DAN Medical Frequently Asked Questions

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Gastrointestinal conditions

Constipation, food allergies, gallstones, heartburn/reflux and hemorrhoids are topics discussed in this section of the medical guide. Constipation is usually a chronic condition arising from a gradual change in bowel habits. It is characterized by hard, small stools, increased straining to pass stool and decreased frequency of bowel movements. Constipation can lead to pain and a sensation of needing to move your bowels while being unable to pass stool. Some diseases — including multiple sclerosis, diabetes and Parkinson's disease — increase the risk of constipation. Constipation is also a side effect of many medications. Medications that can cause constipation include iron-rich supplements, antacids, antihistamines (such as allergy and motion-sickness medicines), depression medicines, blood-pressure–lowering medicines and narcotic painkillers. Consumption of alcohol or of products that contain caffeine can lead to dehydration, which contributes to constipation. Boating can provoke constipation, too, due to the associated dietary changes, sedentary lifestyle, insufficient hydration, inconvenience of passing stool and use of motion-sickness medication.

Common symptoms of constipation include cramping in the lower left quadrant of the abdomen and rectal pressure. Pain often varies throughout the day and is relieved by having a bowel movement. Those who are constipated often feel bloated and may feel nauseated. An exam of the rectum may reveal a hard lump of stool. Palpation (gentle but firm pressure) of the abdomen may mildly increase pain, but palpation should not cause severe pain. Blood should not be present when you're having a bowel movement, but blood may be evident as a result of complications of constipation, such as an anal or rectal fissure — a small tear in the tissue lining the anus or rectum. If you see blood in your stool (as opposed to around your stool or on your toilet paper), you should seek prompt evaluation by a physician, especially if other symptoms of blood loss or severe abdominal pain are also present.

If you suspect you may be constipated, increase your consumption of water and increase your intake of dietary fiber to 20 to 35 grams a day. Good sources of fiber include fruits (especially prunes), vegetables, nuts and whole-wheat bread. If these steps are not helpful, laxatives are an option. Some laxatives work similarly to fiber in your diet; these include Metamucil, Citrucel, FiberCon and Benefiber. Others work by drawing more water into your stool; these include MiraLax, GlycoLax, magnesium citrate and magnesium hydroxide. And still others work by stimulating your bowels to move; these include senna and bisacodyl. In some cases, medications delivered by enema — liquids delivered through a tube inserted into the rectum — may help relieve constipation. The pain associated with constipation may limit your activity level, but a return to normal bowel habits should resolve your symptoms. If you experience constipation while boating, over-the-counter medications and dietary modifications should help. If constipation leads to bloating and/or severe and unremitting abdominal pain with associated nausea and vomiting, you should seek urgent examination by a physician.

The best way to prevent constipation is to avoid medications that may cause constipation; these are listed above. Regular activity and exercise may help prevent constipation as well. Also be sure to stay well hydrated, drinking at least eight 8-ounce glasses of water a day, and be sure you have an adequate intake of fiber. Moving your bowels whenever you feel the urge can help prevent constipation, too.Authors: Dr. Dave Lambert, UPENN and Dr. Miguel Aquilera, UPENN

Food allergies occur in our population with rate of approximately 4-5%. The condition involves a hypersensitivity to an ingested substance that may be unique to the affected individual. A true allergy to food involves a response by the immune system that can manifest with a variety of symptoms. Even a small amount of an allergy-inducing substance can lead to symptoms.

Relatively benign symptoms can include scratchy throat, nasal congestion, runny nose, sneezing, red, itchy and watery eyes or hives. Gastrointestinal symptoms, such as tingling or itching in the mouth, nausea, vomiting or abdominal discomfort, may also occur.

More severe symptoms include swelling, which can occur anywhere on the body, but which becomes life threatening when air passages are affected, making it difficult to breathe. These symptoms can range from tightening of the airways with mild wheezing or severe asthma to swelling of the oral cavity (tongue, throat, lips) along with a rapid pulse and loss of consciousness all of which are part of a life threatening condition known as anaphylaxis. Profound hypotension or low blood pressure may also occur with rapid heart rate that may be difficult to examine.

Common Offending Foods
Common foods known to trigger food allergies include: milk; eggs; nuts; fish; shellfish; grains such as wheat, barley, oats, rye and corn; and soy, including edamame, tofu and miso. Gluten is also a common allergen and is found in some grains. Many prepared foods have gluten, wheat or corn in them. Other food additives like MSG may cause a variety of allergy symptoms.

Treatment
Treatment depends on severity of symptoms. Simple non-life-threatening symptoms can be treated with common over-the-counter medications such as decongestants, anti-histamines or topical hydrocortisone creams. Patients with history of asthma may require stronger medications if aggravated symptoms do not resolve with their usual medications.

Immediate use of an Epinephrine auto-injector is necessary for anyone experiencing difficulty breathing due to swelling of the face or tongue or severe asthma. This is a life-threatening condition known as anaphylaxis, and immediate medical attention is mandatory.

Prevention
To prevent symptoms, avoid known foods that cause problems. Prepared foods often contain a variety of substances. Learn what ingredients are included in your prepared foods. Read the labels on packaged foods. If you have a life threatening food allergy, wear a bracelet and inform your traveling companions.

Impact on Boating
Simple non-life threatening symptoms can be tolerated with minimal impact on
boating. They can usually be controlled with non-prescription remedies. Life threatening symptoms such as persistent difficulty breathing or uncontrolled high or low blood pressure may require immediate evacuation to nearest medical facility for physician evaluation and treatment.Gallstones is the popular term for several chronic conditions of the gallbladder, including biliary colic and cholelithiasis; they are characterized by the presence of gallstones in your bile ducts or gallbladder. Gallstones may obstruct your biliary system and prevent the excretion of bile into your duodenum. If you have gallstones, pressure on your abdomen will cause or increase pain. The pain may be episodic and transitory, however. The condition can worsen and result in prolonged, acute episodes of pain. Cirrhosis, diabetes, hemolysis (the rupture or destruction of red blood cells) and Crohn's disease may elevate your risk of gallstones. A gallbladder typically generates pain and cramping in the upper right quadrant of your abdomen, just below your right rib cage.

The pain may radiate to your right shoulder and scapula (shoulder blade). Gallstones are classically seen in obese women more than 40 years old, but they also occur in a wide range of the general population. In fact, gallstones are found in more than 5 percent of asymptomatic people.

The key symptom of gallstones is pain in the upper right quadrant of the abdomen, radiating to the back, often after a fatty meal. However, such pain can occur at other times, too, often at night. The pain from gallstones is usually unaffected by your position, by whether you have or have not had a bowel movement, or by flatus (abdominal gas). Gallstones may also cause nausea and vomiting. Imaging studies are typically required to confirm a diagnosis of gallstones. A worsening of upper-right-quadrant pain, accompanied by fever and chills, is likely caused by inflammation of the gallbladder, known as cholecystitis; in such a case, prompt medical attention is indicated. If you're far from medical expertise, you may be able to distinguish cholecystitis from simple cholelithiasis, or gallstones, by having someone palpate (apply gentle but firm pressure) to the area just under your right rib cage. If you have cholecystitis, palpation while you're taking a deep breath will often elicit sharp pain, due to the inflammation caused by the infection. Simple cholelithiasis, on the other hand, seldom elicits sharp pain upon palpation.

If you suspect you simply have cholelithiasis while you're boating, you can usually manage the pain with analgesics. You should also avoid fatty foods, as they may make the symptoms recur or worsen. In some cases, however, the pain may be too severe for an affected individual to do much work aboard the boat. Severe pain, nausea and/or vomiting or cramps may necessitate light duties or even bed rest for a period of 2 to 6 hours. On the other hand, if you suspect you may have cholecystitis — if your pain is accompanied by generalized symptoms, including fever and chills — you should seek evacuation and prompt medical care. If it's possible to start an IV, that can help keep the affected individual hydrated and facilitate the administration of antibiotics. Cholecystitis often requires removal of the gallbladder in a surgical procedure known as a cholecystectomy. Some individuals also experience occasional biliary colic, or the temporary blockage of a bile duct. Conservative, nonsurgical treatment of biliary colic is reasonable for most people. But if you have experienced biliary colic and plan to go on an extended voyage, far from adequate medical care for a prolonged period of time, you should discuss the advisability of surgery with your physician, since the chance of complications like cholecystitis increases 2 to 3 percent a year in individuals who suffer from biliary colic.

To prevent gallstones, avoid foods that may exacerbate or cause symptoms; the consumption of coffee, vitamin C, polyunsaturated fat and nuts has been linked to the development of gallstones. Obesity and a sedentary lifestyle, as well as rapid weight loss, may also increase the risk of gallstones.Heartburn has nothing to do with the heart. It is a symptom of a condition called gastroesophageal reflux disease (GERD) — a burning sensation in the center of your chest and your upper abdomen. It is caused by the leakage of acidic fluids from your stomach into the lower portion of your esophagus. The esophagus cannot tolerate acids as well as the stomach, and the presence of stomach acids in the esophagus causes inflammation and pain. Heartburn is often worsened by large meals, certain types of food, bending forward, straining, or lying flat (especially after meals or in the morning). Reflux is common, especially in pregnant women, obese individuals, those who eat spicy foods or eat late at night and those who drink excessive amounts of alcohol.

The most common symptom of GERD is a burning sensation in the center of the chest; the sensation typically moves up the esophagus toward the back of the throat. It is often associated with belching, nausea, a chronic dry cough, a sour or bitter taste in the back of the mouth, discomfort when swallowing and occasionally hoarseness. The abdominal pain is usually worse after meals and is often accompanied by a sensation of fullness or bloating, but this is not always present in every person. Over time, the leaking of acids into your esophagus can cause permanent damage. GERD is diagnosed primarily based on your history, except in extreme circumstances, when a procedure called endoscopy — the use of a flexible tube to look down your esophagus — may be performed in your doctor's office.

The best treatment for GERD is to avoid of foods and habits that worsen reflux. Once symptoms start, treatments are mostly lifestyle-associated and include elevating the head of your bed at least six inches so gravity helps prevent leaking stomach acids from moving upward; eating smaller-portioned meals at least 3 to 4 hours before lying down or going to bed; avoiding late-night snacks or alcohol before bedtime; limiting foods that can worsen reflux (see the "Prevention" section below); refraining from smoking; wearing loose-fitting clothing to reduce abdominal pressure, which may increase reflux; and maintaining a healthy weight. Medications, including over-the-counter antacids, may help reduce acid reflux, but some antacids have side effects — including constipation, diarrhea and/or decreased absorption of other medications — so their chronic use is not recommended. Other medications for GERD include drugs called H2 blockers and proton-pump inhibitors. They are both effective medications and worth having on hand, but they work slowly over time rather than offering immediate relief of acute symptoms. Only if reflux is associated with severe, unremitting abdominal pain or with bloody vomiting is emergency treatment warranted.

The best way to avoid GERD is to avoid the foods that lead to increased acid production in the stomach and that are commonly associated with worsening reflux. Such foods include citrus fruits, chocolate, caffeine, spicy foods, fatty foods, fried foods, garlic, onions, peppermint and tomatoes. The lifestyle modifications mentioned in the "Treatment" section above can also be helpful in preventing GERD.Hemorrhoids are swollen blood vessels in the rectum. They are characterized by itching, burning, pain or swelling in the rectal area. Symptoms can occur both during defecation and while at rest. Hemorrhoids are classified as either internal or external. Internal hemorrhoids are inside the rectum and are therefore not visible upon external examination. External hemorrhoids can be seen and felt upon external examination — usually a swollen, flesh-colored to purplish lump. Hemorrhoids are common in individuals with chronic constipation or diarrhea, pregnant women and the elderly. Straining during bowel movements or sitting too long on the toilet can worsen preexisting hemorrhoids.

The most common symptoms of hemorrhoids are itching around the anus, rectal pain, swelling of the tissue around the anus and painless rectal bleeding. Bleeding associated with hemorrhoids is usually limited to a small amount of bright red blood in the toilet or on your toilet paper after wiping. Anyone experiencing rectal bleeding should be evaluated by a physician to determine the definite cause. However, if you're experiencing only intermittent, bright-red bleeding from your rectum, rather than bloody stools, the problem can typically be managed at a later date. But if you exhibit signs of significant blood loss (lightheadedness, generalized weakness, fatigue, headache or passing out for no apparent reason), you should seek prompt medical evaluation.

Hemorrhoids often are easily treatable at home. They may be painful but are not life-threatening. The pain is often worse after a bowel movement, but it can typically be relieved by applying a topical medication, resting and avoiding constipation and/or straining while moving your bowels. If you have hemorrhoids caused by a problem like constipation, you should treat the underlying cause with stool softeners or laxatives, as well as a diet rich in fiber, whole grains and plenty of water. Pain from hemorrhoids can be relieved with pramoxine ointment, hydrocortisone rectal cream or benzocaine ointment. Soaking the area in warm water can also help with the pain and irritation of hemorrhoids. Hemorrhoids that are extremely painful or not responding to the measures described here may need treatment by a physician, usually at your convenience rather than on an urgent basis.

The best way to prevent hemorrhoids is to avoid constipation and straining when having a bowel movement. This can be done by staying well hydrated, eating plenty of fruits and vegetables and/or taking fiber supplements or stool softeners.


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