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Peritonitis

Related Terms

Abdominal pain, abdominal wall inflammation, achalasia, acid reflux, anal fistula, appendicitis, bleeding stomach ulcers, bloating, Chinese restaurant syndrome, colic, colonic spasm, colonoscopy, digestive enzyme, digestive enzyme insufficiency, digestive tonic, digestion, difficulty swallowing, diverticular disease, diverticulosis, duodenal ulcer, dyspepsia, dysphagia, esophageal spasm, fat excretion in stool, fatty liver, fistula, flatulence, gas, gastric spasm, gastric ulcer, gastritis, gastroenteritis, gastroesophageal, gastroesophageal reflux disease, gastrointestinal, gastrointestinal concerns, gastrointestinal conditions, gastrointestinal disorders, gastrointestinal tract, H. pylori, H. pylori gastric infection, H. pylori infection, heartburn, Helicobacter pylori bacteria, hiccough, hiccup, hypochlorhydria, ileus, indigestion, infantile colic, intestinal disorders, intestinal malabsorption, low stomach acid, Menkes' kinky-hair disease, necrotizing enterocolitis, non-tropical sprue, non-ulcer dyspepsia, pancreatic enzyme insufficiency, peritonitis, poor appetite, poor digestion, post-operative ileus, proctitis, pyloric stenosis, rectal inflammation, rectal prolapsed, reflux, regional enteritis, spleen disorders, splenomegaly, sprue, steatorrhea, stomach inflammation, stomachache, stomach upset, swallowing, upset stomach, zinc malabsorption.

Background

Gastroinestinal disorders occur when the digestive tract (gastrointestinal) does not function properly. As a result, patients may have difficulty digesting food, absorbing nutrients, or having normal bowel movements.

Several body parts, including the mouth, esophagus, stomach, small intestine, large intestine, and anus, make up the digestive (gastrointestinal) tract. The digestive process begins when food enters the mouth.

When a person begins chewing food, digestive enzymes in the saliva break down the food before it is swallowed.

The esophagus is a muscular tube that carries food and liquids 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, or waste, from the body. The anus is the external opening of the rectum. It allows waste (feces) to be excreted from the body.

There are many different types of gastrointestinal disorders. Some gastrointestinal disorders affect multiple parts of the digestive tract, while others only affect the esophagus, abdomen/stomach, intestines, or anus/rectum. The severity of gastrointestinal disorders varies significantly, depending on the specific type of the disease. Some disorders, such as indigestion, are mild while others, such as Crohn's disease, are life-long.

Integrative 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:

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.

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.

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 Lactobacillus 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.

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.

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 decrease 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.

Cinnamon: Laboratory studies have found that cinnamon extract does not appear to be effective in curing Helicobacter pylori infection. Further studies are warranted.

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.

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.

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.

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 against bacteria in the mouth, genital herpes, urine bacteria, intestinal giardia infections, and Helicobacter pylori infection. Additional research is needed before a recommendation can be made.

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.

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.

Thiamin (vitamin B1): Decreased serum thiamin 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.

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.

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 bael (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.

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).

Prevention

Patients should not take laxatives more frequently than the packaging label suggests. If symptoms persist, patients should consult their healthcare providers to diagnose and properly treat the underlying cause.

Patients who have a history of indigestion should eat smaller, more frequent meals to help prevent symptoms. Limiting spicy, fried, or fatty foods may also reduce the risk of indigestion.

Patients should not consume excessive amounts of alcohol because it irritates the stomach. Abusing alcohol may cause inflammation or bleeding in the stomach.

Patients are encouraged not to smoke because smoking damages the protective lining of the stomach. Smoking increases an individual's risk of developing gastritis and ulcers. In addition, smoking increases the amount of stomach acid and delays healing, which increases a patient's risk of developing stomach cancer.

Patients should limit their use of nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Motrin? or Advil?) because they may cause stomach inflammation and bleeding, as well as ulcers.

Patients should properly wash all produce thoroughly before eating to reduce the risk of developing gastrointestinal infections.

Individuals who are in areas of the world that have poor sanitation should only drink bottled water to avoid the risk of gastrointestinal infections. If this is not possible, individuals should boil their water before drinking it. This kills any disease-causing bacteria or parasites that may be living in the water.

Patients should only consume dairy products that have been pasteurized. This reduces the risk of developing a gastrointestinal infection that may cause diarrhea.

Individuals should avoid or limit their intake of the artificial sweeteners sorbitol and mannitol because they may cause diarrhea. These artificial sweeteners are commonly found in sugar-free products and chewing gum.

Patients with gastrointestinal disorders should take their medications exactly as prescribed in order to prevent complications from occurring.

Author information

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

Bibliography

American Chronic Pain Foundation. .

American Gastroenterological Association. .

Becker JM. Surgical therapy for ulcerative colitis and Crohn's disease. Gastroenterol Clin North Am. 1999 Jun;28(2):371-90, viii-ix. .

Farivar, A, and Farivar, M. Clinical, Endoscopic and Pathologic Manifestations of Bile Reflux Esophagitis. Caritas Norwood Hospital and Boston University School of Medicine, Norwood, MA. .

International Foundation for Functional Gastrointestinal Disorders. .

Marmouz F. Adult coeliac disease. Allerg Immunol (Paris). 2007 Jan;39(1):23-5. .

Marshall RE, Anggiansah A, Owen WA, et al. The relationship between acid and bile reflux and symptoms in gastro-oesophageal reflux disease. Gut. 1997 Feb;40(2):182-7.

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No authors listed. NIH Consensus Development Conference on Celiac Disease. NIH Consens State Sci Statements. 2004 Jun 28-30;21(1):1-23. .

Seksik P, Daniel F, Marteau P, et al. [Refractory proctitis.] [Article in French.] Gastroenterol Clin Biol. 2007 Apr;31(4):393-7. .

Disorders that affect multiple parts of the gastrointestinal tract

Diarrhea: Diarrhea occurs when an individual has loose stools or watery stools. Diarrhea is a symptom of an underlying health problem, such as an infection, that prevents the intestines from properly absorbing nutrients from food. Acute diarrhea lasts a few days and affects nearly everyone at some point in their lives. Chronic diarrhea generally lasts longer than four weeks and may be a sign of a serious condition such as inflammatory bowel disease (IBD) or gastroenteritis.

Diarrhea is usually caused by a viral, bacterial, or parasitic infection. Diarrhea that is caused by an infection (often called infectious diarrhea) may be passed from person to person. Viruses, such as the Norwalk virus, cytomegalovirus, viral hepatitis herpes simplex virus, and rotavirus are the most likely to cause diarrhea. Infants and young children are most likely to develop diarrhea as a result of a rotavirus infection. If an individual consumes food or water that is contaminated with certain bacteria or parasites, he/she may develop diarrhea. This type of diarrhea is often called traveler's diarrhea because it frequently occurs in people who are traveling to developing countries. Common bacterial causes of diarrhea include campylobacter, salmonella, Escherichia coli (E. coli), Shigelladysenteriae, and Clostridium difficile. Common parasites that are known to cause diarrhea include Giardia lamblia and cryptosporidium.

Diarrhea may be caused by a number of other factors, including lactose intolerance, certain medications (especially antibiotics and anti-HIV medications called antiretrovirals), artificial sweeteners called sorbitol and mannitol (commonly found in sugar-free products and many types of chewing gum), surgery, or other gastrointestinal disorders (such as irritable bowel syndrome or IBS).

Symptoms of diarrhea often include frequent and loose stools, abdominal pain or cramping, bloating, fever, excessive thirst, and dehydration. Diarrhea causes dehydration because the body loses water and salts. Infants and young children are at risk of developing severe dehydration as a result of diarrhea. Patient with severe diarrhea may be unable to control the passage of stool, a condition known as fecal incontinence. When a patient experiences frequent, severe, and bloody diarrhea, the condition is often called dysentery.

Diarrhea usually requires little to no medical treatment. Individuals with diarrhea should drink plenty of water. Patients may also benefit from drinks that contain electrolytes, including Pediatric Electrolyte?, Pedialyte?, or Enfalyte?. Individuals should avoid diuretics, such as caffeine, because they worsen symptoms of dehydration. Certain foods, including rice, dry toast, and bananas may help reduce symptoms of diarrhea. In addition, anti-diarrheal medications, such as bismuth subsalicylate (Pepto-bismol?, Bismatrol?, or Kaopectate?), diphenoxylate atropine (Lomotil?, Lofene?, or Lonox?), or loperamide hydrochloride (Imodium?), may also be taken to reduce diarrhea in patients older than three years of age.

If diarrhea continues for longer than four days or blood is present in the stool, patients should visit their healthcare providers to determine the underlying cause. If an infection is causing symptoms, an antimicrobial medication may be prescribed. The specific type, dose, and duration of treatment depend on the severity and type of infection.

Irritable bowel syndrome (IBS): Irritable bowel syndrome (IBS), also called spastic colon, mucous colitis, spastic colitis, nervous stomach, or irritable colon, is a long-term condition that is characterized by abdominal pain, cramping, diarrhea, and constipation. IBS is a functional bowel disorder because the bowel appears normal but does not function properly.

Although the exact cause of irritable bowel syndrome (IBS) is unknown, researchers believe that poor diet, neurotransmitter imbalances, and infections may contribute to the development of the disorder.

The colon contracts (colon motility) to move the contents inside the colon toward the rectum. During this passage, water and nutrients are absorbed into the body and waste is excreted as stool. A few times each day, contractions push the stool down the colon resulting in a bowel movement.

In IBS patients, the muscles of the colon, sphincters, and pelvis do not contract properly. As a result, patients experience constipation or diarrhea. This causes symptoms of abdominal pain, cramping, bloating, and a sense of incomplete stool movement. Symptoms may improve after the patient has a bowel movement.

Health complications arising from IBS include hemorrhoids (aggravated by diarrhea and/or constipation), depression, weight loss, vitamin and mineral deficiencies, and psychosocial problems.

Most people can control symptoms of IBS with diet, stress management, lifestyle modification, and prescribed medications. A medication called loperamide (Imodium?) is commonly used to treat IBS patients with diarrhea. Laxatives, such as polyethylene glycol (Miralax?), sorbitol, and lactulose (Cephulac?), may be used. Phosphate enemas (Fleet Phospho-soda?) and emollient enemas (Colace Microenema?) have also been used. Suppositories, such as bisacodyl (Dulcolax?), may also be taken. The most widely studied drugs for the treatment of abdominal pain are a group of drugs called antispasmodics, which cause muscle relaxation. Commonly used antispasmodics include hyoscyamine (Levsin? or Levsinex?), dicyclomine (Bentyl?), and methscopolamine (Pamine?).

For some patients, however, IBS may be disabling. They may be unable to work, attend social events, or even travel short distances due to urgency to defecate (pass stool) and/or pain in the colon.

Inflammatory bowel disease (IBD): Inflammatory bowel disease (IBD) refers to two chronic diseases that cause inflammation of the intestines: ulcerative colitis and Crohn's disease.

The cause of IBD remains unknown. However, current research indicates that IBD most likely involves a complex interaction of factors, including heredity, the immune system, and antigens in the environment.

The symptoms of these two illnesses are very similar, which often makes it difficult to distinguish between the two. In fact, about 10% of colitis (inflamed colon) cases cannot be diagnosed as either ulcerative colitis or Crohn's disease. When physicians cannot diagnose the specific IBD, the condition is called indeterminate colitis.

IBD causes chronic inflammation in the gastrointestinal tract and may lead to complications, such as colon cancer. The most common symptoms of both ulcerative colitis and Crohn's disease are diarrhea (ranging from mild to severe), abdominal pain, decreased appetite, and weight loss. If the diarrhea is extreme, it may lead to dehydration, increased heartbeat, and decreased blood pressure. As food moves through inflamed areas of the gastrointestinal tract, it may cause bleeding. Continued loss of blood in the stool may result in low levels of iron in the blood, a condition called anemia.

In addition, Crohn's disease may also cause intestinal ulcers, fever, fatigue, arthritis, eye inflammation, skin disorders, and inflammation of the liver or bile ducts.

Ulcers may extend through the intestinal wall creating a fistula (an abnormal opening). If an internal fistula develops, food may not reach the area of the intestine involved in absorption. External fistulas in the anus may result in continuous bowel drainage onto the skin. Fistulas may also become infected, a condition that can be life threatening if left untreated. Symptoms of a fistula may include pain, fever, tenderness, itching, and general feeling of discomfort.

Toxic megacolon is a rare, but potentially life-threatening complication of severe IBD. Toxic megacolon is characterized by a dilated colon (megacolon), abdominal distension (bloating), and occasionally fever, abdominal pain, or shock. In severe cases, the condition may cause the colon to become paralyzed. Toxic megacolon prevents the individual from having bowel movements. If the condition is not treated, the colon may rupture, resulting in peritonitis, a life-threatening condition that requires emergency surgery.

Other complications may include dehydration, malnutrition, obstruction, ulcers, and anal fissures.

Many medications are used to treat IBD. Anti-inflammatories, such as sulfasalazine (Azulfidine?), mesalamine (e.g. Asacol? or Rowasa?), olsalazine (Dipentum?), and balsalazide (Colazal?), help reduce inflammation. Corticosteroids, such as prednisone (Deltasone?), have been shown to effectively reduce inflammation of the gastrointestinal tract in IBD patients. Medications, called immunosuppressants, have been used to treat IBD. Examples include azathioprine (Imuran?), mercaptopurine (Purinethol?), cyclosporine (e.g. Neoral? or Sandimmune?), and infliximab (Remicade?). A fiber supplement, such as psyllium powder (Metamucil?) or methylcellulose (Citrucel?), may help relieve symptoms of mild to moderate diarrhea. Inflammation may cause the intestines to narrow, resulting in constipation. Laxatives may be taken to relieve symptoms of constipation. Oral laxatives such as Correctol? have been used. A qualified healthcare provider may recommend acetaminophen (Tylenol?) to relieve mild pain. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil? or Motrin?) or naproxen (Aleve?), as researchers have found a strong relationship between NSAIDs and IBD flare-ups. Therefore, NSAIDs should not be taken.

If all other treatments fail to relieve symptoms, a qualified healthcare provider may recommend surgery. Surgery is more commonly performed in ulcerative colitis patients because inflammation is limited to the colon. During the procedure, the entire colon and rectum is removed (proctocolectomy).

A new procedure, known as ileoanal anastomosis, eliminates the need for recovered patients to wear a bag to collect stool. This new procedure involves attaching a pouch directly to the anus, allowing the patient to expel waste normally. However, the patient may have as many as five to seven watery bowel movements a day because there is no longer a colon to absorb water. Between 25 and 40% of patients with ulcerative colitis eventually need surgery.

Indigestion (non-ulcer dyspepsia): Indigestion, also called non-ulcer dyspepsia (upset stomach), is a general term that describes discomfort in the upper abdomen. Patients who have indigestion typically suffer from several symptoms, including heartburn, bloating, belching, and nausea.

Indigestion affects nearly everyone from time to time, and it is not considered a serious health condition.

Indigestion may occur if a patient eats too much of a particular food (especially fatty or spicy foods) or eats too quickly. Alcohol, stress, and anxiety may also contribute to indigestion.

Because indigestion is such a common condition, it generally does not require a diagnosis. However, patients who frequently experience indigestion should visit their healthcare providers because it may be a symptom of an underlying medical condition, such as acid reflux disease.

Antacids, such as calcium carbonate (e.g. Tums?, Alka-Mints?, and Rolaids Calcium Rich?), may be taken by mouth to treat symptoms of heartburn and upset stomach. Anti-flatulant medications, such as alpha-galactosidase enzyme (Beano?), simethicone (Gas-X?, Genasyme?, or Mylanta? Gas Relief), may be taken by mouth to prevent and/or treat symptoms of bloating and flatulence (gas).

Monosodiumglutamate symptom complex (Chinese restaurant syndrome): Monosodium glutamate symptom complex, also called Chinese restaurant syndrome, is a group of symptoms that some patients develop after eating Chinese foods. Symptoms typically include flushing, headache, sweating, facial pain or swelling, numbness or burning around the mouth, and chest pain.

Although it has been suggested that a food additive in Chinese food, called monosodium glutamate (MSG), may cause the reaction, it has not been proven. Since there is limited scientific data about the condition, it remains unknown if the frequency and amount of MSG exposure increases or decreases an individual's risk of experiencing symptoms.

Patients generally do not require treatment for monosodium glutamate symptom complex because symptoms are mild and resolve on their own. However, if patients experience chest pain or difficulty breathing, they should seek immediate medical treatment because this may be a sign of a serious allergic reaction called anaphylaxis.

Diverticulosis and diverticulitis: Diverticulosis refers to small, bulging pouches (diverticula) in any part of the digestive tract. Diverticula are most often found in the large intestine (colon). However, they may also develop in the esophagus, stomach, or small intestine.

Diverticulosis is a common condition that affects more than half of Americans who are older than 60 years of age. Most patients do not know they have diverticulosis because they do not experience any signs or symptoms of the condition.

However, if the diverticula become infected or inflamed, the condition is called diverticulitis. Patients with diverticulitis typically experience intense abdominal pain, nausea, bloating, bleeding from the rectum, tenderness in the abdomen, difficulty or pain during urination, fever, and changes in bowel movements.

Diverticulitis is usually diagnosed after a computerized tomography (CT) scan is performed. A machine produces images of the internal organs in the abdomen. Inflamed diverticula will be apparent if the patient has diverticulitis.

Mild cases of diverticulitis can be treated with rest, changes in the diet, and antibiotics. Patients should not eat any fiber, including whole grains, fruits and vegetables, for several days. This restricted diet gives the colon time to heal. Antibiotics, such as metronidazole (Flagyl?), moxifloxacin (Avelox?), ciprofloxacin (Cipro?), amoxicillin/clavulanate (Augmentin?), and Imipenem (Primaxin?) are commonly prescribed to kill the bacteria that are infecting the diverticula.

Serious cases of diverticulitis may eventually require surgery to remove the infected part of the colon.

Peptic ulcers: An ulcer is an open sore or break in a body tissue. Peptic ulcers develop on the inside lining of the stomach (gastric peptic ulcer), upper small intestine (duodenal peptic ulcer), or esophagus (esophageal peptic ulcer).

Researchers have found that a bacterial infection with Helicobacter pylori is the most common cause of gastric and duodenal ulcers. Some medications, including aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Motrin? or Advil?), may also cause gastric and duodenal ulcers. In addition, smoking tobacco increases a patient's risk of developing ulcers. It remains unclear whether or not excessive alcohol consumption leads to an increased risk of ulcers.

Esophageal peptic ulcers are usually associated with acid reflux disease.

Contrary to popular beliefs, diet and stress do not cause peptic ulcers. However, high levels of stress and acid foods and beverages, such as coffee, may aggravate symptoms of peptic ulcers.

Peptic ulcers generally cause pain that may be felt anywhere from the chest to the stomach. Pain may last a few minutes to several hours. Symptoms are often the worst when the stomach is empty or at night. They may also come and go for a few days to weeks. Less common symptoms include vomiting blood, dark blood in the stools, nausea, vomiting, and unexplained weight loss.

Most ulcers are diagnosed after an X-ray is taken of the upper gastrointestinal tract. An endoscopy may also be performed. During the procedure, a thin tube with a camera (endoscope) is inserted into the mouth and into the digestive tract. This allows the healthcare provider to see if ulcers are present.

Patients take antibiotics, such as amoxicillin (Amoxil?), clarithromycin (Biaxin?), or metronidazole (Flagyl?), if an H. pylori infection is causing peptic ulcers. Patients also take medications called acid-blockers, which reduce the amount of acid in the stomach. As a result, the patient experiences less pain, and the gastrointestinal tract is able to heal. Examples of acid blockers include ranitidine (Zantac?), famotidine (Pepcid?), cimetidine (Tagamet?), and nizatidine (Axid?).

Patients should take their medications exactly as prescribed. If medication is not taken regularly or stopped too early, the ulcer may not heal properly. Also, during treatment, patients should not smoke, consume alcohol, or take nonsteroidal anti-inflammatory drugs (NSAIDs) because they may worsen symptoms.

Pyloric stenosis: Pyloric stenosis is a rare condition that occurs when babies are born with abnormally large muscles at the opening at the bottom of the stomach (pylorus). The pylorus connects the stomach to the small intestine.

Babies with pyloric stenosis are unable to transport food into the small intestine. This may lead to: extremely forceful vomiting (also called projectile vomiting) that may contain blood, weight loss, dehydration, and electrolyte imbalances. Babies are usually hungry after vomiting. They may cry without tears because they are dehydrated.

The exact cause of pyloric stenosis remains unknown. However, researchers believe that genetics plays a role.

Most patients are diagnosed and treated when they are three to 12 weeks old. Babies with pyloric stenosis need to have surgery as soon as possible to correct the pylorus. The surgical procedure, called pyloromyotomy, involves reducing the size of the pylorus muscles. Patients typically experience an improvement in symptoms about 24 hours after surgery.

Colic (infancy): Colic is usually defined as crying for more than three hours a day, three days per week, for longer than three weeks in an otherwise healthy baby.

It remains unknown what causes colic. However, researchers have suggested that it may be caused by gastrointestinal problems, such as lactose intolerance or an immature digestive system. This is because sometimes a colic episode stops after a baby passes gas or has a bowel movement. Other possible causes include maternal anxiety, differences in the way a baby is fed or comforted, and/or allergies.

There is currently no treatment that has been proven to be effective for the treatment of colic in babies. Colic typically goes away once the baby reaches three months of age.

Biliary colic: Biliary colic, also called a gallbladder attack, describes pain and nausea that accompanies many disorders that affect the gallbladder. The gallbladder is an organ that stores digestive fluids that are needed to break down fats in foods.

Biliary colic may occur when a gallstone moves through the biliary tract towards the small intestine. An attack may also be the result of cholestasis, which occurs when the flow of bile is blocked. Gallbladder attacks may also occur if the gallbladder becomes inflamed.

Gallbladder attacks generally last one to four hours. Common symptoms include pain on the right side of the abdomen, nausea, vomiting, and bloating. The gallbladder, which is located in the lower right side of the abdomen, is usually tender to the touch. The pain may be dull, sharp, or excruciating. It is common for the pain to radiate to the right shoulder blade.

A healthcare provider will be able to tell if a patient is having gallbladder attacks after a detailed medical history and physical examination is performed. The next step is to determine the underlying cause of the symptoms.

Blood tests and liver function tests may be performed to determine if the patient has cholestasis. If the patient's alkaline phosphatase levels are three times higher than normal, cholestasis is indicated.

A computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, or ultrasound may also be performed. These tests produce images of the internal organs and may help the healthcare provider detect abnormalities, such as gallstones, that may be causing the condition.

An endoscopic retrograde cholangiopancreatography (ERCP) may be performed at the hospital to check for problems in the liver, gallbladder, bile ducts, and pancreas. During the procedure, a thin, flexible tube with a camera is inserted through the mouth into the small intestine. The tube then hooks into the bile duct, allowing the healthcare provider to see the biliary tract.

Treatment of gallbladder attacks depends on the underlying cause. For instance, a gallstone may need to be surgically removed if it is causing symptoms. Antibiotics may be prescribed if an infection is the cause. If a medication is the suspected cause, a healthcare provider may recommend an alternative medication.

Gastroenteritis: Gastroenteritis describes inflammation of the stomach and intestine that causes diarrhea, vomiting, and cramps.

Gastroenteritis is often mistaken for the stomach flu or food poisoning because it causes similar symptoms. Although some doctors may call gastroenteritis the flu, gastroenteritis is not caused by any of the influenza viruses.

An infection in the digestive tract may cause gastroenteritis. This may happen if patients consume foods or beverages that contain disease-causing bacteria, viruses, or parasites. In some cases, the food itself may irritate the patient's digestive tract. For instance, if a lactose intolerant patient consumes a dairy product, the stomach and intestines become irritated, which may lead to gastroenteritis. In addition, some mediations, including aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), some antibiotics, caffeine, laxatives, and steroids, may cause gastroenteritis.

Most patients recover quickly from gastroenteritis. However, babies and the elderly have a greatest risk of developing life-threatening complications, such as dehydration and poor nutrition.

If an infection is causing gastroenteritis, patients take medications called antimicrobials to kill the disease-causing organisms. Commonly prescribed antimicrobials include ciprofloxacin (Cipro?), trimethoprim/sulfamethoxazole (Bactrim?), and rifaximin (Xifaxan?, RedActiv?, or Flonorm?). Adults may also take medications, called antiemetics, which reduce vomiting. Commonly prescribed antiemetics include promethazine (Phenergan? or Anergan?), prochlorperazine (Compazine?), or ondansetron (Zofran?). Anti-diarrheals, such as diphenoxylate atropine (Lomotil?, Lofene?, or Lonox?) or loperamide hydrochloride (Imodium?), may also be taken to reduce diarrhea in patients older than three years old.

Gaucher's disease: Gaucher's disease is a rare, inherited disorder that occurs when a fatty substance called glucocerebroside accumulates in the spleen, liver, lungs, and bone marrow. In some cases, it also affects the functioning of the brain.

Patients with Gaucher's disease are born with low levels of a digestive enzyme called glucocerebrosidase, which breaks down glucocerebroside. This deficiency causes glucocerebroside to build up in the body.

There are three types of Gaucher's disease: Type I, Type II, and Type III. Type I is the most common form. It causes enlargement of the liver (hepatomegaly) and spleen (splenomegaly) and it may also affect the lungs and kidneys. When fat develops in the liver, it is often called hepatic steatosis. Type I may develop at any age. Type II is a fatal condition that develops during infancy and causes severe brain damage. Most children with Type II Gaucher's disease die by the age of two years old. Type III causes the liver and spleen to enlarge and brain damage gradually occurs over time. Type III usually occurs in children and adolescents.

Gaucher's disease is diagnosed after a blood test. Patients with the disorder will have low levels of glucocerebrosidase in their blood.

There is currently no cure for Gaucher's disease. Patients with Type I and Type III Gaucher's disease take enzyme replacement therapy, which has been proven to effectively manage symptoms. However, there is no effective treatment to manage the symptoms of Type II.

Esophageal disorders

Gastroesophageal reflux disease (GERD): Gastroesophageal reflux disease (GERD), also called acid reflux disease, occurs when liquid from the stomach backs up (regurgitates) into the esophagus. This liquid may contain stomach acids and bile. In some cases, the regurgitated stomach liquid can cause inflammation (esophagitis), irritation, and damage to the esophagus.

It remains unknown exactly what causes GERD. Several factors, including hiatal hernias (when the stomach pushes up through a hole in the diaphragm muscle), abnormally weak contractions of the lower esophageal sphincter, and abnormal emptying of the stomach after a meal, have been associated with GERD.

Common symptoms of GERD include a burning sensation in the chest that may spread to the throat (heartburn), chest pain (especially when lying down), difficulty swallowing (dysphagia), regurgitating food or sour liquid, coughing, hoarseness, sore throat, and wheezing.

Several factors may worsen symptoms of the condition. For instance, spicy foods, fatty foods, chocolate, caffeine, tomato sauce, carbonated beverages, mint, alcoholic beverages, large meals, lying down after eating, some medications (e.g. sedatives, tranquilizers, or blood pressure drugs), and cigarette smoking may worsen symptoms of GERD.

Most cases of GERD can be diagnosed based on the patient's symptoms.

GERD is usually a lifelong condition because there is no cure for the disorder. Patients must take medications for the rest of their lives to manage symptoms. In addition, patients should not smoke because it may increase the amount of stomach acid and worsen symptoms.

Patients with mild cases of GERD may be able to manage their symptoms with over-the-counter medications and changes in the diet. Patients may experience improvements in symptoms if they eat smaller meals and eliminate foods that are known to cause heartburn.

Antacids, such as Gelusil?, Rolaids?, Mylanta?, Maalox?, or Tums?, may neutralize stomach acid and provide quick relief of GERD symptoms. However, they will not help the esophagus heal. Patients who take antacids frequently may experience diarrhea or constipation.

Some over-the-counter H-2 receptor blockers, such as cimetidine (Tagamet HB?), famotidine (Pepcid AC?), nizatidine (Axid AR?), and ranitidine (Zantac 75?), may also help provide quick relief of symptoms. These medications reduce the amount of stomach acid that is produced. Side effects of H-2 receptor blockers, which are uncommon, may include changes in bowel movements, dry mouth, dizziness, or drowsiness. Proton pump inhibitors, such as omeprazole (Prilosec?), may also be taken short-term to help the esophagus heal. Patients should not take these medications long term unless they talk with their healthcare providers first.

Patients with persistent GERD may require prescription-strength medications to manage symptoms and prevent esophageal damage. H-2 blockers, such as Axid?, Pepcid?, Tagamet?, and Zantac?, are commonly prescribed. Examples of prescription-strength proton pump inhibitors include esomeprazole (Nexium?), lansoprazole (Prevacid?), omeprazole (Prilosec?), pantoprazole (Protonix?), and rabeprazole (Aciphex?).

Achalasia: Achalasia is a rare disease that occurs when the muscles of the esophagus are unable to relax. The esophageal sphincter, which is the muscle between the lower esophagus and stomach, is unable to relax enough to allow food to pass into the stomach. Also, the lower half of the esophagus does not contract and relax properly. As a result, the food is not properly pushed down into the stomach, and patients have difficulty swallowing food (dysphagia).

The exact cause of achalasia remains unknown. Researchers believe that several factors, including infections, genetics, and abnormalities in the immune system, may contribute to the development of the condition.

The most common symptom of achalasia is difficulty swallowing solid foods and liquids. Some patients experience heavy sensations in the chests after eating that feels like chest pain. If food collects in the esophagus, it may cause irritation and lead to esophagitis (inflamed esophagus). Some patients may regurgitate their food if it is trapped in the esophagus. If regurgitated food enters the windpipe (trachea), it may cause infections such as pneumonia.

Since patients have difficulty swallowing and consuming foods and beverages, they typically experience weight loss. Other complications may include malnutrition and dehydration.

Achalasia is usually diagnosed after a video-esophagram is performed. During the procedure, the patient drinks a barium solution and video X-rays are taken of the esophagus. The healthcare provider is able to see if the barium enters the stomach properly. If the patient has achalasia, the barium will stay in the esophagus longer than normal. In addition, the lower end of the esophagus will be very narrow.

Some patients may experience an improvement in symptoms if they eat slowly, take small bites, and chew their food thoroughly.

In addition, patients with achalasia usually take nitrates, such as isosorbide dinitrate (Isordil?), and calcium-channel blockers, such as nifedipine (Procardia?) or verapamil (Calan?), to relax the muscles of the esophagus. These medications provide short-term relief of symptoms.

A procedure called forceful dilation, or stretching of the lower esophageal sphincter, is often needed to open the esophagus and allow food to enter the stomach. During the procedure, a tube with a balloon at the end is inserted into the patient's esophagus. The balloon is placed across the sphincter and inflated. As a result, the sphincter stretches out. Forceful dilation successfully treats 65-90% of patients with achalasia. The most serious complication of forceful dilation is rupture of the esophagus, which occurs in about five percent of patients. If a rupture occurs, antibiotics and/or surgery may be required. Forceful dilation is generally quicker and less expensive than surgery.

If forceful dilation is unsuccessful, a surgical procedure, called esophagomyotomy, may be performed. During the procedure, the sphincter is cut, which expands the esophagus and makes it easier for the patient to swallow. The procedure is more effective than forceful dilation. An estimated 80-90% of patients are treated successfully with esophagomyotomy. However, in some cases, dysphagia may return. The most common side effect of esophagomyotomy is GERD. In order to prevent GERD, the esophagomyotomy may be modified so that it does not completely cut the sphincter or the esophagomyotomy may be combined with anti-reflux surgery. Regardless of which surgery is performed, some healthcare providers recommend lifelong treatment with GERD medications, such as Axid?, Pepcid?, Tagamet?, or Zantac?. Other doctors only recommend lifelong treatment if GERD is diagnosed 24 hours after surgery.

Botox injections in the lower sphincter are the newest treatment for achalasia. The botulinum toxin is injected to weaken the sphincter. The effects of treatment usually last for several months. Patients may require additional injections. Patients who are elderly or unable to undergo surgery typically receive this treatment. It may also be performed to help patients gain weight and improve their nutritional status before surgery.

Esophageal spasms: Patients may experience spasms in the esophagus. Esophageal spasms may cause difficulty swallowing, painful swallowing, sensation that something is stuck in the throat, heartburn, and chest pain.

The exact cause of spasms remains unknown. However, eating hot or cold foods may contribute to the condition. Also, gastroesophageal reflux disease (GERD) or heartburn may also play a role in the development of esophageal spasms.

Patients typically take nitrates, such as isosorbide dinitrate (Isordil?), or calcium-channel blockers, such as nifedipine (Procardia?) or verapamil (Calan?), to relax the muscles.

Acute abdomen and stomach disorders

Appendicitis: Appendicitis occurs when an organ in the lower right-side of the abdomen, called the appendix, becomes inflamed and filled with pus.

The cause of appendicitis is not always clear. In some cases, appendicitis may occur if food waste or a solid piece of stool becomes trapped in an opening near the appendix. It may also occur after an infection.

The most common symptom of appendicitis is severe pain in the lower right-hand side of the abdomen. Additional symptoms may include nausea, vomiting, loss of appetite, low-grade fever, constipation, bloating or inability to pass gas, diarrhea, and abdominal swelling.

Patients with appendicitis will have high levels of white blood cells in their blood. Imaging studies are also performed to determine if the appendix is enlarged.

Patients with appendicitis must have their appendix surgically removed as quickly as possible. Since the appendix has no known purpose, the patient's life is unaffected after the appendix is removed.

If the appendix is not removed quickly, it may break open or rupture. If the appendix ruptures, it may lead to an infection in the lining of the abdominal cavity. Infections may cause a condition called peritonitis, which occurs when the abdominal lining becomes inflamed. If the appendix ruptures, the patient may start to feel better. However, soon after, the abdomen may swell because it becomes full of gas and fluid. At this point, the abdomen usually feels hard, tight, and tender to the touch. Severe pain also develops throughout the entire abdomen. Patients may be unable to pass gas or have a bowel movement. Additional symptoms of peritonitis include fever, thirst, and decreased urination.

Patients who have symptoms of peritonitis should seek immediate medical treatment. Even if the condition is treated quickly, it may be fatal. Patients will receive aggressive treatment with intravenous antibiotics. Surgery is necessary to remove the burst appendix. Patients will also receive all fluids and nutrition through injections until their condition is improved.

Stomach inflammation (gastritis): Stomach inflammation, also called gastritis, may develop suddenly (acute) or gradually over a longer period of time (chronic).

Most cases of gastritis are caused by an infection with the same bacterium (Helicobacter pylori) that causes stomach ulcers. Gastritis may also be caused by traumatic injury or surgery, excessive alcohol consumption, and regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin? or Advil?) or naproxen (Aleve?).

A condition called bile reflux disease may also cause, or occur simultaneously with, gastritis. Bile reflux occurs when bile, a fluid that helps digest fats, flows upward from the small intestine into the stomach and esophagus. Bile reflux has also been found to be common after gallbladder removal, or as a result of complications from gastric surgery which may damage the pyloric valve (a ring of muscle that separates the stomach from the duodenum) such as gastrectomy, or gastric bypass. Further inflammation and damage to the lining of the stomach and esophagus may occur as a result.

In rare cases, gastritis may occur when the body's own immune cells attack the stomach. It remains unknown what triggers this autoimmune reaction. The acid in the stomach may worsen symptoms of gastritis.

Symptoms of gastritis generally include a burning pain or aching in the upper abdomen that may worsen when food is eaten, nausea, vomiting, loss of appetite, bloating, feeling of fullness in the upper abdomen after eating, and weight loss. In some cases, gastritis may cause stomach bleeding. Symptoms of stomach bleeding include blood in the vomit and black or dark-colored stools.

In some cases, gastritis may lead to ulcers and an increased risk of stomach cancer.

In most cases, patients fully recover quickly once treatment is started. Patients typically take antacids, such as Tums?, Mylanta?, or Rolaids?, to help neutralize the stomach acid. This helps reduce symptoms of gastritis quickly. Acid blockers, such as cimetidine (Tagamet?), ranitidine (Zantac?), nizatidine (Axid?), or famotidine (Pepcid?), may be taken to reduce the amount of stomach acid that is produced. Proton pump inhibitors, such as omeprazole (Prilosec?), lansoprazole (Prevacid?), rabeprazole (Aciphex?), and esomeprazole (Nexium?), may also be taken to reduce the amount of stomach acid produced.

If an infection with H. pylori is causing gastritis, patients generally receive a combination of antibiotics and proton pump inhibitors. Commonly prescribed antibiotics include amoxicillin (Amoxil?), clarithromycin (Biaxin?), and metronidazole (Flagyl?).

Hypochlorhydria (low stomach acid): Hypochlorhydria occurs when patients have low levels of stomach acid, also called hydrochloric acid. The body needs stomach acid in order to break down foods so that they can be absorbed in the intestines.

Natural aging, a poor diet, chronic use of certain medications, and past infection with the Helicobacter pylori bacteria may limit a patient's ability to produce hydrochloric acid.

Hypochlorhydria may also be a symptom of an underlying medical condition such as Addison's disease, depression, asthma, eczema, gallstones, hepatitis, osteoporosis, psoriasis, thyroid disease, and autoimmune disorders.

If there is low acidity in the stomach, patients may only be able to partially digest food. This may lead to malnutrition. Symptoms of hypochlorhydria may include bloating, gas, belching, burning or dryness of the mouth, heartburn, multiple food allergies, rectal itching, redness or dilated blood vessels in the cheeks and nose, adult acne, hair loss (in women), iron deficiency, undigested foods in the stool, yeast infection, as well as diarrhea or constipation. Patients with hypochlorhydria also have an increased risk of developing infections in the gastrointestinal tract because it provides an ideal environment for disease-causing organisms, such as bacteria.

Patients with hypochlorhydria take betaine hydrochloride or glutamic acid hydrochloride with meals and snacks. These medications increase the amount of stomach acid, which helps the body properly break down and digest foods.

Ileus: Ileus occurs when the small and/or large intestine is partially or completely blocked. Ileus is a non-mechanical blockage. Unlike mechanical blockages, which occur when the bowel is physically blocked, a non-mechanical blockage occurs when the rhythmic contractions that move material through the bowel, called peristalsis, stops.

Ileus is usually associated with an infection of the peritoneum, which is the membrane that lines the abdomen. This is most common in infants and children. Intestinal surgery may lead to temporary ileus that lasts two to three days. Ileus may also be a complication of surgery on other body parts, such as the chest or joints. Other medical conditions, including kidney disease and heart disease, may cause ileus. Some chemotherapy drugs, such as vincristine (Oncovin?, Vincasar PES?, or Vincrex?) or vinblastine (velban? or Velsar?), may cause ileus.

Symptoms of ileus may include abdominal distention, abdominal cramping, nausea, vomiting, bloating or failure to pass gas, and difficulty having bowel movements.

Patients with ileus must receive nutrition and fluids intravenously to give the intestines time to heal. If an infection is causing the condition, antibiotics are prescribed. Other medications, including cisapride and vasopressin (Pitressin?), may be prescribed to stimulate the intestines to contract and relax.

Intestinal disorders

Celiac disease (non-tropical sprue): Celiac disease, also called non-tropical sprue, is a digestive disorder that occurs when an individual's immune system overreacts to gluten, a protein found in wheat, rye, barley, and oats.

When a patient with the disease eats food that contains gluten, the immune cells flood to the stomach and intestine to destroy the gluten. However, among these immune cells are autoantibodies that attack the lining of the intestine by mistake. As a result, the intestinal lining becomes damaged.

It has not been determined what triggers this reaction in celiac patients. However, celiac disease is associated with autoimmune disorders, such as lupus. Autoimmune disorders occur when the patient's immune system mistakenly identifies body cells as harmful invaders, such as bacteria. As a result, the immune cells in celiac patients attack the patient's intestinal cells when gluten is consumed.

Celiac disease causes symptoms of abdominal pain and bloating after consuming gluten.

Additionally, complications, including poor absorption, may occur if the patient continues to eat gluten-containing foods. When the intestinal lining is damaged, patients have difficulty absorbing nutrients. Symptoms of poor nutrition include weight loss, diarrhea, abdominal cramps, gas, bloating, fatigue, foul-smelling or grayish stools that may be oily (steatorrhea), stunted growth in children, and osteoporosis (hollow, brittle bones).

If celiac disease is suspected, blood tests will be performed to determine whether or not the patient has autoantibodies associated with the disease. If autoantibodies are present, a positive diagnosis is made.

Although there is currently no cure for celiac disease, the condition can be managed with a gluten-free diet. Patients should avoid all foods that contain gluten. This includes any type of wheat (including farina, graham flour, semolina, and durum), barley, rye, bulgur, Kamut, kasha, matzo meal, spelt, and triticale. Therefore, foods such as bread, cereal, crackers, pasta, cookies, cake, pie, gravy, and sauce should be avoided unless they are labeled as gluten-free. In general, patients who strictly follow a gluten-free diet can expect to live normal, healthy lives. Symptoms will subside several weeks after the diet is started, and patients will be able to absorb food normally once they avoid eating gluten. A dietician or certified nutritionist may help a patient with celiac disease develop a healthy diet. Patients with celiac disease may also find gluten-free cookbooks to be a helpful resource. Many products, including rice flour and potato flour, can be used as substitutes for gluten-containing flour.

Menke's kinky hair disease: Menke's kinky hair disease, also called Menke's disease, is an inherited disorder that decreases the body's ability to absorb copper. Cells in the body need copper to function properly. The disease is characterized by sparse and coarse hair, short stature, and progressive deterioration of the nervous system.

Symptoms develop during infancy. Babies with Menke's kinky hair disease show slightly slowed development for two to three months after birth. The baby's condition will worsen after this time and he/she will lose previously developed skills. Other symptoms include silver or colorless hair, seizures, and osteoporosis (hollow and brittle bones).

There is currently no cure for Menke's kinky hair disease. Patients may receive injections of copper. However, patients typically die by the age of ten.

Acrodermatitis enteropathica: Acrodermatitis enteropathica is an inherited condition that occurs when the body is unable to absorb zinc. This trace element is necessary for the functioning of over 300 different enzymes and plays a vital role in an enormous number of biological processes.

The exact cause of acrodermatitis enteropathica remains unknown. However, researchers believe that genetics may play a role.

Symptoms of acrodermatitis enteropathica may include red and swollen patches of dry and scaly skin, crusted or pus-filled blisters on the skin, swollen skin around the nails, mouth ulcers, red and glossy tongue, impaired wound healing, as well as hair loss on the scalp, eyelashes, and eyebrows. Additional symptoms may include pinkeye, sensitivity to light, decreased appetite, diarrhea, irritability, failure to grow, and depressed mood.

A zinc deficiency can be diagnosed after a blood test.

Although there is no cure for the disorder, zinc supplements taken by mouth daily have been shown to effectively manage symptoms. Without treatment, acrodermatitis enteropathica will lead to death. Skin lesions usually heal one to two weeks after treatment is started. Other symptoms begin to improve within 24 hours.

Anorectal disorders

Hemorrhoids: Hemorrhoids are inflamed veins in the anus and rectum. Hemorrhoids may develop inside or outside of the rectum, depending on the specific veins that are affected.

Hemorrhoids are common, affecting nearly half of individuals who are older than 50 years of age.

Hemorrhoids develop when there is increased pressure in the veins of the anus and rectum. This is often due to straining during constipation, sitting or standing for extended periods of time, pregnancy, childbirth, and diarrhea. Obese patients have an increased risk of developing hemorrhoids.

Internal hemorrhoids are not painful because pain nerves are not present inside the membranes of the rectum. However, internal hemorrhoids may cause bleeding when stools are passed. External hemorrhoids are usually painful. The veins outside of the rectum are swollen and may itch. Bleeding may occur, especially when straining to move the bowels.

External hemorrhoids can be diagnosed after observing the inflamed veins. If internal hemorrhoids are suspected, a healthcare provider may examine the rectum with an anoscope, proctoscope, or sigmoidoscope.

Mild cases of hemorrhoids are usually treated with over-the-counter creams or ointments, such as Preparation H?. Warm baths may also help improve symptoms.

If a blood clot forms in a hemorrhoid, a healthcare provider can make a surgical incision to remove the clot.

Rubber band litigation may be used to treat severe or persistent cases of hemorrhoids. During the procedure, small rubber bands are inserted around the base of the hemorrhoids. This cuts off the blood supply in the vein until the hemorrhoid falls off.

During a procedure called sclerotherapy, a chemical is injected near the hemorrhoid to shrink the inflamed vein.

If these therapies are ineffective, the hemorrhoids may be surgically removed in a process called hemorrhoidectomy.

Rectal prolapse: Rectal prolapse occurs when the inner lining of the rectum, called the rectal mucosa, protrudes from the anus. Rectal prolapse occurs when the tissues that normally support that rectal mucosa become loose and allow the tissue to slip down through the anus.

Without treatment, the condition may worsen and a large part of the rectum may protrude from the body through the anus. When this happens, the condition is called a complete prolapse. Most patients do not realize that they have rectal prolapse until it reaches this stage. Initially, the rectum may protrude during certain activities, such as coughing or laughing. Eventually, the prolapsed rectum may protrude more frequently or permanently.

Patients may be able to feel the tissue protruding out of the anus. Common symptoms of rectal prolapsed include pain during bowel movements, mucus or bleeding from the protruding tissue, and inability to control bowel movements.

Most patients with rectal prolapsed require surgery. The surgeon reattaches the rectum to the backside of the inner pelvis. Surgery may be performed through the abdomen or the perineum.

Stool softeners, such as calcium docusate (Surfak?) or sodium docusate (Colace?), may help reduce pain and straining during bowel movements.

Rectal inflammation (proctitis): Rectal inflammation, also called proctitis, occurs when the lining of the rectum (rectal mucosa) becomes swollen. Patients with proctitis often experience rectal bleeding, anal and rectal pain, frequent urge to have a bowel movement, passing mucus through the rectum, feeling of rectal fullness, and diarrhea.

There are many potential causes of proctitis. The most common cause is sexually transmitted diseases, which are acquired through anal or oral-anal intercourse. Other causes may include inflammatory bowel disease (IBD) and bacterial infections, such as streptococcus. Less common causes include chemicals (such as hydrogen peroxide enemas), injury to the rectum, radiation therapy that is applied near the rectum (for conditions such as prostate or cervical cancer), and medications or objects that are inserted into the rectum.

Several tests may be performed to diagnose the underlying cause of proctitis. Blood tests may be performed to detect possible infections. A colonoscopy may be performed to examine the inside of the colon for abnormalities. Healthcare providers may also use a swab to collect a sample of fluid from the rectum or urethra. The sample is then tested for STDs.

Most cases of proctitis are effectively treated and patients experience a full recovery. Treatment depends on the underlying cause of proctitis. If a bacterial infection is present, antibiotics, such as ciprofloxacin (Cipro?), levofloxacin (Levaquin?), penicillin, amoxicillin (Amoxil? or Trimox?), azithromycin (Zithromax?), clarithromycin (Biaxin?), or clindamycin (Cleocin?), may be taken. If a viral infection (e.g. herpes) causes proctitis, antivirals, such as such as acyclovir (Zovirax?), may be taken. Corticosteroids may be taken if radiation therapy is causing proctitis. If IBD is causing symptoms, anti-inflammatories, such as sulfasalazine (Azulfidine?) or anti-diarrheals, such as psyllium powder (Metamucil?), may be taken.

Laxative-induced colon damage: Laxatives are medications that are used to stimulate bowel movements. They are primarily used to treat constipation. Patients who overuse laxatives may develop colon damage. Long-term use of laxatives may cause the muscles in the colon to become weak from lack of use. The nerves in the lining of the colon may also become damaged. As a result, this may slow intestinal mobility and cause constipation.

Symptoms of laxative abuse include weight loss, hair loss, vomiting, abdominal pain, low energy, dehydration, dry eyes, headaches, mood swings, and bone pain.

Therefore, patients should not take laxatives more frequently than the packaging label suggests. If symptoms persist, patients should consult their healthcare providers to diagnose and properly treat the underlying cause.

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