Originally published in The Ottawa Citizen January 09, 2005
Original Title: Toxic Soup

All the ingredients for a potential health calamity are present

The tsunami survivors face great health challenges. To date there have not been reports of epidemics of cholera or other infectious diseases. However, the massive aid pouring into the affected regions is designed to address the health risks that have the potential to cause further harm.

All the ingredients for a potential health calamity are present: a contaminated water supply, lack of sanitation infrastructures, overcrowding, malnutrition, and endemic infectious diseases.

Human waste and decaying corpses contribute to the massive contamination. In effect, some of the survivors are living amongst a biologic toxic soup containing myriad pathogenic micro-organisms.

It is the children who will suffer most. Their weakened state impairs their ability to resist disease. Many can live without food for a week or more, but survival time is measured in days without clean water; they will rapidly succumb to dehydration, especially within the hot tropical environment.

With weakened immune systems comes an increased incidence of diarrheal illnesses, pneumonia, urinary tract infections and skin infections, among others. The severity of the illness and the survival rate is usually proportional to the time it takes to diagnose and treat it.

Indeed, bacterial diseases such as typhoid (Salmonella typhii), cholera (Vibrio cholerae), and enterotoxigenic E. coli are a major cause of dehydration, and are endemic in developing countries in Asia and Africa. All these organisms are found in contaminated food and water. They will also pass from person to person. Lack of adequate shelter makes it impossible to isolate the sick from the uninfected population.

Although the manner in which they cause disease (pathogenesis) differs, the end result is similar: They will infect and damage the intestines (enteric disease).

The small intestine absorbs most of the nutrients from food while the large intestine absorbs about 99 per cent of all water that flows through it. Damage to these structures can lead to bleeding and reduced absorptive capacity causing massive diarrhea.

Children and the elderly do not have as great a fluid reserve as do younger adults. In many instances, they must receive intravenous fluid replacement to compensate for their losses from diarrhea. The availability of clean water to drink will not help them in this case because the large intestine has lost its ability to absorb it.

The supportive care to treat cholera and other enteric diseases requires many litres of intravenous fluid replacement per patient. Some may need between 10 and 20 litres during the course of disease. Given the thousands of people that will contract these diseases, the resources alone for this one condition can strain available medical resources and supplies.

Contaminated pools of water attract disease-carrying flies, malaria and dengue fever-laden mosquitoes, and also harbour hepatitis A.

Without adequate shelter and netting for nighttime protection, the survivors are at risk for malaria and dengue fever. Left untreated, many will die. Waterborne parasites can also cause intestinal infection leading to cramps, bleeding and diarrhea. Most healthy people will recover from hepatitis A without any major consequences. However, the survivors of the tsunami have a greater risk of complications because of their weakened state.

Tuberculosis, a disease that affects two billion people worldwide — roughly one-third of the world’s population, most in developing countries — will claim more victims. This highly contagious person-to-person disease will have the opportunity to infect many others because of the living conditions and migration of people to temporary shelters or camps.

Some will have physical injuries that require proper wound care. Without treatment, these wounds will fester and infections will develop. Cellulitis is a common and potentially serious skin infection that normally starts in areas where there is pre-existing skin damage. The skin becomes swollen, red and hot and has a poorly defined border. The area of redness (erythema) rapidly expands and creeps along the skin within hours.

If diagnosed early, treatment consists of an oral antibiotic. Intravenous antibiotics are used if oral treatment fails or if there is an initial extensive spread of the infection. However, many of the survivors will not have access to prompt medical treatment. The end result is that a readily treatable infection will spread and increase the risk of septic shock and death.

The relief efforts are designed to counter the problems outlined, here. Setting up proper sewage and waste management systems will take time. Burying the dead, decontaminating water supplies, providing food and shelter and tending to the sick and injured are the initial focus of the recovery program. This in turn will slowly introduce order into a chaotic situation, but it will take months or years to remedy.

© Dr. Barry Dworkin 2005

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2. Have needle, will travel
3. The onus is on you to prevent illness when on vacation

Originally published in The Ottawa Citizen August 17, 2004
Original Title:”Mommy, my stomach hurts”

There are numerous causes for abdominal pain and cramps, warranting a thorough evaluation; diagnoses include peptic ulcer disease, acid reflux, colitis and bowel cancer, among others.

Evaluation of abdominal pain is a complex process because many diseases share common symptoms. When a thorough history, physical examination and appropriate diagnostic testing eliminate most causes, thoughts turn to irritable bowel syndrome.

Studies indicate that the worldwide incidence of IBS varies from three to 22 per cent. Approximately 50 per cent of people experience symptoms before the age of 35, and 40 per cent between 35 and 50 years of age. They account for about half of all consults to gastroenterologists.

Women have a greater prevalence accounting for 70 per cent of all IBS patients. Many women with IBS suffer from chronic pelvic pain, menstrual period pain (dysmenorrhea) or painful intercourse (dyspareunia). They may have a history of several abdominal surgeries.

Physicians use a set of specific guidelines like the Rome II Diagnostic Criteria to assist in the diagnosis (www.helpforibs.com/footer/rome_guidelines.asp). For most people there are distinct symptoms: constipation or diarrhea in concert with bloating and abdominal cramps and distention. Indeed, the symptoms and signs of the disease will determine what kind of IBS the patient has.

There are three overlapping types of IBS: constipation-, diarrhea- and pain-predominant.

Some patients will have changes in their bowel movement frequency. Others may have mucousy stools, a sensation of an ongoing need to defecate or a feeling of not being able to fully empty the bowel. In IBS, bowel movements usually provide immense relief from the abdominal spasms, bloating and pain.

There is a risk of using the post hoc ergo propter hoc (“it happened after so it was caused by”) approach with respect to IBS triggers, because there is no unifying cause for this disorder. Most people do not share a common set of factors that trigger their IBS.

Indeed, myriad seemingly unrelated factors are implicated in the expression of IBS: dietary factors, impaired ability of the small and large intestine to move contents forward, sexual and physical abuse, drug and alcohol abuse, fibromyalgia and chronic fatigue syndrome, among many others.

The important point is that this disorder is not imagined. It is real and is debilitating. What does the evidence to date indicate?

The relationship between IBS and food intolerance and allergy is not clear-cut because only a small percentage of patients have these conditions. Low-fibre diets seem to contribute to IBS. Indeed, the addition of a fibre-rich foods or supplements has helped a minority of patients. Populations that follow high-fibre diets seem to have a low incidence of IBS.

IBS patients experience over-reactive and intense intestinal spasm in response to certain emotional and physical triggers. This response can be triggered following a meal, by a low pain threshold or rectal pressure. Endoscopic procedures like colonoscopy can reproduce this intense response.

Blaming IBS on psychiatric factors is not in keeping with the available evidence because chronic disease can lead to depression and anxiety related reactions. Indeed, more than 50 per cent of people with IBS have a psychiatric illness. People who abuse drugs and alcohol or who have experienced severe emotional trauma (e.g. divorce, death of a family member or sexual abuse) seem to have a greater risk of developing IBS.

Treatment of IBS depends on the patient’s understanding of their triggers and symptoms. Treatment includes changing dietary habits, increasing fibre content of foods (note that high fibre diets may worsen diarrhea-predominant IBS), re-training the bowel, increased physical activity, stress-reduction counselling and medications.

Dietitians provide an invaluable service in the preparation of a dietary plan to minimize food triggers and maximize proper nutrition. They will help you achieve a balance between soluble and insoluble fibre.

Avoiding intestinal stimulants such as caffeine, nuts, corns, seeds, alcohol and nicotine may help alleviate the symptoms.

There are many medications available to control the intestinal spasm. Tegaserod (Zelnorm), trimebutine (Modulon) and pinaverium bromide (Dicetel) help restore the bowel’s normal contraction process Tegaserod is indicated for women with constipation-predominant IBS whereas the others treats all types.

There is no standard approach to treatment because of the nature of this disease. Your doctor and dietitian can help you develop a comprehensive treatment program that may include other therapies and medications not mentioned in this column; it is by no means complete.

For more information, visit the Canadian Society of Intestinal

Research website at www.badgut.com/index.php?contentFile=ibs&title=Irritable%20Bowel %20Syndrome .

For an IBS symptom checklist and questionnaire, go to www.ibsvillage.com/info/c/c10.jsp .

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2. Crohn’s disease can be controlled
3. Screening for Abdominal Aortic Aneurysms

Originally published in The Ottawa Citizen May 29, 2004
Original Title: Bugs down the gullet

They have exotic names but they are less than endearing. Intestinal parasites come in all shapes and sizes. Each has its own way of taking advantage of the body’s metabolism and anatomy.

Although there’s a wide variety of parasites, let’s look at the most common vermin to hitchhike the intestinal highway (sorry, if you are eating breakfast).

Pinworm or Enterobius vermicularis is a worldwide infection affecting about 200 million adults and approximately 30 per cent of children.

These small roundworms or nematodes measure eight to 13 millimetres for females and two to five millimetres for males. Transmission of the parasite’s eggs occurs via the fecal-oral route. Poor hand washing and hygiene can transfer them from person to person.

Once the eggs are swallowed, they hatch in the initial portion of the small intestine called the duodenum. From there they migrate to the large intestine and settle in the cecum located in the right lower quadrant of your abdomen. The female will take a nightly crawl from the cecum to the outside edge of the rectum where she will lay up to 15,000 eggs.

This infestation causes few symptoms, is self-limiting and lasts about six weeks (if the host person remains isolated from any new infected contacts).

Rectal, vaginal and perineal (the skin between the rectum and vagina or scrotum) irritation and itch are the most common symptoms. Indeed, children who complain of rectal itch and are unable to sleep may have pinworm. Weight loss, bladder infections and appendicitis are very rare complications.

Applying cellophane tape to the rectal area will pick up the eggs. They can be seen under the microscope.

One dose of mebendazole (Vermix) taken two weeks apart will kill the pinworms. Prevention includes treating household contacts and cleaning the bedrooms and beds.

Giardia lamblia often invades individuals who hike in the wilderness, hence its nickname “beaver fever.” Poor sanitation and contaminated waterways contribute to this protozoan’s worldwide presence. Like pinworm, it follows a fecal-oral route of transmission but lives in water.

Indeed this infection, known as zoonosis, can survive in chlorinated city water and cold mountain streams. It infects many species including beavers, dogs, rodents, cattle and bighorn sheep, thus ensuring a rich reservoir.

Giardia will incubate for about two weeks before symptoms occur. It may cause an upset stomach, nausea, fatigue, gas, cramps, fatty stools, weight loss and diarrhea. Some may have itching and rashes. The infection persists two to four weeks. Malaise, fatigue and depression may wax and wane over many months if the condition is not treated.

A stool examination for ova (eggs) and parasites will uncover giardia. Treatment with the antibiotic metronidazole will eradicate the infection in adults.

The infection can be prevented by employing proper sewage treatment and disposal. Travellers to at-risk areas should drink only bottled water. Water treatment options include boiling for one minute, using iodine water-purifying tablets eight hours prior to drinking, and proper handwashing technique.

Entameba histolytica is another protozoal infection spread by the fecal-oral route. Poor hygienic food preparation techniques and food grown in soil fertilized with human waste are common worldwide problems. Ten per cent of the world’s population carries the infection. Although 90 per cent of infected people do not have symptoms, the remaining 10 per cent or 50 million people will experience intestinal bleeding, fatigue, weight loss, severe abdominal cramps and pain, copious bloody diarrhea and fever — worldwide, 100,000 die each year from it.

It can escape from the intestine, causing abscesses in the liver and the tissues lining the lung (pleura) and heart (pericardium).

Metronidazole is a common antibiotic choice for uncomplicated infestation. Avoid eating unpeeled fruits and vegetables when travelling to endemic areas. Stick to bottled water and use iodine tablets for any non-bottled water source.

Consult your doctor should you experience diarrhea and malaise after travel.

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3. The onus is on you to prevent illness when on vacation

Originally published in The Ottawa Citizen December 2, 2003
Original Title: Wasting away on a full stomach

Part I – Don’t wait to deal with heartburn pain

Richard (not his real name) was a happy one year-old infant. After his first birthday he developed bloating and diarrhea and lost weight. His growth slowed. This condition persisted for months.

His mother, suspicious about a food-related condition, maintained a food diary. She noted that bread and cereal seemed to make him worse. A preliminary diagnosis of celiac disease (sprue or gluten-sensitive enteropathy) was made and was subsequently confirmed by a biopsy of the small intestine.

Reports of celiac disease began in the late 19th century. However, it was not until the mid 20th century when the removal of wheat and wheat products from the diet led to dramatic improvements. Celiac disease occurs when the protein gluten, found in wheat, stimulates a complex series of immune system events. These events produce an antibody that attacks the small intestine (an autoimmune reaction) compromising its ability to absorb nutrients. Certain autoimmune diseases like lupus and rheumatoid arthritis among others are associated with celiac disease.

Celiac disease affects one in 250 people. Some do not manifest any gastrointestinal symptoms but tend to have other problems like chronic fatigue, chronic diarrhea, unexplained weight loss, short stature, epilepsy and infertility.

If someone has a first-degree family member with celiac, his/her risk of developing celiac increases by ten to twenty per cent. Seven per cent of type 1 diabetics will also have celiac disease.

Celiac disease usually begins in infancy. Infants typically develop failure to thrive, bloating and abdominal distention, diarrhea, developmental delay and occasional severe malnutrition. Left undiagnosed, the condition can become a medical emergency.

The effects of celiac disease tend to be less severe in later childhood. Indeed, older children may end up with brittle teeth due to enamel breakdown or remain short for their age as the only signs of the disease.

Women comprise 75 per cent of new adult celiac disease cases. Common digestive system symptoms include diarrhea, constipation, bloating, gas and burping. They may experience chronic fatigue, fibromyalgia-like symptoms, mouth ulcers, stomach ache, acid reflux and heartburn and bone pain.

About ten per cent of adults will develop an intensely itchy red rash with tiny bubbles or vesicles that look like herpes on the buttocks, knees, back and elbows. This rash, dermatitis herpetiformis, can be misdiagnosed as a form of psoriasis or eczema.

Iron is absorbed by the small intestine. Iron deficiency anemia is commonly found in about half of the new cases of celiac disease because of the damage to the small intestine. This damage can also cause intestinal bleeding in about 50 per cent of patients too. Vitamin B12 and folic acid deficiency can also occur.

The diagnosis of celiac disease can be made on the basis of a blood test. This test looks for the antibodies that attack the intestine. The most accurate test is the IgA antiendomysial antibody test.

Many of the complications of the disease relate to the lack of nutrient absorption in the small intestine. The lack of calcium and vitamin D absorption can lead to a reduction in bone calcium ranging from mild loss (osteopenia) to severe loss (osteoporosis).

Nerve and brain damage may occur because the celiac-created antibodies (autoantibodies) attack the arteries of the brain. Calcium may deposit in the brain tissue potentially leading to epilepsy. Other nerve damage includes an inability to maintain posture and peripheral neuropathy (reduced sensation in the lower legs and feet).

Untreated patients are at risk for two forms of cancer, a leukemia called T-cell lymphoma and bowel adenocarcinoma. Proper life-long treatment and control of celiac disease will reduce this risk to that of the general population.

It is imperative to have a dietician design an appropriate diet. Completely removing gluten and its related proteins, found in wheat, barley and rye, is the only means to control the disease. The disease’s complications can be prevented or reversed with the addition of iron, folic acid, calcium and vitamin D supplements to the gluten-free diet.

Rice, corn, maize, flax, quinoa, tapioca, potato, amaranth, and other grain substitutes, such as nuts and beans, are safe. Pure oats are considered safe in small quantities but commercial oat products may contain wheat and other “impurities”

Fruits, vegetables, meats, and most dairy products are safe to eat. Specialty stores sell gluten-free breads, cereals, cookies and chips.

Consult your family doctor if you have chronic fatigue and diarrhea, unexplained weight loss, irritable bowel syndrome, iron deficiency anemia, epilepsy, short stature, infertility, a medical history of thyroid disease or type I diabetes or a family history of Celiac disease. This is another of the “silent” diseases out there that can be effectively treated.

Richard has followed a gluten-free diet for ten years. He remains in good health and lives a normal kid life.

For more information:
Canadian Celiac Association: http://www.celiac.ca/
Celiac Canada: http://www.penny.ca/Celiac-canada.htm

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2. Iron Overload
3. Helping vegetarian teens thrive

Originally published in The Ottawa Citizen November 18, 2003
Original Title: Into the bowels of hell

Mandy (not her real name) came to the office complaining of nausea and intense abdominal cramping with bloody mucousy diarrhea. She could not sleep or eat because of the severe pain. Investigations led to a diagnosis of Crohn’s disease.

Crohn’s disease causes mild to severe inflammation of the digestive tract in children and adults. It attacks the digestive tract from the mouth to the anus. This chronic condition cycles between remission and relapses. Many people can live long normal lives with treatment. Indeed some will live symptom-free for years. Remission rates after the first attack range between ten to 20 per cent.

Symptoms of Crohn’s include weight loss, mouth sores and ulcers, fever, diarrhea, fatigue, mild to intense intestinal cramping, nausea, bowel obstruction and blood in the stool. Extraintestinal (outside the intestine) signs and symptoms include skin rashes in 15 per cent of Crohn’s sufferers, red eyes in five per cent, joint pain and at times liver damage and gallstones.

Other diseases like ulcerative colitis, irritable bowel syndrome among others can share similar characteristics. Colonoscopy, barium imaging tests and the presence of specific symptoms help differentiate each condition and provide an accurate diagnosis.

The cause of Crohn’s disease remains elusive. It tends to run in families and affect certain groups of people (women, Caucasians and Jewish people) more than others suggesting a genetic predisposition. The incidence of the disease is greater in Europe and North America than in Asia and Africa.

The current working theory states that the immune system of genetically susceptible people over-reacts when exposed to a triggering substance (certain bacteria and foods may play a role). The immune system erroneously causes inflammation and intestinal damage.

The disease’s complications depend upon the affected site. Often, inflammation occurs at the junction between the small intestine (ileum) and the beginning of large intestine (cecum). Intestinal damage can create tunneling passages between the intestine and other organs (fistulas), intestinal wall perforation and narrowing and blockage of the digestive tract. Splitting of the skin (fissures), ulcerations, abscesses and fistulas around the rectum and anal region occur in 35 to 45 percent of patients with Crohn’s disease.

The choice of medical therapy depends upon the site of inflammation and symptoms. Your doctor will provide several options and detail the risks and benefits of each. The common medications include sulfasalazine, 5-Aminosalicylates, antibiotics, steroids and newer class of drugs called immunomodulators like Remicade.

The choice of foods and diet plan is a critical adjunct to therapy. Many people can identify foods that exacerbate their disease. Without a proper dietary plan, many suffer pain, cramps, bloating and diarrhea. Patients tend to shun food with prolonged discomfort. Fifty to 70 per cent of Crohn’s patients become malnourished. Regular assessment of nutritional status can prevent the complications of malnutrition. A dietitian’s expertise is critical to this success. Patients should not restrict their dietary intake unless they are instructed to do so by their doctor or dietitian.

Malnutrition is especially problematic for children and adolescents. It can delay the onset of puberty, delay growth and lead to osteoporosis from reduced calcium intake among other problems. It can be psychologically devastating to the adolescent because it interferes with their normal growth and development. Lacking a sense of normalcy, their self-esteem suffers. They may have difficulty participating in activities and shun the normal social interactions necessary to develop interpersonal skills and a sense of self.

Regular exercise will maintain fitness and help prevent osteoporosis that occurs in up to 30 per cent of patients. Smoking worsens Crohn’s disease as well as the use of ibuprofen (Advil, Motrin) and nonsteroidal anti-inflammatory drugs (NSAIDs).

There is an increased risk of colorectal cancer but it can take many years to develop. Regular scheduled colonoscopy screening programs can help identify precancerous and cancerous changes before they lead to devastating effects.

Although surgery does not cure Crohn’s disease, 80 per cent of patients will require it to treat bleeding, repair fistulas, bypass obstructions and remove severely damaged portions of the intestine. 85 and 90 percent of patients are symptom-free during the year following surgery, and up to 20 percent of patients are still symptom-free 15 years after surgery. Long-term medical and dietary therapy is critical to keep this condition under control or in remission.

Indeed, despite medical treatment Mandy required surgery to remove part of her damaged intestine. Although not curative, it did help her return to a normal life. She remains vigilant and takes medications to keep the disease under control and at times, in remission.

For more information, please visit the Crohn’s and Colitis Foundation of Canada at http://www.ccfc.ca/en/index.html

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2. Fighting Back Against the “Silent Disease”
3. For many, lactose intolerance is a lifelong inherited problem

Originally published in The Ottawa Citizen July 15, 2003
Original Title: The Stones Wrong Address Part 1: How green is my valley

Part 2
Part 3

The Canadian Museum of Nature has exquisite colourful and exotic-looking crystal, mineral and stone collections. The human body also harbours interesting mineral, stones and crystal deposits.

Stones commonly form in the gallbladder, kidney and salivary glands. Crystals form in several joints most, notably the knee and the big toe as seen with gout. Starting with the gallbladder, we will look at how each arises, where they collect and how to treat and prevent serious complications.

The gallbladder is a seven to 15-centimetre muscular sac-like organ located in the upper right side of the abdomen hanging off the underside of the liver.

A duct system connects the gallbladder to the liver, pancreas and small intestine. It functions as a reservoir for bile salts, cholesterol and other fatty substances produced in the liver. Bile aids in digesting of fatty foods. The gallbladder contracts after a fatty meal, pumping bile into the intestine.

Gallstones form under conditions that promote a hardening of these substances. Surgical removal of the gallbladder, or cholecystectomy, is the most common abdominal surgery in medicine.

Gallstones come in two types: cholesterol and pigment. Eighty to 90 per cent of all gallstones are cholesterol stones. Pigmented stones contain less than 20 percent cholesterol and account for the remaining ten to 20 per cent.

There are numerous risk factors for gallstone formation. People of Scandinavian, Native American Pima Indian, Hispanic, and western Caucasian backgrounds are at greater risk. So are those with a maternal family history of gallstones. Pregnant women and women in general are at greater risk, as are middle-aged and obese people.

Those who have fasted frequently and undergone rapid weight loss are also at risk. So are those who have taken the birth control pill, postmenopausal estrogens, progesterone and cholesterol-lowering fibrates (Gemfibrozil, Bezalip, Lipidil Micro, Lipidil Supra) among others. Cholesterol lowering statins do not cause gallstones

Other risk factors include high levels of triglyceride (a type of fatty molecule), diabetes, Crohn’s disease, cirrhosis (scarring) of the liver and bile duct and Sickle cell disease among other conditions associated with rapid destruction of red blood cells.

Sixty per cent of people with gallstones do not have symptoms and are often unaware they have them. Usually gallstones are found during an abdominal ultrasound done for other medical reasons.

If someone experiences a gallstone attack, the likelihood of another is about 70 per cent.

Symptoms occur when the stone either leaves the gallbladder and winds its way down the common bile duct into the intestine or becomes lodged in the neck of the gallbladder. Typically, the pain will begin suddenly, intensify over 15 minutes and last for about three hours.

Pain typically localizes just below the bottom tip of the breastbone and shift toward the upper right-hand side of the abdomen. Palpating this area produces more discomfort. The pain may radiate directly to the upper back or to the back of the right shoulder.

Other symptoms can include nausea, vomiting, and intolerance to fatty foods. This sudden attack is biliary colic although the term ‘colic’ is a misnomer since the pain is steady and does not wax and wane. Once the gallbladder relaxes several hours after eating, the stone will often fall back into it and the pain subsides.

The most common imaging test to diagnose and screen for gallstones is an abdominal ultrasound. There are other tests available for specific studies of gallbladder function. X-rays play a lesser diagnostic role since they can only detect mineral-rich pigmented stones.

Of the 40 per cent of people who develop symptoms of gallstones, 70 to 80 percent experience biliary colic and ten per cent will develop infections and inflammation of the gallbladder (acute cholecystitis).

The gallbladder is likely to become infected and/or inflamed if the stone partially or completely blocks the small duct that leads out of it. Fever can develop and pain lasts longer than three hours. Acute cholecystitis is a surgical emergency. In many elderly patients, there may be no fever and pain, only some local tenderness in the right upper quadrant.

The goal is to prevent the complications of duct blockage: perforation of the gallbladder, infection or inflammation of the gall bladder or bile duct, inflammation of the pancreas (pancreatitis) or liver damage.

Next week’s column will look at the treatment and prevention of gallstone complications.

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Originally published in The Ottawa Citizen June 3, 2003
Original Title: Lactose intolerance is not an allergy

Often, the term milk allergy is used to describe any physical reaction to milk consumption. Many mistake lactose intolerance for milk allergy.

Lactose intolerance is the inability to break down the dairy sugar lactose (found in milk, cheese and ice cream) into glucose and galactose because of the absence of the enzyme, lactase.

For most lactose intolerant people, ingestion of eight to 12 ounces of milk can produce intestinal cramps and pain, gas (flatulence), bloating and loose watery stools.

These symptoms can vary depending upon the amount of ingested lactose, the person’s ethnic origin and age. Older individuals tend to have less lactase and more severe symptoms.

In milk allergy, the milk proteins cause an allergic reaction that includes itchy red rashes, hives or breathing problems among other symptoms.

Given our culture’s northern European origins, we tend to think lactose intolerance is an abnormal condition. However, it is one of the few lifelong inherited “disorders” that is normal for most people and for others the result of an intestinal infection, medication use or disease.

Although some people can drink a small amount of milk without any symptoms, others are unable to tolerate it.

Lactase levels decrease (hypolactasia) in all land mammals including humans after weaning. Ninety to 95 per cent of lactase is lost by two years of age and continues to wane throughout life.

Worldwide, the loss of lactase is a natural phenomenon. Indeed, almost 100 per cent of adult Asians and North American aboriginals, 60 to 80 per cent of blacks and Ashkenazi Jews, 50 to 80 per cent of Latinos and two per cent of whites of northern European origin lose the lactase enzyme.

It is uncertain whether continued lifetime consumption of dairy products stimulates the production and retention of lactase. It could also be the result of a genetic mutation leading to continued lactase production.

The absence of lactase leaves the undigested lactose to concentrate within the small intestine. This draws fluid into the intestine by a mechanism (similar to some laxatives) called osmosis.

As the lactose moves along the intestinal tract, the intestinal bacteria will ferment it producing gas and further fluid accumulation within the gut.

Lactose is present in some prepared foods including:

• Breads and baked goods
• Processed breakfast cereals
• Pancake, biscuits, and cookie mix
• Instant mashed potatoes
• Soups
• Instant breakfast drinks
• Some margarines
• Non-kosher luncheon meats
• Salad dressings
  Candies and other snacks
• Powdered coffee creamers
• Whipped toppings
• Yogurt with live bacterial cultures contains bacterial enzymes that help digest lactose.

Some people may tolerate some dairy products like chocolate milk, skim milk and ice cream.?

Dairy products provide about 75 per cent of the daily-recommended calcium plus vitamin A and D, riboflavin and phosphorus.

If dairy products are not an option, eating other high-calcium containing foods like oysters, sardines, shrimp, broccoli, brussel sprouts, kale, collard and mustard greens are reasonable substitutions. Certain brands of orange juice have added calcium.

The mainstay of treatment is dietary restriction of lactose-containing foods. Lactase enzyme supplementation can help people with mild lactose intolerance but are not a substitute for dietary restriction because they may not eliminate all of the symptoms. Nondairy drinks, such as soymilk and rice milk are useful substitutes for milk. Most will tolerate non-dairy synthetic adjuncts like Coffee-Mate.

Drinking smaller servings of milk products is less likely to cause problems.

Combining other foods when drinking milk can slow the process of lactose digestion and reduce the symptoms of lactose intolerance.

Ice cream, milkshakes and aged (hard) cheeses are easier than milk for most people with lactose intolerance but they are high in fat. People with normal weight and cholesterol levels can try them.

Lactaid, a lactose-reduced milk has about 70 per cent less lactose than regular milk can substitute for regular milk. You can also add lactase enzyme into milk prior to drinking.

Irritable bowel syndrome (IBS) is a non-fatal gastrointestinal disorder that can mimic lactose intolerance. This complicates the diagnoses because milk products can cause the same reaction for both conditions. Indeed, 25 per cent of IBS sufferers are intolerant of dairy products.

Restricting lactose may improve these problems. There are diagnostic tests for lactose intolerance that can help differentiate between the two problems.

People who develop lactose intolerance later in life may have colitis or other serious intestinal disorder and should consult their doctor.

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3. Get to the root cause of abdominal pain

Originally published in The Ottawa Citizen December 17, 2002
Original Title: Oh please, not another space shuttle endurance test!

Part 1

Last week’s column reviewed the principal causes of stomach and duodenal ulcers: the bacterium Helicobacter Pylori (H. Pylori) and non-steroidal anti-inflammatory medications (NSAIDS). What diagnostic tests are available to aid in the treatment and management of ulcers?

One of the first tests to do for patients with ulcer symptoms is an H. Pylori blood test. This test measures H. Pylori antibody levels. A positive indicates the immune system is actively fighting the microbe. Two other methods of H. Pylori detection, breath and stool tests, are less commonly done. The immune response cannot defeat H. Pylori by itself.

Patients with more disconcerting symptoms such as anemia (blood loss), difficulty swallowing, dark black tarry stools, weight loss and vomiting with small black pieces or blood need further investigation.

Gastroscopy is a common procedure used to visualize the stomach and duodenal lining. A narrow fibre-optic tube with a camera at its end passes through the mouth into the stomach. A small claw-like device within the tube is available to take tissue samples. The advantage to the gastroenterologist is that he/she can see the ulcers, identify areas suspicious for H. Pylori infection and control bleeding ulcers by either cauterization or injection of adrenaline.

Most patients dread this test. As a participant, I can tell you first hand that it is a necessary yet unpleasant experience particularly for those with a strong gag reflex. Despite abundant freezing of the throat to control the gag reflex, the tube’s descent into the stomach is akin to being sick on a roller coaster that never stops.

The barium swallow, an older test in which x-rays are taken as the patient drinks the solution is not as good at detecting ulcers and other stomach or duodenal problems.

Medical therapy is the standard approach to ulcer healing. About two to five percent of ulcer sufferers require surgery. The goal is to reduce stomach acid secretion and if present, eradicate H. Pylori infections.

The treatment plan is a mix of prevention and medical therapy. This is important to help prevent ulcer recurrence and to promote healing.

Patients should stop using aspirin containing compounds or NSAIDS. If unsure, your doctor or pharmacist can help identify these products for you.

Smokers should make every effort to quit because the chemicals from cigarettes directly injure the stomach lining and stimulate acid secretion.

Caffeine and alcohol also stimulate acid secretion. Avoid coffee, tea, caffeinated beverages and soft drinks and, as much as it pains me to say this, chocolate (for a while). Alcohol will impair ulcer healing. Although some people will identify other foods that cause stomach upset, there is little evidence that they prevent ulcer healing or cause recurrence.

The use of antacids can provide temporary relief from ulcer pain but should not be the sole treatment. Use them one hour before or two hours after taking medications since they can interfere with their absorption reducing their efficacy.

Alleviating stress can reduce acid secretion and will improve overall health. Herbal medications and supplements (such as licorice, marshmallow, and glutamine) probably have no role in the treatment of peptic ulcers since conventional medications have proven to be very effective and safe.

Treatment of H. Pylori involves taking several medications, usually two antibiotics along with a medication that reduces stomach acid, for seven to 14 days. These treatment plans can successfully cure infection in up to 90 percent of people. The most common cause of treatment failure is when patients do not take the medications as directed by the physician’s instructions.

There are two groups of acid-reducing medications: proton pump inhibitors (Losec, Pantaloc, Prevacid, Nexium, Pariet) and H2 blockers (Ranitidine (Zantac), cimetidine, Axid and Pepcid). Protons are the acidic hydrogen secreted by the stomach. The proton pump inhibitors are potent agents that stop the stomach’s secretion of acid. A six to eight week course of treatment will promote complete ulcer healing.

Most patients with uncomplicated successfully treated duodenal ulcers do not need follow-up testing unless symptoms recur or do not improve. Those with complications such as bleeding or perforation need repeat H. Pylori testing to ensure its complete eradication.

Patients with stomach ulcers usually require a repeat space shuttle endurance test, er, gastroscopy, to ensure healing and that the ulcer did not harbour any cancer. Duodenal ulcers do not develop into cancer.

Patients who have frequent recurrences or a history of ulcer complications usually remain on long-term acid suppression therapy. Those successfully treated for uncomplicated ulcers due to H. pylori usually do not require medical therapy.

One of the problems with over-the-counter (OTC) antacids and Zantac among others is their haphazard use. Although they provide symptom relief, they may not prevent ulcers. Indeed most people do not take OTC Zantac or Pepcid long enough to prevent or successfully treat ulcers. Further, these preparations are half the prescription dose strength. Take the time to see your doctor about your heartburn. The chocolate will taste even better afterward.

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2. Great variety of drugs helps treatment of diabetics
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Originally published in The Ottawa Citizen December 10, 2002
Original Title: It’s my heartburn and I’ll cry if I want to

Part II – Ulcer treatment uses medicine and prevention

A common complaint in the family practice setting is bloating and heartburn. Usually the patient suffers with this condition for several months with the hope that it will spontaneously resolve.

Indeed many become chief financial supporters of the TUMS and Rolaids companies before they conclude that they may need more definitive help. As one who has experienced first hand the gnawing, bloating and searing pit-in-your-stomach pain at three o’clock in the morning, all you want to do is to jump out of your body to escape the pain and discomfort. It is a truly helpless feeling.

Many people believe that stomach (peptic) ulcers occur because of an elevation of acid levels. While this is true for some people, it does not tell the whole story.

The stomach is a food reservoir. Its function is to secrete moderately strong acid and enzymes to predigest proteins and sugars. It regulates the rate that this gruel squirts into the initial portion of the small intestine (duodenum) for further digestion and absorption.

The cells lining both the stomach and duodenum have a number of ways of preventing the acid from digesting itself. They secrete a layer of mucous creating a protective barrier against the ravages of the acidic digestive juices. Another defense mechanism is the secretion of an acid neutralizing substance.

With damage to this lining, the acid can cause ulcerations to the stomach and duodenum. The acid can splash up into the lower portion of the esophagus, the tube connecting the throat and stomach, eroding tissue that has no protection from acid at all. Each year, millions of North Americans develop ulcers.

Some people wait longer than they should before consulting their doctor’s advice because the symptoms can be infrequent or are relieved by over-the-counter medications. The problem is that temporary relief does not necessarily prevent ulcer formation.

• Signs and symptoms of ulcers or excessive acid production include:
• Pain or discomfort (usually in the upper abdomen)
• Bloating
• An early sense of fullness with eating
• Lack of appetite
• Nausea
• Vomiting
• Vomiting digested blood that looks like coffee grounds
• Black and tarry-looking stools (melena) due to a rapidly bleeding ulcer
• Anemia (blood loss)

Many of the symptoms described above can be due to other diseases. Your doctor will be able to help you determine which condition is responsible.

Although there is a by-the-book symptom list for duodenal ulcers, burning, gnawing, aching pinpoint pain just below the bottom tip of the breastbone, it does not need to be so. Symptoms tend to get better after eating and return about an hour and a half thereafter. These symptoms may worsen after midnight when the stomach usually produces the most acid.

People with stomach or gastric ulcers report more severe pain soon after meals. Eating a meal or taking an antacid does not provide much relief.

The common causes of peptic ulcers are infection and anti-inflammatory medications (NSAIDS) such as Ibuprofen (Advil, Motrin) or Acetylsalicylic Acid (ASA) found in Aspirin and other products.

A bacterium frequently found in the stomach, Helicobacter pylori (H. Pylori), is the most common cause of stomach and duodenal ulcers. About half the world’s population harbours it. It causes the release of some toxic substances and enzymes that disrupt the normal protective mucous layer. The cells erode due to the stomach acid leading to chronic inflammation and for some, ulcers.

NSAIDS are responsible for many instances of peptic ulcer disease (not due to H. Pylori) especially in the elderly. The development of NSAID-induced ulcers depends upon the dose, duration and individual patient medical history.

Smoking, alcohol, and caffeine can irritate the stomach lining through direct chemical damage and stimulating acid production. Alcohol and cigarettes interfere with ulcer healing. Various foods do not seem be a contributing factor to ulcer disease. Although some foods are acidic, they are much weaker than stomach acid and contribute little to ulcer formation.

Ulcers can spontaneously heal or continue to erode and potentially hemorrhage: the most serious complication of peptic ulcers. NSAID-induced ulcers in the elderly may not have many symptoms. Unlike younger adults, they have little reserve capacity to deal with rapid blood loss.

Ulcers can perforate allowing the stomach contents to directly empty into the abdomen.

The diagnosis of peptic ulcer disease is not straightforward because there are disease symptoms that mimic peptic ulcers. These conditions range include non-ulcer dyspepsia (ulcer-like symptoms without a specific cause), abnormal stomach emptying, acid reflux (acid splashing up into the esophagus), gallbladder disease and more rarely, stomach cancer. A thorough medical history and appropriate use of tests can lead to the proper diagnosis.

Next week’s column will review some of the tests, therapies and preventive measures available to treat this common disease. Pass the salsa, extra chilies.

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Originally published in The Ottawa Citizen December 3, 2002
Original Title: Cruise Ship: The perils of adult daycare

Recent reports of three cruise ship outbreaks of viral diarrheal illness (gastroenteritis) bring into focus how easily infections spread. Each ship had hundreds of passengers who fell ill. Carnival’s cruise ship Fascination, Disney’s Magic and Holland America’s Amsterdam all underwent extensive decontamination procedures.

Florida’s Department of Health and Atlanta’s Centers for Disease Control (CDC) both think that Norwalk virus is the culprit. Food borne disease is a significant cause of gastroenteritis. The CDC tabulated approximately 76 million diarrheal illnesses, 325,000 hospitalizations, and 5000 deaths each year in the United States based upon surveillance data from multiple sources.

Norwalk virus is the one of the most common causes of gastroenteritis in children and adults. The virus grows within the gastrointestinal tract. It is spread by fecal-oral route. As the term implies, ineffective hand washing after a bowel movement leaves viral residue on the hands. This residue spreads by contact. When another person touches the residue-laden object or hand and brings their hand to their mouth, voila, the porcelain throne becomes an important piece of furniture.

Indeed, passengers disembarking at Caribbean and Central American ports are exposed to the local food and water supply. Although most travelers are aware of the risks it is difficult to ensure complete protection from illness. With thousands of passengers on cruise ships, the potential for viral propagation through this ‘captive’ population is great.

The dense passenger population on cruise ships is akin to the children’s daycare scenario. The Norwalk virus causes most school and daycare-based cases of gastroenteritis. Soiling of clothes, lack of handwashing and close physical contact between children with less than perfect hygiene habits are fertile breeding grounds for this disease.

Cruise ships are adult playgrounds with unlimited buffets and drinks, numerous contact sports and activities, close contact between people, and ports of call to towns and cities with potential sources of food and water contamination. These factors contribute to an increase in overall risk of infection. Indeed, it only requires one infected person among the passengers to contaminate all these open and available sources.

According to Holland America, the decontamination process involves everything passengers and crew touch. All items touched by people need to be cleansed. A spokesperson for Holland America stated “The cleaning crew had to steam clean 300,000 square feet of carpet, replace 4,000 pillows and hand scrub every dish, eating utensil, glass and poker chip. Places where passengers put their hands, such as door handles, chair armrests, railings and tabletops also were scrubbed with a strong chlorine solution for several minutes, the only way to kill the virus. Even the ship directory in every cabin was replaced.”

Despite this due diligence, the Norwalk virus continues to be a problem. The recent closure of several Eastern Ontario hospitals attests to the difficulties controlling and limiting the spread of this virus.

The Norwalk virus can cause either a mild fever with watery diarrhea or a more severe fever with vomiting, headache, muscle ache and fatigue. Once infected, the virus will incubate about 24 to 48 hours before the symptoms begin. Stomach cramps and nausea are the first to appear starting gradually or hit full force. Vomiting follows thereafter. A low-grade fever of 38.3 to 38.9ºC (101 to 102ºF) occurs in approximately one-half of cases. The infection lasts about 48 to 72 hours. Infected persons typically have non-bloody, watery diarrhea with four to eight bowel movements over a 24 hour period. There is usually no mucous seen in the stools because the walls of the small intestine do not become inflamed. Recovery is usually rapid. Children in particular are at risk for dehydration.

The Norwalk virus is shed in the stools. This shedding occurs over the first 24 to 48 hours after the illness. It is rarely detected beyond 72 hours after the onset of vomiting or diarrhea.

If you are planning a cruise vacation or any vacation for that matter, there may be some instances and locales where hand washing facilities may be substandard or unavailable.

Judicious use of a particular product can reduce your risk of gastroenteritis and other infections in combination with the usual travel precautions. Purell(r) is an alcohol gel disinfectant available in a pump or small squeeze tube format. The gel’s alcohol concentration is great enough to kill most viruses and bacteria. It does not require water to rinse or wash the hands. The gel dries in about ten to 20 seconds after its application. It can be used as many times as is necessary. Carry it with you at all times.

As thorough as the ship decontamination efforts seem to be, will they reduce future ship-wide viral outbreaks? Although the cruise lines have done their best to reduce the risk, it is impossible to screen each passenger for disease. Further not all people are equally effective with hygiene procedures.

Ultimately, the onus is on travelers to do their best to reduce their risk of travel-related illnesses.

© Dr. Barry Dworkin 2002

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