The document discusses diverticulosis, which is a condition where pouches form in the lining of the large intestine. As people age, the continuous pressure in the colon from waste material can cause these pouches, called diverticula, to bulge outward. When diverticula become infected or rupture, it is called diverticulitis. Diverticulosis is rare before age 40 but becomes more common with age, affecting up to 65% of people by age 85. A diet low in fiber is a main risk factor as it can cause harder stools that require more pressure to pass. Symptoms range from none to abdominal pain, constipation, fever and more. Treatment depends on severity but may include fiber supplements, antibiotics

1. Presentation by Rowell Angeles

2.  The large intestine is a long tube-like
structure that stores and eliminates waste
material. During normal lower intestinal
function, the waste material (stool or
feces) is slowly pushed along the large
intestine to the rectum by the muscular
bands in the colon. As a person ages, this
continuous pressure can cause a bulging
pocket of tissue or sac (called a
diverticulum) that pushes out from the
colon wall. More than one sac is called
diverticula. Diverticula can occur
throughout the large intestine, but are
most commonly found near the end of the
left intestine (called the sigmoid colon).
The condition of having diverticula in the
large intestine is called diverticulosis.
 When a diverticulum ruptures or becomes
infected, this condition is called
diverticulitis. Diverticulitis develops when
a mass of hardened waste matter (called a
fecalith) forms in the pouch and reduces
the blood supply to the thin walls of the
pouch (by means of pressure against the
wall), making them susceptible to
infection by the bacteria of the colon.

3.  Diverticulosis is rare before the age of 40, but the likelihood of
developing this condition increases with passing decades. It is
estimated that 30 percent of all people over the age of 45 have
diverticulosis; at the age of 60, 50 percent of all people will develop
this condition; and by the age of 85, 65 percent of all people will
have diverticulosis.
 Researchers believe that diverticulosis may be age related,
genetically based and most importantly, caused by not enough fiber
in the diet. A diet low in fiber can lead to small, hard stools that are
difficult to pass and require more pressure to push them through
the large intestine. Over time, these vigorous contractions in the
large intestine push the inner intestinal lining outward, causing
diverticula.

4. Most people with diverticulosis have few Symptoms of inflammatory diverticulitis are:
or no symptoms. Doctors refer to  abdominal pain
diverticulosis with no symptoms as
 constipation
asymptomatic diverticulosis. For people
who experience symptoms, the  fever
condition is called symptomatic  bloating
diverticulosis. Symptomatic  vomiting
diverticulosis is categorized into three
Symptoms of bleeding diverticulosis are:
types - painful diverticulosis,
inflammatory diverticulitis (inflamed and  sudden, mild cramps
infected diverticula) and bleeding  urge to have a bowel movement
diverticulosis (the blood vessel in the  bright red blood clots and maroon-
wall of the diverticulum ruptures). colored stool
 If sufficient blood is lost in a short amount
Symptoms of painful diverticulosis are: of time, the person may experience:
 abdominal pain (usually located in  increased thirst
the lower left abdomen) that  dizziness
subsides after a bowel movement or  rapid heart beat
passing gas
 fainting
 constipation, followed by bouts of
diarrhea
 bloating

5.  Diverticulosis is often unsuspected and discovered by an x-ray or
intestinal examination performed for an unrelated reason. The
doctor may see the diverticula through a flexible tube (a
colonoscope) that is inserted through the anus. Through this scope,
the diverticula may be seen as dark passages leading out of the
normal colon wall.
 The doctor also may do a barium enema (an x-ray that reveals
outpouchings in the walls of the colon). If rectal bleeding occurs, the
doctor may take a special x-ray (an angiography). In this procedure,
dye is injected into an artery that goes to the colon so that the site
of the bleeding problem can be located.

6.  If the patient has diverticulosis with no symptoms, no treatment is needed.
Some doctors advise eating a special high fiber diet, consisting of fresh
vegetables, fresh fruits, whole-grain breads, cereals and bran.
 Additionally, adding a fiber supplement (such as Metamucil or Hydrocil) to
the diet, and avoiding certain foods with small seeds, such as strawberries,
raspberries, whole cranberries and nuts is helpful in treating diverticulosis.
 Patients experiencing bloating or abdominal pain may benefit from anti-
spasmodic drugs, such as Librax, Bentyl, Donnotal and Levsin.
 If this condition turns into diverticulitis, bedrest, antibiotics or
hospitalization may be needed. The vast majority of patients will recover
from diverticulitis without surgery. Sometimes, patients need surgery to
drain an abscess that has resulted from a ruptured diverticulum and to
remove that portion of the colon. Surgery is reserved for patients with very
severe or multiple attacks. In such cases, the involved segment of colon can
be removed and the colon can then be rejoined.

7.  A hiatal hernia is an anatomical
abnormality in which part of the stomach
protrudes through the diaphragm and up
into the chest. Although hiatal hernias
are present in approximately 15% of the
population, they are associated with
symptoms in only a minority of those
afflicted.
 Normally, the esophagus or food tube
passes down through the chest, crosses
the diaphragm, and enters the abdomen
through a hole in the diaphragm called
the esophageal hiatus. Just below the
diaphragm, the esophagus joins the
stomach. In individuals with hiatal
hernias, the opening of the esophageal
hiatus (hiatal opening) is larger than
normal, and a portion of the upper
stomach slips up or passes (herniates)
through the hiatus and into the chest.
Although hiatal hernias are occasionally
seen in infants where they probably have
been present from birth, most hiatal
hernias in adults are believed to have
developed over many years.

8. It is thought that hiatal hernias are caused by a larger-than-normal
esophageal hiatus, the opening in the diaphragm through which the
esophagus passes from the chest into the abdomen; as a result of the
large opening, part of the stomach "slips" into the chest. Other
potentially contributing factors include:
 A permanent shortening of the esophagus (perhaps caused by
inflammation and scarring from the reflux or regurgitation of
stomach acid) which pulls the stomach up.
 An abnormally loose attachment of the esophagus to the diaphragm
which allows the esophagus and stomach to slip upwards.

9. The vast majority of hiatal hernias are of the sliding type, and most of them are
not associated with symptoms. The larger the hernia, the more likely it is to
cause symptoms. When sliding hiatal hernias produce symptoms, they almost
always are those of gastroesophageal reflux disease (GERD) or its
complications. This occurs because the formation of the hernia often interferes
with the barrier (lower esophageal sphincter) which prevents acid from
refluxing from the stomach into the esophagus. Additionally, it is known that
patients with GERD are much more likely to have a hiatal hernia than individuals
not afflicted by GERD. Thus, it is clear that hiatal hernias contribute to GERD.
However, it is not clear if hiatal hernias alone can result in GERD. Since GERD
may occur in the absence of a hiatal hernia, factors other than the presence of a
hernia can cause GERD.
Symptoms of uncomplicated GERD include:
 heartburn
 regurgitation
 nausea

10.  Hiatal hernias are diagnosed incidentally when an upper
gastrointestinal x-ray or endoscopy is done during testing to
determine the cause of upper gastrointestinal symptoms such as
upper abdominal pain. On both the x-ray and endoscopy, the hiatal
hernia appears as a separate "sac" lying between what is clearly the
esophagus and what is clearly the stomach. This sac is delineated by
the lower esophageal sphincter above and the diaphragm below. The
hernia may only be visible during swallows.

11.  Treatment of large para-esophageal hernias causing symptoms
requires surgery. During surgery, the stomach is pulled down into
the abdomen, the esophageal hiatus is made smaller, and the
esophagus is attached firmly to the diaphragm. This procedure
restores the normal anatomy.
 Since sliding hiatal hernias rarely cause problems themselves but
rather contribute to acid reflux, the treatment for patients with
hiatal hernias is usually the same as for the associated GERD. If the
GERD is severe, complicated, or unresponsive to reasonable doses of
medications, surgery often is performed. At the time of surgery, the
hiatal hernia is eliminated in a manner similar to the repair of para-
esophageal hernias. However, in addition, part of the upper stomach
is wrapped around the lower sphincter to augment the pressure at
the sphincter and further prevent acid reflux.

12.  A peptic ulcer is a hole in the gut
lining of the stomach, duodenum,
or esophagus. A peptic ulcer of the
stomach is called a gastric ulcer; of
the duodenum, a duodenal ulcer;
and of the esophagus, an
esophageal ulcer. An ulcer occurs
when the lining of these organs is
corroded by the acidic digestive
juices which are secreted by the
stomach cells. Peptic ulcer disease
is common, affecting millions of
Americans yearly. The medical cost
of treating peptic ulcer and its
complications runs in the billions of
dollars annually. Recent medical
advances have increased our
understanding of ulcer formation.
Improved and expanded treatment
options are now available.

13.  For many years, excess acid was believed to be the major cause of
ulcer disease. Accordingly, treatment emphasis was on neutralizing
and inhibiting the secretion of stomach acid. While acid is still
considered significant in ulcer formation, the leading cause of ulcer
disease is currently believed to be infection of the stomach by a
bacteria called "Helicobacter pyloricus" (H. pylori). Another major
cause of ulcers is the chronic use of anti-inflammatory medications,
commonly referred to as NSAIDs (nonsteroidal anti-inflammatory
drugs), including aspirin. Cigarette smoking is also an important
cause of ulcer formation and ulcer treatment failure.
 H. pylori bacteria is very common, infecting more than a billion
people worldwide. It is estimated that half of the United States
population older than age 60 has been infected with H. pylori.
Infection usually persists for many years, leading to ulcer disease in
10 % to 15% of those infected. H. pylori is found in more than 80% of
patients with gastric and duodenal ulcers. While the mechanism of
how H. pylori causes ulcers is not well understood, elimination of
this bacteria by antibiotics has clearly been shown to heal ulcers and
prevent ulcer recurrence.

14.  NSAIDs are medications for arthritis and other painful inflammatory
conditions in the body. Aspirin, ibuprofen (Motrin), naproxen
(Naprosyn), and etodolac (Lodine) are a few of the examples of this
class of medications. Prostaglandins are substances which are
important in helping the gut linings resist corrosive acid damage.
NSAIDs cause ulcers by interfering with prostaglandins in the
stomach.
 Cigarette smoking not only causes ulcer formation, but also
increases the risk of ulcer complications such as ulcer bleeding,
stomach obstruction and perforation. Cigarette smoking is also a
leading cause of ulcer medication treatment failure.
 Contrary to popular belief, alcohol, coffee, colas, spicy foods, and
caffeine have no proven role in ulcer formation. Similarly, there is no
conclusive evidence to suggest that life stresses or personality types
contribute to ulcer disease.

15.  Symptoms of ulcer disease are variable. Many ulcer patients
experience minimal indigestion or no discomfort at all. Some report
upper abdominal burning or hunger pain one to three hours after
meals and in the middle of the night. These pain symptoms are
often promptly relieved by food or antacids. The pain of ulcer
disease correlates poorly with the presence or severity of active
ulceration. Some patients have persistent pain even after an ulcer is
completely healed by medication. Others experience no pain at all,
even though ulcers return. Ulcers often come and go spontaneously
without the individual ever knowing, unless a serious complication
(like bleeding or perforation) occurs.

16.  The diagnosis of an ulcer is made by either a barium upper GI x-ray
or an upper endoscopy (EGD-esophagogastroduodenoscopy) The
barium upper GI x-ray is easy to perform and involves no risk or
discomfort. Barium is a chalky substance administered orally. Barium
is visible on x- ray, and outlines the stomach on x-ray film.
However, barium x-rays are less accurate and may not detect ulcers
up to 20% of the time.
 An upper endoscopy is more accurate, but involves sedation of the
patient and the insertion of a flexible tube through the mouth to
inspect the stomach, esophagus, and duodenum. Upper endoscopy
has the added advantage of having the capability of removing small
tissue samples (biopsies) to test for H. pylori infection. Biopsies can
also be examined under a microscope to exclude cancer. While
virtually all duodenal ulcers are benign, gastric ulcers can
occasionally be cancerous. Therefore, biopsies are often performed
on gastric ulcers to exclude cancer.

17.  The goal of ulcer treatment is to relieve pain and to prevent ulcer complications, such as
bleeding, obstruction, and perforation. The first step in treatment involves the reduction
of risk factors (NSAIDs and cigarettes). The next step is medications.
 Antacids neutralize existing acid in the stomach. Antacids such as Maalox, Mylanta, and
Amphojel are safe and effective treatments. However, the neutralizing action of these
agents is short-lived, and frequent dosages are required. Magnesium containing
antacids, such as Maalox and Mylanta, can cause diarrhea, while aluminum agents like
Amphojel can cause constipation. Ulcers frequently return when antacids are
discontinued.
 Studies have shown that a protein in the stomach called histamine stimulates gastric acid
secretion. Histamine antagonists (H2 blockers) are drugs designed to block the action of
histamine on gastric cells, hence reducing acid output. Examples of H2 blockers are
cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). While
H2 blockers are effective in ulcer healing, they have limited role in eradicating H. pylori
without antibiotics. Therefore, ulcers frequently return when H2 blockers are stopped.
Generally, these drugs are well tolerated and have few side effects even with long term
use. In rare instances, patients report headache, confusion, lethargy, or hallucinations.
Chronic use of cimetidine may rarely cause impotence or breast swelling. Both cimetidine
and ranitidine can interfere with body's ability to handle alcohol. Patients on these drugs
who drink alcohol may have elevated blood alcohol levels. These drugs may also interfere
with the liver's handling of other medications like Dilantin, Coumadin, and theophylline.
Frequent monitoring and adjustments of the dosages of these medications may be
needed.

18.  Proton-pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid),
pantoprazole (Protonix), esomeprazole (Nexium), and rabeprazole (Aciphex) are more
potent than H2 blockers in suppressing acid secretion. Different proton-pump inhibitors
are very similar in action and there is no evidence that one is more effective than
another in healing ulcers. While proton-pump inhibitors are comparable to H2 blockers
in effectiveness in treating gastric and duodenal ulcers, it is superior to H2 blockers in
treating esophageal ulcers. Esophageal ulcers are more sensitive than gastric and
duodenal ulcers to minute amounts of acid. Therefore, more complete acid suppression
accomplished by proton-pump inhibitors are important for esophageal ulcer healing.
Proton-pump inhibitors are well tolerated. Side effects are uncommon; they include
headache, diarrhea, constipation, nausea and rash. Interestingly, proton-pump
inhibitors do not have any effect on a person's ability to digest and absorb nutrients.
Proton-pump inhibitors have also been found to be safe when used long term, without
serious adverse health effects reported.
 Sucralfate (Carafate) and misoprostol (Cytotec) are agents that strengthen the gut lining
against attacks by acid digestive juices. Carafate coats the ulcer surface and promotes
healing. The medication has very few side effects. The most common side effect is
constipation and the interference with the absorption of other medications. Cytotec is a
prostaglandin-like substance commonly used to counteract the ulcer effects of NSAIDs.
Studies suggest that Cytotec may protect the stomach from ulceration in those who take
NSAIDs on a chronic basis. Diarrhea is a common side effect. Cytotec can cause
miscarriages when given to pregnant women, and should be avoided by women of
childbearing age.

19.  Many people harbor H. pylori in their stomachs without ever having pain or ulcers. It is
not completely clear whether these patients should be treated with antibiotics. More
studies are needed to answer this question. Patients with documented ulcer disease and
H. pylori infection should be treated with antibiotic combinations. H. pylori can be very
difficult to completely eradicate. Treatment requires a combination of several antibiotics,
sometimes in combination with a proton-pump inhibitor, H2 blockers or Pepto-Bismol.
Commonly used antibiotics are tetracycline, amoxicillin, metronidazole (Flagyl),
clarithromycin (Biaxin), and levofloxacin (Levaquin). Eradication of H. pylori prevents the
return of ulcers (a major problem with all other ulcer treatment options). Elimination of
this bacteria may also decrease the risk of developing gastric cancer in the future.
Treatment with antibiotics carries the risk of allergic reactions, diarrhea, and sometimes
severe antibiotic-induced colitis (inflammation of the colon).
 There is no conclusive evidence that dietary restrictions and bland diets play a role in
ulcer healing. No proven relationship exists between peptic ulcer disease and the intake
of coffee and alcohol. However, since coffee stimulates gastric acid secretion, and
alcohol can cause gastritis, moderation in alcohol and coffee consumption is often
recommended.

20. Intestinal malrotation is a birth defect involving a malformation of the intestinal tract.
Intestinal malrotation is an abnormality that occurs while a fetus is forming in its mother's
uterus.
As a fetus is growing in its mother's uterus before birth, different organ systems are
developing and maturing.
 The digestive tract starts off as a straight tube from the stomach to the rectum.
 Initially, it is located in the fetus' abdomen, but, for a while, part of the intestine moves
into the umbilical cord.
 At about the 10th week of pregnancy, the intestine leaves the umbilical cord and goes
back into the abdomen.
 After returning to the abdomen, the intestine makes two turns, and is no longer a straight
tube.
Malrotation occurs when the intestine does not make these turns as it should.
In addition, intestinal malrotation causes the cecum (the end of the small intestine) to
develop abnormally. The cecum is normally located in the lower right side of the abdomen.
With malrotation, the cecum and the appendix (which is attached to the cecum) stay in the
upper right side of the abdomen. Bands of tissue called Ladd's bands form between the
cecum and the intestinal wall and can create a blockage in the duodenum (the beginning of
the small intestine).
A volvulus is a problem that can occur after birth as a result of intestinal malrotation. The
intestine becomes twisted, causing an intestinal blockage. This twisting can also cut off the
blood flow to the intestine, and the intestine can be damaged.

22. The following are the most common symptoms of malrotation and
volvulus. However, each individual may experience symptoms
differently. When the intestine becomes twisted, or obstructed by
Ladd's bands, the symptoms may include:
 vomiting bile (green digestive fluid)
 drawing up the legs
 abdominal pain
 abdominal distention (the abdomen becomes swollen)
 rapid heart rate
 rapid breathing
 bloody stools
The symptoms of malrotation and volvulus may resemble other
conditions or medical problems. Consult your child's physician for
diagnosis.

23. In addition to a physical examination and medical history, diagnostic
procedures for malrotation and volvulus may include various imaging studies
(tests that show pictures of the inside of the body). These are performed to
evaluate the position of the intestine, and whether it is twisted or blocked.
These tests may include:
 abdominal x-ray - a diagnostic test which may show intestinal obstructions.
 barium swallow / upper GI test - a procedure performed to examine the
intestine for abnormalities. A fluid called barium (a metallic, chemical,
chalky, liquid used to coat the inside of organs so that they will show up on
an x-ray) is swallowed. An x-ray of the abdomen may show an abnormal
location for the small intestine, obstructions (blockages), and other
problems.
 barium enema - a procedure performed to examine the intestine for
abnormalities. A fluid called barium (a metallic, chemical, chalky, liquid used
to coat the inside of organs so that they will show up on an x-ray) is given
into the rectum as an enema. An x-ray of the abdomen may show that the
large intestine is not in the normal location.

24. Specific treatment for malrotation and volvulus will be determined by
your child's physician based on the following:
 the extent of the problem
 your child's age, overall health, and medical history
 the opinion of the surgeon and other physicians involved in your
child's care
 expectations for the course of the problem
 your opinion and preference
Malrotation of the intestines is not usually evident until the intestine
becomes twisted (volvulus) or obstructed by Ladd's bands and
symptoms are present. A volvulus is considered a life-threatening
problem, because the intestine can die when it is twisted and does not
have adequate blood supply.
Children may be started on IV (intravenous) fluids to prevent
dehydration and antibiotics to prevent infection. A tube called a
nasogastric (or NG) tube may be guided from the nose, through the
throat and esophagus, to the stomach to prevent gas buildup in the
stomach.

25.  A volvulus is usually surgically repaired as soon as possible. The intestine is
untwisted and checked for damage. Ideally, the circulation to the intestine
will be restored after it is unwound, and it will turn pink.
 If the intestine is healthy, it is replaced in the abdomen. Since the appendix
is located in a different area than usual, it would be difficult to diagnose
appendicitis in the future; therefore, an appendectomy (surgical removal of
the appendix) is also usually performed.
 If the blood supply to the intestine is in question, the intestine may be
untwisted and placed back into the abdomen. Another operation will be done
in 24 to 48 hours to check the health of the intestine. If it appears the
intestine has been damaged, the injured section may be removed.
 If the injured section of intestine is large, a significant amount of intestine
may be removed. In this case, the parts of the intestine that remain after the
damaged section is removed cannot be attached to each other surgically. A
colostomy may be done so that the digestive process can continue. With a
colostomy, the two remaining healthy ends of intestine are brought through
openings in the abdomen. Stool will pass through the opening (called a
stoma) and then into a collection bag. The colostomy may be temporary or
permanent, depending on the amount of intestine that needed to be
removed.