The Digestive System

The digestive system is the tube that goes from the mouth through the chest and abdomen to the anus. It is divided into several segments each of which has a specialised function. There are two other organs involved in digestion, the liver and pancreas. They are attached to the gut by small tubes which carry bile and enzymes to mix with food.

Food, fluid and finally waste products are pushed along the gut by muscular contractions in the wall which are called peristalsis. The time taken for food to go from the mouth to the anus varies from 12 to 48 hours depending on the type of food eaten.

Parts of the gut:

• The Mouth :
  The mouth is the beginning of the digestive tract where food an fluids enter the body. Some people have difficulty chewing and swallowing food because of the poor state of their teeth or because they have a very dry mouth that doesn’t produce saliva.
• The Oesophagus :
  The oesophagus is the tube that goes from the mouth to the stomach. Muscle contractions in the oesophagus gently push food down into the stomach. There is a little valve between the oesophagus and the stomach called the lower oesophageal valve. It prevents reflux of acid and food back up into the oesophagus.
• The Stomach :
  The stomach has several functions. It produces acid which can kill bacteria which may be swallowed in the food or saliva. The thick muscular walls of the stomach contract to mix solid food, stomach acid and saliva in order to aid digestion. The stomach also makes substances which help absorb iron and vitamins.
• The Duodenum :
  The duodenum is the first part of the small intestine. It receives bile from the liver and enzymes from the pancreas through small ducts or tubes.
• The Pancreas :
  This organ makes special enzymes that help digestion and also makes the hormone insulin which controls blood sugar.
• The Liver and Gall Bladder :
  The liver produces bile, which is stored in the gall bladder until it is needed after meals. Bile helps to digest fats.
• The Small Intestine :
  The small bowel is five metres in length in an adult and half that length for a baby. If all the folds were flattened out, the surface area would equal that of a doubles tennis court. This allow large amounts of digested nutrients to pass through the lining of the small intestine into the blood stream, which distributes them through out the body.
• The Large Intestine or Colon :
  The colon is like a waste treatment works. It contains numerous bacteria which help in this process. It receives liquid waste from the small intestine and processes it into formed bowel motions. Fluid is absorbed through the bowel surface into the blood stream. Peristalsis pushes the motion down into the rectum. When it is time for a person to empty their bowels, the anal sphincter at the very end of the gut relaxes and allows the motion to pass through

Heartburn and reflux

Heartburn or reflux or oesophageal reflux is very common. Almost everyone has it at sometime. It is a feeling of discomfort, burning or pain felt rising up from the lower chest into the neck. Some people call it indigestion. It is caused by stomach acid rising up into the oesophagus, where it can cause pain and inflammation. Occasionally heartburn is associated with food or fluid coming into the mouth. This is called regurgitation. If Heartburn occurs regularly, for example a few days per week or even every day, it can be distressing and may require treatment.

Causes

• Foods :
  Many people have reflux symptoms no matter what they eat. Sometimes, however, the foods we eat can make heartburn worse. Foods which can make heartburn worse include: fatty foods, chocolate, coffee, alcohol, cola drinks and peppermint. Cigarettes can also make heartburn worse.
  
  Some people know that a specific food can give them heartburn, for example, cucumber or capsicum or garlic. Foods which you know cause you trouble should be avoided.
• Timing :
  Some people find that the time of eating can also influence their complaint. For example fatty foods before going to bed, a lot of coffee at the end of the day.
• Body Weight :
  some people benefit from losing weight if they are overweight.

Diagnosis

Usually tests are not required. Heartburn is common and doctors know a great deal about the cause and how to treat it. However, if the medication your doctor suggests does not help, if you have the feeling that food is getting stuck in your oesophagus, if you have pain when you swallow, if you have vomited or lost weight, your doctor may suggest you have a test called an endoscopy. During an endoscopy, which is done while you are under sedation, the doctor can inspect the inside of your oesophagus using a flexible tube. They may then suggest a change in your treatment.

Very rarely, further tests are required to check the muscles in the oesophagus or the amount of time that acid refluxes up out of the stomach.

Treatment

The treatment depends on how severe your symptoms are. People who have mild symptoms may respond to antacids, which neutralise the acids produced by the stomach. Other people may require drugs that reduce the amount of acid the stomach produces. You can buy some of these medications over the counter at the pharmacy. To get some others you need a prescription from your doctor. Treatment is very effective and safe. Unfortunately most people who experience reflux symptoms continue to have trouble if they don’t take medications. However you don’t have to take the medications every day. You can modify the regime to suit your symptoms.

Helicobactor Pylori

Helicobacter pylori (H. pylori) is a bacterium or germ that lives in the lining of the stomach, where it produces a number of chemicals that damage the stomach lining. Once the infection is present it may persist for many years if not for life. It is uncertain how the H. pylori is spread, but it is thought that it most likely it occurs when people share food or eating utensils. Spread between family members (eg. Mother and child) is not uncommon. It is very rare to catch H. pylori as an adult.

Most people are infected as children and in Australia about 40% of persons over the age of 60 years are infected. There is no difference in the infection rate between men and women. However, it is much more common in older people and in certain ethnic populations (e.g. Middle Eastern, Asian and Eastern European)

Diagnosis

There are several ways of diagnosing whether you have Helicobacter pylori infection:

• Breath Tests
  Breath Testing shows if you are infected by analysing a sample of your breath. This is an accurate, safe, simple and quick means of testing. This is a particularly useful test to check whether the infection has been successfully treated. Certain drugs will affect the accuracy of this test(eg antibiotics in the month preceding the test and ulcer healing drugs in the previous 1-2 weeks)
• Blood Tests
  Blood Tests can detect current or recent infection. They are not a useful means of checking the success of treatment because the antibody to H. pylori stays in the blood for years.
• Endoscopy
  Endoscopy is a procedure during which, the doctor will pass a flexible tube into your stomach. This allows small samples to be taken, to detect H.pylori. The pathologist can a use a number of methods to detect the presence of H.pylori, including looking under the microscope, detecting it with a chemical test (rapid urease test) or growing it in the laboratory. These tests are very accurate, although recent use of antibiotics or drugs that treat ulcers can cause false results.
• Faecal Test
  It is also possible to check for H.pylori using a sample of bowel motion. This is the method most commonly used for children.

Symptoms

Most people who are infected with H.pylori have no symptoms. However, it can cause:

• Inflammation of the lining of the stomach – Gastritis
• Duodenal Ulcers (Ulceration of the first part of the small bowel. H.pylori is the cause of about 90% of the ulcers in the duodenum
• Stomach Ulcers – Gastric. H. pylori is the cause of about 70% of stomach ulcers. The majority of the remaining 30% are caused by the effects of drugs taken for arthritis (non-steroidal anti-inflammatory drugs), or aspirin taken to prevent heart disease or stroke. Some people have both risk factors, and this increases the chance of a stomach ulcer.
• Modern anti-ulcer drugs heal virtually all duodenal and stomach ulcers, but there is a very high chance that the ulcer will come back if a person stops the medication and H.pylori is not eliminated. If H. pylori infection is cured, the risk of the ulcer recurring is very low (unless aspirin or anti-inflammatory drugs need to be taken). Paracetamol does not cause ulcers). Paracetamol does not cause ulcers.
• Some Cancers of the stomach, including a rare type called lymphoma. Cancer of the stomach is very rare in Australia, but H.pylori increases the risk. Only very small numbers of infected people ever develop this problem.
• Non-ulcer dyspepsia – Most people who experience dyspepsia do not have an ulcer, they have ‘non-ulcer’ dyspepsia This is a very common problem and is thought to have many possible causes. Some people with this problem also have H.pylori infection, but treatment for the H.pylori does not always help with the dyspepsia.

Who to Test

The people who should be tested for Helicobacter pylori include:

• People with Duodenal Ulcer: everyone with a duodenal ulcer should be tested for H.pylori and treated if infected. This includes people with active ulcers and those who have had a duodenal ulcer in the past.
• People with Stomach Ulcers: everyone with a stomach ulcer or has previously had stomach ulcers should be tested and treated. This includes people who were taking aspirin and anti-arthritis drugs when the ulcer developed.
• People with Non-ulcer Dyspepsia: treatment may not cure the dyspepsia. However treatment may reduce the chance of getting ulcers (or possible stomach cancer) in the future. The side effects and cost of treatment must be weighed against the potential benefits

Treatment

The treatments available include a number of drug combinations. The most successful of these are successful in 80 – 90% of people. To be successful the drugs must be taken exactly as directed. The treatment combinations include anti-ulcer drugs and two antibiotics. The use of drug combinations reduces the risk of H.pylori becoming resistant to treatments. However taking three drugs increases the side effect, which may include nausea, taste disturbances, diarrhoea, skin rashes, and interactions with other medications or unpleasant reactions to alcohol. Very rarely, more serious side effects may occur, such as bacterial infection of the large bowel (pseudomembranous enterocolitis) or a sudden drop in blood pressure(anaphylaxis). It is important to tell us if you have experienced any side effects with antibiotics.

After Treatment

If you take the treatment exactly as directed, the chance of success is high. H.pylori elimination should be checked if you have had a serious ulcer complication (bleeding or perforation), or if your ulcer has often recurred. If you have to undergo another gastroscopy, it is very simple to look at H.pylori using one of the methods described previously. If you do not require another gastroscopy your doctor may order another breath test. These tests can not be performed until at least 4 weeks have elapsed since the treatment has been completed to ensure an accurate result. Not everyone has a follow-up test. If treatment is unsuccessful another combination of drugs can be tried.

Definitions

An ulcer is a break in the lining of the stomach or upper small bowel(the duodenum) Dyspepsia describes the pain, discomfort or other symptoms in the upper abdomen.

Coeliac Disease

Coeliac Disease is a condition in which the lining of the small intestine becomes damaged when it is exposed to even small amounts of gluten, which is a protein found in wheat, barley, rye and possibly oats. As a result affected people absorb food and nutrients poorly. This can result in bowel symptoms and deficiencies of vitamins, minerals and other nutrients. It is a relatively uncommon condition. In Australia about one person in 2000 is diagnosed with the condition.

Symptoms and Diagnosis :

Coeliac Disease can vary in its symptoms, ranging from many to none at all. There are no specific symptoms of the disease. Diarrhoea, loss of weight, nausea, flatulence and abdominal discomfort are common complaints. Tiredness and weakness are also common, usually because of a degree of iron and/or folic acid deficiency, sometimes resulting in anaemia. Some patients may also be diagnosed following investigation for osteoporosis. Less commonly, mouth ulceration, recurring miscarriages or infertility can be the presenting feature in adults.

In children coeliac disease often causes poor weight gain, delayed growth and development, irritability and a poor appetite, in addition to bowel problems and anaemia.

Many of these symptoms are common in the community and are not usually related to coeliac disease. In any case it is widely accepted that this disease is under-diagnose and should be considered in a broader range of people than has been the practice in the past. It can run in families – about 1 in 10 close family relatives of an affected patient may also have coeliac disease. If someone in your family has coeliac disease, the best advice is to contact your local doctor should be your first contact. There are blood tests available that are useful to screen for coeliac disease. You may then be referred to a specialist for an endoscopy to enable a biopsy of tissue from the intestine. This tissue is then examined by a pathologist who will determine whether coeliac disease is present. If coeliac disease is suspected, a gluten free diet should NOT be started until the condition has been properly diagnosed. Otherwise this may interfere with establishing a correct diagnosis. The gluten-free-diet should always be undertaken with medical supervision.

Treatment :

Coeliac Disease is successfully treated by avoiding all foods containing gluten. This is called a gluten-free-diet. Medication is rarely necessary. The diet needs to be continued for life, because the sensitivity to gluten does not disappear.

Basic information regarding the diet can be obtained from your doctor. A visit to a dietician is highly recommended for a comprehensive explanation and planning of the gluten free diet. In addition the Coeliac Society of Australia and its state branches are invaluable aids. They are self-help organisations for people with coeliac disease.

You will need ongoing monitoring of your health through your local doctor, gastro-enterologist and/or dietician. It is usual practice to repeat the biopsy about 6 – 12 months after diagnosis. It is also recommended to have certain blood tests periodically at the discretion of your doctor. A bone density test should be performed at the time of diagnosis and thereafter as indicated by your doctor.

Long term problems associated with failure to adhere to a gluten-free diet include increased risk of bowel cancer, osteoporosis, infertility, chronic ill-health. The risk of these conditions is no greater than normal when a gluten-free diet is followed.

Irritable Bowel Syndrome

The Large Intestine is a muscular tube about 2 metres long. Its main function is to absorb water and allow fibre to be broken down by bacteria. The mass of bacteria and food residue pass along the bowel to become faeces. The rate of movement of the residue is determined by the muscular action of the colon. Normally, the movement of the colon is well co-ordinated, but if the rhythm is disturbed, pain and alteration in bowel habit occur.

Irritable Bowel Syndrome (IBS) causes abdominal pain and an abnormal bowel habit and bloating. Some people suffer constipation, some have diarrhoea and some alternate between the two. The pain may get better or worse when a bowel motion occurs.

It is uncertain exactly what causes Irritable Bowel Syndrome but it is thought to be due to a combination of increased sensitivity to the function of the bowel, which can be responsible for discomfort, and abnormal contractions in the bowel muscles. No-one has determined exactly why this occurs. Sometimes these symptoms occur after a person has had a gut infection such as gastroenteritis or food poisoning or even a course of antibiotics. In most cases no cause can be found.

Symptoms and Diagnosis

Most symptoms occur because the muscular action of the colon is not coordinated resulting in spasm in the bowel.

Abdominal Pain is usually in the lower abdomen, frequently on the left side. It is often worse in the morning and relieved by passing wind or a bowel motion. A common pattern is pain soon after waking, with an urge to pass a motion which is repeated several times. Gas, bloating and abdominal distension are common, often worse at the end of the day. Offensive wind is also common.

There may be constipation diarrhoea or alternating periods of both. Rectal bleeding is not due to irritable bowel and ALWAYS requires investigation.

Irritable Bowel Syndrome is very common – up to 30% of the population may have symptoms. It occurs at any age but usually before the age of 40 years.

Females are affected more often that males and symptoms may be worse at certain times during the menstrual cycle.

Symptoms may be worse at times of stress.

Some people may be sensitive to particular foods.

Your doctor can usually diagnose Irritable Bowel Syndrome from your pattern of symptoms, and some simple tests. Further investigations may be undertaken to exclude other causes. If the tests do not show any problem, it does not mean “there s nothing wrong”. Irritable Bowel is diagnosed by exclusion of other causes for the symptoms experienced by the patient.

Treatment

Treatment of Irritable Bowel is achieved by treating the symptoms. Therefore understanding the disease is important. Look for lifestyle factors which aggravate your symptoms and which may need attention.

• Are the symptoms worse with stress?
• Do you drink too much alcohol?
• Are your symptoms worse after milk or cheese?
• Are you taking medications which may aggravate diarrhoea? For example antibiotics, antacids, laxatives, some antihypertensive medications
• Are you taking medications which may aggravate constipation? For example nerve tablets, pain killers, , some antihypertensive medications

Diet

A good healthy diet is essential. You should make sure your diet contains:

• Eating Most: fruit, vegetables, breads, legumes, seeds and nuts
• Eating Moderately: lean fish, meat, chicken; cheese, yoghurt, milk and eggs
• Eating Least: foods high in salt, fat and sugar

Polyps

Polyps are growths in the lining of the bowel. Most are not cancerous and d o not cause any symptoms. Polyps may bleed and occasionally cause diarrhoea or pain. Any polyp can develop into a cancer so and it is important to note that almost all bowel cancers start as polyps. As a result it is important that all polyps be removed.

Bowel Cancer

Cancer of the bowel is the most common type of cancer of internal organs in Australia. One (1) in twenty-one (21) Australians will develop bowel cancer. The risk begins at age 40 and it increases with age.

The risk is further increased if:

• One or more close relatives (mother, father, brother sister or child) has polyps large bowel cancer;
• You have had polyps or large bowel cancer;
• You have had extensive inflammation of the bowel for more than eight (8) years.

Many bowel cancers occur without any risk factors, There may be no symptoms. There may be a small amount of bleeding which is not easily visible but may be detected with a special test of bowel motions. The Faecal Occult Blood Test is currently being circulated via mail to all Victorians aged 55 year and 65 years. You will be notified of your results and your General Practitioner can give you advice on what to do if you have a positive result.

If you are in a high risk group (i.e. you have a close relative who developed bowel cancer at an early age) you should consult your doctor regarding investigations that may need to be undertaken.

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