Indigestion and peptic ulcers affect twice as many men as women, with over 60 per cent of the adult male population suffering symptoms at some time during their lives.
Indigestion is a common term covering a variety of symptoms related to eating. These include feelings of distension from swallowing air, flatulence from excessive wind in the intestines, nausea, abdominal pain and sensations of burning due to acid reflux.
GASTRO-OESOPHAGEAL REFLUX DISEASE
Gastro-oesophageal reflux disease (GORD) is due to acidic stomach contents refluxing up into the oesophagus the tube connecting the mouth and stomach. Normally this reflux is prevented by a muscle sphincter and by a downward-propelling action of the oesophageal muscles. If, however, muscle action is uncoordinated, if a hiatus hernia is present, or if the stomach is excessively full, reflux can occur.
The main symptom of GORD is heartburn. This hot, burning sensation is felt behind the sternum and may rise up into the throat. It usually comes on within 30 minutes of eating a meal and may be precipitated by exercise or by bending or lying down, especially after eating. Meals containing fat, pastry, chocolate, peppermint, fruit juices, coffee or alcohol frequently trigger attacks.
In men under the age of 40, antacids, prokinetic agents (which co-ordinate muscle contraction) and drugs that damp down acid secretions (e.g. cimetidine, ranitidine) are used to damp down symptoms.
In men over the age of 40, or for those with more sinister symptoms (weight loss, difficulty swallowing, vomiting, bleeding, anaemia, early feelings of fullness, severe pain), further investigation is required to eliminate the possibility of a peptic ulcer or stomach cancer.
Tips to Alleviate the Symptoms of GORD
• Lose any excess weight.
• If you smoke, stop or cut down.
• Eat little and often throughout the day, rather than the traditional three large meals.
• Avoid drinking large quantities of liquid at any one time.
• Avoid hot, acid, spicy, fatty foods.
• Avoid peppermint, chocolate and fruit juices.
• Avoid tea and coffee.
• Cut back on alcohol intake.
• Avoid aspirin and related drugs use paracetamol.
• Avoid stooping, bending or lying down after eating.
• Avoid late-night eating.
• Elevate the head of your bed by about 1520 cm (68 in).
• Wear loose clothing.
• Drinking a glass of milk may ease your symptoms.
• If you feel blown out with wind, take a teaspoon of bicarbonate of soda dissolved in a glass of warm water every hour for up to three hours but do not take any more than this.
NB Losing weight and giving up smoking are the two most useful measures for reducing gastro-oesophageal reflux.
If you suffer from recurrent indigestion, it is important to tell your doctor. A recent Gallup poll of over 1,000 people found that within the past 12 months 48 per cent had suffered heartburn but that only 25 per cent had sought help.
If you have tried over-the-counter antacids and they haven't controlled your symptoms, you should also tell this to the doctor, otherwise you may end up with a similar preparation instead of something stronger. This is important, as it has been found that taking antacids does not protect against the damage done by acid on delicate stomach and intestinal tissues. After 1020 years, scarring (and a resulting difficulty swallowing) can occur. One in 10 people taking regular antacids could have a serious underlying problem, so always consult a doctor.
GASTRITIS
The stomach is normally protected from digesting itself by a lining of mucus. If this mucus mantle is eroded, however, inflammation of the stomach wall can occur. Gastritis produces symptoms similar to those of a stomach ulcer: burning or gnawing pain in the upper abdomen, nausea and vomiting. If gastritis is severe, there may be blood in the vomit (haematemesis). The blood is usually partly digested and clotted, so that is resembles dark brown coffee grounds in the vomit.
Acute gastritis can be triggered by substances that irritate the stomach lining, such as cigarettes, alcohol, aspirin, ibuprofen and other non-steroidal anti-inflammatory analgesic drugs.
Helicobacter pylori
The primary cause of gastritis is now known to be infection of the stomach with a bacterium called Helicobacter pylori. In the UK, at least 20 per cent of 30-year-old men and 50 per cent of those over the age of 50 are infected. In some parts of the world such as in South America and Africa, colonization rates are higher, with up to 90 per cent of 20 year olds infected.
Helicobacter pylori is a motile bacterium that burrows into the mucous lining of the stomach and exposes the stomach wall to acid attack. It can survive the high concentrations of acid by producing an enzyme (urease) which converts small quantities of urea into a bubble of ammonia gas. This alkaline bubble coats the bacterium and protects it from stomach acids. At the same time, the ammonia acts as another irritant to inflame the stomach wall.
Helicobacter pylori can be tested for in a number of ways:
• blood tests to look for antibodies to the bacteria
• breath tests the patient swallows some radioactive urea, then half an hour later breathes into a sealed bag. If Helicobacter is present, its enzyme will convert urea to ammonia, so that radioactive ammonia will be detected in the bag.
• a new non-invasive test picks up signs of infection from saliva
Once diagnosed, Helicobacter can be eradicated by a mixture of two antibiotics plus bismuth (triple therapy) or one antibiotic plus a drug that stops the stomach from making acid (double therapy). Unfortunately this treatment (especially triple therapy) is unpleasant with side-effects of a sore mouth, a disagreeable metallic after-taste left in the mouth, nausea, diarrhoea, abdominal pain and blackening of the stools and tongue. One in five patients drops out of treatment with triple therapy; double therapy is better tolerated.
New research from New Zealand suggests that honey made from the flower of the Manuka, or New Zealand Tea Tree, contains a unique antibiotic that can also eradicate Helicobacter. Taking four teaspoons of Manuka honey four times per day on an empty stomach for eight weeks can eradicate infection. Manuka honey is available in some healthfood shops.
NB Men with diabetes should consult their doctor before using honey treatments.
PEPTIC ULCERS
Peptic ulcers affect twice as many men as women, and in the UK one in 30 adults suffers at some stage during his or her life. Duodenal ulcers (affecting the duodenum the tube that leads out of the stomach) are more common, affecting around one in 10 adults. The peak age for developing a duodenal ulcer is 2040 years. Gastric ulcers tend to occur 1020 years later.
In the UK, it is estimated that in any one year up to a million people suffer a peptic ulcer. Ninety per cent of these are recurrent ulcers.
Helicobacter pylori infection is associated with 85 per cent of gastric ulcers and virtually all duodenal ulcers. The increasing recognition and treatment of this important infection has resulted in the incidence and recurrence rates of peptic ulcers starting to fall.
Peptic ulcers typically produce symptoms of:
• gnawing, localized pain
• pain at night
• pain that is relieved by antacids
• pain that is relieved by vomiting
• pain that (in the case of stomach ulcers) may be exacerbated by eating
• pain that (in the case of duodenal) ulcers may be relieved by eating
In men under the age of 40, a trial of anti-ulcer treatment is usually given to see if symptoms improve. Smoking and aspirin-related drugs should be stopped as these may have triggered the problem in the first place. If symptoms recur after treatment, investigation is essential to confirm the diagnosis and to rule out the possibility of stomach cancer.
In men over the age of 40 years, investigation is necessary before anti-ulcer treatment is started. Antacids can be used To relieve symptoms while awaiting the results of this investigation.
The most usual modern investigation of peptic pain is endoscopy. A light sedative is given into a vein to relax you and to minimize discomfort. A thin, flexible tube is then passed down into the stomach through the mouth. This tube contains a light, a magnified viewing system and biopsy forceps. It allows visual inspection of The lining of the stomach and duodenum and will identify areas of inflammation (gastritis), ulceration, bleeding and scarring. Suspicious areas can be biopsied (a small sample taken out) and examined so that the possibility of malignancy can be ruled out.
Although you are awake throughout an endoscopy, most patients do not remember it afterwards because of the sedative they are given.
Treatment
There are several different treatments for peptic ulcers. Self-help measures include giving up smoking, avoiding alcohol, tea and coffee, aspirin and related drugs such as ibuprofen, and eating several small meals per day rather than three larger ones. Other simple treatments include:
• antacids (e.g. aluminium hydroxide, calcium carbonate, magnesium salts, sodium bicarbonate), which neutralize excess acidity
• H2 blockers (e.g. ranitidine, cimetidine, famotidine, nizatidine), which reduce acid secretion by blocking the receptors on acid-producing cells. These heal up to 85 per cent of ulcers within two months. Around 80 per cent of ulcers will recur within a year of stopping treatment, however, so long-term maintenance therapy is used for some patients.
• proton pump inhibitors (e.g. omeprazole), which stop acid secretion and promote more rapid ulcer healing than H2 blockers. Ninety per cent of ulcers are healed within one month, but again, relapse is common once treatment has stopped.
• Cytoprotectants (e.g. sucralfate, carbenoxolone, misoprostol), which either increase mucus secretion in the stomach or coat the ulcer to act as a barrier to acid.
• Helicobacter eradication therapy (see above). Only 12 per cent of patients have recurrent peptic ulceration following this procedure.
Complications
If a peptic ulcer erodes a blood vessel, bleeding results. If bleeding is low key and recurrent, iron-deficiency anaemia can result, with progressive tiredness, pallor and even shortness of breath. More usually, bleeding is due to erosion of an artery, which can produce sudden, severe haemorrhage. Nausea and vomiting occur, with either bright red or semi-digested blood in the vomit which resembles coffee grounds. Digested blood that continues down the intestinal tract produces foul-smelling, tarry black bowel motions.
Rarely, a peptic ulcer may perforate the wall of the digestive tract. Irritant intestinal secretions full of acids and enzymes leak into the abdominal cavity to produce severe inflammation and pain due to peritonitis.
Chronic ulceration can produce scarring of the exit from the stomach and the duodenum. This causes narrowing in the passages and obstructs the downward course of food, resulting in vomiting and weight loss.
All peptic ulcer complications require urgent admission to hospital for emergency treatment which usually involves surgery.
Contact a doctor for advice if:
• your pain is very severe
• any abdominal pain lasts more than four hours, especially if it starts to get worse
• prolonged vomiting occurs
• you vomit blood, brown-stained liquid or what looks like brown coffee grounds
• you start to pass very dark or black bowel motions
• you feel very weak or faint.
IRRITABLE BOWEL SYNDROME
Irritable bowel syndrome (IBS) affects at least a quarter of the population. Although only one in three sufferers is male, this still represents a sizable proportion of the adult male population around one in 12. Symptoms usually begin between the ages of 15 and 40 but it can affect anyone at any age. It is also known as irritable colon, spastic colon or mucous colitis.
The cause of IBS is not understood. The basic problem is a disturbance of muscle contraction in the intestinal tract, but no physical abnormality has yet been found as its cause.
The intestines are a long muscular tube which contracts in ordered waves. This propels food along while nutrients and water are absorbed. In irritable bowel syndrome, these contractions are uncoordinated and cramps occur. Nobody yet knows why.
The main symptoms of IBS are pain, wind, bloating, distension, sensations of incompletely evacuating the bowels, increased mucus from the back passage, and constipation or diarrhoea (or bouts of each).
As these symptoms also occur in more serious bowel conditions it is important to have them checked by your doctor you should never make a diagnosis of IBS yourself. Most importantly, if you notice any change in your usual bowel habit, any blood or blackness in your stools, or weight loss, seek urgent medical advice.
The pain of IBS is cramp-like or colicky and comes and goes in waves. It is felt anywhere in the abdomen but is often worse on the lower left-hand side. The pain may worsen after eating as this stimulates contraction of the colon (gastrocolic reflex). Sufferers usually find that opening the bowels or passing wind brings relief.
Wind is a common problem. Because the bowels are not contracting properly, air that is naturally swallowed when eating and drinking builds up. It burbles around causing pain, distension and noises (borborygmi) until escaping suddenly and sometimes explosively.
Constipation is another common feature of IBS, as spasm of the muscular bowel walls squashes its contents rather than pushing them through. As a result the bowels may not open for days at a time. When they do, straining is necessary to push out hard, rabbity pellets or thin ribbons of faeces.
The bowels also frequently work overtime, with increased mucus secretion and intestinal hurry (diarrhoea). Constipation and diarrhoea often alternate and sufferers may notice an unpleasant sensation of not completely evacuating the bowels.
At present, IBS is a diagnosis of exclusion, there is no definitive test that can pick it up. Initial examination of the abdomen is performed to elicit areas of tenderness and check for obvious lumps. A digital rectal examination is mandatory for any bowel problem. This is only slightly uncomfortable and gives important information regarding the texture of the bowel lining and whether the rectum is full or empty of stool, and can enable the detection of rectal tumours.
Blood tests may be taken to look for anaemia, thyroid problems and signs of infection or inflammation. Further investigation of the lower bowel involves a barium enema, or endoscopy in which a scope is passed into the rectum and lower (sigmoid) colon. If a higher part of the bowel is examined via colonoscopy, light sedation is given. (A colonoscopy is a procedure in which a viewing device is inserted into the back passage so that the large colon can be examined and biopsied.)
Treatment
Once more serious conditions such as bowel tumours or inflammatory bowel disease are ruled out, the treatment of IBS is aimed at controlling symptoms. Unfortunately, as yet there is no cure. Controlling the symptoms involves:
• antispasmodics (e.g. alverine, mebeverine, peppermint oil) to relax the bowel and dampen painful spasms
• peppermint capsules to prevent wind distention
• following a high-fibre diet and taking bulking agents (e.g. bran, methylcellulose)
• anti-diarrhoeal agents (e.g. loperamide) to relieve bowel looseness.
In up to a quarter of men, a high-fibre diet initially makes the bloating and distension of IBS worse. This effect disappears after two or three weeks, however, so it is important to per-severe. The bloating may be related to not drinking enough fluids. Bulking agents usually come in the form of granules which are taken once or twice a day with plenty of water. The fibre swells up in the bowel and provides bulk for the intestines to grip. This helps propel waste through efficiently.
The diarrhoea associated with IBS is often worse in the first few hours of waking. In this case, an anti-diarrhoeal drug such as loperamide is best taken last thing before bed and again after the first bowel action of the day. Treatment should only be used for short periods of time without the advice of your doctor. It is also worth avoiding fruit juices and prunes and cutting down on milk and dairy products if your bowels are very loose.
Self-help Tips
There are many dietary and lifestyle changes you can make to help your symptoms:
• Cut out all prepacked or processed foods and stick to a natural, whole food diet
• Eat a high-fibre diet containing wholegrain bread, wholemeal pasta, brown rice and unsweetened wholegrain breakfast cereals such as muesli (granola) or porridge. Some people find this makes their symptoms worse, but persevere for three to four weeks before deciding this is not working for you.
• Fresh fruit and vegetables especially nuts, seeds, figs, apricots, prunes, peas, sweetcorn and beans are especially high in fibre.
• Cut down on the amount of saturated fat in your diet. Avoid dairy products such as butter, cream and whole-fat milk. Instead, try semi-skimmed or skimmed milk, and olive-oil based products in place of butter. Low-fat fromage frais is a delicious and healthy substitute for cream.
• Many people find that live bio-yoghurt containing a culture of the bacterium Lactobacillus acidophilus relieves their symptoms. Lactobacilli are able to colonize the bowel and this may help damp down symptoms.
• Try avoiding red meat and see if this improves your symptoms. Eat more fish and skinless white meat in its place.
• Avoid sugar, cakes, sweets and chocolate.
• Do not fry or roast your food, grill, bake, casserole or steam instead.
• Many natural herbs and spices contain substances that calm the bowels, relieve spasm and prevent a build-up of wind. These include aniseed, chamomile, lemon balm, clove, dill, fennel, black pepper, marjoram, parsley, peppermint, rosemary and spearmint. Use them as a garnish on food or as soothing, herbal teas. Plain infusions of chamomile or peppermint are available, as are delicious combinations such as chamomile and spearmint or fennel and lemon balm.
• Stop smoking and avoid passive smoking, too. There are receptors in the intestinal tract which react with nicotine and cause the bowel to constrict, making symptoms worse.
• Increase the amount of exercise you take. This hastens bowel emptying and can relieve bloating and distension. For those who are immobile, abdominal massage is an alternative.
• Try to avoid unnecessary stress. The bowel contains receptors that interact with stress hormones, which will make spasm and diarrhoea worse.
Many alternative treatments can help to relieve IBS. They include acupuncture, homoeopathy, floatation therapy and hypnotherapy.
At present there is no cure for IBS, but research is ongoing and may provide answers in the future. For example, it was recently found that patients who had an operation for haemorrhoids also noticed a significant improvement in their symptoms of IBS. This might be due to the cutting of small nerves which prevented feedback hyperstimulation of the intestines.
HAEMORRHOIDS
Haemorrhoids (piles) are surprisingly common, with up to 40 per cent of adult males affected. A pile is a swollen varicose vein in the back passage (rectum). Haemorrhoids are frequently multiple and, if they occur close to the anal opening, can protrude to form external piles. If they occur higher up, so they are hidden from view, they are known as internal piles.
External piles tend to be dark red or purple in colour as they are covered by a thick layer of skin. Internal piles are lined by a mucous membrane and are therefore bright red, shiny and moist.
Haemorrhoids form because our rectal veins are the lowest in the system carrying blood from the liver to the heart. This means an enormous weight of blood bears down on them due to the effects of gravity. This causes stretching of the veins and rupturing of their containing tissues, especially if you spend long periods of time standing on your feet. Piles can also be hereditary and associated with congenital weakness of veins in the back passage. Any increase in pressure such as straining from constipation will also cause them to expand. In fact, the commonest cause of piles is long-term constipation due to lack of fibre in the diet.
The symptoms commonly associated with piles are:
• bleeding from the back passage usually bright red blood
• dull, dragging aching sensations in the back passage
• pain, especially on opening your bowels
• mucous discharge
• itching.
You should not diagnose piles yourself as many of their symptoms are similar to those of more serious diseases such as inflammatory bowel disease or even cancer. Always consult a doctor, especially if you notice blood either in or on your motions.
Treatment
Mild haemorrhoids are helped by drinking plenty of fluids and eating a high-fibre diet. This keeps bowel movements regular and soft and avoids straining.
It is important to get into a regular routine of opening your bowels at least once per day. But never strain hard or you will make your piles worse. Leaning forward from the hips while sitting on the toilet will help to reduce straining.
• Always go to the toilet when you first feel the need do not delay opening your bowels however busy you are.
• The area around the anus should be cleaned with unperfumed soap and warm water after every bowel movement. This prevents infection and encourages healing. A bidet is ideal. Pat yourself dry with absorbent tissue or use a hairdryer rather than rubbing the area with a towel.
• Keep your bottom as dry as possible. Cotton underwear is more absorbent than nylon. Many people also keep a tissue or cotton wool (changed frequently) between their buttocks. But this may rub, so do be careful.
• Rectal suppositories and creams are soothing. These contain local anaesthetics and drugs which damp down inflammation, itching, swelling and pain. Some of the best ones are only available on prescription.
• Take regular exercise to encourage a healthier circulation, and lose any excess weight.
• If you get a bad attack of pain and discomfort, raise the foot of your bed by 1520 cm (68 in) and lie down so your feet are higher than your head. Gravity will then help blood drain away from your haemorrhoids. External piles can be gently pushed back using the fingers and plenty of soothing, lubricating cream, but don't press too hard.
Sometimes blood becomes trapped inside an external pile and starts to clot. The pile is then said to have strangulated, causing intense pain. Instant relief can be obtained by a doctor anaesthetizing the pile with local anaesthetic cream, and then making a small incision to shell out the clotted blood.
When haemorrhoids are bad enough to interfere with your daily life, it is best to have something permanent done about them. Piles can be:
• sealed off with a sclerosant injection
• shrivelled with a freezing cryoprobe
• tied off with a tight elastic band. Banding is painless and no anaesthetic is needed. The procedure cuts off the blood supply to the haemorrhoid, which then withers and drops off painlessly within a few days.
• removed under general anaesthetic via a haemorrhoidectomy operation. The piles are cut away, together with some of the rectal wall lining, and sutured. Unfortunately, this operation is quite painful and you will need strong painkillers and laxatives to see you through the first few days after surgery. Hospitalization is necessary until you can open your bowels easily. Complete healing takes three to six weeks.
