Digestion, health and nutrition: Dr. Anil Minocha, a gastroenterologist and nutritionist

Constipation, dolichocolon and colonic kinks

Dolichocolon causes constipation-really? What is dolichocolon anyway and what is the evidence to support its role in constipation.

The Dolichocolon concept was the brainchild of Arbuthnot Lane and is based on the the theory that kinking of colon leads to constipation. While colon is like a country road with its own twists and turns (and of course each "colonic country road" is different), the Lane theory suggests that gravity leads to unnatural "kinking" or twisting initially in the fixed parts of colon on the left side. It gradually progresses upward and proximally causing elongation and further kinking.

In fact, Lane was a proponent of colonic resection or a byepass. While initially colonic resection became very popular, it came into disrepute in the early 20th century and now is performed in rare selected cases only.

Lets face it-the concept of dolichocolon or kinking causing a partial obstruction appears simple, straightforward, appealing and plausible (perhaps too simple and straightforward). Furthermore, theoretically speaking, the kinking along with elongation of colon has potential for increased fecal stasis in colon leading to increased water absorption from the fecal contents resulting in "drier" stool and constipation. However, scientific data to support these theoretical concepts is lacking. At the same time, constipation does not appear to be correlated with colonic length and surgery is not beneficial in cases of colonic "kinks" unless a volvulus is present.

Do you or someone close to you have constipation? What is the cause of constipation in your opinion? Does the Lane's theory of dolichocolon make sense and sound believable to you? Please share your thoughts.

Stool stasis, autointoxication due to fecal matter

Undigested food staying in gut too long, creating toxins leading to disease--have you heard of this?

The phenomenon is known as autointoxication and has its origins in ancient Egyptian civilization as far back as 16th century BC. Sir William Lane in the early 20th century in his treatise published in the Proceedings of the Royal Society of Medicine (1913) asserted that "autointoxication is the cause of all the chronic diseases of civilization".

Is this concept of autointoxication a fact or a myth?  The proponents argue that slowed gut transit or increased stasis of fecal matter in the colon results in greater putrefaction and production of toxins. These toxins get absorbed and cause chronic illnesses with or without low grade inflammation.

It is difficult to demonstrate such a toxin experimentally especially since such a toxin(s) may not be universally present. It is entirely possible that a multitude of toxins is involved and the disease results from individual susceptibility. Furthermore, there may not be a special toxin, but the disease may be a consequence of some normal product of bacterial putrefaction that is not necessarily absorbed but has a direct action on colonic wall affecting the gut immune cells, endocrine-neuro-immune system and ultimately the entire body system. In addition to all the above unknowns, we cannot exclude the possibility of yet unknown toxin being involved.

So what is the verdict? Is the concept of autointoxication a hard fact or just a myth perpetuated by "quacks" over the centuries. We do not have the perfect answer, atleast not yet. One thing we do know however that having a bowel movement everyday is essential for positive health.

What are your thoughts on autointoxication? Do you or someone you know believe in and practice any methods  to counter it? Please share your thoughts.

Gut smells like nose olfaction. Really?

Gut has a nose and can smell! You have heard of ”gut reactions” and “my gut tells me”. Can the gut smell? Could these "gut reactions" be mediated via smelling function of the gut?

Braun and colleagues from Germany recently studied whether nasal olfactory (smell) receptors are present in human gut and whether odorants present in spices, fragrances, detergents, and cosmetics can cause release of neurotransmitters like 5HT or serotonin. As you know, serotonin regulates intestinal motility as well as secretions and is involved in pathogenesis of vomiting, diarrhea, and irritable bowel syndrome as well as psychological conditions like depression.

These investigators found 4 olfactory receptors in human gut. Odorant ligands of the these olfactory receptors via cascade of events lead to serotonin release thus have potential to affect gut function.

The authors concluded that odorants present in the gut/intestinal lumen may stimulate 5HT/serotonin release via these olfactory receptors in gut mucosa. Some physicians especially gastroenterologoists do use antidepressants including SSRIs for the treatment of intestinal conditions like irritable bowel syndrome, cyclic vomiting and abdominal migraine.

Now based on this article, could you also legitimately say, “my gut can smell it” in addition to “my gut reaction is” and “my gut tells me”.

Nurses smell stool for diarrhea cause: nursing nose makes odiferous diagnosis

Can nurses smell the diagnosis better than doctors and tests? Especially by smelling stool for cause of diarrhea?

Nurses have long been contributing to astute observations that have stood the test of time. A shining example is Sister Mary Joseph's nodule.

All diarrheas are not the same and nurses can smell and actually diagnose the cause for diarrhea. An early diagnosis can help early specific treatment.

While rotavirus gastroenteritis appears clinically to be similar to other types of diarrhea, nurses were able to correctly diagnose Rotavirus as the cause in 69% on the bases of the stool smell alone. This was reported by Poulton and colleagues in the Archives of Diseases in Childhood.

Clostridium difficile diarrhea can be devastating and prompt treatment may help attenuate the seriousness pending results of investigations. Johansen and colleagues studied diarrheal stool sample and found that nurses could identify Clostridium difficile toxin positivity in 31 out of 37 cases yielding a sensitivity and specificity of 84 and 77% respectively. The authors concluded that there is a characteristic “Clostridial odor” that helps nurses identify the cause.

These results of the odiferous diagnosis were confirmed in a more recent study by Burdette and Bernstein and published in the journal Clinical Infectious Diseases 2007.

Do you believe the data above that nurses have sharp noses and can actually identify cause of diarrhea? Do you think it is because they tend to be more perceptive as an occupation OR that nurses are predominantly women and that women are more perceptive than men? Please share your thoughts.

Hiccup home remedies, causes and drugs

Hiccup or singultus (from singult in Latin meaning catching breath while sobbing.) is an involuntary nuisance bodily action of no functional value. Most hiccups resolve spontaneously without any active intervention. Hiccups may occur even prior to birth.

Hiccup frequency varies with individual (4 to 20 per minute, going as high as 60/minute in some cases). Similarly the duration of hiccups is variable from few minutes to hours, days and even weeks.

An episode of hiccups may last as long as 48 hours. Some patients have persistent hiccups lasting as long as one month. Intractable hiccup episodes may continue beyond 2 months in rare cases.

How hiccups occur?

Hiccups occur due to contraction of muscles of diaphragm and inspiratory respiratory muscles causing sudden inspiration with closure of the glottis. What provokes a bout of hiccups remains an enigma. “Hiccup reflex arc” comprising of connection of intercostal muscles with multiple nervous connections including phrenic and vagus nerves, sympathetic nervous system, central nervous system (probably brain stem especially respiratory centers. has been implicated.

What causes hiccups?

A bout of hiccup is usually instigated by distention of the stomach as a result overeating or excessive air in stomach due to carbonated beverages, swallowing air. Simple things like upper respiratory infection or a hair in ear in contact with ear drum can provoke an episode. Gastroesophageal reflux disease (GERD), and hiatal hernia have also been implicated. More serious causes include tumors and infections throat, ears and brain. AIDS is another possible cause.

Other stimulants include a drugs, toxins, alcoholism, kidney failure, sudden excitement and changes in temperature, alcohol intake, and tobacco use. Stress has also been implicated.

Failure to identify a cause for persistent or intractable hiccups may suggest a psychogenic etiology. Occurrence of hiccups during sleep makes a psychogenic cause less likely.

Investigations: Most episodes of hiccups are brief, self-limiting and don’t require investigations. Work up should be undertaken in cases of persistent and intractable hiccups. This generally includes a thorough history and physical exam, as well as simple labs like complete blood count (CBC), comprehensive metabolic panel., liver and pulmonary function tests, drug and tox screen. The use of x rays, CT or MRI scans, EEG, lumbar puncture, EGD (esophagogastroduodenoscopy or upper GI scope) needs to be individualized. Treatment of hiccups — There is paucity of rigorously tested scientific data on this subject. Of course if an underlying cause is found, treatment can be directed at that the cause.

Drug options:These include chlorpromazine, antireflux or anti GERD heartburn medications like Prilosex, muscle relaxants like Baclofen, prokinetic like metoclopramide (Reglan), antidepressants and antiepileptic agents.

One AIDS patient used marijuana to get rid of his hiccups.

Home or non-drug remedies: These time tested home remedies for hiccups have been passed on through the generations.

My favorite is closing the ears with your fingers/hands while drinking water through a straw.

Other popular home remedies include:

• Take a deep breath and hold as long as you can
• Gargle with ice water
• Pull the tongue
• Valsalva
• Bite on lemon

There are also reports of successful use of alternative and complementary therapies like hypnosis and acupuncture.

As a last resort, surgery as well as implantation of breathing pacemakers and vagus nerve stimulators have been undertaken.

Do you know of someone with a major hiccup problem? Do you know of a home remedy that works for you. Please share with us.

Dysphagia swallowing problems with normal upper GI endoscopy

Dysphagia or swallowing problems can occur in patients despite all tests including upper GI (UGI) xray and upper GI endoscopy (EGD or esophagogastroduodenoscopy) showing normal esophagus or no obstruction to the food pipe. This is called nonobstructive dysphagia. However patients continue to have problems complaining that the food ends up in the esophagus and this will not go down or go down slowly.

First, what is dysphagia? Dysphagia means difficulty swallowing. It is of two types: 1) transfer or oropharyngeal dysphagia and 2) esophageal dysphagia.

Dysphagia or difficulty swallowing can be due to problem with transfer of food between them mouth and the upper esophageal sphincter, resulting in failure of food to enter into the esophagus.  This is transfer dysphagia. Esophageal dysphagia implies food has difficulty arriving from the upper esophageal sphincter past the lower esophageal sphincter of the esophagus into the stomach.

Non-obstructive dysphagia involves a variety of causes including motility being abnormal or some unrecognized disorder like eosinophilic esophagitis. Eosinophilic esophagitis can only be confirmed by performing biopsies of the esophagus and documenting increased number of eosinophils in the biopsy specimens. Motility disorders can be confirmed by performing esophageal manometry.

Frequently despite expensive and extensive investigations, no cause is found for nonobstructive dysphagia and food still feels like hanging up in esophagus. GERD may be the culprit in some cases. In such cases, aggressive acid suppression for acid reflux using high doses of proton pump inhibitors (acid blockers like Prilosec, Prevacid, Nexium, Protonix, Aciphex) may be helpful.

We used to perform dilation of esophagus using large dilator. However majority of the evidence including our study suggests that such dilation of the esophagus is not effective if there is no narrowing of esophagus.

Do you or someone in your family have dysphagia or swallowing problems. Did the investigations turn up to be normal or abnormal and what was done to treat the problem.

Feeding tube gastrostomy, PEG, feeding disorder in dementia

The issue of feeding in patients with dementia is complex. The feeding disorder, dysphagia, swallowing problms result in inadequate feeding or nutrition are common in dementia patients. A feeding tube (PEG or surgical gastrostomy) is often done. The question is, does it help? Are we helping our loved ones or are we just making ourselves good. If you were the one making the determnation for your elderly loved one and were told that such feeding tubes, PEG (gastrostomy tube) are unlikely help in anyway or change anything, what would you think? What would be your position when asked for consent?

A recent study examined  the issue of published evidence related to alternative feeding via tubes in patients with dementia. Garrow and colleagues reviewed the evidence found that available evidence does not support any beneficial impact of artificial feeding on survival, pressure ulcers, nutritional status, or aspiration pneumonia. The authors suggest that hand feeding may be a viable alternative in such patients although there is no head-to-head comparison of such feeding with artificial feeding via gastrostomy tube, whether surgical or endoscopic (PEG).

Finucane and colleagues argue that medical system favors use of tube feeding despite lack of beneficial effect, and affects decision-makers, physicians and administrators . There is constant urge to "do something" in sick patients especially when clinical situation is turning downhill.  The medical system wishes to avoid regulatory sanctions, bad publicity, and risk for malpractice law suits.

Getting back to our original question, should the medical system withold feeding tubes in case of patients with dementia unable to feed themselves adequately? How would you react as surrogate decision maker regarding giving consent for feeding tube in your loved one with dementia who is ingest himself or herself. 

Chronic abdominal pain or IBS in kids

Chronic abdominal pain, IBS or irritable bowel syndrome in children is a major, perplexing problem. Some have it as abdominal colic, others get termed as "irritable bowel syndrome" or "spastic colon". A recent study published in Archives of Disease in Childhood, December 2007  showed that chronic abdominal pain or tummy ache occurs in 33% girls and 13% boys of 11-14 years of age.

Only a parents knows the magnitude of the problem of abdominal pain and how nerve-wrecking it can be for the entire family. They try all sorts of things, medicines, healers and frequently no relief. Usually no physical abnormalities are found despite extensive investigations. Now there is hope if you like to think outside of the box.

A recent study double blind randomized controlled trial compared usual medical treatment with gut directed hypnosis. The study titled " Hypnotherapy for children with functional abdominal pain or irritable bowel syndrome: a randomized controlled trial" was published in the prestigious journal Gastroenterology.

The investigators found that gut directed hypnosis was significantly superior to standard medical therapy. In fact the relief of chronic abdominal pain was sustained at 12 months in hypnosis group versus standard therapy (85% versus 25%) even though hypnosis sessions occurred for only 3 months.

Do you or someone in your family have chronic abdominal pain? Have you tried alternative therapies like hypnosis, cognitive behavioral therapy? If not, would you try hypnosis if other therapies are not working for you?

Colitis, diverticulitis and diverticulosis

Terms like colitis, diverticulitis, diverticulosis and irritable bowel syndrome, spastic colon can be confusing. Colitis, diverticulitis, IBS, irritable bowel syndrome, spastic colon although different are often used interchangeably by some people. Colitis means inflammation of the colon or large intestines. Colitis may be acute or chronic and may occur due to infections, drugs, toxins, ischemia, radiation therapy etc. Colitis may also be a manifestation of chronic IBD or idiopathic inflammatory bowel disease (ulcerative colitis and Crohn’s disease).

Diverticulosis is the presence of divertculi (plural for diverticulum), usually in the colon. The colonic divertculosis is very common in the western society presumably because of lack of fiber in diet. As many as 50% or more may have colonic diverticulosis by the age of 50 years and this number may exceed 80% by the time one reaches the age of 80 years. Usually these diverticuli are asymptomatic and an incidental finding on barium enema or colonoscopy. In a minority of cases, they may cause complications such as diverticulitis and bleeding etc which may even become life-threatening.

Diverticulitis occurs as a result of micro-perforation in the colon at the site of diverticulum. It is usually on the left side of colon and usually contained giving rise to localized infection and inflammation. This usually responds to medical measures including antibiotics. At times, such a perforation may form an abscess, cause bacteremia and become even become life-threatening. Surgery may be needed in severe cases.

Diverticular bleed occurs more commonly from right sided diverticulosis. It is usually painless and massive and usually requires hospitalization and blood transfusions. Majority of such bleeds stop spontaneously. Recurrent cases may need suregry.

Do you or someone you know has colitis or diverticulosis? What has been your experience with these terms? Please share your thoughts.

Better clear liquid diet for Colonoscopy preparation

Colonoscopy or endoscopy of colon (large intestine) is often dreaded by some. Colonoscopy is also called lower GI scope and is different from barium enema. Colonic cleaning and clear liquid diet is needed as part preparation as a prelude to colonoscopy. Colonoscopy as well as barium enema patients go through this misery of colonoscopy preparation on liquids like water or clear juices, carbonated beverages, electrolyte-rich sports drinks like Gatorade ®, flavored drinks e.g. Crystal-Light ®, Jello, sorbet and plain tea/coffee.

Lesser known fact is that there are clear nutritional supplements available that serve the purpose equally well and you would be less hungry since they also provide nutrition. These include Enlive ® (ww.rosstore.com), ResourceBreeze ® (ww.novartisnutrition.com) and Carnation Instant Breakfast ® juice drink (www. Nestle-nutrition.com). Do not use regular Carnation Instant breakfast as part of clear liquid diet.

Mix-and-match the clear liquids with the clear liquids nutritional supplements and try your tasty mixed drinks such as slushies, ice-pops etc.

Caution: do not use anything any red, purple liquids.

Have you or someone you know has had a colonoscopy? What was your experience with clear liquid diet prior to the exam? Could you suggest some recipes employing above components that the readers could use to make their pre-colonoscopy experience better?