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GASTROENTEROLOGY

INDIGESTION AND HEARTBURN

 

Indigestion is a nonspecific term used to describe discomfort in your abdomen that often occurs after eating. Indigestion is not a disease. It is a collection of symptoms, including discomfort or burning in your upper abdomen, nausea and a bloated or full feeling that belching may relieve.

The cause of indigestion is sometimes difficult to pinpoint. In some people, eating certain foods or drinking alcohol may trigger it. A common form of indigestion is heartburn. Each day, as many as 10 percent of adults experience the burning sensation commonly called heartburn. Technically called gastroesophageal reflux, heartburn occurs when stomach acids back up into your esophagus (food pipe). A sour taste and the sensation of food coming back into your mouth may accompany the burning sensation behind your breastbone.

Why do these acids back up? Normally, a circular band of muscle at the bottom of your esophagus, called a sphincter, closes off the stomach but allows food to enter your stomach when you swallow. If the sphincter relaxes abnormally or becomes weakened, stomach acid can wash back up (reflux) into your esophagus and cause irritation.

Various factors can cause reflux. Being overweight puts too much pressure on your abdomen. Some medications, foods and beverages can relax the esophageal sphincter muscle or irritate the esophagus.

Overeating or lying down after a meal also can encourage reflux.

 

Self-care

Changing what and how you eat is the first step to prevent heartburn.

Manage your weight. Slim down if you are overweight.

Eat small, frequent meals.

Avoid foods and drinks that relax the esophageal sphincter or irritate the esophagus (such as fatty foods, alcohol, caffeinated or carbonated beverages, decaffeinated coffee, peppermint, spearmint, garlic, onion, cinnamon, chocolate, citrus fruits and juices and tomato products).

Stop eating 2 to 3 hours before you lie down or go to bed.

Elevate the head of your bed.

Quit smoking; eliminate nicotine use.

Do not wear tight clothing and tight belts.

Avoid excessive stooping or bending or heavy exertion for 1 hour after eating.

Over-the-counter antacids can relieve mild heartburn by neutralizing stomach acids temporarily. However, prolonged or excessive use of antacids containing magnesium can cause diarrhea.

Calcium- or aluminum-based products can lead to constipation.

Another type of medication such as Pepcid, Tagamet and Zantac may relieve or prevent heartburn symptoms by reducing the production of stomach acid. These medicines are available in over-the-counter and prescription strengths.

 

Medical help

Most problems with indigestion and heartburn are occasional and mild. But if you have severe or daily discomfort, don’t ignore your symptoms. Left untreated, chronic heartburn can cause scarring in the lower esophagus. This can make swallowing difficult. In rare cases, severe heartburn can lead to a condition called Barrett’s esophagus, which may increase your risk for cancer. Heartburn and indigestion symptoms may signal the presence of a more serious underlying disease. Contact your health care pro- vider if your symptoms are persistent or severe, or if you have difficulty in swallowing.

 

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

 

 

HEMORRHOIDS AND RECTAL BLEEDING

 

More than 75 percent of Americans have problems with hemorrhoids at some time in their lives. Itching, burning and pain around the anus may signal their presence. You also may notice small amounts of bright red blood on your toilet tissue or in the toilet bowl.

Hemorrhoids occur when veins in your rectum become enlarged. They usually form over time as you strain to pass hard stools. Hemorrhoids may develop inside the anal canal or protrude outside the anal opening. Lifting heavy objects, obesity, pregnancy, childbirth, stress and diarrhea also can increase the pressure on these veins and lead to hemorrhoids. This condition seems to run in families.

In addition to hemorrhoids, bleeding from the rectum can occur for other reasons, some of which can be serious. Passing hard, dry stools may scrape the anal lining. An infection of the lining of the rectum or tiny cracks or tears in the lining of your anus called anal fissures also can cause rectal bleeding. With these types of problems, you may notice small drops of bright red blood on your stool, on your toilet tissue or in the toilet bowl.

Black, tarry stools, maroon stools or bright red blood in your stools also may signal more extensive bleeding elsewhere in your digestive tract. Small sacs that protrude from your large intestines (called diverticula), ulcers, small growths called polyps, cancer and some chronic bowel disorders can all cause bleeding.

 

Self-care

Although uncomfortable, hemorrhoids are not a serious medical condition. Most hemorrhoids respond well to the following self-care measures:

Drink at least 8 to 10 glasses of water each day and eat plenty of high-fiber foods such as wheat bran cereal, whole wheat bread, fresh fruit and vegetables.

Bathe or shower daily to cleanse the skin around your anus gently with warm water. Soap is not necessary and may aggravate the problem.

Stay active. Exercise. If at work or home you must sit or stand for long periods, take quick walks or breaks from work.

Try not to strain during bowel movements or sit on the toilet too long.

Take warm baths.

Apply ice packs.

For flares of pain or irritation, apply over-the-counter creams, ointments or pads containing witch hazel or a topical numbing agent. Keep in mind that these products can only help relieve mild itching and irritation.

Try fiber supplements (Metamucil, Citrucel) to keep stools soft and regular.

 

Medical help

Hemorrhoids become most painful when a clot forms in the enlarged vein. If your hemorrhoids are extremely painful, your health care provider may prescribe a cream or suppository containing hydrocortisone to reduce inflammation. Some troublesome internal hemorrhoids may require operation or other procedures to shrink or

eliminate them.

Diagnosing the cause of rectal bleeding can be difficult. You should see your health care provider for evaluation. Seek immediate emergency care if you notice large amounts of rectal bleeding, light-headedness, weakness or rapid heart rate (more than 100 beats per minute).

 

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

 

 

 

WHAT IS A PEPTIC ULCER?

Too much stress, too much spicy food, and you may be headed for an ulcer— or so the thinking used to go.

Not long ago, the common belief was that peptic ulcers were a result of lifestyle. A great deal has changed. Doctors now know that a bacterial infection or medication, not stress or diet, causes most ulcers. And instead of taking months or years to treat,

ulcers can often be cured in 2 to 4 weeks.

Peptic ulcers are open sores that develop on the inside lining of your stomach or upper small intestine. The most prominent symptom of a peptic ulcer is pain.

There are two types of peptic ulcers. A peptic ulcer that occurs in your stomach is called a gastric ulcer. If the ulcer develops in your small intestine, it’s named for the section of the intestine where it develops. The most common is a duodenal (doo-o-DEE-nul) ulcer that develops in the duodenum, the first part of the small intestine.

Peptic ulcers are common. Five percent to 10 percent of Americans experience a peptic ulcer at some point in their lives. The good news is that the rate of bacterial infections that can cause some peptic ulcers seems to be dropping in the United States.

 

Signs and Symptoms

Gnawing pain is the most common symptom of a peptic ulcer. The pain is caused both by the ulcer and by acid coming in contact with the ulcerated area. The pain typically may:

-Be felt anywhere from your navel to your breastbone

-Last from a few minutes to many hours

-Be worse when your stomach is empty

-Flare at night

-Often be temporarily relieved by eating food or by taking an acid-reducing medication

Less often, ulcers may cause severe signs or symptoms such as:

-Vomiting blood --which may appear red or black

-Dark blood in stools or stools that turn black or tarry

-Nausea or vomiting

-Unexplained weight loss

-Pain in the upper back

Causes

Although stress and spicy foods were once thought to be the main causes of peptic ulcers, doctors now know that many ulcers are caused by the corkscrew-shaped bacterium Helicobacter pylori . A major breakthrough in the understanding and treatment of peptic ulcers occurred in 1983, when two Australian researchers found H. pylori in biopsy specimens of people who had ulcers and persistent stomach inflammation (gastritis).

H. pylori lives and multiplies within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame and erode digestive tissues, producing an ulcer. Approximately one in six people infected with H. pylori get an ulcer. One reason may be that these people already have damage to the lining of the stomach or small intestine, making it easier for bacteria to invade and inflame tissues. H. pylori may be the most common gastrointestinal infection in the world. Eighty percent of people in developing countries are infected. In the United States, 20 percent of young adults and half of people older than age 60 are infected. Although it’s not clear exactly how H. pylori spreads, it appears to be transmitted from person to person by close contact.

H. pylori is the most common, but not the only, cause of peptic ulcers. H. pylori accounts for about half of all peptic ulcers in the United States. In certain populations, such as inner cities with crowded conditions and a low socioeconomic standard of living, the rate of H. pylori infection is higher than in other parts of the country.

Besides H. pylori , other causes of peptic ulcers, or factors that may aggravate them, include:

Regular use of pain relievers

Nonsteroidal anti-inflammatory drugs (NSAIDS) can irritate or inflame the lining of your stomach and small intestine. The medications are available both by prescription and over the counter.

Nonprescription NSAIDS include aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve) and ketoprofen (Orudis). To help avoid digestive upset, take NSAIDS with meals.

About 20 percent of people who take NSAIDS regularly develop ulcers. The drugs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormonelike substances help protect your stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers.

It’s uncertain, but seems possible, that regular use of NSAIDS also may increase the risk of ulcers in people infected with H. pylori.

Smoking

Nicotine in tobacco increases the volume and concentration of stomach acid, increasing your risk of an ulcer. Smoking also may slow healing during ulcer treatment.

Excessive alcohol

Alcohol can irritate and erode the mucous lining of your stomach and intestines, causing inflammation and bleeding. It’s uncertain, however, whether this alone can progress into an ulcer or whether other contributing factors must be present, such as H. pylori bacteria or ulcer-causing medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).

The role of stress

Although stress isn’t a cause of peptic ulcers, it is a contributing factor. Stress may aggravate symptoms of peptic ulcers and in some cases delay healing. You may undergo stress for a number of reasons -- an emotionally disturbing circumstance or event, surgery or a physical trauma, such as a burn or other severe injury.

 

When to Seek Medical Advice

An ulcer isn’t something that you should treat on your own, without a doctor’s help. Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the relief is always short-lived. With a doctor’s help, you can find prompt relief from ulcer pain as well as a lifelong cure from the disease.

Screening and Diagnosis

An ulcer is generally discovered in one of two ways. Your doctor may begin with an upper gastrointestinal (GI) X-ray outlining your stomach and duodenum. Before the X-ray, you swallow a white, metallic liquid (barium) that coats your digestive tract and makes an ulcer more visible. An upper GI X-ray can detect some ulcers, but not all.

Endoscopy may follow an upper GI X-ray if the X-ray suggests a possible ulcer, or your doctor may perform endoscopy first in place of an X-ray. In this more sensitive procedure, a long, narrow tube with an attach-camera is threaded down your throat and esophagus into your stomach and duodenum. With this instrument, your doctor can view your upper digestive tract and identify an ulcer. If an ulcer is found, your doctor may remove small tissue samples (biopsy) near the ulcer. These samples are examined under a microscope to rule out stomach cancer. A biopsy can also identify the presence of H. pylori in your stomach lining.

Because cancer of the duodenum is rare, a biopsy of a duodenal ulcer is seldom necessary.

In addition to a biopsy, three other tests can determine if the cause of your ulcer is H. pylori infection:

-Blood test. This test checks for the presence of H. pylori antibodies. A disadvantage of this test is that it sometimes can’t differentiate between past exposure and current infection. After H. pylori bacteria have been eradicated, you may still get a positive result for many months.

-Breath test. This procedure uses a radioactive carbon atom to detect H. pylori. First, you blow into a small plastic bag, which is then sealed. Then you drink a small glass of clear, tasteless liquid. The liquid contains radioactive carbon as part of a substance (urea) that will be broken down by H. pylori. Thirty minutes later you blow into a second bag, which also is sealed. If you’re infected with H. pylori, your second breath sample will contain the radioactive carbon in the form of carbon dioxide. It takes about a day to get the test results. If you’re taking a medication called a proton pump inhibitor, it’s important that you stop taking the medication for at least 3 days

before the breath test, because the medication can interfere with the test results.

The breath test is sensitive to the presence of H. pylori nearly 90 percent of the time. That’s similar to the blood test. The advantage of the breath test is that it can monitor the effectiveness of treatment to eradicate H. pylori detecting almost immediately when the bacteria have been killed or eradicated. With the blood test, H. pylori antibodies may sometimes still be present a year or more after the infection is gone.

-Stool antigen test. This newer test checks for H. pylori in stool samples. It’s useful in helping to diagnose H. pylori infection. It may also be useful in monitoring the success of treatment.

 

Complications

Left untreated, peptic ulcers can cause internal bleeding and can “eat” a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis). The ulcer can also irritate or inflame your pancreas, leading to pancreatitis and disrupting the functions of that organ.

Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight. On rare occasions, a gastric ulcer may be malignant.

 

Treatment

Because most ulcers stem from H. pylori bacteria, doctors use a two-pronged approach:

-Kill the bacteria.

-Reduce the level of acid in your digestive system to relieve pain and encourage healing.

Accomplishing these two steps requires the use of at least two, and sometimes three or four, of the following medications:

Antibiotics

Several combinations of antibiotics kill H. pylori . Most of the medications are equally effective, killing the bacteria nearly 90 percent of the time. However, for the treatment to work, it’s essential that you follow your doctor’s instructions precisely. Antibiotics most commonly prescribed for treatment of H. pylori include amoxicillin (Amoxil, Wymox), clarithromycin (Biaxin), metronidazole (Flagyl) or tetracycline (Achromycin). Some pharmaceutical companies package a combination of two antibiotics together, with an acid suppressor or cytoprotective agent specifically for treatment of H. pylori infection. These combination treat- ments are sold under the names Prevpac and Helidac.

You’ll need to take antibiotics for only 1 to 2 weeks, depending on the type and number your doctor prescribes. Other medications prescribed in conjunction with antibiotics generally are taken for a longer period.

Acid blockers

Acid blockers — also called histamine (H2) blockers -- reduce the amount of hydrochloric acid released into your digestive tract to relieve ulcer pain and encourage healing.

Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric

acid.

Available by prescription or over-the-counter (OTC), acid blockers, include the medications ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid) and cimetidine (Tagamet). For treatment of ulcers, prescription acid blockers are more effective because they’re stronger than OTC products.

Antacids

Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one.

Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.

Proton pump inhibitors

A more effective way to reduce stomach acid is to shut down the “pumps” within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. They include the prescription medications omeprazole, lansoprazole, rabeprazole and esomeprazole. Another drug, pantoprozole, can be taken orally or administered intravenously in the hospital. Proton pump inhibitors also appear to inhibit H. pylori . However, the drugs cost almost twice as much as acid blockers. Uncommon side effects include stomach pain, diarrhea and headache.

 

Cytoprotective agents

These medications are designed to help protect the tissues that line the stomach and small intestine. They include the prescription medications sucralfate and misoprostol. The drugs carry some side effects. Sucralfate may cause constipation.

Misoprostol may cause diarrhea and uterine bleeding. Misoprostol shouldn’t be taken by pregnant women because it can cause miscarriage.

Another cytoprotective agent is bismuth subsalicylate. In addition to protecting the lining of your stomach and intestines, bismuth preparations appear to inhibit H. pylori activity.

Ulcers that fail to heal

Approximately 90 percent of all peptic ulcers heal within 1 to 3 months. Those that don’t are called refractory ulcers. There are many reasons why an ulcer may fail to heal. Not taking medications according to directions is one reason. Another is that some types of H. pylori are resistant to antibiotics. Other factors that can interfere with the healing process include regular use of tobacco, alcohol or nonsteroidal anti-inflammatory drugs (NSAIDS). Sometimes the problem is accidental: People are unaware that a medication they’re taking contains an NSAID.

In rare cases, refractory ulcers may be a result of extreme overproduction of stomach acid, an infection other than H. pylori, or other digestive diseases, including Crohn’s disease or cancer. Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with stronger doses of ulcer medications. Sometimes, additional medications may be included. Surgery to help heal an ulcer is necessary only when the ulcer doesn’t respond to aggressive drug treatment.

 

Self-care

Before the discovery of H. pylori, people with ulcers were often placed on a restricted diet and told to reduce the amount of stress in their lives. Now that food and stress have been eliminated as causes of ulcers, these factors no longer apply. However, while an ulcer is healing, it’s still advisable to watch what you eat and to control stress. Acidic or spicy foods may increase ulcer pain. The same is true for stress. Stress may increase acid and slow digestion, allowing food and digestive acid to remain in your stomach and intestines for a longer period. If stress is severe, it may delay the healing of an ulcer.

Your doctor may also suggest these steps:

-Don’t smoke. Smoking interferes with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid.

-Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding.

-Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). If you use pain relievers regularly, use acetaminophen (Tylenol, generics).

Regular use of NSAIDs inhibits production of an enzyme that makes prostaglandins. These substances protect your stomach lining from chemical and physical injury. Without prostaglandins, stomach acids can erode the lining, causing bleeding and ulceration.

 

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

 

NEW TREATMENT FOR PEPTIC ULCERS

 

A two-drug combination is the latest step toward simplifying the treatment of what was once a very misunderstood disease. The Food and Drug Administration allows medications such as Prilosec, Prevacid, Aciphex or Protonix, which suppress stomach acid production, in combination with an antibiotic called Biaxin for the treatment of peptic ulcers. The two drugs are used together for 14 days, followed by 14 days of treatment with the acid-suppressant alone. This treatment approach is the latest refinement in an effort to cure a common illness that was once thought to be incurable.

 

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

 

 

 

WHAT IS HEPATITIS A?

Each year, an estimated 23,000 Americans contract hepatitis A — a highly contagious liver infection caused by the hepatitis A virus (HAV). Like other hepatitis viruses, HAV causes the liver to become inflamed, which affects its ability to function.

This is significant because the liver performs dozens of essential tasks—detoxifying harmful substances, aiding in digestion and manufacturing vital nutrients.

Most people contract hepatitis A from contaminated food or water or from close contact with someone who’s already infected.

You’re especially at risk if you’re an international traveler —particularly if you’re visiting a developing country.

Fortunately, in most cases of hepatitis A, the liver heals completely without serious problems. Mild cases don’t require treatment, and most people who are infected recover completely with no permanent liver damage. Unlike hepatitis B and C, hepatitis A doesn’t develop into chronic hepatitis or cirrhosis — both potentially fatal conditions. In addition, effective vaccines are available for people who are most at risk.

Signs and Symptoms

Some people may have hepatitis A and never develop symptoms. Young children, especially, tend to have mild cases, while symptoms in older children and adults are likely to be more severe. In general, you will have the virus for 2 to 3 weeks before developing any symptoms. When symptoms do appear, they often come on suddenly, and you may mistake them for intestinal flu.

Common symptoms include:

- Fatigue.

- Nausea and vomiting.

- Abdominal pain or discomfort, especially in the area of your liver on the right side beneath your lower ribs.

- Loss of appetite.

- Low-grade fever.

- Yellowing of the skin and the whites of the eyes (jaundice). Not all people with hepatitis A develop jaundice. It occurs when your liver isn’t able to remove the residue of old red blood cells — known as bilirubin — from your blood. Eventually, the level of bilirubin builds up and is deposited in the skin, causing a yellow color.

- Muscle pain.

- Itching.

You’ll likely have more energy after symptoms disappear, and your liver may be completely healed within 1 or 2 months. About 15 percent of people with hepatitis A will have relapses over a 6- to 9-month period, however.

 

Causes

Your liver is located on the right side of your abdomen, just beneath your lower ribs. It performs more than 500 vital functions, including processing most of the nutrients absorbed from your intestine, removing drugs, alcohol and other harmful substances from your bloodstream and manufacturing bile –- the greenish fluid stored in your gallbladder that helps digest fats. Your liver also produces cholesterol, blood clotting factors and certain other proteins.

Because of the complexity of the liver and its exposure to so many potentially toxic substances, it would seem especially vulner- able to disease. But the liver has an amazing capacity for regeneration –- it can heal itself by replacing or repairing injured cells. It is also constructed so that healthy cells will take over the function of damaged cells, either indefinitely or until the damage has been repaired. Yet in spite of this, your liver is prone to a number of diseases, including viral hepatitis.

Hepatitis A is one of six currently identified strains of viral hepatitis—the others are B, C, D, E and G. The strains differ in severity and in the way they’re spread. HAV is usually transmitted via the “fecal-oral” route. That means someone with the virus handles food you eat without washing his or her hands after using the bathroom. You can also contract the virus by drinking contaminated water, eating raw shellfish from water polluted with sewage or being in close contact with a person who’s infected—even if that person has no symptoms. In fact, the disease is most contagious before symptoms ever appear.

 

Risk Factors

About one-third of Americans have antibodies to HAV, which means they have been exposed to the virus at some time in their life. You’re at increased risk if you:

- Travel or work in regions with high rates of hepatitis A. These include many countries in Africa, Asia, India and South America.

- You’re at some risk even if you stay in luxury hotels and are careful about what you eat.

- Live in an American Indian, Alaska Native or other community where lack of public services tends to lead to outbreaks of hepatitis A.

- Are a sexually active gay or bisexual man.

- Work in a research setting where you may be exposed to the virus.

- Have hemophilia, or receive clotting-factor concentrates for another medical condition. Rarely, hepatitis A may be transmitted through blood transfusions.

In general, food handlers, health care workers and children who attend child care are not at increased risk of contracting HAV.

Although outbreaks of hepatitis A sometimes occur in child-care settings, they can be prevented if workers follow good hygiene practices.

 

Screening and Diagnosis

See your doctor if you have symptoms of hepatitis A or think you may have been exposed to the virus. Tests can accurately diagnose whether you’ve been infected. In some cases, your doctor may check the amount of bilirubin in your blood. Normally this residue of worn-out red blood cells is metabolized in your liver and excreted in your urine. But hepatitis interferes with your liver’s ability to metabolize bilirubin, leading to higher levels in your blood. Your doctor may also look for elevated blood levels of enzymes known as aminotransferases, which are released when your liver is damaged.

Although both these tests can suggest the presence of hepatitis, you’ll need a blood test called a radioimmunoassay to pinpoint the exact type of hepatitis you have. This test identifies antibodies your immune system has formed in response to the presence of antigens —proteins that are unique to a particular virus. Antibodies may not appear for weeks or even months after you develop hepatitis, so having the test too soon may give a false- negative result. In addition, you continue to have antibodies even after you recover. For that reason, the presence of some antibodies doesn’t necessarily indicate an active infection.

 

Complications

In most cases of hepatitis A, the liver heals completely in a month or two with no lasting damage. Furthermore, the virus doesn’t remain in your body once you’ve recovered. Older adults and people with other medical problems such as congestive heart failure, diabetes and anemia may take longer to recover and are likely to have a more serious course of the disease. In rare cases, fulminant hepatitis –- a life-threatening condition that causes liver failure –- may develop. Especially at risk are people with chronic liver disease or a liver transplant. In addition, some studies suggest that the inflammation triggered by hepatitis A may contribute to hardening of the arteries (atherosclerosis)—the gradual buildup of hardened deposits in your arteries.

Treatment

No specific treatment exists for hepatitis A. Instead, the main focus is on making sure you get adequate nutrition and avoiding any permanent liver damage. If you’re nauseated, eating small snacks throughout the day instead of three large meals may help. Soft, easily digested foods such as soup or broth, yogurt and toast may be the most appealing. You may also find you can tolerate food better in the morning than later in the day. As soon as you’ve received a diagnosis of hepatitis A, talk to your doctor about any medications you take, including those you buy over-the-counter. Your doctor may recommend stopping or changing some of them. Also, avoid drinking alcohol during the acute phase of your illness. Even after you’ve recovered, don’t mix alcohol and acetaminophen (Tylenol, others), which can cause liver damage even in people who haven’t had hepatitis.

 

Prevention

Hepatitis A is highly contagious. Preventing the spread of the virus involves protecting both yourself and others from infection.

 

Protecting yourself

The following measures can help protect you from HAV infection: Receive immune globulin or a hepatitis vaccine. The best way to protect yourself is to receive an injection of immune globulin—a preparation of antibodies—or a hepatitis vaccine. Immune globulin provides short-term protection, while a hepatitis vaccine may protect you for up to 20 years. The Food and Drug Administration (FDA) approved the first vaccines for hepatitis A in the mid- 1990s. These vaccines— Havrix and Vaqta—contain inactivated forms of HAV and are safe for children over age 2 as well as for most adults, including those with compromised immune systems. At-risk children under 2 years of age should receive immune globulin. The vaccine causes only minor side effects, although allergic reactions can sometimes occur. Because it takes 4 weeks for the vaccine to take effect, get an immune globulin shot if you’re traveling to a high-risk region before you’re fully immunized. In addition, get a booster shot in 6 to 12 months.

The FDA approved another hepatitis vaccine, Twinrix, in May 2001. Twinrix protects people 18 years of age and older against both HAV and the hepatitis B virus (HBV). Studies have shown Twinrix to be as effective as the separate HAV and HBV vaccines. The side effects are usually minor and include soreness at the injection site, headache and fatigue. These symptoms should disappear within 48 hours. If you’re at high risk of hepatitis A and don’t have health insurance, talk to your state or county health department. In most areas, free or low-cost vaccines are available.

Keep in mind that if you’ve already had hepatitis A, you won’t need to be immunized because you’ve developed your own protective antibodies. These antibodies won’t protect you from other forms of hepatitis, however.

Follow safety precautions for international travelers. If you’re traveling in regions where hepatitis A outbreaks occur, you can help prevent infection by peeling and washing all fresh fruits and vegetables yourself and by avoiding raw or undercooked meat and fish. Be sure to drink bottled water and avoid ice cubes in beverages. If bottled water isn’t available, boil tap water for at least 10 minutes before drinking. Don’t forget to use bottled water for tooth brushing and try not to sing in the shower! Follow good hygiene practices. Simply washing your hands well and often can help protect you from infection with a number of viruses and bacteria. Wash after using the bathroom, before preparing food or eating, and after changing a child’s diaper. In addition, don’t share towels, eating utensils or toothbrushes.

 

Protecting others

If you have hepatitis A, the following measures can help prevent you from passing the virus to others:

If you’re a gay or bisexual man, avoid sexual activity. Because HAV can be transmitted through oral-anal and digital-anal activity, using a condom won’t necessarily protect your partner.

Wash your hands thoroughly after using the bathroom. Scrub vigorously for at least 10 seconds and rinse well. If possible, dry your hands with a disposable towel.

Keep your utensils separate from those used by other members of your household. Wash utensils and dishes in a dishwasher or with plenty of hot, soapy water.

Don’t prepare food for others while you’re actively infected.

 

Complementary and Alternative Medicine

In Europe, the herb milk thistle (Silybum marianum ) has been used for centuries to treat jaundice and other liver disorders. Today, scientific studies have confirmed that the chief constituent of milk thistle, silymarin, may aid in healing and rebuilding the liver. Silymarin seems to stimulate the production of antioxidant enzymes that help the liver neutralize toxins. It also seems to increase the production of new liver cells and may even improve the severe scarring of cirrhosis. But although milk thistle can help the liver, it won’t cure hepatitis and it won’t protect you from contracting the virus. Milk thistle is available in capsules or alcohol-free extracts. Check with your doctor before trying this or any other herb to make sure it won’t interact with other medications you’re taking.

 

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER).

 

 

WHAT IS HEPATITIS B?

 

Hepatitis B is a serious liver infection caused by the hepatitis B virus (HBV). More than 1 billion adults and children are infected with HBV worldwide. In the United States, 1 in every 20 people will contract the virus some time in their life.

HBV is transmitted in the blood and body fluids of someone who is infected—the same way the human immunodeficiency virus (HIV), the virus that causes AIDS, spreads. Yet hepatitis B is nearly 100 times more infectious than HIV. You’re especially at risk if you are an intravenous (IV) drug user who shares needles or other paraphernalia, have unprotected sexual contact with an infected partner, or were born in or travel to parts of the world where hepatitis B is widespread. In addition, women with HBV can pass the infection to their babies during childbirth.

In some people, HBV infection can become chronic, leading to cirrhosis —a condition that causes permanent liver damage— liver failure or liver cancer. As many as 5,000 Americans die each year of a hepatitis B-related illness. Worldwide, the virus kills nearly 1 million people annually.

Most people infected as adults recover fully from hepatitis B, even if their symptoms are severe. Infants and children are much more likely to develop a chronic infection.

Although no cure exists for hepatitis B, a highly effective vaccine can prevent the disease. The vaccine is now administered to most children in the United States along with their other routine immunizations. Adolescents who haven’t been vaccinated and at-risk adults should also receive the vaccine. If you’re already infected, taking certain precautions can help prevent HBV from spreading to others.

 

Signs and Symptoms

Most infants and children with hepatitis B never develop symptoms. The same is true for about one-third of adults. Symptoms usually appear 4 to 6 weeks after you’re infected and can range from mild to severe. They may include some or all of the following:

- Loss of appetite.

- Nausea and vomiting.

- Weakness and fatigue.

- Abdominal pain, especially around your liver, which is located just below your ribs on your right side.

- Yellowing of the skin and the whites of the eyes (jaundice). This occurs when your liver isn’t able to remove the residue of old red blood cells—known as bilirubin— from your blood. Eventually, bilirubin builds up and is deposited in your skin, causing a yellow color.

Joint pain.

Hepatitis B can damage your liver — and spread to others— even if you don’t have any symptoms. That’s why it’s important to be tested if you think you’ve been exposed to hepatitis B or you engage in behavior that puts you at risk.

 

Causes

Your liver is located on your right side, just beneath your lower ribs. The largest internal organ in your body, it performs more than 500 vital functions, including processing most of the nutrients absorbed from your intestine, removing drugs, alcohol and other harmful substances from your blood and manufacturing bile— the greenish fluid stored in your gallbladder that helps digest fats. Your liver also produces cholesterol, vitamin A, blood-clotting factors and certain proteins.

Because of the complexity of the liver and its exposure to so many potentially toxic substances, it would seem especially vulnerable to disease. But the liver has an amazing capacity for regeneration —it can heal itself by replacing or repairing injured tissue. In addition, healthy cells take over the function of damaged cells, either indefinitely or until the damage has been repaired. Yet in spite of this, your liver is prone to a number of diseases that can cause serious or irreversible damage, including hepatitis B. Hepatitis B infection may be either acute —lasting less than 6 months— or chronic, lasting 6 months or longer. If the disease is acute, your immune system is able to clear the virus from your body and you should recover completely within a few months. When your immune system can’t fight off the virus, HBV infection may become lifelong, leading to serious illnesses such as cirrhosis and liver cancer.

Most people who acquire hepatitis B as adults have an acute infection. But the outlook isn’t nearly as hopeful for infants and children. Nearly 90 percent of infants infected with HBV during the first year of life and 30 percent to 50 percent of children infected between 1 and 4 years of age become chronically infected. Chronic infection may go undetected for as long as 20 to 40 years until a person becomes seriously ill from liver disease. Approximately 1.25 million Americans are chronically infected with HBV.

Hepatitis B is one of six currently identified strains of viral hepatitis—the others are A, C, D, E and G.

Each strain is unique, differing from the others in severity and in the way it spreads. In industrialized countries such as the United States, you’re most likely to become infected with HBV in the following ways:

Sexual transmission. You may become infected if you have unprotected vaginal, anal or oral sex with an infected partner whose blood, saliva, semen or vaginal secretions enter your body.

You can also become infected from shared sexual devices if they’re not washed or covered with a condom. The virus is present in the secretions of someone who’s infected and enters your body through small tears that can develop in your rectum or vagina during sexual activity.

Transmission through needle sharing. HBV is easily transmitted through needles and syringes contaminated with infected blood. That’s why sharing IV drug paraphernalia puts you at high risk of hepatitis B. Your risk increases if you inject drugs frequently or also engage in high-risk sexual behavior. Although avoiding the use of injected drugs is the most reliable way to prevent infection, you may not choose to do this. If so, one way to reduce your risk is to participate in a needle exchange program in your community. These programs allow you to exchange used needles and syringes for sterile equipment. In addition, consider seeking counseling or treatment for your drug use.

Transmission through accidental needle sticks. Hepatitis B is a concern for health care workers and anyone else who comes in contact with human blood. If you fall into one of these categories, get vaccinated against hepatitis B in addition to following routine precautions when handling needles and other sharp instruments.

Transmission from mother to child. Pregnant women infected with HBV can pass the virus to their babies. If you have hepatitis B, having your baby receive a shot of hepatitis B immune globulin (H-BIG) at birth, along with the first in a series of three hepatitis B vaccines, will greatly reduce your baby’s risk of getting the virus.

To become infected with HBV, infected blood, semen, vaginal secretions or saliva must enter your body. You can’t become infected through casual contact—hugging, dancing or shaking hands —with someone who has hepatitis B. You also can’t be infected in any of the following ways:

- Coming into contact with the sweat or tears of someone with HBV

- Sharing a swimming pool, telephone or toilet seat with someone who has the virus

- Donating blood

 

Risk Factors

Anyone of any age, race, nationality, sex or sexual orientation can be infected with HBV. But you’re at greatest risk of Hepatitis B if you:

- Have unprotected sex with more than one partner. You’re at risk whether you’re heterosexual, homosexual or bisexual.

Unprotected sex means having sex without using a new latex or polyurethane condom every time.

- Have unprotected sex with someone who’s infected with HBV.

- Have received a diagnosis of a sexually transmitted disease such as gonorrhea or chlamydia.

- Share needles during IV drug use.

- Share a household with someone who has a chronic HBV infection.

- Have a job that exposes you to human blood.

- Received a blood transfusion or blood products before 1970—the date the blood supply began to be tested for HBV. Today, the risk of contracting HBV per unit of donated blood is approximately 1 in 250,000. Furthermore, new methods of blood screening promise to make the blood supply even safer. Older tests screen donor blood for antibodies — substances produced by the immune system in response to invading organisms such as viruses. Nucleic acid testing, on the other hand, screens for the virus itself. This means tiny amounts of the virus can be detected before an antibody response ever occurs in a donor’s immune system.

- Receive hemodialysis for end-stage kidney (renal) disease.

-Travel to regions with high infection rates of HBV, such as sub-Saharan Africa, Southeast Asia, the Amazon Basin, the Pacific Islands and the Middle East.

- Are an adolescent or young adult residing in a United States correctional facility.

- Newborns whose mothers are infected with HBV are also at high risk.

- The same is true of infants and children whose parents were born in areas where HBV infection is widespread. In many developing countries, the most common method of transmission of the virus is between mother and child or among children living in the same household. In parts of sub-Saharan Africa, Asia and the Pacific, nearly all children are infected.

- You also can become infected with HBV even if you have no known risk factors for the disease.

 

When to Seek Medical Advice

Seek medical care if you have symptoms of hepatitis B or are at risk of the disease and haven’t been vaccinated or don’t know if you’re protected.

Most children in this country now receive HBV vaccine along with other routine shots. But some children—especially those who don’t have access to regular medical care or whose parents have emigrated from countries with high infection rates —may be overlooked. If your child hasn’t been vaccinated, contact a doctor, your state health department or a public health clinic. Many states offer low-cost or free vaccines for those who need them.

Lifelong monitoring of liver function and screening for liver cancer are important for adults and children with chronic HBV infection.

If you or your child has already developed signs of liver disease, your doctor will refer you to a specialist for additional care.

 

Screening and Diagnosis

If you’re pregnant, get screened for HBV early in your pregnancy.

Also get tested if you have unprotected sex with more than one partner, inject drugs or have emigrated from areas where hepatitis B is widespread.

If you adopt children from areas where hepatitis B is common, have your children tested when they arrive in the United States. Tests done in other countries may not always be reliable. To best meet the special needs of adopted children, make testing for HBV part of a comprehensive evaluation.

You or your child can be tested at your doctor’s office, a hospital or a public health clinic. Many public clinics offer free testing for HBV and other sexually transmitted diseases. Testing is important to protect yourself and your children and to prevent transmission of the virus to others.

Because you often don’t have symptoms with hepatitis B infection, doctors diagnose the disease on the basis of one or more blood tests. These tests include:

Hepatitis B surface antigen (HbsAg). Hepatitis B surface antigen is the outer surface of the virus. Testing positive for this antigen means you can easily pass the virus to others. A negative test means you’re not currently infected.

Antibody to hepatitis B surface antigen (Anti-HBs). A positive result on this test means you have antibodies to HBV. This may be due to a prior HBV infection from which you’ve recovered. Or, you may already have been vaccinated. In either case, you can’t infect others or become infected yourself; you’re protected by the vaccine or your own natural immunity.

Antibody to hepatitis B core antigen (Anti-HBc). Although this test identifies people who have a chronic infection, the results can sometimes be ambigious. If you test positive for hepatitis B core antibodies, you may have a chronic infection that you can transmit to others. But you also may be recovering from an acute infection or have a slight immunity to HBV that can’t otherwise be detected. How this test is interpreted often depends on the results of the other two tests. When the results are uncertain, you may need to repeat all three tests.

 

Additional tests

If you receive a diagnosis of hepatitis B, your doctor may perform tests to check the severity of the HBV infection as well as the health of your liver. These tests include:

- E-antigen test. This blood test looks for the presence of a protein secreted by HBV-infected cells. A positive result means you have high levels of the virus in your blood and can easily infect others. If the test is negative, you have lower blood levels of HBV

and are less likely to spread the infection.

- Liver tests. These blood tests check for elevated levels of liver enzymes such as alanine aminotransferase and aspartate aminotransferase, which leak into the bloodstream when liver cells are injured.

- Alpha-fetoprotein (AFP) test. High blood levels of this protein may sometimes be a sign of liver cancer.

- Liver biopsy. In this procedure, a small sample of liver tissue is removed for microscopic analysis. A biopsy can accurately show the extent of any liver damage and may help determine the best treatment for your hepatitis.

Complications

Having a chronic HBV infection may eventually lead to your developing serious liver diseases such as cirrhosis, liver failure and liver cancer. Having had HBV infection as an infant or child gives you a greater chance of developing these illnesses as an adult.

Cirrhosis causes permanent scarring of the liver. It also can lead to a number of other complications, including esophageal bleeding and severe fluid retention in the abdomen (ascites). Toxins that accumulate in the blood can affect mental functioning, leading to confusion and even coma (hepatic encephalopathy). In the United States, cirrhosis claims the lives of nearly 25,000 people

annually.

In addition, as many as 200 Americans die each year of hepatitis B-related acute liver failure —a condition in which all the vital

functions of the liver shut down. When that occurs, a liver transplant is necessary to sustain life.

The risk of chronic infection and death from cirrhosis, liver failure and liver cancer is inversely related to the age at which infection with HBV occurs. People who become chronically infected later in life have a 15 percent chance of dying of liver disease, while those chronically infected as infants and children have a 25 percent chance of dying from cirrhosis or liver cancer.

Anyone chronically infected with HBV is also susceptible to infection with another strain of viral hepatitis—hepatitis D. Formerly known as delta virus, the hepatitis D virus needs the outside coat of HBV in order to infect cells. You can’t become infected with hepatitis D unless you’re already infected with HBV.

Injection drug users with hepatitis B are most at risk, but you can also contract hepatitis D if you have unprotected sexual contact with an infected partner or live with someone infected with hepatitis D. Having both hepatitis B and hepatitis D makes it more likely you’ll develop cirrhosis or liver cancer.

 

Treatment

If you know you’ve been exposed to HBV, call your doctor immediately. Receiving an injection of hepatitis B immune globulin within 24 hours of coming in contact with the virus may help protect you from developing hepatitis B. You should also receive the first in a series of three shots of the hepatitis B vaccine.

Once you’ve developed chronic hepatitis B, few treatment options exist. In some cases —especially if you don’t have symptoms or liver damage —your doctor may suggest monitoring, rather than treating, your condition. In other cases, your doctor may recommend treatment with antiviral medications. When liver damage is severe, liver transplantation may be the only option.

 

Drug therapies

Doctors use two drugs to treat chronic HBV infection:

- Interferon. Your body naturally produces interferon to help protect against invading organisms such as viruses. Giving additional interferon that has been manufactured in a laboratory may stimulate your body’s immune response to HBV and help prevent the virus from replicating in your cells. Not everyone is a candidate for treatment with interferon. In a few cases, interferon eliminates the virus completely, although the infection can later return. Interferon has a number of side effects —many of which resemble symptoms of hepatitis B. These include depression, fatigue, muscle pains, body aches, fever and nausea.

Symptoms are usually worse during the first 2 weeks of treatment and in the first 4 to 6 hours after receiving an injection of interferon. You commonly receive three injections of interferon a week for 4 to 6 months. A more serious side effect that may occur over time is a decreased production of red blood cells. The Food and Drug Administration (FDA) recently approved the use of another drug, pegylated interferon. This medication is given just once a week and is an alternative to standard interferon treatments.

- Lamivudine (Epivir). This antiviral medication helps prevent HBV from replicating in your cells. It’s usually taken in pill form, once a day for 12 months. Lamivudine helps about 40 percent of people who take the medication. Common side effects include cough, diarrhea, nausea or vomiting and hair loss. If you experience worsening jaundice or any unusual bruising, bleeding or fatigue, call your doctor right away.

 

Liver transplantation

When your liver has been severely damaged, a liver transplant may be an option. The encouraging news is that these transplants are increasingly successful. Today, more than 90 percent of people are alive a year after having this procedure. Unfortunately, not enough donor organs are available for every person who needs a transplant.

Prevention

A hepatitis B vaccine (Engerix-B) has been available since 1981. It’s given in a series of three immunizations and provides more than 90 percent protection for both adults and children. Studies show this protection lasts years and may even be lifelong. In the last decade, the vaccine has been produced in the United States using recombinant DNA technology. That means the HBV antigen used in the vaccine is produced in a laboratory and not derived from the blood of people infected with the virus.

Almost anyone can receive the vaccine, including infants, older adults and those with compromised immune systems. Infants

often receive the vaccine in the first year of life — typically at 2, 4 and 9 months of age.

Side effects tend to be mild and may include weakness, fatigue, headache, nausea and soreness or swelling at the injection site. In recent years, concerns have been raised that the vaccine may trigger serious autoimmune diseases, especially multiple sclerosis (MS)—a potentially debilitating disease that affects the brain and spinal cord. These fears were fueled in the 1990s when several people developed MS shortly after receiving the hepatitis B vaccine.

In February 2001, the results of the first long-term study of the hepatitis B vaccine and MS were published in the New England Journal of Medicine . According to the study, researchers at the Harvard School of Public Health found no link between the administration of Engerix-B and MS.

Some people have also expressed concern that giving hepatitis B vaccine to infants may contribute to sudden infant death syndrome (SIDS). Between 1991 and 1998, 18 newborns died after receiving the hepatitis B vaccine, but investigators have been unable to establish a direct connection between these deaths and the vaccine.

Although vaccination is the best way to protect yourself and others from hepatitis B, the measures listed below can also help

keep you safe.

 

If you’re not infected with HBV

The following measures can help keep you from becoming infected with HBV:

- Educate yourself and others. Make sure you understand what HBV is and how the virus is transmitted.

- Know the HBV status of any sexual partner. Don’t engage in unprotected sex unless you’re absolutely certain your partner isn’t infected with HBV, HIV or any other sexually transmitted disease.

- Use a new latex or polyurethane condom every time you have sex. If you don’t know the health status of your partner, use a new latex condom every time you have anal or vaginal sex. If you’re allergic to latex, use a plastic (polyurethane) condom. Avoid lambskin condoms; they do not protect you from sexually transmitted viruses. If you don’t have a male condom, use a female condom. Use only water-based lubricants, not petroleum jelly, cold cream or oils. Oil-based lubricants can weaken condoms and cause them to break. During oral sex use a condom, dental dam (a piece of medical-grade latex) or plastic wrap. Remember that although condoms can reduce your risk of contracting HBV, they don’t eliminate the risk entirely. Condoms can break or develop small tears, and people don’t always use them properly.

- Use a sterile needle. If you use a needle to inject drugs, make sure it’s sterile, and don’t share it. Take advantage of needle exchange programs in your community and consider seeking help for your drug use.

-Talk to your doctor if you’re traveling internationally. If you’re planning an extended trip to a region where hepatitis B is endemic, ask your doctor about the hepatitis B vaccine well in advance. It’s usually given in a series of three injections over a 6-month period.

- Be cautious about blood products in certain countries. Although the blood supply is now well screened in the United States, this isn’t always the case in other countries. If an emergency requires that you receive blood or blood products in another country, get tested for HBV as soon as you return home.

- If you’re pregnant, get tested.

 

If you’re infected with HBV

If you’ve received a diagnosis of HBV, the following guidelines can help protect others:

- Follow safer sex practices. The only foolproof way to protect your sexual partner or partners from HBV infection is to avoid practices that expose them to blood, saliva, semen or vaginal secretions. Barring that, carefully follow guidelines for safer sex, including using a new latex condom every time you have vaginal or anal sex and a dental dam, condom or piece of plastic wrap during oral sex. If you use sexual devices, don’t share them.

-Tell your sexual partner(s) you have HBV. It’s important to tell anyone with whom you’ve had sex that you have HBV. Your partners need to be tested and receive medical care if they have the virus.

They also need to know their HIV status so they don’t infect others.

- Don’t share needles or syringes. If you use IV drugs, never share your needles and syringes with anyone.

- Don’t donate blood or organs.

- Don’t share razor blades or toothbrushes. These items may carry traces of infected blood. Some experts also suggest not sharing your comb, hairbrush and nail clippers.

- If you’re pregnant, be sure to tell your doctor you have HBV. That way, your baby can be treated as soon as he or she is born.

 

Self -care

If you’ve received a diagnosis of hepatitis B, your doctor will likely recommend certain lifestyle changes. These simple measures

will help keep you healthy longer:

- Avoid drinking alcohol. Alcohol speeds the progression of liver disease.

- Avoid medications that may cause liver damage. Your doctor can advise you about these medications, which may include over-

the-counter (OTC) medications as well as prescription drugs.

It’s especially important to avoid mixing acetaminophen (Tylenol, others), which can cause liver damage even in healthy people. - Eat the healthiest diet you can. Emphasize fresh fruits and vegetables, whole grains and lean protein. Healthy foods help<

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