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Gastrointestinal complaints and HIV

Related Terms

Acquired immune deficiency syndrome, acquired immunodeficiency syndrome, AIDS, anorectal lesions, anorectal symptoms, antiretroviral therapy, antiretrovirals, ART, aphthous ulcers, bacterial infection, candidiasis, canker sore, chlamydia, condyloma, colitis, esophageal candidiasis, esophageal lesions, esophagitis, esophagus, fungal infection, gastrointestinal complications, gastrointestinal disease, gastrointestinal disorder, gastrointestinal symptoms, gonorrhea, HAART, herpes simplex virus, highly active antiretroviral therapy, histoplasmosis, HIV, HPV, human immunodeficiency virus, human papillomavirus, immune, immune defense system, immune system, immunocompromised, immunodeficiency, infection, Kaposi's sarcoma, KS, MAC, mycobacterium avium complex, perianal lesions, OHL, oral hairy leukoplakia, oral lesions, oral thrush, salmonella, sarcoma, sexually transmitted disease, sexually transmitted infection, STD, STI, syphilis, viral infection, virus.

Background

Patients who have the human immunodeficiency virus (HIV) commonly experience gastrointestinal (digestive) complications, including oral lesions, esophageal lesions, diarrhea, and anorectal diseases (disease that affects the anus and/or rectum).

HIV is a retrovirus that causes AIDS (acquired immune deficiency syndrome). The retrovirus primarily attacks the body's immune system and, as a result, the patient is extremely vulnerable to opportunistic infections.

Opportunistic infections occur in individuals who have weakened immune systems. The organisms (bacteria, fungi, or viruses) that cause these infections do not cause illnesses in patients who have healthy immune systems because they are able to fight off the infection.

HIV primary infects and destroys the CD4 T-cells, which are white blood cells that help coordinate the immune system's response to infection and disease. Healthy individuals have a CD4 cell count between 600 and 1,200 per microliter of blood. HIV patients progress to AIDS when their CD4 cell counts drop to lower than 200 cells per microliter of blood. Individuals with a CD4 cell lower than 200 cells per microliter of blood have the greatest risk of developing opportunistic infections.

HIV patients often suffer from gastrointestinal symptoms because they are vulnerable to bacterial, parasitic, and fungal infections. Gastrointestinal symptoms may also be side effects of antiretroviral therapy (ART), which is used to suppress HIV.

Several body parts, including the mouth, esophagus, stomach, small intestine, large intestine, and anus, make up the gastrointestinal tract. The digestive process begins when food enters the mouth. Digestive enzymes in the saliva break down the food before it is swallowed. The esophagus is a muscular tube that carries food from the mouth to the stomach. The stomach contains harsh enzymes that break down food so it can be absorbed by the body. Food then enters the small intestine, which contains three parts: the duodenum, jejunum, and ileum. Most of digestion occurs in the small intestine because it is responsible for absorbing nutrients from food. The remaining food then enters the colon, which also has three parts: the cecum, colon, and rectum. The large intestine absorbs any remaining water from indigestible food matter and eliminates the unusable food matter from the body. The anus is the external opening of the rectum. It allows waste (feces) to be excreted from the body.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

AIDS InfoNet. .

American Academy of Dermatology. .

Centers for Disease Control and Prevention. .

Fichtenbaum C, Aberg J. Candidiasis and HIV. HIV InSite Knowledge Base Chapter. February 2006. .

Natural Standard: The Authority on Integrative Medicine. .

The Body: The Complete HIV/AIDS Resource. .

Integrative therapies

Note: Currently, there is insufficient evidence available on the safety and effectiveness of integrative therapies for the treatment of specific gastrointestinal symptoms of HIV. The integrative therapies listed below should be used only under the supervision of a qualified healthcare provider, and should not be used in replacement of other proven therapies.

Strong scientific evidence:

Calcium: As an antacid, calcium carbonate (Tums?, Rolaids?) is a U.S. Food and Drug Administration (FDA) approved over-the-counter (OTC) drug used to treat gastric hyperacidity (high acid levels in the stomach).

Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with hypercalcemia (high levels of calcium in the blood), hypercalciuria (high levels of calcium in urine), hyperparathyroidism (high levels of parathyroid hormone), bone tumors, digitalis toxicity, ventricular fibrillation (ventricles of the heart contract in unsynchronized rhythm), kidney stones, kidney disease, or sarcoidosis (inflammation of lymph nodes and various other tissues). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria (absence of hydrochloric acid in gastric juices) or arrhythmia (irregular heartbeat). Calcium appears to be safe in pregnant or breastfeeding women; a healthcare provider should be consulted to determine appropriate dosing during pregnancy and breastfeeding.

Probiotics: Probiotics are beneficial bacteria (sometimes referred to as "friendly germs") that help to maintain the health of the intestinal tract and aid in digestion. They also help keep potentially harmful organisms in the gut, such as those that cause ulcers, under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be consumed as capsules, tablets, beverages, powders, yogurts, and other foods. Antibiotics are the main treatment to eradicate Helicobacter pylori, the cause of most stomach ulcers. Side effects commonly include bloating, diarrhea, and taste disturbances. Probiotics reduce these side effects and generally help people tolerate the treatment. They may also reduce levels of Helicobacter pylori in children and adults. Yogurt-containing probiotics suppresses Helicobacter pylori infection and may lead to more complete eradication during antibiotic treatment.

Probiotics are generally regarded as safe for human consumption. Long-term consumption of probiotics is considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

Saccharomyces boulardii: There is good evidence that concurrent use of Saccharomyces boulardii with antibiotic therapy reduces the incidence of developing antibiotic-associated diarrhea (AAD) (Clostridium difficile and other). In general, positive results occur only when Saccharomyces boulardii is continued for several days to several weeks after the course of antibiotics is stopped. Duplication of these results should be attempted to confirm these findings.

Avoid if allergic or hypersensitive to yeast, Saccharomyces boulardii, Saccharomyces cerevisiae, or other species in the Saccharomycetaceae family. Use cautiously in immunocompromised or critically ill patients. Use cautiously with indwelling central venous catheters, colitis, cancer, or constipation. Use cautiously in the elderly, in individuals undergoing chemotherapy, and in infants. Use cautiously if taking antidiarrheal agents. Avoid with a yeast infection. Avoid if pregnant or breastfeeding.

Zinc: Multiple studies in developing countries found that zinc supplementation may reduce the severity and duration of diarrhea in children, especially those that are malnourished and with low zinc levels. Additionally, the healing process of gastric ulcers may be enhanced through treatment with zinc, although further studies will be needed to determine to what extent zinc may be beneficial for patients with this condition.

Good scientific evidence:

Aloe: The transparent gel from the pulp of the meaty leaves of aloe (Aloe vera) has been used topically (on the skin) for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Limited evidence suggests that aloe in a cream preparation is an effective treatment for genital herpes in men. Additional research is warranted in this area.

Caution is advised when taking aloe supplements, as adverse effects including diarrhea and drug interactions are possible. Aloe supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor. Do not use for more than three days without consulting a doctor.

Cranberry: Based on early research, cranberry may reduce the ability of Helicobacter pylori bacteria to live in the stomach and cause ulcers. Further research is needed to better determine the effects of cranberry on Helicobacter pylori infection.

Avoid if allergic to cranberries, blueberries or other plants of the Vaccinium genus. Sweetened cranberry juice may effect blood sugar levels. Use cautiously with history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

Fennel: For centuries, fennel fruits have been used as herbal medicines in Europe and China. Fennel tea is often used to treat infants with digestive disorders. It has a mild flavor and seems to be well-tolerated. An emulsion of fennel seed oil and an herbal tea containing fennel have been shown to reduce infantile colic. Additional studies are warranted in order to confirm these findings.

Avoid if allergic or hypersensitive to fennel or other members of the Apiaceae family. Fennel is generally well-tolerated. However, serious allergic reactions may occur. Use cautiously with diabetes. Avoid with epilepsy. Avoid in infants and toddlers. Avoid if pregnant or breastfeeding.

Globe artichoke: Globe artichoke is a perennial, thistle-like plant originating in southern Europe around the Mediterranean Sea. Globe artichoke leaf extract has been found to increase bile secretion in animal, human, and laboratory studies. Additional human study is needed to make a firm recommendation for artichoke as a choleretic for patients who have cholestasis.

Use cautiously if allergic/hypersensitive to members of the Asteraceae or Compositae family (e.g. chrysanthemums, daisies, marigolds, ragweed, and arnica), due to possible cross-reactivity. Use cautiously with cholelithiasis or biliary/bile duct obstruction or kidney disease. Avoid if pregnant or breastfeeding.

Hypnotherapy: Hypnotherapy involves the power of suggestion during a deep state of relaxation. Early research suggests that hypnotherapy may lower the sensory and motor component of the gastro-colonic (intestinal) responses in patients with irritable bowel syndrome. Better studies are necessary to make a conclusion.

Use cautiously with mental illnesses (e.g. psychosis, schizophrenia, manic depression, multiple personality disorder, or dissociative disorders) or seizure disorders.

Lemon balm: Several clinical studies have reported that a topical preparation of lemon balm (Melissa officinalis) heals sores associated with oral herpes simplex virus infections (herpes simplex type 1). More studies are needed in this area.

Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of cream suggested minimal side effects for up to 10 days of application. Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.

Peppermint: Peppermint (Mentha piperita) oil has been shown to have antispasmodic effects and may improve irritable bowel syndrome (IBS) symptoms such as cramping and bloating. Several clinical trials have used enteric-coated peppermint oil in IBS or recurrent abdominal pain in children. Significant improvements in symptoms of IBS were reported. However, more research is needed before a firm conclusion can be made.

There is preliminary evidence that a combination of peppermint oil and caraway oil may be beneficial for dyspepsia (heartburn) and indigestion. It should be noted that heartburn might actually be a side effect of taking oral peppermint oil. Enteric-coated peppermint oil (which decreases gastrointestinal side effects) has been used in clinical studies for peptic ulcer and other stomach problems. A qualified healthcare provider should evaluate patients with chronic heartburn.

Caution is advised when taking peppermint supplements, as adverse effects including heartburn, anal burning, and drug interactions are possible. Peppermint oil by mouth may increase blood levels of the drugs felodipine (Plendil?) and simvastatin (Zocor?). Peppermint oil increases levels of cyclosporine in the blood. Peppermint oil used on the skin with 5-fluorouracil (5-FU) may increase the rate of absorption of 5-FU. Peppermint supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor. Do not use peppermint oil in individuals with gallbladder problems.

Para-aminobenzoic acid: Evidence of para-aminobenzoic acid's (PABA) possible antiviral activity have led to its study as a therapeutic agent for herpetic keratitis. Actipol? is a 0.007% PABA solution for ophthalmic use that has been studied for this purpose and found to be effective in most patients. Further randomized trials may help to confirm its effectiveness for this indication.

Sunlight exposure, particularly ultraviolet B (UVB) radiation (290-320nm), has been shown to stimulate recurrence of the herpes simplex virus infection on the mouth. Sunscreens are known to prevent erythema and sunburn following exposure to UVB rays. For this reason, it is hypothesized that sunscreens may be capable of preventing UVB-induced reactivation of recurrent herpes labialis infection (prevention) in predisposed patients.

Avoid with known hypersensitivity to PABA or its derivatives. Avoid oral use in children and pregnant or nursing women. Use cautiously in patients with renal disease, bleeding disorders or those taking anticoagulants, diabetics or patients at risk for hypoglycemia. Discontinue use if rash, nausea, or anorexia occurs. Pharmaceutical doses of PABA and its derivatives should only be taken under appropriate medical supervision. PABA should not be given concurrently with sulfonamides.

Probiotics: Lactobacillus GG may reduce the risk of nosocomial (originating in a healthcare setting) diarrhea in children and infants, particularly cases caused by rotavirus gastroenteritis. Probiotics may reduce the duration of diarrhea and related hospital stays in children. Fermented formula and formula supplemented with probiotics may reduce both the number and duration of episodes of diarrhea. There is tentative support for probiotics for diarrhea prevention in adults and children. Supplementation may benefit HIV-positive men, and yogurt containing Lactobacillus casei may help reduce incidence in healthy young adults. Children may benefit from Bifidobacterium lactis (strain Bb 12) added to their formula. Probiotics may reduce duration of symptoms in adults and children with infectious diarrhea by 17 to 30 hours. Effective forms include Lactobacillus strain GG, Lactobacillus reuteri, combination Lactobacillus rhamnosus and Lactobacillus reuteri, and combination Lactobacillus acidophilus and Lactobacillus bifidus. More studies are needed to evaluate types, dosages, duration of treatment, and relationships to specific pathogens.

E. coli Nissle 1917 appears to be as effective as the drug mesalamine in the treatment of ulcerative colitis. However, it is not currently available in the United States. A variety of Bifidophilus preparations have shown effects of preventing relapse or maintaining remission. These include Bifidophilus alone, Bifidophilus in fermented milk products, and a synbiotic preparation. A probiotic combination consisting of VSL#3 plus balsalazide may be more effective than balsalazide or mesalamine alone. More studies are needed to more clearly determine what outcomes can be expected.

Many varieties and combinations of probiotics have been studied in clinical trials for irritable bowel syndrome (IBS). Findings frequently report reductions of symptoms including pain, flatulence, bloating, and stool frequency. There is some evidence of reduced inflammation. The magnitude of benefit seen in most studies is modest. Not all studies, however, show beneficial effects. More studies are needed to determine the best protocols and the level of benefit that can be expected. Commonly used probiotics for IBS include Lacobacillus acidophilus and Saccharomyces boulardii.

Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

Psyllium: Psyllium, also known as ispaghula, comes from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber and is the main ingredient in many commonly used laxatives, such as Metamucil? and Serutan?. Psyllium has been studied for the treatment of diarrhea, particularly in patients undergoing tube feeding. It has also been studied in addition to treatment with orlistat (a lipase inhibitor that is designed to help people lose weight) in hopes of decreasing gastrointestinal effects (diarrhea and oily discharge) of this weight loss agent. An effective stool bulking effect has generally been found in scientific studies.

Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Prescription drugs should be taken one hour before or two hours after psyllium. Use cautiously if pregnant or breastfeeding because psyllium may lower blood sugar levels.

Saccaromyces boulardii: Saccharomyces boulardii has been used to treat and prevent diarrhea that is caused by many different factors. Several trials suggest the efficacy of Saccharomyces boulardii in the treatment of diarrhea in children. Further studies are still required. Use of Saccharomyces boulardii may be advantageous in both the reduction of stool frequency per day and the duration of diarrhea in this age group.

Avoid if allergic/hypersensitive to yeast, Saccharomyces boulardii, Saccharomyces cerevisiae, or other species in the Saccharomycetaceae family. Use cautiously in immunocompromised or critically ill patients. Use cautiously with indwelling central venous catheters, colitis, cancer, or constipation. Use cautiously in the elderly, in individuals undergoing chemotherapy, and in infants. Use cautiously if taking antidiarrheal agents. Avoid with a yeast infection. Avoid if pregnant or breastfeeding.

Sage: Early laboratory and clinical evidence suggests that sage extracts may be useful in the treatment of herpes skin manifestations. Additional research is needed in this area.

Avoid if allergic or hypersensitive to sage, its constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use the essential oil or tinctures cautiously in patients with epilepsy. Avoid if pregnant or breastfeeding.

Soy: Numerous studies report that infants and young children (ages two to 36 months) with diarrhea who are fed soy formula experience fewer bowel movements per day and fewer days of diarrhea. This research suggests soy to have benefits over other types of formula, including cow milk-based solutions. The addition of soy fiber to soy formula may increase the effectiveness. Better quality research is needed before a firm conclusion can be made on the use of soy for acute diarrhea in infants and young children.

Parents are advised to speak with a qualified healthcare provider if infants experience prolonged diarrhea, become dehydrated, develop signs of infection such as fever, or experience blood in the stool. A healthcare provider should be consulted for current breastfeeding recommendations, and to suggest long-term formulas with adequate nutritional value. A doctor may recommend a specially designed soy formula, but regular soy milk should not be given to infants.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, such as increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with their doctors and/or pharmacists before taking soy supplements.

Zinc: Proper nutrition, including vitamins and minerals, has been reported to help in decreasing recurrent herpes simplex virus infections. Lesser quality studies have been conducted to assess the effects of zinc (topical or taken by mouth) in herpes type 1 or type 2. A small study found that oral zinc sulphate appeared to reduce both the number of episodes and the time to recovery of herpes labialis. Several of these studies used combination treatments or permitted the continued use of other medications, so the exact role of zinc in those studies is unclear. However, the positive results obtained in most trials suggest that zinc may represent a safe and effective alternative or adjunct treatment for herpes type 1 and 2, and should encourage further research into the topic using well-designed studies.

Unclear or conflicting scientific evidence:

Acupressure, shiatsu: The practice of applying finger pressure to specific acupoints throughout the body has been used in China for thousands of years, prior to the use of acupuncture. It is proposed that acupressure may reduce muscle pain and tension, improve blood circulation, release endorphins, and release/eliminate toxins. A small study suggests that acupressure may improve gastrointestinal motility. Additional research is necessary before a firm conclusion can be drawn.

With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious long-term complications have not been reported in the available literature. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Acupuncture: Preliminary study has used acupuncture for acute and chronic colitis and irritable bowel syndrome, however, more studies are needed. Currently, there is insufficient available evidence to recommend for or against the use of acupuncture in functional dyspepsia.

Avoid acupuncture in patients who have valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in the elderly or medically compromised patients, diabetics or with history of seizures.

Acustimulation: Acustimulation involves electrical stimulation at various points on the body (as an alternative to needles in acupuncture) and may be applied to reduce certain symptoms. Limited available study suggests that acustimulation to points on the wrist and below the knee may help patients with irritable bowel syndrome to reduce symptoms and pain. However, the design was weak, and more studies are needed to determine benefits for this indication.

A known side effect of acustimulation devices is slight skin irritation under the electrodes when the wristband is used. It is recommended to switch wrists to prevent this from happening. Acustimulation devices should only be used on the designated area. Use cautiously with pacemakers. Avoid if the cause of medical symptoms is unknown. Keep acustimulation devices out of the reach of children.

Agrimony: Anecdotally, agrimony (Agrimonia eupatoria) has been used for many gastrointestinal disorders such as appendicitis, mild diarrhea, stimulation of appetite and ulcers. Human data is currently lacking for these uses.

Caution is advised when taking agrimony supplements, as adverse effects including increased bleeding, lowered blood pressure, and drug interactions are possible. Agrimony supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.

Aloe: There is limited but promising research of the use of oral aloe vera in ulcerative colitis, compared to placebo. However, it is not clear how aloe vera compares to other treatments used for ulcerative colitis.

People with known allergy to garlic, onions, tulips, or other plants of the Liliaceae family may have allergic reactions to aloe. Individuals using aloe gel for prolonged times have developed allergic reactions including hives and eczema-like rash. Although topical (skin) use of aloe is unlikely to be harmful during pregnancy or breastfeeding, oral (by mouth) use is not recommended due to theoretical stimulation of uterine contractions. It is not known whether active ingredients of aloe may be present in breast milk. Breastfeeding mothers should not consume the dried juice of aloe leaves.

Arnica: Arnica has not been well studied for its effects on diarrhea, but early study suggests that homeopathic arnica may decrease the duration of acute diarrhea in children. Further study is needed to make a strong recommendation.

Avoid if allergic or hypersensitive to arnica or any member of the Asteraceae or Compositae families (sunflowers, marigolds or any related plants like daisies, ragweed or asters). Use cautiously with blood thinners, protein-bound drugs, cholesterol or heart medications, or diabetes drugs. Use cautiously with a history of stroke. Avoid contact with open wounds or near the eyes and mouth. Avoid if pregnant or breastfeeding.

Arrowroot: Arrowroot refers to any plant of the genus Maranta, but the term is most commonly used to describe the easily digestible starch obtained from the rhizomes of Maranta arundinacea. Arrowroot is an edible starch with proposed demulcent (soothing) effects and is a well-known traditional remedy for diarrhea. Early research suggests it may have a beneficial effect in the treatment of diarrhea in irritable bowel syndrome (IBS) patients. Additional study is needed in this area.

Avoid if allergic or hypersensitive to arrowroot (Marantana arundinacea), its constituents, or members of the Marantaceae family. Use cautiously with a history of constipation. Although arrowroot has been used traditionally in infants, pregnant and breastfeeding women should avoid this herb due to a lack of scientific safety evidence.

Art therapy: It is not clear if play with modeling clay is an effective therapeutic intervention in children with constipation and encopresis (fecal incontinence associated with psychiatric disorders). In one study, play with modeling clay was associated with improvement in five of six children, but was limited by lack of a control group.

Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.

Asparagus: Asparagus (Asparagus racemosus, or Shatavari) is used in Ayurvedic medicine for dyspepsia (upset stomach). Additional study is needed before a firm conclusion can be made.

Avoid if allergic or hypersensitive to asparagus or other members of the Liliaceae family. Use cautiously with edema (accumulation of fluid) caused by impaired kidney or heart function. The safety of asparagus for pregnant or breastfeeding mothers has not been determined.

Ayurveda: Ayurveda is a form of natural medicine that originated in ancient India more than 5,000 years ago. It is an integrated system of techniques that uses diet, herbs, exercise, meditation, yoga, and massage or bodywork to achieve optimal health on all levels. Preliminary evidence suggests that the gum resin of Boswellia serrata may improve or alleviate symptoms in patients with chronic colitis with minimal side effects. More studies are needed to confirm this finding.

A compound Ayurvedic preparation with Aegle marmelos correa and Bacopa monnieri Linn is a traditional herbal preparation used for digestive disturbances and diarrhea. There is evidence from limited available study suggesting that this combination may have short-term benefits for patients with irritable bowel syndrome in general, and in particular those with diarrhea. However, benefits may not be maintained in the long term. More studies are needed to further evaluate this treatment.

Ayurvedic herbs can interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before taking. Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages, and medical conditions that require surgery.

Bacopa: Bacopa (Bacopa monnieri) is a commonly used herb in the Ayurvedic (Hindu Indian) system of medicine. In limited available study, a combination of bacopa leaf and bael fruit (Aegle marmelos correa) was used to treat irritable bowel syndrome. The effect of bacopa cannot be isolated in this study, and more high-quality studies using bacopa alone are needed.

Caution is advised when taking bacopa supplements, as adverse effects including drug interactions are possible. Bacopa supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.

Barley: Germinated barley foodstuff (GBF) has been suggested as possibly helpful in patients with ulcerative colitis. Scientific evidence in this area is preliminary, and further research is needed before GBF can be recommended for ulcerative colitis.

Patients who are allergic to barley flour or beer should avoid barley products. Severe allergic reactions (anaphylaxis) and skin rashes have been reported from drinking beer made with malted barley. Patients with allergy/hypersensitivity to grass pollens, rice, rye, oats or wheat may also react to barley. Barley appears to be well tolerated in non-allergic, healthy adults in recommended doses for short periods of time, as a cereal or in the form of beer. Avoid consuming large amounts of barley sprouts if pregnant. Avoid if breastfeeding.

Belladonna: Belladonna has been used for centuries to treat many medical conditions. It has been used historically for the treatment of irritable bowel syndrome, and its mechanism of action suggests that it may be effective for some symptoms of this disorder. However, the few studies that are available do not clearly show that belladonna alone (not as part of a mixed product) provides this effect.

Avoid if allergic to belladonna or plants of the Solanaceae(nightshade) family (such as bell peppers, potatoes, or eggplants). Avoid with a history of heart disease, high blood pressure, heart attack, abnormal heartbeat, congestive heart failure, stomach ulcer, constipation, stomach acid reflux, hiatal hernia, gastrointestinal disease, ileostomy, colostomy, fever, bowel obstruction, benign prostatic hypertrophy (enlarged prostate), urinary retention, glaucoma (narrow angle), psychotic illness, Sj?gren's syndrome, dry mouth, neuromuscular disorders (such as myasthenia gravis), or Down's syndrome. Avoid if pregnant or breastfeeding.

Berberine: Berberine is a bitter-tasting, yellow, plant alkaloid with a long history of medicinal use in Chinese and Ayurvedic medicine. Berberine has been evaluated as a treatment for infectious diarrhea, including choleric diarrhea, although the data is conflicting. Therefore, there is currently insufficient evidence regarding the efficacy of berberine in the management of infectious diarrhea.

Berberine has also been compared with antibacterial drugs and ranitidine (Zantac?) in stimulation of ulcer healing and Helicobacter pylori clearance. Berberine was suggested to be less effective at ulcer healing than ranitidine, but potentially more effective at eliminating Helicobacter pylori infection. Additional study is needed in this area.

Avoid if allergic or hypersensitive to berberine, to plants that contain berberine (Hydrastis canadensis (goldenseal), Coptis chinensis (coptis or goldenthread), Berberis aquifolium (Oregon grape), Berberis vulgaris (barberry), and Berberis aristata (tree turmeric), or to members of the Berberidaceae family. Avoid in newborns due to the potential for an increase in free bilirubin, jaundice, and development of kernicterus. Use cautiously with cardiovascular disease, gastrointestinal disorders, hematologic disorders, leukopenia, kidney disease, liver disease, respiratory disorders, cancer, hypertyraminemia, diabetes, or low blood pressure. Use cautiously in children due to a lack of safety information. Use cautiously in individuals with high exposure to sunlight or artificial light. Use cautiously for longer than eight weeks due to theoretical changes in bacterial gut flora. Use cautiously if taking anticoagulants, antihypertensives, sedatives, anti-inflammatories, medications metabolized by CYP P450 3A4 including cyclosporin, or any prescription medications. Avoid if pregnant or breastfeeding.

Betel nut: Currently, there is a lack of satisfactory evidence to recommend the use of betel nut for ulcerative colitis. Based on the known toxicities of betel nut use, the risks may outweigh any potential benefits.

Avoid if allergic to betel nut or other plants of the Palmaceae family. Avoid if pregnant or breastfeeding.

Bilberry: Bilberry is an herb made from the wrinkled, black berries of a small deciduous shrub. The use of bilberry fruit in traditional European medicine dates back to the 12th Century. A close relative of blueberry, bilberry is commonly used to make jams, pies, cobblers, syrups, and alcoholic/non-alcoholic beverages. Bilberry has traditionally been used to treat diarrhea, but human research is needed to determine safety and efficacy. Bilberry extract has also been suggested as a treatment to help stomach ulcer healing. There is some support for this use from laboratory and animal studies, but reliable human evidence for use of bilberry for peptic ulcer disease (PUD) is currently lacking.

Long-term side effects and safety of bilberry remain unknown. Avoid if allergic to bilberry, anthocyanosides (a component of bilberry), or other plants in the Ericaceae family. Do not consume bilberry leaves. Use cautiously with bleeding disorders or diabetes. Use cautiously if taking anticoagulant/anti-platelet medications or drugs that alter blood sugar levels. Stop use before surgeries or dental or diagnostic procedures that have bleeding risks. Use cautiously in doses higher than recommended. Avoid if pregnant or breastfeeding, due to a lack of safety evidence.

Blessed thistle: Blessed thistle (Cnicus benedictus) is traditionally believed to stimulate stomach acid secretion and has been used as a treatment for dyspepsia, indigestion, or flatulence. However, there is limited scientific study in these areas. Additional research is needed before a firm conclusion can be reached.

Avoid if allergic to blessed thistle, mugwort, bitter weed, blanket flower, chrysanthemum, coltsfoot, daisy, dandelion, dwarf sunflower, goldenrod, marigold, prairie sage, ragweed, Echinacea or any plants of the Asteraceae or Compositae families. Use cautiously with peptic ulcer disease. Avoid with a history of bleeding diseases or gastroesophageal reflux disease (GERD), or if taking drugs for blood thinning, stroke, stomach diseases, or to control stomach acid. Avoid if pregnant or breastfeeding. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures.

Boswellia: Boswellia has been noted in animal and laboratory studies to possess anti-inflammatory properties. Based on these observations, boswellia has been suggested as a potential treatment for ulcerative colitis and Crohn's disease. At this time, however, only a limited number of poor-quality human trials have evaluated this use of boswellia, with inconclusive results. Therefore, there is inadequate evidence for or against this use of boswellia.

Avoid if allergic to boswellia or other herbs in the Burseraceae family (like myrrh or garuga). Boswellia is generally believed to be safe when used as directed, although safety and toxicity have not been well studied in humans. Indian literature suggests that boswellia may promote menstruation and induce abortion. However, there is insufficient scientific evidence regarding the safety of boswellia. Therefore, pregnant or breastfeeding women should avoid boswellia.

Bovine colostrum: Bovine colostrum is the pre-milk fluid produced from cow mammary glands during the first two to four days after birth. Bovine colostrum confers growth, nutrient, and immune factors to the offspring. Bovine colostrum may be effective for improving gastrointestinal health. Preliminary evidence suggests that colostrum inhibits the adhesion or activity of certain bacteria to intestinal cells, which may help in the treatment of diarrhea. Additional study is needed in this area.

Preliminary evidence suggests that bovine colostrum may improve gastrointestinal health and may be an effective treatment for colitis. More studies are needed.

Laboratory studies suggest that bovine (cow) colostrum may help improve immune system function and also may inhibit the growth of Helicobacter pylori in the gastrointestinaltract. Bovine colostrum has been clinically studied in a placebo-controlled trial for treatment of peptic ulcers, but there was no apparent benefit when used for Helicobacter pylori infection. Further studies are required before recommendations can be made.

Avoid if allergic to dairy products. Use bovine colostrum cautiously because toxic compounds, such as polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane (DDT), and dichlordiphenyldichloroethylene (DDE), have been found in human colostrum and breast milk. Thus, it is possible that these agents may be found in bovine colostrum. Avoid with, or if at risk of, cancer. Use cautiously with immune system disorders or atherosclerosis (hardening of the arteries). Use cautiously if taking medications, such as anti-diarrheal agents (e.g. Imodium?), insulin, or CNS agents (such as amphetamines, caffeine). Avoid if pregnant or breastfeeding.

Carob: Carob (Ceratonia siliqua) is a leguminous evergreen tree of the family Leguminosae (pulse family). Traditionally, carob has been used for the treatment of gastrointestinal conditions, especially diarrhea. Preliminary study used different types of carob products as an adjunct to oral rehydrating solution for diarrhea in children and showed promising results.Carob may also be helpful in gastroesophageal reflux disease in infants. However, additional study is needed in this area.

Avoid if allergic/hypersensitive to carob (Ceratonia siliqua), its constituents, or any plants in the Fabaceae family, including tamarind. Avoid with metabolic disorders, with a chromium, cobalt, copper, iron, or zinc disorder or deficiency, kidney disorders, or acute diarrhea. Avoid in underweight infants. Use cautiously in patients with anemia, known allergy to peanuts and other nuts, complications with powdered, bulk forming laxative drinks, diabetes, or hyperlipidemia (high cholesterol). Use cautiously if taking oral herbs or drugs. Use cautiously in hypouricemic patients. Avoid if pregnant or breastfeeding.

Carrot: A carrot-rice based rehydration solution decreased the duration of acute diarrhea when compared to two conventional rehydration solutions. However, more research is needed.

Avoid if allergic or hypersensitive to carrot, its constituents, or members of the Apiaceae family. Use cautiously with hypoglycemia (low blood sugar) or diabetes, or if taking hypoglycemics. Use cautiously with bowel obstruction, if taking oral drugs, herbs, or supplements, with hormone-sensitive conditions, and in children. Use cautiously with known allergy/hypersensitivity to carrot or birch pollen-related allergens, as cross-sensitivity has been documented. Use cautiously and only in food amounts in pregnant and breastfeeding women.

Chamomile: Chamomile is reputed to have anti-spasmodic effects and has been used traditionally for numerous gastrointestinal conditions, including digestive disorders, "spasm" or colic, and infantile colic.

Preliminary study reports that chamomile with apple pectin may reduce the length of time that children experience diarrhea. There is a lack of research on this use in adults. Further research is needed before a recommendation can be made for diarrhea in children.

Early study also reports that chamomile ointment may improve hemorrhoids. Better evidence is needed before a recommendation can be made.

Avoid if allergic to chamomile or any related plants, such as aster, chrysanthemum, mugwort, ragweed, or ragwort. Avoid with heart disease, breathing disorders, hormone-sensitive conditions, or central nervous system disorders. Avoid if taking cardiac depressive agents, central nervous system depressants, respiratory depressive agents, or anticoagulants. Use cautiously if taking benzodiazepine, anti-arrhythmic medications, calcium channel blockers, alcohol, sedative agents, anxiolytic medications, spasmolytic drugs, oral medications, or agents that are broken down by the liver. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.

Chiropractic: Chiropractic is a health care discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Although chiropractic is used anecdotally in colic therapy, there is not enough reliable scientific evidence on the effects of chiropractic techniques in the management of infantile colic. There is also currently not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of duodenal ulcer.

Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.

Chlorella: Clinical study indicates that chlorella may increase the ulceration associated with ulcerative colitis. Although the results are promising, more high quality studies are needed to confirm these studies' findings.

Avoid in patients with known allergy/hypersensitivity to chlorella, its constituents, mold, or members of the Oocystaceae family. Avoid long-term supplementation or with manganese supplementation. Avoid in patients using warfarin or other anticoagulant therapy. Use cautiously in patients with hypotension or taking antihypertensives, or in patients taking immunomodulators or with altered immune function. Use cautiously in patients with cancer. Use cautiously in patients with photosensitivity, taking photosensitizers, or in those exposed to the sun.

Chlorophyll: Oral consumption of chlorophyll liquid was reported in clinical study to be effective for herpes simplex infections. More clinical research is needed.

Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.

Cinnamon: Laboratory studies have found that cinnamon extract does not appear to be effective in curing Helicobacter pylori infection. There is also currently a lack of available evidence to support the use of cinnamon for AIDS patients with advanced oral candidiasis. More study is needed.

Avoid if allergic or hypersensitive to cinnamon, its constituents, members of the Lauraceae family, or Balsam of Peru. Use cautiously if prone to atopic reactions or if taking cytochrome P450 metabolized agents, anticoagulants (blood thinners), insulin or blood sugar-altering medications, antibiotics, or cardiovascular agents. Avoid if pregnant or breastfeeding.

Clay: There is currently not enough scientific evidence to recommend the medicinal use of clay by mouth in patients with gastrointestinal disorders. Some clay preparations have been found to be similar to Kaolin? and Kaopectate?, which are used to treat functional gastrointestinal disorders including diarrhea. However, overall, there are significant potential risks that accompany the use of clay, including intestinal blockage and injury as well as lead poisoning.

It is not clear if play with modeling clay is an effective therapeutic intervention in children with constipation and encopresis (fecal incontinence associated with psychiatric disorders). In one study, play with modeling clay was associated with improvement in five of six children, but was limited by lack of a control group.

There is a lack of reports of allergy to clay in the available scientific literature. However, in theory, allergy/hypersensitivity to clay, clay products, or constituents of clay may occur. Avoid if pregnant or breastfeeding.

Colon therapy/colonic irrigation: Preliminary study shows possible benefits of regular irrigation of the lower part of the colon in the treatment of fecal incontinence. Further study is needed before a conclusion can be made.

Excessive treatments may allow the body to absorb too much water, which causes electrolyte imbalances, nausea, vomiting, heart failure, fluid in the lungs, abnormal heart rhythms or coma. Infections have been reported, possibly due to contaminated equipment or as a result of clearing out normal colon bacteria that destroys infectious bacteria. There is a risk of the bowel wall breaking, which is a serious complication that can lead to septic shock and death. Avoid with diverticulitis, ulcerative colitis, Crohn's disease, severe or internal hemorrhoids, rectal/colon tumors, or recovering from bowel surgery. Avoid frequent treatments with heart or kidney disease. Colonic equipment must be sterile. Colonic irrigation should not be used as the only treatment for serious conditions. Avoid if pregnant or breastfeeding due to lack of scientific data.

Corydalis: Early studies suggest that corydalis may be of benefit for Helicobacterpylori infection with chronic atrophic gastritis. However, more evidence is needed before a recommendation may be made.

Corydalis is generally considered safe. Avoid if allergic or sensitive to corydalis. Avoid if taking sedative or hypnotic drugs, drugs that treat abnormal heart rhythms (including bepridil), pain relievers, and anti-cancer drugs. Avoid if pregnant or breastfeeding.

Dandelion: Early study suggests that a combination herbal preparation containing dandelion may improve chronic pain associated with colitis. Because multiple herbs were used, and this study was not well-designed or reported, the effects of dandelion are not clear.

Avoid if allergic to chamomile, feverfew, honey, yarrow, or any related plants such as aster, daisies, sunflower, chrysanthemum, mugwort, ragweed, or ragwort. Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Potassium blood levels should be monitored. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

DHEA: Initial research reports have shown that DHEA (dehydroepiandrosterone) supplements are safe for short-term use in patients with Crohn's disease. Preliminary research suggests possible beneficial effects, although further research is necessary before a clear conclusion can be drawn.

Avoid if allergic to DHEA products. Avoid if pregnant or breastfeeding because DHEA is a hormone.

DMSO: When used with acid blocking drugs (like ranitidine), dimethyl sulfoxide (DMSO, a sulfur containing compound) may help treat gastritis. More research is needed. Cases of nausea, vomiting, constipation, garlic-like breath, garlic taste, and diarrhea have been reported.

Avoid if allergic DMSO. Use cautiously with urinary tract cancer, liver disorders, or kidney disorders. Avoid if pregnant or breastfeeding due to a lack of safety evidence.

Gamma linolenic acid (GLA): Clinical study suggests that a combination of GLA plus eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) does not prolong the period of disease remission in ulcerative colitis. Further well-designed clinical trials are required in this area before recommendations can be made.

GLA is generally considered nontoxic and well tolerated for up to 18 months. Avoid if pregnant or breastfeeding due to insufficient evidence.

Gamma oryzanol: Little research has been done on the effects of gamma oryzanol on gastritis. Additional study is needed to assess its potential use for this indication.

Avoid if allergic/hypersensitive to gamma oryzanol, its components, or rice bran oil. Use cautiously if taking anticoagulants (blood thinners), central nervous system (CNS) suppressants, growth hormone, drugs that alter blood sugar levels, immunomodulators, luteinizing hormone or luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering agents, thyroid drugs, and herbs or supplements with similar effects. Use cautiously with diabetes, hypothyroidism, hypoglycemia, hyperglycemia, or high cholesterol. Avoid if pregnant or breastfeeding.

Ginkgo: Ginkgo biloba has been used medicinally for thousands of years. Today, it is one of the top selling herbs in the United States. In early study, ginkgo was shown to be effective in the treatment of patients with acute hemorrhoidal attacks. Further research is needed to confirm these results.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin?)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Globe artichoke: Several studies have found that globe artichoke supplements may decrease symptoms associated with irritable bowel syndrome, such as gas, bloating, and cramping. However, there is insufficient evidence from these controlled clinical trials to recommend for or against the use of artichoke in relieving the symptoms of this disorder.

Several clinical studies report benefit when using globe artichoke (Cynara scolymus) for dyspepsia. One proposed cause of non-ulcer dyspepsia is bile duct dyskinesia or sluggishness. Because globe artichoke extract has been studied as a choloretic (bile stimulant), it has been hypothesized that it may also function as an antidyspeptic agent. Preliminary evidence supports this hypothesis, although more study is needed.

Caution is advised when taking globe artichoke supplements, as adverse effects including an increase in bleeding and drug interactions are possible. Globe artichoke supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.

Glucosamine: Preliminary research reports improvements with N-acetyl glucosamine as an added therapy in inflammatory bowel disease. Further scientific evidence is necessary before a recommendation can be made.

Avoid if allergic to shellfish or iodine. In most human studies, glucosamine sulfate has been well tolerated for 30 to 90 days. Avoid if pregnant or breastfeeding.

Goldenseal: Goldenseal is one of the five top-selling herbal products in the United States. Berberine, a constituent from goldenseal, has been used as a treatment for diarrhea caused by bacterial infections (including infectious diarrhea from cholera). Due to the very small amount of berberine in most goldenseal products, it is unclear whether goldenseal contains enough berberine to have the same effects. Therefore, there is currently not enough scientific evidence to make a recommendation in this area.

Avoid if allergic or hypersensitive to goldenseal or any of its constituents, like berberine and hydrastine. Use cautiously with bleeding disorders, diabetes, or low blood sugar. Avoid if pregnant or breastfeeding.

Greater celandine: Greater celandine(Chelidonium majus)and turmeric (Curcuma longa) have traditionally been used to support the liver and gallbladder. However, clinical study is currently lacking. Early human study provides initial data on the efficacy of a Chelidonium and Curcuma combination for pain relief in biliary colic and dyskinesia. The herbs did not appear to be beneficial in resolving associated symptoms, raising questions about the usefulness of this combination in fully restoring biliary function. Additional research is necessary to clarify the optimal dose, length of treatment, and clinical applications for these two herbs individually and in combination.

Use cautiously in patients taking amphetamines, morphine, hexobarbital, MAOIs, dopaminergic drugs, or serotonergic drugs. Use cautiously in patients undergoing radiation therapy. Avoid in patients with liver disease, or in pregnant and lactating women.

Honey: Early research suggests that honey may be used for the treatment of infantile gastroenteritis. High quality clinical study is needed to determine safety and effectiveness.

Limited available clinical study found that topical honey may be effective in treating labial but not genital herpes. More research is needed in this area to draw a conclusion.

Avoid if allergic or hypersensitive to honey, pollen, celery or bees. Honey is generally considered safe in the recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.

Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. There is preliminary evidence supporting the use of sitz baths for people with anorectal lesions such as hemorrhoids and anal fissures, particularly for symptom relief. Sitz baths are offered to patients in many hospitals. However, controlled studies are needed to determine the effectiveness and optimal use of sitz baths. A sitz bath can refer to a bath where the pelvic region is immersed in warm water, or to a type of tub, which makes taking the sitz bath easier.

Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.

Hypnotherapy: Early research indicates that gut-oriented hypnosis may have a beneficial effect on shortening gastric emptying both in dyspepsia and in healthy subjects and in improving symptoms of duodenal ulcer. There is inconclusive evidence from preliminary research in this area. Additional study is needed before a firm conclusion can be drawn.

A small study showed potential benefit of a hypnotherapeutic treatment program for patients suffering from recurrent orofacial herpes infections. Further research is needed to confirm these results.

Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder, or dissociative disorders. Use cautiously with seizure disorders.

Lactobacillus acidophilus: Several studies report that the related species Lactobacillus GG may be helpful for diarrhea prevention in children and travelers.Lactobacillus acidophilus may aid in the management of chronic or persistent diarrhea and bacterial-overgrowth related diarrhea. Further research is needed to determine what dose may be safe and effective for diarrhea treatment in children.

There is conflicting information from several human studies as to whether using Lactobacillus acidophilus by mouth improves digestion of lactose. More research is needed before a conclusion can be made on the use of Lactobacillus for lactose intolerance.Additionally, human studies report mixed results in the improvement of irritable bowel syndrome symptoms after taking Lactobacillus acidophilus by mouth.

Lactobacillus acidophilus may be difficult to tolerate if allergic to dairy products containing L. acidophilus. Avoid with a history of an injury or illness of the intestinal wall, immune-disease, or heart valve surgery. Avoid if taking prescription drugs (such as corticosteroids) because of the risk of infection. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus.Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

Lemon balm: Limited clinical evidence is available supporting the use of lemon balm for the treatment of chronic colitis. Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks.

Clinical evidence of varying quality suggests that lemon balm (Melissa officinalis), as a component of combination products, may help reduce dyspepsia. However, further research is necessary before a conclusion can be drawn.

Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.

Licorice: There has been some study of deglycyrrhizinated licorice (DGL) in gastrointestinal bleeding, but it is not clear what effects DGL has on bleeding stomach ulcers caused by aspirin. Early studies indicate that the herbal preparation STW 5, which contains licorice among many other herbal extracts, may help improve symptoms in patients with functional dyspepsia. Additional research is needed.

Licorice (Glycyrrhiza glabra) has been found in laboratory studies to hinder the spread and infection of the herpes simplex virus. However, human reports are lacking. Additional study is needed to make a conclusion.

Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or with diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities. Licorice contains a chemical called glycyrrhizic acid, which is responsible for many of the reported side effects. DGL (deglycyrrhizinated licorice) has had the glycyrrhizic acid removed and therefore is considered safer for use.

Mastic: Mastic is the resin of Pistacia lentiscus and has been used by traditional Mediterranean healers to treat intestinal ulcers since the 13th Century. Mastic has been shown to have antibacterial action against Helicobacter pylori in vitro, which may help to explain its potential role in duodenal ulcer and gastric ulcer healing. Additional research is needed. Mastic may also decrease the severity of induced gastric ulceration, but its exact mechanism of action is unknown.

Well-designed studies evaluating the effects of mastic ingestion beyond four weeks are lacking. Therefore, the long-term use of mastic cannot be recommended. Avoid if allergic to any members of the Anacardiaceae family (the cashew family; trees and shrubs and vines with sticky juice). Use cautiously with gastric or duodenal ulcer or if taking ACE inhibitors. Avoid if pregnant or breastfeeding.

Meditation: Various forms of meditation have been practiced for thousands of years throughout the world. Some forms of meditation may help to ease the symptoms of irritable bowel syndrome. However, more research is needed before recommendations can be made.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and should explore how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnose or treat any condition with more proven techniques or therapies. Meditation should not be used as the sole approach to illnesses.

Melatonin: Based on preliminary study, melatonin may be a promising therapeutic agent for irritable bowel disease. Further research is needed before a recommendation can be made.

Case reports raise concerns about risks of blood clotting abnormalities (particularly in patients taking warfarin), increased risk of seizure, and disorientation with melatonin overdose. Melatonin supplementation should be avoided in women who are pregnant or attempting to become pregnant, based on possible hormonal effects. High levels of melatonin during pregnancy may increase the risk of developmental disorders.

Milk thistle: Milk thistle (Silybum marianum) has been used medicinally in China for over 2,000 years, most commonly for the treatment of liver and gallbladder disorders. An herbal preparation containing milk thistle may be effective in decreasing symptoms of functional dyspepsia. However, milk thistle alone has not been researched for this use.

Caution is advised when taking milk thistle supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Milk thistle should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Moxibustion: Moxibustion is a healing technique employed across the diverse traditions of acupuncture and oriental medicine for over 2,000 years. Moxibustion uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi. Moxibustion is closely related to acupuncture as it is applied to specific acupuncture points. Evidence from several small studies suggests that moxibustion with acupuncture may have potential in treatment of colitis and Crohn's disease. However, there is insufficient evidence on which to base concrete recommendations at this time.

Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," cardiac disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, inflammatory conditions, over allergic skin conditions or ulcerated sores, or skin adhesions. Avoid if pregnant or breastfeeding. Avoid areas with an inflamed organ, contraindicated acupuncture points, face, genitals, head, inflamed areas in general, nipples, and skin adhesions. Avoid in patients who have just finished exercising or taking a hot bath or shower.

Neem: Neem (Azadirachta indica) has been reported to have protective and healing effects on gastroduodenal ulcers in preliminary human study. However, comparisons to other agents used for this purpose such as proton pump inhibitors or H2-antagonsits have not been conducted. Therefore, there is currently insufficient evidence for the use of neem for gastroduodenal ulcers. More studies are needed.

Avoid if allergic or hypersensitive to neem (Azadirachta indica) or members of the Meliaceae family. Use cautiously with liver disease. Avoid in children and infants. Avoid if pregnant or breastfeeding.

Omega-3 fatty acids: It has been suggested that effects of omega-3 fatty acids on inflammation may be beneficial in patients with ulcerative colitis or Crohn's disease when added to standard therapy, and several studies have been conducted in this area. Better research is necessary before a clear conclusion can be drawn.

Avoid if allergic to fish. The U.S. Food and Drug Administration classifies low intake of omega-3 fatty acids from fish as GRAS (Generally Regarded as Safe). Caution may be warranted, however, in diabetic patients due to potential (albeit unlikely) increases in blood sugar levels, patients at risk of bleeding, or in those with high levels of low-density lipoprotein (LDL). Fish meat may contain methylmercury, and caution is warranted in young children and pregnant/breastfeeding women.

Probiotics: Saccharomyces boulardii and a probiotic formula Escherichia coli Nissle 1917 (EcN) solution have been shown to moderately improve acute diarrhea in children. However, all probiotic preparations may not have the same effectiveness. Although some data support the use of probiotics for the treatment and prevention of antibiotic-associated diarrhea (AAD), other studies have found a lack of benefit. Although probiotics are considered a safe and reasonable approach for AAD, larger and better-designed studies are needed for definitive recommendations. There is also limited evidence suggesting that probiotics may reduce recurrence of Clostridium difficile associated diarrhea and may help in the treatment of bacterial overgrowth-related chronic diarrhea. More studies are needed to provide guidelines for these uses.

Supplementation of infant formulas with probiotics is a potential approach for the management of cow's milk allergy, but there is conflicting evidence as to whether it improves digestion of lactose. More research is needed before a conclusion can be made on the use of probiotics for lactose intolerance.

Additionally, there is currently not enough evidence on which to form conclusions for the use of probiotics in collagenous colitis or inflammatory bowel disease. Study results are mixed. Saccharomyces boulardii, E. coli Nissle, probiotics, yogurt, and high doses of probiotics have shown the most promise. More research is needed.

Early research suggests that probiotics may help prevent peptic ulcers. However, more research is needed to determine if this is an effective therapy.

Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

Propolis: Animal and laboratory studies suggest that propolis may help treat various types of infections. Initial human research reports possible benefits for Helicobacter pylori infection. Early research also suggests that cheese containing probiotics may help reduce the risk of a fungal mouth infection, called thrush, in the elderly. Additional research is needed.

A limited number of laboratorystudies have demonstrated effectiveness of propolis and its constituents against herpes simplex virus types 1 and 2. Preliminary results from human trials suggest some degree of efficacy of topical propolis for resolving the lesions associated with genital herpes virus infections.

Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, or Balsam of Peru. Severe allergic reactions have been reported. There has been one report of kidney failure with the ingestion of propolis that improved upon discontinuing therapy and deteriorated with re-exposure. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.

Psychotherapy: Psychodynamic-interpersonal psychotherapy therapy or cognitive psychotherapy may improve dyspepsia symptoms, both short- and long-term, in patients with mild to moderate dyspepsia, but further evaluation is required. There is currently insufficient evidence to confirm the efficacy of psychological intervention in non-ulcer dyspepsia (NUD). Additionally, short-term cognitive psychotherapy may not reduce the long-term recurrence of duodenal ulcer. More research is needed in these areas.

Psychotherapy may also not improve the course of Crohn's disease, although patients undergoing psychotherapy tended to have fewer operations and relapses. More research is needed.

Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions.

Psyllium: Human studies report that psyllium containing products reduced symptoms of hemorrhoids. Further evidence is needed to confirm these results.

There is currently limited and unclear evidence regarding the use of psyllium in patients with inflammatory bowel disease. Psyllium preparations have also been studied in the treatment of irritable bowel syndrome symptoms. Results of available trials have been conflicting. In some cases, insoluble fiber may worsen the clinical outcome.

Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or prolonged psyllium exposure who have not manifested allergic or hypersensitive symptoms. Psyllium may decrease the amount of medications (both prescription and OTC) available to the body. If using psyllium products, take medications at least one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.

Qi gong: Qi gong is a type of traditional Chinese medicine (TCM) that is thought to be at least 4,000 years old. There is some evidence supporting the use of internal Qi gong in the treatment of gastritis. Further research is needed.

Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.

Reflexology: Preliminary study of reflexology in humans with irritable bowel syndrome and infantile colic has not yielded definitive results. Better research is needed.

Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

Relaxation therapy: Early research in humans suggests that relaxation may aid in the prevention and relief of irritable bowel disease symptoms. Large, well-designed trials are needed to confirm these results.

Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses such as heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time to diagnosis or treatment with more proven techniques.

Rhubarb: Clinical study indicates that topically applied rhubarb-sage extract cream may reduce the symptoms of herpes. It was compared to acyclovir (Zovirax?) cream and was equally effective in relieving the symptoms. More high quality studies using rhubarb as a monotherapy are needed to discern rhubarb's effect on herpes symptoms.

Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to potential water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

Rutin: Rutin is an antioxidant found mainly in citrus fruits. Preliminary evidence suggests that rutin may be a safe and effective treatment for hemorrhoids. Studies investigating the effect of rutin in different populations, as well as efficacy on third or fourth degree hemorrhoids, are warranted in future studies.

Avoid if allergic/hypersensitive to O-(beta-hydroxyethyl)-rutosides or plants that rutin is commonly found in, such as rue, tobacco or buckwheat. Use cautiously in elderly patients. Use cautiously with skin conditions. Use cautiously if taking medications for edema, diuretics, or anti-coagulation medications. Use cautiously if pregnant or breastfeeding.

Saccaromyces boulardii: For the treatment of Clostridium difficile associated recurrent diarrhea, Saccharomyces boulardii has been shown to decrease recurrences by about 50%, especially when combined with high-dose vancomycin.While only small studies have been performed, treatment with Saccharomyces boulardii may improve quality of life in chronic diarrhea in AIDS patients. As fungemia has been associated with Saccharomyces boulardii administration in patients with central lines, care should be exercised in treating these patients.Preliminary evidence also supports the use of Saccharomyces boulardii for diarrhea prevention during tube feeding. However, the role of antibiotics in the results is unclear. Although evidence supports the use of Saccharomyces boulardii for other forms of diarrhea, little evidence exists to support standard treatment with Saccharomyces boulardii for traveler's diarrhea. More studies need to be performed.

Early evidence supports mild improvement of symptoms and quality of life in patients with Crohn's disease who use Saccharomyces boulardii, although studies have been small. Additionally, limited available study has shown that Saccharomyces boulardii may be an effective treatment of irritable bowel syndrome. More clinical trials are required before recommendations can be made.

SAMe: SAMe (S-adenosyl-L-methionine) is a natural substance found in every cell of the body. SAMe may be beneficial for pruritus (severe itching) and serum bilirubin levels associated with cholestasis. Additional study is needed. Currently, there is insufficient available evidence to determine if SAMe is an effective treatment for cholestasis during pregnancy. Information on the use of SAMe prior to the third trimester is currently lacking.

Avoid if allergic to SAMe. Use cautiously with diabetes or anxiety disorders. Avoid with bipolar disorder. Avoid in the first and second trimesters of pregnancy or if breastfeeding, due to a lack of safety information.

Sea buckthorn: Poor quality study has indicated that sea buckthorn oil may be beneficial when added to other therapies for gastric ulcers. More high-quality research is needed in this area.

Avoid if allergic or hypersensitive to sea buckthorn, its constituents, or members of the Elaeagnaceae family. Use cautiously if taking angiotensin converting enzyme (ACE) inhibitors, anticoagulants and antiplatelet agents (blood thinners), antineoplastics (anticancer agents), or cyclophosphamide or farmorubicin. Avoid higher doses than food amounts if pregnant or breastfeeding.

Slippery elm: Slippery elm has been traditionally used to treat gastrointestinal disorders and inflammatory conditions of the digestive tract such as gastritis, peptic ulcer disease, and enteritis.

Slippery elm has also been used to treat diarrhea. While theoretically the tannins found in the herb may decrease water content of stool, and the mucilage may act as a soothing agent to inflamed mucous membranes, reliable scientific evidence to support the use of slippery elm for this indication is currently lacking. Systematic research is necessary in this area before a clear conclusion can be drawn.

Avoid if allergic or hypersensitive to slippery elm. Avoid if pregnant or breastfeeding.

Soy: Although soy has been shown to help treat acute diarrhea in children, it remains unknown if it can treat diarrhea in adults. Due to limited human study, there is not enough evidence to recommend for or against the use of soy-polysaccharide/fiber in the treatment of diarrhea in this patient population. Further research is needed before a recommendation can be made.

Due to limited human study, there is not enough evidence to determine if soy is an effective treatment for gallstones (cholelithiasis). Further research is needed before a conclusion can be made.

Due to limited human study, there is not enough evidence to recommend for or against the use of soy as a therapy in preventing Crohn's disease. Further research is needed before a recommendation can be made.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, such as an increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy supplementation.

Tea tree oil: Tea tree oil is purported to have antiseptic properties, and has been used traditionally to prevent and treat infections. Although tea tree oil has been found to have activity against several fungus species in laboratory study, there is currently insufficient human evidence to determine if it is an effective topical treatment for thrush (oral Candida albicans). Tea tree oil has also been proposed as a potential topical therapy for genital herpes simplex virus infections based on in vitro findings of antiviral activity. However, at this time there is insufficient human evidence to recommend either for or against this use of tea tree oil for recurrent herpes labialis infection.

Tea tree oil may be toxic when taken by mouth and therefore, should not be swallowed. Avoid if allergic to tea tree oil or plants of the Myrtle (Myrtaceae) family, Balsam of Peru, or benzoin. Use cautiously with a history of eczema. Avoid if pregnant or breastfeeding.

Thiamin (vitamin B1): Decreased serum thiamine levels have been reported in patients with Crohn's disease. It is not clear if routine thiamin supplementation is beneficial in such patients generally.

Allergic reactions to thiamin supplements are rare. A small number of life-threatening anaphylactic reactions have been observed with large parenteral (intravenous, intramuscular, subcutaneous) doses of thiamin, generally after multiple doses. Thiamin is generally considered safe and relatively nontoxic, even at high doses. Thiamin appears to be safe at recommended doses during pregnancy and breastfeeding.

Thymus extract: Preliminary clinical evidence suggests that thymus extract speeds healing of gastritis (gastric inflammation). Further well-designed clinical trials are still required.

Thymus extract is also of interest in the treatment of human papilloma virus due to its role in immunostimulation. Preliminary positive results were found in several cases.

Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.

Turmeric: Animal research reports that adding the turmeric constituent, curcumin, to the diet reduces the incidence of chemically-induced gallstones in mice, and it has been suggested that turmeric may inhibit the formation of cholesterol gallstones. Preliminary human data suggest that curcumin may function as a cholagogue (gallbladder contracting agent) and may be of benefit for cholelithiasis prevention. However, use of turmeric may be inadvisable in patients with active gallstones.

Limited available study investigated the effects of Curcuma xanthorriza on irritable bowel syndrome and found that treatment did not show any therapeutic benefit over placebo. More studies are needed to verify these findings.

Turmeric has traditionally been used to treat indigestion from a fatty meal. There is preliminary evidence that turmeric may be of benefit for dyspepsia and peptic ulcer disease. However, at high doses or with prolonged use, turmeric may actually irritate or upset the stomach. More research is needed.

Avoid if allergic to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma or Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously if taking blood-thinners like warfarin (e.g. Coumadin? or aspirin). Use cautiously if pregnant or breastfeeding.

Usnea: Usnea and usnic acid both are reported in laboratory studies to have antiviral activity. A combination of usnic acid and zinc sulfate may help treat human papilloma virus. Additional study of usnea alone, and not in combination with other agents, is needed to a make a conclusion.

Avoid if allergic or hypersensitive to usnea, its constituents, or related lichens. Use cautiously as a topical preparation with a known allergy to perfumes. Use cautiously if taking antiplatelet or anticoagulant medications (blood-altering) or medications or dietary supplements that are metabolized by the cytochrome P450 microsomal enzyme system. Avoid with compromised liver function or if taking hepatotoxic agents. Avoid if pregnant or breastfeeding.

Vitamin A: Vitamin A is an essential fat-soluble vitamin. Vitamin A may reduce the severity and duration of diarrheal episodes in malnourished children but not in well-nourished children. Since diarrhea is a major cause of morbidity and mortality in developing countries, vitamin A supplementation may be considered in undernourished children with diarrhea.

Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may be at an increased risk for lung cancer or heart disease. Vitamin A appears safe in pregnant women if taken at recommended doses. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.

Vitamin C: Vitamin C (ascorbic acid) is a water-soluble vitamin, which is necessary in the body to form collagen in bones, cartilage, muscle, and blood vessels, and aids in the absorption of iron. Dietary sources of vitamin C include fruits and vegetables, particularly citrus fruits such as oranges. Early evidence suggests that vitamin C may help bleeding stomach ulcers caused by aspirin. Also, adding vitamin C to triple therapy with omeprazole, amoxicillin, and clarithromycin for Helicobacter pylori infection may allow the dose of clarithromycin to be lower. Further research is needed in this area.

Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods and if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder).

Wheatgrass: Clinical study reported potential benefits of wheatgrass in the treatment of ulcerative colitis. However, further research is needed to confirm these findings.

Wheatgrass is generally considered safe, but should be avoided in patients who are allergic to it. Because it is grown in soils or water and consumed raw, wheatgrass may be contaminated with bacteria, molds or other substances. Because it is grown in soils or water and consumed raw, wheatgrass may be contaminated with bacteria, molds or other substances. Theoretically, women who are pregnant or breastfeeding should use wheatgrass cautiously.

White horehound: White horehound (Marrubium vulgare) has been found to have antispasmodic properties and has been used traditionally to treat intestinal disorders. However, there are few well-designed studies in this area, and little information is available about the effectiveness of white horehound for this use.

The expert German panel, the Commission E, has approved white horehound as a choleretic. In Germany, white horehound is also approved for the treatment of heartburn and poor appetite, based on historical use. However, there is currently not enough information from clinical studies to evaluate the effectiveness of white horehound for these conditions.

Avoid if allergic to white horehound or any member of the Lamiaceae (mint) family. White horehound is generally considered safe when used to flavor foods. Use cautiously with diabetes, high/low/unstable blood pressure, high levels of sodium in the blood, irregular heartbeats, or gastrointestinal disease. Use cautiously if taking diuretics. Avoid if pregnant or breastfeeding.

Witch hazel: Witch hazel is a common ingredient in over-the-counter skin preparations for hemorrhoids; however, human study evaluating the effectiveness for this indication is currently lacking.

Avoid if allergic or sensitive to witch hazel. Avoid if pregnant or breastfeeding. Use cautiously in people with liver or kidney disorders, diabetes, and in children.

Yoga: Early evidence suggests that yoga may be beneficial in the management of adolescent irritable bowel syndrome by helping to regulate colon function through exercise. Further research is needed in this area.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Zinc: Preliminary research of zinc supplements in patients with Crohn's disease has yielded positive results. Well-designed clinical trials are needed to confirm these results.

Zinc is regarded as a relatively safe and generally well tolerated when taken at recommended doses, and few studies report side effects. Occasionally adverse affects such as nausea, vomiting, or diarrhea has been observed. Zinc acetate should only be used during pregnancy if clearly needed. Zinc appears to be safe in amounts that do not exceed the established tolerable upper intake level. Zinc chloride should be given to a pregnant woman only if clearly needed under medical supervision.

Fair negative scientific evidence:

Ayurveda: Limited available study compared the three Ayurvedic preparations bel (Aegle marmelos), thankuni (Hydrocotyle asiatica), and gandhavadulia (Paederia foetida) with ampicillin in dysentery (shigellosis), and found them to have no effect.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.

Beta-carotene: Dietary supplementation with beta-carotene has not been found to be effective for Helicobacter pylori infection.

Avoid if sensitive to beta-carotene, vitamin A, or any other ingredients in beta-carotene products.

Echinacea: Initial human studies suggest that echinacea is not helpful in the treatment of genital herpes. More research is needed to confirm these results.

Avoid if allergic to echinacea, its constituents, or any members of the Asteraceae/Compositae family (ragweed, chrysanthemums, marigolds, daisies). Use cautiously in patients prone to atopic reactions and in those with hemochromatosis and diabetes. Some natural medicine experts discourage the use of echinacea by people with conditions affecting the immune system, such as HIV/AIDS, some types of cancer, multiple sclerosis, tuberculosis, and rheumatologic diseases (such as rheumatoid arthritis or lupus). Use parenteral preparations of echinacea(no longer approved for use in Germany) cautiously. Use tinctures cautiously with alcoholic patients or in patients taking disulfiram or metronidazole. Avoid using echinacea in patients presenting for anesthesia. Use cautiously if pregnant or breastfeeding.

Garlic: Early studies in humans show no effect of garlic on gastric or duodenal ulcers associated with Helicobacter pylori infection.

Avoid if allergic or hypersensitive to garlic or other members of the Lilaceae(lily) family (e.g. hyacinth, tulip, onion, leek, or chive). Avoid with a history of bleeding problems, asthma, diabetes, low blood pressure or thyroid disorders. Stop using supplemental garlic two weeks before and immediately after dental/surgical/diagnostic procedures with bleeding risks. Avoid in supplemental doses if pregnant or breastfeeding.

Licorice: Licorice extracts, DGL, and carbenoxolone, have been studied for treating peptic ulcer disease. DGL (but not carbenoxolone) may offer some benefits. However, most studies are poorly designed and some results conflict. Therefore, it is unclear whether there is any benefit from licorice for this condition.

Probiotics: Fair evidence suggests that probiotics may not be helpful in treating HIV-associated diarrhea. Probiotic therapy appears to be well tolerated for diarrhea in HIV patients on antiretroviral therapy, but may not be helpful for gastrointestinal symptoms.

Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

Traditional Chinese medicine (TCM): TCM has been studied for diarrhea predominant irritable bowel syndrome but herbal formulations used in available studies have not led to global symptom improvement. Further studies may be necessary to characterize the role of TCM in the management of IBS.

Chinese herbs can be potent and may interact with other herbs, foods or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.

Urine therapy: An oral urea preparation (carbamine) has been used in therapy for peptic ulcers. However, there is insufficient evidence from clinical studies to support the use of urine or urea in the treatment of this condition. Additional study is needed to draw any firm conclusions.

Avoid if allergic or hypersensitive to urine or any of its metabolites. Use cautiously in children because there is insufficient data on the use of urine therapy in this population. Use cautiously if taking medications, especially antidepressants, antipsychotics and/or sedative/hypnotic agents, because some medications are excreted as active metabolites in the urine; and thus, urine consumption in large quantities may increase serum levels of the drug. Use cautiously with gastrointestinal problems because urine therapy may increase diarrhea and vomiting. Avoid with urinary tract or kidney infection because the urine will contain bacteria. Avoid if pregnant or breastfeeding.

Zinc: In a very small study, oral zinc supplements did not seem to improve the clinical condition of patients with unresponsive celiac disease. Early studies have also found that zinc supplementation does not seem to improve inflammatory bowel disease.

Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.

Strong negative scientific evidence:

Bael fruit: Indian bael, an indigenous plant of India, has spread over wide areas of Southeast Asia. Indian bael has traditionally been used as a treatment for diarrhea. However, capsules of dried powder of the unripe fruit were not effective in treating diarrhea in patients with dysentery (shigellosis). Additional study investigating different preparations of bael fruit would help confirm this finding.

Avoid if allergic or hypersensitive to Indian bael or any of its constituents. Avoid dosages that exceed those of use in traditional medicine. Indian bael in large quantities theoretically may result in digestive complaints and constipation, given that tannins are constituents. Use cautiously if taking hypoglycemic agents or thyroid hormone, herbs for thyroid disorders, or herbs that may exacerbate or induce hyperthyroidism. Avoid if pregnant or breastfeeding as Indian bael leaves have been traditionally used to induce abortion and to sterilize women (theoretical).

Traditional or theoretical uses lacking sufficient evidence:

Barberry: Barberry has been used in Indian folk medicine for centuries, and the Chinese have used berberine, a constituent of barberry, since ancient times. Barberry has been suggested as a possible treatment for sexually transmitted diseases, including chlamydia. However, human studies are lacking.

Because of the lack of available evidence investigating barberry, no firm recommendations can be made regarding barberry's safety. Avoid if allergic or hypersensitive to barberry, any of its constituents (including berberine), or any member of the Berberidaceae family. Use cautiously with heart disease, gastrointestinal disorders, or kidney disease. Use cautiously in children due to a lack of sufficient available evidence. Barberry has exhibited uterine stimulant properties, and berberine has been shown to have anti-fertility activity. Avoid if pregnant or breastfeeding.

Boswellia: Historically, boswellia has been used to treat sexually transmitted diseases, including genital warts and syphilis. However, further research in humans is needed to determine if it is a safe and effective treatment.

Avoid if allergic to boswellia. Avoid with a history of stomach ulcers or gastroesophageal reflux disease (GERD). Avoid if pregnant or breastfeeding.

Kava: Kava is a member of the pepper family and is native to many Pacific Ocean islands. Traditionally, kava has been used to treat syphilis. However, human studies have not tested the safety and effectiveness of this treatment. Further research is warranted.

Avoid if allergic to kava or kavapyrones. Avoid with a history of liver disease, Parkinson's disease, heart disease, lung disease, eye disease, depression, bipolar disease, or blood cell disorders. Avoid while driving or operating heavy machinery because kava may cause drowsiness. Avoid if pregnant or breastfeeding.

Lysine: In preliminary study, lysine has been investigated for its effects on the herpes simplex virus. Study results are conflicting at this time. Additional high quality clinical research is needed to make a conclusion.

Neem: Neem is thought to have originated in Assam (a state in northeast India) and Myanmar. Neem has been used to treat infections, skin conditions, and reduce inflammation. Although neem has been traditionally used to treat sexually transmitted disease, studies have not been performed to determine if it is effective.

Reiki: Reiki is a Buddhist practice that is about 2,500 years old. Treatments involve the systematic placing of hands in varying positions either directly on a clothed patient or held above the skin. Sessions may last 30-90 minutes. Reiki has been suggested as a possible treatment for venereal diseases, but human evidence is currently lacking. Further research is warranted in this area.

Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.

Prevention

Highly active antiretroviral therapy (HAART): Many gastrointestinal complications related to HIV occur because HIV patients have weakened immune systems and are vulnerable to opportunistic infections. Therefore, treatment with highly active antiretroviral therapy (HAART) is used to suppress the HIV virus and boost the body's immune system. This therapy usually combines antiretrovirals (anti-HIV drugs) from at least two different classes of antiretroviral drugs.

Oral lesions

Aphthous ulcers (canker sore): HIV patients often suffer from aphthous ulcers, also called canker sores. These sores are usually more severe in HIV patients than in immunocompetent patients. They form single or multiple ulcers in the mouth, which are painful, especially when drinking or eating. They may develop on the tongue, roof of the mouth, inside the cheeks or lips, or on the base of the gums.

The exact cause of canker sores remains unknown, although researchers believe that stress or tissue injury may play a role. Immunocompromised individuals are more likely to have canker sores than healthy individuals.

Minor ulcers generally require no treatment. Pain usually decreases after several days, and canker sores typically heal within one to three weeks. Avoiding acidic foods like tomatoes and citrus foods (like oranges) when ulcers are present may help reduce pain. Painkillers like ibuprofen (Motrin? or Advil?) have been used before meals to relieve pain. Liquid medications like tetracycline (Helidac Therapy?, Sumycin?), with or without or hydrocortisone (corticosteroid used to reduce swelling), have been used to treat canker sores and alleviate pain and swelling.

Candidiasis (oral thrush): Oral candidiasis or oral thrush is an opportunistic infection of the mouth that is caused by the fungus Candida albicans.

The Candida albicans fungus is found almost everywhere in the environment. Most people have small amounts of Candida albicans present in their mouths and/or vagina (in women) at any given time, but healthy individuals are able to prevent the fungus from multiplying and causing an infection.

Oral candidiasis usually develops in HIV patients once their CD4 cell count drops below 350. HIV infects and destroys the CD4 cells, which are white blood cells that make up the immune system. Candidiasis causes an inflammation and thick white coating and lesions on the mucous membranes of the mouth, including the cheeks, roof of the mouth, gums, tonsils, and tongue. The lesions are often painful and may bleed slightly when rubbed or scraped. While oral thrush is the least serious of the fungal infections associated with HIV, it may indicate that a patient's HIV condition is worsening. The oral infection can progress to esophageal candidiasis, which occurs when thrush spreads to the esophagus.

Candidiasis infections are treatable. HIV patients who have candidiasis infections usually receive treatment with antifungals to clear the infection. Amphotericin B, fluconazole, ketoconazole, and nystatin are the drugs most commonly used to treat oral and esophageal candidiasis. Treatment generally tests 10 to 14 days. Some of these medications may cause liver damage. Therefore, blood tests should be performed regularly during treatment.

Human papillomavirus (HPV): The human papillomavirus (HPV) is a term used to describe more than 100 types of the virus. HPV can cause warts on the lips, mouth, or genitals. These warts, which are either flat or cauliflower shaped, are generally painless. Patients typically experience multiple warts at once.

Lesions will clear up without treatment. However, patients can choose to have them removed. A healthcare provider may use a scalpel, electrosurgery, laser ablation, or liquid nitrogen to remove the warts. Surgical removal of the warts does not prevent future outbreaks.

In June 2006, the U.S. Food and Drug Administration (FDA) approved the first HPV vaccine called Gardasil?. However, the safety and effectiveness of Gardasil? in HIV patients have not been determined. The drug, developed by Merck & Co. Inc., is a recombinant vaccine (contains no live virus) that is given as three injections over the course of six months. However, patients will not be protected if they have been infected with the HPV type(s) prior to vaccination, and the drug does not protect against less common types of HPV.

Kaposi's sarcoma: Kaposi's sarcoma (KS), a type of cancer that develops in connective tissues like bone, cartilage, fat, blood vessels, muscle, tendons, or ligaments, may also affect the gastrointestinal tract of HIV patients. KS causes tumors to form in the tissues below the skin or face or in the mucous membranes of the nose, mouth, or anus.

Researchers believe a herpes virus called human herpes virus 8 (HHV-8) causes HIV-related Kaposi's sarcoma. However, not everyone who has HIV and HHV-8 develops KS.

Common symptoms include skin lesions that may erupt at many places on the body, including on the skin (raised lumps that may be purple, brown or red), in the mouth, on the lymph nodes, and other organs (especially organs in the gastrointestinal tract, lungs, liver, and spleen). Most patients experience enlarged lymph nodes and unexplained fever or weight loss. Sometimes patients experience painful swelling, especially in the legs, groin area, or skin around the eyes.

While the skin lesions may be disfiguring, they are not usually life threatening. In some cases, the lesions may be painful or cause swelling. If KS develops in the lungs, liver, or gastrointestinal tract, however, the disease may be life threatening, causing internal bleeding or difficulty breathing. During a diagnosis, a healthcare provider will determine how far the disease has spread. The patient's response to treatment is then monitored.

Highly active antiretroviral therapy (HAART), which involves combinations of antiretrovirals, has been shown to reduce the risk of fatality in patients who have AIDS-related KS. Local therapies, including radiation therapy, intralesional vinblastine, cryotherapy (use of cold temperatures to treat disease), and vitamin A have been used to treat patients who experience lesions that are limited to one particular area. However, local therapy does not prevent the development of new lesions. Systemic therapies (therapies used to treat multiple body areas), including interferon-alpha and chemotherapy, are used when multiple organs are involved.

With new treatments for AIDS, including HAART, as well as greater awareness of HIV, the number of KS cases due to HIV infection has decreased about 85% to 90%, according to researchers. Before HAART was available, an estimated 90% of patients who had AIDS-related KS died from the disease. Today, researchers estimate that in areas where antiretroviral therapy is available, 47% of patients who have AIDS-related KS die.

Oral hairy leukoplakia (OHL): Oral hairy leukoplakia (OHL) occurs when fuzzy, white patches form on the gums, inside of the cheeks, and sometimes, the tongue. The Epstein-Barr virus, also known as infectious mononucleosis, causes the condition. Although OHL is not an AIDS-defining illness (the development of OHL does not mean that the patient has progressed to AIDS), it may indicate that HIV is worsening.

Treatment may include antiviral medications like acyclovir (Zovirax?) or valacyclovir (Valtrex? Caplets). In addition, research has shown that OHL responds well to highly active antiretroviral therapy (HAART), which suppresses HIV and helps restore the immune system.

Esophageal lesions

Esophageal candidiasis: Esophageal candidiasis is the most common infection that affects the esophagus of HIV patients. This is the result of an overabundance of the fungus whose scientific name is Candida albicans. Patients typically have oral thrush first, which spreads to the esophagus. Esophageal candidiasis typically occurs when the HIV patient's CD4 cell counts are 200 or less. According to the U.S. Centers for Disease Control and Prevention (CDC), esophageal candidiasis is considered an AIDS-defining illness. This means that when HIV-infected patients develop esophageal candidiasis, they have progressed from HIV to AIDS.

Common symptoms of esophageal candidiasis include pain or difficulty swallowing and a sensation of food sticking to the throat. The pain may be so severe that it is difficult to eat. A fever may indicate that the infection has spread beyond the esophagus to areas such as the heart, brain, eyes, or joints.

Esophageal herpes simplex virus: HIV patients are also vulnerable to developing the herpes simplex virus (HSV) because they have weakened immune systems. When HSV infects the esophagus, it causes fluid-filled blisters to form. Common symptoms include painful swallowing, difficulty swallowing, pain behind the breastbone, nausea, and vomiting.

Untreated patients can develop tracheoesophageal fistulas, which are abnormal openings between the esophagus and trachea. The infection may also kill cells in the esophagus, cause the esophagus to narrow and may lead to internal bleeding.

HIV patients with esophageal HSV typically receive intravenous antiviral treatment with acyclovir (Zovirax?).

Diarrhea

General: Bacterial, viral, or parasitic infections and certain medications can cause diarrhea in HIV patients. Individuals with advanced HIV are vulnerable to many opportunistic infections that may cause diarrhea. Opportunistic infections occur in individuals who have weakened immune systems.

Serious complications are associated with diarrhea, making it the most common cause of death among HIV patients worldwide. Complications of diarrhea may include weight loss, dehydration, malnutrition, and poor absorption of medication (including antiretrovirals).

Antiretroviral side effects: Diarrhea is a common side effect of antiretrovirals (drugs used to suppress HIV). The most common antiretrovirals that cause diarrhea are nelfinavir (Viracept?), ritonavir (Norvir?), didanosine (Videx?), and tipranavir (Aptivus?).

Bacterial causes: The most common causes of diarrhea in HIV patients living in the United States are bacteria called salmonella, Clostridium difficile, mycobacterium avium complex (MAC), and shigella.

Domestic and wild animals, including poultry, cattle, and pets, can transmit salmonella infections to human. However, it usually occurs after an individual drinks unpasteurized milk or eats undercooked poultry or poultry products (like eggs). Kitchen counters and cooking utensils should be washed thoroughly with soap and water after they come into contact with raw meat. Common symptoms include headache, fever, abdominal pain, diarrhea, nausea, and vomiting. Salmonella can be treated with medications such as TMP/SMX (Bactrim?, Septa?) or azithromycin (Zithromax?).

Clostridium difficile infection causes diarrhea and it has also been associated with colitis, a condition where inflammation of the large intestine occurs. Common symptoms include high fever (temperature of 102-104 degrees Fahrenheit), severe diarrhea with blood (more than 10 watery stools a day), severe abdominal pain, and tenderness. The bacteria are often found in healthcare facilities and nursing homes. Patients who have received antibiotics like clindamycin (Cleocin?, Cleocin? Vaginal Ovules, Clinda-Derm?, Clindagel?, Clindets? Pledgets), ampicillin (Principen?), amoxicillin (Amoxil?, Prevpac?, Trimox?), and cephalosporins (Keflex?) are also vulnerable to infection. HIV patients who develop Clostridium difficile infections typically receive treatment with metronidazole (Flagyl?) for about 10-14 days.

Mycobacterium avium complex (MAC), or mycobacterium avium intracellulare (MAI), is a bacterial infection that is caused by one of two bacteria whose scientific names are Mycobacterium avium and Mycobacterium intracellulare. These bacteria are very common. However, a healthy immune system will prevent the bacteria from causing an infection. Since HIV/AIDS patients have weakened immune systems, they have an increased risk of developing MAC infections. MAC infections typically occur in patients with advanced AIDS (CD4cell count of less than 50 cells per microliter of blood). Common symptoms of MAC include weight loss, fever, chills, night sweats, swollen glands, abdominal pain, diarrhea, inflamed muscles, and overall weakness. MAC usually affects the intestines and inner organs first. In general, MAC infection is treated with two or three antimicrobials for life in order to prevent the infection from recurring. Commonly prescribed antimicrobials include clarithromycin (Biaxin?), ethambutol (Myambutol?), and azithromycin (Zithromax?).

Shigella is also a common bacterial infection that affects HIV patients. The bacteria are generally transmitted through feces. Humans can contract the virus by eating contaminated food or drinking contaminated water. This infection is especially common in areas of poor sanitation. Common symptoms include bloody diarrhea, fever, nausea, vomiting, and cramps. People with mild infections usually recover within a few days without special treatment. Severe infections may require antibiotics.

Fungal infections: The Histoplasma capsulatum fungus causes histoplasmosis. The fungus is commonly found in damp soil that is rich in organic material. Individuals may be exposed to the fungus while gardening or by eating produce that is grown in soil. All produce should be washed thoroughly before eating to prevent exposure to disease-causing organisms. Symptoms of histoplasmosis typically develop about 17 days after exposure. When the infection involves the gastrointestinal tract, symptoms typically include diarrhea, fever, pain, and weight loss. Histoplasmosis is usually treated with antifungals like amphotericin B (Abelcet?) or itraconazole (Sporanox?). Treatment is generally lifelong in order to prevent the infection from recurring.

Parasitic infections: A parasite called Cryptosporidium parvum can cause diarrhea, especially in HIV patients. Animals that are infected with the parasite excrete parasitic eggs in their feces. Humans typically develop the infection after drinking water or eating produce items that are contaminated with these eggs. Cryptosporidium parvum can survive extreme temperatures and can withstand exposure to chlorine. HIV patients who become infected with the parasite may be sick for several months and often suffer from severe diarrhea that can lead to dehydration and electrolyte disturbances. Patients generally receive a drug called paromomycin (Humatin?), which kills the parasite. Treatment generally lasts from five to 10 days.

Many parasites of the Microsporidia species have been shown to cause infections in HIV patients. Microsportia organisms, including Encephalitozoon intestinalis and Enterocytozoon bieneusi, may cause severe diarrhea and weight loss in HIV patients. These organisms typically cause long-term, debilitating infections if not treated. Patients typically receive treatment with a drug called albendazole (Albenza?), which kills the parasites.

Another parasite called Entamoeba histolytica can lead to diarrhea in HIV patients. The eggs of this parasite are found in animal feces. Humans are usually exposed to the parasite after coming into contact with contaminated food or water or after handling contaminated soil (e.g. gardening). Only about 10% of people who are infected with the parasite experience symptoms, researchers estimate. However, some patients may experience abdominal pain, diarrhea, bloody stools, and painful bowel movements. A diagnosis can be made after detecting the organism in the patient's stools or after a blood test. Patients who experience symptoms typically receive treatment with a drug called metronidazole (Flagyl?) for about ten days. Healthcare providers disagree whether or not treatment is beneficial in patients who excrete the eggs in their feces but experience no symptoms of infection. These patients may receive a drug called iodoquinol (Yodoxin?) for about three weeks to kill the parasite.

Giardia lamblia is among the most common parasites throughout the world. The parasite causes an infection called giardia, which results in severe diarrhea. Animals that are infected with the parasite excrete the parasite's eggs in their feces. Humans become infected if they ingest food or water that is contaminated with these eggs. Most humans will not become infected after ingesting the eggs. Patients who do develop an infection may or may not experience symptoms. Symptoms typically include severe diarrhea, gas, and weight loss, which may lead to dehydration and electrolyte disturbances. A diagnosis is made after the eggs are detected in a patient's stool. Once diagnosed, patients typically receive treatment with a drug called metronidazole (Flagyl?) for about five days.

Viral infections: Diarrhea caused by viral infections is generally short-term and usually does not require treatment.

The cytomegalovirus (CMV) can lead to colitis (inflammation of the large intestine) in patients with advanced AIDS (CD4 count lower than 50 cells per microliter of blood). CMV can be transmitted through airborne droplets. People become infected with the virus when they inhale particles of infected sputum from the air. It may also be sexually transmitted through bodily fluids such as blood, semen, vaginal discharge, and breast milk. Most individuals with healthy immune systems will not develop symptoms of infection. However, since HIV patients have weakened immune systems, they are vulnerable to CMV infections. Common symptoms of CMV that affect the gastrointestinal tract include diarrhea, abdominal pain, gastrointestinal bleeding, nausea and vomiting, fever, difficulty or painful swallowing, and weight loss.

In general, HIV patients who have CMV receive drugs like ganciclovir (Cytovene?) or foscarnet (Foscavir?). Highly active antiretroviral therapy (HAART) is also required to prevent the infection from recurring. Patients who receive HAART take a combination of antiretroviral drugs (anti-HIV drugs) from different classes to suppress the virus and help boost the body's immune system.

Anorectal disease

General: Anorectal (related to the anus and/or rectum) diseases are typically caused by viral infections (like herpes) and sexually transmitted diseases (like gonorrhea, syphilis, and chlamydia).

Condyloma: Condylomas are wart-like growths around the anus, vulva, or tip of the penis. HIV patients who have the human papillomavirus (HPV) typically develop these warts in the perianal region. The warts may be flat or cauliflower shaped. Multiple warts usually develop at the same time. Small warts may spontaneously resolve. Lesions can be removed at a doctor's office with a scalpel, by electrosurgery, laser ablation, or liquid nitrogen. However, surgical removal of the warts does not cure the virus or prevent future outbreaks.

Because certain types of HPV have been associated with anal cancer, a tissue biopsy should be performed in patients who experience extensive lesions and who do not respond to therapy. During the procedure, a small sample of tissue is removed and analyzed for cancerous cells.

In June 2006, the U.S. Food and Drug Administration (FDA) approved the first HPV vaccine called Gardasil?. However, the safety and effectiveness of Gardasil? in HIV-positive people have not been determined. The drug, developed by Merck & Co. Inc., is a recombinant vaccine (contains no live virus) that is given as three injections over the course of six months. However, patients will not be protected if they have been infected with the HPV type(s) prior to vaccination and the drug does not protect against less common types of HPV.

Gonorrhea, syphilis, and chlamydia: Gonorrhea, syphilis, and chlamydia are sexually transmitted diseases that often cause anorectal symptoms in HIV patients. Patients who are infected with gonorrhea or chlamydia may experience symptoms such as anal discharge, pain, straining to have a bowel movement, and bleeding. Patients typically receive one dose of ceftriaxone (Rocephin?), followed by either azithromycin (Zithromax?) or doxycycline (Doryx?, Doxy 100?, Monodox?, Vibramycin?, Calcium Syrup, Vibramycin?, Hyclate, Vibramycin? Monohydrate, Vibra-Tabs?).

Syphilis can also cause sores around the anus or rectum, which may or may not be painful. Sores may also develop in other areas of the body, including the vulva, clitoris, opening of the urethra, cervix, penis, and mouth. Patients receive an antibiotic called penicillin to kill the bacteria that causes syphilis.

Herpes simplex virus: Another sexually transmitted disease called the herpes simplex virus (HSV) often causes anorectal disease in HIV patients. There are two types of HSV: type 1 (HSV1) and type 2 (HSV2). Both types cause similar symptoms, which may include blisters and sores near the mouth, nose, genitals, and anus. These small blisters may burst to form ulcers, which then crust over. When HSV affects the anus, it may cause ulcers or fissures (tears) in the perianal region. Ulcers typically last about 12 days.

Patients are generally given oral antivirals like acyclovir (Zovirax?) or valacyclovir (Valtrex? Caplets) for 10 to 14 days. However, since the virus may remain but become dormant in the body, relapses are common. Acyclovir has been used daily to prevent recurrent outbreaks.

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