STUDY - Technical - New Dacian's Medicine
Indigestion
(2)
Translation Draft
We're going to talk about food intolerance now. In some people, certain foods or types of foods appear to be correlated with indigestion. Careful documentation of this relationship is sometimes of great help to reach an etiological diagnosis. Some foods may be slightly tolerated due to batch consistency. Patients with esophageal strictures or carcinoma may tolerate fluids well, but may experience embarrassment, especially retrosternal suffering after ingestion of solids.
Citrus fruits, perhaps due to relatively low pH and spicy foods often cause symptoms in patients with peptic ulcerative disease or peptic esophagitis. Certain foods can be hard to tolerate due to impaired digestion or intestinal absorption, as happens with the ingestion of fatty foods in patients with pancreatic disease or bile duct. Patients may have a congenital or acquired deficiency of a specific enzyme necessary for the intestinal absorption of a particular nutrient.
One example is the deficiency of lactase, an enzyme in the intestinal mucosa that catalyzes the hydrolysis of lactose. In some people who are lactazo-deficient, ingestion of milk (containing lactose) causes abdominal cramps, distension, diarrhea and flatulence. Sugar can cause similar symptoms in people with hereditary sucrose-isomaltase deficiency. Certain nutrients can cause important systemic effects due to the patient's biochemical defects, which make the substances particularly risky, as in the intolerance to galactose of people with galactosemia.
Some foods or food additives may initiate allergic reactions, which should be suspected when symptoms appear after ingestion of a particular food, reappear in challenge tests and are associated with other characteristics of the allergic reaction, such as swelling of the lips, urticaria, angioedema, asthma or, rarely, anaphylactic shock. Acute igE-mediated reactions are most commonly associated with cow's milk (in infants), shellfish, flour, eggs, nuts and chocolate and can be confirmed in some cases by the radioallergoabsorption test.
Delayed hypersensitivity reactions may also occur and may be associated with less serious symptoms, including joint and muscle pain, fatigue, severe otitis and altered spatial perception, making it more difficult to correlate with certain foods. Some foods may exert toxic effects on the intestine in susceptible people (e.g. gluten in patients with celiac sprue). In many situations it is not understood the mechanism by which indigestion is associated with indigestion of certain foods.
Thus, a history of intolerance to fatty foods or suffering after ingestion of spicy foods is usually obtained from patients with indigestion (however, the mechanisms that lead to the appearance of symptoms in these circumstances are often unclear).
A "relationship symptom" is represented by aerophagy. In patients who accuse chronic, repetitive eructations ("laughter"), it can be observed that each eructation is preceded by swallowing air, most of which only partially passes down the esophagus and is then regurgitated. Such excessive eructation results from aerophagy or swallowing of air, not from excessive gas production in the stomach or intestine.
A certain degree of aerophagy also occurs in normal individuals, but some people overeat air due to chronic anxiety, rapid feeding, carbonated drinks or the use of straw, chewing gum, hard sucking candy, smoking cigarettes, postnasal leaks, inappropriate dental appliances or esophageal speech. Since eructation following aerophagy may cause a temporary improvement on the patient, a vicious circle of aerophagy and eructation may occur.
About 20-60% of intestinal gases represent the air swallowed. Because nitrogen and oxygen are the only gases present in the atmosphere in appreciable concentrations and because they are not produced in the gastrointestinal tract, their detection by chromatographic analysis of the intestinal gas indicates whether the swallowed air is the source. The swallowed air that is not eructated passes into the stomach and intestine.
Accumulation of air swallowed in the stomach can lead to fullness and postprandial pressure and X-ray detection of a large amount of air in the gastric fornix. This complex of symptoms, called air bag syndrome (i.e. gastric bubbles), can occur when a patient lies lying after a rich meal, thus allowing gastric air to be "caught" under the gastroesophageal junction by the liquid above and impossible to eructate.
Failure to eruct is also assumed to be the cause of the "gas filling" syndrome observed after surgical resolution of the hiatal hernia. Acute gastric distension by swallowed air can sometimes produce sharp pains that can mimic angina. Swallowed air that successfully passes the stomach can either produce diffuse abdominal distension or is captured in the splenic flexure of the colon.
This last case, splenic flexure syndrome, is characterized by a feeling of fullness and pressure in the left hypochondrium with irradiation in the left side of the chest. Pain relief often occurs after defecation or removal of gas. The diagnosis is suggested by the discovery of increased eardrumism in the extreme left lateral portion of the upper abdomen upon physical examination or large amounts of air in the splenic flexure of the colon on a simple abdominal X-ray.
We now move on to meteorism, bloating and flatulence. Despite the widespread belief that sensations of diffuse abdominal pain and bloating are often caused by excessive amounts of intestinal gas, studies using a technique of "complete cleansing" of intestinal gas have shown that patients complaining of excessive gas have a normal volume of intestinal gas. In some cases, the primary anomaly causing functional bloating and pain appears to be a motility disorder that causes the patient to perceive pain at a volume of gas that is well tolerated by normal subjects.
Alternatively, intestinal motility may be normal in such people, but they may be excessively receptive to normal impulses coming from the intestinal tract (visceral hypersensitivity). A major source of intestinal gas is the fermentative disease of intestinal bacteria on carbohydrates and proteins in the lumen. Normally, these bacteria are limited to the colon and the main gases produced are carbon dioxide and hydrogen (along with small amounts of odorous gases such as indoles, scatols and sulfur-containing compounds, which confer the characteristic smell). In the upper small intestine, carbon dioxide is also produced when hydrochloric acid in the stomach or ingested fatty acids are neutralized by bicarbonate (this may in part explain the indigestion associated with fatty foods).
About a third of adults produce appreciable amounts of methane in the colon, which seems to be a family trait and not related to the ingestion of certain foods. An increase in intraluminal gas production leading to abdominal distension, bloating and flatulence occurs after ingestion of certain foods, such as vegetables and some cereals, which contain significant amounts of complex and non-absorbable carbohydrates, which pass into the colon where they supply the gas-forming substrate for colonic bacteria.
The best studied example of this kind is beans containing oligosaccharides (stahiosis and refinosis), which cannot be split by the enzymes of the intestinal mucosa, but are metabolized by colonic bacteria. Less appreciated is the fact that fructose, a natural or added sweetener, from fruits (especially figs, curmals, plums and grapes), fruit juices, soft drinks, and present in oligosaccharides in onions, asparagus, flour, can be incompletely absorbed into the small intestine and therefore contribute to abdominal distension, bloating and flatulence.
By contrast, intestinal absorption of fructose is more likely to be complete when fructose is mixed with glucose or ingested as sucrose (glucose-fructose). Intestinal malabsorption of sorbitol may be the cause of symptoms of abdominal distension, flatulence and diarrhea associated with certain fruits, or when sorbitol is used as a sweetener in sugar-free gum and dietary candy or as an "inert" ingredient in some medications. Increased production of intraluminal gas may also result from abnormal bacterial colonization of the small intestine (bacterial overproliferation syndrome) or infection with Giardia lamblia.
There are also some things to discuss about indigestion due to intestinal disorders. A number of extraintestinal conditions can lead to indigestion. Such indigestion can be important in congestive heart failure, pulmonary tuberculosis, neoplastic disease and uremia. Also, a variety of drugs such as aspirin, nonsteroidal anti-inflammatory agents and glucocorticoids can cause indigestion due to their ulcerative properties.
Let's move on to the patient approach. Indigestion is a challenging and difficult diagnostic problem because of its nonspecific nature. It is necessary to obtain a clear and detailed description of nonspecific symptoms, in particular the patient's definition for the term indigestion. The nature of the suffering, the frequency and timing of its occurrence, its relationship with the meals and the special circumstances leading to its exacerbation or improvement must be requested.
Bowel symptoms associated with nausea and vomiting, abnormal bowel habits, diarrhoea, steatorea and melena will be sought and an assessment of nutrition status, appetite and weight changes should be carried out. A careful history should also include an assessment of the patient's general health, including the possible presence of extraintestinal disorders that may cause indigestion. A careful history of diet is essential and asking the patient to keep track of ingested foods can prove revealing.
Similarly, the patient's medication should be reviewed, especially for agents that can slow down intestinal transit, such as narcotics, anticholinergics and calcium antagonists. Psychological factors can play an etiological and contributing role and the presence of anxiety, depressive symptoms or hysteria should be noted. Physical examination rarely establishes the specific diagnosis, but can be useful in detecting diseases in other organic systems that can affect intestinal function (e.g. congestive heart failure). The appearance of occult stools and haemorrhages must be tracked.
If further diagnostic investigations are indicated, they depend on the specific nature of the patient's accusations and his age (taking into account that the likelihood of gastrointestinal malignancy is higher in older patients). Abdominal pain can be assessed by radiological and imaging investigations of the esophagus, stomach, small intestine, colon, pancreas and bile ducts.
Esophagogastroscopy, endoscopic cholangiopancreatography, sigmoidoscopy or colonoscopy may be considered, depending on the specific symptoms. On the other hand, in patients under 40 years of age with epigastric pain typical of peptic ulcers, routine diagnostic investigations have little possibility of detecting serious diseases (such as gastric carcinoma) and are in fact often negative.
Additional options in such patients include serological testing for H. pylori and empirical treatment with "triple therapy" (one bismuth compound and two antibiotics) in people who are seropositive or an empirical test with antacids, hydrogen-receptor blockers or sucralfate. In contrast to peptic ulcer, nonulcerous dyspepsia improves inconsistently as a result of antacids and other standard antiulcer treatments.
Esophagogastroscopy may be reserved for patients with symptoms that persist despite therapy or reappear soon after discontinuation of therapy. However, in patients with H. pylori to endoscopic anthral biopsy without further explanation for indigestion (e.g. without ulcers), h. pylori eradication has not been shown to be beneficial in controlled studies. In fact, the cost-effectiveness approach in the assessment of dyspepsia, including the relative merits of initial endoscopy versus empirical therapy and the choice of empirical therapy, is still being discussed. In general, most authorities do not recommend treatment to eradicate H. pylori if peptic ulcer is not confirmed.
In individual accusations of excessive eructation, the mere demonstration that aerophagy reproduces symptoms may be sufficient to confirm the diagnosis and promatily discontinue the habit. Patients complaining of excessive gas, bloating, distension and flatulence should be carefully questioned about dietary preferences and the relationship of symptoms with the ingestion of certain foods. In some cases, the removal of certain foods (e.g. milk, vegetables) from the diet followed by reprovocation can confirm the cause.
In other cases, a more detailed assessment, including examination of the stool for fats and muscle fibres and parasites at G. lamblia, respiratory tests for the testing of carbohydrate malabsorption or bacterial proliferation, esophageal manometry and ambulatory pH monitoring, measurement of gastric emptying rate of solid meal and study of gastrointestinal motility may be necessary. When no precise explanation for meteorism can be identified, attempts with activated charcoal to reduce the meteorism associated with carbohydrate malabsorption or simeticone to alter the elasticity of gas bubbles may be taken into account, although their value is uncertain.
In many cases of indigestion no clear explanation is obtained, even after careful diagnostic investigation and multiple therapeutic tests. Some cases represent disorders of intestinal motility, perhaps due to subtle physiological disorders, undetectable by the methods currently available. In some of these situations, it may be beneficial to implement an empirical test with gastric prokinetic agents (e.g. cisaprid, metoclopramide) that increase gastrointestinal motility.
Other cases represent early stages of pathological processes that can only be diagnosed by conventional methods at a late date. Others, however, are psychogenic and may respond to appropriate psychiatric measures. The essential assessment of indigestion therefore requires maximum sensitivity, diligence and care on the examiner's side.
I'm done! As of June 18th, I've been addressing diarrhea and constipation...
We're going to talk about food intolerance now. In some people, certain foods or types of foods appear to be correlated with indigestion. Careful documentation of this relationship is sometimes of great help to reach an etiological diagnosis. Some foods may be slightly tolerated due to batch consistency. Patients with esophageal strictures or carcinoma may tolerate fluids well, but may experience embarrassment, especially retrosternal suffering after ingestion of solids.
Citrus fruits, perhaps due to relatively low pH and spicy foods often cause symptoms in patients with peptic ulcerative disease or peptic esophagitis. Certain foods can be hard to tolerate due to impaired digestion or intestinal absorption, as happens with the ingestion of fatty foods in patients with pancreatic disease or bile duct. Patients may have a congenital or acquired deficiency of a specific enzyme necessary for the intestinal absorption of a particular nutrient.
One example is the deficiency of lactase, an enzyme in the intestinal mucosa that catalyzes the hydrolysis of lactose. In some people who are lactazo-deficient, ingestion of milk (containing lactose) causes abdominal cramps, distension, diarrhea and flatulence. Sugar can cause similar symptoms in people with hereditary sucrose-isomaltase deficiency. Certain nutrients can cause important systemic effects due to the patient's biochemical defects, which make the substances particularly risky, as in the intolerance to galactose of people with galactosemia.
Some foods or food additives may initiate allergic reactions, which should be suspected when symptoms appear after ingestion of a particular food, reappear in challenge tests and are associated with other characteristics of the allergic reaction, such as swelling of the lips, urticaria, angioedema, asthma or, rarely, anaphylactic shock. Acute igE-mediated reactions are most commonly associated with cow's milk (in infants), shellfish, flour, eggs, nuts and chocolate and can be confirmed in some cases by the radioallergoabsorption test.
Delayed hypersensitivity reactions may also occur and may be associated with less serious symptoms, including joint and muscle pain, fatigue, severe otitis and altered spatial perception, making it more difficult to correlate with certain foods. Some foods may exert toxic effects on the intestine in susceptible people (e.g. gluten in patients with celiac sprue). In many situations it is not understood the mechanism by which indigestion is associated with indigestion of certain foods.
Thus, a history of intolerance to fatty foods or suffering after ingestion of spicy foods is usually obtained from patients with indigestion (however, the mechanisms that lead to the appearance of symptoms in these circumstances are often unclear).
A "relationship symptom" is represented by aerophagy. In patients who accuse chronic, repetitive eructations ("laughter"), it can be observed that each eructation is preceded by swallowing air, most of which only partially passes down the esophagus and is then regurgitated. Such excessive eructation results from aerophagy or swallowing of air, not from excessive gas production in the stomach or intestine.
A certain degree of aerophagy also occurs in normal individuals, but some people overeat air due to chronic anxiety, rapid feeding, carbonated drinks or the use of straw, chewing gum, hard sucking candy, smoking cigarettes, postnasal leaks, inappropriate dental appliances or esophageal speech. Since eructation following aerophagy may cause a temporary improvement on the patient, a vicious circle of aerophagy and eructation may occur.
About 20-60% of intestinal gases represent the air swallowed. Because nitrogen and oxygen are the only gases present in the atmosphere in appreciable concentrations and because they are not produced in the gastrointestinal tract, their detection by chromatographic analysis of the intestinal gas indicates whether the swallowed air is the source. The swallowed air that is not eructated passes into the stomach and intestine.
Accumulation of air swallowed in the stomach can lead to fullness and postprandial pressure and X-ray detection of a large amount of air in the gastric fornix. This complex of symptoms, called air bag syndrome (i.e. gastric bubbles), can occur when a patient lies lying after a rich meal, thus allowing gastric air to be "caught" under the gastroesophageal junction by the liquid above and impossible to eructate.
Failure to eruct is also assumed to be the cause of the "gas filling" syndrome observed after surgical resolution of the hiatal hernia. Acute gastric distension by swallowed air can sometimes produce sharp pains that can mimic angina. Swallowed air that successfully passes the stomach can either produce diffuse abdominal distension or is captured in the splenic flexure of the colon.
This last case, splenic flexure syndrome, is characterized by a feeling of fullness and pressure in the left hypochondrium with irradiation in the left side of the chest. Pain relief often occurs after defecation or removal of gas. The diagnosis is suggested by the discovery of increased eardrumism in the extreme left lateral portion of the upper abdomen upon physical examination or large amounts of air in the splenic flexure of the colon on a simple abdominal X-ray.
We now move on to meteorism, bloating and flatulence. Despite the widespread belief that sensations of diffuse abdominal pain and bloating are often caused by excessive amounts of intestinal gas, studies using a technique of "complete cleansing" of intestinal gas have shown that patients complaining of excessive gas have a normal volume of intestinal gas. In some cases, the primary anomaly causing functional bloating and pain appears to be a motility disorder that causes the patient to perceive pain at a volume of gas that is well tolerated by normal subjects.
Alternatively, intestinal motility may be normal in such people, but they may be excessively receptive to normal impulses coming from the intestinal tract (visceral hypersensitivity). A major source of intestinal gas is the fermentative disease of intestinal bacteria on carbohydrates and proteins in the lumen. Normally, these bacteria are limited to the colon and the main gases produced are carbon dioxide and hydrogen (along with small amounts of odorous gases such as indoles, scatols and sulfur-containing compounds, which confer the characteristic smell). In the upper small intestine, carbon dioxide is also produced when hydrochloric acid in the stomach or ingested fatty acids are neutralized by bicarbonate (this may in part explain the indigestion associated with fatty foods).
About a third of adults produce appreciable amounts of methane in the colon, which seems to be a family trait and not related to the ingestion of certain foods. An increase in intraluminal gas production leading to abdominal distension, bloating and flatulence occurs after ingestion of certain foods, such as vegetables and some cereals, which contain significant amounts of complex and non-absorbable carbohydrates, which pass into the colon where they supply the gas-forming substrate for colonic bacteria.
The best studied example of this kind is beans containing oligosaccharides (stahiosis and refinosis), which cannot be split by the enzymes of the intestinal mucosa, but are metabolized by colonic bacteria. Less appreciated is the fact that fructose, a natural or added sweetener, from fruits (especially figs, curmals, plums and grapes), fruit juices, soft drinks, and present in oligosaccharides in onions, asparagus, flour, can be incompletely absorbed into the small intestine and therefore contribute to abdominal distension, bloating and flatulence.
By contrast, intestinal absorption of fructose is more likely to be complete when fructose is mixed with glucose or ingested as sucrose (glucose-fructose). Intestinal malabsorption of sorbitol may be the cause of symptoms of abdominal distension, flatulence and diarrhea associated with certain fruits, or when sorbitol is used as a sweetener in sugar-free gum and dietary candy or as an "inert" ingredient in some medications. Increased production of intraluminal gas may also result from abnormal bacterial colonization of the small intestine (bacterial overproliferation syndrome) or infection with Giardia lamblia.
There are also some things to discuss about indigestion due to intestinal disorders. A number of extraintestinal conditions can lead to indigestion. Such indigestion can be important in congestive heart failure, pulmonary tuberculosis, neoplastic disease and uremia. Also, a variety of drugs such as aspirin, nonsteroidal anti-inflammatory agents and glucocorticoids can cause indigestion due to their ulcerative properties.
Let's move on to the patient approach. Indigestion is a challenging and difficult diagnostic problem because of its nonspecific nature. It is necessary to obtain a clear and detailed description of nonspecific symptoms, in particular the patient's definition for the term indigestion. The nature of the suffering, the frequency and timing of its occurrence, its relationship with the meals and the special circumstances leading to its exacerbation or improvement must be requested.
Bowel symptoms associated with nausea and vomiting, abnormal bowel habits, diarrhoea, steatorea and melena will be sought and an assessment of nutrition status, appetite and weight changes should be carried out. A careful history should also include an assessment of the patient's general health, including the possible presence of extraintestinal disorders that may cause indigestion. A careful history of diet is essential and asking the patient to keep track of ingested foods can prove revealing.
Similarly, the patient's medication should be reviewed, especially for agents that can slow down intestinal transit, such as narcotics, anticholinergics and calcium antagonists. Psychological factors can play an etiological and contributing role and the presence of anxiety, depressive symptoms or hysteria should be noted. Physical examination rarely establishes the specific diagnosis, but can be useful in detecting diseases in other organic systems that can affect intestinal function (e.g. congestive heart failure). The appearance of occult stools and haemorrhages must be tracked.
If further diagnostic investigations are indicated, they depend on the specific nature of the patient's accusations and his age (taking into account that the likelihood of gastrointestinal malignancy is higher in older patients). Abdominal pain can be assessed by radiological and imaging investigations of the esophagus, stomach, small intestine, colon, pancreas and bile ducts.
Esophagogastroscopy, endoscopic cholangiopancreatography, sigmoidoscopy or colonoscopy may be considered, depending on the specific symptoms. On the other hand, in patients under 40 years of age with epigastric pain typical of peptic ulcers, routine diagnostic investigations have little possibility of detecting serious diseases (such as gastric carcinoma) and are in fact often negative.
Additional options in such patients include serological testing for H. pylori and empirical treatment with "triple therapy" (one bismuth compound and two antibiotics) in people who are seropositive or an empirical test with antacids, hydrogen-receptor blockers or sucralfate. In contrast to peptic ulcer, nonulcerous dyspepsia improves inconsistently as a result of antacids and other standard antiulcer treatments.
Esophagogastroscopy may be reserved for patients with symptoms that persist despite therapy or reappear soon after discontinuation of therapy. However, in patients with H. pylori to endoscopic anthral biopsy without further explanation for indigestion (e.g. without ulcers), h. pylori eradication has not been shown to be beneficial in controlled studies. In fact, the cost-effectiveness approach in the assessment of dyspepsia, including the relative merits of initial endoscopy versus empirical therapy and the choice of empirical therapy, is still being discussed. In general, most authorities do not recommend treatment to eradicate H. pylori if peptic ulcer is not confirmed.
In individual accusations of excessive eructation, the mere demonstration that aerophagy reproduces symptoms may be sufficient to confirm the diagnosis and promatily discontinue the habit. Patients complaining of excessive gas, bloating, distension and flatulence should be carefully questioned about dietary preferences and the relationship of symptoms with the ingestion of certain foods. In some cases, the removal of certain foods (e.g. milk, vegetables) from the diet followed by reprovocation can confirm the cause.
In other cases, a more detailed assessment, including examination of the stool for fats and muscle fibres and parasites at G. lamblia, respiratory tests for the testing of carbohydrate malabsorption or bacterial proliferation, esophageal manometry and ambulatory pH monitoring, measurement of gastric emptying rate of solid meal and study of gastrointestinal motility may be necessary. When no precise explanation for meteorism can be identified, attempts with activated charcoal to reduce the meteorism associated with carbohydrate malabsorption or simeticone to alter the elasticity of gas bubbles may be taken into account, although their value is uncertain.
In many cases of indigestion no clear explanation is obtained, even after careful diagnostic investigation and multiple therapeutic tests. Some cases represent disorders of intestinal motility, perhaps due to subtle physiological disorders, undetectable by the methods currently available. In some of these situations, it may be beneficial to implement an empirical test with gastric prokinetic agents (e.g. cisaprid, metoclopramide) that increase gastrointestinal motility.
Other cases represent early stages of pathological processes that can only be diagnosed by conventional methods at a late date. Others, however, are psychogenic and may respond to appropriate psychiatric measures. The essential assessment of indigestion therefore requires maximum sensitivity, diligence and care on the examiner's side.
I'm done! As of June 18th, I've been addressing diarrhea and constipation...
Let's hear it for good!
Dorin, Merticaru