Gastrointestinal Diseases
Gastrointestinal tract is the entry point for food which ultimately provides energy, our body needs. Besides neuro-humoral control at the general level, it has its own enteric nervous system and hormones to participate in the control process. The number of neurons in enteric nervous system is close to the number in the entire spinal cord! This has reflection in G.I. tract disease as we shall see later.
Motility and secretions are principle processes through which this tubal system operates. In G.I.Tract diseases, orderly control over motility/secretions is lost.
Pathophysiology
Most of the time some irritant from food or infection, triggers an inflammatory response. It may be just congestion as in dyspepsia, catarrhal process as in colitis, ulceration in ulcerative colitis, fibrosis with stricture formation as in pyloric stenosis.
Motility may get altered. Relaxation, slowness, atony may lead to constipation. Increased peristalsis may result into diarrhoea. e.g. Spasmodic contraction of intestine, the so called intestinal colic, accompanies many disorders of G.I. Tract. It is necessary to mention of number of sphincters in G.I. Tract which may be a seat of disease e.g. in Gastroesophageal Reflux Disease (GERD) tone of lower esophageal sphincter is decreased.
Hemorrhage from G.I. Tract can occur in duodenal ulcer, ulcerative colitis or piles/fissure at anus.
Ca of G.I. Tract is observed especially in aged population.
G.I. Tract may be affected in diseases like diabetes mellitus causing hypo motility or scleroderma where sclerosis and hardening can occur in G.I. Tract musculature.
One can say that although the gastric tract is exposed to various noxious agents due to indiscretions in diet, fast food etc. to which we are exposed, G.I. Tract deals with it effectively. However, concomitant mal-absorption/assimilation may result into excess/deficiency of substances like proteins, fats, carbohydrates etc. It is necessary, therefore to have control at entry point itself! Here the concept of diet in Ayurveda coupled with knowledge of dietics in biomedicine will be extremely useful to manage the problem.
Manifestations of Gastrointestinal diseases:
When a patient present with following common complaints, we attribute it to G.I. Tract disorders.
- Bloating of abdomen, eructations, heart burn, regurgitation of food, nausea, vomiting.
- Loss of appetite, altered taste in mouth, water brash
- Abdominal pain, diarrhea, constipation
- Hemorrhage – hematemesis or malena
- Dyspepsia –
It is commonly called as indigestion. Dyspepsia includes a group of symptoms like heaviness of abdomen, eructations, heart burn etc. most of the time it is acute and results from irregular diet, undue physical or mental exertion etc. It can be managed well with homoeopathic treatment along with advice on diet in relation to concomitant factors.
2. Gastro Esophageal Reflux Disease (GERD)
It results when gastroduodenal contents enter into oesophagus for prolonged period of time. Most common causes are reduced tone of lower oesophageal sphincter, hiatus hernia (i.e. herniation of stomach into thorax through oesophageal hiatus in the diaphragm.)
The presenting symptoms are heart burn, regurgitation especially on lying down. Water brash is often present. Occasionally patient wakes up at night with choking sensation with reflux fluid irritating the throat.
Diagnosis of GERD is mostly clinical. Investigations are necessary, if the patient is in late middle age and above, and the symptoms are noticed for the first time. There may be weight loss, anaemia or persistent dysphagia. Ca G.I.Tract is to be ruled out.
GERD generally does not lead to complications except in a few cases oesophagitis may be persistent. GERD patients can be managed well under homeopathic treatment. The frequency comes down and in few cases it almost disappears.
3. Non ulcer dyspepsia
A patient, below 40 years, presents with symptoms of dyspepsia like bloating of abdomen, mild epigastric pain resembling ‘ulcer’, aversion to food etc. No organic cause is found.
The cause of NUD is not known. Psychological factors may have a role. From management point of view, besides homeopathic treatment he/she may need supportive Ayurvedic programmes.
4. Peptic ulcer disease
It refers to ulcer in lower oesophagus, stomach (gastric ulcer), duodenum (duodenal ulcer) or even jejunum. However, duodenal ulcer is most common and occurs predominantly in males.
The most common cause of D.U. is H. pylori infection. It should be noted that many people with H. pylori infection remain asymptomatic. The organism provokes inflammatory response in duodenal epithelium. It may be that gastric secretion, which is already more in D.U. patient, is increased due to H. pylori. This leads to excess acid and pepsin by which mucosal resistance is reduced leading to ulceration. Non steroidal anti-inflammatory drugs can impair mucosal defense leading to ulcer formation.
The disease manifests by exacerbations and remissions. A patient presents with recurrent epigastric pain, 3 to 4 hours after eating which is relived by eating. Occasionally vomiting is noted.
Diagnosis of ulcer is through endoscopic examination. It is advisable to test for H. pylori infection, if facilities are available. It is important to advice endoscopy in a patient with typical symptoms of ulcer or in a patient with N.U.D. who does not respond to treatment.
With strict diet control, Homoeopathic treatment and if required relevant Ayurveda programme, the cases can be managed well.
Rarely one may come across complications of peptic ulcer disease.
a. Perforation – wherein the contents of stomach travel to peritoneal cavity and produces peritonitis. Patient presents with sudden severe pain, first in upper abdomen and then spreads all over the abdomen. Pain in shoulder may occur due to diaphragmatic irritation. As the diaphragmatic movements are restricted, respiration becomes shallow and patient can be seen in ‘shock’. Board like rigidity of abdomen, absence of bowel sounds is noticed. Surgical treatment is necessary.
b. Pyloric Stenosis leading to obstruction – This can occur due to stricture formation at pyloric outlet. Patient presents with nausea, vomiting, abdominal distention. If persists, dehydration occurs. Patient needs hospitalization for further management.
c. Hemorrhage – Ulcer can bleed resulting into hematemesis or malena which may go unnoticed. Anaemia may be present. If severe, hospitalization is necessary.
Vomiting
It is a symptom noticed in variety of diseases besides G.I. Tract diseases. In day to day practice, vomiting is mostly due to dyspepsia and can be managed well with Homeopathic treatment.
Other causes of vomiting include peptic ulcer disease, cancer, liver or pancreatic disease, appendicitis, intestinal obstruction. Vomiting can be controlled well in most of these conditions with Homeopathic treatment. However, meticulous history and clinical examination is necessary to detect the underlying disease and necessary treatment.
Dysphagia
It means difficulty in swallowing. This is a symptom and may arise due pharyngitis, oesophageal irritation, psychogenic factors where patient may complain of lump in the throat. Inspite of Homeopathic treatment if the symptom persists, it is advisable to advice endoscopic examination or Ba- swallow X-ray to rule out especially the malignancy
We shall now turn to lower G.I.Tract. The patients in this category, by and large, present with diarrhea/constipation, flatulence, bloating of abdomen, bleeding per rectum and sometimes with loss of appetite, weight loss, vomiting etc.
Acute diarrhea most of the time results from infection or intolerance to certain food items.It can be controlled well with Homoeopathic treatment and other supportive measures, if required.
Chronic diarrhea with loose, mucoid stool with mild to moderate abdominal pain can occur with protozoal infection as in Amoebiasis caused by Entamoeba histolytica or Giardiasis caused by Giardia lamblia. In amoebiasis there may be intermittent pain especially in right lower quadrant resembling appendicitis. These infections are more common on village side than in urban areas.
Irritable bowel syndrome (IBS) is a functional disorder associated with change in bowel habit. There may be pain in lower abdomen relieved by defecation. Ineffectual urge for defecation, flatulence, 3 to 4 stools with mucus can occur. Constipation alternating with loose stool is also noticed. IBS is supposed to result from psychological stress, altered motility of G.I.Tract, food allergy etc. The diagnosis is clinical. Laboratory investigation, like stool examination, sigmoidoscopy etc. are normal.
Occasionally one meets with ulcerative colitis, an inflammatory bowel disease as the name suggests. In ulcerative colitis inflammation starts in the rectum (proctitis) but can spread to sigmoid colon and occasionally whole colon. Inflammation is limited to mucosal layer. The disease is supposed to result due to altered immune response (auto-immune disease). Inflammation in crypts may lead to cryptabscess. Persistent inflammation may lead to dysplasia which later on may take a malignant turn.
Most of the time first attack of ulcerative colitis is severe with pain in abdomen and bloody diarrhea. Later on, the disease occurs by relapses and remission. Occasionally constipation can occur with small hard stool. Extensive colitis results into bloody diarrhea with mucus. Generally constitutional symptoms are absent.
Abdominal Tuberculosis
Tuberculosis can affect any part of G.I.Tract although ileocecal region is most commonly involved. Long standing mild to moderate abdominal pain occurs with diarrhea.Mild fever, weight loss etc. may raise the suspicion. Laboratory findings including histopathology may be negative. Diagnosis is possible on biopsy specimen by PCR- based techniques.
Anorectal disorders
Pain at the anal region, rectal bleeding, anal itching, peri-anal abscess are the presenting symptoms of fissure, hemorrhoids (piles) or fistula. Most often fissure and hemorrhoids exist together.
Fissure
It is a superficial mucosal tear in anal mucosal layer. It causes severe pain after defecation and there may be little bleeding, mucus discharge or pruritus at anal region. The skin may get indurated over the area andoedematous skin tag called ‘sentinel pile’ is common.
Hemorrhoids
It involves congestion of veins around the anal canal. The cause is not known. Depending on severity, the condition is divided into
First degree piles—bleed, it does not come out of the anus
Second degree piles— bleed and protrude but retract
Third degree piles— where prolapse piles need manual replacement. Bright red blood after defecation is common. Pain,mucus, pruritus can occur.
Fourth degree piles– where permanent prolapse occur.
Fistula
Perianal abscess developing between internal andexternal anal sphincters with opening at perianal region lead to fistula. There may be severe pain which is relived once the pus is drained from the abscess. However,healing is difficult due to zigzag tract and the condition continues by exacerbation and remission.
Gastric carcinoma
An old age patient, presenting with loss of appetite, pain in epigastric region, symptoms of dyspepsia, weight loss, hematemesis or melena should be investigated for gastric cancer.