonoscopy unless there is an important reason for it. Colonoscopy is a more expensive procedure than a barium enema and other endoscopic colon tests (such as proctoscopy or sigmoidoscopy), but it can be done less often over time if results are normal. Colonoscopy is recommended every: o 10 years for people with normal results. o 3 to 5 years for people with increased risk factors for colorectal cancer or when problems are found during the colonoscopy. Most experts, including the American Gastroenterological Association, recommend that people with no risk factors for colorectal cancer start screening tests at age 50. Fecal occult blood testing (FOBT) or a sigmoidoscopy test may be recommended or a colonoscopy or doublecontrast barium enema (DCBE) may be used. If results from FOBT or sigmoidoscopy show a problem, a follow-up colonoscopy is recommended. For more information, see the medical tests Fecal Occult Blood Test, Sigmoidoscopy, and Barium Enema. The American Gastroenterological Association recommends that people with risk factors for colorectal cancer start screening tests at age 40. Tests may include FOBT, sigmoidoscopy, barium enema, or colonoscopy. If you are at increased risk of colon cancer, talk to your doctor about which test is best for you and how often you should do the tests. Talk to your doctor if you are considering virtual colonoscopy to screen for colon cancer. This procedure is a newer method that uses a CT scan to take two- or three-dimensional pictures of the colon. o Virtual colonoscopy is less uncomfortable than standard colonoscopy and may be a good test for people with an average risk for colon

o o

cancer. However, if you have a virtual colonoscopy and a problem is found, you may need a standard colonoscopy so a biopsy can be done. Virtual colonoscopy may not find small colon polyps as well as a standard colonoscopy. For people with a risk for colon cancer, standard colonoscopy may be a better choice because a biopsy can be done or a polyp can be taken out. Virtual colonoscopy is not covered by all health insurance plans. Check with your insurance plan before having the test. Virtual colonoscopy uses the same colon prep as colonoscopy. For many people, the prep for a colonoscopy is more bothersome than the actual test.

Stool Analysis
A stool analysis is a series of tests done on a stool (feces) sample to help diagnose certain conditions affecting the digestive tract . These conditions can include infection (such as from parasites, viruses, or bacteria), poor nutrient absorption, or cancer. For a stool analysis, a stool sample is collected in a clean container and then sent to the laboratory. Laboratory analysis includes microscopic examination, chemical tests, and microbiologic tests. The stool will be checked for color, consistency, weight (volume), shape, odor, and the presence of mucus. The stool may be examined for hidden (occult) blood, fat, meat fibers, bile, white blood cells, and sugars called reducing substances. The pH of the stool also may be measured. A stool culture is done to find out if bacteria may be causing an infection. Why It Is Done Stool analysis is done to: Help identify diseases of the digestive tract, liver, and pancreas. Certain enzymes (such as trypsin or elastase) may be evaluated in the stool to help determine how well the pancreas is functioning. Help find the cause of symptoms affecting the digestive tract, including prolonged diarrhea, bloody diarrhea, an increased amount of gas, nausea, vomiting, loss of appetite, bloating, abdominal pain and cramping, and fever. Screen for colon cancer by checking for hidden (occult) blood. Look for parasites, such as pinworms or Giardia lamblia. Look for the cause of an infection, such as bacteria, a fungus, or a virus. Check for poor absorption of nutrients by the digestive tract (malabsorption syndrome). For this test, all stool is collected over a 72-hour period and then checked for the fat and meat fibers. This test is called a 72-hour stool collection or quantitative fecal fat test.

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will indicate. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How To Prepare

Many medicines can change the results of this test. You will need to avoid certain medications, such as antacids, antidiarrheal medications, antiparasite medications, antibiotics, enemas, and laxatives for 1 to 2 weeks before you have the test. Be sure to tell your doctor about all the nonprescription and prescription medicines you take. Be sure to tell your doctor if you have: Recently had an X-ray test using barium contrast material, such as a barium enema or upper gastrointestinal series (barium swallow). Barium can interfere with test results. Traveled in recent weeks or months, especially if you have traveled outside the country. Parasites, fungi, viruses, or bacteria from other countries may affect the test.

If your stool is being tested for blood, you will need to follow a special diet for 2 days before the stool collection period begins. Your doctor will give you a list of recommended foods. Do not eat red meat, turnips, cauliflower, broccoli, bananas, cantaloupe, beets, or parsnips. Do not drink alcohol, including wine and beer. Do not take aspirin, ibuprofen, or vitamin C.

How It Is Done Stool samples can be collected at home, in your doctor's office, at a medical clinic, or at the hospital. If you collect the samples at home, you will be given stool collection kits to use each day. Each kit contains applicator sticks and two sterile containers. You may need to collect more than one sample over 1 to 3 days. Follow the same procedure for each day. Collect the samples as follows: Urinate before collecting the stool so that you do not get any urine in the stool sample. Put on gloves before handling your stool. Stool can contain material that spreads infection. Wash your hands after you remove your gloves. Pass stool (but no urine) into a dry container. You may be given a plastic basin that can be placed under the toilet seat to catch the stool. o Either solid or liquid stool can be collected. o If you have diarrhea, a large plastic bag taped to the toilet seat may make the collection process easier; the bag is then placed in a plastic container. o If you are constipated, you may be given a small enema. o Do not collect the sample from the toilet bowl. o Do not mix toilet paper, water, or soap with the sample. Using one of the applicator sticks, place a small amount of stool in each of the two containers. Place the lid on the container and label it with your name, your doctor's name, and the date the stool was collected. Use one container for each day's collection, and collect a sample only once a day unless your doctor gives you other directions.

Take the sealed container to your doctor's office or the laboratory as soon as possible. You may need to deliver your sample to the lab within a certain time. Tell your doctor if you think you may have trouble getting the sample to the lab on time. If the stool is collected in your doctor's office or the hospital, you will pass the stool in a plastic container that is inserted under the toilet seat or in a bedpan. A health professional will package the sample for laboratory analysis. You will need to collect stool for 3 days in a row if the sample is being tested for quantitative fats. You will begin collecting stool on the morning of the first day. The samples are placed in a large container and then refrigerated. You may need to collect several stool samples over 7 to 10 days if you have digestive symptoms after traveling outside the country. Samples from babies and young children may be collected from diapers (if the stool is not contaminated with urine) or from a small-diameter glass tube inserted into the baby's rectum while the baby is held on an adult's lap. Sometimes a stool sample is collected using a rectal swab that contains a preservative. The swab is inserted into the rectum, rotated gently, and then withdrawn. It is placed in a clean, dry container and sent to the lab right away. How It Feels There is no pain while collecting a stool sample. If you are constipated, straining to pass stool may be painful. If your health professional uses a rectal swab to collect the sample, you may feel some pressure or discomfort as the swab is inserted into your rectum. Risks Any stool sample may contain germs that can spread disease. It is important to carefully wash your hands and use careful handling techniques to avoid spreading infection. Results A stool analysis is a series of tests done on a stool (feces) sample to help diagnose certain conditions affecting the digestive tract . Stool analysis test results usually take at least 1 to 3 days. Stool analysis Normal: The stool appears brown, soft, and well-formed in consistency. The stool does not contain blood, mucus, pus, harmful bacteria, viruses, fungi, or parasites. The stool is shaped like a tube. The pH of the stool is about 6. The stool contains less than 2 milligrams per gram (mg/g) of sugars

called reducing factors. Abnormal: The stool is black, red, white, yellow, or green. The stool is liquid or very hard. There is too much stool. The stool contains blood, mucus, pus, harmful bacteria, viruses, fungi, or parasites. The stool contains low levels of enzymes, such as trypsin or elastase. The pH of the stool is less than 5.3 or greater than 6.8. The stool contains more than 5 mg/g of sugars called reducing factors; between 2 and 5 mg/g is considered borderline.

Many conditions can change the results of a stool analysis. Your doctor will talk with you about any abnormal results that may be related to your symptoms and medical history. Abnormal values High levels of fat in the stool may be caused by diseases such as pancreatitis, sprue (celiac disease), cystic fibrosis, or other disorders that affect the absorption of fats. The presence of undigested meat fibers in the stool may be caused by pancreatitis. A pH greater than 6.8 may be caused by poor absorption of carbohydrate or fat and problems with the amount of bile in the digestive tract. Stool with a pH less than 5.3 may indicate poor absorption of sugars. Blood in the stool may be caused by bleeding in the digestive tract. White blood cells in the stool may be caused by inflammation of the intestines, such as ulcerative colitis, or a bacterial infection. Rotaviruses are a common cause of diarrhea in young children. If diarrhea is present, testing may be done to look for rotaviruses in the stool. High levels of reducing factors in the stool may indicate a problem digesting some sugars. Low levels of reducing factors may be caused by sprue (celiac disease), cystic fibrosis, or malnutrition. Medicine such as colchicine (for gout) or birth control pills may also cause low levels.

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include:

Taking medicines such as antibiotics, antidiarrheal medications, barium, bismuth, iron, ascorbic acid, aspirin, and magnesium. Eating certain foods. For example, a diet high in red meat can cause falsepositive results in testing for hidden (occult) blood. Contaminating a stool sample with urine, menstrual blood, bleeding hemorrhoids, or chemicals found in toilet paper and paper towels. Exposing the stool sample to air or room temperature or failing to send the sample to a laboratory within 1 hour of collection.

What To Think About Stool may be checked for hidden (occult) blood. For more information, see the medical test Fecal Occult Blood Test (FOBT). A stool culture is done to find the cause of an infection, such as bacteria, a virus, a fungus, or a parasite. For more information, see the medical test Stool Culture. A bowel transit time test is done to help find the cause of abnormal movement of food through the digestive tract. For more information, see the medical test Bowel Transit Time. The D-xylose absorption test is done to help diagnose problems that prevent the small intestine from absorbing nutrients in food. This test may be done when symptoms of malabsorption syndrome (such as chronic diarrhea, weight loss, and weakness) are present. For more information, see the medical test D-Xylose Absorption Test. A stool analysis to measure trypsin or elastase is not as reliable as the sweat test to detect cystic fibrosis. For more information, see the medical test Sweat Test.

Abdominal X-ray
An abdominal X-ray is a picture of structures and organs in the belly (abdomen). This includes the stomach, liver, spleen, large and small intestines, and the diaphragm, which is the muscle that separates the chest and belly areas. Often two X-rays will be taken from different positions. If the test is being done to look for certain problems of the kidneys or bladder, it is often called a KUB (for kidneys, ureters, and bladder ). X-rays are a form of radiation, like light or radio waves, that are focused into a beam, much like a flashlight beam. X-rays can pass through most objects including the human body. When X-rays strike a piece of photographic film, they make a picture. Dense tissues in the body, such as bones, block (absorb) many of the X-rays and look white on an X-ray picture. Less dense tissues, such as muscles and organs, block fewer of the X-rays (more of the X-rays pass through) and look like shades of gray on an X-ray. X-rays that pass only through air, such as the lungs, look black. An abdominal X-ray may be one of the first tests done to find a cause of belly pain, swelling, nausea, or vomiting. Why It Is Done An abdominal X-ray is done to: Look for a cause of pain in the belly or ongoing nausea and vomiting. Find a cause of pain in the lower back on either side of the spine (flank pain). An abdominal X-ray can show the size, shape, and position of the liver, spleen, and kidneys. Other tests (such as ultrasound, CT scan, or intravenous pyelography) may be used in addition to look for more specific problems. Find an object that has been swallowed or put into a body cavity. Confirm the proper position of tubes used by your doctor in your treatment, such as a tube to drain the stomach (nasogastric tube), a feeding tube in the stomach, a tube to drain the kidney (nephrostomy tube), a catheter used for dialysis, a shunt to drain fluid from the brain into the stomach (V-P shunt), or other drainage tubes or catheters.

How To Prepare Before the X-ray test, tell your health professional if you: Are or might be pregnant. An abdominal X-ray is not usually done during pregnancy because of the risk of radiation exposure to your baby (fetus). Many times an abdominal ultrasound is done instead. Have had an X-ray test using barium contrast material (such as a barium enema) or have taken a medicine (such as Pepto-Bismol) that has bismuth in the last 4 days. Barium and bismuth can block a clear picture.

You may be asked to empty your bladder before the test. You may need to take off any jewelry that may be in the way of the X-ray picture, such as if you have a pierced belly button. You will need to sign a consent form that says you understand the risks of an X-ray and agree to have the test done. Talk to your health professional about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?).

How It Is Done An abdominal X-ray is taken by a radiology technologist. The X-ray pictures are read by a radiologist. Some other doctors, such as emergency room doctors, can also look at abdominal X-rays to check for common problems, such as a blocked intestine. You may need to take off all or most of your clothes. You will be given a gown to use during the test. You will lie on your back on a table. A lead apron may be placed over your lower pelvic area to protect it from the X-ray. A woman's ovaries cannot be protected during this test because they lie too close to the belly organs that are X-rayed. A man's testicles can sometimes be protected during the test. After the X-ray machine is positioned over your belly, you will be asked to hold your breath while the X-ray pictures are taken. You need to lie very still so the pictures are clear. Many times, two pictures are taken: one while you are lying down (supine) and the other one while you are standing (erect view). The erect view can help find a blockage of the intestine or a hole (perforation) in the stomach or an intestine that is leaking air. If you are not able to stand, the X-ray may be taken while you lie on your side with your arm over your head. An abdominal X-ray takes about 5 to 10 minutes. You will be asked to wait about 5 minutes while the X-rays are developed in case more pictures need to be taken. In some clinics and hospitals, X-ray pictures can be made immediately on a computer screen (digitally). How It Feels You will feel no discomfort from the X-rays. The X-ray table may feel hard and the room may be cool. You may find that the positions you need to hold are uncomfortable or painful, especially if you have an injury. Risks There is always a slight chance of damage to cells or tissue from radiation, including the low levels of radiation used for this test. However, the chance of damage from the X-rays is usually very low compared with the benefits of the test. Results An abdominal X-ray takes a picture of structures and organs in the belly (abdomen). This includes the stomach, liver, spleen, large and small intestines, and the diaphragm, which is the muscle that separates the chest and belly areas. In an emergency, the results of an abdominal X-ray are ready in a few minutes. Otherwise, results are ready in 1 to 2 days. Abdominal X-ray Normal: The bowel gas pattern (stomach, small and large bowel) and soft tissue densities (liver, spleen, kidneys, and bladder) are normal in size, shape, and location. No growths, abnormal amounts of fluid (ascites), or foreign objects are seen. Normal amounts of air and fluid are seen in the intestines. Normal amounts of stool are seen in the large intestine.

Abnormal: A blocked intestine may be seen because a portion of the intestine is larger than usual or areas in the intestine have abnormal air or fluid in them). See an illustration of a blocked intestine . A collection of air inside the belly cavity but outside the intestines (caused by a hole in the stomach or intestines) may be seen. The walls of the intestines may look abnormal or thick. The size, shape, or location of the bladder or kidneys may be abnormal. Kidney stones may be seen in the kidney, ureters, bladder, or urethra. In some cases, gallstones can be seen on an abdominal X-ray. Abnormal growths, such as large tumors, or ascites may be seen. An object is seen or a medical device looks abnormal or out of position. What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: Being pregnant. If a view of a pregnant woman's belly is needed, an ultrasound test may be done instead. Having recent tests using barium or bismuth. These substances show up on X-ray films and block a clear picture of the belly. Not being able to lie still and hold your breath during the test.

What To Think About Sometimes your X-ray results may be different because you were tested at a different medical center or earlier test results are not available to compare to the new test findings. Certain results seen on an abdominal X-ray may mean more tests are needed to find the cause of the problem. These tests may include endoscopy, ultrasound, a computed tomography (CT) scan, a barium enema, or intravenous pyelography (IVP). For more information, see the medical tests Upper Gastrointestinal Endoscopy, Abdominal Ultrasound, Kidney Scan, CT Scan of the Body, Barium Enema, and Intravenous Pyelogram (IVP). An abdominal X-ray cannot find certain problems, such as a bleeding stomach ulcer. A chest X-ray may be done at the same time as an abdominal X-ray. For more information, see the medical test Chest X-ray. Portable X-ray equipment may be used if a person is physically not able to go to a hospital or clinic X-ray department. However, pictures from stationary Xray equipment are often better than pictures from portable X-ray equipment.

Upper Gastrointestinal (UGI) Series


An upper gastrointestinal (UGI) series looks the upper and middle sections of the gastrointestinal tract (intestines). The test uses barium contrast material, fluoroscopy, and X-ray. Before the test, you drink a mix of barium (barium contrast material) and water. The barium is often combined with gas-making crystals. Your doctor watches the movement of the barium through your esophagus, stomach, and the first part of the small intestine (duodenum ) on a video screen. Several X-ray pictures are taken at different times and from different views. A small bowel follow-through may be done immediately after a UGI to look at the rest of the small intestine. If just the throat and esophagus are looked at, it is called an esophagram (or barium swallow). See barium swallow images . Upper endoscopy is done instead of a UGI in certain cases. Endoscopy uses a thin, flexible tube (endoscope) to look at the lining of the esophagus, stomach, and upper small intestine (duodenum). Why It Is Done An upper gastrointestinal (UGI) series is done to: Find the cause of gastrointestinal symptoms, such as difficulty swallowing, vomiting, burping up food, belly pain (including a burning or gnawing pain in the center of the stomach, or indigestion. These may be caused by conditions such as hiatal hernia. Find narrow spots (strictures) in the upper intestinal tract, ulcers, tumors, polyps, or pyloric stenosis. Find inflamed areas of the intestine, malabsorption syndrome, or problems with the squeezing motion that moves food through the intestines (motility disorders). Find swallowed objects.

Generally, a UGI series is not used if you do not have symptoms of a gastrointestinal problem. A UGI series is done most often for people who have: A hard time swallowing. A history of Crohn's disease. A possible blocked intestine (obstruction). Belly pain that is relieved or gets worse while eating. Severe heartburn or heartburn that occurs often.

How To Prepare Tell your doctor if you: Are taking any medicine. Are allergic to any medicines, barium, or any other X-ray contrast material. Are or might be pregnant. This test is not done during pregnancy because of the risk of radiation to the developing baby (fetus).

You may be asked to eat a low-fiber diet for 2 or 3 days before the test. You may also be asked to stop eating for 12 hours before the test. Your doctor will tell you if you need to stop taking certain medicines before the test.

The evening before the test, you may be asked to take a laxative to help clean out your intestines. If your stomach cannot empty well on its own, you may have a special tube put through your nose and down into your stomach just before the test begins. A gentle suction on the tube will drain the stomach contents. If you are having the small bowel follow-through after the UGI series, you will need to wait between X-rays. The entire small bowel follow-through exam takes up to 6 hours, so bring along a book to read or some other quiet activity. You may be asked to sign a consent form. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done A UGI series is usually done in your doctor's office, clinic, or X-ray department of a hospital. You do not need to stay overnight in the hospital. The test is done by a radiologist and a radiology technologist. You will need to take off your clothes and put on a hospital gown. You will need to take out any dentures and take off any jewelry. You may not smoke or chew gum during the test, since the stomach will respond by making more gastric juices and this will slow the movement of the barium through the intestines. You will lie on your back on an X-ray table. The table is tilted to bring you to an upright position with the X-ray machine in front of you. Straps may be used to keep you safely on the table. The technologist will make sure you are comfortable during changes in table position. You will have one X-ray taken before you drink the barium mix. Then you will take small swallows repeatedly during the series of X-rays that follow. The radiologist will tell you when and how much to drink. By the end of the test, you may have swallowed 1 cup to 2.5 cups of the barium mixture. See an illustration of a barium swallow test . The radiologist watches the barium pass through your gastrointestinal tract using fluoroscopy and X-ray pictures. The table is tilted at different positions and you may change positions to help spread the barium. Some gentle pressure is put on your belly with a belt or by the technologist's gloved hand. You may be asked to cough so that the radiologist can see how that changes the barium flow. See a photograph of a barium swallow . If you are having an air-contrast study, you will sip the barium liquid through a straw with a hole in it or take pills that make gas in your stomach. The air or gas that you take in helps show the lining of the stomach and intestines in greater detail. If you are also having a small bowel study, the radiologist watches as the barium passes through your small intestine into your large intestine. X-ray pictures are taken every 30 minutes. The UGI series 30 to 40 minutes. The UGI series with a small bowel study takes 2 to 6 hours. In some cases, you may be asked to return after 24 hours to have more Xray pictures taken. When the UGI series is done, you may eat and drink whatever you like, unless your doctor tells you not to.

You may be given a laxative or enema to flush the barium out of your intestines after the test to prevent constipation. Drink a lot of fluids for a few days to flush out the barium. How It Feels The barium liquid is thick and chalky, and some people find it hard to swallow. A sweet flavor, like chocolate or strawberry, is used to make it easier to drink. Some people do not like it when the X-ray table tilts. You may find that pressure on your belly is uncomfortable. After the test, many people feel bloated and a little nauseated. For 1 to 3 days after the test, your stool (feces) will look white from the barium. Call your doctor if you are not able to have a bowel movement in 2 to 3 days after the test. If the barium stays in your intestine, it can harden and cause a blockage. If you become constipated, you may need to use a laxative to pass a stool. Risks Barium does not move into the blood, so allergic reactions are very rare. Some people gag while drinking the barium fluid. In rare cases, a person may choke and inhale (aspirate) some of the liquid into the lungs. There is a small chance that the barium will block the intestine or leak into the belly through a perforated ulcer. A special type of contrast material (Gastrografin) can be used if you have a blockage or an ulcer. There is always a small chance of damage to cells or tissue from being exposed to any radiation, even the low level of radioactive tracer used for this test. Results An upper gastrointestinal (UGI) series looks at the upper and middle sections of the gastrointestinal tract (intestines). Results are usually ready in 1 to 3 days. Upper gastrointestinal (UGI) series Normal: The esophagus, stomach, and small intestine all look normal.

Abnormal: A narrowing (stricture), inflammation, a mass, a hiatal hernia, or enlarged veins (varices) may be seen. Spasms of the esophagus or a backward flow (reflux) of barium from the stomach may occur. The UGI series may show a stomach (gastric) or intestinal (duodenal) ulcer, a tumor, or something pushing on the intestines from outside the gastrointestinal tract. Narrowing of the opening between the stomach and the small intestine (pyloric stenosis) may be seen. The small bowel follow-through may show inflammation or changes in the lining that may explain poor absorption of food. This may be caused by Crohn's disease or celiac disease).

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: Eating before or during the test. Too much air in the small intestine.

What To Think About A gastrointestinal (GI) motility study may be done if the squeezing motions of the small intestine are not normal during the UGI series and small bowel follow-through. The movement of the barium through the lower intestinal tract is recorded every few hours for up to 24 hours. A barium enema or colonoscopy may be needed to confirm the diagnosis. Upper endoscopy is done instead of a UGI test in certain cases. Endoscopy uses a thin, flexible tube (endoscope) to look at the lining of the esophagus, stomach, and upper small intestine (duodenum). For more information, see the medical test Upper Gastrointestinal Endoscopy. The UGI series test: o Cannot show irritation of the stomach lining (gastritis) or esophagus (esophagitis) or ulcers that are smaller than about 0.25 in. in diameter. o Cannot show an infection with the bacteria Helicobacter pylori, which may be a cause of stomach ulcers. A biopsy cannot be done during the UGI if a problem is found.

C-Reactive Protein (CRP)


A C-reactive protein (CRP) test is a blood test that measures the amount of a protein called C-reactive protein in your blood. C-reactive protein measures general levels of inflammation in your body. High levels of CRP are caused by infections and many long-term diseases. However, a CRP test cannot show where the inflammation is located or what is causing it. Other tests are needed to find the cause and location of the inflammation. Why It Is Done A C-reactive protein (CRP) test is done to: Check for infection after surgery. CRP levels normally rise within 2 to 6 hours of surgery and then go down by the third day after surgery. If CRP levels stay elevated 3 days after surgery, an infection may be present. Identify and keep track of infections and diseases that cause inflammation, such as: o Cancer of the lymph nodes (lymphoma). o Diseases of the immune system, such as lupus. o Painful swelling of the blood vessels in the head and neck (giant cell arteritis). o Painful swelling of the tissues that line the joints (rheumatoid arthritis). o Swelling and bleeding of the intestines (inflammatory bowel disease). o Infection of a bone (osteomyelitis). Check to see how well treatment is working, such as treatment for cancer or for an infection. CRP levels go up quickly and then become normal quickly if you are responding to treatment measures.

A special type of CRP test, the high-sensitivity CRP test (hs-CRP), may be done to find out if you have an increased chance of having a sudden heart problem, such as a heart attack. Inflammation can damage the inner lining of the arteries and make having a heart attack more likely. However, the connection between high CRP levels and heart attack risk is not very well-understood. How To Prepare There is no special preparation for a C-reactive protein (CRP) test. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will indicate. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done The health professional taking a sample of your blood will: Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with alcohol. Put the needle into the vein. More than one needle stick may be needed. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected.

Put a gauze pad or cotton ball over the needle site as the needle is removed. Put pressure on the site and then put on a bandage.

How It Feels The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch. Risks There is very little chance of a problem from having blood sample taken from a vein. You may get a small bruise at the site. You can lower the chance of bruising by keeping pressure on the site for several minutes. In rare cases, the vein may become swollen after the blood sample is taken. This problem is called phlebitis. A warm compress can be used several times a day to treat this. Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medicines can make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medicine, tell your doctor before your blood sample is taken.

Results A C-reactive protein (CRP) test is a blood test that measures the amount of a protein called C-reactive protein in your blood. Normal Normal values may vary from lab to lab. Results are usually available within 24 hours. C-reactive protein (CRP) Normal: 01.0 mg/dL or less than 10 mg/L (SI units)

Any condition that results in sudden or severe inflammation may increase your CRP levels. Some medicines may decrease your CRP levels. High-sensitivity C-reactive protein (hs-CRP) levels The hs-CRP test measures your risk for heart problems. It may be done to find out if you have an increased chance of having a sudden heart problem, such as a heart attack. However, the connection between high CRP levels and heart attack risk is not very well-understood. High-sensitivity C-reactive protein (hs-CRP) levels Less than 1.0 mg/L 1.0 to 3.0 mg/L More than 3.0 mg/L Lowest risk Average risk Highest risk

Many conditions can change CRP levels. Your doctor will talk with you about any abnormal results that may be related to your symptoms and medical history. What Affects the Test You may not be able to have the test or the results may not be helpful if: You have just exercised. You take certain medicines, such as hormone replacement therapy (HRT), birth control pills, nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, corticosteroids, or medicine to lower your cholesterol (for example, pravastatin). You have an intrauterine device (IUD) in place. You are pregnant. You are very overweight (obese).

What To Think About High-sensitivity C-reactive protein (hs-CRP) measures very low amounts of CRP in the blood. This test may be helpful in predicting your risk for heart problems, especially when it is combined with total cholesterol and HDL cholesterol tests. High CRP levels before a major surgery may indicate that you are at risk for developing an infection after surgery. CRP testing can be used to see how well you respond to cancer treatment or treatment for an infection. Your CRP levels will rise quickly and then quickly return to normal if the treatment is working. High CRP levels may increase your chances of having other diseases, such as age-related macular degeneration and colon cancer.

Probiotics

What are probiotics? Probiotics are bacteria that help maintain the natural balance of organisms (microflora) in the intestines . The normal human digestive tract contains about 400 types of probiotic bacteria that reduce the growth of harmful bacteria and promote a healthy digestive system. The largest group of probiotic bacteria in the intestine is lactic acid bacteria, of which Lactobacillus acidophilus, found in yogurt, is the best known. Yeast is also a probiotic substance. Probiotics are also available as dietary supplements. It has been suggested that probiotics be used to treat problems in the stomach and intestines. But only certain types of bacteria or yeast (called strains) have been shown to work in the digestive tract. It still needs to be proven which probiotics (alone or in combination) work to treat diseases. At this point, even the strains of probiotics that have been proven to work for a specific disease are not widely available. What are probiotics used for? In most circumstances, people use probiotics to prevent diarrhea caused by antibiotics. Antibiotics kill "good" (beneficial) bacteria along with the bacteria that cause illness. A decrease in beneficial bacteria may lead to diarrhea. Taking probiotic supplements (as capsules, powder, or liquid extract) may help replace the lost beneficial bacteria and thus help prevent diarrhea. A decrease in beneficial bacteria may also lead to development of other infections, such as vaginal yeast and urinary tract infections, and symptoms such as diarrhea from intestinal illnesses. Research has shown that certain probiotics may restore normal bowel function and may help reduce:1 Diarrhea that is a side effect of antibiotics. Certain types of infectious diarrhea. Inflammation of the ileal pouch (pouchitis) that may occur in people who have had surgery to remove the colon.

These results suggest that eventually probiotics may also be used to: Help with other causes of diarrhea. Help prevent infections in the digestive tract. Help control immune response (inflammation), as in inflammatory bowel disease (IBD).

Researchers are studying the use of probiotics for inflammatory bowel disease, colon cancer, and irritable bowel syndrome (IBS). The results of some early studies suggest that probiotics found in yogurt may help prevent diarrhea caused by antibiotics.1 But more studies are needed to confirm that yogurt is effective. To offer benefit, the yogurt must contain active cultures. Most yogurt containers indicate whether active cultures are present.

Are probiotics safe? Probiotic bacteria are already part of the normal digestive system and are considered safe. The U.S. Food and Drug Administration (FDA) does not regulate dietary supplements in the same way it regulates medication. A dietary supplement can be sold with limited or no research on how well it works or on its safety. Always tell your doctor if you are using a dietary supplement or if you are thinking about combining a dietary supplement with your conventional medical treatment. It may not be safe to forgo your conventional medical treatment and rely only on a dietary supplement. This is especially important for women who are pregnant or breast-feeding. When using dietary supplements, keep in mind the following: Like conventional medicines, dietary supplements may cause side effects, trigger allergic reactions, or interact with prescription and nonprescription medicines or other supplements you are taking. A side effect or interaction with another medicine or supplement may make other health conditions worse. Dietary supplements may not be standardized in their manufacturing. This means that how well they work or any side effects they cause may differ among brands or even within different lots of the same brand. The form you buy in health food or grocery stores may not be the same as the form used in research. The long-term effects of most dietary supplements, other than vitamins and minerals, are not known. Many dietary supplements are not used long-term.

Enteral nutrition or total parenteral nutrition (TPN) for inflammatory bowel disease
The following nutritional treatments may be used for inflammatory bowel disease (ulcerative colitis or Crohn's disease).

Enteral nutrition Enteral nutrition is a fluid given through a tube that is inserted into the nose, down the throat, and into the stomach. This tube is called a nasogastric, or NG, tube. The fluid contains essential nutrients and helps supplement or replace a regular diet. The intestines absorb nutrients from the fluid more easily than from regular food. Feedings may be given during the day or at night during sleep. Total parenteral nutrition (TPN) Total parenteral nutrition (TPN) is liquid nutrition given through a needle that is inserted into a large vein in or near the shoulder, neck, or arm. This method bypasses the digestive tract completely and places nutrients directly into the bloodstream. TPN allows the bowel to rest so that medicines can work. TPN may be helpful in stopping the symptoms of Crohn's disease in certain people, but the treatment is still unproven. TPN has not been shown to have any benefit in treating ulcerative colitis. But parenteral nutrition may offer nutritional benefits to patients even if it doesn't help with the treatment of disease.

Aminosalicylates for inflammatory bowel disease


Examples balsalazide disodium Colazal mesalamine Asacol Lialda Pentasa Rowasa olsalazine sodium Dipentum sulfasalazine Azulfidine How It Works These medicines may relieve symptoms and inflammation in the intestines and help IBD go into remission (a period without symptoms). They also may help prevent the disease from becoming active again. Why It Is Used Aminosalicylates usually are the first medicines used to treat inflammatory bowel disease (IBD). These medicines have been used to treat IBD for more than 30 years. Ulcerative colitis Oral and topical aminosalicylates are used to treat mild to moderate ulcerative colitis. They also are used to help keep the disease in remission. Oral aminosalicylates are used to treat mild to moderate extensive disease (pancolitis). Mesalamine (Rowasa) is placed in the rectum as a retention enema or suppository. Enemas are useful if the disease affects only the lower third of the large intestine . Suppositories may be used if the disease affects only the lower rectum (proctitis).

Crohn's disease Oral aminosalicylates are used to treat mild Crohn's disease.

How Well It Works These medicines are effective for mild to moderate ulcerative colitis and mild Crohn's disease. Their use depends on the type of medicine (oral or topical) and whether it treats disease that is active or in remission. Ulcerative colitis Treatment for mild to moderate ulcerative colitis often begins with sulfasalazine. But it cannot be used by people who are allergic to or cannot tolerate sulfa drugs. Sulfasalazine works 40% to 80% of the time to make ulcerative colitis symptoms better or keep them from coming back.1 Mesalamine, olsalazine, and balsalazide do not contain sulfa, so they may be used to treat mild to moderate ulcerative colitis if you cannot take sulfasalazine. About 80% of people who can't take sulfasalazine can use mesalamine without problems.1 Mesalamine is becoming the medicine that doctors use first to treat mild to moderate ulcerative colitis. Mesalamine enemas are effective in treating symptoms of mild to moderate distal (left-sided) ulcerative colitis and in maintaining remission. Topical mesalamine enemas and suppositories work more quickly, have fewer side effects, and do not need to be used as often as oral mesalamine. They are most effective when used while you are sleeping. Mesalamine suppositories are preferred for people who have proctitis.

Mesalamine, balsalazide, and olsalazine can be used to maintain remission in ulcerative colitis.

Crohn's disease Sulfasalazine may be used for mild Crohn's disease of the colon. Some people are allergic to sulfa drugs and cannot take sulfasalazine. Mesalamine has been shown to stop the symptoms of Crohn's disease in some people. Studies show that about 45% to 55% of people treated with mesalamine go into remission (a period without symptoms).2 Aminosalicylates do not seem to keep symptoms from coming back when a person is in remission caused by drugs (like corticosteroids). But aminosalicylates sometimes keep symptoms from coming back in people who have had surgery.3

Side Effects Sulfasalazine Side effects may include headache, nausea, loss of appetite, vomiting, rash, fever, and decreased white blood cell count. Sulfasalazine also can temporarily reduce sperm production in men while they are taking the medicine. Most side effects can be relieved by taking smaller doses with food at intervals throughout the day (instead of a single large dose), using coated tablets, or lowering the dose. Folic acid supplements and regular blood tests to check the white blood cell count may be needed while taking sulfasalazine. Mesalamine Side effects may include stomach pain and cramps, diarrhea, gas, nausea, headache, and dizziness. The medicine may cause kidney problems if taken in high doses or for a long time. Olsalazine Diarrhea is the most common side effect. Uncommon side effects may include headache, rash, fatigue, hair loss, inflammation of the pancreas (pancreatitis), or inflammation of the tissue surrounding the heart (pericarditis). Balsalazide The most common side effects are headaches and abdominal pain. Other possible side effects are nausea, diarrhea, and vomiting. See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.) What To Think About Aminosalicylates are used for long-term maintenance in ulcerative colitis. They are not as effective for long-term treatment of Crohn's disease.

Corticosteroids for inflammatory bowel disease


Examples betamethasone Celestone budesonide Entocort EC dexamethasone Decadron hydrocortisone acetate (intrarectal foam) Proctofoam HC hydrocortisone (oral) Cortef hydrocortisone (retention enema) Cortenema methylprednisolone (retention enema) prednisolone Orapred prednisone triamcinolone Clinacort Kenalog

Some of these medicines may be taken as pills. If the disease affects only the lower part of the colon, corticosteroids can be given by enema. For disease that only affects the rectum, suppositories and topical creams can be used. In severe cases, some corticosteroids are given through a needle in a vein (IV) . How It Works These medicines reduce inflammation. Why It Is Used Corticosteroids are used to treat ulcerative colitis and Crohn's disease (inflammatory bowel disease, or IBD). Ulcerative colitis Corticosteroid pills are used to stop symptoms of moderate to severe ulcerative colitis when aminosalicylates, such as sulfasalazine or mesalamine, have not worked. Corticosteroid enemas, suppositories, creams, or foam can be used to treat mild to moderate ulcerative colitis that is limited to the rectum or lower part of the colon. Severe extensive disease sometimes requires treatment with intravenous (IV) corticosteroids.

Crohn's disease Oral or intravenous (IV) corticosteroids can be used to treat: Mild to moderate Crohn's disease. Budesonide (Entocort EC), a corticosteroid you take as a pill, affects only the intestinal tract. Because of this, it causes less side effects than other corticosteroids.1 Budesonide doesn't work as well for Crohn's disease as other corticosteroids. But it has worked to put mild to moderate disease in remission (a period without symptoms). It is not used long-term. Moderate to severe disease. The corticosteroids prednisone and prednisolone lead to disease remission in 60% to 70% of people.2 Severe disease. For severe disease, you will most likely get corticosteroids (like hydrocortisone) through a vein (intravenous or IV). This is usually done in the hospital.

How Well It Works Corticosteroids improve or stop the symptoms of ulcerative colitis and Crohn's disease. These medicines are used to put the disease in remission (a period without symptoms). They are not used long-term. Corticosteroids do not keep ulcerative colitis or Crohn's disease in remission for the long term. When the disease has gone into remission, your doctor will gradually reduce the strength and the amount of corticosteroid you are taking. Only people who do not get better with other medicines-less than half of people with IBD-need to take corticosteroids. Of these people, most people get better after taking corticosteroids (84%).3 Some people with IBD may need to keep taking a small dose of corticosteroids to help keep them in remission. Steroid enemas may be especially helpful for inflammation in the lower colon and the rectum.

Side Effects Some common side effects of corticosteroids include: Increased risk of infection. High blood pressure (hypertension).

Other side effects may appear after you take this medicine for a long time. These include: Weight gain. Acne. Mood swings. Psychosis. Increased facial hair. Osteoporosis. Cataracts. Higher blood sugar level. Bone damage without infection (aseptic necrosis).

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.) What To Think About Long-term use of corticosteroids is discouraged because of the high risk of longlasting side effects. Symptoms of inflammatory bowel disease may come back after a person stops taking corticosteroids. Your doctor may have you take an aminosalicylate (such as sulfasalazine or mesalamine) or an immunomodulator (such as azathioprine or 6-mercaptopurine) at the same time you are taking corticosteroids. These medicines will help keep your symptoms from coming back when you stop taking the corticosteroid. People who take corticosteroids for more than 2 to 3 months should take calcium and vitamin D supplements or other medicines, such as bisphosphonates, to prevent osteoporosis. For more information, see the Medications section of the topic Osteoporosis. Your doctor may want you to have a bone density test to check for osteoporosis. Short-term use of corticosteroids by children generally is considered safe. Long-term use carries the risk of a delay in growth, as well as the side effects that occur in adults. However, the negative effects of severe IBD on a child's growth and development are worse than the possible side effects of steroids, if the child needs steroids to control the disease. Corticosteroids are safe during pregnancy to treat a flare-up of symptoms. Newer steroids in enema form may be useful for longer-term management of IBD, because the enema form causes fewer side effects that affect the whole body.

Immunomodulators for inflammatory bowel disease


Examples azathioprine (AZA) Imuran methotrexate (MTX) Mexate Rheumatrex mycophenolate mofetil CellCept tacrolimus Prograf thalidomide Thalomid 6-mercaptopurine (6-MP) Purinethol

How It Works Immunomodulator medicines, such as azathioprine (AZA), 6-mercaptopurine (6-MP), and methotrexate, weaken or suppress the immune system. These medicines are used most often to prevent the body from rejecting a newly transplanted organ, but they are also helpful in treating inflammatory bowel disease (IBD). Why It Is Used Immunomodulators are used for inflammatory bowel disease (IBD) that: Has not responded to other treatments. Can be controlled only with long-term use of corticosteroids.

Immunomodulators may be used so that the doctor can lower the dose of corticosteroids that a person is taking. This is called "steroid sparing." How Well It Works Immunomodulator medicines are effective against inflammatory bowel disease. AZA and 6-MP are used to maintain remission (a period without symptoms) in ulcerative colitis and Crohn's disease. Both medicines are effective in treating fistulas in Crohn's disease. Crohn's disease It may take 4 months or more for azathioprine (AZA) and 6-mercaptopurine (6-MP) to improve symptoms. These medicines are used to keep a person in remission and allow the person to stop using corticosteroids. These are the most commonly used immunomodulators. They usually work well, but the disease often comes back after you stop taking the medicine.1 Methotrexate improves symptoms more quickly than 6-MP, but it has not been studied as extensively. A few studies have shown that methotrexate stops the symptoms of Crohn's disease and keeps the disease in remission.1 Usually, methotrexate is used when azathioprine (AZA) and 6-mercaptopurine (6-MP) don't work. Tacrolimus can be used in Crohn's disease when corticosteroids do not work or fistulas develop. It also may be applied topically for Crohn's disease that affects the mouth or perineal area.2 Mycophenolate mofetil has been studied in active Crohn's disease, with mixed results. More research is needed to confirm its role.3 Thalidomide has been shown to work in Crohn's disease when corticosteroids did not. It has also been used to treat fistulas. Controlled studies still need to be done. There is some worry about serious side effects of thalidomide.1 Ulcerative colitis Azathioprine (AZA) and 6-mercaptopurine (6-MP) are used for moderate to severe ulcerative colitis to keep symptoms of the disease from coming back after a person has reached a period without symptoms (remission). Azathioprine has been shown to keep 80% to 90% of people in remission for over 2 years. It also allows people to stop taking corticosteroids.4 Oral azathioprine (taken by mouth) is used with steroids or cyclosporine in moderate or severe colitis. Using azathioprine to maintain remission in this way reduces the

chances that symptoms will come back. It also makes it less likely that a person will need a colectomy.4 Side Effects Side effects of immunomodulator medicines include: Nausea, vomiting, diarrhea, or stomach ulcers. Rash. General feeling of being ill (malaise). Liver inflammation.

Rare side effects include: Suppression of blood cell production (bone marrow suppression), which may increase the risk of infection or serious bleeding. Return to normal blood cell production may take several weeks after the medicine is stopped. Fever. Inflammation of the pancreas (pancreatitis). This may occur with AZA and 6MP.

Extremely rare side effects of azathioprine include a possible increased risk of cancer. Mycophenolate mofetil may increase the risk of cancer of the lymph system (lymphoma) and other types of cancer. See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.) What To Think About Regular blood tests are needed to check for effects that these medicines may have on the bone marrow, liver, and kidneys. Immunomodulator medicines are less likely than corticosteroid medicines to cause growth failure in children. Since these medicines weaken or suppress the immune system, they increase your risk of infection. If you are pregnant or want to become pregnant, talk to your doctor about whether you can take immunomodulator medicines. Some of these medicines are used in pregnancy, but only when the benefit outweighs the potential risk of harm to the fetus. Methotrexate and thalidomide should not be used because they can cause birth defects and pregnancy loss.

Tumor necrosis factor (TNF) antagonists for inflammatory bowel disease


Examples adalimumab Humira infliximab Remicade How It Works A tumor necrosis factor (TNF) antagonist is a type of antibody that inhibits tumor necrosis factor, a protein that increases inflammation in the body. Infliximab and adalimumab block the inflammatory response that happens in Crohn's disease and ulcerative colitis. They are both given as a shot. Infliximab is given as a shot in a

vein (intravenous, or IV) and adalimumab is given as a shot under the skin (subcutaneous). Why It Is Used Infliximab was first used to treat abnormal connections (fistulas) between the intestines and organs in moderate to severe Crohn's disease. Now it is used to induce and maintain remission (a period without symptoms) in people who have Crohn's disease or ulcerative colitis that has not improved with other medicines. Adalimumab is used to induce and maintain remission in people with Crohn's disease who have not improved with other medicines and who no longer respond to or cannot tolerate treatment with infliximab. How Well It Works Infliximab can induce remission in people with moderate to severe Crohn's disease, including the closing of fistulas. In one study, some people who were treated with infliximab had symptoms that came back after 3 months. It is now recommended that people treated with infliximab continue to get the medicine at regular intervals. This is called maintenance therapy. In multiple studies, almost 70% of people taking infliximab had fewer symptoms or had healed fistulas.1 In one study, between 60% and 70% of people with ulcerative colitis were better 8 weeks after getting infliximab treatment. In another study, twice as many people got better after receiving infliximab compared to those taking a placebo.2 Adalimumab has shown promise in treating Crohn's disease in multiple studies.3 It works like infliximab and may be good for people who are allergic to infliximab. The long-term effectiveness of both medicines is still being studied. Side Effects Infliximab is given only in a vein (intravenously). Adalimumab is given under the skin (subcutaneously). Side effects include: Chest pain. Nausea. Fever. Chills. Itching (pruritus). Facial flushing. Headache. Rash. Fatigue. Dizziness.

Warnings about serious side effects of TNF antagonists have been issued. The U.S. Food and Drug Administration (FDA) and the drugs manufacturers have warned about: An increased risk of blood or nervous system disorders, some potentially fatal. Contact your health professional if you have symptoms of blood disorders (such as bruising or bleeding) or symptoms of nervous system problems (such as numbness, weakness, tingling, or vision problems).

An increased risk of a serious infection (such as tuberculosis). If you have had tuberculosis (TB) or know someone who has, tell your doctor. TNF antagonists also affect your body's ability to fight all infections, so if you are taking the medicine and get a fever, cold, or flu, let your doctor know right away. An increased risk of liver injuries, some potentially fatal. Call your doctor if your skin starts to look yellow, if you have dark brown urine or a fever, or if you are very tired. A possible increased risk of developing lymphoma (a type of blood cancer). It is not clear if this increase is because of the drug or because people with Crohn's disease may already have a higher risk.4 There have been reports of a rare kind of lymphoma, occurring mostly in children and teens taking TNF antagonists, that often results in death. A possible reaction to the shot. Some people will have hives, trouble breathing, or low blood pressure after an infusion of infliximab. Some people can have an allergic reaction to a shot of adalimumab. Signs of a serious allergic reaction include a skin rash, a swollen face, or trouble breathing. These reactions most often occur right away, and your doctor may give you medicines to prevent or stop the reaction.

What To Think About Infliximab is more expensive than other medicines used to treat Crohn's disease. This medicine is used for Crohn's disease and ulcerative colitis that has not improved (refractory disease) when treated with corticosteroids, aminosalicylates, antibiotics, azathioprine, or 6-mercaptopurine. Infliximab is recommended to be used when other medicines don't work. The use of infliximab during pregnancy is still being studied. It may be used when other medicines have not worked and the health of the mother or of the fetus (or both) is at risk. It is not known if infliximab can pass from the mother to the baby in breast milk. If you have inflammatory bowel disease and you are pregnant, thinking about becoming pregnant, or breast-feeding, talk to your doctor about what medicines are safe for you to use. Because adalimumab is given as a shot under the skin, you may be able to do the shots yourself after your doctor has shown you how.

Osteoporosis

Osteoporosis is a progressive disease that causes bones to become thin and brittle, making them more likely to break. Both women and men are more apt to have osteoporosis if they fail to reach their optimum bone mineral density during the childhood and teenage years, critical times for building bones. Osteoporosis is related to the loss of bone mass that occurs as part of the natural process of aging. Although osteoporosis can occur in men, it is most common in women who have gone through menopause. Not getting adequate calcium and phosphorus-two minerals needed for bone density and strength-and a lack of vitamin D can also contribute to the development of osteoporosis. Not being physically active can also lead to osteoporosis. Prevention and treatment of osteoporosis include eating a diet with sufficient calcium and vitamin D, getting regular exercise, quitting smoking, avoiding excess alcohol, and taking medicine to reduce bone loss and increase bone thickness.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain and fever and to reduce swelling and inflammation caused by injury or diseases such as arthritis. Aspirin, ibuprofen, ketoprofen, and naproxen are commonly used NSAIDs. NSAIDs may cause side effects. The most common are stomach upset, heartburn, and nausea. Taking NSAIDs with food may help prevent these problems. Frequent or long-term use of NSAIDs may lead to stomach ulcers or high blood pressure. They can also cause a severe allergic reaction. NSAIDs have the potential to increase the risk of heart attack, stroke, skin reactions, and serious stomach and intestinal bleeding. These risks are greater if NSAIDs are taken at higher doses or for longer periods than recommended. Aspirin, unlike other NSAIDs, has been shown to reduce the risk of heart attack and stroke. It does carry the risks of serious stomach and intestinal bleeding as well as skin reactions.

NSAIDs should be taken exactly as prescribed or according to the label. Taking a larger dose or taking the medicine longer than recommended can increase the risk of dangerous side effects. People who are older than 65 or who have existing heart, stomach, or intestinal disease are at higher risk for problems. Aspirin should not be given to anyone younger than 20 because of the risk of Reye's syndrome, a rare but serious disease

Short bowel syndrome

Short bowel syndrome is a condition that prevents a person from digesting food and absorbing nutrients properly. It occurs when a large amount of the small intestine has been surgically removed or is affected by disease (such as Crohn's disease). The main symptom of short bowel syndrome is watery diarrhea. A person with short bowel syndrome usually needs a special diet along with vitamin and mineral supplements. Complications may include kidney stones, gallstones, and significant weight loss.

Toxic megacolon

Toxic megacolon is a rare but dangerous condition that occurs when the colon swells to many times its normal size. It is usually a complication of an inflammatory bowel disease, such as ulcerative colitis or Crohn's disease. Severe inflammation and ulceration can weaken muscles in the colon, causing the colon to swell. Symptoms may include a swollen belly, abdominal pain or tenderness, rapid heartbeat, or fever. Over time, holes (perforations) may form in the colon, and stool may spill into the abdominal cavity, causing a serious infection. This can be lifethreatening. Toxic megacolon is an emergency that requires immediate medical treatment to prevent dehydration and shock. Surgery may be needed to remove all or part of the colon (colectomy).

Pancreatitis

Pancreatitis is an inflammation of the pancreas, which is an organ in the upper abdomen that makes insulin and digestive enzymes. Pancreatitis may cause sudden, severe abdominal pain. Pancreatitis is most commonly caused by excessive use of alcohol or by a blockage of the tube (duct) that leads from the pancreas to the beginning of the small intestine (duodenum), usually by a gallstone. Other causes include an infection, an injury, or certain medicines. It may develop suddenly (acute), or it may be a longterm, recurring (chronic) problem. Treatment in the hospital includes pain medicine and fluids given through a vein (IV) until the inflammation goes away. Nutrition is given through a tube to avoid stimulating the pancreas. Although most people recover fully from pancreatitis, complications such as bleeding, infection, or organ failure may develop.

Sprue

Sprue is a disorder in which the intestines are unable to absorb nutrients from food. It can cause loss of appetite, diarrhea, weight loss, muscle cramps, pale skin, and bone pain. Sprue occurs in two forms, tropical and nontropical. Tropical sprue affects people who live in tropical areas. Its exact cause is unclear, but it likely results from a viral or bacterial infection of the lining of the intestine and, possibly, poor nutrition. Tropical sprue is treated by taking antibiotics for 3 to 6 months along with vitamin supplements. Nontropical sprue, sometimes called celiac disease, is present from birth, although some people may not develop symptoms until later in life. This type of sprue is treated by permanently adopting a strict gluten-free diet. This means a person can not eat foods that contain gluten, which is a form of protein found in many grains, such as wheat, barley, and rye.

Rotavirus infection

Rotavirus infection is an infection of the digestive tract. It is the most common cause of vomiting and severe diarrhea in babies and young children; other symptoms include fever and stomach pain. Rotavirus is spread by oral contact with stool (feces) containing the virus. A rotavirus infection in babies or young children is usually minor, generally lasting for about 3 to 8 days. The infection usually goes away on its own. Occasionally, rotavirus infection can lead to severe loss of body fluids (dehydration), which can be life-threatening. Preventing dehydration is an important part of treatment for rotavirus infection. By 2 years of age, most children have had a rotavirus infection and have developed some immunity to the virus.

Fecal Occult Blood Test (FOBT)


A fecal occult blood test finds blood in the stool by placing a small sample of stool on a chemically treated card, pad, or wipe. Then a special chemical solution is put on top of the sample. If the card, pad, or cloth turns blue, there is blood in the stool sample. Fecal occult blood may be done to check for some intestinal conditions or colorectal cancer. Colorectal cancer affects the large intestine (colon ) and the rectum. In

the United States, colorectal cancer is the second leading cause of all cancer deaths. Blood in the stool may be the only symptom of colorectal cancer, but not all blood in the stool is caused by cancer. Other conditions that can cause blood in the stool include: Hemorrhoids. These are enlarged, swollen veins in the anus. Hemorrhoids can develop inside the anus (internal hemorrhoids) or outside of the anus (external hemorrhoids). Anal fissures. These are thin tears in the tissue from the muscles that control the anus (anal sphincters) up into the anal canal. Colon polyps. These small growths of tissue often look like a stem or stalk with a round top that is attached to the colon. Peptic ulcers. These craterlike sores develop when the digestive juices made in the stomach eat away the lining of the digestive tract. Ulcerative colitis. This type of inflammatory bowel disease (IBD) causes inflammation and craterlike sores (ulcers) in the inner lining of the colon and rectum. Gastroesophageal reflux disease (GERD). This is the abnormal backflow (reflux) of food, stomach acid, and other digestive juices into the esophagus. Crohn's disease. This type of inflammatory bowel disease causes inflammation and ulcers that may affect the deep layers of the lining of the digestive tract. Use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).

A fecal occult blood test may be used to check for colorectal cancer, but it is never used to diagnose this condition. Other tests for colorectal cancer include a digital rectal examination, barium enema, flexible sigmoidoscopy, colonoscopy, or CT scan. Checking for hidden (occult) blood in the stool can be done at home. You can buy a test kit at a pharmacy without a prescription, or your health professional can order a test kit for you to use at home. If a home fecal occult blood test finds blood in your stool, call your health professional.

Bowel Transit Time


A bowel transit time test measures how long it takes for food to travel through the digestive tract . Bowel transit time depends on what types of food you eat and how much you drink. For example, people who eat lots of fruits, vegetables, and whole grains tend to have shorter transit times than people who eat mostly sugars and starches. Because different people have different transit times, experts disagree about how useful this test is. After you chew and swallow your food, it moves into your stomach, where it is mixed with acid and digestive enzymes. After your food leaves your stomach, it is squeezed through your small intestine, where, vitamins and water are absorbed for use by your body. The food then goes into your large intestine (colon). Whatever hasn't been digested and absorbed by your intestines combines with water, bacteria, and other waste products and becomes stool (feces). Stool is expelled from your body through your anus. The time it takes for food to travel from your mouth to your anus as stool is your bowel transit time. There are several methods to test your bowel transit time. Each method uses a swallowed substance (called a food marker) that goes through your body and leaves in your stool without being digested. Because the results of these tests are not

consistent, experts disagree about their usefulness. Some doctors do not recommend bowel transit time testing. Dye test For a dye test, you swallow a pill that has dye in it and keep track of how long it takes before the dye shows up in your stool. Home test For a home test, you will drink some red vegetable dye or eat a food like corn kernels or beets. You will then keep track of how long it takes for the dye or vegetable to show up in your stool. Pellet test For a pellet test, you swallow small pills (pellets) before having X-rays of your belly. The pellets look like white spots or rings in the X-ray pictures. You will have X-rays over 2 or 3 days to keep track of how fast the pellets move through your intestines. Why It Is Done Bowel transit time tests may be done to: Help find the cause of severe constipation. Show how different foods speed up or slow down the movement of food through the body.

Bowel transit time tests are not done to find the cause of diarrhea. How To Prepare If you plan to use food markers (such as corn or beets) to measure bowel transit time at home, do not eat these foods for about a week before starting the test. If you are using a red vegetable dye, do not eat or drink foods that contain red dye, such as red gelatin or fruit drinks, for about a week before starting the test. Tell your doctor if you are or might be pregnant before having a pellet test. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done Dye test or home test For the dye test or home test, swallow two gelatin capsules filled with a dye called carmine red (Cochineal) or eat a large helping of seeds, beets, or corn kernels to serve as markers. Look at your next couple of bowel movements and write down how many hours it takes after eating until the markers appear in your stool. Pellet test Your doctor will give you small, indigestible pellets to swallow with instructions about when to take the pellets. You may have to take them at a certain time for 2 or 3 days in a row. You will then have X-rays taken of your belly. These are usually done on day 4 and again on day 7. Your doctor will compare how many pellets show up on the first X-ray with the number of pellets that can be seen on the later X-ray pictures and also compare where the pellets show up in each picture. This time it takes for

the pellets to show up and how fast they move through your intestines is your bowel transit time. How It Feels Bowel transit time tests do not cause pain. You will not feel discomfort from the X-rays used for the pellet test. The X-ray table may feel hard and the room may be cool. You may find that the positions you need to hold are uncomfortable. Risks There is no chance for problems from dye tests and the home tests. The pellet test is not recommended if you are pregnant because the radiation from the X-ray can harm your developing baby (fetus). Results A bowel transit time test measures how long it takes for food to travel through the digestive tract . Bowel transit time depends on what types of food you eat and how much you drink. Different people have different bowel transit times. Talk to your doctor if you do a bowel transit test at home and you do not think that the results are normal. Bowel transit time The dye, food marker, or first pellets show up in the stool within 14 to 24 hours. The last pellets show up within 36 to 48 hours.

Normal:

The dye, food marker, or pellets take more than 72 hours to show up in Slowed: the stool.

What Affects the Test You may have an abnormal bowel transit time if you: Have an infection in your intestines. Do not drink enough fluids (dehydration). Have a disease, such as a narrowing (stricture) in your intestine, an underactive thyroid gland (hypothyroidism), diabetes, or Hirschsprung's disease. Are eating less than you usually do or you are eating different kinds of food than usual. Take medicines, such as cold medicines, iron, or medicine used to control blood pressure and pain.

Women normally have slower bowel transit times than men.

What To Think About The red dye in the gelatin capsules used for home testing is harmless and passes out of your body in your stool. Pellet testing is not recommended if you are or might be pregnant. Many doctors do not think that bowel transit time testing is useful. Different people have different bowel transit times on different days. You can usually speed up bowel transit time if you increase the amount of fruits, vegetables, and whole grains that you eat each day. For more information, see the topic Healthy Eating. It is possible to have a daily bowel movement but still have a slow bowel transit time.

D-xylose Absorption Test


The D-xylose absorption test measures the level of D-xylose, a type of sugar, in a blood or urine sample. This test is done to help diagnose problems that prevent the small intestine from absorbing nutrients in food. D-xylose is normally easily absorbed by the intestines. When problems with absorption occur, D-xylose is not absorbed by the intestines, and its level in blood and urine is low. Why It Is Done A test for D-xylose is done to: Check to see if malabsorption syndrome is causing symptoms, such as chronic diarrhea, weight loss, and weakness. A person with malabsorption syndrome is unable to absorb nutrients, vitamins, and minerals from the intestinal tract into the bloodstream. Find the cause of a child's failure to gain weight, especially when the child seems to be eating enough food.

How To Prepare For 24 hours before a D-xylose test, do not eat foods high in pentose, a sugar similar to D-xylose; these foods include fruits, jams, jellies, and pastries. Medicines such as aspirin and indomethacin can interfere with the results of a Dxylose test. For this reason, your health professional may instruct you to temporarily stop these medicines before the test. Do not eat or drink anything except water for 8 to 12 hours before having this test. Children younger than 9 years old should not eat or drink anything except water for 4 hours before the test. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done The amount of D-xylose in urine and blood samples is measured before and after you drink a D-xylose solution. To begin the test, a sample of your first urine of the day and a sample of your blood is collected.

Next you will drink a D-xylose solution. For adults, a blood sample is usually taken 2 hours after drinking the solution. For children, a blood sample may be taken 1 hour after drinking the solution. Another blood sample may be drawn 5 hours after drinking the solution. You will need to collect all of the urine you produce for 5 hours after drinking the sugar solution. Sometimes urine is collected for 24 hours after drinking the sugar solution. Blood test The health professional taking a sample of your blood will: Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with alcohol. Put the needle into the vein. More than one needle stick may be needed. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected. Put a gauze pad or cotton ball over the needle site as the needle is removed. Put pressure to the site and then put on a bandage.

Urine test You start collecting your urine in the morning. When you first get up, empty your bladder but do not save this urine. Write down the time that you urinated to mark the beginning of your 5-hour collection period. For the next 5 hours, collect all your urine. Your doctor or lab will usually provide you with a large container that holds about 1 gal. The container has a small amount of preservative in it. Urinate into a small, clean container and then pour the urine into the large container. Do not touch the inside of the container with your fingers. Keep the large container in the refrigerator during the collection period. Empty your bladder for the final time at or just before the end of the 5-hour period. Add this urine to the large container and record the time. Do not get toilet paper, pubic hair, stool (feces), menstrual blood, or other foreign matter in the urine sample.

You will not be allowed to eat until the test is completed.

Sweat Test
A sweat test measures the amount of salt chemicals (sodium and chloride) in sweat. It is done to help diagnose cystic fibrosis. Normally, sweat on the skin surface contains very little sodium and chloride. People with cystic fibrosis have 2 to 5 times the normal amount of sodium and chloride in their sweat. During the sweat test, medicine that causes a person to sweat is applied to the skin (usually on the arm or thigh). The sweat is then collected on a paper or a gauze pad, and the amount of salt chemicals in the paper or gauze is measured in a lab. Generally, chloride (sweat chloride) is measured. See a picture of a sweat test . A sweat test is done on any baby suspected of having cystic fibrosis. An initial test may be done as early as 48 hours of age. However, a sweat test done during the

first month of life may need to be repeated. Younger babies may not produce enough sweat to give reliable test results. Also, younger babies may naturally have lower sweat chloride levels than older babies and children with cystic fibrosis. Why It Is Done The sweat test is done to help diagnose cystic fibrosis. It also may be used to test people with a family history of cystic fibrosis and for anyone with symptoms of cystic fibrosis. How To Prepare No special preparation is needed before having this test. Your child may eat, drink, and exercise normally before the test. If your child takes any medicines, he or she may take them on the usual schedule. You may help with the test and stay with your child during the test. If you cannot stay, you may want to ask a family member or friend to stay with your child. Bring your child's favorite book or toy to help pass the time while the test is done. See if your child might be able to watch a movie during the test. Talk with your health professional about any concerns you have regarding the need for the test, its risks, or how it will be done. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done The sweat test is usually done on a baby's right arm or thigh. On an older child or adult, the test is usually done on the inside of the right forearm. Sweat may be collected and analyzed from two different sites. The skin is washed and dried, then two small gauze pads are placed on the skin. One pad is soaked with a medicine that makes the skin sweat, called pilocarpine. The other pad is soaked with salt water. Other pads called electrodes are placed over the gauze pads. The electrodes are hooked up to an instrument that produces a mild electric current, which pushes the medicine into the skin. Another testing method collects the sweat into a coil (macroduct technique). After 5 to 10 minutes, the gauze pads and electrodes are removed, and the skin is cleaned with water and then dried. The skin will look red in the area under the pad that contained the medicine. A dry gauze pad, paper collection pad, or special tubing is taped to the red patch of skin. This pad is covered with plastic or wax to prevent fluid loss (evaporation). The new pad will soak up the sweat for up to 30 minutes, then it is removed and placed in a sealed bottle. It is then weighed to measure how much sweat the skin produced, and it is checked to find out how much salt chemical (sodium and/or chloride) the sweat contains. After the collection pad is removed, the skin is washed and dried again. The test site may look red and continue to sweat for several hours after the test.

The sweat test usually takes 45 minutes to 1 hour. How It Feels This test does not cause pain. Some children feel a light tingling or tickling when the electric current is applied to the skin. If the gauze pads are not properly placed, the electric current may produce a burning sensation.

Risks There is very little risk of complications from this test. However, the test should always be done on an arm or leg (not the chest) to prevent the possibility of electric shock. The electric current may cause skin redness and excess sweating for a short time after the test is done. In rare cases, the current may make the skin look slightly sunburned. Results A sweat test measures the amount of salt chemicals (sodium and chloride) in sweat. Generally, chloride (sweat chloride) is measured. Results are usually available in 1 or 2 days. Normal results vary from lab to lab. Sweat chloride Normal: Less than 40 millimoles per liter (mmol/L)

Borderline: 4060 mmol/L Abnormal: More than 60 mmol/L

Many conditions can change sodium and chloride levels. Your health professional will discuss any significant abnormal results with you in relation to your symptoms and medical history. The test results do not indicate how severe the cystic fibrosis is. The test only shows if a person could have the disease. Abnormal (high) values High values: Usually mean a person has cystic fibrosis. Some people with cystic fibrosis have borderline or even normal sweat chloride levels. May be caused by other conditions. However, the sweat test is not used to diagnose these conditions, which include: o Adrenal gland problems, such as adrenal insufficiency or Addison's disease. o Hypothyroidism. o Kidney failure.

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: A baby's age. Babies younger than 4 weeks may not produce enough sweat to give reliable test results and may have lower sweat chloride levels than older babies and children. A minimum amount of sweat is needed for accurate test results regardless of the child's age. A skin rash or sore on the area of the skin where the gauze pads are attached.

Acute or severe illness. Dehydration or heavy sweating. Decreased sweating. Normal fluctuations in sodium and chloride during puberty. A decrease in the hormone aldosterone. Steroid medicines, such as fludrocortisone (Florinef).

What To Think About Usually, two sweat tests are done to confirm a diagnosis of cystic fibrosis. Younger babies may not produce enough sweat to give reliable test results and may have lower sweat chloride levels than older babies and children with cystic fibrosis. A sweat test cannot identify carriers of the cystic fibrosis gene. If your child is diagnosed with cystic fibrosis, you may wish to talk with your health professional about genetic counseling. For more information, see the topic Cystic Fibrosis Carrier Screening. Adults generally have higher salt concentrations in their sweat than children. Also, sweat test results in adults can vary widely. This is especially true in women, because the amount of salt in their sweat can vary with the phase of their menstrual cycle. Enough sweat must be collected to get accurate test results. If results of a sweat test are positive or unclear (especially in babies), a blood test may be done to detect changes in the genetic material (DNA) that causes cystic fibrosis. Blood test results are usually ready in 10 to 21 days. For more information, see the medical test Genetic Test. Sweat tests should be done at labs that are certified by the Cystic Fibrosis Foundation. These labs perform a large number of sweat tests and are skilled at sweat test techniques and interpretation.

Intravenous pyelogram (IVP)

An intravenous pyelogram (IVP) is an X-ray test that uses a special dye (contrast material) to outline the structure of the kidneys and the tubes leading away from the kidneys (ureters). IVP helps a health professional evaluate symptoms that may be related to the kidneys. An intravenous pyelogram can help reveal problems with: The structure of the kidneys Blood flow through the kidneys Urine flow from the kidneys to the bladder (for example, caused by obstruction from a kidney stone).

Upper Gastrointestinal Endoscopy


An upper gastrointestinal (UGI) endoscopy is a procedure that allows your doctor to look at the interior lining of your esophagus, your stomach, and the first part of your small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope. The tip of the endoscope is inserted through your mouth and then gently moved down your throat into the esophagus, stomach, and duodenum (upper gastrointestinal tract).

Since the entire upper gastrointestinal (GI) tract can be examined during this test, the procedure is sometimes called esophagogastroduodenoscopy (EGD). Using the endoscope, your doctor can look for ulcers, inflammation, tumors, infection, or bleeding. Tissue samples can be collected (biopsy), polyps can be removed, and bleeding can be treated through the endoscope. Endoscopy can reveal problems that do not show up on X-ray tests, and it can sometimes eliminate the need for exploratory surgery. Why It Is Done An upper gastrointestinal endoscopy may be done to: Find problems in the upper gastrointestinal (GI) tract. These problems can include: o Inflammation of the esophagus (esophagitis). o Gastroesophageal reflux disease (GERD). o A narrowing (stricture) of the esophagus. o Barrett's esophagus, a condition that increases the risk for developing esophageal cancer. o Hiatal hernia. o Ulcers. o Cancer. Find the cause of vomiting blood (hematemesis). Find the cause of symptoms, such as upper abdominal pain or bloating, difficulty in swallowing (dysphagia), vomiting, or unexplained weight loss. Find the cause of an infection. Document the healing of stomach ulcers. Look at the inside of the stomach and upper small intestine (duodenum) after surgery. Look for a blockage in the opening between the stomach and duodenum (gastric outlet obstruction).

Endoscopy may also be done to: Check for an esophageal injury in an emergency (for example, if the person has swallowed poison). Collect tissue samples (biopsy) for examination in the laboratory. Remove growths from inside the esophagus, stomach, or small intestine (gastrointestinal polyps). Treat upper gastrointestinal bleeding, including bleeding caused by engorged veins in the esophagus (esophageal varices). Remove foreign objects that have been swallowed. Look for bleeding that may be causing a decrease in the amount of oxygencarrying substance (hemoglobin) found in red blood cells (anemia).

How To Prepare Before having an upper gastrointestinal endoscopy, tell your doctor if you: Are allergic to any medicines, including anesthetics. Are taking any medicines. Have bleeding problems or take blood-thinning medicine, such as warfarin (Coumadin).

Have heart problems. Are or might be pregnant. Are diabetic and take insulin. Have had surgery or radiation treatments to your esophagus, stomach, or the upper part of your small intestine.

How To Prepare continued... You may be asked to stop taking aspirin products or iron supplements 7 to 14 days before the test. If you take blood-thinning medicines regularly, discuss with your doctor how to manage your medicine. Do not take sucralfate (Carafate) or antacids the day of the test. These medicines can interfere with your doctor's ability to view the gastrointestinal tract. If biopsy samples are taken or polyps are removed during the test, bleeding may also occur. This bleeding usually stops on its own without treatment. To reduce this risk, avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) for several days before the endoscopy. If you take blood-thinning medicine, you may be instructed to stop the medicine temporarily before the test. Do not eat or drink anything for 6 to 8 hours before the test. An empty stomach helps your doctor see your stomach clearly during the test. It also reduces your chances of vomiting. If you vomit, there is a small risk that your stomach contents could enter your lungs (aspiration). If the test is done in an emergency, a tube may be inserted through your nose or mouth to empty your stomach. Before the test, you will put on a hospital gown; if you are wearing dentures, jewelry, contact lenses, or glasses, remove them. For your own comfort, empty your bladder before the test begins. Arrange to have someone take you home after the test because you will be given a sedative before the test. How It Is Done A gastrointestinal endoscopy may be done in a doctor's office, clinic, or a hospital. An overnight stay in the hospital usually is not needed. The test is most often performed by a doctor who specializes in problems of the digestive system (gastroenterologist). The doctor may also have an assistant. Some family medicine doctors, internists, and surgeons are also trained to do endoscopy. Before the procedure, blood tests may be done to check for a low blood count or clotting problems. Your throat may be numbed with an anesthetic spray, gargle, or lozenge to relax your gag reflex and make it easier to insert the endoscope into your throat. During the test, you may receive a pain medication and a sedative through an intravenous (IV) line in your arm or hand. These medications reduce pain and will make you feel relaxed and drowsy during the test. You may not remember much about the actual test. You will be asked to lie on your left side with your head bent slightly forward. A mouth guard may be placed in your mouth to protect your teeth from the endoscope. Then the lubricated tip of the endoscope will be guided into your mouth and your doctor may gently press your tongue out of the way. You may be asked to swallow to help move the tube along. It is helpful to remember that the instrument is no thicker than many foods you swallow and will not cause problems with breathing

How It Is Done continued... Once the endoscope is in your esophagus, your head will be tilted upright; this makes it easier for the scope to slide down your esophagus. During the procedure, try not to swallow unless requested to. An assistant may remove the saliva from your mouth with a suction device, or you can allow the saliva to drain from the side of your mouth. Your doctor will slowly advance the endoscope while looking through an eyepiece or watching on a video monitor to examine the walls of your esophagus, stomach, and duodenum. Air or water may be injected through the scope to help clear a path for the scope or to clear its lens, and suction may be applied to remove air or secretions. A camera attached to the endoscope takes pictures for viewing on the monitor and stores some pictures for later study. The doctor may also insert tiny instruments (forceps, loops, swabs) through the colonoscope to collect tissue samples (biopsy) or remove growths. The biopsy test is completely painless. To make it easier for your doctor to see different parts of your upper gastrointestinal (GI) tract, you may be repositioned or have gentle pressure applied to your belly. When the examination is completed, the endoscope is slowly withdrawn. See an illustration of upper gastrointestinal endoscopy .

Upper gastrointestinal endoscopy

After the test The test usually takes 30 to 45 minutes, but it may take longer, depending upon what is found and what is done during the test. After the test, you will be observed for 1 to 2 hours until the medications wear off. If your throat was numbed before the test, you should not eat or drink until your throat is no longer numb and your gag reflex has returned to normal. When you are fully recovered, you can go home. You will not be able to drive or operate machinery for 12 hours after the test. Your doctor will tell you when you can

resume your usual diet and activities. Do not drink alcohol for 12 to 24 hours after the test. How It Feels You may notice a brief, sharp pain when the intravenous (IV) needle is placed in a vein in your arm. The local anesthetic sprayed into your throat usually tastes slightly bitter and will make your tongue and throat feel numb and swollen. Some people report that they feel as if they cannot breathe at times because of the tube in their throat, but this is a false sensation caused by the anesthetic. There is always plenty of breathing space around the tube in your mouth and throat. Remember to relax and take slow, deep breaths. During the test, you may feel very drowsy and relaxed from the sedative and pain medicines. You may have some gagging, nausea, bloating, or mild abdominal cramping as the tube is moved. If you are having pain, alert your doctor with an agreed-upon signal or a tap on the arm. Even though you won't be able to talk during the procedure, you can still communicate. How It Feels continued... The suction machine used to remove secretions may be noisy but does not cause pain. The removal of biopsy samples is also painless. You will feel groggy after the test until the medicine wears off, usually in a few hours. Many people report that they remember very little of the test because of the sedative given before and during the test. After the test, you may belch and feel bloated for a while. You may also have a tickling, dry throat; slight hoarseness; or a mild sore throat. These symptoms may last several days. Throat lozenges and warm saltwater gargles can help relieve the throat symptoms. Do not drink alcohol after the test. Risks Complications from gastrointestinal endoscopy are rare. There is a slight risk of puncturing your throat (esophagus), stomach, or upper small intestine (duodenum) and require surgery to repair. There is also a slight chance of infection after an endoscopy. Bleeding may also occur from the test or if a tissue sample (biopsy) is taken, but this usually stops on its own without treatment. If you vomit during the examination and some of the material you vomit enters your lungs, aspiration pneumonia is a possible risk. If it develops, it can be treated with antibiotics. People who have certain types of heart murmurs, artificial heart valves, or previous infections of a heart valve will need antibiotics before and after the test to prevent infection. An irregular heartbeat may occur during the test but nearly always subsides on its own without treatment. People with abnormal heart valves or an artificial heart valve may receive antibiotics before and after the procedure to prevent infection. The procedure has more risk for people with serious heart disease, older adults, and those who are frail or physically weakened. Although complications are rare, you should discuss your specific risks with your doctor. After the test After the test, call 911 or other emergency services immediately if you develop:

Chest pain. Moderate to severe difficulty breathing.

After the test, call your doctor immediately if you: Feel short of breath or dizzy. Have symptoms of infection, such as fever or chills. Vomit blood, whether it is fresh and red or is old and looks like coffee grounds.

Results An upper gastrointestinal (UGI) endoscopy is a procedure that allows your doctor to look at the interior lining of your esophagus, your stomach, and the first part of your small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope. Your doctor may be able to talk to you about some of the findings with you immediately after your upper gastrointestinal endoscopy. However, the medicines given to help relax you may impair your memory, so your doctor may wait until the medicines wear off completely. Other results are usually available in 2 to 4 days. Tests for certain infections may take several weeks. Upper gastrointestinal endoscopy Normal: The esophagus, stomach, and upper small intestine (duodenum) look normal. Stomach or duodenal ulcers or inflammation are found in the esophagus (esophagitis), stomach (gastritis), or small intestine. Bleeding, an ulcer, a tumor, a tear, or dilated veins (esophageal varices) are found in the esophagus, stomach, of duodenum. A hiatal hernia or narrowing (stricture) or widening (dilation) is found in the esophagus, stomach, or duodenum. A foreign object is found in the esophagus, stomach, or duodenum. A biopsy sample may be taken to: Find out if tumors or ulcers contain cancer cells. Identify a type of bacteria called Helicobacter pylori (H. pylori).

Abnormal:

Many conditions can change the results of an upper gastrointestinal endoscopy.Your doctor will talk with you about any abnormal results that may be related to your symptoms and medical history. What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include:

Having had another test that uses barium contrast material. An upper gastrointestinal endoscopy should not be done less than 2 days after you have an upper gastrointestinal (GI) series so your doctor can see your stomach and small intestine. Moderate to severe bleeding in the gastrointestinal tract.

What To Think About An upper gastrointestinal endoscopy is the best way to examine your esophagus, stomach, and upper small intestine (duodenum). Your doctor can take a tissue sample to test for Helicobacter pylori infection, which is believed to be the main cause of stomach or duodenal ulcers. For more information, see the medical test Helicobacter pylori Tests. Cancer can be identified or ruled out using endoscopy. Endoscopy may be done after an upper gastrointestinal series test identifies a problem. For more information, see the medical test Upper Gastrointestinal Series. Endoscopy can be safely performed on small children. Endoscopic retrograde cholangiopancreatogram (ERCP) is a test of the ducts that drain the liver, gallbladder, and pancreas. It can be done to find the cause of jaundice if your doctor thinks you may have blockage of the bile or pancreatic ducts and when other tests (such as ultrasound, liver scan, and Xray studies) are not clear. For more information, see the medical test Endoscopic Retrograde Cholangiopancreatogram (ERCP).

Perineum

The perineum is the muscle and tissue near the anus. In a woman, the perineum is between the anus and the vulva, while in a man, it is between the anus and the scrotum.

How is Crohn's disease treated? The symptoms and severity of Crohn's disease vary among patients. Patients with mild or no symptoms may not need treatment. Patients whose disease is in remission (where symptoms are absent) also may not need treatment. There is no medication that can cure Crohn's disease. Patients with Crohn's disease typically will experience periods of relapse (worsening of inflammation) followed by periods of remission (reduced inflammation) lasting months to years. During relapses, symptoms of abdominal pain, diarrhea, and rectal bleeding worsen. During remissions, these symptoms improve. Remissions usually occur because of treatment with medications or surgery, but occasionally they occur spontaneously without any treatment. Since there is no cure for Crohn's disease, the goals of treatment are to 1) induce remissions, 2) maintain remissions, 3) minimize side effects of treatment, and 4) improve the quality of life. Treatment of Crohn's disease and ulcerative colitis with medications is similar though not always identical. Medications for treating Crohn's disease include 1) antiinflammatory agents such as 5-ASA compounds, corticosteroids, topical antibiotics, 2) immuno-modulators, 3) other medications. Antiinflammatory medications Antiinflammatory medications that decrease intestinal inflammation are analogous to arthritis medications that decrease joint inflammation. Different types of antiinflammatory medications used in the treatment of Crohn's disease are: 5-ASA compounds such as sulfasalazine (Azulfidine) and mesalamine (Pentasa, Asacol, Dipentum, Colazal, Rowasa enema, Canasa suppository) that act via direct contact (topically) with the inflamed tissue in order to be effective. Corticosteroids that act systemically (without the need for direct contact with the inflamed tissue) to decrease inflammation throughout the body. Systemic corticosteroids have important and predictable side effects if used long-term. A new class of topical corticosteroid (for example, budesonide) that acts via direct contact (topically) with the inflamed tissue. This class of corticosteroids has fewer side effects than systemic corticosteroids which are absorbed into the body. Antibiotics such as metronidazole (Flagyl) and ciprofloxacin (Cipro) that decrease inflammation by an unknown mechanism 5-ASA (mesalamine) oral medications 5-aminosalicylic acid (5-ASA), also called mesalamine, is similar chemically to aspirin. Aspirin has been used for many years for treating arthritis, bursitis, and tendonitis (conditions of tissue inflammation). Aspirin, however, is not effective in

treating Crohn's disease and ulcerative colitis, and even may worsen the inflammation. On the other hand, 5-ASA can be effective in treating Crohn's disease and ulcerative colitis if the drug can be delivered topically onto the inflamed intestinal lining. For example, mesalamine (Rowasa) is an enema containing 5-ASA that is effective in treating inflammation in the rectum. However, the enema solution cannot reach high enough to treat inflammation in the upper colon and the small intestine. Therefore, for most patients with Crohn's disease involving both the ileum (distal small intestine) and colon, 5-ASA must be taken orally. If pure 5-ASA is taken orally, however, most of the 5-ASA would be absorbed in the stomach and the upper small intestine, and very little 5-ASA would reach the ileum and colon. To be effective as an oral agent in treating Crohn's disease, 5-ASA has to be modified chemically to escape absorption by the stomach and the upper intestines. Sulfasalazine (Azulfidine) Sulfasalazine (Azulfidine) was the first modified 5-ASA compound used in the treatment of Crohn's colitis and ulcerative colitis. It has been used successfully for many years to induce remissions among patients with mild to moderate ulcerative colitis. Sulfasalazine also has been used for prolonged periods for maintaining remissions. Sulfasalazine consists of a 5-ASA molecule linked chemically to a sulfapyridine molecule. (Sulfapyridine is a sulfa antibiotic.) Connecting the two molecules together prevents absorption by the stomach and the upper intestines. When sulfasalazine reaches the ileum and the colon, the bacteria that normally are present break the link between the two molecules. After breaking away from 5-ASA, sulfapyridine is absorbed into the body and later eliminated in the urine. Most of the active 5-ASA, however, is available within the terminal ileum and colon to treat the colitis. Most of the side effects of sulfasalazine are due to the sulfapyridine molecule. These side effects include nausea, heartburn, headache, anemia, skin rashes, and, in rare instances, hepatitis and kidney inflammation. In men, sulfasalazine can reduce the sperm count. The reduction in sperm count is reversible, and the count usually becomes normal after the sulfasalazine is discontinued or changed to a different 5ASA compound. Because the newer 5ASA compounds [for example, mesalamine (Asacol and Pentasa)] do not have the sulfapyridine component and have fewer side effects than sulfasalazine, they are being used more frequently in treating Crohn's disease and ulcerative colitis. Asacol Asacol is a tablet consisting of the 5-ASA compound surrounded by an acrylic resin coating. Asacol is sulfa-free. The resin coating prevents the 5-ASA from being absorbed as it passes through the stomach and the small intestine. When the tablet reaches the terminal ileum and the colon, the resin coating dissolves, and the active 5-ASA drug is released.

Asacol is effective in inducing remissions in patients with mild to moderate ulcerative colitis. It also is effective when used in the longer term to maintain remissions. Some studies have shown that Asacol also is effective in treating Crohn's ileitis and ileocolitis, as well as in maintaining remission in patients with Crohn's disease. The recommended dose of Asacol for inducing remissions is two 400 mg tablets three times daily (a total of 2.4 grams a day). At least two tablets of Asacol twice daily (1.6 grams a day) is recommended for maintaining remission. Occasionally, the maintenance dose is higher. As with Azulfidine, the benefits of Asacol are dose-related. If patients do not respond to 2.4 grams a day of Asacol, the dose frequently is increased to 3.6 - 4.8 grams a day to induce remission. If patients fail to respond to the higher doses of Asacol, then other alternatives such as corticosteroids are considered. Pentasa Pentasa is a capsule consisting of small spheres containing 5-ASA. Pentasa is sulfafree. As the capsule travels down the intestines, the 5-ASA inside the spheres is released slowly into the intestine. Unlike Asacol, the active drug 5-ASA in Pentasa is released into the small intestine as well as the colon. Therefore, Pentasa can be effective in treating inflammation in the small intestine and is currently the most commonly used 5-ASA compound for treating mild to moderate Crohn's disease in the small intestine. Patients with Crohn's disease occasionally undergo surgery to relieve small intestinal obstruction, drain abscesses, or remove fistulae. Usually, the diseased portions of the intestines are removed during surgery. After successful surgery, patients can be free of disease and symptoms (in remission) for a while. In many patients, however, Crohn's disease eventually returns. Pentasa helps maintain remissions and reduces the chances of the recurrence of Crohn's disease after surgery. In the treatment of Crohn's ileitis or ileocolitis, the dose of Pentasa usually is four 250 mg capsules four times daily (a total of 4 grams a day). For maintenance of remission in patients after surgery, the dose of Pentasa is between 3-4 grams daily. Olsalazine (Dipentum) Olsalazine (Dipentum) is a capsule in which two molecules of 5-ASA are joined together by a chemical bond. In this form, the 5-ASA cannot be absorbed from the stomach and intestine. Intestinal bacteria are able to break apart the two molecules releasing the active individual 5-ASA molecules into the intestine. Since intestinal bacteria are more abundant in the ileum and colon, most of the active 5-ASA is released in these areas. Therefore, olsalazine is most effective for disease that is limited to the ileum or colon. Although clinical studies have shown that olsalazine is effective for maintenance of remission in ulcerative colitis, up to 11% of patients experience diarrhea when taking olsalazine. Because of this, olsalazine is not often used. The recommended dose of olsalazine is 500 mg twice a day.

Balsalazide (Colazal) Balsalazide (Colazal) is a capsule in which the 5-ASA is linked by a chemical bond to another molecule that is inert (without effect on the intestine) and prevents the 5ASA from being absorbed. This drug is able to travel through the intestine unchanged until it reaches the end of the small bowel (terminal ileum) and colon. There, intestinal bacteria break apart the 5-ASA and the inert molecule releasing the 5-ASA. Because intestinal bacteria are most abundant in the terminal ileum and colon, balsalazide is used to treat inflammatory bowel disease predominantly localized to the colon. Side effects of oral 5-ASA compounds The 5-ASA compounds have fewer side effects than Azulfidine and also do not reduce sperm counts. They are safe medications for long-term use and are well-tolerated. Patients allergic to aspirin should avoid 5-ASA compounds because they are similar chemically to aspirin. Rare kidney and lung inflammation has been reported with the use of 5-ASA compounds. Therefore, 5-ASA should be used with caution in patients with kidney disease. It also is recommended that blood tests of kidney function be done before starting and periodically during treatment. Rare instances of worsening of diarrhea, cramps, and abdominal pain, at times accompanied by fever, rash, and malaise, may occur. This reaction is believed to represent an allergy to the 5-ASA compound. 5-ASA rectal medications (Rowasa Canasa) Rowasa is 5-ASA in enema form. 5-ASA by enema is most useful for treating ulcerative colitis involving only the distal colon since the enema easily can reach the inflamed tissues of the distal colon. Rowasa also is used in treating Crohn's disease in which there is inflammation in and near the rectum. Each Rowasa enema contains 4 grams of 5-ASA. The enema usually is administered at bedtime, and patients are encouraged to retain the enema through the night. The enema contains sulfite and should not be used by patients with sulfite allergy. Otherwise, Rowasa enemas are safe and well-tolerated. Canasa is 5-ASA in suppository form. It is used for treating ulcerative proctitis. Each suppository contains 500 mg of 5-ASA and usually is administered twice daily. Both enemas and suppositories have been shown to be effective in maintaining remission in patients with ulcerative colitis limited to the distal colon and rectum. Corticosteroids Corticosteroids (for example, prednisone, prednisolone, hydrocortisone, etc.) have been used for many years to treat patients with moderate to severe Crohn's disease and ulcerative colitis and to treat patients who fail to respond to 5-ASA. Unlike 5-

ASA, corticosteroids do not require direct contact with the inflamed intestinal tissues to be effective. Oral corticosteroids are potent antiinflammatory medications. After absorption, corticosteroids exert prompt antiinflammatory actions throughout the body, including the intestines. Consequently, they are used in treating Crohn's disease anywhere in the small intestine, as well as ulcerative and Crohn's colitis. In critically ill patients, intravenous corticosteroids (such as hydrocortisone) can be given in the hospital. For patients with proctitis, hydrocortisone enemas (Cortenema) can be used to deliver the corticosteroid directly to the inflamed tissue. By using the corticosteroid topically, less of it is absorbed into the body and the frequency and severity of side effects are lessened (but not eliminated) as compared with systemic corticosteroids. Corticosteroids are faster-acting than 5-ASA, and patients frequently experience improvement in their symptoms within days of beginning them. Corticosteroids, however, do not appear to be useful in maintaining remission in Crohn's disease and ulcerative colitis or in preventing the return of Crohn's disease after surgery. Side effects of corticosteroids The frequency and severity of side effects of corticosteroids depend on the dose and duration of their use. Short courses of corticosteroids, for example, usually are welltolerated with few and mild side effects. Long-term use of high doses of corticosteroids usually produces predictable and potentially serious side effects. Common side effects include: rounding of the face (moon face), acne, increased body hair, diabetes, weight gain, high blood pressure, cataracts, glaucoma, increased susceptibility to infections, muscle weakness, depression, insomnia, mood swings,

personality changes, irritability, and thinning of the bones (osteoporosis) with fractures of the spine. Children receiving corticosteroids experience stunted growth. The most serious complication from long term corticosteroid use is aseptic necrosis of the hip joints. Aseptic necrosis is a condition in which there is death and degeneration of the hip bone. It is a painful condition that can ultimately lead to the need for surgical replacement of the hip. Aseptic necrosis also has been reported in the knee joints. It is not known how corticosteroids cause aseptic necrosis. The estimated incidence of aseptic necrosis among corticosteroid users is 3%-4%. Patients on corticosteroids who develop pain in the hips or knees should report the pain to their doctors promptly. Early diagnosis of aseptic necrosis with cessation of corticosteroids might decrease the severity of the aseptic necrosis and the need for hip replacement surgery. Prolonged use of corticosteroids can depress the ability of the body's adrenal glands to produce cortisol (a natural corticosteroid necessary for proper functioning of the body). Therefore, abruptly discontinuing corticosteroids can cause symptoms due to a lack of natural cortisol (a condition called adrenal insufficiency). Symptoms of adrenal insufficiency include nausea, vomiting, and even shock. Withdrawing corticosteroids too quickly also can produce symptoms of joint pain, fever, and malaise. Therefore, when corticosteroids are discontinued, the dose usually is tapered gradually rather than stopped abruptly. Even after corticosteroids are discontinued, the adrenal glands' ability to produce cortisol can remain depressed from months up to two years. The depressed adrenal glands may not be able to produce increased amounts of cortisol to help the body handle the stress of accidents, surgery, and infections. Therefore, patients need additional corticosteroids during stressful situations to avoid developing adrenal insufficiency. Because corticosteroids are not useful in maintaining remission in ulcerative colitis and Crohn's disease, and because they have predictable and potentially serious side effects, they should be used for the shortest possible length of time. Proper use of corticosteroids Once the decision is made to use systemic corticosteroids, treatment usually is initiated with prednisone, 40-60 mg daily. The majority of patients with Crohn's disease respond with an improvement in symptoms within a few weeks. Once symptoms have improved, prednisone is reduced by 5-10 mg per week until a dose of 20 mg per day is reached. The dose then is reduced at a slower rate until the corticosteroid is discontinued. Gradually reducing corticosteroids not only minimizes the symptoms of adrenal insufficiency, it also reduces the chances of an abrupt recurrence of inflammation. Many doctors use 5-ASA compounds and corticosteroids together. In patients who achieve remission with corticosteroids, 5-ASA compounds often are continued alone to maintain remission.

In patients whose symptoms return corticosteroids are slowly being reduced, the dose of corticosteroids is increased slightly to control the symptoms. Once the symptoms are under control, the reduction of corticosteroids can resume at a slower pace. Unfortunately, many patients who require corticosteroids to induce remissions become corticosteroid dependent. These patients consistently develop symptoms whenever the corticosteroid dose falls below a certain level. In such patients who are corticosteroid dependent as well as in patients who are unresponsive to corticosteroids and other antiinflammatory medications, immuno-modulator medications or surgery must be considered. The management of patients who are corticosteroid dependent or patients with severe disease that responds poorly to medications is complex. Doctors who are experienced in treating ulcerative colitis and Crohn's disease and in using immuno-modulators should evaluate these patients. Prevention of osteoporosis Long-term use of corticosteroids can cause osteoporosis. Calcium is very important in the formation and maintenance of healthy bones. Corticosteroids decrease the absorption of calcium from the intestine and increase the loss of calcium from the kidneys. Increasing dietary calcium intake is important but alone cannot halt corticosteroid-induced osteoporosis. To prevent or minimize osteoporosis, management of patients on long-term corticosteroids should include: Adequate intake of calcium (1000 mg daily in premenopausal women, 1,500 mg daily in postmenopausal women) and vitamin D (800 units daily). Periodic review with the doctor of the need for continued corticosteroid treatment and use of the lowest effective dose if continued treatment is necessary. For patients taking corticosteroids for more than three months, a bone density study may be helpful in determining the extent of bone loss and the need for more aggressive treatment. Regular weight-bearing exercise and stopping smoking (cigarettes). Discussion with the doctor regarding the use of alendronate (Fosamax), risedronate (Actonel), or etidronate (Didronel) to prevent or treat corticosteroid-induced osteoporosis. Budesonide (Entocort EC) Budesonide (Entocort EC) is a new type of corticosteroid for treating Crohn's disease. Like other corticosteroids, budesonide is a potent antiinflammatory medication. Unlike other corticosteroids, however, budesonide acts only via direct contact with the inflamed tissues (topically) and not systemically. As soon as budesonide is absorbed into the body, the liver converts it into inactive chemicals. Therefore, for effective treatment of Crohn's disease, budesonide, like topical 5-ASA, must be brought into direct contact with the inflamed intestinal tissue. Budesonide capsules contain granules that allow a slow release of the drug into the ileum and the colon. In a double-blind multicenter study (published in 1998), 182

patients with Crohn's ileitis and/or Crohn's disease of the right colon were treated with either budesonide (9 mg daily) or Pentasa (2 grams twice daily). Budesonide was more effective than Pentasa in inducing remissions while the side effects were similar to Pentasa. In another study comparing the effectiveness of budesonide with corticosteroids, budesonide was not better than corticosteroids in treating Crohn's disease but had fewer side effects. Because budesonide is broken down by the liver into inactive chemicals, it has fewer side effects than systemic corticosteroids. It also suppresses the adrenal glands less than systemic corticosteroids. Budesonide will be available as an enema for the treatment of proctitis. Budesonide has not been shown to be effective in maintaining remission in patients with Crohn's disease. If used long-term, budesonide also may cause some of the same side effects as corticosteroids. Because of this, the use of budesonide should be limited to short-term treatment for inducing remission. Most budesonide is released in the terminal ileum, it will have its best results in Crohn's disease limited to the terminal ileum. It is not known whether budesonide is effective in treating patients with ulcerative colitis, and it is currently not recommended for the treatment of ulcerative colitis. Antibiotics for Crohn's disease Antibiotics such as metronidazole (Flagyl) and ciprofloxacin (Cipro) have been used for treating Crohn's colitis. Flagyl also has been useful in treating anal fistulae in patients with Crohn's disease. The mechanism of action of these antibiotics in Crohn's disease is not well understood. Metronidazole (Flagyl) Metronidazole (Flagyl) is an antibiotic that is used for treating several infections caused by parasites (for example, giardia) and bacteria (for example, infections caused by anaerobic bacteria, and vaginal infections). It is effective in treating Crohn's colitis and is particularly useful in treating patients with anal fistulae. Chronic use of metronidazole in doses higher than 1 gram daily can be associated with permanent nerve damage (peripheral neuropathy). The early symptoms of peripheral neuropathy are numbness and tingling in the fingertips, toes, and other parts of the extremities. Metronidazole should be stopped promptly if these symptoms appear. Metronidazole and alcohol together can cause severe nausea, vomiting, cramps, flushing, and headache. Patients taking metronidazole should avoid alcohol. Other side effects of metronidazole include nausea, headaches, loss of appetite, a metallic taste, and, rarely, a rash. Ciprofloxacin (Cipro) Ciprofloxacin (Cipro) is another antibiotic used in the treatment of Crohn's disease. It can be used in combination with metronidazole.

Summary of antiinflammatory medications Azulfidine, Asacol, Pentasa, Dipentum, Colazal and Rowasa all contain 5-ASA which is the active topical antiinflammatory ingredient. Azulfidine was the first 5-ASA medication used in treating ulcerative colitis and Crohn's disease, but the newer 5-ASA medications have fewer side effects. Pentasa and Asacol have been found to be effective in treating patients with Crohn's ileitis and ileo-colitis. Rowasa enemas and Canasa suppositories are safe and effective for treating patients with proctitis. For mild to moderate Crohn's ileitis or ileo-colitis, doctors usually start with Pentasa or Asacol. If Pentasa or Asacol is ineffective, doctors may try antibiotics such as Cipro or Flagyl for prolonged periods (often months). In patients with moderate to severe disease and in patients who fail to respond to 5-ASA compounds and/or antibiotics, systemic corticosteroids can be used. Systemic corticosteroids are potent and fast-acting antiinflammatory agents for treating Crohn's enteritis and colitis as well as ulcerative colitis. Systemic corticosteroids are not effective in maintaining remission in patients with Crohn's disease. Serious side effects can result from prolonged corticosteroid treatment. To minimize side effects, corticosteroids should be gradually tapered as soon as a remission is achieved. In patients who become corticosteroid dependent or are unresponsive to corticosteroid treatment, surgery or immunomodulator treatment are considered. A new class of topical corticosteroids (budesonide) may have fewer side effects than systemic corticosteroids. Immuno-modulator medications Immuno-modulators are medications that affect the body's immune system. The immune system is composed of immune cells and the proteins that they produce. These cells and proteins serve to protect the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism used by the immune system to defend the body.) Normally, the immune system is activated only when the body is exposed to foreign invaders. In patients with Crohn's disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. Immuno-modulators decrease tissue inflammation by reducing the population of immune cells and/or by interfering with their production of proteins. Decreasing the activity of the immune system with immuno-modulators increases the risk of infections; however, the benefits of controlling moderate to severe Crohn's disease usually outweigh the risks of infection due to weakened immunity. Examples of immuno-modulators are 6-mercaptopurine (6-MP), azathioprine (Imuran), methotrexate (Rheumatrex, Trexall), infliximab (Remicade), adalimumab (Humira).

Azathioprine (Imuran) and 6-mercaptopurine (6-MP, Purinethol) Azathioprine (Imuran) and 6-mercaptopurine (6-MP, Purinethol) are medications that weaken the body's immune system by reducing the population of a class of immune cells called lymphocytes. Azathioprine and 6-MP are related chemically. (Actually, azathioprine is converted into 6-MP within the body.) In high doses, these two drugs have been useful in preventing rejection of transplanted organs and in treating leukemia. In low doses, they have been used for many years to treat patients with moderate to severe Crohn's disease and ulcerative colitis. Azathioprine and 6-MP are increasingly recognized by doctors as valuable drugs in treating Crohn's disease and ulcerative colitis. Some 70% of patients with moderate to severe disease will benefit from these drugs. Azathioprine and 6-MP are used primarily in the following situations: 1. Severe Crohn's disease and ulcerative colitis not responding to corticosteroids. 2. The presence of undesirable corticosteroid-related side effects. 3. Corticosteroid dependency, a condition in which patients are unable to discontinue corticosteroids without developing relapses of their disease. 4. Maintenance of remission. When azathioprine and 6-MP are added to corticosteroids in the treatment of Crohn's disease not responding to corticosteroids alone, there may be an improved response. Also, smaller doses and shorter courses of corticosteroids may be able to be used. Some patients can discontinue corticosteroids altogether without experiencing relapses of their disease. This corticosteroid-lowering effect has earned azathioprine and 6-MP their reputation as "steroid-sparing" medications. In Crohn's disease patients with severe disease who suffer frequent relapses, 5-ASA may not be sufficient, and the more potent azathioprine and 6-MP will be necessary to maintain remissions. In the lower doses used to treat Crohn's disease, the longterm side effects of azathioprine or 6- MP are less serious than those of long-term corticosteroids or repeated courses of corticosteroids. Patients with Crohn's disease may undergo surgery to remove a segment of the intestine that is obstructed or contains a fistula. After surgical removal of the diseased segments, the patients often will be free of disease and symptoms for a while, but many eventually will have their disease recur. During these recurrences, previously healthy intestine can become inflamed. Long-term 5-ASA (such as Pentasa) and 6-MP both are effective in reducing the chances of recurrence after surgery. Anal fistulae can develop in some patients with Crohn's disease. Anal fistulae are abnormal tracts (tunnels) that form between the small intestine or colon and the skin around the anus. Drainage of fluid and mucous from the opening of the fistula is a troublesome problem. These fistulae are difficult to treat and do not heal readily. Metronidazole (Flagyl) has been used with some success in promoting healing of

these fistulae. In difficult cases, azathioprine and 6-MP may be successful in promoting healing. Side effects of azathioprine and 6-MP Side effects of azathioprine and 6-MP include increased vulnerability to infections, inflammation of the liver (hepatitis) and the pancreas (pancreatitis), and bone marrow toxicity (interference with the formation of cells that circulate in the blood). The goal of treatment with azathioprine and 6-MP is to lower the body's production of certain types of white blood cells (lymphocytes) in order to decrease the inflammation in the intestines; however, lowering the number of lymphocytes may increase vulnerability to infections. For example, in a group of patients with severe Crohn's disease unresponsive to standard doses of azathioprine, raising the dose of azathioprine helped to control the disease, but two patients developed cytomegalovirus (CMV) infection. (CMV typically infects individuals with weakened immune systems such as patients with AIDS and cancer patients receiving chemotherapy). Azathioprine and 6-MP can induce inflammation of the liver (hepatitis) and pancreas (pancreatitis). Pancreatitis typically causes severe abdominal pain and sometimes vomiting. Pancreatitis due to azathioprine or 6-MP occurs in 3%-5% of patients, usually during the first several weeks of treatment. Patients who develop pancreatitis should not receive either of these two medications again. Azathioprine and 6-MP also suppress the bone marrow. The bone marrow is where the red blood cells, white blood cells, and platelets are made. Actually, a slight reduction in the white cell count during treatment is desirable since it suggests that the dose of azathioprine or 6-MP is high enough to have an effect; however, excessively low red or white blood cell counts indicates bone marrow toxicity. Therefore, patients on azathioprine or 6-MP should have periodic blood counts (usually every two weeks initially and then every three months during maintenance) to monitor the effect of the drugs on the bone marrow. Patients on long-term, high dose azathioprine to prevent rejection of the kidney after kidney transplantation have an increased risk of developing lymphoma, a malignant disease of lymph cells. There is no evidence at present that long term use of azathioprine or 6-MP, in the lower doses used in Crohn's disease, increases the risk of lymphoma, leukemia or other malignancies. The use of azathioprine and 6-MP in pregnant women must be carefully considered. There are reports suggesting that the use of azathioprine or 6-MP in pregnancy is safer than once thought. The risk of continuing azathioprine or 6-MP during conception and pregnancy must be weighed against the risk of worsening disease if they are stopped. On the other hand, worsening disease has been shown clearly to be a significant risk to the fetus. Other issues with azathioprine and 6-MP One problem with 6-MP and azathioprine is their slow onset of action. Typically, full benefit of these drugs is not realized for three months or longer. During this time,

corticosteroids frequently have to be maintained at high levels to control inflammation. The reason for this slow onset of action is partly due to the way doctors prescribe these drugs. For example, 6-MP is typically started at a dose of 50 mg daily. The blood count is then checked two weeks later. If the lymphocytes are not reduced, the dose of 6-MP is increased. This cautious, stepwise approach helps reduce bone marrow and liver toxicity but also delays benefit from the drug. Studies have shown that giving higher doses of 6-MP early can hasten the benefit of 6-MP without increasing the toxicity in most patients, but some patients do develop severe bone marrow toxicity. Scientists now believe that an individual's vulnerability to 6-MP toxicity is genetically inherited. Blood tests can be performed to identify those individuals with increased vulnerability to 6-MP toxicity. Blood tests also can be performed to measure the levels of certain by-products of 6-MP. The levels of these by-products in the blood help doctors more quickly determine whether the dose of 6MP is right for the patient. TPMT genetics and safety of azathioprine and 6-MP Azathioprine is converted into 6-MP in the body and 6-MP then is partially converted in the body into inactive and non-toxic chemicals by an enzyme called thiopurine methyltransferase (TPMT). These chemicals then are eliminated from the body. The activity of TPMT enzyme (the ability of the enzyme to convert 6-MP into inactive and non-toxic chemicals) is genetically determined, and approximately 10% of the population in the Untied States has a reduced or absent TPMT activity. In this 10% of patients, 6-MP accumulates and is converted into chemicals that are toxic to the bone marrow where blood cells are produced. Thus, when given normal doses of azathioprine or 6-MP, these patients with reduced or absent TPMT activities can develop seriously low white blood cell counts for prolonged periods of time, exposing them to serious life-threatening infections. Doctors now can perform genetic testing for TPMT before starting azathioprine or 6MP. Patients found to have genes associated with reduced or absent TPMT activity are treated with alternative medications or are prescribed substantially lower than normal doses of 6-MP or Azathioprine. A word of caution is in order, however. Having normal TPMT genes is no guarantee against azathioprine or 6-MP toxicity. Rarely, a patient with normal TPMT genes can develop severe toxicity in the bone marrow and a low white blood cell count even with normal doses of 6-MP or azathioprine. Therefore, all patients taking 6-MP or azathioprine (regardless of TPMT genetics) have to be closely monitored by a doctor who will order periodic blood counts for as long as the medication is taken. Another cautionary note; allopurinol (Zyloprim), used in treating high blood uric acids levels, can induce bone marrow toxicity when used together with azathioprine or 6-MP. Zyloprim used together with azathioprine or 6-MP has similar effect as having reduced TPMT activity, causing increased accumulation of the 6-MP metabolite that is toxic to the bone marrow.

6-MP metabolite levels In addition to monitoring blood cell counts and liver tests, doctors also may measure blood levels of the chemicals that are formed from 6-MP (6-MP metabolites), which can be helpful in several situations such as: 1. If a patient's disease is not responding to standard doses of 6-MP or azathioprine and his/her 6-MP blood metabolite levels are low, doctors may increase the 6-MP or azathioprine dose. 2. If a patient's disease is not responding to treatment and his/her 6-MP blood metabolite levels are zero, he/she is not taking his/her medication. The lack of response in this case is due to patient non-compliance. Duration of treatment with azathioprine and 6-MP Patients have been maintained on 6-MP or azathioprine for years without important long-term side effects. Patients on long-term azathioprine or 6-MP, however, should be closely monitored by their doctors. There are data suggesting that patients on long-term maintenance fare better than those who stop these medications. Thus, those who stop azathioprine or 6-MP are more likely to experience recurrence of their disease and are more likely to need corticosteroids or undergo surgery. Infliximab (Remicade) Infliximab (Remicade) is an antibody that attaches to a protein called tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is one of the proteins produced by immune cells during activation of the immune system. TNF-alpha, in turn, stimulates other cells of the immune system to produce and release other proteins that promote inflammation. In Crohn's disease, there is continued production of TNF-alpha as part of the immune activation. Infliximab, by attaching to TNF-alpha, blocks its activity and in so doing decreases the inflammation. Infliximab, an antibody to TNF-alpha, is produced by the immune system of mice after the mice are injected with human TNF-alpha. The mouse antibody then is modified to make it look more like a human antibody, and this modified antibody is infliximab. Such modifications are necessary to decrease the likelihood of allergic reactions when the antibody is administered to humans. Infliximab is given by intravenous infusion over two hours. Patients are monitored throughout the infusion for adverse reactions. In August 1998 the United States Food and Drug Administration approved the use of infliximab for the short-term treatment of moderate to severe Crohn's disease patients who respond inadequately to corticosteroids, azathioprine, or 6-MP. Effectiveness of infliximab Infliximab is an effective and fast-acting drug for the treatment of active Crohn's disease. In a study involving patients with moderate to severe Crohn's disease who were not responding to corticosteroids or immuno-modulators, 65% experienced improvement in their disease after one infusion of infliximab. Some patients noticed

improvement in symptoms within days of the infusion. Most patients experienced improvement within two weeks. In patients who respond to infliximab, the improvements in symptoms can be dramatic. Moreover, there can be impressively rapid healing of the ulcers and the inflammation in the intestines after just one infusion. The anal fistulae of Crohn's disease are troublesome and often difficult to treat. Infliximab has been found to be effective for treating fistulae. Duration of benefits with infliximab The majority of the patients who responded to a first infusion of infliximab developed recurrence of their disease within three months. However, studies have shown that repeated infusions of infliximab every eight weeks are safe and effective in maintaining remission in many patients over a one to two year period. Response to infliximab after repeated infusions sometimes is lost if the patient starts to develop antibodies to the infliximab (which attach to the infliximab and prevent it from working). Studies are now being done to determine the long-term safety and effectiveness of repeated infusions of infliximab. One potential use of infliximab is to quickly control active and severe disease. The use of infliximab then may be followed by maintenance treatment with azathioprine, 6-MP or 5-ASA compounds. Azathioprine or 6-MP also may be helpful in preventing the development of antibodies against infliximab. Side effects of infliximab Infliximab generally is well-tolerated. There have been rare reports of side effects during infusions, including chest pain, shortness of breath, and nausea. These effects usually resolve spontaneously within minutes if the infusion is stopped. Other commonly-reported side effects include headache and upper respiratory tract infection. TNF-alpha is an important protein for defending the body against infections. Infliximab, like immuno-modulators, increases the risk for infection. One case of salmonella colitis and several cases of pneumonia have been reported with the use of infliximab. There also have been cases of tuberculosis (TB) reported after the use of infliximab. Because infliximab is partly a mouse protein, it may induce an immune reaction when given to humans, especially with repeated infusions. In addition to the side effects that occur while the infusion is being given, patients also may develop a "delayed allergic reaction" that occurs 7-10 days after receiving the infliximab. This type of reaction may cause flu-like symptoms with fever, joint pain and swelling, and a worsening of Crohn's disease symptoms. It can be serious, and if it occurs, a physician should be contacted. Paradoxically, those patients who have more frequent infusions of infliximab are less likely to develop this type of delayed reaction compared to those patients who receive infusions separated by long intervals (6-12 months). Although infliximab is only FDA approved for a single infusion at this time,

patients should be aware that they are likely to require repeated infusions once Remicade therapy has been initiated. Rare cases of nerve inflammation such as optic neuritis (inflammation of the nerve of the eye) and mother neuropathy has been reported with the use of infliximab. Precautions with infliximab Infliximab can aggravate and cause the spread of an existing infection. Therefore, it should not be given to patients with pneumonia, urinary tract infection or abscess (localized collection of pus). It now is recommended that patients be tested for TB prior to receiving infliximab. Patients who previously had TB should inform their physician of this before they receive infliximab infliximab can cause the spread of cancer cells; therefore, it should not be given to patients with cancer. Infliximab can promote intestinal scarring (part of the process of healing) and, therefore, can worsen strictures (narrowed areas of the intestine caused by inflammation and subsequent scaring) and lead to intestinal obstruction. It also can cause partial healing (partial closure) of anal fistulae. Partial closure of fistulae impedes drainage of fluid through the fistulae, and may result in collections of fluid in which bacteria multiply, which can result in abscesses. The effects infliximab on the fetus are not known. Because infliximab is partly a mouse protein, some patients can develop antibodies against infliximab with repeated infusions. Such antibodies can decrease the effectiveness of the drug. The chance of developing such antibodies can be decreased by the concomitant use of 6-MP and corticosteroids. There are some reports of worsening heart disease in patients who have received Remicade. The precise mechanism and role of infliximab in the development of this side effect is unclear. As a precaution, individuals with heart disease should inform their physician of this condition before receiving infliximab. While infliximab represents an exciting new class of medications in the fight against Crohn's disease, caution is warranted in its use. The long-term safety and effectiveness is not yet known. Adalimumab (Humira) Adalimumab is an anti-TNF agent similar to infliximab and decreases inflammation by blocking tumor necrosis factor (TNF-alpha). In contrast to infliximab, adalimumab is a fully humanized anti-TNF antibody (no mouse protein). Adalimumab is administered subcutaneously (under the skin) instead of intravenously as in the case of infliximab. Rheumatologists have been using adalimumab for treating inflammation of the joints in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Four recent clinical trials (involving almost 1,500 patients) comparing adalimumab to placebo, have demonstrated that adalimumab is also effective in treating inflammation in the intestines of patients with Crohn's disease and in reducing signs and symptoms of Crohn's disease.

Adalimumab is comparable to infliximab in effectiveness and safety for inducing and maintaining remission in patients suffering from Crohn's disease. Adalimumab is also effective in healing Crohn's anal fistulas. Adalimumab has been shown to be effective for patients who either failed or cannot tolerate infliximab. The Food and Drug Administration in February 2007, approved Humira (adalimumab) to treat adult patients with moderately to severely active Crohn's disease. Adalimumab (Humira) is administered subcutaneously every two weeks. The side effects of Adalimumab Adalimumab generally is well-tolerated. The most common side effect is skin reactions at the site of injection with swelling, itching, or redness. Other common side effects include upper respiratory infections, sinusitis, and nausea. TNF-alpha is an important protein for defending the body against infections. Adalimumab, like infliximab, increases the risk of infection. There have been cases of tuberculosis (TB) reported after the use of infliximab and adalimumab. It now is recommended that patients be tested for TB prior to receiving these agents. Patients who previously had TB should inform their physician of this before they receive these agents. Adalimumab, like infliximab, can aggravate and cause the spread of an existing infection. Therefore, it should not be given to patients with pneumonia, urinary tract infection or abscess (localized collection of pus). Rare cases of lymphoma (cancer of the lymphatic system) have been reported with the use of adalimumab. Rare cases of nervous system inflammation have been reported with the use of adalimumab. The symptoms may include numbness and tingling, vision disturbances, weakness in legs. Some patients receiving adalimumab may rarely develop symptoms that mimic systemic lupus; these symptoms include skin rash, arthritis, chest pain, or shortness of breath. These lupus-like symptoms resolve after stopping the drug. There are some reports of worsening heart disease such as heart failure in patients who have received infliximab or adalimumab. The precise mechanism and role of these agents in the development of this side effect is unclear. As a precaution, individuals with heart disease should inform their physician of this condition before receiving infliximab or adalimumab. Severe allergic reactions with rash, difficulty breathing, and severe low blood pressure or shock are rare, but serious allergic reactions can occur either after the fist injection or after many injections. Patients experiencing symptoms of serious allergic reactions should seek emergency care are immediately Methotrexate (Rheumatrex, Trexall) Methotrexate (Rheumatrex, Trexall) is both an immuno-modulator and antiinflammatory medication. Methotrexate has been used for many years in the treatment of severe rheumatoid arthritis and psoriasis. It has been helpful in treating patients with moderate to severe Crohn's disease who are either not responding to azathioprine and 6- MP or are intolerant of them. Methotrexate also may be effective in patients with moderate to severe ulcerative colitis who are not responding to

corticosteroids, azathioprine, or 6-MP. It can be given orally or by weekly injections under the skin or into the muscles, but it is more reliably absorbed with the injections. One major complication of methotrexate is the development of liver cirrhosis when the medication is given over a prolonged period of time (years). The risk of liver damage is higher in patients who also abuse alcohol or are severely obese. Although it has been recommended that a liver biopsy should be obtained in patients who have received a cumulative (total) methotrexate dose of 1.5 grams or higher, the need for such biopsies is controversial. Other side effects of methotrexate include low white blood cell counts and inflammation of the lungs. Methotrexate should not be used in pregnant women because of toxic effects on the fetus. Surgery in Crohn's disease There is no surgical cure for Crohn's disease. Even when all of the diseased parts of the intestines are removed, inflammation frequently recurs in previously healthy intestines months to years after the surgery. Therefore, surgery in Crohn's disease is used primarily for: 1. Removal of a diseased segment of the small intestine that is causing obstruction. 2. Drainage of pus from abdominal and peri-rectal abscesses. 3. Treatment of severe anal fistulae that do not respond to drugs. 4. Resection of internal fistulae (such as a fistula between the colon and bladder) that are causing infections. Usually, after the diseased portions of the intestines are removed surgically, patients can be free of disease and symptoms for some time, often years. Surgery, when successfully performed, can lead to a marked improvement in a patient's quality of life. In many patients, however, Crohn's disease eventually returns, affecting previously healthy intestines. The recurrent disease usually is located at or near the previous site of surgery. In fact, 50% of patients can expect to have a recurrence of symptoms within four years of surgery. Drugs such as Pentasa or 6-MP have been useful in some patients to reduce the chances of relapse of Crohn's disease after surgery. General measures General measures which may help control Crohn's disease include dietary changes and supplementation. Since fiber is poorly digestible, it can worsen the symptoms of intestinal obstruction. Hence, a low fiber diet may be recommended, especially in those patients with small intestinal disease. A liquid diet may be of benefit when symptoms are more severe. Intravenous nutrition or TPN (total peripheral nutrition)

may be utilized when it is felt that the intestine needs to "rest." Supplementation of calcium, folate and vitamin B12 is helpful when malabsorption of these nutrients is apparent. The use of anti-diarrheal agents [diphenoxylate and atropine (Lomotil), loperamide (Imodium)] and anti-spasmotics also can help relieve symptoms of cramps and diarrhea.

How is Crohn's disease treated? The symptoms and severity of Crohn's disease vary among patients. Patients with mild or no symptoms may not need treatment. Patients whose disease is in remission (where symptoms are absent) also may not need treatment. There is no medication that can cure Crohn's disease. Patients with Crohn's disease typically will experience periods of relapse (worsening of inflammation) followed by periods of remission (reduced inflammation) lasting months to years. During relapses, symptoms of abdominal pain, diarrhea, and rectal bleeding worsen. During remissions, these symptoms improve. Remissions usually occur because of treatment with medications or surgery, but occasionally they occur spontaneously without any treatment. Since there is no cure for Crohn's disease, the goals of treatment are to 1) induce remissions, 2) maintain remissions, 3) minimize side effects of treatment, and 4) improve the quality of life. Treatment of Crohn's disease and ulcerative colitis with medications is similar though not always identical. Medications for treating Crohn's disease include 1) antiinflammatory agents such as 5-ASA compounds, corticosteroids, topical antibiotics, 2) immuno-modulators, 3) other medications. Antiinflammatory medications Antiinflammatory medications that decrease intestinal inflammation are analogous to arthritis medications that decrease joint inflammation. Different types of antiinflammatory medications used in the treatment of Crohn's disease are: 5-ASA compounds such as sulfasalazine (Azulfidine) and mesalamine (Pentasa, Asacol, Dipentum, Colazal, Rowasa enema, Canasa suppository) that act via direct contact (topically) with the inflamed tissue in order to be effective. Corticosteroids that act systemically (without the need for direct contact with the inflamed tissue) to decrease inflammation throughout the body. Systemic corticosteroids have important and predictable side effects if used long-term. A new class of topical corticosteroid (for example, budesonide) that acts via direct contact (topically) with the inflamed tissue. This class of corticosteroids has fewer side effects than systemic corticosteroids which are absorbed into the body. Antibiotics such as metronidazole (Flagyl) and ciprofloxacin (Cipro) that decrease inflammation by an unknown mechanism 5-ASA (mesalamine) oral medications 5-aminosalicylic acid (5-ASA), also called mesalamine, is similar chemically to aspirin. Aspirin has been used for many years for treating arthritis, bursitis, and tendonitis (conditions of tissue inflammation). Aspirin, however, is not effective in

treating Crohn's disease and ulcerative colitis, and even may worsen the inflammation. On the other hand, 5-ASA can be effective in treating Crohn's disease and ulcerative colitis if the drug can be delivered topically onto the inflamed intestinal lining. For example, mesalamine (Rowasa) is an enema containing 5-ASA that is effective in treating inflammation in the rectum. However, the enema solution cannot reach high enough to treat inflammation in the upper colon and the small intestine. Therefore, for most patients with Crohn's disease involving both the ileum (distal small intestine) and colon, 5-ASA must be taken orally. If pure 5-ASA is taken orally, however, most of the 5-ASA would be absorbed in the stomach and the upper small intestine, and very little 5-ASA would reach the ileum and colon. To be effective as an oral agent in treating Crohn's disease, 5-ASA has to be modified chemically to escape absorption by the stomach and the upper intestines. Sulfasalazine (Azulfidine) Sulfasalazine (Azulfidine) was the first modified 5-ASA compound used in the treatment of Crohn's colitis and ulcerative colitis. It has been used successfully for many years to induce remissions among patients with mild to moderate ulcerative colitis. Sulfasalazine also has been used for prolonged periods for maintaining remissions. Sulfasalazine consists of a 5-ASA molecule linked chemically to a sulfapyridine molecule. (Sulfapyridine is a sulfa antibiotic.) Connecting the two molecules together prevents absorption by the stomach and the upper intestines. When sulfasalazine reaches the ileum and the colon, the bacteria that normally are present break the link between the two molecules. After breaking away from 5-ASA, sulfapyridine is absorbed into the body and later eliminated in the urine. Most of the active 5-ASA, however, is available within the terminal ileum and colon to treat the colitis. Most of the side effects of sulfasalazine are due to the sulfapyridine molecule. These side effects include nausea, heartburn, headache, anemia, skin rashes, and, in rare instances, hepatitis and kidney inflammation. In men, sulfasalazine can reduce the sperm count. The reduction in sperm count is reversible, and the count usually becomes normal after the sulfasalazine is discontinued or changed to a different 5ASA compound. Because the newer 5ASA compounds [for example, mesalamine (Asacol and Pentasa)] do not have the sulfapyridine component and have fewer side effects than sulfasalazine, they are being used more frequently in treating Crohn's disease and ulcerative colitis. Asacol Asacol is a tablet consisting of the 5-ASA compound surrounded by an acrylic resin coating. Asacol is sulfa-free. The resin coating prevents the 5-ASA from being absorbed as it passes through the stomach and the small intestine. When the tablet reaches the terminal ileum and the colon, the resin coating dissolves, and the active 5-ASA drug is released.

Asacol is effective in inducing remissions in patients with mild to moderate ulcerative colitis. It also is effective when used in the longer term to maintain remissions. Some studies have shown that Asacol also is effective in treating Crohn's ileitis and ileocolitis, as well as in maintaining remission in patients with Crohn's disease. The recommended dose of Asacol for inducing remissions is two 400 mg tablets three times daily (a total of 2.4 grams a day). At least two tablets of Asacol twice daily (1.6 grams a day) is recommended for maintaining remission. Occasionally, the maintenance dose is higher. As with Azulfidine, the benefits of Asacol are dose-related. If patients do not respond to 2.4 grams a day of Asacol, the dose frequently is increased to 3.6 - 4.8 grams a day to induce remission. If patients fail to respond to the higher doses of Asacol, then other alternatives such as corticosteroids are considered. Pentasa Pentasa is a capsule consisting of small spheres containing 5-ASA. Pentasa is sulfafree. As the capsule travels down the intestines, the 5-ASA inside the spheres is released slowly into the intestine. Unlike Asacol, the active drug 5-ASA in Pentasa is released into the small intestine as well as the colon. Therefore, Pentasa can be effective in treating inflammation in the small intestine and is currently the most commonly used 5-ASA compound for treating mild to moderate Crohn's disease in the small intestine. Patients with Crohn's disease occasionally undergo surgery to relieve small intestinal obstruction, drain abscesses, or remove fistulae. Usually, the diseased portions of the intestines are removed during surgery. After successful surgery, patients can be free of disease and symptoms (in remission) for a while. In many patients, however, Crohn's disease eventually returns. Pentasa helps maintain remissions and reduces the chances of the recurrence of Crohn's disease after surgery. In the treatment of Crohn's ileitis or ileocolitis, the dose of Pentasa usually is four 250 mg capsules four times daily (a total of 4 grams a day). For maintenance of remission in patients after surgery, the dose of Pentasa is between 3-4 grams daily. Olsalazine (Dipentum) Olsalazine (Dipentum) is a capsule in which two molecules of 5-ASA are joined together by a chemical bond. In this form, the 5-ASA cannot be absorbed from the stomach and intestine. Intestinal bacteria are able to break apart the two molecules releasing the active individual 5-ASA molecules into the intestine. Since intestinal bacteria are more abundant in the ileum and colon, most of the active 5-ASA is released in these areas. Therefore, olsalazine is most effective for disease that is limited to the ileum or colon. Although clinical studies have shown that olsalazine is effective for maintenance of remission in ulcerative colitis, up to 11% of patients experience diarrhea when taking olsalazine. Because of this, olsalazine is not often used. The recommended dose of olsalazine is 500 mg twice a day.

Balsalazide (Colazal) Balsalazide (Colazal) is a capsule in which the 5-ASA is linked by a chemical bond to another molecule that is inert (without effect on the intestine) and prevents the 5ASA from being absorbed. This drug is able to travel through the intestine unchanged until it reaches the end of the small bowel (terminal ileum) and colon. There, intestinal bacteria break apart the 5-ASA and the inert molecule releasing the 5-ASA. Because intestinal bacteria are most abundant in the terminal ileum and colon, balsalazide is used to treat inflammatory bowel disease predominantly localized to the colon. Side effects of oral 5-ASA compounds The 5-ASA compounds have fewer side effects than Azulfidine and also do not reduce sperm counts. They are safe medications for long-term use and are well-tolerated. Patients allergic to aspirin should avoid 5-ASA compounds because they are similar chemically to aspirin. Rare kidney and lung inflammation has been reported with the use of 5-ASA compounds. Therefore, 5-ASA should be used with caution in patients with kidney disease. It also is recommended that blood tests of kidney function be done before starting and periodically during treatment. Rare instances of worsening of diarrhea, cramps, and abdominal pain, at times accompanied by fever, rash, and malaise, may occur. This reaction is believed to represent an allergy to the 5-ASA compound. 5-ASA rectal medications (Rowasa Canasa) Rowasa is 5-ASA in enema form. 5-ASA by enema is most useful for treating ulcerative colitis involving only the distal colon since the enema easily can reach the inflamed tissues of the distal colon. Rowasa also is used in treating Crohn's disease in which there is inflammation in and near the rectum. Each Rowasa enema contains 4 grams of 5-ASA. The enema usually is administered at bedtime, and patients are encouraged to retain the enema through the night. The enema contains sulfite and should not be used by patients with sulfite allergy. Otherwise, Rowasa enemas are safe and well-tolerated. Canasa is 5-ASA in suppository form. It is used for treating ulcerative proctitis. Each suppository contains 500 mg of 5-ASA and usually is administered twice daily. Both enemas and suppositories have been shown to be effective in maintaining remission in patients with ulcerative colitis limited to the distal colon and rectum. Corticosteroids Corticosteroids (for example, prednisone, prednisolone, hydrocortisone, etc.) have been used for many years to treat patients with moderate to severe Crohn's disease and ulcerative colitis and to treat patients who fail to respond to 5-ASA. Unlike 5-

ASA, corticosteroids do not require direct contact with the inflamed intestinal tissues to be effective. Oral corticosteroids are potent antiinflammatory medications. After absorption, corticosteroids exert prompt antiinflammatory actions throughout the body, including the intestines. Consequently, they are used in treating Crohn's disease anywhere in the small intestine, as well as ulcerative and Crohn's colitis. In critically ill patients, intravenous corticosteroids (such as hydrocortisone) can be given in the hospital. For patients with proctitis, hydrocortisone enemas (Cortenema) can be used to deliver the corticosteroid directly to the inflamed tissue. By using the corticosteroid topically, less of it is absorbed into the body and the frequency and severity of side effects are lessened (but not eliminated) as compared with systemic corticosteroids. Corticosteroids are faster-acting than 5-ASA, and patients frequently experience improvement in their symptoms within days of beginning them. Corticosteroids, however, do not appear to be useful in maintaining remission in Crohn's disease and ulcerative colitis or in preventing the return of Crohn's disease after surgery. Side effects of corticosteroids The frequency and severity of side effects of corticosteroids depend on the dose and duration of their use. Short courses of corticosteroids, for example, usually are welltolerated with few and mild side effects. Long-term use of high doses of corticosteroids usually produces predictable and potentially serious side effects. Common side effects include: rounding of the face (moon face), acne, increased body hair, diabetes, weight gain, high blood pressure, cataracts, glaucoma, increased susceptibility to infections, muscle weakness, depression, insomnia, mood swings,

personality changes, irritability, and thinning of the bones (osteoporosis) with fractures of the spine. Children receiving corticosteroids experience stunted growth. The most serious complication from long term corticosteroid use is aseptic necrosis of the hip joints. Aseptic necrosis is a condition in which there is death and degeneration of the hip bone. It is a painful condition that can ultimately lead to the need for surgical replacement of the hip. Aseptic necrosis also has been reported in the knee joints. It is not known how corticosteroids cause aseptic necrosis. The estimated incidence of aseptic necrosis among corticosteroid users is 3%-4%. Patients on corticosteroids who develop pain in the hips or knees should report the pain to their doctors promptly. Early diagnosis of aseptic necrosis with cessation of corticosteroids might decrease the severity of the aseptic necrosis and the need for hip replacement surgery. Prolonged use of corticosteroids can depress the ability of the body's adrenal glands to produce cortisol (a natural corticosteroid necessary for proper functioning of the body). Therefore, abruptly discontinuing corticosteroids can cause symptoms due to a lack of natural cortisol (a condition called adrenal insufficiency). Symptoms of adrenal insufficiency include nausea, vomiting, and even shock. Withdrawing corticosteroids too quickly also can produce symptoms of joint pain, fever, and malaise. Therefore, when corticosteroids are discontinued, the dose usually is tapered gradually rather than stopped abruptly. Even after corticosteroids are discontinued, the adrenal glands' ability to produce cortisol can remain depressed from months up to two years. The depressed adrenal glands may not be able to produce increased amounts of cortisol to help the body handle the stress of accidents, surgery, and infections. Therefore, patients need additional corticosteroids during stressful situations to avoid developing adrenal insufficiency. Because corticosteroids are not useful in maintaining remission in ulcerative colitis and Crohn's disease, and because they have predictable and potentially serious side effects, they should be used for the shortest possible length of time. Proper use of corticosteroids Once the decision is made to use systemic corticosteroids, treatment usually is initiated with prednisone, 40-60 mg daily. The majority of patients with Crohn's disease respond with an improvement in symptoms within a few weeks. Once symptoms have improved, prednisone is reduced by 5-10 mg per week until a dose of 20 mg per day is reached. The dose then is reduced at a slower rate until the corticosteroid is discontinued. Gradually reducing corticosteroids not only minimizes the symptoms of adrenal insufficiency, it also reduces the chances of an abrupt recurrence of inflammation. Many doctors use 5-ASA compounds and corticosteroids together. In patients who achieve remission with corticosteroids, 5-ASA compounds often are continued alone to maintain remission.

In patients whose symptoms return corticosteroids are slowly being reduced, the dose of corticosteroids is increased slightly to control the symptoms. Once the symptoms are under control, the reduction of corticosteroids can resume at a slower pace. Unfortunately, many patients who require corticosteroids to induce remissions become corticosteroid dependent. These patients consistently develop symptoms whenever the corticosteroid dose falls below a certain level. In such patients who are corticosteroid dependent as well as in patients who are unresponsive to corticosteroids and other antiinflammatory medications, immuno-modulator medications or surgery must be considered. The management of patients who are corticosteroid dependent or patients with severe disease that responds poorly to medications is complex. Doctors who are experienced in treating ulcerative colitis and Crohn's disease and in using immuno-modulators should evaluate these patients. Prevention of osteoporosis Long-term use of corticosteroids can cause osteoporosis. Calcium is very important in the formation and maintenance of healthy bones. Corticosteroids decrease the absorption of calcium from the intestine and increase the loss of calcium from the kidneys. Increasing dietary calcium intake is important but alone cannot halt corticosteroid-induced osteoporosis. To prevent or minimize osteoporosis, management of patients on long-term corticosteroids should include: Adequate intake of calcium (1000 mg daily in premenopausal women, 1,500 mg daily in postmenopausal women) and vitamin D (800 units daily). Periodic review with the doctor of the need for continued corticosteroid treatment and use of the lowest effective dose if continued treatment is necessary. For patients taking corticosteroids for more than three months, a bone density study may be helpful in determining the extent of bone loss and the need for more aggressive treatment. Regular weight-bearing exercise and stopping smoking (cigarettes). Discussion with the doctor regarding the use of alendronate (Fosamax), risedronate (Actonel), or etidronate (Didronel) to prevent or treat corticosteroid-induced osteoporosis. Budesonide (Entocort EC) Budesonide (Entocort EC) is a new type of corticosteroid for treating Crohn's disease. Like other corticosteroids, budesonide is a potent antiinflammatory medication. Unlike other corticosteroids, however, budesonide acts only via direct contact with the inflamed tissues (topically) and not systemically. As soon as budesonide is absorbed into the body, the liver converts it into inactive chemicals. Therefore, for effective treatment of Crohn's disease, budesonide, like topical 5-ASA, must be brought into direct contact with the inflamed intestinal tissue. Budesonide capsules contain granules that allow a slow release of the drug into the ileum and the colon. In a double-blind multicenter study (published in 1998), 182

patients with Crohn's ileitis and/or Crohn's disease of the right colon were treated with either budesonide (9 mg daily) or Pentasa (2 grams twice daily). Budesonide was more effective than Pentasa in inducing remissions while the side effects were similar to Pentasa. In another study comparing the effectiveness of budesonide with corticosteroids, budesonide was not better than corticosteroids in treating Crohn's disease but had fewer side effects. Because budesonide is broken down by the liver into inactive chemicals, it has fewer side effects than systemic corticosteroids. It also suppresses the adrenal glands less than systemic corticosteroids. Budesonide will be available as an enema for the treatment of proctitis. Budesonide has not been shown to be effective in maintaining remission in patients with Crohn's disease. If used long-term, budesonide also may cause some of the same side effects as corticosteroids. Because of this, the use of budesonide should be limited to short-term treatment for inducing remission. Most budesonide is released in the terminal ileum, it will have its best results in Crohn's disease limited to the terminal ileum. It is not known whether budesonide is effective in treating patients with ulcerative colitis, and it is currently not recommended for the treatment of ulcerative colitis. Antibiotics for Crohn's disease Antibiotics such as metronidazole (Flagyl) and ciprofloxacin (Cipro) have been used for treating Crohn's colitis. Flagyl also has been useful in treating anal fistulae in patients with Crohn's disease. The mechanism of action of these antibiotics in Crohn's disease is not well understood. Metronidazole (Flagyl) Metronidazole (Flagyl) is an antibiotic that is used for treating several infections caused by parasites (for example, giardia) and bacteria (for example, infections caused by anaerobic bacteria, and vaginal infections). It is effective in treating Crohn's colitis and is particularly useful in treating patients with anal fistulae. Chronic use of metronidazole in doses higher than 1 gram daily can be associated with permanent nerve damage (peripheral neuropathy). The early symptoms of peripheral neuropathy are numbness and tingling in the fingertips, toes, and other parts of the extremities. Metronidazole should be stopped promptly if these symptoms appear. Metronidazole and alcohol together can cause severe nausea, vomiting, cramps, flushing, and headache. Patients taking metronidazole should avoid alcohol. Other side effects of metronidazole include nausea, headaches, loss of appetite, a metallic taste, and, rarely, a rash. Ciprofloxacin (Cipro) Ciprofloxacin (Cipro) is another antibiotic used in the treatment of Crohn's disease. It can be used in combination with metronidazole.

Summary of antiinflammatory medications Azulfidine, Asacol, Pentasa, Dipentum, Colazal and Rowasa all contain 5-ASA which is the active topical antiinflammatory ingredient. Azulfidine was the first 5-ASA medication used in treating ulcerative colitis and Crohn's disease, but the newer 5-ASA medications have fewer side effects. Pentasa and Asacol have been found to be effective in treating patients with Crohn's ileitis and ileo-colitis. Rowasa enemas and Canasa suppositories are safe and effective for treating patients with proctitis. For mild to moderate Crohn's ileitis or ileo-colitis, doctors usually start with Pentasa or Asacol. If Pentasa or Asacol is ineffective, doctors may try antibiotics such as Cipro or Flagyl for prolonged periods (often months). In patients with moderate to severe disease and in patients who fail to respond to 5-ASA compounds and/or antibiotics, systemic corticosteroids can be used. Systemic corticosteroids are potent and fast-acting antiinflammatory agents for treating Crohn's enteritis and colitis as well as ulcerative colitis. Systemic corticosteroids are not effective in maintaining remission in patients with Crohn's disease. Serious side effects can result from prolonged corticosteroid treatment. To minimize side effects, corticosteroids should be gradually tapered as soon as a remission is achieved. In patients who become corticosteroid dependent or are unresponsive to corticosteroid treatment, surgery or immunomodulator treatment are considered. A new class of topical corticosteroids (budesonide) may have fewer side effects than systemic corticosteroids. Immuno-modulator medications Immuno-modulators are medications that affect the body's immune system. The immune system is composed of immune cells and the proteins that they produce. These cells and proteins serve to protect the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism used by the immune system to defend the body.) Normally, the immune system is activated only when the body is exposed to foreign invaders. In patients with Crohn's disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. Immuno-modulators decrease tissue inflammation by reducing the population of immune cells and/or by interfering with their production of proteins. Decreasing the activity of the immune system with immuno-modulators increases the risk of infections; however, the benefits of controlling moderate to severe Crohn's disease usually outweigh the risks of infection due to weakened immunity. Examples of immuno-modulators are 6-mercaptopurine (6-MP), azathioprine (Imuran), methotrexate (Rheumatrex, Trexall), infliximab (Remicade), adalimumab (Humira).

Azathioprine (Imuran) and 6-mercaptopurine (6-MP, Purinethol) Azathioprine (Imuran) and 6-mercaptopurine (6-MP, Purinethol) are medications that weaken the body's immune system by reducing the population of a class of immune cells called lymphocytes. Azathioprine and 6-MP are related chemically. (Actually, azathioprine is converted into 6-MP within the body.) In high doses, these two drugs have been useful in preventing rejection of transplanted organs and in treating leukemia. In low doses, they have been used for many years to treat patients with moderate to severe Crohn's disease and ulcerative colitis. Azathioprine and 6-MP are increasingly recognized by doctors as valuable drugs in treating Crohn's disease and ulcerative colitis. Some 70% of patients with moderate to severe disease will benefit from these drugs. Azathioprine and 6-MP are used primarily in the following situations: 1. Severe Crohn's disease and ulcerative colitis not responding to corticosteroids. 2. The presence of undesirable corticosteroid-related side effects. 3. Corticosteroid dependency, a condition in which patients are unable to discontinue corticosteroids without developing relapses of their disease. 4. Maintenance of remission. When azathioprine and 6-MP are added to corticosteroids in the treatment of Crohn's disease not responding to corticosteroids alone, there may be an improved response. Also, smaller doses and shorter courses of corticosteroids may be able to be used. Some patients can discontinue corticosteroids altogether without experiencing relapses of their disease. This corticosteroid-lowering effect has earned azathioprine and 6-MP their reputation as "steroid-sparing" medications. In Crohn's disease patients with severe disease who suffer frequent relapses, 5-ASA may not be sufficient, and the more potent azathioprine and 6-MP will be necessary to maintain remissions. In the lower doses used to treat Crohn's disease, the longterm side effects of azathioprine or 6- MP are less serious than those of long-term corticosteroids or repeated courses of corticosteroids. Patients with Crohn's disease may undergo surgery to remove a segment of the intestine that is obstructed or contains a fistula. After surgical removal of the diseased segments, the patients often will be free of disease and symptoms for a while, but many eventually will have their disease recur. During these recurrences, previously healthy intestine can become inflamed. Long-term 5-ASA (such as Pentasa) and 6-MP both are effective in reducing the chances of recurrence after surgery. Anal fistulae can develop in some patients with Crohn's disease. Anal fistulae are abnormal tracts (tunnels) that form between the small intestine or colon and the skin around the anus. Drainage of fluid and mucous from the opening of the fistula is a troublesome problem. These fistulae are difficult to treat and do not heal readily. Metronidazole (Flagyl) has been used with some success in promoting healing of

these fistulae. In difficult cases, azathioprine and 6-MP may be successful in promoting healing. Side effects of azathioprine and 6-MP Side effects of azathioprine and 6-MP include increased vulnerability to infections, inflammation of the liver (hepatitis) and the pancreas (pancreatitis), and bone marrow toxicity (interference with the formation of cells that circulate in the blood). The goal of treatment with azathioprine and 6-MP is to lower the body's production of certain types of white blood cells (lymphocytes) in order to decrease the inflammation in the intestines; however, lowering the number of lymphocytes may increase vulnerability to infections. For example, in a group of patients with severe Crohn's disease unresponsive to standard doses of azathioprine, raising the dose of azathioprine helped to control the disease, but two patients developed cytomegalovirus (CMV) infection. (CMV typically infects individuals with weakened immune systems such as patients with AIDS and cancer patients receiving chemotherapy). Azathioprine and 6-MP can induce inflammation of the liver (hepatitis) and pancreas (pancreatitis). Pancreatitis typically causes severe abdominal pain and sometimes vomiting. Pancreatitis due to azathioprine or 6-MP occurs in 3%-5% of patients, usually during the first several weeks of treatment. Patients who develop pancreatitis should not receive either of these two medications again. Azathioprine and 6-MP also suppress the bone marrow. The bone marrow is where the red blood cells, white blood cells, and platelets are made. Actually, a slight reduction in the white cell count during treatment is desirable since it suggests that the dose of azathioprine or 6-MP is high enough to have an effect; however, excessively low red or white blood cell counts indicates bone marrow toxicity. Therefore, patients on azathioprine or 6-MP should have periodic blood counts (usually every two weeks initially and then every three months during maintenance) to monitor the effect of the drugs on the bone marrow. Patients on long-term, high dose azathioprine to prevent rejection of the kidney after kidney transplantation have an increased risk of developing lymphoma, a malignant disease of lymph cells. There is no evidence at present that long term use of azathioprine or 6-MP, in the lower doses used in Crohn's disease, increases the risk of lymphoma, leukemia or other malignancies. The use of azathioprine and 6-MP in pregnant women must be carefully considered. There are reports suggesting that the use of azathioprine or 6-MP in pregnancy is safer than once thought. The risk of continuing azathioprine or 6-MP during conception and pregnancy must be weighed against the risk of worsening disease if they are stopped. On the other hand, worsening disease has been shown clearly to be a significant risk to the fetus. Other issues with azathioprine and 6-MP One problem with 6-MP and azathioprine is their slow onset of action. Typically, full benefit of these drugs is not realized for three months or longer. During this time,

corticosteroids frequently have to be maintained at high levels to control inflammation. The reason for this slow onset of action is partly due to the way doctors prescribe these drugs. For example, 6-MP is typically started at a dose of 50 mg daily. The blood count is then checked two weeks later. If the lymphocytes are not reduced, the dose of 6-MP is increased. This cautious, stepwise approach helps reduce bone marrow and liver toxicity but also delays benefit from the drug. Studies have shown that giving higher doses of 6-MP early can hasten the benefit of 6-MP without increasing the toxicity in most patients, but some patients do develop severe bone marrow toxicity. Scientists now believe that an individual's vulnerability to 6-MP toxicity is genetically inherited. Blood tests can be performed to identify those individuals with increased vulnerability to 6-MP toxicity. Blood tests also can be performed to measure the levels of certain by-products of 6-MP. The levels of these by-products in the blood help doctors more quickly determine whether the dose of 6MP is right for the patient. TPMT genetics and safety of azathioprine and 6-MP Azathioprine is converted into 6-MP in the body and 6-MP then is partially converted in the body into inactive and non-toxic chemicals by an enzyme called thiopurine methyltransferase (TPMT). These chemicals then are eliminated from the body. The activity of TPMT enzyme (the ability of the enzyme to convert 6-MP into inactive and non-toxic chemicals) is genetically determined, and approximately 10% of the population in the Untied States has a reduced or absent TPMT activity. In this 10% of patients, 6-MP accumulates and is converted into chemicals that are toxic to the bone marrow where blood cells are produced. Thus, when given normal doses of azathioprine or 6-MP, these patients with reduced or absent TPMT activities can develop seriously low white blood cell counts for prolonged periods of time, exposing them to serious life-threatening infections. Doctors now can perform genetic testing for TPMT before starting azathioprine or 6MP. Patients found to have genes associated with reduced or absent TPMT activity are treated with alternative medications or are prescribed substantially lower than normal doses of 6-MP or Azathioprine. A word of caution is in order, however. Having normal TPMT genes is no guarantee against azathioprine or 6-MP toxicity. Rarely, a patient with normal TPMT genes can develop severe toxicity in the bone marrow and a low white blood cell count even with normal doses of 6-MP or azathioprine. Therefore, all patients taking 6-MP or azathioprine (regardless of TPMT genetics) have to be closely monitored by a doctor who will order periodic blood counts for as long as the medication is taken. Another cautionary note; allopurinol (Zyloprim), used in treating high blood uric acids levels, can induce bone marrow toxicity when used together with azathioprine or 6-MP. Zyloprim used together with azathioprine or 6-MP has similar effect as having reduced TPMT activity, causing increased accumulation of the 6-MP metabolite that is toxic to the bone marrow.

6-MP metabolite levels In addition to monitoring blood cell counts and liver tests, doctors also may measure blood levels of the chemicals that are formed from 6-MP (6-MP metabolites), which can be helpful in several situations such as: 1. If a patient's disease is not responding to standard doses of 6-MP or azathioprine and his/her 6-MP blood metabolite levels are low, doctors may increase the 6-MP or azathioprine dose. 2. If a patient's disease is not responding to treatment and his/her 6-MP blood metabolite levels are zero, he/she is not taking his/her medication. The lack of response in this case is due to patient non-compliance. Duration of treatment with azathioprine and 6-MP Patients have been maintained on 6-MP or azathioprine for years without important long-term side effects. Patients on long-term azathioprine or 6-MP, however, should be closely monitored by their doctors. There are data suggesting that patients on long-term maintenance fare better than those who stop these medications. Thus, those who stop azathioprine or 6-MP are more likely to experience recurrence of their disease and are more likely to need corticosteroids or undergo surgery. Infliximab (Remicade) Infliximab (Remicade) is an antibody that attaches to a protein called tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is one of the proteins produced by immune cells during activation of the immune system. TNF-alpha, in turn, stimulates other cells of the immune system to produce and release other proteins that promote inflammation. In Crohn's disease, there is continued production of TNF-alpha as part of the immune activation. Infliximab, by attaching to TNF-alpha, blocks its activity and in so doing decreases the inflammation. Infliximab, an antibody to TNF-alpha, is produced by the immune system of mice after the mice are injected with human TNF-alpha. The mouse antibody then is modified to make it look more like a human antibody, and this modified antibody is infliximab. Such modifications are necessary to decrease the likelihood of allergic reactions when the antibody is administered to humans. Infliximab is given by intravenous infusion over two hours. Patients are monitored throughout the infusion for adverse reactions. In August 1998 the United States Food and Drug Administration approved the use of infliximab for the short-term treatment of moderate to severe Crohn's disease patients who respond inadequately to corticosteroids, azathioprine, or 6-MP. Effectiveness of infliximab Infliximab is an effective and fast-acting drug for the treatment of active Crohn's disease. In a study involving patients with moderate to severe Crohn's disease who were not responding to corticosteroids or immuno-modulators, 65% experienced improvement in their disease after one infusion of infliximab. Some patients noticed

improvement in symptoms within days of the infusion. Most patients experienced improvement within two weeks. In patients who respond to infliximab, the improvements in symptoms can be dramatic. Moreover, there can be impressively rapid healing of the ulcers and the inflammation in the intestines after just one infusion. The anal fistulae of Crohn's disease are troublesome and often difficult to treat. Infliximab has been found to be effective for treating fistulae. Duration of benefits with infliximab The majority of the patients who responded to a first infusion of infliximab developed recurrence of their disease within three months. However, studies have shown that repeated infusions of infliximab every eight weeks are safe and effective in maintaining remission in many patients over a one to two year period. Response to infliximab after repeated infusions sometimes is lost if the patient starts to develop antibodies to the infliximab (which attach to the infliximab and prevent it from working). Studies are now being done to determine the long-term safety and effectiveness of repeated infusions of infliximab. One potential use of infliximab is to quickly control active and severe disease. The use of infliximab then may be followed by maintenance treatment with azathioprine, 6-MP or 5-ASA compounds. Azathioprine or 6-MP also may be helpful in preventing the development of antibodies against infliximab. Side effects of infliximab Infliximab generally is well-tolerated. There have been rare reports of side effects during infusions, including chest pain, shortness of breath, and nausea. These effects usually resolve spontaneously within minutes if the infusion is stopped. Other commonly-reported side effects include headache and upper respiratory tract infection. TNF-alpha is an important protein for defending the body against infections. Infliximab, like immuno-modulators, increases the risk for infection. One case of salmonella colitis and several cases of pneumonia have been reported with the use of infliximab. There also have been cases of tuberculosis (TB) reported after the use of infliximab. Because infliximab is partly a mouse protein, it may induce an immune reaction when given to humans, especially with repeated infusions. In addition to the side effects that occur while the infusion is being given, patients also may develop a "delayed allergic reaction" that occurs 7-10 days after receiving the infliximab. This type of reaction may cause flu-like symptoms with fever, joint pain and swelling, and a worsening of Crohn's disease symptoms. It can be serious, and if it occurs, a physician should be contacted. Paradoxically, those patients who have more frequent infusions of infliximab are less likely to develop this type of delayed reaction compared to those patients who receive infusions separated by long intervals (6-12 months). Although infliximab is only FDA approved for a single infusion at this time,

patients should be aware that they are likely to require repeated infusions once Remicade therapy has been initiated. Rare cases of nerve inflammation such as optic neuritis (inflammation of the nerve of the eye) and mother neuropathy has been reported with the use of infliximab. Precautions with infliximab Infliximab can aggravate and cause the spread of an existing infection. Therefore, it should not be given to patients with pneumonia, urinary tract infection or abscess (localized collection of pus). It now is recommended that patients be tested for TB prior to receiving infliximab. Patients who previously had TB should inform their physician of this before they receive infliximab infliximab can cause the spread of cancer cells; therefore, it should not be given to patients with cancer. Infliximab can promote intestinal scarring (part of the process of healing) and, therefore, can worsen strictures (narrowed areas of the intestine caused by inflammation and subsequent scaring) and lead to intestinal obstruction. It also can cause partial healing (partial closure) of anal fistulae. Partial closure of fistulae impedes drainage of fluid through the fistulae, and may result in collections of fluid in which bacteria multiply, which can result in abscesses. The effects infliximab on the fetus are not known. Because infliximab is partly a mouse protein, some patients can develop antibodies against infliximab with repeated infusions. Such antibodies can decrease the effectiveness of the drug. The chance of developing such antibodies can be decreased by the concomitant use of 6-MP and corticosteroids. There are some reports of worsening heart disease in patients who have received Remicade. The precise mechanism and role of infliximab in the development of this side effect is unclear. As a precaution, individuals with heart disease should inform their physician of this condition before receiving infliximab. While infliximab represents an exciting new class of medications in the fight against Crohn's disease, caution is warranted in its use. The long-term safety and effectiveness is not yet known. Adalimumab (Humira) Adalimumab is an anti-TNF agent similar to infliximab and decreases inflammation by blocking tumor necrosis factor (TNF-alpha). In contrast to infliximab, adalimumab is a fully humanized anti-TNF antibody (no mouse protein). Adalimumab is administered subcutaneously (under the skin) instead of intravenously as in the case of infliximab. Rheumatologists have been using adalimumab for treating inflammation of the joints in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Four recent clinical trials (involving almost 1,500 patients) comparing adalimumab to placebo, have demonstrated that adalimumab is also effective in treating inflammation in the intestines of patients with Crohn's disease and in reducing signs and symptoms of Crohn's disease.

Adalimumab is comparable to infliximab in effectiveness and safety for inducing and maintaining remission in patients suffering from Crohn's disease. Adalimumab is also effective in healing Crohn's anal fistulas. Adalimumab has been shown to be effective for patients who either failed or cannot tolerate infliximab. The Food and Drug Administration in February 2007, approved Humira (adalimumab) to treat adult patients with moderately to severely active Crohn's disease. Adalimumab (Humira) is administered subcutaneously every two weeks. The side effects of Adalimumab Adalimumab generally is well-tolerated. The most common side effect is skin reactions at the site of injection with swelling, itching, or redness. Other common side effects include upper respiratory infections, sinusitis, and nausea. TNF-alpha is an important protein for defending the body against infections. Adalimumab, like infliximab, increases the risk of infection. There have been cases of tuberculosis (TB) reported after the use of infliximab and adalimumab. It now is recommended that patients be tested for TB prior to receiving these agents. Patients who previously had TB should inform their physician of this before they receive these agents. Adalimumab, like infliximab, can aggravate and cause the spread of an existing infection. Therefore, it should not be given to patients with pneumonia, urinary tract infection or abscess (localized collection of pus). Rare cases of lymphoma (cancer of the lymphatic system) have been reported with the use of adalimumab. Rare cases of nervous system inflammation have been reported with the use of adalimumab. The symptoms may include numbness and tingling, vision disturbances, weakness in legs. Some patients receiving adalimumab may rarely develop symptoms that mimic systemic lupus; these symptoms include skin rash, arthritis, chest pain, or shortness of breath. These lupus-like symptoms resolve after stopping the drug. There are some reports of worsening heart disease such as heart failure in patients who have received infliximab or adalimumab. The precise mechanism and role of these agents in the development of this side effect is unclear. As a precaution, individuals with heart disease should inform their physician of this condition before receiving infliximab or adalimumab. Severe allergic reactions with rash, difficulty breathing, and severe low blood pressure or shock are rare, but serious allergic reactions can occur either after the fist injection or after many injections. Patients experiencing symptoms of serious allergic reactions should seek emergency care are immediately Methotrexate (Rheumatrex, Trexall) Methotrexate (Rheumatrex, Trexall) is both an immuno-modulator and antiinflammatory medication. Methotrexate has been used for many years in the treatment of severe rheumatoid arthritis and psoriasis. It has been helpful in treating patients with moderate to severe Crohn's disease who are either not responding to azathioprine and 6- MP or are intolerant of them. Methotrexate also may be effective in patients with moderate to severe ulcerative colitis who are not responding to

corticosteroids, azathioprine, or 6-MP. It can be given orally or by weekly injections under the skin or into the muscles, but it is more reliably absorbed with the injections. One major complication of methotrexate is the development of liver cirrhosis when the medication is given over a prolonged period of time (years). The risk of liver damage is higher in patients who also abuse alcohol or are severely obese. Although it has been recommended that a liver biopsy should be obtained in patients who have received a cumulative (total) methotrexate dose of 1.5 grams or higher, the need for such biopsies is controversial. Other side effects of methotrexate include low white blood cell counts and inflammation of the lungs. Methotrexate should not be used in pregnant women because of toxic effects on the fetus. Surgery in Crohn's disease There is no surgical cure for Crohn's disease. Even when all of the diseased parts of the intestines are removed, inflammation frequently recurs in previously healthy intestines months to years after the surgery. Therefore, surgery in Crohn's disease is used primarily for: 1. Removal of a diseased segment of the small intestine that is causing obstruction. 2. Drainage of pus from abdominal and peri-rectal abscesses. 3. Treatment of severe anal fistulae that do not respond to drugs. 4. Resection of internal fistulae (such as a fistula between the colon and bladder) that are causing infections. Usually, after the diseased portions of the intestines are removed surgically, patients can be free of disease and symptoms for some time, often years. Surgery, when successfully performed, can lead to a marked improvement in a patient's quality of life. In many patients, however, Crohn's disease eventually returns, affecting previously healthy intestines. The recurrent disease usually is located at or near the previous site of surgery. In fact, 50% of patients can expect to have a recurrence of symptoms within four years of surgery. Drugs such as Pentasa or 6-MP have been useful in some patients to reduce the chances of relapse of Crohn's disease after surgery. General measures General measures which may help control Crohn's disease include dietary changes and supplementation. Since fiber is poorly digestible, it can worsen the symptoms of intestinal obstruction. Hence, a low fiber diet may be recommended, especially in those patients with small intestinal disease. A liquid diet may be of benefit when symptoms are more severe. Intravenous nutrition or TPN (total peripheral nutrition)

may be utilized when it is felt that the intestine needs to "rest." Supplementation of calcium, folate and vitamin B12 is helpful when malabsorption of these nutrients is apparent. The use of anti-diarrheal agents [diphenoxylate and atropine (Lomotil), loperamide (Imodium)] and anti-spasmotics also can help relieve symptoms of cramps and diarrhea.

Inflammatory bowel disease (IBD)

Inflammatory bowel disease (IBD) is a condition that causes ongoing inflammation of the intestines. The condition can affect only the large intestine (ulcerative colitis) or any part of the entire digestive tract, from the mouth to the anus (Crohn's disease). Symptoms of inflammatory bowel disease may include abdominal pain, frequent diarrhea that may contain blood or pus, fever, chills, weight loss, and fatigue. The condition may be mild or severe. The inflammation can also affect other parts of the body, such as the eyes or joints, and may cause a form of arthritis. Inflammatory bowel disease may recur many times in a person's life. It is treated with medications and sometimes with diet changes. If the disease is in remission (not causing symptoms), treatment may not be needed, although medications may help keep the disease in remission. A severe attack may require that the person be hospitalized for treatment. In some cases, surgery may be needed.

Immune system

The immune system is the body's natural defense system that helps fight infections. The immune system is made up of antibodies, white blood cells, and other chemicals and proteins that attack and destroy substances such as bacteria and viruses that they recognize as foreign and different from the body's normal healthy tissues. The immune system is also responsible for allergic reactions and allergies, which may occur when the immune system incorrectly identifies a substance (allergen), such as pollen, mold, chemicals, plants, and medications, as harmful. Sometimes the immune system also mistakenly attacks the body's own cells, which is known as an autoimmune disease.

Anal fissure

An anal fissure is a narrow tear that extends from the muscles that control the anus (anal sphincter) up into the anal canal. These tears usually develop when anal tissue is damaged during a hard bowel movement or when higher-than-normal tension develops in the anal sphincters. Symptoms of an anal fissure include a sharp, stinging, or burning pain during a bowel movement. The pain, which can be severe, may last a few hours. You may also notice spots of bright red blood on toilet tissue. This blood is separate from the stool. Minor anal fissures can often be helped to heal by drinking more fluids, eating a high-fiber diet, allowing enough time for a bowel movement, and using stool softeners.

Fistula

A fistula is an abnormal connection or opening between two organs or parts of the body that are not normally connected, such as between two parts of the intestine. A fistula may be present at birth or may develop as a complication of an infection or a disease, such as Crohn's disease. A fistula may close on its own or may require surgery to repair it.

Colonoscopy

Colonoscopy is the inspection of the entire large intestine (colon) using a long, flexible, lighted viewing scope (colonoscope), which is usually linked to a video monitor similar to a TV screen. A colonoscopy may be done to screen for cancer or to investigate symptoms, such as bleeding.

Colonoscopy is done in the hospital or a doctor's office that has the necessary equipment. Preparation for the test includes emptying the bowels ahead of time using a laxative or enema. The person undergoing colonoscopy is given medication to relieve pain and to make him or her drowsy. The test usually takes 30 to 45 minutes, but it may take longer, depending upon what is found and what is done during the test. A health professional will collect a tissue sample (biopsy) from any abnormal area. The tissue is then analyzed by a pathologist.

Biopsy

A biopsy is a sample of tissue collected from an organ or other part of the body. A biopsy can be done by cutting or scraping a small piece of the tissue or by using a needle and syringe to remove a sample, which is then examined for abnormalities, such as cancer, by a doctor trained to look at tissue samples (pathologist).

Remission

Remission refers to periods of time when a person with a long-lasting illness does not have symptoms. During a remission, a person returns to his or her usual state of health.

Complementary medicine

Complementary medicine is any treatment that is outside the traditional medicine or practice of a person's primary health system. A treatment that is complementary in one culture may be traditional in another; for example, acupuncture, although traditional in China, is considered alternative or complementary in the United States. A central concept of many types of complementary medicine is to give thought and care to the whole person (holistic) rather than providing treatment for a specific disease or symptom. This holistic view and the emphasis on maintaining good health may be appealing for those with chronic illness or for those who want to improve their quality of life through lifestyle changes. The use of complementary medicine in the U.S. is on the rise. People often seek out complementary therapies for long-term (chronic) conditions that have not been successfully treated with conventional medicine as well as to maintain and improve wellness and quality of life.

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Crohn's disease

Crohn's disease is a form of inflammatory bowel disease that causes inflammation and ulcers that may affect the deepest layers of the lining of the digestive tract. It can also cause abnormal openings or connections (fistulas) in the diseased intestine. Crohn's disease is different from ulcerative colitis in that it can affect any part of the digestive tract. Symptoms of Crohn's disease include episodes of diarrhea, abdominal pain, fever, nausea, loss of appetite, and weight loss. People with Crohn's disease may sometimes need to be hospitalized for treatment of their symptoms. Treatment depends on the severity of the attacks and the person's age. It may include medications and, sometimes, surgery for serious cases.

Abscess

An abscess is a pocket of pus that forms at the site of infected tissue. An abscess can form on the skin or on tissues within the body and cause pain, swelling, and tenderness. Bacteria are a common cause of the infections that form abscesses. Depending on the size and location of the abscess, your health professional may treat the abscess by:

Using a needle to drain it. Cutting open the abscess to remove the pus and infectious material. Prescribing antibiotics (pills or a shot). This may be adequate treatment if the abscess is small and treatment is not delayed.

Anemia

Anemia is a decrease in the amount of oxygen-carrying substance (hemoglobin) found in red blood cells. Anemia causes weakness, pale skin, and general tiredness (fatigue). Anemia can be caused by blood loss or bleeding, an increase in the destruction of red blood cells, or a decrease in the production of red blood cells. Types of anemia include iron deficiency anemia, folic acid deficiency anemia, and vitamin B12 deficiency anemia, among others. Each type of anemia is treated differently.

Anal fistula and Crohn's disease

Crohn's disease may cause sores, or ulcers, that tunnel through the intestine and into the surrounding tissue, often around the anus and rectum. These abnormal tunnels, called fistulas, are a common complication of Crohn's disease and may become infected. Crohn's disease can also cause anal fissures, which are narrow tears that extend from the muscles that control the anus (anal sphincters) up into the anal canal. An anal fistula can often be treated with medications, though sometimes surgery to repair the fistula may be necessary. Conservative treatment, including antibiotics and medications to reduce pain and inflammation, is usually tried before surgery. Surgery for an anal fistula, which is usually done only in cases of complications such as an abscess, sometimes results in persistent nonhealing. Anyone with an unusual anal fistula that does not respond to conservative treatment should be examined for Crohn's disease, since a fistula is often the first sign of Crohn's disease. An examination may include anoscopy or sigmoidoscopy, procedures that allow a health professional to view the lower rectum and lower large intestine through a viewing scope. Complete evaluation may require sedation because examination of the area can cause discomfort.

Diverticulitis

Diverticulitis is a condition in which pouches (diverticula) that form in the wall of the large intestine (colon) become inflamed or infected. Symptoms can include pain, fever, and other signs of infection and may last from a few hours to several days. Diverticulitis is usually treated with a high-fiber diet, antibiotics for infection, and pain relievers. Hospitalization or even surgery to remove the diseased part of the colon may be necessary if complications such as an abscess or peritonitis develop or if repeated attacks are not helped by other treatment.

Crohn's disease

Crohn's disease can affect any part of the digestive tract (which goes from the mouth to the anus). Most common is Crohn's disease that affects the ileum (the part of the small intestine that joins the large intestine). But Crohn's disease can be in multiple places in the digestive tract at the same time. The picture above shows Crohn's disease that is affecting the ileum and parts of the large intestine (colon), including the rectum. This kind of disease pattern is called ileocolitis.

Ulcerative colitis

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that causes inflammation and sores (ulcers) in the inner lining of the colon and rectum. It causes diarrhea, abdominal pain, and rectal bleeding. Ulcerative colitis is a chronic condition that may flare up many times during a person's life. Some people may have long periods without symptoms or may have only mild symptoms, while other people have symptoms that are more persistent and severe. Ulcerative colitis is treated with medicines or with surgery to remove the diseased colon. Treatment depends on the severity of the attacks and the person's age. Children and older people may have specific problems that require special care.

Medical history and physical exam for Crohn's disease


A medical history and physical exam are standard tests for people who have abdominal pain and a change in bowel habits. They allow a health professional to determine the seriousness and extent of disease. The medical history for Crohn's disease includes questions about:

Bowel function, including how many bowel movements you have per day or per week, whether you have constipation or diarrhea, whether you have noticed any blood or mucus in your stool, and any recent changes in your bowel habits or the shape of your stools.

Whether your bowel movement patterns have any relationship to your abdominal pain (for example, if passing a stool relieves your pain). Whether your family has any history of similar symptoms. Your use of laxatives or antacids. Factors that may increase your risk of an intestinal infection, such as traveling to a foreign country, drinking untreated water, or recently taking antibiotics. Your sexual history. Some sexually transmitted diseases may infect the rectum and cause symptoms similar to those of Crohn's disease.

Your health professional will do a standard physical exam, which may include: Feeling the abdomen. Performing a digital rectal exam. Listening for bowel sounds with a stethoscope. Examining the eyes, skin, joints, and inside of the mouth. Performing a pelvic exam for women.

Crohn's disease cannot be diagnosed based on the medical history or physical findings alone. The diagnosis may be suggested if: The abdomen is tender. Fissures, fistulas, or abscesses around the anus can be seen or felt during the digital rectal exam. You report frequent episodes of diarrhea, sometimes with blood. You may be awakened at night by an urgent need to have a bowel movement. You appear feverish and pale or look underweight. Children may be small or underdeveloped for their age. You have a family history of Crohn's disease, especially in the immediate family.

Sigmoidoscopy (Anoscopy, Proctoscopy)


Anoscopy, proctoscopy, and sigmoidoscopy tests allow your health professional to look at the inner lining of your anus, rectum, and the lower part of the large intestine (colon). These tests are used to look for abnormal growths (such as tumors or polyps), inflammation, bleeding, hemorrhoids, and other conditions (such as diverticulosis). These test use different scopes look at different sections of the colon. Anoscopy. During an anoscopy, a short, rigid, hollow tube (anoscope) that may contain a light source is used to look at the last 2 in. of the colon (anal canal). Anoscopy can usually be done at any time because it does not require any special preparation (enemas or laxatives) to empty the colon. Proctoscopy. During a proctoscopy, a slightly longer instrument than the anoscope is used to view the inside of the rectum. You usually will have to use enemas or laxatives to empty the colon before the test is done. Sigmoidoscopy. During a sigmoidoscopy, a lighted tube that may be either rigid or flexible is inserted through the anus. Your health professional can remove small growths and collect tissue samples (biopsy) through a sigmoidoscope. You will have to use enemas or laxatives (or both) to empty the colon before the test is done.

The flexible sigmoidoscope is about 2.3 ft long and 0.5 in. wide with a lighted lens system. This instrument allows your health professional to see around bends in the colon. A flexible sigmoidoscope allows a more complete view of the lower colon than a rigid scope and usually makes the examination more comfortable. The flexible sigmoidoscope generally has replaced the rigid sigmoidoscope. The rigid sigmoidoscope is used less often. It is about 10 in. to 12 in. long and 1 in. wide. It allows your health professional to look into the rectum and the bottom part of the colon, but it does not reach as far into the colon as the flexible sigmoidoscope.

Health Tools Health tools help you make wise health decisions or take action to improve your health. Decision Points focus on key medical care decisions that are important to many health problems. Which test should I have to screen for colorectal cancer? Why It Is Done These tests are done to: Detect problems or diseases of the anus, rectum, or lower large intestine (sigmoid colon). These tests are often done to investigate symptoms such as unexplained bleeding from the rectum, long-lasting diarrhea or constipation, blood or pus in the stool, or lower abdominal pain. Remove polyps or hemorrhoids. Monitor the growth of polyps or the treatment of inflammatory bowel disease. Screen for colon cancer or polyps.

How To Prepare Anoscopy Usually, no preparation is needed for an anoscopy. Proctoscopy and sigmoidoscopy Test preparation for a proctoscopy and sigmoidoscopy may be similar. Before the test: Talk with your health professional to find out if you need to stop taking some medicines, such as warfarin, before the test. Talk with your health professional to find out if you need to take antibiotics before the test, especially if you have a heart murmur, an artificial heart valve, or an artificial implant (such as a replacement joint). Tell your health professional if you have been diagnosed with peritonitis, diverticulitis, or toxic megacolon or if you have had recent bowel surgery.

The preparation for these tests usually involves a thorough cleaning of the lower colon, because it must be completely clear of stool (feces). Even a small amount of fecal material can affect the accuracy of the test.

You may be instructed to follow a liquid diet for 1 to 2 days before the test. You may be instructed to not eat for up to 12 hours before the test. You may need to have an enema the night before the test and another enema an hour before the examination. You may not need special preparation, especially if you have watery or bloody diarrhea.

Talk to your health professional about any concerns you have regarding the need for this test, its risks, how it will be done, or what the results may indicate. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done You will usually lie on your left side during the test. You may also be asked to kneel on the table with your bottom raised in the air. Once you are in position: Your health professional will gently insert a gloved finger into your anus to check for tenderness or blockage. For men, your health professional will also check the condition of the prostate gland. The lubricated scope is then inserted. The scope is moved slowly forward into the rectum and lower colon. During a sigmoidoscopy, puffs of air sometimes are blown through the scope to open the colon so that your health professional can see more clearly. Suction may be used to remove watery stool, enema liquid, mucus, or blood through the scope. Once your health professional has moved the scope forward as far as possible, it is slowly withdrawn while tissue is carefully inspected. Your health professional may also insert tiny instruments (forceps, loops, swabs) through the scope to collect tissue samples (biopsy) or to remove growths. Tissue samples may be sent to a laboratory for examination.

See the following pictures: Step 1: The sigmoidoscope is inserted . Step 2: The health professional examines the wall of the sigmoid colon .

After the scope is removed, your anal area will be cleaned with tissues. If you are having cramps, passing gas may help relieve them. The entire examination usually takes 5 to 15 minutes, slightly longer if tissue samples are taken or if polyps are removed. If you received a sedative during the test, do not drive, operate machinery, or sign legal documents for 24 hours after the test. Arrange to have someone drive you home after the test. After the test you may resume your regular diet, unless your health professional gives you other directions. Be sure to drink plenty of liquids to replace those you have lost during the preparation for the sigmoidoscopy.

How It Feels An anoscopy, proctoscopy, and sigmoidoscopy examination can be embarrassing and uncomfortable. You may have cramping, a feeling of pressure or bloating, or feel a brief, sharp pain when the scope is moved forward or when air is blown into your colon. The removal of tissue samples (biopsy) from the colon does not cause discomfort. A local anesthetic is used when a biopsy of the anal area is done. Your anus may be sore for a few days. You may have mild gas pains and may need to pass some gas after the procedure. Walking may help relieve the gas pains. If a biopsy was done or a polyp removed, you may have traces of blood in your stool for a few days. Risks There is very little risk of complications from having an anoscopy, proctoscopy, or sigmoidoscopy. There is a slight chance of piercing the colon (perforation) or causing severe bleeding by damaging the wall of the colon. However, these problems are rare. There is also a slight chance of a colon infection (very rare).

Call your health professional immediately if you have: Heavy rectal bleeding. Severe abdominal pain. A fever.

Results Anoscopy, proctoscopy, and sigmoidoscopy tests allow your health professional to look at the inner lining of your anus, rectum, and the lower part of the large intestine (colon). Your health professional should be able to discuss some of the findings with you immediately after the test. Lab results (such as from a biopsy) may take several days. Anoscopy, proctoscopy, and sigmoidoscopy Normal: The lining of the colon appears smooth and pink, with numerous folds. No abnormal growths, pouches, bleeding, or inflammation is present.

Abnormal: Some of the more common abnormal findings include: Hemorrhoids, which are the most common cause of blood in the stool. Colon polyps . Cancer in the colon . A sore (ulcer).

Pouches in the wall of the colon (diverticulosis). Redness and swelling of the lining of the colon (colitis).

Your health professional will discuss any significant abnormal results with you in relation to your symptoms and past health. What Affects the Test Factors that can interfere with your test or the accuracy of the results include: Stool in the colon or rectum. The structure of the colon, such as a colon that has many turns. A barium enema done within a week before sigmoidoscopy. Rectal bleeding.

What To Think About Follow-up tests, such as colonoscopy, may be needed after sigmoidoscopy. A colonoscopy may also be needed to examine the upper section of the colon if growths were seen during sigmoidoscopy. For more information, see the medical test Colonoscopy. In some cases, the sigmoidoscope may be attached to a video monitor and a recording device that lets your health professional see the inside the colon and record the findings. Most medical experts recommend colon cancer screening beginning at age 50 for people who have an average risk and earlier for those who have an increased risk for colon cancer, such as those with a family history of colon cancer. Talk with your health professional about which colon cancer screening test is best for you. You may not be able to have this test if you have peritonitis, diverticulitis, toxic megacolon, or if you have had recent bowel surgery.

Colonoscopy
Colonoscopy is a test that allows your doctor to look at the inner lining of your large intestine (rectum and colon). He or she uses a thin, flexible tube called a colonoscope to look at the colon. A colonoscopy helps find ulcers, polyps, tumors, and areas of inflammation or bleeding. During a colonoscopy, tissue samples can be collected (biopsy) and abnormal growths can be taken out. Colonoscopy can also be used as a screening test to check for cancer or precancerous growths in the colon or rectum (polyps). The colonoscope is a thin, flexible tube that ranges from 48 in. to 72 in. long. A small video camera is attached to the colonoscope so that your doctor can take pictures or video of the large colon. The colonoscope can be used to look at the whole colon and the lower part of the small colon. A test called sigmoidoscopy shows only the rectum and the lower part of the colon. Before this test, you will need to clean out your colon (colon prep). Colon prep takes 1 to 2 days depending on which type of prep your doctor recommends. Some preps may be taken the evening before the test. For many people, the prep for a colonoscopy is more trying than the actual test. Plan to stay home during your prep time since you will need to use the bathroom often. The colon prep causes loose, frequent stools and diarrhea so that your colon will be empty for the test. The colon prep may be uncomfortable and you may feel hungry on the clear liquid diet. If you need to drink a special solution as part of your prep, be sure to have clear fruit juices or soft drinks to drink after the prep because the solution tastes salty. For more information on screening tests for colon cancer, see: Which test should I have to screen for colorectal cancer? Health Tools Health tools help you make wise health decisions or take action to improve your health. Decision Points focus on key medical care decisions that are important to many health problems. Which test should I have to screen for colorectal cancer? Why It Is Done Colonoscopy is done to: Find problems or diseases of the anus, rectum, or colon. These tests are often done to because you have had problems such as bleeding from the rectum, ongoing diarrhea or constipation, blood or pus in the stool (feces), or ongoing lower belly pain. Check the colon after abnormal results from a barium enema test. Check for colorectal cancer or polyps. o Most experts, including the American Gastroenterological Association, recommend that people with no risk factors for colorectal cancer start screening tests at age 50. Fecal occult blood testing (FOBT) or a sigmoidoscopy test may be recommended or a colonoscopy or doublecontrast barium enema (DCBE) may be used. If results from FOBT or sigmoidoscopy show a problem, a follow-up colonoscopy is recommended.

The American Gastroenterological Association recommends that people with risk factors for colorectal cancer start screening tests at age 40. Tests may include FOBT, sigmoidoscopy, barium enema, or colonoscopy. If you are at increased risk of colon cancer, talk to your doctor about which test is best for you and how often you should do the tests. If you have a family history of colon cancer, you may need a colonoscopy at age 40 or before age 40 in special cases.

Colonoscopy also may be done to: Check for colon or rectal cancer that has come back in people who had treatment. Watch the growth of polyps that cannot be completely removed. See whether treatment of inflammatory bowel disease is working. Take out polyps or take tissue samples (biopsy). Take out foreign bodies. Check for the cause of chronic diarrhea. Check for the cause of bleeding inside the colon.

How To Prepare Before you have a colonoscopy, tell your doctor if you: Are taking any medicines, such as insulin or medicines for arthritis. Check with your doctor about which medicines you need to take on the day of your test. Are allergic to any medicines, including anesthetics. Have bleeding problems or take blood thinners, such as aspirin or warfarin (Coumadin) Have heart disease or heart problems. If you take antibiotics before dental procedures, ask your doctor whether you will need them before your colonoscopy. Had an X-ray test using barium, such as a barium enema, in the last 4 days. Are or might be pregnant.

You may be asked to stop taking aspirin products or iron supplements 7 to 14 days before the test. If you take blood-thinning medications regularly, discuss with your doctor how to manage your medicine. You will be asked to sign a consent form that says you understand the risks of colonoscopy and agree to have the test done. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). Before this test, you will need to clean out your colon. The following information gives you a general idea of the preparation for a colonoscopy. Your doctor will give you specific instructions before your test. One to two days before a colonoscopy, you will stop eating solid foods and drink only clear fluids, such as water, tea, coffee, clear juices, clear broths, Popsicles, and gelatin (such as Jell-O). Do not eat or drink red food items such as red juice or red Jell-O. Some new products, such as the Nutraprep

meal kit or Visicol tablets or oral phospho-soda, are other methods of preparing for a colonoscopy. Ask your doctor whether another method will work for you. Your doctor may have you take a prescription laxative tablet or drink a laxative solution (such as Nulytely or Golytely) the evening before your colonoscopy. This solution will be given to you as a powder that you will mix with 1 gal of water. You are often asked to drink this laxative solution over 1 to 2 hours. This solution may taste very salty and may make you feel sick to your stomach. Each time you drink some of the solution, you may also drink some water or clear fluids (like apple juice) to help get rid of the salty taste in your mouth. You will want to stay home the evening before the test because the colon prep will make you use the bathroom often. Drink plenty of clear fluids during the prep so you will not get dehydrated. This will also help clean out your colon completely after you finish the colon prep. Do not eat any solid foods after drinking the laxative solution. Stop drinking clear liquids 6 to 8 hours before the colonoscopy. Your doctor may have you use an enema 30 to 60 minutes before the test to completely clean out your colon.

Arrange to have someone take you home after the test because you may be given a medicine (sedative) to help you relax before the test. How It Is Done Colonoscopy may be done in a doctor's office, clinic, or a hospital. The test is most often done by a doctor who works with problems of the digestive system (gastroenterologist). The doctor may also have an assistant. Some family doctors, internists, and surgeons are also trained to do colonoscopy. During the test, you may get a pain medicine and a sedative put in a vein in your arm (IV) . These medicines help you relax and feel sleepy during the test. You may not remember much about the test. You will need to take off most of your clothes. You will be given a gown to wear during the test. You will lie on your left side with your knees pulled up to your belly. The doctor will gently put a gloved finger into your anus to check for blockage. Then he or she will put the thin, flexible colonoscope in your anus and move it slowly through your colon. The doctor can look at the lining of the colon through the scope or on a computer screen hooked to the scope. You may feel the need to have a bowel movement while the scope is in your colon. You may also feel some cramping. Breathe deeply and slowly through your mouth to relax your belly muscles. This should help the cramping. You will likely feel and hear some air escape around the scope. There is no need to be embarrassed about it. The passing of air is expected. You may be asked to change your position during the test. Your doctor will look at the whole length of your colon as the scope is gently moved in and then out of your colon. View a slideshow about how a colonoscopy is done.

The doctor may also use tiny tools, such as forceps, loops, or swabs, through the scope to collect tissue samples (biopsy) or take out growths. You will not feel anything if a biopsy is done or if polyps are taken out. The scope is slowly pulled out of your anus and the air escapes. Your anal area will be cleaned with tissues. If you are having cramps, passing gas may help relieve them. The test usually takes 30 to 45 minutes, but it may take longer, depending upon what is found and what is done during the test. After the test, you will be watched for 1 to 2 hours. When you are fully awake, you can go home. You will not be able to drive or operate machinery for 12 hours after the test. Your doctor will tell you when you can eat your normal diet and do your normal activities. Drink a lot of fluid after the test to replace the fluids you may have lost during the colon prep but do not drink alcohol. How It Feels This test can be uncomfortable and you may feel embarrassed. The colon prep will cause diarrhea and cramping which may make you use the bathroom often during the night. During the test, you may feel very sleepy and relaxed from the sedative and pain medicines. You may have cramping or feel brief, sharp pain when the scope is moved or air is blown into your colon. As the scope is moved up the colon, you may feel the need to have a bowel movement and pass gas. If you are having pain, tell your doctor. The suction machine used to remove stool (feces) and secretions may be noisy but does not cause pain. You will feel sleepy after the test for a few hours. Many people say they do not remember very much about the test because of the sedative. After the test, you may have bloating or crampy gas pains and may need to pass some gas. If a biopsy was done or a polyp taken out, you may have traces of blood in your stool (feces) for a few days. If polyps were taken out, your doctor may instruct you to not take aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) for 7 to 14 days. Risks There is a small chance for problems from a colonoscopy. The scope or a small tool may tear the lining of the colon or cause bleeding. People who have certain types of heart murmurs, artificial heart valves, or past infections of a heart valve will need antibiotics before and after the test to prevent infection. An irregular heartbeat may occur during the test but usually goes away without treatment.

After the test After the test, call your doctor immediately if you: Have heavy rectal bleeding. Have severe belly pain. Develop a fever. Are very dizzy. Are vomiting. Have a swollen and firm belly.

Results Colonoscopy is a test that allows your doctor to look at the inner lining of your large intestine (rectum and colon). If a sample of tissue (biopsy) was collected during the colonoscopy, it will be sent to a lab for tests. Samples of colon tissue are usually sent to a pathology lab, where they are looked at under a microscope for diseases. Other samples of colon tissue may be sent to a microbiology lab to see whether an infection is present.

Your doctor may be able to tell you the results immediately after the procedure. Other test results are ready in 2 to 4 days. Test results for certain infections may be ready in several weeks. Colonoscopy Normal: The lining of the colon looks smooth and pink, with a lot of normal folds. No growths, pouches, bleeding, or inflammation are present.

Abnormal: Some common abnormal findings of colonoscopy include hemorrhoids (the most common cause of blood in the stool), polyps, tumors, one or more sores (ulcers), pouches in the wall of the colon (diverticulosis), or inflammation. A red, swollen lining of the colon (colitis) may be caused by infection or inflammatory bowel disease. Types of colon polyps Cancer in the colon

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: Having a barium enema a week before the test. Barium can block your doctor's view of the colon. Having stool (feces) in the colon, a colon that has many turns, past surgery on the colon, or a lot of pain during the test.

Taking iron supplements. This may make your stool turn black and make it hard to clean out the colon. Do not take iron supplements for several days before a colonoscopy. Drinking red fluids or eating red gelatin. This can change the color of secretions in the colon and may be mistaken for blood.

What To Think About In general, pregnant women or people who have severe heart disease, an abdominal infection, or diverticulitis should not have a colonoscopy unless there is an important reason for it. Colonoscopy is a more expensive procedure than a barium enema and other endoscopic colon tests (such as proctoscopy or sigmoidoscopy), but it can be done less often over time if results are normal. Colonoscopy is recommended every: o 10 years for people with normal results. o 3 to 5 years for people with increased risk factors for colorectal cancer or when problems are found during the colonoscopy. Most experts, including the American Gastroenterological Association, recommend that people with no risk factors for colorectal cancer start screening tests at age 50. Fecal occult blood testing (FOBT) or a sigmoidoscopy test may be recommended or a colonoscopy or doublecontrast barium enema (DCBE) may be used. If results from FOBT or sigmoidoscopy show a problem, a follow-up colonoscopy is recommended. For more information, see the medical tests Fecal Occult Blood Test, Sigmoidoscopy, and Barium Enema. The American Gastroenterological Association recommends that people with risk factors for colorectal cancer start screening tests at age 40. Tests may include FOBT, sigmoidoscopy, barium enema, or colonoscopy. If you are at increased risk of colon cancer, talk to your doctor about which test is best for you and how often you should do the tests. Talk to your doctor if you are considering virtual colonoscopy to screen for colon cancer. This procedure is a newer method that uses a CT scan to take two- or three-dimensional pictures of the colon. o Virtual colonoscopy is less uncomfortable than standard colonoscopy and may be a good test for people with an average risk for colon cancer. However, if you have a virtual colonoscopy and a problem is found, you may need a standard colonoscopy so a biopsy can be done. Virtual colonoscopy may not find small colon polyps as well as a standard colonoscopy. o For people with a risk for colon cancer, standard colonoscopy may be a better choice because a biopsy can be done or a polyp can be taken out. o Virtual colonoscopy is not covered by all health insurance plans. Check with your insurance plan before having the test. o Virtual colonoscopy uses the same colon prep as colonoscopy. For many people, the prep for a colonoscopy is more bothersome than the actual test.

Stool Analysis
A stool analysis is a series of tests done on a stool (feces) sample to help diagnose certain conditions affecting the digestive tract . These conditions can include infection (such as from parasites, viruses, or bacteria), poor nutrient absorption, or cancer. For a stool analysis, a stool sample is collected in a clean container and then sent to the laboratory. Laboratory analysis includes microscopic examination, chemical tests, and microbiologic tests. The stool will be checked for color, consistency, weight (volume), shape, odor, and the presence of mucus. The stool may be examined for hidden (occult) blood, fat, meat fibers, bile, white blood cells, and sugars called reducing substances. The pH of the stool also may be measured. A stool culture is done to find out if bacteria may be causing an infection. Why It Is Done Stool analysis is done to: Help identify diseases of the digestive tract, liver, and pancreas. Certain enzymes (such as trypsin or elastase) may be evaluated in the stool to help determine how well the pancreas is functioning. Help find the cause of symptoms affecting the digestive tract, including prolonged diarrhea, bloody diarrhea, an increased amount of gas, nausea, vomiting, loss of appetite, bloating, abdominal pain and cramping, and fever. Screen for colon cancer by checking for hidden (occult) blood. Look for parasites, such as pinworms or Giardia lamblia. Look for the cause of an infection, such as bacteria, a fungus, or a virus. Check for poor absorption of nutrients by the digestive tract (malabsorption syndrome). For this test, all stool is collected over a 72-hour period and then checked for the fat and meat fibers. This test is called a 72-hour stool collection or quantitative fecal fat test.

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will indicate. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How To Prepare Many medicines can change the results of this test. You will need to avoid certain medications, such as antacids, antidiarrheal medications, antiparasite medications, antibiotics, enemas, and laxatives for 1 to 2 weeks before you have the test. Be sure to tell your doctor about all the nonprescription and prescription medicines you take. Be sure to tell your doctor if you have: Recently had an X-ray test using barium contrast material, such as a barium enema or upper gastrointestinal series (barium swallow). Barium can interfere with test results. Traveled in recent weeks or months, especially if you have traveled outside the country. Parasites, fungi, viruses, or bacteria from other countries may affect the test.

If your stool is being tested for blood, you will need to follow a special diet for 2 days before the stool collection period begins. Your doctor will give you a list of recommended foods. Do not eat red meat, turnips, cauliflower, broccoli, bananas, cantaloupe, beets, or parsnips. Do not drink alcohol, including wine and beer. Do not take aspirin, ibuprofen, or vitamin C.

How It Is Done Stool samples can be collected at home, in your doctor's office, at a medical clinic, or at the hospital. If you collect the samples at home, you will be given stool collection kits to use each day. Each kit contains applicator sticks and two sterile containers. You may need to collect more than one sample over 1 to 3 days. Follow the same procedure for each day. Collect the samples as follows: Urinate before collecting the stool so that you do not get any urine in the stool sample. Put on gloves before handling your stool. Stool can contain material that spreads infection. Wash your hands after you remove your gloves. Pass stool (but no urine) into a dry container. You may be given a plastic basin that can be placed under the toilet seat to catch the stool. o Either solid or liquid stool can be collected. o If you have diarrhea, a large plastic bag taped to the toilet seat may make the collection process easier; the bag is then placed in a plastic container. o If you are constipated, you may be given a small enema. o Do not collect the sample from the toilet bowl. o Do not mix toilet paper, water, or soap with the sample. Using one of the applicator sticks, place a small amount of stool in each of the two containers. Place the lid on the container and label it with your name, your doctor's name, and the date the stool was collected. Use one container for each day's collection, and collect a sample only once a day unless your doctor gives you other directions.

Take the sealed container to your doctor's office or the laboratory as soon as possible. You may need to deliver your sample to the lab within a certain time. Tell your doctor if you think you may have trouble getting the sample to the lab on time. If the stool is collected in your doctor's office or the hospital, you will pass the stool in a plastic container that is inserted under the toilet seat or in a bedpan. A health professional will package the sample for laboratory analysis. You will need to collect stool for 3 days in a row if the sample is being tested for quantitative fats. You will begin collecting stool on the morning of the first day. The samples are placed in a large container and then refrigerated. You may need to collect several stool samples over 7 to 10 days if you have digestive symptoms after traveling outside the country.

Samples from babies and young children may be collected from diapers (if the stool is not contaminated with urine) or from a small-diameter glass tube inserted into the baby's rectum while the baby is held on an adult's lap. Sometimes a stool sample is collected using a rectal swab that contains a preservative. The swab is inserted into the rectum, rotated gently, and then withdrawn. It is placed in a clean, dry container and sent to the lab right away. How It Feels There is no pain while collecting a stool sample. If you are constipated, straining to pass stool may be painful. If your health professional uses a rectal swab to collect the sample, you may feel some pressure or discomfort as the swab is inserted into your rectum. Risks Any stool sample may contain germs that can spread disease. It is important to carefully wash your hands and use careful handling techniques to avoid spreading infection. Results A stool analysis is a series of tests done on a stool (feces) sample to help diagnose certain conditions affecting the digestive tract . Stool analysis test results usually take at least 1 to 3 days. Stool analysis Normal: The stool appears brown, soft, and well-formed in consistency. The stool does not contain blood, mucus, pus, harmful bacteria, viruses, fungi, or parasites. The stool is shaped like a tube. The pH of the stool is about 6. The stool contains less than 2 milligrams per gram (mg/g) of sugars called reducing factors. Abnormal: The stool is black, red, white, yellow, or green. The stool is liquid or very hard. There is too much stool. The stool contains blood, mucus, pus, harmful bacteria, viruses, fungi, or parasites.

The stool contains low levels of enzymes, such as trypsin or elastase. The pH of the stool is less than 5.3 or greater than 6.8. The stool contains more than 5 mg/g of sugars called reducing factors; between 2 and 5 mg/g is considered borderline.

Many conditions can change the results of a stool analysis. Your doctor will talk with you about any abnormal results that may be related to your symptoms and medical history. Abnormal values High levels of fat in the stool may be caused by diseases such as pancreatitis, sprue (celiac disease), cystic fibrosis, or other disorders that affect the absorption of fats. The presence of undigested meat fibers in the stool may be caused by pancreatitis. A pH greater than 6.8 may be caused by poor absorption of carbohydrate or fat and problems with the amount of bile in the digestive tract. Stool with a pH less than 5.3 may indicate poor absorption of sugars. Blood in the stool may be caused by bleeding in the digestive tract. White blood cells in the stool may be caused by inflammation of the intestines, such as ulcerative colitis, or a bacterial infection. Rotaviruses are a common cause of diarrhea in young children. If diarrhea is present, testing may be done to look for rotaviruses in the stool. High levels of reducing factors in the stool may indicate a problem digesting some sugars. Low levels of reducing factors may be caused by sprue (celiac disease), cystic fibrosis, or malnutrition. Medicine such as colchicine (for gout) or birth control pills may also cause low levels.

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: Taking medicines such as antibiotics, antidiarrheal medications, barium, bismuth, iron, ascorbic acid, aspirin, and magnesium. Eating certain foods. For example, a diet high in red meat can cause falsepositive results in testing for hidden (occult) blood. Contaminating a stool sample with urine, menstrual blood, bleeding hemorrhoids, or chemicals found in toilet paper and paper towels. Exposing the stool sample to air or room temperature or failing to send the sample to a laboratory within 1 hour of collection.

What To Think About Stool may be checked for hidden (occult) blood. For more information, see the medical test Fecal Occult Blood Test (FOBT).

A stool culture is done to find the cause of an infection, such as bacteria, a virus, a fungus, or a parasite. For more information, see the medical test Stool Culture. A bowel transit time test is done to help find the cause of abnormal movement of food through the digestive tract. For more information, see the medical test Bowel Transit Time. The D-xylose absorption test is done to help diagnose problems that prevent the small intestine from absorbing nutrients in food. This test may be done when symptoms of malabsorption syndrome (such as chronic diarrhea, weight loss, and weakness) are present. For more information, see the medical test D-Xylose Absorption Test. A stool analysis to measure trypsin or elastase is not as reliable as the sweat test to detect cystic fibrosis. For more information, see the medical test Sweat Test.

Abdominal X-ray
An abdominal X-ray is a picture of structures and organs in the belly (abdomen). This includes the stomach, liver, spleen, large and small intestines, and the diaphragm, which is the muscle that separates the chest and belly areas. Often two X-rays will be taken from different positions. If the test is being done to look for certain problems of the kidneys or bladder, it is often called a KUB (for kidneys, ureters, and bladder ). X-rays are a form of radiation, like light or radio waves, that are focused into a beam, much like a flashlight beam. X-rays can pass through most objects including the human body. When X-rays strike a piece of photographic film, they make a picture. Dense tissues in the body, such as bones, block (absorb) many of the X-rays and look white on an X-ray picture. Less dense tissues, such as muscles and organs, block fewer of the X-rays (more of the X-rays pass through) and look like shades of gray on an X-ray. X-rays that pass only through air, such as the lungs, look black. An abdominal X-ray may be one of the first tests done to find a cause of belly pain, swelling, nausea, or vomiting. Why It Is Done An abdominal X-ray is done to: Look for a cause of pain in the belly or ongoing nausea and vomiting. Find a cause of pain in the lower back on either side of the spine (flank pain). An abdominal X-ray can show the size, shape, and position of the liver, spleen, and kidneys. Other tests (such as ultrasound, CT scan, or intravenous pyelography) may be used in addition to look for more specific problems. Find an object that has been swallowed or put into a body cavity. Confirm the proper position of tubes used by your doctor in your treatment, such as a tube to drain the stomach (nasogastric tube), a feeding tube in the stomach, a tube to drain the kidney (nephrostomy tube), a catheter used for dialysis, a shunt to drain fluid from the brain into the stomach (V-P shunt), or other drainage tubes or catheters.

How To Prepare Before the X-ray test, tell your health professional if you: Are or might be pregnant. An abdominal X-ray is not usually done during pregnancy because of the risk of radiation exposure to your baby (fetus). Many times an abdominal ultrasound is done instead. Have had an X-ray test using barium contrast material (such as a barium enema) or have taken a medicine (such as Pepto-Bismol) that has bismuth in the last 4 days. Barium and bismuth can block a clear picture.

You may be asked to empty your bladder before the test. You may need to take off any jewelry that may be in the way of the X-ray picture, such as if you have a pierced belly button. You will need to sign a consent form that says you understand the risks of an X-ray and agree to have the test done. Talk to your health professional about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?).

How It Is Done An abdominal X-ray is taken by a radiology technologist. The X-ray pictures are read by a radiologist. Some other doctors, such as emergency room doctors, can also look at abdominal X-rays to check for common problems, such as a blocked intestine. You may need to take off all or most of your clothes. You will be given a gown to use during the test. You will lie on your back on a table. A lead apron may be placed over your lower pelvic area to protect it from the X-ray. A woman's ovaries cannot be protected during this test because they lie too close to the belly organs that are X-rayed. A man's testicles can sometimes be protected during the test. After the X-ray machine is positioned over your belly, you will be asked to hold your breath while the X-ray pictures are taken. You need to lie very still so the pictures are clear. Many times, two pictures are taken: one while you are lying down (supine) and the other one while you are standing (erect view). The erect view can help find a blockage of the intestine or a hole (perforation) in the stomach or an intestine that is leaking air. If you are not able to stand, the X-ray may be taken while you lie on your side with your arm over your head. An abdominal X-ray takes about 5 to 10 minutes. You will be asked to wait about 5 minutes while the X-rays are developed in case more pictures need to be taken. In some clinics and hospitals, X-ray pictures can be made immediately on a computer screen (digitally). How It Feels You will feel no discomfort from the X-rays. The X-ray table may feel hard and the room may be cool. You may find that the positions you need to hold are uncomfortable or painful, especially if you have an injury. Risks There is always a slight chance of damage to cells or tissue from radiation, including the low levels of radiation used for this test. However, the chance of damage from the X-rays is usually very low compared with the benefits of the test. Results An abdominal X-ray takes a picture of structures and organs in the belly (abdomen). This includes the stomach, liver, spleen, large and small intestines, and the diaphragm, which is the muscle that separates the chest and belly areas. In an emergency, the results of an abdominal X-ray are ready in a few minutes. Otherwise, results are ready in 1 to 2 days. Abdominal X-ray Normal: The bowel gas pattern (stomach, small and large bowel) and soft tissue densities (liver, spleen, kidneys, and bladder) are normal in size, shape, and location. No growths, abnormal amounts of fluid (ascites), or foreign objects are seen. Normal amounts of air and fluid are seen in the intestines. Normal amounts of stool are seen in the large intestine.

Abnormal: A blocked intestine may be seen because a portion of the intestine is larger than usual or areas in the intestine have abnormal air or fluid in them). See an illustration of a blocked intestine . A collection of air inside the belly cavity but outside the intestines (caused by a hole in the stomach or intestines) may be seen. The walls of the intestines may look abnormal or thick. The size, shape, or location of the bladder or kidneys may be abnormal. Kidney stones may be seen in the kidney, ureters, bladder, or urethra. In some cases, gallstones can be seen on an abdominal X-ray. Abnormal growths, such as large tumors, or ascites may be seen. An object is seen or a medical device looks abnormal or out of position. What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: Being pregnant. If a view of a pregnant woman's belly is needed, an ultrasound test may be done instead. Having recent tests using barium or bismuth. These substances show up on X-ray films and block a clear picture of the belly. Not being able to lie still and hold your breath during the test.

What To Think About Sometimes your X-ray results may be different because you were tested at a different medical center or earlier test results are not available to compare to the new test findings. Certain results seen on an abdominal X-ray may mean more tests are needed to find the cause of the problem. These tests may include endoscopy, ultrasound, a computed tomography (CT) scan, a barium enema, or intravenous pyelography (IVP). For more information, see the medical tests Upper Gastrointestinal Endoscopy, Abdominal Ultrasound, Kidney Scan, CT Scan of the Body, Barium Enema, and Intravenous Pyelogram (IVP). An abdominal X-ray cannot find certain problems, such as a bleeding stomach ulcer. A chest X-ray may be done at the same time as an abdominal X-ray. For more information, see the medical test Chest X-ray. Portable X-ray equipment may be used if a person is physically not able to go to a hospital or clinic X-ray department. However, pictures from stationary Xray equipment are often better than pictures from portable X-ray equipment.

Upper Gastrointestinal (UGI) Series


An upper gastrointestinal (UGI) series looks the upper and middle sections of the gastrointestinal tract (intestines). The test uses barium contrast material, fluoroscopy, and X-ray. Before the test, you drink a mix of barium (barium contrast material) and water. The barium is often combined with gas-making crystals. Your doctor watches the movement of the barium through your esophagus, stomach, and the first part of the small intestine (duodenum ) on a video screen. Several X-ray pictures are taken at different times and from different views. A small bowel follow-through may be done immediately after a UGI to look at the rest of the small intestine. If just the throat and esophagus are looked at, it is called an esophagram (or barium swallow). See barium swallow images . Upper endoscopy is done instead of a UGI in certain cases. Endoscopy uses a thin, flexible tube (endoscope) to look at the lining of the esophagus, stomach, and upper small intestine (duodenum). Why It Is Done An upper gastrointestinal (UGI) series is done to: Find the cause of gastrointestinal symptoms, such as difficulty swallowing, vomiting, burping up food, belly pain (including a burning or gnawing pain in the center of the stomach, or indigestion. These may be caused by conditions such as hiatal hernia. Find narrow spots (strictures) in the upper intestinal tract, ulcers, tumors, polyps, or pyloric stenosis. Find inflamed areas of the intestine, malabsorption syndrome, or problems with the squeezing motion that moves food through the intestines (motility disorders). Find swallowed objects.

Generally, a UGI series is not used if you do not have symptoms of a gastrointestinal problem. A UGI series is done most often for people who have: A hard time swallowing. A history of Crohn's disease. A possible blocked intestine (obstruction). Belly pain that is relieved or gets worse while eating. Severe heartburn or heartburn that occurs often.

How To Prepare Tell your doctor if you: Are taking any medicine. Are allergic to any medicines, barium, or any other X-ray contrast material. Are or might be pregnant. This test is not done during pregnancy because of the risk of radiation to the developing baby (fetus).

You may be asked to eat a low-fiber diet for 2 or 3 days before the test. You may also be asked to stop eating for 12 hours before the test. Your doctor will tell you if you need to stop taking certain medicines before the test.

The evening before the test, you may be asked to take a laxative to help clean out your intestines. If your stomach cannot empty well on its own, you may have a special tube put through your nose and down into your stomach just before the test begins. A gentle suction on the tube will drain the stomach contents. If you are having the small bowel follow-through after the UGI series, you will need to wait between X-rays. The entire small bowel follow-through exam takes up to 6 hours, so bring along a book to read or some other quiet activity. You may be asked to sign a consent form. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done A UGI series is usually done in your doctor's office, clinic, or X-ray department of a hospital. You do not need to stay overnight in the hospital. The test is done by a radiologist and a radiology technologist. You will need to take off your clothes and put on a hospital gown. You will need to take out any dentures and take off any jewelry. You may not smoke or chew gum during the test, since the stomach will respond by making more gastric juices and this will slow the movement of the barium through the intestines. You will lie on your back on an X-ray table. The table is tilted to bring you to an upright position with the X-ray machine in front of you. Straps may be used to keep you safely on the table. The technologist will make sure you are comfortable during changes in table position. You will have one X-ray taken before you drink the barium mix. Then you will take small swallows repeatedly during the series of X-rays that follow. The radiologist will tell you when and how much to drink. By the end of the test, you may have swallowed 1 cup to 2.5 cups of the barium mixture. See an illustration of a barium swallow test . The radiologist watches the barium pass through your gastrointestinal tract using fluoroscopy and X-ray pictures. The table is tilted at different positions and you may change positions to help spread the barium. Some gentle pressure is put on your belly with a belt or by the technologist's gloved hand. You may be asked to cough so that the radiologist can see how that changes the barium flow. See a photograph of a barium swallow . If you are having an air-contrast study, you will sip the barium liquid through a straw with a hole in it or take pills that make gas in your stomach. The air or gas that you take in helps show the lining of the stomach and intestines in greater detail. If you are also having a small bowel study, the radiologist watches as the barium passes through your small intestine into your large intestine. X-ray pictures are taken every 30 minutes. The UGI series 30 to 40 minutes. The UGI series with a small bowel study takes 2 to 6 hours. In some cases, you may be asked to return after 24 hours to have more Xray pictures taken. When the UGI series is done, you may eat and drink whatever you like, unless your doctor tells you not to.

You may be given a laxative or enema to flush the barium out of your intestines after the test to prevent constipation. Drink a lot of fluids for a few days to flush out the barium. How It Feels The barium liquid is thick and chalky, and some people find it hard to swallow. A sweet flavor, like chocolate or strawberry, is used to make it easier to drink. Some people do not like it when the X-ray table tilts. You may find that pressure on your belly is uncomfortable. After the test, many people feel bloated and a little nauseated. For 1 to 3 days after the test, your stool (feces) will look white from the barium. Call your doctor if you are not able to have a bowel movement in 2 to 3 days after the test. If the barium stays in your intestine, it can harden and cause a blockage. If you become constipated, you may need to use a laxative to pass a stool. Risks Barium does not move into the blood, so allergic reactions are very rare. Some people gag while drinking the barium fluid. In rare cases, a person may choke and inhale (aspirate) some of the liquid into the lungs. There is a small chance that the barium will block the intestine or leak into the belly through a perforated ulcer. A special type of contrast material (Gastrografin) can be used if you have a blockage or an ulcer. There is always a small chance of damage to cells or tissue from being exposed to any radiation, even the low level of radioactive tracer used for this test. Results An upper gastrointestinal (UGI) series looks at the upper and middle sections of the gastrointestinal tract (intestines). Results are usually ready in 1 to 3 days. Upper gastrointestinal (UGI) series Normal: The esophagus, stomach, and small intestine all look normal.

Abnormal: A narrowing (stricture), inflammation, a mass, a hiatal hernia, or enlarged veins (varices) may be seen. Spasms of the esophagus or a backward flow (reflux) of barium from the stomach may occur. The UGI series may show a stomach (gastric) or intestinal (duodenal) ulcer, a tumor, or something pushing on the intestines from outside the gastrointestinal tract. Narrowing of the opening between the stomach and the small intestine (pyloric stenosis) may be seen. The small bowel follow-through may show inflammation or changes in the lining that may explain poor absorption of food. This may be caused by Crohn's disease or celiac disease).

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include: Eating before or during the test. Too much air in the small intestine.

What To Think About A gastrointestinal (GI) motility study may be done if the squeezing motions of the small intestine are not normal during the UGI series and small bowel follow-through. The movement of the barium through the lower intestinal tract is recorded every few hours for up to 24 hours. A barium enema or colonoscopy may be needed to confirm the diagnosis. Upper endoscopy is done instead of a UGI test in certain cases. Endoscopy uses a thin, flexible tube (endoscope) to look at the lining of the esophagus, stomach, and upper small intestine (duodenum). For more information, see the medical test Upper Gastrointestinal Endoscopy. The UGI series test: o Cannot show irritation of the stomach lining (gastritis) or esophagus (esophagitis) or ulcers that are smaller than about 0.25 in. in diameter. o Cannot show an infection with the bacteria Helicobacter pylori, which may be a cause of stomach ulcers. A biopsy cannot be done during the UGI if a problem is found.

C-Reactive Protein (CRP)


A C-reactive protein (CRP) test is a blood test that measures the amount of a protein called C-reactive protein in your blood. C-reactive protein measures general levels of inflammation in your body. High levels of CRP are caused by infections and many long-term diseases. However, a CRP test cannot show where the inflammation is located or what is causing it. Other tests are needed to find the cause and location of the inflammation. Why It Is Done A C-reactive protein (CRP) test is done to: Check for infection after surgery. CRP levels normally rise within 2 to 6 hours of surgery and then go down by the third day after surgery. If CRP levels stay elevated 3 days after surgery, an infection may be present. Identify and keep track of infections and diseases that cause inflammation, such as: o Cancer of the lymph nodes (lymphoma). o Diseases of the immune system, such as lupus. o Painful swelling of the blood vessels in the head and neck (giant cell arteritis). o Painful swelling of the tissues that line the joints (rheumatoid arthritis). o Swelling and bleeding of the intestines (inflammatory bowel disease). o Infection of a bone (osteomyelitis). Check to see how well treatment is working, such as treatment for cancer or for an infection. CRP levels go up quickly and then become normal quickly if you are responding to treatment measures.

A special type of CRP test, the high-sensitivity CRP test (hs-CRP), may be done to find out if you have an increased chance of having a sudden heart problem, such as a heart attack. Inflammation can damage the inner lining of the arteries and make having a heart attack more likely. However, the connection between high CRP levels and heart attack risk is not very well-understood. How To Prepare There is no special preparation for a C-reactive protein (CRP) test. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will indicate. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?). How It Is Done The health professional taking a sample of your blood will: Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with alcohol. Put the needle into the vein. More than one needle stick may be needed. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected.

Put a gauze pad or cotton ball over the needle site as the needle is removed. Put pressure on the site and then put on a bandage.

How It Feels The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch. Risks There is very little chance of a problem from having blood sample taken from a vein. You may get a small bruise at the site. You can lower the chance of bruising by keeping pressure on the site for several minutes. In rare cases, the vein may become swollen after the blood sample is taken. This problem is called phlebitis. A warm compress can be used several times a day to treat this. Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medicines can make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medicine, tell your doctor before your blood sample is taken.

Results A C-reactive protein (CRP) test is a blood test that measures the amount of a protein called C-reactive protein in your blood. Normal Normal values may vary from lab to lab. Results are usually available within 24 hours. C-reactive protein (CRP) Normal: 01.0 mg/dL or less than 10 mg/L (SI units)

Any condition that results in sudden or severe inflammation may increase your CRP levels. Some medicines may decrease your CRP levels. High-sensitivity C-reactive protein (hs-CRP) levels The hs-CRP test measures your risk for heart problems. It may be done to find out if you have an increased chance of having a sudden heart problem, such as a heart attack. However, the connection between high CRP levels and heart attack risk is not very well-understood. High-sensitivity C-reactive protein (hs-CRP) levels Less than 1.0 mg/L 1.0 to 3.0 mg/L More than 3.0 mg/L Lowest risk Average risk Highest risk

Many conditions can change CRP levels. Your doctor will talk with you about any abnormal results that may be related to your symptoms and medical history. What Affects the Test You may not be able to have the test or the results may not be helpful if: You have just exercised. You take certain medicines, such as hormone replacement therapy (HRT), birth control pills, nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, corticosteroids, or medicine to lower your cholesterol (for example, pravastatin). You have an intrauterine device (IUD) in place. You are pregnant. You are very overweight (obese).

What To Think About High-sensitivity C-reactive protein (hs-CRP) measures very low amounts of CRP in the blood. This test may be helpful in predicting your risk for heart problems, especially when it is combined with total cholesterol and HDL cholesterol tests. High CRP levels before a major surgery may indicate that you are at risk for developing an infection after surgery. CRP testing can be used to see how well you respond to cancer treatment or treatment for an infection. Your CRP levels will rise quickly and then quickly return to normal if the treatment is working. High CRP levels may increase your chances of having other diseases, such as age-related macular degeneration and colon cancer.

Probiotics

What are probiotics? Probiotics are bacteria that help maintain the natural balance of organisms (microflora) in the intestines . The normal human digestive tract contains about 400 types of probiotic bacteria that reduce the growth of harmful bacteria and promote a healthy digestive system. The largest group of probiotic bacteria in the intestine is lactic acid bacteria, of which Lactobacillus acidophilus, found in yogurt, is the best known. Yeast is also a probiotic substance. Probiotics are also available as dietary supplements. It has been suggested that probiotics be used to treat problems in the stomach and intestines. But only certain types of bacteria or yeast (called strains) have been shown to work in the digestive tract. It still needs to be proven which probiotics (alone or in combination) work to treat diseases. At this point, even the strains of probiotics that have been proven to work for a specific disease are not widely available. What are probiotics used for? In most circumstances, people use probiotics to prevent diarrhea caused by antibiotics. Antibiotics kill "good" (beneficial) bacteria along with the bacteria that cause illness. A decrease in beneficial bacteria may lead to diarrhea. Taking probiotic supplements (as capsules, powder, or liquid extract) may help replace the lost beneficial bacteria and thus help prevent diarrhea. A decrease in beneficial bacteria may also lead to development of other infections, such as vaginal yeast and urinary tract infections, and symptoms such as diarrhea from intestinal illnesses. Research has shown that certain probiotics may restore normal bowel function and may help reduce:1 Diarrhea that is a side effect of antibiotics. Certain types of infectious diarrhea. Inflammation of the ileal pouch (pouchitis) that may occur in people who have had surgery to remove the colon.

These results suggest that eventually probiotics may also be used to: Help with other causes of diarrhea. Help prevent infections in the digestive tract. Help control immune response (inflammation), as in inflammatory bowel disease (IBD).

Researchers are studying the use of probiotics for inflammatory bowel disease, colon cancer, and irritable bowel syndrome (IBS). The results of some early studies suggest that probiotics found in yogurt may help prevent diarrhea caused by antibiotics.1 But more studies are needed to confirm that yogurt is effective. To offer benefit, the yogurt must contain active cultures. Most yogurt containers indicate whether active cultures are present.

Are probiotics safe? Probiotic bacteria are already part of the normal digestive system and are considered safe. The U.S. Food and Drug Administration (FDA) does not regulate dietary supplements in the same way it regulates medication. A dietary supplement can be sold with limited or no research on how well it works or on its safety. Always tell your doctor if you are using a dietary supplement or if you are thinking about combining a dietary supplement with your conventional medical treatment. It may not be safe to forgo your conventional medical treatment and rely only on a dietary supplement. This is especially important for women who are pregnant or breast-feeding. When using dietary supplements, keep in mind the following: Like conventional medicines, dietary supplements may cause side effects, trigger allergic reactions, or interact with prescription and nonprescription medicines or other supplements you are taking. A side effect or interaction with another medicine or supplement may make other health conditions worse. Dietary supplements may not be standardized in their manufacturing. This means that how well they work or any side effects they cause may differ among brands or even within different lots of the same brand. The form you buy in health food or grocery stores may not be the same as the form used in research. The long-term effects of most dietary supplements, other than vitamins and minerals, are not known. Many dietary supplements are not used long-term.

Enteral nutrition or total parenteral nutrition (TPN) for inflammatory bowel disease
The following nutritional treatments may be used for inflammatory bowel disease (ulcerative colitis or Crohn's disease).

Enteral nutrition Enteral nutrition is a fluid given through a tube that is inserted into the nose, down the throat, and into the stomach. This tube is called a nasogastric, or NG, tube. The fluid contains essential nutrients and helps supplement or replace a regular diet. The intestines absorb nutrients from the fluid more easily than from regular food. Feedings may be given during the day or at night during sleep. Total parenteral nutrition (TPN) Total parenteral nutrition (TPN) is liquid nutrition given through a needle that is inserted into a large vein in or near the shoulder, neck, or arm. This method bypasses the digestive tract completely and places nutrients directly into the bloodstream. TPN allows the bowel to rest so that medicines can work. TPN may be helpful in stopping the symptoms of Crohn's disease in certain people, but the treatment is still unproven. TPN has not been shown to have any benefit in treating ulcerative colitis. But parenteral nutrition may offer nutritional benefits to patients even if it doesn't help with the treatment of disease.

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