Women & gastrointestinal conditions.

Roxanne Jones was certain she was having a heart attack. It was the middle of the night in 1999, and the pain behind her sternum woke her out of a deep sleep. But after a full physical, her doctor gave her a completely different diagnosis. There was nothing wrong with her heart. But her esophagus ... now, that was a different story.

Ms. Jones, of Harpswell, ME, had gastroesophageal reflux disease, or GERD. The condition occurs when stomach contents and acid back up into the esophagus, often because the muscle at the end of the esophagus relaxes more than usual. Affecting an estimated one out of five Americans, GERD plays a role in about 1,700 deaths a year and 710,000 hospitalizations and leaves 45,000 people a year disabled. (1)

For Ms. Jones, 53, the diagnosis meant giving up her beloved chocolate, eschewing the nightly glass of wine she loved and taking daily medication to reduce the amount of acid her stomach produces (for more on medications for gastrointestinal conditions, see page 5). Soon after she stopped taking the medication a few months ago, her condition worsened into esophagitis, which is inflammation with erosions or ulcers in her esophageal lining. Left untreated, it could, on rare occasions, develop into a precancerous condition called Barrett's esophagus, a cause of esophageal cancer.

Luckily, Ms. Jones's esophagitis is healing nicely. "But I have to stay on the Prilosec religiously," she says, "possibly for the rest of my life, and be very religious about my diet, which I have been."

Ms. Jones is learning what millions of Americans have learned: That gastrointestinal conditions--including ulcers, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), constipation, diarrhea and even simple heartburn--can have a tremendous effect on your overall health and quality of life.

Just ask Fran Katz Watson, 43, a political fundraiser in Washington, DC. In her twenties and throughout most of her thirties, Ms. Watson suffered with a variety of gastrointestinal disorders including diverticulosis (in which small pouches form in the colon) and diverticulitis (when the small pouches become infected or inflamed), IBS, and, as a result of her chronic constipation, a collapsed rectal wall and prolapsed, or "dropped," bladder, which led to chronic kidney infections from backed-up urine.

"I never dated. I was very depressed. I smoked a lot," Ms. Watson recalls. "I couldn't even go out to dinner with anyone because I'd have to be in the bathroom for an hour or more afterward."

Surgery finally corrected many of her problems, and today Ms. Watson is married with two children. However, she hasn't left the world of gastroenterology completely behind. She has terrible GERD, she says, for which she takes Prilosec daily, and she needs a colonoscopy frequently because an earlier one found precancerous polyps.

The Gastrointestinal System

In a perfect world, you eat a nutritious diet, drink plenty of water and get regular exercise. When you eat, your food travels from your mouth to your throat and down your esophagus into your stomach.

A muscle at the bottom of your esophagus closes tightly after letting food through, while your stomach releases acid and enzymes to break down your food. From there, the food, now called "chyme," travels through your small intestine (considered small because of its diameter, not its 11-foot length) where hormones and other chemicals neutralize the acid and further digest the chyme, and finger-like projections from the lining of the small intestine reach out to absorb nutrients into the bloodstream where they literally feed cells throughout your body.

What's left passes into the six-foot-long large intestine, or colon, where water is removed and sent into your bloodstream. The remainder is held in the bottom of the large intestine, called the rectum, until you have your bowel movement.

If it were a perfect world, 60 to 70 million people wouldn't be affected by digestive diseases, resulting in 234,000 deaths, including those from gastrointestinal cancers. (1) Let's take a look at a few of the more common conditions.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is the most common GI diagnosis in the United States and one of the top 10 reasons for visits to primary care physicians. (2)

The condition is diagnosed if you have chronic or recurrent abdominal pain, relief of the abdominal pain by having a bowel movement and/or discomfort associated with changes in your bowel habits (constipation, diarrhea or both). Individuals may also suffer from bloating, gas and other bowel symptoms. Typically, doctors can find no structural reason for your symptoms using routine tests. Although the condition is two to three times more common in women, this may be partially explained by the fact that women are more likely to seek medical care for their symptoms, says Patricia Raymond, MD, gastroenterologist and assistant professor of clinical internal medicine at Eastern Virginia Medical School in Norfolk, VA.

Irritable bowel syndrome is typically treated with over-the-counter medications, some prescription medications, lifestyle changes and mind/body approaches such as hypnotherapy, cognitive behavioral therapy and relaxation training.

One of the few available prescription drugs for treating IBS with predominantly constipation was taken off the market in March because it appears to increase the risk of heart attack and stroke. Although the drug, Zelnorm, is currently not available in the United States, the U.S. Food and Drug Administration (FDA) is working with manufacturer Novartis to develop a program that would make it available to patients for whom nothing else works. (3) The drug is only approved for use in women. That's not because of any gender-specific actions, says Dr. Raymond, but because not enough men were willing to participate in clinical trials.

One of those women is Sherry Lenahan,* of Rocky Hill, CT. Ms. Lenahan says she had IBS with constipation long before there was a name for it. The only relief she ever found came from Zelnorm. "It was amazing, it helped keep me regular and seemed to smooth out the nerves and muscles in my colon," she said. "I felt angry that it was withdrawn and afraid of suffering again." After two months without the medication, she's beginning to experience the severe bloating and abdominal pain of her IBS.

Diverticulosis

If you live long enough, you will get diverticulosis. In fact, it's more "normal" to have diverticulosis than not to have it once you hit your 50s and 60s. Don't rush out to the doctor, however; in most cases, diverticulosis has no symptoms. (4)

Diverticulosis--not to be confused with its nastier cousin, diverticulitis--affects about 2.5 million people in the United States, appearing equally in men and women. (1) Diverticula are little pouches in the colon wall that are the hallmark of the condition. Between 15 to 25 percent of those with diverticulosis develop diverticulitis, which refers to inflammation of the diverticula; another 5 to 15 percent have bleeding from the diverticula. (4) Although the actual cause of diverticulosis remains unknown, it's clear that fiber plays a role. The more fiber in your diet, the less likely you are to develop diverticulosis or complications related to the condition.

Why fiber? Fiber speeds colon transit time, explains Lisa Strate, MD, acting assistant professor of gastroenterology at the University of Washington in Seattle. In other words, the more fiber in your diet, the faster and easier your stool whooshes through your colon. That reduces the risk of straining when you have a bowel movement. When you strain, feces can push against weak spots in the colon wall, forming diverticula. If bits of digested food get stuck in those little pockets, you can develop diverticulitis. The pockets become inflamed, sometimes leading to perforation and local pockets of infection. Typical symptoms include pain and tenderness in the lower abdomen, fever, nausea, vomiting and a high white blood cell count. (5)

Treatment for diverticulitis depends on the severity of the inflammation. For low-grade inflammation, rest and oral antibiotics may suffice. Severe inflammation, however, typically requires intravenous antibiotics and sometimes even surgery to remove the affected part of the colon.

Once you have diverticulosis, says Dr. Strate, the key is preventing complications. The aforementioned high-fiber diet can help. Following such a diet should be easier now that Dr. Strate's own research found no reason for the admonition to avoid nuts and corn doctors typically give patients with diverticulosis. "The take-home message is that if you have diverticulosis, you don't need to avoid corn and popcorn and nuts," she said. "And since they are high in fiber and good for you, that's a good thing."

Inflammatory Bowel Diseases

Don't confuse inflammatory bowel diseases (IBD) with irritable bowel syndrome (IBS). The latter refers to a collection of symptoms without negative long-term effects. IBD refers to two serious diseases: Crohn's disease and ulcerative colitis, which have been associated with increased risk of colon cancer over the long-term.

The diseases are likely caused by an overresponse of the immune system to microbes in the gastrointestinal tract that trigger significant inflammation.

In Crohn's disease, inflammation and ulcers can form anywhere in the digestive tract, from the mouth to the anus. During an acute inflammatory period, called a "flare," people commonly experience significant pain, diarrhea and fever and may pass blood and/or mucous during bowel movements.

Major complications include intestinal blockages, called strictures and fistulas. Fistulas create passages between two nearby or adjacent areas that do not normally connect. This allows contents within the intestine to flow through and may worsen diarrhea and stool leakage. Infected pockets called abscesses can also form around the fistulas. Most patients with Crohn's eventually require surgery to remove or repair the damaged parts of the intestine. (6)

Ulcerative colitis only occurs in the colon, leading to bloody diarrhea, abdominal tenderness, fever and dilated colon in more severe cases. Unlike Crohn's, it rarely leads to fistulas or obstruction. (6)

Although the incidence of inflammatory bowel disease is about the same between men and women, the disease presents special issues in women, says Maria T. Abreu, MD, who directs the Inflammatory Bowel Disease Center at Mt. Sinai School of Medicine in New York. For instance, she notes, women with IBD tend to have flares of diarrhea and bloating during their menstrual periods. They also have difficulty getting pregnant, and if they do get pregnant, are more likely to have premature births, low birthweight babies, complicated labors and cesarean sections than women without the condition.

The primary treatment for IBD is immunosuppressive medications, which make people more susceptible to infection. Women with IBD are more likely to have abnormal Pap smears, Dr. Abreu says, probably because their immune system is less able to fight off the HPV virus, which causes most cases of cervical cancer. So she recommends her patients receive the new HPV vaccine, Gardisil, regardless of their age, to help their body shed HPV viruses. Those immunosuppressive medications, particularly corticosteroids, also increase the risk of osteoporosis in women with IBD.

Although the diseases can take a terrible toll, Dr. Abreu and her colleagues are increasingly optimistic about their ability to treat the disease, thanks to new biologic drugs like infliximab (Remicade) and adalimumab (Humira). A third biologic, certolizumab pegol (Cimzia), is in late-stage clinical trials. (7) These drugs suppress parts of the immune system and are used to prevent and treat flares.

Don't Give Up

No matter what your symptoms or condition, don't simply accept it or let someone tell you it's all in your head. That's what happened to Atlanta-area writer Penny Cassell,* who was diagnosed with IBS with diarrhea. Like many women interviewed for this report, it took several years and many doctors before Ms. Cassell received her diagnosis.

Despite her symptoms--sudden onset of chills and sweats, diarrhea and severe abdominal pain--her doctor told her it was stress related. While it is true that many gastrointestinal conditions, including IBS, can be triggered or worsened by stress and anxiety, and these should be addressed by the appropriate health care providers including social workers and mental health professionals, there are also often specific medical treatments that can help these conditions. Ms. Cassell's advice to other women: "Don't suffer for years before seeking help."

Resources

American Cancer Society

1-800-227-2345

www.cancer.org

Crohn's & Colitis Foundation of America

1-800-932-2423

www.ccfa.org

International Foundation for Functional Gastrointestinal Disorders

1-818-964-2001

www.iffdg.org

National Digestive Diseases Information Clearinghouse

1-800-891-5389

www.digestive.niddk.nih.gov

References

1 Digestive Disease Statistics. NIDDIC web site. http://digestive.niddk.nih.gov/statistics/statistics.htm. Accessed Jun 9, 2007.

2 El-Baba, MF. Irritable Bowel Syndrome, Apr 4, 2007. eMedicine Web site. www.emedicine.com/ped/topic1210.htm. Accessed Jun 9, 2007.

3 Questions and Answers on Zelnorm (tegaserod maleate). FDA Web site. Mar 30, 2007. www.fda.gov/cder/drug/infopage/zelnorm/zelnorm_QA_2007.htm. Accessed Jun 11, 2007.

4 Bogardus ST Jr. What do we know about diverticular disease? A brief overview. J Clin Gastroenterol. 2006 Aug; 40(7 Suppl 3):S108-11.

5 Petruzziello L, lacopini F, Bulajic M, Shah S, Costamagna G. Review article: uncomplicated diverticular disease of the colon. Aliment Pharmacol Ther. 2006 May 15;23(10):1379-91.

6 Baumgart DC, Carding SR. Inflammatory bowel disease: cause and immunobiology. Lancet. 2007 May 12;369(9573):1627-40.

7 UCB Presents Long-Term CIMZIA Data in Crohn's Disease [press release]. May 22, 2007. UCB Group Web site. http://ir.ucb-group.com/phoenix.zhtml?c=1374956p=irol-newsArticle610=10050746highlight=. Accessed Jun 11, 2007.

*Not her real name.

RELATED ARTICLE: Screening for Gastrointestinal Conditions

If you're having intestinal problems with your stomach or colon, your health care professional may want to conduct one or more of the following tests. All are performed on an outpatient basis; you are sedated typically only for colonoscopy and upper endoscopy.

** Fecal occult blood test: You provide your doctor with a stool sample, which is evaluated for microscopic amounts of blood that you cannot see. You should not eat red meat for three days before collecting the stool samples.

** Colonoscopy: A long, flexible tube with a camera and light source at the tip is inserted through your anus, allowing the doctor to view the colon. Polyps can be removed with this instrument.

** Upper endoscopy: A shorter, lighted flexible tube is passed through your mouth into your esophagus, stomach and beginning of your small intestine, called the duodenum. It is typically performed to check for inflammation and ulcers of the esophagus, stomach and duodenum and for other problems such as bleeding and problems swallowing.

** Flexible sigmoidoscopy: A short, flexible tube with a light on the end is used to view the rectum, sigmoid colon and descending colon. It doesn't provide as complete a view as a colonoscopy because it only visualizes less than half the colon.

** Barium enema: An x-ray examination of the large intestine (colon) after it has been expanded with air and a liquid containing barium by inserting a thin catheter into the rectum.

** pH monitoring: A very thin tube is passed through your nose to the bottom of your esophagus and measures acid reflux over 24 hours as you go through your normal activities. The tube is attached to a portable recorder that you wear on your belt for 24 hours. You return in 24 hours to have the tube removed. Another way to monitor pH involves placing a small capsule near the end of your esophagus during an upper endoscopy. Measurements of pH are sent to a pager-sized receiver on your belt via radio waves for 48 hours. You return in 48 hours to drop off the receiver. The capsule eventually falls off and is passed out of your body with your stool.