Is diverticulitis linked to autoimmune disorders. How does diverticulitis relate to inflammatory bowel diseases. What are the common symptoms of diverticulitis and autoimmune digestive conditions. How can understanding the connection between diverticulitis and autoimmunity improve treatment approaches.

The Autoimmune-Digestive System Connection: Unraveling the Mystery

The intricate relationship between the digestive system and autoimmune diseases has become a focal point of medical research in recent years. Autoimmune disorders occur when the body’s immune system mistakenly attacks healthy cells, tissues, or organs. In the context of digestive health, this misdirected immune response can lead to a variety of gastrointestinal issues, including inflammatory bowel diseases (IBD).

Diverticulitis, a condition characterized by the inflammation of small pouches (diverticula) in the digestive tract, has long been considered a distinct entity from autoimmune disorders. However, emerging research suggests there may be more to this connection than previously thought. Could diverticulitis be a form of inflammatory bowel disease with autoimmune components?

Understanding Diverticulitis: Symptoms, Causes, and Risk Factors

Diverticulitis is a common digestive condition that affects millions of people worldwide. It occurs when small, bulging pouches (diverticula) that form in the lining of the digestive system become inflamed or infected. These pouches most commonly develop in the colon, particularly in the sigmoid colon.

Common Symptoms of Diverticulitis

• Severe abdominal pain, usually on the left side
• Fever and chills
• Nausea and vomiting
• Changes in bowel habits (constipation or diarrhea)
• Bloating and gas
• Loss of appetite

While the exact cause of diverticulitis remains unclear, several risk factors have been identified:

1. Age (more common in people over 40)
2. Low-fiber diet
3. Obesity
4. Lack of physical activity
5. Smoking
6. Certain medications (e.g., NSAIDs)

The Autoimmune Hypothesis: Is Diverticulitis an Inflammatory Bowel Disease?

The traditional view of diverticulitis as a purely mechanical issue caused by increased pressure in the colon is being challenged. Recent studies have begun to explore the possibility that diverticulitis may have an autoimmune component, similar to other inflammatory bowel diseases like Crohn’s disease and ulcerative colitis.

Why might researchers suspect an autoimmune link in diverticulitis? There are several compelling reasons:

• Chronic inflammation: Like many autoimmune diseases, diverticulitis involves persistent inflammation in the affected areas of the colon.
• Recurrent nature: Many patients experience multiple episodes of diverticulitis, reminiscent of the relapsing-remitting pattern seen in some autoimmune conditions.
• Systemic symptoms: Some individuals with diverticulitis report systemic symptoms such as fatigue and joint pain, which are common in autoimmune disorders.
• Response to immunosuppressive treatments: In some cases, diverticulitis responds well to treatments typically used for autoimmune conditions, such as corticosteroids.

Inflammatory Bowel Diseases: A Closer Look at Autoimmune Digestive Conditions

To better understand the potential autoimmune connection in diverticulitis, it’s essential to examine established inflammatory bowel diseases (IBDs) that are known to have autoimmune components.

Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory condition affecting the colon and rectum. It is characterized by the formation of ulcers in the lining of the large intestine, leading to symptoms such as abdominal pain, bloody diarrhea, and weight loss. UC is considered an autoimmune disease because the immune system mistakenly attacks the intestinal tissue, causing inflammation and damage.

Crohn’s Disease

Crohn’s disease is another form of IBD that can affect any part of the digestive tract, from the mouth to the anus. Unlike ulcerative colitis, which only impacts the colon and rectum, Crohn’s disease can cause inflammation in patches throughout the entire gastrointestinal system. Symptoms may include abdominal pain, diarrhea, fatigue, and weight loss. Like UC, Crohn’s disease is believed to have an autoimmune component, with the body’s immune system attacking healthy digestive tissue.

Comparing Diverticulitis to Established Inflammatory Bowel Diseases

When examining the similarities and differences between diverticulitis and known inflammatory bowel diseases, several key points emerge:

• Localized vs. Diffuse Inflammation: Diverticulitis typically involves localized inflammation in specific areas where diverticula form, while IBDs like Crohn’s disease and ulcerative colitis often cause more diffuse inflammation throughout the digestive tract.
• Chronic Nature: Both diverticulitis and IBDs can be chronic conditions with periods of remission and flare-ups.
• Immune System Involvement: While the role of the immune system in diverticulitis is still being studied, it is well-established in IBDs.
• Treatment Approaches: Some treatments, such as anti-inflammatory medications and antibiotics, are used in both diverticulitis and IBDs, suggesting potential similarities in underlying mechanisms.

The Gut Microbiome: A Key Player in Digestive Health and Autoimmunity

The gut microbiome, comprising trillions of microorganisms living in our digestive tract, plays a crucial role in both digestive health and immune function. Emerging research suggests that alterations in the gut microbiome may contribute to the development of both diverticulitis and autoimmune digestive conditions.

How Does the Gut Microbiome Influence Digestive Health?

• Immune System Regulation: Gut bacteria help train and modulate the immune system, potentially influencing autoimmune responses.
• Barrier Function: A healthy microbiome supports the integrity of the intestinal barrier, preventing harmful substances from entering the bloodstream.
• Inflammation Control: Certain gut bacteria produce anti-inflammatory compounds, while others may promote inflammation.
• Nutrient Metabolism: The microbiome aids in the breakdown and absorption of nutrients, supporting overall digestive health.

Dysbiosis, or an imbalance in the gut microbiome, has been observed in both diverticulitis and inflammatory bowel diseases. This shared feature further supports the potential link between these conditions and highlights the importance of maintaining a healthy gut microbiome for digestive and immune health.

Diagnostic Challenges: Differentiating Diverticulitis from IBDs

Accurately diagnosing diverticulitis and distinguishing it from inflammatory bowel diseases can be challenging due to overlapping symptoms and similarities in presentation. Healthcare providers typically employ a combination of techniques to reach a diagnosis:

1. Medical History and Physical Examination: Doctors will assess symptoms, family history, and perform a physical exam to look for signs of inflammation or tenderness.
2. Imaging Studies: CT scans, MRIs, or ultrasounds can help visualize the digestive tract and identify diverticula or areas of inflammation.
3. Colonoscopy: This procedure allows direct visualization of the colon and can help differentiate between diverticulitis and IBDs.
4. Blood Tests: Inflammatory markers and other blood tests can provide insight into the presence and extent of inflammation.
5. Stool Tests: These can help rule out infections and assess for signs of IBDs.

As research into the potential autoimmune aspects of diverticulitis progresses, new diagnostic tools and markers may emerge to better differentiate between these conditions and guide treatment decisions.

Treatment Approaches: Bridging the Gap Between Diverticulitis and Autoimmune Digestive Disorders

The management of diverticulitis has traditionally focused on treating acute episodes with antibiotics and, in severe cases, surgery. However, as our understanding of the condition evolves, treatment approaches are beginning to incorporate strategies used in autoimmune digestive disorders. This shift reflects the growing recognition of potential immune system involvement in diverticulitis.

Current Treatment Strategies for Diverticulitis

• Antibiotics for acute flare-ups
• Pain management
• Dietary modifications (e.g., high-fiber diet)
• Probiotics to support gut health
• Surgery for severe or recurrent cases

Emerging Treatment Approaches Inspired by IBD Management

• Anti-inflammatory medications (e.g., mesalamine)
• Immunomodulators in select cases
• Targeted probiotics to address dysbiosis
• Lifestyle interventions to reduce inflammation (e.g., stress reduction, exercise)

By incorporating elements of both traditional diverticulitis management and IBD treatment strategies, healthcare providers aim to address both the mechanical and potential immunological aspects of the condition. This integrative approach may lead to better outcomes and reduced recurrence rates for patients with diverticulitis.

Future Directions: Research and Therapeutic Implications

The hypothesis that diverticulitis may have autoimmune components opens up exciting avenues for future research and potential therapeutic interventions. Some key areas of focus include:

1. Genetic Studies: Investigating genetic markers associated with both diverticulitis and autoimmune disorders to identify common pathways.
2. Immune System Profiling: Analyzing the immune cell populations and cytokine profiles in patients with diverticulitis to better understand immune system involvement.
3. Microbiome Research: Further exploring the role of the gut microbiome in diverticulitis and its potential as a therapeutic target.
4. Novel Therapies: Developing and testing new treatments that target both the mechanical and immunological aspects of diverticulitis.
5. Personalized Medicine: Identifying biomarkers that can help predict individual patient responses to different treatment approaches.

As research in this area progresses, it may lead to a paradigm shift in how we conceptualize and treat diverticulitis. By considering the potential autoimmune aspects of the condition, healthcare providers may be able to offer more targeted and effective treatments, potentially reducing the need for surgical interventions and improving long-term outcomes for patients.

Living with Diverticulitis: Lifestyle Modifications and Self-Care Strategies

Regardless of whether diverticulitis is ultimately classified as an autoimmune condition, patients can benefit from adopting lifestyle modifications and self-care strategies that support overall digestive health and potentially reduce the risk of flare-ups. Some key recommendations include:

• Maintaining a High-Fiber Diet: Gradually increasing fiber intake can help prevent constipation and reduce pressure in the colon.
• Staying Hydrated: Drinking plenty of water supports healthy digestion and can help prevent constipation.
• Regular Exercise: Physical activity promotes healthy bowel function and may help reduce inflammation.
• Stress Management: Chronic stress can exacerbate digestive issues, so incorporating stress-reduction techniques like meditation or yoga may be beneficial.
• Avoiding Trigger Foods: Some individuals find that certain foods exacerbate their symptoms. Keeping a food diary can help identify potential triggers.
• Quitting Smoking: Smoking is associated with an increased risk of diverticulitis and can worsen inflammation throughout the body.
• Probiotics: While more research is needed, some studies suggest that probiotics may help support gut health in individuals with diverticulitis.

By adopting these lifestyle modifications and working closely with healthcare providers, individuals with diverticulitis can take an active role in managing their condition and potentially reducing the frequency and severity of flare-ups.

The Importance of a Multidisciplinary Approach to Digestive Health

As our understanding of the complex interplay between the digestive system, immune function, and overall health continues to evolve, it becomes increasingly clear that a multidisciplinary approach is essential for optimal patient care. This is particularly true when considering conditions like diverticulitis that may have both mechanical and immunological components.

A comprehensive care team for patients with diverticulitis and other digestive disorders might include:

• Gastroenterologists: Specialists in digestive system disorders
• Primary Care Physicians: Coordinating overall care and managing comorbidities
• Nutritionists: Providing guidance on dietary modifications and nutritional support
• Immunologists: Offering insights into potential autoimmune aspects of the condition
• Surgeons: For cases requiring surgical intervention
• Mental Health Professionals: Addressing the psychological impact of chronic digestive disorders
• Pain Management Specialists: Helping patients manage chronic pain associated with their condition

By bringing together experts from various disciplines, healthcare providers can offer more comprehensive and personalized care to patients with diverticulitis, potentially improving outcomes and quality of life.

As research into the potential autoimmune aspects of diverticulitis continues, it is likely that our approach to diagnosing, treating, and managing this common digestive disorder will evolve. By remaining open to new perspectives and embracing a holistic view of digestive health, the medical community can work towards better understanding and more effective treatments for diverticulitis and related conditions.

The Connection Between the Digestive System and Autoimmune Diseases: Advanced Health:

An autoimmune disease is a disease that changes the way the human body views a specific part or feature of the body. It can actually cause the body to change its immune response and to send blood cells to fight off an infection that does not exist. Many people today do not realize that there is a like between the digestive system and autoimmune diseases. This connection can occur because the foods people eat cause an abnormal reaction or because they cannot process certain types of food. An integrative medicine physician can help you learn more about these conditions.

Types of Digestive Autoimmune Diseases

One of the first things to look at are the top digestive autoimmune diseases. While there are several autoimmune diseases connected to the digestive system, the following ones are the most common:

Ulcerative Colitis

Ulcerative colitis is an inflammatory bowel disease (IBD) that causes ulcers to form in the colon and rectum. Many people find that they have IBD after eating foods that are rich or heavy or after overeating. When you finish a large holiday dinner, for example, you may suffer from stomach cramps and other types of stomach pains that leave you unable to sit or stand. The pain can cause quite a bit of discomfort and leave you feeling miserable. It also presents via blood in the stool. The blood appears in your stool because you have bleeding ulcers and your stool mixes with that blood when moving through the rectum.

IBD patients can also suffer from frequent diarrhea. Other symptoms can include fatigue and anemia because your body cannot replenish blood as quickly as it loses it. Problems with your immune system can lead to the system attacking the colon and rectum, which makes the ulcers even worse.

Crohn’s Disease

Crohn’s disease is much more common than UC and presents with some of the same symptoms.  Crohn’s disease occurs because your body misidentifies something in the digestive tract as a disease or toxin and fights back against it. Many people with this condition have blood in their stool, feel tired and have problems digesting certain foods.

One of the more harmful effects of Crohn’s is that it doesn’t impact just one area of the body. It can cause symptoms in your mouth, throat, esophagus and through the entire digestive tract. Those diagnosed with this disease will find that they have a difficult time eating certain foods. They typically cannot eat foods that are spicy or rich because those foods with exacerbate their symptoms.  It is critical to see an integrative medicine physician about your symptoms since the root cause of the disease must be addressed to allow for the disease to go into remission.

Celiac Disease

Another common autoimmune disease is Celiac disease. It is often difficult to diagnosis because the disease affects people differently. The main commonality is that people with Celiac disease cannot properly digest the gluten protein. When they eat gluten, their immune system attacks the small intestine lining, which leads to patients suffering symptoms like stomach cramps, diarrhea, bloating, and vomiting.

There is a big difference between having a gluten intolerance and Celiac disease. People with a gluten intolerance exhibit far fewer symptoms but may feel tired and suffer from some stomach pains after consuming wheat such as in bread, pasta, and beer.  Most people tend to feel sleepy and lethargic after eating large amount of wheat. It’s possible to also exhibit symptoms of gluten intolerance and Celiac disease without actually having the disease.

Connections Between the Digestive System and Autoimmune Diseases

Inflammation is the main connection between autoimmune diseases and the digestive system. When you eat certain poorly digested foods, swelling will develop within your internal organs. Your autoimmune system then views that inflammation as a toxin or a disease that it needs to treat. It attacks that organ to stop the inflammation but actually makes the swelling worse. Red meat, dairy products, wheat, and alcohol are great examples of items that cause inflammation. When you suffer from a common digestive issue and eat a slice of pizza with a glass of wine, your intestines may begin to swell hours later. As the body fights back, the swelling can worsen.

You can also suffer from any of these conditions because of a lack of good bacteria in your digestive tract. While many people assume that all bacteria is bad bacteria, the human body actually relies on some types of good bacteria in order to absorb essential nutrients and have a strong immune system. A healthy balance of good bugs within your digestive tract keeps your bowel movements regular and helps you healthy.  Taking a laxative or antibiotics can be quite harmful to your digestive system since many good bacteria are eliminated from your body. Your immune system will then send more agents to fight the bad bacteria, which can leave you feeling sick. Even consuming an unhealthy diet can eliminate the good bacteria from your body.

Wheat, red meat, dairy products, and sugar are far from the only foods that can trigger an immune system attack. Those diagnosed with some of these conditions often have a difficult time processing many high calorie foods.  For example, chocolate, fish, and tomatoes can also trigger an attack.

Work with a Renowned Integrative Functional Medicine Physician in San Francisco

San Francisco is home to some of the best restaurants in the world, but when you suffer from an autoimmune disease, you may avoid eating out because you do not know how your body will react to the dishes that you consume.

Working with an integrative functional medicine physician in San Francisco who specializes in the digestive system and autoimmune disorders can help you learn more about the connection between your symptoms and how to effectively cope with your condition.

Dr. Payal N. Bhandari, M.D. is a leading practitioner of integrative and functional medicine in San Francisco. She specializes in the digestive, immune and endocrine systems since they are at the heart of inflammation and most chronic diseases. Through personalized medicine, Dr. Bhandari effectively restores patients’ health. Book an appointment today!

Author

Dr. Payal Bhandari M.D.
Dr. Payal Bhandari M.D. is one of U.S.’s top leading integrative functional medical physicians and the founder of San Francisco’ top ranked medical center, SF Advanced Health. Her well-experienced holistic healthcare team collaborates together to deliver whole-person personalized care and combines the best in Western and Eastern medicine.

By being an expert of cell function, Dr. Bhandari defines the root cause of illness and is able to subside any disease within weeks to months. She specializes in cancer prevention and reversal, digestive & autoimmune disorders.

Dr. Bhandari received her Bachelor of Arts degree in biology in 1997 and Doctor of Medicine degree in 2001 from West Virginia University. She the completed her Family Medicine residency in 2004 from the University of Massachusetts and joined a family medicine practice in 2005 which was eventually nationally recognized as San Francisco’s 1st patient-centered medical home.

To learn more, go to www.sfadvancedhealth.com.

Autoimmune Digestive Disorders – Autoimmune Disorders Center

Everyone gets an upset stomach from time to time — but if you’re constantly experiencing discomfort in your gastrointestinal tract, it could be a sign of something more serious.

Millions of people in the United States have one or more autoimmune digestive disorders, which are conditions that occur when the body’s immune system wrongly attacks part of the gastrointestinal tract. “Most of them are relatively common, and certainly not rare phenomenons,” says Rick Desi, MD, a gastroenterologist at Mercy Medical Center in Baltimore.

If you think you might have an autoimmune disorder that is digestive in nature, make an appointment with your physician as soon as possible for an evaluation. Here are some of the most common forms of these disorders.

Celiac Disease

Celiac disease, which affects about 1 person in 200, occurs when a person becomes intolerant to gluten, a protein found in wheat, rye, and barley products. In people with celiac disease, the ingestion of gluten causes the immune system to attack villi, the tiny structures lining the small intestine. This can result in digestive discomforts like diarrhea, vomiting, and abdominal pain. “It’s tough to diagnose sometimes because the symptoms are so nonspecific,” Dr. Desi says. Adults, in particular, may also experience other symptoms, like anemia, arthritis, and fatigue.

The only treatment for celiac disease is a special diet that eliminates gluten completely. Even if you only have mild reactions to gluten, it’s still wise to avoid it, Desi says. Over time, damage to the small intestine can increase your risk of intestinal lymphoma, a type of cancer. “The risk isn’t that high, but it’s higher than the average population,” Desi says. A 2005 study suggested that strict adherence to a gluten-free diet could protect against the development of cancer. Advice on shopping for gluten-free products can be found on the Celiac Disease Foundation Web site.

Crohn’s Disease

This condition occurs when the immune system attacks parts of the digestive tract, causing inflammation, swelling, and even scarring. “It can affect every part from the mouth to the anus,” Desi says. “No part of the digestive tract is spared.” Symptoms of Crohn’s disease include abdominal pain, diarrhea, and fatigue. Some patients may also experience rectal bleeding.

About 500,000 people in North America have Crohn’s disease. It mainly affects people who are relatively young, between the ages of 15 and 35. “It’s pretty equal among genders,” Desi says. “Neither men nor women are more likely to get it.”

Desi says scientists aren’t sure what causes Crohn’s disease to develop in some people, but some theorize that it may have to do with the hyper-disinfected environments of most developed countries. “Crohn’s and other inflammatory bowel diseases are just about unheard of in developing countries,” Desi says. Genes can also play a role; about 20 percent of people with Crohn’s disease also have a relative with Crohn’s or another inflammatory bowel disease.

Treatments include anti-inflammatory drugs, immune-suppressant drugs, and steroids.

Ulcerative Colitis

Desi calls ulcerative colitis the “cousin” of Crohn’s disease, and explains that it happens when the immune system attacks the lining of the rectum and colon, causing ulcers. The ulcers can then bleed and produce pus. The most common symptoms of ulcerative colitis — abdominal pain and diarrhea — are similar to those of Crohn’s. “It can sometimes be difficult to tell if someone’s got Crohn’s disease or ulcerative colitis,” Desi says. People with ulcerative colitis can also experience anemia, rectal bleeding, and fatigue.

About 500,000 people in the United States have ulcerative colitis. Men and women are equally affected, and patients are usually either in their twenties or their fifties and sixties. “People in their thirties and forties are relatively spared,” Desi says.

The pharmaceutical treatments for ulcerative colitis are the same as those for Crohn’s disease. In severe cases of ulcerative colitis, a colectomy, the surgical removal of the colon, might be in order. “Surgery’s always a last-ditch effort, though,” Desi says. “Most people can be controlled with medications.”

Autoimmune Hepatitis

Unlike most types of hepatitis, which are caused by viruses, autoimmune hepatitis happens when the body’s immune system attacks liver cells, causing inflammation. Autoimmune hepatitis affects between 100,000 and 200,000 people in the United States. “It’s not very common, but we do see it from time to time,” Desi says. Type 1, the more common type in North America, is most likely to occur in young women, while Type 2 most often occurs in girls between the ages of 2 and 14.

Symptoms of autoimmune hepatitis include abdominal discomfort, fatigue, nausea, and jaundice, a yellowing of the skin. Many times, the symptoms can be minor, and the disease is only caught during routine blood testing.

Both types of autoimmune hepatitis can be treated with the drugs prednisone and Azasan or Imuran (azathioprine). Prednisone, a steroid, works by suppressing the immune system. Azathioprine is usually added to the treatment plan later, to help patients reduce their prednisone doses. “They both work well in calming down the immune system,” Desi says.

If autoimmune hepatitis is left untreated, it can lead to cirrhosis, which is scarring and hardening of the liver. If cirrhosis develops, the liver will probably need to be replaced with one from a donor. “You can manage cirrhosis of the liver, but eventually, transplantations may be required,” Desi says.

If you notice any of the symptoms of autoimmune digestive disorders, contact your doctor. The sooner you get a diagnosis, the sooner you can begin treatment and start feeling better — and perhaps prevent further damage to the affected organs.

Bowel Disease Information

Inflammatory Bowel Disease (IBD), Ulcerative Colitis and Crohn’s Disease

Ulcerative Colitis and Crohn’s Disease are two types of Inflammatory Bowel Disease – conditions which causes the bowel (colon) to become inflamed and red. Both conditions can affect parts of the body outside the bowel and may be associated with poor general health.

Inflammatory bowel disease is a totally different condition from Irritable Bowel Syndrome (IBS) where the functioning of the bowel is affected but it looks normal in appearance.

Ulcerative Colitis and Crohn’s Disease are long-term, chronic (ongoing) conditions which can flare up on and off throughout life.

Symptoms

• Abdominal pain
• Blood, mucus or pus in the stool
• Diarrhoea
• Fatigue and tiredness
• Weight loss
• Loss of appetite

People with Ulcerative Colitis may also develop other symptoms unrelated to the bowel. These can include mouth ulcers, skin problems, joint pains, and eye or liver problems.

Most of the time many people with Ulcerative Colitis feel well and don’t have symptoms. This means the disease is not ‘active’ at this time, or can be said to be in remission. However, when the disease flares up and causes symptoms, this is known as a relapse. Most of the time a ‘trigger’ for a relapse can’t be identified, although some people find that stress, infections, some medications or certain foods bring on an attack. It should be remembered that none of these is the cause of the disease itself.

Depending on where the inflammation occurs in the large bowel, Ulcerative Colitis can also be called Proctitis (involving the rectum only), Proctosigmoiditis or Distal Colitis (involving the rectum and sigmoid colon), or universal or pan-colitis, which means the entire colon is affected. Doctors don’t know why some people’s disease spreads to involve their entire colon yet in others the disease is confined to one area of it.

Causes of Ulcerative Colitis and Crohn’s Disease

Unfortunately the cause is still unknown despite intensive research. Causative factors that have been suggested include:

• Genetic predisposition
• Infectious agents (bacteria and viruses)
• Drugs
• Smoking
• Psychogenic factors
• Defects in the immune system
• Environmental factors

Some Doctors suggest a combination of some or all of these factors may be involved. Psychological stress and food allergies are not thought to play a role in development of the disease, but they may aggravate symptoms in some people.

Diagnosis

Ulcerative Colitis and Crohn’s Disease are sometimes difficult to diagnose because its symptoms can be similar to other conditions such as bowel infections or Irritable Bowel Syndrome. Most people with the disease will generally need a colonoscopy, sigmoidoscopy, and barium meal or barium enema to confirm the diagnosis. Blood tests can reveal whether you have anaemia or any vitamin or mineral deficiencies.

Inflammatory Bowel Disease and Cancer

If you have had Ulcerative Colitis for a number of years, your risk of developing Colon Cancer is higher than people who do not have Ulcerative Colitis.

Your Doctor will probably advise you to have regular examination by colonoscopy. A biopsy (small tissue sample) will probably be taken during colonoscopy for microscopic examination to detect any changes in bowel tissue that might lead to cancer. Your Doctor will advise you on how often you should have these examinations depending on how long you have had the Ulcerative Colitis.

Diverticular Disease

Diverticular Disease is a common condition but only a small percentage of those with the disease have symptoms, and even fewer will ever require surgery.

Diverticula are pockets that develop in the colon wall, may involve the entire colon but usually in the sigmoid or the descending colon. Diverticulosis describes the presence of these pockets. Diverticulitis describes inflammation or complications of these pockets.

Symptoms

The major symptoms of Diverticular Disease are abdominal pain (usually in the lower left abdomen), diarrhoea, cramps, alteration of bowel habit and occasionally, severe rectal bleeding. These symptoms occur in a small percentage of patients with the condition and are sometimes difficult to distinguish from Irritable Bowel Syndrome.

Diverticulitis – an infection of the diverticula – may cause one or more of the following symptoms: pain, chills, fever and change in bowel habit. More intense symptoms are associated with serious complications such as perforation, abscess or fistula formation.

Causes

Exact cause of the Diverticular Disease is not known, but there are indications are that a low-fibre diet over the years creates increased colon pressure and results in pockets or diverticula.

Diverticular Disease is unknown in rural Africans who eat a high fibre diet, but is common in western societies where many people have a low fibre intake. It is much less common in vegetarians.

Treatment

Diverticulosis and Diverticular Disease are usually treated by diet and occasionally, medications to help control pain, cramps and changes in bowel habits. Increasing the amount of dietary fibre (grains, legumes, vegetables, etc.) – and sometimes restricting certain foods reduces the pressures in the colon, and complications are less likely to arise.

Diverticulitis requires more intense management. Mild cases may be managed without hospitalisation, but this is a decision made by your Doctor.

Treatment is aimed at resting the bowel, relieving pain and fighting infection. A low-fibre, or fluid-only diet, is recommended to rest the bowel.

Severe cases require hospitalisation with intravenous antibiotics and strict dietary restraints. Most acute attacks can be relieved with such methods.

Surgery is reserved for recurrent episodes, complications or severe attacks when there’s little or no response to medication.

Colorectal Cancer

Colorectal Cancer is currently the second most common internal malignancy affecting approximately 1 in 20 Australians; prostate cancer is more common in men and breast cancer more common in women.

Symptoms

• Rectal bleeding
• Altered bowel habit
• Iron deficiency anaemia
• Abdominal pain
• Unexplained weight loss

Colonoscopy is the most appropriate investigation in terms of diagnosis and treatment as nearly all Bowel Cancers start out as polyps. If these are removed the risk of cancer developing in that polyp is also removed.

Reflux

Reflux occurs when the acid in your stomach rises up into your oesophagus (the tube that connects your mouth to your stomach). Your stomach has a thick mucous lining that protects it from the acid inside, but because the oesophagus doesn’t, it can become irritated and painful leading to heartburn.

Heartburn is a burning sensation that rises from your stomach or lower chest up to your throat. It may even feel like food is coming back up, and you may get an acidic or bitter taste in the back of the mouth. Heartburn is often worse after eating, or when lying down, straining or bending over. Heartburn is very common – up to 1 in 5 adult experience heartburn at least once a week. Heartburn is the most common symptom of reflux and gastro-oesophageal reflux disease.

Symptoms

• Heartburn
• Excessive burping
• Regurgitation
• Sudden filling of the mouth with saliva
• Difficulty swallowing
• Sore throat
• Persistent dry cough
• Chest pain (If you are experiencing chest pain contact your Doctor immediately)

Tips for managing reflux

1. Particular foods can make reflux and heartburn worse. These food may differ from person to person.
   Common trigger foods include –
   • Fatty and fried foods
   • Spicy foods and onions
   • Citrus fruits and juices
   • Chocolate and full-fat dairy products
   • Alcohol
   • Coffee & tea
   • Carbonated and/or caffeinated drinks
   • Tomatoes and tomato juice/sauce
   • Pepper
   • Peppermint

   Try to identify and avoid the foods that make your symptoms worse.

2. Smoking can aggravate heartburn, so it’s a good idea to consider quitting.
3. Being overweight puts extra pressure on your stomach so try to lose any excess weight.
4. Avoid clothing with tight waistbands, especially after meals.
5. Raise the head of your bed by 20cm or use a wedge pillow to keep your head higher than your stomach.
6. Try to reduce stress as much as possible.

Coeliac Disease

What is Coeliac Disease?

In people with Coeliac Disease the immune system reacts abnormally to gluten (a protein found in wheat, rye, barley and oats), causing small bowel damage. The tiny, finger-like projections which line the bowel (villi) become inflamed and flattened. This reduces the surface area of the bowel available for nutrient absorption, which can lead to various gastrointestinal and malabsorptive symptoms.

A number of serious health consequences can result if the condition is not diagnosed and treated properly.

Who gets Coeliac Disease?

Coeliac Disease affects people of all ages, both male and female.

You must be born with the genetic predisposition to develop Coeliac Disease. A first degree relative (parent, sibling or child) of someone with Coeliac Disease has about a 10% chance of also having the disease. If one identical twin has Coeliac Disease there is an approximate 70% chance that the other twin will also have Coeliac Disease (but may not necessarily be diagnosed at the same time).

Environmental factors play an important role in triggering Coeliac Disease in infancy, childhood or later in life.

How common is the condition?

Coeliac Disease effects on average approximately 1 in 70 Australians. However, approximately 80% currently remain undiagnosed. This means that approximately 330,000 Australians have Coeliac Disease but don’t yet know it.

More and more people are being diagnosed with Coeliac Disease. This is due to both better diagnosis rates and a true increase in the incidence of Coeliac Disease.

Can Coeliac Disease be cured?

People with Coeliac Disease remain sensitive to gluten throughout their life, so in this sense they are never cured. However, a strict gluten free diet does allow the condition to be managed effectively.

A strict, lifelong gluten free diet is currently the only recognised medical treatment for Coeliac Disease. By removing the cause of the disease, a gluten free diet allows the small bowel lining to heal and symptoms to resolve. As long as the gluten free diet is strictly adhered to, problems arising from Coeliac Disease should not return. Relapse occurs if gluten is reintroduced into the diet.

What are the long term risks of undiagnosed and untreated Coeliac Disease?

The long term consequences of untreated Coeliac Disease are related to chronic systemic inflammation, poor nutrition and malabsorption of nutrients. Fortunately, timely diagnosis of Coeliac Disease and treatment with a gluten free diet can prevent or reverse many of the associated health conditions.

Symptoms

The symptoms of Coeliac Disease vary considerably. Some people experience severe symptoms while others are asymptomatic (they have no obvious symptoms at all).

Symptoms can include one or more of the following:

• Gastrointestinal symptoms e.g. diarrhoea, constipation, nausea, vomiting, flatulence, cramping, bloating, abdominal pain, steatorrhea
• Fatigue, weakness and lethargy
• Iron deficiency anaemia and/or other vitamin and mineral deficiencies
• Failure to thrive or delayed puberty in children
• Weight loss (although some people may gain weight)
• Bone and joint pains
• Recurrent mouth ulcers and/or swelling of mouth or tongue
• Altered mental alertness and irritability
• Skin rashes
• Easy bruising of the skin

People who experience any of the following should also be screened for Coeliac Disease

• early onset osteoporosis
• unexplained infertility
• family history of Coeliac Disease
• liver disease
• autoimmune disease e. g. type 1 diabetes, autoimmune thyroid condition

Lupus Cause Diverticulitis and Irritable Bowel Syndrome

Lupus and Diverticulitis

Today is 9/18/2017 and since three nights ago, I’ve struggled with what I deemed to be menstrual cramps or indigestion.

It began with a general pain near and around the lower abdomen and it progressively worsened to where it was causing pain to move.  By Saturday morning, it was isolated to the right lower abdomen and I suspected appendicitis and knowing the risks, I went to the ER.

After the CT scan, they concluded that I had Diverticulitis.

What is Diverticulitis?

Diverticulosis forms when pouches form in the walls of the colon and when these pouches get inflamed and infected, then it’s called diverticulitis.

It can cause intense pain, bloating, constipation, and diarrhea and some have an acute flare or struggle with chronic diverticulitis.

Diverticulitis Symptoms are Becoming Common

Diverticulitis is becoming increasingly common in the United States in those over-40 years of age. (1) This is like because as we age, we become increasingly sedentary, and eat SAD (Standard American Diet) which lacks fiber, and as a result, many begin to develop small, weak areas in the muscular wall of the colon.  Which is what This allows the colon’s lining to protrude through, forming tiny pouches called diverticula. 

What’s surprising is that its much more common, 50% of people in their 50’s, 60% at age 60 and 70% at age 70’s and 80’s have diverticula (no symptoms) (2).  

Approximately 20 percent of people with diverticulosis develop diverticulitis such as the one I with symptoms including abdominal pain, fever, and constipation.  However, those symptoms can vary greatly between individuals.

Acute Diverticulitis Symptoms

I’ve not had the “acute” symptoms but I can tell you I’ve had Irritable Bowel Syndrome and I believe Lupus and Autoimmune patients are more prone to Diverticulitis and/or Irritable Bowel Syndrome.

Some Acute Symptoms are as follows: Lower abdominal pain (occurs on left side in 70 percent of patients; often described as crampy)

1. Lower abdominal pain (occurs on left side in 70 percent of patients; often described as crampy)
2. Change in bowel habits
3. Nausea and vomiting
4. Constipation
5. Diarrhea
6. Flatulence
7. Bloating
8. Fever

The symptoms are dependent on various factors including the location of the inflammation and the severity of the inflammatory process.

It’s important to note that some may have a single episode while others may never have the problem again.

Symptoms Caused by Complicated Diverticulitis May Be Life-Threatening

In some cases, diverticulitis leads to bleeding; infections; small tears, or blockages in the colon.  Bleeding can lead to blood in the stool.  The infected diverticula can form abscesses or can break and leak the infected fluid into the abdominal cavity, which can lead to sepsis (body-wide infection), fever, chills, and severe abdominal pain.

Fistulas (connection between organs) can form if the infection spreads outside the colon and cause the colon tissue to stick to the nearby organs such as the bladder.  This may cause chronic, severe bladder infections with associated pelvic pain.  Scarring can be caused by this infection and lead to a partial or total blockage of the intestine, intestine obstruction.

When the intestine is blocked, it can result in severe constipation, bloating, and pain can occur in which case hospitalization and surgery are required.

Diverticulitis May Resemble Irritable Bowel Syndrome

Here’s the meat of this blog post.  Truth is that not all people with diverticulitis present like textbook cases, there are lots of variables between individuals.  What’s becoming more evident is that an increasing number of people have a chronic, low-grade form of the diverticular disease with symptoms mimicking irritable bowel syndrome (IBS). (3-4)

Causes

Here’s where it gets interesting.

The causes are low-grade inflammation, dysbiosis (microbiota), hypersensitivity of the gut tissue, and abnormal gut motility. (5)  A lot like leaky gut, right?

IBS is a lot like Fibromyalgia in that you rule out everything else and if you still have those symptoms of abdominal pain, discomfort, bloating, constipation, and diarrhea then you’ll be considered to have IBS.

What to Do If You Suspect Diverticulitis

Here’s the real deal.  Whether you have an acute, severe attack of diverticulitis or a more chronic presentation of the disease, there are options for you.  Conventional treatments involve antibiotics and surgery but new evidence shows that they may not be necessary.

In fact, there’s enough research showing the benefits of natural treatments like probiotics and vitamin D.  The good news is that more gastroenterologists are beginning to recommend them to their patients.

If you have Lupus and have digestive issues, please, begin your regimen with quality Probiotics and Vitamin D to prevent situations like mine.

If you have diverticulitis symptoms, seek out a healthcare provider who is up-to-date on the latest research that shows the benefits of natural treatments like probiotics, vitamin D, and more.

Rebel’s Thoughts

I’ve been living with Lupus for over 19 years and during that time been exposed to chemo, prednisone, pain medications, anti-depressants, Plaquenil, antibiotics, and anti-nausea medications.

Do such meds alter my gut flora?  ABSOLUTELY!

Not a single doctor has mentioned anything about my Lupus, dismissed it completely because this is a condition in and of itself.  That’s what gets me on my soapbox.

I am writing this article from a hospital where they serve processed foods and dismiss the quality of foods and place such emphasis on medications.

I called own to the cafeteria to discuss my personal food preferences and to see if I can have something gluten-free and they said they don’t have gluten-free options.  I had to a la carte my selection and made the best of the meal with steamed veggies.

The point is that Conventional Medicine looks so much into the disease with the microscope that they miss the big picture.  The “food is thy medicine” theory by Hippocrates is completely overlooked.  My resident physicians were sleep deprived, staying awake with coffee, and did not look to me as the epitome of health.

They were busy in their smart brains of  “standardized” medication protocols to address my ills, PERIOD.   They told me I didn’t need to change my diet that this is one of those conditions where the cause is unknown.

Nurses, techs, Dietitians, Physicians, all staff, are just following the policy and procedural process.

I refuse to be a recipient of those procedures.  This is precisely why I fight so hard for my health, because if I don’t,  nobody else will.

Want to address your gut?  I hightly recommend my Alkaline Detox Protocol and our Lupus Gut Healing Guide and/or Lupus Gut Healing Protocol.  Lastly, if you nothing else, please get on the probiotics, it’s the real deal.

Please share, leave me comments, like, and subscribe so you can stay in the loop.

References

1. JAMA Sug.2014:149(3):292-303.
2.  Debunking Myths About Diverticular Disease. Medscape. Apr 07, 2014.
3. Clin Gastroeneterol Hepatol.2013 Dec:11(12): 10.1016/j.cgh.2013.04.048.
4. Therap Adv Gastroenterol.2013 May:6(3):205-213.
5.  Dig Dis Sci. 2015 Oct 12

IBD Mimics: Most Common Conditions Misdiagnosed as IBD

Since there is no single, gold standard diagnostic test for inflammatory bowel disease (IBD) there are many disease processes that can be misdiagnosed as IBD, given its often non-specific symptoms. There is a broad differential diagnosis when considering IBD, however most of the etiologies generally fall into two categories: infectious and non-infectious. Some of these disease states affect a portion of the gastrointestinal (GI) tract which may help differentiate them from IBD and one another. First, we will review the non-infectious etiologies which include autoimmune disorders, vasculidities, ischemia, diverticular disease, drugs, cancer, and radiation-induced disease. It is important to note that while many of the etiologies discussed have histologic changes in colon biopsies in order to diagnosis IBD features of chronicity are warranted.

Non-infectious Mimics

Granulomatous autoimmune disorders, including sarcoidosis and common variable immunodeficiency (CVID), can have similar presentations as IBD. Sarcoidosis can affect many organ systems, but GI involvement occurs <1% of cases and may present with abdominal pain, bloating, diarrhea, and non-specific endoscopic findings. ¹ CVID is usually a disease of the sinopulmonary tract but can include enteropathy in ~10% of patients.² Symptoms include abdominal pain and diarrhea and a hallmark of the diagnostic evaluation is the absence of plasma cells on histology.^2,3 Up to 30% of patients with vasculitis can have gastrointestinal manifestations.⁴ Small vessel vasculidities including antineutrophil cytoplasmic antibody (ANCA)-associated vasculidities including microscopic polyangiitis, granulomatosis with polyangiitis (GPA, Wegener’s granulomatosis), eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss), and immunoglobulin A vasculitis (Henoch-Schönlein purpura) all fall in this category.⁴  Behcet’s disease may classically mimic Crohn’s disease (CD) with oral and genital ulcerating lesions, with a small percentage of patients presenting with luminal disease, plus additional manifestations that may appear like extraintestinal manifestations.^4,5  

Hermansky-Pudlak syndrome is a rare autosomal recessive condition where patients have oculocutaneous albinism, bleeding diathesis and other organ specific involvement including granulomatous colitis which can have features like CD. Patients with this condition who manifest GI disease usually have abdominal pain, fever, bloody stool and weight loss.⁶ The colon is most commonly affected, but like CD, may affect any part of the GI tract.  

Intestinal ischemia is caused by reduced blood flow to an area of the intestinal tract, most commonly the colon due to its limited blood supply and the incidence is roughly 16 cases per 100,000 person-years. Patients with colonic ischemia often present with crampy lower abdominal pain and bloody diarrhea and commonly have had endovascular instrumentation, cardiac surgery, extreme exercise or exposure to certain medications.⁷ Endoscopic evaluation may be utilized to confirm ischemia and rule out other causes. On colonoscopy, gross inflammatory changes are seen including edematous, friable mucosa; erythema; and interspersed pale areas. Biopsies from these areas may show nonspecific changes such as hemorrhage, crypt destruction, capillary thrombosis, granulation tissue with crypt abscesses, and pseudopolyps like CD. ⁸

Solitary rectal ulcer syndrome (SRUS), a form of obstructive defecation (pelvic floor dysfunction), presents with rectal bleeding and incomplete evacuation. On endoscopic evaluation patients can have numerous findings including non-specific erythema, single or multiple ulcers, polyps or mass-like lesions. Anorectal manometry reveals paradoxic pelvic floor contraction, and the presence of collagen infiltration of the lamina propria on histology is pathognomonic for the diagnosis of SRUS.⁹

Diverticulitis or segmental colitis associated with diverticulosis (SCAD) can both have similar presentations to IBD. Diverticulitis presents with abdominal pain, localized to the left lower quadrant, and may be complicated by fistula, abscess, or stricture. The diagnosis is typically made by contrast-enhanced abdominopelvic CT scanning which reveals diverticulosis and colonic inflammation and complications limited to a single segment of colon. SCAD on the other hand, presents with abdominal pain plus diarrhea. Endoscopically, SCAD is limited to areas where diverticula are present and on histologic evaluation there is no evidence of chronicity.¹⁰ Drug induced enteritis and colitis is seen most frequently with nonsteroidal anti-inflammatory drugs (NSAIDs) and immune-based therapies. NSAIDs can cause ulceration throughout the GI tract. Ongoing usage can result in chronicity in histologic evaluation and ulcerations and even stricture development in the small bowel like CD.¹¹ Immune-based chemotherapeutic agents (i.e., ipilimumab) that target a component of cytotoxic T cells can have adverse gastrointestinal events in up to 64% of patients and can present exactly like IBD including similar endoscopic and histologic findings, however these are differentiated based on the correct clinical scenario, namely lung cancer on check-point inhibitor treatment.¹²

Colon cancer may of course present with similar symptoms including abdominal pain, diarrhea (if there is an obstructing lesion) and rectal bleeding but colonoscopic findings usually assist in separating these diagnoses. Primary colonic GI lymphomas (usually diffuse large B cell), however, can be mistaken for IBD on colonoscopy. These cancers are very rare and usually present in older patients who may be immunosuppressed.¹³ While they can present with a mass, often they have mucosal ulceration on endoscopic evaluation.

Infectious Mimics

Infections can present similarly to IBD with abdominal pain, diarrhea, and endoscopic/histologic findings (including chronicity) depending on the portion of the affected bowel. We will review organisms that cause disease in the small bowel, the terminal ileum (TI), and the colon.

Coccidiodes is a fungal infection that usually causes lung disease but can have GI involvement in the small bowel and presents with abdominal pain, nausea, and fever in patients that have traveled to or reside in the Southwest United States.¹⁴ The infection is diagnosed by biopsy or serological testing. Many organisms can cause disease in the TI including Histoplasma, Mycobacterium, Yersinia, and Salmonella. ¹⁵ Histoplasma is a fungus that can cause systemic illness and is usually diagnosed in individuals who have traveled to the Ohio and Mississippi river valleys. GI disease is uncommon but characterized by abdominal pain, fever, diarrhea, and weight loss. Ileocecal lesions with Histoplasmosis infection include erythema, ulcers and even stricture formation and this infection is diagnosed with biopsies or serologic testing.¹⁶ Mycobacterium tuberculosis (“the great mimic”) may coexist with IBD or mimic CD entirely. It is a bacterial infection that can present with myriad GI symptoms. Diagnosis may be hard to ascertain especially since tissue histology can contain caseating and non-caseating granulomas. PCR testing may aid in making the diagnosis, but it is not uncommon for patients to require treatment for TB prior to starting immunosuppression for CD when TB cannot be definitively ruled out.^17,18 Mycobacterium avium-intracellulaire can cause abdominal pain and diarrhea in immunocompromised hosts, however this group does not usually present with new IBD, so this infection is not often mistaken for IBD. ¹⁹  Yersinia is a bacterial infection caused by ingestion of certain meats and may infect the terminal ileum and cecum causing ulceration and mucosal damage mimicking CD. Histologic evaluation of tissue can differentiate Yersinia from CD as the former has preserved architecture on biopsy.¹⁵ Salmonella, a gram-negative rod, can affect both the TI and the colon after ingesting contaminated food or water. Typhoid, characterized by fever, diarrhea, abdominal pain, and possible progression to more systemic disease. Stool culture may help identify this organism as endoscopically and histologically it may be hard to differentiate given TI and right colonic ulceration. Non-typhoid Salmonella infection can present with less severe GI symptoms but can occur concurrently with IBD, especially in those that are immunocompromised because of their IBD therapy.²⁰

Colonic infections besides Salmonella include Shigella, Clostridioides difficile (C. diff), Eschericia coli (E. coli), Campylobacter, Aeromonas and the protozoan Entamoeba histolytica.  Shigella is an invasive, gram negative rod transmitted via the fecal-oral route that causes a left sided colitis and can be detected on stool culture. Patients present with abdominal pain, fever, and watery diarrhea that progresses quickly to bloody diarrhea.²⁰ There are many strains of E. coli that can cause severe illness including abdominal pain and bloody diarrhea and is transmitted via the fecal-oral route. The O157 variant may cause colitis that appears ischemic in nature or with segmental distribution and can be detected on stool cultures.²¹ Campylobacter is a gram-negative bacterium that is transmitted via contaminated food and can cause abdominal pain, fever, and diarrhea. This infection may result in a left sided colitis like ulcerative colitis, but stool studies are helpful in ruling in this infection. Of note, this infection does carry an increased risk of post-infectious IBS which can make differentiation from IBD more complicated. ^22,23 C. difficile is a gram-positive bacillus and the infection (CDI) it produces is most commonly seen in patients with nosocomial exposure or recent antibiotic use, but it is increasingly seen in the community and can co-exist with IBD in the absence of clear risk factors. CDI causes diarrhea and abdominal pain with severe cases leading to toxic megacolon.  PCR testing is used to detect this organism.¹⁵ Aeromonas is a gram-negative bacterium usually limited to tropical or subtropical areas causing numerous systemic symptoms including GI complaints. Clinically patients present with bloody diarrhea and may have segmental or pancolitis on endoscopy with chronicity on histology like IBD.²⁴ Amoebiasis caused by the protozoan Entamoeba histolytica is transmitted by the fecal-oral route and may cause abdominal pain and bloody diarrhea. Endoscopic findings include “flask-shaped ulcers” with colitis on the left or right colon. Diagnosis can be made with PCR testing and sometimes trophozoites and ingested erythrocytes may be seen on tissue examination. ²⁵

Lastly, diarrhea predominant irritable bowel syndrome (IBS) can have clinical features in common with IBD. Patients may report abdominal pain and diarrhea. Lab testing to assess for etiology of the diarrhea should include C-reactive protein level and a fecal calprotectin level (<50mcg/g)  both of which are in the normal range in IBS unlike in IBD.²⁶  

References

1. Vahid B, Spodik M, Braun KN, et al. Sarcoidosis of gastrointestinal tract: a rare disease. Dig Dis Sci.2007;52:3316–3320.
2. Uzzan M, Ko HM, Mehandru S, et al. Gastrointestinal disorders associated with common variable immune deficiency (CVID) and chronic granulomatous disease (CGD). Curr Gastroenterol Rep. 2016;18:17.
3. Abbott JK, Gelfand EW. Common variable immunodeficiency: diagnosis, management, and treatment. Immunol Allergy Clin North Am. 2015;35:637–58.
4. Humbert S, Guilpain P, Puechal X, et al. Inflammatory bowel diseases in anti-neutrophil cytoplasmic antibody-associated vasculitides: 11 retrospective cases from the French Vasculitis Study Group. Rheumatology(Oxford). 2015;54:1970–1975.
5. Kobayashi K, Ueno F, Bito S, et al. Development of consensus statements for the diagnosis and management of intestinal Behçet’s disease using a modified Delphi approach. J Gastroenterol. 2007;42:737–45.
6. Seward SL Jr, Gahl WA.  Hermansky-Pudlak syndrome: health care throughout life.

Pediatrics. 2013;132(1):153. 

1. Yadav S, Dave M, et al.  A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis. Clin Gastroenterol Hepatol. 2015 Apr;13(4):731-8.
2. Mitsudo S, Brandt LJ.  Pathology of intestinal ischemia. Surg Clin North Am. 1992;72(1):43.
3. Tjandra JJ, Fazio VW et al. Clinical and pathologic factors associated with delayed diagnosis in solitary rectal ulcer syndrome.  Dis Colon Rectum. 1993;36(2):146.  
4. Lamps LW, Knapple WL. Diverticular disease-associated segmental colitis. Clin Gastroenterol Hepatol.2007;5:27–31

Coronavirus (COVID-19) and Inflammatory Bowel Disease

You should keep your appointments, but they are going to be in a different form than you might be used to. Most of our patients are having their appointments by telephone, by MyChart, or even now by video visits. So we’ve been able to shift many of our stable patients to those types of visits and we can handle many of your concerns and questions as well as your routine healthy follow up visits doing it this way.

What you should also know is that if you get sick, we are completely available, and we can still see you. And we would work hard to figure out what the best way to do that is. It is safe to come see us in the clinic if you need it, but we’ll work with you to figure out how and when that should be done. We have, on the other hand, rescheduled or deferred most of the elective procedures of colonoscopies or other endoscopic procedures. Most of these procedures that we do to look for precancerous changes or for other indications we feel can be delayed until we’re done with the pandemic and we can move forward safely.

If you need a procedure because of something that’s time sensitive or essential in other ways for your management, we certainly are still offering that and doing it. The best thing to do is to call your doctor or to call your doctor’s team so that you know what options are available for you. But don’t cancel your appointments and certainly don’t stop your medicines.

Some of our patients who receive therapies for inflammatory bowel disease are receiving those therapies by intravenous infusions. And that means they go to an infusion center either at the University of Chicago Medicine or some of the outlying centers that we work with those centers are safe. It’s important to stay on schedule with your infusions. But we have specifically asked and really required that all the infusion centers have a protocol in place to keep our patients safe and also, to keep the nurses who work there safe.

The protocol needs to include screening the patient for any known contacts with COVID-19, screening the patient for any symptoms to suggest COVID-19, including fevers or respiratory symptoms, or as I mentioned, digestive symptoms can sometimes be a clue. And the other things that the infusion centers need to do is to space patients apart at least six feet, to have a single provider working with the patient, meaning one nurse to patient ratio, so that there are not multiple people exposed to the patient. And the provider should all be wearing masks and gloves and offering those to the patient if they don’t already show up with them.

The final part of keeping infusion centers safe is to make sure that after a patient has received their infusion, the chair and the surrounding area is appropriately cleansed and cleaned. If you know that your infusion center is doing that– and I can tell you that the University of Chicago Medicine is doing it and the infusion centers that we work with in the Chicago land and Northwest Indiana areas are doing it– then you should keep your appointments, make sure you get your treatments, and stay in remission. Delaying the infeasible therapies or for that matter, many of our other treatments, can lead to relapse and loss of response to the drugs. We definitely don’t want to deal with that as a consequence of COVID-19. We want to keep you healthy.

The medications we used to treat inflammatory bowel disease include a variety of therapies that work by different mechanisms or target different parts of our immune system. We fortunately, have many options that we’ve been using to treat patients with Crohn’s disease and ulcerative colitis. Some of them are older, like the medicines that are immune modulator therapies called thiopurines or azathioprine and 6MP, or another medicine called methotrexate. And more recently, we have a variety of biological therapies which target different components of the immune system.

The goal of these therapies is not to suppress the immune system so patients are more susceptible to infections, and that would include this particular coronavirus infection, but rather, to control the overactive inflammation of the bowel and let the body heal itself and catch up. We don’t always know how to do this perfectly, but we’ve gotten much better at it. Our biological therapies, for example, aim at specific directed components of the immune system. A whole class of therapies called anti-TNF treatments focus on an inflammatory protein called TNF or tumor necrosis factor. The TNF protein is elevated whenever somebody has an infection or overactive immune response, and therefore, targeting it works quite well for many people with Crohn’s and colitis.

The treatments that are used in the anti-TNF class include drugs that you may have heard of called Remicade or Humira or Cimzia or Simponi. And these therapies are recommended to be continued at the current time even with the pandemic occurring. The other therapy we talk about is a drug that targets the white blood cells that might be on their way to your bowel. That therapy is known as Entyvio. And Entyvio works by actually blocking those white blood cells from getting out of the blood vessels into your intestines. So it’s a more selective therapy in that it only works on the intestinal immune system. And therefore, it may have a different profile and it’s something that we think of in a different way when we talk about risks for infections. The risk for infection might be lower than our anti-TNF and other treatments.

And lastly, we have a treatment that’s known as Stelara, which targets two other inflammatory proteins that go up. And they tend to be proteins that are elevated just where there’s inflammation in your body. So it’s a bit more selective, but it still works on the entire body. So that therapy we also think of a bit differently. The general message regarding all of these therapies is that if you are in remission and the treatment you’re on is working for your Crohn’s and your colitis, you should be staying on that therapy, and you should be communicating with your health care team about any additional thoughts or changes that might be necessary.

For most patients, we are not recommending that they stop treatments, and we are recommending that they adhere to the social distancing and stay at home recommendations. And obviously continue to be very careful about washing their hands and not touching their face. Remember that these treatments are keeping your inflammatory bowel disease under control. If the IBD becomes active the problem then is that you might need to be on corticosteroids like prednisone, which we worry can actually make things worse for you and definitely have a higher risk of infections. So it’s best to stay in remission and to do the best you can to be at home, keep your hands clean, and to follow the other recommendations as they’re coming out.

Many patients have asked whether they should stockpile their medications or whether there is going to be a national shortage of their therapies. The good news is that the answer to that question is, no. We have assurances from the pharmaceutical companies that there’s plenty of medicine available and that they can stay on their schedule, refilling them appropriately, and not worry about this.

Related to that, I would also advise you not to be taking additional supplements at this time. Some patients have asked whether they should be taking extra vitamins or zinc or other things to prevent a viral infection. There’s no data to support that and we don’t want you to start taking new things now that might have a whole other set of side effects or problems that would confuse us during this important time.

Part of an international collaboration to develop guidance for inflammatory bowel disease patients who develop COVID-19 is the important distinction between having symptoms from the infection and having an activation of IBD. So if you have a flare of your IBD, remember that this could be part of the COVID-19 presentation. It might also just be that your IBD is flaring. There are many reasons people flare from their inflammatory bowel disease. One of them that patients often tell us is stress, and of course, we’re all under stress right now.

The other would be if you had stopped your medicines or if your routine in some other way has changed. You might not be exercising like you used to do. Your diet might have changed because you’re staying at home or doing other things. And so there are many different reasons to think that you might actually be relapsing. The good news is that we have ways to sort this out that don’t require you to necessarily come to the clinic or have any procedures done. And with some simple tests, we can often distinguish between what is a flare of your inflammatory bowel disease and what might be due to an infection. Or in some cases, what might be due to stress, but not an activation of your inflammatory bowel disease.

Then we do have good treatments available. And many of these treatments are quite safe to start even when we’re worried about the pandemic going on. There’s guidance that we’ve now developed and we’re publishing that will give people some more information about which treatments to use and when to use them.

But the international group of experts said that if a patient has more severe inflammatory bowel disease, even during this pandemic, the usual treatments we use for IBD are safe and appropriate to be used in this setting. So it’s important to know that you shouldn’t ignore your IBD symptoms or any of your other digestive symptoms. You should be in touch with us so we can work together and get it back under control quickly. The last thing we want is for you to be living with these symptoms and afraid to notify us or afraid to come to the clinic if we need you to when, in fact, we could take care of you and get you better.

We know that there are a lot of inflammatory bowel disease patients who are working as essential workers right now and can’t be working from home, despite the recommendations for people to try to do so. It’s an important question to know whether these individuals should be taking time off of work or whether they should be doing other things to protect themselves above and beyond the usual recommendations. The way to think about this important question is first to know what the likelihood of exposure and contact with people who have COVID-19 is.

For example, those who are working as paramedics or some of the health care professionals doctors, nurses, technicians, respiratory therapists, pharmacists who are interacting with patients are right in front of many people who have COVID-19. They’re a high risk of exposure. And then there are others who are working but are not necessarily as exposed as often.

And the second question is the availability of personal protective equipment if there’s a shortage of PPEs such that the person who is going to be exposed to these patients can’t protect themselves, it is appropriate for them to ask for a leave or to get support from their doctor’s office to do so. It’s also important to know that if you have active and appropriate personal protective equipment, you can be working with patients, you can be doing a lot of your job as long as you’re also thoughtful about not touching your face, washing your hands very carefully, and making sure that you’re talking to your doctor and your doctor’s team to know that you’re in remission, and that your medications are being managed properly.

I know that this is stressful for many people who are in these situations, and it ends up being a case by case basis. But for many of them, we reassure them. We, of course, thank them for their vital role in helping us through this difficult time. And then we work with them so they understand how they can modify their risk or protect themselves better.

We’ve learned a bit about the coronavirus and COVID-19 in pregnant women. And it applies to pregnant patients who have IBD, as well. What we’ve learned so far is that when women who are pregnant develop COVID-19, they recover similar to the general population. And although their babies might be born a bit early or a little underweight, for the most part, the babies seem to do well. And in the early experiences that were reported, the babies did not have the coronavirus infection.

What we haven’t studied enough yet because of the timing of all this is, what happens if a woman who’s pregnant becomes infected with the coronavirus in the first trimester. The data we have from prior coronavirus epidemics and other types of infections suggests it might be OK. But because this is a novel coronavirus and it’s the first time we’ve seen this, we still need to be extra careful.

What we recommend to our patients who have IBD and are pregnant is that first, they make sure they’re staying in remission from their IBD. We definitely don’t want them to relapse because they stop their IBD therapies and then they need to be in a health care system or hospitalized and increase their risk. We also know that when IBD is in remission, the baby does well and the mother does well, so that’s important to keep in mind.

But we’re also recommending that our IBD patients who are pregnant take extra precautions for what we call strict social isolation. That might mean that in addition to staying home, you’re also restricting visitors in specific ways. And even when you need to go out to the grocery store, you wear a mask, you wear gloves, you take extra precautions, and wash your hands, as we’re recommending to everybody. But in this particular case, we’d like you to be extra careful. We don’t have data yet to say that there’s more to worry about, but we don’t want to find out later that we were wrong about this. So I think it’s completely reasonable to be on alert and to take those precautions.

I don’t say this to make people more stressed than they already are. I’m just trying to provide people with knowledge so that they can be empowered to take good care of themselves and to prevent any problems from happening.

Drinking baking soda could be an inexpensive, safe way to combat autoimmune disease — ScienceDaily

A daily dose of baking soda may help reduce the destructive inflammation of autoimmune diseases like rheumatoid arthritis, scientists say.

They have some of the first evidence of how the cheap, over-the-counter antacid can encourage our spleen to promote instead an anti-inflammatory environment that could be therapeutic in the face of inflammatory disease, Medical College of Georgia scientists report in the Journal of Immunology.

They have shown that when rats or healthy people drink a solution of baking soda, or sodium bicarbonate, it becomes a trigger for the stomach to make more acid to digest the next meal and for little-studied mesothelial cells sitting on the spleen to tell the fist-sized organ that there’s no need to mount a protective immune response.

“It’s most likely a hamburger not a bacterial infection,” is basically the message, says Dr. Paul O’Connor, renal physiologist in the MCG Department of Physiology at Augusta University and the study’s corresponding author.

Mesothelial cells line body cavities, like the one that contains our digestive tract, and they also cover the exterior of our organs to quite literally keep them from rubbing together. About a decade ago, it was found that these cells also provide another level of protection. They have little fingers, called microvilli, that sense the environment, and warn the organs they cover that there is an invader and an immune response is needed.

Drinking baking soda, the MCG scientists think, tells the spleen — which is part of the immune system, acts like a big blood filter and is where some white blood cells, like macrophages, are stored — to go easy on the immune response. “Certainly drinking bicarbonate affects the spleen and we think it’s through the mesothelial cells,” O’Connor says.

The conversation, which occurs with the help of the chemical messenger acetylcholine, appears to promote a landscape that shifts against inflammation, they report.

In the spleen, as well as the blood and kidneys, they found after drinking water with baking soda for two weeks, the population of immune cells called macrophages, shifted from primarily those that promote inflammation, called M1, to those that reduce it, called M2. Macrophages, perhaps best known for their ability to consume garbage in the body like debris from injured or dead cells, are early arrivers to a call for an immune response.

In the case of the lab animals, the problems were hypertension and chronic kidney disease, problems which got O’Connor’s lab thinking about baking soda.

One of the many functions of the kidneys is balancing important compounds like acid, potassium and sodium. With kidney disease, there is impaired kidney function and one of the resulting problems can be that the blood becomes too acidic, O’Connor says. Significant consequences can include increased risk of cardiovascular disease and osteoporosis.

“It sets the whole system up to fail basically,” O’Connor says. Clinical trials have shown that a daily dose of baking soda can not only reduce acidity but actually slow progression of the kidney disease, and it’s now a therapy offered to patients.

“We started thinking, how does baking soda slow progression of kidney disease?” O’Connor says.

That’s when the anti-inflammatory impact began to unfold as they saw reduced numbers of M1s and increased M2s in their kidney disease model after consuming the common compound.

When they looked at a rat model without actual kidney damage, they saw the same response. So the basic scientists worked with the investigators at MCG’s Georgia Prevention Institute to bring in healthy medical students who drank baking soda in a bottle of water and also had a similar response.

“The shift from inflammatory to an anti-inflammatory profile is happening everywhere,” O’Connor says. “We saw it in the kidneys, we saw it in the spleen, now we see it in the peripheral blood.”

The shifting landscape, he says, is likely due to increased conversion of some of the proinflammatory cells to anti-inflammatory ones coupled with actual production of more anti-inflammatory macrophages. The scientists also saw a shift in other immune cell types, like more regulatory T cells, which generally drive down the immune response and help keep the immune system from attacking our own tissues. That anti-inflammatory shift was sustained for at least four hours in humans and three days in rats.

The shift ties back to the mesothelial cells and their conversations with our spleen with the help of acetylcholine. Part of the new information about mesothelial cells is that they are neuron-like, but not neurons O’Connor is quick to clarify.

“We think the cholinergic (acetylcholine) signals that we know mediate this anti-inflammatory response aren’t coming directly from the vagal nerve innervating the spleen, but from the mesothelial cells that form these connections to the spleen,” O’Connor says.

In fact, when they cut the vagal nerve, a big cranial nerve that starts in the brain and reaches into the heart, lungs and gut to help control things like a constant heart rate and food digestion, it did not impact the mesothelial cells’ neuron-like behavior.

The affect, it appears, was more local because just touching the spleen did have an effect.

When they removed or even just moved the spleen, it broke the fragile mesothelial connections and the anti-inflammatory response was lost, O’Connor says. In fact, when they only slightly moved the spleen as might occur in surgery, the previously smooth covering of mesothelial cells became lumpier and changed colors.

“We think this helps explain the cholinergic (acetylcholine) anti-inflammatory response that people have been studying for a long time,” O’Connor says.

Studies are currently underway at other institutions that, much like vagal nerve stimulation for seizures, electrically stimulate the vagal nerve to tamp down the immune response in people with rheumatoid arthritis. While there is no known direct connection between the vagal nerve and the spleen — and O’Connor and his team looked again for one — the treatment also attenuates inflammation and disease severity in rheumatoid arthritis, researchers at the Feinstein Institute for Medical Research reported in 2016 in the journal Proceedings of the National Academy of Sciences.

O’Connor hopes drinking baking soda can one day produce similar results for people with autoimmune disease.

“You are not really turning anything off or on, you are just pushing it toward one side by giving an anti-inflammatory stimulus,” he says, in this case, away from harmful inflammation. “It’s potentially a really safe way to treat inflammatory disease.”

The spleen also got bigger with consuming baking soda, the scientists think because of the anti-inflammatory stimulus it produces. Infection also can increase spleen size and physicians often palpate the spleen when concerned about a big infection.

Other cells besides neurons are known to use the chemical communicator acetylcholine. Baking soda also interact with acidic ingredients like buttermilk and cocoa in cakes and other baked goods to help the batter expand and, along with heat from the oven, to rise. It can also help raise the pH in pools, is found in antacids and can help clean your teeth and tub.

The research was funded by the National Institutes of Health.

90,000 Indications and contraindications for treatment

Treatment in the Gorny sanatorium is indicated for diseases and disorders:

• Musculoskeletal system – rheumatic and infectious-allergic polyarthritis, spondylosis, osteochondropathy, osteoarthritis, osteochondrosis, scoliosis, intervertebral hernias, spinal surgery, back and limb injuries;
• Gastrointestinal tract – chronic cholecystitis, biliary dyskinesia, chronic gastritis and enterocolitis, gastric ulcer and 12 duodenal ulcer, chronic pancreatitis;
• Peripheral nervous system – neuralgia, neuritis, polyradiculitis, plexitis of traumatic and infectious origin, vertebrogenic diseases of the peripheral nervous system, as well as other diseases of the peripheral nervous system without exacerbation.

Contraindications:

• Cancer diseases.
• Pregnancy.
• Tuberculosis.
• Condition after surgery up to 6 months. Operations on the gastrointestinal tract no earlier than 1 year later, it is necessary to have a specialist opinion on the profile of the disease and discharge from the hospital.
• Acute viral hepatitis.
• Sexually transmitted diseases (syphilis, gonorrhea)
• Chronic viral hepatitis with a degree of activity – medium and high.
• Acquired immunodeficiency syndrome (HIV, AIDS)
• Addiction.
• Age over 70 years.
• Cardiovascular diseases: atrial fibrillation and any paroxysmal forms of cardiac arrhythmias; heart attacks; circulatory insufficiency of the III-IV stage, uncontrolled arterial hypertension, crisis course of hypertension, cardiomyopathy, complete atrioventricular block with a heart rate of less than 50 in 1 min, the presence of Morgagni-Edams-Stokes attacks.
• Diseases of the musculoskeletal system and the nervous system: any diseases limiting the patient’s self-care and independent movement, cerebrovascular accidents – strokes, seizures and their equivalents; psychopathy, epilepsy, manic-depressive syndrome and other diseases requiring psychiatric control and constant medication. As well as multiple sclerosis, amyotrophic lateral sclerosis, Alzheimer’s disease, myopathies.
• Diseases of the respiratory system: all diseases in the acute period; onset period of bronchial asthma; respiratory failure 3 tbsp.;
• Diseases of the digestive system: all diseases of the gastrointestinal tract during an exacerbation; cirrhosis of the liver, liver failure; autoimmune hepatitis, ulcerative colitis, intestinal diverticulitis.
• Diseases of the endocrine system: type 2 diabetes mellitus on insulin decompensated, type 1 diabetes mellitus insulin-dependent decompensated (ketoacidosis), diffuse toxic goiter (hyperthyroidism).
• Diseases of the urinary system: chronic renal failure, acute and chronic glomerulonephritis.
• Hematological diseases: leukemia, lymphogranulomatosis, hemophilia, T-cell lymphoma, multiple myeloma, moderate and severe anemia.
• Diseases of the rectum.

90,000 ⚕ Which doctor treats the intestines: who to contact ❓

Colonists

If you have problems with the intestines, the doctor therapist prescribes a number of mandatory tests: a general blood and urine test, a biochemical blood test, an immunochemical analysis of feces for occult blood, a coprogram.To clarify the diagnosis, X-ray, ultrasound, MRI, endoscopy can be prescribed.

Based on the clinical manifestations, the etiology of the disease and the analyzes obtained, the therapist gives a referral to one of the doctors specializing in the characteristics of certain pathologies. To exclude diseases of the urinary system and pathologies of the pelvic organs, consultations with a urologist, gynecologist, venereologist are appointed.

Enterology is a science that studies the normal anatomical and physiological structure of the digestive system and gastrointestinal tract, gastroenterologist – “chief” specialist in diseases of the stomach and intestines.The competence of a gastroenterologist includes the treatment of not only intestinal diseases, but also other organs that ensure the functioning of the digestive system – the stomach, pancreas, liver and gallbladder.

The main method of examination by a gastroenterologist is endoscopic (fibrogastroduodenoscopy, colonoscopy, sigmoidoscopy). As a rule, endoscopy is performed simultaneously with a biopsy (taking pieces of tissue from the mucous membranes for further histological examination).Based on the results of this examination, the gastroenterologist can refer the patient to an oncologist for further treatment.

Physician- Oncologist diagnoses and treats precancerous conditions, benign and malignant neoplasms of the gastrointestinal tract, carries out prevention of tumor spread.

Colon cancer (colorectal cancer) is the most common colon cancer. Colon cancer does not have a specific clinical picture and, as a rule, does not manifest itself in any way until stage 3-4, which is fraught with extremely serious consequences.With an operable colon tumor, surgeon -oncologist performs an operation to excision it. Also, oncologists treat hereditary non-polyposis colon cancer, non-epithelial colon tumors, colon cancer, rectum cancer, and anal canal cancer.

Proctologist diagnoses and treats diseases of the large intestine. The most common functional disorder of the colon is irritable bowel syndrome.

90,000 《Autoimmune hemolytic anemia》 (Hematology) – treatment abroad in the world’s best clinics

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Acibadem Group of Clinics

Turkey, Istanbul

The ADJIBADEM network of clinics has been a leader in the field of private medicine in Turkey since 1991. We offer a wide range of services for the diagnosis and treatment of diseases in all medical areas through advanced medical technologies, a highly professional team of specialists, reliable infrastructure and high medical standards confirmed by JCI *.

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Apollo Clinics Group

India, Hyderabad

Throughout its history, the Apollo Hospital Network has affected the lives of more than 45 million patients from 121 countries. The group, which originally consisted of one 150-bed hospital, is now recognized as a pioneer in private healthcare in India, with over 10,000 beds in 64 hospitals, over 2,200 pharmacies, 100 first aid and diagnostic centers, 115 centers telemedicine in 9 countries, health insurance services, consulting global projects, 15 academic institutions and a research center with research in epidemiology, stem cells and genetics.Today, the Apollo Hospitals brand is known not only as a hospitals but also as an integrated healthcare provider in Asia, being a specialist in clinic, pharmacy, insurance and holistic therapy consulting.

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Group of Clinics Memorial

Turkey, Istanbul

Memorial Hospital has been receiving patients since 2000. Memorial is constantly improving the quality of the services provided and, thanks to this, has taken an important place among the best medical institutions in the world.Memorial is the first hospital in Turkey and the 21st in the world to receive the JCI (Joint Commission International) accreditation certificate. In 2005, Memorial became the first hospital in Turkey to renew its accreditation. Also, the hospital received TSE and ISO 9001 quality certificates.

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Medical Center Interbalkan

Greece, Thessaloniki

Medical Center “Interbalkan” is one of the largest and most modern clinics in Europe.It is part of the “Athens Medical Group” – the largest association for the provision of quality medical services in Greece. Located in the city of Thessaloniki, 5 minutes from Macedonia Airport. Interbalkan provides medical services based on the latest developments and achievements in all branches of medicine.

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Fortis Clinic Group

India, Gurgaon

Fortis Healthcare Limited is a leading provider of Integrated Healthcare Services in India.The company’s healthcare verticals mainly include specialized facilities – hospitals, diagnostic centers and outpatient care. The company currently provides medical services in India, Dubai, Mauritius and Sri Lanka and operates 54 medical facilities with about 10,000 beds and 314 diagnostic centers.
In a worldwide survey of the 30 most technologically advanced hospitals in the world, the Fortis Memorial Research Institute (FMRI), the flagship of the Fortis Group, was ranked 2nd (according to ”topmastersinhealthcare.com ”), leaving behind many other prominent medical institutions in the world.

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Bremen Mitte Clinic

Germany, Bremen

Klinikum Bremen Mitte is one of the largest and oldest clinics in Northern Germany. It is part of the Nord Klinik Allianz and is located in the picturesque part of the old city of Bremen. The guarantee of optimal diagnosis and treatment is the modern medical technology we use and the highly qualified specialists who work for us.We have ample opportunities for making a diagnosis and drawing up a treatment plan, as well as performing surgical operations of any degree of complexity, in accordance with German quality standards.

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University Hospital Freiburg

Germany, Freiburg

Welcome to one of the largest medical institutions in Europe! The # 1 choice for foreign patients in Germany! University ClinicFreiburg is one of the three largest in the country. The clinic is famous for its rich history and is one of the oldest and most respected medical institutions in Germany. The clinic was founded on the basis of the Faculty of Medicine of the Albert Ludwig University of Freiburg, which celebrated its 555th anniversary in 2012. Over the years, many outstanding doctors worked and taught in it, 4 of whom became Nobel Prize winners. The clinic is part of the University of Freiburg, which was awarded the title of “elite university” in Germany.The clinic includes 14 specialized clinics, numerous institutes and centers.

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Group of clinics Nord Allianz

Germany, Bremen

Nord Klinik Allianz is a united network of the largest clinics in Northern Germany, whose doctors are ready to help you at any moment. The alliance includes four clinics: Klinikum Bremen Mitte, Klinikum Bremen Ost, Klinikum Bremen Nord and Klinikum Links der Weser, located in a picturesque part of old Bremen.More than 250,000 patients are treated in our clinics every year. The guarantee of optimal diagnosis and treatment is the modern medical technology we use and the highly qualified specialists who work for us. We have ample opportunities for making a diagnosis and drawing up a treatment plan, as well as performing surgical operations of any degree of complexity, in accordance with German quality standards. On this page you will find detailed information about our clinics, areas of activity, doctors, the organization of remote consultations, as well as the organization of treatment for foreign patients.Your health is our priority.

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Anadolu Medical Center

Turkey, Gebze

Working in a strategic partnership with Johns Hopkins Medical Center, Anadolu Foundation has established a modern hospital in Istanbul that has received international recognition. The staff of the Anadolu Medical Center has an ongoing opportunity to organize consultations with the specialists of the Johns Hopkins Medical Center to provide a “second medical opinion” and conduct teleconferences.The area of ​​strategic collaboration with Johns Hopkins Medical Center covers the following areas of activity: clinical and operational programs, medical engineering and technology, information processing applications, human resources and work quality management, treatment quality management, implementation of clinical protocols for health standardization and risk management …

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Soroca Medical Center

Israel, Beer Sheva

The Israeli State Hospital Soroka is a university medical center owned by the Clalit Health Insurance Fund.It is a leading medical center providing exceptional quality medical services, individually tailored to each individual patient, and an example in the field of teaching and medical research. Soroka Medical Center is the holder of the highest quality certificate – JCI accreditation – a strict standard for the quality and safety of medical services of the international organization JCI, which is the world standard for the level of quality and safety in the field of healthcare.

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Assessment of Abdominal Pain in Children – Etiology

Differential diagnosis of abdominal pain in children is extensive and covers almost all organ systems. In addition, in children it can be especially difficult to distinguish acute from chronic abdominal pain. Although the most common etiologies are not directly life-threatening, the first priority is to be able to diagnose an emergency. A detailed history and physical examination, as well as an understanding of the most common conditions affecting the appropriate age group of children, are essential.

Gastrointestinal

The most common sources of the gastrointestinal tract (GI tract) are the cause of abdominal pain in children, encompassing infectious, congenital and mechanical causes.

Constipation

• Common disease with a total prevalence of 9.5% [1] Koppen IJ, Vriesman MH, Saps M, et al. Prevalence of functional defecation disorders in children: a systematic review and meta-analysis. J Pediatr. 2018 Jul; 198: 121-30.e6.
  http://www.ncbi.nlm.nih.gov/pubmed/29656863?tool=bestpractice.com

• Childhood constipation is typically characterized by infrequent bowel movements, large bowel movements, and difficult or painful bowel movements [2] Nurko S, Zimmerman LA. Evaluation and treatment of constipation in children and adolescents. Am Fam Physician. 2014 Jul 15; 90 (2): 82-90.
  https://www.aafp.org/afp/2014/0715/p82.html

  http://www.ncbi.nlm.nih.gov/pubmed/25077577?tool=bestpractice.com

• Symptoms usually arise from a diet that is depleted in fiber and nutrients, as well as low water intake, which leads to significant reabsorption of water in the large intestine and thickening of feces. Additional risk factors include family history, infection, stress, obesity, low birth weight, cerebral palsy, spina bifida, and developmental delay.

• Constipation begins acutely, but can progress to coprostasis and chronic constipation.

• It can develop in three stages of childhood: weaning (younger children), potty training (preschool age), beginning school attendance (older children).

Appendicitis

• Occurs when the lumen of the appendix is ​​blocked by feces, barium suspension, food, or parasites.

• May affect all age groups, but rarely in young children. 2.5% of children suffered from appendicitis by the age of 18, according to a cohort study from Sweden.[3] Omling E, Salö M, Saluja S, et al. Nationwide study of appendicitis in children. Br J Surg. 2019 Nov; 106 (12): 1623-31.
  https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11298

  http://www.ncbi.nlm.nih.gov/pubmed/31386195?tool=bestpractice.com

• Without treatment, acute appendicitis progresses to ischemia, necrosis, and ultimately perforation. The overall perforation rate is up to 30%. [4] Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management.Pediatric Health Med Ther. 2018 Oct 26; 9: 135-45.
  https://www.dovepress.com/perforation-risk-in-pediatric-appendicitis-assessment-and-management-peer-reviewed-fulltext-article-PHMT

  http://www.ncbi.nlm.nih.gov/pubmed/30464677?tool=bestpractice.com
  The risk of perforation increases if appendectomy is delayed. [5] Papandria D, Goldstein SD, Rhee D, et al. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res. 2013 Oct; 184 (2): 723-9.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4398569/

  http://www.ncbi.nlm.nih.gov/pubmed/232

  ?tool=bestpractice.com
  [Figure caption and citation for the preceding image starts]: Necrotized appendix From the collection of Dr. KuoJen Tsao; used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: CT shows coprolite (white arrow) outside the lumen of the appendix corresponding to perforation of the appendix From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

Gastroenteritis

• May be caused by acute or chronic viral infection (especially rotavirus), as well as bacterial or parasitic infection.

• Also causes vague cramping abdominal pains in combination with fever, vomiting and diarrhea.

• Eosinophilic gastroenteritis, defined as a condition of eosinophilic inflammation of the GI tract, occurs with no known cause for eosinophilia and can lead to severe abdominal pain.[6] Sunkara T, Rawla P, Yarlagadda KS, et al. Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clin Exp Gastroenterol. 2019 Jun 5; 12: 239-53.
  https://www.dovepress.com/eosinophilic-gastroenteritis-diagnosis-and-clinical-perspectives-peer-reviewed-fulltext-article-CEG

  http://www.ncbi.nlm.nih.gov/pubmed/31239747?tool=bestpractice.com

• Hemolytic uremic syndrome, characterized by microangiopathic hemolytic anemia, thrombocytopenia and nephropathy, may be a complication of gastroenteritis caused by verotoxin-producing Escherichia coli.Abdominal pain is a common symptom. [7] Salvadori M, Bertoni E. Update on hemolytic uremic syndrome: diagnostic and therapeutic recommendations. World J Nephrol. 2013 Aug 6; 2 (3): 56-76.
  https://www.wjgnet.com/2220-6124/full/v2/i3/56.htm

  http://www.ncbi.nlm.nih.gov/pubmed/24255888?tool=bestpractice.com

Intussusception

• Occurs when the proximal segment of the intestine fits into the lumen of the next distal segment.In most cases, intussusception occurs in the ileocecal area. [Figure caption and citation for the preceding image starts]: Intussusception: blood vessels are pinched between the layers of the intestine, resulting in decreased blood supply, edema, bowel obstruction and gangrene. Eventually sepsis, shock and death can occur. Created by BMJ Education Center [Citation ends].

• Usually occurs in infants 3–12 months of age. The largest number of cases are recorded at the age of 5-7 months.[8] Jiang J, Jiang B, Parashar U, et al. Childhood intussusception: a literature review. PLoS One. 2013; 8 (7): e68482.
  https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0068482

  http://www.ncbi.nlm.nih.gov/pubmed/23894308?tool=bestpractice.com

• In infants of this age group with colic-type abdominal pain, flexion of the lower limbs, fever, drowsiness and vomiting, intussusception should be suspected.

• In infants <2 years of age, episodes of intussusception are most likely due to mesenteric lymphadenopathy associated with a concurrent illness (eg, viral gastroenteritis).In older children, mesenteric lymphadenopathy is also the most likely cause, but a different etiology should be considered (eg, intestinal lymphomas, Meckel's diverticulum). Thus, in children ≥6 years of age with jejuno-jejunal or ileo-ileal intussusception, the head of the intussusception should be assessed for malignancy.

• Ileo-ileal intussusception may also indicate Schönlein-Henoch purpura (PSHG). PSHG is a small vein vasculitis that mainly occurs in children <11 years of age.

Meckel’s diverticulum

• The finger-like outgrowth located in the distal ileum departs from the free edge of the intestine; usually 40-60 cm from the ileocecal valve, 1 to 10 cm long and 2 cm wide. [Figure caption and citation for the preceding image starts]: Intraoperative photo of Meckel’s diverticulum From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

• Most symptomatic patients are children under 2 years of age.

• The prevalence is estimated to be up to 3%. [9] Hansen CC, Søreide K. Systematic review of epidemiology, presentation, and management of Meckel’s diverticulum in the 21st century. Medicine (Baltimore). 2018 Aug; 97 (35): e12154.
  https://journals.lww.com/md-journal/Fulltext/2018/08310/Systematic_review_of_epidemiology,_presentation,.91.aspx

  http://www.ncbi.nlm.nih.gov/pubmed/30170459?tool=bestpractice.com

• Intestinal obstruction is a well-known complication and can occur in about 40% of symptomatic patients with Meckel diverticulum (according to some descriptions).[10] Elsayes KM, Menias CO, Harvin HJ, et al. Imaging manifestations of Meckel’s diverticulum. AJR Am J Roentgenol. 2007 Jul; 189 (1): 81-8.
  https://www.ajronline.org/doi/full/10.2214/AJR.06.1257

  http://www.ncbi.nlm.nih.gov/pubmed/17579156?tool=bestpractice.com
  [11] Lin XK, Huang XZ, Bao XZ, et al. Clinical characteristics of Meckel diverticulum in children: a retrospective review of a 15-year single-center experience. Medicine (Baltimore). 2017 Aug; 96 (32): e7760.
  https: // journals.lww.com/md-journal/Fulltext/2017/08110/Clinical_characteristics_of_Meckel_diverticulum_in.43.aspx

  http://www.ncbi.nlm.nih.gov/pubmed/28796070?tool=bestpractice.com

Mesenteric adenitis

• Refers to inflammation of the mesenteric lymph nodes This process can be acute or chronic.

• It is often confused with other diagnoses such as appendicitis; nonspecific mesenteric adenitis was found in almost 23% of patients undergoing negative appendectomy.[12] Karabulut R, Sonmez K, Turkyilmaz Z, et al. Negative appendectomy experience in children. Ir J Med Sci. 2011 Mar; 180 (1): 55-8.
  http://www.ncbi.nlm.nih.gov/pubmed/20658324?tool=bestpractice.com

• One retrospective study showed that, compared with children with appendicitis, patients with mesenteric adenitis were more likely to have fever (> 39 ℃) and dysuria and were less likely to experience migratory pain, vomiting, or typical abdominal appendicitis on examination.[13] Gross I, Siedner-Weintraub Y, Stibbe S, et al. Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children. Eur J Pediatr. 2017 Feb; 176 (2): 199-205.
  http://www.ncbi.nlm.nih.gov/pubmed/27987102?tool=bestpractice.com

Hirschsprung’s disease

• Most often diagnosed during the first year of life, but may appear later in childhood; somewhat more often observed in males.

• A congenital condition characterized by partial or complete intestinal obstruction due to the absence of intramural gangliocytes.Due to agangliosis, the lumen is tonically reduced, which leads to functional obstruction. The aganglionic part of the large intestine is always distal, but the segment length varies. [Figure caption and citation for the preceding image starts]: Radiography of the abdomen of a newborn with abnormal stool and constipation. Dilatation of the transverse and descending colon indicates Hirschsprung’s disease From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

• May be combined with Down syndrome and type IIA multiple endocrine neoplasia.

Intestinal obstruction

• Obstruction of the small or large intestine can have a different etiology and occur at any age. Abdominal pain may not occur until the obstruction progresses to excessive bloating or bowel ischemia. Intestinal obstruction can mimic intestinal ileus, which usually does not require surgery.

• Etiological factors of intestinal obstruction can be congenital or acquired. Congenital factors include atresia or stenosis, which manifests itself during the neonatal period. Acquired causes of intestinal obstruction include small bowel adhesions, strangulated hernias, or tumors.

• Congenital causes:

  • Atresia or stenosis of the duodenum can cause complete or partial obstruction of the duodenum as a result of impaired recanalization during development.This results in either stenosis with incomplete obstruction of the duodenal lumen (allowing a certain amount of gas and fluid to pass through, but not all) or atresia, where the duodenum ends blindly, resulting in true complete obstruction.

  • Jejunoileal atresia or stenosis is a complete or partial obstruction of any part of the jejunum or ileum. Although it is not known for sure, it is believed to result from a vascular disorder during development.With stenosis of the jejunum, the continuity of the intestinal lumen may persist, however, with a narrowing of the lumen and thickening of the muscle layer. There are four types of intestinal atresia, and all of them lead to complete obstruction due to the fact that the lumen ends blindly.

  • Hernias can be internal or external, congenital or acquired.

  • Colon atresia is an extremely rare complete obstruction of any part of the large intestine, although it usually occurs in the area of ​​the splenic angle.Like jejuno-ileal atresia, it is believed to result from a vascular disorder. [Figure caption and citation for the preceding image starts]: On x-ray of the abdomen, two gas bubbles are observed corresponding to duodenal atresia From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

  • Meconium ileus is an important cause of intestinal obstruction during the neonatal period; suspect cystic fibrosis as a co-morbidity.Concomitant diseases of the pancreas may also be present.

  • Duplicate cysts most often form in the small intestine; they can become the head of the intussusception during volvulus and intussusception, and cause obstruction. With ectopia of the gastric mucosa, duplication cysts of the duodenum, peptic ulcer disease, bleeding or perforation may occur for the second time.

• Acquired causes:

  • Can manifest at any age.

  • Tumors can be located in the intestinal lumen or located extraintestinal.

  • Hernias can be internal or external, congenital or acquired. [Figure caption and citation for the preceding image starts]: Child with a protrusion in the right groin corresponding to a strangulated inguinal hernia Absence of edema and erythema of the skin overlying the mass does not exclude strangulation of the small intestine From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

  • Previous abdominal surgery or a history of inflammation (such as necrotizing enterocolitis) should suggest adhesions in the small intestine.

  • Omental cysts, although rare, may present with intestinal obstruction; on ultrasound, they can be confused with ovarian cysts.

  • In patients with cystic fibrosis, partial bowel obstruction can sometimes be attributed to distal intestinal obstruction syndrome (DIOS), or be the equivalent of meconium ileus.This category is not related to meconium. This concerns the distal obstruction of the small intestine caused by the compacted contents of the intestine; it typically occurs in adolescents and adults with cystic fibrosis.

Volvulus

• May occur in any age group, but is most common in children under 1 year of age; in at least 60% of children it manifests itself before the age of 1 month. [14] Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children.BMJ. 2013 Nov 26; 347: f6949.
  http://www.ncbi.nlm.nih.gov/pubmed/24285798?tool=bestpractice.com
  The most common type is midgut strangulation. Strangulation of the sigmoid colon may also occur.

• Green (bilious) vomiting is the main symptom of duodenal obstruction with midgut volvulus. [14] Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children. BMJ. 2013 Nov 26; 347: f6949.http://www.ncbi.nlm.nih.gov/pubmed/24285798?tool=bestpractice.com

• Incomplete bowel turn is a term that encompassed a range of anatomical relationships resulting from incomplete bowel turn during embryonic development. Volvulus of the entire small intestine and part of the large intestine is possible only if malrotation is present.

• In malrotation, the most significant pathological features are the lack of fixation of the intestine in the retroperitoneal space and the narrow base of the mesentery of the midgut, which predisposes patients to midgut volvulus, which occurs when the duodenum or colon rotates around the base of the mesentery.

Necrotizing enterocolitis

• The disease mainly affects premature infants, especially those weighing less than 1500 g. The pathogenesis is multifactorial and not fully understood, but ischemia, impaired reperfusion, and infectious pathogens play a role.

• Typical symptoms are food intolerance, bloating and bloody diarrhea at 8-10 days of age [15] Neu J, Walker WA. Necrotizing enterocolitis. N Engl J Med.2011 Jan 20; 364 (3): 255-64.
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628622/

  http://www.ncbi.nlm.nih.gov/pubmed/21247316?tool=bestpractice.com
  Other signs and symptoms include apnea, lethargy, abdominal tenderness, abdominal wall erythema, and bradycardia.

Peptic ulcer

• Stomach and esophageal ulcers are not common in the pediatric population [16] Sullivan PB. Symposium: gastroenterology. Peptic ulcer disease in children.Paediatr Child Health. 2010 Oct; 20 (10): 462-4.
  https://www.paediatricsandchildhealthjournal.co.uk/article/S1751-7222(10)00093-4/abstract
  If they do occur, they are classified as primary or secondary peptic ulcers.

• Primary ulcers occur without provoking factors and are often located in the duodenum or pyloric canal. They most often occur in older children and adolescents with a positive family history. Rarely, primary ulcers may occur during the first months of life and present with bleeding and possible perforation.Most of them are located in the stomach. Primary ulcers may be associated with Helicobacter pylori.

• Secondary ulcers are commonly associated with stress, burns, trauma, infection, neonatal hypoxia, chronic illness, and use of ulcerogenic drugs or lifestyle choices (eg NSAIDs, corticosteroids, smoking, caffeine, nicotine, or alcohol use). It is important to treat a condition that may be contributing to the onset of the disease. Exacerbations and remissions can last from several weeks to months.

Inflammatory Bowel Disease

• This category includes ulcerative colitis and Crohn’s disease.

• Ulcerative colitis affects the rectum and spreads proximally, and is also characterized by diffuse inflammation of the colon mucosa and a course with relapses and remissions. Ulcerative colitis is rare in people younger than 10 years old.

• Crohn’s disease can affect any part of the gastrointestinal tract from the mouth to the perianal region.Unlike ulcerative colitis, Crohn’s disease is characterized by segmental lesions. Transmural inflammation often leads to fibrosis, causing intestinal obstruction. Inflammation can also lead to the formation of fistulous ducts, which pass through and penetrate the serous membrane, thus causing the appearance of perforations and fistulas. The peak of the manifestation of the disease falls on the age interval of 15-40 years.

• Ulcerative colitis often presents with bloody diarrhea, which is not common in Crohn’s disease.Both diseases, if present late, cause abdominal cramping, anorexia, and weight loss. Depending on how Crohn’s disease affects an area of ​​the intestine, it can mimic other diseases such as acute appendicitis.

Celiac disease

• A systemic autoimmune disease caused by dietary peptides of gluten found in wheat, rye, barley and related grains.

• Immune activation in the small intestine leads to villous atrophy, hypertrophy of intestinal folds and an increase in the number of lymphocytes in the epithelium and lamina propria.Locally, these changes lead to GI symptoms and malabsorption.

• Celiac disease is common in the United States and Europe. Relatively uniform prevalence was found in many countries, with an overall global seroprevalence and biopsy-proven prevalence of 1.4% and 0.7%, respectively. [17] Singh P, Arora A, Strand TA, et al. Global prevalence of celiac disease: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018 Jun; 16 (6): 823-36.e2.
  https://www.cghjournal.org/article/S1542-3565(17)30783-8/fulltext

  http://www.ncbi.nlm.nih.gov/pubmed/29551598?tool=bestpractice.com

• Patients may present with recurrent abdominal pain, cramps, or bloating. [18] National Institute for Health and Care Excellence. Celiac disease: recognition, assessment and management. Sep 2015 [internet publication].
  https://www.nice.org.uk/guidance/ng20
  Other common symptoms include bloating and diarrhea.Dermatosis herpetiformis, a characteristic rash with severe itching that affects the surfaces of the extensors of the extremities, almost always occurs in conjunction with celiac disease.

Gallstone disease / cholecystitis

• Gallstone disease is described as the presence of gallstones (usually asymptomatic or found incidentally). Biliary colic follows the classic description of intermittent, recurrent right upper quadrant (RHC) pain that resolves without intervention.It is usually caused by intermittent obstruction of the gallbladder duct due to cholelithiasis and contraction of the enlarged gallbladder. [Figure caption and citation for the preceding image starts]: Ultrasound examination of the gallbladder showing characteristic dimming cholelithiasis From the collection of Dr. KuoJen Tsao; used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Radiography of the abdomen with opacities in the right upper quadrant corresponding to gallstones From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

• Cholecystitis corresponds to inflammation of the gallbladder, provoked by obstruction of the exit of bile from the gallbladder duct. Symptoms usually do not resolve spontaneously, and specific signs are observed on diagnostic imaging. Cholecystitis may be without stones or may be calculous (with stones). The term choledocholithiasis describes the presence of gallstone (s) in the common bile duct.

Biliary dyskinesia

• Characterized by symptoms of biliary colic (intermittent, recurrent right upper quadrant (RHC) pain that stops without intervention) in the absence of evidence of gallstones; the diagnosis should be suspected in individuals with symptoms suggestive of biliary colic but negative laboratory and ultrasound findings during evaluation for symptomatic cholelithiasis.

• Caused by abnormal or abnormal contraction of the gallbladder, resulting in biliary colic. Patients often undergo a comprehensive clinical examination before they are diagnosed; an increase in the detection and investigation of this disease has led to a more frequent diagnosis in children.

Viral hepatitis

• Viral hepatitis includes A, B, C, D, and E.

• Hepatitis A virus remains an important etiological factor in the development of acute viral hepatitis and jaundice, especially in developing countries, among travelers to these countries and sporadic food outbreaks in developed countries.

• Hepatitis B virus frequently causes acute hepatitis and is the most common cause of chronic hepatitis in Africa and the Far East.

• Hepatitis C Virus (HCV) is the leading cause of chronic viral hepatitis in developed countries.

• Hepatitis D virus is a defective virus that requires the presence of the hepatitis B virus in order to cause clinically manifest illness.

• The hepatitis E virus causes high mortality in developing countries, especially among pregnant women.

Acute pancreatitis

• Indicates inflammation of the pancreas; does not necessarily mean an infection.

• Pancreatitis in children is often due to drugs, infection, anatomical abnormalities or trauma. [19] Suzuki M, Sai JK, Shimizu T. Acute pancreatitis in children and adolescents. World J Gastrointest Pathophysiol. 2014 Nov 15; 5 (4): 416-26.
  https://www.wjgnet.com/2150-5330/full/v5/i4/416.htm

  http: // www.ncbi.nlm.nih.gov/pubmed/25400985?tool=bestpractice.com
  Corticosteroids, adrenocorticotropic hormones, contraceptives containing estrogens, adrenocorticotropic, asparaginase, tetracycline, chlorothiasis, valproic acid can cause pancreatitis. Congenital causes involve a common bile duct cyst that results in abnormal drainage of pancreatic secretions and bile and division of the pancreas. Infectious causes include mumps and infectious mononucleosis.

• Excessive alcohol consumption and gallstones are the most common causes of pancreatitis in adults and are relatively less common in children, although they can be observed.Pancreatitis in childhood is rare, but an increase in the population of children with gallstones is likely to increase its frequency in the future. [Figure caption and citation for the preceding image starts]: CT of an adolescent girl with pain in the mesogastric region due to biliary pancreatitis. Significant accumulation of fluid in the area of ​​the pancreatic bed (white arrow) and the absence of contrasting of the pancreas indicates colliquation necrosis of the pancreas From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

Spleen infarction and cysts

• Cysts are classified into primary and secondary (acquired). Primary cysts are usually congenital and have a true epithelial lining. Eighty percent of spleen cysts are pseudocysts associated with infection, heart attack, or trauma. [20] Burgener FA, Meyers SP, Tan RK, et al. Differential diagnosis in magnetic resonance imaging. New York: Thieme; 2002: 530. Most cysts are diagnosed incidentally, although some patients complain of dull pain in the left abdomen.In pediatric patients, the most common splenic neoplasms are congenital and / or acquired cysts. [21] Aslam S, Sohaib A, Reznek RH. Reticuloendothelial disorders: the spleen. In: Adam A, Dixon A, eds. Grainger and Allison’s Diagnostic radiology. 5th ed. Philadelphia: Churchill Livingstone; 2008: 1759-70. [Figure caption and citation for the preceding image starts]: CT showing fluid-filled spleen cysts From the collection of Dr. KuoJen Tsao; used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Intraoperative photo of a large splenic cyst From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

• Splenic infarction occurs when the blood vessels of the spleen are occluded. It can affect an entire organ or only part of the spleen, depending on the blood vessels that are affected. The incidence of splenic infarction is difficult to estimate.

Abdominal trauma

• A multicenter prospective study found that abdominal trauma accounted for 3% of admissions to pediatric trauma departments.[22] Bradshaw CJ, Bandi AS, Muktar Z, et al. International study of the epidemiology of pediatric trauma: PAPSA Research Study. World J Surg. 2018 Jun; 42 (6): 1885-94.
  https://link.springer.com/article/10.1007%2Fs00268-017-4396-6

  http://www.ncbi.nlm.nih.gov/pubmed/29282513?tool=bestpractice.com

• They are generally classified as penetrating or blunt. Closed blunt trauma to the abdomen should always be suspected in the setting of an unclear or conflicting history.The liver, spleen, and kidneys are abdominal organs that are most often damaged by blunt trauma. Most cases of blunt trauma to the liver and spleen are treated conservatively.

• It is important to exclude damage to the duodenum and / or pancreas from injuries to the cyclist and / or direct impact to the abdomen. Injury to hollow organs (such as the stomach and intestines) is more common with penetrating trauma.

• It is important to consider the possibility of child abuse / deliberate injury (eg, a blow to the stomach).

Genitourinary

Urinary tract infection (UTI)

• Infection can occur anywhere in the urinary tract, including the urethra, bladder, ureters, and kidneys. Diagnosis and treatment are extremely important to prevent potential delayed side effects, including kidney or urinary tract fibrosis and hypertension.

• Indicators of the true frequency of UTI depend on the indicators of diagnosis and research.UTIs most commonly affect girls. UTIs affect approximately 4% and 10% of children aged 1 and 6 years, respectively. [23] Ladomenou F, Bitsori M, Galanakis E. Incidence and morbidity of urinary tract infection in a prospective cohort of children. Acta Paediatr. 2015 Jul; 104 (7): e324-9.
  http://www.ncbi.nlm.nih.gov/pubmed/25736706?tool=bestpractice.com

• The most common cause is bacterial infections, in particular Escherichia coli.

Primary dysmenorrhea

• Dysmenorrhea, or painful menstruation, is one of the most common gynecological diseases affecting women of reproductive age.[24] De Sanctis V, Soliman A, Bernasconi S, et al. Primary dysmenorrhea in adolescents: prevalence, impact and recent knowledge. Pediatr Endocrinol Rev. 2015 Dec; 13 (2): 512-20.
  http://www.ncbi.nlm.nih.gov/pubmed/26841639?tool=bestpractice.com

• Primary dysmenorrhea is characterized by menstrual pain in the absence of pelvic pathology.

Nephrolithiasis (urolithiasis)

• Indicates the presence of stones that can be found in any area of ​​the genitourinary tract; most often stones are found in the kidneys, then in the bladder and ureters.

• Most patients have a provoking factor such as a family history of nephrolithiasis, a high-risk diet (eg, increased oxalate intake), or a chronic illness (eg, renal tubular acidosis).

• Stones less than 5 mm in diameter usually come out spontaneously.

Testicular torsion

• Urological emergency causes testicular torsion around the spermatic cord, resulting in vasoconstriction and time-dependent ischemia and / or testicular necrosis.[25] Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15; 88 (12): 835-40.
  https://www.aafp.org/afp/2013/1215/p835.html

  http://www.ncbi.nlm.nih.gov/pubmed/24364548?tool=bestpractice.com
  [Figure caption and citation for the preceding image starts]: Boy with pain in right testicle. Testicle swollen, painful and erythematous as a result of torsion of testicular hydatids. Clinical signs and symptoms resemble those of testicular torsion From the collection of Dr. KuoJen Tsao; used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Boy with swelling, soreness and redness of left testicle. The testicle is retracted, indicating testicular torsion From the collection of Dr. KuoJen Tsao; used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Torsion of testicular hydatids leading to acute infarction From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

• Has a bimodal distribution with extravaginal torsion affecting neonates in the perinatal period, and intravaginal torsion affecting men of any age, but most often adolescents. [25] Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15; 88 (12): 835-40.
  https://www.aafp.org/afp/2013/1215/p835.html

  http://www.ncbi.nlm.nih.gov/pubmed/24364548?tool=bestpractice.com

• Pain from torsion of the epididymis can develop more gradually (over days or weeks) and is often punctate (upper pole of the testicles). In addition, systemic symptoms such as nausea and vomiting are usually absent.

Ovarian cyst rupture

• Ovarian cyst rupture is rare and can occur with ovarian torsion.

• Symptoms usually occur before expected ovulation and may resemble those of a ruptured ectopic pregnancy.Pain arises from local peritonitis with hemorrhage. [26] Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, et al., Eds. Comprehensive gynecology. Philadelphia: Mosby; 2007: Chap. 18. [27] Boyle KJ, Torrealday S. Benign gynecologic conditions. Surg Clin North Am. 2008 Apr; 88 (2): 245-64.
  http://www.ncbi.nlm.nih.gov/pubmed/18381112?tool=bestpractice.com
  [28] Schultz KA, Ness KK, Nagarajan R, et al. Adnexal masses in infancy and childhood.Clin Obstet Gynecol. 2006 Sep; 49 (3): 464-79.
  http://www.ncbi.nlm.nih.gov/pubmed/16885654?tool=bestpractice.com

Ovarian torsion

• Although it can occur in women of any age, it most often occurs during early reproductive age. [29] Emeksiz HC, Derinöz O, Akkoyun EB, et al. Age-specific frequencies and characteristics of ovarian cysts in children and adolescents. J Clin Res Pediatr Endocrinol. 2017 Mar 1; 9 (1): 58-62.
  http: // cms.galenos.com.tr/Uploads/Article_15636/58-62.pdf

  http://www.ncbi.nlm.nih.gov/pubmed/28044991?tool=bestpractice.com

• In children, ovarian volvulus is often associated with an ovarian tumor, most often a teratoma.

• Rotation or torsion of the ovary disrupts arterial blood flow and venous return, leading to ischemia, which, if not immediately treated, can affect ovarian vitality. [Figure caption and citation for the preceding image starts]: Intraoperative photo of an ovarian neoplasm that is ovarian torsion From the collection of Dr. KuoJen Tsao; used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: CT of a girl with signs of ovarian torsion. Large cystic lesion of the pelvic cavity containing calcifications (white arrow) and corresponding to a teratoma or dermoid cyst From the collection of Dr. KuoJen Tsao; used with permission [Citation ends].

Pelvic inflammatory disease (PID)

• These are a range of infections of the upper genital tract, including any combination of endometritis, salpingitis, pyosalpinx, tubo-ovarian abscess, and pelvic peritonitis; usually caused by Neisseria gonorrhoeae or Chlamydia trachomatis, and less commonly by normal vaginal microflora, including streptococci, anaerobes, and Gram-negative coli.

• Adolescents have a higher risk of developing PID compared to older women [30] Trent M. Pelvic inflammatory disease. Pediatr Rev. 2013 Apr; 34 (4): 163-72.
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530285/

  http://www.ncbi.nlm.nih.gov/pubmed/23547062?tool=bestpractice.com
  Sexually transmitted infections are a key risk factor.

• PID in young children should be encouraged to be screened for possible sexual abuse, as PID is extremely rare in the absence of sexual activity.

Complications during pregnancy

• Miscarriage and ectopic pregnancy should be suspected in any woman of reproductive age with lower abdominal pain, amenorrhea, and vaginal bleeding.

• Miscarriage is defined as the spontaneous termination of pregnancy before completed weeks 22. [31] WHO Department of Reproductive Health and Research. Vaginal bleeding in early pregnancy. Managing complications in pregnancy and childbirth: a guide for midwives and doctors.2003: S-7.
  https://apps.who.int/iris/bitstream/handle/10665/43972/9241545879_eng.pdf
  Most unreasonable miscarriages occur in the first trimester. [32] American College of Obstetrics and Gynaecology. Early pregnancy loss. Practice bulletin 200. Nov 2018 [internet publication].
  https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss

• Ectopic pregnancy occurs when a fertilized egg is implanted and matured outside the uterine cavity, with the most typical location in the fallopian tube (97%), then in the ovary (3.2%) and in the abdomen (1.3%).[33] Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod. 2002 Dec; 17 (12): 3224-30.
  https://academic.oup.com/humrep/article/17/12/3224/569616

  http://www.ncbi.nlm.nih.gov/pubmed/12456628?tool=bestpractice.com
  Oral contraceptive use before age 16 is associated with an increased risk of ectopic pregnancy. [34] Gaskins AJ, Missmer SA, Rich-Edwards JW, et al. Demographic, lifestyle, and reproductive risk factors for ectopic pregnancy.Fertil Steril. 2018 Dec; 110 (7): 1328-37.
  https://www.fertstert.org/article/S0015-0282(18)31831-4/fulltext

  http://www.ncbi.nlm.nih.gov/pubmed/30503132?tool=bestpractice.com
  It classically presents with pain in the lower abdomen, amenorrhea, and vaginal bleeding. Bleeding from termination of an ectopic pregnancy can be fatal.

Pulmonary

Primary respiratory diseases such as pneumonia or empyema in the pediatric population may present with abdominal pain.Recurrent pneumonia in children is usually the result of a particular susceptibility, such as disorders of immunity and leukocyte function, ciliated epithelium function, anatomical abnormalities, or specific genetic disorders such as cystic fibrosis. [35] Sectish TC, Prober CG. Pneumonia. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 18th ed. Philadelphia: WB Saunders; 2007: 1795-800.

Functional abdominal pain

Functional abdominal pain is also called non-specific abdominal pain; pain is usually chronic or recurrent.Visceral hyperalgesia is the end result of sensitization of medical and psychosocial events against a background of genetic predisposition. [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child / adolescent. Gastroenterology. 2016 May; 150 (6): P1456-68.e2.
http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com
Functional abdominal pain is classified according to Roman IV criteria, which describe functional dyspepsia, irritable bowel syndrome, abdominal migraine and functional abdominal pain, and nothing else.[36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child / adolescent. Gastroenterology. 2016 May; 150 (6): P1456-68.e2.
http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com
[37] Drossman DA, Chang L, Chey WD, et al. Rome IV: functional gastrointestinal disorders, disorders of gut-brain interaction. 4th ed. Raleigh, NC: Rome Foundation; 2017.

• Usually children aged 5 to 14 are affected.

• Prevalence estimates range from 10 to 30% in samples from schoolchildren, and up to 87% in some gastroenterology clinics.[38] Boronat AC, Ferreira-Maia AP, Matijasevich A, et al. Epidemiology of functional gastrointestinal disorders in children and adolescents: a systematic review. World J Gastroenterol. 2017 Jun 7; 23 (21): 3915-27.
  https://www.wjgnet.com/1007-9327/full/v23/i21/3915.htm

  http://www.ncbi.nlm.nih.gov/pubmed/28638232?tool=bestpractice.com

• A typical family history of a functional disorder (irritable bowel syndrome, mental illness, migraine, anxiety).

• Clarifying the type of functional disorder is an important factor in determining which treatments are most likely to improve symptoms.

Functional dyspepsia

• One or more of the following symptoms that disturb at least 4 days a month are defined as: satiety after eating, feeling of quick satiety, epigastric pain or burning, not associated with defecation. After proper examination, the symptoms cannot be fully explained by another disease.[36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child / adolescent. Gastroenterology. 2016 May; 150 (6): P1456-68.e2.
  http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

Irritable bowel syndrome

Three criteria must be met 2 months before diagnosis: [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child / adolescent. Gastroenterology.2016 May; 150 (6): P1456-68.e2.
http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

1. Abdominal pain for at least 4 days per month associated with one or more of the following conditions:

   1. Defecation-related

   2. Changing stool frequency

   3. Changing the shape of the stool.

2. In children with constipation, the pain does not go away after the constipation ends.

3. After proper examination, the symptoms cannot be fully explained by another disease.

Abdominal migraine

All of the following criteria must be met at least 6 months prior to diagnosis and at least twice: [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child / adolescent. Gastroenterology. 2016 May; 150 (6): P1456-68.e2.
http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

1. Emerging attacks of intense acute umbilical, moderate or diffuse abdominal pain lasting at least 1 hour.Abdominal pain should be the most severe and disturbing symptom.

2. Episodes that are weeks or months apart.

3. Pain makes a person disabled and interferes with normal activities.

4. Stereotyped pattern and symptoms in humans.

5. Pain is associated with 2 or more of the following:

   1. Anorexia

   2. nausea

   3. Vomiting

   4. Headache

   6. Photophobia

   7. After proper examination, the symptoms cannot be fully explained by another disease.

   Functional abdominal pain syndrome – no other approaches specified

   Three diagnostic criteria must be met at least four times a month 2 months prior to diagnosis: [36] Hyams JS, Di Lorenzo C, Saps M, et al … Childhood functional gastrointestinal disorders: child / adolescent. Gastroenterology. 2016 May; 150 (6): P1456-68.e2.
   http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

   1. Episodic or persistent abdominal pain that occurs not only during physiological processes (eg, eating, menstruation).

   2. Insufficient criteria for the diagnosis of irritable bowel syndrome, functional dyspepsia or abdominal migraine

   3. After proper examination, the symptoms cannot be fully explained by another disease.

   Signs of anxiety in children with chronic abdominal pain that may indicate an organic or peristalsis-related rather than functional cause include: [36] Hyams JS, Di Lorenzo C, Saps M, et al.Childhood functional gastrointestinal disorders: child / adolescent. Gastroenterology. 2016 May; 150 (6): P1456-68.e2.
   http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

   • Family history of inflammatory bowel disease, celiac disease or peptic ulcer

   • Persistent pain in the right upper or right lower quadrant

   • Dysphagia

   • Single phagia

   Single phagia

   0 intestinal bleeding

   • Nocturnal diarrhea

   • Arthritis

   • Perrectal disease

   • Involuntary weight loss

   • Delayed linear growth

   • Delayed fever

   Ulcerative colitis | ChUZ “KB” RZD-Medicine “Voronezh”

   Ulcerative colitis (UC) is a chronic inflammatory disease of the large intestine with damage to the mucous membrane and submucosal layer with the development of intestinal (local) and extraintestinal (systemic) complications.

   The prevalence of UC is about 80 patients per 100,000 inhabitants. The highest mortality rates are observed during the first year of the disease, due to cases of extremely severe fulminant course of the disease and 10 years after its onset due to the development of colorectal cancer.As etiological factors of the occurrence of UC, such as: infection, autoimmune mechanism, imbalance of the immune system of the gastrointestinal tract are considered.

   Main characteristics of YAK
   Form of the disease (nature of the course):
   • Lightning fast – often fatal;
   • Acute form – the first attack lasting up to 6 months;
   • Chronic relapsing – with repeated exacerbations;
   • Chronic continuous – prolonged exacerbation for more than 6 months with adequate therapy.
   The lesions differ by the length of:
   • Distal colitis – proctitis, proctosigmoiditis;
   • Left-sided colitis – lesion of the colon up to the right bend;
   • Total colitis – affection of the entire colon, often involving the terminal ileum in the inflammatory process (retrograde ileitis)
   The clinical presentation of UC is characterized by local symptoms (intestinal bleeding and diarrhea, accompanied by abdominal pain, tenesmus and sometimes constipation) and general manifestations of toxemia (fever, weight loss, nausea, vomiting, weakness).

   Complications with UC are divided into two groups: local and systemic.

   Local complications – colon perforation, acute toxic dilation of the colon, massive intestinal bleeding, colon cancer.

   Systemic complications (otherwise – extraintestinal manifestations) – damage to the liver, oral mucosa, skin, joints.

   The diagnosis of UC is established on the basis of an assessment of the clinical picture of the disease, sigmoidoscopy data, endoscopic and radiological research methods.

   Differential diagnosis of UC is carried out with:
   • Crohn’s disease of the colon;
   • Ischemic colitis;
   • Pseudomembranous colitis (antibiotic-assisted)
   • Diverticulitis;
   • Hemorrhoids;
   • Colon cancer;
   • Acute intestinal infections;
   • Parasitic infections

   Treatment tactics for UC is determined by the localization of the pathological process in the colon, its length, the severity of the attack, the presence of local and systemic complications and is determined after the examination.

   In the treatment of UC, preparations of 5-aminosalicylic acid are used, and with special indications, glucorticosteroids, cytostatics.

   When is surgical intervention necessary?
   For ulcerative colitis, surgical treatment is prescribed in cases where conservative methods have exhausted themselves and no longer bring the desired effect. In case of NUC, surgery is also prescribed in cases where the risk of developing rectal cancer is high. Patients regularly undergo examinations showing the condition of the intestinal mucosa with the aim of early detection of adverse changes – colonoscopy with biopsy.

   What is the range of possible surgical interventions?
   The range of surgical interventions in case of ineffectiveness of drug treatment and the use of diet for ulcerative colitis includes several types of operations. In our clinic, you can receive high-quality treatment, whatever the causes of UC and its consequences in a particular case. Doctors will select the most appropriate type of intervention for each patient. One operation is enough to completely eliminate the disease.

   Sometimes the doctor considers the possibility of removing the colon while preserving the rectum and anus. At the same time, stool holding is preserved. The disadvantage of this method is that it maintains the risk of developing colitis and cancer in the rest of the rectum.
   Possible complications of ulcerative colitis.

   In complex cases of ulcerative colitis, various complications can develop, up to those that threaten the patient’s life. These include ruptures of the intestine, bleeding, severe infectious processes, accompanied by severe inflammation with high fever and general intoxication of the body.Patients with UC are known to have an increased risk of rectal cancer.

   If anti-inflammatory therapy does not work, an operation is prescribed. Complications after surgery can be the occurrence of various infections – against the background of a general weakening of the body, the progression of the disease in non-remote areas, or due to a rupture of the reservoir.