Piles/ Hemorrhoids are a very common anorectal condition defined as the symptomatic enlargement and distal displacement of the normal anal cushions. They affect millions of people around the world and represent a major medical and socioeconomic problem. Multiple factors have been claimed to be the etiologies of hemorrhoidal development, including constipation and prolonged straining. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoidal disease[rx]. An inflammatory reaction[rx] and vascular hyperplasia[rx,rx] may be evident in hemorrhoids. This article firstly reviewed the pathophysiology and other clinical backgrounds of hemorrhoidal disease, followed by the current approaches to non-operative and operative management.
Types of Hemorrhoids
Hemorrhoids can be classified according to how severe they are
Grade 1 – Slightly enlarged hemorrhoids that can’t be seen from outside the anus.
Grade 2 – Larger hemorrhoids that sometimes come out of the anus, for example, while passing stool or – less commonly – during other physical activities. They then go back inside again on their own.
Grade 3 – Hemorrhoids that come out of the anus when you go to the toilet or do other physical activities, but don’t go back inside on their own. They can be pushed back inside, though.
Grade 4 – Hemorrhoids that are always outside the anus and can no longer be pushed back inside. Usually, a small bit of the anal lining comes out of the anus too. This is also known as rectal prolapse.
Hemorrhoid tissue, cross-section view: normal (above) and enlarged (below)
Causes of Hemorrhoids/Piles
Increased pressure on the anal canal (the last section of the rectum) can cause hemorrhoids to become enlarged. Various factors might make this more likely. For example
Being overweight
Chronic constipation
Frequent diarrhea
Regularly lifting heavy objects
Pregnancy and giving birth
The risk of enlarged hemorrhoids increases with age – probably because the tissue becomes weaker over time. And hemorrhoid problems are thought to run in families too.
Age – as you get older, your body’s supporting tissues get weaker, increasing your risk of hemorrhoids
Pregnant – this can place increased pressure on your pelvic blood vessels, causing them to enlarge; read more about piles in pregnancy
Chronic diarrhea
Lifting heavy weights
Straining when passing a stool
Chronic (long-term) diarrhea can also make you more vulnerable to getting hemorrhoids.
In most cases, the symptoms of piles are not serious. They normally resolve on their own after a few days.
An individual with piles may experience the following symptoms:
A hard, possibly painful lump may be felt around the anus. It may contain coagulated blood. Piles that contain blood are called thrombosed external hemorrhoids.
After passing a stool, a person with piles may experience the feeling that the bowels are still full.
Bright red blood is visible after a bowel movement.
Bleeding when you have a bowel movement – you may see blood (usually bright red) on toilet paper or drips in the toilet or on the surface of your poo
A lump in or around your anus
A slimy discharge of mucus from your anus
A feeling of ‘fullness’ and discomfort in your anus, or a feeling that your bowels haven’t completely emptied after going to the toilet
Itchy or sore skin around your anus
Pain and discomfort after you go to the toilet
Piles can escalate into a more severe condition. This can include
Excessive anal bleeding, also possibly leading to anemia
Infection
Fecal incontinence, or an inability to control bowel movements
Anal fistula, in which a new channel is created between the surface of the skin near the anus and the inside of the anus
Strangulated hemorrhoid, in which the blood supply to the hemorrhoid is cut off, causing complications including infection or a blood clot
Diagnosis of Hemorrhoids/Piles
Internal hemorrhoid grades
Grade
Diagram
Picture
1
2
3
4
Grading
For practical purposes, internal hemorrhoids are further graded based on their appearance and degree of prolapse, known as Goligher’s classification:
First-degree hemorrhoids (grade I) – The anal cushions bleed but do not prolapse;
Second-degree hemorrhoids (grade II) – The anal cushions prolapse through the anus on straining but reduce spontaneously;
Third-degree hemorrhoids (grade III) – The anal cushions prolapse through the anus on straining or exertion and require manual replacement into the anal canal; and
Fourth-degree hemorrhoids (grade IV) – The prolapse stays out at all times and is irreducible. Acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also fourth-degree hemorrhoids[18].
Hemorrhoids are typically diagnosed by physical examination.[rx]
A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.[rx]
A rectal exam may be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses.[rx]
This examination may not be possible without appropriate sedation because of pain, although most internal hemorrhoids are not associated with pain.[rx]Visual confirmation of internal hemorrhoids may require anoscopy, insertion of a hollow tube device with a light attached at one end.[rx]
The two types of hemorrhoids are external and internal. These are differentiated by their position with respect to the pectinate line.[rx] Some persons may concurrently have symptomatic versions of both.[rx] If the pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid.[rx]
Rectal Examination
Your GP may examine the outside of your anus to see if you have visible hemorrhoids, and they may also carry out an internal examination called a digital rectal examination (DRE). During a DRE, your GP will wear gloves and use lubricant. Using their finger, they’ll feel for any abnormalities in your back passage. A DRE shouldn’t be painful, but you may feel some slight discomfort.
Proctoscopy
In some cases, further internal examination using a proctoscope may be needed. A proctoscope is a thin hollow tube with a light on the end that’s inserted into your anus. This allows your doctor to see your entire anal canal (the last section of the large intestine). GPs are sometimes able to carry out a proctoscopy. However, not all GPs have the correct training or access to the right equipment, so you may need to go to a hospital clinic to have the procedure.
Treatment of Hemorrhoids/Piles
Conservative
Conservative treatment typically – consists of foods rich in dietary fiber, intake of oral fluids to maintain hydration, nonsteroidal anti-inflammatory drugs, sitz baths, and rest.[rx] Increased fiber intake has been shown to improve outcomes[rx] and may be achieved by dietary alterations or the consumption of fiber supplements.[rx][rx] Evidence for benefits from sitz baths during any point in treatment, however, is lacking.[rx] If they are used, they should be limited to 15 minutes at a time.[rx] Decreasing the time spent on the toilet and not straining is also recommended.[rx]
While many topical agents and suppositories – are available for the treatment of hemorrhoids, little evidence supports their use.[rx] Steroid-containing agents should not be used for more than 14 days, as they may cause thinning of the skin.[rx] Most agents include a combination of active ingredients.[rx] These may include a barrier cream such as petroleum jelly or zinc oxide, an analgesic agent such as lidocaine, and a vasoconstrictor such as epinephrine.[rx] Some contain Balsam of Peru to which certain people may be allergic.[rx][rx]
Flavonoids – are of questionable benefit, with potential side effects.[rx][rx] Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.[rx] Evidence does not support the use of traditional Chinese herbal treatment[rx].[rx]
Corticosteroid cream – If you have severe inflammation in and around your back passage, your GP may prescribe corticosteroid cream[rx], which contains steroids. You shouldn’t use corticosteroid cream for more than a week at a time as it can make the skin around your anus thinner and the irritation worse.
Painkillers – Common painkilling medication, such as paracetamol, can help relieve the pain of hemorrhoids. But if you have excessive bleeding, avoid using non-steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen, as they can make rectal bleeding worse. You should also avoid using codeine painkillers as they can cause constipation. Your GP may prescribe products that contain a local anesthetic to treat painful hemorrhoids. Like over-the-counter topical treatments, these should only be used for a few days because they can make the skin around your back passage more sensitive.
Laxatives – If you’re constipated, your GP may prescribe a laxative. Laxatives are a type of medicine that can help you empty your bowels.
Injections (sclerotherapy)
A treatment called sclerotherapy may be used as an alternative to banding. During sclerotherapy, a chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the nerve endings at the site of the injection.
It also hardens the tissue of hemorrhoid so a scar is formed. After about 4 to 6 weeks, hemorrhoid should decrease in size or shrivel up. You should avoid strenuous exercise for the rest of the day after having the injection. You may experience minor pain for a while and may bleed a little. You should be able to resume normal activities, including work, the day after the procedure.
Electrotherapy
Electrotherapy, also known as electrocoagulation, is another alternative to banding for people with smaller hemorrhoids. During the procedure, a device called a proctoscope is inserted into the anus to locate hemorrhoid.
An electric current is then passed through a small metal probe placed at the base of hemorrhoid, above the dentate line. The specialist can control the electric current using controls attached to the probe. The aim of electrotherapy is to cause the blood supplying hemorrhoid to thicken, which shrinks it. If necessary, more than one hemorrhoid can be treated during each session.
Electrotherapy can either be carried out on an outpatient basis using a low electric current, or a higher dose can be given while the person is under a general anesthetic or spinal anesthetic. Rectal bleeding is another possible side effect of the procedure, but this is usually short-lived.
Electrotherapy is recommended by the National Institute for Health and Care Excellence (NICE), and has been shown to be an effective method of treating smaller hemorrhoids.
Oral flavonoids
These venotonic agents were first described in the treatment of chronic venous insufficiency and edema. They appeared to be capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability[rx], and facilitating lymphatic drainage[rx] as well as having anti-inflammatory effects[rx].
Although their precise mechanism of action remains unclear, they are used as an oral medication for hemorrhoidal treatment, particularly in Europe and Asia. Micronized purified flavonoid fraction (MPFF), consisting of 90% diosmin and 10% hesperidin, is the most common flavonoid used in clinical treatment[rx].
The micronization of the drug to particles of less than 2 μm not only improved its solubility and absorption but also shortened the onset of action. A recent meta-analysis of flavonoids for hemorrhoidal treatment, including 14 randomized trials and 1514 patients, suggested that flavonoids decreased the risk of bleeding by 67%, persistent pain by 65% and itching by 35%, and also reduced the recurrence rate by 47%[rx]. Some investigators reported that MPFF can reduce rectal discomfort, pain and secondary hemorrhage following hemorrhoidectomy[rx].
Oral Calcium Dobesilate
This is another venotonic drug commonly used in diabetic retinopathy and chronic venous insufficiency as well as in the treatment of acute symptoms of hemorrhoids[rx]. It was demonstrated that calcium dobesilate decreased capillary permeability, inhibited platelet aggregation and improved blood viscosity; thus resulting in a reduction of tissue edema[rx].
A clinical trial of hemorrhoid treatment showed that calcium dobesilate, in conjunction with a fiber supplement, provided an effective symptomatic relief from acute bleeding, and it was associated with a significant improvement in the inflammation of hemorrhoids[rx].
Topical Treatment
The primary objective of most topical treatment aims to control the symptoms rather than to cure the disease. Thus, other therapeutic treatments could be subsequently required. A number of topical preparations are available including creams and suppositories, and most of them can be bought without a prescription.
Strong evidence supporting the true efficacy of these drugs is lacking. These topical medications can contain various ingredients such as local anesthesia, corticosteroids, antibiotics and anti-inflammatory drugs[rx].
Topical treatment may be effective in selected groups of hemorrhoidal patients. For instance, Tjandra et al[rx] showed a good result with topical glyceryl trinitrate 0.2% ointment for relieving hemorrhoidal symptoms in patients with low-grade hemorrhoids and high resting anal canal pressures. However, 43% of the patients experienced a headache during the treatment.
Which contains 0.25% phenylephrine, petrolatum, light mineral oil, and shark liver oil. Phenylephrine is a vasoconstrictor having a preferential vasopressor effect on the arterial site of circulation, whereas the other ingredients are considered protectants. Preparation-H is available in many forms, including ointment, cream, gel, suppositories, and medicated and portable wipes[rx]. It provides temporary relief of acute symptoms of hemorrhoids, such as bleeding and pain on defecation.
Drug Therapy
A vast industry has evolved around preparatory creams and suppositories for treating hemorrhoids. These combinations of steroids, anesthetics, antiseptics and barrier creams may be effective in temporarily relieving the acute symptoms of the haemorrhoidal disease. Patients often return to these agents if symptoms recur, not realizing that symptoms fluctuate with time and may have resolved with simple hygiene alone.
Unlike for these over-the-counter remedies, there is some evidence for the effectiveness of venotonic therapies. Oral flavonoid medication can control acute bleeding.[rx][rx]
Rubber Band Ligation
Various outpatient treatments for symptomatic hemorrhoids exist. In the UK and many other countries, rubber band ligation (RBL) is the most commonly performed of these therapies.[rx] RBL uses a device that allows a rubber band to be applied to each hemorrhoid via a proctoscope.
This band constricts the blood supply causing hemorrhoid to become ischaemic before being sloughed approximately 1–2 weeks later. The resultant fibrosis reduces any element of haemorrhoidal prolapse that may have been present. Although easy to perform, and with a short learning curve, care has to be taken to place the bands correctly to reduce the potential for severe pain.
Injection Sclerotherapy
Various sclerosant solutions have been used for injecting piles. The comparative efficacy of these solutions is unclear. Less potent solutions such as 5% phenol in almond oil are more commonly used and probably have a lower risk of mucosal necrosis. Injection treatment is simple, safe and rapid, but probably not as effective as RBL.[rx]
This treatment modality should probably be reserved for patients where bleeding is the main symptom and conservative therapy has not improved the symptoms (and other causes having been excluded). Other indications possibly include patients with a high risk of secondary hemorrhage (patients on anticoagulants and patients with advanced cirrhosis) and those who are immunocompromised.[rx],[rx]
Infrared Coagulation
Infrared coagulation consists of a direct application of infrared waves to the haemorrhoidal pedicle resulting in necrosis and sloughing of the pile. Several applications are required per hemorrhoid but each takes a few seconds. Complications and efficacy are similar to RBL with some suggesting less pain presumably related to the lower volume of tissue necrosis.[rx]–[rx] Although a potential alternative to RBL, the equipment is expensive and there is a longer learning curve.
Bipolar, direct current and radiofrequency ablation therapy
Application of low wattage bipolar diathermy results in tissue coagulation. The process takes up to 30 s and multiple applications to the same site are often required.[rx] Complications, including pain, bleeding, and fissuring, occur in around 10% of patients.
Direct current therapy has gained recent favor in the form of Ultroid therapy, although the reasons for its popularity, other than aggressive marketing, are unclear. The procedure involves the application of a probe onto the haemorrhoidal cushion and application of a low direct current for around 10 min per hemorrhoid. Results are at best equivalent to injection sclerotherapy[rx] and RBL, but with the procedure taking significantly longer.
Radiofrequency ablation cuts and coagulates haemorrhoidal tissue using less power (and hence less temperature) than other electrical equipment. A comparison with RBL suggested similar efficacy to RBL with less pain.[rx] Again equipment is expensive and the procedure has not gained universal acceptance.
Combination Therapy
Numerous combinations of therapies have been described and include RBL with injection sclerotherapy[rx]or infrared coagulation.[rx] Again, the studies are of poor quality. Indeed, the description of some therapies involves almost daily outpatient visits over a few weeks. Such an intense therapy negates the advantage of an outpatient procedure, particularly as efficacy is not clear.
With this caveat, the combination of RBL with injection sclerotherapy does make practical sense. Not only is the double therapy a ‘belt and braces’ approach but also the bolus of sclerosant below the band ligation may act to secure the band, reducing failure due to premature slippage.
Non-operative Treatment
Sclerotherapy
This is currently recommended as a treatment option for first- and second-degree hemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis. The solutions used are 5% phenol in oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt solution[rx].
It is important that the injection is made into submucosa at the base of the hemorrhoidal tissue and not into the hemorrhoids themselves; otherwise, it can cause immediate transient precordial and upper abdominal pain[rx].
Misplacement of the injection may also result in mucosal ulceration or necrosis, and rare septic complications such as prostatic abscess and retroperitoneal sepsis[rx].
Antibiotic prophylaxis is indicated for patients with predisposing valvular heart disease or immunodeficiency because of the possibility of bacteremia after sclerotherapy[rx].
Rubber Band Ligation
Rubber band ligation (RBL) is a simple, quick, and effective means of treating first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids. Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall.
Placement of rubber band too close to the dentate line may cause severe pain due to the presence of somatic nerve afferents and requires immediate removal. RBL is safely performed in one or more than one place in a single session[rx] with one of several commercially available instruments, including hemorrhoid ligator rectoscope[rx] and endoscopic ligator[rx] which use suction to draw the redundant tissue into the applicator to make the procedure a one-person effort.
Infrared Coagulation
The infrared coagulator produces infrared radiation which coagulates tissue and evaporates water in the cell, causing shrinkage of the hemorrhoid mass. A probe is applied to the base of hemorrhoid through the anoscope and the recommended contact time is between 1.0-1.5 s, depending on the intensity and wavelength of the coagulator[rx].
The necrotic tissue is seen as a white spot after the procedure and eventually heals with fibrosis. Compared with sclerotherapy, infrared coagulation (IRC) is less technique-dependent and avoids the potential complications of misplaced sclerosing injection[rx]. Although IRC is a safe and rapid procedure, it may not be suitable for large, prolapsing hemorrhoids.
Radiofrequency ablation
Radiofrequency ablation (RFA) is a relatively new modality of hemorrhoidal treatment. A ball electrode connected to a radiofrequency generator is placed on the hemorrhoidal tissue and causes the contacting tissue to be coagulated and evaporized[rx].
By this method, vascular components of hemorrhoids are reduced and hemorrhoidal mass will be fixed to the underlying tissue by subsequent fibrosis. RFA can be performed on an outpatient basis and via an anoscope similar to sclerotherapy. Its complications include acute urinary retention, wound infection, and perianal thrombosis. Although RFA is a virtually painless procedure, it is associated with a higher rate of recurrent bleeding and prolapse[rx].
Cryotherapy
Cryotherapy ablates the hemorrhoidal tissue with a freezing cryoprobe. It has been claimed to cause less pain because sensory nerve endings are destroyed at very low temperature. However, several clinical trials revealed that it was associated with prolonged pain, foul-smelling discharge and a high rate of persistent hemorrhoidal mass[rx]. It is therefore rarely used.
Operative Treatment
The operation is indicated when non-operative approaches have failed or complications have occurred. Different philosophies regarding the pathogenesis of hemorrhoidal disease create different surgical approaches.
Summary of different philosophies regarding the pathogenesis of hemorrhoids and related surgical approaches
Theory
Short description
Surgical approach
Sliding anal cushions
Hemorrhoids develop when the supporting tissues of the anal cushions disintegrate or deteriorate
Hemorrhoidectomy, plication
Rectal redundancy
Hemorrhoidal prolapse is associated with an internal rectal prolapse
Stapled hemorrhoidopexy
Vascular abnormality
Hyperperfusion of arteriovenous plexus within anal cushion results in the formation of hemorrhoids
Doppler-guided hemorrhoidal artery ligation
Hemorrhoidectomy
Excisional hemorrhoidectomy is the most effective treatment for hemorrhoids with the lowest rate of recurrence compared to other modalities[rx]. It can be performed using scissors, diathermy[rx,rx], or vascular-sealing device such as Ligasure (Covidien, United States)[rx,rx] and Harmonic scalpel (Ethicon Endosurgery, United States)[rx,rx]. Excisional hemorrhoidectomy can be performed safely under perianal anesthetic infiltration as an ambulatory surgery[rx,rx].
Indications for hemorrhoidectomy include failure of non-operative management, acute complicated hemorrhoids such as strangulation or thrombosis, patient preference, and concomitant anorectal conditions such as anal fissure or fistula-in-ano which require surgery[rx]. In clinical practice, the third-degree or fourth-degree internal hemorrhoids are the main indication for hemorrhoidectomy.
A major drawback of hemorrhoidectomy is postoperative pain[rx]. There has been evidence that Ligasure hemorrhoidectomy results in less postoperative pain, shorter hospitalization, faster wound healing and convalescence compared to scissors or diathermy hemorrhoidectomy[rx–rx]. Other postoperative complications include acute urinary retention (2%-36%), postoperative bleeding (0.03%-6%), bacteremia and septic complications (0.5%-5.5%), wound breakdown, unhealed wound, loss of anal sensation, mucosa prolapse, anal stricture (0%-6%), and even fecal incontinence (2%-12%)[rx–rx]. Recent evidence has suggested that hemorrhoidal specimens can be exempt from pathological examination if no malignancy is suspected[rx].
Plication
Plication is capable of restoring anal cushions to their normal position without excision. This procedure involves oversewing of hemorrhoidal mass and tying a knot at the uppermost vascular pedicle. However, there are still a number of potential complications following this procedure such as bleeding and pelvic pain[rx].
Doppler-guided hemorrhoidal artery ligation
A new technique based on doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy[rx]. Doppler-guided hemorrhoidal artery ligation (DGHAL) has become increasingly popular in Europe. The rationale of this treatment was later supported by the findings from vascular studies[rx,rx], which demonstrated that patients with hemorrhoids had increased caliber and arterial blood flow of the terminal branch of the superior rectal arteries.
Therefore, ligating the arterial supply to hemorrhoidal tissue by suture ligation may improve hemorrhoidal symptoms. DGHAL is most effective for second- or third-degree hemorrhoids. Notably, DGHAL may not improve prolapsing symptoms in advanced hemorrhoids. Short-term outcomes and 1-year recurrence rates of DGHAL did not differ from those of conventional hemorrhoidectomy[rx]. Given the fact that there is the possibility of revascularization and recurrence of symptomatic hemorrhoids, further studies on the long-term outcomes of DGHAL are still required[rx].
Stapled Hemorrhoidopexy
Stapled hemorrhoidopexy (SH) has been introduced since 1998[rx]. A circular stapling device is used to excise a ring of redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids back within the anal canal. Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue is also interrupted.
A recent meta-analysis comparing surgical outcomes between SH and hemorrhoidectomy, which included 27 randomized, controlled trials with 2279 procedures, showed that SH was associated with less pain, earlier return of bowel function, shorter hospital stay, earlier return to normal activities, and better wound healing, as well as a higher degree of patient satisfaction[rx].
However, in the longer term, SH was associated with a higher rate of prolapse[rx,rx,rx]. Considering the recurrence rate, cost of stapling device and potentially serious complications including rectovaginal fistula[rx] and rectal stricture[rx,rx], SH is generally reserved for patients with circumferential prolapsing hemorrhoids and having ≥ 3 lesions of advanced internal hemorrhoids.
Acutely Thrombosed or Strangulated Internal Hemorrhoids
Patients with acutely thrombosed or strangulated internal hemorrhoids usually present with severely painful and irreducible hemorrhoids. The incarcerated hemorrhoids may become necrotic and drain. This situation is quite difficult to treat particularly in a case of extensive strangulation or thrombosis [rx]), or the presence of underlying circumferential prolapse of high-graded hemorrhoids.
Manual reduction of the hemorrhoid masses, with or without intravenous analgesia or sedation, might help reducing pain and tissue congestion. Urgent hemorrhoidectomy is usually required in these circumstances. Unless the tissues are necrotic, mucosa and anoderm should be preserved as much as possible to prevent postoperative anal stricture. In expert hands, surgical outcomes of urgent hemorrhoidectomy were comparable to those of elective hemorrhoidectomy[rx]. Complicated hemorrhoids. A: Strangulated internal hemorrhoid; B: Acutely thrombosed external hemorrhoid.
Acutely Thrombosed External Hemorrhoids
Acutely thrombosed external hemorrhoids often develop in patients with acute constipation, or those with a recent history of prolonged straining. A painful bluish-colored lump at the anal verge is a paramount finding (Figure [rx]. The severity of pain is most intense within the first 24-48 h of onset. After that, the thrombosis will be gradually absorbed and patients will experience less pain.
As a result, surgical removal of acute thrombus or excisional hemorrhoidectomy may be offered if patients experience severe pain especially within the first 48 h of onset. Otherwise, the conservative measure will be exercised including pain control, warm sitz baths, and avoidance of constipation or straining. A resolving thrombosed external hemorrhoid could leave behind as a residual perianal skin tag -which may or may not require a subsequent excision.
Hemorrhoids in Pregnancy
Hemorrhoids are very common during pregnancy especially in the third trimester[rx]. An acute crisis such as profound bleeding and irreducible prolapsing may be found in pregnant women with pre-existing hemorrhoids. Since hemorrhoids and its symptoms will gradually resolve after giving birth, the primary goal of treatment is to relieve acute symptoms related to hemorrhoids – mostly by means of dietary and lifestyle modification.
Kegel exercises, lying on the left side, and avoidance of constipation could reduce the episode and severity of bleeding and prolapse. A fiber supplement, stool softener, and mild laxatives are generally safe for pregnant women. Topical medication or oral phlebotonics may be used with special caution because the strong evidence of their safety and efficacy in pregnancy is lacking. In the case of massive bleeding, anal packing could be a simple and useful maneuver. Hemorrhoidectomy is reserved in strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding.
Hemorrhoids in Immunocompromised Patients
In general, any intervention or operation should be avoided, or performed with careful consideration in immunocompromised patients because of an increased risk of anorectal sepsis and poor tissue healing in such cases[rx]. A conservative measure is a mainstay for the treatment of hemorrhoids in this group of patients.
If required, injection sclerotherapy appeared to be a better and safer alternative to banding and hemorrhoidectomy for treating bleeding hemorrhoids[rx,rx]. Antibiotic prophylaxis is always given before performing any intervention, even a minor office-based procedure, due to the possibility of bacteremia.
Hemorrhoids in Patients with Cirrhosis or Portal Hypertension
A clinician must differentiate bleeding hemorrhoids from bleeding anorectal varices because the latter can be managed by suture ligation along with the course of varices, transjugular intrahepatic portosystemic shunt, or pharmacological treatment of portal hypertension[rx].
Since a majority of bleeding hemorrhoids in such patients is not life-threatening, conservative measure with the correction of any coagulopathy is a preferential initial approach. Of note, rubber band ligation is generally contraindicated in patients with advanced cirrhosis due to the risk of profound secondary bleeding following the procedure.
Injection sclerotherapy is an effective and safe procedure for treating bleeding hemorrhoids in this situation. In a refractory case, suture ligation at the bleeder is advised. Hemorrhoidectomy is indicated when bleeding hemorrhoids are refractory to other approaches.
Hemorrhoids in Patients Having Anticoagulant or Antiplatelet drugs
Anticoagulant or antiplatelet drugs may promote anorectal bleeding in patients with hemorrhoids and increase the risk of bleeding after banding or surgery[rx].
Unless the bleeding is persistent or profound, the discontinuity of antithrombotic drugs may be unnecessary because most of the bleeding episodes are self-limited and stop spontaneously. Conservative measure is, therefore, the mainstay treatment in these patients. Injection sclerotherapy is preferential treatment for bleeding low-graded hemorrhoids refractory to medical treatment.
Rubber band ligation is not recommended in patients with the current use of anticoagulant or antiplatelet drugs due to the risk of secondary bleeding. If banding or any form of surgery for hemorrhoids is scheduled, the cessation of anticoagulant or antiplatelet drugs about 5-7 d before and after the procedure is suggested[rx].
Stapled Hemorrhoidopexy
Stapled hemorrhoidopexy, also known as a procedure for prolapse and hemorrhoids (PPH), is an alternative operation for treating advanced internal hemorrhoids. A circular staple device is used to excise a ring of redundant rectal mucosa just above hemorrhoid bundles – not hemorrhoids per se.
By doing this, prolapsing hemorrhoids will be repositioning (hemorrhoidopexy) and shrinking (due to a partial interruption of blood supply to hemorrhoid plexus). A recent systematic review of 27 randomized controlled trials demonstrated that, compared with conventional hemorrhoidectomy, stapled hemorrhoidopexy had less pain, shorter operative time, and quicker patient’s recovery of a patient, but a significantly higher rate of prolapse and reintervention for prolapse[rx].
Complications
Piles rarely cause any serious problems but sometimes they can lead to the following.
External piles (swellings that develop further down your anal canal, closer to your anus) can become inflamed and swollen; ulcers can also form on them.
Skin tags can form when the inside of a pile shrinks back but the skin remains. For more information, see our FAQ: Skin tags, below.
If mucus leaks from your anus, it can make the surrounding skin very sore.
Internal piles that prolapse (hang down) can sometimes get strangulated and lose their blood supply. If blood clot forms (thrombosis), piles can be very painful. External piles can also become thrombosed.
What Are the Early Warning Signs of UTI/ Urinary Tract Infection is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated. Many cases of uncomplicated UTI will resolve spontaneously, without treatment, but many patients seek treatment for symptoms. Treatment is aimed at preventing spread to the kidneys or developing into upper tract disease/pyelonephritis, which can cause the destruction of the delicate structures in the nephrons and lead to hypertension.[rx][rx][rx]
Types Urinary Tract Infection
Acute Urethral Syndrome
The cardinal symptoms of frequency and dysuria occur in more than 90% of ambulatory patients with acute genitourinary tract infections. However, one-third to one- half of all these patients do not have significant bacteriuria, although most have pyuria.
These patients have an acute urethral syndrome which can mimic both bladder and renal infections. Vaginitis, urethritis, and prostatitis are common causes of acute urethral syndrome.[rx]
Vaginitis
The presence of an abnormal vaginal discharge (leucorrhoea) and irritation makes vaginitis the likely cause of dysuria unless a concomitant UTI can be confirmed by culture. Candida albicans, the most common specific cause of vaginitis, can be demonstrated by culture or by finding yeast cells in a Gram-stained smear of vaginal secretions or in a saline preparation with the addition of potassium hydroxide.
Trichomoniasis can be documented with a saline preparation that shows the motile protozoa of trichomonas vaginitis. Generally, nonspecific vaginitis is associated with Gardnerella vaginitis. A clue of this diagnosis is the presence of many small Gram-negative bacilli that adhere to vaginal epithelial cells.
Urethritis
Acute urinary frequency, dysuria, and pyuria in the absence of vaginal symptoms favor the diagnosis of urethritis or UTI. Chlamydia trachomatis is the common cause of the acute urethral syndrome in women and of nonspecific urethritis in men.
Neisseria gonorrhoeae is an important cause of urethritis and dysuria. Herpes simplex virus usually types 2, is another sexually transmitted agent that can cause severe dysuria through ulceration in close proximity to the urethral orifice.
The diagnosis of Herpes progenitalis can be confirmed by finding giant multinucleated transformed cells in epidermal scrapings stained with Wright’s stain (Tzanck Smear), by isolating the virus in tissue cultures or by a direct fluorescent antibody test.
Prostatitis
Prostatitis is a common problem in men that causes dysuria and urinary frequency in middle-aged and younger men more frequently than urinary tract infection does. Prostate syndromes have classically been divided into four clinical entities
Acute bacterial prostatitis
Chronic bacterial prostatitis
Nonbacterial prostatitis
Prostatodynia
Recently, consensus classification of prostatitis syndromes has come up. This classification includes four categories and two subcategories.[rx]
Inflammatory CP/CPPS; and Non- inflammatory CP/CPPS
Acute Bacterial Prostatitis
The patient often appears acutely ill with the sudden onset of chills and fever, urinary frequency and urgency, dysuria, perineal and low back pain, and constitutional symptoms. Rectal examination should be avoided because of the risk of precipitating sepsis but may disclose a tender, hot and swollen prostate.
Microscopic examination of the urine usually displays numerous white cells. Urine culture is usually positive for enteric Gram-negative bacteria and Gram-positive bacteria staphylococci and enterococci are less frequently isolated.
Chronic Bacterial Prostatitis
Relapsing UTIs is a hallmark of chronic bacterial prostatitis. Urinary frequency, dysuria, nocturia, and low back and perineal pain are the usual symptoms, although patients may have a minimum of symptoms between UTIs. The patient is often afebrile, does not appear acutely ill, and may have an unremarkable prostate examination. Initially, there is a negative midstream urine examination and culture but after prostate massage, the urine is positive for white blood cells and culture grows a uropathogen.
Nonbacterial Prostatitis
This is the most common form of chronic prostatitis. It mimics chronic bacterial prostatitis clinically and displays inflammatory cells on post-prostate massage specimens. However, a bacteriological culture of urine and prostatic secretions are sterile. The etiology is unknown, but some evidence exists for an infectious cause involving organisms that are difficult to culture.
Prostatodynia
This has also been referred to as chronic noninflammatory prostatitis. Clinically, it presents with symptoms similar to other forms of chronic prostatitis. It is distinguished by the absence of inflammatory cells or uropathogens from all specimens.
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
The traditional classification suggested that the prostate was the cause for some patients (nonbacterial prostatitis), whereas other problems were responsible in others (prostatodynia). The characteristic symptoms for either group were very poorly defined. CP/ CPPS acknowledges the central role of pain complaints in the syndrome. Also, there is inherent recognition that the prostate gland may not be responsible for every patient’s symptoms.
Its two subcategories are as follows
Inflammatory CP/CPPS – The consensus classification considers symptomatic patients without bacteriuria but who have inflammation in their expressed prostate secretions, their voided bladder 3 (VB3) or their semen fluid analysis (SFA), to have inflammatory CP/CPPS.
Noninflammatory CP/CPPS – Patients without inflammation in their expressed prostate secretions, their voided bladder 3 (VB3) or their semen fluid analysis (SFA) are considered to have noninflammatory CP/CPPS.
Asymptomatic Inflammatory Prostatitis
The consensus classification also includes a category for patients with objective evidence of prostatic inflammation noted during histological evaluation of prostatic tissue. This diagnosis commonly occurs in patients who have inflammation documented during evaluation of other urologic conditions, for example, prostatic evaluated for a raised prostate-specific antigen.
Another example is seminal fluid inflammation noted during evaluation from an infertile couple. The long-term consequences of such asymptomatic inflammation are unknown. Further, only limited data are available on the relative merits of antimicrobial or other therapies for such asymptomatic patients.
Urine catheterization and functional status deterioration in elderly institutionalized women
Possible risk factors for recurrent urinary tract infection
Immunodeficiency
Diabetes mellitus
Organ transplants
Chronic renal insufficiency
Urinary tract abnormality
Urinary calculi
Urinary tract obstruction
Vesicoureteral reflux
Increased residual urinary volume
Behavioral factors
Spermicide use
Voluntary deferral of micturition
Drinking soft drinks
Estrogen deficiency
Symptoms of Urinary Tract Infection
Vaginitis or vulvovaginal infections (for example Gardnerella, Candida albicans, Trichomonas, bacterial vaginosis)—ask about or examine for the presence of vaginal discharge
Sexually transmitted diseases (ask about sexual activity, recent change of partner)
Urethral syndrome is a complex of symptoms that indicate a urinary tract infection but usually without an underlying infection. It is present in at least one-quarter of patients presenting with lower urinary tract symptoms
Interstitial cystitis (chronic pelvic pain syndrome of unknown etiology; bladder wall is inflamed and irritated) is diagnosed by ruling out other diseases. The basic criteria are urinary frequency, urgency, or pain for at least six months without a diagnosable etiology [rx]
Dysmenorrhoea.
Common uropathogenic bacteria, including Escherichia coli, multiply within the cytoplasm of bladder epithelial cells during acute cystitis.
In relevant animal models, oral antibiotic therapy for acute cystitis does not completely eradicate E. coli from bladder tissue, perhaps enabling same-strain recurrent cystitis.
New therapeutics currently in development aim to target adhesive surface factors of E. coli, such as pili; vaccine targets including pili, siderophores and toxins are also being studied.
The bladder, rather than representing a sterile environment, may, in fact, host a “urinary microbiome” of commensal organisms that may influence UTI and other symptomatic urinary tract conditions.
Recent laboratory advances now permit the modeling of recurrent UTI, ascending renal abscess formation, and catheter-associated UTI in mice.
Infections occurring despite the presence of anatomical protective measures (UTI in males are always complicated UTI)
Infections occurring due to anatomical abnormalities, for example, an obstruction, hydronephrosis, renal tract calculi, or colovesical fistula
Infections occurring due to an immune compromised state, for example, steroid use, post chemotherapy, diabetes, elderly population, HIV)
burning with urination
increased frequency of urination without passing much urine
increased urgency of urination
bloody urine
cloudy urine
urine that looks like cola or tea
urine that has a strong odor
pelvic pain in women
rectal pain in men
A strong, persistent urge to urinate
A burning sensation when urinating
Passing frequent, small amounts of urine
Urine that appears cloudy
Urine that appears red, bright pink or cola-colored — a sign of blood in the urine
Strong-smelling urine
Pelvic pain, in women — especially in the center of the pelvis and around the area of the pubic bone
Diagnosis of UTI
In 2012 the Society for Healthcare Epidemiology of America (SHEA) updated the surveillance definitions of infections in long-term care facilities, based on the growing body of evidence-based literature on infections in older adults living in long-term care facilities.[rx] These guidelines incorporated the acute care hospital surveillance definitions of the Centers for Disease Control and Prevention National Healthcare Safety Network. Major changes were made to the diagnosis of UTI for residents both with and without an indwelling urinary catheter. For residents without an indwelling urinary catheter, the diagnosis of UTI in the revised McGeer criteria includes:
Criteria from both 1 and 2
At least 1 of the following subcriteria of signs or symptoms
Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate
Or
Fever or leukocytosis and at least 1 of the following localizing urinary tract subcriteria
Acute costovertebral angle pain or tenderness
Suprapubic pain
Gross hematuria
New or marked increase in incontinence
New or marked increase in urgency
New or marked increase in frequency
In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract subcriteria
Suprapubic pain
Gross hematuria
New or marked increase in incontinence
New or marked increase in urgency
New or marked increase in frequency
One of the following microbiological subcriteria
At least 105 cfu/mL of no more than 2 species of microorganisms in a voided urine sample
At least 102 of any number of organisms in a specimen collected by in-and-out catheter[rx]
Microscopic examination of urine
In a centrifuged sediment, patients with significant bacteriuria almost always show bacilli in the urine, whereas only approximately 10% of patients with less than 105 CFU per ml show bacteria. About 60-85% of patients with significant bacteriuria have 10 or more white blood cells per high power field in the segment of mid-stream urine. Also 25% of patients with negative urine cultures also have pyuria, 10 or more white blood cells per high power field and only approximately 40% of patients with pyuria have 105or more bacteria per ml of urine by qualitative cultures.
Pyuria
95% of patients with pyuria have a genitourinary tract infection; however, pyuria cannot distinguish a bacterial UTI from the acute urethral syndrome. Tuberculosis,[rx] analgesic nephropathy, interstitial nephritis, perinephric abscess, renal cortical abscess, disseminated fungal infection and appendicitis may also result in pyuria.
Gram Stain
A simple Gram-stained smear can enhance the specificity of the test because morphology and stain characteristics aid in identifying the likely pathogen and in targeting empiric therapy.
Urine Culture
The diagnosis of UTI from simple cystitis to complicated pyelonephritis with sepsis can be established with absolute certainty only by cultures of urine. The major indications for urine cultures are:
Patients with symptoms or signs of UTIs
Follow-up of recently treated UTI
Removal of indwelling urinary catheter
Screening for asymptomatic bacteriuria during pregnancy; and
Patients with obstructive uropathy and stasis, before instrumentation.
Urine specimens must be cultured promptly within 2h or can be preserved by refrigeration or a suitable chemical additive (boric acid-sodium formate). Acceptable methods of collection are:
Midstream urine after careful washing
Urine obtained by single catheterization
Urine obtained by suprapubic needle aspiration; and
Sterile needle aspiration of urine from the tube of a closed catheter drainage system.
Micro-organisms in young men are similar to the organisms that cause uncomplicated infections in women. Enterococci and coagulase-negative staphylococci are more common in elderly men; most likely representing recent instrumentation or catheterization. C. albicans is rarely encountered except in patients with indwelling catheters, nosocomial UTIs or relapsing infections after multiple courses of antibiotics. Although the likely organism and usual susceptible patterns are sufficient to guide initial empiric therapy of uncomplicated UTI, adequate treatment of acute bacterial pyelonephritis and complicated UTIs necessitates precise therapy based on isolation of the causative bacterium and its antimicrobial susceptibility.[rx]
Imaging Studies
In general, imaging should be done 3-6 weeks after cure of acute infection to identify abnormalities predisposing to infection or renal damage or which may affect management.[rx] Rarely, imaging is carried out in the acute phase, particularly where there is severe loin pain, to identify possible sepsis (pyonephrosis or abscess) or to differentiate acute pyelonephritis from ureteric colic. It is important to recognize that abnormalities will be found in less than 5% of unselected cases.
Plain X-ray of the Abdomen
These are used to show the presence and extent of calcification in the urinary tract. They are less sensitive in the detection of ureteric calculi. Plain films are of value in monitoring change in position, size and number of calculi.
Ultrasound
Ultrasound (USG) combined with plain X-ray has become the imaging method of choice in patients with recurrent infections. It is a sensitive detector of pelvicalyceal dilatation, indicative of possible obstruction. Echoes within a dilated pelvicalyceal system, either diffuse or layered, suggest the presence of pyonephrosis. Drainage of an obstructed kidney can be guided by ultrasonography. It provides accurate renal length measurements and identifies the majority of renal scars, abscesses and perinephric fluid collections.[rx]
Ultrasound may show short segments of dilated ureter adjacent to the renal pelvis, at pelvic brim level or behind the full bladder. It can also assess the bladder for wall thickness, calculi, diverticula and emptying as well as assess prostate size.
Intravenous Urography
Intravenous urography (IVU) provides anatomical detail of the calyces, pelvis and ureter not obtained from ultrasonography. Calyceal detail is essential to diagnose papillary necrosis and medullary sponge kidney and careful assessment of the calyces and overlying parenchyma is necessary to diagnose reflex nephropathy.
Gram-negative bacilli have the ability to impede ureteral peristalsis and transient abnormalities of the IVU are common with acute pyelonephritis. These include hydroureter,vesicoureteric reflux, diminished pyelogram, loss of renal outline and renal enlargement. IVU should also be avoided for the first 6-12 weeks after pregnancy to allow resolution of the physiological dilatation of the pelvicalyceal system and ureter.
Computed Tomography
CT is the most common method of detecting renal and ureteric calculi, including calculi that are lucent on plain radiographs. It is a sensitive detector of pelvicalyceal dilatations, renal abscesses and perinephric collections than US. Contrast enhanced CT is very sensitive for acute pyelonephritis.[rx]
However, CT involves more radiation than even IVU, the potential risks of contrast media and is more expensive and less readily available than US. Therefore, it should be reserved as a second-line investigation for patients with severe infection not responding to appropriate treatment or for diagnostic problems not resolved by IVU or US.
Static Renal Scintigraphy
Di-mercapto-succinic acid (DMSA) scintigraphy is a sensitive detector of renal parenchymal infection in children.
Indications and Choice of Renal Imaging
Acute infection
Patients who have severe loin pain or whose infection does not settle on treatment should have US and plain X-ray to exclude pyonephrosis, intrarenal or perinephric sepsis or calculi. CT may be undertaken if no abnormality is seen on US in such patients. If ureteric colic is suspected, IVU or spiral CT should be used.[rx]
Imaging After Treatment of Infection
In women, there is no indication for imaging following a single or infrequent infection. Recurrent attacks more often than 2 per 6 months should be investigated by USG and plain KUB. In men, UTI is much less common than in women, and imaging is indicated after the first documented bacteriuria to exclude predisposing factors especially impaired bladder emptying. USG and plain film are the best first choice.[Rx]
Imaging should be considered if urinary infection is slow to resolve, if there is relapse or if there are risk factors for papillary necrosis. IVU is the method of choice to check for papillary necrosis, medullary sponge kidney or reflux nephropathy. IVU is also indicated in all patients over the age of 40 who have gross hematuria because of the risk of associated cancer.
Micturating Cystourography
MCU is not usually indicated in adults with urinary infection unless they have loin or abdominal pain during voiding, suggestive of reflux or as part of the investigation of impaired bladder emptying.
Urodynamic Studies
These may be necessary in patients with unexplained impairment of bladder emptying.
Treatment of Urinary Tract Infection
For effective management of UTI, the following principles must be recognized.
Asymptomatic patients should have colony counts greater than or equal to 105 per ml on at least 2 occasions before treatment is considered.
Unless symptoms are present, no attempt should be made to eradicate bacteriuria until catheters, stones or obstructions are removed.
Selected patients with chronic bacteriuria may benefit from suppressive therapy.
A patient who develops bacteriuria as a result of catheterization should be treated to re-establish sterile urine.
Efficacy of treatment should be evaluated by urine culture, one week after completion of therapy except in nonpregnant adult women with uncomplicated cystitis and uncomplicated pyelonephritis who respond to therapy.
Uncomplicated infections can be diagnosed and treated based on symptoms alone.[rx] Antibiotics taken by mouth such as trimethoprim/sulfamethoxazole (TMP/SMX), nitrofurantoin, or fosfomycin are typically first line.[rx] Cephalosporins, amoxicillin/clavulanic acid, or a fluoroquinolone may also be used.[rx] However, resistance to fluoroquinolones among the bacterial that cause urinary infections has been increasing.[rx]
Antimicrobial prophylaxis regimens and recommend doses from the current guidelines
Second-line drugs (B) (same clinical efficacy, bacteriologically not as effective as fluoroquinolones)
Cefpodoxime proxetil
200 mg 2 × daily
10 days
Ceftibuten
400 mg 1 × daily
10 days
In cases of known pathogen sensitivity (B) (not for empirical treatment)
Co-trimoxazole
160/800 mg 2 × daily
14 days
Amoxicillin/clavulanate
0.875/0.125 g 2 × daily
14 days
Amoxicillin/clavulanate
0.5/0.125 g 3 × daily
14 days
Initial parenteral therapy in severe infection
After clinical improvement, in cases with known pathogen sensitivity, oral follow-on treatment using one of the treatment regimes given above may be started. Total treatment duration is 1 to 2 weeks; for this reason, no duration is given for the parenteral antibiotic treatment.
First-line drugs (A)
Daily dose
Ciprofloxacin
400 mg 2 × daily
Levofloxacin
(250–) 500 mg 1 × daily
Levofloxacin
750mg 1 × daily
Second-line drugs (B)
Cefepime
1–2 g 2 × daily
Ceftazidime
1–2 g 3 × daily
Ceftriaxone
1–2 g 1 × daily
Cefotaxime
2 g 3 × daily
Amoxicillin/clavulanate
1/0.2 g 3 × daily
Ampicillin/sulbactam
1/0.5 g 3 × daily
Piperacillin/tazobactam
2/0.5–4/0.5 g 3 × daily
Amikacin
15 mg/kg 1 × daily
Gentamicin
5 mg/kg 1 × daily
Doripenem
0.5 g 3 × daily
Ertapenem
1 g 1 × daily
Imipenem/cilastatin
0.5/0.5 g 3 × daily
Meropenem
1 g 3 × daily
Asymptomatic Bacteriuria
Pregnancy
Pregnancy increases the risk of UTI complications. The rate of prematurity in children born to women who have bacteriuria during pregnancy is increased, and 20-40% of these patients develop pyelonephritis. Successful therapy of these patients with bacteriuria decreases the risk of symptomatic infection by 80-90%.
Therefore, all women should be screened twice during pregnancy for asymptomatic bacteriuria. All bacteriuric patients should be treated for seven days, with follow-up cultures to identify relapses. In selecting therapy, risk to foetus should be considered. Amoxicillin or cephalexin usually suffice.[rx]
Children
Asymptomatic bacteriuria in young children and school-aged girls may signify underlying vesicoureteral reflux. Therefore, asymptomatic bacteriuria should be treated with follow-up urologic evaluation after six weeks.
General Population
Asymptomatic bacteriuria in men and nonpregnant women, a common condition in the elderly,[rx] does not appear to cause renal damage in the absence of obstructive uropathy or vesicoureteral reflux and therefore it should not be treated.
Instrumentation of genitourinary tract should be avoided in patients with asymptomatic bacteriuria or, if necessary done under the cover of prophylactic antibiotic therapy. Selected high-risk patients (renal transplantation or neutropenia) may benefit from therapy for asymptomatic bacteriuria.
Diabetis Mellitus
Patients with asymptomatic bacteriuria who have conditions predisposing to papillary necrosis such as diabetis mellitus must be considered at risk of potentially harmful extension of infection to the kidney which may accelerate interstitial damage. Treatment is similar to that used for sysmptomatic patients.
Uncomplicated Cystitis
This is almost exclusively a disease of sexually active women mostly between the ages of 15 and 45 years. Although reinfection is common, complications are rare.
Common Treatment Options for Uncomplicated Cystitis
Antibiotic
Mechanism
Dosage
Notes
Nitrofurantoin monohydrate/macrocrystals
Inhibits protein, DNA, RNA, and cell wall synthesis
100 mg orally, twice daily for 5 d
Low resistance rates and risk of adverse side effects. Similar efficacy compared to a 3-d regimen of trimethoprim-sulfamethoxazole
Trimethoprim- sulfamethoxazole
Inhibits nucleic acid synthesis by folate synthesis inhibition
160 mg/800 mg (1 double-strength tablet), twice daily for 3 d
Only for use when local resistance rates do not exceed 20% and in patients who do not have sulfa drug allergies
Fosfomycin trometamol
Blocks cell wall synthesis by inactivating enolpyruvyl transferase
3 g in a single dose
Minimal resistance and risk of collateral damage. Inferior efficacy compared to other regimens
Pivmecillinam
Disrupts synthesis of cell wall by inhibiting formation of peptidoglycan cross-links
400 mg, once daily for 3–7 d
Low resistance rates and risk of adverse side effects. Not available in North America
Short Course Therapy
Infections truly confined to bladder or urethra respond as well to single-dose or short-course (3 day) therapy as to conventional therapy for 10-14 days. However, it has been observed that three- day therapy is more effective than single-dose therapy.[rx] A three-day regimen of amoxillin-clavulinate was found to be significantly less effective than a three-day regimen of ciprofloxacin in treating uncomplicated UTIs in women.[rx]
However, resistance has increased to various antimicrobials and more than one quarter of E. coli strains causing acute cystitis are resistant to amoxicillin, sulfa drugs and cephalexin and resistance to co-trimoxazole is now approaching these levels. Resistance to fluoroquinolones is also rising. Thus, knowledge of local resistance pattern is needed to guide empirical therapy.[rx]
Seven-Day Regimen
A longer course of therapy for cystitis should be given to patients with complicating factors that lead to lower success rates and a higher risk of relapse. These factors include a history of prolonged symptoms (more than seven days), recent UTI, diabetes, age above 65 years and use of a diaphragm. Importantly, both elderly and diabetic women frequently have concurrent renal infection, thus short course therapy should not be used in them.
Recurrent Cystitis (re-infections)
Some women especially whose periurethral and vaginal epithelial cells avidly support attachment of coli-form bacteria suffer from recurrent episodes of cystitis in the absence of recognized structural abnormalities of the urinary tract. Management in such women include the following:
Post-coital prophylaxis
Continuous low dose prophylaxis and
Self-administered therapy.
Postcoital prophylaxis is the most helpful for patients who associate recurrent UTIs with sexual intercourse. In these women, a single dose of an antimicrobial after sexual intercourse significantly reduces the frequency of UTIs. Women with recurrent UTIs (more than three UTIs per year) benefit from thrice weekly bed time antibiotic therapy. Such therapy significantly reduces the frequency of episodes of cystitis from an average of 3 per patient-year to 0.1 per patient-year.[rx] This regimen is known as continues low dose prophylaxis.
Women with fewer than three UTIs per year can be offered self-administered treatment. At the first sign/symptom of a UTI, such women should take a single-dose regimen of TMP-SMX or a fluoroquinolone. This is both effective and well tolerated.[rx]
Several prospective studies have demonstrated the efficacy of either nitrofurantoin 50 mg or nitrofurantoin macrocrystals 100 mg at bed time for prophylaxis against recurrent reinfection of urinary tract. Such a regimen has little if any effect on the faecal flora and presumably acts by providing intermittent urinary antibacterial activity.
Perhaps, the most popular prophylactic regimen currently used in women susceptible to recurrent UTI is low-dose TMP-SMX; as little as half a tablet (trimethoprim, 40 mg, sulfamethoxazole, 200 mg) three times weekly at bed-time is associated with an infection frequency of less than 0.2 per patient-year.
The efficacy of this prophylactic regimen appears to remain unimpaired even after several years. Similar to TMP-SMX, the fluoroquinolones may be used in a low-dose prophylactic regimen. The efficacy of these regimens is further delineated by their potency in preventing UTI in the far challenging population of kidney transplant recipients.
Acute Bacterial Pyelonephritis
In this setting, blood and urine cultures should be obtained.
Out-Patient Therapy
For uncomplicated acute pyelonephritis, a fluoroquinolone or co-trimoxazole is the drug of choice for initial therapy. After culture results are available, a full 10-14 day course of the antimicrobial to which the organism is susceptible should be instituted.[rx]
In-Patient Therapy
Patients who require admission to the hospital should be treated initially with a third-generation cephalosporin or a fluoroquinolone and gentamicin 4-7 mgs every 24 h if the urine shows Gram-negative bacilli on microscopy. If gram-positive cocci are seen in the urine, intra-venous ampicillin 1g every 4 hours should be given in addition to gentamicin, to cover the possibility of enterococcal infection. If no complications ensue and patient becomes afebrile, the remaining two-week course can be completed with oral therapy.
Recurrent Renal Infections (Relapses)
Chronic bacterial pyelonephritis is one of the most refractory problems as relapse rates are as high as 90% occur.
Acute Symptomatic Infection
The treatment of acute symptoms and signs of UTI in a patient with chronic renal bacteriuria is the same as for patients with acute bacterial pyelonephritis.
Prolonged Treatment
Some patients with relapsing bacteriuria respond to six weeks of antimicrobial therapy. This is especially true of patients with no underlying structural abnormality and of men with the normal prostatic examination.
Suppressive Therapy
Patients who fail the longer therapy, who have repeated episodes of symptomatic infection or who have progressive renal disease despite corrective measures, are candidates for suppressive antibiotic therapy. These patients should have two to three days of specific high-dose antimicrobial therapy to which their infecting bacteria are susceptible to reduce the colony counts in their urine. The preferred agent for long-term suppression is methenamine mandelate. Alternative therapy is cotrimoxazole, two tablets twice daily or nitrofurantoin 50-100 mg twice daily.[rx]
Prostatitis
Acute bacterial prostatitis
The drug of choice is cotrimoxazole or fluoroquinolone. However, treatment must be ultimately based on an accurate microbiological diagnosis and continued for 30 days to prevent chronic bacterial prostatitis. Urethral catheterization should be avoided. If acute urinary retention develops, drainage should be by supra-public needle aspiration or if prolonged bladder drainage is required by a suprapubic cystostomy tube.
Chronic bacterial prostatitis
The hallmark of chronic bacterial prostatitis is relapsing UTI. It is most refractory to treatment. Although erythromycin with alkalinization of urine is effective against susceptible Gram-positive pathogens, most instances of chronic bacterial prostatitis are caused by gram-negative enteric bacilli. Cotrimoxazole or fluoroquinolone is the drug of choice.
Approximately 75% of patients improve and 33% are cured with 12 weeks of cotrimoxazole therapy. For patients who cannot tolerate cotrimoxazole or a fluoroquinolone, nitrofurantoin 50 or 100 mg once or twice daily can be used for long-term (6-12 months) suppressive therapy.[rx]
Nonbacterial chronic prostatitis
Therapy is difficult because an exact etiology has not been identified. Owing to a concern for C. trachomatis, Ureaplasma urealyticum and other fastidious and difficult to culture organism, many experts recommended a six- week trial of tetracycline or erythromycin. Symptomatic therapy with NSAIDs and alpha-receptor blockers has also been used.
Catheter-Associated Infection
Urinary catheters are valuable devices for enabling drainage of the urinary bladder but their use is associated with an appreciable risk of infection. For a single (in-and-out) catheterization, the risk is small (12%), though this prevalence is much higher in diabetic and elderly women. However, bacteriuria occurs in virtually all patients with indwelling catheters within three to four days unless placement is done under sterile conditions and a sterile, closed drainage system is maintained. The use of a neomycin-polymyxin irrigate does not prevent catheter-associated infection.
Catheter-associated bacteriuria should only be treated in the symptomatic patient. When the decision to treat is made, removal of the catheter is an important aspect of therapy, because if an infected catheter remains in place, relapsing infection is very common. The interaction between the organisms and catheter cause the organism to form a biofilm, an area in which antibiotics are unable to completely eradicate these organisms. The empiric therapy of these infections is similar to that of complicated UTIs. Patients who rapidly respond to the therapy may be treated only for seven days.
The use of catheters impregnated with antimicrobial agents reduces the incidence of asymptomatic bacteriuria in patients catheterized for less than two weeks. Despite precautions, the majority of patients catheterized for more than two weeks eventually develop bacteriuria.[rx]
Fungal Urinary Tract Infection
The most common form of fungal infection of urinary tract is that caused by Candida species. Such infections usually occur in patients with indwelling catheters who have been receiving broad-spectrum antibiotics, particularly if diabetes mellitus is also present or corticosteroids are being administered.
Although most of these infections remain limited to the bladder and clear with the removal of the catheter, cessation of antibiotics and control of diabetes mellitus, the urinary tract is the source of approximately 10% of episodes of candidemia, usually in association with urinary tract manipulation or obstruction.[rx] Spontaneously occurring lower UTI caused by Candida species is far less common, although papillary necrosis, caliceal invasion and fungal ball obstruction have all been described as resulting from ascending candidal UTI that is not related to catheterization.
Antimicrobial prophylaxis regimens and recommend doses from the current guidelines
Oestrogen
Oestrogen use stimulates the proliferation of lactobacillus in the vaginal epithelium, reduces pH and avoids vaginal colonization by uropathogens. After the menopause, estrogen levels and lactobacilli numbers drop; this plays a significant role in the development of bacteriuria and makes post-menopausal women susceptible to UTIs.
Vaginal estrogen use reduces RUTIs by 36–75% and has minimal systemic absorption. Based on a Cochrane review in post-menopausal women with RUTIs, when compared to a placebo, vaginal estrogens were found to prevent RUTIs, but oral estrogen did not have the same effect.[rx],[rx]
Local estrogen cream twice a week and an Oestradiol-releasing vaginal ring are both effective in reducing RUTI attacks.[rx,rx,rx] They restore vaginal flora, reduce pH and therefore reduce UTIs; however, the reappearance of vaginal lactobacilli takes at least 12 weeks when using an estrogen vaginal ring.[rx–rx] Although the evidence does not support using a particular type or form of vaginal estrogen topical creams are cheaper than an Oestradiol-releasing vaginal ring but have more side effects.[rx,rx,rx,rx]
Cranberry Juice and Tablets
Cranberry juice and tablets have been shown to reduce RUTIs as they contain a compound called tannin, or proanthocyanidin, which reduces E. coli vaginal colonization.[rx],[rx] Although earlier, smaller studies have shown that consuming cranberry juice or tablets can prevent RUTIs, an updated Cochrane review showed that evidence for its benefit in preventing UTIs is small; therefore, cranberry juice cannot be recommended any longer for UTI prevention.[rx],[rx–rx]
Acupuncture
Recent studies indicate that the rate of cystitis among cystitis-prone women treated with acupuncture was one-third the rate of that among untreated women and half the rate among women treated by sham acupuncture. Therefore, acupuncture may prevent RUTIs in healthy adult women.[rx,rx,rx]
Probiotics
Probiotics are beneficial microorganisms that could protect against UTIs. Lactobacilli strains are the best-known probiotics and are found in fermented milk products, mainly yogurt. Other probiotics include Lactobacilli bifidobacteria, rhamnosus, casei, planetarium, bulgaricus and salivarius; Streptococcus thermophiles and Enterococcus faecium.
Reid et al. showed in vitro that lactobacillus can prevent uropathogen infections.[rx,rx] Other trials have showed that L. rhamnosus gr-1 and L. fermentum rc-14 can colonise the vagina, which could subsequently prevent UTIs. Nevertheless, more clinical studies need be carried out to determine their role in RUTI prevention.[rx–rx]
Immunoprophylaxis
Immunoprophylaxis taken orally may prove an effective alternative to antibiotics in the prevention of RUTIs. A meta-analysis of 5 studies showed that oral immunoprophylaxis with the Uro-Vaxom E. coliextract (Terra-Laba, Zagreb, Croatia) taken for a period of 3 months was effective in preventing RUTIs over a period of 6 months.[rx] Another double-blind study has confirmed that E. coli extracts are efficient and well-tolerated in the treatment of UTIs, reducing the need for antibiotics and preventing RUTIs.[rx]
Other Therapies
Methenamine hippurate is used for prophylaxis and treatment of RUTIs. Methenamine is hydrolysed to ammonia and formaldehyde when in acidic urine, which act as a bactericide to some strains of bacteria.[rx]
They are well-tolerated and have mild adverse effects, such as gastrointestinal upsets, rashes, anorexia, and stomatitis. Patients should be informed regarding adequate hydration, adverse effects and the need to avoid milk products and antacids to help keep the urine acidic.
A recent Cochrane review on the use of methenamine hippurate concluded that short-term use is effective in preventing RUTIs in patients with a normal renal tract. Nevertheless, it is not effective in women who have urinary tract abnormalities or a neuropathic bladder.[rx,rx]
Toothaches at Night; How can I Stop a Toothache at Night/Dental Pain also is known as dental pain is a pain in the teeth and/or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases? Common causes include inflammation of the pulp, usually in response to tooth decay, dental trauma, or other factors, dentin hypersensitivity (short, sharp pain, usually associated with exposed root surfaces), apical periodontitis (inflammation of the periodontal ligament and alveolar bone around the root apex), dental abscesses (localized collections of pus, such as apical abscess, pericoronal abscess, and periodontal abscess), alveolar osteitis (“dry socket”, a possible complication of tooth extraction, with loss of the blood clot and exposure of bone), acute necrotizing ulcerative gingivitis (a gum infection, also called “trench mouth”), temporomandibular disorder and others.
A toothache is the most common cause of oral pain [rx]. Although fractured teeth and exposed dentin may produce dentin hypersensitivity and cause dental pain [rx], untreated dental decay has been reported as the most important reason for a toothache which can impact routine daily activities such as eating, studying, concentrating on delicate tasks, and so on [rx–rx]. Several investigations that studied the impact of dental and facial pain emphasized that tooth and mouth diseases directly influence the quality of life in a community [rx, rx].
A wide range of toothache prevalence has been reported from 5% to 88% [rx–rx]. Dental pain has been confirmed as a public health problem [rx]. A recent investigation of children and adolescents revealed that overall, about one-tenth of patients complaining of pain suffered from a toothache [rx].
Causes of Dental Pain
Infection
Gum disease
Grinding teeth (bruxism)
Tooth trauma
An abnormal bite
Tooth eruption (in babies and school-age children)
A toothache in or around a tooth or several teeth caused by different factors can lead to crippling pain.
Gum inflammation
Gum disease
Tooth decay
Damaged tooth filling
Abscessed tooth
Infected gums
Tooth fracture
Even teeth grinding
Severe, persistent gum pains;
Pain when you open your mouth wide;
Migraines and fevers caused by mouth pains;
Consistent bad tasting fluids draining from your gum.
Toothaches are sometimes sharp, dull, intermittent or persistent. To feel the pain in some instances, you have to press against the tooth or gum.
TMJ/TMD (Temporomandibular Joint Disorder), sinus or ear infections, and tension in the facial muscles can cause discomfort that resembles a toothache, but often these health problems are accompanied by a headache.
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Pain around the teeth and the jaws can be symptoms of heart disease such as angina. If your dentist suspects a medical illness could be the cause of your toothache, he or she may refer you to a physician
Symptoms of Dental Pain
Because the symptoms of a toothache may resemble other medical conditions or dental problems, it can be difficult to diagnose the cause without a complete evaluation by your dentist. If you notice pus near the source of the pain, your tooth may have become abscessed, causing the surrounding bone to become infected. Or the pus could indicate gum disease, which is usually characterized by inflammation of the soft tissue, bleeding gums and abnormal loss of bone surrounding the teeth.
Contact your dentist immediately if you have any of the following symptoms:
Fever
Difficulty breathing or swallowing
Swelling around the tooth area
Pain when you bite
A foul-tasting discharge
Continuous lasting pain
While tooth decay is often the primary cause of a toothache, it’s important for you to have a complete oral examination to determine the cause. Other causes of a toothache can include the following.
Parameter
Dentin hypersensitivity:
Reversible pulpitis:
Irreversible pulpitis
Pulp necrosis
Apical periodontitis
Periodontal abscess
Pericoronitis
Myofascial pain
Maxillary sinusitis
Site
Poorly localized
Poorly localized
Variable; localized or diffuse
No pain
Well localized
Usually well localized
Well localized, associated with a partially impacted tooth
Diffuse, often over many muscles
Back teeth top jaw
Onset
Gradual
Variable
Variable
From the pain of reversible pulpitis to no pain in days
Gradual typically follows weeks of thermal pain in the tooth
Sudden, no episode of thermal sensitivity
Sudden
Very slow; weeks to months
Sudden
Character
Sharp, quickly reversible
Sharp, shooting
Dull, continuous pain. Can also be sharp
No pain
Dull, continuous throbbing pain
Dull, continuous throbbing pain
Sharp, with continuous dull
Dull, aching
Dull, aching, occasional thermal sensitivity in back top teeth
Radiation
Does not cross the midline
Does not cross the midline
Does not cross the midline
N/A
Does not cross the midline
Little, well localized
Moderate, into jaw/neck
Extensive, neck/temple
Moderate, into other facial sinus areas
Associated symptoms
The patient may complain of receding gums and/or toothbrush abrasion cavities
Can follow restorative dental work or trauma
Follows period of pain that does not linger
Follows the period of spontaneous pain
The tooth may feel raised in the socket
May follow the report of something getting “stuck” in gum
Tooth eruption (“cutting”) or impacted tooth
Tension headaches, neck pain, periods of stress or episode of mouth open for long period
Hypersensitivity as long as the stimulus is applied; often worse in cold weather
Pain as long as the stimulus is applied
Lingering pain to hot or cold or spontaneous pain
The absence of pain following days or weeks of intense, well-localized pain
Pain on biting following constant dull, aching pain development
Dull ache with an acute increase in pain when the tooth is moved, minimal thermal sensitivity
Constant dull ache without the stimulus
Spontaneous, worse with eating, chewing, or movement of jaw
Spontaneous, worse when head is tipped forward
Exacerbating and relieving factors
Exacerbating: thermal, particularly cold
Exacerbating: thermal, sweet
Simple analgesics have little effect
Prolonged heat may elicit pain
Same as irreversible pulpitis, or no response to cold, lingering pain to hot, pain with biting or lying down
Tapping tooth makes worse, the cleansing area may improve pain
The cleansing area can improve pain
Rest or ice makes pain better, movement and chewing make it worse
Tilting head forward, jarring movements (jumping) make pain worse
Severity
Less severe than pulpitis
Severe, for short periods
Variable; pain dissipates until periapical tissue affected
Severe
Severe
Severe
Mild to severe
Mild to moderate
Mild to severe
Effect on sleep
None
None usually
Disrupts sleep
None
Disrupts sleep
Variable, can disrupt sleep
If moderate to severe will disrupt
Unusual
Unusual
Treatment/Toothaches at Night
Acetaminophen
An over-the-counter medicine like acetaminophen is useful in treating toothaches, and it’s the most common medications given after dental treatment, according to the American Dental Association. The National Institutes of Health notes that acetaminophen is an analgesic and changes the way your body perceives pain, which is what makes an ache tolerable.
NSAIDs
Toothaches are often accompanied by inflammation, swelling, and redness of the gums, or irritation to other parts of the mouth.
These symptoms may benefit from taking an anti-inflammatory, such as naproxen or ibuprofen, Etoricoxib as a single dosage with metronidazole and PPI (or any of the other nonsteroidal anti-inflammatory drugs (NSAIDs). You should only take one of these medications if you know for certain that you have no allergies to the ingredients, and you should always ensure you take an NSAID with food to avoid irritation to the stomach.
Holding an ice pack or a package of frozen peas to the outside of your face can be surprisingly helpful. The cold helps numb the pain. Apply the ice for a few minutes at a time and then take a break.
Topical Medication
Products such as benzocaine applied directly to the tooth can also provide you with some short-term relief from pain. Your dentist may recommend Colgate Orabase 20% Benzocaine for this purpose, as it contains 20% Benzocaine to provide clinically proven pain relief for mouth irritations.
Ice Packs
Avoid Hard Foods
Toothaches are frequently caused either by a broken tooth or a dental cavity, so until you are sure of the reason for your pain, it’s best to take precautions. While you’re waiting for and directly after toothache treatment, sticking to soft foods will help you to avoid further damage to brittle or sensitive teeth.
Keep it Clean
It is essential to maintain good dental hygiene even when you have a toothache. If it’s too painful to perform your regular daily brushing and flossing, try a product such as Colgate Peroxyl Mouth Sore Rinse. The bubbling action cleans and alleviates discomfort to promote healing. It’s not always convenient to get the treatment you require at the time you need it, but these options will help reduce the pain enough to see you through until you can get professional help.
Home Remedies for a Toothache
Cloves
Cloves contain a chemical called eugenol. Eugenol is an anesthetic chemical, means it numbs the nerves and stops the sensation of pain. Eugenol also has antiseptic properties that help kill germs. You can also use Clove oil to treat the pain. Just dab a small cotton ball and rub the oil on the tooth which has pain. You can use the clove or clove oil remedy up to 3 times a day, Eugenol can be poisonous if consumed in high amounts.
Asafoetida (Hing)
For this, you will need a tablespoon of orange juice as well. Just mix a pinch of Asafoetida in the orange juice and dab a cotton ball in the mix. Place this cotton ball on the painful teeth or the jaw for 5 to 10 minutes. This remedy works immediately in reducing pain and hence it is very popular.
Ice Cube
Massage the jaws near the painful teeth for 3 to 4 times in a day with an Ice cube. A 5-minute massage with Ice cube can significantly lower the inflammation and pain.
Salt mouthwash
A toothache caused by mild infection or injury will be reduced by time. To fasten this process, mix 1 tablespoon of salt in a cup of lukewarm water. Now take a gulp of this water in your mouth and squish it over the painful area. Repeat this 2-3 three times and the pain will be eased off.
Garlic
Garlic has antibiotic properties and the ability to fight various types of infection. If your toothache is due to some type of infection, and cure the pain. You can simply chew a clove of Garlic or you can mash the garlic clove to make a paste and apply the paste on the tooth. Garlic has Elicin, a chemical which is a potent antibiotic. Remember to use fresh garlic or freshly made garlic paste.
Instant Relief from Toothache
A mouth rinse with alcohol (Hard drinks like whiskey or vodka) provides instant relief from a toothache. Alcohol numbs the nerve fibers in the jaws immediately and prevents the sensation of pain.
Should you go see a Dentist?
Yes, you should see a doctor, if the pain lasts more than a day. If the pain is not resolved and persistent, you should visit a Dentist. Upon inspection and diagnosis of the problem, a dentist may advise you to go for many Orthodontal procedures such as tooth extraction, root canal surgery or if the tooth has a cavity; get a filling done. The longer you avoid to visit the doctor, the worse pain will get.
If a toothache isn’t treated properly, the dental pulp can eventually become infected. This can lead to serious dental problems with severe and throbbing pain.
Allopathic treatment for a toothache
The treatment for a toothache will depend on the reason for the pain. Your dentist will observe your teeth, jaws and may carry out an X-ray to try to rectify the cause of pain. Some of the commonly practiced medicines and procedures are listed below:
Hydrogen Peroxide
Dip a Q-tip in the Hydrogen peroxide and apply it to the affected tooth. This will clean the area around and help in numbing the pain for some time. Keep the hydrogen peroxide for 2-3 minutes in the mouth, then rinse it off with clean water. Do not swallow it
Painkillers
You can take painkillers such as Acetaminophen or Ibuprofen orally to control tooth pain. If the patient is an adult then aspirin can be given to him. Aspirin is not advised to children to reduce the tooth pain.
Dental Filling
A dentist will clean the decayed area (cavity) and fill it with a filling substance.
In some cases, the filling gets loose due to wear-and-tear over time, Then the dentist will remove old filling and replace it with a new one.
Root Canal
Root canal treatment is administered when the dental pulp is severely infected and damaged. It is a serious surgical procedure. Depending on your teeth condition, root canal treatment can take up to 2-5 sessions with a dentist if. In this procedure, a dentist will completely remove the infected dental pulp then fill the teeth with a special type of filling. The doctor will also seal the treated tooth with a dental crown and cap to prevent future infections.
Dental Implants
Many times the decay occurs on a critical area of teeth and it becomes difficult to treat it by above-discussed methods. Then the doctor will have to remove the affected teeth. The doctor will fix a dental implant to replace the removed tooth.
Preventing Toothache
The best way to prevent getting a toothache and many other dental problems; is to keep your gums and teeth as healthy as possible. To maintain good health of teeth and gums, you should follow these steps:
Brush twice
Use a toothpaste that contains fluoride to brush your teeth twice every day. The best times to brush, as usual; are before breakfast in the morning and before going to bed at night. Gently brush your gums and tongue as well.
Dental Floss
Sometimes, the bristles of a toothbrush are not capable of cleaning the teeth thoroughly. Just use a thin dental floss to remove dirt from in-between the teeth. If you feel like it, use a freshening mouthwash.
Control Sugar intake
Avoid the consumption of sugary foods and drinks. Sugar residues on teeth and gums can encourage the growth of bacteria and trigger the infection.
Avoid Tobacco
Chewing of Smoking tobacco can cause tooth decay and oral cancer. Tobacco can worsen many dental problems.
Examine Regularly
Visit your Dentist at regular intervals to get your teeth tested. Well, the gap between check-ups can vary, depending on the health and condition of your teeth. Go for check up at every 6 months, and prevent decay or other dental problems.
Drug Abuse Disorders is when you take drugs that are not legal. It’s also when you use alcohol, prescription medicine, and other legal substances too much or in the wrong way. So substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of the substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases, criminal or anti-social behavior occurs when the person is under the influence of a drug, and long-term personality changes in individuals may occur as well. In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties,
Types of Drug Abuse Disorders
Cigarettes
A distinctive smell on the breath and clothing
Cigarettes and lighter in his or her possession
Cigarette butts outside a bedroom window or in other odd places around the home.
Alcohol
Alcoholic beverages missing from the home storage cabinet
Alcohol or mouthwash (used to cover up alcohol) breath or hangover symptoms (nausea, vomiting, or a headache), if recently used.
Marijuana
Sweet smell on clothing or bloodshot eyes, if recently used, and frequent use of eyedrops to reduce the redness
Drug paraphernalia (pipes) in his or her possession
Carelessness in grooming, increased fatigue, and changes in eating and sleeping patterns, if using regularly
Inhalants
Chemical breath, red eyes, or stains on clothing or face, if recently used
Soaked rags or empty aerosol containers in the trash
Club drugs
Skin rash similar to acne
Small bottles with liquid or powder in his or her possession
Stimulants
A persistent runny nose and nosebleeds, injection marks on arms or other parts of the body, or long periods of time without sleep
Possession of drug paraphernalia, such as syringes, spoons with smoke stains, small pieces of glass, and razor blades
LSD or other Hallucinogens
Trance-like appearance with dilated pupils, if recently used
Small squares of blotter paper (sometimes stamped with cartoon characters) or other forms of the drug in his or her possession
Heroin
Very small pupils and a drowsy or relaxed look, if recently used
Possession of injecting supplies called an outfit or rig, that may consist of a spoon or bottle cap, syringe, tourniquet, cotton, and matches
Anabolic steroids
An unpleasant breath odor
Mood changes, including increased aggression
Changes in physical appearance that can’t be attributed to expected patterns of growth and development
Possession of medicines or syringes
Other general signs
Changes in sleeping patterns
Changes in appetite or weight loss
Changes in dress
Loss of interest and motivation
Hoarseness, wheezing, or a persistent cough
Causes and Effects of Drug Abuse Disorders
While many individuals experiment with drugs and/or alcohol, there is a fine line that can be crossed that differentiates between experimentation and substance abuse. When an individual abuses a substance or substances to such a degree that it begins to negatively affect his or her life and ability to function on a daily basis, that person is likely suffering from an addiction.
According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a person who is struggling with an addiction to drugs and/or alcohol will meet some or all of the following diagnostic criteria:
The consumption of the substance occurs in larger amounts, and more often than intended
Despite a desire to end, one’s substance abuse, unsuccessful attempts have been made
A great deal of time is spent acquiring, using, and recovering from the abuse of a substance
Overpowering cravings for one’s substance of choice are present
Failure to adhere to responsibilities occur due to substance abuse
Substance abuse continues despite problems caused by the substance abuse
Activities are given up in favor of substance abuse
Substance abuse occurs in a situation where it could be dangerous
One continues to abuse substances despite knowing that it has caused problems
Tolerance to a given substance or substances develops
Withdrawal symptoms manifest when one is not able to abuse a substance
If you or someone you care about meets the criteria listed above, it is important to seek treatment. By seeking treatment for a substance abuse problem, a brighter, happier, healthier tomorrow can be achieved.
Statistics of Drug Abuse Disorders
The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that as many as twenty million Americans suffer from addictions to substances, but that only fifteen percent of those individuals actually seek treatment. Additionally, research conducted by the National Institute on Drug Abuse (NIDA) states that somewhere between eighty and ninety percent of people in the United States have abused substances during their lifetimes, with alcohol, marijuana, and prescription drugs being the most frequently abused substances in today’s society.
Causes & Risk Factors for Drug Abuse Disorders
There are many reasons why a person may turn to the abuse of drugs and/or alcohol. The following are the causes and risk factors that experts in the field of addiction believe to be true in terms of what makes some individuals more susceptible to abusing substances than others
Genetic – Researchers have discovered a set of genes that can make an individual vulnerable to developing a substance abuse problem. Given this information, if a person has a first-degree relative who has struggled with substance abuse, addiction, and/or chemical dependency, that individual is at risk of also struggling with similar challenges at some point during his or her lifetime.
Environmental – In addition to genetic influences, the environment and places one spends most of his or her time can have an impact on whether or not an individual will come to abuse substances. For example, those who are exposed to substance abuse from an early age are vulnerable to also abusing substances if they lack effective coping skills and proper social support. Additionally, if an individual resides in an impoverished area, has a history of experiencing trauma, or associates him or herself with others who also abuse drugs and/or alcohol, there is a higher risk for substance abuse to occur at some point in that person’s life.
Risk Factors of Drug Abuse Disorders
Possessing an impulsive personality
Possessing a novelty-seeking temperament
Personal history of trauma
The family history of substance abuse, addiction. and/or chemical dependency
The family history of mental health concerns
Personal history of mental health concerns
Living in an impoverished area
Lacking coping skills
Having an inadequate support system
Symptoms of Drug Abuse Disorders
Each substance affects people differently, but there are some signs of addiction that are fairly universal
The onset of withdrawal symptoms after the person suddenly stops using the substance
Feeling as though he or she must consume the substance to deal with the stresses of daily life
Increased tolerance levels requiring the person to consume more of the substance to achieve the same effect
Uncharacteristic or irrational behavior such as angry or violent outbursts
Dramatic changes in appearance like weight loss, hair loss, or skin problems
Loss of interesting previously enjoyable activities
Loss of important relationships
Lying to cover up consumption patterns
Impaired performance at work, home, or school
Incessantly borrowing money or stealing money
Legal, medical, or personal problems associated with consumption of the substance
Or
Decreased involvement in activities the person used to enjoy
Trouble managing responsibilities at work, school, or home
Problems with relationships related to substance use
Increase in risk-taking behaviors
A lot of time spent seeking the substance, or dealing with its aftereffects (e.g., being hungover)
Inability to stop using the substance or change behavior, even when the problems above are present
In some cases, physical or psychological signs may be observed as well
Substance abuse can wreak havoc on a person’s life. Depending on the longevity and severity of the addiction itself, the effects that could result can be life-changing. The effects listed below are among those that may occur if a person continues to abuse substances without seeking professional help:
Some individuals who are grappling with mental health concerns turn to the abuse of drugs and/or alcohol as a means of coping with their turmoil. Additionally, there are those who only begin to suffer from mental health disorders once they start abusing substances. In either case, it is possible for a person to seek treatment for an substance abuse and be diagnosed with a mental illness at the same time. The following mental health conditions are among those that people can suffer from at the same time as a substance abuse problem:
Effects of withdrawal: The longer than an individual abuses drugs and/or alcohol, the more likely that person will be to develop a tolerance to his or her substance(s) of choice. When this occurs, it can signify that that individual has become chemically dependent on that substance(s) and will thusly experience withdrawal symptoms in the event he or she ceases his or her substance abuse. The process of withdrawing from a substance can be extremely uncomfortable and, unfortunately, trigger a person to seek out his or her substance of choice once more. The following are signs and effects of withdrawal, which also suggest that a person is in need of treatment for his or her addiction:
For many substances of abuse, there is an ever-present risk of overdose when drugs and/or alcohol are used on an ongoing basis. Depending on the substance that is being abused, the telltale warning signs of overdose can vary. If any of the following occur, it should heed as a warning that emergency medical attention is needed in order to prevent a grave outcome
If a healthcare provider suspects that you are misusing alcohol or medications, he or she will first confirm that you are dependent on a harmful substance by:
The CAGE questionnaire is often used by healthcare providers to establish whether you have a drinking problem. It has four questions:
“Have you ever felt you should cut down on your drinking?”
“Have you ever felt annoyed by criticism about your drinking?”
“Have you ever felt guilty or bad about drinking?”
“Have you ever felt the need for a drink (an “eye-opener”) in the morning to steady your nerves?”
Rational scale to assess the harm of recreational drug use
Drug
Drug class
Physical
harm
Dependence
liability
Social
harm
Total
harm
Heroin
Opioid
2.78
3.00
2.54
2.77
Cocaine
CNS stimulant
2.33
2.39
2.17
2.30
Barbiturates
CNS depressant
2.23
2.01
2.00
2.08
Methadone
Opioid
1.86
2.08
1.87
1.94
Alcohol
CNS depressant
1.40
1.93
2.21
1.85
Ketamine
Dissociative anesthetic
2.00
1.54
1.69
1.74
Benzodiazepines
Benzodiazepine
1.63
1.83
1.65
1.70
Amphetamine
CNS stimulant
1.81
1.67
1.50
1.66
Tobacco
Tobacco
1.24
2.21
1.42
1.62
Buprenorphine
Opioid
1.60
1.64
1.49
1.58
Cannabis
Cannabinoid
0.99
1.51
1.50
1.33
Solvent drugs
Inhalant
1.28
1.01
1.52
1.27
4-MTA
Designer SSRA
1.44
1.30
1.06
1.27
LSD
Psychedelic
1.13
1.23
1.32
1.23
Methylphenidate
CNS stimulant
1.32
1.25
0.97
1.18
Anabolic steroids
Anabolic steroid
1.45
0.88
1.13
1.15
GHB
Neurotransmitter
0.86
1.19
1.30
1.12
Ecstasy
Empathogenic stimulant
1.05
1.13
1.09
1.09
Alkyl nitrites
Inhalant
0.93
0.87
0.97
0.92
Khat
CNS stimulant
0.50
1.04
0.85
0.80
Treatment of Drug Abuse Disorders
When you drink alcohol with some medications, the alcohol can make the effect of the medication dangerously strong. For example, taking alcohol with pills for sleeping, pain, anxiety, or depressioncan produce harmful effects. In particular, you should avoid alcohol if you take:
If you are addicted to smoking, you have probably tried to quit many times. But another serious try is always worth it, even if you are among the very old. Quitting at any age slows the decline in lung function.
Let your healthcare provider know that you want to stop smoking. Together, you will take the following steps
Get involved in a support group or buddy system to help keep you motivated
Self-help for substance abuse and co-occurring disorders
In addition to getting professional treatment, there are plenty of self-help steps you can take to address your substance abuse and mental health issues. Remember: Getting sober is only the beginning. As well as continuing mental health treatment, your sustained recovery depends on learning healthier coping strategies and making better decisions when dealing with life’s challenges.
Recovery tip 1
Learn how to manage stress – Drug and alcohol abuse often stems from misguided attempts to manage stress. Stress is an inevitable part of life, so it’s important to have healthy coping skills so you can deal with stress without turning to alcohol or drugs. Stress management skills go a long way towards preventing relapse and keeping your symptoms at bay.
Cope with unpleasant feelings – Many people turn to alcohol or drugs to cover up painful memories and emotions such as loneliness, depression, or anxiety. You may feel like doing drugs is the only way to handle unpleasant feelings, but Help guide’s free Emotional Intelligence Toolkit can teach you how to cope with difficult emotions without falling back on your addiction.
Know your triggers and have an action plan – When you’re coping with a mental disorder as well as a substance abuse problem, it’s especially important to know signs that your illness is flaring up. Common causes include stressful events, big life changes, or unhealthy sleeping or eating patterns. At these times, having a plan in place is essential to preventing a drink or drug relapse. Who will you talk to? What do you need to do to avoid slipping?
Recovery tip 2
Make a face-to-face connection with friends and family a priority – a Positive emotional connection to those around you is the quickest way to calm your nervous system. Try to meet up regularly with people who care about you. If you don’t have anyone you feel close to, it’s never too late to meet new people and develop meaningful friendships.
Get therapy or stay involved in a support group – Your chances of staying sober improve if you are participating in a social support group like Alcoholics Anonymous or Narcotics Anonymous or if you are getting therapy.
Follow doctor’s orders –Once you are sober and you feel better, you might think you no longer need medication or treatment. But arbitrarily stopping medication or treatment is a common reason for relapse in people with co-occurring disorders. Always talk with your doctor before making any changes to your medication or treatment routine.
Make healthy lifestyle changes
Exercise regularly – Exercise is a natural way to bust stress, relieve anxiety, and improve your mood and outlook. To achieve the maximum benefit, aim for at least 30 minutes of aerobic exercise on most days.
Practice relaxation techniques – When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and deep breathing can reduce symptoms of stress, anxiety, and depression, and increase feelings of relaxation and emotional well-being.
Adopt healthy eating habits – Start the day right with breakfast, and continue with frequent small meals throughout the day. Going too long without eating leads to low blood sugar, which can make you feel more stressed or anxious. Getting enough healthy fats in your diet can help to boost your mood.
To stay alcohol- or drug-free for the long term, you’ll need to build a new, meaningful life where substance abuse no longer has a place.
Develop new activities and interests – Find new hobbies, volunteer activities, or work that gives you a sense of meaning and purpose. When you’re doing things you find fulfilling, you’ll feel better about yourself and substance use will hold less appeal.
Avoid the things that trigger your urge to use – If certain people, places, or activities trigger a craving for drugs or alcohol, try to avoid them. This may mean making major changes to your social life, such as finding new things to do with your old buddies—or even giving up those friends and making new connections.
Group support for substance abuse and co-occurring disorders
As with other addictions, groups are very helpful, not only in maintaining sobriety but also as a safe place to get support and discuss challenges. Sometimes treatment programs for co-occurring disorders provide groups that continue to meet on an aftercare basis. Your doctor or treatment provider may also be able to refer you to a group for people with co-occurring disorders.
Just make sure your group is accepting of the idea of co-occurring disorders and psychiatric medication. Some people in these groups, although well-meaning, may mistake taking psychiatric medication as another form of addiction. You want a place to feel safe, not pressured.
Helping a loved one with a substance abuse and mental health problem
Helping a loved one with both a substance abuse and a mental health problem can be a roller coaster. Resistance to treatment is common and the road to recovery can be long.
The best way to help someone is to accept what you can and cannot do. You cannot force someone to remain sober, nor can you make someone take their medication or keep appointments. What you can do is make positive choices for yourself, encourage your loved one to get help, and offer your support while making sure you don’t lose yourself in the process.
Seek support – Dealing with a loved one’s mental illness and substance abuse can be painful and isolating. Make sure you’re getting the emotional support you need to cope. Talk to someone you trust about what you’re going through. It can also help to get your own therapy or join a support group.
Set boundaries – Be realistic about the amount of care you’re able to provide without feeling overwhelmed and resentful. Set limits on disruptive behaviors and stick to them. Letting the co-occurring disorders take over your life isn’t healthy for you or your loved one.
Educate yourself – Learn all you can about your loved one’s mental health problem, as well as substance abuse treatment and recovery. The more you understand what your loved one is going through, the better able you’ll be to support recovery.
Stomach Cramping is one of the more common problems that may affect more than 90% of the population. The intensity of the pain may often scare us, but it is not necessarily due to something serious. However, lingering symptoms can indicate a chronic disease that should be treated. Sometimes, its intensity may seem pretty scary, but it does not necessarily mean that you are dealing with a serious health problem. However, oftentimes it indicates a chronic condition that you should treat.
Types of Stomach Ache
Acute Stomach Ache
Acute abdominal pain can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock. One of the most common conditions associated with acute abdominal pain is acute appendicitis.
Selected Causes
Traumatic
Blunt or perforating trauma to the stomach, bowel, spleen, liver, or kidney
Inflammatory
Infections such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess
Perforation of a peptic ulcer, a diverticulum, or the caecum
Complications of inflammatory bowel disease such as Crohn’s disease or ulcerative colitis
Mechanical
Small bowel obstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms
Large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or a hernia
Vascular: occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery
Differences in the location and rate of progression of lesions within the abdominal cavity may be summarized as outlined by Rx in terms of five possible components.
Visceral pain – alone is asymmetric pain located in the midline anteriorly, with or without associated vasomotor phenomena.
On occasion – when visceral pain is of rapid onset and of great severity, at the peak intensity of the pain it may “spill over” at the spinal cord level by viscerosensory and visceromotor reflexes into the corresponding cerebrospinal pathways, producing somatic findings without pathologic involvement of somatic receptors.
Visceral and somatic pain – often become combined as the causative lesion progresses from the viscus to involve adjacent somatic nerves. Visceral pain may continue, but a new and different pain is added.
Somatic pain – may be so severe that it overshadows the visceral pain of origin in the affected viscus, making an accurate diagnosis difficult.
Referred pain – due to irritation of the phrenic, obturator, and genitofemoral nerves are unique and diagnostically important findings remote from the abdomen that may provide clues to the source of abdominal pain.
The clinical significance of the pathways and stimuli responsible for the production of abdominal pain can perhaps best be appreciated by an analysis of the pathogenesis of acute appendicitis, as that disease process correlates with symptoms and physical findings common to that disorder.
Rx
Conditions such as continual bloating, frequent vomiting, diarrhea and blood in the stool, which persist for more than two weeks are signs that ask for immediate medical attention so that a more serious diagnosis is avoided.Abdominal pain can be any kind of discomfort felt between the chest and groin. Since this is an extensive area of the body, it is necessary to know the exact location of the pain so you can easier find the cause.
The evaluation of abdominal pain requires an understanding of the possible mechanisms responsible for pain, a broad differential of common causes, and recognition of typical patterns and clinical presentations. All patients do not have classic presentations.The map on the picture above will help you identify your pain.
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Causes of Stomach Ache
Whether it’s a mild stomach ache, sharp pain, or stomach cramps, abdominal pain can have numerous causes. Some of the more common causes include:
from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
from the spine: radiculitis
from the genitals: testicular torsion
Metabolic disturbance
uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal
Blood vessels
aortic dissection, abdominal aortic aneurysm
Immune system
sarcoidosis
vasculitis
familial Mediterranean fever
Idiopathic
irritable bowel syndrome (affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain)
Symptoms of Stomach Ache
If your abdominal pain is severe or recurrent or if it is accompanied by any of the following symptoms, contact your health care provider as soon as possible:
Fever
Inability to keep food down for more than 2 days
Any signs of dehydration
Inability to pass stool, especially if you are also vomiting
Painful or unusually frequent urination
The abdomen is tender to the touch
The pain is the result of an injury to the abdomen
The pain lasts for more than a few hours
These symptoms can be an indication of an internal problem that requires treatment as soon as possible. Seek immediate medical care for abdominal pain if you:
Vomit blood
Have bloody or black tarry stools
Have difficulty breathing
Have pain occurring during pregnancy
Doctors determine the cause of abdominal pain by relying on:
Characteristics of the pain
Physical examination
Exams and tests
Surgery and Endoscopy
Diagnosis of Stomach Ache
In order to better understand the underlying cause of abdominal pain, one can perform a thorough history and physical examination.
The process of gathering a history may include:
Identifying more information about the chief complaint by eliciting a history of present illness; i.e. a narrative of the current symptoms such as the onset, location, duration, character, aggravating or relieving factors, and temporal nature of the pain. Identifying other possible factors may aid in the diagnosis of the underlying cause of abdominal pain, such as recent travel, recent contact with other ill individuals, and for females, a thorough gynecologic history.
Learning about the patient’s past medical history, focusing on any prior issues or surgical procedures.
Clarifying the patient’s current medication regimen, including prescriptions, over-the-counter medications, and supplements.
Confirming the patient’s drug and food allergies.
Discussing with the patient any family history of disease processes, focusing on conditions that might resemble the patient’s current presentation.
Discussing with the patient any health-related behaviors (e.g. tobacco use, alcohol consumption, drug use, and sexual activity) that might make certain diagnoses more likely.
Reviewing the presence of non-abdominal symptoms (e.g., fever, chills, chest pain, shortness of breath, vaginal bleeding) that can further clarify the diagnostic picture.
After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam.
Additional investigations that can aid diagnosis include:
Blood tests including complete blood count, basic metabolic panel, electrolytes, liver function tests, amylase, lipase, troponin I, and for females, a serum pregnancy test.
If the diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include
Computed tomography of the abdomen/pelvis
Abdominal or pelvic ultrasound
Endoscopy and/or colonoscopy
Differential diagnosis of Stomach Ache
The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), inflammation of the stomach (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder (gallstones or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%). More common in those who are older, mesenteric ischemia and abdominal aortic aneurysms are other serious causes.
Once an initial evaluation has been completed, your health care provider may have you undergo some tests to help find the cause of your pain. These may include stool or urine tests, blood tests, barium swallows or enemas, an endoscopy, X-ray, ultrasound, or CT scan.
Extra-abdominal causes of abdominal pain (i.e., radicular pain, sickle cell disease, myocardial ischemia, pneumonia, among others)
Gastritis/peptic ulcer
Gastroenteritis
Gynecologic pain
Hernias
Iatrogenic pain (both drugs and surgery)
Inflammatory bowel disease
Liver disease (i.e., liver cirrhosis, hepatitis)
Nonspecific abdominal pain (NSAP)
Nonspecific abdominal pain in pregnant women
Oncologic pain
Others (i.e., all those conditions not precisely otherwise classified, such as sarcoidosis, adeno mesenteritis, muscle pain, overeating, alcohol and/or abuse substances, abdominal wall abscess or hematoma, vascular abdominal diseases)
Pancreatitis
Renal colic
Urinary tract infection and other urologic pain (i.e., testicular, prostatic)
Differential Diagnosis of Abdominal Gas, Bloating, and Distention
Aerophagia
Anorexia and bulimia
Gastroparesis
Gastric outlet obstruction (partial or complete)
Functional bloating
Functional dyspepsia
Dietary factors
– Lactose intolerance
– Fructose intolerance
– Fructan consumption
– Consumption of sorbitol or other nonabsorbable sugars
– Carbohydrate intake
– Gluten sensitivity
Celiac disease
Chronic constipation
Irritable bowel syndrome
Disturbances in colonic microflora
Small intestinal bacterial overgrowth
Abnormal small intestinal motility (eg, scleroderma)
Small bowel diverticulosis
Abnormal colonic transit
Evacuation disorders of the pelvic floor
Laboratory tests
Laboratory tests such as the complete blood count (CBC), liver enzymes, pancreatic enzymes (amylase and lipase), pregnancy test and urinalysis are frequently ordered.
An elevated white count suggests inflammation or infection (as with appendicitis, pancreatitis, diverticulitis, or colitis).
A low red blood cell count may indicate a bleed in the intestines.
Amylase and lipase (enzymes produced by the pancreas) commonly are elevated in pancreatitis.
Liver enzymes may be elevated with gallstone attacks or acute hepatitis.
Blood in the urine suggests kidney stones.
When there is diarrhea, white blood cells in the stool suggest intestinal inflammation or infection.
A positive pregnancy test may indicate an ectopic pregnancy (a pregnancy in the fallopian tube instead of the uterus).
Plain X-rays of the abdomen
Plain X-rays of the abdomen also are referred to as a KUB (because they include the kidney, ureter, and bladder). The KUB may show enlarged loops of intestines filled with copious amounts of fluid and air when there is an intestinal obstruction. Patients with a perforated ulcer may have air escape from the stomach into the abdominal cavity. The escaped air often can be seen on a KUB on the underside of the diaphragm. Sometimes a KUB may reveal a calcified kidney stone that has passed into the ureter and resulted in referred abdominal pain or calcifications in the pancreas that suggests chronic pancreatitis.
Radiographic studies
Ultrasound – is useful in diagnosing gallstones, cholecystitis appendicitis, or ruptured ovarian cysts as the cause of the pain.
Computerized tomography (CT) of the abdomen – is useful in diagnosing pancreatitis, pancreatic cancer, appendicitis, and diverticulitis, as well as in diagnosing abscesses in the abdomen. Special CT scans of the abdominal blood vessels can detect diseases of the arteries that block the flow of blood to the abdominal organs.
Barium X-rays of the stomach and the intestines (upper gastrointestinal series or UGI with a small bowel follow-through) can be helpful in diagnosing ulcers, inflammation, and blockage in the intestines.
Capsule enteroscopy – uses a small camera the size of a pill swallowed by the patient, which can take pictures of the entire small bowel and transmit the pictures onto a portable receiver. The small bowel images can be downloaded from the receiver onto a computer to be inspected by a doctor later. Capsule enteroscopy can be helpful in diagnosing Crohn’s disease, small bowel tumors, and bleeding lesions not seen on x-rays or CT scans.
Endoscopic Procedures
Esophagogastroduodenoscopy – or EGD is useful for detecting ulcers, gastritis (inflammation of the stomach), or stomach cancer.
Colonoscopy or flexible sigmoidoscopy is useful for diagnosing infectious colitis, ulcerative colitis, or colon cancer.
Endoscopic ultrasound (EUS) is useful for diagnosing pancreatic cancer or gallstones if the standard ultrasound or CT or MRI scans fail to detect them.
Balloon enteroscopy, the newest technique allows endoscopes to be passed through the mouth or anus and into the small intestine where small intestinal causes of pain or bleeding can be diagnosed, biopsied, and treated.
Breath Testing Breath testing is the most widely used diagnostic test for SIBO. Breath testing is based on the principle that bacteria produce H2 and CH4 gas in response to nonabsorbed carbohydrates in the intestinal tract; H2 gas can then freely diffuse to the bloodstream, where it is exhaled by the patient. A carbohydrate load, typically lactulose or glucose, is administered to the patient, and exhaled breath gases are analyzed at routine intervals. With lactulose, a normal response would be a sharp increase in breath H2(and/or CH4) once the carbohydrate load passes through the ileocecal valve into the colon. In a normal small intestine, glucose should be fully absorbed prior to reaching the ileocecal valve; therefore, any peak in breath H2 or CH4 is indicative of SIBO. There is significant laboratory-to-laboratory variation as to what constitutes a positive breath test; generally, an increase in H2 of 20 parts per million within 60–90 minutes is considered to be diagnostic of SIBO.Rx Elevated fasting levels of H2 and CH4 have also been shown to be highly specific, but not sensitive, for the diagnosis of SIBO.Rx Earlier studies have demonstrated that 14–27% of subjects will not excrete H2 in response to varying loads of lactulose; however, these nonproducers of H2 were found to have significantly higher levels of CH4 after lactulose ingestion. Thus, the addition of CH4 analysis may increase the sensitivity of the H2 breath test.Rx
Empiric Antibiotics A direct test for SIBO is an empiric course of antibiotics, an approach that is similar to a trial of proton pump inhibitors for patients with acid reflux symptoms. The use of empiric antibiotics is limited by their adverse effects, which include the potential to cause pseudomembranous colitis; however, these risks have decreased in recent years with the advent of poorly absorbable antibiotics such as rifampin (Xifaxan, Salix). Few trials to date have evaluated an empiric trial of antibiotics for SIBO, although this approach would be reasonable for any patient with symptoms consistent with SIBO and/or any condition that would predispose the patient to this condition (ie, scleroderma or previous surgery involving the ileocecal valve). Empiric antibiotic trials are not without risks, due to the potential for promoting drug resistance and other side effects, including nausea, abdominal pain, and upper respiratory infections. However, a number of studies have shown that rifaximin has rates of adverse effects that are similar to those associated with placebo.Rx
Treatment of Stomach Ache
Medications
Medications that may help in managing the signs and symptoms of nonulcer stomach pain include
Over-the-counter gas remedies – Drugs that contain the ingredient simethicone may provide some relief by reducing gas. Examples of gas-relieving remedies include Mylanta and Gas-X.
Medications to reduce acid production – Called H-2-receptor blockers, these medications are available over-the-counter and include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac 75). Stronger versions of these medications are available in prescription form.
Medications that block acid ‘pumps – Proton pump inhibitors shut down the acid “pumps” within acid-secreting stomach cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps.
Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24HR) and omeprazole (Prilosec OTC). Stronger proton pump inhibitors also are available by prescription.
Medication to strengthen the esophageal sphincter – Prokinetic agents help your stomach empty more rapidly and may help tighten the valve between your stomach and esophagus, reducing the likelihood of upper abdominal discomfort. Doctors may prescribe the medication metoclopramide (Reglan), but this drug doesn’t work for everyone and may have significant side effects.
Low-dose antidepressants –Tricyclic antidepressants and drugs known as selective serotonin reuptake inhibitors (SSRIs), taken in low doses, may help inhibit the activity of neurons that control intestinal pain.
Antibiotics – If tests indicate that a common ulcer-causing bacterium called H. pylori is present in your stomach, your doctor may recommend following drugs
Aluminum Hydroxide and Magnesium Hydroxide – Aluminum Hydroxide and Magnesium Hydroxide contain antacids, prescribed for preventing ulcers, heartburn relief, acid indigestion, and stomach upsets. Aluminum Hydroxide and Magnesium Hydroxide neutralize acid in the stomach.
Aztreonam – Aztreonam is monobactam antibiotic, prescribed for serious infections caused by susceptible gram negative bacteria like urinary tract infection, lower respiratory tract infection. It works by killing sensitive bacteria that cause infection.
Budesonide – Budesonide is a corticosteroid, prescribed for inflammatory bowel disease, asthma, and also for breathing trouble.
Cefuroxime axetil – Cefuroxime axetil is a semi synthetic cephalosporin antibiotic, prescribed for different types of infections such as lung, ear, throat, urinary tract, and skin.
Dexlansoprazole – Dexlansoprazole is a proton pump inhibitor, prescribed for esophagitis and heartburn due to gastro-esophageal reflux disease (GERD).
Famotidine – Famotidine is a histamine (H2-receptor antagonist), prescribed for an ulcer.
Fenoverine – Fenoverine is an antispasmodic, prescribed for muscle spasms.
Hyoscyamine – Hyoscyamine is an anticholinergic agent, used as a pain killer (Belladonna alkaloid). It blocks cardiac vagal inhibitory reflexes during anesthesia induction and intubation, used to relax muscles.
Levofloxacin – Levofloxacin is prescribed for treating certain bacterial infections, and preventing anthrax. It is a quinolone antibiotic. It kills sensitive bacteria.
Mepenzolate – Mepenzolate is an antimuscarinic agent, prescribed for the treatment of peptic ulcer combined with other medication. It decreases acid secretion in the stomach and controls intestinal spasms.
Mesalamine(Mesalazine) – Mesalamine(Mesalazine) is an anti-inflammatory agent, prescribed for the induction of remission and for the treatment of patients with mild to moderate ulcerative colitis (inflammation of the colon).
Nitrofurantoin – Nitrofurantoin is an antibiotic, prescribed for urinary tract infections.
Rabeprazole – Rabeprazole is a proton pump inhibitor, prescribed for duodenal ulcer, gastro esophageal reflux disease (GERD), and Zollinger-Ellison (gastric acid hyper secretion) syndrome. It works by decreasing the amount of acid made in the stomach.
Gabapentin– Gabapentin, and pregabalin are used in the treatment of a number of chronic pain syndromesRx These compounds bind with high affinity to α2δ subunits of voltage-gated calcium channels in areas of the central nervous system involved in pain signaling. Both gabapentin and pregabalin have been demonstrated to alter pain and sensory thresholds to rectal distension in IBS patientsRx They should, therefore, be considered as adjunctive therapies in patients with refractory symptoms.
Cognitive–behavioral therapy (CBT)– the most common type of psychotherapy employed for FGIDs, is based on the complex interactions between thoughts, feelings, and behaviors. The aims of CBT include learning better coping and problem-solving skills, identification of triggers and reduction of maladaptive reactions to them. Specific techniques can include keeping a diary of symptoms, feelings, thoughts, and behaviors; adopting relaxation and distraction strategies; using positive and negative reinforcement for behavior modification; confronting assumptions or beliefs that may be unhelpful; and gradually facing activities that may have been avoided. The American Academy of Pediatrics subcommittee on chronic abdominal pain recently concluded that CBT may be useful in “improving pain and disability outcome in the short term” [Rx].
Relaxation – is usually used in conjunction with other psychosocial therapies with the goal of reducing psychological stress by achieving a physiological state that is the opposite of how the body reacts under stress [Rx]. A variety of methods can be employed with effects such as decreasing heart rate, respiratory rate, blood pressure, muscle tension, oxygen consumption or brain-wave activity [Rx]. Abdominal or deep breathing stimulates the parasympathetic nervous system to increase feelings of calmness and relaxation. In progressive muscle relaxation, children are guided to systematically tense and relax each muscle group of the body. Patients are then encouraged to maintain attention on the relaxed feeling that results after tensing muscles. Guided imagery is a specific form of relaxed and focused concentration where patients are taught to imagine themselves in a peaceful scene to create an experience void of stress and anxiety. This can be combined with other relaxation techniques to produce a state of increased receptiveness to gut-specific suggestions and ideas, also known as ‘gut-directed’ hypnotherapy.
Biofeedback – uses electronic equipment in combination with controlled breathing, hypnotic or relaxation techniques to generate a visual or auditory indicator of muscle tension, skin temperature or anal control, allowing the child to have external validation of physiological changes.
Probiotics – Commensal bacteria of the GI tract are believed to play an important role in homeostasis, while alterations to these populations have been implicated in dysmotility, visceral hypersensitivity, abnormal colonic fermentation and immunologic activation [Rx]. This hypothesis has been further supported by reports of IBS triggered by gastrointestinal infections and antibiotic use, both of which can disrupt normal enteric bacteria, as well as the finding of significantly decreased populations of normal Lactobacillus and bifidobacteria in patients with diarrhea-predominant IBS [Rx]. Probiotics commonly contain Lactobacillus, bifidobacteria or other living microorganisms thought to be healthy for the host organism when ingested in sufficiently large amounts. Probiotics may improve IBS symptoms by restoring the microbial balance in the gut through metabolic competition with pathogens, by enhancing the intestine’s mucosal barrier or by altering the intestinal inflammatory response [Rx]. Different methods, formulations, dosages and outcome measures have made it difficult to make conclusions about the efficacy of probiotics. A recent meta-analysis concluded that probiotics as a class appeared to be efficacious for adults with IBS, although the magnitude of benefit and most effective species, strain and dosing are not clear [Rx]. Data in pediatric studies have been equally conflicting. In a double-blind placebo-controlled trial, Bausserman et al. randomized 64 children with IBS according to Rome II criteria to receive either Lactobacillus GG (1 × 1010 colony forming units) or placebo twice daily for 6 weeks [Rx]. Patients had similar rates of abdominal pain relief regardless of treatment: 44% in the Lactobacillus GG group compared with 40% in the placebo group. There was no significant difference in other gastrointestinal symptoms, except for decreased perception of abdominal distension for patients receiving Lactobacillus.
Antispasmodics – Antispasmodic medications, such as peppermint oil and hyoscyamine, are thought to be helpful for FAP and IBS through their effects on decreasing smooth muscle spasms in the GI tract that may produce symptoms such as pain. In a recent meta-analysis, antispasmodics as a class were superior to placebo in the treatment of adults with IBS [Rx]. There was a significant amount of variability among included studies in terms of antispasmodic preparation, measured outcomes, and overall methodological quality. Several agents included in the meta-analysis, such as otilonium, cimetropium, and pinaverium, are not currently available in the USA.
Antidepressants – Antidepressants are among the most studied pharmacologic agents for FGIDs. Mechanisms of action are thought to include reduction of pain perception, improvement of mood and sleep patterns, as well as modulation of the GI tract, often through anticholinergic effects. A recent review of adult studies found that antidepressants, such as tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), were beneficial for the treatment of FGIDs [Rx]. However, in the last few years, overall use of antidepressant medications in children and adolescents has been somewhat tempered by concerns for increased suicidal thoughts and/or behavior, especially after the US FDA issued formal ‘black-box’ warnings in 2004. A subsequent meta-analysis did not find evidence that these suicidal thoughts or behaviors led to an increased risk of suicide [Rx].
Monoamine uptake inhibitors – such as duloxetine and venlafaxine, represent a newer group of antidepressant medications with effects on serotonergic and adrenergic pain inhibition systems. These medications have shown evidence of analgesia in patients with fibromyalgia and diabetic neuropathy, but there have been no studies on the treatment of pediatric FGIDs [Rx].
Selective serotonin reuptake inhibitors – act by blocking uptake of 5-hydroxytryptamine (5-HT), increasing its concentration at presynaptic nerve endings. In addition to its CNS effects on mood and anxiety, SSRIs may also be beneficial for gastrointestinal complaints, since serotonin is an important neurotransmitter in the GI tract and greater than 80% of the body’s stores are located in enterochromaffin cells of the gut [Rx]. The exact role of serotonin in the GI tract has not been fully elucidated, but it has been implicated in the modulation of colonic motility and visceral pain in the gut.
Tricyclic antidepressants – primarily act through noradrenergic and serotonergic pathways but also have antimuscarinic and antihistaminic properties. Anticholinergic effects on the GI tract in terms of slowing transit can be beneficial for patients with IBS characterized by diarrhea but may worsen constipation. Additional side effects include the potential for inducing cardiac arrhythmias, so evaluation for prolonged QT syndrome with a baseline ECG is recommended by the American Heart Association [Rx]. Owing to sedative properties, TCAs should be given at bedtime. The usual starting dose is 0.2 mg/kg and is increased to a therapeutic dose of approximately 0.5 mg/kg.
Hyoscyamine and dicyclomine – are both considered antispasmodics owing to their anticholinergic effects on smooth muscle. Hyoscyamine has occasionally been used in children on a short-term basis for gastrointestinal symptoms of pain, but long-term use has been associated with anticholinergic side effects such as dry mouth, urine retention, blurred vision, tachycardia, drowsiness, and constipation. There have been no studies of either medication for pediatric FAP or IBS, but hyoscyamine was found to have consistent evidence of efficacy in an adult meta-analysis [Rx].
Cyproheptadine – Cyproheptadine is a medication with multiple mechanisms, including antihistaminic, anticholinergic and antiserotonergic properties, as well as possible calcium channel blockade effects. It has been used in appetite stimulation and prevention of pain and vomiting in an abdominal migraine and cyclic vomiting syndrome. Sadeghian et al. studied the use of cyproheptadine in 29 children and adolescents (aged 4.5–12 years) diagnosed with FAP in a 2-week, double-blind placebo-controlled trial. At the end of the study, 86% in the cyproheptadine group had improvement or resolution of abdominal pain compared with 35.7% in the placebo group (p = 0.003) [Rx]. These results need to be confirmed with additional larger trials.
Acid suppressants – Acid suppression agents, such as H2 blockers and proton pump inhibitors, are among the most common medications that are used in children with abdominal pain. Famotidine was studied by See et al. in a randomized, double-blind, placebo-controlled crossover trial of 25 children (aged 5–18 years) who met Apley’s criteria for RAP and reported symptoms of dyspepsia [Rx]. Children who met the criteria for IBS were excluded. Patients received famotidine 0.5 mg/kg per dose twice daily for at least 14 days, although the total treatment length was variable depending on symptom response. On a subjective global assessment scale, more patients reported improvement on famotidine (68%) versus placebo (12%). However, there was no significant difference between famotidine and placebo on quantitative measures of symptom frequency and severity. There have been no controlled studies on the use of proton pump inhibitors for FAP or IBS.
Prokinetics – Prokinetic agents that stimulate gastrointestinal motility have been employed for patients with FGIDs, especially for conditions involving constipation or delayed gastric emptyings, such as IBS and functional dyspepsia [Rx]. Tegaserod is a serotonin agonist that induces acceleration of small bowel and colonic transit through activation of 5-HT4 receptors in the enteric nervous system. When combined with polyethylene glycol (PEG) 3350, tegaserod was found to be more effective in alleviating abdominal pain and increasing the number of bowel movements in adolescents with constipation-predominant IBS compared with PEG 3350 alone [Rx]. However, owing to an increased rate of cardiovascular events in adults taking the medication, tegaserod was removed from the market in March 2007. Two other serotonin-based agents with actions upon the 5-HT3 receptor, alosetron, and cilansetron, were also shown to be effective for adults with diarrhea-predominant IBS, but complications of severe constipation, ischemic colitis and perforations prompted the withdrawal of these medications from the market in 2000 [Rx]. Dopamine (D2) receptor antagonists, such as metoclopramide and domperidone, improve gastric motility, but their use in pediatric FAP and IBS is limited by concerns for side effects including extrapyramidal reactions, drowsiness, agitation, irritability and fatigue [Rx]. Erythromycin, an antibiotic with motilin receptor agonist properties in the stomach at doses of 1–2 mg/kg per dose may also be helpful for symptoms of pain or dyspepsia, but there are no pediatric data to support its routine use in FAP or IBS [Rx].
Loperamide – is an opioid receptor agonist that slows colonic transit by acting on myenteric plexus receptors of the large intestine. Although loperamide is commonly used for treating diarrhea and urgency in patients with diarrhea-predominant IBS, adult studies have shown efficacy only against symptoms of diarrhea and not abdominal pain [Rx]. For patients with FAP or IBS associated with constipation, stool softeners and laxatives have been likewise employed. In the previously mentioned study of adolescents with constipation-predominant IBS conducted by Khoshoo et al., patients treated with PEG 3350 oral solution as sole therapy did have a significant increase in a number of bowel movements, but no improvement in abdominal pain [Rx].
Several herbal preparations – including Chinese herbal medications, ginger, bitter candytuft monoextract and peppermint oil (which was discussed previously in this article) have been employed for the treatment of FGIDs. Bensoussan et al. found that adults with IBS who received Chinese herbal medications in a randomized double-blind trial of 116 patients had significant improvements in bowel symptom scores as rated by patients (p = 0.03) and by gastroenterologists (p = 0.001) when compared with placebo [Rx]. Patients receiving Chinese herbal medications also reported significantly higher overall scores on a global improvement scale. On the other hand, in a later study by Leung et al., traditional Chinese herbal medications were not found to be superior to placebo in terms of symptoms and quality of life in adult patients with diarrhea-predominant IBS [Rx].
Acupuncture – also adapted from traditional Chinese medicine, is postulated to have effects on acid secretion, gastrointestinal motility and sensation of visceral pain, possibly mediated through the release of opioid peptides in the CNS and enteric nervous system. Two recent adult trials, however, did not find evidence to support the superiority of acupuncture compared with sham acupuncture in the treatment of IBS [Rx]. There have been no studies using acupuncture to treat children with FAP or IBS. A small, noncontrolled study of 17 children with chronic constipation reported an increased frequency of bowel movements with true acupuncture compared with placebo acupuncture [Rx]. Massage therapy has been hypothesized to reduce excitation of visceral afferent fibers and possibly dampen central pain perception processing, but there are limited data on the usefulness of massage therapy for FAP or IBS.
Behavior Therapy- Working with a counselor or therapist may help relieve signs and symptoms that aren’t helped by medications. A counselor or therapist can teach you relaxation techniques that may help you cope with your signs and symptoms. You may also learn ways to reduce stress in your life to prevent nonulcer stomach pain from recurring.
Herbal supplements. Herbal remedies that may be of some benefit for nonulcer stomach pain include a combination of peppermint and caraway oil. These supplements may relieve some of the symptoms of nonulcer stomach pain, such as fullness and gastrointestinal spasms. Artichoke leaf extract may also reduce symptoms of nonulcer stomach pain, including vomiting, nausea and abdominal pain.
Relaxation techniques. Activities that help you relax may help you control and cope with your signs and symptoms. Consider trying meditation, yoga or other activities that may help reduce your stress levels.
Osmotic Laxatives These agents, the most common of which is polyethylene glycol, improve symptoms of constipation. Rx One prospective study found that symptoms of bloating improved when patients with chronic constipation were treated with a polyethylene glycol solution. Rx These agents have not been studied in patients who complain predominantly of bloating.
Neostigmine – Neostigmine is a potent cholinesterase inhibitor that is used in the hospital setting to treat acute colonic pseudo-obstruction. In a prospective study of 28 patients with abdominal bloating who underwent jejunal gas infusion, intravenous neostigmine induced significant and immediate clearance of retained gas compared to placebo. Rx A randomized, placebo-controlled study using pyridostigmine in patients with IBS and bloating (n=20) demonstrated only a slight improvement in symptoms of bloating. Rx The small sample sizes of these studies and the need to use neostigmine in a carefully supervised setting limit the applicability of these results.
Cisapride – Cisapride is a mixed 5-HT3/5-HT2 antagonist and 5-HT4 agonist that was previously used to treat reflux, dyspepsia, gastroparesis, constipation, and IBS symptoms. Tfe drug was withdrawn from the US market in July 2000. In a study of FD patients, cisapride improved symptoms of bloating in some patients, although the benefits were not overwhelming.Rx Cisapride did not improve bloating in patients with IBS and constipation.Rx
Domperidone – Domperidone is a dopamine antagonist used to treat FD, gastroparesis, and chronic nausea. Rx–Although this drug may improve dyspeptic symptoms (including upper abdominal bloating) in some patients, its routine use in clinical practice is precluded by the absence of prospective, randomized, controlled studies evaluating its efficacy in patients with functional bloating.
Metoclopramide – Metoclopramide is a dopamine antagonist approved for treatment of diabetic gastroparesis. Rx Patients with FD and gastroparesis frequently have symptoms of bloating. Rx One small study found that metoclopramide did not improve symptoms of abdominal distention in dyspeptic patients.Rx
Tegaserod – Tegaserod is a 5-HT4 (serotonin type 4) receptor agonist that stimulates GI peristalsis, increases intestinal fluid secretion, and reduces visceral sensation. Rx In July 2002, this drug was approved by the US Food and Drug Administration for the treatment of IBS with constipation in women, as studies showed an improvement in bloating symptoms with the drug.Rx Although tegaserod has since been withdrawn from the US market, it is still available for emergency use. Other 5-HT4 agonists (ie, prucalopride) may become available in the United States in the future.
Chloride Channel Activators
Lubiprostone – Two phase III studies evaluated the safety and efficacy of lubiprostone (Amitiza, Sucampo) in patients with IBS and constipation.Rx A total of 1,171 adults (91.6% women) who had been diagnosed with constipation-predominant IBS (based on Rome II criteria) were randomized to receive either 12 weeks of twice-daily lubiprostone (8 mcg) or placebo. The primary efficacy variable was a global question that rated overall IBS symptoms. Patients who received lubiprostone were nearly twice as likely as those who received placebo to achieve overall symptom improvement (17.9% vs 10.1%; P=.001). Secondary endpoints, including bloating, were significantly improved in the lubiprostone group compared to the placebo group (P<.05 for all endpoints). The most common treatment-related side effects were nausea (8%) and diarrhea (6%); these side effects occurred in 4% of the placebo group.
Linaclotide – Linaclotide is a 14-amino-acid peptide that stimulates the guanylate cyclase receptor. Lembo and colleagues conducted a multicenter, placebo-controlled study of 310 patients with chronic constipation (based on modified Rome II criteria). Rx Patients were randomized to receive 1 of 4 linaclotide doses (75 µg, 150 µg, 300 µg, or 600 µg) or placebo once daily for 4 weeks. Patient measures of bloating were significantly better for all linaclotide doses compared to placebo. A multicenter, double-blind, placebo-controlled, dose-ranging study of 420 patients with constipation-predominant IBS (based on modified Rome II criteria; <3 complete spontaneous bowel movements [CSBMs]/week) compared daily linaclotide (75 µg, 150 µg, 300 µg, or 600 µg) to placebo during a 12-week study period. Rx The primary endpoint was the change in CSBM frequency, while other bowel symptoms (eg, abdominal pain and bloating) were secondary endpoints. A total of 337 patients (80%) completed the study. Using a strict intention-to-treat analysis, all doses of linaclotide were shown to significantly improve stool frequency (P<.023 or better) as well as improve symptoms of straining, bloating, and abdominal pain (all with P<.05, except for the 150-µg dose and bloating, which was not statistically better than placebo).
Home Remedies for Stomach Aches & Cramps
Stomach aches, also broadly called “abdominal pain,” are tricky things to find remedies for unless you know the cause. Ranging from indigestion and irritable bowel syndrome to gastritis and GERD, an aching tummy can stem from many things. Assuming you are dealing with an uncomplicated stomach ache, these remedies can help bring relief from the pain and discomfort that’s making you miserable.
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1. Enjoy a Cup of Chamomile Tea
Chamomile can help ease the pain of a stomach ache by working as an anti-inflammatory (for example the lining of the stomach can become inflamed as a result common gastritis, caused by bacteria) and by relaxing the smooth muscle of the upper digestive track. When it relaxes that muscle, the contractions that are pushing food through your system ease up a bit and lessen the pain of cramping and spasms.
You will need
1 teabag of chamomile tea OR 1-2 teaspoons of dried chamomile
A mug
Hot water
Directions – Pour boiling water over a teabag and cover your mug, letting it steep for 10 minutes. If using dried chamomile, place 1-2 teaspoons in a mug and cover with boiling water. Cover the mug and let steep for 15-20 minutes. Sip slowly.
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2. Use a “Hot” Pack
I put hot in quotations because you don’t truly want it hot-just very warm, but comfortably so. You can also use a hot water bottle for this as well. Heat helps to loosen and relax muscles, so if you find yourself cramping up, some warmth can go a long ways for relieving you of the dreadful discomfort.
You will need
A hot pack, hot water bottle, or something similar
A cozy place to lie down
Directions – Find a place to lie down, and rest the hot pack on your belly. It should be a comfortable temperature, but definitely warm. Do this for at least 15 minutes, or as long as you need to, reheating as necessary.
3. Rice Water
Rice water is exactly what it sounds like-the water left-over after you cook rice. It acts a demulcent, meaning a substance that relieves inflammation by forming a sort of soothing barrier over a membrane, in this case, the lining of your stomach.
You will need
1/2 cup of white rice
2 cups of water
A pot
Directions – Cook your rice with twice the amount of water you normally would for your chosen amount. In this case, I am using plain old long-grain white rice. Put your rice in a pot on the stove and add the water, cooking over medium-low heat. As the rice starts to become tender, remove it from the heat and let it soak for 3 minutes with the lid on the pan. Drain and drink the water warm, adding a smidge of honey if needed. Save the rice for a bland meal later.
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4. Enjoy Some Mint
Fresh peppermint tea (or just peppermint tea in general) can help relax stomach muscles. It also helps improve the flow of bile, which helps you digest properly. This is especially useful if suffering from indigestion or gas/bloating.
You will need
A handful of fresh peppermint leaves OR 1-2 teaspoons dried
Mug
1 cup water
Directions – Cover the peppermint with 1 cup of boiling water, cover, and let steep for 5-10 minutes. Sip slowly while it’s still toasty warm. If using the fresh peppermint leaves, you can chew on them as well to ease stomach pains. You can also just use a pre-made teabag if you find that more desirable.
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5. Warm Lemon Water
Lemon water, if your issue is indigestion, helps a stomachache. The high acidity level stimulates the production of hydrochloric acid, which breaks down our food. By upping the amount of HCL being produced, you help move digestion along at a healthy pace. You get the added bonus of the hydration too, which keeps the system flushed and running smoothly.
You will need
1 fresh lemon
warm water
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6. Ginger Root Tea
Ginger contains naturally occurring chemicals called gingerols and shogaols. These chemicals can help relax smooth muscle, such as the muscle that lines the intestinal track, and therefore relieve stomach cramps or a colicky stomach ache. Ginger root is also great for relieving nausea, which may accompany a stomachache. Sipping on some warm tea can prove very useful as a home remedy for stomach aches and is, in my opinion, more effective than ginger ale.
You will need
1 ginger root, 1-2 inches
A sharp knife or peeler
1-2 cups of water
Honey (optional)
Directions – Wash, peel, and then grate or finely chop 1-2 inches of fresh ginger root. Bring 1-2 cups of fresh water to a boil (use less water and more ginger if you want a more concentrated drink) and add your ginger. Boil for 3 minutes and then simmer for 2 more. Remove from heat, strain, and add honey to taste. Sip slowly and relax.
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7. Chew Fennel Seeds
Let’s say your stomach ache is being caused by indigestion. In this case, chewing fennel seeds will help as they contain anethole, a volatile oil that can stimulate the secretion of digestive juices to help move things along. It can also help tame inflammation, and reduce the pain caused by it. If you are suffering from gastritis, inflammation of the stomach, this may provide some relief from the discomfort.
You will need
1/2-1 teaspoon of fennel seeds
Directions – After a meal, chew ½-1 teaspoon of fennel seeds thoroughly. If you are pregnant, avoid fennel.
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8. Drink Club Soda and Lime
Like lemon, lime can help ease an aching tummy. Combine the lime with club soda and you have an easy drink to sip on to wash away the pain. If you overate and have a stomach ache as a result, the carbonation in club soda will encourage you to burp, therefore relieving pressure in your belly. It has been shown to help greatly with dyspepsia (basically indigestion) and constipation.
You will need
8 ounces of cool club soda
Fresh lime juice
Directions – Mix 8 ounces of club soda with the juice of half a lime. Stir and sip slowly.
I myself have had more than a few unfortunate run-ins with stomach aches, particularly this past year. Thanks to some generous family genes, I seem quite prone to them. Second, to headaches, I find chronic stomach pain to be one of the most distracting to deal with day-to-day. By keeping a couple options for stomach ache remedies on hand at all time, I find I can usually be prepared to ward it off should it start to creep up.
Precautions About Stomach Ache
Apply heat on your abdomen for 20 to 30 minutes every 2 hours for as many days as directed. Heat helps decrease pain and muscle spasms.
Make changes to the food you eat as directed. Do not eat foods that cause abdominal pain or other symptoms. Eat small meals more often.
Eat more high-fiber foods if you are constipated. High-fiber foods include fruits, vegetables, whole-grain foods, and legumes.
Do not eat foods that cause gas if you have to bloat. Examples include broccoli, cabbage, and cauliflower. Do not drink soda or carbonated drinks, because these may also cause gas.
Do not eat foods or drinks that contain sorbitol or fructose if you have diarrhea and bloating. Some examples are fruit juices, candy, jelly, and sugar-free gum.
Do not eat high-fat foods, such as fried foods, cheeseburgers, hot dogs, and desserts.
Limit or do not drink caffeine. Caffeine may make symptoms, such as heart burn or nausea, worse.
Drink plenty of liquids to prevent dehydration from diarrhea or vomiting. Ask your healthcare provider how much liquid to drink each day and which liquids are best for you.
Manage your stress. Stress may cause abdominal pain. Your healthcare provider may recommend relaxation techniques and deep breathing exercises to help decrease your stress. Your healthcare provider may recommend you talk to someone about your stress or anxiety, such as a counselor or a trusted friend. Get plenty of sleep and exercise regularly.
Limit or do not drink alcohol. Alcohol can make your abdominal pain worse. Ask your healthcare provider if it is safe for you to drink alcohol. Also, ask how much is safe for you to drink.
Do not smoke. Nicotine and other chemicals in cigarettes can damage your esophagus and stomach. Ask your healthcare provider for information if you currently smoke and need help to quit. E-cigarettes or smokeless tobacco still contain nicotine. Talk to your healthcare provider before you use these products.
Homeopathic medicines of Stomach Ache
Arsenicum Album – The pain is burning, and is worse during the nighttime and when eating cold foods or sitting in cold weather. Vomiting, diarrhea, anxiety, restlessness, and weakness are present. You feel better with warmth and when drinking milk.
Bryonia Alba – This is one of homeopathy’s best remedies for conditions striking the abdomen. The pains are sharp and stitching, occurring if you move even slightly, cough, or draw a deep breath. Better when lying still, especially on the painful side.
Aconite – Useful when there are emotional symptoms such as fright, shock, fear, anxiety, and/or restlessness. Helpful for the pain that happens suddenly, after cold weather. Sneezing and jarring movements make it worse.
Carcinosin – Mineral good for burning pain accompanied by hard, dry stools. You may be constipated and be craving sugary foods. Symptoms are worse in the late afternoon, and better when you put pressure on the stomach.
Lycopodium – Good for pain on the right side, along with bloating and rumbling sounds. Cabbage, wheat, oysters, and onions tend to make things worse — as does the early evening. You feel better with loose clothing and warm drinks, and when passing gas.
Belladonna – This common remedy battles those sharp stomach pains that strike and then disappear suddenly. The pain is worse with motion and better with steady pressure and when lying on the stomach.
Chamomilla – This remedy’s hallmark symptom consists of irritability and anger caused by the pain. You experience bad cramps, have green diarrhea, and need to arch your back during painful spasms. The pain is worse at night, after eating, after coffee, and after an angry fit.
Alumina – is an excellent remedy for very severe constipation in elderly people when the desire to open the bowels seems to have been lost. The individual may sit and strain and even feel impelled to use fingers to try to expel hard, knotty motions.
Bryonia – is helpful for people who get constipated when they travel and who experience a burning sensation when they open their bowels in this constipated state.
Calcarea carbonica – is useful in chubby people who paradoxically quite like the sensation of being constipated. They may lose the desire to open their bowels, but suffer no ill effects from it.
Arsenicum album – is extremely useful in very neat, anxious, restless people. The diarrhea produces a burning sensation around the anus, which may become quite red and inflamed. The motions are usually watery and offensive.
China – For cases which start in the early morning or just after midnight China is useful. The motions are watery with undigested residues present.
Sulphur – is useful for people who are forced out of bed every morning, often at 5 or 6 am, by a sudden desire to open the bowels. The motions are loose and extremely offensive.
Zollinger-Ellison syndrome is a rare disorder that is usually caused by a gastrinoma, or tumor, that originates from the pancreas or, less likely, from the small intestine.The tumor secretes a hormone known as gastrin, and this results in an overproduction of hydrochloric acid in the stomach.
The syndrome is caused by a gastrinoma, a neuroendocrine tumor that secretes a hormone called gastrin.The tumor causes excessive production of gastric acid, which leads to the growth of gastric mucosa and proliferation of parietal and ECL cells.ZES may occur on its own or as part of an autosomal dominant syndrome called multiple endocrine neoplasia type 1 (MEN 1). The primary tumor is usually located in the pancreas, duodenum or abdominal lymph nodes, but ectopic locations (e.g., heart, ovary, gallbladder, liver, and kidney) have also been described.
Causes of Zollinger–Ellison Syndrome
It is not clear exactly what causes Zollinger-Ellison syndrome, nor the gastrinomas that characterize it.
Gastrinomas release excessive quantities of gastrin, resulting in too much gastric acid in the stomach and duodenum. This eventually causes peptic ulcers to form in the lining of the duodenum. This often results in multiple ulcers that may cause pain or upper gastrointestinal bleeding.
As well as causing excess acid production, the gastrinomas may be malignant, or cancerous. The cancer can spread to other parts of the body, most commonly to nearby lymph nodes or the liver.Some cases of the syndrome are caused by a genetic disorder known as multiple endocrine neoplasia type 1, or MEN 1. MEN1 is a genetic syndrome that causes multiple endocrine cancers.
It is inherited in an autosomal dominant manner, which means that if a parent is affected, they have a 50 percent chance of passing the condition to the next generation.An individual may be at risk for developing a gastrinoma if they have had several family members with endocrine cancers, or if they have a family member with MEN1.
Association with MEN 1
Zollinger-Ellison syndrome may be caused by an inherited condition called multiple endocrine neoplasia, type 1 (MEN 1). People with MEN 1 also have tumors in the parathyroid glands and may have tumors in their pituitary glands.About 25 percent of people who have gastrinomas have them as part of MEN 1. They may have also have tumors in the pancreas and other organs.
Symptoms of Zollinger–Ellison Syndrome
The diagnosis is also suspected in patients who have severe ulceration of the stomach and small bowel, especially if they fail to respond to treatment.
Chronic diarrhea, including steatorrhea (fatty stools)
Pain in the esophagus, especially between and after meals at night
a person has severe ulcers that bleed or cause holes in the duodenum or stomach.
a health care provider diagnoses a person or the person’s family member with MEN1 or a person has symptoms of MEN1.
Gastrinomas may occur as single tumors or as multiple small tumors. About one-half to two-thirds of single gastrinomas are malignant tumors that most commonly spread to the liverand to lymph nodes near the pancreas and small bowel.
Diagnosis of Zollinger–Ellison Syndrome
Zollinger–Ellison syndrome may be suspected when the above symptoms prove resistant to treatment, when the symptoms are especially suggestive of the syndrome, or when endoscopy is suggestive. The diagnosis is made through several laboratory tests and imaging studies
Secretin stimulation test, which measures evoked gastrin levels. Note that the mechanism underlying this test is in contrast to the normal physiologic mechanism whereby secretin inhibits gastrin release from G cells. Gastrinoma cells release gastrin in response to secretin stimulation,thereby providing a sensitive means of differentiation.
Fasting gastrin levels on at least three separate occasions
Gastric acid secretion and pH (normal basal gastric acid secretion is less than 10 mEq/hour; in Zollinger–Ellison patients, it is usually more than 15 mEq/hour)
An increased level of chromogranin A is a common marker of neuroendocrine tumors.
Endoscopic ultrasound – This procedure involves using a special endoscope called an endoechoscope to perform ultrasound of the pancreas. The endoechoscope has a built-in miniature ultrasound probe that bounces safe, painless sound waves off organs to create an image of their structure.
Angiogram – An angiogram is a special kind of x ray in which an interventional radiologist—a specially trained radiologist—threads a thin, flexible tube called a catheter through the large arteries, often from the groin, to the artery of interest. The radiologist injects contrast medium through the catheter so the images show up more clearly on the x ray.
Somatostatin receptor scintigraphy – An x-ray technician performs this test, also called Octreo Scan, at a hospital or an outpatient center, and a radiologist interprets the images. A person does not need anesthesia.
Computerized tomography (CT) scan – A CT scan is an x ray that produces pictures of the body. A CT scan may include the injection of a special dye, called contrast medium. CT scans use a combination of x rays and computer technology to create images. CT scans require the person to lie on a table that slides into a tunnel-shaped device where an x-ray technician takes x rays.
Magnetic resonance imaging (MRI) – MRI is a test that takes pictures of the body’s internal organs and soft tissues without using x rays. A specially trained technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The person does not need anesthesia, though people with a fear of confined spaces may receive light sedation, taken by mouth.
In addition, the source of the increased gastrin production must be determined using MRI or somatostatin receptor scintigraphy.
Treatment of Zollinger–Ellison Syndrome
Over-the-counter proton pump inhibitors — Proton pump inhibitors shut off the stomach’s acid production.Proton pump inhibitors are very effective. They can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin their effect.
Proton pump inhibitors– should not be combined with an H2 blocker. The H2 blocker can prevent the proton pump inhibitor from working.These are prescribed at higher doses than those available in over-the-counter forms.
Motility drugs – These medications may help to decrease esophageal reflux. But they are not usually used as the only treatment for Zollinger-Ellison syndrome,. They help the stomach to empty faster, which decreases the amount of time during which reflux can occur.
Mucosal protectors – These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).
Antacids – Doctors often first recommend antacids to relieve heartburn and other mild GER and Zollinger-Ellison syndrome. Antacids include over-the-counter medicines such as. Antacids can have side effects, including diarrhea and constipation.
H2 blockers – H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with GER and Zollinger-Ellison syndrome,. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include
Proton pump inhibitors (PPIs) – PPIs lower the amount of acid your stomach makes. PPIs are better at treating Zollinger-Ellison syndrome (ZES) than H2 blockers. They can heal the esophageal lining in most people with . Doctors often prescribe PPIs for long-term Zollinger-Ellison syndrome (ZES) treatment. Such as
A health care provider treats Zollinger-Ellison syndrome with medications to reduce gastric acid secretion and with surgery to remove gastrinomas. A health care provider sometimes uses chemotherapy—medications to shrink tumors—when tumors are too widespread to remove with surgery.
Indigestion also known as dyspepsia, is a condition of impaired digestion. Symptoms may include upper abdominal fullness, heartburn, nausea, belching, or upper abdominal pain.People may also experience feeling full earlier than expected when eating.Dyspepsia is a common problem and is frequently caused by gastroesophageal reflux disease (GERD) or gastritis. In a small minority of cases it may be the first symptom of peptic ulcer disease (an ulcer of the stomach or duodenum) and, occasionally, cancer. Hence, unexplained newly onset dyspepsia in people over 55 or the presence of other alarming symptoms may require further investigations
H-2-receptor antagonists–These reduce stomach acid levels and last longer than antacids. However, antacids act more quickly. Some of these are OTC, while others are only available on prescription.
Proton pump inhibitors (PPIs) – Examples include Aciphex, Nexium, Prevacid, Prilosec, Protonix, and Zegerid. PPIs are highly effective for people who also have gastroesophageal reflux disease (GERD). They reduce stomach acid and are stronger than H-2-receptor antagonists.
Prokinetics – This medication is helpful for stomachs that empty slowly. One example of a prokinetic drug is Reglan. Side effects may include tiredness, depression,sleepiness, anxiety, and muscle spasms.
Antibiotics – If H. pylori is causing peptic ulcers that result in indigestion, an antibiotic will be prescribed. Side effects may include an upset stomach,diarrhea, and fungal infections.
The doctor may also recommend making changes to a person’s current medication schedule if they suspect that it could be causing indigestion. A course of aspirin or ibuprofen may sometimes be stopped and alternative medications advised.
Prevention of Indigestion
The best way to prevent indigestion is to avoid the foods and situations that seem to cause it. Keeping a food diary is helpful in identifying foods that cause indigestion. Here are some other suggestions:
Eat small meals so the stomach does not have to work as hard or as long.
Eat slowly.
Avoid foods that contain high amounts of acids, such as citrus fruits and tomatoes.
Reduce or avoid foods and beverages that contain caffeine.
If stress is a trigger for your indigestion, re-evaluating your lifestyle may help to reduce stress. Learn new methods for managing stress, such as relaxation andbiofeedback techniques.
Smokers should consider stopping smoking, or at least not smoking right before or after eating, as smoking can irritate the stomach lining.
Cut back on alcohol consumption because alcohol can irritate the stomach lining.
Avoid wearing tight-fitting garments because they tend to compress the stomach, which can cause its contents to enter the oesophagus.
Do not exercise on a full stomach. Rather, exercise before a meal or at least one hour after eating a meal.
Do not lie down right after eating.
Eat your last meal of the day at least three hours before going to bed.
Sleep with your head elevated (at least 6 inches) above your feet using thick books or bricks under the bed to achieve this. This will help enable digestive juices to flow into the intestines rather than into the oesophagus.
Natural Home Remedies For Indigestion
Fennel Seeds
The first remedy in the list of top 21 home remedies for indigestion is fennel seeds. In fact, fennel seeds are really beneficial in treating indigestion which is caused by consuming fatty or spicy foods.
“Fennel seeds have volatile oils helping you decrease nausea as well as control flatulence.”
Remedy:
Ingredients:
½ teaspoon of fennel seed powder
A little water
Process:
You simply mix the fennel seed powder well with enough water and drink this remedy two times per day.
On another way, you may drink the fennel tea which is made by steeping 2 teaspoons of grinded fennel seeds in 1 cup of hot water.
Or you just chew 1 spoonful of fennel seeds to relieve this problem.
Baking Soda
Indigestion often occurs when the levels of stomach acids are high. Baking soda will be an effective and simple treatment for this condition because it works as an antacid, which, in turn, aids you in neutralizing your digestive tract acids. In addition, baking soda has the ability to break down foods you consumed and thus making digestion easier. Plus, the baking soda addition is able to balance the pH level of your body as well as reduce bloating and excess gas.
Remedy:
Ingredients:
½ teaspoon of baking soda
½ glass of water
Process:
You firstly mix the baking soda with the water and stir well.
Then you drink this mixture to balance the acid in the stomach as well as give you complete relief from bloating.
You should apply this process whenever you have the indigestion symptoms.
Peppermint Herbal Tea
Consuming herbal tea, especially peppermint tea, after you have a heavy meal may greatly decrease indigestion. Peppermint tea is one of the effective herbal home remedies for indigestion pain. This herb is capable of calming your stomach muscles and also improving bile flow, which, will allow foods to more easily move through your stomach into your small intestine. Here is one of the home remedies for indigestion with peppermint herbal tea that you may follow.
Remedy:
You simply dip a peppermint herbal tea bag into 1 cup of hot water.
You allow it to steep for about 5 minutes.
Then you drink this tea when it is still warm.
Coriander And Buttermilk
Coriander is considered as an effective spicy to heal indigestion because it can promote the digestive enzymes production as well as help you to calm your stomach. Apart from coriander, buttermilk is also used for many years as a natural effective treatment for indigestion. It can help you to neutralize acids causing indigestion and coat your stomach.
Remedy:
Ingredients:
1 teaspoon of coriander seed powder (roasted)
1 glass of buttermilk
Process:
First of all, you add the roasted coriander seed powder in the buttermilk
Then you stir them well to make a fine mixture
You drink this mixture one or two times per day.
Besides, to decrease acidity in your stomach, you extract a teaspoon of the fresh coriander leaves juice and then mix it in a cup of buttermilk. You should drink this 2 or 3 times a day.
Boiling Water
This available herb may be useful for people who are suffering from indigestion. In fact, cinnamon can help you in your digestive process as well as provide relief from bloating and cramps. The extract of cinnamon has been used for ages to aid in treating gastrointestinal conditions and calming your stomach. Besides, cinnamon is known as a carminative that is an agent breaking up intestinal gas. In traditional, this agent has been used to fight against morning sickness and diarrhea.
Remedy:
Ingredients:
½ teaspoon of cinnamon powder
1 cup of boiling water
Process:
Now, you add the cinnamon powder into the boiling water
You allow it to steep for at least 5 minutes.
Then you drink this cinnamon tea when it is still warm to get the best results.
This home remedy will help you to alleviate the symptoms of indigestion. But once you have excessive vomiting or intense abdominal pain, you have to see a doctor immediately.
Basil Leaves, Sea Salt, Black Pepper, Hot Water, & Plain Yogurt
Basil is one of the excellent home remedies for indigestion along with acid reflux. Basil leaves also help you to relieve intestinal gas because of its carminative properties. You can chew some basil leaves after your meals to soothe your stomach and esophageal lining as well as relieve the soreness and irritation of your digestive tract. Besides, you can apply one of two home remedies for indigestion, using basil leaves as the main ingredient below:
Basil and hot water
Ingredients:
1 teaspoon of basil
1 cup of hot water
Process:
You firstly mix the basil with the hot water
Then you stir well and let it steep for about 10 minutes.
You should drink about 3 cups of this tea per day.
Basil leaves, sea salt, black pepper, and plain yogurt for indigestion
Yogurt is known as a smooth, cool, and alkaline food which owns a soothing effect on your esophagus. It is also comprised of probiotics that are beneficial bacteria found in your digestive tract. In addition, yogurt has the ability to boost your immune system and thus ensuring good overall health. Yogurt is used to aid your body in absorbing proteins and nutrients properly while black pepper is capable of stimulating your digestion process as well as extremely effective for getting rid of acid reflux.
Ingredients:
4 to 6 ground basil leaves
2 or 3 tablespoons of plain yogurt
¼ teaspoon of black pepper powder
¼ teaspoon of sea salt
Process
You simply mix all 4 ingredients above together to make a mixture.
Then you consume this mixture 2 or 3 times per day to get rid of indigestion.
Cumin Seed, Black Pepper, & Buttermilk
Cumin is beneficial in healing many digestive problems such as indigestion, nausea, flatulence, and diarrhea. In fact, cumin may stimulate the pancreatic enzymes secretion that helps to aid digestion. Here are two home remedies for indigestion with using cumin seed as the main ingredient that you can follow.
Cumin seed powder and water
Ingredients
1 teaspoon of cumin seed powder (roasted)
1 glass of water
Process:
Firstly, you mix the cumin seed powder which is roasted in the water.
Then you stir them well and drink it.
You should drink this cumin water whenever you have any indigestion problem.
Cumin seed, black pepper, & buttermilk for indigestion
Ingredients:
¼ teaspoon of cumin seed powder (roasted)
¼ teaspoon of black pepper
1 glass of buttermilk
Process:
For heaviness in your stomach, you add the roasted cumin seed powder, black pepper in the buttermilk.
You stir them well to make a fine mixture and then drink this mixture 2 or 3 times per day for several days.
Carom Seeds, Ginger, & Black Pepper
In fact, carom seeds (known as a Bishop’s weed) contain carminative and digestive properties which may help you a lot in treating indigestion, diarrhea, and flatulence, while ginger has a tendency to aid in neutralizing the toxin and acid balance found in your stomach and thus being used to treat indigestion. Besides, ginger is also proven to have the ability to control movement through your intestines as well as produce much more saliva and also various digestive fluids secreted in your body.
Remedy:
Ingredients:
A few carom seeds
Some dried ginger slices
½ teaspoon of black pepper
1 cup of lukewarm water
Process:
At first, you grind the carom seeds with the dried ginger to make a fine powder.
Then you add 1 teaspoon of this mixture powder with the black pepper in the warm water.
You stir well and drink it once or twice per day.
Or you can simply eat ½ teaspoon of carom seeds to help you relieve the indigestion symptoms.
Ginger, Lemon Juice, Table Salt, Black Salt, & Honey
Ginger has the ability to stimulate the digestive juices along with the enzymes flow which will help you to digest your food. Hence, ginger is considered as an effective remedy for healing indigestion, particularly when you eat too much.
In fact, you may sprinkle a little salt on the fresh ginger slices and then chew it thoroughly after you eat a heavy meal as a preventive measure.
Ginger juice, lemon juice, table salt, and black salt for indigestion
In fact, lemon juice is packed with a high source of vitamin C known as a potent antioxidant having the ability to remove harmful toxins from your body. You can try applying the combination of ginger and lemon juice along with a bit of table salt and black salt as one among home remedies for indigestion.
Ingredients:
2 teaspoons of ginger juice
1 teaspoon of lemon juice
A pinch of black salt and table salt
Process:
At first, you mix all these ingredients thoroughly to make a mixture.
Then you consume this mixture (or with water) whenever you have any problem in your digest.
Remedy 2: ginger juice and manuka honey
This special kind of honey is very high in natural enzymes which will assist you a lot in digesting foods properly.
To do it, you cut a ginger root into slices.
Then you grind the slices and squeeze to get the ginger juice.
Now, you mix 2 teaspoons of ginger juice and 1 teaspoon of honey together.
You consume this mixture several times per day.
Besides, you may also drink the homemade ginger tea to help you get an instant relief from cramps, bloating, and gas along with stomach aches. To make the ginger tea, you simply add
Apple Cider Vinegar And Honey
Thanks to its natural acidic, apple cider vinegar will provide you with an alkalizing effect which helps you to get rid of indigestion while active manuka honey is loaded with antibiotics in nature, which, in turn, coats, protects, and soothes your esophagus outer lining.
Remedy:
Ingredients:
1 tablespoon of unfiltered and raw apple cider vinegar
1 cup of water
1 teaspoon of honey
Process:
Firstly, you add the apple cider vinegar in the water.
Then you mix them well and add the raw honey in this mixture.
You stir thoroughly and drink this solution 2 to 3 times per day for a quick relief.
Turmeric
Generally, turmeric is beneficial in healing stomach bloating, diarrhea, stomach pain, intestinal gas, and heartburn. In addition, turmeric contains a superpower compound called curcumin which has many beneficial properties. Besides, it also promotes gallbladder contractions. Hence, you should include turmeric every day in any form to help you in healing indigestion.
Pomegranate Juice And Honey
If you are suffering from indigestion along with giddiness, this is one of the simple and natural home remedies that you must try. Pomegranate juice, in fact, is able to aid in balancing the acid in your stomach while honey is both free radical scavenging and antioxidant. When combining pomegranate juice with honey, you will have an effective solution which will help you to get rid of indigestion faster.
Remedy:
Ingredients:
A tablespoon of pomegranate juice
1 tablespoon of honey
Process:
To do it, at first, you mix the pomegranate juice well with the honey.
Next, you to stir them well until they transfer a consistent mixture.
Now, you drink this mixture twice per day to keep indigestion at bay.
Black Pepper, & Cumin Seeds
In fact, you can run away from the garlic smell which might linger in the mouth. However, this little ingredient contains phenomenal properties which may stimulate the gastric system to assist you in getting relief from many ingestion problems. Besides, garlic has the pungent heating quality that can make it work so effectively. You may use garlic mixed with black pepper and cumin seeds as one of the home remedies for indigestion.
Remedy:
Ingredients:
Some ground garlic cloves
A teaspoon of black pepper powder
A teaspoon of cumin seeds powder
Process:
You firstly put the ground garlic cloves in the water and then boil this mixture.
After the mixture boils, you add the black pepper powder and cumin seeds powder in it. You continue to let it boil for a few minutes and strain this mixture.
You allow the mixture to cool down and drink this 2 or 3 times per day to get the fruitful results.
Or you may include the garlic in your hot soup which is hot to help it get absorbed by the digestive system faster.
Gentian
Gentian is a common bitter herb and it has hundreds of varieties available in all over the world. All varieties of gentian have a bitter component and this will help a lot in stimulating digestion. This herb can reduce many symptoms including indigestion and bloat. In addition, it also has the ability to promote the bile flow from your liver. Hence, it is recommended that consuming about 2 grams of the dried gentian root per day in the tea form is very useful for your digestion.
Artichoke Leaf
Another remedy in the list of top 21 home remedies for indigestion is artichoke leaf. A study in 2003 evaluated proved that using artichoke leaf extract is much more beneficial than placebo in healing the symptoms of indigestion. Therefore, 6 grams of dried artichoke leaf (or its equivalent) every day is the ideal dosage for people who are suffering from indigestion. Remember that the artichoke leaf extract must be consumed based on the instruction on the label.
Asafoetida
Asafoetida is also known as Hing. It is a digestive spicy that is cultivated commonly in India, Afghanistan, Iran, and Pakistan. Asafoetida is an effective herb which can help you to treat many digestive problems such as flatulence, constipation, and stomach ache.
To apply it, you simply take 1 pinch of asafoetida
Then you add it to a glass of lukewarm water
You stir well and consume this mixture 2 to 3 times per day to get an amazing result.
Dried Amla
Amla (known as Gooseberry) is one of the perfect and home remedies for indigestion and acidity. If you take it when you have an empty stomach, it will aid you in fighting against indigestion problems and also curing constipation. In addition, it is also beneficial in increasing the level of insulin in your body, which, in turn, protects against cancer. Here is a homemade remedy with using dried amla that you can follow to treat indigestion.
Remedy
You simply boil a few amla pieces in the water.
Then you mix them with salt and let them dry with the helping of sunshine.
Now, after they become dries, you put them in an airtight jar and chew 1 to 2 dried amla pieces whenever you suffer from indigestion.
Cardamom
A common kitchen spice that may be very beneficial in treating indigestion is cardamom. In fact, cardamom contains the volatile oil that can help you to heal a number of digestive problems including indigestion and gas. You simply consume the cardamom seeds alone or add the roasted cardamom powder into the vegetables while you cook your meal. Additionally, cardamom tea is a very effective way to heal indigestion. You may drink the cardamom tea several times per day to assist you in speeding up your digestive process.
Sex position is a position of the body that an individual or couple people may use for sexual intercourse or other sexual activities. Sexual acts are generally described by the positions the participants adopt in order to perform those acts. Though sexual intercourse generally involves penetration of the body of one person by another, sex positions commonly involve penetrative or non-penetrative sexual activities.
Three categories of sexual intercourse are commonly practiced: vaginal intercourse (involving vaginal penetration), anal penetration, and oral sex (especially mouth-on-genital stimulation). Sex acts may also involve other forms of genital stimulation, such as solo or mutual masturbation, which may involve rubbing or penetration by the use of fingers or hands or by a device (sex toy), such as a dildo or vibrator. The act may also involve anilingus. There are numerous sex positions that participants may adopt in any of these types of sexual intercourse or acts; some authors have argued that the number of sex positions is essentially limitless.
Is your sex life screaming for an upgrade? Yeah, we hear you. Getting freaky has a way of getting stale the more time you log with your partner. The good news. It’s easy to turn things around by switching up your sex positions
With more than 35 orgasm-inducing ways—dude, that’s one (and then some!) for each day of the month—to get your grind on, our best sex positions guide will help fulfill all your naughty needs. Scroll on down, down, down—and enjoy yourself.
Take our sex survey to help us learn more about what helps get you off—and we’ll share the results in an upcoming issue!
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SEX POSITION: PRETZEL DIP
How
You lie on your right side; he kneels, straddling your right leg and curling your left leg around his left side.
Benefit
With this sex position you get the deeper penetration of doggy style while still being able to make that important eye contact.
Bonus
Get your guy to put his hands to work
SEX POSITION: FLATIRON
How
You lie facedown on the bed, legs straight, hips slightly raised.
Benefit
This sex position creates a snug fit. Your guy’s penis will seem even larger.
Bonus
Some shallow thrusts and deep breathing will help him last longer.
SEX POSITION: G-WHIZ
How
You lie back with your legs resting on each of his shoulders.
Benefit
This sex position is awesome because when you raise your legs, it narrows the vagina and helps target your G-spot.
Bonus
Ask him to start rocking you in a side-to-side or up-and-down motion. That should bring his penis into direct contact with your G-spot.
SEX POSITION: FACE-OFF
How
He sits on a chair or the edge of the bed; you face him, seated on his lap.
Benefit
During this sex position, you’re in control of the angle and depth of the entry and thrust. Being seated provides support, so it’s great for marathon sex.
Bonus
Let your fingers (and hands) do the talking. Once seated, you can put your hands anywhere on your body or his to make things more interesting.
Get even more stimulation by sliding the Big O Multi-Stage Vibrating Penis Ring before things get started.
SEX POSITION: COWGIRL’S HELPER
How
Similar to the popular Cowgirl sex position, you kneel on top of him, pushing off his chest and sliding up and down his thighs. But he helps by supporting some of your weight and grabbing your hips or thighs while he rises to meet each thrust.
Benefit
This sex position puts sess stress on your legs, making climaxing easier. Plus, female-dominant sex positions delay his climax, so everyone wins.
Bonus
Alternate between shallow and deep thrusting to stimulate different parts of the vagina.
SEX POSITION: LEAP FROG
How
This is a modified doggy-style. Get on your hands and knees, then, keeping hips raised, rest your head and arms on the bed.
Benefit
This sex position creates deeper penetration—and gives you a chance to rest on a pillow.
Bonus
Use your hands to stimulate your clitoris.
SEX POSITION: BALLET DANCER
How
Standing on one foot, face your guy and wrap your other leg around his waist while he helps support you.
Benefit
This sex position allows for quality face time and connecting.
Bonus
If you’re a Flexi Lexie, try putting the raised leg on his shoulder for even deeper penetration.
SEX POSITION: COWGIRL
How
You kneel on top of him, pushing off his chest and sliding up and down his thighs. You can relieve some of your weight from his pelvis by leaning back and supporting yourself on his thighs.
Benefit
By being the dominant in this sex position, you’ll delay his climax and intensify yours.
Bonus
Discover new sensations for both of you by widening your knees or bringing them closer to his body.
SEX POSITION: CORKSCREW
How
Near the edge of a bed or bench, rest on the hip and forearm of one side and press your thighs together. Your man stands and straddles you, entering from behind.
Benefit
Keeping your legs pressed together during this sex position allows for a tighter hold on him as he thrusts.
Bonus
Instead of letting him do all the work, try thrusting you hips slightly to match his tempo.
SEX POSITION: WHEELBARR
How
Get on your hands and feet and have him pick you up by the pelvis. Then grip his waist with your thighs.
Benefit
Aside from being a fabulous arm workout for you, this male-dominant sex position allows him deeper penetration and an amazing view of your assets.
Bonus
Try resting on a table or the side of the bed and give your arms a brace
Use this fun tool and
SEX POSITION: MISSIONARY
How
Lie on your back while he lies facedown on top of you.
Benefit
This sex position is simple, elegant, effective, and surprisingly versatile.
Bonus
You can drastically change the sensation for both of you by shifting the angle of your legs.
SEX POSITION: DOGGIE STYLE/REAR ENTRY
How
Get on all fours. He kneels behind you, with his upper body straight up or slightly draped over you.
Benefit
This sex position allows for deep penetration and easier G-spot stimulation.
Bonus
Stimulate your clitoris with one hand, or ask him to do the finger work for you.
SEX POSITION: X-FACTOR
How
He enters you from the missionary position, then slides his chest and legs off your body so his pelvis is in the same location but his limbs form an “X” with yours.
Benefit
You feel more of his body in motion with this sex position.
Bonus
Use this unique angle to massage his back, butt, or legs as he thrusts.
SEX POSITION: THE CABOOSE
How
While he sits on the bed or a chair, back yourself into his lap and spoon each other while seated.
Benefit
You can’t see your partner during this sex position, which means fantasizing is easier and can add to the excitement.
Bonus
Tighten the muscles of your pelvic floor so you can grip him and keep him erect.
SEX POSITION: REVERSE COWGIRL
How
He lies on his back; you straddle him, facing his feet.
Benefit
Lets you take control and show your guy the pace and rhythm you like.
Bonus
To get more leverage, put your knees and shins inside his legs and under his thighs.
SEX POSITION: STAND AND DELIVER
How
With both of you standing, you bend over at the waist; he enters you from behind.
Benefit
Bending over during this sex position helps make the vaginal walls tighter and increases the intensity of the friction.
Bonus
Have him tickle your clitoris with his free hand, or loosely tie your hands together with a silky scarf.
SEX POSITION: SCOOP ME UP
How
Both of you lie on your sides, facing the same direction. You bring your knees up slightly while he slides up behind your pelvis and enters you from behind.
Benefit
This sex positin allows for more skin-to-skin contact, increasing your stimulation.
Bonus
Have him place his hands on your shoulders to increase the intensity and deepness of the thrust.
SEX POSITION: REVERSE SCOOP
How
From the missionary position, without disengaging, turn together onto your sides, using your arms to support your upper bodies.
Benefit
You get the same full-body press and can gaze into each other’s eyes.
Bonus
Try intertwining your legs with his or fondling him down below.
SEX POSITION: MAGIC MOUNTAIN
How
He sits, legs bent, leaning back on his hands and forearms. You do the same and then inch toward him until you connect.
Benefit
You’ll both feel really connected looking at each other. Increase your stimulation by grinding your clitoris against his pelvis.
Bonus
Slide ice cubes down his chest and let the cold water collect at the base of his pelvis.
SEX POSITION: THE CHAIRMAN
How
He sits on the edge of the bed and you sit on him, facing away.
Benefit
This sex position will hit the spot…as in your G-spot. Good for G-spot stimulation while you can use your hands to stimulate his scrotum or perineum.
Bonus
Bring your knees closer to your chest, supporting your feet on the bed.
SEX POSITION: COWBOY
How
You lie on your back while he straddles you. He then gently inserts his penis through the tight opening created by your semi-closed legs.
Benefit
Tightness increases the intensity of the penetration.
Bonus
Have him fondle your breasts or gently hold down your wrists.
SEX POSITION: GOLDEN ARCH
How
He sits with his legs straight and you sit on top of him with bent knees on top of his thighs, and you both lean back.
Benefit
Gives you both nice views of each other’s full bodies. You’ll also have control over the depth, speed, and angle of the thrusts.
Bonus
Have him use his hand to rub your clitoris, or use your own. Lean back farther for extra G-spot stimulation.
SEX POSITION: THE SEASHELL
How
Lie back with your legs raised all the way up and your ankles crossed behind your own head. He enters you from a missionary position.
Benefit
Your hands are free to work your clitoris.
Bonus
Have him “ride high,” rubbing his pubic bone against your clitoris, or “ride low,” directly stimulating your G-spot with the head of his penis.
SEX POSITION: BUTTER CHURNER
How
Lie on your back with your legs raised and folded over so that your ankles are on either side of your head, while he squats and dips his penis in and out of your vagina.
Benefit
Aside from getting that eye contact, the extra rush of blood into your head will increase the ecstasy.
Bonus
Have him dribble chocolate syrup or honey into your mouth. It gets more of your senses involved and amps up the whole experience.
SEX POSITION: THE PINBALL WIZARD
How
You get into a partial bridge position, with your weight resting on your shoulders. He enters you from a kneeling position.
Benefit
It allows him easy access to stimulate your clitoris and massage the mons pubis.
Bonus
Throw one leg up against his shoulder for deeper penetration.
SEX POSITION: CHAMPAGNE ROOM
How
He sits and you sit on top of him, facing away.
Benefit
It helps you regulate the pace and intensity of his thrusts.
Bonus
Try doing it on the stairs or the edge of the tub.
SEX POSITION: THE OM
How
He sits cross-legged (yoga-style), you sit in his lap facing him. Wrap your legs around him and hug each other for support.
Benefit
Best for tantric sex. Rocking, not thrusting, is the key when it comes to this very intimate position.
Bonus
Lock into each other’s deep gaze to put some extra “oh” into the big O.
SEX POSITION: UPSTANDING CITIZEN
How
You straddle him, wrapping your legs around his body. He stands and supports you in his arms. You can start on the bed and have him pick you up without disengaging. (Or for the truly bold, you can hop aboard from standing position!).
Benefit
He needs to spread his thighs slightly and not lock his knees. But if he has a bad back, this is a very bad idea!
Bonus
Have him push you up against a wall—very carefully.
SEX POSITION: VALEDICTORIAN
How
From missionary position, you raise your legs and extend them straight out (forming a “V”).
Benefit
This allows for good body contact with the vulva.
Bonus
Try grabbing your ankles. It can give you stability and an added stretch.
SEX POSITION: BELLY DOWN
How
Lie on your stomach with your hands thrust between your legs. Grind your legs together and move your hips up and down so that your clitoris and pubic mound rub against your firmly held fingers.
Benefit
Simple yet superb satisfaction.
Bonus
It’s easy to add to most rear-entry positions, like the Flatiron or the Leapfrog.
SEX POSITION: BUBBLE THE FUN
How
With your body submerged and legs dangling out of the tub, start by giving yourself a rubdown up top before you move down to roam around under the water.
Benefit
Relaxing in a warm sweet-smelling bath helps relieve tension, ease stress, and definitely gets you in the mood.
Bonus
Add in a waterproof vibe—like the Bathing Bunny Waterproof Vibrator —to make waves or take advantage of the “pulse” setting on your detachable showerhead. Steady streams of water on the clitoris can be extremely pleasurable.
SEX POSITION: CIRCLE PERK
How
From a seated position, use your finger to “draw” a circle around your clitoris. Start slowly and increase speed and pressure, depending on your reaction.
Benefit
This move is great for women who find direct clitoral pressure too intense for prolonged stimulation.
Bonus
Tired of the “O” shape? Try tracing the letters of the alphabet on your c-spot to vary the sensation.
SEX POSITION: COUCH GRIND
How
Ride the arm of a stuffed chair or couch, or the edge of a table or desk with a thick towel or blanket folded over it. Start with a small movement of the hips, and slowly build momentum.
Benefit
Great if you like solid, steady pressure on your clitoris.
Bonus
Grip the arm with your thighs and have your guy enter you from behind like the Doggy Style position. Just make sure not to break any furniture.
SEX POSITION: GET TO THE G-SPOT
How
Lie on your back and bring your knees in toward your chest. Insert one or two fingers deeply into your vagina. As you withdraw your finger, press against the front of your vagina and urethra and curl your finger in a beckoning gesture.
Benefit
With this motion it’s normal to feel a slight urgency to urinate at first, but with practice and several sessions, you can expect to experience a warm, pleasurable experience.
Bonus
Try it with only one leg bent to your chest, extending the other, for a variation on the sensation.
SEX POSITION: TAP DANCE
How
Lay on one side with one leg extended and the other bent. With one hand, gently separate and hold your labia to the sides, and apply a tiny drop of lube to your exposed clitoris. Then, with the opposite hand, begin tapping gently on it.
Benefit
Tapping, instead of rubbing, can cause quick and intense sensations for those who find direct stimulation too intense.
Bonus
Tapping harder or faster will create different sensations. See how long you can last or ask your partner to take part in the fun.
SEX POSITION: LOOK AND LEARN
How
Holding a hand mirror, sit in a comfortable chair with one leg propped up on the bed or couch. Now that you can check out the goods, venture away from your sensitive clitoris to discover new erogenous zones. Explore the opening, inside, and back wall of your vagina with your fingers, pressing and changing pressure until you find something that feels right.
Benefit
With this sex position you get a new point of view. Yyou may learn a new way to ring your bell, which can help alleviate the frustration many women feel when they can come in only one position.
Bonus
Try it with your favorite sex toy—we recommend the best-selling Fingo Nubby Finger Vibrator or your man, entering you from the Seashell or Butter Churner position.
alzell, Tom; Victor, Terry, eds. (2014). The Concise New Partridge Dictionary of Slang and Unconventional English (2 ed.). Routledge. p. 1966. ISBN9781317625117.
Sleep is the secret sauce. There isn’t one facet of your mental, emotional, or physical performance that’s not affected by the quality of your sleep.The big challenge is that in our fast-paced world today, millions of people are chronically sleep deprived and suffering the deleterious effects of getting low-quality sleep.The consequences of sleep deprivation aren’t pretty either. Try immune system failure, diabetes, cancer, obesity,depression, and memory loss, just to name a few. Most people don’t realize that their continuous sleep problems are also a catalyst for the diseases and appearance issues they’re experiencing.
How Way Can i sleep Better Tonight
Always remember the value of your sleep. You will perform better, make better decisions, and have a better body when you get the sleep you require. Sleep is not an obstacle we need to go around. It’s a natural state your body requires to boost your hormone function; heal your muscles, tissues, and organs; protect you from diseases; and make your mind work at its optimal level. The shortcut to success is not made by bypassing dreamland. You will work better, be more efficient, and get more stuff done when you’re properly rested.Follow these 50 tips, from my book Sleep Smarter, to get a better night’s sleep, starting tonight.
PLAN AHEAD
When you know you have a big task, project, or event coming up, pull out a calendar and plan ahead how you can get your ideal number of sleep hours in. Oftentimes it’s as simple as setting up a schedule. But people overlook it because, well, it’s just too easy
Cange Your Perspective
Begin reframing your idea of sleep. Instead of seeing sleep as an obstacle to work around (something you “have to” do), start seeing it as a special treat for yourself (something that you “get to” do) and love the entire process.
When it comes to sleep benefits, all sunlight is not created equal. The body clock is most responsive to sunlight in the early morning, between 6:00 a.m. and 8:30 a.m.
Exposure to sunlight later is still beneficial but doesn’t provide the same benefit. Of course, this is going to vary depending on the time of the year, but make it a habit to get some sun exposure during that prime time light period.
Find Outside Time
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Find Outside Time
If you are stuck in a cubical dungeon away from natural light at work, use your break time to strategically go and get some sun on your skin. Just a few minutes of outside time can makeover you mood.
Even on an overcast day, the sun’s rays will make their way through and positively influence your hormone function. You can take your 10 or 15 minute breaks outdoors or near a window, or if you’re really playing at a high level, you can make a habit of eating your lunch or having your meetings outside.
UVA v. UVB
Only getting sunlight on your skin through the filter of a window might not be the best idea for your health.
The sun has a plethora of wavelengths that impact our bodies, but the two you most need to know about are UVA and UVB. UV stands for ultraviolet, and these sun rays have long been known to influence our physiology. UVB is the most valuable for human health, as it’s the only wavelength that triggers your body to produce vitamin D.
Limit Screen Time
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Limit Screen Time
If you want to give your body the deep sleep it needs, make it a mandate to turn off all screens at least 90 minutes before bedtime in order to allow melatonin and cortisol levels to normalize. As an added bonus, cutting television time can also boost your weight loss.
If you ignore this and continue to have problems sleeping, I promise you Jimmy Fallon is not going to pay your hospital bills.
Read … Remember That
Read … Remember That
Use an alternative medium for nighttime activity. Remember those papery things called books we talked about? You can actually open one of those ancient relics and enjoy consuming a great story, inspiration, or education that way. And remember when people actually talked to each other face-to face? You can talk to the people in your life, listen to how their day went, and find out what they’re excited about and what they may be struggling with. They can obviously do the same for you, too.
In our world, where we’re more connected than ever before in some ways, we are often desperately lacking connection in others. Getting off our electronic devices, having a conversation, and showing affection is vital to our long-term health and well-being.
Nix the Notifications
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Nix the Notifications
Turn off the cues. Behavioral psychologist Susan Weinschenk, PhD, says, “One of the most important things you can do to prevent or stop a dopamine loop, and be more productive (and get better sleep!), is to turn off the cues. Adjust the settings on your cell phone and on your laptop, desktop, or tablet so that you don’t receive the automatic notifications. Automatic notifications are touted as wonderful features of hardware, software, and apps. But they are actually causing you to be like a rat in a cage.”
If you want to get the best sleep possible, and take back control of your brain, turning off as many visual and auditory cues as you can will be an instant game-changer.
Establish a Caffeine Curfew
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Establish a Caffeine Curfew
Set an unbreakable caffeine curfew to make sure your body has time to remove the majority of it from your system before bedtime.
For most people, that’s generally going to be before 2:00 p.m. But, if you’re really sensitive to caffeine, you might want to make your curfew even earlier, or possibly avoid caffeine altogether.
Perfect the Thermostat
Perfect the Thermostat
Make sure that the temperature in your bedroom stays close to the recommended 68°F at night. For some people, this is just right, but others may have images of Jack Frost and Frosty the Snowman.
Trust me (and the science), you will sleep better if you’re a little cooler; just don’t overdo it—60°F is the recommended minimum. You can still have your covers and pj’s, but don’t overdo that either or you’ll keep your body temperature too high (chances are your lover or would-be lover doesn’t want to sleep next to a flannel-clad, multiple-layered lumberjack at night anyway). Get a nice, cool environment in your room and snuggle up to sleep more soundly.
Make Time for a Bath
If you have trouble falling asleep, try taking a warm bath one-and-a-half to two hours before hitting the sack.
This may seem counterintuitive, but while your core temperature will increase from the bath, it will fall accordingly and level out a little cooler right around the time you turn in for the night. Many parents know that this is the secret method for helping young kids fall asleep and stay asleep at night.
Set a Bedtime
Set a Bedtime
The 10:00 p.m. recommended bed time isn’t exact with all of the variation in time zones, daylight saving time, how far you are from the equator, the time of year, etc. If we get too neurotic about the exact time to go to sleep, it can get a little ridiculous.
To get the highest-quality sleep possible, you want to aim for getting to bed within a few hours of it getting dark outside. For most people, this is going to mean somewhere between 9:00 p.m. and 11:00 p.m. most of the year.
Follow Bedtime With Sun Time
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Follow Bedtime With Sun Time
To help reset your sleep cycle so that you’re actually tired when the optimal bedtime rolls around, make a habit of getting some sunlight as soon as possible when you wake up. This is going to help boost your natural cortisol levels and fully wake your system up.
Your body knows what to do, and it will find its natural sleep cycle when you practice good sleep hygiene.
Embrace Topical Magnesium
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Embrace Topical Magnesium
Keep the topical magnesium right by your bedside and apply it right before you hop under the covers. The best places to apply it are:
1. Anywhere that you are sore
2. In the center of your chest (a major position aligned with your heart—one of the most magnesium-dependent organs in your body—and your thymus gland—one of the major regulators of your immune system)
3. Around your neck and shoulders (where many people carry a lot of their stress)
Spray it on liberally and massage it in. Four to six sprays per area is a great baseline to go with.
Add Magnesium-Rich Foods to the Diet
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Add Magnesium-Rich Foods to the Diet
Incorporate magnesium-rich foods in your diet, too. A study done by James Penland, PhD, at the Human Nutrition Research Center in Grand Forks, North Dakota, found that a diet high in magnesium and low in aluminum was associated with deeper, uninterrupted sleep.
Green leafy veggies, seeds like pumpkin and sesame, and superfoods like spirulina and Brazil nuts can provide very concentrated sources of magnesiumfor you.
Don’t Skimp on Gut Health
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Don’t Skimp on Gut Health
Do your best to avoid potentially gut-damaging chemicals that can hinder serotonin and melatonin production. Strive to eat organic, locally grown, unprocessed foods for the bulk of your diet.
Leave some room for fun stuff, but make it a mandate that the vast majority of your foods are safe and nourishing to your gut health, brain, and sleep . Be sure to get in three to five servings of foods that contain the good-sleep nutrients above every day, and you’ll be well on your way to improving your sleep from the inside out.
Decorate With House Plants
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Decorate With House Plants
Get at least one houseplant to improve the air quality in your home and go from there. If you don’t have a green thumb and can barely take care of your own personal grooming (let alone a plant), then get a really low maintenance plant, please.
The pros of having a houseplant are simply too good to pass up; just make sure that it’s something that suits you and not an additional stressor.
Keep Work Out of the Bedroom
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Keep Work Out of the Bedroom
If you share a sleeping space with someone else, make an agreement with them to keep office work out of the bedroom.
This is a sacred space for both of you, and usually it just takes a heart to-heart conversation to make sure that everyone is on the same page. The biggest person to hold to the agreement is yourself, so have the discipline to keep your bed reserved for sleep and sex.
Go for the ‘O’
. Go for the ‘O’
Get physical. An obvious aspect of sex’s impact on sleep is the physical exertion involved. When you put in some work bumpin’ and grindin’, you’ll naturally feel more fatigued after the session is over, and it’s no secret that the big ‘O’ impacts your sleep.
You don’t have to just lie there most of the time all vanilla-ice-cream style. Move around, get involved, and put your back into it. Lying back and receiving is super fine as well, but if you want to earn your sleep black belt, then you’ve got to put some work in, too.
Change Your Alarm Clock
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Change Your Alarm Clock
You don’t just want to block out the light from outside; you want to eliminate the troublesome light inside your bedroom, too. One of the biggest culprits is that angry alarm clock staring at you. The alarm clocks with the white or blue digits are more disruptive than ones with red digits.
You can start by simply covering the alarm clock up as one tactic. Another option is to find a digital alarm clock with a dimmer adjustment that allows you to turn the clock light all the way off. Cover the clock up or get a better clock—either way, you’ll be doing yourself a favor
Give Your Lamps a Makeover
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Give Your Lamps a Makeover
In preparation for sleeping in your pitch-black room, lowering the luminosity of the lights in your home (turning down the lights) or utilizing different color bulbs is a very good idea.
As the data shows, red lights are great, plus candle light can be a nice alternative. Additionally, Himalayan salt lamps feature a soft pinkish-orange tint. Some research indicates that salt lamps can produce a small amount of health-giving negative ions. So this goes to show that you don’t have to really love tie-dyed shirts in order to enjoy a salt lamp.
Consider Blackout Curtains
Consider Blackout Curtains
The purpose of using blackout curtains is really to block out unnatural light that would be making its way into your home. But if you live in an area where you don’t have street lights, a neighbor’s porch light, or cars constantly driving up and down your road, then getting blackout curtains is not totally necessary.
Sure, you might have some illuminating moonlight during certain times of the month, but moonlight is only a fraction of a percent of what you’d be hit with from any other type of light. The caution over light pollution has more to do with unnatural light, not the natural light you’d get from the moon subtly reflecting the rays of the sun.
Start Your Day With a Workout
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Start Your Day With a Workout
Whether you choose to do a full workout in the morning or afternoon, make sure to get some activity in during the first part of the day regardless. You don’t have to hit the gym to encourage that natural hormone spike that helps to set you up for great sleep at night, and set up any of these You can take just a few minutes to do some bodyweight exercises, go for a power walk, do some rebounding on a mini-trampoline (studies show that a trampoline can even prevent cancer), do some yoga (these 5 essential morning yoga poses are the way to get started), hit a few sets of kettlebell swings, do Tabata, or so many other things.
Doing just a few minutes of any of these won’t interfere with your training later in the day (if that’s when you choose to train). If you prefer to do a full workout in the morning, then simply do that. Whatever way you slice it, the clinically proven benefits of activity in the morning are just too good to pass up.
Make the Time to Work Out
Take out a schedule and block off specific appointment times for you to work out, and follow these 5 rules to fit exercise into your busy schedule. You can set a time for the morning or early evening; just ensure that you’re giving yourself the best advantage for getting great sleep.
If you’re really serious about being the healthiest person you can be, you’ll set your personal exercise appointment and sleep time first, then schedule everything else around them.
Do Something You Enjoy
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Do Something You Enjoy!
The best form of exercise is the exercise you’ll actually do, because there’s nothing worse than dreading your fitness
It’s difficult enough to fit exercise in with all of the things we have going on today. Why make it harder by planning to do something you don’t like?
Get an Accountability Partner
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Get an Accountability Partner
Statistics show that having external accountability drastically increases your rate of follow-through, and having a group of friends at your morning spin class ensure you’ll actually make it out of bed in time for the session.
When it comes to workout accountability, the most important prerequisite is to have a person (or people) who believes in you. It’s not the best idea to look for support in people who might doubt you and shut you down (even unintentionally).
Go for Strength
Go for Strength
Make sure that you’re lifting weights at least two days per week, and follow this guide to strength training for beginners to get going. Focus on compound lifts that really give you the most bang for your buck and reap the benefits when it comes to bedtime, because science has proven: strength training totally beats cardio.
Use an Actual Alarm Clock
Many people use their phones as a Swiss Army knife to replace a lot of other useful devices. One of those useful devices is an alarm clock.
To avoid this seduction of keeping your cell phone near your bedside, simply take action to use an actual alarm clock. You can use an alarm clock with the full shut-off dimmer; you can use a traditional buzzer alarm clock; or you can even use a rooster for all I care. Just stop using your cell phone if you don’t have to.
Keep a Distance From Electronics
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Keep a Distance From Electronics
It’s suggested that things like televisions, stereos, air conditioner units, computers, and refrigerators be at least six feet away from your bed at night (that means six feet in the vertical sense, too!).
If you’re at all able to position your bed in a way that it achieves this recommended distance, then that’s great. Sometimes there are extenuating circumstances, but always do the best you can with what you have right now. Science has even proved that cell phones and technology have been ruining your child’s sleep, so the whole family is seeing the effects of screen time during bedtime.
Think About Going Off the Grid
If you think there’s a chance your sleep and your health are being affected by WiFi exposure in your home , simply get in the habit of turning off the WiFi at night.
Biomechanist and bestselling author Katy Bowman utilizes a basic electrical timer to do this automatically. You simply install it in the socket where you plug your router in, and just set it to turn the power off during your preferred sleepy time.
Keep Your Phone in Another Room
I know it might sound crazy, but everything will be okay if you keep your phone in another room while you sleep. It’s 99.999 percent likely that you won’t miss anything important.
But, you will radically improve your sleep quality if you’re not allowing your cell phone’s notifications and radiation to disrupt your valuable sleep. Go on a cell phone free test drive. Just give it a shot for one week, and if the world ends while you’re sleeping peacefully during that period, I’ll try to call you the next day and let you know.
Snack Carefully
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Snack Carefully
If you really need to have something to eat closer to bedtime, have a high-fat, low-carb snack. These 8 bedtime snacks for weight loss will also ensure that your blood sugar stays stable.
In contrast, if you eat a higher-carb snack right before bed, your blood sugar will spike, and the impending blood sugar crash can be enough to wake you up out of sleep. This is why, in our culture, we have the concept of waking up to get a “midnight snack,” and that’s just one of the many eating mistakes messing with your sleep. But hey, that’s why they put a light in the refrigerator in the first place, right?
Up Your Micronutrient Intake
Remember this always: Nutrient deficiency will lead to persistent overeating (which will lead to poor sleep and poor overall health), so it’s time to ditch these anti-nutrients.
By improving your sleep quality, you will inherently get an uptick in leptin sensitivity. And focusing on eating micronutrient-rich food as the bulk of your diet (with some room for fun stuff) will ensure that your body is producing leptin and filling the nutritional gaps that had you ravenously hungry in the first place. Game, set, match. You win.
Go Big for Breakfast
Have your first meal be an epic one. Start your day off smart because science shows you should never skip breakfast.
Most people in our modern world have been programmed to start their day by having dessert for breakfast: oatmeal, toast, pancakes, bagels, cereal, fruit smoothies, and more. You’re starting your day with a huge insulin spike and setting yourself up for a day of fat storage because of this.
Cut Off the Drinks
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Cut Off the Drinks
Wrap up the drinks at least three hours before hitting the sack.
If you want to play at a high level and still hang out with your friends for drinks, then hook up with them for happy hour instead of an all-night bender. Respect the Road
Practice sleeping smarter to get the rest and recovery your body really needs so that you don’t put yourself in a dangerous driving position in the first place. Extenuating circumstances can happen, though, so if you have the symptoms of sleepiness coming on strong, just pull the car over.
Board certified sleep medicine physician Dr. Lisa Shives says, “Find a safe place and try to take a 10- to 20-minute nap. Studies have shown that shorter naps result in greater alertness and better performance.”
Experts also recommend avoiding driving alone for long distances late at night. And the National Sleep Foundation recommends taking a break every two hours if you are driving on a long road trip.
Pick Your Favorite Position … and Start There
Pick Your Favorite Position … and Start There
Our sleep position habits are just like any other habits: They can take some time to change, and every sleep position affects our health.
Start off the night in your ideal sleep position, and if you wake up during the night and find yourself in a position that you don’t want to be in, simply make a conscious effort to get into one that you prefer.
Communicate With Your Partner
Make sure to communicate your sleeping needs and preferences to your partner—this simply cannot be emphasized enough.
Talk to them with intention and compassion. Understand their sleeping needs, and make sure that you’re doing what you can to make them feel comfortable, too.
Sync Up on Tech
Sync Up on Tech
Reminders about the importance of communication in a relationship have become cliché. Yet the reality of the situation is that communication is the basis for any successful union.
If you want to get the TV out of your bedroom but you are worried that your partner won’t want to go along with it, simply have a compassionate heart-to-heart with them. Explain why this is important to you, and ask them if they’d be willing to work with you on this because you respect them and want them to be happy as well. You’ll probably be surprised what a little extra love and communication can do
Get the Right Mattress
Set your sights on getting a nontoxic, non-off-gassing mattress that has a higher level of resiliency than the industry standard if at all possible.
Again, you spend about one-third of your entire life on the mattress you choose, so make sure that it’s one that’s adding to your health and not taking away from it.
Meditate
Meditate
If you decide to meditate at night to help you wind down for sleep, try doing it before you get into the bed, not while you’re in bed, and start with this simple meditation for beginners.
Again, the neuro-association you want to have with your bed is sleep (and sex if you’re too sexy for this party), and that’s it. You can sit by your bedside and meditate for a few minutes, then slide your way into bed for a great night’s sleep.
Supplement, If Necessary
Find the right dose for you. Some companies recommend dosages of their products that are often too low or too high for certain individuals. Height, weight, gut health, stress levels, inflammation, and more are all factors that play into how much of a supplement would be ideal for you.
The best advice is to start low and work your way up, unless you are 100 percent certain in what you are doing, or begin with some natural sleep aids when first embarking on your sleep transformation.
Stay Safe With Pills
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Stay Safe With Pills
Don’t mix sleep aids with alcohol. By mixing the two together, you can relax muscles too much, stop breathing, and find yourself waking up like Bruce Willis in The Sixth Sense. (Spoiler alert: He was dead and didn’t know it.)
Seriously, taking any sleeping aid (be it medication or a supplement) along with alcohol is a really bad idea. Be smart, be safe, and don’t talk to the kid who says, “I see dead people.”
Set a Schedule
Go to bed within 30 minutes of the same time each night and wake up at the same time each day. Many people in our modern world try to “catch up” on sleep and sleep in on the days that they don’t have to get up for work. Though the argument can be made for sleeping in on the weekends, research shows that loading up on sleep on the weekends is a bad plan.
By throwing off your sleep schedule like this, you’ll usually find that you’re more tired than you want to be on your off days, and really dreading getting out of bed once Monday rolls around. Remember, a consistent sleep schedule is important for your health
Pamper Yourself
Book yourself a massage this week. When’s the last time you got a massage? If it’s recently, I’d like to congratulate you. Right now, about 10 percent of the US population gets a massage regularly, and that number is growing fast, especially since massages can even boost your immunity.
If you don’t know of, or don’t currently have the resources for a private massage therapist, then book an appointment at one of the national massage studios because they always have great deals for new clients. It would be the best idea ever to get yourself a monthly membership at one of these massage studios as well. It’ll make sure that you’re going in at least once a month, and it will also give you the ability to try different forms of massage and different therapists until you find one who clicks with you.
Try Muscle Relaxation
Try Muscle Relaxation
Give progressive muscle relaxation a shot. You might think that your muscles are relaxed, but they’re probably not. Many of us hold in constant muscle tension where our muscles are slightly “on” even when we consciously believe that we are fully relaxed. On top of that, many people are in the habit of holding their breath (realize it or not), which further tenses your muscles. Try a 15-second breathing exercise that’ll help reboot your whole body.
To help combat this and truly relax those muscles, the best thing you can do is fully tense them up first. Sound strange?
DIY Your Massage
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DIY Your Massage
There are many other tools that you can use for self-massage at home, including foam rollers, tennis balls, lacrosse balls, and trigger point massage tools, just to name a few.
And, of course, you have your own hands for self-massage or a partner’s hands if you know how to ask nicely. Make it a consistent part of your nightly ritual to get just a couple minutes of bodywork in to de-stress from the day
Dress for the Occasion
A 2011 Harvard study found that women who do not wear bras had half the risk of breast cancer compared to avid bra users. Take bedtime as an optimal opportunity to go bra free. This is a great start to improving your health and cutting down on your programmed bra dependency. Tight clothing is also one of the biggest sleep mistakes making you gain weight, so ditch the restrictive wear for speedier weight loss, too.
For the guys, avoid wearing tight underwear to bed that keeps your testicles pressed against your body. You’re potentially overheating your family jewels, and not allowing them to extend and retract based on a more natural temperature. Bedtime is a perfect time to wear something looser or to not wear anything at all.
Get Some Vitamin G
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Get Some Vitamin G
Make it a regular practice to get some quality time with your bare feet on the ground and practice grounding at least 150 minutes a week (really). This means conductive surfaces like soil, grass, sand (at the beach), and even living bodies of water like the ocean. The practice is one of the best alternative therapies you can try, and reap the health benefits that come with it.
There are other surfaces that are conductive, like concrete and brick, but their effectiveness depends on several factors. It’s best to get your vitamin G (your daily interaction with the earth) from the soil and grass itself. By the way, have you ever noticed that when you take a vacation and go to a beach, you tend to get really amazing sleep? A lot of people actually fall asleep at the beach before they can even make it back inside.
Now you know it’s not a coincidence; it’s the natural response of someone who finally gets connected with the earth again.
Embrace Earthing Technology
Embrace Earthing Technology
If you live in a climate where getting your quality vitamin G time isn’t always feasible, that’s when access to earthing technology can be so helpful.
The earthing products also allow you to not shift your life around too much to get the benefits of earthing. You can simply continue doing things you normally do—work at your computer, sleep, etc.—and be connected to the earth the whole time. You can have one earthing product or earthing products everywhere—there are mats, sheets, mattresses, mouse pads, and even bands you can put on specific pain points on your body that are used clinically to reduce pain and inflammation.
Vitamin B12 deficiency, also known as cobalamin deficiency, is the medical condition of low blood levels of vitamin B12. In mild deficiency, a person may feel tired and have a reduced number of red blood cells (anemia). In moderate deficiency, there may be inflammation of the tongue and the beginning of neurological problems including abnormal sensations such as pins and needles, while severe deficiency may include reduced heart function and greater neurological problems. Neurological problems may include changes in reflexes, poor muscle function, memory problems, decreased taste, and in extreme cases psychosis. Sometimes temporary infertility may also occur. In young children, symptoms include poor growth, poor development, and difficulties with movement. Without early treatment, some of the changes may be permanent.
Vitamin B12 (Cobalamin) is a water-soluble vitamin that is derived from animal products such as red meat, dairy, and eggs. Intrinsic factor is a glycoprotein that is produced by parietal cells in the stomach and necessary for the absorption of B12 in the terminal ileum. Once absorbed, B12 is used as a cofactor for enzymes that are involved in the synthesis of DNA, fatty acids, and myelin. As a result, a B12 deficiency can lead to hematologic and neurologic symptoms. B12 is stored in excess in the liver; however, in cases in which B12 cannot be absorbed for a prolonged period (e.g., dietary insufficiency, malabsorption, lack of intrinsic factor), hepatic stores are depleted, and deficiency occurs.[rx][rx][rx]
Causes of Vitamin B12 Deficiency
Vitamin B12 deficiency has 3 primary etiologies:
Autoimmune – Pernicious anemia is an autoimmune condition in which antibodies to intrinsic factor are produced. Anti-intrinsic factor antibodies bind to and inhibit the effects of intrinsic factor, resulting in an inability of B12 to be absorbed by the terminal ileum.
Malabsorption–Parietal cells in the stomach produce intrinsic factor; therefore, any patient with a history of gastric bypass surgery may be at risk for developing a B12 deficiency because their new alimentary pathway bypasses the site of intrinsic factor production. In patients with normal intrinsic factor production, any damage to the terminal ileum, such as surgical resection due to Crohn disease, will impair the absorption of B12 and lead to a deficiency. Other damage to the small intestine, such as inflammation from Celiac disease or infection with the tapeworm Diphyllobothrium latum, may also result in a B12 deficiency.
Dietary Insufficiency – Vitamin B12 is stored in excess in the liver; however, patients who have followed a strict vegan diet for approximately three years may develop a B12 deficiency from a lack of dietary intake.
Inadequate dietary intake of vitamin B12 –Vitamin B12 occurs in animal products (eggs, meat, milk) and in some edible algae. B12 isolated from bacterial cultures is also added to many fortified foods, and available as a dietary supplement. Vegans, and to a lesser degree vegetarian, may also be at risk for B12 deficiency due to inadequate dietary intake of B12, if they do not supplement. Children are at a higher risk for B12 deficiency due to inadequate dietary intake, as they have fewer vitamin stores and a relatively larger vitamin need per calorie of food intake.
Selective impaired absorption of vitamin B12 due to intrinsic factor deficiency – This may be caused by the loss of gastric parietal cells in chronic atrophic gastritis (in which case, the resulting megaloblastic anemia takes the name of “pernicious anemia”), or may result from wide surgical resection of stomach (for any reason), or from rare hereditary causes of impaired synthesis of intrinsic factor. B12 deficiency is more common in the elderly because gastric intrinsic factor, necessary for absorption of the vitamin, is deficient, due to atrophic gastritis.
Impaired absorption of vitamin B12 – in the setting of more generalized malabsorption or maldigestion syndrome. This includes any form due to structural damage or wide surgical resection of the terminal ileum (the principal site of vitamin B12 absorption).
Forms of achlorhydria – (including that artificially induced by drugs such as proton pump inhibitors and histamine 2 receptor antagonists) can cause B12 malabsorption from foods, since acid is needed to split B12 from food proteins and salivary binding proteins. This process is thought to be the most common cause of low B12 in the elderly, who often have some degree of achlorhydria without being formally low in intrinsic factor. This process does not affect the absorption of small amounts of B12 in supplements such as multivitamins since it is not bound to proteins, as is the B12 in foods.
Surgical removal of the small bowel – (for example in Crohn’s disease) such that the patient presents with short bowel syndrome and is unable to absorb vitamin B12. This can be treated with regular injections of vitamin B12.
Long-term use of ranitidine hydrochloride may contribute to a deficiency of vitamin B12.
Untreated celiac disease may also cause impaired absorption of this vitamin, probably due to damage to the small bowel mucosa. In some people, vitamin B12 deficiency may persist despite treatment with a gluten-free diet and require supplementation.
Some bariatric surgical procedures, especially those that involve removal of part of the stomach, such as Roux-en-Y gastric bypass surgery. (Procedures such as the adjustable gastric band type do not appear to affect B12metabolism significantly).
Bacterial overgrowth within portions of the small intestine, such as may occur in blind loop syndrome, (a condition due to a loop forming in the intestine) may result in increased consumption of intestinal vitamin B12 by these bacteria.
The diabetes medication metformin may interfere with B12 dietary absorption.
A genetic disorder, transcobalamin II deficiency can be a cause.
Alcoholism – if a “diet” of excessive alcohol intake is substituted for a diet adequate in sources of B12.
Nitrous oxide exposure, and recreational use.
Infection with the Diphyllobothrium latum tapeworm
Chronic exposure to toxigenic molds and mycotoxins found in water damaged buildings.
Increased needs by the body due to AIDS, or hemolysis the breakdown of red blood cells.
Can Calcium Supplements Protect Against PPI-Induced Vitamin B12 Deficiency?
Vitamin B12 is a member of the water-soluble B-vitamin family and therefore is an essential nutrient that must be acquired from the diet [rx]. Vitamin B12 belongs to a class of naturally occurring colbalt-containing compounds known as cobalamins, which contain a planar corrin ring that binds a single colbalt atom. Colbalt is the functional part of vitamin B12, which serves as an enzyme cofactor for two vitamin B12-dependent, enzyme-catalyzed reactions in mammals.
Patients taking acid reducers long term are at greater risk for hypochlorhydria-induced vitamin B12 malabsorption.
Both proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) can block the activity of intrinsic factor. However, the risk is widely inconsistent across studies due to variable samples and confounding designs.
Atrophic gastritis, Crohn’s disease, celiac disease, total or partial gastrectomy, gastric surgery, pancreatectomy, pancreatitis, and ileal resection can also cause vitamin B12 malabsorption. Calcium supplementation may reverse the effect of hypoparathyroidism and metformin-induced vitamin B12 malabsorption.
The Journal of Nutrition Health and Aging recently published a study that shows calcium supplements temper gastric acid inhibitor-induced vitamin B12 malabsorption. This retrospective cross-sectional study collected data from the Quebecois Geriatric Assessment Unit inpatients discharged from January 2008 through March 2012.
Enrolled patients received scheduled H2RA or PPI therapy upon admission. The researchers excluded patients with missing records and hospital stays shorter than 5 days. The prevalence of vitamin B12 deficiency in this cohort (41.3%) was similar to that seen in other studies enrolling patients in rehabilitation units.
Previous studies have shown that calcium chelators decrease intestinal vitamin B12 absorption. No research has shown that PPIs or H2RAs have chelating actions, but PPIs limit absorption of calcium carbonate, the most commonly used calcium supplement.
Quite by accident, the researchers found that patients taking PPIs (but not H2RAS) without concomitant calcium supplements were more likely to have vitamin B12 deficiency than those taking PPIs plus calcium. This indicated that calcium modifies the effect of PPIs significantly.
In the study, calcium supplements protected patients from the effect of gastric acid reducers. Inconsistent prevalence of calcium supplement co-administration between studies can explain the variable risk of vitamin B12 absorption.
The researchers concluded that calcium supplements reduce the vitamin B12 malabsorption effect of gastric acid reducers. They believe future studies should consider calcium supplement co-administration to be a confounder in the risk of vitamin B12 malabsorption.
up date May2017
HealthDay Reporter
(HealthDay News) — People who take certain acid-reflux medications might have an increased risk of vitamin B-12 deficiency, according to new research.
Taking proton pump inhibitors (PPIs) to ease the symptoms of excess stomach acid for more than two years was linked to a 65 percent increase in the risk of vitamin B-12 deficiency. Commonly used PPI brands include Prilosec, Nexium and Prevacid.
Researchers also found that using acid-suppressing drugs called histamine-2 receptor antagonists — also known as H2 blockers — for two years was associated with a 25 percent increase in the risk of B-12 deficiency. Common brands include Tagamet, Pepcid and Zantac.
“This study raises the question of whether or not people who are on long-term acid suppression need to be tested for vitamin B-12 deficiency,” said study author Dr. Douglas Corley, a research scientist and gastroenterologist at Kaiser Permanente’s division of research in Oakland, Calif.
Corley said, however, that these findings should be confirmed by another study. “It’s hard to make a general clinical recommendation based on one study, even if it is a large study,” he said.
Vitamin B-12 is an important nutrient that helps keep blood and nerve cells healthy, according to the U.S. Office of Dietary Supplements (ODS). It can be found naturally in meat, fish, poultry, eggs, milk and other dairy products. According to the ODS, between 1.5 percent and 15 percent of Americans are deficient in B-12.
Although most people get enough B-12 from their diet, some have trouble absorbing the vitamin efficiently. A deficiency of B-12 can cause tiredness, weakness, constipation and a loss of appetite. A more serious deficiency can cause balance problems, memory difficulties and nerve problems, such as numbness and tingling in the hands or feet.
Stomach acid is helpful in the absorption of B-12, Corley said, so it makes sense that taking medications that reduce the amount of stomach acid would decrease vitamin B-12 absorption.
More than 150 million prescriptions were written for PPIs in 2012, according to background information included in the study. Both types of medications also are available in lower doses over the counter.
Corley and his colleagues reviewed data on nearly 26,000 people who had been diagnosed with a vitamin B-12 deficiency and compared them to almost 185,000 people who didn’t have a deficiency.
While 12 percent of people with a vitamin B-12 deficiency had taken PPIs for more than two years, 7.2 percent of those without a deficiency had taken the medications long-term.
Of those with a deficiency, 4.2 percent took an H2 blocker for two years or longer, while 3.2 percent of those without a deficiency took the drugs for two years or more.
The risk of developing a vitamin B-12 deficiency was 65 percent higher for the long-term PPI users and 25 percent higher for those taking H2 blockers, according to the study.
People who took higher doses were more likely to develop a vitamin B-12 deficiency. People who took an average of 1.5 PPI pills per day had almost double the risk of developing a deficiency compared to those who averaged 0.75 pills per day, the study found.
Women had a greater risk of deficiency than men, and people younger than 30 taking these medications had a greater risk of developing a deficiency than older people, according to the study.
The risk of vitamin B-12 deficiency decreases when you stop taking the medications, but doesn’t disappear completely, Corley said.
The study’s findings were published in the Dec. 11 issue of the Journal of the American Medical Association. Although the study found an association between taking acid-reflux drugs long-term and having a higher risk of a B-12 deficiency, it didn’t establish a cause-and-effect relationship.
If you’re taking acid-suppressing medications, Corley said, “our study doesn’t recommend stopping those medications, but you should take them at the lowest effective dose.” And people shouldn’t start taking vitamin B-12 supplements on their own, but should discuss it with their doctor, he said.
One expert had concerns about how frequently acid-suppressing drugs are used.
“This study found an adverse effect associated with taking these drugs,” said Victoria Richards, an associate professor of medical sciences at the Frank H. Netter M.D. School of Medicine at Quinnipiac University, in Hamden, Conn. “It’s also concerning that these drugs are used at such a high rate. Why do so many people have the need to suppress acid so much?”
The bottom line, Richards said, is that if you are having any symptoms of vitamin B-12 deficiency and you’ve been taking these medications, talk to your doctor about whether you should be tested for a deficiency. Tell your doctor if you’ve been taking over-the-counter acid-suppressing medications, so your doctor can properly evaluate your risk.
Interactions with: Vitamin B12 (Cobalamin)
If you are currently being treated with any of the following medications, you should not use vitamin B12 supplements without first talking to your health care provider.
Medications that reduce levels of B12 in the body include:
Anticonvulsants — include phenytoin (Dilantin), phenobarbital, primidone (Mysoline)
Bile acid sequestrants — used to lower cholesterol; include colestipol (Colestid), cholestyramine (Questran), and colsevelam (Welchol)
H2 blockers — used to reduce stomach acid; include cimetidine (Tagamet), famotidine (Pepcid AC), ranitidine (Zantac)
Metformin (Glucophage) — medication taken for diabetes
Proton pump inhibitors — used to reduce stomach acid; include esomeprazole (Nexium), lansprazole (Prevacid), omeprazole (Prilosec), rabeprazole (Aciphex)
Antibiotics, Tetracycline:Vitamin B12 should not be taken at the same time as tetracycline because it interferes with the absorption and effectiveness of this medication. Vitamin B12 should be taken at different times of the day from tetracycline. (All vitamin B complex supplements act in this way and should be taken at different times from tetracycline.)
In addition, long-term use of antibiotics can deplete vitamin B levels in the body, particularly B2, B9, B12, and vitamin H (biotin), which is considered part of the B complex vitamins.
Oxytocin is a powerful hormone that acts as a neurotransmitter in the brain. It regulates social interaction and sexual reproduction, playing a role in behaviors from maternal-infant bonding and milk release to empathy, generosity, and orgasm. When we hug or kiss a loved one, oxytocin levels increase; hence, oxytocin is often called “the love hormone.” In fact, the hormone plays a huge role in all pair bonding. The hormone is greatly stimulated during sex, birth, and breastfeeding. Oxytocin is the hormone that underlies trust. It is also an antidote to depressive feelings.
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Oxytocin is a hormone secreted by the posterior lobe of the pituitary gland, a pea-sized structure at the base of the brain.
It’s sometimes known as the “cuddle hormone” or the “love hormone,” because it is released when people snuggle up or bond socially. Even playing with your dog can cause an oxytocin surge, according to a 2009 study published in the journal Hormones and Behavior. But these monikers may be misleading.
Oxytocin can also intensify memories of bonding gone bad, such as in cases where men have poor relationships with their mothers. It can also make people less accepting of people they see as outsiders. In other words, whether oxytocin makes you feel cuddly or suspicious of others environment.
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Oxytocin in women
Oxytocin is a particularly important hormone for women. “Oxytocin is a peptide produced in the brain that was first recognized for its role in the birth process, and also in nursing,” said Larry Young, a behavioral neuroscientist at Emory University in Atlanta, Georgia.
The hormone causes uterine contractions during labor and helps shrink the uterus after delivery. When an infant suckles at his or her mother’s breast, the stimulation causes a release of oxytocin, which, in turn, orders the body to “let down” milk for the baby to drink.
Oxytocin also promotes mother-child bonding. Studies show that “female rats find pups to be aversive if [the females are] virgins,” Young told Live Science. “But once they give birth, the brain is transformed, so they find the pups irresistible,” he said. And similar findings are seen in humans.
A 2007 study published in the journal Psychological Science found that the higher a mom’s oxytocin levels in the first trimester of pregnancy, the more likely she was to engage in bonding behaviors such as singing to or bathing her baby.
Although maternal bonding may not always be hardwired — after all, human females can adopt babies and take care of them — oxytocin released during pregnancy “does seem to have a role in motivation and feelings of connectedness to a baby,” Young said. Studies also show that interacting with a baby causes the infant’s own oxytocin levels to increase, he added.
Oxytocin in men
In men, as in women, oxytocin facilitates bonding. Dads who got a boost of oxytocin via a nasal spray played more closely with their 5-month-old babies than dads who didn’t get the hormone zap, a 2012 study found. (There is another hormone, called vasopressin, which plays a stronger role in men.)
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Another study found that men in relationships given a burst of oxytocin spray stood farther away from an attractive woman than men who weren’t given any oxytocin. Single men didn’t see any effect from the hormone, suggesting oxytocin may work as a fidelity booster for guys who are already bonded with another woman.
This anti-social effect of a social hormone brings some nuance to the story of oxytocin. In one study, researchers found that Dutch students given a snort of the hormone became more positive about fictional Dutch characters, but were more negative about characters with Arab or German names. The finding suggests that oxytocin’s social bonding effects are targeted at whomever a person perceives as part of their in-group, the researchers reported in January 2011 in the journal PNAS.
In another study, published in PNAS in 2010, men were given a dose of oxytocin and asked to write about their mothers. Those with secure relationships described their moms as more caring after the hormone dose. Those with troubled relationships actually saw their mothers as less caring. The hormone may help with the formation of social memories, according to the study researchers, so a whiff strengthens previous associations, whether good or bad.
“My view of what oxytocin is doing in the brain is making social information more salient,” Young said. “It connects brain areas involved in processing social information — whether it’s sights, faces, sounds or smells — and helps link those areas to the brain’s reward system.”
Oxytocin sprays and side effects
Oxytocin nose sprays also have been considered for use in treating autism. The neurological disorder is marked by struggles with social functioning, so a small 2013 study published in the journal PNAS gave a dose to children and teens with autism and asked the participants to identify emotions based on pictures of people’s eyes.
The participants weren’t any better at identifying the emotions after the oxytocin burst, but the regions of their brains associated with social interaction became more active. The increased processing could mean that a burst of oxytocin might help cement behavioral therapy for kids with the disorder.
“When you think about using oxytocin to treat diseases like autism, you want to make sure you do it in a context where the social information is positive,” Young said.
Use of oxytocin sprays outside of a medical context is far murkier, however. The sprays sold online without a prescription promise stress relief and social ease, but they are not regulated by the Food and Drug Administration (FDA). That means that nothing is known about their efficacy, side effects, or even whether they contain any oxytocin.
There are no long-term studies on the side effects of the legitimate oxytocin sprays used in hormone research; most studies give people one dose of the hormone only. Pitocin, a synthetic version of oxytocin given intravenously to stimulate labor, has side effects that include nausea, vomiting and stomach pain.
Some Interesting Effects of Oxytocin
Intro
Oxytocin the so-called “love hormone” is being increasingly shown to trigger a wide variety of physical and psychological effects in both women and men.
The hormone’s influence on our behavior and physiology originates in the brain, where it’s produced by the by a structure called the hypothalamus, and then transfers to the pituitary gland which releases into the bloodstream.. Like antennas picking up a signal, oxytocin receptors are found on cells throughout the body. Levels of the hormone tend to be higher during both stressful and socially bonding experiences, according to the American Psychological Association.
“It’s like a hormone of attachment, you might say,” said Carol Rinkleib Ellison, a clinical psychologist in private practice in Loomis, California and former assistant clinical psychiatry professor at the University of California, San Francisco. “It creates feelings of calm and closeness.”
Thought scientists have long known about oxytocin’s rolein breastfeeding and childbirth, “We’re just learning more about it now,” Ellison said.
A stream of studies in the last decade have focused on oxytocin’s effects on body and mind. Here’s a look at what we’ve learned.
Oxytocin promotes attachment
Pregnant women with higher levels of oxytocin during their first trimester bonded more strongly with their babies after they were born, according to a 2007 study in the journal Psychological Science. And compared with other women, women with higher levels throughout their pregnancy and in the first month after birth reported engaging in more behaviors such as singing, feeding and bathing their infants in specific ways that promoted an exclusive relationship between the two, the study found.
Oxytocin solidifies relationships
Comparing urine levels of oxytocin and a related hormone called vasopressin in biological and adoptive children who lived in Russian and Romanian orphanages, researchers found that oxytocin rose in biological children after having contact with their mothers. The study, published in 2005 in the journal Proceedings of the National Academy of Sciences, showed that oxytocin levels remained static in the adoptive children in the same situation, suggesting a physiological basis for why some adoptive.
Oxytocin eases stress
Research done on prairie voles showed that those separated from their siblings exhibited signs of anxiety, stress and depression that abated after they were injected with oxytocin. The study, presented at a 2007 meeting of the Society for Neuroscience, indicated the hormone’s effects were more evident under stressful situations.
Oxytocin crystallizes emotional memories
A November study in the journal Proceedings of the National Academy of Sciences supported researchers’ theory that oxytocin would amplify men’s early memories of their mothers. In a group of 31 men, those who inhaled a synthetic version of the hormone found the hormone intensified fond memories of their mothers if their relationships had been positive. Those whose ties with their mom’s had frayed downgraded their opinions after inhaling oxytocin, the study showed.
Oxytocin facilitates childbirth and breastfeeding
In its best understood role, oxytocin is released in large amounts during labor, intensifying the uterine contractions that open the cervix and allow the baby to pass through the birth canal. Physicians have been using synthetic oxytocin, also known by its brand name Pitocin, to induce or augment labor since the early 1900s. After birth, the hormone continues to stimulate uterine contractions that discourage hemorrhaging, and more is released when the nipples are stimulated during suckling, promoting the letdown of milk into the nipples.
Oxytocin boosts sexual arousal
Spontaneous erections in rats were observed after oxytocin was injected into their cerebrospinal fluid in a 2001 study in the journal Physiological Review. And a cocktail of brain chemicals that includes oxytocin is released in men during ejaculation. These chemicals can intensify bonding between sexual partners , though, Ellison noted, “it isn’t the same for everyone.”
“I think there is a variability,” said Ellison, who also teaches sexuality classes to health professionals. “For people who can really get into the sensualness of hugging and cuddling, that is the hormone released in this process. For people who don’t get into it, maybe they’re not releasing the oxytocin. It may be a circular thing.”
Oxytocin improves social skills
A February study in the journal Proceedings of the National Academy of Sciences showed that inhaling oxytocin significantly improved the ability of people with autism to interact with others. Previous studies indicated natural oxytocin levels were lower in those with autism, a developmental disorder characterized by difficulties in communication and social relationships. Oxytocin also reduced autistic individuals’ fear of others, researchers said.
Oxytocin triggers protective instincts
A June study in the journal Science suggested oxytocin triggers defensive aggression against outsiders who might threaten someone’s social group, such as in soldiers who defend their comrades. Prior animal studies had shown that the hormone promotes protectionist behavior, but this research was the first to demonstrate a similar effect in humans.
Oxytocin released in the brain under stress-free conditions naturally promotes sleep , according to a 2003 study in the journal Regulatory Peptides. Ellison said this link makes sense because oxytocin counters the effects of cortisol, which is the known as the stress hormone. “It has a calming effect,” she said. “It leaves you feeling tranquil and loving, and certainly that helps our path to sleep.”
Biological function
Oxytocin has peripheral (hormonal) actions, and also has actions in the brain. Its actions are mediated by specific, oxytocin receptors. The oxytocin receptor is a G-protein-coupled receptor that requires magnesium and cholesterol. It belongs to the rhodopsin-type (class I) group of G-protein-coupled receptors.
Studies have looked at oxytocin’s role in various behaviors, including orgasm, social recognition, pair bonding, anxiety, and maternal behaviors.
Physiological
The peripheral actions of oxytocin mainly reflect secretion from the pituitary gland. The behavioral effects of oxytocin are thought to reflect release from centrally projecting oxytocin neurons, different from those that project to the pituitary gland, or that are collaterals from them.Oxytocin receptors are expressed by neurons in many parts of the brain and spinal cord, including the amygdala, ventromedial hypothalamus, septum, nucleus accumbens, and brainstem.
Milk ejection reflex/Letdown reflex: In lactating (breastfeeding) mothers, oxytocin acts at the mammary glands, causing milk to be ‘let down’ into subareolar sinuses, from where it can be excreted via the nipple. Suckling by the infant at the nipple is relayed by spinal nerves to the hypothalamus. The stimulation causes neurons that make oxytocin to fire action potentials in intermittent bursts; these bursts result in the secretion of pulses of oxytocin from the neurosecretory nerve terminals of the pituitary gland.
Uterine contraction: Important for cervical dilation before birth, oxytocin causes contractions during the second and third stages of labor. Oxytocin release during breastfeeding causes mild but often painful contractions during the first few weeks of lactation. This also serves to assist the uterus in clotting the placental attachment point postpartum. However, in knockout mice lacking the oxytocin receptor, reproductive behavior and parturition are normal.
Due to its similarity to vasopressin, it can reduce the excretion of urine slightly. In several species, oxytocin can stimulate sodium excretion from the kidneys (natriuresis), and, in humans, high doses can result in low sodium levels (hyponatremia).
Cardiac effects: Oxytocin and oxytocin receptors are also found in the heart in some rodents, and the hormone may play a role in the embryonal development of the heart by promoting cardiomyocyte differentiation.However, the absence of either oxytocin or its receptor in knockout mice has not been reported to produce cardiac insufficiencies.
Modulation of hypothalamic-pituitary-adrenal axis activity: Oxytocin, under certain circumstances, indirectly inhibits release of adrenocorticotropic hormone and cortisol and, in those situations, may be considered an antagonist of vasopressin.
Preparing fetal neurons for delivery: Crossing the placenta, maternal oxytocin reaches the fetal brain and induces a switch in the action of neurotransmitter GABA from excitatory to inhibitory on fetal cortical neurons. This silences the fetal brain for the period of delivery and reduces its vulnerability to hypoxic damage.
Feeding: A 2012 paper suggested that oxytocin neurons in the para-ventricular hypothalamus in the brain may play a key role in suppressing appetite under normal conditions and that other hypothalamic neurons may trigger eating via inhibition of these oxytocin neurons. This population of oxytocin neurons are absent in Prader-Willi syndrome, a genetic disorder that leads to uncontrollable feeding and obesity, and may play a key role in its pathophysiology.
Psychological
Autism: Oxytocin has been implicated in the etiology of autism, with one report suggesting autism is correlated with genomic deletion of the gene containing the oxytocin receptor gene (OXTR). Studies involving Caucasian and Finnish samples and Chinese Han families provide support for the relationship of OXTR with autism . Autism may also be associated with an aberrant methylation of OXTR.
Bonding
In the prairie vole, oxytocin released into the brain of the female during sexual activity is important for forming a pair bond with her sexual partner. Vasopressin appears to have a similar effect in males.Oxytocin has a role in social behaviors in many species, so it likely also does in humans. In a 2003 study, both humans and dog oxytocin levels in the blood rose after five to 24 minutes of a petting session. This possibly plays a role in the emotional bonding between humans and dogs.
Maternal behavior: Female rats given oxytocin antagonists after giving birth do not exhibit typical maternal behavior.By contrast, virgin female sheep show maternal behavior toward foreign lambs upon cerebrospinal fluid infusion of oxytocin, which they would not do otherwise. Oxytocin is involved in the initiation of maternal behavior, not its maintenance; for example, it is higher in mothers after they interact with unfamiliar children rather than their own.
In group bonding: Oxytocin can increase positive attitudes, such as bonding, toward individuals with similar characteristics, who then become classified as “in-group” members, whereas individuals who are dissimilar become classified as “out-group” members. Race can be used as an example of in-group and out-group tendencies because society often categorizes individuals into groups based on race (Caucasian, African American, Latino, etc.). One study that examined race and empathy found that participants receiving nasally administered oxytocin had stronger reactions to pictures of in-group members making pained faces than to pictures of out-group members with the same expression. This shows that oxytocin may be implicated in our ability to empathize with individuals of different races and could potentially translate into willingness to help individuals in pain or stressful situations. Moreover, individuals of one race may be more inclined to help individuals of the same race than individuals of another race when they are experiencing pain.
Brain health refers to the ability to remember, learn, play, concentrate and maintain a clear, active mind. Simply, brain health is all about making the most of your brain and helping reduce some risks to it as you age.
Let’s get to work building a strong and healthy brain that is resilient against brain diseases, memory loss, and cognitive impairment. Even if you’ve already started experiencing a serious brain disease, you can benefit from following these principles of improved brain health.
To build a sensational brain, you need to eat a diet that is high in brain-building nutrients, including amino acids found in protein, healthy sugars found in healthy complex carbohydrates, and essential fatty acids found in healthy fats, as well as a mix of vitamins and minerals. When you eat a healthy, brain-building diet, your body will break down the foods into these components, which act as the building blocks of a healthy brain. (In as little as 30 days, you can be a whole lot slimmer, way more energetic, and so much healthier just by following the simple, groundbreaking plan.
Cut back on red meat and dairy products.
As you’ve already learned, red meat and dairy products contain saturated fats that tend to increase blood cholesterol levels and encourage your body’s production of beta-amyloid plaques in your brain, increasing your risk of brain diseases such as Alzheimer’s.
Eat no more than one serving of meat or dairy products (1/2 cup of dairy or 6 oz of meat) no more than five times weekly. On the days you avoid red meat, you can eat up to 6 oz of lean poultry or fish. Ideally, you should be having a couple of vegetarian days a week, as well. Some people already occasionally have “meatless Mondays,” and if you’re among them, you’re halfway there.
While meat and poultry are fine in small amounts, most people eat far too much of these foods, and that contributes to excess amounts of omega-6 fatty acids, and worse, excessive amounts of saturated fats that break down into inflammatory arachidonic acid.
Some foods that are high in digestible and highly usable protein include avocados, legumes such as lentils or kidney beans, nuts, nut butter, almond milk, soy milk, tofu, bean sprouts, and alfalfa sprouts. Also, when bean sprouts are eaten raw, they have loaded with highly absorbable protein thanks to enzymes they contain that allow for quick-and-easy digestion.
Avoid refined grains and enjoy whole grains, instead
Emphasize gluten-free options like quinoa, brown rice, millet, wild rice, amaranth, teff, tapioca, arrowroot, and sorghum. Your body breaks down healthy carbs into the natural sugars that your brain needs for its energy supply. I can almost hear some readers justifying their sugar addictions with that statement. However, your body has specific sugar needs. Refined or concentrated sugars, such as those found in sodas, ice cream, cakes, cookies, or other sugary foods, provide a quick sugar rush that just as quickly causes blood sugar levels to plummet. That kind of sugar roller coaster is detrimental to your brain health, not to mention your immune system.
Instead, your brain requires sustained energy from healthy carbs such as fruits, whole grains, and legumes. Legumes are high in both protein and carbs, making them an excellent food choice for brain health.
Better sources of gluten-free whole grains and carbohydrates include brown rice, wild rice, black rice, almond flour, tapioca flour, amaranth, arrowroot, and quinoa. Brown rice is more nutritious and a better option than white rice. It offers vitamin E and is high in fiber. Quinoa, a staple of the ancient Incas who revered it as sacred, is not a true grain, but rather a seed. It is a complete protein and is high in iron, B vitamins, and fiber. Amaranth is an ancient grain that is packed with important nutrients and devoid of gluten.
Go gluten-free if you are experiencing depression or another mental illness.
A recent study in the journal Biological Psychiatry found that gluten sensitivity and celiac disease may be linked to schizophrenia and psychosis. Scientists at the Department of Pediatrics at Johns Hopkins School of Medicine studied 471 people, including 129 with recently developed psychosis, 191 with mild schizophrenia, and 151 with neither condition to act as controls for the experiment.
The scientists measured levels of various types of antibodies to determine whether people with either schizophrenia or psychosis had any greater sensitivity to gluten than people without mental illness. Less than 1% of those with mental illness showed signs of celiac disease—a disease characterized by an inability to digest gluten and many resulting disabling symptoms. However, a significant number of people with schizophrenia and psychosis had high levels of antibodies to gluten.
The people with mental illness exhibited many of the same symptoms as people with celiac disease, but they had a different immune response. Those with mental illness also differed substantially in their reactions to gluten compared to the control group without mental illness. This study suggests that an abnormal immune response to gluten may be involved with these forms of mental illness. Of course, further research is needed, but this study gives people an important dietary factor to consider when dealing with mental illness.
Eat three square meals and snacks.
Be sure to eat at least three meals daily with healthy snacks in between to help keep your blood sugar levels stable. Blood sugar is the fuel your brain requires for optimal performance. And it needs a slow and steady supply, which is the exact opposite of the way most people eat: skipping meals, lots of sugar or sweets at certain times of day, and lots of sugar highs and crashes. The best part of eating three meals and a couple of snacks every day is that you don’t have to count calories, grams of protein, or other information.
Eliminate trans fats, hydrogenated fats, and all foods that contain them (margarine, shortening, pastries, biscuits, etc.)
Completely avoid all products that contain trans fats or hydrogenated fats. Stanford-trained research scientist J. Robert Hatherill, Ph.D., found that diets containing trans fats make brain cell membranes excessively permeable, allowing viruses greater access to the brain, disrupting brain signals, causing brain cells to become dysfunctional, and promoting cognitive decline. As if that wasn’t bad enough, trans fats also incorporate themselves into the myelin sheath—the protective coating of nerves and brain cells. This changes the electrical conductivity of nerve and brain cells, thereby negatively affecting the body’s communications. Trans fats have also been shown to increase the risk of stroke (and heart disease, too).
Vegetables and fruits should make up at least 80% of your diet.
Vegetables should make up the bulk of it. Sorry, white potatoes don’t count. Try to incorporate a wide variety of different vegetables and fruits, such as squash, leafy greens, peppers, cabbage, onions, sweet potatoes, apples, pomegranates, cherries, and blueberries. Get at least five servings of vegetables daily.
One serving equals approximately ½ cup of each vegetable. Get at least two servings of fruit daily. One serving of fruit equals approximately ½ cup of each fruit or one fruit with a pit. Be sure to include at least three of the essential brain-boosting foods each day. They include blueberries, grapes, pomegranates, tomatoes, walnuts, and wild salmon
While many of the best brain boosters are fruits and vegetables, other foods belong on this list as well, as you can see from the inclusion of walnuts and wild salmon. Additionally, choose at least two of the other great brain boosters each day. They include apricots, peaches, plums, celery and celery seeds, cherries, coffee, ginger, kidney beans, sage, rosemary, and tea.
Switch to coconut oil or extra virgin olive oil for cooking and baking.
That means no canola, vegetable oil, shortening, margarine, etc. While coconut oil contains saturated fats, a growing body of research shows that these saturated fats act differently in your body than saturated fats from animal products, such as meat and dairy.
Eat at least ½ cup of legumes daily
You can choose whichever kind you like best: chickpeas, black beans, kidney beans, navy beans, lentils, peas, etc. Only count legumes in which the fiber is still intact—whole beans. That means soy milk and tofu don’t count, because the fiber has been removed from these foods. Of course, you can still eat these foods, just don’t count them toward your daily legume intake.
Avoid artificial sweeteners such as sucralose, aspartame, and saccharin.
Choose only stevia or whole food sweeteners (raisins, dates, applesauce, etc.) to sweeten recipes. Keep sugars of all kinds to a minimum. Splenda is also known as sucralose, and while it is advertised as a natural sweetener, it isn’t. According to Joseph Mercola, DO, it “has been altered to the point that it’s actually closer to DDT and Agent Orange than to sugar.” Aspartame also goes by the names AminoSweet and Neotame and has been linked to brain cancer. Saccharin, a coal tar derivative, is also known as Sweet’N Low, Sweet Twin, and Necta Sweet and is considered a “probable carcinogen.”
Significantly reduce your sugar intake
Cut back on sweets of all kinds: cookies, cakes, pastries, etc. If you crave something sweet, opt for fruit. If you experience depression or another mental illness, do your best to avoid concentrated sugars altogether. Fruit is fine in moderation
Choose unrefined sea salt over iodized salt
Instead of iodized salt, choose unrefined or Celtic sea salt. Iodized salt is sodium with iodine added, while unrefined sea salt naturally contains sodium along with many other valuable minerals, including potassium, calcium, and magnesium. While salt is never a great source of these types of minerals, unrefined or Celtic sea salt also has many trace minerals that, as their name suggests, your body needs in trace amounts. Iodized salt has none of these trace minerals. Therefore, it is best to choose unrefined sea salt that naturally contains many different minerals, not just sodium and iodine.
Get 30 minutes of brisk exercise at least five times a week.
Brisk walking, running, hiking, cycling, inline skating, or any other brisk activity is fine. Exercise is critical to ensure that healthy, oxygen-rich blood is delivered in adequate quantities to your brain. A total loss of oxygen for 6 minutes can result in permanent damage to your brain, and 7 minutes can result in death. Because you obtain oxygen through breathing, simply breathing shallowly or not getting sufficient exercise can reduce the amount of oxygen-rich blood that pumps to your brain. By exercising regularly, you’ll boost that supply.
Take a high-quality multivitamin and mineral supplement
It should be free of iron, copper, sugar, additives, colors, and artificial sweeteners. Consume iron supplements only if your physician has instructed you to do so. Make sure your multivitamin contains at least 50 g of B-complex vitamins and 50 mcg of folate and B12. Studies link a vitamin B12 deficiency to an increased risk of Alzheimer’s disease, memory loss, and depression. Research also shows that simply getting more B vitamins (such as from a multiple plus extra vitamin B12) can halve the rate of brain shrinkage associated with aging.
Always remember the value of your sleep. You will perform better, make better decisions, and have a better body when you get the sleep you require. Sleep is not an obstacle we need to go around. It’s a natural state your body requires to boost your hormone function; heal your muscles, tissues, and organs; protect you from diseases; and make your mind work at its optimal level. The shortcut to success is not made by bypassing dreamland. You will work better, be more efficient, and get more stuff done when you’re properly rested.Follow these 50 tips, from my book Sleep Smarter, to get a better night’s sleep, starting tonight.
Make sure that the temperature in your bedroom stays close to the recommended 68°F at night. For some people, this is just right, but others may have images of Jack Frost and Frosty the Snowman.
ound crazy, but everything will be okay if you keep your phone in another room while you sleep. It’s 99.999 percent likely that you won’t miss anything important.
