The digestive or gastrointestinal (GI) system consists of one continuous tube from the mouth to the rectum (see Figure). It digests and absorbs food so that the nutrients can be used by the body. In disorders of the digestive system, people generally have many of the same symptoms regardless of age. However, as we age, the gut becomes stiffer and contractions of the gut decrease. In addition, other diseases, such as hardening of the arteries and diabetes, can upset the function of the gut and lead to symptoms and complications. Many medications commonly used in older adults can also result in problems in the GI system.

Problems in various digestive organs can cause many different symptoms, such as difficulty swallowing, stomachache, nausea, diarrhea, and constipation. Digestive problems can also quickly affect appetite and nutrition, which can lead to fatigue and weight loss.

• Swallowing Difficulties
• Heartburn
• Heartburn caused by medication
• Diagnosis and treatment
• Abdominal Pain
• Dyspepsia (stomachache)
• Peptic Ulcer
• Gallbladder Problems
• Gastrointestinal Bleeding
• Appendicitis
• Diarrhea
• Clostridium difficile infection
• Excess Gas
• Constipation
• Loss of Bowel Control
• Diverticulitis
• Irritable Bowel Syndrome
• Colonic Angiodysplasia
• Tumors of the Colon
• Polyps
• Colon cancer
• Prevention
• Other Colon Problems
• Hemorrhoids and Other Rectal Problems

Muscles in the mouth, throat, and esophagus (food pipe that travels from the mouth to the stomach) must all work together for normal swallowing. Difficulty swallowing is not a normal sign of aging, and it can be quite serious. For example, difficulty swallowing is the most common symptom of cancer of the esophagus. Swallowing problems should always be thoroughly evaluated.

Swallowed food travels through the esophagus, which is a long muscular tube that runs from the mouth to the stomach. Problems in the upper part of the esophagus make it difficult to begin swallowing. This causes food to stick in the back of the throat, usually without pain on swallowing. Disorders of older adults that can affect the upper esophagus include myasthenia gravis (a condition in which the muscles of the face get tired easily), an underactive thyroid, Parkinson's disease, stroke, cancer, and an "outpouching" of the esophagus called Zenker's diverticulum.

People with swallowing difficulties in the middle or lower esophagus often report that food gets stuck in their throat or chest and that swallowing may be painful. These people usually point to their breastbone as the problem area. Problems of the lower esophagus can include heartburn or acid coming back up the food pipe, cancer, and a ring of scar tissue at the bottom of the esophagus called a stricture.

The best way for your healthcare provider to examine your esophagus is by using endoscopy. In this procedure, a flexible fiberoptic tube (like a camera) is passed into the esophagus so that it can be examined in detail. If needed, a biopsy can also be taken during this procedure. Treatment depends on the underlying problem. In some cases, eating with a cup, straw, or spoon or changing the consistency of the diet may improve swallowing when the problem is with the muscles involved. Other conditions in the esophagus might require other changes, including the timing of meals, medications, or stretching the esophagus. See also Nutrition.

Heartburn is caused when acid and enzymes from the stomach back up into the esophagus and burn its lining. A one-way valve normally prevents stomach acid from backing up into the esophagus. Heartburn results when this valve does not close properly. The medical term for chronic heartburn is gastroesophageal reflux disease (GERD), or simply acid reflux.

Heartburn can develop in people of all ages but is most common in older adults. It typically happens after meals and becomes worse when the person lies down. Often, an older person has a hiatal hernia, in which the stomach moves out of its usual position. This makes it easier for the acid to back up into the esophagus. Certain medications can also make reflux more likely. Twenty percent of older Americans have symptoms of heartburn or acid reflux at least once a week. Over half of older adults have symptoms at least once a month. Symptoms range from a mild burning in the chest to very severe chest pain. Coughing and wheezing can happen at night as a result of stomach acid entering the airways. Sometimes, the only sign is hoarseness.

Heartburn can also be caused by pills that do not pass completely into the stomach and irritate the lining of the esophagus, make the stomach more acid, or loosen the valve that usually prevents acid from backing up the esophagus. Heartburn caused by pills that do not pass completely into the stomach can cause sudden pain when trying to swallow anything-even saliva. Pills that can lead to this problem include tetracycline antibiotics, aspirin or other nonsteroidal anti-inflammatory drug (NSAIDs), mineral supplements that contain potassium or iron, and a drug (alendronate) that is used to treat osteoporosis. Some foods and medications can also loosen the valve the prevents acid reflux and can cause heartburn, including alcohol, chocolate, mint and other foods, muscle relaxants, and sedative medications.

The heartburn caused by medications can be avoided by following some simple precautions:

• Follow the directions provided on the medication bottle (eg, take pills with meals or plenty of water, etc).
• Take all medications with at least 8 ounces of water.
• Stand up when taking pills and do not lie down for 30 minutes.
• Do not take pills close to bedtime, unless specifically instructed by your healthcare provider. Salivation and swallowing are much less during sleep, so pills taken at night are more likely to stick in the throat or esophagus. Plus, drinking a lot of fluid before bed can lead to having to urinate during the night (which interrupts sleep) or to bedwetting.

Treatment for acid reflux is generally aimed at simple changes in lifestyle:

• eating smaller meals
• eating more than 3 hours before lying down
• wearing loose collars
• avoiding certain foods and drugs, including alcohol, coffee, tomato sauce, chocolate, and some medicines
• sleeping with the head of the bed raised up 6 to 8 inches (with bricks or blocks)
  Using pillows to prop yourself up in bed is usually not enough, because you will change positions while you sleep
• maintaining a healthy weight.

Medications can be used to bring relief faster or to treat heartburn that does not respond to lifestyle changes.

A more thorough evaluation is needed if heartburn is accompanied by bleeding, anemia, vomiting, or swallowing problems. Endoscopy is usually done, as well as other procedures that test the esophagus for acidity and how well the muscles of the esophagus contract.

The two most popular classes of drugs used to treat heartburn or acid reflux are called H2-blockers and proton-pump inhibitors, although many people find good relief with over-the-counter antacids such as magnesium aluminum hydroxide liquid or calcium carbonate pills. H2-blockers and proton-pump inhibitors are available in both prescription and over-the-counter strengths. They work by decreasing the amount of acid produced by the stomach. Proton-pump inhibitors are a little more effective than H2-blockers, but they are also more expensive, and the risks of taking these medications for many years are less clear. These medicines can cure heartburn and heal the irritation of the esophagus in almost all cases.

Drug treatment for acid reflux should continue for at least 8 weeks. Symptoms often come back after treatment is stopped, and lifelong therapy is commonly needed. How quickly the heartburn comes back can be used as a guide to longer-term therapy. For example, symptoms that come back in less than 3 months suggest that treatment needs to be continuous. Symptoms that do not come back for more than 3 months can usually be managed by treatment only when needed.

In the few people for whom medication is not effective and for people who do not want to take medications long term, surgery is a possibility. Older adults who need to have a hiatal hernia repaired may also benefit from this surgery. Anti-reflux surgery can be performed using laparoscopy, a procedure that involves passing a flexible, fiberoptic instrument through a small incision in the abdomen. This surgery is successful more than 90% of the time.

Abdominal pain can be caused by problems with any of the structures in the lower chest, abdomen, or pelvis. Fairly minor problems sometimes cause abdominal pain (eg, upset stomach), but they can also be a sign of serious illness. Pain accompanied by bleeding, fever, or other problems, such as substantial constipation or difficulty swallowing, requires urgent medical attention. Abdominal pain that keeps getting worse and worse also requires medical evaluation.

The location of abdominal pain offers clues to the problem (see Figure). For example, stomach problems often cause pain in the middle of the upper abdomen. The nature or type of pain can also help identify the cause. For example, pain from the bowel or gallbladder tends to be sharp and come and go (like gas pain), while pain from other areas of the gut tends to be more constant. Pain that gets worse and worse could be one of several possible problems, including the following:

• gallbladder attack
• infection of the gallbladder or liver
• obstruction (blockage) of the bowel
• twisting of the bowel
• infection within the abdominal cavity from a hole or tear in the large intestine
• not enough blood being circulated in the bowel or other areas of the GI tract

Dyspepsia refers to pain or discomfort in the upper abdomen, where the stomach is found. The discomfort can be chronic, or come and go. In older adults, the major causes of dyspepsia are peptic ulcer, acid reflux, and stomach cancer. Although stomach cancer is not very common in the United States, the risk of getting stomach cancer (or any cancer) increases with age. A flexible endoscope is often used to look for signs of an ulcer, cancer, or other stomach problems, and to take a biopsy if needed. Treatment is aimed at the underlying problem(s).

A peptic plcer is an erosion or crater in the lining of the stomach or the first part of the small intestine. Ulcers generally develop when the normal defenses of the lining of the stomach and intestines break down and no longer protect against stomach acid. Peptic ulcers are most common in people with one or more risk factors, including the following:

• bacterial infection with Helicobacter pylori (H. pylori)
• chronic use of NSAIDs
• cigarette smoking
• alcohol abuse

In the United States, H. pylori infection is involved in most peptic ulcers. Ulcers are also five times more common among older adults who take NSAIDs (eg, aspirin, indomethacin, ibuprofen, or naproxen) for arthritis or other problems. Most NSAIDs are available as over-the-counter pain relievers. NSAIDs also increase the risk of complications from an ulcer (eg, bleeding or tear into the abdomen), which often require hospitalization.

Most older adults with ulcers have frequent stomachaches. The classic symptom is a hunger pain or a burning in the upper part of the abdomen that is relieved by antacids or food. However, many older adults have only vague abdominal discomfort, poor appetite, vomiting, or weight loss. Some older adults have no abdominal pain or symptoms until a complication such as bleeding, a tear, or a blockage develops. Dark-colored vomit or dark, tarry, foul-smelling feces indicate bleeding in the GI tract. Often, the only sign of bleeding is anemia.

The history and physical examination can suggest an ulcer, but additional tests are needed to make a certain diagnosis. Usually, a flexible endoscope is used to inspect the lining of the esophagus, stomach, and small intestine for ulcers or signs of irritation and bleeding. The endoscope can also be used to treat any bleeding sites, and to take a biopsy of any area that looks suspicious to check for cancer or infection. Another possible test is taking an x-ray of the abdomen after a small amount of barium has been swallowed. Barium is a dye that coats the stomach and intestine so that they can be seen better on the x-ray. Barium x-rays are not performed if a hole or tear of the stomach is suspected.

Treatment depends on the underlying cause. Helicobacter pylori infection is treated with antibiotics. Drugs that may cause irritation, especially NSAIDs, should be eliminated if possible. The same acid-reducing drugs used to treat heartburn are usually used to treat ulcers. Most ulcers heal in 8 weeks, but some require 12 weeks. If an ulcer has not healed after 12 weeks, a biopsy should be taken to check for cancer.

The gallbladder stores bile, which is a digestive fluid that helps to break down fats. When the bile gets too concentrated, it can crystallize and form stones. When stones move from the gallbladder, they can create severe pain (see Figure).

The pain of a gallbladder attack is usually felt in the right upper part of the abdomen, just below the ribs. However, pain may travel to the back or shoulder blades. The pain can be either sharp and crampy, or steady and consistent. During a gallbladder attack, a person may feel restless or nauseated, and may vomit. Other possible symptoms include a bloated feeling after eating and problems eating fatty foods. If a gallstone blocks the opening of the bile duct into the intestine, fever and chills can develop. In addition, the skin and eyes may turn yellowish (a condition called jaundice). Attacks usually last more than an hour and typically come back after several weeks.

The gallbladder can also become inflamed. When this happens, discomfort tends to come and go, but eventually the gallbladder could rupture, followed by an infection of the abdomen (called peritonitis) or blood poisoning.

History, physical examination, and blood tests can suggest gallbladder disease, but a definite diagnosis requires imaging studies, such as ultrasound. Ultrasound uses sound waves to look at structures in the body. It can detect gallstones, an enlarged gallbladder or bile duct, or an abscess. Ultrasound can also be combined with endoscopy to evaluate the area. CAT scans, MRI tests, and dye studies can also be used to diagnose gallbladder disorders.

If gallstones are not causing any symptoms, surgery is generally not needed. When gallstones do cause problems, the gallbladder is usually removed. The gallbladder can be removed using an endoscope, which speeds up recovery and can lesson pain and complications after surgery. Drugs to dissolve the gallstones can be tried for older adults who are unable to have surgery.

Bleeding into the GI tract can begin on its own, or it may be related to disease in another organ system. Important causes of GI bleeding include peptic ulcers, hemorrhoids, diverticulosis, cancer, and problems with the blood vessels that line the colon.

The symptoms depend largely on the location of the GI bleeding. Bright, red blood passed from the rectum suggests bleeding in the colon or rectum. Bleeding from the stomach or upper intestine usually results in dark, tar-colored bowel movements, because the blood is digested. People with bleeding in the upper digestive tract may vomit blood, which can be bright red or look like coffee grounds. Sometimes, there is bleeding in the GI tract, but no blood is seen outside the body. This is called occult bleeding.

Occult bleeding that goes on for a long time often shows up as anemia for which no other cause can be found. A test for occult blood in the feces can detect blood loss from any location in the GI tract. Unfortunately, tests for occult blood are not always accurate, and false alarms are common. However, this test is still useful to help diagnose bleeding from cancer in an early stage, when it is treatable. Other causes of occult bleeding include inflammation of the esophagus, peptic ulcer, cancer of the esophagus or stomach, colon polyps, inflammatory bowel disease, and hemorrhoids.

Anemia or finding any blood in the feces should be evaluated promptly. Because of the high risk of colon or rectal cancer in older adults, this evaluation should generally include a colonoscopy if the person is able to take cancer treatments, such as surgery and/or chemotherapy, if a cancer were found. Other diagnostic procedures are guided by the history and specific symptoms.

Treatment for GI bleeding depends on the source. Fortunately, most bleeding stops on its own. Large amounts of bleeding are a medical emergency, and surgery or blood transfusions may be needed.

The appendix is a narrow, worm-like sac that attaches to the first part of the colon. Appendicitis develops when material such as hardened fecal matter gets stuck in the appendix and causes inflammation.

Appendicitis is sometimes thought of as a disease of only young people. However, about 5% of cases are in people 60 years old and older. Unfortunately, appendicitis is more difficult to diagnose in older adults, because often the typical signs and symptoms of appendicitis do not develop. Often, the only signs are fever or chills. Complications (eg, tearing of the appendix with serious infection, other illnesses, etc), including complications after surgery, are also more common among older adults.

Diagnosis relies on history, physical examination, and diagnostic tests. Test results that suggest appendicitis include a high white blood cell count, and characteristic x-rays or other imaging studies (eg, CAT scan, ultrasound, etc). The treatment is surgery to remove the inflamed appendix.

Diarrhea is the body's way of rapidly getting rid of bacteria or poisons in the digestive system. It can also be caused by any illness that irritates the bowel, causing it to spasm. Emotional stress can also cause loose bowels. Diarrhea is usually thought of as the passage of loose feces that contain more water than normal. It can also be the urgent need to have a bowel movement. Diarrhea can cause a loss of bowel control that can be disabling.

Chronic diarrhea in older adults can be caused by many different problems, including cancer, inflammatory bowel disease (eg, Crohn's disease), irritable bowel syndrome, infection, and fecal impaction. In fecal impaction, the bowel becomes packed with feces that do not pass, and liquid feces are forced through the bowel and dribble around the impaction.

Diarrhea is also commonly caused by medications. Any medication should be considered a potential cause of diarrhea. In fact, infections and antibiotics cause about one-third of the cases of diarrhea in older adults. Diet also needs to be considered, especially diarrhea caused by a lack of ability to digest milk and other dairy products.

Underlying illnesses such as thyroid disease and diabetes must also be considered. People who have had diabetes for a long time can have severe diarrhea, especially if the diabetes affects the nervous system. In this case, there is usually watery, brown diarrhea that is generally worse at night.

If you have diarrhea that lasts more than a week, you should contact your healthcare practitioner. Severe diarrhea or any bloody feces needs immediate medical attention.

The initial evaluation usually includes the history, physical examination, and examination of the feces. Fecal samples are often sent to a laboratory to look for bacteria, toxins, or parasites. A colonoscopy may be performed, which involves passing a flexible fiberoptic tube (like a camera) through the rectum.

Because the body loses a lot of water in diarrhea, dehydration can be a serious complication. People with diarrhea should make sure to keep up their fluid intake, usually with clear liquids. Avoiding milk for a few days is a good idea, because it can make the diarrhea worse. Specific treatments for diarrhea depend on the underlying cause.

Clostridium difficile is a bacterium that is being recognized as the cause of diarrhea in many people in hospitals and nursing homes and in people who have recently taken antibiotics. This infection is usually triggered by the use of antibiotics that kill off healthy gut organisms, which allows the Clostridium difficile bacteria to grow faster because it does not have to compete as much for food. Signs and symptoms include watery diarrhea, crampy abdominal pain, fever, abdominal tenderness and bloating, and high numbers of white blood cells when the fecal sample is sent to the laboratory. Complications can be serious and include severe dehydration, blockage or tearing of the bowel, blood problems, a bloated colon, and death.

Diagnosis usually involves testing the feces for poisons produced by this bacterium. Treatment involves antibiotics for 10-14 days. Up to 20% of people may have a relapse and need additional treatment. In some cases, people might benefit from adding healthy organisms that are called probiotics to the gut.

There are two main causes of intestinal gas:

• swallowed air
• gas produced by bacteria in the bowel as they digest food

Some people swallow large amounts of air, which they eventually burp up. These people can often learn to avoid swallowing air. Certain sugars are not absorbed by the small intestine, but instead are broken down by bacteria in the colon, causing significant gas production. Some older people have difficulty absorbing the sugar in milk (lactose), which can cause diarrhea, abdominal bloating, and gas.

Making some dietary changes can help reduce gas production. Foods to eliminate from the diet include the following:

• beans
• cabbage
• legumes
• raisins
• nonabsorbable sugars (such as some artificial sweeteners)

Constipation is defined as any of the following:

• difficulty in passing a bowel movement (eg, straining)
• a feeling of not evacuating completely
• a reduced number of bowel movements (ie, less than two per week)

Complications of constipation include a sense of "not feeling right," reduced appetite, intestinal blockage, an extremely stretched-out bowel, and loss of bowel and bladder control. The colon can be blocked by a large amount of hard feces or by cancer or scar tissue. Being constipated over many years can lead to a condition called megacolon, in which the colon becomes extremely stretched out and contracts very poorly. Megacolon can be seriously worsened by various medications, including drugs used for Parkinson's disease, iron supplements, and some drugs that affect the nervous system. Older people who have developed megacolon are at increased risk of having the colon twist around itself, which is a very serious condition called volvulus.

Evaluation of constipation includes examination of the abdomen and rectum, and perhaps colonoscopy or x-rays. Other more sophisticated techniques can also monitor bowel movement, gut contractions, rectal sensation, etc, but are usually not needed.

The treatment of constipation in older adults begins with stopping medications that slow down the bowel (such as narcotics). The diet should be changed to increase fiber intake. Sources of fiber include the following:

• bran (the most effective)
• apples
• cabbage
• lettuce
• raw vegetables

Additional ways to prevent constipation include the following:

• having regularly scheduled mealtimes
• drinking plenty of liquids to stay well hydrated
• exercising regularly

Bulk laxatives, such as psyllium (eg, Metamucil®) or calcium polycarbophil, can increase the frequency of bowel movements as well as soften the feces. Relaxation and biofeedback exercises may help people with constipation that stems from weak pelvic muscles. Stool softeners, large-volume enemas, and glycerin suppositories may also be helpful. Stimulant or saline laxatives may be needed to manage constipation in people who are not able to move around much, or who have specific diseases that affect the intestines (eg, Parkinson's disease). However, the regular use of stimulant-type laxatives (eg, castor oil, cascara, or phenolphthalein), is strongly discouraged for people who are otherwise physically active. In the long run, these stimulants can damage the delicate nerve supply to the intestines and end up worsening the condition. Using stimulant laxatives for a long time can also cause low potassium levels, loss of protein, and decrease bowel contractions.

Severe constipation with impacted fecal material is treated with a series of enemas until the colon is completely empty. To prevent fecal impaction from happening again, people may need a fiber-restricted diet and frequent enemas (eg, every day or twice a week). Surgery is occasionally needed to remove a colon that has become severely stretched out and weak.

The medical term for loss of bowel control is fecal incontinence. Fecal incontinence affects 2%-7% of adults, mostly older adults in poor general health. If fecal incontinence is minor, occasionally gas and a small amount of liquid feces pass accidentally. If fecal incontinence is severe, a large amount of liquid or solid feces may leak or pass involuntarily. Fecal incontinence is often seen along with urinary problems, including loss of bladder control. Loss of bowel control greatly affects quality of life and may lead to social isolation. It also significantly increases the burden on caregivers and often results in placing the older person in a nursing home.

The normal process of having a bowel movement is complex. Fecal material moves into the rectum, which causes internal muscles to relax involuntarily. However, you control when you have a bowel movement by voluntarily relaxing the anal muscles and applying abdominal pressure. The ability to control this process depends on many factors, including physical and mental health, consistency of the feces, muscle functions, and proper sensation and reflexes. Many conditions can disrupt this process and lead to loss of bowel control:

• Long-term constipation and impaction
• Loss of normal control mechanisms
• Nerve damage affecting the rectum and anus
• Decreased nerve reflexes
• Damage from surgery or childbirth
• Problems that overwhelm the normal control mechanisms
• Diarrhea
• Poor access to toileting facilities
• Psychological and behavioral problems
• Dementia
• Severe depression

Many middle-aged and older women have weakened pelvic muscles from going through labor and delivery earlier in life. The process of childbirth can cause anal muscles to weaken and lead to fecal incontinence. Weak anal muscles can also result from previous anal surgery or disorders of the nervous system, such as spinal nerve injury (eg, slipped disks) or nerve damage secondary to diabetes. People with Alzheimer's disease or who have had a stroke sometimes lose bowel control due to brain damage. If the rectum is irritated or inflamed, the urgency and frequency of bowel movements may increase, leading to loss of bowel control. Surprisingly, blockage is a common cause of fecal incontinence, because it inhibits muscle tone and allows liquid feces to leak.

Psychological and behavioral problems, such as dementia or depression, can also cause fecal incontinence. For example, in severe depression, a person may be unable to reach the toilet in time. In dementia, a person may be unwilling to do so or unable to interpret the urge to defecate.

The history and physical examination usually focus on function of the nervous system, mental function, and child-bearing history. The abdomen and rectum are examined especially carefully, and a colonoscopy or similar procedure may be needed to check for inflammation or cancer. X rays are sometimes needed as well as other special tests to measure anal muscle tone, reflexes, sensation, and "squeeze pressure."

Treatment is based on underlying problems such as constipation, diarrhea, nerve damage, etc. Medical therapy is aimed at reducing the frequency of passing feces with anti-diarrheal drugs and at improving the consistency of the feces with "bulking" agents. Older patients with incontinence related to mental problems or physical disability may benefit from establishing a regular schedule for bowel movements (ie, at the same time every day). A glycerin suppository may stimulate the anal muscles and prepare the person for a planned bowel movement. The best time for this is usually just after waking up or shortly after eating, because this will take advantage of the normal bowel reflexes.

Many people can benefit from biofeedback therapy, as long as the anal muscles are functional. This method retrains the muscles in the pelvis and abdominal wall to contract appropriately and voluntarily. The process "conditions" a person to be able to tell when the rectum is full and to learn how and when to contract the muscles involved in passing a bowel movement.

A damaged anal sphincter can be repaired surgically or replaced with an artificial sphincter. An artificial sphincter is a tube that is inflated to maintain continence and deflated to defecate. A colostomy may be needed for people with symptoms that continue despite other treatments.

Diverticuli are small outpouchings in the wall of the large bowel that become more common with age (see Figure). The medical term for this condition is diverticulosis, and most people do not develop symptoms. However, these pouches become irritated, which is called diverticulitis, in about 20% of people. About 10% of people with these outpouchings develop bleeding, which is usually painless and stops on its own.

Older people with diverticulitis may have few symptoms or painful spasms in the lower abdomen. Some people have abdominal cramping, bloating, gas, or irregular bowel habits. Other possible symptoms include low-grade fever, nausea, vomiting, constipation, diarrhea, and difficulty urinating.

Diverticulitis is potentially serious because it can lead to tears or holes in the bowel wall. This can lead to an abscess, peritonitis (inflammation of the lining of the abdomen), or blood poisoning. Other serious conditions with symptoms similar to those of diverticulitis include colon cancer, fecal impaction, poor circulation in the bowel, appendicitis, and urinary tract infection. You should seek medical attention promptly if you develop abdominal symptoms that persist.

A high white blood cell count is common in diverticulitis. Diagnosis of diverticulitis usually requires medical imaging techniques, most commonly a CAT scan. A CAT scan can also identify peritonitis and other complications. A colonoscopy may be needed to see the bowel wall, look for bowel cancer, etc.

Diverticulosis is often found when tests are done on the GI tract for some other reason, for example, when screening for cancer in someone without any symptoms. Treatment is not generally needed unless diverticulitis develops. However, it is a good idea to include more fiber in the diet to reduce the risk of developing diverticulitis and its complications.

Almost all people with diverticulitis respond to resting the bowels by eating only clear liquids and taking antibiotics. Hospitalization is needed only if there is no improvement. Solid food can be eaten again once the diverticulitis clears up. Elective surgery to remove the inflamed diverticuli can prevent the problem from coming back, but most people don't need to resort to that.

After one episode of diverticulitis, a third of people do not have symptoms again, a third have abdominal cramps from time to time, and a third will have a second attack of diverticulitis. If the diverticulitis is complicated by tears or holes in the bowel wall or by infection, surgery is usually required. In most cases, the part of the colon containing the inflamed diverticuli is removed and the two ends are stitched together. About 10% of people need a second surgery because of another attack of diverticulitis.

People with irritable bowel syndrome (IBS) have abdominal pain, bloating, and either constipation or diarrhea (or both). IBS is most common before the age of 50, but it can affect people (primarily women) of any age. It is not caused by a physical problem with the bowel. IBS is a functional problem that is probably caused by changes in bowel or brain chemistry. It comes and goes, and is often brought on by stress. It is not life threatening but can severely affect quality of life.

Irritable bowel is a diagnosis of exclusion. This means that other illnesses with similar symptoms must be ruled out. For example, in older adults these conditions include diverticulosis, colon cancer, or inflammatory bowel disease. This requires a number of tests to be done including blood work, a colonoscopy, and a CAT scan of the abdomen and small bowel.

Depending on the type of IBS, treatment includes reassurance, medications for intestinal spasms or diarrhea, and fiber supplements.

Angiodysplasias (also called arteriovenous malformations or AVMs) are enlarged or widened blood vessels with thin walls that are similar to varicose veins. These abnormal vessels are found mostly in the lining of the large bowel but can be found anywhere in the GI tract.

Angiodysplasias can be caused by direct injury to the GI tract or by damage that is secondary to heart, lung, or blood vessel problems. People with angiodysplasias may have no symptoms, or they may show signs of bleeding from the GI tract. This bleeding can be visible (eg, streaks of blood on stool or toilet paper) or microscopic, depending on the location of the problem.

Angiodysplasias are usually diagnosed during a colonoscopy. Treatment is not necessary unless there is bleeding. Although bleeding from angiodysplasias can be controlled during a colonoscopy, it often starts again later. Removing the affected part of the colon provides a more permanent solution, but more bleeding from other angiodysplasias still happens about a third of the time. Estrogen therapy has successfully corrected bleeding from angiodysplasias in women, but this treatment can cause serious side effects, including cancer, embolism, and uterine bleeding.

Tumors of the colon can be benign or malignant. Benign tumors are referred to as polyps.

Polyps do not usually cause symptoms, although they may bleed and can lead to cancer. A large percentage of Americans over the age of 50 have one or more polyps. Polyps are more common in men than in women. Risk factors for polyps include old age and a family history of polyps or colon cancer. The risk of colon cancer increases with age and the number of polyps.

Polyps are most often found during screening tests for colon cancer, such as sigmoidoscopy or colonoscopy. A test on the feces for microscopic blood will detect polyps that bleed, but not all polyps bleed. Removing polyps significantly decreases the chances that they will develop into colon cancer. Polyps can usually be removed during colonoscopy, but abdominal surgery may be needed if there are large numbers of polyps or the polyps contain cancer cells where they attach to the colon.

Cancer of the colon or rectum (colorectal cancer) is the third leading cause of cancer in the United States. The risk of colorectal cancer increases dramatically with age, with more than 90% of cases in people over 50 years old. Colon cancer appears to be more common in people who eat diets that are low in fiber and high in refined sugar and animal fat. Other factors that increase the risk of colon cancer are polyps in the colon, inflammatory bowel disease (ie, Crohn's disease or ulcerative colitis), a family history of colon cancer, previous breast cancer or cancer of the ovaries or uterus, and long-standing infection with parasites.

Symptoms depend largely on where the cancer is located within the colon. Common signs and symptoms of colorectal cancer include the following:

• blood in the feces
• evidence of occult (hidden) bleeding, such as a positive fecal test for microscopic blood
• anemia caused by low iron
• abdominal pain
• pain when passing a bowel movement
• a change in bowel habits (eg, unusual constipation, diarrhea, or urgency)
• pencil-thin feces
• general symptoms of fatigue, weakness, and loss of energy

Colorectal cancer is close enough to the anus for a physician to be able to feel it with his or her finger in only 10% of cases. Therefore, a colonoscopy should be done in all cases of bloody feces, occult bleeding, or anemia. Other procedures that can detect colon cancer include a sigmoidoscopy (which examines only the lower colon) and a barium enema.

The best treatment for colon cancer is surgical removal. The affected section of the colon is removed, and usually a temporary colostomy is put in. This is a new opening for the colon on the outside of the body, usually on the surface of the abdomen. The bowel contents are redirected through this opening into a disposable plastic pouch. This allows the colon to rest and heal. Later, a second surgery can be done to reattach the two ends of the colon and allow normal elimination of feces through the rectum.

Other treatments include laser surgery and freezing, which are most often used for rectal cancers that cannot be reached through the abdomen. Laser surgery may also be able to improve symptoms in people who are not candidates for extensive surgery. Chemotherapy may be recommended if there is a risk that cancer has spread to other areas of the body (see also Cancer).

Screening for colon cancer is extremely important because colon cancer is treatable if it is detected early and because early colon cancer does not cause symptoms. The main screening tests for colon cancer are the fecal occult blood test and a colonoscopy. Occult blood tests are easy and painless, but positive results are often false and need to be further investigated by colonoscopy. Also, fecal occult blood tests do not detect polyps that are precancerous unless they bleed. Although having a colonoscopy can cause some discomfort, it is a very accurate, informative, and often life-saving procedure.

Everyone older than 50 years should have at least one screening colonoscopy. Individuals with polyps should be screened every 3-5 years. Yearly screening is recommended for people who have already had cancer removed or large polyps that are precancerous. This is because additional cancer or large polyps develop within 3 years in about a third of affected people.

The colon can be damaged by circulation problems that are common among older adults with certain types of heart disease, such as hardening of the arteries or atrial fibrillation (see Diseases of the Heart and Circulatory System). Areas of the colon can become swollen and discolored, and ulcers can develop because of poor blood supply. The main symptoms are abdominal pain and bleeding of the lower GI tract. Complications, such as tearing or scarring of the colon, are common, even with supportive treatment. Surgery to remove the damaged section of the colon is often necessary.

The colon can sometimes become greatly enlarged, even though there is no obvious physical obstruction or blockage. In older adults, this problem is often caused by a nerve disease (eg, Parkinson's or stroke), but it can also be caused by trauma, recent surgery or immobility, or long-term use of narcotics. Emergency colonoscopy may be needed to make sure there are no other problems (eg, cancer) and to "decompress" the colon. Usually this problem improves rapidly with supportive care and treatment, and discontinuing use of narcotics.

Hemorrhoids are swellings of rectal tissue that are caused by enlarged veins. They are often caused by frequent straining to pass bowel movements or by anal irritation. Usually, hemorrhoids are not painful, but hemorrhoids that have clotted (called thrombosed hemorrhoids) can cause severe pain around the rectum. Hemorrhoids can also enlarge and protrude as reddish masses from the anus (see Figure). Sometimes, these protruding hemorrhoids go back into the rectum on their own, or they may need to be pushed back in place with a finger.

Tears along the lining of the anus are called fissures. They usually cause pain while passing a bowel movement. Abscesses around the rectal area also cause pain that increases when trying to pass a bowel movement.

Hemorrhoids, fissures, and abscesses can be identified on a rectal examination. Healthcare providers use a tube called a proctoscope to examine the anus and rectal area.

Hemorrhoids are treated with the following:

• increasing the amount of fiber in the diet
• using dietary fiber and stool softeners to reduce straining
• using pain-relieving ointments or pads to reduce swelling
• taking sitz baths

More aggressive treatment is needed for hemorrhoids that do not respond to these treatments, to reduce inflammation and scarring, and to prevent the hemorrhoids from attaching to underlying muscle. Surgery is often necessary for clotted hemorrhoids.

Fissures are treated with sitz baths, stool softeners, and pain-relieving ointments. Tissues that do not heal may require surgery. Abscess usually need to be drained surgically.