Natural Treatment to get rid of Flatulence and Bloating

Ultimate Flatulence Cure

With the Ultimate Flatulence Cure developed by Joseph Arnold, you will learn a system that functions to treatment flatulence and also other gas troubles forever and holistically, without using damaging drugs and spending a lot of money. This easy-to-apply system will work from the inside to cleanse your body. This program requires the process of learning how to cure their extreme burps, stomach gas, pain and cramps, bloating issues, and smelly farts. Using the program, people will find out the basis causes of flatulence, and just how to get rid of them easily. The program also guides people preventing this disease from coming back. In combination with the guides which come packaged with it as a set of free gifts, this book will not only give you the tools to cure your own flatulence, it will also give you important tips which will allow you to feel better in a number of different ways. Instead of wasting money on medications which may work as a stop-gap, taking heed of this guide will allow you to see benefits above and beyond the stopping of symptoms.

Ultimate Flatulence Cure Overview


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Get Rid Of Gas

100% Natural Cure to Flatulence and Stomach Aches. Did you know that Gas Pain is more likely caused by an underlying and even bigger problem? Dear Gas Pain Sufferer, If you're like most people, then you might not think of flatulence as a major problem. Perhaps you even get rid of one by popping a pill. But did you know that even Laxatives, which are known to be the most commonly known cure to flatulence can even worsen the problem? Finally, an all-natural alternative to cure Flatulence is here! This guide will help you cure the causes of not just flatulence but also other problems like: stomach ache abdominal pains indigestion diarrhea

Get Rid Of Gas Overview

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Who Should Be Referred for Surgery

Surgery is an effective therapy for GERD and the surgical option is a reasonable consideration for any patient with documented persistent acid or nonacid reflux associated with their symptoms, particularly young patients and those with poor compliance. On the other hand, patients should be cautioned that surgery is not 100 successful, and that there is also a risk of developing new symptoms, including dysphagia, bloating, inability to belch, and increased flatulence. We do not recommend surgery for patients labeled as medical failures by persistent symptoms despite medical therapy unless their symptoms have been documented to be related to reflux, either acid or nonacid. Chapter 12 (Surgery for Gastroesophageal Reflux Disease) covers surgery for gastroesophageal reflux.

Constipation in Pregnancy

Dietary modifications, such as increased fluid and fiber intake, are the most physiologic and safest approachs to constipation during pregnancy. As with all patients, pregnant women should be warned that fiber can cause abdominal bloating or flatulence and that sufficient amounts of fluid should be consumed daily. Fiber supplements should be started with small amounts and gradually increased as tolerated. In our experience, PEG is not as problematic in terms of abdominal bloating and flatulence as is sorbitol and lactu-lose. Although safety during pregnancy has not been established (Federal Drug Administration pregnancy Category C), PEG is inert, absorption is minuscule, and toxicity is unlikely.

Symptoms after Cholecystectomy

The most common postoperative symptoms after chole-cystectomy are dyspepsia, bloating, and flatulence, which mostly precede the surgery. A smaller subset of patients, however, will present with severe abdominal pain, nausea, vomiting, and or jaundice. Diagnostic workup is more likely to yield a specific disorder in the latter group. In patients with more severe symptoms, especially if accompanied by fever, leukocytosis, and or jaundice, bile peritonitis, secondary to a bile leak, has to be suspected and ruled out.

Bulk Forming Laxatives

Dietary fiber and bulk laxatives with adequate fluid intake are the most physiologic and safest of medical therapies. However, they may be counterproductive in patients with idiopathic slow transit constipation or with constipation associated with irritable bowel syndrome (IBS) because they often worsen bloating and abdominal distension in these populations. Dietary fiber in cereals contain cell walls that resist digestion and retain water within their cellular structures, whereas those found in citrus fruits and legumes stimulate the growth of colonic flora and increase fecal mass. Wheat bran is the most effective fiber laxative with a clear dose response on fecal output. Patients with poor dietary habits may add 2 to 4 tablespoons of bran to each meal, followed by a glass of water or another beverage. A laxative effect may not be observed for 3 to 5 days. Patients should be cautioned that large amounts of bran can cause abdominal bloating or flatulence therefore, they should start...

Johanna C EscherMD PhD and Hans A BullerMD PhD

Lactose intolerance is a clinical diagnosis and consists of symptoms such as abdominal pain, cramps, nausea, bloating, acidic diarrhea and flatulence after the ingestion of lactose (Suarez et al, 1995). The symptoms can begin 30 minutes to 2 hours after eating or drinking foods containing lactose, primarily dairy products. The severity of symptoms varies depending on the amount of lactose each individual can tolerate. Lactose intake varies with age. Lactose is the primary carbohydrate in milk, accounting for almost 35 to 55 of the daily caloric intake in infants. As weaning foods are introduced, lactose intake falls and gradually approaches the levels ingested by adults. The carbohydrate intake of adults on a typical western diet is approximately 300 g, with a lactose content of 5 (Chitkara et al, 2003). Intolerance to lactose-containing foods is a common problem worldwide except in northern Europe. The prevalence is high in the population from eastern Asia (90 or more), among Native...

Alternative Procedures

Bilio-pancreatic diversion is a procedure used by a small number of bariatric surgeons more commonly in Europe and Canada. Only 1-2 of the surgeons in America perform this procedure. It is a combination of a gastric restriction with malabsorption. The patient can eat almost the normal amount of food, but without absorbing most of the fat and carbohydrate content. The metabolic abnormalities are less than those of jejuno-ileal bypass. Bilio-pancreatic diversion is technically a more demanding procedure than others with a higher incidence of complications. The weight loss is similar to that of RYGB. One of the most undesirable side effects is the uncontrollable flatulence that the patient may develop.

Incised internal sphincte

Significant complications of LIS include infection abscess, recurrence or failure to heal, and incontinence. In a consecutive series of 53 patients, we noted a 1.8 incidence of abscess formation, a 5.7 incidence of recurrence or failure to heal, and a 1.8 incidence of incontinence to flatus. These figures are consistent with published figures in the literature (21,22). Abscess is easily managed in the office with drainage or superficial fistulotomy. A recurrent or nonhealing fissure will, in most cases, respond to repeat lateral internal sphincterotomy, usually on the opposite side. Anal incontinence, usually to flatus, is a difficult complication commonly related to division of the internal sphincter too proximally. It is usually transient but, if persistent, may require sphincter repair.

Extent of Lymph Node Dissection

Regardless of the type of gastric resection or lymphadenectomy, the postoperative management is similar. A feeding jejunostomy is not routine. When the patient is passing flatus an oral diet is started. We encourage the patient to eat whatever he can tolerate and do not recommend restrictive postgastrectomy diets. Frequent small, high caloric meals work best to prevent significant weight loss and for rapid postoperative recovery.

Long Term Bowel Function at Adult

In adulthood, defective fecal continence has significant social consequences. The main problem is fecal soiling that restricts social activities. In the series of Rintala et al. 83 , 85 of the adult patients reported social disability related to soiling. Other problems, especially those that disturb occupational life, were inability to hold back flatus and fecal urgency. Hassink et al. 85 reported that adult patients had a significantly lower educational level than expected. A striking finding in both these series was that after their childhood, most of the adult patients were not followed up by clinicians who were familiar with ARM. Consequently, their medical and social support has not been appropriate and most of the patients had had to attain bowel control by themselves.

Signs symptoms diagnosis and investigations

In patients with cancer, compression of the bowel lumen develops slowly and often remains partial. As a consequence of the partial or complete occlusion to the lumen and or dysmotility, the accumulation of the unabsorbed secretions produces nausea, vomiting, intermittent or complete constipation, pain, and colicky activity to surmount the obstacle that causes colicky pain. Abdominal distension may be absent in high obstruction that is, of the duodenum or proximal jejunum and when the bowel is plastered down by extensive mesenteric spread.

Citrus aurantium L Fam Rutaceae

For abdominal distension and pain, constipation, belching with a fetid odor due to stagnation of undigested food, it is used with Fructus Crataegi (Shan Zha) and Fructus Hordei Germinatus (Mai Ya). For constipation and abdominal distension due to accumulation of Heat, it is used with Cortex Magnoliae Officinalis (Hou Po) and Radix et Rhizoma Rhei (Da Huang). For abdominal distension after meals caused by Spleen Deficiency, it is used with Rhizoma Atractylodis Macrocephalae (Bai Zhu). For diarrhea with tenesmus due to the accumulation of Damp Heat, it is used with Radix et Rhizoma Rhei (Da Huang), Rhizoma Coptidis (Huang Lian), and Radix Scutellariae (Huang Qin) in The Pills of Aurantii Immaturus for Removing Stagnancy (Zhi Shi Dao Zhi Wan).

General Clinical Aspects

Prenatal diagnosis of persistent cloaca has been reported, but is not always accurate 12,13 . In contrast, clinical diagnosis is simple. In girls, a single opening on the perineum is always suspicious of a cloacal malformation. The length of the introitus is characteristically shorter than in a normal girl. Cloacas have only rarely been reported in boys in whom the urethra and rectum has coalesced into a common channel that is connected to the external surface in the perineal or anal area 14 . In girls, an abdominal mass and severe abdominal distension resulting from hydrome-trocolpos and or rectal obstruction can frequently be observed. Additional malformations of the lower limbs, genitalia, skin (hemangioma), urogenital tract, vertebral, cardiac, and gastrointestinal deformities, among others may occur. A rarity is the posterior clo

Citrus aurantium L or Citrus sinensis Osbeck Fam Rutaceae

For chest congestion, and pain in the rib areas, it is used with Pericarpium Trichosanthis (Gua Lou Pi), Rhizoma Cyperi (Xiang Fu), and Radix Cur-cumae (Yu Jin). For abdominal distension and pain, it is used with Radix Aucklandiae (Mu Xiang), Fructus Meliae Radicis (Chuan Lian Zi), and Fructus Evodiae (Wu Zhu Yu).

Drugdose ActionsComments

Fluid administered should be assessed carefully. High levels of intravenous and subcutaneous fluids may result in more bowel secretions, thus it is necessary to keep a balance between the efficacy of the treatment and the side effects such as increased vomiting, abdominal distension, and pain. The intensity of dry mouth and thirst are independent of the quantity of parenteral and oral hydration. The intensity of nausea, however, is considerably lower in patients treated with more than 1 litre day of parenteral fluids. Hydration can also improve fatigue and delirium in selected patients. Intravenous hydration can be difficult and uncomfortable for some patients with end stage cancer. Hypodermoclysis is a simple technique for rehydration that offers many advantages over the intravenous route, especially in patients at home. The role of TPN in the management of patients with inoperable bowel obstruction is controversial. No data are available on the survival rates or quality of life in...

Gracilis Muscle Transplant

Pubis Malformation

By the palmaris longus muscle interrupting the evacuation of flatus. Note the spontaneous relaxation of the internal anal sphincter. AR Anorectum, ARP anorectal resting pressure profile (also ARRPP), R rectum, prop. preoperatively, postpone. postoperatively by the palmaris longus muscle interrupting the evacuation of flatus. Note the spontaneous relaxation of the internal anal sphincter. AR Anorectum, ARP anorectal resting pressure profile (also ARRPP), R rectum, prop. preoperatively, postpone. postoperatively

Free Autogenous Muscle Transplant for Strengthening of the Levator Ani Palmaris Longus Transplant

Gracilis Muscle Transplant

Studies in the rat 20 have shown that necrosis increases in proportion to the degree of prestretching. In human studies, six out of nine patients treated with Hakelius-Grotte free muscle transplantation became continent for solid bowel contents, and three for liquid content, but none were continent for flatus. These results are less favorable than those reported by Hake-lius et al. 13-15 and Grotte et al. 16 . Postoperative electromanometric studies have shown that the ano-

Entamoeba histolytica and Entamoeba dispar Amebiasis

Occasionally, E. histolytica infections are characterized by nonbloody diarrhea, abdominal cramps, flatulence, fatigue, and weight loss. Fever is uncommon. Treatment includes metronidazole, a potent, well-absorbed drug that is active both in the bowel lumen and wall, as well as in other tissues. Metronidazole, however, is often not sufficient as a luminal amebicide when used alone (up to 50 failure rate) and therefore should be followed with one of the luminal-acting oral drugs (iodoquinol, paramomycin, or diloxinide furoate).

Ileoanal Pouch Frequent Evacuation

The majority of patients with normally functioning IPAAs should evacuate between four and eight times per day, and once or twice at night. After the initial postoperative phase, IPAA patients should not have extreme fecal urgency and should be able to distinguish between the urges of flatus and feces. Approximately 10 to 20 of IPAA patients experience minor leakage of stool, especially at night, when they may need to wear a pad (Meagher et al, 1998). However, they should be continent during the day. Passage of stools should be painless, should not be accompanied by the need to strain, and should feel complete. In taking the history, the features of diarrhea need to be defined precisely increased fecal frequency needs to be distinguished from urgency, fecal leakage, or gross incontinence.

Clinical Presentation

Abdominal distension with or without passage of gas or meconium per urethra. The association of bilious vomiting with early gross distension of the abdomen in a case of ARM is strongly suggestive of congenital CPC. In females, the colon is often associated with a cloacal anomaly. The female baby presents with passage of meconium from an abnormal opening, absent anus, and abdominal distension, and on examination a cloaca is usually found. Although reported by others, in this author's series, there was no case of colout-erine or colovestibular fistula. There may be a double or septate vagina, and the fistulous communication may open in one of the hemivaginae or between the two into the cloaca (Table. 11.4). In cases of colonic perforation occurring early in patients with CPC, the baby may present with septicemia, gross abdominal distension with prominent veins, fluid and electrolyte imbalance, and features of peritonitis.

Qualityof Life Measurements

Diseth and Emblem 3 used semistructured interviews and questionnaires, such as the Child Assessment Schedule, Child Behavior Check List, and self report in 33 adolescents with ARM. Psychosocial functions were impaired in 73 of the adolescents, and 58 met the criteria for psychiatric diagnosis. The authors found a significant correlation of the degree of flatus incontinence with the degree of psychosocial impairment and of continence of flatus with mental health symptom scores.

Postoperative management

Psoas Hitch Technique

If patients are restricted to bed following urogenital fistula repair, a laxative should be administered to prevent excessive straining at stool. Following abdominal repair of an intestinovaginal fistula patients should either have a nasogastric tube inserted or be restricted to nil by mouth until they are passing flatus the majority prefer the latter approach. Once oral intake is allowed, or following vaginal repair of a rectovaginal fistula, a low-residue diet should be administered until at least the fifth postoperative day. Some authorities advocate total parenteral nutrition throughout the first week postoperatively for all intestinovaginal fistulas. Enemas and suppositories should be avoided, although a mild aperient such as dioctyl sodium (docusate sodium) is advised to ease initial bowel movements.

Common Water Chemistry Diseases in Aquaculture Associated with Water Recirculation or Reuse

Marked abdominal distension due to marked gastric dilation - 'water belly syndrome'. (Photo courtesy of Dr D. Groman, Atlantic Veterinary College.) Fig. 12.13. Marked abdominal distension due to marked gastric dilation - 'water belly syndrome'. (Photo courtesy of Dr D. Groman, Atlantic Veterinary College.)

Cryptosporidium parvum Cryptosporidiosis

This organism is a spore-forming protozoan that is highly infectious and is transmitted directly from person-to-person or by contaminated water or food. An estimated 300,000 illnesses occur annually in the United States, and approximately 1 to 3 of the US population is estimated to be asymptomatic carriers. In immunocompetent persons, the illness is usually self-limited, lasting from 7 to 28 days, and ranges from mild diarrhea with flatulence to more severe nonbloody, watery diarrhea. In immunocompromised persons, particularly those with acquired immunodeficiency syndrome (AIDS), chronic diarrhea commonly occurs (accounts for 10 to 30 of AIDS patients with chronic diarrhea not on antiretroviral therapy) and a fulminant illness characterized by profuse, cholera-like watery diarrhea, electrolyte imbalance, weight loss, and malabsorption can result. Biliary tract infection (cholangitis) can also occur. Diagnosis is made by examining up to three stools for characteristic oocysts, using a...

Continence and the Mechanism of Defecation in Normal Individuals

Caused by filling of the stomach or ileum, respectively) as well as voluntary contraction of the abdominal musculature, may initiate defecation by filling the rectum with colonic contents. The increasing intrarec-tal pressure stimulates the distension receptors in the puborectalis muscle and the parapuborectal tissues, and desire to pass stool is consciously felt. At the same time, a reflex relaxation of the internal anal sphincter occurs. This allows even the smallest amounts of stool to reach the anal canal. The hypersensitive mucosa of the anal canal is able to distinguish the difference between flatus and liquid or solid stool. The reflex contraction of the external anal sphincter and the puborectalis will prevent expulsion of stool from the anal canal and thus inhibit fecal soiling. This effect is increased by the compression of the lower anal canal by the engorged hemorrhoidal vessels of the rectum and the corrugator muscle of the anus. This allows the rectum time to adapt...

Pharmacologic Management

There should be no peritoneal signs, blood pressures must be > 90 60 mm Hg, and pulse > 60 beats min. Contraindications to neostigmine use include recent use of p-blockers, bradycardia, hypotension, acidosis, recent myocardial infarction, renal failure, acute bronchospasm, and signs of bowel perforation. Mechanical obstruction must first be excluded by a Gastrografin study. Atropine must be available. Neostigmine is given intravenously at a dose of 2.5 mg in 100 mL saline infused over 5 minutes with electrocardiographic monitoring in the ICU. Neostigmine is effective and rapid decompression can be expected after a single dose. Median time to clinical response varies from 4 to 30 minutes as measured by time to pass flatus or stool. An abdominal film is obtained in 60 minutes to assess radiographic response. A second dose may be required and should be given 3 hours following the first dose. Side effects include postural hypotension, symptomatic bradycardia requiring atropine,...

Familial Visceral Myopathy

Familial visceral myopathy or hollow visceral myopathy are believed to be the most common causes of primary disease (Faulk et al, 1978). Clinically affected family members may be asymptomatic or suffer from abdominal pain, dysphagia, abdominal distension, constipation, early satiety, nausea, and vomiting. Radiographic demonstration of intestinal distension via plain films or barium studies further supports the diagnosis. Involvement of the bladder and ureter commonly occurs. Gross and microscopic features, as described by Mitros and colleagues (1982), include dilatation of various segments of the intestinal tract, most commonly the duodenum (leading to megaduodenum) and microscopic changes, including fibrosis and muscle cell degeneration.

Gastrointestinal obstruction

Malignant obstruction of the gastrointestinal tract may be due to occlusion of the lumen by tumour or distortion of gut and mesentery by tumour, or may be functional due to a failure of normal peristalsis. Obstruction may be partial or complete and may develop gradually with self resolving episodes of partial obstruction preceding a complete obstruction. The treatment of choice for a single level of occlusion is surgery, but when the patient is unfit for surgery, or when there are multiple levels of obstruction, an alternative treatment regimen is necessary to palliate symptoms of nausea, vomiting, colic, abdominal distension, and peritoneal pain.

Feline cellassociated herpesvirus FCAHV

Wasting and abdominal distension due to fibrinous peritonitis. Fatal in a few weeks. There is often pleurisy and necrotic inflammatory lesions in many organs. Infective virus is present in ascitic fluid and organ extracts. There is hypogammaglobulinemia and there may be meningo-encephalitis and panoph-thalmitis. Recombinants, known as type II strains, have been found naturally which arose by recombination with Canine coronavirus.

Parviz NikoomaneshMD and Salim A JafferMD

Patients with acute pseudo-obstruction have a soft, but distended, and tympanic abdomen. Bowel sounds are high pitched to absent. Patients usually do not have peritoneal signs or colicky pain, but may precipitate vague abdominal pain as the cecum distends. Nausea and vomiting may be present. Patients may pass flatus and liquid stools or they may be obstipated. White blood cell (WBC) count is usually normal.

Anorectal Hystolgic Function

The clinical evaluation of fecal incontinence should include measures of both severity and impact on quality of life. Although these factors are closely intertwined, they may show surprising divergence in many cases. For example, one patient may refuse to leave her home due to fear of incontinence to flatus, whereas another may be little impacted by occasional episodes of complete incontinence. Accordingly, severity and quality of life should be measured separately (Shelton and Madoff, 1997) Even in the absence of a commonly accepted standard measure of incontinence severity, the key features (frequency and nature of incontinent episodes) are largely agreed upon. We measure the impact of incontinence on quality of life using the validated Fecal Incontinence Quality of Life Scale (FIQL) (Rockwood et al, 2000).


At the beginning of the change in diet there may be some abdominal discomfort, which will take the form of flatulence and spasmodic cramps due to the formation of intestinal gases, but this can be expected to disappear after some time. It is possible to make food more digestible by thoroughly chewing it, making sure that meals are unhurried, and ensuring that there are sufficient rest periods between meals. It is best to begin with more easily digestible foodstuffs such as fruit pur es, boiled vegetables, salads, oatmeal, and bread made of more finely ground wholemeal. Flatulence or a feeling of fullness can be relieved by drinking fennel

Dietary Fiber

Will result in a mechanical stimulation of the bowel. An increase in roughage can be achieved not just by increasing the percentage of vegetable foodstuffs ingested, but also by choosing products with more roughage. As fruits and vegetables largely consist of cellulose, such a substitution is limited, because the roughage in fruits and vegetables, with the exception of pulses, is only around 1-3 7,8 . Berries and dried fruits have the highest roughage content. The vegetables with the highest amount of roughage are green peas, leeks, cabbages, and pulses however, they are also more indigestible and can lead to flatulence. One should eat four to five portions of vegetables, uncooked vegetables, salads, fruit, and or fruit juices every day.

Clinical Features

Newborns present usually 3-5 days after birth with abdominal distension. Bilious vomiting may be associated in cases with delayed presentation. The condition may mimic and needs to be differentiated from long-segment Hirschsprung's disease, intestinal atresia, colonic atresia, and meco-nium ileus. A forceful anal rectal catheterization may easily perforate the bowel resulting in peritonitis and septicemia. Physical examination reveals marked abdominal distension with a normal-appearing anus and perineum. The diagnosis becomes evident when a rectal a thermometer, finger, or a red rubber catheter is passed and stops at about 1.5-3 cm depth from the anal verge. Associated anomalies, although rare, may be sacral, cardiac, or renal anomalies 7,8 .

Making the Diagnosis

Hypoactive bowel sounds may be seen in intestinal pseudo-obstruction as opposed to the high-pitched bowel sounds in mechanical obstruction. Abdominal distension and tympany on percussion may be seen in both disorders. Peristaltic waves are more common in mechanical obstruction.

Enteral Nutrition

The gastrointestinal tract should be used whenever possible because enteral nutrients may help to maintain gastrointestinal function and the mucosal barrier and thus prevent translocation of bacteria and systemic infection 61 . Even small amounts of enteral diets exert a protective effect on the intestinal mucosa. Recent animal experiments suggest that enteral feeds may exert additional advantages in acute renal failure (ARF) patients 63 in glycerol-induced ARF in rats enteral feeding improved renal perfusion, A, and preserved renal function, B. For patients with ARF who are unable to eat because of cerebral impairment, anorexia, or nausea, enteral nutrition should be provided through small, soft feeding tubes with the tip positioned in the stomach or jejunum 61 . Feeding solutions can be administered by pump intermittently or continuously. If given continuously, the stomach should be aspirated every 2 to 4 hours until adequate gastric emptying and...

The disease

Catfish Disease

Spring viraemia of carp. (a) Lateral view of carp showing distended abdomen and haemorrhage in skin and in anal and caudal fin. (b) Ventral view of gross abdominal distension in experimentally infected carp (top) compared with control fish (bottom). Fig. 5.1. Spring viraemia of carp. (a) Lateral view of carp showing distended abdomen and haemorrhage in skin and in anal and caudal fin. (b) Ventral view of gross abdominal distension in experimentally infected carp (top) compared with control fish (bottom).

Dietary Stimulants

Lactose or concentrated sugar solutions made of lactose also stimulate intestinal motility because lactose is digested more slowly than sucrose (normal sugar) due to the physiologically reduced activity of lactase in the small intestine. If larger amounts are ingested the lactose will reach the intestine without being digested. The laxative effect is due to the increase in the amount of liquid because of the osmotic activity of the lactose. The increased distension stimulus in the colon leads to an increase in intestinal motility. Lactose is partly broken down in the colon by bacteria in a similar manner to water-soluble roughage. This results in the creation of short-chain fatty acids, such as lactic acid, acetic acid, and formic acid, and carbon dioxide. In addition to the increased motility because of intestinal gas formation, the short-chain fatty acids help regenerate the intestinal mucosa and create an acidic intestinal milieu. Intestinal bacteria, Sugar substitutes such as...

Anal Fissure

Botulinum toxin injection is indicated for patients who are unresponsive to or have contraindications for nitric oxide treatment. Two, 0.1 mL doses of diluted toxin are injected beneath the anal fissure with a short, thin needle injections can be repeated if necessary. There is a risk for minor incontinence, flatus, and soiling with this treatment. Surgical lateral sphincterotomy is associated with a greater risk of incontinence and is offered to patients who relapse or fail these newer nonsurgical methods. Sphincterotomy can be performed under local, regional, or general anesthesia as an open or closed procedure and is routinely performed on an outpatient basis.


Considerably and we prefer to instruct patients to self-titrate their dose gradually, aiming to achieve a target effect of three to five soft or semiliquid bowel movements per day. Unfortunately, a common error in management of encephalopathy is the omission of education of patients on the correct use of lactulose. Frequent side effects of lactulose therapy include glucose elevation in diabetics, excessive sweet taste, abdominal distention, cramping, and flatulence. Oral lactulose is appropriate for patients with stage I or II encephalopathy, but for those who have severe encephalopathy or hepatic coma (stages III or IV), a naso-gastric tube should be used to instil lactulose. We prefer the use of lactulose colonic retention enemas in this setting because it allows greater dosing (enemas of 300 mL of lactulose plus 700 mL of tap water) and avoid the risks of pulmonary aspiration in these patients who have severe compromise of the mental status. Although quite effective, this route of...

Lactose Intolerance

And adult life, although rare congenital deficiencies can occur. Symptoms of lactase insufficiency are usually dose related and include bloating, flatulence, and diarrhea. Secondary lactase deficiency can result from viral gastroenteritis, radiation enteritis, Crohn's disease (CD), and celiac sprue. It is important from a management standpoint to understand that individuals with constitutive lactose intolerance (1) do not suffer severe and potentially life-threatening complications of ingesting lactose and (2) are able to consume naturally lactose free diary products including most cheeses and yogurts. This contrasts with cow's milk allergic individuals who may suffer anaphylactic or asthmatic reactions to dairy products and must avoid all foods containing the culprit cow's milk protein allergen, usually casein or p-lactoglobulin. There is a chapter on carbohydrate intolerance (see Chapter 62, Lactose Intolerance).

Figure 930

Autosomal-dominant polycystic kidney disease (ADPKD) renal replacement therapy. Transplantation nowadays is considered in any ADPKD patient with a life expectancy of more than 5 years and with no contraindications to surgery or immunosuppression. Pretransplant workup should include abdominal CT, echocardiogra-phy, myocardial stress scintigraphy, and, if needed (see Figure 9-26), screening for intracranial aneurysm. Pretransplant nephrectomy is advised for patients with a history of renal cyst infection, particularly if the infections were recent, recurrent, or severe. Patients not eligible for transplantation may opt for hemodialysis or peritoneal dialysis. Although kidney size is rarely an impediment to peritoneal dialysis, this option is less desirable for patients with very large kidneys, because their volume may reduce the exchangeable surface area and the tolerance for abdominal distension. Outcome for ADPKD patients following renal replacement therapy is similar to that of...

Osmotic Laxatives

Sorbitol and lactulose are poorly absorbed sugars that are hydrolyzed to acidic metabolites by coliform bacteria, which stimulate fluid accumulation in the colon and usually produce soft, well-formed stools. As sorbitol is less expensive and as effective as lactulose, we prefer sorbitol as the low cost choice. Major side effects of these agents are abdominal bloating and flatulence. does not contain electrolytes (MiraLax) is more palatable and may be mixed with any fluid. The amount taken daily is adjusted based on clinical response. As colonic bacteria do not hydrolyze PEG, abdominal bloating or flatulence are not as problematic as with fiber or poorly absorbed sugars. This agent is costly and, as with lactulose and sorbitol, available by prescription only.