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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


What Your Doctor Is Saying What Your Doctor Is Saying
 

Top Five Digestion Misconceptions


October 10, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center


I saw a patient the other day who asked me if it was true that heartburn is just another name for ulcers. As I started to answer, it occurred to me that problems with the digestive system are not only very common but medical terminology about them seems particularly confusing. So when it comes to matters of digestion, don't trust your gut (sorry, couldn't resist). Here's a quick guide to common symptoms and conditions related to digestion to help you understand what your doctor is saying and make sure your doctor understands you.

1. Upset Stomach

Consider all the terms doctors and patients use to describe "an upset stomach": indigestion, heartburn, dyspepsia, reflux, gastritis, esophagitis, ulcer (or peptic ulcer), epigastric distress, and my personal favorite, pyrosis. It's not rare for these terms to be used loosely, interchangeably and incorrectly (or, in the case of pyrosis, not at all). For example, while not all stomach upset is due to ulcer disease, many people describe any discomfort in the upper abdomen as "My ulcer's kicking up."

And not all "stomach upset" is due to a problem in the stomach at all! An ulcer in the duodenum (the first part of the small intestine into which the stomach empties) and esophagitis (inflammation of the esophagus) are good examples, but it's commonly assumed, incorrectly, that anything amiss in the upper abdomen is due to stomach trouble.

Here's a quick review of each of these terms and conditions:

  • Dyspepsia — pain, discomfort or other unpleasant sensations in the upper abdomen that may be associated with nausea
  • Indigestion — a non-medical term for dyspepsia
  • Heartburn — a sharp, burning discomfort in the upper abdomen or lower esophagus, often due to gastroesophageal reflux disease or GERD (See next item.)
  • GERD — a condition in which stomach acid washes back (refluxes) into the lower esophagus, causing pain, discomfort and esophageal injury
  • Esophagitis — an inflammation of the esophagus; common causes include infection, irritation due to a medication or GERD
  • Gastritis — an inflammation of the lining of the stomach, often accompanied by pain and nausea. It may cause bleeding and may be associated with an ulcer. Gastritis may also be due to medication (especially non-steroidal anti-inflammatory drugs, such as aspirin or ibuprofen), alcohol, or a bacterial infection (called Helicobacter pylori)
  • Ulcer or peptic ulcer disease — damage extending below the surface (lining) of the stomach or duodenum. Peptic ulcers may cause pain or bleeding or may cause no symptoms at all. Causes of peptic ulcers include medications (especially non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen or naproxen), H. pylori bacterial infection, or tumor.
  • Epigastric distress — another term for indigestion
  • Pyrosis — the medical term for heartburn; may also refer to GERD

While these terms overlap extensively, doctors generally favor one over another when referring to a specific condition, its symptoms, and exam findings. Making the right diagnosis is key because the treatment, complications, and monitoring of these different conditions may differ dramatically. For example, indigestion is a symptom people with GERD, ulcer disease or gastritis may experience. But an ulcer must meet certain criteria and is generally easy to distinguish from gastritis with appropriate diagnostic testing.

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2. Irritable Bowel Syndrome (IBS) Vs. Inflammatory Bowel Disease (IBD)

It's easy to confuse these two conditions. The cause of each is unknown, symptoms may overlap, and the common acronyms (IBS and IBD) differ by only one letter. But they are quite different.

  • IBS — People with IBS often complain of intermittent or episodic constipation or diarrhea, cramps, and bloating. The colon appears normal during a colonoscopy — a test in which a doctor inspect the colon through a long, flexible tube with a light on the end — and the intestinal tissue is normal when biopsies are taken.
  • IBD (including ulcerative colitis and Crohn's Disease) — Diarrhea is much more common than constipation, the pain may be severe, and there may be bleeding from the intestinal tract. Biopsies typically show inflammation (colitis). In Crohn's Disease, abnormal connections (fistulas) may develop between the colon and other parts of the body, such as the skin or bladder. These complications never occur with IBS.

Treatment of these conditions also differs dramatically. For example, dietary changes and an anti-spasmodic medication, such as dicyclomine (Bentyl), may be the mainstay of treatment for patients with IBS. IBD, on the other hand, may be treated with anti-inflammatory, antibiotic, and immune suppressive medications and sometimes surgery is required.

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3. Bowel Movement

Doctors and patients use the term "bowel movement" in much the same way. But while it may be the polite way to describe the event, the term is not entirely accurate.

The bowels are nearly always moving, churning and propelling their contents along the intestinal tract. There are times, however, when the bowels are at near or total rest. After major surgery, for example, it's common to develop a condition called "ileus" during which there is little or no action in the intestines for a day or more — not even rumbling or passing gas (flatus). A patient's discharge from the hospital may even be delayed until the bowels "wake up" and start moving again. Doctors know this when they listen to the abdomen with a stethoscope and hear rumbling, even if you're not having a bowel movement.

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4. Piles

During my medical training, a patient told me she had never had a medical problem except for "piles." I never heard this term before, so I asked her what she meant. "You know, piles!"

Well, I didn't know and looking it up wasn’t easy either. But I found an older physician who told me that piles are a lay term for hemorrhoids. According to my medical dictionary, the term probably comes from from the Latin "pila" or ball, referring to a hemorrhoid's shape.

A hemorrhoid is a swelling near the anus that contains blood vessels (especially veins), muscle and elastic lining tissues. They can be outside (an external hemorrhoid) or inside the rectum (an internal hemorrhoid) and may be a source of pain, itching, burning or bleeding. In general, they're associated with conditions in which pressure in the abdomen is high, such as pregnancy, repeated straining to have a bowel movement (as with chronic constipation), or obesity.

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5. Dysentery

This term refers to any severe inflammation of the intestines, usually within the colon and usually caused by an infection. The term is attributed to Hippocrates, and originates from "dys," meaning bad or abnormal, and "entera," referring to the intestines or bowels.

Common symptoms include pain, diarrhea, and stools containing blood and mucus. While the term is often used to describe highly contagious infections that spread among people living in poverty and unsanitary conditions, anyone can develop dysentery. For example, contaminated drinking or bathing water may cause outbreaks in third world countries, but examples of dysentery affecting soldiers, schoolchildren and tourists are not rare.

Common infections that may cause dysentery include bacteria (Shigella, Salmonella, E. coli species, to name a few) and parasites (including amoeba). Perhaps the most recognized example of dysentery is cholera, explosive watery diarrhea caused by the toxin-producing bacteria called Vibrio cholerae.

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The Amazing Digestive Tract

While we may have invented confusing terminology to describe the many ways things can wrong in the digestive tract, it's worth noting how amazing this complex organ system is and how well it works with very little maintenance.

From mouth to anus, the digestive tract spans more than 25 feet and must absorb key nutrients while keeping out harmful toxins and infectious agents. It must also keep the body's metabolic, nutritional, and fluid needs in balance. Perhaps the biggest surprise is that things don't go wrong more often.

You can help keep your digestive tract healthy with relatively little effort:

  • Maintain a well-balanced, high fiber diet.
  • Avoid excessive alcohol intake.
  • If you find you are frequently straining during bowel movements, increase the fiber in your diet or use a stool softener.
  • Carefully read the labels of any over-the-counter medications you are taking and take your prescription medications only as directed. Be particularly wary of non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, which may cause serious ulcer disease. Several medications can cause constipation, diarrhea and indigestion.
  • Get screened for colon polyps and cancer starting at age 50, or younger if you have specific risk factors. Recommended screening tests include stool testing for blood, flexible sigmoidoscopy and colonoscopy.

 

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The Bottom Line

Don't be surprised if your doctor uses slightly different lingo than you when talking about your digestive tract. Ask questions until it's clear that you are both talking about the same thing.

While there are no guarantees of perfect digestive health, the simple steps above will increase the chances that your digestive tract will be just fine.

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Robert H. Shmerling, M.D., is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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